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PURPOSE: Long-term use of hydrochlorothiazide increases the risk of non-melanoma skin cancer. We aimed to evaluate potential changes in the use of hydrochlorothiazide in Switzerland after a direct healthcare professional communication (DHPC) in November 2018 by Swissmedic. METHODS: We performed interrupted time-series analyses using a large Swiss healthcare claims database (2015-2021). Within monthly intervals, we quantified the total number of claims and the total dispensed 'defined daily doses' (DDD) for preparations containing (1) hydrochlorothiazide, (2) angiotensin-converting enzyme (ACE) inhibitors and angiotensin-II-receptor blockers (ARB), (3) calcium-channel blockers (CCB) and (4) thiazide-like diuretics per 10 000 persons. Using segmented linear regression, we quantified the pre-DHPC trend, the immediate change and the post-DHPC change in trend for total claims and DDD for the four drug classes weighted for the demographic distribution of the Swiss population. RESULTS: ACE inhibitors and ARB were the most frequently claimed antihypertensive drugs with 300-400 claims per 10 000 persons, which increased by 5.4% during the study period. The average number of hydrochlorothiazide claims (157/10 000 persons in 2015) declined by 35% between 2015 and 2021. The decrease started prior to the DHPC, but the DHPC was associated with an immediate 6.1% decline and an accelerated decline in claims over time after the DHPC (similar results for DDD). This coincided with a 23% increase in claims of CCB (dihydropyridine type) over 7 years, whereas use of other antihypertensives increased less. CONCLUSION: Our results suggest that the DHPC by Swissmedic in 2018 accelerated a pre-existing decline in the use of hydrochlorothiazide in Switzerland.
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Antihipertensivos , Hidroclorotiazida , Análisis de Series de Tiempo Interrumpido , Neoplasias Cutáneas , Humanos , Suiza/epidemiología , Hidroclorotiazida/efectos adversos , Antihipertensivos/efectos adversos , Neoplasias Cutáneas/epidemiología , Masculino , Femenino , Persona de Mediana Edad , Anciano , Bases de Datos Factuales/estadística & datos numéricos , Adulto , Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Antagonistas de Receptores de Angiotensina/efectos adversos , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiologíaRESUMEN
Objective: To assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on protests by health workers. Methods: We conducted an interrupted time series analysis of data from 159 countries for 2 years before and after the World Health Organization classified COVID-19 as a pandemic in March 2020, thus between 2018 and 2022. We produced models examining two main outcomes: (i) the total weekly number of health worker protests globally; and (ii) the number of countries with one or more health worker protests in a given week. Findings: In total, there were 18 322 health worker protests in 133 countries between 2018 and 2022. The number of weekly health worker protests globally increased by 47% (30.1/63.5), an increase of 30.1 protests per week (95% confidence interval, CI: 11.7-48.6) at the onset of the COVID-19 pandemic. Furthermore, the number of countries experiencing such protests in a given week increased by 24% (5.7/24.1) following the declaration of the pandemic (an increase of 5.7 countries; 95% CI: 3.5-7.8). Conclusion: The pandemic increased the overall level of health worker protests globally as well as the number of countries experiencing such protests. These protests highlight discontent in the health workforce. Given the ongoing global health workforce crisis, understanding and addressing the drivers of health worker discontent is important for global health policy and security.
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COVID-19 , Personal de Salud , Análisis de Series de Tiempo Interrumpido , SARS-CoV-2 , Humanos , COVID-19/epidemiología , Pandemias , Salud GlobalRESUMEN
Background: China's National Essential Medicines Policy (NEMP) has been implemented for over 15 years; yet empirical evidence on its long-term impacts is lacking, particularly in remote and rural regions. This study aims to assess the short-and long-term effects of NEMP on the drug availability, price, and usage in a deprived rural county in southwestern China. Methods: A quasi-experimental design was employed, featuring a single-group pre-and-post comparison. We gathered 74,436 procurement records spanning from 2009 to 2016 from the drug warehouses of local medical institutions. Pharmaceutical data were analyzed quarterly, considering various policy and therapeutic attributes. Fisher's Drug Price Index (DPI-F) was calibrated for the retail and wholesale prices of a consistent collection of 405 medications. We conducted interrupted time-series analysis to examine the immediate and enduring impacts of NEMP's initial (commencing in January 2011) and second (starting from December 2015) stages. Results: After initiation of NEMP, the number of available essential medicines surged by 115 but subsequently faced a steady quarterly decline (-9.1) in township healthcare centers (THCs, primary care). Conversely, county hospitals (secondary care) initially saw a reduction of 40 in drug availability but later exhibited a steady increase (+4.2 per quarter) up to the second-stage NEMP. Regarding price, THCs encountered abrupt (-26.1%/-15.9% in retail/wholesale price) and sustained (-0.2%/-0.3% per quarter) price drops after NEMP. The immediate price change after NEMP in county hospitals were milder but significant in non-essential medicines, and long-term declines were also observed in all drugs. As for total sales, a significant long-term disparity emerged between THCs (+0.9% per quarter) and county hospitals (+3.3% per quarter). Following the second-stage NEMP, retail prices in county hospitals further decreased, although wholesale prices did not; however, following price upward trends were observed in both THCs and county hospitals. Lastly, the influences of NEMP varied across different therapeutical categories of medicines. Conclusion: NEMP has successfully regulated drug prices in primary and secondary healthcare facilities in remote and rural areas, both short-term and long-term. However, a remarkable disparity in medicine availability and utilization was observed between different levels of facilities over time. Continuous monitoring is essential, with increased attention needed on the uneven impacts of the policy on diverse drugs, facilities, regions, and demographics.
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Medicamentos Esenciales , Política de Salud , Análisis de Series de Tiempo Interrumpido , Población Rural , China , Medicamentos Esenciales/economía , Medicamentos Esenciales/provisión & distribución , Humanos , Población Rural/estadística & datos numéricos , Costos de los Medicamentos/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Comercio/estadística & datos numéricosRESUMEN
BACKGROUND: Key populations (KP), including men who have sex with men (MSM), female sex workers (FSW), and transgender women (TGW), experience a disproportionate burden of HIV, even in generalized epidemics like South Africa. Given this disproportionate burden and unique barriers to accessing health services, sustained provision of care is particularly relevant. It is unclear how the COVID-19 pandemic and its associated restrictions may have impacted this delivery. In this study, we aimed to describe patterns of engagement in HIV prevention and treatment services among KP in South Africa and assess the impact of different COVID-19 restriction levels on service delivery. METHODS: We leveraged programmatic data collected by the US President's Emergency Plan for AIDS Relief (PEPFAR)-supported KP partners in South Africa. We divided data into three discrete time periods based on national COVID-19 restriction periods: (i) Pre-restriction period, (ii) High-level restriction period, and (iii) After-high level restriction period. Primary outcomes included monthly total HIV tests, new HIV cases identified, new initiations of pre-exposure prophylaxis (PrEP), and new enrollments in antiretroviral therapy (ART). We conducted interrupted time series segmented regression analyses to estimate the impact of COVID-19 restrictions on HIV prevention and treatment service utilization. RESULTS: Between January 2018 and June 2022, there were a total of 231,086 HIV tests, 27,051 HIV positive cases, 27,656 pre-exposure prophylaxis (PrEP) initiations, and 15,949 antiretroviral therapy initiations among MSM, FSW and TGW in PEPFAR-supported KP programs in South Africa. We recorded 90,457 total HIV tests during the 'pre-restriction' period, with 13,593 confirmed new HIV diagnoses; 26,134 total HIV tests with 2,771 new diagnoses during the 'high-level restriction' period; and 114,495 HIV tests with 10,687 new diagnoses during the after high-level restriction period. Our Poisson regression model estimates indicate an immediate and significant decrease in service engagement at the onset of COVID-19 restrictions, including declines in HIV testing, treatment, and PrEP use, which persisted. As programs adjusted to the new restrictions, there was a gradual rebound in service engagement, particularly among MSM and FSW. Towards the end of the high-level restriction period, with some aspects of daily life returning to normal but others still restricted, there was more variability. Some indicators continued to improve, while others stagnated or decreased. CONCLUSION: Service provision rebounded from the initial shock created by pandemic-related restrictions, and HIV services were largely maintained for KP in South Africa. These results suggest that HIV service delivery among programs designed for KP was able to be flexible and resilient to the evolving restrictions. The results of this study can inform plans for future pandemics and large-scale disruptions to the delivery of HIV services.
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COVID-19 , Infecciones por VIH , Análisis de Series de Tiempo Interrumpido , Humanos , Sudáfrica/epidemiología , COVID-19/prevención & control , COVID-19/epidemiología , Infecciones por VIH/prevención & control , Infecciones por VIH/epidemiología , Masculino , Femenino , Adulto , Trabajadores Sexuales/estadística & datos numéricos , Accesibilidad a los Servicios de Salud , Personas Transgénero/estadística & datos numéricos , Homosexualidad Masculina/estadística & datos numéricosRESUMEN
BACKGROUND: Increased length of stay after surgery is associated with increased healthcare utilization and adverse patient outcomes. While enhanced recovery after surgery (ERAS) protocols have been shown to reduce length of stay after colorectal surgery in trial settings, their effectiveness in real-world settings is more uncertain. The aim of this study was to assess the impact of ERAS protocol implementation on length of stay after colorectal surgery, using real-world data. METHODS: In 2012, ERAS protocols were introduced at 15 Ontario hospitals as part of the iERAS study. A cohort of patients undergoing colorectal surgery treated at these hospitals between 2008 and 2019 was created using health administrative data. Mean length of stay was computed for the intervals before and after ERAS implementation. Interrupted time series analyses were performed for predefined subgroups, namely all colorectal surgery, colorectal surgery without complications, right-sided colorectal surgery, and left-sided colorectal surgery. Sensitivity analyses were then conducted using adjusted length of stay, accounting for length of stay predictors, including: patient age, sex, marginalization, co-morbidities, and diagnosis; surgeon volume of cases, years in practice, and colorectal surgery expertise; hospital volume; and other contextual factors, including procedure type and timing, surgical approach, and in-hospital complications. RESULTS: A total of 32 612 patients underwent colorectal surgery during the study interval. ERAS implementation led to a decrease in length of stay of 1.05 days (13.7%). Larger decreases in length of stay were seen with more complex surgeries, with a level change of 1.17 days (15.6%) noted for the subgroup of patients undergoing left-sided colorectal surgery. The observed decreases in length of stay were durable for the length of the study interval in all analyses. When adjusting for predictors of length of stay, the effect of ERAS implementation on length of stay was larger (reduction of 1.46 days). CONCLUSION: Introducing formal ERAS protocols reduces length of stay after colorectal surgery significantly, independent of temporal trends toward decreasing length of stay. These effects are durable, demonstrating that ERAS protocol implementation is an effective hospital-level intervention to reduce length of stay after colorectal surgery.
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Recuperación Mejorada Después de la Cirugía , Tiempo de Internación , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Ontario , Cirugía Colorrectal , Análisis de Series de Tiempo Interrumpido , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Protocolos Clínicos , Recto/cirugíaRESUMEN
BACKGROUND: Overcrowded emergency departments (EDs) are associated with higher morbidity and mortality and suboptimal quality-of-care. Most ED flow management strategies focus on early identification and redirection of low-acuity patients to primary care settings. To assess the impact of redirecting low-acuity ED patients to medical clinics using an electronic clinical decision support system on four ED performance indicators. METHODS: We performed a retrospective observational study in the ED of a Canadian tertiary trauma center where a redirection process for low-acuity patients was implemented. The process was based on a clinical decision support system relying on an algorithm based on chief complaint, performed by nurses at triage and not involving physician assessment. All patients visiting the ED from 2013 to 2017 were included. We compared ED performance indicators before and after implementation of the redirection process (June 2015): length-of-triage, time-to-initial-physician-assessment, length-of-stay and rate of patients leaving without being seen. We performed an interrupted time series analysis adjusted for age, gender, time of visit, triage category and overcrowding. RESULTS: Of 242,972 ED attendees over the study period, 9546 (8% of 121,116 post-intervention patients) were redirected to a nearby primary medical clinic. After the redirection process was implemented, length-of-triage increased by 1 min [1;2], time-to-initial assessment decreased by 13 min [-16;-11], length-of-stay for non-redirected patients increased by 29 min [13;44] (p < 0.001), minus 20 min [-42;1] (p = 0.066) for patients assigned to triage 5 category. The rate of patients leaving without being seen decreased by 2% [-3;-2] (p < 0.001). CONCLUSION: Implementing a redirection process for low-acuity ED patients based on a clinical support system was associated with improvements in two of four ED performance indicators.
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Servicio de Urgencia en Hospital , Triaje , Humanos , Estudios Retrospectivos , Femenino , Masculino , Persona de Mediana Edad , Adulto , Sistemas de Apoyo a Decisiones Clínicas , Aglomeración , Gravedad del Paciente , Tiempo de Internación/estadística & datos numéricos , Anciano , Indicadores de Calidad de la Atención de Salud , Canadá , Análisis de Series de Tiempo InterrumpidoRESUMEN
BACKGROUND: Little is known about the trends in morbidity and mortality at the population level that followed the introduction of newer once-daily long-acting bronchodilators for COPD. The purpose of the study was to evaluate whether the availability of new bronchodilators was associated with changes in the temporal trends in severe COPD exacerbations and mortality between 2007 and 2018 in the older population with COPD; and whether this association was homogeneous across sex and socioeconomic status classes. METHODS: We used an interrupted time-series and three segments multivariate autoregressive models to evaluate the adjusted changes in slopes (i.e., trend effect) in monthly severe exacerbation and mortality rates after 03/2013 and 02/2015 compared to the tiotropium period (04/2007 to 02/2013). Cohorts of individuals > 65 years with COPD were created from the nationally representative database of the Quebec Integrated Chronic Disease Surveillance System in the province of Quebec, Canada. Whether these trends were similar for men and women and across different socioeconomic status classes was also assessed. RESULTS: There were 130,750 hospitalizations for severe exacerbation and 104,460 deaths, including 24,457 (23.4%) respiratory-related deaths, over the study period (928,934 person-years). Significant changes in trends were seen after 03/2013 for all-cause mortality (-1.14%/month;95%CI -1.90% to -0.38%), which further decreased after 02/2015 (-1.78%/month;95%CI -2.70% to -0.38%). Decreases in respiratory-related mortality (-2.45%/month;95%CI -4.38% to -0.47%) and severe exacerbation (-1,90%/month;95%CI -3.04% to -0.75%) rates were only observed after 02/2015. These observations tended to be more pronounced in women than in men and in higher socioeconomic status groups (less deprived) than in lower socioeconomic status groups (more deprived). CONCLUSIONS: The arrival of newer bronchodilators was chronologically associated with reduced trends in severe exacerbation, all-cause and respiratory-related mortality rates among people with COPD > 65 years. Our findings document population benefits on key patient-relevant outcomes in the years following the introduction of newer once-daily long-acting bronchodilators and their combinations, which were likely multifactorial. Public health efforts should focus on closing the gap between lower and higher socioeconomic status groups.
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Broncodilatadores , Progresión de la Enfermedad , Enfermedad Pulmonar Obstructiva Crónica , Humanos , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Enfermedad Pulmonar Obstructiva Crónica/mortalidad , Masculino , Femenino , Broncodilatadores/uso terapéutico , Anciano , Quebec/epidemiología , Anciano de 80 o más Años , Hospitalización/estadística & datos numéricos , Bromuro de Tiotropio/uso terapéutico , Estudios de Cohortes , Análisis de Series de Tiempo Interrumpido , Causas de Muerte , Clase SocialRESUMEN
Introduction: The COVID-19 pandemic triggered global health crises, affecting population health directly through infections and fatalities, and indirectly by increasing the burden of chronic diseases due to disrupted healthcare access and altered lifestyle behaviors. Amidst these challenges, concerns regarding reproductive health and fertility rates have emerged, necessitating an understanding of their implications for policymaking and healthcare planning. Furthermore, Kazakhstan's healthcare landscape underwent significant changes with the reintroduction of compulsory social health insurance system in January 2020, coinciding with the onset of the COVID-19 pandemic. This study aims to assess the impact of the COVID-19 pandemic and compulsory social health insurance system on fertility rates in Kazakhstan by examining live birth data from 2019 to 2024. Methods: Using Interrupted Time Series analysis, we evaluated the effect of the COVID-19 lockdown announcement and compulsory social health insurance system implementation on monthly birth rates, adjusted for the number of women of reproductive age from January 2019 to December 2023. Results: In the final model, the coefficients were as follows: the effect of the COVID-19 lockdown was estimated at 469 (SE = 2600, p = 0.8576); the centering variable was estimated at 318 (SE = 222, p = 0.1573), suggesting no significant trend in monthly birth rates over time; the insurance effect was estimated at 7,050 (SE = 2,530, p < 0.01); and the effect of the number of women of reproductive age was estimated at -0.204 (SE = 0.0831, p = 0.01). Discussion: The implementation of the compulsory social health insurance system, rather than the announcement of the COVID-19 lockdown, has had a significant positive impact on live birth rates in Kazakhstan. However, despite governmental efforts, live birth rates are declining, potentially due to unaddressed health needs of fertile women and economic challenges. Urgent policy-level actions are needed to address gaps in healthcare services and promote reproductive health.
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Tasa de Natalidad , COVID-19 , Análisis de Series de Tiempo Interrumpido , Nacimiento Vivo , Humanos , Kazajstán/epidemiología , COVID-19/epidemiología , Tasa de Natalidad/tendencias , Femenino , Adulto , Nacimiento Vivo/epidemiología , Seguro de Salud/estadística & datos numéricos , Pandemias , SARS-CoV-2 , EmbarazoRESUMEN
BACKGROUND: Kenya introduced a monovalent rotavirus vaccine administered orally at 6 and 10 weeks of age into her National Immunization Program in July 2014. The study evaluated the long-term impact of the vaccine on hospitalization for all-cause and rotavirus-specific acute gastroenteritis (AGE) and strain epidemiology in Kenya. METHODS: Data on all-cause and rotavirus-specific AGE and strain distribution were derived from an eleven-year hospital-based surveillance of AGE among children aged <5 years at Kiambu County Teaching and Referral Hospital (KCTRH) in Central Kenya between 2009 and 2020. Fecal samples were screened for group A rotavirus using ELISA and genotyped using multiplex semi-nested RT-PCR. Trends in all-cause and rotavirus-related AGE and strain distribution were compared between the pre-vaccine (July 2009-June 2014), early post-vaccine (July 2014-June 2016) and late post-vaccine (February 2019-October 2020) periods. RESULTS: Rotavirus-specific AGE was detected at 27.5% (429/1546, 95% CI: 25.5-30.1%) in the pre-vaccine period; 13.8% (91/658, 95% CI: 11.3-16.6%) in the early post-vaccine period (July 2014-June 2016); and 12.0% (229/1916, 95% CI: 10.6-13.5%) in the late post-vaccine period (February 2019-October 2020). This amounted to a decline of 49.8% (95% CI: 34.6%-63.7%) in rotavirus-specific AGE in the early post-vaccine period and 53.4% (95% CI: 41.5-70.3%) in the late post-vaccine period when compared to the pre-vaccine period. All-cause AGE hospitalizations declined by 40.2% (95% CI: 30.8%-50.2%) and 75.3% (95% CI: 65.9-83.1%) in the early post-vaccine and late post-vaccine periods, respectively, when compared to the pre-vaccine period. G3P [8] was the predominant strain in the late post-vaccine period, replacing G1P[8] which had predominated in the pre-vaccine and early post-vaccine periods. Additionally, we detected considerable proportions of uncommon strains G3P[6] (4.8%) and G12P[6] (3.5%) in the post-vaccine era. CONCLUSION: Rotavirus vaccination has resulted in a significant decline in all-cause and rotavirus-specific AGE, and thus, provides strong evidence for public health policy makers in Kenya to support the sustained use of the rotavirus vaccine in routine immunization. However, the shift in strain dominance and age distribution of rotavirus AGE in the post-vaccine era underscores the need for continued surveillance to assess any possible vaccine-induced selective pressure that could diminish the vaccine effectiveness over time.
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Gastroenteritis , Programas de Inmunización , Análisis de Series de Tiempo Interrumpido , Infecciones por Rotavirus , Vacunas contra Rotavirus , Rotavirus , Vacunación , Humanos , Vacunas contra Rotavirus/administración & dosificación , Vacunas contra Rotavirus/inmunología , Infecciones por Rotavirus/prevención & control , Infecciones por Rotavirus/epidemiología , Gastroenteritis/epidemiología , Gastroenteritis/virología , Gastroenteritis/prevención & control , Kenia/epidemiología , Preescolar , Rotavirus/inmunología , Rotavirus/genética , Lactante , Vacunación/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Femenino , Heces/virología , Masculino , Genotipo , Vacunas Atenuadas/inmunología , Vacunas Atenuadas/administración & dosificaciónRESUMEN
OBJECTIVE: The aim of this study was to examine the association between prolonged time in the COVID-19 pandemic and rates of positive routine suicide screens among youth accessing healthcare in the pediatric emergency department. METHODS: Participants were English- and Spanish-speaking youth aged 10-18 years presenting without an acute mental/behavioral health concern to the emergency department or urgent care of a large hospital system, serving a 7-state region, who completed routine screening for suicide risk. Visits between March 1, 2019 and December 31, 2021 were included. We conducted a quasi-experimental interrupted time series analysis and categorized visits into the prepandemic year, COVID-19 year 1 (Y1), and COVID-19 year 2 (Y2). The primary outcome measure was rate of positive suicide screen. RESULTS: A total of 33,504 children completed routine suicide screening; 2689 children had a positive screen. The overall rate of positive suicide screens increased throughout the pandemic compared with baseline (7.5% prepandemic, 8.4% Y1, 9.3% Y2; P < 0.01). Rates of positive suicide screens in Y1 increased 0.04% per week and surpassed prepandemic rates, then decreased 0.1% per week throughout Y2 ( P < 0.01), during a time when social distancing mitigation efforts decreased. CONCLUSIONS: Cumulative time in the COVID-19 pandemic was associated with increased positive suicide screens in children. School reopening and normalization of social routines preceded an observed negative trend in rates of positive suicide screens in Y2 of the pandemic. This study demonstrates fluctuating trends in suicide screen positivity, potentially influenced by social distancing and public health measures. Our study may support that maintaining social connectedness and access to school-based or community resources may be a protective factor for youth suicide risk during a pandemic or other natural occurrence.
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COVID-19 , Servicio de Urgencia en Hospital , Tamizaje Masivo , Humanos , COVID-19/epidemiología , COVID-19/prevención & control , COVID-19/psicología , Niño , Servicio de Urgencia en Hospital/estadística & datos numéricos , Adolescente , Masculino , Femenino , Tamizaje Masivo/métodos , Salud Pública , Suicidio/estadística & datos numéricos , Suicidio/psicología , Análisis de Series de Tiempo Interrumpido , SARS-CoV-2 , Prevención del Suicidio , PandemiasRESUMEN
Importance: Deliberate self-poisoning using pesticides as a means of suicide is an important public health problem in low- and middle-income countries. Three highly toxic pesticides-dimethoate, fenthion, and paraquat-were removed from the market in Sri Lanka between 2008 and 2011. In 2015, less toxic pesticides (chlorpyrifos, glyphosate, carbofuran, and carbaryl) were restricted. Subsequent outcomes have not been well described. Objective: To explore the association of pesticide bans with pesticide self-poisonings and in-hospital deaths. Design, Setting, and Participants: In this cross-sectional study with an interrupted time series design, data were prospectively collected on all patients with deliberate self-poisonings presenting to 10 Sri Lankan hospitals between March 31, 2002, and December 31, 2019, and analyzed by aggregated types of poisoning. The correlates of pesticide bans were estimated within the pesticide group and on self-poisonings within other substance groups. The data analysis was performed between April 1, 2002, and December 31, 2019. Exposures: Implementation of 2 sets of pesticide bans. Main Outcomes and Measures: The main outcomes were changes in hospital presentations and in-hospital deaths related to pesticide self-poisoning as measured using segmented Poisson regression. Results: A total of 79â¯780 patients (median [IQR] age, 24 [18-34] years; 50.1% male) with self-poisoning from all causes were admitted to the study hospitals, with 29â¯389 poisonings (36.8%) due to pesticides. A total of 2859 patients died, 2084 (72.9%) of whom had ingested a pesticide. The first restrictions that targeted acutely toxic, highly hazardous pesticides were associated with an abrupt and sustained decline of the proportion of poisonings with pesticides (rate ratio [RR], 0.85; 95% CI, 0.78-0.92) over the study period and increases in poisonings with medications (RR, 1.11; 95% CI, 1.02-1.21) and household and industrial chemicals (RR, 1.20; 95% CI, 1.05-1.36). The overall case fatality of pesticides significantly decreased (RR, 0.33; 95% CI, 0.26-0.42) following the implementation of the 2008 to 2011 restrictions of highly hazardous pesticides. Following the 2015 restrictions of low-toxicity pesticides, hospitalizations were unchanged, and the number of deaths increased (RR, 1.98; 95% CI, 1.39-2.83). Conclusions and Relevance: These findings support the restriction of acutely toxic pesticides in resource-poor countries to help reduce hospitalization for and deaths from deliberate self-poisonings and caution against arbitrary bans of less toxic pesticides while more toxic pesticides remain available.
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Plaguicidas , Humanos , Sri Lanka/epidemiología , Plaguicidas/envenenamiento , Masculino , Femenino , Estudios Transversales , Adulto , Persona de Mediana Edad , Intoxicación/epidemiología , Intoxicación/mortalidad , Suicidio/estadística & datos numéricos , Mortalidad Hospitalaria , Adulto Joven , Análisis de Series de Tiempo Interrumpido , Intento de Suicidio/estadística & datos numéricos , Adolescente , Estudios ProspectivosRESUMEN
Interrupted time series (ITS) designs are increasingly used for estimating the effect of shocks in natural experiments. Currently, ITS designs are often used in scenarios with many time points and simple data structures. This research investigates the performance of ITS designs when the number of time points is limited and with complex data structures. Using a Monte Carlo simulation study, we empirically derive the performance-in terms of power, bias and precision- of the ITS design. Scenarios are considered with multiple interventions, a low number of time points and different effect sizes based on a motivating example of the learning loss due to COVID school closures. The results of the simulation study show the power of the step change depends mostly on the sample size, while the power of the slope change depends on the number of time points. In the basic scenario, with both a step and a slope change and an effect size of 30% of the pre-intervention slope, the required sample size for detecting a step change is 1,100 with a minimum of twelve time points. For detecting a slope change the required sample size decreases to 500 with eight time points. To decide if there is enough power researchers should inspect their data, hypothesize about effect sizes and consider an appropriate model before applying an ITS design to their research. This paper contributes to the field of methodology in two ways. Firstly, the motivation example showcases the difficulty of employing ITS designs in cases which do not adhere to a single intervention. Secondly, models are proposed for more difficult ITS designs and their performance is tested.
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COVID-19 , Análisis de Series de Tiempo Interrumpido , Método de Montecarlo , Pandemias , Instituciones Académicas , COVID-19/epidemiología , COVID-19/prevención & control , Humanos , SARS-CoV-2/aislamiento & purificación , Aprendizaje , Simulación por Computador , Tamaño de la MuestraRESUMEN
AIM: To study the use of a quasi-experimental design to assess the effects of scaling reimbursement policies on the incidence of chronic-periodontitis procedures. MATERIALS AND METHODS: Interrupted time series analysis was used to compare the effects before and after policy implementation using data on the number of periodontitis-related procedures from the Korean National Health Insurance Service-National Sample Cohort (n = 740,467) and the Health Screening Cohort (n = 337,904). Periodontitis-related procedures with diagnosis codes were categorized into basic (scaling or root planing), intermediate (subgingival curettage) and advanced (tooth extraction, periodontal flap surgery, bone grafting for alveolar bone defects or guided tissue regeneration). Subjects' demographics and comorbidities were considered. The incidence rate of immediate changes and gradual effects before and after policy implementation was assessed. RESULTS: Following the policy implementation from July 2013, an immediate increase was observed in total and basic procedures. No significant changes were noted in intermediate and advanced procedures initially. A decrease in the slope of intermediate procedures was observed in both databases. Advanced procedures showed varied trends, with no change in the National Sample Cohort but an increase in the Health Screening Cohort, particularly among subjects with comorbidities. CONCLUSIONS: Following the new policy implementation, the number of intermediate procedures decreased while the number of advanced procedures increased, especially among patients with comorbidities. These findings offer valuable insights on policy evaluation.
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Periodontitis Crónica , Raspado Dental , Análisis de Series de Tiempo Interrumpido , Humanos , Masculino , Femenino , República de Corea , Persona de Mediana Edad , Periodontitis Crónica/economía , Adulto , Raspado Dental/economía , Política de Salud , Anciano , Estudios de Cohortes , Reembolso de Seguro de Salud/estadística & datos numéricos , Mecanismo de ReembolsoRESUMEN
Importance: Local-level data are needed to understand whether the relaxation of X-waiver training requirements for prescribing buprenorphine in April 2021 translated to increased buprenorphine treatment. Objective: To assess whether relaxation of X-waiver training requirements was associated with changes in the number of clinicians waivered to and who prescribe buprenorphine for opioid use disorder and the number of patients receiving treatment. Design, Setting, and Participants: This serial cross-sectional study uses an interrupted time series analysis of 2020-2022 data from the HEALing Communities Study (HCS), a cluster-randomized, wait-list-controlled trial. Urban and rural communities in 4 states (Kentucky, Massachusetts, New York, and Ohio) with a high burden of opioid overdoses that had not yet received the HCS intervention were included. Exposure: Relaxation of X-waiver training requirements (ie, allowing training-exempt X-waivers) on April 28, 2021. Main Outcomes and Measures: The monthly number of X-waivered clinicians, X-waivered buprenorphine prescribers, and patients receiving buprenorphine were each summed across communities within a state. Segmented linear regression models to estimate pre- and post-policy change by state were used. Results: The number of individuals in 33 participating HCS communities included 347â¯863 in Massachusetts, 815â¯794 in Kentucky, 971â¯490 in New York, and 1â¯623â¯958 in Ohio. The distribution of age (18-35 years: range, 29.4%-32.4%; 35-54 years: range, 29.9%-32.5%; ≥55 years: range, 35.7%-39.3%) and sex (female: range, 51.1%-52.6%) was similar across communities. There was a temporal increase in the number of X-waivered clinicians in the pre-policy change period in all states, which further increased in the post-policy change period in each state except Ohio, ranging from 5.2% (95% CI, 3.1%-7.3%) in Massachusetts communities to 8.4% (95% CI, 6.5%-10.3%) in Kentucky communities. Only communities in Kentucky showed an increase in the number of X-waivered clinicians prescribing buprenorphine associated with the policy change (relative increase, 3.2%; 95% CI, 1.5%-4.9%), while communities in other states showed no change or a decrease. Similarly, only communities in Massachusetts experienced an increase in patients receiving buprenorphine associated with the policy change (relative increase, 1.7%; 95% CI, 0.8%-2.6%), while communities in other states showed no change. Conclusions and Relevance: In this serial cross-sectional study, relaxation of X-waiver training requirements was associated with an increase in the number of X-waivered clinicians but was not consistently associated with an increase in the number of buprenorphine prescribers or patients receiving buprenorphine. These findings suggest that training requirements may not be the primary barrier to expanding buprenorphine treatment.
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Buprenorfina , Tratamiento de Sustitución de Opiáceos , Trastornos Relacionados con Opioides , Pautas de la Práctica en Medicina , Buprenorfina/uso terapéutico , Humanos , Estudios Transversales , Pautas de la Práctica en Medicina/estadística & datos numéricos , Massachusetts , Tratamiento de Sustitución de Opiáceos/métodos , Trastornos Relacionados con Opioides/tratamiento farmacológico , Ohio , Masculino , Femenino , New York , Adulto , Análisis de Series de Tiempo Interrumpido , Kentucky , Persona de Mediana Edad , Analgésicos Opioides/uso terapéutico , Antagonistas de Narcóticos/uso terapéuticoRESUMEN
BACKGROUND: Federal deregulation of opioid agonist therapies are an attractive policy option to improve access to opioid use disorder care and achieve widespread beneficial impacts on growing opioid-related harms. There have been few evaluations of such policy interventions and understanding effects can help policy planning across jurisdictions. METHODS: Using health administrative data from eight of ten Canadian provinces, this study evaluated the impacts of Health Canada's decision in May 2018 to rescind the requirement for Canadian health professionals to obtain an exemption from the Canadian Drugs and Substance Act to prescribe methadone for opioid use disorder. Over the study period of June 2017 to May 2019, we used descriptive statistics to capture overall trends in the number of agonist therapy prescribers across provinces and we used interrupted time series analysis to determine the effect of this decision on the trajectories of the agonist therapy prescribing workforces. RESULTS: There were important baseline differences in the numbers of agonist therapy prescribers. The province with the highest concentration of prescribers had 7.5 more prescribers per 100,000 residents compared to the province with the lowest. All provinces showed encouraging growth in the number of prescribers through the study period, though the fastest growing province grew 4.5 times more than the slowest. Interrupted time series analyses demonstrated a range of effects of the federal policy intervention on the provinces, from clearly positive changes to possibly negative effects. CONCLUSIONS: Federal drug regulation policy change interacted in complex ways with provincial health professional regulation and healthcare delivery, kaleidoscoping the effects of federal policy intervention. For Canada and other health systems such as the US, federal policy must account for significant subnational variation in OUD epidemiology and drug regulation to maximize intended beneficial effects and mitigate the risks of negative effects.
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Política de Salud , Análisis de Series de Tiempo Interrumpido , Metadona , Tratamiento de Sustitución de Opiáceos , Trastornos Relacionados con Opioides , Humanos , Canadá , Metadona/uso terapéutico , Trastornos Relacionados con Opioides/tratamiento farmacológico , Trastornos Relacionados con Opioides/epidemiología , Tratamiento de Sustitución de Opiáceos/estadística & datos numéricos , Analgésicos Opioides/uso terapéutico , Control de Medicamentos y Narcóticos/legislación & jurisprudencia , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/tendenciasRESUMEN
PURPOSE: There is limited evidence regarding the impact of public health restrictions on hip fracture hospitalization by place of fracture occurrence. This study aimed to examine the impact of COVID-19 public health restrictions on fall-related hip fracture hospitalization rates by place of occurrence. METHODS: This retrospective cohort study was conducted using hospitalization data in New South Wales, Australia, between January 2014 and June 2022. Older adults aged ≥65 years admitted to hospital following a fall-related hip fracture. An interrupted time-series analysis using autoregressive integrated moving average models evaluated the impact of public health restrictions on fall-related hip fracture hospitalization by place of fracture occurrence (home/residence, residential aged care facility (RACF), or away from usual residence). RESULTS: The mean observed fall-related hip fracture hospitalization rate during COVID-19 public health restrictions (36.3 per 100,000 people per month) was 13.4 % lower than the forecasted rate (41.1 per 100,000 people per month). The mean observed hospitalization rates for fall-related hip fractures at home/residence, at a RACF, and away from the usual residence were 3.8 %, 18.5 %, and 40.1 % lower than the forecasted rates, respectively. Level changes in the fall-related hip fracture hospitalization rates at RACFs and away from usual residences were -0.9 per 100,000 people per month (95 % CI -1.6 to -0.2) and -1.7 per 100,000 people per month (95 % CI -2.5 to -0.9), respectively. CONCLUSIONS: There was a decline in fall-related hip fracture hospitalization rates among older adults, where the fracture occurred at RACFs and away from a person's usual residence during COVID-19 public health restrictions.
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Accidentes por Caídas , COVID-19 , Fracturas de Cadera , Hospitalización , Análisis de Series de Tiempo Interrumpido , Salud Pública , Humanos , COVID-19/epidemiología , COVID-19/prevención & control , Fracturas de Cadera/epidemiología , Hospitalización/estadística & datos numéricos , Accidentes por Caídas/estadística & datos numéricos , Accidentes por Caídas/prevención & control , Anciano , Femenino , Masculino , Anciano de 80 o más Años , Estudios Retrospectivos , SARS-CoV-2 , Nueva Gales del Sur/epidemiologíaRESUMEN
There is abundant research showing the disproportionate impacts of violence on health in disadvantaged neighborhoods, making an understanding of recent violent crime trends essential for promoting health equity. Carjackings have been of particular interest in the media, although little research has been undertaken on this violent crime. We use interrupted time series models to examine the impact of the police killing of George Floyd on the spatiotemporal patterns of carjacking in Minneapolis in relation to neighborhood disadvantage. To provide grounding, we compare our results to the well-studied patterns of homicides. Results indicate that carjackings both increased and dispersed spatially after the murder of George Floyd and subsequent social unrest, more so than homicides. Socially disadvantaged neighborhoods experienced the greatest absolute increase while more advantaged neighborhoods saw a greater relative increase. The challenge ahead is to identify policy responses that will effectively curb such violence without resorting to harsh and inequitable policing and sentencing practices.
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Homicidio , Análisis de Series de Tiempo Interrumpido , Policia , Humanos , Homicidio/estadística & datos numéricos , Homicidio/tendencias , Policia/estadística & datos numéricos , Características de la Residencia/estadística & datos numéricos , Violencia/estadística & datos numéricosRESUMEN
Controls on essential/precursor chemicals from commercial companies have been associated with many large downturns in illicit drug markets and attendant problems. My colleagues and I brought this to light in the studies that are the subject of Giommoni's review. McKetin et al. in an earlier review considered several of our studies on chemical controls for methamphetamine, all centered in North America. Giommoni discusses not only those studies but also our later work on chemical controls for cocaine and heroin. This later work evaluates US essential/precursor chemical policies targeting illicit drug producers outside of North America, and it examines impacts on illicit drug availability and use (the studies reviewed by McKetin et al. predominantly focused on outcomes such as drug-related hospitalizations, arrests, and treatment). Giommoni's review is a new resource that will help make the varied topics in essential/precursor chemical control research more accessible to many readers. After noting this, I discuss some common methodological misconceptions about our studies. For example, our studies generally used multi-replication interrupted time series analysis, a research design among the most powerful of all quasi-experimental designs. Authors, however, typically discuss the studies as if they used single-intervention interrupted time series analysis, a less powerful design. Multi-replication and single-intervention interrupted time series analyses also differ regarding likely confounders; awareness of this is critical to accurately assessing our findings and critiquing alternative explanations. Finally, I note that commercial chemical companies function as the silent, albeit usually unwitting, partners in the large-scale production of several illicit drugs, including fentanyl. And many governments are implementing essential/precursor chemical controls to help stymie this partnership. But they are doing so largely without evaluation and study-a poor policy practice. To remedy this, I suggest establishing multi-disciplinary applied research teams to help assess, guide and improve essential/precursor chemical control efforts.
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Control de Medicamentos y Narcóticos , Drogas Ilícitas , Análisis de Series de Tiempo Interrumpido , Humanos , Control de Medicamentos y Narcóticos/legislación & jurisprudencia , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/prevención & controlRESUMEN
BACKGROUND: Between June and November 2017, four supervised consumption sites (SCS) began operating in Montreal, Quebec. Earlier studies on SCS focused on examining their effects on blood-borne viral infections and overdose mortality. Our objective was to examine the effect of Montreal's SCS on the incidence, health service use and outcomes of injection-related infections (IRI) in people who inject drugs. METHODS: We used Quebec's provincial administrative health data to identify people who inject drugs in Montreal and calculated the incidence of IRI in this population between December 2014 and December 2019. We conducted a retrospective, population-based interrupted time series to estimate the effect of Montreal's four SCS on the monthly incidence rates of IRI-related hospitalizations, emergency department (ED) visits, physician visits, and mortality. We also examined the effects of SCS on average length of IRI-related hospitalizations and incidence of hospitalizations involving surgery. RESULTS: The average age of Montreal's people who inject drugs was 41.84 years, and 66.41% were male. After the implementation of SCS, there was a positive level change in the incidence of hospitalizations (0.97; 95% confidence interval [CI]: 0.26, 1.68) for IRI. There was also a significant post-intervention decline in hospitalization trends (-0.05; 95% CI: -0.08, -0.02), with modest trend changes in ED visits (-0.02; 95% CI: -0.05, 0.02). However, post-intervention changes in level (0.72; 95% CI: -3.85, 5.29) and trend (0.06; 95% CI: -0.23, 0.34) for physician visits remained limited. SCS had no effect on the average length of hospitalizations, but there was a decreasing post-intervention trend in hospitalizations involving surgery (-0.03; 95% CI: -0.06, 0.00). CONCLUSION: Following the opening of the SCS, there was a moderate decline in the rate of hospitalizations to treat IRI, but the impact of the sites on the rate of physician visits remained limited. These findings suggest that SCS may mitigate the incidence of more serious and complicated IRI over time.
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Hospitalización , Análisis de Series de Tiempo Interrumpido , Abuso de Sustancias por Vía Intravenosa , Humanos , Masculino , Femenino , Quebec/epidemiología , Adulto , Abuso de Sustancias por Vía Intravenosa/complicaciones , Abuso de Sustancias por Vía Intravenosa/epidemiología , Hospitalización/estadística & datos numéricos , Estudios Retrospectivos , Incidencia , Persona de Mediana Edad , Servicio de Urgencia en Hospital/estadística & datos numéricos , Programas de Intercambio de AgujasRESUMEN
Importance: Despite the proliferation of pharmacy standing-order naloxone dispensing across many US states before the change to over-the-counter status, few policy analyses have evaluated the implementation of pharmacy naloxone standing orders in addressing opioid overdose fatality among communities. Objective: To determine whether the implementation of pharmacy standing-order naloxone was associated with lower opioid fatality rates compared with communities without pharmacies with standing-order naloxone. Design, Setting, and Participants: This retrospective multisite study was conducted with an interrupted time series analysis across 351 municipalities in Massachusetts over 24 quarters (from January 1, 2013, through December 31, 2018). Standing-order naloxone dispensing data were collected from 2 sources for all major chain pharmacies and many independent pharmacies, covering 70% of retail pharmacies in Massachusetts. Municipalities had various standing-order naloxone implementation inceptions during the study period. Data were analyzed from December 2021 to November 2023. Exposure: The main exposure was measured by the first quarter with standing-order naloxone dispensation as the actual implementation inception. Main Outcomes and Measures: The primary study outcome was municipal opioid fatality rate per 100â¯000 population obtained from the Massachusetts Registry of Vital Records and Statistics. Results: The median (IQR) population size across 351 municipalities was 10â¯314 (3635 to 21â¯781) people, with mean (SD) proportion of female individuals was 51.1% (2.8 percentage points). Pharmacies from 214 municipalities (60.9%) reported dispensing standing-order naloxone over the study period. At the baseline of the first quarter of 2013, municipalities that eventually had standing-order naloxone had greater quarterly opioid fatality rates compared with those that never implemented standing-order naloxone (3.51 vs 1.03 deaths per 100â¯000 population; P < .001). After adjusting for municipal-level sociodemographic and opioid prevention factors, there was significant slope decrease of opioid fatality rates (annualized rate ratio, 0.84; 95% CI, 0.78-0.91; P < .001) following standing-order naloxone dispensing, compared with the municipalities that did not implement standing-order naloxone. There were no significant level changes of opioid fatality rates in the adjusted models. Sensitivity analyses yielded similar and significant findings. Conclusions and Relevance: These findings suggest that community pharmacy dispensing of naloxone with standing orders was associated with a relative, gradual, and significant decrease in opioid fatality rates compared with communities that did not implement the standing-order naloxone program. These findings support the expansion of naloxone access, including over-the-counter naloxone as part of a multifaceted approach to address opioid overdose.