The use of controls in interrupted time series studies of public health interventions

The associations of supervised consumption services with the rates of opioid-related mortality and morbidity outcomes at the public health unit level in Ontario (Canada): A controlled interrupted time-series analysis

INTRODUCTION

This study aimed to assess the impact of the implementation of legally sanctioned supervised consumption sites (SCS) in the Canadian province of Ontario on opioid-related deaths, emergency department (ED) visits and hospitalisations at the public health unit (PHU) level.

METHODS

Monthly rates per 100,000 population of opioid-related deaths, ED visits and hospitalisations for PHUs in Ontario between December 2013 and March 2022 were collected. Aggregated and individual analyses of PHUs with one or more SCS were conducted, with PHUs that instituted an SCS being matched to control units that did not. Autoregressive integrated moving average models were used to estimate the impact of SCS implementation on opioid-related deaths, ED visits and hospitalisations.

RESULTS

Twenty-one legally sanctioned SCS were implemented across nine PHUs in Ontario during the study period. Interrupted time series analyses showed no statistically significant changes in opioid-related death rates in aggregated analyses of intervention PHUs (increase of 0.02 deaths/100,000 population/month; p = 0.27). Control PHUs saw a significant increase of 0.38 deaths/100,000 population/month; p < 0.001. No statistically significant changes were observed in the rates of opioid-related ED visits in intervention PHUs (decrease of 0.61 visits/100,000 population/month; p = 0.39) or controls (increase of 0.403 visits; p = 0.76). No statistically significant changes to the rates of opioid-related hospitalisations were observed in intervention PHUs (0 hospitalisations/100,000 population/month; p = 0.98) or controls (decrease of 0.05 hospitalisations; p = 0.95).

DISCUSSION AND CONCLUSIONS

This study did not find significant mortality or morbidity effects associated with SCS availability at the population level in Ontario. In the context of a highly toxic drug supply, additional interventions will be required to reduce opioid-related harms.

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

BACKGROUND

The 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.

METHODS

Our 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.

RESULTS

NO2 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.

CONCLUSION

Our 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.

The association between introduction of the micro-axial flow pump Impella in hospitals and in-hospital mortality in patients treated with extracorporeal membrane oxygenation: interrupted time-series analyses

BACKGROUND

The micro-axial flow pump Impella, a new mechanical circulatory device for cardiogenic shock, is still only available in a limited number of hospitals, due to the facility certification requirements and insufficient evidence of the benefit of introducing Impella in hospitals. This study aimed to evaluate the impact of introducing Impella in hospitals on in-hospital mortality of patients treated with extracorporeal membrane oxygenation (ECMO).

METHODS

Using a nationwide Japanese inpatient database, we identified patients who received ECMO during hospitalization between 1 April 2014 and 31 March 2021. A hospital-level propensity score-matched cohort was created matching hospitals that introduced Impella (exposure group) to those that did not introduce Impella (control group). The inclusion period in each hospital was divided into two time periods according to the time of Impella introduction in the exposure group and the corresponding hospital in the control group (before and after exposure). The primary outcome was in-hospital mortality. Uncontrolled and controlled interrupted time-series analyses involved before-after exposure comparison and exposure-control comparison.

RESULTS

Out of 34,379 eligible patients, we created a matched cohort of 8351 patients from 86 hospitals with Impella introduction (exposure group) and 7230 patients from 86 hospitals without Impella introduction (control group). In-hospital mortality before and after exposure was 62.5% and 59.3, respectively, in the exposure group; and 66.8% and 63.7%, respectively, in the control group. Uncontrolled interrupted time-series analysis showed no significant level change or trend change in the before-after exposure comparison in both the exposure and the control groups. Controlled interrupted time-series analysis also showed no significant level change (-0.01%; 95% confidence intervals -5.36% to + 5.33%) or trend change (+ 0.10%, -0.30% to + 0.40%) after exposure in the exposure-control comparison.

CONCLUSIONS

This nationwide inpatient database study showed no association between Impella introduction in hospitals and in-hospital mortality of patients who underwent ECMO. Because this study confined itself to analze of the impact of the introduction of Impella solely at the hospital level, further detailed studies are warranted to assess its efficacy at the patient level.

Trends in COPD severe exacerbations, and all-cause and respiratory mortality, before and after implementation of newer long-acting bronchodilators in a large population-based cohort

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.

Assessing the impact of COVID-19 non-pharmaceutical interventions and relaxation policies on Class B respiratory infectious diseases transmission in China

This study investigates the incidence of Class B respiratory infectious diseases (RIDs) in China under the Coronavirus disease 2019 (COVID-19) epidemic and examines variations post-epidemic, following the relaxation of non-pharmaceutical interventions (NPIs). Two-stage evaluation was used in our study. In the first stage evaluation, we established counterfactual models for the pre-COVID-19 period to estimate expected incidences of Class B RIDs without the onset of the epidemic. In the second stage evaluation, we constructed seasonal autoregressive integrated moving average intervention (SARIMA-Intervention) models to evaluate the impact on the Class B RIDs after NPIs aimed at COVID-19 pandemic were relaxed. The counterfactual model in the first stage evaluation suggested average annual increases of 10.015%, 78.019%, 70.439%, and 67.799% for tuberculosis, scarlet fever, measles, and pertussis respectively, had the epidemic not occurred. In the second stage evaluation, the total relative reduction in 2023 of tuberculosis, scarlet fever, measles and pertussis were - 35.209%, - 59.184%, - 4.481%, and - 9.943% respectively. The actual incidence declined significantly in the first stage evaluation. However, the results of the second stage evaluation indicated that a rebound occurred in four Class B RIDs after the relaxation of NPIs; all of these showed a negative total relative reduction rate.

Automated local lockdowns for SARS-CoV-2 epidemic control-assessment of effect by controlled interrupted time series analysis

Objectives

During the COVID-19 pandemic, broad non-pharmaceutical interventions such as national lockdowns were effective but had significant drawbacks, prompting targeted approaches, such as Denmark's localized lockdowns, based on specific epidemiological criteria. This study evaluates the effect of Denmark's automated local lockdown strategy on epidemic control to inform future response.

Methods

This was a register-based controlled interrupted time series analysis, examining SARS-CoV-2 infection rates in Danish parishes from March to September 2021. The matching of control parishes was based on location, time, and pre-lockdown infection trends, with the lockdown's start defined as the day after a parish exceeded the lockdown criteria. Follow-up included 3-week pre-lockdown and 2-week post-lockdown.

Results

A total of 30 parishes were mandated to lockdown, approximately 3.5% of the population of Denmark. A total of 94 control parishes were used as 109 controls. The decrease in the incidence during the 2-week follow-up period after the initiation of the lockdown was 13% points higher in case parishes: in case parishes, the incidence was reduced by 78% compared with 65% in control parishes.

Conclusions

Our findings demonstrate that local lockdowns did have a positive effect in mitigating the spread of the SARS-CoV-2 virus, making them valuable in the fight against the COVID-19 pandemic and an important alternative to national lockdowns.

State Mandates On Naloxone Coprescribing Associated With Short-Term Increase In Naloxone Codispensing

In the midst of the opioid crisis in the US, efforts to mitigate overdose risks have become paramount, leading some states to introduce mandates for coprescribing the life-saving overdose reversal drug naloxone. These mandates were designed to specifically address people receiving opioid analgesics who had an elevated risk for overdose. This included people receiving high opioid dosages, those concurrently using benzodiazepines, or those with a history of substance use disorder or overdose. Using a nationally representative, multipayer cohort of patients receiving prescription opioids, we investigated how naloxone codispensing rates changed at the state level from 2016 to 2021 among patients with an elevated risk for overdose. Then we used controlled interrupted time series analyses to assess mandates' longitudinal impact on naloxone codispensing in ten states that implemented mandates. We observed an immediate and significant increase in the naloxone codispensing rates in eight states after the implementation of mandates. Nevertheless, in five of these states, the codispensing rates exhibited a subsequent downward trend after the initial increase. State mandates show potential for improving naloxone codispensing; however, mandates alone might not be adequate for sustained change. Further research is needed to identify strategies complementing and enhancing the impact of mandates in combating the overdose crisis.

Short- and long-term impacts of the National Essential Medicines Policy on drug availability, price, and usage in a deprived rural county in southwestern China: an interrupted time series analysis across 8 years

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.

The effect of Montreal's supervised consumption sites on injection-related infections among people who inject drugs: An interrupted time series

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.

Assessing the impact of stricter drink driving policy on alcohol consumption in a population of Hanoi, Vietnam using wastewater analysis

INTRODUCTION

On 1 January 2020, Vietnam introduced a new law with harsher fines and penalties for driving under the influence of alcohol. Reports of empty beer restaurants following this implementation suggested the new law has the potential to reduce population-level alcohol consumption. This pilot study aims to quantify short-term changes in alcohol consumption levels after the implementation of the new law and assess whether it could lead to a reduction in total alcohol consumption in the population.

METHODS

Wastewater samples were collected from two sites along a sewage canal in Hanoi during two periods: Period 1 (15 December 2018 to 14 January 2019) and Period 2 (15 December 2019 to 14 January 2020). Ethyl sulfate, a specific metabolite of alcohol, was quantified to monitor the trend of alcohol consumption. Both interrupted time series and controlled interrupted time series approaches were utilised, with Period 1 and Period 2 serving as the control and intervention periods, respectively.

RESULTS

Our analysis indicated that the implementation of the new law did not result in an immediate and significant reduction in alcohol consumption at the population level. Meanwhile, there was no significant difference in alcohol consumption between weekdays and weekends both before and after the implementation of the new law.

DISCUSSION AND CONCLUSIONS

Long-term monitoring is needed to assess the impact of stricter DUI policy on alcohol consumption in the urban areas of Vietnam.

Evaluating the impact of the 2010 Swedish choice reform in primary health care on avoidable hospitalization and socioeconomic inequities: an interrupted time series analysis using register data

BACKGROUND

The Swedish Primary Health Care (PHC) system has, like in other European countries, undergone a gradual transition towards marketization and privatization, most distinctly through a 2010 choice reform. The reform led to an overall but regionally heterogenous expansion of private PHC providers in Sweden, and with evidence also pointing to possible inequities in various aspects of PHC provision. Evidence on the reform's impact on population-level primary health care performance and equity in performance remains scarce. The present study therefore aimed to examine whether the increase in private provision after the reform impacted on population-average rates of avoidable hospitalizations, as well as on corresponding socioeconomic inequities.

METHODS

This register-based study used a multiple-group interrupted time-series design for the study period 2001-2017, with the study population (N = 51 million observations) randomly drawn from the total Swedish population aged 18-85 years. High, medium, and low implementing comparison groups were classified by tertiles of increase in private PHC providers after the reform. PHC performance was measured by avoidable hospitalizations, and socioeconomic position by education and income. Interrupted time series analysis based on individual-level data was used to estimate the reform impact on avoidable hospitalization risk, and on inequities through the Relative Index of Inequality (RII).

RESULTS

All three comparisons groups displayed decreasing risk of avoidable hospitalizations but increasing socioeconomic inequities across the study period. Compared to regions with little change in provision after the reform, regions with large increase in private provision saw a steeper decrease in avoidable hospitalizations after the reform (relative risk (95%): 1.6% (1.1; 2.1)), but at the same time steeper increase in inequities (by education: 2.0% (0.1%; 4.0); by income: 2.2% (-0.1; 4.3)).

CONCLUSIONS

The study suggests that the increase in private health care centers, enabled by the choice reform, contributed to a small improvement when it comes to overall PHC performance, but simultaneously to increased socioeconomic inequities in PHC performance. This duality in the impact of the Swedish reform also reflects the arguments in the European health policy debate on patient choice PHC models, with hopes of improved performance but fears of increased inequities.

Estimated changes in free sugar consumption one year after the UK soft drinks industry levy came into force: controlled interrupted time series analysis of the National Diet and Nutrition Survey (2011-2019)

BACKGROUND

The UK soft drinks industry levy (SDIL) was announced in March 2016 and implemented in April 2018, encouraging manufacturers to reduce the sugar content of soft drinks. This is the first study to investigate changes in individual-level consumption of free sugars in relation to the SDIL.

METHODS

We used controlled interrupted time series (2011-2019) to explore changes in the consumption of free sugars in the whole diet and from soft drinks alone 11 months after SDIL implementation in a nationally representative sample of adults (>18 years; n=7999) and children (1.5-19 years; n=7656) drawn from the UK National Diet and Nutrition Survey. Estimates were based on differences between observed data and a counterfactual scenario of no SDIL announcement/implementation. Models included protein consumption (control) and accounted for autocorrelation.

RESULTS

Accounting for trends prior to the SDIL announcement, there were absolute reductions in the daily consumption of free sugars from the whole diet in children and adults of 4.8 g (95% CI 0.6 to 9.1) and 10.9 g (95% CI 7.8 to 13.9), respectively. Comparable reductions in free sugar consumption from drinks alone were 3.0 g (95% CI 0.1 to 5.8) and 5.2 g (95% CI 4.2 to 6.1). The percentage of total dietary energy from free sugars declined over the study period but was not significantly different from the counterfactual.

CONCLUSION

The SDIL led to significant reductions in dietary free sugar consumption in children and adults. Energy from free sugar as a percentage of total energy did not change relative to the counterfactual, which could be due to simultaneous reductions in total energy intake associated with reductions in dietary free sugar.

The monthly trends of malaria cases in children under 5 years of age in Guinea: comparative analysis between a seasonal malaria chemoprevention (SMC) and a non-SMC health district

BACKGROUND

The Republic of Guinea, where malaria represents the leading cause of morbidity and mortality among children, the seasonal malaria chemoprevention (SMC) is deployed only in areas with very seasonal modes of transmission. It should target children at the highest risk of serious illness. The objective of the study was to prevent uncomplicated and serious cases of malaria in the target population. This study aimed to analyse the monthly trends in malaria-related morbidity among children under the age of 5 in Guinea.

METHODS

This was a quasi-experimental study with routine data from the National Health Information System (SNIS). The two districts Mamou (the SMC intervention site) and Kindia (the control site) were selected to compare the monthly trends in malaria cases among children under the age of 5, from July to October, covering the years from 2015 to 2020. The statistical analysis used interrupted time series to estimate the effects of the SMC.

RESULTS

The SMC programme contributed to a significant average reduction in the number of malaria cases of 225 cases per month in the intervention district (95% CI - 362 to - 88; p = 0.002), compared to the control district. However, the study also revealed that the effect of SMC varied between cycles, presenting different monthly malaria cases.

CONCLUSION

The SMC contributed to a significant reduction in malaria cases among children under the age of 5 in the health district of Mamou from 2018 to 2020. However, this reduction varied by monthly SMC cycle. This study suggests extending the SMC in other areas with high perennial seasonal transmission respecting the World Health Organization SMC eligibility criteria, as a strategy in the dynamic of reducing malaria cases in children under the age of 5 in Guinea.

The performance of interrupted time series designs with a limited number of time points: Learning losses due to school closures during the COVID-19 pandemic

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.

Interrupted Time Series Design and Analyses in Health Policy Assessment

Interrupted time series design is a quasi-experimental study design commonly used to evaluate the impact of a particular intervention (e.g., a health policy implementation) on a specific outcome. Two of the most often recommended analytical approaches to interrupted time series analysis are autoregressive integrated moving average (ARIMA) and Generalized Additive Models (GAM). We conducted simulation tests to determine the performance differences between ARIMA and GAM methodology across different policy effect sizes, with or without seasonality, and with or without misspecification of policy variables. We found that ARIMA exhibited more consistent results under certain conditions, such as with different policy effect sizes, with or without seasonality, while GAM were more robust when the model was misspecified. Given these findings, the variation between the models underscores the need for careful model selection and validation in health policy studies.

Evaluating the impact of minimum unit pricing (MUP) on alcohol sales after 3 years of implementation in Scotland: A controlled interrupted time-series study

BACKGROUND AND AIMS

On 1 May 2018, Scotland introduced minimum unit pricing (MUP), a strength-based floor price below which alcohol cannot be sold, throughout all alcoholic beverages. The legislation necessitates an evaluation of its impact across a range of outcomes that will inform whether MUP will continue beyond its sixth year. We measured the impact of MUP on per-adult alcohol sales (as a proxy for consumption) after 3 years of implementation.

DESIGN, SETTING AND PARTICIPANTS

Controlled interrupted time-series regression was used to assess the impact of MUP on alcohol sales in Scotland after 3 years of implementation, with England and Wales (EW) being the control group. In adjusted analyses, we included household disposable income, on-trade alcohol sales (in off-trade analyses) and substitution between drink categories (in drink category analyses) as covariates.

MEASUREMENTS

Weekly data were assessed on the volume of pure alcohol sold in Scotland and EW between January 2013 and May 2021, expressed as litres of pure alcohol per adult. The impact of MUP on total (on- and off-trade combined), off-trade and on-trade alcohol sales was assessed separately.

RESULTS

The introduction of MUP in Scotland was associated with a 3.0% (95% confidence interval = 1.8-4.2%) net reduction in total alcohol sales per adult after adjustment for the best available geographical control, disposable income and substitution. This reflects a 1.1% fall in Scotland in contrast to a 2.4% increase in EW. The reduction in total alcohol sales in Scotland was driven by reduced sales of beer, spirits, cider and perry. The reduction in total sales was due to reductions in sales of alcohol through the off-trade. There was no evidence of any change in on-trade alcohol sales.

CONCLUSION

Minimum unit pricing has been effective in reducing population-level alcohol sales in Scotland in the 3 years since implementation.

A national evaluation of Project Cautioning And Relationship Abuse ('CARA') awareness raising workshops for first time offenders of domestic violence and abuse: protocol for a concurrent mixed-methods evaluation design

Introduction

Interventions related to the perpetration of Domestic Violence and Abuse (DVA) have gained traction over the past several years, in response to dissatisfaction by victims, an inadequate response from the criminal justice system, increased demand on police time and a lack of rehabilitative responses to the perpetration of domestic abuse. The CARA model is a conditional diversionary caution, offered by police for first time offenders of 'standard' or 'medium risk' domestic abuse, that engages perpetrators in awareness raising workshops and signposts them onto further services. Although quasi-experimental studies have indicated that CARA showed promise at reducing reoffending, the CARA model has yet to be evaluated nationally and there is no qualitative evidence related to understanding or learning about the lived experience of perpetrators and victims as they engage with the intervention.

Methods

Using a concurrent pragmatic mixed methods design model we will undertake a national evaluation of CARA by triangulating quantitative data from up to nine police forces, and routine data from service providers, with qualitative data from workshop participants, victims and professional stakeholders to: (1) understand the long-term impact of CARA implementation on DVA reoffending and engagement with services and (2) explore perceptions and experiences of both delivery and receipt of CARA. We will use qualitative methodologies that draw on interpretivist and phenomenological perspectives, as well as quantitative methodologies using interrupted time series models, Poisson regression models, Geo mapping and a cost benefits analysis.

Ethics and dissemination

Where currently the CARA model is being introduced as a national option for standard risk first-time offending, we will engage with policymakers and academics nationally in the live debate on its effectiveness and suitability during its roll-out. Ethical approval was approved by the University of Southampton on the 1 st June 2022 (Ref: ERGO ID: 71818.A1).

Social Inequalities in Child Development: Analysis of Low-Birth-Weight Trends in Brazil, 2010-2020

INTRODUCTION

Low birth weight (LBW) is a global issue prevalent in low-income countries. Economic assessments of interventions to reduce this burden are crucial to guide health policies. However, there is a relative scarcity of research that illustrates the magnitude of LBW by country and region to support the design of public policies.

OBJECTIVE

This study aimed to analyze the temporal trend of fetal growth in newborns in Brazil between 2010 and 2020.

METHODS

A time series study was conducted using data from the Live Births Information System (SINASC), which is managed by the Department of Information and Informatics of the Unified Health System (DATASUS) of the Brazilian Ministry of Health. The Prais-Winsten linear model was applied to analyze the annual proportions of LBW. The annual percentage changes (APC) and their respective 95% confidence intervals (95%CI) were calculated. Prevalence rate averages of LBW were calculated and displayed on thematic maps to visualize the evolution dynamics in each Federation Unit (FU).

RESULTS

A total of 31,887,329 women from all Federative Units of Brazil were included in the study from 2010 to 2020. The Southeast region had the largest proportion of participants, with records from 2015 accounting for 9.5% of the total. Among the women in the study, 49.6% were between the ages of 20 and 29, and the majority (75.5%) had between 8 and 12 years of schooling. The newborns of these women were predominantly male (58.8%) and non-white (59.5%). The study found that there was a trend towards stabilization of increasing proportions of LBW in the North, Northeast, and Centre-West regions between 2010 and 2020. In Brazil and other regions, these tendencies remained stable.

CONCLUSION

To improve living conditions and reduce social inequalities and health inequities, public policies and actions are necessary. Strengthening the Unified Health System (SUS), income transfer programs, quota policies for vulnerable groups, and gender equality measures such as improving access to education for women and the labor sector are among the suggested approaches.

Impact of an enhanced sobriety checkpoints programme and publicity campaign on motor vehicle collisions, injuries and deaths in Leon, MX: a synthetic control study

OBJECTIVE

Drunk driving is a major cause of road traffic injuries and deaths in Latin America. We evaluated the impact of a drunk driving intervention in Leon, Mexico on road traffic safety.

METHODS

The intervention included increased drunk driving penalties, enhanced sobriety checkpoints and a young adult-focused mass media campaign, beginning 19 December 2018. We created a synthetic control Leon from 12 Mexican municipalities from a pool of 87 based on similarity to Leon using key predictors from 2015 to 2019. We assessed the effect of the intervention on road traffic collisions overall and collisions with injuries, deaths and involving alcohol, using data from police, insurance claims and vital registration.

RESULTS

As compared with the synthetic control, Leon experienced significant postintervention lower police-reported total collision rate (17%) and injury collisions (33%). Alcohol-involved collisions were 38% lower than the synthetic control. Fatal collisions reported by police were 28% lower while vital registration road traffic deaths were 12% lower, though these declines were not statistically significant. We found no impact on insurance collision claims. There was heterogeneity in these changes over the evaluation year, with stronger initial effects and weaker effects by the end of the year.

CONCLUSIONS

Drunk driving policies in Leon led to fewer traffic collisions and injuries during the first year of implementation, with a weakening of this effect over time, similar to interventions in high-income settings and other Latin American countries. Supporting the expansion of similar policies to other cities in the region could improve road safety.

Impact of government-issued financial incentive to medical facilities on management of secondary dysmenorrhea

AIM

In April 2020, the Japanese government introduced a Specific Medical Fee for managing secondary dysmenorrhea (SD). This initiative provided financial incentives to medical facilities that provide appropriate management of SD with hormonal therapies. We aimed to assess how this policy affects the management processes and outcomes of patients with SD.

METHODS

Using a large Japanese administrative claims database, we identified outpatient visits of patients diagnosed with SD from April 2018 to March 2022. We used an interrupted time-series analysis and defined before April 2020 as the pre-introduction period and after April 2020 as the post-introduction period. Outcomes were the monthly proportions of outpatient visits due to SD and hormonal therapy among women in the database and the proportions of outpatient visits for hormonal therapy and continuous outpatient visits among patients with SD.

RESULTS

We identified 815 477 outpatient visits of patients diagnosed with SD during the pre-introduction period and 920 183 outpatient visits during the post-introduction period. There were significant upward slope changes after the introduction of financial incentives in the outpatient visits due to SD (+0.29% yearly; 95% confidence interval, +0.20% to +0.38%) and hormonal therapies (+0.038% yearly; 95% confidence interval, +0.030% to +0.045%) among the women in the database. Similarly, a significant level change was observed after the introduction of continuous outpatient visits among patients with SD (+2.68% monthly; 95% confidence interval, +0.87% to +4.49%).

CONCLUSIONS

Government-issued financial incentives were associated with an increase in the number of patients diagnosed with SD, hormonal therapies, and continuous outpatient visits.

Oil and gas development exposure and atrial fibrillation exacerbation: a retrospective study of atrial fibrillation exacerbation using Colorado's all payer claims dataset

Introduction

Emerging risk factors for atrial fibrillation (AF) incidence and episodes (exacerbation), the most common and clinically significant cardiac arrhythmia, include air and noise pollution, both of which are emitted during oil and natural gas (O&G) well site development.

Methods

We evaluated AF exacerbation risk and proximity to O&G well site development by employing a novel data source and interrupted time-series design. We retrospectively followed 1,197 AF patients living within 1-mile of an O&G well site (at-risk of exposure) and 9,764 patients living >2 miles from any O&G well site (unexposed) for AF claims in Colorado's All Payer Claims Dataset before, during, and after O&G well site development. We calculated AF exacerbation risk with multi-failure survival analysis.

Results

The analysis of the total study population does not provide strong evidence of an association between AF exacerbation and proximity to O&G wells sites during (HR = 1.07, 95% CI: 0.94, 1.22) or after (HR = 1.01, 95% CI: 0.88, 1.16) development. However, AF exacerbation risk differed by patient age and sex. In patients >80 years living within 0.39 miles (2,059 feet) of O&G well site development, AF exacerbation risk increased by 83% (HR = 1.83, 95% CI: 1.25, 2.66) and emergency room visits for an AF event doubled (HR = 2.55, 95% CI: 1.50, 4.36) during development, with risk increasing with proximity. In female patients living within 0.39 miles of O&G well site development, AF exacerbation risk increased by 56% percent (95% CI: 1.13, 2.15) during development. AF exacerbation risk did not persist past the well development period. We did not observe increased AF exacerbation risk in younger or male patients.

Discussion

The prospect that proximity to O&G well site development, a significant noise and air pollution source, may increase AF exacerbation risk in older and female AF patients requires attention. These findings support appropriate patient education to help mitigate risk and development of mitigation strategies and regulations to protect the health of populations in O&G development regions.

Hospital accreditation in Mexico fails to improve the quality of healthcare: lessons from an impact evaluation

Healthcare quality in low- and middle-income countries poses a significant challenge, contributing to heightened mortality rates from treatable conditions. The accreditation of health facilities was part of the former health reform in Mexico, proposed as a mechanism to enhance healthcare quality. This study assesses the performance of hospital accreditation in Mexico, utilizing indicators of effectiveness, efficiency, and safety. Employing a longitudinal approach with controlled interrupted time series analysis (C-ITSA) and fixed effects panel analysis, administrative data from general hospitals in Mexico is scrutinized. Results reveal that hospital accreditation in Mexico fails to enhance healthcare quality and, disconcertingly, indicates deteriorating performance associated with increased hospital mortality. Amidst underfunded health services, the implemented accreditation model proves inadequately designed to uplift care quality. A fundamental redesign of the public hospital accreditation model is imperative, emphasizing incentives for structural enhancement and standardized processes. Addressing the critical challenge of improving care quality is urgent for Mexico's healthcare system, necessitating swift action to achieve effective access as a benchmark for universal healthcare coverage.

The impact of precursor regulations on illicit drug markets: An analysis of Cunningham et al.'s studies

This review examines a series of twelve studies led by James K. Cunningham and his team, focusing on the effects of precursor regulation on illicit drug markets. Their research shows that the regulation of chemicals essential for the production of drugs such as heroin, cocaine, and methamphetamine is associated with several positive outcomes. These include a decrease in drug purity, a reduction in seizures, lower demand for treatment and hospitalization, and an increase in drug prices. According to the research, this decrease in harmful outcomes results from a combination of diminished overall consumption and a reduction in harm per dose. However, this review identifies some inconsistencies within their studies. These inconsistencies include premature assumptions about the timing of intervention impacts, uneven influences of similar interventions, variations in the implementation of these interventions, and the disregard of alternate explanations for sudden shifts in drug markets. Cunningham's work can be considered one of the most substantial contributions in this field. However, to secure the full confidence of the drug policy community in the authenticity of their findings, they must effectively address the issues identified in this review.

Road safety implications of the partial legalisation of cannabis in Germany: protocol for a quasi-experimental study

INTRODUCTION

Germany is reforming its legal approach to cannabis, allowing the possession and cultivation of cannabis for recreational purposes. The objective of this study is to investigate the impact of the policy reform on (1) The prevalence of cannabis use in the general population and (2) Driving under the influence of cannabis (DUIC) among regular users.

METHODS AND ANALYSIS

A quasi-experimental research design will be employed, with repeated cross-sectional surveys on self-reported DUIC and cannabis use conducted at three measurement points in Germany (intervention group) and Austria (control group) over a 2-year observation period (2023-2025). Data will be collected from approximately 50 000 individuals aged between 18 years and 64 years. To minimise reporting biases in the measurement of DUIC, we will use direct and indirect assessments via crosswise model and motor vehicle accident data from official statistics. In a difference-in-difference framework, regression analyses and interrupted time series analysis will be carried out for hypothesis testing.

ETHICS AND DISSEMINATION

Participants will be informed about voluntary participation, data protection laws and the option to delete data on request. Ethical approval was obtained from the Local Psychological Ethics Committee of the Centre for Psychosocial Medicine in Hamburg, Germany (reference number: 0686). Findings will be disseminated through scientific networks and will be key for a comprehensive evaluation of the cannabis law reform. The findings will facilitate the design and implementation of road safety measures.

Replacing the Clinical Institute Withdrawal Assessment-Alcohol revised with the modified Richmond Agitation and Sedation Scale for alcohol withdrawal to support management of alcohol withdrawal symptoms: potential impact on length of stay and complications

PURPOSE

We evaluated impact on length of stay and possible complications of replacing the Clinical Institute Withdrawal Assessment-Alcohol Revised (CIWA-Ar) scale with a slightly modified Richmond Agitation and Sedation Scale (mRASS-AW) to support managing patients admitted with alcohol withdrawal symptoms in a community hospital. Since mRASS-AW is viewed as easier and quicker to use than CIWA-Ar, provided use of mRASS-AW does not worsen outcomes, it could be a safe alternative in a busy ED environment and offer an opportunity to release nursing time to care.

METHODS

Retrospective time-series analysis of mean quarterly length of stay. All analyses exclusively used our hospital's administrative discharge diagnoses database. During April 1st 2012 to December 14th 2014, the CIWA-Ar was used in the ED and in-patient units to guide benzodiazepine dosing decisions for alcohol withdrawal symptoms. After this point, CIWA-Ar was replaced with mRASS-AW. Data was evaluated until December 31st 2020.

PRIMARY OUTCOME

mean quarterly length of stay.

SECONDARY OUTCOMES

delirium, intensive care unit (ICU) admission, other post-admission complications, mortality.

RESULTS

N = 1073 patients. No association between length of stay and scale switch (slope change 0.3 (95% CI - 0.03 to 0.6), intercept change, 0.06 (- 0.03 to 0.2). CIWA-Ar (n = 317) mean quarterly length of stay, 5.7 days (95% 4.2-7.1), mRASS-AW (n = 756) 5.0 days (95% CI 4.3-5.6). Incidence of delirium, ICU admission or mortality was not different. However, incidence of other post-admission complications was higher with CIWA-Ar (6.6%) than mRASS-AW (3.4%) (p = 0.020).

CONCLUSIONS

This was the first study to compare patient outcomes associated with using mRASS-AW for alcohol withdrawal symptoms outside the ICU. Replacing CIWA-Ar with mRASS-AW did not worsen length of stay or complications. These findings provide some evidence that mRASS-AW could be considered an alternative to CIWA-Ar and potentially may provide an opportunity to release nursing time to care.

Navigating grey areas in HIV and mental health implementation science

INTRODUCTION

Implementation science (IS) offers methods to systematically achieve the Ending the HIV Epidemic goals in the United States, as well as the global UNAIDS targets. Federal funders such as the National Institutes of Mental Health (NIMH) have invested in implementation research to achieve these goals, including supporting the AIDS Research Centres (ARCs), which focus on high-impact science in HIV and mental health (MH). To facilitate capacity building for the HIV/MH research workforce in IS, "grey areas," or areas of IS that are confusing, particularly for new investigators, should be addressed in the context of HIV/MH research.

DISCUSSION

A group of IS experts affiliated with NIMH-funded ARCs convened to identify common and challenging grey areas. The group generated a preliminary list of 19 grey areas in HIV/MH-related IS. From the list, the authors developed a survey which was distributed to all ARCs to prioritize grey areas to address in this paper. ARC members across the United States (N = 60) identified priority grey areas requiring clarification. This commentary discusses topics with 40% or more endorsement. The top grey areas that ARC members identified were: (1) Differentiating implementation strategies from interventions; (2) Determining when an intervention has sufficient evidence for adaptation; (3) Integrating recipient perspectives into HIV/MH implementation research; (4) Evaluating whether an implementation strategy is evidence-based; (5) Identifying rigorous approaches for evaluating the impact of implementation strategies in the absence of a control group or randomization; and (6) Addressing innovation in HIV/MH IS grants. The commentary addresses each grey area by drawing from the existing literature (when available), providing expert guidance on addressing each in the context of HIV/MH research, and providing domestic and global HIV and HIV/MH case examples that address these grey areas.

CONCLUSIONS

HIV/MH IS is key to achieving domestic and international goals for ending HIV transmission and mitigating its impact. Guidance offered in this paper can help to overcome challenges to rigorous and high-impact HIV/MH implementation research.

Effects of the COVID-19 pandemic on the rates of adverse birth outcomes and fetal mortality in Japan: an analysis of national data from 2010 to 2022

BACKGROUND

Although the coronavirus disease 2019 (COVID-19) pandemic affected trends of multiple health outcomes in Japan, there is a paucity of studies investigating the effect of the pandemic on adverse birth outcomes and fetal mortality. This study aimed to investigate the effect of the onset of the pandemic on the trends in adverse birth outcomes and fetal mortality using national data in Japan.

METHODS

We used the 2010-2022 birth and fetal mortality data from the Vital Statistics in Japan. We defined the starting time of the effect of the pandemic as April 2020, and the period from January 2010 to March 2020 and that from April 2020 to December 2022 were defined as the pre- and post- pandemic period, respectively. The rates of preterm birth, term low birth weight (TLBW), small-for-gestational-age (SGA), large-for-gestational-age (LGA), spontaneous fetal mortality, and artificial fetal mortality were used as outcomes. An interrupted time series analysis was conducted using monthly time series data of the outcomes to evaluate the effects of the pandemic. In addition, a modified Poisson regression model was used to evaluate the effects of the pandemic on these outcomes using individual-level data, and the adjusted risk ratio of the effect was calculated.

RESULTS

The adverse birth and fetal mortality outcomes showed a decreasing trend over the years, except for preterm birth and LGA birth rates, and SGA birth rates tended to reach their lowest values after the onset of the pandemic. The interrupted time series analysis revealed that the pandemic decreased preterm birth, TLBW, and SGA birth rates. In addition, the regression analysis revealed that the pandemic decreased the TLBW, SGA, and artificial fetal mortality rates.

CONCLUSIONS

Analyses performed using national data suggested that the pandemic decreased the TLBW and SGA rates in Japan.

Speed limits and their effect on air pollution in Mexico City: A quasi-experimental study

Speed limits are an evidence-based intervention to prevent traffic collisions and deaths, yet their impact on air pollution in cities is understudied. The objective of this study was to investigate the association between lower speed limits and air pollution. We leverage the introduction of a new road safety policy in Mexico City in December 2015 which lowered speed limits, increased fines, and installed speed radars to enforce compliance. We tested whether the policy had an impact on particulate matter (PM2.5) and nitrogen dioxide (NO2) at the city level, and whether air-quality monitoring stations' proximity to speed radars moderated this effect due to more acceleration and deceleration around radars. NO2 and PM2.5 concentrations from January 2014 to December 2018 were obtained from the National System of Air Quality Information. Air-quality monitoring stations were classified as in close-proximity or far-from-speed radars. Interrupted time series analyses were conducted for each outcome separately, using linear mixed models and adjusting for seasonality and time-varying confounders: registered vehicles, temperature, wind-speed and relative humidity. The results suggest improvement in both contaminants after the speed limits policy. For NO2, the pre-policy trend was flat, while the post-policy trend showed a decline in concentrations of 0.04 ppb/week. For PM2.5, concentrations were increasing pre-policy by 0.08 μg/m3 per week, then this trend flattened in the post-policy period to a weekly, non-significant, increase of 0.03 μg/m3 (p = 0.08). Air-quality monitors' proximity to speed radars did not moderate the effect of the policy on either of the pollutants. In conclusion, the speed limits policy implemented in Mexico City in 2015 was associated with improvements in air pollution.

Five steps to high quality antimicrobial stewardship research

The escalating threat of antimicrobial resistance (AMR) necessitates impactful, reproducible, and scalable antimicrobial stewardship strategies. This review addresses the critical need to enhance the quality of antimicrobial stewardship intervention research. We propose five considerations for authors planning and evaluating antimicrobial stewardship initiatives. Antimicrobial stewards should consider the following mnemonic ABCDE: (A) plan Ahead using implementation science; (B) Be clear and thoroughly describe the intervention by using the TidIER checklist; (C) Use a Checklist to comprehensively report study components; (D) Select a study Design carefully; and (E) Assess Effectiveness and implementation by selecting meaningful outcomes. Incorporating these recommendations will help strengthen the evidence base of antimicrobial stewardship literature and support optimal implementation of strategies to mitigate AMR.

Impact of capitation on physicians' behavior among patients with hypertension: an interrupted time series study in rural China

OBJECTIVE

The purpose of this study is to explore the change in physicians' hypertension treatment behavior before and after the reform of the capitation in county medical community.

METHODS

Spanning from January 2014 to December 2019, monthly data of outpatient and inpatient were gathered before and after the implementation of the reform in April 2015. We employed interrupted time series analysis method to scrutinize the instantaneous level and slope changes in the indicators associated with physicians' behavior.

RESULTS

Several indicators related to physicians' behavior demonstrated enhancement. After the reform, medical cost per visit for inpatient exhibited a reverse trajectory (-53.545, 95%CI: -78.620 to -28.470, p < 0.01). The rate of change in outpatient drug combination decelerated (0.320, 95%CI: 0.149 to 0.491, p < 0.01). The ratio of infusion declined for both outpatient and inpatient cases (-0.107, 95%CI: -0.209 to -0.004, p < 0.1; -0.843, 95%CI: -1.154 to -0.532, p < 0.01). However, the results revealed that overall medical cost per visit and drug proportion for outpatient care continued their initial upward trend. After the reform, the decline of drug proportion for outpatient care was less pronounced compared to the period prior to the reform, and length of stay also had a similar trend.

CONCLUSION

To some extent, capitation under the county medical community encourages physicians to control the cost and adopt a more standardized diagnosis and treatment behavior. This study provides evidence to consider the impact of policy changes on physicians' behavior when designing payment methods and healthcare systems aimed at promoting PHC.

Effect of methenamine hippurate shortage on antibiotic prescribing for urinary tract infections in Norway-an interrupted time series analysis

BACKGROUND

Despite a lack of conclusive evidence of effect, methenamine hippurate is widely prescribed as preventive treatment for recurrent urinary tract infections (UTIs) in Norway. A national discontinuation of methenamine hippurate treatment due to a 4-month drug shortage in 2019 presented an opportunity to evaluate its preventive effect on UTIs among regular users.

OBJECTIVE

To estimate the impact of the methenamine hippurate drug shortage on prescription frequency of UTI antibiotics.

METHODS

Data from The Norwegian Prescription Database was analysed using an interrupted time series design. The time series consisted of 56 time periods of 14 days. The model included two naturally occurring interruptions: (i) the methenamine hippurate drug shortage, and (ii) reintroduction of the drug. The study population were 18 345 women ≥50 years receiving ≥2 prescriptions of methenamine hippurate in the study period before the shortage. Main outcome measure was number of prescriptions of UTI antibiotics per 1000 methenamine hippurate users. Prescription rates of antibiotics for respiratory tract infections were analysed to assess external events affecting antibiotic prescribing patterns.

RESULTS

We found a significant increase of 2.41 prescriptions per 1000 methenamine hippurate users per 14-day period during the drug shortage (95%CI 1.39, 3.43, P < 0.001), followed by a significant reduction of -2.64 prescriptions after reintroduction (95%CI -3.66, -1.63, P < 0.001).

CONCLUSIONS

During the methenamine hippurate drug shortage, we found a significant increase in prescribing trend for UTI antibiotics followed by a significant decrease in prescribing trend after reintroduction. This change in trend seems to reflect a preventive effect of the drug on recurrent UTIs.

Improving healthcare accessibility for pregnant women and children in the context of health system strengthening initiatives and terrorist attacks in Central Mali: a controlled interrupted time series analysis

INTRODUCTION

The Health and Social Development Program of the Mopti Region (PADSS2) project, launched in Mali's Mopti region, targeted Universal Health Coverage (UHC). The project addressed demand-side barriers by offering an additional subsidy to household contributions, complementing existing State support (component 1). Component 2 focused on supply-side improvements, enhancing quality and coverage. Component 3 strengthened central and decentralised capacity for planning, supervision and UHC reflection, integrating gender mainstreaming. The study assessed the impact of the project on maternal and child healthcare use and explored how rising terrorist activities might affect these health outcomes.

METHODS

The impact of the intervention on assisted births, prenatal care and curative consultations for children under 5 was analysed from January 2016 to December 2021. This was done using an interrupted time series analysis, incorporating a comparison group and spline regression.

RESULTS

C1 increased assisted deliveries by 0.39% (95% CI 0.20 to 0.58] and C2 by 1.52% (95% CI 1.36 to 1.68). C1-enhanced first and fourth antenatal visits by 1.37% (95% CI 1.28 to 1.47) and 2.07% (95% CI 1.86 to 2.28), respectively, while C2 decreased them by 0.53% and 1.16% (95% CI -1.34 to -0.99). For child visits under 5, C1 and C2 showed increases of 0.32% (95% CI 0.20 to 0.43) and 1.36% (95% CI 1.27 to 1.46), respectively. In areas with terrorist attacks, child visits decreased significantly by 24.69% to 39.86% compared with unexposed areas.

CONCLUSION

The intervention had a limited impact on maternal and child health, falling short of expectations for a health system initiative. Understanding the varied effects of terrorism on healthcare is key to devising strategies that protect the most vulnerable in the system.

Opioid Prescribing and Outcomes in Patients With Sickle Cell Disease Post-2016 CDC Guideline

Importance

Although the intention of the 2016 US Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain was not to limit pain treatment for patients with sickle cell disease (SCD), clinicians and patients have recognized the possibility that the guideline may have altered outcomes for this population. However, the outcomes of the 2016 guideline for this patient population are unknown.

Objective

To examine changes in opioid prescribing patterns and health outcomes among patients with SCD before and after the release of the 2016 CDC guideline.

Design, Setting, and Participants

This retrospective cohort study conducted interrupted time series analysis of claims data from the Merative MarketScan Commercial Database from January 1, 2011, to December 31, 2019. In this population-based study in the US, individuals with SCD who were at least 1 year of age, had no cancer diagnosis, and had pharmacy coverage for the month of measurement were included. The data were analyzed from January 2021 to November 2023.

Exposure

The CDC Guideline for Prescribing Opioids for Chronic Pain released in March 2016.

Main Outcomes and Measures

The main variables measured in this study included the practice of opioid prescribing among patients with SCD (ie, rate of opioid prescriptions dispensed, mean number of days supplied, mean total morphine milligram equivalents [MME] per patient, and mean daily MME per opioid prescription) and pain-related health outcomes (rates of emergency department visits related to vaso-occlusive crises [VOC] and hospitalizations related to VOC).

Results

The cohort included 14 979 patients with SCD (mean [SD] age, 25.9 [16.9] years; 8520 [56.9%] female). Compared with the preguideline trends, the following changes were observed after the guideline was released: significant decreases in the coefficient for change in slope of the opioid dispensing rate (-0.29 [95% CI, -0.39 to -0.20] prescriptions per 100 person-month; P < .001), the number of days supplied per prescription (-0.05 [95% CI, -0.06 to -0.04] days per prescription-month; P < .001), and opioid dosage (-141.0 [95% CI, -219.5 to -62.5] MME per person-month; P = .001; -10.1 [95% CI, -14.6 to -5.6] MME/prescription-month; P < .001). Conversely, a significant increase in VOC-related hospitalizations occurred after the guideline release (0.16 [95% CI, 0.07-0.25] hospitalizations per 100 person-month; P = .001). These changes were observed to a greater extent among adult patients, but pediatric patients experienced similar changes in several measures, even though the guideline focused exclusively on adult patients.

Conclusions and Relevance

This retrospective cohort study showed that the 2016 CDC guideline may have had unintended negative outcomes on the patient population living with SCD.

Breast Cancer Stage and Size Detected with Film versus Digital Mammography in New South Wales, Australia: A Population-Based Study Using Routinely Collected Data

BACKGROUND

Digital mammography has replaced film mammography in breast-screening programs globally, including Australia. This led to an increase in the rate of detection, but whether there was increased detection of clinically important cancers is uncertain.

METHODS

In this population-wide retrospective cohort study in New South Wales, Australia spanning 2004 to 2016 and including 4,631,656 screens, there were 22,965 cancers in women screened with film (n = 11,040) or digital mammography (n = 11,925). We examined the change in tumor characteristics overall and how these rates changed over time, accounting for changes in background rates using an interrupted time-series. Comparisons were made with unscreened women (n = 26,326) during this time.

RESULTS

We found increased detection of in situ cancer (3.36 per 10,000 screens), localized invasive, and smaller-sized breast cancers attributable to the change in mammography technology, whereas screen-detected intermediate-sized and metastatic breast cancers decreased. Rates of early-stage and intermediate-sized interval cancers increased, and late-stage (-1.62 per 10,000 screens) and large interval cancers decreased. In unscreened women, there were small increases in the temporal trends of cancers across all stages.

CONCLUSIONS

At least some of the increased detection of smaller early-stage cancers may have translated into a reduction in larger and late-stage cancers, indicating beneficial detection of cancers that would have otherwise progressed. However, the increased detection of smaller early-stage and small cancers may also have increased over-diagnosis of lesions that would otherwise have not caused harm.

IMPACT

Robust evaluation of potential benefits and harms is needed after changes to screening programs. See related In the Spotlight, p. 638.

The effect of a minimum price per unit of alcohol in Scotland on alcohol-related ambulance call-outs: A controlled interrupted time-series analysis

BACKGROUND AND AIMS

On 1 May 2018, Scotland introduced a minimum unit price (MUP) of £0.50 for alcohol, with one UK unit of alcohol being 10 ml of pure ethanol. This study measured the association between MUP and changes in the volume of alcohol-related ambulance call-outs in the overall population and in call-outs subsets (night-time call-outs and subpopulations with higher incidence of alcohol-related harm).

DESIGN

An interrupted time-series (ITS) was used to measure variations in the daily volume of alcohol-related call-outs. We performed uncontrolled ITS on both the intervention and control group and a controlled ITS built on the difference between the two series. Data were from electronic patient clinical records from the Scottish Ambulance Service.

SETTING AND CASES

Alcohol-related ambulance call-outs (intervention group) and total ambulance call-outs for people aged under 13 years (control group) in Scotland, from December 2017 to March 2020.

MEASUREMENTS

Call-outs were deemed alcohol-related if ambulance clinicians indicated that alcohol was a 'contributing factor' in the call-out and/or a validated Scottish Ambulance Service algorithm determined that the call-out was alcohol-related.

FINDINGS

No statistically significant association in the volume of call-outs was found in both the uncontrolled series [step change = 0.062, 95% confidence interval (CI) = -0.012, 0.0135 P = 0.091; slope change = -0.001, 95% CI = -0.001, 0.1 × 10-3 P = 0.139] and controlled series (step change = -0.01, 95% CI = -0.317, 0.298 P = 0.951; slope change = -0.003, 95% CI = -0.008, 0.002 P = 0.257). Similarly, no significant changes were found for the night-time series or for any population subgroups.

CONCLUSIONS

There appears to be no statistically significant association between the introduction of minimum unit pricing for alcohol in Scotland and the volume of alcohol-related ambulance call-outs. This was observed overall, across subpopulations and at night-time.

Impact of comprehensive air pollution control policies on six criteria air pollutants and acute myocardial infarction morbidity, Weifang, China: A quasi-experimental study

Comprehensive air pollution control policies may reduce pollutant emissions. However, the impact on disease morbidity of the change for the concentration of air pollutants following the policies has been insufficiently studied. We aim to assess the impact of comprehensive air pollution control policies on the levels of six criteria air pollutants and acute myocardial infarction (AMI) morbidity in Weifang, China. This study performed an interrupted time series analysis. The linear model with spline terms and generalized additive quasi-Poisson model were used to estimate the immediate change from 2016 to 2019 in the daily concentration of six air pollutants (PM2.5, PM10, SO2, NO2, O3, and, CO) and AMI incident cases (Age ≥35) associated with the implementation of air pollution control policies in Weifang, respectively. After the implementation of air pollution control policies, air quality in Weifang had been improved. Specifically, the daily concentrations of PM2.5, PM10, SO2, and, CO immediately decreased by 27.9 % (95 % CI: 6.6 % to 44.3 %), 32.9 % (95 % CI: 17.5 % to 45.5 %), 14.6 % (95 % CI: 0.4 % to 26.8 %), and 33.9 % (95 % CI: 22.0 % to 44.0 %), respectively. In addition, the policies implementation was also associate with the immediate decline in the AMI morbidity (-6.5 %, 95 % CI: -10.4 % to -2.3 %). And subgroup analyses indicate that the health effects of the policy intervention were only observed in female (-9.4 %, 95 % CI: -14.4 % to -4.2 %) and those aged ≥65 years (-10.5 %, 95 % CI: -14.6 % to -6.2 %). During the final 20 months of the study period, the policy intervention was estimated to prevent 1603 (95 % CI: 574 to 2587) cases of incident AMI in Weifang. Our results provide strong rationale that the policy intervention significantly reduced ambient pollutant concentrations and AMI morbidity, which highlighted the importance for a comprehensive and rigorous air pollution control policy in regions with severe air pollution.

Reduced pertussis disease severity in infants following the introduction of pertussis vaccination of pregnant women in Spain, 2015-2019

BACKGROUND

Maternal pertussis vaccination during the third trimester of pregnancy was implemented in 2015 in Spain, reaching a national coverage of 84% in 2019. In this ecological study, we investigated whether there was a change in the disease severity for pertussis in infants upon introduction of prenatal pertussis vaccination.

METHODS

We performed a time-trend analysis of infant pertussis hospitalizations during 2005-2019 in Spain using national register data. Annual hospitalization rates per 100,000 population and the mean length of hospitalization were calculated for infants < 3 months of age (target group benefiting from the prenatal vaccination) and a reference group aged 3-11 months. We compared overall rates and annual percent changes of the above variables in both groups for the time period before (2005-2014) and after vaccination introduction (2015-2019), using segmented Poisson regression.

RESULTS

During the pre-vaccination period, infants aged 0-2 months had a 5-times higher rate of pertussis hospitalization and spent on average 50 % longer in hospital than the reference group. After the maternal vaccination introduction, the hospitalization rate decreased more rapidly in infants aged 0-2 months than in infants aged 3-11 months: annual reduction of 34 % (95 % CI: 31-38) versus 26 % (95 % CI: 21-31) in the hospitalization rate and 13 % (95 % CI: 11-15) versus 6 % (95 % CI: 2-9) in the mean hospital stay, respectively. In 2019, the mean hospital stay for pertussis was about 4.5 days in both groups.

CONCLUSIONS

Maternal pertussis vaccination in Spain led to a reduction in disease severity in the target group as compared to older infants, highlighting the need for increased efforts on educating healthcare professionals on the importance of maternal vaccinations.

National prevalence of smoking among adolescents at tobacco tax increase and COVID-19 pandemic in South Korea, 2005-2022

Prior research has predominantly focused on the overall effects of the tobacco tax increase and the COVID-19 pandemic on adolescent smoking behavior. However, there is a need to examine both the immediate and sustained associations of these two factors on subgroups of adolescents, employing an interrupted time-series model. We aimed to investigate the immediate and sustained association of tobacco tax increase and the COVID-19 pandemic on adolescent smoking prevalence. This study utilized data from the Korea Youth Risk Behavior Web-Based Survey to analyze the prevalence of current smoking among all participants (CSP) and the prevalence of daily smoking among current smokers (DSP) of Korean adolescents (n = 1,159,995; mean, age 14.99; male 51.5%) over 18 years from 2005 to 2022. The study examined 18-year trends in CSP and DSP among Korean adolescents, emphasizing the influences of the 2015 tobacco tax increase and the COVID-19 pandemic, using β coefficients and their differences (βdiff) from an interrupted time-series ARIMA model. While CSP exhibited a decreasing trend, DSP exhibited an increasing trend. Tobacco tax increase was associated with both the short and long terms in smoking prevalence, however, the short-term association on prevalence (CSP, - 3.076 [95% CI, - 3.707 to - 2.445]; DSP, - 4.112 [95% CI, - 6.488 to - 1.735]) was stronger. The pandemic was associated with an immediate increase in DSP (9.345 [95% CI, 5.285-13.406]). These effects were strongest among adolescents from low economic status and those exposed to familial secondhand smoking. Supportive programs for adolescents in low-income families will help overcome the effects associated with the pandemic. As a tobacco tax increase was associated with a reduction in smoking prevalence, this could be one method to overcome the effects of the pandemic.

Evaluation of an automated feedback intervention to improve antibiotic prescribing among primary care physicians (OPEN Stewardship): a multinational controlled interrupted time-series study

Tools to advance antimicrobial stewardship in the primary health care setting, where most antimicrobials are prescribed, are urgently needed. The aim of this study was to evaluate OPEN Stewarship (Online Platform for Expanding aNtibiotic Stewardship), an automated feedback intervention, among a cohort of primary care physicians. We performed a controlled, interrupted time-series study of 32 intervention and 725 control participants, consisting of primary care physicians from Ontario, Canada and Southern Israel, from October 2020 to December 2021. Intervention participants received three personalized feedback reports targeting several aspects of antibiotic prescribing. Study outcomes (overall prescribing rate, prescribing rate for viral respiratory conditions, prescribing rate for acute sinusitis, and mean duration of therapy) were evaluated using multilevel regression models. We observed a decrease in the mean duration of antibiotic therapy (IRR = 0.94; 95% CI: 0.90, 0.99) in intervention participants during the intervention period. We did not observe a significant decline in overall antibiotic prescribing (OR = 1.01; 95% CI: 0.94, 1.07), prescribing for viral respiratory conditions (OR = 0.87; 95% CI: 0.73, 1.03), or prescribing for acute sinusitis (OR = 0.85; 95% CI: 0.67, 1.07). In this antimicrobial stewardship intervention among primary care physicians, we observed shorter durations of therapy per antibiotic prescription during the intervention period. The COVID-19 pandemic may have hampered recruitment; a dramatic reduction in antibiotic prescribing rates in the months before our intervention may have made physicians less amenable to further reductions in prescribing, limiting the generalizability of the estimates obtained.IMPORTANCEAntibiotic overprescribing contributes to antibiotic resistance, a major threat to our ability to treat infections. We developed the OPEN Stewardship (Online Platform for Expanding aNtibiotic Stewardship) platform to provide automated feedback on antibiotic prescribing in primary care, where most antibiotics for human use are prescribed but where the resources to improve antibiotic prescribing are limited. We evaluated the platform among a cohort of primary care physicians from Ontario, Canada and Southern Israel from October 2020 to December 2021. The results showed that physicians who received personalized feedback reports prescribed shorter courses of antibiotics compared to controls, although they did not write fewer antibiotic prescriptions. While the COVID-19 pandemic presented logistical and analytical challenges, our study suggests that our intervention meaningfully improved an important aspect of antibiotic prescribing. The OPEN Stewardship platform stands as an automated, scalable intervention for improving antibiotic prescribing in primary care, where needs are diverse and technical capacity is limited.

The decrease in alcohol consumption and suicide rate during the COVID-19 pandemic and their association

Despite the considerable change in alcohol consumption during the COVID-19 pandemic, the impact of the pandemic on the suicide rate in terms of alcohol consumption was not studied. This study was performed to examine whether the change in the suicide rate during the COVID-19 pandemic was related to alcohol consumption and whether the relation was specific to suicides when compared to mortality due to other causes. We performed a comparative interrupted time series (CITS) analysis for the suicide rate of people aged 19 to 60 with three comparison groups (the suicide rate of people aged 19 and under, the cancer death rate of people aged 19 to 60, and alcohol-induced death rates). The suicide rate of people aged 19 to 60 and alcohol consumption per capita, along with alcohol-induced death rates, continued to decrease during the pandemic in 2020 and 2021, while the suicide rate of people aged 19 and under and the cancer death rate showed increases. In the comparative interrupted time series model, alcohol consumption had an increasing effect on the adult suicide rate compared to comparison groups when time trends and changes associated with COVID-19 were adjusted. This study shows that the decrease in the adult suicide rate in Korea during the pandemic was associated with the decrease in alcohol use among the adult population. Considering that means restriction is the most effective way of controlling suicide and that alcohol can be the most potent and final trigger for suicide, the decrease in suicides during the pandemic and its association with alcohol consumption should be understood as a call for further efforts to decrease alcohol consumption.

Does HIV index testing bring patients into treatment at earlier stages of HIV disease? Results from a retrospective study in Ukraine

BACKGROUND

Over one-third of people living with HIV (PLH) in Ukraine are not on treatment. Index testing services, which link potentially exposed partners (named partners) of known PLH (index patients) with testing and treatment services, are being scaled in Ukraine and could potentially close this gap.

METHODS

This retrospective study included patient data from 14,554 adult PLH who initiated antiretroviral treatment (ART) between October 2018 and May 2021 at one of 35 facilities participating in an intervention to strengthen index testing services. Mixed effects modified Poisson models were used to assess differences between named partners and other ART initiators, and an interrupted time series (ITS) analysis was used to assess changes in ART initiation over time.

RESULTS

Compared to other ART initiators, named partners were significantly less likely to have a confirmed TB diagnosis (aRR = 0.56, 95% CI = 0.40, 0.77, p < 0.001), a CD4 count less than 200 cells/mm3 (aRR = 0.84, 95% CI = 0.73, 0.97, p = 0.017), or be categorized as WHO HIV stage 4 (aRR = 0.68, 9% CI = 0.55, 0.83, p < 0.001) at the time of ART initiation, and were significantly more likely to initiate ART within seven days of testing for HIV (aRR = 1.36, 95% CI = 1.22, 1.50, p < 0.001). Our ITS analysis showed a modest 2.34% (95% CI = 0.26%, 4.38%; p = 0.028) month-on-month reduction in mean ART initiations comparing the post-intervention period to the pre-intervention period, although these results were likely confounded by the COVID epidemic.

CONCLUSION

Our findings suggest that index testing services may be beneficial in bringing PLH into treatment at an earlier stage of HIV disease and decreasing delays between HIV testing and ART initiation, potentially improving patient outcomes and retention in the HIV care cascade.

Design and statistical analysis reporting among interrupted time series studies in drug utilization research: a cross-sectional survey

INTRODUCTION

Interrupted time series (ITS) design is a commonly used method for evaluating large-scale interventions in clinical practice or public health. However, improperly using this method can lead to biased results.

OBJECTIVE

To investigate design and statistical analysis characteristics of drug utilization studies using ITS design, and give recommendations for improvements.

METHODS

A literature search was conducted based on PubMed from January 2021 to December 2021. We included original articles that used ITS design to investigate drug utilization without restriction on study population or outcome types. A structured, pilot-tested questionnaire was developed to extract information regarding study characteristics and details about design and statistical analysis.

RESULTS

We included 153 eligible studies. Among those, 28.1% (43/153) clearly explained the rationale for using the ITS design and 13.7% (21/153) clarified the rationale of using the specified ITS model structure. One hundred and forty-nine studies used aggregated data to do ITS analysis, and 20.8% (31/149) clarified the rationale for the number of time points. The consideration of autocorrelation, non-stationary and seasonality was often lacking among those studies, and only 14 studies mentioned all of three methodological issues. Missing data was mentioned in 31 studies. Only 39.22% (60/153) reported the regression models, while 15 studies gave the incorrect interpretation of level change due to time parameterization. Time-varying participant characteristics were considered in 24 studies. In 97 studies containing hierarchical data, 23 studies clarified the heterogeneity among clusters and used statistical methods to address this issue.

CONCLUSION

The quality of design and statistical analyses in ITS studies for drug utilization remains unsatisfactory. Three emerging methodological issues warranted particular attention, including incorrect interpretation of level change due to time parameterization, time-varying participant characteristics and hierarchical data analysis. We offered specific recommendations about the design, analysis and reporting of the ITS study.

The impact of policy and policy communication on COVID-19 vaccination inequalities among Venezuelan refugees and migrants in Colombia: a comparative cross-sectional interrupted time-series analysis

INTRODUCTION

Equitable access to vaccines for migrants and refugees is necessary to ensure their right to health and to achieve public health goals of reducing vaccine-preventable illness. Public health policies require regulatory frameworks and communication to effect uptake of effective vaccines among the target population. In Colombia, the National COVID-19 Vaccination Plan implicitly included Venezuelan refugees and migrants; however, initial communication of the policy indicated that vaccine availability was restricted to people with regular migration status. We estimated the impact of a public announcement, which clarified access for refugees and migrants, on vaccination coverage among Venezuelans living in Colombia.

METHODS

Between 30 July 2021 and 5 February 2022, 6221 adult Venezuelans participated in a cross-sectional, population-based health survey. We used a comparative cross-sectional time-series analysis to estimate the effect of the October 2021 announcement on the average biweekly change in COVID-19 vaccine coverage of Venezuelans with regular and irregular migration status.

RESULTS

71% of Venezuelans had an irregular status. The baseline (preannouncement) vaccine coverage was lower among people with an irregular status but increased at similar rates as those with a regular status. After the announcement, there was a level change of 14.49% (95% CI: 1.57 to 27.42, p=0.03) in vaccination rates among individuals with irregular migration status with a 4.61% increase in vaccination rate per biweekly period (95% CI: 1.71 to 7.51, p=0.004). By February 2022, there was a 26.2% relative increase in vaccinations among individuals with irregular migration status compared with what was expected without the announcement.

CONCLUSION

While there was no policy change, communication clarifying the policy drastically reduced vaccination inequalities across migration status. Lessons can be translated from the COVID-19 pandemic into more effective global, regional and local public health emergency preparedness and response to displacement.

Transition to Weight-Based High-Flow Nasal Cannula Use Outside of the ICU for Bronchiolitis

Importance

Most children's hospitals have adopted weight-based high-flow nasal cannula (HFNC) bronchiolitis protocols for use outside of the intensive care unit (ICU) setting. Whether these protocols are achieving their goal of reducing bronchiolitis-related ICU admissions remains unknown.

Objective

To measure the association between hospital transition to weight-based non-ICU HFNC use and subsequent ICU admission.

Design, Setting, and Participants

This multicenter retrospective cohort study was conducted with a controlled interrupted time series approach and involved 18 children's hospitals that contribute data to the Pediatric Health Information Systems database. The cohort included patients aged 0 to 24 months who were hospitalized with a diagnosis of bronchiolitis between January 1, 2010, and December 31, 2021. Data were analyzed from July 2023 to January 2024.

Exposure

Hospital-level transition from ICU-only to weight-based non-ICU protocol for HFNC use. Data for the ICU-only group were obtained from a previously published survey.

Main Outcomes and Measures

Proportion of patients with bronchiolitis admitted to the ICU.

Results

A total of 86 046 patients with bronchiolitis received care from 10 hospitals in the ICU-only group (n = 47 336; 27 850 males [58.8%]; mean [SD] age, 7.6 [6.2] years) and 8 hospitals in the weight-based protocol group (n = 38 710; 22 845 males [59.0%]; mean [SD] age, 7.7 [6.3] years). Mean age and sex were similar for patients between the 2 groups. Hospitals in the ICU-only group vs the weight-based protocol group had higher proportions of Black (26.2% vs 19.8%) and non-Hispanic (81.6% vs 63.8%) patients and patients with governmental insurance (68.1% vs 65.9%). Hospital transition to a weight-based HFNC protocol was associated with a 6.1% (95% CI, 8.7%-3.4%) decrease per year in ICU admission and a 1.5% (95% CI, 2.8%-0.1%) reduction per year in noninvasive positive pressure ventilation use compared with the ICU-only group. No differences in mean length of stay or the proportion of patients who received invasive mechanical ventilation were found between groups.

Conclusions and Relevance

Results of this cohort study of hospitalized patients with bronchiolitis suggest that transition from ICU-only to weight-based non-ICU HFNC protocols is associated with reduced ICU admission rates.

Evaluating the impact of minimum unit pricing for alcohol on road traffic accidents in Scotland after 20 months: An interrupted time series study

BACKGROUND AND AIMS

On 1 May 2018, Scotland implemented Minimum Unit Pricing (MUP) of £0.50 per unit of alcohol with the aim to lower alcohol consumption and related harms, and reduce health inequalities. We measured the impact of MUP on the most likely categories of road traffic accidents (RTAs) to be affected by drink-driving episodes (fatal and nighttime) up to 20 months after the policy implementation. Further, we checked whether any association varied by level of socio-economic deprivation.

METHODS

An interrupted time series design was used to evaluate the impact of MUP on fatal and nighttime RTAs in Scotland and any effect modification across socio-economic deprivation groups. RTAs in England and Wales (E&W) were used as a comparator. Covariates representing severe weather events, bank holidays, seasonal and underlying trends were adjusted for.

RESULTS

In Scotland, MUP implementation was associated with 40.5% (95% confidence interval: 15.5%, 65.4%) and 11.4% (-1.1%, 24.0%) increases in fatal and nighttime RTAs, respectively. There was no evidence of differential impacts of MUP by level of socio-economic deprivation. While we found a substantial increase in fatal RTAs associated with MUP, null effects observed in nighttime RTAs and high uncertainty in sensitivity analyses suggest caution be applied before attributing causation to this association.

CONCLUSION

There is no evidence of an association between the introduction of minimum unit pricing for alcohol in Scotland and a reduction in fatal and nighttime road traffic accidents, these being outcome measure categories that are proxies of outcomes that directly relate alcohol consumption to road traffic accidents.

Impact of the COVID-19 pandemic on antibiotic prescribing in high-prescribing primary care physicians in Switzerland

OBJECTIVES

The aim of this study was to evaluate antibiotic prescribing of medium-to-high prescribing primary care physicians being followed up after the completion of a Swiss national intervention trial of antibiotic prescription audit and feedback in the first SARS-CoV-2 pandemic year.

METHODS

We used health insurer based claims data to calculate monthly antibiotic prescription rates per 100 consultations (primary endpoint) and applying interrupted time series (ITS) analysis methods, we estimated the immediate (step change) and sustained effects (slope) of the SARS-CoV-2 epidemic in 2020 on antibiotic prescribing compared to the pre-pandemic trial period from 2017-2019.

RESULTS

We analysed data of 2945 of 3426 physicians (86.0%) from the trial with over 4 million consultations annually, who were in 2020 still in practice. Consultations dropped by 43% during the first pandemic year compared with 2017. Median monthly antibiotic prescription rates per 100 consultations in 2017 were 8.44 (Interquartile range [IQ] 6.32-11.50) and 8.35 (6.34-11.74) in the intervention and control groups, respectively, and increased to 15.63 (10.69-23.81) and 16.31 (10.65-24.72) per 100 consultations in 2020. ITS-derived incidence rate ratios for overall antibiotic prescriptions were 2.32 (95% CI 2.07-2.59) for the immediate pandemic effect, and 0.96 (0.95-0.98) for the sustained effect (change in slope in 2020 compared with 2017-2019).

DISCUSSION

The SARS-CoV-2 pandemic had a major impact on antibiotic prescription patterns in primary care in Switzerland. For future viral pandemics, intervention plans with timely activation steps to minimize unjustified antibiotic consumption in primary care should be prepared.

Impact of the UK soft drinks industry levy on health and health inequalities in children and adolescents in England: An interrupted time series analysis and population health modelling study

BACKGROUND

The soft drinks industry levy (SDIL) in the United Kingdom has led to a significant reduction in household purchasing of sugar in drinks. In this study, we examined the potential medium- and long-term implications for health and health inequalities among children and adolescents in England.

METHODS AND FINDINGS

We conducted a controlled interrupted time series analysis to measure the effects of the SDIL on the amount of sugar per household per week from soft drinks purchased, 19 months post implementation and by index of multiple deprivation (IMD) quintile in England. We modelled the effect of observed sugar reduction on body mass index (BMI), dental caries, and quality-adjusted life years (QALYs) in children and adolescents (0 to 17 years) by IMD quintile over the first 10 years following announcement (March 2016) and implementation (April 2018) of the SDIL. Using a lifetable model, we simulated the potential long-term impact of these changes on life expectancy for the current birth cohort and, using regression models with results from the IMD-specific lifetable models, we calculated the impact of the SDIL on the slope index of inequality (SII) in life expectancy. The SDIL was found to have reduced sugar from purchased drinks in England by 15 g/household/week (95% confidence interval: -10.3 to -19.7). The model predicts these reductions in sugar will lead to 3,600 (95% uncertainty interval: 946 to 6,330) fewer dental caries and 64,100 (54,400 to 73,400) fewer children and adolescents classified as overweight or obese, in the first 10 years after implementation. The changes in sugar purchasing and predicted impacts on health are largest for children and adolescents in the most deprived areas (Q1: 11,000 QALYs [8,370 to 14,100] and Q2: 7,760 QALYs [5,730 to 9,970]), while children and adolescents in less deprived areas will likely experience much smaller simulated effects (Q3: -1,830 QALYs [-3,260 to -501], Q4: 652 QALYs [-336 to 1,680], Q5: 1,860 QALYs [929 to 2,890]). If the simulated effects of the SDIL are sustained over the life course, it is predicted there will be a small but significant reduction in slope index of inequality: 0.76% (95% uncertainty interval: -0.9 to -0.62) for females and 0.94% (-1.1 to -0.76) for males.

CONCLUSIONS

We predict that the SDIL will lead to medium-term reductions in dental caries and overweight/obesity, and long-term improvements in life expectancy, with the greatest benefits projected for children and adolescents from more deprived areas. This study provides evidence that the SDIL could narrow health inequalities for children and adolescents in England.

Evaluating the effects of the 2017 National Health Insurance coverage expansion on amenable mortality and its disparities between areas in South Korea using Bayesian structural time-series models

To improve the low coverage rate of the National Health Insurance (NHI), South Korea implemented the NHI coverage expansion plan in 2017 to cover medically essential non-covered services and reduce copayment rates. This study aimed to estimate the effects of the 2017 NHI coverage expansion on amenable mortality and its disparities between areas in South Korea under a controlled interrupted time-series design using Bayesian structural time-series models. Age-standardized amenable mortality rates and rate differences (RDs) and rate ratios (RRs) between areas for amenable mortality were calculated monthly between July 2012 and December 2021 and used as the response series. The non-equivalent control series were monthly non-avoidable mortality rates and their regional disparities. After the coverage expansion, amenable mortality rates decreased for both males (-8.8%, 95% credible interval [CrI] -13.4% to -3.9%) and females (-8.3%, 95% CrI -13.4% to -2.4%), with the largest decline in the non-Seoul-Capital metropolitan area (-11.6%, 95% CrI -16.5% to -6.3%) rather than the Seoul Capital Area (-7.5%, 95% CrI -11.9% to -2.5%) and a non-significant reduction in the non-Seoul-Capital non-metropolitan area in females. RDs and RRs between areas for amenable mortality decreased non-significantly (-16.2%, 95% CrI -31.3% to 2.6% for RD and -1.2%, 95% CrI -3.7% to 1.5% for RR), except for a significant decrease in RD in males (-21.8%, 95% CrI -38.0% to -1.5%), and decreased less in females than in males. The coverage expansion was generally effective in reducing amenable mortality rates by area, but had limited effects in closing amenable mortality disparities between areas, favoring males and the non-Seoul-Capital metropolitan area. These results implied that additional measures are necessary to improve access to quality health care for females and underserved areas to enhance the effectiveness of the coverage expansion.

Interpretation of coefficients in segmented regression for interrupted time series analyses

Background Segmented regression, a common model for interrupted time series (ITS) analysis, primarily utilizes two equation parametrizations. Interpretations of coefficients vary between the two segmented regression parametrizations, leading to occasional user misinterpretations. Methods To illustrate differences in coefficient interpretation between two common parametrizations of segmented regression in ITS analysis, we derived analytical results and present an illustration evaluating the impact of a smoking regulation policy in Italy using a publicly accessible dataset. Estimated coefficients and their standard errors were obtained using two commonly used parametrizations for segmented regression with continuous outcomes. We clarified coefficient interpretations and intervention effect calculations. Results Our investigation revealed that both parametrizations represent the same model. However, due to differences in parametrization, the immediate effect of the intervention is estimated differently under the two approaches. The key difference lies in the interpretation of the coefficient related to the binary indicator for intervention implementation, impacting the calculation of the immediate effect. Conclusions Two common parametrizations of segmented regression represent the same model but have different interpretations of a key coefficient. Researchers employing either parametrization should exercise caution when interpreting coefficients and calculating intervention effects.