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Countermeasures against COVID-19: how to navigate medical practice through a nascent, evolving evidence base - a European multicentre mixed methods study.

Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria.Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Wien, Austria.Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria.Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria.Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria.Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria.Research Platform Data Science, University of Vienna, Vienna, Austria.Pediatric Nephrology, Center for Child and Adolescent Medicine, Heidelberg University, Heidelberg, Germany.Department of Pediatric Nephrology, University Hospital Vall d'Hebron, Barcelona, Spain.Division of Pediatric Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey.Pediatric Center, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania.Department of Pediatric Nephrology, KfH Children's Kidney Center, Marburg, Germany.Pediatric Nephrology, Dialysis and Transplant Unit, La Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milano Policlinico, Milano, Italy.Pediatric Nephrology, Dialysis and Transplant Unit, La Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milano Policlinico, Milano, Italy.Department of Pediatric Nephrology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France.Renal Unit, UCL Great Ormond Street Hospital for Children NHS Foundation Trust and Institute of Child Health, London, UK.Department of Pediatric Nephrology, Mitera Children's Hospital, Athens, Greece.Department of Pediatric Nephrology, Utoped, Universitair Ziekenhuis Gent, Ghent, Belgium.Dialysis Unit, Department of Pediatrics, IRCCS Giannina Gaslini, Genoa, Italy.Department of Pediatric Nephrology, University Hospital Motol, Prague, Czech Republic.Department of Pediatric Nephrology, Medical University of Gdansk, Gdansk, Poland.Division of Nephrology and Vascular Biology Research Center, Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria christoph.aufricht@meduniwien.ac.at.

BMJ open. 2021;(2):e043015
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Abstract

OBJECTIVES In a previously published Delphi exercise the European Pediatric Dialysis Working Group (EPDWG) reported widely variable counteractive responses to COVID-19 during the first week of statutory public curfews in 12 European countries with case loads of 4-680 infected patients per million. To better understand these wide variations, we assessed different factors affecting countermeasure implementation rates and applied the capability, opportunity, motivation model of behaviour to describe their determinants. DESIGN We undertook this international mixed methods study of increased depth and breadth to obtain more complete data and to better understand the resulting complex evidence. SETTING This study was conducted in 14 paediatric nephrology centres across 12 European countries during the COVID-19 pandemic. PARTICIPANTS The 14 participants were paediatric nephrologists and EPDWG members from 12 European centres. MAIN OUTCOME MEASURES 52 countermeasures clustered into eight response domains (access control, patient testing, personnel testing, personal protective equipment policy, patient cohorting, personnel cohorting, suspension of routine care, remote work) were categorised by implementation status, drivers (expert opinion, hospital regulations) and resource dependency. Governmental strictness and media attitude were independently assessed for each country and correlated with relevant countermeasure implementation factors. RESULTS Implementation rates varied widely among response domains (median 49.5%, range 20%-71%) and centres (median 46%, range 31%-62%). Case loads were insufficient to explain response rate variability. Increasing case loads resulted in shifts from expert opinion-based to hospital regulation-based decisions to implement additional countermeasures despite increased resource dependency. Higher governmental strictness and positive media attitude towards countermeasure implementation were associated with higher implementation rates. CONCLUSIONS COVID-19 countermeasure implementation by paediatric tertiary care centres did not reflect case loads but rather reflected heterogeneity of local rules and of perceived resources. These data highlight the need of ongoing reassessment of current practices, facilitating rapid change in 'institutional behavior' in response to emerging evidence of countermeasure efficacy.

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Publication Type : Multicenter Study

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