Search Results (312)

Background/Objectives: Hand hygiene is a cornerstone of infection prevention, yet the extent to which multimodal institutional hand hygiene interventions translate into measurable reductions in healthcare-associated infections (HAIs) remains uncertain. This systematic review aimed to evaluate the association between hospital-wide or multi-ward multimodal hand hygiene interventions and clinical HAI outcomes in acute care hospitals. Methods: A structured literature search was conducted in PubMed, Scopus, Embase, and Google Scholar using a combination of Medical Subject Headings (MeSH) and free-text terms related to hand hygiene, healthcare-associated infections, hospital settings, and intervention strategies. Eligible studies were quasi-experimental designs, including before–after, controlled before–after, and interrupted time-series studies, evaluating multimodal hand hygiene interventions implemented at hospital-wide or multi-ward level and reporting clinical HAI outcomes. Two reviewers independently assessed risk of bias using the ROBINS-I tool, and certainty of evidence across major outcome categories was summarized using GRADE. Results: twelve studies met the inclusion criteria. Overall, multimodal hand hygiene interventions were generally associated with favorable directional trends in clinical outcomes. Reductions were most consistent for broader institutional HAI measures and some device-associated infections, particularly central line-associated bloodstream infections. In contrast, organism-specific outcomes, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and Clostridioides difficile, were more heterogeneous across studies and settings. All included studies were judged to be at serious or critical overall risk of bias, primarily because of confounding, lack of contemporaneous controls, co-interventions, and phased implementation. Conclusions: Multimodal hand hygiene programs in acute care hospitals may be associated with improvement in selected clinically relevant HAI outcomes, particularly at the institutional level. However, the overall certainty of evidence remains low to very low, and the strength of inference is limited by the non-randomized nature of the available studies and the difficulty of isolating the independent effect of hand hygiene within complex infection-prevention strategies. Full article

Background/Objectives: Central line-associated bloodstream infection (CLABSI) remains a major healthcare-associated infection in intensive care units (ICUs). This study evaluated changes in CLABSI incidence following the implementation of a multimodal infection control intervention in the ICU. Methods: We conducted a quasi-experimental study in the adult ICUs of a referral hospital from January 2023 to December 2025. The interventions included staff education, performance feedback, infection control-led rounds, optimization of catheter practices, and reinforcement of environmental hygiene. The primary outcome was CLABSI incidence per 1000 central line-days. An interrupted time-series analysis using segmented Poisson regression with robust standard errors was used to assess temporal trends. Results: A total of 17 CLABSI cases occurred during the pre-intervention period, and 25 during the post-intervention period. There was no significant difference in CLABSI incidence between the two periods (incidence rate ratio, 1.07; 95% confidence interval, 0.58–1.98). However, interrupted time-series analysis demonstrated a significant decreasing trend in CLABSI incidence following the intervention (rate ratio, 0.89 per month; 95% confidence interval, 0.81–0.97; p = 0.01). This trend was observed despite the higher patient severity and increased use of advanced supportive therapies in the post-intervention period. The device utilization ratio and monthly blood culture rate remained unchanged. Avoidance of femoral venous access increased, and adherence to catheter-handling protocols significantly improved. Conclusions: A staged, multimodal intervention was associated with a significant decreasing trend in CLABSI incidence over time, suggesting a potential benefit of comprehensive infection prevention strategies in ICU settings. Full article

Objective: This study examines the effect of DRG payment reform on nutritional therapy costs, hospitalization expenditures, and resource utilization among gastric cancer surgery patients using a quasi-experimental design. Methods: We conducted an interrupted time series analysis using inpatient data from a tertiary hospital in a major Chinese city between January 2018 and December 2024, including 761 gastric cancer surgery patients. Segmented regression models estimated changes in baseline trend, immediate level, and post-intervention slope for nutritional therapy expenditures, total hospitalization costs, surgical fees, and length of stay. Subgroup analyses were performed by type of medical insurance, and robustness checks were conducted. Results: Following DRG implementation, enteral nutrition costs showed a significant immediate increase (β₂ = 395.703, p = 0.032) followed by a significant downward slope change (β₃ = −7.778, p = 0.032). Total hospitalization costs demonstrated a significant immediate rise (β₂ = 15,959.403, p = 0.019) and subsequent decline (β₃ = −632.069, p < 0.001). Parenteral nutrition costs exhibited a significant immediate reduction (β₂ = −2917.276, p = 0.001) without sustained trend changes. Surgical fees showed a significant downward baseline trend (β₁ = −39.951, p < 0.001) and a significant upward slope change (β₃ = 68.107, p < 0.001). Subgroup analyses revealed that policy effects were concentrated among patients with Urban Employee Basic Medical Insurance, with no significant effects observed for those with Urban and Rural Resident Basic Medical Insurance. Robustness checks confirmed the main findings. Conclusions: DRG payment reform significantly reshaped nutritional therapy and hospitalization expenditure patterns among gastric cancer surgery patients, with effects concentrated in the employee insurance population. The observed temporal pattern, characterized by an initial change followed by a gradual trend shift, suggests the need for continuous policy monitoring, insurance-tailored strategies, and refinement of nutritional support practices within DRG frameworks. Full article

Background: Hospital-acquired multidrug-resistant organism (HA-MDRO) infections remain a major patient-safety threat linked to antimicrobial exposure, but long-term hospital-level evidence on whether integrated stewardship can reduce HA-MDRO burden remains limited. Methods: We conducted a quasi-experimental interrupted time-series study at a large multi-campus tertiary teaching hospital in China. A hospital-wide integrated intervention combining diagnostic stewardship and antimicrobial prescribing stewardship was implemented on 1 November 2021. Monthly aggregated hospital data from July 2018 to December 2024, including 2,145,489 hospitalizations, were analyzed. The primary outcome was HA-MDRO infection incidence density per 1000 patient-days. Results: HA-MDRO incidence density decreased immediately at the start of the COVID period (IRR = 0.246; p < 0.001) and then increased over time (IRR per month = 1.074; p < 0.001). After intervention implementation, the post-intervention trend declined significantly relative to the COVID-period trajectory (IRR per month = 0.938; p < 0.001). Microbiological testing increased immediately and continued to rise (OR = 1.381 and 1.016 per month, respectively), whereas restricted antibiotic use declined after implementation (OR = 0.979 per month; all p < 0.05). The control outcome showed no consistent post-intervention change. Counterfactual analysis estimated that 15,274 HA-MDRO cases were averted over follow-up. Conclusions: A hospital-wide integrated stewardship intervention was associated with reversal of the increasing HA-MDRO trajectory observed during the COVID period, together with improved microbiological testing and reduced restricted antibiotic use. These findings support the value of integrating diagnostic and prescribing stewardship in high-volume tertiary hospital settings. Full article

Computer-aided design (CAD) courses require students to develop both procedural skills and higher-order modeling competencies. This 10-year repeated cross-sectional study (N = 1952 students, 2013–2023) examined how replacing mandatory graded homework and the structured practice and feedback mechanisms it provided with optional short instructional videos affected performance. Using descriptive statistics, one-way ANOVA, interrupted time-series models, and student-level regression with clustered standard errors, we analyzed outcomes across pre-intervention (homework), post-intervention (video), and COVID remote-instruction periods. Results show that although homework and video instruction produced equivalent performance on basic modeling tasks (PE1), the homework period was associated with significantly higher performance on complex modeling tasks (PE2) and modestly higher final grades. The video-based period was associated with elevated failure rates, particularly for complex exams, whereas COVID period introduced temporary grade inflation that masked these effects. Findings indicate that while instructional videos effectively support basic procedural learning, structured homework with feedback remains essential for developing advanced modeling competencies. The results highlight the importance of aligning self-learning methods with task complexity and suggest that a combined approach may best support student success in CAD education. Full article

Background: A non-penal bicycle helmet mandate was implemented in the Republic of Korea on 28 September 2018, yet post-implementation epidemiologic evidence remains limited. This study evaluated changes in helmet wearing and injury outcomes before and after the mandate and identified factors associated with helmet non-use. Methods: We conducted a retrospective observational study using Korea Trauma Data Bank records from January 2017 to December 2022. After exclusions, 7653 bicycle-injured patients were identified, and 1:1 optimal propensity score matching (caliper 0.10) produced 4798 patients (2399 pairs). Outcomes included helmet use, physiological status (AVPU scale and Revised Trauma Score), Injury Severity Score (ISS), Abbreviated Injury Scale by body region, and mortality. Monthly helmet use trends were analyzed using a regression tree to detect data-driven breakpoints and segmented logistic regression at the legal implementation point (22 months) and the regression-tree-identified split (19.5 months). Multivariable logistic regression identified factors independently associated with helmet non-use. Results: Helmet use increased modestly from 17.4% pre-mandate to 21.9% post-mandate (p < 0.001). Interrupted time-series analyses showed no immediate level or slope change at either breakpoint, suggesting gradual uptake. ISS values were higher post-mandate, with ISS > 15 increasing from 21.5% to 24.4% (p = 0.02). Total mortality rose from 3.9% to 5.3% (p = 0.02). Helmet non-use was independently associated with age 80–89 years, female sex, non-Korean nationality, and residence in Jeollabuk-do. Conclusions: The mandate was associated with a modest increase in helmet wearing without an abrupt behavioral shift. These findings suggest that legislation without enforcement may have limited impact as a stand-alone measure and should be complemented by targeted education, visitor-focused communication, and region-specific safety measures. Full article

Introduction: Influenza has a major impact on public health. The best way to prevent it is through vaccination. In Catalonia, influenza vaccination has been recommended for children aged 6 to 59 months since the 2023–24 season. Objective: To assess the association between the implementation of this vaccination program and changes in influenza diagnoses in primary care and influenza-related hospitalizations in all age groups. Materials and Methods: Quasi-experimental study with interrupted time series (ITS) analysis. All influenza diagnoses made in primary care (PC) and all influenza-related hospitalizations in the Central Catalonia health region between October 2018 and August 2025 were included. The monthly aggregated cases were analyzed using segmented negative binomial regression models that accounted for temporal trends, the onset of COVID-19, and the introduction of systematic pediatric influenza vaccination. Results: A total of 6804 influenza diagnoses made in PC and 3252 hospitalizations for influenza were analyzed. A statistically significant decrease was observed in the percentage of influenza diagnoses in PC in the 2–4 (13.5% vs. 10.6%) and 5–14 (26.1% vs. 16.3%) age groups. In the ITS analysis conducted in primary care (PC) settings, the vaccination period was significantly associated with a 13% reduction in expected influenza cases among individuals aged 15–64 years (RR 0.87 [0.78; 0.99]). After sensitivity analysis, these results were no longer statistically significant. The ITS analysis in the hospital setting has not shown a significant reduction in expected influenza cases or in expected admissions. Conclusions: Systematic influenza vaccination in children aged 6 to 59 months has not been shown to be associated with a reduction in influenza cases in primary care or hospitals settings during the early stages of implementation of the new vaccination program. Full article

Background: Chronic Obstructive Pulmonary Disease (COPD) poses a substantial public health challenge in China owing to its increasing prevalence and substantial economic burden. In response, the diagnosis–intervention packet (DIP) payment reform was implemented to control healthcare costs and enhance service efficiency. Methods: To evaluate the effect of the DIP reform on medical costs, hospitalization days, and individual out-of-pocket payments for COPD inpatients in M City, a pilot city in central China, we conducted an interrupted time series (ITS) analysis using monthly reimbursement records from January 2020 to December 2023. The study included 84,410 hospitalized patients from a city-wide database of 3,241,233 inpatient records with COPD who met the inclusion criteria. The analysis focused on the total healthcare costs, length of stay, and individual out-of-pocket costs. Results: The DIP reform resulted in a 3.7% reduction (95% CI: 0.9% to 6.5%) in the total hospitalization costs in the first month post-reform, with a sustained monthly decline of 0.8% (95% CI: 0.5% to 1.1%). The length of stay decreased from 9.53 (95% CI: 9.31 to 9.75) to 8.74 days (95% CI: 8.62 to 8.86). Conversely, the proportion of out-of-pocket payments relative to total costs increased. Conclusions: While the DIP reform effectively reduced hospitalization costs and days, it led to an increase in individual out-of-pocket payments. Future research should focus on optimizing payment rules, enhancing the supervision of medical services, and refining health insurance policies to achieve the reform’s objectives better and alleviate the financial burden on patients. Full article

Background: Organised colorectal cancer (CRC) screening programmes have been widely implemented across Europe; however, robust population-level evaluations of their real-world effectiveness, particularly for programmes based exclusively on faecal immunochemical testing (FIT), remain limited. The Galician CRC screening programme was progressively implemented between 2013 and 2019. Methods: We conducted a population-based ecological time-series study using data from the Galician Tumour Registry (ICD-10 C18–C21) for 2015–2023. Age-standardised mortality (ASMR) and incidence (ASIR) rates were analysed. They were calculated using the direct standardisation method, applying age-specific rates to the 2013 European Standard Population (ESP2013). Structural changes associated with programme implementation were evaluated using interrupted time-series (ITS) models, estimating annual percent change (APC) before and after implementation and the net change in slope (ΔAPC). Absolute and relative changes in ASMR and ASIR were calculated by comparing 2015–2017 and 2019–2023. Analyses were performed for the overall population and for individuals aged 50–69 years. Results: Between 2015 and 2023, overall CRC mortality declined significantly (APC −3.00%; 95% CI −3.37 to −2.63). ITS analysis demonstrated a marked modification of mortality trajectories following programme implementation. Mortality shifted from an increasing pre-implementation slope (APC +13.70%; 95% CI 10.12, 17.39) to a significant annual decline post-implementation (APC −3.62%; 95% CI −4.47, −2.76), yielding a ΔAPC of −17.32. In individuals aged 50–69 years, the structural change was more pronounced (ΔAPC −19.88), with post-implementation mortality decreasing by −8.08% annually (95% CI −10.43, −5.66). Incidence showed a comparable structural modification. Overall APC changed from +15.26% (95% CI 5.48, 25.95) before implementation to −2.48% (95% CI −5.29, 0.41) afterwards (ΔAPC −17.74). In the screening-eligible population, APC shifted from +21.32% (95% CI 4.60, 40.71) to −3.74% (95% CI −7.62, 0.30), corresponding to a ΔAPC of −25.06. Descriptively, ASMR declined from 41.92 to 35.91 per 100,000 (−14.33%), and ASIR from 98.37 to 85.16 per 100,000 (−13.42%) between 2015 and 2017 and between 2019 and 2023. Relative reductions were larger in individuals aged 50–69 years and were more pronounced for colon cancer than for rectal cancer. Conclusions: Implementation of an organised FIT-based screening programme was associated with a structural change in CRC mortality and incidence trends, particularly among individuals aged 50–69 years. Full article

This study examines how the COVID-19 period is associated with changes in digital payment usage, rather than simply whether adoption increased, in Saudi Arabia using monthly data from January 2019 to July 2025. An Interrupted Time Series (ITS) approach is employed to assess both the immediate and long-term effects associated with the pandemic on a digital payment Intensity (DPI) index constructed from national point-of-sale (POS) transaction data to capture aggregate electronic payment usage relative to cash withdrawals. The results show that the onset of the COVID-19 period is associated with a sharp and statistically significant one-time increase of approximately 7 to 13% in digital payment intensity, followed by stabilization at a higher level rather than sustained acceleration. This finding challenges the common view that digital payment adoption followed a continuously accelerating path, instead showing that the pandemic induced a discrete upward shift without altering the underlying growth trajectory. The estimated effects remain robust across multiple model specifications, including dynamic ITS models, seasonal adjustments, alternative break dates, exclusion of overlapping usage variables, and parsimonious infrastructure-only models. Inflation and ATM usage consistently show negative associations with digital payment intensity, highlighting the role of macroeconomic stability and cash substitution in shaping payment behavior. The study therefore offers a more nuanced interpretation of post-pandemic digital adoption by showing that the main effect of COVID-19 was a one-time level shift rather than a lasting change in growth dynamics. Focusing on aggregate usage intensity rather than access or account ownership, it provides a system-level perspective on digital payment behavior in response to large-scale shocks. Overall, the evidence suggests that the pandemic period coincided with a discrete upward realignment in digital payment usage in Saudi Arabia, reflecting the interaction between crisis-driven behavioral change and strong pre-existing digital infrastructure under Vision 2030. Full article

Invasive candidiasis is a severe opportunistic infection whose incidence may be influenced by major disruptive events. The COVID-19 pandemic substantially altered hospital dynamics in Colombia. This study aimed to evaluate temporal trends, seasonality, and potential changes in the incidence of invasive candidiasis between 2019 and 2024. We conducted an observational time-series study using confirmed cases of invasive candidiasis from medium- and high-complexity hospitals in three major Colombian cities. Cases were aggregated quarterly. An interrupted time-series (ITS) analysis was performed. A total of 1294 cases were analyzed. An increasing trend was observed until mid-2022, followed by a decline during 2023. Seasonal decomposition revealed persistent seasonality with recurrent peaks in the second and fourth quarters. The ITS analysis did not demonstrate statistically significant changes in level or slope after the interruption (p > 0.05), although clinically relevant fluctuations were observed. No significant differences in temporal trends were identified across Candida species. Invasive candidiasis in Colombia exhibited a complex temporal evolution during and after the COVID-19 pandemic characterized by sustained seasonality and an increase followed by a decline. Although the ITS analysis did not identify statistically significant post-pandemic changes, the findings support the use of time-series models as valuable tools for epidemiological surveillance and trend monitoring. Full article

Background/Objectives: The clinical utility of summarizing long-term C-reactive protein (CRP) trends with a single mean remains unclear. We systematically characterized annual changes in CRP test volume and CRP level distributions using large-scale laboratory data collected at Dankook University Hospital (2008–2023) across the coronavirus 2019 pandemic period. Methods: Overall, 1,845,258 CRP values were analyzed; annual arithmetic, harmonic, and geometric means were calculated; long-term trends were assessed using weighted least squares (WLS) regression weighted by annual test volume; and temporal changes around the pandemic period were examined using a WLS-based interrupted time-series (ITS) segmented model with a prespecified 2020 break. Results: The annual test volume rose from 2008 to 2013 and 2019, dropped in 2020, increased in 2022, and declined in 2023. The arithmetic mean showed no long-term trend, whereas the harmonic and geometric means declined. ITS models exhibited no statistically significant immediate level-change term in 2020; however, post-2020 slope changes indicated a decline in the arithmetic mean and attenuation of the prior decline in the harmonic mean. As only four annual observations were available after 2020, these post-2020 trend estimates should be interpreted cautiously. Conclusions: Within this single-center tertiary-care dataset, different CRP summary measures showed different long-term patterns and post-2020 trend changes, without evidence of an abrupt shift in 2020, suggesting stratum-specific shifts that may be invisible to arithmetic mean-based surveillance. These findings are best interpreted as institution-specific and hypothesis-generating, and broader interpretive or operational implications require validation in multicenter settings with differing case-mix and care structures. Full article

Background/Objectives: Avoidable mortality—deaths before age 75 from preventable or treatable causes—is a key indicator of health system performance. In Mexico, nearly two-thirds of municipalities lack hospital beds, yet no study has examined the municipal-level association between healthcare infrastructure and avoidable mortality. This study assessed whether healthcare desert status is independently associated with avoidable mortality after adjusting for social deprivation. Methods: This ecological study analyzed 1891 Mexican municipalities (population ≥ 1000) over 2015–2024. Avoidable deaths were classified per OECD/Eurostat criteria (January 2022 revision). Healthcare desert status was defined by municipal hospital bed availability from 2019 facility data. Negative binomial mixed-effects regression estimated incidence-rate ratios (IRRs) adjusted for social deprivation, age structure, and state-level heterogeneity. Interrupted time-series analysis quantified pandemic disruption. Results: Of 4,960,244 deaths under 75 years, 81.2% were avoidable. Of 1891 municipalities, 1187 (62.8%) lacked hospital beds (healthcare deserts). Desert municipalities had 42.5% higher avoidable mortality (IRR = 1.425; 95% CI: 1.370–1.482; pre-pandemic 2015–2019), which attenuated to 1.353 after age-structure adjustment. Each standard-deviation increase in hospital beds (1 SD ≈ 2.2 beds per 1000) was associated with 7.9% lower mortality (IRR = 0.921). Avoidable mortality exhibited strong spatial clustering (Moran’s I = 0.382) in southern Mexico. By 2024, the desert–adequate mortality gap had widened by approximately five fold (from $\sim$12 to 69 per 100,000 population). Conclusions: Healthcare deserts are independently associated with substantially higher avoidable mortality in Mexico. The COVID-19 pandemic durably amplified pre-existing disparities associated with healthcare infrastructure deficits. Targeted hospital expansion in underserved municipalities is urgently needed, alongside investment in social determinants of health. Full article

To map and describe the scientific evidence on germicidal ultraviolet C (UV-C) light for hospital surface disinfection, this scoping review examined device types, reported operational parameters, microbiological and clinical outcomes, and implementation aspects. Primary studies conducted in hospital settings and evaluating UV-C or ultraviolet germicidal irradiation on environmental surfaces were searched in four databases without date restrictions. Data were synthesized descriptively in tables and narrative form following JBI and PRISMA-ScR guidance. Eleven studies (2007–2025) met the inclusion criteria. Reported microbial reductions ranged from 1 to ≥5 log₁₀. Higher and more consistent reductions were predominantly observed under laboratory or controlled experimental conditions, whereas reductions in real-world hospital surface sampling were more variable and influenced by pathogen type, surface material, room geometry, and shadowing. Integration of UV-C with manual cleaning and multi-position irradiation cycles was associated with greater effectiveness. Reporting of key radiometric parameters (dose, exposure time, and distance) was frequently incomplete, limiting reproducibility and cross-study comparability. Clinical findings were heterogeneous: some interrupted time-series analyses suggested reductions in healthcare-associated infections, although effects were not uniform across microorganisms. Implementation reports described room-level cycle times compatible with turnover, variable staffing requirements, and limited economic evaluation. Overall, UV-C appears to be a promising adjunct to standard cleaning practices in hospital environments. However, standardized radiometric reporting, multicenter studies, and robust clinical and economic evaluations are necessary to support safe, reproducible, and sustainable large-scale implementation. Full article

The COVID-19 pandemic constitutes one of the most significant exogenous shocks to global financial markets in recent history, raising questions about the robustness of market efficiency under extreme uncertainty. This study examines whether the pandemic affected the weak-form efficiency of the Bitcoin market or merely heightened volatility without introducing return predictability. Using daily Bitcoin log returns from January 2013 to February 2026, the analysis first evaluates weak-form market efficiency through the Variance Ratio (VR) test. The VR statistics remain close to unity across multiple holding horizons, and the null hypothesis of a random walk cannot be rejected, indicating that daily Bitcoin returns are consistent with weak-form efficiency. Building on this baseline, an Interrupted Time Series (ITS) framework is employed to assess whether the onset of the COVID-19 pandemic in March 2020 led to structural changes in Bitcoin return dynamics. The ITS results reveal no statistically significant changes in level or slope following the outbreak. To further account for autoregressive and moving-average dynamics while explicitly modelling the intervention, an ARIMAX (0, 0, 7) model with COVID-19 intervention variables is estimated. Both the pandemic dummy and its interaction term are statistically insignificant, indicating no material change in the return-generating process after controlling for serial dependence. The moving-average structure indicates that shocks dissipate over approximately one trading week, consistent with weekly trading cycles and liquidity patterns in cryptocurrency markets rather than persistent return predictability. Diagnostic checks, including the Ljung–Box and Shapiro–Wilk tests, confirm the absence of residual autocorrelation and support the model’s white-noise properties. Although volatility increased during the pandemic period, daily Bitcoin returns continued to align with weak-form market efficiency. The evidence, therefore, suggests that COVID-19 served as a stressor without generating persistent inefficiencies. These findings reinforce the distinction between volatility and predictability, demonstrating that heightened uncertainty does not necessarily undermine informational efficiency. Full article