Interrupted Time Research Articles

Analysis of Opioid Prescribing Trends Following Thyroidectomy and Parathyroidectomy Before and After the 2021 American Academy of Otolaryngology-Head and Neck Surgery Opioid Prescribing Clinical Practice Guidelines.

To evaluate the trends in opioid and nonopioid prescribing for thyroidectomy and parathyroidectomy before and after the publication of guidelines by the American Academy of Otolaryngology-Head and Neck Surgery in April 2021. Retrospective. Eighty-three health care organizations in the United States that contribute to the TriNetX database. Deidentified patient data were retrieved from the TriNetX. Patients who were prescribed either opioids or nonopioid analgesic within 1 to 5 days following thyroid surgery and parathyroidectomy were included. Evaluation of the prescription trends was performed by interrupted time series analysis in Statistical Analysis System 9.4 with significance set at P < .05 to assess trends before and after the new opioid prescription guidelines. For thyroid surgery, there was an immediate effect of the guideline change indicated by a 3.3% decrease in the opioid prescription trend (P = .03) and a significant increase in nonopioid use of overtime by 0.13% every 3 months (P < .0001). The opioid prescription trend following parathyroidectomy significantly decreased over time by 0.28% every 3 months (P < .0001), while the nonopioid prescription trend increased by 0.14% (P < .0001). There was an associated immediate reduction in the opioid prescribing trend for thyroidectomy, but the change was not sustained overtime. There was an associated decrease in the opioid prescribing trend for parathyroidectomy, but not immediately after the initial publication of the prescription guidelines. Level III.

Early Effects of the End-Stage Renal Disease Treatment Choices Model on Kidney Transplant Waitlist Additions.

Despite the mortality benefit of kidney transplantation over dialysis, only 13% of patients with end-stage kidney disease are on the transplant waitlist. Given the low rates of transplant waitlisting in the US, Medicare launched the End-Stage Renal Disease Treatment Choices (ETC) Model in 2021, the largest mandatory trial of payment incentives in kidney disease, which randomized 30% of healthcare markets to financial bonuses/penalties to improve kidney transplantation and home dialysis use. This study examines the effect of ETC payment adjustments on US kidney transplant waitlist additions. Using data from the Organ Procurement and Transplantation Network registry, we examined kidney transplant waitlisting trends between 01/01/2017 and 06/30/2022. Participants were divided into intervention and control arms of the ETC Model. Using an interrupted time series design, we compared slope changes in waitlist additions post-ETC Model implementation (implementation date: 01/01/2021) between the two arms, while accounting for differential changes during the COVID-19 pandemic. Results were stratified by race and ethnicity (White, Black, Hispanic, and other). To examine balance between the two ETC arms, we conducted supplementary analyses using United States Renal Data System and Medicare data. Following implementation of the ETC Model, there were 5,550 waitlist additions in the intervention and 11,332 additions in the control arm (versus 14,023 and 30,610 additions before the ETC Model). Post-ETC, there were no significant differences in kidney transplant waitlist additions between the two arms for the overall cohort (slope difference 6.9 new listings/month, 95% CI: -7.4 to 21.1) or among either White (slope difference 2.6/month, 95% CI -3.0 to 8.1), Black (slope difference 2.2/month, 95% CI: -4.3 to 8.7), or Hispanic (slope difference 0.2/month, 95% CI: -4.5 to 4.9) patients. In the 18 months following implementation, the ETC Model was not associated with significant changes in new kidney transplant waitlist additions.

Impact of the COVID-19 pandemic on initiation of antihypertensive drugs in Sweden: an interrupted time series study

ObjectivesAntihypertensives reduce the risk of myocardial infarction and stroke. Restrictions during the COVID-19 pandemic limited access to healthcare, which may have had a negative impact on drug prescribing. This study...

Implementation of a Telehealth Smoking Cessation Program in Primarily Socioeconomically Disadvantaged Black Patients: Courage to Quit Rolling-Virtual (CTQ-RV).

Preliminary data indicate that smoking cessation offered in a rolling group format is feasible and effective. The current study evaluated theimplementation and outcomes of the remote Courage to Quit-Rolling Virtual (CTQ-RV) smoking group treatment compared to its precursor in-person format (Courage to Quit-Rolling, CTQ-R). Virtual materials for CTQ-RV were adapted from in-person evidence-based programming, thus content in both groups was similar but delivered via videoconference or in-person. We used an interrupted time series design to examine feasibility by comparing attendance, monthly enrollment, and program completion between those who attended CTQ-R (July 2018-March 2020) versus CTQ-RV (April 2020-December 2022). There were 611 patients enrolled in tobacco cessation (N = 221 CTQ-R, N = 390 CTQ-RV). The average age was 59.4 years and most patients reported Black/African American race (81%) and female sex (69.5%). CTQ-RV proved feasible relative to CTQ-R, with higher rates of attendance (5.5 vs. 2.7 sessions, respectively), program completion (39.4% vs. 19%) and increased enrollment across each year (from 44.6 sessions per month in CTQ-R vs. 72.3 in CTQ-RV). CTQ-RV patients requested nicotine replacement therapy (NRT) at substantially higher rates (81.4%) than CTQ-R members (42.1%). Self-reported smoking abstinence at final session was higher in CTQ-RV compared with CTQ-R (33.3% vs. 15.7%). Within CTQ-RV, more than half (57%) of patients attended by video format, with outreach improving rates of video attendance each year. Results show that a transition to virtual rolling enrollment smoking group treatment is feasible and can augment treatment outcomes, such as engagement, NRT use, and self-reported cessation.

What influences interruption of continuous renal replacement therapy in intensive care unit patients: A review with meta-analysis on outcome variables.

Evidence suggests that 8%-10% of ICU patients receive renal replacement therapy. However, there is a high rate of unplanned CRRT interruption, ranging between 17% and 74%. Studies on unplanned interruption of CRRT mainly focused on the retrospective investigation of related risk factors and conclusions have been diverse. This article aims to clarify the main influencing factors related to unplanned interruption of continuous renal replacement therapy (CRRT) in adult patients in intensive care units (ICUs). A literature review and meta-analysis were undertaken. Following the application of the Newcastle-Ottawa Scale (NOS), a total of 15 articles were included in a total of 2132 patients who underwent 3690 CRRT procedures and 2181 unplanned interruption times. The methodological guideline of a scoping review was applied for the evidence synthesis while applying the meta-analysis quantitative methodological guideline to identify and clarify main influencing factors related to unplanned interruption of CRRT. The reporting Prisma Protocol was followed. Longer filter life and prothrombin activation time, higher red blood cell count, greater transmembrane pressure, faster blood flow rate, intermittent saline irrigation, lower creatinine level, low prothrombin activity and pre-dilution are factors identified to potentially affect unplanned CRRT in ICU patients. Available evidence suggests four clinical challenges associated with unplanned CRRT interruption, namely: (a) effects of red blood cell count, filter life, cross-mode pressure, blood flow velocity, prothrombin activity and activated partial thrombin time on unplanned interruption; (b) influence of dilution mode on unplanned interruption; (c) influence of intermittent saline irrigation on unplanned interruption; (d) influence of Scr level on unplanned interruption. The potential to increase the ability to better manage unplanned CRRT in ICUs has been identified in this article and constitutes a relevant potential health care management contribution that can be implemented by nurses.

Triple broadly neutralizing antibody (bnAb) combination therapy: a cure for pediatric HIV?

Abstract Background In 2022, UNAIDS estimated out of the 1.7 million children living with HIV, only 57.1% had access to antiretroviral therapy (ART). Though ART has significantly decreased HIV-associated morbidity and mortality, it cannot eliminate the latent viral reservoir. Consequently, most people living with HIV demonstrate viral rebound when ART is interrupted. There is therefore a critical need for alternative therapeutic to achieve long term ART free viral control. Broadly neutralizing antibodies (bnAb) have shown promising results in preclinical and clinical studies, but their potential efficacy is limited by the emergence of escape variants, especially with monotherapy. We previously tested the neutralizing and non-neutralizing functions of different bnAb combinations and identified a triple bnAb combination that showed robust neutralization potency and breadth, as well as non-neutralizing functions. In this project, we investigated the impact of combination bnAb therapy on viral rebound in SHIV infected infant rhesus macaques (RMs). Methods Ten infant rhesus macaques were orally challenged with SHIV.C.CH505 at 4 weeks of age. Oral challenge is a well-established method that is used to mimic breastmilk transmission of HIV, which contributes to almost 50% of pediatric HIV infections every year. A triple bnAb combination of simianized 3BNC117 (CD4 binding site), PGDM1400 (V2 glycan dependent), and PGT151 (interface) was subcutaneously administered twice at 40 mg/kg of each antibody. The initial infusion was administered at ART initiation (8 weeks post-infection) while the second infusion with administered at the time of analytical treatment interruption (ATI) (49 weeks post-infection). RMs were monitored weekly from the beginning of infection until 12 weeks post-ATI. Enzyme-linked Immunosorbent Assay (ELISA) was used to monitor plasma concentrations of each bNab and Env-specific IgG binding responses. Results Env-specific antibody binding levels against HIV envelope proteins gp120 and gp41 peaked in plasma 8 weeks after infection. The antibody levels then slightly decreased during ART and increased again after viral rebound following ATI. BnAb plasma concentrations peaked 1-2 weeks after each bnAb infusion, then slowly declined. After the initial infusion, all RMs had undetectable levels of 3BNC117 and PGT151 by 8 weeks post initial infusion, and only 2/10 RMs had detectable PGDM1400 levels. All animals experienced viral rebound following ATI.). Importantly, the average time to virus rebound (7 weeks, range 3-10 weeks) was significantly longer than a s control group of RMs without any immune-based intervention (~2.5 weeks). By the time of viral rebound, most animals had undetectable plasma levels of 3BNC117, PGDM1400 or PGT151. However, in some animals, rebound occurs when passively administered antibodies were still detectable, suggesting the emergence of bnAb resistant variants. Conclusion Passive immunization with a triple-bnAb combination of 3BNC117, PGT151 and PGDM1400 was associated with delayed viral rebound, but more investigation is needed to understand the potential role of this strategy in the HIV therapeutic portfolio. Future work will investigate the sensitivity of the rebound viruses to the bnAb combination to evaluate the contribution of bnAb escape to viral rebound.

Potential impact of rotavirus vaccine introduction in India’s Universal Immunisation Programme on private sector vaccine utilisation: an interrupted time series analysis

BackgroundDespite free immunisation services through the Universal Immunisation Programme (UIP), around 14% of Indian households seek immunisation in the private sector. We examined the potential impact of rotavirus vaccine (RVV) introduction in the Universal Immunisation Programme (UIP) on private-sector rotavirus vaccine utilisation.MethodsWe analysed nationally representative private-sector vaccine sales data. The intervention under consideration is RVV introduction in the UIP in selected Indian states. The outcome is the ‘monthly RVV sales volume’—a proxy for vaccine utilisation. We performed a Poisson regression interrupted time series analysis to detect the pre-intervention trend, post-intervention level change and trend change relative to the pre-intervention for monthly rotavirus vaccine utilisation.ResultsPoisson segmented regression analysis showed that immediately after RVV introduction in the UIP private-sector RVV sales showed a decline in Rajasthan by 37.4% (Incidence Risk Ratio (IRR): 0.626; 95% CI: 0.504–0.779), in Tamil Nadu by 26% (IRR: 0.740; 95% CI: 0.513–1.068), in Uttar Pradesh-East by 72.2% (IRR: 0.278; 95% CI: 0.178–0.436) and in Kerala by 3% (IRR: 0.970; 95% CI: 0.651–1.447). Rajasthan, Tamil Nadu and Kerala had sustained reduction in the postintervention trend relative to the preintervention trend by 20.1% (IRR: 0.799; 95% CI: 0.763–0.836), 6.4% (IRR: 0.936; 95% CI: 0.906–0.967) and 3.3% (IRR: 0.967; 95% CI: 0.926–0.960) per month, respectively. However, in Haryana and UP-west, in the first-month post-UIP introduction, the private-sector RVV sales increased by 101% and 3.8%, respectively which was followed by a sustained decrease of 14.2% (IRR: 0.858; 95% CI: 0.688–1.070) and 5.8% (IRR: 0.942; 95% CI: 0.926–0.960) per month, respectively. In terms of long-term impact, the private sector RVV sales post-UIP introduction decreased at a monthly rate of 4.4% (IRR: 0.956, 95% CI: 0.939–0.974) in Rajasthan but increased by 5.5% (IRR: 1.055; 95% CI: 1.040–1.070) in UP-east, 0.3% (IRR: 1.003, 95% CI: 0.976–1.031)) in Kerala and 0.2% (IRR: 1.002, 95% CI: 0.993–1.011) in Tamil Nadu whereas Haryana and UP-west had a reduction in RVV utilisation by 2.8% (IRR: 0.972; 95% CI: 0.955–0.990) and 1% (IRR: 0.990; 95% CI: 0.982–0.998), respectively.ConclusionsThe study provides evidence that access to RVV through UIP leads to a reduction in private-sector RVV utilisation. We recommend strengthening UIP to expand the basket of new vaccines.

Sociodemographic differences in the response to changes in COVID-19 testing guidelines.

During the coronavirus disease 2019 (COVID-19) pandemic, Sweden emphasized voluntary guidelines over mandates. We exploited a rapid change and reversal of the Public Health Agency of Sweden's COVID-19 testing guidelines for vaccinated and recently infected individuals as a quasi-experiment to examine sociodemographic differences in the response to changes in pandemic guidelines. We analyzed daily polymerase chain reaction tests from 1 October 2021 to 15 December 2021, for vaccinated or recently infected adults (≥20 years; n = 1596321) from three Swedish regions (Stockholm, Örebro, and Dalarna). Using interrupted time series analysis, we estimated abrupt changes in testing rates at the two dates when the guidelines were changed (1 November and 22 November). Stratified analysis and meta-regression were employed to explore sociodemographic differences in the strength of the response to the guideline changes. Testing rates declined substantially when guideline against testing of vaccinated and recently infected individuals came into effect on 1 November [testing rate ratio: 0.50 (95% confidence interval, CI 0.41, 0.61)], and increased again from these lowered levels by a similar amount upon its reversal on 22 November [testing rate ratio: 2.19 (95% CI: 1.69, 2.85)]. Being Sweden-born, having higher household income, or higher education, were all associated with a stronger adherent response to the guideline changes. Adjusting for stratum-specific baseline testing rates and test-positivity did not influence the results. Our findings suggest that the population was responsive to the rapid changes in testing guidelines, but with clear sociodemographic differences in the strength of the response.

Munich’s selective diesel vehicle ban and its impact on nitrogen dioxide concentrations: A quasi-experimental study

BackgroundThe current limit on NO2 concentrations of 40 μg/m3, set by the European Union, has been regularly exceeded in Munich, Germany. This limit will likely be reduced towards the WHO recommended target of 10 μg/m3. Against this backdrop, the city implemented a selective diesel vehicle ban within the existing low-emission zone in February 2023, targeting Euro 4 and older diesel vehicles. Our study investigated the effect of Munich’s selective diesel vehicle ban on NO2 concentrations, focusing on the half-year period following its implementation. MethodsOur study utilized a synthetic control approach (primary analysis) and a controlled interrupted time series approach (secondary analysis). These quasi-experimental methodologies create a ‘counterfactual’ no-intervention scenario, enabling comparison between observed and counterfactual scenarios to estimate an intervention effect. We employed historical controls, using routine data from multiple monitoring stations located within and outside the low-emission zone for 2014 to 2022, and considered possible confounders. ResultsNO2 concentrations within Munich’s low-emission zone showed overall declining trends from August 2014 to July 2023. Effects of the selective diesel vehicle ban were small and wide confidence intervals indicate large uncertainty in the magnitude and direction of the effect. 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 confirmed these findings, reinforcing uncertainty about the effect of the intervention. ConclusionOur study suggests that Munich’s selective diesel vehicle ban had a limited effect on lowering NO2 concentrations. Possible explanations include the ban’s focus on Euro 4 and older diesel vehicles, many exemptions to the selective ban, and unclear enforcement. This highlights that comprehensive approaches and ongoing, well-designed monitoring and evaluation are crucial for addressing urban air pollution and protecting public health.

A time-series analysis examining implementation strategies to increase use of an early-supported discharge hospital at home model.

Early-supported discharge (ESD) hospital-at-home (HaH) programs facilitate hospitalized patients to receive ongoing acute-level care at home, thereby promoting patient-centeredness while improving hospital throughput. The current study aimed to test multiple implementation strategies to increase and sustain HaH ESD utilization. We conducted interrupted time series analyses to evaluate the effectiveness of implementation strategies on weekly HaH ESD referrals and capacity utilization at five hospitals. Intervention 1 included provider-focused education and HaH nurse navigator support (July 2021 to May 2022). Intervention 2 added provider-level referral performance feedback and daily electronic health record-based eligibility reports (May 2022 to December 2022). During postintervention (January 2023 to June 2023), implementation strategies were no longer supported by the study team. Clinical outcomes were assessed over time and between patient subgroups. There were 5951 HaH ESD patients overall. After Intervention 2, we observed immediate increases in weekly HaH ESD referrals (level change mean difference [MD, 95% confidence interval]: 14.8, 5.9-23.6) and capacity utilization (level change MD: 13.9%, 6.2%-21.5%) and additional week-to-week increases in capacity utilization (slope change MD: 0.6%, 0.2%-0.9%), compared to Intervention 1 trends. HaH ESD referrals and capacity utilization were sustained postintervention. The proportion of provider-initiated referrals increased over time (Intervention 1: 79.4%, Intervention 2: 90.9%, postintervention: 95.2%). As HaH ESD utilization increased, we observed shorter inpatient length of stay and fewer HaH ESD encounters per visit (p < 0.01). There were small, statistically significant differences in 30-day mortality and readmission for residents of rural and socioeconomically disadvantaged areas. Applying referral-focused provider feedback and daily eligibility reports were effective within a multicomponent approach to increase and sustain HaH ESD utilization.

Uptake of biosimilars in China: a retrospective analysis of the case of trastuzumab from 2018 to 2023

BackgroundThe Chinese biosimilar industry has demonstrated rapid growth in recent years. Limited evidence is available about biosimilar uptake at the national level. This study aimed to assess biosimilar uptake in the case of trastuzumab and to explore potential factors influencing the biosimilar penetration at national and provincial levels.MethodsThis study employed an interrupted time series analysis to assess the level and trend changes of national trastuzumab originator consumption and the overall trastuzumab consumption after the price reduction of the originator and the introduction of the first biosimilar using the China Hospital Pharmacy Audit procurement data from March 2018 to February 2023. A latent class trajectory model (LCTM) was also adopted to estimate the biosimilar penetration across 30 provincial-level administrative divisions (PLADs). Based on the LCTM grouping results, provincial characteristics were analyzed.ResultsAfter rapid growth, the penetration of biosimilars demonstrated a moderate ascending trend at the national level, reaching 27% in February 2023. Following the introduction of the first biosimilar in July 2021, the consumption of the originator decreased by 0.5% per month (P = 0.008), and the growth rate of overall trastuzumab consumption decreased by 1.1% per month (P = 0.014). LCTM fit the best when the number of trajectory classes was two, dividing 30 PLADs into a group demonstrating a faster increase in biosimilar penetration and the other with a slower increase. The PLADs in the fast-increasing group had a higher proportion of the population covered by the national basic health insurance, a lower proportion of the urban population, a lower proportion of the population covered by the urban employee health insurance program, a lower gross domestic product per capita, a lower total health expenditure per capita, and a lower out-of-pocket expenditure.ConclusionsThe uptake of trastuzumab biosimilars in China was lower compared with major European countries. The introduction of trastuzumab biosimilars presented a substitutional effect. Perceptions of physicians and patients, the medicines procurement model, competition from other biologics, and health insurance payment methods may influence biosimilar uptake. Enhancing a comprehensive understanding of biosimilars among physicians and patients, including biologics with biosimilars in the national pooled procurement, and implementing provider payment reforms could foster biosimilar penetration.

Post-pandemic consumption of outpatient antibiotics in Switzerland up to pre-pandemic levels, 2018–2023: An interrupted time series analysis

BackgroundThe COVID-19 pandemic has been a challenge for health-care systems and antibiotic stewards as uncertainty regarding treatment and bacterial coinfections raised concern. MethodsThis retrospective observational study examined the association of the pandemic on outpatient antibiotic sales and prescriptions in Switzerland using interrupted time series (ITS) analyses. Data from IQVIA™ and the Sentinella Network were used to analyze antibiotic consumption and prescription patterns over a 72-month period from January 2018 to December 2023, divided into pre-pandemic, pandemic, and post-pandemic periods. ResultsAntibiotic consumption decreased during the pandemic and returned to pre-pandemic levels in the post-pandemic period. A decrease in level was most pronounced in the French-speaking region (−2.82 defined daily doses per 1,000 inhabitants per day (DID) per month, 95 %CI [−4.34, −1.30], p < 0.001) and the Italian-speaking region (−2.80 DID per month, 95 %CI [−4.78, −0.82], p < 0.01), followed by the German-speaking region (−1.72 DID per month, 95 %CI [−2.71, −0.74], p < 0.01). Similarly, in the ITS, the relative change of model estimates in antibiotic prescriptions by GPs and pediatricians for upper respiratory tract infections, was of −36.0 % and −50.3 % resp. in the pandemic period and +10.1 % and −2.6 % in the post-pandemic period compared with the pre-pandemic period. ConclusionsA decrease of antibiotic prescriptions was observed in GPs and pediatricians during the COVID-19 pandemic, followed by a return to pre-pandemic levels. The patterns in antibiotic prescriptions aligned with the epidemiology of respiratory infections and demonstrated a pronounced association with the implementation and subsequent removal of non-pharmaceutical interventions.

Impact of COVID-19 on referrals to paediatric liaison psychiatry at Children's Health Ireland at Crumlin as the pandemic moved to endemic status.

Rates of acute mental health presentations in youth were increasing pre-pandemic internationally. Longitudinal studies following COVID-19 attest to ongoing deterioration in youth mental health, recognising adverse unintended consequences following public health restrictions. To examine whether the initial post-COVID-19 increase in mental health presentations persisted following the reclassification of COVID-19 to endemic status, accompanied by the removal of most restrictions. All referrals to paediatric liaison psychiatry (PLP) between January 2018 and December 2022 in a Dublin tertiary children's hospital were included in the study. An interrupted time series analysis with autoregressive integrated moving average models was conducted, examining referrals with respect to different phases of COVID-19 and application of public health restrictions. Some 1385 referrals to PLP were received over the 5-year study. There was a significant decrease in PLP referrals immediately post-COVID-19, followed by a significant and sustained increase as the pandemic progressed and moved to endemic status. Public health restriction phases had a unique effect on those presenting with suicidal ideation, with a significant increase in the number of referrals. There was no effect of restrictions on other clinical profiles. Increased referrals for youth with mental health difficulties, reported during the COVID-19 pandemic, persisted into the early endemic stage, after COVID-19 public health restrictions ceased. Specific impacts of restrictions on suicidal ideation referrals require further study. Investment in child and adolescent mental health services remains a priority, and future pandemic response strategies need to examine unintended consequences of any enforced public health measure.

Changes in Mental Health Among Adolescents in South Korea Before and After COVID-19: An Interrupted Time Series Analysis From 2015 to 2022

PurposeThis study aimed to examine changes in mental health among adolescents by comparing data from the period following the onset of the COVID-19 pandemic with the period before the pandemic. MethodsWe estimated the annual prevalence of stress perception, depressive symptoms, and suicidal ideation among middle and high school students using data from the Korean Youth Health Behavior Survey spanning from 2015 to 2022. We then compared mental health status across 2 periods—pre-COVID-19 (2015–2019) and during COVID-19 (2020–2022)—employing an interrupted time series analysis. We adjusted for covariates, such as household economic status, residence type, self-rated health, and history of hospitalization, due to violence. ResultsWe analyzed data from 472,385 adolescents (242,819 boys and 230,016 girls). Stress perception, depressive symptoms, and suicidal ideation showed an increasing trend during the pre-COVID-19 period, followed by a decrease in the first year of the pandemic and an increasing trend in the second and third years. Boys experienced a faster increase in stress and depressive symptoms during the second and third years of the pandemic compared with the pre-COVID-19 period, whereas girls showed trends similar to those observed before the pandemic. Middle school students experienced a more rapid increase in these indicators than high school students during the second and third years. DiscussionAdolescents' mental health initially improved in the first year of COVID-19 but worsened during the second and third years of the pandemic. This suggests a need for intervention policies and programs to support adolescent mental health.

Reducing unnecessary outpatient group and screen testing at a regional cancer center.

Unnecessary group and screens (G&S) can lead to unnecessary antibody investigations, use of technologist time, and laboratory resources. A baseline audit at our institution identified that 25% of G&S from the cancer center were unnecessary. We aimed to reduce the ratio of monthly G&S to CBC samples processed from the cancer center by 10% (from 0.034 to 0.031) by January 2024. This represents an interrupted time series design from November 2022 to January 2024. Using Plan Do Study Act (PDSA) cycles, we aimed to increase the use of an existing reflex testing system, termed "do not test." When this option is selected, the blood bank will only process the G&S sample if specific CBC criteria are met (e.g., hemoglobin <9.0 g/dL). Educational sessions increased awareness of this feature and sought feedback from end-users on its usability. With feedback, the design was updated to include a modifiable hemoglobin threshold for G&S testing, automatic re-selection of the "do not test" feature for future G&S orders, and aesthetic changes to make the feature more visible. The percentage of samples with "do not test" selected increased from 7.2% to 63.0% (p < .0001) and the ratio of G&S to CBC specimens improved from 0.034 to 0.028, exceeding the target of 0.031. We noted an improvement in the appropriateness of G&S orders from 75% at baseline (n = 20) to 97.5% (n = 80) post intervention (p = .003). We describe an effective strategy to improve G&S utilization at our institution's cancer center using a reflex testing system.

Canada's Recreational Cannabis Legalization and Medical Cannabis Patient Activity, 2017-2022.

Objectives. To estimate changes in medical cannabis patient activity after Canada's recreational cannabis legalization. Methods. I used linear regressions of interrupted times series models to analyze medical cannabis patient registrations per 10 000 residents, purchases per 100 registrations, and packages per purchase in Canada's 10 provinces between April 2017 and December 2022. I tested relationships between the recreational law's passage in June 2018, recreational sales starting in October 2018, and the arrival of edibles and vapes in December 2019. Results. Medical patient registrations initially increased; they slowed after the law passed and started decreasing after edibles became available. Medical purchasing frequencies initially decreased; they decreased further in proportion to recreational sales but stabilized after edibles became available. Medical purchase sizes were initially stable; they began increasing after edibles became available. Conclusions. Canada saw substantial decreases in medical cannabis patient registrations, but the remaining patients stabilized their purchasing frequencies and increased their purchase sizes. Public Health Implications. Other countries might see significant changes in patient usage of their medical cannabis systems after nationwide recreational cannabis legalization. (Am J Public Health. Published online ahead of print October 3, 2024:e1-e8. https://doi.org/10.2105/AJPH.2024.307721).

Evaluating the effects, implementation experience and political economy of primary healthcare facility autonomy reforms within counties in Kenya: a mixed methods study protocol

IntroductionThere is a growing emphasis on improving primary healthcare (PHC) services and granting frontline service providers more decision-making autonomy. In October 2023, Kenya enacted legislation mandating nationwide facility autonomy. There...

Assessing the impact of the COVID-19 pandemic on the mental health–related hospitalization rate of youth in Canada: an interrupted time series analysis

Introduction This study evaluated the effect of the COVID-19 pandemic on temporal trends in mental health and addiction–related inpatient hospitalization rates among youth (aged 10–17 years) in Canadian provinces and territories (excluding Quebec) from 1 April 2018 to 5 March 2022. Methods We conducted an interrupted time series analysis across three periods: T0 (pre-pandemic: 1 April 2018 to 15 March 2020); T1 (early pandemic: 15 March 2020 to 5 July 2020); and T2 (later pandemic: 6 July 2020 to 5 March 2022). Results Pre-pandemic mental health and addiction–related hospitalization rates had significant regional variability, with weekly rates from 6.27 to 85.59 events per 100 000 persons in Manitoba and the territories combined, respectively. During T1, the national (excluding Quebec) weekly hospitalization rate decreased from a pre-pandemic level of 12.82 (95% CI: 12.14 to 13.50) to 5.11 (95% CI: 3.80 to 6.41) events per 100 000 persons. There was no statistically significant change in the mental health and addiction– related hospitalization rate across provinces and territories in T2 compared to T0. However, there was a significant increase in the rate of self-harm–related hospitalizations among females Canada-wide and in most provinces during this period. Conclusion Although several Canadian studies have reported increases in mental health and addiction–related outpatient and emergency department visits among youth during the COVID-19 pandemic, this did not correspond to an increase in the inpatient hospital burden, with the notable exception of self-harm among young females.

Impact of California's naloxone co-prescription law on emergency department visits, 30-day mortality, and prescription patterns.

Opioid overdose is a public health epidemic adversely impacting individuals and communities. To combat this, California passed a law mandating that prescribers offer a naloxone prescription in certain circumstances. Our objective was to evaluate associations with California's naloxone prescription mandate and emergency department (ED) overdose visits/hospitalizations, opioid and naloxone prescribing, and 30-day mortality. This retrospective cohort study included data from January 1, 2018, to December 31, 2019, and included all Kaiser Permanente Southern California (KPSC) members aged >10 years across 15 KPSC EDs. Exposure was defined as presentation to the ED within the study period. The primary outcome was ED visits for opioid overdose pre- and post-implementation of California's naloxone prescription mandate. A total of 1.1 million ED visits (534K pre/576K post) were included in the study population. ED opioid overdose visits were 344 (6.4/10,000) pre-policy and 351 (6.1/10,000) post-policy implementation, while non-opioid overdose visits were 309 (5.8/10,000) pre-implementation and 411 (7.1/10,000) post-implementation. The unadjusted rate of visits with opioid prescriptions decreased significantly (14.9% pre to 13.5% post) after implementation. ED naloxone prescriptions increased substantially (104 pre vs. 6031 post). Primary adjusted interrupted time series analysis found no statistical difference between monthly opioid overdose visits pre versus post (odds ratio 1.02, 95% confidence interval [CI] 0.98‒1.07). Difference-in-differences analysis revealed no significant changes in hospitalization (coefficient [CE]=‒0.05, 95% CI=‒0.11 to 0.02) or 30-day mortality (CE=‒0.01, 95% CI=‒0.03 to 0.01). This study revealed that the implementation of California's naloxone prescription mandate was associated with significantly increased naloxone prescribing and decreased opioid prescribing, but no significant change in ED opioid overdose visits, hospitalizations, or 30-day mortality. This indicates that increasing naloxone prescribing alone may not be sufficient to lower opioid overdose rates.

Impact of the COVID-19 pandemic on maternal, neonatal and child health service utilisation, delivery and health outcomes in Gauteng province, South Africa: an interrupted time series (ITS) analysis.

Gauteng was one of the provinces in South Africa most hit by COVID-19. However, there has been no assessment of the pandemic's impact on essential maternal, neonatal and child health (MNCH) services in Gauteng, for planning against future emergencies. This study sought to assess the impact of the COVID-19 pandemic on essential MNCH service utilisation, delivery and health outcomes in Gauteng province. We employed a quasi-experimental interrupted time series (ITS) study design, using the District Health Information System (DHIS) data set to evaluate the impact of COVID-19 on eight key MNCH indicators between March 2019 to February 2021. Using Stata V.17.0 and 5% alpha, a segmented linear regression (ITS) model quantified the trends of the indicators before COVID-19 (March 2019 to February 2020) (β1), the immediate change in level due to the March 2020 lockdown (β2), the post-lockdown (March 2020 to February 2021) trend (β4) and the change in gradient from before to after the lockdown (β3). COVID-19 lockdown exerted a significant decline in primary healthcare headcount<5 years (n) (β2= -60 106.9 (95% CI, -116 710.4; -3503.3), p=0.039); and postnatal care visits within 6 days (rate) (β2=-8.2 (95% CI, -12.4; -4.1), p=0.001). Antenatal care first visits before 20 weeks (rate) declined during COVID-19 (β3=-0.4 (95% CI, -0.7; -0.1), p=0.013) compared with the pre-COVID-19 period. COVID-19 adverse effects on service delivery (measles second dose coverage and fully immunised<1 year) and health outcomes (facility deaths 0-6 days, maternal mortality ratio and pneumonia case fatality<1 year) were insignificant. While some indicators post-lockdown attempted to recover, others deteriorated. In Gauteng province, the COVID-19 pandemic significantly disrupted essential MNCH service utilisation, particularly during the March 2020 lockdown. The mechanism of MNCH service disruption by COVID-19 was induced by both supply and demand services. It is imperative to strike a balance between maintaining routine healthcare services and managing an outbreak.