The Rise of the State: Broadband Policy in New Zealand 2000-2011

<p>Between 2000 and 2011, changes in government policy significantly increased the role of the state in telecommunications markets in New Zealand. In both regulatory and investment activities, the historic approach of liberal market regulation was transformed into active intervention. This changed approach aimed at speeding access to high-speed broadband services. There was a remarkable lack of political debate between the major political parties as to the objective being sought, or direction of policy towards greater intervention in order to achieve it. This research outlines in broad terms the background to the debates underpinning policy change, and the history of New Zealand’s approach. It outlines in detail the key policy changes made. In the regulatory domain, four key changes are discussed. These are: the implementation of sector-specific legislation (Telecommunications Act 2001); the decision not to unbundle the copper local loop (2004); amendments to the Telecommunications Act strengthening the regulator and imposing ‘operational separation’ of Telecom (2006); and the ‘structural separation’ of Telecom and the debate on regulatory forbearance (2011). By the end of the case period, these changes meant that generic competition law had been replaced by sector-specific legislation, a specialist regulator with broad powers to monitor and regulate the industry, and a leading solution to discrimination issues with the complete ownership separation of network and services in copper and fibre-optic telecommunications networks. In the investment domain, five key stages are discussed. These are: Project PROBE (2001-4), the Broadband Challenge (2005), the Broadband Investment Fund (2008), the Ultra-Fast Broadband Initiative (2009) and the Rural Broadband Initiative (2009). Together these saw public spending on telecommunications infrastructure rise from nothing in 2000, to a combined package in the two final (and current) initiatives of around $1.6bn of public funds. This money combines with private investment to deliver fibre-optic broadband infrastructure to three-quarters of homes, and significant improvements to the availability of higher-speed broadband in rural and remote parts of New Zealand. Increasing levels of government intervention in these markets was an opportunity for considerable political contest. Instead the case period 2000-2011 is characterised by similarities rather than differences between National and Labour. The thesis suggests that an explanation for this similarity arose from the perceived importance of high-speed broadband infrastructure for New Zealand’s economic prospects, and a shared analysis by Labour and National that market provision would not suffice. This imperative defeated temptations to politicise the project.</p>

The Rise of the State: Broadband Policy in New Zealand 2000-2011

<p>Between 2000 and 2011, changes in government policy significantly increased the role of the state in telecommunications markets in New Zealand. In both regulatory and investment activities, the historic approach of liberal market regulation was transformed into active intervention. This changed approach aimed at speeding access to high-speed broadband services. There was a remarkable lack of political debate between the major political parties as to the objective being sought, or direction of policy towards greater intervention in order to achieve it. This research outlines in broad terms the background to the debates underpinning policy change, and the history of New Zealand’s approach. It outlines in detail the key policy changes made. In the regulatory domain, four key changes are discussed. These are: the implementation of sector-specific legislation (Telecommunications Act 2001); the decision not to unbundle the copper local loop (2004); amendments to the Telecommunications Act strengthening the regulator and imposing ‘operational separation’ of Telecom (2006); and the ‘structural separation’ of Telecom and the debate on regulatory forbearance (2011). By the end of the case period, these changes meant that generic competition law had been replaced by sector-specific legislation, a specialist regulator with broad powers to monitor and regulate the industry, and a leading solution to discrimination issues with the complete ownership separation of network and services in copper and fibre-optic telecommunications networks. In the investment domain, five key stages are discussed. These are: Project PROBE (2001-4), the Broadband Challenge (2005), the Broadband Investment Fund (2008), the Ultra-Fast Broadband Initiative (2009) and the Rural Broadband Initiative (2009). Together these saw public spending on telecommunications infrastructure rise from nothing in 2000, to a combined package in the two final (and current) initiatives of around $1.6bn of public funds. This money combines with private investment to deliver fibre-optic broadband infrastructure to three-quarters of homes, and significant improvements to the availability of higher-speed broadband in rural and remote parts of New Zealand. Increasing levels of government intervention in these markets was an opportunity for considerable political contest. Instead the case period 2000-2011 is characterised by similarities rather than differences between National and Labour. The thesis suggests that an explanation for this similarity arose from the perceived importance of high-speed broadband infrastructure for New Zealand’s economic prospects, and a shared analysis by Labour and National that market provision would not suffice. This imperative defeated temptations to politicise the project.</p>

Risk of Hospitalization for Vaso-Occlusive Episode in Patients with Sickle Cell Disease after out-Patient Exposure to Systemic Corticosteroids

Introduction : Sickle cell disease (SCD) is an inherited disorder which affects 300,000 newborns per year. Vaso-occlusive episodes (VOEs) cause an important morbi-mortality and a decreased quality of life in patients with SCD. Some risk factors of VOE are well known, like infection, cold exposure, stress, pulmonary diseases and dehydration. Exposure to systemic corticosteroids has been suspected to increase the occurrence of VOEs in few case reports or series. However, no comparative study has been conducted to demonstrate this risk which is still debated, resulting in discrepancies among guidelines on SCD management. This study aimed to assess the risk of hospitalization for VOE associated with out-hospital exposure to systemic corticosteroids in patients with SCD in France. Methods : Data source was the French national health insurance system database, named SNDS (Système National des Données de Santé) between 2010 and 2018. The SNDS links sociodemographic, out- and in-hospital data for the entire French population (&gt;66 million inhabitants). The study population consisted in all patients with SCD with at least one hospitalization for VOE during the study period, identified with a primary discharge diagnosis of VOE (D57.0 code of the international classification of disease, 10 th version; positive predictive value: 98.6%). All genotypes (homozygous SS-SCD and double-heterozygous SCD) were included. Because we assessed out-hospital exposure to corticosteroids, patients hospitalized during the three months before the first VOE were excluded. We performed a case-case-time-control study (Figure 1). This self-controlled design results in self-adjustment for time-independent confounders, including genotype. The outcome was the first hospitalization for VOE. The exposure to oral and injectable corticosteroids, identified using out-hospital reimbursement data, was assessed during a case period (28 days before the outcome) compared to the exposure during a control period (28 days, starting 84 days before the outcome). The same comparison was made among future cases (matched patients hospitalized for VOE the year after the given case), in order to adjust for the trend of exposure to corticosteroids (calendar variations of corticosteroid exposure). Results : Overall, 5,151 cases of VOEs were included in the main analysis. Median age at first VOE was 16.9 years; 317 (6.2%) patients were exposed to corticosteroids during the case period. In the main analysis, corticosteroid exposure was significantly associated with the occurrence of hospitalizations for VOEs: adjusted Odds Ratio (aOR): 3.81, 95% confidence interval (95% CI): 2.44 to 5.61. In patients exposed to hydroxyurea, the aOR was 2.61, 95% CI: 1.07 to 6.39, compared with an aOR of 4.00, 95% CI: 2.53 to 6.30 in unexposed patients. In the subgroup analysis by age, the aOR was 2.81, 95% CI: 1.49 to 5.30 in children, and 4.45, 95% CI: 2.37 to 8.37 in adults. The results were consistent in all sensitivity analyses. Conclusion : This study showed an association between outpatient exposure to systemic corticosteroids with an increased risk of hospitalization for VOE, in both adults and children. Hydroxyurea may reduce this risk in adults. Figure 1 Figure 1. Disclosures Bartolucci: GBT: Consultancy; Emmaus: Consultancy; Fabre Foundation: Research Funding; AGIOS: Consultancy; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Lecture fees, Steering committee, Research Funding; Jazz Pharma: Other: Lecture fees; INNOVHEM: Other: Co-founder; Bluebird: Consultancy, Research Funding; F. Hoffmann-La Roche Ltd: Consultancy; Hemanext: Consultancy; Addmedica: Consultancy, Other: Lecture fees, Research Funding. Moulis: Argenx: Membership on an entity's Board of Directors or advisory committees; Sobi: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Grifols: Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Membership on an entity's Board of Directors or advisory committees, Research Funding.

Changes in antithrombotic treatment in patients with abdominal aortic aneurysmal disease and incident atrial fibrillation: a population-based case-crossover analyses

Background Abdominal aortic aneurysmal (AAA) disease is associated with a high risk of cardiovascular events, and prophylaxis with platelet-inhibitors are recommended at diagnosis. Incident atrial fibrillation (AF) changes that indication to oral anticoagulative (OAC) therapy. However, it is unknown to what extent the recommended change of indication is reflected in the actual antithrombotic treatment in clinical practice. Purpose To evaluate the antithrombotic therapy after an incident diagnosis of atrial fibrillation in patients with established AAA. Methods In this population-based case-crossover study, using nationwide Danish registries, we identified all patients registered with a diagnosis of AAA between 1997 and 2018, and a subsequent diagnosis of AF. The case-crossover analysis was performed to compare the within-subject antithrombotic therapy in 1-year time-periods before and after AF diagnosis in the study population. A blanking period of 30 days before AF-diagnosis was applied to avoid bias from potentially delayed hospital diagnosis of AF (Figure 1.1). We excluded patients with no eligible reference window due to recent cohort entry and patients with no AF-related indication for shift to OAC (CHA2DS2-VASc score of &lt;1 in men and &lt;2 in women). Odds ratios (OR) with 95% confidence intervals (CIs) comparing antithrombotic therapy before and after AF diagnosis was calculated using McNemars test for matched pair's data. Subgroup analyses of patients diagnosed with AAA between 2011 and 2018 were performed to evaluate changes after introduction of current antithrombotic treatment regimens and direct oral anticoagulants. Results A total of 3052 patients were included in the case-crossover analyses. Mean age was 77.8 years and 22.3% were females. Median time from AAA to AF diagnosis was 4.6 years (IQR; 2.6–7.8). Stroke risk in the study population was high with a median CHA2DS2-VASc score of 4 (IQR: 3–5). In the case-period after AF diagnosis, 1004 prescription claims of platelet-inhibitors were registered compared with 1461 claims in the control-period before AF diagnosis, corresponding to a matched OR of 0.31 (95% CI, 0.26–0.36) (Figure 1.2). Conversely, there were 1392 prescription claims for OAC in the case-period compared with 355 in the control-period, corresponding to an OR of 15.75 (95% CI, 12.38–20.31). When restricting the study-population to patients diagnosed with AAA during 2011–2018, the OR was 0.11 (95% CI, 0.07–0.16) for a prescription claim of platelet-inhibitors and 17.7 (95% CI, 11.22–29.17) for OAC before and after AF diagnosis (Figure 1.2). Conclusion In patients with established AAA and high risk of stroke, incident AF was associated with low likelihood of treatment with platelet-inhibitor and a high likelihood of OAC-treatment compared with before AF. This association was further strengthened in patients diagnosed after 2011. FUNDunding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The Obel Family Foundation, DenmarkThe Augustinus Foundation, DenmarkThe sponsors played no role in the study design; data collection, analysis, or interpretation; abstract writing; or in the decision to submit the abstract. Figure 1

Impact of COVID-19 on routine immunization in Oyo State, Nigeria: Trend analysis of immunization data in the pre-and post-index case period; 2019 – 2020

Background The response to COVID-19 pandemic has posed new obstacles to the fragile health system, most especially in the area of vaccination across much of Africa. As the response to the pandemic intensifies through the application of non-pharmacologic interventions as well as enforcement of the lockdowns across African cities, there is a significant risk that more children will miss out on life-saving vaccines that can prevent childhood killer diseases. This study was therefore conducted to look at the impact of COVID-19 pandemic on routine immunization in Oyo State, Nigeria. Method: We conducted a descriptive secondary analysis of immunization data between July 2019 and August 2020. These data were retrieved from the Monitoring and Evaluation Unit of Oyo State Primary Health Care Board. The data were extracted from the original paper format and entered into Excel sheets. Line graphs were plotted to compare the trends of the coverage rates before and after the index case of COVID-19 pandemic. Results The average coverage rates for BCG before and after index case was 85.8% and 82.1% respectively, while it was 63.5% and 60.0% for HBV0. For the co-administered vaccines at 14 weeks, Penta 3, OPV 3, PCV 3 and IPV coverage rates dropped from 76.1%, 75.4%, 75.1% and 73.5–72.0%, 71.4%, 72.0% and 71.9% respectively. The average coverage rates for yellow fever and measles dropped sharply from 77.0% and 74.5–64.6% and 58.6% respectively. The average drop-out rates for the pre-and post-index case periods were 5.0% and 4.7% respectively. For the planned fixed and outreach sessions, none of the monthly sessions met the target of 100.0% in the post-index case period. Conclusion Decreased vaccination coverage for vaccine-preventable diseases could cause parallel outbreaks with COVID-19 and further exacerbate the strain on health systems attempting to end the acute phase of this pandemic. Therefore, as the dramatic second wave unfolds, the Government of Nigeria must take deliberate steps to strike a balance between a fresh lockdown and the imperative of uninterrupted social service. In this wise, it must remain committed to a timely vaccination programme

Temporal relationship between atrial fibrillation and ischaemic stroke in a large cohort with continuous rhythm monitoring

Background/Introduction Atrial fibrillation (AF) increases the risk of ischaemic stroke, but the temporal relationship is uncertain. Purpose To assess the temporal relationship between AF episodes and ischaemic stroke in patients with cardiovascular implantable electronic devices (CIED) utilizing a case-crossover analysis. Methods We linked a very large U.S. aggregated de-identified electronic health record database (2007–2017), containing claims for ischaemic stroke hospitalizations, to a manufacturer's CIED database with continuous AF monitoring. All stroke patients with ≥120 days of pre-stroke rhythm data were included. For each stroke patient, we compared the presence of a day with ≥5.5 hours of AF (the TRENDS study threshold) in the case period (days 1–30 pre-stroke) to that in the control period (days 91–120 pre-stroke). Matched analyses for dichotomous outcomes generated odds ratios with confidence intervals and p values. Results We identified 891 ischaemic stroke patients (71.3±10.5 years, 65% male, 27% pacemakers, 60% defibrillators, 13% insertable cardiac monitors) with continuous monitoring data in the 120 days pre-stroke. The vast majority had either no AF in both the case and control periods (n=682, 77%) or AF in both periods (n=143, 16%), i.e., non-informative records. However, among the 66 patients with informative, discordant arrhythmic states, 52 had AF in the case period versus 14 in the control period, for an odds ratio of 3.71 (95% C.I. 2.06–6.70, p&lt;0.001). Analysed by 5-day periods, stroke risk was markedly increased within 30 days of the AF episode (figure). For days 1–5 following an AF episode, the odds ratio was 9.7 (95% C.I. 5.9–16.1). Risk diminished towards non-AF risk after 30 days. Conclusion Our analysis of this largest cohort with continuous rhythm monitoring prior to ischaemic stroke demonstrates that stroke risk is highest within a few days of an episode of AF and diminishes rapidly thereafter. Our findings support a strategy of time-limited anticoagulation for patients with infrequent episodes of AF and available continuous rhythm monitoring. Funding Acknowledgement Type of funding source: None

Clinician-recalled quoted speech in electronic health records and risk of suicide attempt: a case–crossover study

ObjectiveClinician narrative style in electronic health records (EHR) has rarely been investigated. Clinicians sometimes record brief quotations from patients, possibly more frequently when higher risk is perceived. We investigated whether the frequency of quoted phrases in an EHR was higher in time periods closer to a suicide attempt.DesignA case–crossover study was conducted in a large mental health records database. A natural language processing tool was developed using regular expression matching to identify text occurring within quotation marks in the EHR.SettingElectronic records from a large mental healthcare provider serving a geographic catchment of 1.3 million residents in South London were linked with hospitalisation data.Participants1503 individuals were identified as having a hospitalised suicide attempt from 1 April 2006 to 31 March 2017 with at least one document in both the case period (1–30 days prior to admission) and the control period (61–90 days prior to admission).Outcome measuresThe number of quoted phrases in the control as compared with the case period.ResultsBoth attended (OR 1.05, 95% CI 1.02 to 1.08) and non-attended (OR 1.15, 95% CI 1.04 to 1.26) clinical appointments were independently higher in the case compared with control period, while there was no difference in mental healthcare hospitalisation (OR 0.99, 95% CI 0.98 to 1.01). In addition, there was no difference in the levels of quoted text between the comparison time periods (OR 1.09, 95% CI 0.91 to 1.30).ConclusionsThis study successfully developed an algorithm to identify quoted speech in text fields from routine mental healthcare records. Contrary to the hypothesis, no association between this exposure and proximity to a suicide attempt was found; however, further evaluation is warranted on the way in which clinician-perceived risk might be feasibly characterised from clinical text.

Cardiovascular risk of nonsteroidal anti-inflammatory drugs in dialysis patients: a nationwide population-based study

Background Given the cardiovascular risk of nonsteroidal anti-inflammatory drugs (NSAIDs), it is essential to identify the relationship between NSAIDs and cardiovascular outcomes in dialysis patients who have elevated cardiovascular risk. Methods A case-crossover study was conducted to assess the association of NSAIDs with major adverse cardiac and cerebrovascular events (MACCEs) and mortality using the Korean Health Insurance dataset. The case period was defined as 1–30 days prior to the event date and the control periods were defined as 61–90 days and 91–120 days prior to the event date. Results There were 3433 and 8524 incident dialysis patients who experienced MACCEs and mortality, respectively, after exposure to NSAIDs within 120 days before each event. NSAIDs significantly increased the risk of MACCEs {adjusted odds ratio [aOR] 1.37 [95% confidence interval (CI) 1.26–1.50]} and mortality [aOR 1.29 (95% CI 1.22–1.36)]. Nonselective NSAIDs, but not selective cyclooxygenase-2 inhibitors, significantly increased the risk of MACCEs and mortality. However, the MACCE and mortality risk did not increase in a dose-dependent manner in the analysis according to the cumulative defined daily dosage of NSAIDs. The incidence of MACCEs in the case period tended to be more common in patients who had recent exposure to NSAIDs than in patients who did not have recent exposure to NSAIDs. Conclusions Clinicians should be particularly cautious when prescribing NSAIDs to dialysis patients considering the associations of NSAIDs with cardiovascular outcomes and mortality, which might occur independent of the dose and duration of exposure.

Risk of Vaccine-Induced Immune Thrombocytopenia in Children. Nationwide Case Cross-over and Self-Controlled Case Series Studies in France

Introduction: The association of measles, mumps and rubella (MMR) vaccination with immune thrombocytopenia (ITP) occurrence has been shown. The risk of ITP with other vaccines is still not known. This study was aimed at assessing the association of recommended vaccinations in children with ITP occurrence. Methods: We conducted a population-based study in France including all children newly diagnosed for primary ITP between July 2009 and June 2015. This cohort was built using a validated algorithm in the nationwide French health insurance database (SNDS). We assessed the risk of ITP with MMR vaccine, all combined vaccines containing diphtheria, tetanus and poliomyelitis (DTP) vaccines, pneumococcal and meningococcal C vaccines. We used two self-controlled designs: a case cross-over and a self-controlled case series. For the case cross-over, we compared the frequency of exposure to vaccines during a 6-week period immediately preceding the event (case period) with the frequency of exposure during a previous time period (control period, having the same duration as the case period). We performed sensitivity analyses using 8- and 12-week periods. Analyses were adjusted for exposure to other drugs known as inducers of ITP and seasonality. Odds ratios (OR) and their 95% confidence intervals (CI) were calculated. For the self-controlled case series, we compared the ITP incidence within periods of risk (following vaccination, named exposure period) with the incidence within the control period of non-exposure. The exposure period was defined by the 6 weeks after the vaccine dispensing in the principal analysis (8 and 12 weeks in sensitivity analyses). We further excluded the 2 weeks prior to vaccine dispensing from the non-exposure period to address selective survival bias (healthy vaccinee effect). The observation period was censored at ITP occurrence, due to variation of vaccination probability after ITP diagnosis and to the impossibility to distinguish ITP relapses from chronic ITP in the database. Analyses were adjusted for seasonality. Incidence rate ratios (IRRs) and their 95% CI were calculated. We assessed the exposure to each vaccine, and conducted subgroup analyses in patients without any concurrent vaccination during case and control periods for the case cross-over study and exposure periods for the self-controlled case series study. We also calculated the number of ITP cases occurring during the 6 weeks after vaccination divided by the number of vaccine doses dispensed in the French children population during the study period. Results: We included 2,549 newly diagnosed primary ITP children. Among them, median age was 5.1 years and 46.5 % were females; 41.4% had been exposed to at least one studied vaccine before ITP onset. The results of the principal analysis are detailed in the Table. There was an increased occurrence of ITP following MMR vaccination (OR: 1.60, 95% CI: 1.09-2.34; IRR: 1.30, 95% CI: 0.95-1.80). Analyses excluding the patients with concurrent vaccination, notably meningococcal vaccination, led to similar results (OR: 1.66, 95% CI: 1.02-2.71; IRR: 1.39, 95% CI: 0.80-2.42). There was also an increased occurrence of ITP with the meningococcal C vaccine (OR: 1.92, 95% CI: 0.95-3.86; IRR: 1.40, 95% CI: 0.86-2.29). Analyses conducted in patients without any concurrent vaccination, notably MMR vaccination, confirmed these results with wide 95% CI because of fewer patients included (OR: 1.64, 95% CI: 0.57-4.71; IRR: 1.64, 95% CI: 0.69-3.86). No association was observed between other vaccines and ITP occurrence. The numbers of ITP cases occurring in the 6 weeks following vaccination per million doses dispensed were 8.2 for pneumococcal, 9.2 for DTP, 9.6 for meningococcal and 11.5 for MMR vaccines. Of note, these numbers overestimate the probability of vaccine-induced ITP. Indeed, they are ITP cases chronologically compatible with vaccine adverse reaction without any individual causality assessment (a worst-case scenario considering that all cases were triggered by vaccines). Conclusion: This study showed an increased occurrence of ITP after MMR and meningococcal C vaccines. It is reassuring for other vaccines. We cannot exclude temporal association with MMR and meningococcal C vaccines due to the peak of ITP incidence at 12 months of age in the general population. However, vaccine-induced ITP is a very rare event, which does not cast doubt on the interest of vaccination. Disclosures No relevant conflicts of interest to declare.

Changes in drinking as predictors of changes in sickness absence: a case-crossover study

BackgroundWe investigated whether changes in alcohol use predict changes in the risk of sickness absence in a case-crossover design.MethodsFinnish public sector employees were surveyed in 2000, 2004 and 2008 on alcohol use and covariates. Heavy drinking was defined as either a weekly intake that exceeded recommendations (12 units for women; 23 for men) or having an extreme drinking session. The responses were linked to national sickness absence registers. We analysed the within-person relative risk of change in the risk of sickness absence in relation to change in drinking. Case period refers to being sickness absent within 1 year of the survey and control period refers to not being sickness absent within 1 year of the survey.ResultsPeriods of heavy drinking were associated with increased odds of self-certified short-term (1–3 days) sickness absence (multivariable-adjusted OR 1.21, 95% CI 1.07 to 1.38 for all participants; 1.62, 95% CI 1.19 to 2.21 for men and 1.15, 95% CI 1.00 to 1.33 for women). A higher risk of short-term sickness absence was also observed after increase in drinking (OR=1.27, 95% CI 1.07 to 1.52) and a lower risk was observed after decrease in drinking (OR=0.83, 95% CI 0.69 to 1.00). Both increase (OR=1.38, 95% CI 1.21 to 1.57) and decrease (OR=1.27, 95% CI 1.19 to 1.43) in drinking were associated with increased risk of long-term (>9 days) medically certified all-cause sickness absence.ConclusionIncrease in drinking was related to increases in short-term and long-term sickness absences. Men and employees with a low socioeconomic position in particular seemed to be at risk.