Interrupted Time Series Methods Research Articles

The impact of recreational cannabis legalization on cannabis-related acute care events among adults with schizophrenia.

Patients with schizophrenia have a higher risk of cannabis use disorder and may be uniquely affected by the legalization of recreational cannabis. This study examined whether cannabis legalization led to changes in acute care utilization among patients with schizophrenia. Using linked health administrative data, we included adult patients with schizophrenia in Ontario from October 2015 to May 2021 (n = 121,061). We examined the differences in cannabis, psychosis, and mental health-related emergency department (ED) visits over three periods: pre-legalization, legalization of flowers and herbs (phase 1), and legalization of edibles, extracts, and topicals (phase 2) using interrupted time-series methods. Our study found that phase 1 was associated with decreases in cannabis-related, mental health-related, and cannabis + psychosis-related ED visits among the patients with schizophrenia. Notably, an immediate 25.8% (95% CI 13.8-37.6%) decrease in cannabis-related ED visits was observed in men, and an immediate 18.5% decrease in mental health-related ED visits (95% CI 6.0-31.2%) in women. These decreases were also shown in the comparative ITS models, demonstrating that the changes observed were distinct from trends in the general population. However, phase 2 was not associated with any significant changes. Despite higher baseline rates of acute care utilization among patients with schizophrenia, cannabis legalization was associated with significant reductions, particularly during phase 1. Our findings suggest that regulatory measures accompanying legalization could enhance the quality and safety of cannabis products, potentially leading to fewer adverse health outcomes in vulnerable patient populations. Further research is needed to optimize healthcare responses for this vulnerable population.

Time Series Methods to Assess the Impact of Regulatory Action: A Study of UK Primary Care and Hospital Data on the Use of Fluoroquinolones.

To illustrate the interest in using interrupted time series (ITS) methods, this study evaluated the impact of the UK MHRA's March 2019 Risk Minimisation Measures (RMM) on fluoroquinolone usage. Monthly and quarterly fluoroquinolone use incidence rates from 2012 to 2022 were analysed across hospital care (Barts Health NHS Trust), primary care (Clinical Practice Research Datalink (CPRD) Aurum and CPRD GOLD), and linked records from both settings (East Scotland). Rates were stratified by age (19-59 and ≥ 60 years old). Seasonality-adjusted segmented regression and ARIMA models were employed to model quarterly and monthly rates, respectively. Post-RMM, with segmented regression, both age groups in Barts Health experienced nearly complete reductions (> 99%); CPRD Aurum saw 20.19% (19-59) and 19.29% ( 60) reductions; no significant changes in CPRD GOLD; East Scotland had 45.43% (19-59) and 41.47% ( 60) decreases. Slope analysis indicated increases for East Scotland (19-59) and both CPRD Aurum groups, but a decrease for CPRD GOLD's 60; ARIMA detected significant step changes in CPRD GOLD not identified by segmented regression and noted a significant slope increase in Barts Health's 19-59 group. Both models showed no post-modelling autocorrelations across databases, yet Barts Health's residuals were non-normally distributed with non-constant variance. Both segmented regression and ARIMA confirmed the reduction of fluoroquinolones use after RMM across four different UK primary care and hospital databases. Model diagnostics showed good performance in eliminating residual autocorrelation for both methods. However, diagnostics for hospital databases with low incident use revealed the presence of heteroscedasticity and non-normal white noise using both methods.

Use of interrupted time series methods in the evaluation of the Jordanian National Strategy for Women Empowerment (JNSWE) from 2013 to 2017 and its gender action plan for STEM field

AbstractEven though we have varied backgrounds, experiences, roles, and privileges in the community research field, we are all committed to studying equity theory and associated literature in educational contexts. The purpose of this evaluation is to assess the Jordanian national strategy for women's empowerment from 2013 to 2017 and its gender equality program in its efforts to increase Jordanian women's representation in scientific studies, achieve gender equality, and empower all women and girls, in addition to the goals related to other objectives. This analysis considers interrupted time series methods (randomized controlled trials) to measure the impacts of Jordanian National Strategy for Women Empowerment (JNSWE). Pre‐ and post‐policy periods were compared. Trend, regression analysis, r and r2, and the Mann–Whitney U test were utilized. The impact of this strategy delivers impressive results. This evaluation indicates that between 2013 and 2017, the JNSWE was effective in increasing Jordanian women's presence in STEM studies due to addressing gender inequality, the gender pay gap, and training deficiencies in the field. The first hypothesis was accepted (Z = −2.812, P > .005, df = 11), and the JNSWE's implementation from 2013 to 2017 increased the number of Jordanian women in science. The execution of the JNSWE (2013–2017) supported the representation of Jordanian women in telecommunications more than before, and Hypothesis H2 was accepted (Z = −2.892, P > .004, df = 11). Ultimately, Hypothesis H3 was approved (Z = −2.254, P > .024, df = 11), and the JNSWE's implementation from 2013 to 2017 increased the number of Jordanian women pursuing careers in engineering and mathematics. In this sense, this evaluation is innovative and responsive to the rising calls and concerns of feminists to empirically address the low presence of Jordanian women in scientific studies science, technology, engineering, and mathematics, known by the acronym STEM, and seeks to eliminate all forms of gender bias against women in the public spheres, including pay inequality. Included are the study's recommendations for further research.

The trend of poisonings before and after the COVID-19 pandemic

The COVID-19 pandemic has substantially affected people and healthcare systems. One of the main challenges was the reduction and change in the pattern of non-COVID-19 diseases and conditions. Moreover, due to the mental burden of the pandemic, the trend of poisonings and abuses changed. In this study, we aimed to assess the trends of poisonings from different agents before and during the COVID-19 pandemic using the interrupted time series method. This study was conducted at one of the main Tehran referral centers for poisoning, Baharloo Hospital. Pre-COVID-19 period was defined as April 2018 to January 2020 while the COVID-19 time was from February 2020 to March 2022. The total number of monthly poisoning cases in addition to eight categories of drugs/substances/agents were identified, including drugs (such as psychiatric drugs, cardiovascular drugs, and analgesics), opioids, stimulants, methanol, ethanol, cannabis, pesticides, and carbon monoxide. Interrupted time series analysis was performed to compare the pre-pandemic trend of total monthly cases from each category in addition to the proportion (%) of each one. In total, 13,020 cases were poisoned during the study period, among which 6088 belonged to the pre-pandemic period and 6932 were admitted during the COVID-19 era. There was no significant difference in terms of demographic characteristics of patients before and during the pandemic (p-value > 0.05). At the beginning of the pandemic, there was a sudden fall in the number of poisoning patients (− 77.2 cases/month, p-value = 0.003), however, there was a significant increasing trend during the COVID time (3.9 cases/month, p-value = 0.006). Most of the categories had a sharp decrease at the beginning of the pandemic except for methanol and ethanol which had increases, although not significant. Cannabis also had a significant change in slope (− 0.6 cases/month, p-value = 0.016), in addition to the sudden decrease at the beginning of the pandemic (− 10 cases/month, p-value = 0.007). Regarding the proportion of each category from total monthly poisoning cases, methanol, and ethanol had immediate rises of 4.2% per month and 10.1% per month, respectively (both significant). The pandemic had significant effects on the pattern of poisonings from different agents in Iran, the most important of which were alcohol (ethanol and methanol). These differences had policy implications that can be helpful for policymakers and healthcare systems in combating similar situations in the future.

Fiscal austerity and municipal health spending: an interrupted time series study.

To analyze the impact of the fiscal austerity policy (PAF) on health spending in Brazilian municipalities, considering population size and source of funds. The interrupted time series method was used to analyze the effect of the PAF on total expenditure, resources transferred by the Federal Government, and own/state per capita resources allocated to health in the municipalities. The time series analyzed covered the period from 2010 to 2019, every six months. The first semester of 2015 was adopted as the start date of the intervention. The municipalities were grouped into small (up to 100,000 inhabitants), medium (101,000 to 400,000 inhabitants), and large (over 400,000 inhabitants). The data was obtained from the Sistema de Informações sobre Orçamentos Públicos em Saúde (Information System on Public Health Budget). The results for the national average of municipalities show that the PAF had a negative impact on the level of total expenditure and own/state resources allocated to health in the first half of 2015, without causing statically significant changes in the trends of any of the indicators analyzed in the period after 2015. Small municipalities saw a drop in total expenditure, while large municipalities saw a drop in own/state resources, and medium-sized municipalities saw a drop in both variables. There was no statistically significant drop in the volume of funds transferred by the Federal Government in the immediate aftermath of the implementation of the PAF in any of the municipal groups analyzed. In the medium-term, the PAF only had a negative impact on the large municipalities, which saw significant reductions in the trends of own/state resources and those transferred by the Union for health. In general, the impact of the PAF on health financing in municipalities was immediate and based on the decrease in own/state resources allocated to health. In large municipalities, however, the impact lasted from 2015 to 2019, mainly affecting health expenditure from federal funds.

Emergency department visits and hospital admissions for suicidal ideation, self-poisoning and self-harm among adolescents in Canada during the COVID-19 pandemic.

The COVID-19 pandemic had profound effects on the mental wellbeing of adolescents. We sought to evaluate pandemic-related changes in health care use for suicidal ideation, self-poisoning and self-harm. We obtained data from the Canadian Institute for Health Information on emergency department visits and hospital admissions from April 2015 to March 2022 among adolescents aged 10-18 years in Canada. We calculated the quarterly percentage of emergency department visits and hospital admissions for a composite outcome comprising suicidal ideation, self-poisoning and self-harm relative to all-cause emergency department visits and hospital admissions. We used interrupted time-series methods to compare changes in levels and trends of these outcomes between the prepandemic (Apr. 1, 2015-Mar. 1, 2020) and pandemic (Apr. 1, 2020-Mar. 31, 2022) periods. The average quarterly percentage of emergency department visits for suicidal ideation, self-poisoning and self-harm relative to all-cause emergency department visits was 2.30% during the prepandemic period and 3.52% during the pandemic period. The level (0.08%, 95% confidence interval [CI] -0.79% to 0.95%) or trend (0.07% per quarter, 95% CI -0.14% to 0.28%) of this percentage did not change significantly between periods. The average quarterly percentage of hospital admissions for the composite outcome relative to all-cause admissions was 7.18% during the prepandemic period and 8.96% during the pandemic period. This percentage showed no significant change in level (-0.70%, 95% CI -1.90% to 0.50%), but did show a significantly increasing trend (0.36% per quarter; 95% 0.07% to 0.65%) during the pandemic versus prepandemic periods, specifically among females aged 10-14 years (0.76% per quarter, 95% CI 0.22% to 1.30%) and females aged 15-18 years (0.56% per quarter, 95% CI 0.31% to 0.81%). The quarterly change in the percentage of hospital admissions for suicidal ideation, self-poisoning and self-harm increased among adolescent females in Canada during the first 2 years of the COVID-19 pandemic. This underscores the need to promote public health policies that mitigate the impact of the pandemic on adolescent mental health.

Construction and effectiveness evaluation of a knowledge-based infectious disease monitoring and decision support system

To improve the hospital's ability to proactively detect infectious diseases, a knowledge-based infectious disease monitoring and decision support system was established based on real medical records and knowledge rules. The effectiveness of the system was evaluated using interrupted time series analysis. In the system, a monitoring and alert rule library for infectious diseases was generated by combining infectious disease diagnosis guidelines with literature and a real medical record knowledge map. The system was integrated with the electronic medical record system, and doctors were provided with various types of real-time warning prompts when writing medical records. The effectiveness of the system's alerts was analyzed from the perspectives of false positive rates, rule accuracy, alert effectiveness, and missed case rates using interrupted time series analysis. Over a period of 12 months, the system analyzed 4,497,091 medical records, triggering a total of 12,027 monitoring alerts. Of these, 98.43% were clinically effective, while 1.56% were invalid alerts, mainly owing to the relatively rough rules generated by the guidelines leading to several false alarms. In addition, the effectiveness of the system's alerts, distribution of diagnosis times, and reporting efficiency of doctors were analyzed. 89.26% of infectious disease cases could be confirmed and reported by doctors within 5 min of receiving the alert, and 77.6% of doctors could complete the filling of 33 items of information within 2 min, which is a reduction in time compared to the past. The timely reminders from the system reduced the rate of missed cases by doctors; the analysis using interrupted time series method showed an average reduction of 4.4037% in the missed-case rate. This study proposed a knowledge-based infectious disease decision support system based on real medical records and knowledge rules, and its effectiveness was verified. The system improved the management of infectious diseases, increased the reliability of decision-making, and reduced the rate of underreporting.

Medicaid expansion and risk of eclampsia

Eclampsia is an indicator of severe maternal morbidity and can be prevented through increased prenatal care access and early prenatal care utilization. The 2014 Medicaid expansion under the Patient Protection and Affordable Care Act allowed states to expand Medicaid coverage to nonelderly adults with incomes up to 138% of the federal poverty level. Its implementation has led to a significant increase in prenatal care access and utilization. This study aimed to assess the association of Medicaid expansion under the Affordable Care Act with eclampsia incidence. This natural experiment study was based on US birth certificate data from January 2010 to December 2018 in 16 states that expanded Medicaid in January 2014 and in 13 states that did not expand Medicaid during the study period. The outcome was eclampsia incidence, the intervention was the implementation of the Medicaid expansion, and the exposure was state expansion status. Using the interrupted time series method, we compared temporal trends in the incidence of eclampsia before and after the intervention in expansion vs non-expansion states with adjustments for patient and hospital county characteristics. Of the 21,570,021 birth certificates analyzed, 11,433,862 (53.0%) were in expansion states and 12,035,159 (55.8%) were in the postintervention period. The diagnosis of eclampsia was recorded in 42,677 birth certificates or 19.8 per 10,000 (95% confidence interval, 19.6-20.0). The incidence of eclampsia was higher for Black people (29.1 per 10,000) than for White (20.7 per 10,000), Hispanic (15.3 per 10,000), and birthing people of other race and ethnicity (15.4 per 10,000). In the expansion states, the incidence of eclampsia increased during the preintervention period and decreased during the postintervention period; in the nonexpansion states, a reverse pattern was observed. A statistically significant difference was observed between expansion and nonexpansion states in temporal trends between the pre- and postintervention periods, with an overall 1.6% decrease (95% confidence interval, 1.3-1.9) in the incidence of eclampsia in expansion states compared with nonexpansion states. The results were consistent in subgroup analyses according to maternal race and ethnicity, education level (less than high school or high school and higher), parity (nulliparous or parous), delivery mode (vaginal or cesarean delivery), and poverty in the residence county (high or low). Implementation of the Affordable Care Act Medicaid expansion was associated with a small statistically significant reduction in the incidence of eclampsia. Its clinical significance and cost-effectiveness remain to be determined.

The impacts of the national centralized drug procurement policy on the use of policy-related antibiotic agents: the case of Shaanxi province, China

ABSTRACT Objectives The purpose of NCDP policy was to reduce the price of drugs. However, it is unclear that a reduction in the price of a single antibiotic will lead to an increase in other alternatives, which is crucial for antibiotic management. The aim of this study was to evaluate the impact of policy on the consumption of policy-related antibiotic. Methods Quasi-experimental interrupted time series methods were used to assess the effects of the policy. Results After the implementation of the policy, the consumption of the winning products increased rapidly, with a significant difference in growth (β 2 = 88.03). For nonwinning products, the level of purchase volume decreased (β 2 =-22.83) in the intervention group, and after adding the comparison group, this number fell further in statistical significance (β 2 =-114.53). Among all the nonwinning products, the level of purchase volume (β 2 =-73.59) and expenditures (β 2 =-346.71) of the generic drugs that passed the conformance evaluation decreased significantly after the policy in the difference model. The purchase volume of J01DC, J01DD and total antibiotics significantly increased in control group compared with the intervention. Conclusion The implementation of the volume-based procurement policy promoted the use of winning products and decreased the usage of its alternative watch antibiotics.

STOP Signs: A Population-based Interrupted Time Series Analysis of Antibiotic Duration for Complicated Intraabdominal Infection Before and After the Publication of a Landmark RCT.

To determine if the STOP-IT randomized controlled trial changed antibiotic prescribing in patients with Complicated Intraabdominal Infection (CIAI). CIAI is common and causes significant morbidity. In May 2015, the STOP-IT randomized controlled trial showed equivalent outcomes between four-day and clinically determined antibiotic duration. This was a population-based retrospective cohort study using interrupted time series methods. The STOP-IT publication date was the exposure. Median duration of inpatient antibiotic prescription was the outcome. All adult patients admitted to four hospitals in Calgary, Canada between July 2012 and December 2018 with CIAI who survived at least four days following source control were included. Analysis was stratified by infectious source as appendix or biliary tract (group A) versus other (group B). Among 4384 included patients, clinical and demographic attributes were similar before vs after publication. In Group A, median inpatient antibiotic duration was 3 days and unchanged from the beginning to the end of the study period [adjusted median difference -0.00 days, 95% confidence interval (CI) -0.37 - 0.37 days]. In Group B, antibiotic duration was shorter at the end of the study period (7.87 vs 6.73 days; -1.14 days, CI-2.37 - 0.09 days), however there was no change in trend following publication (-0.03 days, CI -0.16 - 0.09). For appendiceal or biliary sources of CIAI, antibiotic duration was commensurate with the experimental arm of STOP-IT. For other sources, antibiotic duration was long and did not change in response to trial publication. Additional implementation science is needed to improve antibiotic stewardship.

Evolving Face Mask Guidance During a Pandemic and Potential Harm to Public Perception: Infodemiology Study of Sentiment and Emotion on Twitter.

Throughout the COVID-19 pandemic, US Centers for Disease Control and Prevention policies on face mask use fluctuated. Understanding how public health communications evolve around key policy decisions may inform future decisions on preventative measures by aiding the design of communication strategies (eg, wording, timing, and channel) that ensure rapid dissemination and maximize both widespread adoption and sustained adherence. We aimed to assess how sentiment on masks evolved surrounding 2 changes to mask guidelines: (1) the recommendation for mask use on April 3, 2020, and (2) the relaxation of mask use on May 13, 2021. We applied an interrupted time series method to US Twitter data surrounding each guideline change. Outcomes were changes in the (1) proportion of positive, negative, and neutral tweets and (2) number of words within a tweet tagged with a given emotion (eg, trust). Results were compared to COVID-19 Twitter data without mask keywords for the same period. There were fewer neutral mask-related tweets in 2020 (β=-3.94 percentage points, 95% CI -4.68 to -3.21; P<.001) and 2021 (β=-8.74, 95% CI -9.31 to -8.17; P<.001). Following the April 3 recommendation (β=.51, 95% CI .43-.59; P<.001) and May 13 relaxation (β=3.43, 95% CI 1.61-5.26; P<.001), the percent of negative mask-related tweets increased. The quantity of trust-related terms decreased following the policy change on April 3 (β=-.004, 95% CI -.004 to -.003; P<.001) and May 13 (β=-.001, 95% CI -.002 to 0; P=.008). The US Twitter population responded negatively and with less trust following guideline shifts related to masking, regardless of whether the guidelines recommended or relaxed mask usage. Federal agencies should ensure that changes in public health recommendations are communicated concisely and rapidly.

Psychiatric Emergencies in Los Angeles County During, and After, Initial COVID-19 Societal Restrictions: An Interrupted Time-Series Analysis

Emergency department (ED) visits for psychiatric care in the US reportedly declined during the COVID-19 pandemic. This work, however, does not control for strong temporal patterning in visits before the pandemic and does not examine a potential “rebound” in demand for psychiatric care following the relaxation of initial societal restrictions. Here, we examine COVID-19-related perturbations in psychiatric care during and after the 1st stage of societal restrictions in the largest safety-net hospital in Los Angeles. We retrieved psychiatric ED visit data (98,888 total over 156 weeks, Jan 2018 to Dec 2020) from Los Angeles County + USC Medical Center. We applied interrupted time series methods to identify and control for autocorrelation in psychiatric ED visits before examining their relation with the 1st stage of societal restrictions (i.e., March 13 to May 8, 2020), as well as the subsequent “rebound” period of relaxed restrictions (i.e., after May 8, 2020). Psychiatric ED visits fell by 78.13 per week (i.e., 12%) during the 1st stage of societal restrictions (SD = 23.99, p < 0.01). Reductions in ED visits for alcohol use, substance use, and (to a lesser extent) anxiety disorders accounted for the overall decline. After the 1st stage of societal restrictions, however, we observe no “rebound” above expected values in psychiatric ED visits overall (coef = − 16.89, SD = 20.58, p = 0.41) or by diagnostic subtype. This pattern of results does not support speculation that, at the population level, foregoing ED care during initial societal restrictions subsequently induced a psychiatric “pandemic” of urgent visits.

Toward More Inclusive Professional Learning Communities

Collaboration among teachers is an important vehicle for teacher development, shared leadership, improving student achievement, building school culture, and attracting and retaining effective teachers. However, if professional collaborative environments are not truly diverse and inclusive or marginalize individual teachers or groups of teachers based on their identities, the professional communities are less effective and efforts to increase teacher diversity and student achievement by attracting and retaining teachers of color will be thwarted. We investigate whether a sustained commitment to anti-racism and/or diversity, equity, and inclusion (DEI) through districtwide teacher training efforts contributes to more inclusive professional learning communities within schools and whether these efforts, in creating more inclusive professional learning communities (PLCs), increase recruitment and retention of teachers of color. We investigate trends in two selected case study districts that implemented districtwide training for all teachers on anti-racism and/or DEI, using comparative interrupted time series and synthetic control methods. We find mixed and mainly null findings on teacher reports of inclusive PLCs following DEI initiatives, but the efforts do lead to small and not significant positive effects on teacher diversity.

Impact of anti-tobacco legislation on hospitalization of patients with respiratory diseases in three regions of the Russian Federation

AIM: Tо assess the impact of anti-tobacco measures under federal anti-tobacco law on the hospital admissions for pneumonia of various diagnoses, and other acute respiratory infections of the lower respiratory tract, bronchial asthma, and asthmatic status in the Samara, Arkhangelsk regions, and the Chuvash Republic.&#x0D; MATERIAL AND METHODS: A retrospective analysis of monthly hospital admissions for pneumonia (ICD-10 J12J18), and other acute respiratory infections of the lower respiratory airways (ICD-10 J20J22), asthma (ICD-10 J45), and status asthmaticus (ICD-10 J46) was carried out in the three selected regions of the Russian Federation from the 1st of January, 2012, till the 31st of December, 2017, and in subgroups (014, 1559, 60 years, and older). The analytical approach used was the interrupted time series method, which was performed using the STATA 15.0 software package.&#x0D; RESULTS: From this study, it was revealed that there was a decrease in the hospital incidence of respiratory airways infections after each stage of enacting the anti-tobacco policy in all the three selected regions of the Russian Federation. In the Arkhangelsk region, this decrease amounted to 19% in 2013, and 22% in 2014. In the Samara region, 20% and 23% respectively, and the Chuvash Republic, 31% and 39% respectively. A significant decrease in hospital admissions for asthma and status asthmaticus was observed only in the Chuvash Republic (the decrease occurred by 11% in 2013, and by 12% in 2014). In other regions, the observed decrease was not significant.&#x0D; CONCLUSION: From this study, the results obtained have shown that the anti-tobacco measures introduced in Russia in 2013 and 2014 were responsible for the decrease in the number of hospitalizations for lower respiratory airways infections within the same period.

The disruption of elective procedures due to COVID-19 in Brazil in 2020

Elective procedures were temporarily suspended several times over the course of the pandemic of COVID-19. Monthly data from the Unified Health System (SUS) were used for the period between January 2008 and December 2020 and the interrupted time series method was used to estimate the effect of the pandemic on the number of elective surgeries and elective procedures that were not performed. Considering a 9-month period, a reduction of 46% in the number of elective procedures carried out in the SUS could be attributed to COVID-19, corresponding to about 828,429 elective procedures cancelled, ranging from 549,921 to 1,106,936. To a full recovery of pre-pandemic performance, SUS would need to increase about 21,362 hospital beds, ranging from 12,370 to 36,392 hospital beds during a 6 month-period. This effort would represent an increase of 8.48% (ranging from 4.91 to 14.45%) in relation to the total number of SUS’s hospital beds in 2019. As a result, the pandemic will leave a large number of elective procedures to be carried out, which will require efforts by health agencies to meet this demand.

Prophylactic Enoxaparin Against Catheter-Associated Thrombosis in Postoperative Cardiac Children: An Interrupted Time Series Analysis.

The effectiveness of pharmacologic prophylaxis against catheter-associated thrombosis in children is unclear. We evaluated the compliance and outcomes associated with a prophylactic enoxaparin protocol in postoperative cardiac children. The protocol was implemented as a quality improvement initiative and then analyzed using interrupted time series method. Data collected from November 2014 to December 2018 were divided into preprotocol (period 1), protocol implementation (period 2), and protocol revision (period 3). A 12-bed academic pediatric cardiac ICU. Children less than or equal to 18 years old with congenital heart disease admitted postoperatively with central venous catheter in situ for greater than or equal to 1 day. Before 2016, prophylactic enoxaparin was administered according to physician preference. In January 2016, an enoxaparin protocol was implemented with a goal anti-Xa range of 0.25-0.49 international units/mL. Protocol was revised in February 2017 to increase the starting dose by 25% for infants less than 1 year old. We analyzed 780 hospitalizations from 636 children. Median percentage of catheter-days on prophylactic enoxaparin was 33% (interquartile range [IQR], 23-47%), 42% (IQR, 30-51%), and 38% (IQR, 35-52%) in periods 1-3, respectively. Percentage of catheter-days on enoxaparin showed immediate increase of 90% (95% CI, 17-210%) between periods 1 and 2 and sustained increase of 2% (95% CI, 0.3-4%) between periods 2 and 3. Median rates of thrombosis per 1,000 catheter-days were 5.8 (IQR, 0-9.3), 3.8 (IQR, 0-12), and 0 (IQR, 0-5.3) in periods 1-3, respectively. Rate of thrombosis showed immediate decrease of 67% (95% CI, 12-87%) between periods 1 and 2 and sustained decrease of 11% (95% CI, 2-18%) between periods 1 and 3. The temporal association between increase in percentage of catheter-days on enoxaparin and decrease in rate of thrombosis suggests the effectiveness of prophylactic enoxaparin.

Antimicrobial stewardship in high-risk febrile neutropenia patients

BackgroundThe 2011 4th European Conference on Infections in Leukemia (ECIL4) guidelines recommend antibiotics de-escalation/discontinuation in selected febrile neutropenia (FN) patients. We aimed to assess the impact of an antimicrobial stewardship (AMS) program based on these guidelines on antibiotics use and clinical outcomes in high-risk FN patients.MethodsWe conducted an observational study in the hematology department of Cochin University Hospital in Paris, France. An ECIL4-based antibiotics de-escalation and discontinuation strategy was implemented jointly by the hematologists and the AMS team. The pre-intervention (January–October 2018) and post-intervention (January-October 2019) periods were compared. We retrospectively collected clinical and microbiological data. We compiled antibiotics consumptions via hospital pharmacy data and standardized them by calculating defined daily doses per 1000 patient-days. We analyzed the two-monthly antibiotic consumption using an interrupted time series method and built a composite endpoint for clinical outcomes based on transfer to the intensive care unit (ICU) and/or hospital death.ResultsOverall, 273 hospital stays (164 patients) in the pre-intervention and 217 (148 patients) in the post-intervention periods were analyzed. Patients were mainly hospitalized for intensive chemotherapy for acute leukemia or autologous stem-cell transplant for myeloma. Patients were slightly younger in the pre-intervention compared to the post-intervention period (median age 60.4 vs 65.2 years, p = 0.049), but otherwise comparable. After implementation of the AMS program, glycopeptide and carbapenem use decreased by 85% (p = 0.03) and 72% (p = 0.04), respectively. After adjustment on confounders, the risk of transfer to the ICU/death decreased significantly after implementation of the AMS program (post-intervention period: odds-ratio = 0.29, 95% Confidence Interval: 0.15–0.53, p < 0.001).ConclusionImplementation of a multidisciplinary AMS program for high-risk neutropenic patients was associated with lower carbapenem and glycopeptide use and improved clinical outcomes.

Evaluation of different antimicrobial stewardship models at a rehabilitation hospital: An interrupted time series (ITS) study.

To evaluate different prospective audit-and-feedback models on antimicrobial prescribing at a rehabilitation hospital. Retrospective interrupted time series (ITS) and qualitative methods. A 178-bed rehabilitation hospital within an academic health sciences center. ITS analysis was used to analyze monthly days of therapy (DOT) per 1,000 patient days (PD) and monthly urine cultures ordered per 1,000 PD. We compared 2 sequential intervention periods to the baseline: (1) a period when a dedicated antimicrobial stewardship (AMS) pharmacist performed prospective audit and feedback and provided urine culture education followed by (2) a period when ward pharmacists performing audit and feedback. We conducted an electronic survey with physicians and semistructured interviews with pharmacists, respectively. Audit and feedback conducted by an AMS pharmacist resulted in a 24.3% relative reduction in total DOT per 1,000 PD (incidence rate ratio [IRR], 0.76; 95% confidence interval [CI], 0.58-0.99; P = .04), whereas we detected no difference between ward pharmacist audit and feedback and the baseline (IRR, 1.20; 95% CI, 0.53-2.70; P = .65). We detected no statistically significant change in monthly urine-culture orders between the AMS pharmacist period and the baseline (level coefficient, 0.81; 95% CI, 0.65-1.01; P = .07). Compared to baseline, the ward pharmacist period showed a statistically significant increase in urine-culture ordering over time (slope coefficient, 1.04; 95% CI, 1.01-1.08; P = .02). The barrier most identified by pharmacists was insufficient time. Audit and feedback conducted by an AMS pharmacist in a rehabilitation hospital was associated with decreased antimicrobial use.

Effect of the Rise in Online Motorcycle Taxi Services on the Number of Motorcycles using the Interrupted Time Series Method

The substantial growth of motorcycle users in Indonesia is hypothesized to be influenced by a government policy on motorcycle purchase waivers and the massive growth of online motorcycle taxis. This study aims to analyse the relationship between the emergence of online motorcycle taxis and government policy changes towards the number of motorcycles and compare the estimation model seen from the consumer and sales sides. The data were collected from the Indonesian Bureau of Statistics, Motorcycle Industry Association, and World Bank. Several estimation models were built using the interrupted time series method. The results showed that changes in government policy and income per capita significantly increased the number of motorcycles. However, the emergence of online motorcycle taxis negatively affected the increasing number of motorcycles. The results also showed that models with data representing motorcycle usage behavior provided better results than the model with motorcycle sales.

Does price deregulation increase drug price in China? An interrupted time series analysis.

The Chinese government removed the price ceiling of most drugs in June 2015 to establish a market-driven pricing system. The purpose of this study is to examine the impact of the elimination of drug ceiling price (EDCP) policy on drug prices. Using a national macro-level dataset, we employed an interrupted time series method to study the abrupt level and gradual trend changes of Chinese and Western medicine consumer price index (CPI) between June 2014 and June 2017. The policy exerted level change on Chinese medicine CPI, increasing 0.201% (95% CI 0.026% to 0.376%, p=0.026). And the trend in Chinese medicine CPI was still decreased nonsignificantly after the EDCP policy. However, there was no significant price change in Western medicine. The EDCP policy has different effects on the prices of Chinese and Western medicines. Therefore, we need to pay more attention to the drug pricing mechanism in the future.