Estimating the effect of moving meat-free products to the meat aisle on sales of meat and meat-free products: A non-randomised controlled intervention study in a large UK supermarket chain

Background Reducing meat consumption could bring health and environmental benefits, but there is little research to date on effective interventions to achieve this. A non-randomised controlled intervention study was used to evaluate whether prominent positioning of meat-free products in the meat aisle was associated with a change in weekly mean sales of meat and meat-free products. Methods and findings Weekly sales data were obtained from 108 stores: 20 intervention stores that moved a selection of 26 meat-free products into a newly created meat-free bay within the meat aisle and 88 matched control stores. The primary outcome analysis used a hierarchical negative binomial model to compare changes in weekly sales (units) of meat products sold in intervention versus control stores during the main intervention period (Phase I: February 2019 to April 2019). Interrupted time series analysis was also used to evaluate the effects of the Phase I intervention. Moreover, 8 of the 20 stores enhanced the intervention from August 2019 onwards (Phase II intervention) by adding a second bay of meat-free products into the meat aisle, which was evaluated following the same analytical methods. During the Phase I intervention, sales of meat products (units/store/week) decreased in intervention (approximately −6%) and control stores (−5%) without significant differences (incidence rate ratio [IRR] 1.01 [95% CI 0.95–1.07]. Sales of meat-free products increased significantly more in the intervention (+31%) compared to the control stores (+6%; IRR 1.43 [95% CI 1.30–1.57]), mostly due to increased sales of meat-free burgers, mince, and sausages. Consistent results were observed in interrupted time series analyses where the effect of the Phase II intervention was significant in intervention versus control stores. Conclusions Prominent positioning of meat-free products into the meat aisle in a supermarket was not effective in reducing sales of meat products, but successfully increased sales of meat-free alternatives in the longer term. A preregistered protocol (https://osf.io/qmz3a/) was completed and fully available before data analysis.

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Home-Based Versus Out-Patient/In-Patient Care for People with Serious Mental Illness

The British Journal of Psychiatry ◽

10.1192/bjp.165.2.204 ◽

1994 ◽

Vol 165 (2) ◽

pp. 204-210 ◽

Cited By ~ 68

Author(s):

B. Audini ◽

I. M. Marks ◽

R. E. Lawrence ◽

J. Connolly ◽

V. Watts

Keyword(s):

Phase I ◽

Patient Care ◽

Phase Ii ◽

Emergency Admission ◽

Care Quality ◽

Patient Admissions ◽

Seriously Mentally Ill ◽

Home Based ◽

Randomised Controlled ◽

Home Based Care

Background.The effect of a randomised controlled withdrawal of home-based care was studied for half of a sample of seriously mentally ill (SMI) patients from an inner London catchment area, compared with the effects of continuing home-based care.Method.Patients, aged 18–64, had entered the trial at month 0 when facing emergency admission for SMI. After at least 20 months home-based care (Phase I), patients were randomised at month 30 into Phase II (months 30–45) to have either further home-based care (DLPII, n = 33) or be transferred to out-/in-patient care (DLP-control, n = 33). They were assessed at 30, 34, and 45 months. Phase I control patients (n = 10) were assessed again at month 45. Measures used were number and duration of in-patient admissions, independent ratings of clinical and social function, and patients' and relatives' satisfaction.Results.The slim clinical and social gains from home-based v. out-/in-patient care during Phase I were largely lost in Phase II. Duration of crisis admissions increased from Phase I to Phase II in both DLPII and DLP-control patients. During Phase II, patients' and relatives' satisfaction remained greater for home-based than out-/in-patient care patients. At 45 months, compared with the Phase I controls, DLPII patients and relatives were more satisfied with care. Such satisfaction was independent of clinical/social gains.Conclusions.The loss of Phase I gains were perhaps due to attenuation of home-based care quality and to benefits of Phase I home-based care lingering into Phase II in DLP-controls. The Phase II home-based care team suffered from low morale.

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Interim outcome analysis of a prospective phase I trial of surgical resection with intracavitary hyperthermic cisplatin and gemcitabine for patients with resectable malignant pleural mesothelioma.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.7588 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. 7588-7588

Author(s):

William G. Richards ◽

Marcelo C Dasilva ◽

Hannah M. Eisen ◽

Julianne C Barlow ◽

Raphael Bueno ◽

...

Keyword(s):

Phase I ◽

Phase Ii ◽

Phase I Trial ◽

Treatment Strategies ◽

Outcome Analysis ◽

Extrapleural Pneumonectomy ◽

Epithelial Tumor ◽

Qualitative Comparison ◽

Kaplan Meier ◽

Secondary Endpoints

7588 Background: We completed a phase I trial of cisplatin and dose-escalated gemcitabine in a hyperthermic intra-operative lavage (IOHC) following extrapleural pneumonectomy (EPP arm) or extended pleurectomy (PD arm). Primary and secondary endpoints including gemcitabine MTD (1000 mg/m2 with 175 mg/m2 cisplatin) and pharmacokinetics, toxicity and mortality were reported (IMIG congress, 9/11-14/2012, abstract IIB.4 [1]). To define phase II indications, we explored patient outcome in comparison to published phase II results of a similar trial using cisplatin IOHC alone following EPP (J Thorac Cardiovasc Surg 2009, 138:405 [2]). Methods: The protocol was registered and IRB approved. Informed consent was obtained. Overall survival was calculated from the date of surgery to the date of death or censored at the date of most recent contact. Patients who were treated on the EPP arm at 500 to 1000 mg/m2 gemcitabine dose levels were included, grouped by epithelial (E) or non-epithelial (NE) histological subtype. Median, 1-year and 2-year survival was estimated using Kaplan-Meier methods. Results: 141 patients were registered. Median age was 65 (43-85) and 22 (21%) were women. Histology was epithelial (63), biphasic (32), and sarcomatoid (8). Two patients died perioperatively (2%). 59 patients were treated on the EPP arm of which the 27 (13 censored) treated at 500 to 1000 mg/m2 gemcitabine were studied. Qualitative comparison with a prior phase II trial of cisplatin IOHC (ref [2]) suggests incremental survival benefit to adding gemcitabine for patients with epithelial but not non-epithelial tumor histology (Table). Conclusions: Patients with epithelial histology tumors who require EPP for macroscopic complete resection appear likely to benefit from the addition of gemcitabine and should be included in a phase II investigation of this combination. Patients with non-epithelial biopsy who require EPP should be considered for other treatment strategies. Clinical trial information: NCT00571298. [Table: see text]

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

10.1101/640318 ◽

2019 ◽

Author(s):

Steven Horng ◽

Joshua W Joseph ◽

Shelley Calder ◽

Jennifer P Stevens ◽

Ashley L O’Donoghue ◽

...

Keyword(s):

Emergency Department ◽

Time Series ◽

Incidence Rate ◽

Rate Ratio ◽

Negative Binomial ◽

Incidence Rate Ratio ◽

Interrupted Time Series ◽

Alert Fatigue ◽

Visual Aid ◽

Electronic Health

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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Impact of the Introduction of Rotavirus Vaccine on Hospital Admissions for Diarrhea Among Children in Kenya: A Controlled Interrupted Time-Series Analysis

Clinical Infectious Diseases ◽

10.1093/cid/ciz912 ◽

2019 ◽

Vol 70 (11) ◽

pp. 2306-2313 ◽

Cited By ~ 3

Author(s):

Grieven P Otieno ◽

Christian Bottomley ◽

Sammy Khagayi ◽

Ifedayo Adetifa ◽

Mwanajuma Ngama ◽

...

Keyword(s):

Time Series ◽

Time Series Analysis ◽

Negative Binomial ◽

Substantial Reduction ◽

Interrupted Time Series ◽

Rotavirus Vaccine ◽

Interrupted Time Series Analysis ◽

Control Series ◽

Vaccine Introduction ◽

Series Analysis

Abstract Background Monovalent rotavirus vaccine, Rotarix (GlaxoSmithKline), was introduced in Kenya in July 2014 and is recommended to infants as oral doses at ages 6 and 10 weeks. A multisite study was established in 2 population-based surveillance sites to evaluate vaccine impact on the incidence of rotavirus-associated hospitalizations (RVHs). Methods Hospital-based surveillance was conducted from January 2010 to June 2017 for acute diarrhea hospitalizations among children aged <5 years in 2 health facilities in Kenya. A controlled interrupted time-series analysis was undertaken to compare RVH pre– and post–vaccine introduction using rotavirus-negative cases as a control series. The change in incidence post–vaccine introduction was estimated from a negative binomial model that adjusted for secular trend, seasonality, and multiple health worker industrial actions (strikes). Results Between January 2010 and June 2017 there were 1513 and 1652 diarrhea hospitalizations in Kilifi and Siaya; among those tested for rotavirus, 28% (315/1142) and 23% (197/877) were positive, respectively. There was a 57% (95% confidence interval [CI], 8–80%) reduction in RVHs observed in the first year post–vaccine introduction in Kilifi and a 59% (95% CI, 20–79%) reduction in Siaya. In the second year, RVHs decreased further at both sites, 80% (95% CI, 46–93%) reduction in Kilifi and 82% reduction in Siaya (95% CI. 61–92%); this reduction was sustained at both sites into the third year. Conclusions A substantial reduction in RVHs and all-cause diarrhea was observed in 2 demographic surveillance sites in Kenya within 3 years of vaccine introduction.

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The indirect impact of COVID-19 pandemic on inpatient admissions in 204 Kenyan hospitals: An interrupted time series analysis

PLOS Global Public Health ◽

10.1371/journal.pgph.0000029 ◽

2021 ◽

Vol 1 (11) ◽

pp. e0000029

Author(s):

Steven Wambua ◽

Lucas Malla ◽

George Mbevi ◽

Amen-Patrick Nwosu ◽

Timothy Tuti ◽

...

Keyword(s):

Time Series ◽

Negative Binomial ◽

Interrupted Time Series ◽

Public Hospitals ◽

Hospital Ownership ◽

Private Hospitals ◽

Live Births ◽

Inpatient Services ◽

First Case ◽

The Impact

The first case of severe acute respiratory coronavirus 2 (SARS-CoV-2) was identified in March 2020 in Kenya resulting in the implementation of public health measures (PHM) to prevent large-scale epidemics. We aimed to quantify the impact of COVID-19 confinement measures on access to inpatient services using data from 204 Kenyan hospitals. Data on monthly admissions and deliveries from the District Health Information Software version 2 (DHIS 2) were extracted for the period January 2018 to March 2021 stratified by hospital ownership (public or private) and adjusting for missing data using multiple imputation (MI). We used the COVID-19 event as a natural experiment to examine the impact of COVID-19 and associated PHM on use of health services by hospital ownership. We estimated the impact of COVID-19 using two approaches; Statistical process control (SPC) charts to visualize and detect changes and Interrupted time series (ITS) analysis using negative-binomial segmented regression models to quantify the changes after March 2020. Sensitivity analysis was undertaken to test robustness of estimates using Generalised Estimating Equations (GEE) and impact of national health workers strike on observed trends. SPC charts showed reductions in most inpatient services starting April 2020. ITS modelling showed significant drops in April 2020 in monthly volumes of live-births (11%), over-fives admissions for medical (29%) and surgical care (25%) with the greatest declines in the under-five’s admissions (59%) in public hospitals. Similar declines were apparent in private hospitals. Health worker strikes had a significant impact on post-COVID-19 trends for total deliveries, live-births and caesarean section rate in private hospitals. COVID-19 has disrupted utilization of inpatient services in Kenyan hospitals. This might have increased avoidable morbidity and mortality due to non-COVID-19-related illnesses. The declines have been sustained. Recent data suggests a reversal in trends with services appearing to be going back to pre- COVID levels.

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Impact of the Pilot Volume-Based Drug Purchasing Policy in China: Interrupted Time-Series Analysis with Controls

Frontiers in Pharmacology ◽

10.3389/fphar.2021.804237 ◽

2021 ◽

Vol 12 ◽

Author(s):

Yilin Chen ◽

Xu Ji ◽

Hong Xiao ◽

Joseph M Unger ◽

Yi Cai ◽

...

Keyword(s):

Time Series ◽

Prescription Drugs ◽

Economies Of Scale ◽

Negative Binomial ◽

Generic Drugs ◽

Interrupted Time Series ◽

Chinese Government ◽

Drug Spending ◽

Purchase Quantity ◽

Purchasing Policy

Centralizing procurement for prescription drugs has the potential to reduce drug spending by creating economies of scale and by improving purchasing power. In March 2019, the Chinese government launched a volume-based purchasing (VBP) pilot program using a competitive bidding process to purchase accredited generic drugs for which branded drug substitutes were available. We performed an interrupted time-series design to estimate the change in monthly drug purchase quantity and spending comparing 14 months before and 7 months after the VBP pilot. We obtained monthly prescription drug purchase data for all purchases from public medical institutions in the three large pilot cities (Beijing, Shanghai and Xi’an) and two non-pilot cities (Changsha and Zhengzhou) between January 2018 to September 2019. We used negative binomial regression and log-linked Gamma Generalized Linear Model for purchase quantity and spending respectively. We evaluated heterogeneity of impact by pilot city, drug type (selected or non-selected drugs), and therapeutic class (cardiovascular disease, mental disorder and cancer) separately. The implementation of the pilot reform was associated with a 132% (95%-CI: 104–165%, p < 0.001) increase in the purchase quantity of selected drugs in pilot cities compared to an 17% decrease (95%-CI: 9–25%, p < 0.001) in control cities. In contrast, the purchase quantity of branded and other drugs in pilot cities decreased by 38% (95%-CI: 27–46%, p < 0.001) and 77% (95%-CI: 71–81%, p < 0.001), respectively; while in control cities, these remained at similar levels. Overall, in pilot cities, there was a 35% (95%-CI: 28–41%, p < 0.001) decrease in the purchase spending for all drugs in the first post-policy month, from 8.1 billion CNY estimated in the absence of VBP down to 5.3 billion CNY; in control cities, the change was negligible. The largest reduction in spending occurred for drugs for the treatment of cardiovascular diseases. The evidence suggests a positive impact of the VBP pilot in reducing overall drug spending and increasing the use of accredited generics in three pilot cities. This overall trend is not observed in two non-pilot cities. Assessments of long-term impact of the VBP policy on additional key outcomes including drug prescriptions, drug utilization, patients’ health outcomes and payments on drugs are needed.

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Impact of free maternity policies in Kenya: an interrupted time-series analysis

BMJ Global Health ◽

10.1136/bmjgh-2020-003649 ◽

2021 ◽

Vol 6 (6) ◽

pp. e003649

Author(s):

Stacey Orangi ◽

Angela Kairu ◽

Lucas Malla ◽

Joanne Ondera ◽

Boniface Mbuthia ◽

...

Keyword(s):

Time Series ◽

Maternal Health ◽

Time Series Analysis ◽

Negative Binomial ◽

Health Information System ◽

Interrupted Time Series ◽

Interrupted Time Series Analysis ◽

Faith Based ◽

Public Facilities ◽

Series Analysis

BackgroundUser fees have been reported to limit access to services and increase inequities. As a result, Kenya introduced a free maternity policy in all public facilities in 2013. Subsequently in 2017, the policy was revised to the Linda Mama programme to expand access to private sector, expand the benefit package and change its management.MethodsAn interrupted time-series analysis on facility deliveries, antenatal care (ANC) and postnatal care (PNC) visits data between 2012 and 2019 was used to determine the effect of the two free maternity policies. These data were from 5419 public and 305 private and faith-based facilities across all counties, with data sourced from the health information system. A segmented negative binomial regression with seasonality accounted for, was used to determine the level (immediate) effect and trend (month-on-month) effect of the policies.ResultsThe 2013 free-maternity policy led to a 19.6% and 28.9% level increase in normal deliveries and caesarean sections, respectively, in public facilities. There was also a 1.4% trend decrease in caesarean sections in public facilities. A level decrease followed by a trend increase in PNC visits was reported in public facilities. For private and faith-based facilities, there was a level decrease in caesarean sections and ANC visits followed by a trend increase in caeserean sections following the 2013 policy.Furthermore, the 2017 Linda Mama programme showed a level decrease then a trend increase in PNC visits and a 1.1% trend decrease in caesarean sections in public facilities. In private and faith-based facilities, there was a reported level decrease in normal deliveries and caesarean sections and a trend increase in caesarean sections.ConclusionThe free maternity policies show mixed effects in increasing access to maternal health services. Emphasis on other accessibility barriers and service delivery challenges alongside user fee removal policies should be addressed to realise maximum benefits in maternal health utilisation.

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Evaluation of an automated feedback intervention to improve antimicrobial prescribing among primary care physicians (OPEN Stewardship): protocol for an interrupted time-series and usability analysis in Ontario, Canada and Southern Israel

BMJ Open ◽

10.1136/bmjopen-2020-039810 ◽

2021 ◽

Vol 11 (1) ◽

pp. e039810

Author(s):

Jean-Paul R Soucy ◽

Marcelo Low ◽

Kamal Raj Acharya ◽

Moriah Ellen ◽

Anette Hulth ◽

...

Keyword(s):

Primary Care ◽

Time Series ◽

Primary Care Physicians ◽

Bacterial Infections ◽

Negative Binomial ◽

Interrupted Time Series ◽

New Drugs ◽

Feedback Intervention ◽

Antimicrobial Prescribing ◽

Automated Feedback

IntroductionAntimicrobial resistance undermines our ability to treat bacterial infections, leading to longer hospital stays, increased morbidity and mortality, and a mounting burden to the healthcare system. Antimicrobial stewardship is increasingly important to safeguard the efficacy of existing drugs, as few new drugs are in the developmental pipeline. While significant progress has been made with respect to stewardship in hospitals, relatively little progress has been made in the primary care setting, where the majority of antimicrobials are prescribed. OPEN Stewardship is an international collaboration to develop an automated feedback platform to improve responsible antimicrobial prescribing among primary care physicians and capable of being deployed across heterogeneous healthcare settings. We describe the protocol for an evaluation of this automated feedback intervention with two main objectives: assessing changes in antimicrobial prescribing among participating physicians and determining the usability and usefulness of the reports.Methods and analysisA non-randomised evaluation of the automated feedback intervention (OPEN Stewardship) will be conducted among approximately 150 primary care physicians recruited from Ontario, Canada and Southern Israel, based on a series of targeted stewardship messages sent using the platform. Using a controlled interrupted time-series analysis and multilevel negative binomial modelling, we will compare the antimicrobial prescribing rates of participants before and after the intervention, and also to the prescribing rates of non-participants (from the same healthcare network) during the same period. We will examine outcomes targeted by the stewardship messages, including prescribing for antimicrobials with duration longer than 7 days and prescribing for indications where antimicrobials are typically unnecessary. Participants will also complete a series of surveys to determine the usability and usefulness of the stewardship reports.Ethics and disseminationAll sites have obtained ethics committee approval to recruit providers and access anonymised prescribing data. Dissemination will occur through open-access publication, stakeholder networks and national/international meetings.

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Evaluation of an OPEN Stewardship generated feedback intervention to improve antibiotic prescribing among primary care veterinarians in Ontario, Canada and Israel: protocol for evaluating usability and an interrupted time-series analysis

BMJ Open ◽

10.1136/bmjopen-2020-039760 ◽

2021 ◽

Vol 11 (1) ◽

pp. e039760

Author(s):

Kamal Raj Acharya ◽

Gabrielle Brankston ◽

Jean-Paul R Soucy ◽

Adar Cohen ◽

Anette Hulth ◽

...

Keyword(s):

Time Series ◽

Antibiotic Stewardship ◽

Negative Binomial ◽

Interrupted Time Series ◽

Well Being ◽

Antibiotic Prescribing ◽

Feedback Report ◽

Feedback Intervention ◽

Scientific Publications ◽

The Impact

IntroductionAntimicrobial resistance (AMR) impacts the health and well-being of animals, affects animal owners both socially and economically, and contributes to AMR at the human and environmental interface. The overuse and/or inappropriate use of antibiotics in animals has been identified as one of the most important drivers of the development of AMR in animals. Effective antibiotic stewardship interventions such as feedback can be adopted in veterinary practices to improve antibiotic prescribing. However, the provision of dedicated financial and technical resources to implement such systems are challenging. The newly developed web-based Online Platform for Expanding Antibiotic Stewardship (OPEN Stewardship) platform aims to automate the generation of feedback reports and facilitate wider adoption of antibiotic stewardship. This paper describes a protocol to evaluate the usability and usefulness of a feedback intervention among veterinarians and assess its impact on individual antibiotic prescribing.Methods and analysisApproximately 80 veterinarians from Ontario, Canada and 60 veterinarians from Israel will be voluntarily enrolled in a controlled interrupted time-series study and their monthly antibiotic prescribing data accessed. The study intervention consists of targeted feedback reports generated using the OPEN Stewardship platform. After a 3-month preintervention period, a cohort of veterinarians (treatment cohort, n=120) will receive three feedback reports over the course of 6 months while the remainder of the veterinarians (n=20) will be the control cohort. A survey will be administered among the treatment cohort after each feedback cycle to assess the usability and usefulness of various elements of the feedback report. A multilevel negative-binomial regression analysis of the preintervention and postintervention antibiotic prescribing of the treatment cohort will be performed to evaluate the impact of the intervention.Ethics and disseminationResearch ethics board approval was obtained at each participating site prior to the recruitment of the veterinarians. The study findings will be disseminated through open-access scientific publications, stakeholder networks and national/international meetings.

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Abstract 12127: The Effect of Daylight Savings Time Transitions on the Incidence of Out-of-Hospital Cardiac Arrest: An Interrupted Time Series Analysis

Circulation ◽

10.1161/circ.144.suppl_2.12127 ◽

2021 ◽

Vol 144 (Suppl_2) ◽

Author(s):

Jack Hook ◽

Karen L Smith ◽

Emily Andrew ◽

Jocasta Ball ◽

Ziad Nehme

Keyword(s):

Time Series ◽

Cardiac Arrest ◽

Time Series Analysis ◽

Negative Binomial ◽

Interrupted Time Series ◽

Cumulative Effects ◽

Interrupted Time Series Analysis ◽

Series Analysis ◽

Increased Risk ◽

Hospital Cardiac Arrest

Introduction: Many studies have reported increases in the risk of acute cardiovascular events following daylight savings time (DST) transitions. We sought to investigate the effect of DST transitions on the incidence of out-of-hospital cardiac arrest (OHCA) in Victoria, Australia. Methods: Between January 2000 and December 2020, we performed an interrupted time series analysis of the daily number of OHCA cases of medical etiology from the Victorian Ambulance Cardiac Arrest Registry. The effect of DST transition on OHCA incidence was estimated using negative binomial models and reported as either ‘immediate’ or ‘cumulative’ effects. Immediate effects were the average effects observed on the day of DST transition or each of the 6 days after DST transition. Cumulative effects were the sum of the average effects up to 6 days after the day of DST transition. Models were adjusted for population growth, temporal trends, and public holidays. Results: A total of 89,409 adult OHCA of medical etiology were included. Following the spring DST transition (i.e. shorter day), there was an immediate 13% (IRR 1.13, 95% CI: 1.02, 1.25; p=0.02) increased risk of OHCA on the day of transition (Sunday) and the cumulative risk of OHCA remained higher over the first 2 days (IRR 1.17, 95% CI: 1.02, 1.34; p=0.03) compared to non-transitional days. Following the autumn (fall) DST transition (i.e. longer day), there was a significant lagged effect on the Tuesday following transition, with a 12% (IRR 0.88, 95% CI: 0.77, 0.99; p=0.04) reduced risk of OHCA. The autumn (fall) DST transition also showed a cumulative effect on OHCA incidence, with a 30% (IRR 0.70, 95% CI: 0.51, 0.96; p=0.03) reduction in the incidence of OHCA by the end of the transitional week. Subgroups aged > 65 years and cases with initial non-shockable rhythms were most vulnerable to DST transitions. Conclusions: This study showed that there is a modest increased risk of OHCA in the 2 days following the spring DST transition and a decreased risk of OHCA in the week following the autumn DST transition. These findings should promote further research exploring strategies to reduce the risk of OHCA in vulnerable populations.

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