Interrupted Time Series Studies Research Articles

Impact of Medicaid expansion and state-level racial diversity on breast cancer endocrine therapy prescriptions: A quasi-experimental, comparative interrupted time series study

AimsTo determine whether Medicaid expansion impacted racially more diverse states similarly as racially less diverse states in endocrine therapy (ET) prescriptions. MethodsA quasi-experimental, comparative interrupted time series study of Medicaid-financed ET prescriptions from 2011 to 2018 Medicaid State Drug Utilization Database. The exposures were state’s Medicaid expansion and racial diversity status. The outcome was state’s quarterly number ET prescriptions per 100,000 non-elderly adult females (NAFs). ResultsDuring the year of expansion, ET prescriptions increased sharply in expansion states but remained flat in nonexpansion states (slope: 11.96 vs. 0.43 prescriptions per 100,000 NAFs per quarter, p < 0.001). After that, the slopes were similar between expansion and nonexpansion states (1.75 vs. 0.24, p = 0.057) but the level of prescriptions in expansion states maintained at a higher level. When stratified by state’s racial diversity status, the slope of increase in the first year was sharper for raciallymore diverse expansion states (16.49, p = 0.008) than racially less diverse expansion states (8.46, p < 0.001), resulting in significant differences in ET prescriptions between racially more diverse expansion and nonexpansion states but largely nonsignificant differences between racially less diverse expansion and nonexpansion states. ConclusionsAlthough Medicaid expansion significantly increased ET prescriptions in expansion vs. nonexpansion states, this difference was only observed among raciallymore diverse states. Racially more diverse nonexpansion states had the lowest rates of ET prescriptions and the gaps from racially more diverse expansion states significantly widened after expansion. Policy summaryOur study shows that, before expansion, racially more diverse nonexpansion states had the lowest rates of ET prescriptions. After expansion, the gaps between these states and racially more diverse expansion states significantly widened. These results highlighted the importance of continuing to examine the health impacts of states not expanding Medicaid, including the health equity impacts for low income racial/ethnic minority populations with cancer and other life-threatening diseases.

51. Sustained Impact of an Antimicrobial Stewardship (AS) Initiative Targeting Asymptomatic Bacteriuria and Pyuria in the Emergency Department (ED)

BackgroundThe sustainability of unique AS initiatives are largely unstudied. A multi-faceted initiative to reduce inappropriate treatment of asymptomatic pyuria (ASP) and asymptomatic bacteriuria (ASB) in the ED was implemented at our institution in 2016. A pre-post intervention analysis demonstrated reduction in the inappropriate treatment (tx) of ASP/ASB from 100% to 32% (p< 0.001) following the intervention. The purpose of this present study was to determine the sustained impact of the initiative and determine if re-education provided in Oct 2020 could further reduce inappropriate tx.MethodsThis was a retrospective, interrupted time series study conducted at an 885 bed academic medical center. Patients (pts) discharged from the ED in Nov 2019 – Feb 2020 (group 1) and Nov 2020 – Feb 2021 (group 2) were retrospectively screened in chronologic order until 50 pts in each group met study criteria. Similar to the 2016 study, pts were included if they were ≥ 18 years old and had a positive urine culture or pyuria. Pts were excluded if they had symptoms of a urinary tract infection (UTI), another infection requiring antibiotics (ABX), indwelling catheter, ureteral stent, or nephrostomy tube, or if pregnant or immunocompromised. The primary outcome was the proportion of pts prescribed ABX within 72 hrs of ED discharge. The secondary outcome was the number of pts returning to the ED with symptomatic UTI within 30 days of discharge. Group 1 was compared to the 2016 study’s post group to determine the sustained impact of the initial initiative; group 2 was compared to group 1 to determine the impact of re-education, which involved a presentation to ED providers and a posted algorithm and fact sheet. ResultsResults from all time periods are summarized in Table 1. Improvement in inappropriate tx was still noted 3 years after the intervention (28% vs 32%; p = NS). Re-education did not further improve inappropriate prescribing, with 28% of group 2 pts still receiving tx.Table 1. ConclusionThe decrease in inappropriate use of ABX for ASP/ASB was still noted 3 years after implementation of a multi-faceted AS initiative. Re-education did not result in further improvement. Disclosures James Johnson, PharmD, FLGT (Shareholder) Vera Luther, MD, Nothing to disclose

Did States’ Adoption of More Rigorous Standards Lead to Improved Student Achievement? Evidence From a Comparative Interrupted Time Series Study of Standards-Based Reform

This study was designed to assess the effects of states’ adoption of more rigorous standards as part of the current wave of standards-based reform on student achievement using comparative interrupted time series analyses based on state-level NAEP data from 1990 to 2017. Results show that the effects of adopting more rigorous standards on students’ mathematics achievement were generally small and not significant. The effects on students’ reading achievement were also generally small, but negative and statistically significant for Grade 4. The study also revealed that the effects of states’ adoption of more rigorous standards varied across NAEP subscales and student subgroups.

Changes in respiratory diseases in South Korea during the COVID-19 pandemic: an interrupted time series study

IntroductionIn South Korea, non-pharmaceutical interventions such as mask-wearing, hand washing and social distancing were strictly implemented to prevent the spread of COVID-19 after a national crisis alert was raised to...

Impact of recommendations on sodium valproate prescription among women with epilepsy: An interrupted time-series study

BackgroundThe European Medicines Agency (EMA) has developed risk minimization measures (RMMs) to reduce the use of the teratogenic drug, sodium valproate (VPA). The objective was to assess the impact of these RMMs among females with epilepsy in France. MethodsWe used data from the French National Health Insurance Database (SNDS), including 114,936 females aged under 50, with a reimbursement claim for an antiepileptic drug from January 2011 to December 2017, and identified as people with epilepsy. We used a controlled interrupted time series stratifying on age: girls (0–14 years old) and women of childbearing age (15–49 years), and with 129,917 males as controls. ResultsVPA prevalent use among girls and women of childbearing age with epilepsy decreased significantly after the issue of the RMMs (trend changes of, respectively, −5 and −4 users per 1000 females at-risk per quarter in comparison to the control group). We did not detect any significant change in VPA incident use. ConclusionsVPA use decreased over the study period among females with epilepsy but there were still 317 women and 206 girls started on VPA therapy VPA in 2017 (8 per 1000 at-risk and 18 per 1000, respectively). This suggests that either the measures should be strengthened or that the lowest level of VPA use has been reached. In this context, the introduction of a new RMM (in 2018) needs to be evaluated.

Real-world experience of how chlorhexidine bathing affects the acquisition and incidence of vancomycin-resistant enterococci (VRE) in a medical intensive care unit with VRE endemicity: a prospective interrupted time-series study

BackgroundCritically ill patients in intensive care units (ICUs) often acquire opportunistic infections or are colonized by vancomycin-resistant enterococci (VRE), which limits therapeutic options and results in high case-fatality rates. In clinical practice, the beneficial effects of universal chlorhexidine gluconate (CHG) bathing on the control of VRE remain unclear. This study aimed to investigate whether 2% CHG daily bathing reduced the acquisition of VRE in the setting of a medical ICU (MICU) with VRE endemicity.MethodsThis quasi-experimental intervention study was conducted in a 23-bed MICU of a tertiary care hospital in Korea from September 2016 to December 2017. In a prospective, interrupted time-series analysis (ITS) with a 6-month CHG bathing intervention, we compared the acquisition and incidence of VRE and the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Acinetobacter baumannii (CRAB) between the pre-intervention and intervention periods. The primary and secondary outcomes were a change in the acquisition of VRE and incidence of VRE, MRSA, or CRAB between the two periods, respectively.ResultsAll the adult patients admitted to the MICU were enrolled in the pre-intervention (n = 259) and intervention (n = 242). The overall CHG daily bathing compliance rate was 72.5%. In the ITS, there was a significant intervention effect with a 58% decrease in VRE acquisition (95% CI 7.1–82.1%, p = 0.038) following the intervention. However, there was no significant intervention effects on the incidence trend of VRE, MRSA, and CRAB determined by clinical culture between the pre-intervention and intervention periods.ConclusionIn this real-world study, we concluded that daily bathing with CHG may be an effective measure to reduce VRE cross-transmission among patients in MICU with a high VRE endemicity.

Evaluation of a quality improvement bundle aimed to reduce opioid prescriptions after Cesarean delivery: an interrupted time series study

PurposeTo evaluate whether opioid prescriptions at discharge after Cesarean delivery decreased following implementation of a quality improvement bundle.MethodsA quality improvement bundle was instituted at Mount Sinai Hospital in Toronto. Interventions included opioid prescribing instructions in resident orientation, nursing and patient education, and standard electronic prescriptions. We used an interrupted time series study design and included patients who had a Cesarean delivery six months pre intervention and six months post intervention. Primary outcome data (opioids prescribed at discharge in morphine milliequivalents [MME]), were aggregated (averaged) by calendar week and analyzed using interrupted time series. Secondary outcomes were assessed using bivariate methods and included opioid use for breakthrough pain in hospital, and amount of opioids prescribed by prescriber specialty and training level.ResultsWe included 2,578 women in our analysis. Based on the segmented regression analysis, prescribed opioids decreased from 97.6 MME in 2018 to 35.8 MME in 2019 (difference in means, − 61.7; 95% confidence interval [CI], − 72.2 to − 51.3; P < 0.001), and this decrease was sustained over the study period. Post intervention, there were no visits to our postnatal assessment clinic for inadequate pain control.ConclusionA quality improvement bundle was associated with a marked and sustained decrease in discharge prescriptions of opioids post Cesarean delivery at a large Canadian tertiary academic hospital.

Addressing missing values in routine health information system data: an evaluation of imputation methods using data from the Democratic Republic of the Congo during the COVID-19 pandemic

BackgroundPoor data quality is limiting the use of data sourced from routine health information systems (RHIS), especially in low- and middle-income countries. An important component of this data quality issue comes from missing values, where health facilities, for a variety of reasons, fail to report to the central system.MethodsUsing data from the health management information system in the Democratic Republic of the Congo and the advent of COVID-19 pandemic as an illustrative case study, we implemented seven commonly used imputation methods and evaluated their performance in terms of minimizing bias in imputed values and parameter estimates generated through subsequent analytical techniques, namely segmented regression, which is widely used in interrupted time series studies, and pre–post-comparisons through paired Wilcoxon rank-sum tests. We also examined the performance of these imputation methods under different missing mechanisms and tested their stability to changes in the data.ResultsFor regression analyses, there were no substantial differences found in the coefficient estimates generated from all methods except mean imputation and exclusion and interpolation when the data contained less than 20% missing values. However, as the missing proportion grew, k-NN started to produce biased estimates. Machine learning algorithms, i.e. missForest and k-NN, were also found to lack robustness to small changes in the data or consecutive missingness. On the other hand, multiple imputation methods generated the overall most unbiased estimates and were the most robust to all changes in data. They also produced smaller standard errors than single imputations. For pre–post-comparisons, all methods produced p values less than 0.01, regardless of the amount of missingness introduced, suggesting low sensitivity of Wilcoxon rank-sum tests to the imputation method used.ConclusionsWe recommend the use of multiple imputation in addressing missing values in RHIS datasets and appropriate handling of data structure to minimize imputation standard errors. In cases where necessary computing resources are unavailable for multiple imputation, one may consider seasonal decomposition as the next best method. Mean imputation and exclusion and interpolation, however, always produced biased and misleading results in the subsequent analyses, and thus, their use in the handling of missing values should be discouraged.

Is a Low-Cost Drill Cover System Noninferior to Conventional Surgical Drills for Skeletal Traction Pin Placement?

The Drill Cover system was developed as a low-cost alternative to conventional surgical drills with specific applicability to low- and middle-income countries. However, the system may also be useful for the sterile placement of traction pins in the emergency department of high-income country hospitals. In September 2019, a US-based Level-1 trauma center began using the Drill Cover system to apply skeletal traction pins in patients with femoral shaft fractures. With these data, we performed a retrospective interrupted time series study to determine if the Drill Cover system was noninferior to conventional surgical drills in terms of infections at the traction pin site. The study included 205 adult patients with femoral shaft fractures initially placed in skeletal traction using a conventional surgical drill (n = 150, preintervention group) or the Drill Cover system (n = 55, postintervention group). The primary outcome was an infection at the site of skeletal traction pin placement that required surgery or antibiotics, which was compared between groups using a noninferiority test with a 1-sided alpha of 0.05 and a noninferiority margin of 3%. No infections at the site of skeletal traction pin placement were found in either the preintervention or the postintervention group (difference, 0%; 95% confidence interval: 0.0%-1.4%; noninferiority P value < 0.01). The results suggest that the Drill Cover system was noninferior to conventional surgical drills regarding infections at the site of skeletal traction pins. The Drill Cover system may be a safe alternative to the more expensive surgical drills for skeletal traction pin placement in the emergency room environment.

The Impact of the Covid-19-Related Transition to Telehealth on Visit Adherence in Mental Health Care: An Interrupted Time Series Study.

Covid-19 has led to an unprecedented shift to telemental health (TMH) in mental healthcare. This study examines the impact of this transition on visit adherence for mental health services in an integrated behavioral health department. Monthly visit data for 12,245 patients from January, 2019 to January, 2021 was extracted from the electronic medical record. Interrupted time series (ITS) analysis examined the impact of the Covid-19 transition to TMH on immediate level and trend changes in the percentage of cancelled visits and no shows in the 10 months following the transition. ITS also compared changes across the three largest services types: adult, pediatric, and substance use. Following the TMH-transition, completed visits increased by 10% amounting to an additional 3644 visits. In April, 2020, immediately following the TMH-transition, no shows increased by 1.4%, (95% CI 0.1, 2.7, p < 0.05) and cancellations fell by 13.5% (95% CI − 17.9, − 9.0, p < 0.001). Across the 10-month post-TMH period, 18.2% of visits were cancelled, compared to 28.3% across the 14-month pre-TMH period. The proportion of no-shows remained the same. The pattern was similar for pediatric and adult sub-clinics, but no significant changes in cancellations or no shows were observed in the substance use sub-clinic. TMH during the Covid-19 pandemic is associated with improved visit adherence over time and may be a promising model for improving the efficiency of mental health care delivery once it is safe to resume in person care.

Assessment of Federal Value-Based Incentive Programs and In-Hospital Clostridioides difficile Infection Rates

Health care facility-onset Clostridioides difficile infection (HO-CDI) rates reported to the US Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) became a target quality metric for 2 Centers for Medicare & Medicaid Services (CMS) value-based incentive programs (VBIPs) in October 2016. The association of VBIPs with HO-CDI rates is unknown. To examine the association between VBIP implementation and HO-CDI rates. This interrupted time series study evaluated HO-CDI rates among adults hospitalized from January 2013 to March 2019 at 265 acute-care hospitals. Implementation of VBIPs in October 2016. Quarterly rates of HO-CDI per 10 000 patient-days, as reported to NHSN by participating hospitals, were evaluated. Generalized estimating equations were used to fit negative binomial regression models to estimate immediate program effect size (ie, level change) and changes in the slope of HO-CDI rates, controlling for each hospital's predominant method of CDI testing (ie, nucleic acid amplification test [NAAT], enzyme immunoassay [EIA] for toxin, or other testing methods). The study cohort included 24 332 938 admissions, 109 371 136 patient-days, and 74 681 HO-CDI events at 265 hospitals (145 [55%] with 100-399 beds; 205 [77%] not-for-profit hospitals; 185 [70%] teaching hospitals; 229 [86%] in metropolitan areas). Compared with EIA, rates of HO-CDI were higher when detected by NAAT (adjusted incidence rate ratio [aIRR], 1.55; 95% CI, 1.40-1.70; P < .001) and other testing methods (aIRR, 1.47; 95% CI, 1.26-1.71; P < .001). There were no significant changes in testing methods used by hospitals immediately after VBIP implementation. Controlling for CDI testing method, VBIP implementation was associated with a 6% level decline in HO-CDI rates in the immediate postpolicy quarter (aIRR, 0.94; 95% CI, 0.89-0.99; P = .01) and a 4% decline in slope per quarter (aIRR, 0.96; 95% CI, 0.95-0.97; P < .001). Results were similar in a sensitivity analysis using a 1-year roll-in period accounting for the period after the announcement of the HO-CDI VBIP policy and prior to its implementation. In this study, VBIP implementation was associated with improvements in HO-CDI rates, independent of CDI testing method. Given that CMS payment policies have not previously been associated with improvements in other targeted health care-associated infection rates, future research should focus on elucidating the specific processes that contributed to improvement in HO-CDI rates to inform the design of future VBIP interventions.

Construct Validity and Responsiveness of the Rapid Assessment of Physical Activity in Adults Living With HIV

ObjectiveTo evaluate the construct validity and responsiveness of the Rapid Assessment of Physical Activity (RAPA) for measuring physical activity (PA) in adults living with HIV. DesignSecondary analysis of an interrupted time-series intervention study. SettingCommunity-based fitness facility in Toronto, Canada. ParticipantsSixty-seven adults (N=67) living with HIV (n=5 women; mean age, 51.8±11.6 years) with available baseline data to assess for construct validity of the RAPA, of which 50 (n=4 women; age, 53.2±11.4 years) had follow-up data to evaluate responsiveness. InterventionsTwo months of a community-based exercise intervention involving thrice weekly multicomponent exercises. Main Outcome MeasuresWe used a single-item PA questionnaire as a convergent outcome to the RAPA, while peak oxygen consumption, general health status, and number of concurrent health conditions were divergent outcomes. We tested 11 a priori hypotheses (6 construct validity, 5 responsiveness) using Spearman ρ, Wilcoxon signed-rank tests, Cohen's d, standardized effect size (SES), and standardized response mean (SRM). We considered acceptable construct validity and responsiveness if >75% of hypotheses were confirmed. ResultsAll of the hypotheses (100%) for construct validity were confirmed. The RAPA demonstrated moderate correlations with the single-item PA questionnaire (ρ=0.61), and negligible correlations with divergent outcome measures (ρ=0.08-0.21). Two of the 5 hypotheses (40.0%) for responsiveness were confirmed. RAPA scores were significantly greater after 2 months of training (P<.001) and demonstrated a small to moderate effect size (d=0.50, SES=0.47, SRM=0.48). There was a low correlation between change in RAPA scores and change in single-item PA questionnaire scores (ρ=0.48). ConclusionsThe RAPA demonstrated acceptable construct validity and poor responsiveness in adults living with HIV. Therefore, the RAPA can be used cross-sectionally but may be used in conjunction with other measures of PA for adults living with HIV.

Evaluating compliance of extended venous thromboembolism prophylaxis following abdominopelvic surgery for cancer: A multidisciplinary quality improvement project.

Despite quality evidence supporting postoperative extended venous thromboembolism prophylaxis (eVTEp) following abdominopelvic cancer surgery, baseline use of eVTEp at our institution was 3%. Our project aim was to improve the proportion of patients prescribed eVTEp following surgery for gynecologic, hepatobiliary, and colorectal cancers by a 30% absolute increase. We performed an interrupted time series study using quality improvement methodology. Postoperative order sets, pre-printed prescriptions, process checklists, and multimodal education were introduced. Process and outcome data were collected and analyzed on statistical process control charts. We included 324 patients with gynecologic and hepatobiliary cancers. Despite efforts to include them, the colorectal team did not participate. The monthly mean order set-use was 58% (SD = 14%), by specialty: gynecology 79%, hepatobiliary 47%. The proportion of patients prescribed eVTEp increased from 3% to 70% (SD = 14%). The target goal was surpassed and sustained by both cohorts. Patient compliance was 73% (n = 117/160, SD = 16%). Of those who stopped eVTEp early, 45% (n = 14/31) objected because of the injectable nature. Bleeding events were infrequent (0.6%, n = 2/324). Three process changes and multimodal education resulted in a significant increase in eVTEp use. Failure to identify improvement champions limited project expansion to colorectal patients. Patient compliance was largely limited by the injectable nature of the medication.

The impact of COVID-19 on School of Medicine students’ performance: an interrupted time series study

BackgroundThe COVID-19 pandemic has profoundly challenged the whole educational system. Shifting towards emergency remote teaching (ERT) has raised questions about its quality and effectiveness, especially for those university students enrolled on courses including interactive learning and clerkship modules as well. Therefore, we employed an interrupted time series analysis, to assess the impact of lockdown (March 2020) and subsequent shifting to ERT on exam enrollments and performance for students at the School of Medicine of the University “Federico II” of Naples, one of the largest universities nationwide, between January 2017 and February 2021.MethodsWe extracted data from 49 course modules within 14 courses of study offered by the School. Multilevel linear models were employed to account for the hierarchical structure of the data (multiple exam sessions within each module). Model covariates were time, term, course of study, and gender.ResultsIn the summer term 2020 there was a 23% increase in students enrolled on exams, as compared with the previous year (2019: 16,237; 2020: 20,091), with a 0.92% (SD 0.04) pass rate and an average mark of 26.39 (SD 2.64), as compared with the 0.89% (SD 0.78) pass rate and an average mark of 26.50 (SD 2.55) for the previous year. Considering the whole study period, we found that for the winter term following the national lockdown (March 2020) there was a 0.38 increase in the pass rate (coeff. 0.38; 95%CI 0.04,0.71), as compared with the period before the lockdown, which however was not sustained over time (slope change: -0.04; 95%CI -0.09, 0.00). No differences were found when considering changes in the average exam mark (step change: -1.38; 95%CI -2.83,0.07, slope change: 0.03; 95%CI -0.01,0.06).ConclusionsAlthough students promoted the online examination method as part of the ERT considering the increase in enrollment and the initial increase in pass rate, this change was not sustained by an improvement in their performance.Key messages The shifting toward emergency remote teaching as educational system response to COVID-19 in Italy has increased exam enrollment but not students’ performance at School of Medicine.Ensuring high quality of teaching during emergencies is fundamental. Mixed-methods follow-up studies should be conducted to evaluate students’ perception and identify ways for quality improvement.

Attempted suicide rates before and during the COVID-19 pandemic: interrupted time series analysis of a nationally representative sample.

To characterize the association between the protracted biopsychosocial coronavirus disease 2019 (COVID-19) pandemic exposures and incident suicide attempt rates. Data were from a nationally representative cohort based on electronic health records from January 2013 to February 2021 (N = 852 233), with an interrupted time series study design. For the primary analysis, the effect of COVID-19 pandemic on incident suicide attempts warranting in-patient hospital treatment was quantified by fitting a Poisson regression and modeling the relative risk (RR) and the corresponding 95% confidence intervals (CIs). Scenarios were forecast to predict attempted suicide rates at 10 months after social mitigation strategies. Fourteen sensitivity analyses were performed to test the robustness of the results. Despite the increasing trend in the unexposed interval, the interval exposed to the COVID-19 pandemic was statistically significant (p < 0.001) associated with a reduced RR of incident attempted suicide (RR = 0.63, 95% CI 0.52-0.78). Consistent with the primary analysis, sensitivity analysis of sociodemographic groups and methodological factors were statistically significant (p < 0.05). No effect modification was identified for COVID-19 lockdown intervals or COVID-19 illness status. All three forecast scenarios at 10 months projected a suicide attempt rate increase from 12.49 (7.42-21.01) to 21.38 (12.71-35.99). The interval exposed to the protracted mass social trauma of the COVID-19 pandemic was associated with a lower suicide attempt rate compared to the unexposed interval. However, this trend is likely to reverse 10 months after lifting social mitigation policies, underscoring the need for enhanced implementation of public health policy for suicide prevention.

An Interrupted Time-series Evaluation of the Association Between State Laws Mandating Prescriber Use of Prescription Drug Monitoring Programs and Discontinuation of Chronic Opioid Therapy in US Veterans.

Most states have recently passed laws requiring prescribers to use prescription drug monitoring programs (PDMPs) before prescribing opioid medications. The impact of these mandates on discontinuing chronic opioid therapy among Veterans managed in the Veterans Health Administration (VA) is unknown. We assess the association between the earliest of these laws and discontinuation of chronic opioid therapy in Veterans receiving VA health care. We conducted a comparative interrupted time-series study in the 5 states mandating PDMP use before August 2013 (Ohio, West Virginia, Kentucky, New Mexico, and Tennessee), adjusting for trends in the 17 neighboring control states without such mandates. We modeled 25 months of prescribing for each state centered on the month the mandate became effective. We included Veterans prescribed long-term outpatient opioid therapy (305 of the preceding 365 d). Our outcomes were discontinuation of chronic opioid therapy (primary outcome) and the average daily quantity of opioids per Veteran over the following 6 months (secondary outcome). We included 250 monthly cohorts with 225,665 unique Veterans and 3.4 million Veteran-months. Baseline discontinuation rates before the PDMP mandates were 0.4%-2.7% per month. Kentucky saw a discontinuation increase of 1 absolute percentage point following its PDMP mandate which decreased over time. The other 4 states had no significant association between their mandates and change in opioid discontinuation. There was no evidence of decreasing opioid quantities following PDMP mandates. We did not find consistent evidence that state laws mandating provider PDMP use were associated with the discontinuation of chronic opioid therapy within the VA for the time period studied.

Changes in antibiotic consumption, AMR and Clostridioides difficile infections in a large tertiary-care center following the implementation of institution-specific guidelines for antimicrobial therapy: A nine-year interrupted time series study.

BackgroundInstitution-specific guidelines (ISGs) within the framework of antimicrobial stewardship programs offer locally tailored decision support taking into account local pathogen and resistance epidemiology as well as national and international guidelines.ObjectivesTo assess the impact of ISGs for antimicrobial therapy on antibiotic consumption and subsequent changes in resistance rates and Clostridioides difficile infections (CDIs).MethodsThe study was conducted at the Leipzig University Hospital, a 1,451-bed tertiary-care medical center, and covered the years 2012 to 2020. Since 2014, ISGs were provided to optimize empirical therapies, appropriate diagnostics, and antimicrobial prophylaxis. We used interrupted time series analysis (ITSA) and simple linear regression to analyze changes in antimicrobial consumption, resistance and CDIs.ResultsOver the study period, 1,672,200 defined daily doses (DDD) of antibiotics were dispensed, and 85,645 bacterial isolates as well as 2,576 positive C. difficile cultures were collected. Total antimicrobial consumption decreased by 14% from 2012 to 2020, without clear impact of the deployment of ISGs. However, implementation of ISGs was associated with significant decreases in the use of substances that were rarely recommended (e.g., fluoroquinolones). Over the whole study period, we observed declining resistance rates to most antibiotic classes of up to 25% in Enterobacterales, staphylococci, and Pseudomonas aeruginosa. Switching from ceftriaxone to cefotaxime was associated with reduced resistance to third-generation cephalosporins. The number of CDI cases fell by 65%, from 501 in 2012 to 174 in 2020.ConclusionsWell-implemented ISGs can have a significant, immediate, and lasting impact on the prescription behavior. ISGs might thereby contribute to reduce resistance rates and CDI incidences in the hospital setting.

Effectiveness and safety of a program for appropriate urinary catheter use in stroke care: A multicenter prospective study.

Since patients with stroke frequently develop bladder dysfunction, a careful approach is required to reduce unnecessary indwelling urinary catheter (IUC) for preventing catheter-associated urinary tract infection (CAUTI). This study aimed to assess the effectiveness and safety of a program to promote appropriate IUC use in stroke care. We conducted a prospective interrupted time series study in three tertiary care hospitals in Japan. Adult patients with acute stroke were eligible. The study consisted of three phases: baseline, education and implementation. Our program included an assessment of IUC indications, educational meetings among healthcare professionals, reminders for removal of inappropriate IUC and a urinary retention protocol. The primary outcome was the proportion of inappropriate IUC use to assess effectiveness. The device utilization ratio and incidence of CAUTI were examined to assess effectiveness, and incidences of urinary retention and all symptomatic urinary tract infection (UTI) were examined to assess safety. Among 976 patients who met the inclusion criteria, 738 were analysed. Inappropriate IUC use decreased from 50.1% in the baseline phase to 22.5% in the implementation phase (absolute risk reduction in interrupted time series analysis 42.4% [95% confidence interval, 19.2%-65.6%]). The device utilization ratio decreased from 0.302 to 0.194 (p < 0.001), whereas CAUTI did not change significantly (from 8.81 to 8.28 per 1000 catheter-days; incidence rate ratio 0.95 [0.44-1.94]). All symptomatic UTI decreased from 9.5% to 4.9% (p=0.015), with no increase in urinary retention. Our program improved the appropriateness of IUC use in stroke care while ensuring safety.

The effectiveness of Check of Medication Appropriateness for antimicrobial stewardship: an interrupted time series analysis.

Inappropriate prescribing of antimicrobials in hospitals contributes to the emergence of resistance and adverse drug events. To support antimicrobial stewardship (AMS), clinical decision rules focusing on antimicrobial therapy were implemented in the 'Check of Medication Appropriateness' (CMA). The CMA is a hospital-wide pharmacist-led medication review service consisting of a clinical rule-based screening for potentially inappropriate prescriptions (PIPs). We aimed to investigate the impact of the CMA on antimicrobial prescribing. An interrupted time series study was performed at the University Hospitals Leuven. The pre-implementation cohort was exposed to standard-of-care AMS. Afterwards, an AMS-focused CMA comprising 41 specific clinical rules, targeting six AMS objectives, was implemented in the post-implementation period. A regression model was used to assess the impact of the intervention on the number of AMS-related residual PIPs between both periods. The total number of recommendations and acceptance rate was recorded for the 2 year post-implementation period. Pre-implementation, a median proportion of 75% (range: 33%-100%) residual PIPs per day was observed. After the CMA intervention, the proportion was reduced to 8% (range: 0%-33%) per day. Use of clinical rules resulted in an immediate relative reduction of 86.70% (P < 0.0001) in AMS-related residual PIPs. No significant underlying time trends were observed during the study period. Post-implementation, 2790 recommendations were provided of which 81.32% were accepted. We proved that the CMA approach reduced the number of AMS-related residual PIPs in a highly significant and sustained manner, with the potential to further expand the service to other AMS objectives.

Administration of epinephrine by advanced emergency medical technicians for out-of-hospital cardiac arrest in a rural emergency medical services system.

ObjectiveEpinephrine in out‐of‐hospital cardiac arrest (OHCA) remains controversial and understudied in rural emergency medical services (EMS) systems. We evaluated the effects of allowing advanced emergency medical technicians (AEMTs) to administer epinephrine during OHCA in a rural EMS system.MethodsAn interrupted time series study was conducted using statewide EMS electronic records. Patients with OHCA before (phase I) and after (phase II) a protocol change expanding the AEMT scope of practice to include epinephrine for OHCA were identified. Number and timing of initial epinephrine administration, return of spontaneous circulation, and 30‐day survival rates were compared using descriptive statistics, logistic regression, regression discontinuity, and propensity score matching.ResultsA total of 1037 OHCAs met the inclusion criteria. In phase 1 compared with phase 2, 275 (56.12%) patients received epinephrine versus 624 (83.53%; P < 0.001). The mean time to first administration of epinephrine for unwitnessed and bystander‐witnessed OHCA were 11.73 minutes versus 8.17 minutes (P < 0.001) and 11.59 minutes versus 8.85 minutes (P < 0.01), respectively. Unadjusted analysis showed a decrease in 30‐day survival rates among patients receiving epinephrine from 18.01% to 12.66% (P < 0.05). Adjusted analysis showed an increase in 30‐day survival with decreased time to first epinephrine dose(OR 0.960, 1.005; 95% confidence interval, 0.929, 0.992).ConclusionAdding epinephrine for OHCA to the AEMT scope of practice was associated with an increased percentage of patients receiving epinephrine and decreased time to first administration of epinephrine for patients with unwitnessed OHCA. Unadjusted analysis showed a decrease in 30‐day survival rates among patients receiving epinephrine. Adjusted analysis found that earlier administrationof epinephrine was associated with increased ROSC and 30‐day survival.