Comparative Interrupted Time Series Research Articles

Association of Formulary Prior Authorization Policies With Buprenorphine-Naloxone Prescriptions and Hospital and Emergency Department Use Among Medicare Beneficiaries

Prior authorization requirements may be a barrier to accessing medications for opioid use disorder treatment and may, therefore, be associated with poor health care outcomes. To determine the association of prior authorization with use of buprenorphine-naloxone and health care outcomes. This comparative interrupted time series analysis examined enrollment and insurance claims data from Medicare beneficiaries with an opioid use disorder diagnosis or who filled a prescription for an opioid use disorder medication between 2012 and 2017. Over this period, 775 874 members were in 1479 Part D plans that always required prior authorization, 113 286 members were in 206 plans that removed prior authorization, 189 461 members were in 489 plans that never required prior authorization, and 619 919 members were in 485 plans that added prior authorization. Data analysis was performed from April 2019 to February 2020. Removal or addition of prior authorization and new prescriptions filled for buprenorphine-naloxone. Buprenorphine-naloxone use, inpatient admissions, emergency department visits, and prescription drug and medical expenditures. The study population in 2012 included 949 206 Medicare beneficiaries (mean [SD] age, 57 [15] years; 550 445 women [58%]). Removal of prior authorization was associated with an increase of 17.9 prescriptions (95% CI, 1.1 to 34.7 prescriptions) filled for buprenorphine-naloxone per plan per year, which is a doubling of the number of prescriptions, on average. Each prescription filled was associated with statistically significant decreases in adverse health care outcomes: substance use disorder-related inpatient admissions decreased by 0.1 admission per plan per year (95% CI, -0.2 to -0.1 admission per plan per year), and substance use disorder-related emergency department visits decreased by 0.1 visit per plan per year (95% CI, -0.13 to -0.03 visit per plan per year) (all P < .001). Combining these results, removal of prior authorization was associated with a reduction in substance use disorder-related inpatient admissions by 2.0 admissions per plan per year (95% CI, -4.3 to -0.1 admissions per plan per year) and substance use disorder-related emergency department visits by 1.4 visits per plan per year (95% CI, -3.2 to -0.1 visits per plan per year). Removing prior authorization for buprenorphine-naloxone was associated with an increase in the medication use and decreases in health care utilization and expenditures.

Is “Whole Child” Education Obsolete? Public School Principals’ Educational Goal Priorities in the Era of Accountability

Objectives: Working under the constraints of external accountability policy, public school principals are faced with challenges in prioritizing educational goals. Using the Schools and Staffing Survey (SASS) data sets, this study examined the nature and sources of changes in principals’ educational goal priorities in the era of accountability, including the No Child Left Behind Act (NCLB). Method: Difference-in-differences method was used to compare the national average trends of educational goal priorities between public and private schools during 1991–2012 period. Comparative interrupted time series method was also used to explore the impact of NCLB accountability policy on those trends across 50 states. At the school level, logistic regression was applied to examine the effect of NCLB Adequate Yearly Progress status on principals’ educational priorities. Results: While academic goals gained traction over the 1991–2012 period, there were setbacks for other goals of education, particularly personal growth and vocational skills. Notably, public schools’ priority changes were more drastic than private schools’ changes. The divergent trends largely persisted after NCLB across the states. On the other hand, public school principals who previously failed to meet NCLB targets gave more emphasis on basic skills and less emphasis on academic excellence and personal growth. Conclusion: Public school principal’s priorities on academic goals have been shaped by test-driven accountability measures, while other equally important goals have been possibly deprioritized. It gives implications for the implementation of the Every Student Succeeds Act, in which educational leaders can redesign accountability systems and incorporate nonacademic measures for whole child education.

The relationship between joining a US free trade agreement and processed food sales, 2002-2016: a comparative interrupted time-series analysis.

To examine changes in sales of highly processed foods, including infant formulas, in countries joining free trade agreements (FTAs) with the US. Annual country-level data for food and beverage sales come from Euromonitor International. Analyses are conducted in a comparative interrupted time-series (CITS) framework using multivariate random-effects linear models, adjusted for key confounders: gross domestic product (GDP) per capita, percent of the population living in urban areas and female labor force participation rate. Memberships in other FTAs and investment treaties are also explored as possible confounders. Changes are assessed between 2002 and 2016. Ten countries joining US FTAs are compared with eleven countries without US FTAs in force; countries are matched on national income level, world region and World Trade Organization membership. After countries join a US FTA, sales are estimated to increase by: 0·89 (95 % CI 0·16, 1·6; P = 0·016) kg per capita per annum for ultra-processed products, 0·81 (95 % CI 0·47, 1·1; P < 0·001) kg per capita per annum for processed culinary ingredients and 0·17 (95 % CI 0·052, 0·29; P = 0·005) kg per capita under age 5 per annum for baby food. No significant change is estimated for minimally processed foods. In statistical models, large unexplained variations in country-specific trends suggest additional unmeasured country-level factors also impact sales trends following entry into US FTAs. These findings strongly support the conclusion that joining US FTAs can contribute to detrimental changes in national dietary consumption that increase population risk of non-communicable diseases.

Tuberculosis among economic migrants: a cross-sectional study of the risk of poor treatment outcomes and impact of a treatment adherence intervention among temporary residents in an urban district in Ho Chi Minh City, Viet Nam

BackgroundTuberculosis (TB) remains a major cause of avoidable deaths. Economic migrants represent a vulnerable population due to their exposure to medical and social risk factors. These factors expose them to higher risks for TB incidence and poor treatment outcomes.MethodsThis cross-sectional study evaluated WHO-defined TB treatment outcomes among economic migrants in an urban district of Ho Chi Minh City, Viet Nam. We measured the association of a patient’s government-defined residency status with treatment success and loss to follow-up categories at baseline and performed a comparative interrupted time series (ITS) analysis to assess the impact of community-based adherence support on treatment outcomes. Key measures of interest of the ITS were the differences in step change (β6) and post-intervention trend (β7).ResultsShort-term, inter-province migrants experienced lower treatment success (aRR = 0.95 [95% CI: 0.92–0.99], p = 0.010) and higher loss to follow-up (aOR = 1.98 [95% CI: 1.44–2.72], p < 0.001) than permanent residents. Intra-province migrants were similarly more likely to be lost to follow-up (aOR = 1.86 [95% CI: 1.03–3.36], p = 0.041). There was evidence that patients > 55 years of age (aRR = 0.93 [95% CI: 0.89–0.96], p < 0.001), relapse patients (aRR = 0.89 [95% CI: 0.84–0.94], p < 0.001), and retreatment patients (aRR = 0.62 [95% CI: 0.52–0.75], p < 0.001) had lower treatment success rates. TB/HIV co-infection was also associated with lower treatment success (aRR = 0.77 [95% CI: 0.73–0.82], p < 0.001) and higher loss to follow-up (aOR = 2.18 [95% CI: 1.55–3.06], p < 0.001). The provision of treatment adherence support increased treatment success (IRR(β6) = 1.07 [95% CI: 1.00, 1.15], p = 0.041) and reduced loss to follow-up (IRR(β6) = 0.17 [95% CI: 0.04, 0.69], p = 0.013) in the intervention districts. Loss to follow-up continued to decline throughout the post-implementation period (IRR(β7) = 0.90 [95% CI: 0.83, 0.98], p = 0.019).ConclusionsEconomic migrants, particularly those crossing provincial borders, have higher risk of poor treatment outcomes and should be prioritized for tailored adherence support. In light of accelerating urbanization in many regions of Asia, implementation trials are needed to inform evidence-based design of strategies for this vulnerable population.

Effect of State Policy Changes in Florida on Opioid-Related Overdoses

With a rapid increase in prescription opioid overdose deaths and a proliferation of pain clinics in the mid-2000s, Florida emerged as an epicenter of the opioid overdose epidemic. In response, Florida implemented pain clinic laws and operationalized its Prescription Drug Monitoring Program. This study examines the effect of these policies on rates of inpatient stays and emergency department visits for opioid-related overdoses. Using data from the 2008-2015 State Emergency Department Databases and State Inpatient Databases, quarterly rates of inpatient stays and emergency department visits for prescription opioid-related overdoses and heroin-related overdoses were computed. A comparative interrupted time series analysis examined the effect of these policies on opioid overdose rates. North Carolina served as a control state because it did not implement similar policies during the study period. The data were analyzed in 2019. Compared with North Carolina, Florida's polices were associated with reductions in the rates of prescription opioid-related overdose inpatient stays and emergency department visits, a level reduction of 2.31 per 100,000 and a reduction in the trend of 0.16 per 100,000 population each quarter. The policies were associated with a reduction of 13,532 inpatient stays and emergency department visits for prescription opioid-related overdoses during the study period. No statistically significant association was found between the policies and heroin-related overdose inpatient stays and emergency department visits. To address the opioid overdose epidemic, states have implemented policies such as Prescription Drug Monitoring Programs and pain clinic laws designed to reduce inappropriate opioid prescribing. Such laws may be effective in reducing prescription opioid-related overdoses.

Medicaid Expansion's Spillover to the Criminal Justice System: Evidence from Six Urban Counties.

Spillovers from the Affordable Care Act Medicaid expansion to other social-sector outcomes have received little attention. One that may be especially salient for public policy is the impact of expanded eligibility on jail-related outcomes. This study compares recidivism outcomes in three non-expansion counties to nearby expansion counties before and after Medicaid expansion. Using forty-eight months of arrest data from six urban county jails, we conduct comparative interrupted time series analyses to describe changes in the probability of rearrest and the number of arrests before and after Medicaid expansion. Consistent with previous literature, we find mixed results. In two case studies, Medicaid expansion is associated with decreased rates of recidivism. In the other, we find differential increases in jail-based recidivism after Medicaid expansion. We use contextual information from site visits and stakeholder interviews to understand the factors that may mediate and moderate the relationship between Medicaid expansion and return to jail.

The Impact of Thin Capitalization Rules on Subsidiary Financing: Evidence from Belgium

In order to prevent excessive profit shifting using internal debt by multinational firms, several countries have introduced thin capitalization rules limiting the deductibility of interests on internal loans. While prior research has consistently found that firms affected by thin capitalization rules reduce their internal debt-to-equity ratio, the means through which this reduction is achieved are understudied. This paper employs a Comparative Interrupted Time Series methodology to identify the short-term effects of newly introduced thin capitalization rules on subsidiaries’ financing preferences, using a new dataset of detailed firm-level accounting data. The results indicate a reduction in internal debt and an increase in equity for affected firms, both by an increase in paid-up capital and by an increase in retained earnings. These findings about the way firms react may help lawmakers to estimate impact of future tax regulations.

Interrupted time series analyses on the effect on integrated care among the older population

Abstract Background Current health and social care systems in most European countries, are highly fragmented into specialist services, and poorly designed to provide health and social care for patients with multiple health problems and social needs. As some groups of patients might have greater difficulties navigating in a fragmented and divided system than others, current system also risks increasing inequalities in access and use of health and social care services. The aim of this study is to investigate if a comprehensive integrated care system perform better than ‘standard care’ in regards to emergency department visits, hospitalization for ambulatory care sensitive conditions (ACSC), costs and re-admissions as well as increase equity in health care among older people. Methods This study is an intervention study based on a comparative interrupted time series design comparing data from Norrtälje, where an integrated care system was implemented in 2006, with other areas of Stockholm county with a standard care system. The time series consists of register data from 2000-2015, obtained from the Stockholm County Council’s administrative database of healthcare utilization and population data on socio-demographic characteristics from national registers. Preliminary results The preliminary results based on data from 2000-2011 suggest that the introduction of an integrated care system in Norrtälje did not affect the rate of hospitalization for ACSC, costs or rates of emergency department visits. When stratifying on income group we saw that the lowest income group did improve in some of the outcomes. Conclusions The integrated care system in Norrtälje seems to have no significant effect on the outcome measures included. Whether socioeconomic inequity was affected is still to be investigated further. Key messages In this study we used interrupted time series to investigate organisational changes in the health care sector. Introducing integrated care in Norrtälje seems to have little effect on register based outcome measures.

PNS16 IMPROVING ACCESS TIME IN NUCLEAR CARDIOLOGY TOWARDS QUALITY DELIVERY OF HEALTHCARE SERVICES

This research aims to explore the timeliness of access to outpatient myocardial perfusion imaging (MPI) in a nuclear cardiology facility which caters for cardiac and non-cardiac scans. Access is a key health system performance indicator to measure quality delivery of healthcare services at an institutional level. The final (impact) outcome is to increase the proportion of patients undergoing MPI within an access time (AT) of <14 calendar days(gold standard) from 2% to 50% or higher over 6 months. AT is defined as the interval difference between the MPI request and scheduled appointment in days. Interventions are directed at best practices to address gaps and deficiencies within the system. First, the backlog reduction plan was aimed at elimination of backlog by recalibration of the scheduling system. Secondly, the surge contingency plan enables the utilization of available non-cardiac appointment slots to perform outpatient MPI. Thirdly, the adaptive workforce plan utilizes staggered working hours to accommodate for increase in number of appointment slots. A theory of change was developed to outline a road map of the sequence of events connecting the resources to the activities, and how it can lead to the desired short-, intermediate-, and long-term outcomes and impact. A comparative interrupted time series design is used. AT to outpatient cardiac computed tomography will serve as the comparison group to account for any time-varying fixed effect. Data are collected at various points over time before and after an intervention to determine whether the intervention had an effect significantly greater than the underlying trend to demonstrate causal-and-effect provided the parallel trend assumption is met. A qualitative survey will be performed to understand patient expectations on AT. Findings are aimed to guide evidence-based policy making in nuclear cardiology prior to wider implementation across other modalities in cardiac imaging for quality improvement and system management.

Association Between State-Mandated Protocolized Sepsis Care and In-hospital Mortality Among Adults With Sepsis

Beginning in 2013, New York State implemented regulations mandating that hospitals implement evidence-based protocols for sepsis management, as well as report data on protocol adherence and clinical outcomes to the state government. The association between these mandates and sepsis outcomes is unknown. To evaluate the association between New York State sepsis regulations and the outcomes of patients hospitalized with sepsis. Retrospective cohort study of adult patients hospitalized with sepsis in New York State and in 4 control states (Florida, Maryland, Massachusetts, and New Jersey) using all-payer hospital discharge data (January 1, 2011-September 30, 2015) and a comparative interrupted time series analytic approach. Hospitalization for sepsis before (January 1, 2011-March 31, 2013) vs after (April 1, 2013-September 30, 2015) implementation of the 2013 New York State sepsis regulations. The primary outcome was 30-day in-hospital mortality. Secondary outcomes were intensive care unit admission rates, central venous catheter use, Clostridium difficile infection rates, and hospital length of stay. The final analysis included 1 012 410 sepsis admissions to 509 hospitals. The mean age was 69.5 years (SD, 16.4 years) and 47.9% were female. In New York State and in the control states, 139 019 and 289 225 patients, respectively, were admitted before implementation of the sepsis regulations and 186 767 and 397 399 patients, respectively, were admitted after implementation of the sepsis regulations. Unadjusted 30-day in-hospital mortality was 26.3% in New York State and 22.0% in the control states before the regulations, and was 22.0% in New York State and 19.1% in the control states after the regulations. Adjusting for patient and hospital characteristics as well as preregulation temporal trends and season, mortality after implementation of the regulations decreased significantly in New York State relative to the control states (P = .02 for the joint test of the comparative interrupted time series estimates). For example, by the 10th quarter after implementation of the regulations, adjusted absolute mortality was 3.2% (95% CI, 1.0% to 5.4%) lower than expected in New York State relative to the control states (P = .004). The regulations were associated with no significant differences in intensive care unit admission rates (P = .09) (10th quarter adjusted difference, 2.8% [95% CI, -1.7% to 7.2%], P = .22), a significant relative decrease in hospital length of stay (P = .04) (10th quarter adjusted difference, 0.50 days [95% CI, -0.47 to 1.47 days], P = .31), a significant relative decrease in the C difficile infection rate (P < .001) (10th quarter adjusted difference, -1.8% [95% CI, -2.6% to -1.0%], P < .001), and a significant relative increase in central venous catheter use (P = .02) (10th quarter adjusted difference, 4.8% [95% CI, 2.3% to 7.4%], P < .001). In New York State, mandated protocolized sepsis care was associated with a greater decrease in sepsis mortality compared with sepsis mortality in control states that did not implement sepsis regulations. Because baseline mortality rates differed between New York and comparison states, it is uncertain whether these findings are generalizable to other states.

Academic, Attendance, and Behavioral Outcomes of a Suspension Reduction Policy: Lessons for School Leaders and Policy Makers

Background: Exclusionary discipline (e.g. suspension and expulsion) is associated with lower student achievement, drop-out, and involvement in the juvenile justice system. Recently, states and school districts have begun to restrict exclusionary discipline, but there remains much to be learned about the potential impact on students. Research Design: I use a comparative interrupted time series to estimate whether a state policy prohibiting out-of-school suspension as a consequence for truancy affected student achievement, attendance, truancy, or disciplinary referrals. Findings: After testing a variety of specifications checks, I find evidence of slight increases in attendance, particularly for disadvantaged students, with suggestive evidence of improvements in test scores and reductions in disciplinary referrals for some students. Conclusions: These improvements were quite modest relative to what we might expect from an intuitively appealing policy and were likely influenced by incomplete compliance, particularly in areas serving more students from traditionally disadvantaged backgrounds. Implications for policy design and school leadership are discussed.

Evaluating Missouri's Handgun Purchaser Law: A Bracketing Method for Addressing Concerns About History Interacting with Group.

In the comparative interrupted time series design (also called the method of difference-in-differences), the change in outcome in a group exposed to treatment in the periods before and after the exposure is compared with the change in outcome in a control group not exposed to treatment in either period. The standard difference-in-difference estimator for a comparative interrupted time series design will be biased for estimating the causal effect of the treatment if there is an interaction between history in the after period and the groups; for example, there is a historical event besides the start of the treatment in the after period that benefits the treated group more than the control group. We present a bracketing method for bounding the effect of an interaction between history and the groups that arises from a time-invariant unmeasured confounder having a different effect in the after period than the before period. The method is applied to a study of the effect of the repeal of Missouri's permit-to-purchase handgun law on its firearm homicide rate. We estimate that the effect of the permit-to-purchase repeal on Missouri's firearm homicide rate is bracketed between 0.9 and 1.3 homicides per 100,000 people, corresponding to a percentage increase of 17% to 27% (95% confidence interval: 0.6, 1.7 or 11%, 35%). A placebo study provides additional support for the hypothesis that the repeal has a causal effect of increasing the rate of state-wide firearm homicides.

Association Between Pharmacy Closures and Adherence to Cardiovascular Medications Among Older US Adults

It is unknown whether and how pharmacy closures alter medication adherence. To examine the association between pharmacy closures and adherence to statins, β-blockers, and oral anticoagulants among adults 50 years or older in the United States. In this retrospective cohort study, comparative interrupted time series analyses were performed using a nationally representative 5% random sample of anonymized, longitudinal, individual-level pharmacy claims from IQVIA LRx LifeLink. Analyses included all prescription claims for individuals followed up between January 1, 2011, and December 31, 2016. Separate cohorts were derived for users of statins, β-blockers, and oral anticoagulants. The differential association of pharmacy closure was examined as a function of baseline adherence, pharmacy, and individual characteristics. Difference in monthly adherence, measured as proportion of days covered, during 12-month baseline and follow-up periods among patients using a pharmacy that subsequently closed (closure cohort) compared with their counterparts (control cohort). Among 3 089 803 individuals filling at least 1 statin prescription between January 1, 2011, and December 31, 2016 (mean [SD] age, 66.3 [9.3] years; 52.0% female), 3.0% (n = 92 287) filled at a pharmacy that subsequently closed. Before closure, monthly adherence was similar in the closure and control cohorts (mean [SD], 70.5% [26.7%] vs 70.7% [26.5%]). In multivariable models, individuals filling at pharmacies that closed experienced an immediate and significant decline (on average, an absolute change of -5.90%; 95% CI, -6.12% to -5.69%) in statin adherence during the first 3 months after closure compared with their counterparts. This difference persisted over 12 months of follow-up. A similar decline in adherence was observed when examining cohorts using β-blockers (-5.71%; 95% CI, -5.96% to -5.46%) or oral anticoagulants (-5.63%; 95% CI, -6.24% to -5.01%). The mean association of pharmacy closure with adherence was greater among individuals using independent pharmacies (-7.89%; 95% CI, -8.32% to -7.47%) or living in neighborhoods with fewer pharmacies (-7.98%; 95% CI, -8.50% to -7.47%) compared with their counterparts. Pharmacy closures are associated with persistent, clinically significant declines in adherence to cardiovascular medications among older adults in the United States. Efforts to reduce nonadherence to prescription medications should consider the role of pharmacy closures, especially among patients at highest risk.

Modeling lottery incentives for daily adherence.

Many health issues require adherence to recommended daily activities, such as taking medication to manage a chronic condition, walking a certain distance to promote weight loss, or measuring weights to assess fluid balance in heart failure. The cost of nonadherence can be high, with respect to both individual health outcomes and the healthcare system. Incentivizing adherence to daily activities can promote better health in patients and populations and potentially provide long‐term cost savings.Multiple incentive structures are possible. We focus here on a daily lottery incentive in which payment occurs when both the participant's lottery number matches the number drawn and the participant adheres to the targeted daily behavior.Our objective is to model the lottery's effect on participants' probability to complete the targeted task, particularly over the short term. We combine two procedures for analyzing such binary time series: a parameter‐driven regression model with an autocorrelated latent process and a comparative interrupted time series. We use the output of the regression model as the control generator for the comparative time series in order to create a quasi‐experimental design.

Effects of mandatory prescription drug monitoring program (PDMP) use laws on prescriber registration and use and on risky prescribing

BackgroundComprehensive mandatory use laws for prescription drug monitoring programs (PDMPs) have been implemented in a number of states to help address the opioid overdose epidemic. These laws may reduce opioid-related overdose deaths by increasing prescribers’ use of PDMPs and reducing high-risk prescribing behaviors. MethodsWe used state PDMP data to examine the effect of these mandates on prescriber registration, use of the PDMP, and on prescription-based measures of patient risk in three states—Kentucky, Ohio, and West Virginia—that implemented mandates between 2010 and 2015. We conducted comparative interrupted time series analyses to examine changes in outcome measures after the implementation of mandates in the mandate states compared to control states. ResultsMandatory use laws increased prescriber registration and utilization of the PDMP in the mandate states compared to controls. The multiple provider episode rate, rate of opioid prescribing, rate of overlapping opioid prescriptions, and rate of overlapping opioid/benzodiazepine prescriptions decreased in Kentucky and Ohio. Nevertheless, the magnitude of changes in these measures varied among mandates states. ConclusionsThese findings indicate that PDMP mandates have the potential to reduce risky opioid prescribing practices. Variation in the laws may explain why the effectiveness varied between states.

An evaluation of the effects of lowering blood alcohol concentration limits for drivers on the rates of road traffic accidents and alcohol consumption: a natural experiment

SummaryBackgroundDrink driving is an important risk factor for road traffic accidents (RTAs), which cause high levels of morbidity and mortality globally. Lowering the permitted blood alcohol concentration (BAC) for drivers is a common public health intervention that is enacted in countries and jurisdictions across the world. In Scotland, on Dec 5, 2014, the BAC limit for drivers was reduced from 0·08 g/dL to 0·05 g/dL. We therefore aimed to evaluate the effects of this change on RTAs and alcohol consumption.MethodsIn this natural experiment, we used an observational, comparative interrupted time-series design by use of data on RTAs and alcohol consumption in Scotland (the interventional group) and England and Wales (the control group). We obtained weekly counts of RTAs from police accident records and we estimated weekly off-trade (eg, in supermarkets and convenience stores) and 4-weekly on-trade (eg, in bars and restaurants) alcohol consumption from market research data. We also used data from automated traffic counters as denominators to calculate RTA rates. We estimated the effect of the intervention on RTAs by use of negative binomial panel regression and on alcohol consumption outcomes by use of seasonal autoregressive integrated moving average models. Our primary outcome was weekly rates of RTAs in Scotland, England, and Wales. This study is registered with ISRCTN, number ISRCTN38602189.FindingsWe assessed the weekly rate of RTAs and alcohol consumption between Jan 1, 2013, and Dec 31, 2016, before and after the BAC limit came into effect on Dec 5, 2014. After the reduction in BAC limits for drivers in Scotland, we found no significant change in weekly RTA rates after adjustment for seasonality and underlying temporal trend (rate ratio 1·01, 95% CI 0·94–1·08; p=0.77) or after adjustment for seasonality, the underlying temporal trend, and the driver characteristics of age, sex, and socioeconomic deprivation (1·00, 0·96–1·06; p=0·73). Relative to RTAs in England and Wales, where the reduction in BAC limit for drivers did not occur, we found a 7% increase in weekly RTA rates in Scotland after this reduction in BAC limit for drivers (1·07, 1·02–1·13; p=0·007 in the fully-adjusted model). Similar findings were observed for serious or fatal RTAs and single-vehicle night-time RTAs. The change in legislation in Scotland was associated with no change in alcohol consumption, measured by per-capita off-trade sales (−0·3%, −1·7 to 1·1; p=0·71), but a 0·7% decrease in alcohol consumption measured by per-capita on-trade sales (−0·7%, −0·8 to −0·5; p<0·0001).InterpretationLowering the driving BAC limit to 0·05 g/dL from 0·08 g/dL in Scotland was not associated with a reduction in RTAs, but this change was associated with a small reduction in per-capita alcohol consumption from on-trade alcohol sales. One plausible explanation is that the legislative change was not suitably enforced—for example with random breath testing measures. Our findings suggest that changing the legal BAC limit for drivers in isolation does not improve RTA outcomes. These findings have significant policy implications internationally as several countries and jurisdictions consider a similar reduction in the BAC limit for drivers.FundingNational Institute for Health Research Public Health Research Programme.

Can volunteer community health workers manage multiple roles? An interrupted time-series analysis of combined HIV and maternal and child health promotion in Iringa, Tanzania.

Community health workers (CHWs) play a critical role in health promotion, but their workload is often oriented around a single disease. Renewed interest in expansion of multipurpose CHWs to cover an integrated package of services must contend with the debate over how effectively CHWs can perform an increased range of tasks. In this study, we examine whether an existing cadre of HIV-focused paid volunteer CHWs in Iringa, Tanzania, can take on new maternal, newborn and child health (MNCH) promotion tasks without adversely affecting their HIV role. HIV household visits conducted per month were extracted from CHW summary forms covering up to 14 months pre-intervention and 12 months of intervention data. A comparative interrupted time series using a generalized estimating equation assessed population-averaged longitudinal trends in monthly HIV visit count in the intervention ('dual-role' CHWs) vs comparison group ('single-role' CHWs). Analyses were stratified by district, accounting for secular trends, seasonality and covariates. The time series consisted of 4022 observations for HIV visit count from 187 CHWs (41% dual role). Prior to MNCH training, dual-role CHWs averaged 25-30% more HIV visits per month compared with single-role CHWs, with no other significant pre-intervention differences between groups. CHWs began conducting MNCH visits shortly after receiving training, but in the initial month of intervention, there was a 6-9% drop in the mean number of HIV visits per month among dual-role CHWs. Otherwise, there was no significant difference between single- and dual-role CHWs in the trajectories of monthly HIV visits before and after adding MNCH tasks. Dual-role CHWs appeared able to maintain their HIV client workload after adding MNCH tasks to their routines, albeit with an initial slight decline in HIV workload. This dual-role CHW model suggests potential spare capacity in vertically oriented programmes, with productivity gains possible through integration.

Intervention study on the effect of integrated care on equity in healthcare

Background: Continuity, integration, and collaboration between health and social care providers are essential if we are to adapt to the needs of an ageing population. The aim of this study is to investigate if a comprehensive integrated care system is better at avoiding emergency department visits and hospitalization for ambulatory care sensitive conditions ACSC and increase equity in health care in comparison to “standard care” among older people. Methods: This study is an intervention study based on a comparative interrupted time series design comparing data from Norrtalje, where an integrated care system was implemented in 2006, with other areas of Stockholm county whit the standard care system. The time series will consist of register data from 2000-2015, obtained from the Stockholm County Council’s administrative database for analysis and follow-up of healthcare utilization and from the Longitudinal Integration database for Health Insurance and labour market studies from Statistics Sweden. Preliminary results: The preliminary descriptive results based on data from 2000-2011 suggest that the introduction of an integrated care system in Norrtalje did not affect the rate of hospitalization for ACSC. When stratifying on income group we saw that the lowest income group decreased the rate of ACSC after 2006, however income group 2 and 3 increased. Further analytical analyses are needed in order to interpret these trend changes. Conclusion: The integrated care system in Norrtalje seems to have no effect on the rate of hospitalization for ACSC. Whether socioeconomic inequity in rates of ACSC was affected is still to be investigated. The results of the effect on emergency department visits is jet to be performed.

Who loses public health insurance when states pass restrictive omnibus immigration-related laws? The moderating role of county Latino density

In the United States, there is widespread concern that state laws restricting rights for noncitizens may have spillover effects for Latino children in immigrant families. Studies into the laws’ effects on health care access have inconsistent findings, demonstrating gaps in our understanding of who is most affected, under what circumstances. Using comparative interrupted time series methods and a nationally-representative sample of US citizen, Latino children with noncitizen parents from the National Health Interview Survey (2005–2014, n = 18,118), this study finds that living in counties with higher co-ethnic density placed children at greater risk of losing Medicaid and Children's Health Insurance Program coverage when their states passed restrictive state omnibus immigrant laws. This study is the first to demonstrate the importance of examining how the health impacts of immigration-related policies vary across local communities.

Short Comparative Interrupted Time Series Using Aggregate School-Level Data in Education Research

Short comparative interrupted times series (CITS) designs are increasingly being used in education research to assess the effectiveness of school-level interventions. These designs can be implemented relatively inexpensively, often drawing on publicly available data on aggregate school performance. However, the validity of this approach hinges on a variety of assumptions and design decisions that are not clearly outlined in the literature. This article aims to serve as a practice guide for applied researchers when deciding how and whether to use this approach. We begin by providing an overview of the assumptions needed to estimate causal effects using school-level data, common threats to validity faced in practice and what effects can and cannot be estimated using school-level data. We then examine two analytic decisions researchers face in practice when implementing the design: correctly modeling the pretreatment functional form, which is modeling the preintervention trend, and selecting comparison cases. We then illustrate the use of this design in practice drawing on data from the implementation of the school improvement grant (SIG) program in Ohio. We conclude with advice for applied researchers implementing this design.