Trauma system accreditation and patient outcomes in British Columbia: an interrupted time series analysis

Abstract Objective We aim to assess the impact of several accreditation cycles of trauma centers on patient outcomes, specifically in-hospital mortality, complications and hospital length of stay. Design Interrupted time series. Setting British Columbia, Canada. Participants Trauma patients admitted to all level I and level II trauma centers between January 2008 and March 2018. Exposure Accreditation. Main Outcomes and Measures We first computed quarterly estimates of the proportions of in-hospital mortality, complications and survival to discharge standardized for change in patient case-mix using prognostic scores and the Aalen–Johansen estimator of the cumulative incidence function. Piecewise regressions were then used to estimate the change in levels and trends for patient outcomes following accreditation. Results For in-hospital mortality and major complications, the impact of accreditation seems to be associated with short- and long-term reductions after the first cycle and only short-term reductions for subsequent cycles. However, the 95% confidence intervals for these estimates were wide, and we lacked the precision to consistently conclude that accreditation is beneficial. Conclusions Applying a quasi-experimental design to time series accounting for changes in patient case-mix, our results suggest that accreditation might reduce in-hospital mortality and major complications. However, there was uncertainty around the estimates of accreditation. Further studies looking at clinical processes of care and other outcomes such as patient or health staff satisfaction are needed.

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Impact of trauma centre accreditation on mortality and complications in a Canadian trauma system: an interrupted time series analysis

BMJ Quality & Safety ◽

10.1136/bmjqs-2020-011271 ◽

2020 ◽

pp. bmjqs-2020-011271

Author(s):

Brice Batomen ◽

Lynne Moore ◽

Erin Strumpf ◽

Howard Champion ◽

Arijit Nandi

Keyword(s):

Time Series ◽

Patient Outcomes ◽

Major Trauma ◽

Interrupted Time Series ◽

Trauma Centre ◽

Case Mix ◽

Patient Case ◽

Trauma Centres ◽

Level Ii ◽

Level I

BackgroundPeriodic external accreditation visits aiming to determine whether trauma centres are fulfilling the criteria for optimal care are part of most trauma systems. However, despite the growing trend towards accreditation of trauma centres, its impact on patient outcomes remains unclear. In addition, a recent systematic review found inconsistent results on the association between accreditation and patient outcomes, mostly due to the lack of robust controls. We aim to address these gaps by assessing the impact of trauma centre accreditation on patient outcomes, specifically in-hospital mortality and complications, using an interrupted time series (ITS) design.MethodsWe included all major trauma admissions to five level I and four level II trauma centres in Quebec, Canada between 2008 and 2017. In order to perform ITS, we first obtained monthly and quarterly estimates of the proportions of in-hospital mortality and complications, respectively, for level I and level II centres. Prognostic scores were used to standardise these proportions to account for changes in patient case mix and segmented regressions with autocorrelated errors were used to estimate changes in levels and trends in both outcomes following accreditation.ResultsThere were 51 035 admissions, including 20 165 for major trauma during the study period. After accounting for changes in patient case mix and secular trend in studied outcomes, we globally did not observe an association between accreditation and patient outcomes. However, associations were heterogeneous across centres. For example, in a level II centre with worsening preaccreditation outcomes, accreditation led to −9.08 (95% CI −13.29 to −4.87) and −9.60 (95% CI −15.77 to −3.43) percentage point reductions in mortality and complications, respectively.ConclusionAccreditation seemed to be beneficial for centres that were experiencing a decrease in performance preceding accreditation.

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Investigating the association of alerts from a national mortality surveillance system with subsequent hospital mortality in England: an interrupted time series analysis

BMJ Quality & Safety ◽

10.1136/bmjqs-2017-007495 ◽

2018 ◽

Vol 27 (12) ◽

pp. 965-973 ◽

Cited By ~ 5

Author(s):

Elizabeth Cecil ◽

Alex Bottle ◽

Aneez Esmail ◽

Samantha Wilkinson ◽

Charles Vincent ◽

...

Keyword(s):

Time Series ◽

Relative Risk ◽

Hospital Mortality ◽

Surveillance System ◽

Interrupted Time Series ◽

Regression To The Mean ◽

Interrupted Time Series Analysis ◽

Risk Of Mortality ◽

The Impact ◽

Mortality Surveillance

ObjectiveTo investigate the association between alerts from a national hospital mortality surveillance system and subsequent trends in relative risk of mortality.BackgroundThere is increasing interest in performance monitoring in the NHS. Since 2007, Imperial College London has generated monthly mortality alerts, based on statistical process control charts and using routinely collected hospital administrative data, for all English acute NHS hospital trusts. The impact of this system has not yet been studied.MethodsWe investigated alerts sent to Acute National Health Service hospital trusts in England in 2011–2013. We examined risk-adjusted mortality (relative risk) for all monitored diagnosis and procedure groups at a hospital trust level for 12 months prior to an alert and 23 months post alert. We used an interrupted time series design with a 9-month lag to estimate a trend prior to a mortality alert and the change in trend after, using generalised estimating equations.ResultsOn average there was a 5% monthly increase in relative risk of mortality during the 12 months prior to an alert (95% CI 4% to 5%). Mortality risk fell, on average by 61% (95% CI 56% to 65%), during the 9-month period immediately following an alert, then levelled to a slow decline, reaching on average the level of expected mortality within 18 months of the alert.ConclusionsOur results suggest an association between an alert notification and a reduction in the risk of mortality, although with less lag time than expected. It is difficult to determine any causal association. A proportion of alerts may be triggered by random variation alone and subsequent falls could simply reflect regression to the mean. Findings could also indicate that some hospitals are monitoring their own mortality statistics or other performance information, taking action prior to alert notification.

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The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis

Journal of the American Medical Informatics Association ◽

10.1136/amiajnl-2011-000504 ◽

2012 ◽

Vol 19 (4) ◽

pp. 615-620 ◽

Cited By ~ 23

Author(s):

D. W. Dowding ◽

M. Turley ◽

T. Garrido

Keyword(s):

Time Series ◽

Time Series Analysis ◽

Electronic Health Record ◽

Patient Outcomes ◽

Interrupted Time Series ◽

Health Record ◽

Interrupted Time Series Analysis ◽

Series Analysis ◽

Electronic Health ◽

The Impact

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Evaluating service development in critical care: The impact of establishing a medical high dependency unit on intensive care unit workload, case mix, and mortality

Journal of the Intensive Care Society ◽

10.1177/1751143718755014 ◽

2018 ◽

Vol 19 (3) ◽

pp. 226-235

Author(s):

Nabeel Amiruddin ◽

Gordon J Prescott ◽

Douglas A Coventry ◽

Jan O Jansen

Keyword(s):

Intensive Care Unit ◽

Time Series ◽

Critical Care ◽

Intensive Care ◽

Interrupted Time Series ◽

Case Mix ◽

High Dependency Unit ◽

Medical Patients ◽

High Dependency ◽

The Impact

Background Critical care services underpin the delivery of many types of secondary care, and there is increasing focus on how to best deliver such services. The aim of this study was to investigate the impact of establishing a medical high dependency unit, in a tertiary referral center, on the workload, case mix, and mortality of the intensive care unit. Methods Single-center, 11-year retrospective study of patients admitted to the general intensive care unit, before and after the opening of the medical high dependency unit, using interrupted time series methodology. Results Over the duration of the study period, 3209 medical patients were admitted to the intensive care unit. There was a constant rate of medical admissions to the intensive care unit until the opening of the medical high dependency unit, followed by a statistically significant decline thereafter. There was a statistically significant decrease in the average severity of illness of medical patients prior to the opening of the medical high dependency unit, but there was no evidence of a change following the opening of the unit. There was no evidence of a statistically significant change in the estimated mean standardized mortality ratio for either medical or surgical admissions after the intervention. Conclusions The opening of a medical high dependency unit had a minimal impact on the intensive care unit. There was, in all likelihood, an unmet need—of less seriously ill patients, who were previously looked after on a normal ward, but did not require intensive care unit admission—who are now cared for in the new medical high dependency unit. Interrupted time series analysis, although not without limitations, is a useful mean of evaluating changes in service delivery.

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The Impact of Lockdown in England on Daily Confirmed Cases of COVID-19 and Related Deaths Compared to Sweden: A Comparative Interrupted Time Series Analysis

SSRN Electronic Journal ◽

10.2139/ssrn.3629457 ◽

2020 ◽

Author(s):

Moaath Mustafa Ali ◽

Yazan Samhouri ◽

Marwa Sabha ◽

Lynna Alnimer

Keyword(s):

Time Series ◽

Time Series Analysis ◽

Interrupted Time Series ◽

Interrupted Time Series Analysis ◽

Series Analysis ◽

The Impact

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Correction to: Measuring the impact of the Afordable Care Act Medicaid expansion on access to primary care using an interrupted time series approach

Health Research Policy and Systems ◽

10.1186/s12961-021-00740-y ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Elizabeth A. Brown ◽

Brandi M. White ◽

Walter J. Jones ◽

Mulugeta Gebregziabher ◽

Kit N. Simpson

Keyword(s):

Primary Care ◽

Time Series ◽

Interrupted Time Series ◽

Medicaid Expansion ◽

Time Series Approach ◽

Access To Primary Care ◽

The Impact

An amendment to this paper has been published and can be accessed via the original article.

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Does admission prevalence change after reconfiguration of inpatient services? An interrupted time series analysis of the impact of reconfiguration in five centres

BMC Health Services Research ◽

10.1186/s12913-021-06070-7 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Joanne Martin ◽

Edwin Amalraj Raja ◽

Steve Turner

Keyword(s):

Time Series ◽

Time Series Analysis ◽

Emergency Admission ◽

Interrupted Time Series ◽

Interrupted Time Series Analysis ◽

Emergency Admissions ◽

Series Analysis ◽

Inpatient Services ◽

The Impact ◽

Admission Prevalence

Abstract Background Service reconfiguration of inpatient services in a hospital includes complete and partial closure of all emergency inpatient facilities. The “natural experiment” of service reconfiguration may give insight into drivers for emergency admissions to hospital. This study addressed the question does the prevalence of emergency admission to hospital for children change after reconfiguration of inpatient services? Methods There were five service reconfigurations in Scottish hospitals between 2004 and 2018 where emergency admissions to one “reconfigured” hospital were halted (permanently or temporarily) and directed to a second “adjacent” hospital. The number of emergency admissions (standardised to /1000 children in the regional population) per month to the “reconfigured” and “adjacent” hospitals was obtained for five years prior to reconfiguration and up to five years afterwards. An interrupted time series analysis considered the association between reconfiguration and admissions across pairs comprised of “reconfigured” and “adjacent” hospitals, with adjustment for seasonality and an overall rising trend in admissions. Results Of the five episodes of reconfiguration, two were immediate closure, two involved closure only to overnight admissions and one with overnight closure for a period and then closure. In “reconfigured” hospitals there was an average fall of 117 admissions/month [95% CI 78, 156] in the year after reconfiguration compared to the year before, and in “adjacent” hospitals admissions rose by 82/month [32, 131]. Across paired reconfigured and adjacent hospitals, in the months post reconfiguration, the overall number of admissions to one hospital pair slowed, in another pair admissions accelerated, and admission prevalence was unchanged in three pairs. After reconfiguration in one hospital, there was a rise in admissions to a third hospital which was closer than the named “adjacent” hospital. Conclusions There are diverse outcomes for the number of emergency admissions post reconfiguration of inpatient facilities. Factors including resources placed in the community after local reconfiguration, distance to the “adjacent” hospital and local deprivation may be important drivers for admission pathways after reconfiguration. Policy makers considering reconfiguration might consider a number of factors which may be important determinants of admissions post reconfiguration.

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Recession and risk of suicide in Denmark during the 2009 global financial crisis: an ecological register-based study

Scandinavian Journal of Public Health ◽

10.1177/14034948211013270 ◽

2021 ◽

pp. 140349482110132

Author(s):

Agnieszka Konieczna ◽

Sarah Grube Jakobsen ◽

Christina Petrea Larsen ◽

Erik Christiansen

Keyword(s):

Time Series ◽

Financial Crisis ◽

Time Series Analysis ◽

Suicide Rate ◽

Global Financial Crisis ◽

Interrupted Time Series ◽

Interrupted Time Series Analysis ◽

Series Analysis ◽

Prevention Programmes ◽

The Impact

Aim: The aim of this study is to analyse the potential impact from the financial crisis (onset in 2009) on suicide rates in Denmark. The hypothesis is that the global financial crisis raised unemployment which leads to raising the suicide rate in Denmark and that the impact is most prominent in men. Method: This study used an ecological study design, including register data from 2001 until 2016 on unemployment, suicide, gender and calendar time which was analysed using Poisson regression models and interrupted time series analysis. Results: The correlation between unemployment and suicide rates was positive in the period and statistically significant for all, but at a moderate level. A dichotomised version of time (calendar year) showed a significant reduction in the suicide rate for women (incidence rate ratio 0.87, P=0.002). Interrupted time series analysis showed a significant decreasing trend for the overall suicide rate and for men in the pre-recession period, which in both cases stagnated after the onset of recession in 2009. The difference between the genders’ suicide rate changed significantly at the onset of recession, as the rate for men increased and the rate for women decreased. Discussion: The Danish social welfare model might have prevented social disintegration and suicide among unemployed, and suicide prevention programmes might have prevented deaths among unemployed and mentally ill individuals. Conclusions: We found some indications for gender-specific differences from the impact of the financial crises on the suicide rate. We recommend that men should be specifically targeted for appropriate prevention programmes during periods of economic downturn.

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