Interrupted Time Research Articles

The impact of the COVID-19 pandemic on the dispensing of systemic anti-cancer therapy (SACT) in Ireland: a population based study

ObjectivesThe COVID-19 pandemic had considerable implications for cancer related care. This study aimed to examine its impact on the dispensing of systemic anti-cancer therapy (SACT) in Ireland. Study designA repeated cross-sectional design was used which involved a quasi-experimental interrupted time series analysis (ITSA), and autoregressive integrated moving average (ARIMA) models. MethodsThis nationally representative study utilised monthly pharmacy claims (i.e. dispensing) data from community and hospital schemes. Dispensed items among individuals prescribed any SACT from January 2019 to April 2021 were included. ResultsDuring the study period, 641,273 SACT items were dispensed, including 57,199 chemotherapeutic agents (8.9%), 15,970 immunotherapeutic agents (2.5%), 87,813 targeted therapies (13.7%), and 480,291 (74.9%) endocrine therapies. There were on average 3.3 and 4.1 fewer immunotherapy and targeted therapy agents, respectively, dispensed per 100,000 population per month post-March 2020 (vs. expected), compared to the level prior to March 2020. For endocrine therapy, there was a significant slowing of the trend post-March 2020 compared to the pre-pandemic period (slope change = -1.72, 95% CI -2.9 to -0.5; p<0.01). ConclusionThere was a significant level decrease in the dispensing of immunotherapy and targeted therapy during the first year of the pandemic, and a slowing of the trend for endocrine therapies. However, no differences in the dispensing of other SACT were observed.

Examining the Potential Impact of Recreational Cannabis Legalization on Individuals Receiving Treatment for Substance Use Disorder: An Interrupted Time Series Study in Guelph, Ontario, Canada

Objective: The present research evaluated the impact of legalizing recreational cannabis among individuals with substance use disorders (SUDs) who may already use cannabis at high rates. Method: Using an interrupted time series study design, we evaluated the potential impact of legalizing recreational cannabis among individuals seeking treatment for SUD within a hospital-based treatment setting in Guelph, Ontario. We examined 2,925 individuals who entered an inpatient SUD treatment program between April 2017 and December 2021. We performed segmented regression analyses using both the date of cannabis legalization and the date of edibles legalization as the interruption time point. We also performed stratified analyses to examine potential sex differences. Results: We found no significant changes in the frequency of cannabis use using either of the interruption time points. However, among the subsample who had used cannabis, there was evidence of increasing CUD severity post-legalization of edibles, as well as an overall decreasing trend in readiness to quit over time. Stratified analyses also suggested possible sex differences in frequency of cannabis use, CUD severity, and readiness to quit. Conclusions: Results point to some small but potentially important impacts of recreational cannabis legalization that may only continue with time. Nevertheless, there is a need to continue to monitor cannabis use trends over time to understand any potential lagged effects.

Effect of the second and third COVID-19 pandemic waves on routine outpatient malaria indicators and case management practices in Uganda: an interrupted time series analysis

BackgroundReports on the impact of COVID-19 pandemic on the quality of malaria care and burden in sub Saharan Africa have provided a mixed picture to date. The impact of the 2nd (Delta) and 3rd (Omicron) COVID-19 waves on outpatient malaria indicators and case management practices was assessed at three public health facilities with varying malaria transmission intensities in Uganda.MethodsIndividual level data from all patients presenting to the out-patient departments (OPD) of the three facilities (Kasambya, Walukuba and Lumino) between January 2019 and February 2022 were included in the analysis. Outcomes of interest included total number of outpatient (OPD) visits, proportion of patients suspected to have malaria, proportion of suspected malaria cases tested with a malaria diagnostic test, test positivity rates (TPR) and proportion of malaria cases prescribed artemether-lumefantrine (AL). Using the pre-COVID-19 trends between January 2019 and February 2020, interrupted time series analysis was used to predict the expected trends for these study outcomes during the 2nd wave (May 2021–August 2021) and 3rd wave (November 2021–February 2022). The observed trends of the study outcomes were compared with the expected trends.ResultsThere were no significant differences between the observed versus expected overall outpatient visits in the 2nd wave, however, a significant decline in OPD attendance was observed during the 3rd wave (15,101 vs 31,154; incidence rate ratio (IRR) = 0.48 [0.41–0.56]). No significant differences in the overall observed versus expected proportions of suspected malaria cases and test positivity rates in both COVID waves. However, a significant decrease in the overall proportion of suspected malaria cases tested with a malaria diagnostic test was observed during the 3rd wave (99.86% vs 99.99%; relative percent ratio [RPR] = 0.99 [0.99–0.99]). Finally, a significant decline in the overall proportion of malaria cases prescribed AL was observed during the 2nd wave (94.99% vs 99.85%; RPR = 0.95 [0.92–0.98]) but not the 3rd wave.ConclusionSignificant declines in OPD attendance and suspected malaria cases tested with malaria diagnostic test were observed during the 3rd COVID-19 wave, while AL prescription significantly reduced during the 2nd COVID-19 wave. These findings add to the body of knowledge highlighting the adverse impact of COVID-19 pandemic on the malaria which could explain the increase in the malaria burden observed during this period.

Using implementation science to encourage Serious Illness Conversations on general medicine inpatient services: An interrupted time series.

Serious Illness Conversations (SICs) are not consistently integrated into existing inpatient workflows. We assessed the implementation of multiple interventions aimed at encouraging SICs with hospitalized patients. We used the Consolidated Framework for Implementation Research to identify determinants for conducting SICs by interviewing providers and the Expert Recommendations for Implementing Change to develop a list of interventions. Adult patient encounters with a Readmission Risk Score (RRS) > 28% admitted to a general medicine service from January 2019 to October 2021 and without standardized SIC documentation in the prior year were included. A multivariable segmented logistic regression model, suitable for an interrupted time series analysis, was used to assess changes in the odds of standardized SIC documentation. Barriers included those associated with the COVID-19 pandemic, such as extreme census. Facilitators included the presence of the Speaking About Goals and Expectations program and palliative care consultations. Key interventions included patient identification via the existing Quality and Safety Dashboard (QSD), weekly emails, in-person outreach, and training for faculty and trainees. There was no significant change in the odds of standardized SIC documentation despite interventions (change in temporal trend odds ratio (OR) 1.16, 95% Confidence Interval (CI) 0.98-1.39). The lack of significant change in standardized SIC documentation may be attributed to insufficient or ineffective interventions and COVID-19-related challenges. Although patient identification is a known barrier to SICs, this issue was minimized with the use of the QSD and RRS. Further research is needed to enhance the implementation of SICs in inpatient settings.

The shift from inpatient to outpatient settings of a surgical DRG for pediatric patients in Portugal

Abstract Background The shift of selected surgical procedures from inpatient to outpatient settings has been seen as a solution to improve health care provision. These shifts often occur under pay-for-performance schemes, pay-for-efficiency schemes, or other forms of financial incentives. For this study, we aimed to assess the effect of Decree 132/2009, implemented on February 1, 2009, which increased the relative weights of DRG 60 (“tonsillectomy and/or adenoidectomy, age &amp;lt;18”) performed in outpatient settings, thus acting as a financial incentive. Methods We performed a quasi-experimental study and employed interrupted time series (ITS) and controlled interrupted time series (CITS) designs, using monthly pediatric data provided by The Central Administration of the Health System (ACSS), with discharges between January 2006 and February 2012 (having 37 months pre- and post-decree implementation) of inpatient and outpatient episodes for DRG 60 (affected group) and DRG 163 (“hernia procedures age &amp;lt;18”, the selected control group). We used as study outcomes proportions (number of outpatient episodes divided by the sum of outpatient and inpatient episodes) to quantify increases in outpatient episodes and ratios (number of outpatient episodes divided by the number of inpatient episodes) to quantify decreases in inpatient episodes. Fourier terms were included to adjust for seasonality. Results We obtained statistically significant results only at the trend level for ratios when using the ITS model (0.01574) and for proportions only when using the CITS model (0.00310), although small non-statistically significant increases were obtained for the employed ITS as well as for the CITS design. Conclusions Decree 132/2009, which created financial incentives for the shift from inpatient to outpatient for DRG 60, showed low and non-statistically significant increases using both ITS and CITS models. Key messages • We analyzed the impact of Decree 132/2009 on the pediatric surgeries under DRG 60 performed in outpatient settings in Portugal using interrupted time series and control interrupted time series. • The decree had a small effect at the national level for DRG 60.

A quantitative study on the impact of a new outdoor advertising restrictions policy in Bristol (UK)

Abstract Background Bristol was the first city outside London to introduce a policy to restrict adverts for high fat, salt and sugar (HFSS) products and other unhealthy commodities (alcohol, gambling, payday loans) on council sites in 2021. This research evaluates the impact of this policy. Methods We conducted a controlled repeated cross-sectional study of Bristol (intervention) and neighbouring South Gloucestershire (control) residents before (n = 2,543) and after (n = 2,043) the policy came into effect. Self-reported exposure to adverts of HFSS products, alcohol and gambling and consumption/use of these products was collected. The intervention effect was analysed using a weighted controlled before-after design. In addition, we analysed 2020-23 timeseries of foods and drinks purchased by 1,012 households from Bristol (n = 217) and control areas (n = 795) from Kantar’s Worldpanel Take Home data. A controlled interrupted time series design was used to estimate the impact of the policy on weekly household purchases of energy and nutrients from HFSS products. Results Preliminary results did not indicate significant changes in exposure to unhealthy commodity adverts or consumption/use of unhealthy commodities post-intervention. However, the majority of results suggested a potential reduction; with for example a -22.1 (95% CI -47.3, 16.2) percentage point decrease in reported consumption of fast-food compared to controls. We also did not observe significant differences in weekly energy purchased from HFSS products compared to counterfactual; 897.6Kcal, 95%CI -57.7, 1,853.0, nor in purchases of fat (39.0g, 95%CI -20.1, 98.1), sugar (48.0g, 95%CI -19.8, 115.7) or salt (-0.4g, 95%CI -4.1, 3.2) from HFSS products. Conclusions Preliminary results indicate the new policy had no clear impact on exposure to unhealthy commodity adverts or purchasing and consumption of HFSS products. This may be attributable to the relatively small amount of total advertisement space owned by Bristol City Council (∼30%). Key messages • Policies restricting adverts of HFSS products and other unhealthy commodities are potentially effective tools to improve diet and to reduce diet-related diseases and public health inequalities. • We did not observe a measurable impact of this policy in Bristol, which may be attributable to the relatively small Council-owned advertisement estate within the total available advertisement space.

Smoke-Free Policies and Cigarette Consumption Impact on Myocardial Infarction Mortality in Europe

Abstract Background Limited evidence exists on the association between smoke-free policies and per-capita cigarette consumption and mortality due to acute myocardial infarction (AMI) in Europe. Therefore, our study aimed to assess this association and evaluate influencing factors. Methods We conducted an interrupted time series analysis involving 27 European Union member states and the UK, examining per-capita cigarette consumption and AMI mortality. A multivariate meta-regression assessed potential influencing factors. Results Approximately half of introduced smoke-free policies were associated with level or slope changes, or both, in per-capita cigarette consumption and AMI mortality (17 of 35). Notably, the smoking ban in Poland in 2010 resulted in the most substantial level reduction in cigarette consumption (rate ratio (RR): 0.47; 95% CI: 0.41, 0.53), while the intervention in Bulgaria in 2012 led to the largest level reduction in AMI mortality (RR: 0.38; 95% CI: 0.34, 0.42). More recent policies or those from countries with lower human development indices were linked to greater decreases in cigarette consumption. Furthermore, smoking bans encompassing bars exhibited a stronger inverse association with both cigarette consumption and AMI mortality. Conclusions Our findings indicate the effectiveness of smoke-free policies in reducing per-capita cigarette consumption and AMI mortality. Continued monitoring and data collection on tobacco, prevalence, and consumption are crucial for concerted efforts to address its health impacts. Key messages • Smoke-free policies lower cigarette consumption, reducing heart attack deaths in Europe. • Monitoring tobacco data crucial for health efforts: Study shows smoke-free policies save lives.

A selective diesel vehicle ban’s impact on NO2 concentrations in Munich: a quasi-experimental study

Abstract Background The European Union’s current NO2 concentration limit of 40 μg/m³ is regularly exceeded in Munich, Germany. This limit is likely to be reduced towards the WHO recommended target of 10 μg/m³. In response, the city enacted a selective ban on older diesel vehicles, specifically those categorized as Euro 4 or older, within the current low-emission zone in February 2023. Our study examined how Munich’s selective ban on diesel vehicles impacted NO2 levels, concentrating on the six-month period after its introduction. Methods We employed a synthetic control approach in the primary analysis and a controlled interrupted time series approach in the secondary analysis. These quasi-experimental methods establish a ‘counterfactual’ no-intervention scenario, allowing for comparison with the actual observed scenario and estimation of the impact of the intervention. Historical data from monitoring stations within and outside the low-emission zone from 2014 to 2022 were utilized as controls, while potential confounders were considered. Results NO2 concentrations within Munich’s low-emission zone decreased across the study period. Effects of the selective diesel vehicle ban at monitoring stations within the low-emission zone were minimal, with wide confidence intervals indicating uncertainty. At Landshuter Allee, the average intervention effect was -2.67 μg/m3 (95%-CI = [-12.72; 7.38]), at Stachus it was -2.74 μg/m3 (95%-CI = [-9.91; 4.42]) and at Lothstrasse, it was -1.03 μg/m3 (95%-CI = [-7.75; 5.69]). The secondary analysis confirms these findings. Conclusions Munich’s selective diesel vehicle ban had limited effects in reducing NO2 concentrations. Factors such as its narrow focus on Euro 4 diesel vehicles, numerous exemptions, and unclear enforcement may explain this outcome. Comprehensive strategies and continuous monitoring and evaluation are crucial for effectively addressing urban air pollution and protecting public health. Key messages • Munich’s selective diesel vehicle ban had minimal effects on reducing NO2 levels, possibly due to its narrow scope, many exemptions, and unclear enforcement. • Current guidelines and court rulings signal the need for more effective solutions beyond selective bans, emphasizing the importance of well-designed interventions and rigorous evaluation.

The impact of the tobacco law on tobacco-related hospitalizations in Portugal - a natural experiment

Abstract Introduction Tobacco is responsible for approximately 8 million deaths annually worldwide, with 1.2 million resulting from passive exposure to smoke, as reported by the WHO. Comprehensive tobacco control policies have been enacted across Europe, yet their impacts are seldom assessed. This study evaluates the effects of the anti-tobacco legislation enacted in Portugal in 2007 on tobacco-related hospitalizations between 2002 and 2018. Methods Data from all in-patient admissions in public hospitals throughout the 2002-2018 period were utilized. A quasi-experimental interrupted time series design was employed, treating 2008 as an exogenous shock. The dependent variables include the municipality-based incidence of hospitalizations by year for tobacco-related diseases, namely, Acute Myocardial Infarction, stroke, lower respiratory tract infections, chronic obstructive pulmonary disease, and asthma. The analysis was adjusted for the percentage of women, the percentage of individuals aged over 65, and purchasing power in the municipality. Time trend graphs for each variable were generated, followed by an adjustment using the Poisson regression model to forecast their trends. A comparison was conducted between observed post-law implementation data and projected values from the regression model to ascertain the percentage difference between the two. Expected Results The 2007 tobacco law led to significant reductions in tobacco-related disease incidence, with the most notable effects immediately post-implementation. The impact varies across age groups, with younger individuals (30-49 years) showing a sharper decrease. The effect diminished over time, as indicated by negative coefficients in time:law interactions, such as -0.03. Conclusions The anti-tobacco laws implemented in Portugal have effectively decreased hospitalizations related to tobacco use, suggesting potential increases in life expectancy and reduction in health system burden. Key messages • Public health policies are crucial for the long-term improvement of people’s health. • Non-exposure to tobacco can bring health gains on several levels.

Time taken for cardiology care and one-year results for primary care physicians' referrals for cardiology consultation in heart failure patients: clinical implications for heart failure management

Abstract Background and Purpose The clinical trajectory of patients with heart failure (HF) is characterised by frequent episodes of decompensation requiring urgent medical assistance, hospitalisations, and an increased risk of mortality. HF clinical guidelines recommend early visits by health professionals after hospital discharge, yet little evidence exists regarding the associations between delayed medical attention and outcomes in HF patients. To assess the clinical impact of the time taken to receive cardiology care for referrals from primary care physicians (PCPs) to a cardiology department in HF patients, we selected 6,859 HF patients who visited the cardiology service at least once between 2010 and 2021. Methods Using an interrupted time series regression model, we analysed the impact of integrating e-consultations into the healthcare model (implemented in 2013) and evaluated the time taken to receive cardiology care, as well as all-cause, cardiovascular (CV), and HF-related hospital admissions and mortality. The primary objective of this analysis was to examine the associations between delays in cardiology care following a PCP referral and 1-year outcomes (HF-related, cardiovascular, and total hospitalisations; and HF-related, cardiovascular, and total mortality). Results Almost 50% were women, and the mean age was 77.8 years. Arterial hypertension (79.6%), diabetes (34%), atrial fibrillation (51.4%), ischemic heart disease (20.4%), and cerebrovascular disease were the most prevalent comorbidities. The mean time from PCP referral to cardiology consultation in the overall population was 22.3 days: &amp;lt;8 days in 53.9%, 8-14 days in 17.1%, 15-30 days in 15.9%, and &amp;gt;30 days in 13.0% of patients, respectively. One year after cardiology consultation, 68.6% of patients required assistance in an Emergency Department; 22.5% were hospitalised for any cause, 14.9% for cardiovascular reasons, and 9.2% for HF-related issues. Moreover, total mortality at 1-year was 8.6%, comprising 4.3% cardiovascular mortality and 1.3% HF-related deaths. Multivariate analysis of the relationship between the time taken to receive cardiology care and 1-year outcomes revealed a significant increased risk associated with a longer delay in cardiology assistance, particularly evident in the subgroup of patients with previous hospital admissions due to worsening HF (see Table). Conclusions Throughout the follow-up period, a reduced time taken to receive care was independently associated with better 1-year outcomes. We believe that our experience can contribute to the development of a more efficient ambulatory care pathway for HF patients, especially those at high risk, such as those with a history of hospitalisation due to worsening events. Our findings further support the clinical guideline recommendation for early contact by health professionals following hospital discharge, extending it to include PCP referrals for cardiology consultations.

Youth mental health care use during COVID-19: Evidence from administrative data in Alberta, Canada

Abstract Background The COVID-19 pandemic affected health care service delivery and accessibility. Our study examined how Canadian youth used mental health services before and during the COVID-19 pandemic, and whether youth access and use patterns differed for subgroups based on social determinants previously associated with health care access. Methods Cross-sectional population-based administrative health care data from the province of Alberta in Canada was used to examine youth (ages 15-24) mental health care use from 2018/19 to 2021/22. Data was analyzed using an interrupted time series design and segmented regression modeling on type of mental health care use. Outcome measures were mental health care use for: general physician visits, psychiatrist visits, emergency department, hospitalization, and different mental health diagnoses. We stratified by factors related to social determinants, including gender and socioeconomic status. Results The analysis indicates an overall increase in the proportion of youth that used mental health care from 2018/19 to 2021/22 (14.4% vs 17.5%, respectively). There was an immediate drop in use with the onset of the COVID-19 pandemic in Canada, followed by a steady rise during the pandemic years, which was largely due to an increase in general physician visits. This rise was seen for most mental health diagnoses of study (i.e., anxiety, adjustment, attention-deficit/hyperactivity disorder, schizophrenia, and self-harm disorders). Service use increased for young women/girls compared to young men/boys and for youth from wealthier neighborhoods. Conclusions This study provides evidence to support health services planning and delivery to respond to the mental health needs of youth and to prepare for future public health emergencies. Key messages • Our study findings indicate changes in health care use for mental health among Canadian youth (ages 15-24) during the COVID-19 pandemic, with use patterns differing for youth subgroups. • Administrative health data can provide evidence to support health services planning and delivery to respond to the mental health needs of youth and to prepare for future public health emergencies.

Impact of a clinician-to-clinician electronic consultation program in heart failure patients with previous hospitalization. Implications for heart failure multidisciplinary management

Abstract Background A clinician-to-clinician electronic consultation (e-consultation) programme may not only improve the accessibility to care but may also impact patient outcomes, particularly in heart failure (HF) patients with a previous episode of hospitalization (HFH), group of patients associated with a worse outcome. Purpose To evaluate the impact of an outpatient care management programme that includes a clinician-to-clinician e-consultation on delay time in care, hospital admissions, and mortality in a high-risk group of patients with heart failure (HF) and previous episodes of HF hospitalization (HFH). Materials and methods We selected 6444 HF patients who visited the cardiology service at least once between 2010 and 2021. Of these, 4146 were attended in e-consultation, and 2230 had previous HFH (Fig 1a). Using an interrupted time series regression model, we analysed the impact of incorporating e-consultation into the healthcare model in the group of patients with HFH and evaluated the elapsed time to cardiology care, HF, cardiovascular (CV), and all-cause hospital admissions and mortality, calculating the incidence relative risk (iRR). We performed a multivariate logistic regression for each of these outcomes in both groups. Results Patients with HFH had a higher prevalence of men (P &amp;lt; 0.001) but had a similar age (P = 0.267) compared to patients without HFH. Patients with HFH had a higher prevalence of diabetes (P &amp;lt; 0.001), ischaemic heart disease (P = 0.036), and peripheral arterial disease (P = 0.008) (Fig 1b). In the group of patients with HFH, the introduction of e-consult substantially decreased waiting times to cardiology care (8.6 [8.7] vs. 55.4 [79.9] days, P &amp;lt; 0.001) (Fig 2a). In that group of patients, after e-consult implantation, hospital admissions for HF were reduced (iRR [95%CI]: 0.837 [0.840–0.833]), 0.900 [0.862–0.949] for CV and 0.699 [0.678–0.726] for all-cause hospitalizations (Fig 2b). There was also lower mortality (iRR [95%CI]: 0.715 [0.657–0.798] due to HF, 0.737 [0.764–0.706] for CV and 0.687 [0.652–0.718] for all-cause) (Fig 2c). The improved outcomes after e-consultation implementation were significantly higher in the group of patients with previous HFH. The multivariate analyses showed a higher risk of hospitalizations in men, patients with HFH, and those who required more emergency department assistance (Fig 2d). Conclusions In patients with HFH, an outpatient care programme that includes an e-consultation significantly reduced waiting times to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year. Our results may have implications for optimize the heart failure care organization.Figure 1Figure 2

Electronic consultation from primary care to a cardiology department improves outcomes in patients with cancer

Abstract Background The number of cancer patients with known cardiovascular (CV) disease is increasing due to improved cancer prognosis. Purpose The objective of this study is to assess the long-term results of cancer patients referred to a cardiology department by primary care using electronic consultation (e-consultation). Methods We analysed the patients with previous diagnosis of cancer referred to a cardiology department (CD) from 2010 to 2021 (n=6.889), selected from a total of 68.518 patients (61.629 without cancer), and compared two assistance models: in-person practice (from 2010 to 2012) and e-consultation (from 2013 to 2021). In the first period, all the patients referred by primary care physicians (PCPs) were seen in an in-person consultation and in the e-consultation model the cardiologist reviewed the electronic records (e-consultation) and decided to solve without any visit or, if it was necessary, with an in-person consultation. The outcomes between both periods were analysed using an interrupted time series regression model: 1) delay time to cardiology assistance; 2) all-cause and cardiovascular hospital admissions, and 3) all-cause and cardiovascular mortality during the first year after the initial consultation or e-consultation to the CD. Results Among cancer patients referred to cardiology consultation, the introduction of e-consultation decreased waiting times to cardiology care by 51,8% (95% CI: 51,7%-51,9%) (Fig 1). Over 60% of referrals were resolved in less than 8 days, with this proportion significantly higher after the e-consultation program was introduced (p&amp;lt;0,001). Furthermore, we observed a reduction in the one-year rate of outcomes, with an incidence rate ratio (iRR) [IC 95%] of 0,75 [0,73-0,77] for CV-related hospitalizations (Fig 2b), 0,43 [0,42-0,44] for all-cause hospitalization (Fig 2a), and 0,87 [0,86-0,88] for all-cause mortality. In the multivariate analysis, the delay in receiving cardiology care was significantly associated with an independent increase in 1-year mortality (OR [95% CI] 1,39 [1,06-1,83]) and hospital admission (OR [95% CI] 1,25 [1,02-1,52]). Furthermore, the implementation of the e-consult model was associated with a reduction in hospital admission rates (OR [95% CI] 0,19 [0,14-0,25]). Conclusions In comparison to the in-person consultation period, an outpatient care program that incorporates e-consultation for cancer patients significantly reduced waiting times for cardiology care and shown to be safe, associated with lower rates of hospital admissions.Figure 1Figure 2

Residual loneliness in the Netherlands after the COVID-19 pandemic: An application of the single interrupted time series design with pre-, peri- and post-pandemic observations

ObjectivesDuring the COVID-19 pandemic, many countries implemented policies to physically separate citizens. As a consequence, an increased prevalence of loneliness was observed. This article examined whether the prevalence of loneliness in the Netherlands has returned to pre-pandemic levels after the restrictive policy was ended. We studied age differences in the course of loneliness. Study designSingle interrupted time series design. MethodsData were from the Longitudinal Internet Studies for the Social Sciences (age range 16–102 years) and the Longitudinal Aging Study Amsterdam (age range 65–101 years). Both studies included respondents sampled from the Dutch population registers. Data collected relatively soon and later after the pandemic outbreak (nine and five observations in 2020–2023, respectively) were compared to extrapolated trend data based on a long period of time before the outbreak (since 2008 and 1992, respectively). ResultsWith two exceptions, the results of the two studies including five age categories and three types of loneliness measurement instruments showed that after an increased prevalence during the pandemic, prevalence at the last observation was at or below the level of the extrapolated trend. ConclusionsIt is highly likely that the pandemic was indeed an interruption and not a fundamental trend change in loneliness. This shows individuals’ resilience and the ability to reactivate social ties after the interruptive pandemic.

Effects of COVID-19 on flex route transit utilization: An interrupted time series analysis

The COVID-19 outbreak has exerted serious effects on the transportation system, especially public transport. Flex route transit (FRT), one of public transport, has shown significant advantages in transporting passengers during COVID-19 due to its high flexibility and relatively large cabin spaces. This study aims to estimate the effects of the lockdown and first lockdown ease on FRT utilization through interrupted time series analysis. A survey was conducted in Beijing to collect data regarding the daily FRT utilization of individuals, spanning from December 2019 to May 2020. Results indicated that FRT utilization was immediately reduced during the lockdown, and a decreased trend was observed. After the first lockdown ease was rolled out, FRT utilization showed a rising level and trend. Private car owners showed a lower dependence on FRT than non-car owners. The level of income exerted varying effects in a wide range of periods. FRT utilization among the higher income group was more likely to take effect than the lower income group. The study yields various policy implications for FRT operations during COVID-19 or other pandemics.

The long-term effect of the coronavirus pandemic on parkrun participation: an interrupted time series analysis

BackgroundThe growth of parkrun between 2004 and 2019 has been heralded as a success story for public health as a result of its physical activity and wellbeing benefits for participants. However, parkrun was not immune from the COVID-19 pandemic - with events in mainland England cancelled from March 2020 to July 2021. This study explores the lasting impact of the pandemic on parkrun participation to February 2023, and its implications across the socioeconomic spectrum.MethodsThe study combines aggregated parkrun weekly finisher data from 32,470 Lower Layer Super Output Areas (LSOA) in England from January 2015 to February 2023 with Office of National Statistics (ONS) data on population and deprivation. Interrupted time series analysis using segmented Poisson regression models was used to estimate the immediate change in parkrun participation and the change in the rate of growth following the pandemic. Models were fitted for each Index of Multiple Deprivation (IMD) quintile separately to assess whether this effect differed by socioeconomic deprivation.ResultsVisualisation and interrupted time series analysis showed a significant and long-term decrease in parkrun participation following the reopening of parkrun events. This was consistent across all IMD quintiles, indicating that the inequalities in parkrun participation according to IMD observed prior to the pandemic remained after the pandemic. Between March 2020 and February 2023, almost 13 million fewer parkrun finishes are estimated to have occurred relative to what would have occurred in the absence of the pandemic.ConclusionThe reduction in parkrun participation during the pandemic and following the reopening of events is likely to have negatively impacted wellbeing in would-be participants. Going forwards, policymakers must make the difficult trade-off between the long-term health and social implications of restricting outdoor physical activity events against the benefits associated with a reduction in infectious disease transmission.

Mitigating Medical Adverse Events Following Spinal Surgery: The Effectiveness of a Postoperative Quality Improvement (QI) Care Bundle.

Spine surgery is associated with a high incidence of postoperative medical adverse events (AEs). Many of these events are considered "minor" though their cost and effect on outcome may be underestimated. We sought to examine the clinical and cost-effectiveness of a postoperative quality improvement (QI) care bundle in mitigating postoperative medical AEs in adult surgical spine patients. We collected 14-year prospective observational interrupted time series (ITS) with two historical cohorts: 2006 to 2008, pre-implementation of the postoperative QI care bundle; and 2009 to 2019, post-implementation of the postoperative QI care bundle. Adverse Events were identified and graded (Minor I and II) using the previously validated Spine AdVerse Events Severity (SAVES) system. Pearson Correlation tested for changes across patient and surgical variables. Adjusted segmented regression estimated the effect of the postoperative QI care bundle on the annual and absolute incidences of medical AEs between the two periods. A cost model estimated the annual cumulative cost savings through preventing these "minor" medical AEs. We included 13,493 patients over the study period with a mean of 964 per year (SD±73). Mean age, mean Charlson Comorbidity Index (CCI), and mean spine surgical invasiveness index (SSII) increased from 48.4 to 58.1years; 1.7 to 2.6; and 15.4 to 20.5, respectively (p<0.001). Unadjusted analysis confirmed a significant decrease in the annual number of all medical AEs (p<0.01). When adjusting for age, CCI and SSII, segmented regression demonstrated a significant absolute reduction in the annual incidence of cardiac, pulmonary, nausea and medication-related AEs by 9.58%, 7.82%, 11.25% and 15.01%, respectively (p<0.01). The postoperative QI care bundle was not associated with reducing the annual incidence of delirium, electrolyte levels or GI AEs. Annual projected cost savings for preventing Grade I and II medical AEs were $1,808,300 CAD and $11,961,500 CAD. Postoperative QI care bundles are effective for improving patient care and preventing medical care-related AEs, with significant cost savings. Postoperative QI care bundles should be tailored to the specific vulnerability of the surgical population for experiencing AEs.

Effect of 10-valent pneumococcal conjugate vaccine on trends of pneumococcal meningitis in children under five years, Uganda, 2003-2022.

Pneumococcal meningitis, a vaccine-preventable disease caused by Streptococcus pneumoniae (Spn) is the leading bacterial meningitis in under five children. In April 2014, Uganda introduced routine immunization with 10-valent Pneumococcal Conjugate Vaccine (PCV10) for infants. The target coverage for herd immunity is ≥ 90% with three doses (PCV10-dose 3). We assessed the effect of PCV10 introduction and coverage on the trends of pneumococcal meningitis in under five children. We analyzed laboratory-confirmed pediatric bacterial meningitis (PBM) data at two high-volume WHO-accredited sentinel surveillance hospitals in Kampala City and Gulu District, from 2003 to 2022. We used confirmed cases to estimate the minimum incidence of pneumococcal meningitis in the host districts and calculated annual incidence of pneumococcal meningitis per one million populations, and the proportion of confirmed PBM attributable to Spn. We divided the study period into 2003-2013 (pre-PCV10) and 2014-2022 (post-PCV10), and conducted interrupted time series analysis using autoregressive integrated moving average models for the effect of PCV10 on trends of pneumococcal meningitis and PBM attributable to Spn. We analyzed reported PCV10 data in DHIS2 from 2014 to 2022 for annual PCV10-dose 3 coverage. Among the 534 confirmed PBM cases, 331(62%) were pneumococcal meningitis; 227(69%) from Gulu District and 104(31%) from Kampala City. The majority (95%) of the isolates were not serotyped. The majority (57%) were male and unimmunized (98%); median age = 14(IQR = 6-27) months with most (55%) aged ≥ 12 months. The case-fatality rate was 9%. During Pre-PCV10 period, the overall incidence of pneumococcal meningitis in the host districts increased; slope change = 1.0 (95%CI = 0.99999, 1.00001) but declined in post-PCV10 period (2014-2022) by 92% from 86 cases /1,000,000 in 2014 to 7/1,000,000 in 2022, slope change= -1.00006 (95%CI=-1.00033, -0.99979). Whereas there was an immediate decline in the proportion of confirmed PBM attributable to Spn in the host districts, level change=-1.84611(95%CI=-1.98365,-1.70856), an upward trend was recorded from 2016 to 2022, slope change = 1.0 (95%CI = 0.99997, 1.00003). During 2015-2022, PCV10-dose 3 coverage was largely > 90% for Gulu District and 52-72% for Kampala City. The PCV10 routine immunization program reduced the incidence of pneumococcal meningitis in Kampala City and Gulu District. There was no effect on the confirmed PBM proportionately attributable to Spn. Kampala City persistently recorded PCV10-dose3 coverage < 90%. We recommend enhancing serotyping and periodic nasopharyngeal carriage surveys to ascertain the maximum vaccine effectiveness and monitor Spn serotypes, and strengthening routine immunization in Kampala City.

An observational analysis of the impact of deltamethrin + piperonyl butoxide insecticide-treated nets on malaria case incidence and entomological indicators in Ebonyi State, Nigeria, 2017–2021

BackgroundIntense pyrethroid resistance threatens the effectiveness of the primary vector control intervention, insecticide-treated nets (ITNs), in Nigeria, the country with the largest malaria burden globally. In this study, the epidemiological and entomological impact of a new type of ITN (piperonyl-butoxide [PBO] ITNs) distributed in Ebonyi State were evaluated. The epidemiological impact was also compared to the impact of standard pyrethroid-only ITNs in Cross River State.MethodsA controlled interrupted time series analysis was conducted on monthly malaria incidence data collected at the health facility level, using a multilevel mixed-effects negative binomial model. Data were analysed two years before and after the PBO ITN campaign in Ebonyi State (December 2017 to November 2021). A pre-post analysis, with no comparison group, was used to assess the impact of PBO ITNs on human biting rates and indoor resting density in Ebonyi during the high transmission season immediately before and after the PBO ITN campaign.ResultsIn Ebonyi, PBO ITNs were associated with a 46.7% decrease (95%CI: -51.5, -40.8%; p < 0.001) in malaria case incidence in the 2 years after the PBO ITN distribution compared to a modelled scenario of no ITNs distributed, with a significant decrease from 269.6 predicted cases per 1000 population to 143.6. In Cross River, there was a significant 28.6% increase (95%CI: -10.4, 49.1%; p < 0.001) in malaria case incidence following the standard ITN distribution, with an increase from 71.2 predicted cases per 1000 population to 91.6. In Ebonyi, the human biting rate was 72% lower (IRR: 0.28; 95%CI 0.21, 0.39; p < 0.001) and indoor resting density was 73% lower (IRR: 0.27; 95%CI 0.21, 0.35; p < 0.001) after the PBO ITNs were distributed.ConclusionsThe epidemiological and entomological impact of the PBO ITNs underscore the impact of these ITNs in areas with confirmed pyrethroid resistance. These findings contribute to ongoing research on the impact of new types of ITNs in Nigeria, providing critical evidence for the Nigeria National Malaria Elimination Programme and other countries for future ITN procurement decisions as part of mass ITN campaign planning and malaria programming.

“Competitive” Food and Beverage Laws and Obesity Among Diverse Youth in California High Schools

PurposeTo investigate associations between the California “competitive” food and beverage (CF&B) laws and overweight/obesity (OV/OB) among high school youth by gender, school-neighborhood income, and race/ethnicity, and to examine racial/ethnic OV/OB disparities before and after CF&B policies. MethodsUsing an interrupted time series design paired with retrospective cross-sectional Fitnessgram data from 3,565,260 youth-level records on ninth-grade students in California public schools, we estimated gender, school-neighborhood income, and racial/ethnic OV/OB prevalence trends before (2002-2007) and after the CF&B policies were in effect (2008-2012). ResultsIn the period before the CF&B policies, OV/OB prevalence increased annually among the majority of subgroups regardless of gender, school-neighborhood income and race/ethnicity. In the period after the policies took place, OV/OB increased at a slower rate, plateaued or declined. Changes in log odds of OV/OB trends ranged from −0.03 to −0.07. In the period before the CF&B policies, OV/OB disparities widened between African American and Latino versus White males within each school-neighborhood income tertile; afterwards, disparities ceased to increase or slightly narrowed. DiscussionThe California CF&B laws for high schools are associated with favorable trends in youth OV/OB. This is the first study to examine these associations among multiple socio-demographically diverse high school youth simultaneously considering gender, school-neighborhood income and race/ethnicity. The degree to which observed changes in OV/OB trends are attributable to CF&B policies is unclear. Nevertheless, the results suggest that strengthening CF&B policies may help further reduce OV/OB among youth of different genders and ethnicities in schools across neighborhoods of varying income levels.