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1.
Gut ; 69(2): 274-282, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31196874

RESUMO

OBJECTIVES: To better understand the real-world impact of biologic therapy in persons with Crohn's disease (CD) and ulcerative colitis (UC), we evaluated the effect of marketplace introduction of infliximab on the population rates of hospitalisations and surgeries and public payer drug costs. DESIGN: We used health administrative data to study adult persons with CD and UC living in Ontario, Canada between 1995 and 2012. We used an interrupted time series design with segmented regression analysis to evaluate the impact of infliximab introduction on the rates of IBD-related hospitalisations, intestinal resections and public payer drug costs over 10 years among patients with CD and 5 years among patients with UC, allowing for a 1-year transition. RESULTS: Relative to what would have been expected in the absence of infliximab, marketplace introduction of infliximab did not produce significant declines in the rates of CD-related hospitalisations (OR at the last observation quarter 1.06, 95% CI 0.811 to 1.39) or intestinal resections (OR 1.10, 95% CI 0.810 to 1.50), or in the rates of UC-related hospitalisations (OR 1.22, 95% CI 1.07 to 1.39) or colectomies (OR 0.933, 95% CI 0.54 to 1.61). The findings were similar among infliximab users, except that hospitalisation rates declined substantially among UC patients following marketplace introduction of infliximab (OR 0.515, 95% CI 0.342 to 0.777). There was a threefold rise over expected trends in public payer drug cost among patients with CD following infliximab introduction (OR 2.98,95% CI 2.29 to 3.86), suggesting robust market penetration in this group, but no significant change among patients with UC (OR 1.06, 95% CI 0.955 to 1.18). CONCLUSIONS: Marketplace introduction of infliximab has not yielded anticipated reductions in the population rates of IBD-related hospitalisations or intestinal resections, despite robust market penetration among patients with CD. Misguided use of infliximab in CD patients and underuse of infliximab in UC patients may largely explain our study findings.


Assuntos
Fármacos Gastrointestinais/uso terapêutico , Hospitalização/estatística & dados numéricos , Doenças Inflamatórias Intestinais/tratamento farmacológico , /uso terapêutico , Adulto , Colectomia/estatística & dados numéricos , Colectomia/tendências , Colite Ulcerativa/tratamento farmacológico , Colite Ulcerativa/epidemiologia , Colite Ulcerativa/cirurgia , Doença de Crohn/tratamento farmacológico , Doença de Crohn/epidemiologia , Doença de Crohn/cirurgia , Custos de Medicamentos/estatística & dados numéricos , Custos de Medicamentos/tendências , Feminino , Hospitalização/tendências , Humanos , Doenças Inflamatórias Intestinais/epidemiologia , Doenças Inflamatórias Intestinais/cirurgia , Análise de Séries Temporais Interrompida , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Fatores Socioeconômicos
2.
Rev Saude Publica ; 53: 99, 2019.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31800916

RESUMO

OBJECTIVE: To evaluate the performance of the Mobile Emergency Medical Services (SAMU) in the ABC Region, using myocardial infarction as tracer condition. METHODS: The analysis of interrupted time series was the approach chosen to test immediate and gradual effects of the intervention on the study population. The research comprised adjusted monthly time series of the hospital mortality rate by myocardial infarction in the period between 2000 and 2011. Data were extracted from the Mortality Information System (SIM), using segmented regression analysis to evaluate the level and trend of the intervention before and after its implementation. To strengthen the internal validity of the study, a control region was included. RESULTS: The analysis of interrupted time series showed a reduction of 0.04 deaths per 100,000 inhabitants in the mortality rate compared to the underlying trend since the implementation of the Emergency Medical Services (p = 0.0040; 95%CI: -0.0816 - -0.0162) and a reduction in the level of 2.89 deaths per 100,000 inhabitants (p = 0.0001; 95%CI: -4.3293 - -1.4623), both with statistical significance. Regarding the control region, Baixada Santista, the difference in the result trend between intervention outcome and post-intervention control of -0.0639 deaths per 100,000 inhabitants was statistically significant (p = 0.0031; 95%CI: -0.1060 - -0.0219). We cannot exclude confounders, but we limited their presence in the study by including control region series. CONCLUSIONS: Although the analysis of interrupted time series has limitations, this modeling can be useful for analyzing the performance of policies and programs. Even though the intervention studied is not a condition that in itself implies effectiveness, the latter would not be present without the former, which, integrated with other conditions, generates a positive result. SAMU is a strategy that must be expanded when formulating and consolidating policies focusing on emergency care.


Assuntos
Ambulâncias/estatística & dados numéricos , Mortalidade Hospitalar/tendências , Unidades Móveis de Saúde/estatística & dados numéricos , Infarto do Miocárdio/mortalidade , Adulto , Ambulâncias/normas , Brasil , Serviços Médicos de Emergência , Estudos de Viabilidade , Feminino , Humanos , Análise de Séries Temporais Interrompida , Masculino , Unidades Móveis de Saúde/normas , Qualidade da Assistência à Saúde , Valores de Referência , Análise de Regressão , Estações do Ano , Fatores Socioeconômicos , Fatores de Tempo
3.
Rev Saude Publica ; 53: 94, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31644724

RESUMO

OBJECTIVE: To evaluate trends in the use of generic and non-generic medicines to treat hypertension and diabetes under the Farmácia Popular Program (FP) and its impact on generic medicines sales volume and market share in the Brazilian pharmaceutical market. METHODS: This longitudinal, retrospective study used interrupted time series design to analyze changes in monthly sales volume and proportion of medicines sales (market share) for oral antidiabetic and antihypertensive medicines for generic versus non-generic products. Analyses were conducted in a combined dataset that aggregate monthly sales volumes from the Farmácia Popular program and from the QuintilesIMS™ (IQVIA) national market sales data from January 2007 to December 2012. The Farmácia Popular program phases analyzed included: a) 2009 reductions in medicines reference prices (AFP-II) and b) 2011 implementation of free medicines program for hypertension and diabetes, the Saúde não tem preço (SNTP - Health has no price). RESULTS: Patterns of use for FP-covered antidiabetic and antihypertensive medicines were similar to their use in the market in general. After one year of the decreases in government subsidies in April 2010, market share of antidiabetic and antihypertensive medicines experienced relative declines of -54.5% and -59.9%, respectively. However, when FP-covered medicines were made free to patients, overall market volume for antidiabetic and antihypertensive generics increased dramatically, with 242.6% and 277.0% relative increases by February 2012, as well as non-generics with relative increase of 209.7% and 279% for antidiabetic and antihypertensive medicines, respectively. CONCLUSIONS: Ministry of Health policies on the amount of patient cost sharing and on the choice of medicines on coverage lists have substantial impacts on overall generic sales volume in retail pharmacies.


Assuntos
Anti-Hipertensivos/uso terapêutico , Comércio/tendências , Serviços Comunitários de Farmácia/tendências , Medicamentos Genéricos/uso terapêutico , Hipoglicemiantes/uso terapêutico , Programas Nacionais de Saúde/tendências , Brasil , Comércio/estatística & dados numéricos , Serviços Comunitários de Farmácia/estatística & dados numéricos , Diabetes Mellitus/tratamento farmacológico , Política de Saúde , Humanos , Hipertensão/tratamento farmacológico , Análise de Séries Temporais Interrompida , Estudos Longitudinais , Programas Nacionais de Saúde/estatística & dados numéricos , Farmácias/estatística & dados numéricos , Farmácias/tendências , Avaliação de Programas e Projetos de Saúde , Valores de Referência , Estudos Retrospectivos , Fatores de Tempo
6.
Zhonghua Liu Xing Bing Xue Za Zhi ; 40(9): 1159-1163, 2019 Sep 10.
Artigo em Chinês | MEDLINE | ID: mdl-31594165

RESUMO

Interrupted time-series (ITS) is a quasi-experimental design which evaluates the effectiveness of an intervention based on time-series outcome variables. Compared with the single group of ITS, the two groups of ITS can better control the influence of pre-interventional confounding factors and evaluate the effectiveness of the intervention. This paper summarizes the principles and statistical methods of two groups of ITS by an example of evaluating vaccine effect on the incidence of a disease in two cities. The regression model is fitted by Prais-Winsten method and Newey-West method and the results are explained and compared in detail. When the intervention is performed with other confounding interventions at the same time, the two groups of ITS can be more effective to balance the existing trends before the intervention, and evaluate the effectiveness of intervention. The method of two groups of ITS has important practical significance, providing new insights in program evaluation.


Assuntos
Análise de Séries Temporais Interrompida , Avaliação de Programas e Projetos de Saúde , Projetos de Pesquisa
7.
BMC Health Serv Res ; 19(1): 687, 2019 Oct 10.
Artigo em Inglês | MEDLINE | ID: mdl-31601199

RESUMO

BACKGROUND: Social inequities are widening globally, contributing to growing health and health care inequities. Health inequities are unjust differences in health and well-being between and within groups of people caused by socially structured, and thus avoidable, marginalizing conditions such as poverty and systemic racism. In Canada, such conditions disproportionately affect Indigenous persons, racialized newcomers, those with mental health and substance use issues, and those experiencing interpersonal violence. Despite calls to enhance equity in health care to contribute to improving population health, few studies examine how to achieve equity at the point of care, and the impacts of doing so. Many people facing marginalizing conditions experience inadequate and inequitable treatment in emergency departments (EDs), which makes people less likely to access care, paradoxically resulting in reliance on EDs through delays to care and repeat visits, interfering with effective care delivery and increasing human and financial costs. EDs are key settings with potential for mitigating the impacts of structural conditions and barriers to care linked to health inequities. METHODS: EQUIP is an organizational intervention to promote equity. Building on promising research in primary health care, we are adapting EQUIP to emergency departments, and testing its impact at three geographically and demographically diverse EDs in one Canadian province. A mixed methods multisite design will examine changes in key outcomes including: a) a longitudinal analysis of change over time based on structured assessments of patients and staff, b) an interrupted time series design of administrative data (i.e., staff sick leave, patients who leave without care being completed), c) a process evaluation to assess how the intervention was implemented and the contextual features of the environment and process that are influential for successful implementation, and d) a cost-benefit analysis. DISCUSSION: This project will generate both process- and outcome-based evidence to improve the provision of equity-oriented health care in emergency departments, particularly targeting groups known to be at greatest risk for experiencing the negative impacts of health and health care inequities. The main deliverable is a health equity-enhancing framework, including implementable, measurable interventions, tested, refined and relevant to diverse EDs. TRIAL REGISTRATION: Clinical Trials.gov # NCT03369678 (registration date November 18, 2017).


Assuntos
Assistência à Saúde/normas , Serviço Hospitalar de Emergência/normas , Equidade em Saúde/organização & administração , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/estatística & dados numéricos , Colúmbia Britânica , Protocolos Clínicos , Serviço Hospitalar de Emergência/organização & administração , Humanos , Índios Norte-Americanos/estatística & dados numéricos , Análise de Séries Temporais Interrompida , Serviços de Saúde Mental/normas , Serviços de Saúde Mental/estatística & dados numéricos , Atenção Primária à Saúde/organização & administração , Racismo/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/reabilitação , Violência/estatística & dados numéricos
8.
BMJ ; 366: l5274, 2019 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-31554617

RESUMO

OBJECTIVE: To assess the immediate impact of the introduction of minimum unit pricing in Scotland on household alcohol purchases. DESIGN: Controlled interrupted time series analysis. SETTING: Purchase data from Kantar Worldpanel's household shopping panel for 2015-18. PARTICIPANTS: 5325 Scottish households, 54 807 English households as controls, and 10 040 households in northern England to control for potential cross border effects. INTERVENTIONS: Introduction of a minimum price of 50p (€0.55; $0.61) per UK unit (6.25p per gram) for the sale of alcohol in Scotland on 1 May 2018. MAIN OUTCOME MEASURES: Price per gram of alcohol, number of grams of alcohol purchased from off-trade by households, and weekly household expenditure on alcohol. RESULTS: The introduction of minimum unit pricing in Scotland was associated with an increase in purchase price of 0.64p per gram of alcohol (95% confidence interval 0.54 to 0.75), a reduction in weekly purchases of 9.5 g of alcohol per adult per household (5.1 to 13.9), and a non-significant increase in weekly expenditure on alcohol per household of 61p (-5 to 127). The increase in purchase price was higher in lower income households and in households that purchased the largest amount of alcohol. The reduction in purchased grams of alcohol was greater in lower income households and only occurred in the top fifth of households by income that purchased the greatest amount of alcohol, where the reduction was 15 g of alcohol per week (6 to 24). Changes in weekly expenditure were not systematically related to household income but increased with increasing household purchases. CONCLUSIONS: In terms of immediate impact, the introduction of minimum unit pricing appears to have been successful in reducing the amount of alcohol purchased by households in Scotland. The action was targeted, in that reductions of purchased alcohol only occurred in the households that bought the most alcohol.


Assuntos
Consumo de Bebidas Alcoólicas/epidemiologia , Bebidas Alcoólicas/economia , Comércio , Comportamento do Consumidor/economia , Comportamento do Consumidor/estatística & dados numéricos , Humanos , Análise de Séries Temporais Interrompida , Reino Unido
10.
PLoS Negl Trop Dis ; 13(9): e0007721, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31545803

RESUMO

This study aimed to assess the impact of the Zika epidemic on the registration of birth defects in Brazil. We used an interrupted time series analysis design to identify changes in the trends in the registration of congenital anomalies. We obtained monthly data from Brazilian Live Birth Information System and used two outcome definitions: 1) rate of congenital malformation of the brain and eye (likely to be affected by Zika and its complications) 2) rate of congenital malformation not related to the brain or eye unlikely to be causally affected by Zika. The period between maternal infection with Zika and diagnosis of congenital abnormality attributable to the infection is around six months. We therefore used September 2015 as the interruption point in the time series, six months following March 2015 when cases of Zika started to increase. For the purposes of this analysis, we considered the period from January 2010 to September 2015 to be "pre-Zika event," and the period from just after September 2015 to December 2017 to be "post-Zika event." We found that immediately after the interruption point, there was a great increase in the notification rate of congenital anomalies of 14.9/10,000 live births in the brain and eye group and of 5.2/10,000 live births in the group not related with brain or eye malformations. This increase in reporting was in all regions of the country (except in the South) and especially in the Northeast. In the period "post-Zika event", unlike the brain and eye group which showed a monthly decrease, the group without brain or eye malformations showed a slow but significant increase (relative to the pre-Zika trend) of 0.2/10,000 live births. These findings suggest an overall improvement in the registration of birth malformations, including malformations that were not attributed to Zika, during and after the Zika epidemic.


Assuntos
Anormalidades Congênitas/epidemiologia , Sistema de Registros/normas , Infecção por Zika virus/complicações , Encéfalo/anormalidades , Brasil/epidemiologia , Anormalidades Congênitas/virologia , Coleta de Dados/normas , Epidemias/estatística & dados numéricos , Anormalidades do Olho/epidemiologia , Feminino , Humanos , Análise de Séries Temporais Interrompida , Gravidez , Complicações Infecciosas na Gravidez/epidemiologia , Complicações Infecciosas na Gravidez/virologia , Zika virus , Infecção por Zika virus/epidemiologia
11.
Pediatrics ; 144(4)2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31488696

RESUMO

BACKGROUND: In May 2016, the American Academy of Pediatrics published a clinical practice guideline for brief resolved unexplained events (BRUEs). We evaluated for changes in the management of BRUE after guideline publication. METHODS: Using a pediatric multicenter administrative database, we compared rates of admission, testing, revisits, and diagnoses in patients diagnosed with a BRUE or apparent life-threatening event (ALTE) during 2017 with rates of admission, testing, revisits, and diagnoses in patients diagnosed with ALTE during 2015. We used interrupted time series analysis to test if the guideline was associated with changes in admission rate for all patients with ALTE or BRUE between 2015 and 2017. We stratified analyses by age (0-60 and 61-365 days). RESULTS: A total of 9501 patients were included (5608 in 2015 and 3893 in 2017). The admission rate decreased by 5.7% (95% confidence interval, 3.8% to 7.5%) for infants 0 to 60 days and by 18.0% (95% confidence interval, 15.3% to 20.7%) for infants 61 to 365 days from 2015 to 2017. Patients in 2017 had lower rates of EEG, brain MRI, chest radiography, laboratory testing, and urinalyses compared with patients in 2015. In the interrupted time series analysis model (n = 13 977), guideline publication was associated with decreasing admission rates (0.2% per week) for infants 61 to 365 days (P < .001). CONCLUSIONS: Compared with patients evaluated in 2015, patients with BRUE or ALTE in 2017 have lower rate of admissions and testing. Findings may be due to changes in the definition of BRUE and guideline recommendations.


Assuntos
Hospitalização/estatística & dados numéricos , Sintomas Inexplicáveis , Guias de Prática Clínica como Assunto , Intervalos de Confiança , Eletroencefalografia/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Análise de Séries Temporais Interrompida , Imagem por Ressonância Magnética/estatística & dados numéricos , Radiografia Torácica/estatística & dados numéricos
12.
BMC Health Serv Res ; 19(1): 645, 2019 Sep 06.
Artigo em Inglês | MEDLINE | ID: mdl-31492134

RESUMO

BACKGROUND: Maternal and perinatal mortality is a major public health concern across the globe and more so in low and middle-income countries. In Kenya, more than 6000 maternal deaths, and 35,000 stillbirths occur each year. The Government of Kenya abolished user fee for maternity care under the Free Maternity Service policy, in June of 2013 in all public health facilities, a move to make maternity services accessible and affordable, and to reduce maternal and perinatal mortality. METHOD: An observational retrospective study was carried out in 3 counties in Kenya. Six maternal health output indicators were observed monthly, 2 years pre and 2 years post- policy implementation. Data was collected from daily maternity registers in 90 public health facilities across the 3 counties all serving an estimated population of 3 million people. Interrupted Time Series Analysis (ITSA) with a single group was used to assess the effects of the policy. Standard linear regression using generalized least squares (gls) model, was used to run the results for each of the six variables of interest. Absolute and relative changes were calculated using the gls model coefficients. RESULTS: Significant sustained increase of 89, 97, and 98% was observed in the antenatal care visits, health facility deliveries, and live births respectively, after the policy implementation. An immediate and significant increase of 27% was also noted for those women who received Emergency Obstetric Care (EmONC) services in either the level 5, 4 and 3 health facilities. No significant changes were observed in the stillbirth rate and caesarean section rate following policy implementation. CONCLUSION: After 2 years of implementing the Free Maternity Service policy in Kenya, immediate and sustained increase in the use of skilled care during pregnancy and childbirth was observed. The study suggest that hospital cost is a major expense incurred by most women and their families whilst seeking maternity care services and a barrier to maternity care utilization. Overall, Free Maternity Service policy, as a health financing strategy, has exhibited the potential of realizing the full beneficial effects of maternal morbidity and mortality reduction by increasing access to skilled care.


Assuntos
Serviços de Saúde Materna/economia , Cesárea/economia , Cesárea/estatística & dados numéricos , Parto Obstétrico/economia , Parto Obstétrico/estatística & dados numéricos , Serviços Médicos de Emergência/economia , Serviços Médicos de Emergência/estatística & dados numéricos , Utilização de Instalações e Serviços , Feminino , Instalações de Saúde/economia , Instalações de Saúde/estatística & dados numéricos , Humanos , Análise de Séries Temporais Interrompida , Quênia/epidemiologia , Saúde Materna/economia , Saúde Materna/estatística & dados numéricos , Serviços de Saúde Materna/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Mortalidade Perinatal , Gravidez , Cuidado Pré-Natal/economia , Cuidado Pré-Natal/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde , Estudos Retrospectivos , Natimorto/epidemiologia
13.
R I Med J (2013) ; 102(6): 24-26, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31398964

RESUMO

The opioid epidemic presents an urgent public health problem. Rhode Island has enacted comprehensive rules to address primary prevention of opioid overdose. This study evaluates the efficacy of those regulations in altering prescribing behavior, specifically regarding the initial prescription. Using data extracted from the Rhode Island Prescription Drug Monitoring Program (PDMP), before and after the publication of updated acute pain management regulations, we studied the rate of opioid prescribing using statistical process control (SPC) charts and found that the rate of prescribing unsafe doses of opioids, more than 30 morphine milligram equivalents (MMEs) per day or more than 20 doses to opioid naïve patients, decreased significantly.


Assuntos
Overdose de Drogas/epidemiologia , Prescrição Inadequada/legislação & jurisprudência , Padrões de Prática Médica/legislação & jurisprudência , Programas de Monitoramento de Prescrição de Medicamentos/legislação & jurisprudência , Analgésicos Opioides/uso terapêutico , Overdose de Drogas/prevenção & controle , Humanos , Prescrição Inadequada/prevenção & controle , Análise de Séries Temporais Interrompida , Padrões de Prática Médica/normas , Programas de Monitoramento de Prescrição de Medicamentos/normas , Medicamentos sob Prescrição/uso terapêutico , Rhode Island/epidemiologia
14.
BMC Infect Dis ; 19(1): 705, 2019 Aug 09.
Artigo em Inglês | MEDLINE | ID: mdl-31399064

RESUMO

BACKGROUND: In recent times, emerging and re-emerging infectious diseases are posing a public health threat in developing countries, and vigilant surveillance is necessary to prepare against these threats. Analyses of multi-year comprehensive infectious disease syndrome data are required in Mongolia, but have not been conducted till date. This study aimed to describe the trends in the incidence of infectious disease syndromes in Mongolia during 2009-2017 using a nationwide syndrome surveillance system for infectious diseases established in 2009. METHODS: We analyzed time trends using monthly data on the incidence of infectious disease syndromes such as acute fever with rash (AFR), acute fever with vesicular rash (AFVR), acute jaundice (AJ), acute watery diarrhea (AWD), acute bloody diarrhea (ABD), foodborne disease (FD) and nosocomial infection (NI) reported from January 1, 2009 to December 31, 2017. Time series forecasting models based on the data up to 2017 estimated the future trends in the incidence of syndromes up to December 2020. RESULTS: During the study, the overall prevalence of infectious disease syndromes was 71.8/10,000 population nationwide. The average number of reported infectious disease syndromes was 14,519 (5229-55,132) per year. The major types were AFR (38.7%), AFVR (31.7%), AJ (13.9%), ABD (10.2%), and AWD (1.8%), accounting for 96.4% of all reported syndromes. The most prevalent syndromes were AJ between 2009 and 2012 (59.5-48.7%), AFVR between 2013 and 2014 (54.5-59%), AFR between 2015 and 2016 (67.6-65.9%), and AFVR in 2017 (62.2%). There were increases in the prevalence of AFR, with the monthly number of cases being 37.7 ± 6.1 during 2015-2016; this could be related to the measles outbreak in Mongolia during that period. The AFVR incidence rate showed winter's multiplicative seasonal fluctuations with a peak of 10.6 ± 2 cases per 10,000 population in 2017. AJ outbreaks were identified in 2010, 2011, and 2012, and these could be associated with hepatitis A outbreaks. Prospective time series forecasting showed increasing trends in the rates of AFVR and ABD. CONCLUSIONS: The evidence-based method for infectious disease syndromes was useful in gaining an understanding of the current situation, and predicting the future trends of various infectious diseases in Mongolia.


Assuntos
Doenças Transmissíveis/epidemiologia , Doenças Transmissíveis Emergentes/epidemiologia , Surtos de Doenças , Doenças Transmitidas por Alimentos/epidemiologia , Humanos , Incidência , Análise de Séries Temporais Interrompida , Sarampo/epidemiologia , Mongólia/epidemiologia , Vigilância da População/métodos , Prevalência , Estudos Prospectivos , Estudos Retrospectivos , Síndrome
15.
Cochrane Database Syst Rev ; 8: CD012736, 2019 08 14.
Artigo em Inglês | MEDLINE | ID: mdl-31425624

RESUMO

BACKGROUND: Larviciding refers to the regular application of chemical or microbial insecticides to water bodies or water containers to kill the aquatic immature forms of the mosquito (the larvae and pupae). OBJECTIVES: To summarize research evidence evaluating whether larviciding with chemical or microbial insecticides prevents malaria transmission. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE; Embase; CAB Abstracts; LILACS; the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP); ClinicalTrials.gov; and the ISRCTN registry up to 6 June 2019. SELECTION CRITERIA: We included cluster-randomized controlled trials (cRCTs), interrupted time series (ITS), randomized cross-over studies, non-randomized cross-over studies, and controlled before-and-after studies (CBAs) that compared larviciding with no larviciding. DATA COLLECTION AND ANALYSIS: We independently assessed trials for eligibility and risk of bias, and extracted data. We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS: Four studies (one cRCT, two CBAs, and one non-randomized cross-over design) met the inclusion criteria. All used ground application of larvicides (people hand-delivering larvicides); one evaluated chemical and three evaluated microbial agents. Studies were carried out in The Gambia, Tanzania, Kenya, and Sri Lanka. Three studies were conducted in areas where mosquito aquatic habitats were less extensive (< 1 km²), and one where habitats were more extensive (> 1 km²; a cross-over study from The Gambia).For aquatic habitats of less than 1 km², one cRCT randomized eight villages in Sri Lanka to evaluate chemical larviciding using insect growth regulator; and two CBA studies undertaken in Kenya and Tanzania evaluated microbial larvicides. In the cRCT, larviciding across all villages was associated with lower malaria incidence (rate ratio 0.24, 4649 participants, low-certainty evidence) and parasite prevalence (risk ratio (RR) 0.26, 5897 participants, low-certainty evidence) compared to no larviciding. The two CBA studies reported lower malaria prevalence during the intervention period (parasite prevalence RR 0.79, 95% confidence interval (CI) 0.71 to 0.89; 70,902 participants; low-certainty evidence). The Kenyan study also reported a reduction in the incidence of new malaria cases (RR 0.62, 95% CI 0.38 to 1.01; 720 participants; very low-certainty evidence).For aquatic habitats of more than 1 km², the non-randomized cross-over trial using microbial larvicides did not detect an effect for malaria incidence (RR 1.58, 95% CI 0.94 to 2.65; 4226 participants), or parasite prevalence (RR 1.15, 95% CI 0.41 to 3.20; 3547 participants); both were very low-certainty evidence. The Gambia trial also reported the mean haemoglobin level, and there was no difference across the four comparisons (mean difference -0.13, 95% CI -0.40 to 0.13; 3586 participants).We were unable to summarize or pool entomological outcomes due to unreported and missing data. AUTHORS' CONCLUSIONS: Most controlled studies on larviciding have been performed with microbial agents. Ground larviciding for non-extensive larval habitats may have an effect on malaria transmission, and we do not know if there is an effect in large-scale aquatic habitats. We found no studies using larviciding application techniques that could cover large aquatic habitats, such as aerial spraying using aircraft.


Assuntos
Reservatórios de Doenças/parasitologia , Inseticidas/farmacologia , Malária/prevenção & controle , Controle de Mosquitos/métodos , Animais , Culicidae , Ecossistema , Humanos , Análise de Séries Temporais Interrompida , Larva/efeitos dos fármacos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos
16.
Med Care ; 57(10): 757-765, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31453891

RESUMO

BACKGROUND: Medicare's Hospital Readmission Reduction Program (HRRP) penalizes hospitals with elevated 30-day readmission rates for acute myocardial infarction (AMI), heart failure (HF), or pneumonia. To reduce readmissions, hospitals may have increased referrals to skilled nursing facilities (SNFs) and home health care. RESEARCH DESIGN: Outcomes included 30-day postdischarge utilization of SNF and home health care, including any use as well as days of use. Subjects included Medicare fee-for-service beneficiaries aged 65 years and older who were admitted with AMI, HF, or pneumonia to hospitals subject to the HRRP. Using an interrupted time-series analysis, we compared utilization rates observed after the announcement of the HRRP (April 2010 through September 2012) and after the imposition of penalties (October 2012 through September 2014) with projected utilization rates that accounted for pre-HRRP trends (January 2008 through March 2010). Models included patient characteristics and hospital fixed effects. RESULTS: For AMI and HF, utilization of SNF and home health care remained stable overall. For pneumonia, observed utilization of any SNF care increased modestly (1.0%, P<0.001 during anticipation; 2.4%, P<0.001 after penalties) and observed utilization of any home health care services declined modestly (-0.5%, P=0.008 after announcement; -0.7%, P=0.045 after penalties) relative to projections. Beneficiaries with AMI and pneumonia treated at penalized hospitals had higher rates of being in the community 30 days postdischarge. CONCLUSIONS: Hospitals might be shifting to more intensive postacute care to avoid readmissions among seniors with pneumonia. At the same time, penalized hospitals' efforts to prevent readmissions may be keeping higher proportions of their patients in the community.


Assuntos
Utilização de Instalações e Serviços/tendências , Serviços de Assistência Domiciliar/estatística & dados numéricos , Readmissão do Paciente/legislação & jurisprudência , Reembolso de Incentivo/legislação & jurisprudência , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Análise de Séries Temporais Interrompida , Masculino , Medicare/legislação & jurisprudência , Estados Unidos
17.
BMC Health Serv Res ; 19(1): 576, 2019 Aug 16.
Artigo em Inglês | MEDLINE | ID: mdl-31419977

RESUMO

BACKGROUND: Affordability and availability of quality medicines to all its citizens has been a key priority area for South Africa since democracy in 1994. In order to introduce transparency in the private market the government introduced the Single Exit Price (SEP) for medicines in 2004, for all prescription medicines, comprising of a fixed ex-factory price with a logistics fee component (and value added tax) for medicines sold to all purchasers other than the State. This is complemented with a provision for an annual regulated maximum percentage increase. The study evaluates the impact of the SEP on a basket of originator medicines, in terms of costs, immediate price reductions and projected price reductions. METHOD: This is an analytical, quantitative study. A basket of medicines was selected, based on the WHO/HAI list, and adapted to include registered medicines in South Africa. Prices of 50 originator medicines were assessed from 1999 to 2014 in terms of the single exit price and the changes in prices in accordance with legislation using a time series analysis methodology. RESULTS: Of the 50 originator medicines investigated 35 showed a statistically significant change in level. For the Global Core list, the percentage change ranged from 2.45-39.12% (mean = 19.87%, SD = 10.62%, IQR = 10.2%). The range for the Regional Core list was 1.77-42.17% (mean = 23.38%, SD = 12.43%, IQR = 15.65%). The Supplementary list was 11.68-55.86% (mean = 22.97%, SD = 16.26%, IQR = 17.34). This study indicates that the SEP regulation had an impact on medicine pricing in South Africa in both the short and long term. Most medicines investigated showed a smaller yearly increase in price compared to before regulations due to the controlled pricing environment introduced by Government. CONCLUSION: This study provides evidence of the impact of medicine pricing intervention from a middle-income country, and other developing countries looking at introducing medicine price controls can draw useful lessons.


Assuntos
Custos de Medicamentos/estatística & dados numéricos , Indústria Farmacêutica/economia , Medicamentos sob Prescrição/economia , Comércio/economia , Custos e Análise de Custo , Estudos de Avaliação como Assunto , Humanos , Análise de Séries Temporais Interrompida , Medicamentos sob Prescrição/provisão & distribução , África do Sul/epidemiologia
18.
BMC Health Serv Res ; 19(1): 536, 2019 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-31366363

RESUMO

BACKGROUND: Many low- and middle-income countries (LMIC) are moving towards enforcing prescription-only access to antibiotics. This systematic literature review aims to assess the interventions used to enforce existing legislation prohibiting over-the-counter (OTC) sales of antibiotics in LMICs, their impact and examine the methods chosen for impact measurement including their strengths and weaknesses. METHODS: Both PubMed and Embase were systematically searched for studies reporting on impact measurement in moving towards prescription only access to antibiotics in LMICs. The PRISMA methodological review framework was used to ensure systematic data collection and analysis of literature. Narrative data synthesis was used due to heterogeneity of study designs. RESULTS: In total, 15 studies were included that assessed policy impact in 10 different countries. Strategies employed to enforce regulations prohibiting OTC sales of systemic antibiotics included retention of prescriptions for antibiotics by pharmacies, government inspections, engaging pharmacists in the design of interventions, media campaigns for the general public and educational activities for health care workers. A variety of outcomes was used to assess the policy impact; changes in antimicrobial resistance rates, changes in levels of antibiotic use, changes in trends of antibiotic use, changes in OTC supply of antibiotics, and changes in reported practices and knowledge of pharmacists, medicine sellers and the general public. Differences in methodological approaches and outcome assessment made it difficult to compare the effectiveness of law enforcement activities. Most effective appeared to be multifaceted approaches that involved all stakeholders. Monitoring of the impact on total sales of antibiotics by means of an interrupted time series (ITS) analysis and analysis of pharmacies selling antibiotics OTC using mystery clients were the methodologically strongest designs used. CONCLUSIONS: The published literature describing activities to enforce prescription-only access to antibiotics in LMICs is sparse and offers limited guidance. Most likely to be effective are comprehensive multifaceted interventions targeting all stakeholders with regular reinforcement of messages. Policy evaluation should be planned as part of implementation to assess the impact and effectiveness of intervention strategies and to identify targets for further activities. Robust study designs such as ITS analyses and mystery client surveys should be used to monitor policy impact.


Assuntos
Antibacterianos , Comércio/legislação & jurisprudência , Aplicação da Lei , Legislação de Medicamentos , Medicamentos sem Prescrição , Comércio/estatística & dados numéricos , Países em Desenvolvimento , Humanos , Análise de Séries Temporais Interrompida
19.
Bone Joint J ; 101-B(8): 1015-1023, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31362544

RESUMO

AIMS: Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control. MATERIALS AND METHODS: We undertook an interrupted time series study with data from all patients aged more than 60 years with a hip fracture in England (2000 to 2018) using the Hospital Episode Statistics Admitted Patient Care (HES APC) data set linked to national death registrations. Difference-in-differences (DID) analysis incorporating equivalent data from the Scottish Morbidity Record was used to control for secular trends. The outcomes were 30-day and 365-day mortality, 30-day re-admission, time to operation, and acute length of stay. RESULTS: There were 1 037 860 patients with a hip fracture in England and 116 594 in Scotland. Both 30-day (DID -1.7%; 95% confidence interval (CI) -2.0 to -1.2) and 365-day (-1.9%; 95% CI -2.5 to -1.3) mortality fell in England post-intervention when compared with outcomes in Scotland. There were 7600 fewer deaths between 2010 and 2016 that could be attributed to interventions driven by pay-for-performance. A pre-existing annual trend towards increased 30-day re-admissions in England was halted post-intervention. Significant reductions were observed in the time to operation and length of stay. CONCLUSION: This study provides evidence that a pay-for-performance programme improved the outcomes after a hip fracture in England. Cite this article: Bone Joint J 2019;101-B:1015-1023.


Assuntos
Fixação de Fratura/economia , Fraturas do Quadril/economia , Melhoria de Qualidade/economia , Reembolso de Incentivo , Idoso , Idoso de 80 Anos ou mais , Inglaterra , Feminino , Seguimentos , Fixação de Fratura/estatística & dados numéricos , Fraturas do Quadril/mortalidade , Fraturas do Quadril/cirurgia , Humanos , Análise de Séries Temporais Interrompida , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Melhoria de Qualidade/estatística & dados numéricos , Escócia , Tempo para o Tratamento/economia , Resultado do Tratamento
20.
Zhonghua Yu Fang Yi Xue Za Zhi ; 53(8): 858-864, 2019 Aug 06.
Artigo em Chinês | MEDLINE | ID: mdl-31378050

RESUMO

Interrupted time series (ITS) is a statistical method for the quasi-experimental design specific to the outcome of time series, in which the effectiveness of an intervening measure is evaluated by examining change in slope and immediate change in level. The key feature of ITS is that the secular trend of time series prior to the intervention can be effectively controlled so as to accurately estimate the intervention effect. The design principle and statistical method for ITS were illustrated by an example of evaluating halving policy for the expert registration fee in the general hospital of a city. The segmented linear regression was used to fit the above time series data and the results were explained in detail. Meanwhile, the study design and model fitting along with explanations of the results with respect to the effects of two types of successive interventions and on different time-points of an intervention were illustrated as well in this paper. The existed upward or downward trend should be taken into account in order to accurately estimate the intervention effect as it exists in most of the public health surveillance data. Two parameters, known as change in slope and immediate change in level, were employed to evaluate the effect of the intervention. The ITS analysis can be widely applied to the program evaluation as it could enrich methods of the evaluation compared to the traditional model of the program evaluation.


Assuntos
Análise de Séries Temporais Interrompida , Projetos de Pesquisa , Avaliação de Programas e Projetos de Saúde
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