Getting Beyond Interruptive Alerts: Reducing Unintentional Duplicate Orders using a Visual Aid

ABSTRACTImportanceElectronic health records (EHRs) allow teams of clinicians to simultaneously care for patients but an unintended consequence could result in duplicate ordering of tests and medications.ObjectiveWe asked if a simple visual aid would reduce duplicate ordering of tests and medications for busy teams of clinicians in our emergency department by placing a red highlight around the checkbox of a computer-based order if previously ordered.DesignWe performed an interrupted time series to analyze all patient visits 1 year before and 1 year after the intervention. Significance testing was performed using a negative binomial regression with Newey-West standard errors, correcting for patient level variables and environmental variables that might be associated with duplicate orders.SettingThe emergency department of an academic hospital in Boston, MA with 55,000 visits annually.Participants184,722 consecutive emergency department patients.ExposureIf an order had previously been placed during that ED visit, we cue the user by showing a red highlight around the checkbox of that order.Main OutcomeNumber of unintentional duplicate orders.ResultsAfter deployment of the non-interrupting nudge, the rate of unintentional duplicates for laboratory orders decreased 49% (incidence rate ratio 0.51, 95% CI 0.45-0.59) and for radiology orders decreased with an incidence rate ratio of 0.60 (0.44-0.82). There was no change in unintentional medication duplicate orders. We estimated that the nudge eliminated 17,936 clicks in our EHR.Conclusions and RelevancePassive visual queues that provide just-in-time decision support are effective, not disruptive of workflow, and may decrease alert fatigue in busy clinical environments.Key PointsQuestionCan a simple visual aid reduce duplicate ordering in an electronic health record?FindingsIn this interrupted time series, the rate of unintentional duplicates for laboratory orders decreased 49% and for radiology orders decreased 40%. There was no change in unintentional medication duplicate orders. We estimated that the nudge eliminated 17,936 clicks in our EHR.MeaningQuality improvement often relies on changing clinician behavior. We believe guiding clinicians to a right action is better than telling the clinician they have already made an error. Our approach will help reduce alert fatigue and lessen clinician complaints about EHRs.

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Hospital Presentations in Long-Term Survivors of Stroke

Stroke ◽

10.1161/strokeaha.120.030656 ◽

2020 ◽

Vol 51 (12) ◽

pp. 3673-3680

Author(s):

Nadine E. Andrew ◽

Monique F. Kilkenny ◽

Vijaya Sundararajan ◽

Joosup Kim ◽

Steven G. Faux ◽

...

Keyword(s):

Emergency Department ◽

Incidence Rate ◽

Rate Ratio ◽

Associated Factors ◽

Negative Binomial ◽

Incidence Rate Ratio ◽

Study Cohort ◽

Quality Of Life Scale ◽

Long Term Survivors

Background and Purpose: A comprehensive understanding of the long-term impact of stroke assists in health care planning. We aimed to determine changes in rates, causes, and associated factors for hospital presentations among long-term survivors of stroke. Methods: Person-level data from the AuSCR (Australian Stroke Clinical Registry) during 2009 to 2013 were linked with state-based health department emergency department and hospital admission data. The study cohort included adults with first-ever stroke who survived the first 6 months after discharge from hospital. Annualized rates of hospital presentations (nonadmitted emergency department or admission)/person/year were calculated for 1 to 12 months prior, and 7 to 12 months (inclusive) after hospitalization. Multilevel, negative binomial regression was used to identify associated factors after adjustment for prestroke hospital presentations and stratification for perceived impairment status. Perceived impairments to health were defined according to the subscales and visual analog health status scores on the 5-Dimension European Quality of Life Scale. Results: There were 7183 adults with acute stroke, 7-month survivors (median age 72 years; 56% male; 81% ischemic, and 42% with impairment at 90–180 days) from 39 hospitals included in this landmark analysis. Annualized presentations/person increased from 0.88 (95% CI, 0.86–0.91) to 1.25 (95% CI, 1.22–1.29) between the prestroke and poststroke periods, with greater rate increases in those with than without perceived impairment (55% versus 26%). Higher presentation rates were most strongly associated with older age (≥85 versus 65 years, incidence rate ratio, 1.52 [95% CI, 1.27–1.82]) and greater comorbidity score (incidence rate ratio, 1.06 [95% CI, 1.02–1.10]), whereas reduced rates were associated with greater social advantage (incidence rate ratio, 0.71 [95% CI, 0.60–0.84]). Poststroke hospital presentations (7–12 months) were most frequently related to recurrent cardiovascular and cerebrovascular events and sequelae of stroke. Conclusions: A large increase in annualized hospital presentation rates after stroke indicates the potential for improved community management and support for this vulnerable patient group.

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Self-harm following release from prison: A prospective data linkage study

Australian & New Zealand Journal of Psychiatry ◽

10.1177/0004867416640090 ◽

2016 ◽

Vol 51 (3) ◽

pp. 250-259 ◽

Cited By ~ 20

Author(s):

Rohan Borschmann ◽

Emma Thomas ◽

Paul Moran ◽

Megan Carroll ◽

Ed Heffernan ◽

...

Keyword(s):

Mental Health ◽

Emergency Department ◽

Confidence Interval ◽

Mental Disorder ◽

Incidence Rate ◽

Rate Ratio ◽

Incidence Rate Ratio ◽

History Of ◽

Self Harm ◽

Release From Prison

Objective: Prisoners are at increased risk of both self-harm and suicide compared with the general population, and the risk of suicide after release from prison is three times greater than for those still incarcerated. However, surprisingly little is known about the incidence of self-harm following release from prison. We aimed to determine the incidence of, identify risk factors for and characterise emergency department presentations resulting from self-harm in adults after release from prison. Method: Cohort study of 1325 adults interviewed prior to release from prison, linked prospectively with State correctional and emergency department records. Data from all emergency department presentations resulting from self-harm were secondarily coded to characterise these presentations. We used negative binomial regression to identify independent predictors of such presentations. Results: During 3192 person-years of follow-up (median 2.6 years per participant), there were 3755 emergency department presentations. In all, 83 (6.4%) participants presented due to self-harm, accounting for 165 (4.4%) presentations. The crude incidence rates of self-harm for males and females were 49.2 (95% confidence interval: [41.2, 58.7]) and 60.5 (95% confidence interval: [44.9, 81.6]) per 1000 person-years, respectively. Presenting due to self-harm was associated with being Indigenous (incidence rate ratio: 2.01; 95% confidence interval: [1.11, 3.62]), having a lifetime history of a mental disorder (incidence rate ratio: 2.13; 95% confidence interval: [1.19, 3.82]), having previously been hospitalised for psychiatric treatment (incidence rate ratio: 2.68; 95% confidence interval: [1.40, 5.14]) and having previously presented due to self-harm (incidence rate ratio: 3.91; 95% confidence interval: [1.85, 8.30]). Conclusion: Following release from prison, one in 15 ex-prisoners presented to an emergency department due to self-harm, within an average of 2.6 years of release. Demographic and mental health variables help to identify at-risk groups, and such presentations could provide opportunities for suicide prevention in this population. Transition from prison to the community is challenging, particularly for those with a history of mental disorder; mental health support during and after release may reduce the risk of adverse outcomes, including self-harm.

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Effect of newborn screening for critical CHD on healthcare utilisation

Cardiology in the Young ◽

10.1017/s1047951120001742 ◽

2020 ◽

Vol 30 (8) ◽

pp. 1157-1164

Author(s):

Rie Sakai-Bizmark ◽

Hiraku Kumamaru ◽

Eliza J. Webber ◽

Dennys Estevez ◽

Laurie A. Mena ◽

...

Keyword(s):

Pulse Oximetry ◽

Incidence Rate ◽

Rate Ratio ◽

Incidence Rate Ratio ◽

Healthcare Utilisation ◽

Interrupted Time Series ◽

Sensitivity Analyses ◽

Health Issues ◽

Increasing Trend ◽

The Impact

AbstractObjective:To evaluate the impact of state-mandated policies for pulse oximetry screening on healthcare utilisation, with a focus on use of echocardiograms.Data sources/study setting:Healthcare Cost and Utilisation Project, Statewide Inpatient Databases from 2008 to 2014 from six states.Methods:We defined pre- and post-mandate cohorts based on dates when pulse oximetry became mandated in each state. Linear segmented regression models for interrupted time series assessed associations between implementation of the screening and changes in rate of newborns with Critical CHD-negative echocardiogram results. We also evaluated the changes in rate of newborns who underwent echocardiogram but were not diagnosed with any health issues that could cause hypoxemia.Results:We identified 5967 critical CHD-negative echocardiograms (2847 and 3120 in the pre- and post-mandate periods, respectively). Our models detected a statistically significant increasing trend in rate of critical CHD-negative echocardiograms in the pre-mandate period (Incidence Rate Ratio: 1.08, p = 0.02), but did not detect any statistical differences in changes between pre- and post-mandate periods (Incidence Rate Ratio: 0.93, p = 0.14). Among non-Whites, an increasing trend of Critical CHD-negative echocardiogram during the pre-mandate period was detected (Incidence Rate Ratio 1.12, p < 0.01) and was attenuated during the post-mandate period (Incidence Rate Ratio 0.89, p = 0.02). Similar results were observed in the sensitivity analyses among both Whites and non-Whites.Conclusions:Results suggest that mandatory state screening policies are associated with reductions in false-positive screening rates for hypoxemic conditions, with reductions primarily attributed to trends among non-Whites.

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Effect of Pokémon Go on Self-Harm Using Population-Based Interrupted Time-Series Analysis: Quasi-Experimental Study

JMIR Serious Games ◽

10.2196/17112 ◽

2020 ◽

Vol 8 (2) ◽

pp. e17112

Author(s):

Rosa Sze Man Wong ◽

Frederick Ka Wing Ho ◽

Keith Tsz Suen Tung ◽

King-Wa Fu ◽

Patrick Ip

Keyword(s):

Incidence Rate ◽

Rate Ratio ◽

Incidence Rate Ratio ◽

Interrupted Time Series ◽

Well Being ◽

Quasi Experimental ◽

Adjusted Incidence Rate ◽

Self Harm ◽

Pokémon Go ◽

Adjusted Incidence

Background Pokémon Go is a very popular location-based augmented reality game with widespread influences over the world. An emerging body of research demonstrates that playing Pokémon Go can lead to improvements in physical activity and psychosocial well-being; however, whether Pokémon Go reduces self-harm incidence at the population-level is still questionable. Objective This study aimed to quantify how the launch of Pokémon Go in Hong Kong affected the incidence of self-harm using a quasi-experimental design. Methods An interrupted time-series design with Poisson segmented regression adjusted for time and seasonality trends was used on data from 2012 to 2018 to detect any changes in the number of accident and emergency attendances due to self-harm, after Pokémon Go was launched. The findings were validated using a baseline control period and using other intentional injuries and minor noninjuries as control outcomes. We also assessed intervention effects by age group. Results From January 1, 2012 to July 31, 2018, there were 13,463 accident and emergency attendances due to self-harm in Hong Kong. During the period after launching Pokémon Go, self-harm attendances dropped by 34% (adjusted incidence rate ratio: 0.66, 95% CI 0.61-0.73). When analyzed by age group, a reduction in self-harm incidence was only apparent in adults (18 to 24 years of age: adjusted incidence rate ratio: 0.78, P=.02; 25 to 39 years of age: adjusted incidence rate ratio: 0.75, P<.001; 40 years of age and older: adjusted incidence rate ratio: 0.57, P<.001). Conclusions Self-harm incidence in the population, particularly in adults, showed a significant decline in the period after Pokémon Go was launched. Augmented reality games such as Pokémon Go show great promise as a tool to enhance psychosocial well-being and improve mental health.

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Intradialytic Hypotension and Cardiac Arrhythmias in Patients Undergoing Maintenance Hemodialysis

Clinical Journal of the American Society of Nephrology ◽

10.2215/cjn.06810619 ◽

2020 ◽

Vol 15 (6) ◽

pp. 805-812 ◽

Cited By ~ 1

Author(s):

Finnian R. Mc Causland ◽

Jim A. Tumlin ◽

Prabir Roy-Chaudhury ◽

Bruce A. Koplan ◽

Alexandru I. Costea ◽

...

Keyword(s):

United States ◽

Confidence Interval ◽

Incidence Rate ◽

Rate Ratio ◽

Negative Binomial ◽

Incidence Rate Ratio ◽

The United States ◽

Maintenance Hemodialysis ◽

Intradialytic Hypotension ◽

Clinically Significant

Background and objectivesPatients receiving maintenance hemodialysis (HD) have a high incidence of cardiac events, including arrhythmia and sudden death. Intradialytic hypotension (IDH) is a common complication of HD and is associated with development of reduced myocardial perfusion, a potential risk factor for arrhythmia.Design, setting, participants, & measurementsWe analyzed data from the Monitoring in Dialysis study, which used implantable loop recorders to detect and continuously monitor electrocardiographic data from patients on maintenance HD (n=66 from the United States and India) over a 6-month period (n=4720 sessions). Negative binomial mixed effects regression was used to test the association of IDH20 (decline in systolic BP >20 mm Hg from predialysis systolic BP) and IDH0–20 (decline in systolic BP 0–20 mm Hg from predialysis systolic BP) with clinically significant arrhythmia (bradycardia≤40 bpm for ≥6 seconds, asystole≥3 seconds, ventricular tachycardia ≥130 bpm for ≥30 seconds, or patient-marked events) during HD.ResultsThe median age of participants was 58 (25th–75th percentile, 49–66) years; 70% were male; and 65% were from the United States. IDH occurred in 2251 (48%) of the 4720 HD sessions analyzed, whereas IDH0–20 occurred during 1773 sessions (38%). The number of sessions complicated by least one intradialytic clinically significant arrhythmia was 27 (1.2%) where IDH20 occurred and 15 (0.8%) where IDH0–20 occurred. Participants who experienced IDH20 (versus not) had a nine-fold greater rate of developing an intradialytic clinically significant arrhythmia (incidence rate ratio, 9.4; 95% confidence interval, 3.0 to 29.4), whereas IDH0–20 was associated with a seven-fold higher rate (incidence rate ratio, 7.2; 95% confidence interval, 2.1 to 25.4).ConclusionsIDH is common in patients on maintenance HD and is associated with a greater risk of developing intradialytic clinically significant arrhythmia.

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Effect of Pokémon Go on Self-Harm Using Population-Based Interrupted Time-Series Analysis: Quasi-Experimental Study (Preprint)

10.2196/preprints.17112 ◽

2019 ◽

Author(s):

Rosa Sze Man Wong ◽

Frederick Ka Wing Ho ◽

Keith Tsz Suen Tung ◽

King-Wa Fu ◽

Patrick Ip

Keyword(s):

Incidence Rate ◽

Rate Ratio ◽

Incidence Rate Ratio ◽

Interrupted Time Series ◽

Well Being ◽

Quasi Experimental ◽

Adjusted Incidence Rate ◽

Self Harm ◽

Pokémon Go ◽

Adjusted Incidence

BACKGROUND Pokémon Go is a very popular location-based augmented reality game with widespread influences over the world. An emerging body of research demonstrates that playing Pokémon Go can lead to improvements in physical activity and psychosocial well-being; however, whether Pokémon Go reduces self-harm incidence at the population-level is still questionable. OBJECTIVE This study aimed to quantify how the launch of Pokémon Go in Hong Kong affected the incidence of self-harm using a quasi-experimental design. METHODS An interrupted time-series design with Poisson segmented regression adjusted for time and seasonality trends was used on data from 2012 to 2018 to detect any changes in the number of accident and emergency attendances due to self-harm, after Pokémon Go was launched. The findings were validated using a baseline control period and using other intentional injuries and minor noninjuries as control outcomes. We also assessed intervention effects by age group. RESULTS From January 1, 2012 to July 31, 2018, there were 13,463 accident and emergency attendances due to self-harm in Hong Kong. During the period after launching Pokémon Go, self-harm attendances dropped by 34% (adjusted incidence rate ratio: 0.66, 95% CI 0.61-0.73). When analyzed by age group, a reduction in self-harm incidence was only apparent in adults (18 to 24 years of age: adjusted incidence rate ratio: 0.78, P=.02; 25 to 39 years of age: adjusted incidence rate ratio: 0.75, P<.001; 40 years of age and older: adjusted incidence rate ratio: 0.57, P<.001). CONCLUSIONS Self-harm incidence in the population, particularly in adults, showed a significant decline in the period after Pokémon Go was launched. Augmented reality games such as Pokémon Go show great promise as a tool to enhance psychosocial well-being and improve mental health.

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Trends in Prevalence and Severity of Pre/Perinatal Cerebral Palsy Among Children Born Preterm From 2004 to 2010: A SCPE Collaboration Study

Frontiers in Neurology ◽

10.3389/fneur.2021.624884 ◽

2021 ◽

Vol 12 ◽

Author(s):

Catherine Arnaud ◽

Virginie Ehlinger ◽

Malika Delobel-Ayoub ◽

Dana Klapouszczak ◽

Oliver Perra ◽

...

Keyword(s):

Cerebral Palsy ◽

Incidence Rate ◽

Gestational Age ◽

Rate Ratio ◽

Negative Binomial ◽

Incidence Rate Ratio ◽

Age Groups ◽

Negative Binomial Regression ◽

Population Based ◽

Preterm Born

Aim: To report on prevalence of cerebral palsy (CP), severity rates, and types of brain lesions in children born preterm 2004 to 2010 by gestational age groups.Methods: Data from 12 population-based registries of the Surveillance of Cerebral Palsy in Europe network were used. Children with CP were eligible if they were born preterm (<37 weeks of gestational age) between 2004 and 2010, and were at least 4 years at time of registration. Severity was assessed using the impairment index. The findings of postnatal brain imaging were classified according to the predominant pathogenic pattern. Prevalences were estimated per 1,000 live births with exact 95% confidence intervals within each stratum of gestational age: ≤27, 28–31, 32–36 weeks. Time trends of both overall prevalence and prevalence of severe CP were investigated using multilevel negative binomial regression models.Results: The sample comprised 2,273 children. 25.8% were born from multiple pregnancies. About 2-thirds had a bilateral spastic CP. 43.5% of children born ≤27 weeks had a high impairment index compared to 37.0 and 38.5% in the two other groups. Overall prevalence significantly decreased (incidence rate ratio per year: 0.96 [0.92–1.00[) in children born 32–36 weeks. We showed a decrease until 2009 for children born 28–31 weeks but an increase in 2010 again, and a steady prevalence (incidence rate ratio per year = 0.97 [0.92–1.02] for those born ≤27 weeks. The prevalence of the most severely affected children with CP revealed a similar but not significant trend to the overall prevalence in the corresponding GA groups. Predominant white matter injuries were more frequent in children born <32 weeks: 81.5% (≤27 weeks) and 86.4% (28–31 weeks), compared to 63.6% for children born 32–36 weeks.Conclusion: Prevalence of CP in preterm born children continues to decrease in Europe excepting the extremely immature children, with the most severely affected children showing a similar trend.

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Diet quality and mental health in subsequent years among Canadian youth

Public Health Nutrition ◽

10.1017/s1368980012000535 ◽

2012 ◽

Vol 15 (12) ◽

pp. 2253-2258 ◽

Cited By ~ 35

Author(s):

Seanna E McMartin ◽

Stefan Kuhle ◽

Ian Colman ◽

Sara FL Kirk ◽

Paul J Veugelers

Keyword(s):

Mental Health ◽

Incidence Rate ◽

Diet Quality ◽

Rate Ratio ◽

Adolescent Depression ◽

Negative Binomial ◽

Incidence Rate Ratio ◽

Negative Binomial Regression ◽

Canadian Youth ◽

Internalizing Disorder

AbstractObjectiveTo examine the association between diet quality and the diagnosis of an internalizing disorder in children and adolescents.DesignA prospective study examining the relationship between diet quality and mental health. FFQ responses of 3757 children were used to calculate a composite score for diet quality and its four components: variety, adequacy, moderation and balance. Physicians’ diagnoses on internalizing disorders were obtained by linking the children's dietary information to administrative health data. Negative binomial regression models were used to examine the association between diet quality and diagnosis of an internalizing disorder.SettingThe Canadian province of Nova Scotia.SubjectsA provincially representative sample of grade 5 students (age 10–11 years).ResultsDiet quality was not found to be associated with internalizing disorder in a statistically significant manner (incidence rate ratio = 1·09; 95 % CI 0·73, 1·63). However, relative to children with little variety in their diets, children with greater variety in their diet had statistically significant lower rates of internalizing disorder in subsequent years (incidence rate ratio = 0·45; 95 % CI 0·25, 0·82).ConclusionsThese findings suggest the importance of variety in children's diet and opportunities in the prevention of adolescent depression and anxiety.

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Inflammatory Bowel Disease and Risk of Major Bleeding During Anticoagulation for Venous Thromboembolism

Inflammatory Bowel Diseases ◽

10.1093/ibd/izaa337 ◽

2021 ◽

Author(s):

Susanna Scharrer ◽

Christian Primas ◽

Sabine Eichinger ◽

Sebastian Tonko ◽

Maximilian Kutschera ◽

...

Keyword(s):

Ulcerative Colitis ◽

Inflammatory Bowel Disease ◽

Venous Thromboembolism ◽

Incidence Rate ◽

Rate Ratio ◽

Incidence Rate Ratio ◽

Fatal Bleeding ◽

Adjusted Incidence Rate ◽

Inflammatory Bowel ◽

Adjusted Incidence

Abstract Background Little is known about the bleeding risk in patients with inflammatory bowel disease (IBD) and venous thromboembolism (VTE) treated with anticoagulation. Our aim was to elucidate the rate of major bleeding (MB) events in a well-defined cohort of patients with IBD during anticoagulation after VTE. Methods This study is a retrospective follow-up analysis of a multicenter cohort study investigating the incidence and recurrence rate of VTE in IBD. Data on MB and IBD- and VTE-related parameters were collected via telephone interview and chart review. The objective of the study was to evaluate the impact of anticoagulation for VTE on the risk of MB by comparing time periods with anticoagulation vs those without anticoagulation. A random-effects Poisson regression model was used. Results We included 107 patients (52 women, 40 with ulcerative colitis, 64 with Crohn disease, and 3 with unclassified IBD) in the study. The overall observation time was 388 patient-years with and 1445 patient-years without anticoagulation. In total, 23 MB events were registered in 21 patients, among whom 13 MB events occurred without anticoagulation and 10 occurred with anticoagulation. No fatal bleeding during anticoagulation was registered. The incidence rate for MB events was 2.6/100 patient-years during periods exposed to anticoagulation and 0.9/100 patient-years during the unexposed time. Exposure to anticoagulation (adjusted incidence rate ratio, 3.7; 95% confidence interval, 1.5-9.0; P = 0.003) and ulcerative colitis (adjusted incidence rate ratio, 3.5; 95% confidence interval, 1.5-8.1; P = 0.003) were independent risk factors for MB events. Conclusion The risk of major but not fatal bleeding is increased in patients with IBD during anticoagulation. Our findings indicate that this risk may be outweighed by the high VTE recurrence rate in patients with IBD.

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An interrupted time series analysis of the lockdown policies in India: a national-level analysis of COVID-19 incidence

Health Policy and Planning ◽

10.1093/heapol/czab027 ◽

2021 ◽

Author(s):

Winter M Thayer ◽

Md Zabir Hasan ◽

Prithvi Sankhla ◽

Shivam Gupta

Keyword(s):

Time Series ◽

Time Series Analysis ◽

Incidence Rate ◽

Case Reports ◽

National Level ◽

Model Development ◽

Interrupted Time Series ◽

Interrupted Time Series Analysis ◽

Additional Time ◽

Series Analysis

Abstract India implemented a national mandatory lockdown policy (Lockdown 1.0) on 24 March 2020 in response to Coronavirus Disease 2019 (COVID-19). The policy was revised in three subsequent stages (Lockdown 2.0–4.0 between 15 April to 18 May 2020), and restrictions were lifted (Unlockdown 1.0) on 1 June 2020. This study evaluated the effect of lockdown policy on the COVID-19 incidence rate at the national level to inform policy response for this and future pandemics. We conducted an interrupted time series analysis with a segmented regression model using publicly available data on daily reported new COVID-19 cases between 2 March 2020 and 1 September 2020. National-level data from Google Community Mobility Reports during this timeframe were also used in model development and robustness checks. Results showed an 8% [95% confidence interval (CI) = 6–9%] reduction in the change in incidence rate per day after Lockdown 1.0 compared to prior to the Lockdown order, with an additional reduction of 3% (95% CI = 2–3%) after Lockdown 4.0, suggesting an 11% (95% CI = 9–12%) reduction in the change in COVID-19 incidence after Lockdown 4.0 compared to the period before Lockdown 1.0. Uptake of the lockdown policy is indicated by decreased mobility and attenuation of the increasing incidence of COVID-19. The increasing rate of incident case reports in India was attenuated after the lockdown policy was implemented compared to before, and this reduction was maintained after the restrictions were eased, suggesting that the policy helped to ‘flatten the curve’ and buy additional time for pandemic preparedness, response and recovery.

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