What is the current situation?
In response to the COVID-19 pandemic, the World Health Organization (WHO) released two new International Classification of Diseases Revision 10 (ICD-10) codes to identify COVID-19 cases: U07.1 (COVID-19, virus identified: lab confirmed SARS-CoV2 infection) and U07.2 COVID-19 (suspected/probable SARS-CoV2 infection, lab confirmation inconclusive/unavailable).
What was the aim of the study?
To investigate the operating characteristics of ICD-10 based case definitions of both confirmed and suspected/probable SARS-CoV2 infection.
How was the study conducted?
We used three data sources: i) hospital data warehouses from Quebec (CODA-19
registry), Ontario (the General Medicine Inpatient Initiative GEMINI), and The Ottawa Hospital (TOH); ii) the COVID-19 multi-province data accessed via Canada’s Health Data Research Network (HDRN); and iii) the national Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN). Data spanned BC, Alberta, Saskatchewan, Manitoba, Quebec, Ontario, and maritime provinces. Analyses were restricted to adults (≥ 18 years) with a polymerase chain reaction (PCR) SARS-CoV-2 test or a COVID-19 ICD-10 diagnostic code within electronic health data. Descriptive statistics were used to characterize the study populations, healthcare encounters and PCR test characteristics (e.g., test results and specimens collected). PCR results were the reference
standard. Stratified analyses included demographics/timing of the first PCR.
What did the study find?
ICD-10 code U07.1 has high sensitivity, specificity, and positive predictive value (PPV) in identifying PCR-confirmed COVID-19 cases, particularly from hospitalization data but may miss cases within non-hospitalized ED patients (e.g., discharged from ED before the result of the test is known). Sensitivity, specificity, and PPV were higher if PCR testing was done within a 24–48-hour period before hospital admission/ED presentation. Results from hospitalization data were comparable across the provinces, and sensitivity and specificity
tended to be higher in older individuals and urban areas. The sensitivity of ICD-10 code U07.2 for suspected COVID-19 was poor. This code seems to be used infrequently when PCR testing is indeterminate or unavailable, and more often used for PCR confirmed cases (where U07.1 should have been used) or PCR negative scenarios (where according to WHO’s definition, U07.2 does not apply)
Data warehouse sensitivity estimates for hospitalized patients were as high as 97.8% (95% confidence interval, CI 95.9-98.9, in GEMINI). In CCEDRRN data, the sensitivity of ICD-10 code U07.1 for lab-confirmed SARS-CoV-2 was 93.6% (95% CI 93.0-94.1) in those hospitalized from ED and 83.0% (95% CI 82.1- 83.9) in those discharged from ED. The sensitivity of code U07.2 for suspected COVID- 19 was very low both in people discharged from the ED and in those who were hospitalized from the ED. In HDRN data, ICD-10 code U07.1 sensitivity was good, and highest in Ontario for those hospitalized at 90.9% (95% CI 90.8-91.0), with lower sensitivity in Ontario for those discharged from ED at 71.8% (95% CI 71.7-71.9).
Evidence-based COVID Decision-making Starts in Canada’s Emergency Departments
As an emergency physician, CAN-AIM researcher Dr. Corinne Hohl (UBC) is a ‘front line’ care provider for some of the very sickest COVID patients. While COVID was rapidly emerging as the greatest public health threat in a century, she was struck by the gaps in knowledge concerning emergency care. Spurred on by this, she is leading investigators from 51 emergency departments across 8 Canadian provinces to conduct a CIHR-funded multi-centre national cohort study. This cohort study is enrolling patients presenting consecutively to ERs with suspected COVID. Standardized prospective data will be collected and linked to electronic patient records to provide answers about key outcomes such as COVID test results, hospitalization, ICU stays, ventilation requirements, mortality, discharge safety, and other patient-centred data.
The results will be used to develop and validate clinical decision rules regarding patients presenting with suspected COVID. This will subsequently allow personalized evidence-based recommendations to improve COVID treatment (and outcomes) right from the time of presentation. Given the difficulty that every nation on the planet has had generating evidence for guiding COVID treatment, this study will not only have a long-lasting impact on guidelines in Canada. Still, it may also inform international guidelines. As an added value, this new project will form the basis for an enduring national network of collaboration to optimize COVID treatment in Canada. It is anticipated that this network will generate 30-50 sub-studies of high relevance to the Canadian pandemic response.
CONCEPTION: Short- and long-term impact of COVID-19 public health guidelines and hospital policies on maternal and child mental and physical health
As a long-time CAN-AIM researcher and the director of its pillar on drug safety in pregnancy and offspring, Dr. Anick Berard (Sainte-Justine Research Centre researcher and full professor at the Université de Montréal) is dedicated to providing clinicians, patients, and regulators with the data they need to optimize health outcomes. Science has already established that major stressful episodes can have a big impact on pregnancy, the physical and mental health of pregnant women, and even the children of pregnant mothers during these traumatizing events. Always at the cutting edge, Dr. Berard has now launched an international, multi-province, and multi-university COVID research initiative called CONCEPTION to tackle key knowledge gaps. The scientific team from Canada, the United States, and Europe will assess how measures such as confinement, physical distancing, school closures, quarantine and restrictions on companions during medical appointments and labour have a physical and mental health impact on expecting mothers and their babies.
CONCEPTION builds on existing collaborations and infrastructures in Canada and abroad. Pregnant women are being recruited via a social media campaign with an online collection of epidemiologic data (at recruitment and 2 months post-partum), with data linkage to the ongoing longitudinal multi-provincial Canadian Mother-Child Cohort (CAMCCO) Active Surveillance Initiative (built with province-specific administrative, hospital and birth certificate data linkage, supported by CIHR and the Canadian Foundation for Innovation). The study was launch on social media in June and intends to recruit 5,000 eligible pregnant women from Canada, the USA, France, Austria, Denmark, Sweden, and the Emirates, of which 4,239 who have been recruited and completed the baseline questionnaire. CONCEPTION provides a timely portrait of the consequences of COVID-related public health decisions and changes in the provision of healthcare during the peri- and post-natal period and the effect of the unprecedented public health crisis on pregnant and post-partum women and newborns.
Hydroxychloroquine: Enthusiasm for a potential COVID cure affects patients
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that can potentially lead to serious organ complications and even death. Its global burden is huge in terms of economic costs and the capacity to compromise the health-related quality of life. Hydroxychloroquine (HCQ) is one of the safest, most effective SLE drugs and is used by almost every SLE patient in North America. At the start of the COVID-19 pandemic, the unprecedented public and scientific optimism for HCQ as a potential treatment created urgent concern about shortages of this inexpensive medication, which is such a cornerstone of SLE therapy. CAN-AIM members Dr. Evelyne Vinet, Dr. Arielle Mendel, and Dr. Sasha Bernatsky (McGill) quickly organized both a national and an international survey of rheumatologists about their experience of HCQ shortages. The results, published in Annals of the Rheumatic Diseases in May (national) and June (international), reveal that most respondents reported difficulties in accessing or renewing the drug.
The problem was much more apparent in Quebec, where 90% of rheumatologists reported HCQ access issues. This was potentially an unintended consequence of provincial regulators to tightly control HQN prescriptions. That unfortunately affected patients with SLE and other rheumatic diseases (e.g. rheumatoid arthritis, RA, affecting 1% of Canadians). The international survey revealed similar problems in Europe and the USA, though respondents from four countries (Sweden, Denmark, Singapore, South Korea) reported no HCQ access issues.
Drs. Mendel, Vinet and Bernatsky have since established the CAnadian Network for REsearch on COVID-19 in Rheumatology (CAN-RECOVR) to understand better how the pandemic affects rheumatic disease care. This collaborative network will connect Canadian rheumatology researchers to study priority COVID-related questions with harmonized data collection—one project led by Drs. Mendel and Vinet studied thrombotic risk related to antibody production using the Quebec COVID-19 biobank.