Population-based Time Series Analysis Research Articles

Eating Disorders in Children, Adolescents, and Young Adults During and After the COVID-19 Pandemic: ADanishNationwide Register-Based Study.

To assess incidence rates of clinically diagnosed eating disorders among Danish youth before, during, and after the COVID-19 pandemic. This study used a population-based time series analysis with individual-level data from Danish healthcare registries. Participants included all Danish individuals aged 6-24 years from January 1, 2015, to December 31, 2023. Monthly incident cases of any eating disorder, anorexia nervosa, and bulimia nervosa were analyzed using interrupted time-series analysis. We estimated the cumulative number of excess cases of incident eating disorder diagnoses and risk ratios (RR) associated with the pandemic and post-pandemic periods compared with pre-pandemic predictions. The study population encountered a mean of 1,310,542 individuals during the study period. The study included 11,693 individuals diagnosed with an eating disorder, median age 17 (IQR 14-20 years). Incident cases increased during the pandemic (RR 1.29, 95% CI 1.15-1.45) and normalized post-pandemic (RR 1.07, 95% CI 0.91-1.25) compared with pre-pandemic predictions. Similar patterns were seen for anorexia and bulimia. Increases were significant for ages 13-16 (RR 1.19, 95% CI 1.02-1.38), 17-19 (RR 1.51, 95% CI 1.25-1.83), and 20-24 (RR 1.35, 95% CI 1.12-1.64). Post-pandemically, a continued increase was observed only for ages 20-24 (RR 1.32, 95% CI 1.02-1.71). The study documents a temporary increase in diagnosed eating disorders among Danish youths during the COVID-19 pandemic, with rates later returning to pre-pandemic levels. These results provide insights into the pandemic's impact on adolescents and youths.

Post-lockdown burden of road injury involving hospitalisation in Victoria, Australia: A statewide, population-based time series analysis.

Ever since COVID-19, short-term changes in transport injury patterns have been observed. The aim is to examine both the initial and the enduring impact of government lockdown and the pandemic on road injuries requiring hospitalisation and road fatalities. Time series analysis of Transport Accident Commission (TAC) claims involving hospitalisation and fatalities in Victoria, Australia, from July 2016 to May 2023, including lockdown (March 2020 to October 2020) and post-lockdown (November 2020 onwards). A total of 46 450 TAC claims were included. Average claims during the pre-pandemic period were 652/month. Lockdown restrictions were associated with a statistically significant fall in monthly claims (-255, 95% confidence interval [CI] = -315 to -194, P < 0.01). This was consistent across road users, days of the week, hours of the day, injury severity, sex and central versus rural locations. The post-lockdown period had a statistically significant reduction in monthly claims to 76% (95% CI = 67-84) of pre-pandemic levels (-158, 95% CI = -213 to -102, P <0.01). This was consistent across all subgroups except bicyclist injuries, which remained constant (-8, 95% CI = -16 to 0, P = 0.05). There was a significant upward trend in the fatality-to-claim ratio post-lockdown (0.001, 95% CI = 0-0.001, P <0.01). Road injury requiring hospitalisation decreased significantly during governmental lockdown and has returned to three-quarters of pre-pandemic levels (except bicyclist injuries that have remained constant), but there is an increasingly disproportionate number of fatalities. This represents a new baseline of injury burden for EDs and hospitals that manage trauma patients.

A population-based time-series analysis of opioid agonist treatment dispensed during pregnancy.

Identifying effective opioid treatment options during pregnancy is a high priority due to the growing prevalence of opioid use disorder across North America. We assessed the temporal impact of three population-level interventions on the use of opioid agonist treatment (OAT) during pregnancy in Ontario, Canada. This was a population-based time-series analysis to identify trends in the monthly prevalence of pregnant people dispensed methadone and buprenorphine. The impact of adding buprenorphine/naloxone to the public drug formulary, the release of pregnancy-specific guidance and the start of the COVID-19 pandemic were assessed. The study was conducted in Ontario, Canada between 1 July 2013 and 31 March 2022, comprising people who delivered a live or stillbirth in any Ontario hospital during the study period. We identified any prescription for methadone or buprenorphine dispensed between the estimated conception date and delivery date and calculated the monthly prevalence of OAT-exposed pregnancies among all pregnant people in Ontario. Overall, rates of OAT during pregnancy have declined since mid-2018. Methadone-exposed pregnancies decreased from 0.46% of all pregnancies in Ontario in 2015 to a low of 0.16% in 2022. In the primary analysis, none of the interventions had a statistically significant impact on overall OAT rates; however, in the stratified analyses, there was a small increase in buprenorphine after the formulary change [0.006%, 95% confidence interval (CI) = 0.0032-0.0081, P < 0.0001] and a decrease in buprenorphine after the release of the 2017 guidelines (-0.005%, 95% CI = -0.0080 to -0.0020, P = 0.001) and the start of the COVID-19 pandemic (-0.003%, 95% CI = -0.0054 to -0.0006, P = 0.015). Despite changes in guidance and funding, opioid agonist treatment during pregnancy has been declining in Ontario, Canada since 2018.

The impact of expanded access to direct acting antivirals for Hepatitis C virus on patient outcomes in Canada.

Hepatitis C virus (HCV) has high global prevalence and can lead to liver complications and death. Access to direct-acting antivirals (DAAs) in Canada increased following several policy changes, however the real-world impact of expanded DAA access and increased use of these drugs is unknown. We aimed to determine the early change in rates of HCV-related hospitalizations overall and HCV-related hospitalizations with hepatocellular carcinoma (HCC) after expanded DAA access. We conducted a population-based time series analysis using national administrative health databases in Canada. Rates of HCV-related hospitalizations and HCV-related hospitalizations with HCC were enumerated monthly between April 2006 and March 2020. We used Autoregressive Integrated Moving Average (ARIMA) models with ramp functions in October 2014 and January 2017 to evaluate the impact of policies to expand DAA access on hospitalization outcomes. Rates of HCV-related hospitalizations in Canada increased between 2006 and 2014, and gradually declined thereafter. The decrease after October 2014, or the first policy change, was significant (p = 0.0355), but no further change was found after the second policy change in 2017 (p = 0.2567). HCV-related hospitalizations with HCC increased until end of 2013, followed by a plateau, before declining in 2016. No significant shifts were found after the first policy change in 2014 (p = 0.1291) nor the second policy change in 2017 (p = 0.6324). Subgroup analyses revealed that those aged 50-64 and males had observable declines in rates of HCV-related hospitalizations in the year prior to the first policy change. Expanding DAA access was associated with a drop in HCV-related hospitalizations in the overall Canadian population coinciding with the 2014 policy change. In light of the time required for HCV-related complications to manifest, continued ongoing research examining the real-world effectiveness of DAAs is required.

Assessing the impact of the slow-release oral morphine drug shortages in Ontario, Canada: A population-based time series analysis.

Slow-release oral morphine (SROM) is used to manage pain, and as opioid agonist treatment (OAT). Between 2017 and 2021 in Canada, several drug shortages occurred for Kadian© (SROM-24). The purpose of this study was to evaluate the impact of these shortages on people's ability to remain on this medication. We conducted a retrospective population-based time series analysis of SROM-24 dispensed between January 1, 2014, and December 31, 2021, in Ontario, Canada. Using interventional autoregressive integrated moving average models (ARIMA) models, we evaluated the association between SROM-24 drug shortages and treatment discontinuation. Analyses were also stratified by the SROM-24 indication (pain or OAT). We identified 22,479 SROM-24 recipients, of which one-third (33.9%) were aged 65 or above and just over half (51.9%) were female. In our primary analysis of monthly SROM-24 discontinuation, we observed a significant sustained monthly increase following the shortages in November 2019 (+0.29%/month; 95% CI: 0.16%, 0.43%; p<.001) with significant sudden, temporary changes following the shortages in March 2020 (+2.00%; 95% CI: 0.95%, 3.05%; p<.001), July 2021 (+3.53%; 95% CI: 2.20%, 4.86%; p<.001), and August 2021 (+4.98%; 95% CI: 3.49%, 6.47%; p<.001). Similar results were observed in our stratified analyses, with sustained high rates of discontinuation among people accessing SROM-24 as OAT. The SROM-24 shortages resulted in significant treatment disruptions across all recipients. These findings have important implications for those with few treatment alternatives, including people using SROM-24 as OAT who are at risk of adverse outcomes following treatment disruptions.

Calculating the fraction of Kawasaki disease potentially attributable to seasonal pathogens: a time series analysis.

Kawasaki disease is an acute, febrile, systemic vasculitis of children that primarily affects medium-sized blood vessels with a tropism for the coronary arteries. Although the etiological factors remain unknown, infections have been suggested as the trigger of Kawasaki disease. We sought to calculate the fraction of Kawasaki disease potentially attributable to seasonal infections. This cohort study used a population-based time series analysis from the French hospitalisation database (Programme de Médicalisation des Systèmes d'Information), which includes all inpatients admitted to any public or private hospital in France. We included all children aged 0-17 years hospitalised for Kawasaki disease in France over 13 years. The monthly incidence of Kawasaki disease per 10,000 children over time was analysed by a quasi-Poisson regression model. The model accounted for seasonality by using harmonic terms (a pair of sines and cosines with 12-month periods). The circulation of eight common seasonal pathogens (adenovirus, influenza, metapneumovirus, Mycoplasma pneumoniae, norovirus, rhinovirus, rotavirus, respiratory syncytial virus, and Streptococcus pneumonia) over the same period was included in the model to analyse the fraction of Kawasaki disease potentially attributable to each pathogen. Infections were identified on the basis of polymerase chain reaction or rapid antigen testing in hospital laboratories. Between Jan 1, 2007, and Dec 31, 2019, we included 10,337 children with Kawasaki disease and 442,762 children with the selected infectious diseases. In the Kawasaki disease cohort, the median age [IQR] was 2 [0-4] years, 6164 [59.6%] were boys. Adenovirus infection was potentially responsible for 24.4% [21.5-27.8] (p<0.001) of Kawasaki diseases, Norovirus for 6.7% [1.3-11.2] (p=0.002), and RSV 4.6% [1.2-7.8] (p=0.022). Sensitivity analyses found similar results. This cohort study of data from a comprehensive national hospitalisation database indicated that approximately 35% of Kawasaki diseases was potentially attributable to seasonal infections. None.

Examining the immediate and ongoing impact of the COVID-19 pandemic on population-based estimates of dementia: a population-based time series analysis in Ontario, Canada

ObjectivesPopulation-based chronic disease surveillance systems were likely disrupted by the COVID-19 pandemic. The objective of this study was to examine the immediate and ongoing impact of the COVID-19 pandemic on...

Outpatient purchasing patterns of hydroxychloroquine and ivermectin in the USA and Canada during the COVID-19 pandemic: an interrupted time series analysis from 2016 to 2021.

Hydroxychloroquine and ivermectin received widespread attention after initial studies suggested that they were effective against COVID-19. However, several of these studies were later discredited. We explored the impact of scientific articles, public announcements and social media posts on hydroxychloroquine and ivermectin purchases in the USA and Canada during the COVID-19 pandemic. We conducted a retrospective, population-based time series analysis of retail hydroxychloroquine and ivermectin purchases in the USA and Canada from February 2016 through to December 2021, using IQVIA's Multinational Integrated Data Analysis database. We fitted the purchasing rates with interventional autoregressive integrated moving average models. We used Google Trends to identify the most influential interventions to include in the models. There were significant pulse increases in hydroxychloroquine purchases in March 2020 in both the USA (P < 0.0001) and Canada (P < 0.0001). For ivermectin, there were no significant changes in April 2020 in either the USA (P = 0.41) or Canada (P = 0.16); however, significant pulse increases occurred from December 2020 to January 2021 in both the USA (P = 0.0006) and Canada (P < 0.0001), as well as significant ramp increases from April to August 2021 in both the USA (P < 0.0001) and Canada (P = 0.02). The increases in ivermectin purchases were larger in the USA than in Canada. Increases in hydroxychloroquine and ivermectin purchasing rates aligned with controversial scientific articles and social media posts. This highlights the importance of scientific integrity and disseminating accurate epidemiologic information during pandemics.

Methods for early characterisation of the severity and dynamics of SARS-CoV-2 variants: a population-based time series analysis in South Africa

BackgroundAssessment of disease severity associated with a novel pathogen or variant provides crucial information needed by public health agencies and governments to develop appropriate responses. The SARS-CoV-2 omicron variant of concern (VOC) spread rapidly through populations worldwide before robust epidemiological and laboratory data were available to investigate its relative severity. Here we develop a set of methods that make use of non-linked, aggregate data to promptly estimate the severity of a novel variant, compare its characteristics with those of previous VOCs, and inform data-driven public health responses.MethodsUsing daily population-level surveillance data from the National Institute for Communicable Diseases in South Africa (March 2, 2020, to Jan 28, 2022), we determined lag intervals most consistent with time from case ascertainment to hospital admission and within-hospital death through optimisation of the distance correlation coefficient in a time series analysis. We then used these intervals to estimate and compare age-stratified case-hospitalisation and case-fatality ratios across the four epidemic waves that South Africa has faced, each dominated by a different variant.FindingsA total of 3 569 621 cases, 494 186 hospitalisations, and 99 954 deaths attributable to COVID-19 were included in the analyses. We found that lag intervals and disease severity were dependent on age and variant. At an aggregate level, fluctuations in cases were generally followed by a similar trend in hospitalisations within 7 days and deaths within 15 days. We noted a marked reduction in disease severity throughout the omicron period relative to previous waves (age-standardised case-fatality ratios were consistently reduced by >50%), most substantial for age strata with individuals 50 years or older.InterpretationThis population-level time series analysis method, which calculates an optimal lag interval that is then used to inform the numerator of severity metrics including the case-hospitalisation and case-fatality ratio, provides useful and timely estimates of the relative effects of novel SARS-CoV-2 VOCs, especially for application in settings where resources are limited.FundingNational Institute for Communicable Diseases of South Africa, South African National Government.

Impact of Ontario's Harmonized Heat Warning and Information System on emergency department visits for heat-related illness in Ontario, Canada: a population-based time series analysis.

Ontario's Harmonized Heat Warning and Information System (HWIS) brings harmonized, regional heat warnings and standard heat-health messaging to provincial public health units prior to periods of extreme heat. Was implementation of the harmonized HWIS in May 2016 associated with a reduction in emergency department (ED) visits for heat-related illness in urban locations across Ontario, Canada? We conducted a population-based interrupted time series analysis from April 30 to September 30, 2012-2018, using administrative health and outdoor temperature data. We used autoregressive integrated moving average models to examine whether ED rates changed following implementation of the harmonized HWIS, adjusted for maximum daily temperature. We also examined whether effects differed in heat-vulnerable groups (≥65 years or <18 years, those with comorbidities, those with a recent history of homelessness), and by heat warning region. Over the study period, heat alerts became more frequent in urban areas (6 events triggered between 2013 and 2015 and 14 events between 2016 and 2018 in Toronto, for example). The mean rate of ED visits was 47.5 per 100,000 Ontarians (range 39.7-60.1) per 2-week study interval, with peaks from June to July each year. ED rates were particularly high in those with a recent history of homelessness (mean rate 337.0 per 100,000). Although rates appeared to decline following implementation of HWIS in some subpopulations, the change was not statistically significant at a population level(rate 0.04, 95% CI: -0.03 to 0.1, p=0.278). In urban areas across Ontario, ED encounters for heat-related illness may have declined in some subpopulations following HWIS, but the change was not statistically significant. Efforts to continually improve HWIS processes are important given our changing Canadian climate.

Opioid sales and opioid-related poisonings in Switzerland: A descriptive population-based time-series analysis.

SummaryBackgroundTo examine time trends and characteristics of calls related to opioid poisonings reported to the National Poison Centre and opioid sales in Switzerland.MethodsWe used population-level data from the Swiss National Poisons Information Centre on reported opioid-related poisonings and data provided by the Swiss Pharmacists’ Association (pharmaSuisse) based on IQVIA data to identify sold opioid packages. The rate of opioid-related poisoning calls and dispensed opioid packages per 100,000 Swiss inhabitants between 2000 and 2019 were plotted by year and annual trends were assessed. All analyses were stratified by individual opioid and potency (strong vs weak).FindingsThere was a significant 177% increase in the rate of calls for opioid-related poisonings (1·4 to 3·9 per 100,000 inhabitants, p<0·001) and a 91·3% increase in opioid sales (from 14,364·0 to 27,477·6 per 100,000 inhabitants, p<0.001). The increase associated with strong opioids was higher when compared to weak opioids, in both poison centre calls and sales. In 2019, tramadol was the most frequently reported opioid in the poison centre data (35·7%, n=133) and sales (37·5%, n=8,863,377), followed by oxycodone calls (24·4%, n=91) and sales 23·4%, n= 552,751). Poisoning calls and sales related to oxycodone increased substantially between 2009 and 2016, as did the rate of poison centre calls requiring medical care.InterpretationCalls to the Swiss National poison centre and sales for opioid have increased substantially in Switzerland in the last two-decades. Increases were primarily driven by oxycodone and tramadol; however, sales have attenuated since 2016. Our findings mirror other European countries and stress the importance of surveillance and monitoring.FundingThe research did not receive external funding. Translation of the abstract in German, French and Italian are available in the Supplementary section.

Impact of the COVID-19 pandemic on the prevalence of opioid agonist therapy discontinuation in Ontario, Canada: A population-based time series analysis

BackgroundWe assessed the impact of COVID-19, which includes the declaration of a state of emergency and subsequent release of pandemic-specific OAT guidance (March 17, 2020 to March 23, 2020) on the prevalence of OAT discontinuation. MethodsWe conducted a population-based time series analysis using interventional autoregressive integrated moving average models among Ontario residents who were stable (>60 days of continuous use) and not yet stable on OAT. Specifically, we examined whether COVID-19 impacted the weekly percentage of individuals who discontinued OAT, overall and stratified by treatment type (methadone vs. buprenorphine/naloxone). Additionally, we compared demographic characteristics and patient outcomes among people stable on OAT who discontinued treatment during (March 17, 2020 to November 30, 2020) and prior (July 3, 2019 to March 16, 2020) to the pandemic. ResultsThe weekly prevalence of OAT discontinuation across the study period ranged between 0.6% and 1.1%, among those stable on treatment compared to 7.3% and 16.6%, among those not stable on treatment. Following COVID-19, there was no significant change in the percentage of Ontarians who discontinued OAT, regardless of whether they were stabilized on treatment. Among those stable on OAT, a similar proportion of patients restarted therapy and experienced opioid-related harm following an OAT discontinuation. However, mortality following OAT discontinuation must be noted, as approximately 1.4% and 0.8% of people who discontinued methadone and buprenorphine/naloxone respectively, died within 30 days of discontinuation. ConclusionsTrends in the prevalence of OAT discontinuation did not significantly change during the first eight months of the COVID-19 pandemic.

Uptake of re-resection in T1 bladder cancer: An interrupted population-based time series analysis among different groups of surgeons.

A second transurethral resection of the bladder tumor (TURBT) within 2 - 6 weeks after initial TURBT is thought to have diagnostic, therapeutic, and prognostic benefits in T1 bladder cancer (BC). However, little is known about the real-world uptake of this guideline-endorsed intervention. We aimed (1) to measure re-resection rates over time, (2) to investigate if a guideline revision (April 2008) explicitly endorsing re-resection within 2 - 6 weeks in all T1 BC patients led to an increase in re-resection rates, and (3) to investigate the uptake among different groups of surgeons. Province-wide BC pathology reports (January 2001 to December 2015; Ontario, Canada) were linked with health administrative data to (1) identify primary cases of T1 BC and to (2) ascertain whether these patients received re-resection. The resulting patients were then aggregated into quarterly time series and investigated by descriptive analysis, interventional autoregressive moving average (ARIMA) modeling, and Poisson regression analysis. A cohort of 7,373 patients was aggregated into a time series. We observed a linear increase in re-resection rates from 8.4% in 2001 to 28.3% in 2015. An actual effect of the guideline revision in April 2008 on re-resection rates could not be detected (P = 0.41). However, we observed a rather heterogeneous uptake behavior among different groups of surgeons. Specifically, female surgeons, more junior surgeons, high-volume surgeons, Canadian graduates, and surgeons without an academic affiliation were all independently more likely to re-resect their patients (all P-values < 0.05 in adjusted analysis). Re-resection rates in primary T1 BC increased between 2001 and 2015 in the province of Ontario regardless of the guideline revision in April 2008. Our study demonstrates that the uptake of this guideline-endorsed intervention varies among different groups of surgeons and therefore warrants further research to identify barriers to change that can be addressed by tailored interventions.

Impact of the COVID-19 pandemic on the provision of take-home doses of opioid agonist therapy in Ontario, Canada: A population-based time-series analysis.

BackgroundIn March 2020, the Ontario government declared a state of emergency due to the growing risk of COVID-19. In response, new guidance for the management of opioid agonist therapy (OAT) was released, which included the expansion of eligibility for take-home doses. We investigated the impact of these changes on trends in the distribution of take-home doses of OAT.MethodsWe conducted a population-based time series analysis among residents of Ontario, Canada who were dispensed OAT between June 25, 2019 and November 30, 2020. For each week of the study period, we calculated the percentage of people dispensed (a) methadone and (b) buprenorphine/naloxone by the number of take-home doses received. We used interventional autoregressive integrated moving average models to estimate changes in the percentage of people dispensed each category of take-home doses in the weeks following the declaration of the state of emergency and release of the OAT dispensing guidance.ResultsFollowing the state of emergency and release of the OAT dispensing guidance, there was a significant increase in the percentage of Ontarians dispensed 7 to 13 (3.6% increase; p = 0.033) and 14 or more (0.8% increase; p<0.001) take-home doses of methadone, and in the percentage of people dispensed 7 to 13 (4.3% increase; p = 0.001), 14 to 27 (2.8% increase; p<0.001), and 28 or more (0.3% increase; p = 0.008) take-home doses of buprenorphine/naloxone. There were significant decreases in the percentage of Ontarians receiving daily dispensed buprenorphine/naloxone (-3.1%; p = 0.001), as well as the percentage dispensed 1 to 6 take-home doses of methadone (-4.5%; p = 0.001) and buprenorphine/naloxone (-4.9%; p = 0.001).ConclusionThe new guidance for dispensing OAT in Ontario resulted in increases in the duration of take-home doses of methadone and buprenorphine/naloxone supplied. However, given that changes were small, strategies to improve retention in OAT and ensure equitable access to take-home dosing should continue.

Association of meteorological factors and ambient air pollution on medical care utilization for urolithiasis: a population-based time-series study

BackgroundTo identify the association of meteorological factors/ambient air pollutants with medical care utilization for urolithiasis and estimate the effect size/time lags.MethodsThis is a population-based time-series analysis of 300,000 urolithiasis cases from eight large metropolitan areas in Korea. Seventeen meteorological factors and ambient air pollutants were measured daily during 2002–2017 for each metropolis. Data on daily medical utilization owing to urolithiasis were collected. A generalized additive model was used while factoring in the nonlinear relationship between meteorological factors/ambient air pollutants and urolithiasis and a time lag of ≤10 days. A multivariate analysis was performed. Backward elimination with an Akaike information criterion was used for fitting the multivariate model.ResultsUrolithiasis was significantly associated with average temperature, diurnal temperature range, sunshine duration, particulate matter (PM) ≤2.5 μm, and carbon monoxide (CO) levels. The incidence of ureteral stones was positively correlated with average temperature, PM ≤2.5 μm level, and CO level (time lags 0–9, 2–4, and 0–9 days, respectively). The incidence of renal stones was positively correlated with PM ≤2.5 μm and CO levels (time lags 2–4 and 0–9 days, respectively). PM ≤2.5 μm (0.05 and 0.07% per 10 μg/m3) and CO (2.05 and 2.25% per 0.1 ppm) conferred the highest excess risk on ureteral and renal stones.ConclusionsUrolithiasis is affected by various meteorological factors and ambient air pollutants, PM ≤2.5 μm, and CO levels may be novel potential risk factors for this condition.

Trends in Lower Extremity Revascularization and Amputation for Peripheral Artery Disease Over the Last Two Decades: A Population-Based Time Series Analysis

We examined the temporal changes in population-based rates of lower extremity revascularization and amputation procedures for peripheral artery disease (PAD) among residents of Ontario, Canada aged ≥40 years from 2002 to 2019.

Trends in Lower Extremity Revascularization and Amputation for Peripheral Arterial Disease over the Last Two Decades: A Population-Based Time Series Analysis

While considering changes over time in population demographics and comorbidity, our objective was to describe temporal trends in lower extremity revascularization and amputation for peripheral artery disease (PAD) in Ontario, Canada from 2002 to 2019.

Effects of hospital funding reform on wait times for hip fracture surgery: a population-based interrupted time-series analysis

BackgroundHealth care funding reforms are being used worldwide to improve system performance but may invoke unintended consequences. We assessed the effects of introducing a targeted hospital funding model, based on fixed price and volume, for hip fractures. We hypothesized the policy change was associated with reduction in wait times for hip fracture surgery, increase in wait times for non-hip fracture surgery, and increase in the incidence of after-hours hip fracture surgery.MethodsThis was a population-based, interrupted time series analysis of 49,097 surgeries for hip fractures, 10,474 for ankle fractures, 1,594 for tibial plateau fractures, and 40,898 for appendectomy at all hospitals in Ontario, Canada between April 2012 and March 2017. We used segmented regression analysis of interrupted monthly time series data to evaluate the impact of funding reform enacted April 1, 2014 on wait time for hip fracture repair (from hospital presentation to surgery) and after-hours provision of surgery (occurring between 1700 and 0700 h). To assess potential adverse consequences of the reform, we also evaluated two control procedures, ankle and tibial plateau fracture surgery. Appendectomy served as a non-orthopedic tracer for assessment of secular trends.ResultsThe difference (95 % confidence interval) between the actual mean wait time and the predicted rate had the policy change not occurred was − 0.46 h (-3.94 h, 3.03 h) for hip fractures, 1.46 h (-3.58 h, 6.50 h) for ankle fractures, -3.22 h (-39.39 h, 32.95 h) for tibial plateau fractures, and 0.33 h (-0.57 h, 1.24 h) for appendectomy (Figure 1; Table 3). The difference (95 % confidence interval) between the actual and predicted percentage of surgeries performed after-hours − 0.90 % (-3.91 %, 2.11 %) for hip fractures, -3.54 % (-11.25 %, 4.16 %) for ankle fractures, 7.09 % (-7.97 %, 22.14 %) for tibial plateau fractures, and 1.07 % (-2.45 %, 4.59 %) for appendectomy.ConclusionsWe found no significant effects of a targeted hospital funding model based on fixed price and volume on wait times or the provision of after-hours surgery. Other approaches for improving hip fracture wait times may be worth pursuing instead of funding reform.

The impact and cost-effectiveness of introducing the 10-valent pneumococcal conjugate vaccine into the paediatric immunisation programme in Iceland-A population-based time series analysis.

IntroductionStreptococcus pneumoniae is a cause of infections that range in severity from acute otitis media (AOM) to pneumonia and invasive pneumococcal disease (IPD). The 10-valent pneumococcal conjugate vaccine (PHiD-CV10) was introduced into the Icelandic paediatric immunisation programme in 2011. The aim was to estimate the population impact and cost-effectiveness of PHiD-CV10 introduction.MethodsData on primary care visits from 2005–2015 and hospitalisations from 2005–2017 were obtained from population-based registries. A Bayesian time series analysis with synthetic controls was employed to estimate the number of cases of AOM, pneumonia and IPD that would have occurred between 2013–2017, had PHiD-CV10 not been introduced. Prevented cases were calculated by subtracting the observed number of cases from this estimate. The cost of the programme was calculated accounting for cost-savings due to prevented cases.ResultsThe introduction of PHiD-CV10 prevented 13,767 (95% credible interval [CI] 2,511–29,410) visits for AOM from 2013–2015, and prevented 1,814 (95%CI -523-4,512) hospitalisations for pneumonia and 53 (95%CI -17-177) admissions for IPD from 2013–2017. Visits for AOM decreased both among young children and among children 4–19 years of age, with rate ratios between 0.72–0.89. Decreases were observed in both pneumonia hospitalisations (rate ratios between 0.67–0.92) and IPD (rate ratios between 0.27–0.94). The total cost of implementing PHiD-CV10 in Iceland was -7,463,176 United States Dollars (USD) (95%CI -16,159,551–582,135) with 2.1 USD (95%CI 0.2–4.7) saved for every 1 USD spent.ConclusionsThe introduction of PHiD-CV10 was associated with large decreases in visits and hospitalisations for infections commonly caused by pneumococcus and was cost-saving during the first five years of the immunisation programme.

Long-term macrolide therapy for chronic obstructive pulmonary disease: a population-based time series analysis.

Background:Macrolides are recommended as an adjunctive treatment for patients with moderate to severe chronic obstructive pulmonary disease (COPD) who experience recurrent exacerbations. The objective of this study was to examine temporal trends in the provision of long-term macrolide therapy, specifically before and after publication of the landmark MACRO trial in August 2011 showing efficacy of macrolides for this indication.Methods:We performed an interrupted time series analysis using population-level health administrative data. The study cohort consisted of all Ontario residents who had COPD, were using at least 1 long-acting inhaler, and were aged 65 years and older between Apr. 1, 2004, and Mar. 31, 2018. We compared the baseline characteristics of eligible patients before and after publication of the MACRO trial. Our primary outcome was overall prevalence of long-term macrolide therapy; secondary outcomes were incidence of COPD-related hospitalizations, emergency department visits and outpatient exacerbations requiring high-dose steroids in each quarter. We performed an interrupted time series analysis to assess for changes in the incidence of macrolide prophylaxis by quarter-year over the study period.Results:The rate of long-term macrolide use increased from 0.8 per 1000 people in 2004 to 13.8 per 1000 people in 2018 (in the severe COPD group, the rate increased from 1.3 to 32.3 per 1000 people). The interrupted time series analysis showed that, before 2011, the prevalence of macrolide prophylaxis increased at a rate of 0.44 (95% confidence interval [CI] 0.39–0.50) per 1000 people per year; after 2011, the rate of increase grew by 1.18 (95% CI 1.07–1.29) per 1000 people to 1.63 (95% CI 1.56–1.69) per 1000 people per year. The seasonal pattern of COPD-related health care visits remained stable over the study period, and there was no detectable reduction in hospitalizations or emergency department visits at the population level.Interpretation:In the past decade, there has been a significant rise in the use of long-term macrolide therapy for patients with COPD. As this practice becomes increasingly common, it will be important to monitor its potential benefits on COPD exacerbations but also its potential effects on adverse events and antimicrobial resistance patterns.