Prediction model for prolonged length of stay in patients with community-acquired pneumonia based on Japanese administrative data

BACKGROUND

The length of hospital stay in community-acquired pneumonia patients is closely associated with medical costs, the burden of which is increasing in aging societies. Herein, we developed and validated models for predicting prolonged length of stay in community-acquired pneumonia patients to support efficient care in these patients.

METHODS

We obtained data of 32,916 patients hospitalized for pneumonia who were discharged between 2012 and 2013 from 304 acute care hospitals in Japan. Logistic regression models were developed with prolonged length of stay as the outcome and patient characteristics as predictors. The models were internally validated using bootstrapping and externally validated using pneumonia patients discharged in 2014.

RESULTS

The median length of stay was 11 (interquartile range, 8-17) days. The following were significant predictors of prolonged length of stay (odds ratio >1.6): age ≥75 years, Barthel index score ≤6, fraction of inspired oxygen ≥35%, Japan Coma Scale score of 100-300, anemia, muscle wasting and atrophy, bedsores, dysphasia, and methicillin-resistant Staphylococcus aureus infection. Our validation models had a c-statistic of 0.78 (95% confidence interval, 0.77-0.79) and a calibration slope of 0.98.

CONCLUSIONS

Our prediction models may help policymakers in developing strategies for the optimal management of community-acquired pneumonia patients with a focus on patients at a high risk of prolonged length of stay.

Preferences in end of life care substantially differ between the Netherlands and Japan: Results from a cross-sectional survey study

Strategies to increase appropriateness of EoL care, such as shared decision making (SDM), and advance care planning (ACP) are internationally embraced, especially since the COVID-19 pandemic. However, individuals preferences regarding EoL care may differ internationally. Current literature lacks insight in how preferences in EoL care differ between countries and continents. This study's aim is to compare Dutch and Japanese general publics attitudes and preferences toward EoL care, and EoL decisions. Methods: a cross-sectional survey design was chosen. The survey was held among samples of the Dutch and Japanese general public, using a Nationwide social research panel of 220.000 registrants in the Netherlands and 1.200.000 in Japan. A quota sampling was done (age, gender, and living area). N = 1.040 in each country.More Japanese than Dutch citizens tend to avoid thinking in advance about future situations of dependence (26.0% vs 9.4%; P = .000); say they would feel themselves a burden for relatives if they would become dependent in their last phase of life (79.3% vs 47.8%; P = .000); and choose the hospital as their preferred place of death (19.4% vs 3.6% P = .000). More Dutch than Japanese people say they would be happy with a proactive approach of their doctor regarding EoL issues (78.0% vs 65.1% JPN; P = .000).Preferences in EoL care substantially differ between the Netherlands and Japan. These differences should be taken into account a) when interpreting geographical variation in EoL care, and b) if strategies such as SDM or ACP - are considered. Such strategies will fail if an international "one size fits all" approach would be followed.

Transformational improvement in quality care and health systems: the next decade

BACKGROUND

Healthcare is amongst the most complex of human systems. Coordinating activities and integrating newer with older ways of treating patients while delivering high-quality, safe care, is challenging. Three landmark reports in 2018 led by (1) the Lancet Global Health Commission, (2) a coalition of the World Health Organization, the Organisation for Economic Co-operation and Development and the World Bank, and (3) the National Academies of Sciences, Engineering and Medicine of the United States propose that health systems need to tackle care quality, create less harm and provide universal health coverage in all nations, but especially low- and middle-income countries. The objective of this study is to review these reports with the aim of advancing the discussion beyond a conceptual diagnosis of quality gaps into identification of practical opportunities for transforming health systems by 2030.

MAIN BODY

We analysed the reports via text-mining techniques and content analyses to derive their key themes and concepts. Initiatives to make progress include better measurement, using the capacities of information and communications technologies, taking a systems view of change, supporting systems to be constantly improving, creating learning health systems and undergirding progress with effective research and evaluation. Our analysis suggests that the world needs to move from 2018, the year of reports, to the 2020s, the decade of action. We propose three initiatives to support this move: first, developing a blueprint for change, modifiable to each country's circumstances, to give effect to the reports' recommendations; second, to make tangible steps to reduce inequities within and across health systems, including redistributing resources to areas of greatest need; and third, learning from what goes right to complement current efforts focused on reducing things going wrong. We provide examples of targeted funding which would have major benefits, reduce inequalities, promote universality and be better at learning from successes as well as failures.

CONCLUSION

The reports contain many recommendations, but lack an integrated, implementable, 10-year action plan for the next decade to give effect to their aims to improve care to the most vulnerable, save lives by providing high-quality healthcare and shift to measuring and ensuring better systems- and patient-level outcomes. This article signals what needs to be done to achieve these aims.

Economic impact of antimicrobial-resistant bacteria outbreaks on Japanese hospitals

BACKGROUND

Economic evaluation from the perspective of hospitals is important for the optimization of resources for infection control measures.

METHODS

We considered outbreaks that occurred from 2006 to 2016 in Japan. Cost identification analyses were conducted using data from 23 outbreaks by antimicrobial-resistant bacteria. Linear and multivariable regression analyses were conducted to explore the association between potential factors and main outcomes. The potential factors included duration of the outbreaks, duration of bed blocking, timely public announcement, delay of external consultation, and number of patients at the time of external consultation.

RESULTS

The largest productivity loss was 4.62 million USD. The maximum total cost for containment was 678,000 USD. After considering the overall interactions, timely public announcement was significantly associated with productivity loss (adjusted estimate of coefficient: 1.24 USD, 95% confidence interval [CI] 179,000 to 2.31 million USD, P = .02), and the number of patients at external consultation was significantly associated with containment costs (3 430 USD, 630 to 6 240 USD, P = .02).

CONCLUSIONS

The costs of healthcare-associated infection outbreaks of antimicrobial-resistant bacteria can be significant. The productivity loss was much greater than the containment costs. Therefore, hospitals should meet the costs for prevention of these outbreaks.

A qualitative study on knowledge, perception, and practice related to non-communicable diseases in relation to happiness among rural and urban residents in Bhutan

PURPOSE

Bhutan, known as a country of happiness, has experienced rapid social changes and the increasing burden of non-communicable diseases (NCDs) that can impact health and happiness. To inform future NCD prevention programs in Bhutan, this study explores knowledge, perception, and the practices of Bhutanese related to NCDs in the context of the philosophy of happiness.

METHODOLOGY

Research was conducted in rural and urban communities of Bhutan in 2017 among 79 inhabitants of both genders, aged ≥18. Participants were recruited through purposive sampling with the data collected by in-depth interviews, participatory observation, and anthropometric measurements. Data were analyzed by thematic analysis.

RESULTS/DISCUSSION

Across participants, health was considered as an important element of "happiness". However, lifestyle-related NCD risk factors prevailed due to the lack of effective education programs on NCDs and thus the lack of practical knowledge for NCD prevention across society. We further found that the value of happiness "finding happiness in any situation is virtue" was universal as well as other traditional values and customs, shaping people's health behaviors. From these observations, it is recommended that more practical NCD education/prevention programs should be urgently introduced in Bhutan that involve multiple generations, religion authorities, educational settings, and medical services.

ORIGINALITY

This is the first comprehensive qualitative study on the NCD-related lifestyle risks among Bhutanese concerning the concept of happiness.

Factors associated with high-dose antipsychotic prescriptions in outpatients with schizophrenia: An analysis of claims data from a Japanese prefecture

Background

Antipsychotics are commonly prescribed in high doses in combination with multiple psychotropic drugs. This study focused on the high‐dose antipsychotic prescriptions in patients with schizophrenia, while aiming to identify their associations with patients’ characteristics and concurrent psychotropic prescriptions.

Methods

This cross‐sectional study used claims data from a prefecture in Japan, between October 2014 and March 2015, to investigate antipsychotic prescriptions in adult outpatients with schizophrenia. The objective variable was the presence/absence of a high‐dose prescription. The explanatory variables included sex, age (category), presence of comorbid conditions, and the use of psychiatrist's therapy.

Results

After exclusion, a total of 13 471 patients with schizophrenia were analyzed. The frequency of high‐dose prescriptions was higher in men, with chlorpromazine‐equivalent values highest in the age ranges of 45‐54 and 35‐44 years for men and women, respectively. Patients aged below 65 years with cerebrovascular diseases showed a decrease in high‐dose prescriptions. There was a high frequency of polypharmacy psychotropic drug use in combination with a high‐dose antipsychotic prescription in patients aged below 65 years.

Conclusion

High‐dose antipsychotics are often used in combination with several psychotropic agents in patients with schizophrenia. Our findings emphasize the need to evaluate the prescribing behavior of physicians to avoid high‐dose antipsychotic prescriptions for improved patient care.

This study aimed to identify the association between concurrent psychotropic prescriptions and high‐dose antipsychotic prescriptions in patients with schizophrenia in Japan. In this study, high‐dose antipsychotics were often used in combination with several psychotropic agents in patients with schizophrenia. Our findings emphasize the need to evaluate the prescribing behavior of physicians to avoid high‐dose antipsychotic prescriptions for improved patient care.

Effectiveness of combined antithrombin and thrombomodulin therapy on in-hospital mortality in mechanically ventilated septic patients with disseminated intravascular coagulation

Septic patients can develop disseminated intravascular coagulation (DIC), which is characterized by systemic blood coagulation and an increased risk of life-threatening haemorrhage. Although antithrombin (AT) and thrombomodulin (TM) combination anticoagulant therapy is frequently used to treat septic patients with DIC in Japan, its effectiveness in improving patient outcomes remains unclear. In this large-scale multicentre retrospective study of adult septic patients with DIC treated at Japanese hospitals between February 2010 and March 2016, we compared in-hospital mortality between AT monotherapy and AT + TM combination therapy. We performed logistic regression analysis with in-hospital mortality as the dependent variable and anticoagulant therapy as the main independent variable of interest. Covariates included patient demographics, disease severity, and body surface area. The AT group and AT + TM group comprised 1,017 patients from 352 hospitals and 1,205 patients from 349 hospitals, respectively. AT + TM combination therapy was not significantly associated with lower mortality when compared with AT monotherapy (odds ratio: 0.97, 95% confidence interval: 0.78-1.21; P = 0.81). AT + TM combination therapy was also not superior to AT monotherapy in reducing mechanical ventilation or hospitalization durations. Despite its widespread use for treating sepsis with DIC, AT + TM combination therapy is not more effective in improving prognoses than the simpler AT monotherapy.

Association between clinic physician workforce and avoidable readmission: a retrospective database research

BACKGROUND

To reduce hospitalization costs, it is necessary to prevent avoidable hospitalization as well as avoidable readmission. This study aimed to examine the relationship between clinic physician workforce and unplanned readmission for ambulatory care sensitive conditions (ACSCs).

METHODS

The present study was a retrospective database research using nationwide administrative claims database of acute care hospitals in Japan. We identified patients aged ≥65 years who were admitted with ACSCs from home and discharged to home between April 2014 and December 2014 (n = 127,209). The primary outcome was unplanned readmission for ACSCs within 30 or 90 days of hospital discharge. A hierarchical logistic regression model was developed with patients at the first level and regions (secondary medical service areas) at the second level.

RESULTS

The 30-day and 90-day ACSC-related readmission rates were 3.7 and 4.6%, respectively. The high full-time equivalents (FTEs) of clinic physicians per 100,000 population were significantly associated with decreased odds ratios for 30-day and 90-day ACSC-related readmissions. This association did not change even when sensitivity analyses was conducted.

CONCLUSIONS

Among patients who had history of admission for ACSCs, greater clinic physician workforce prevented the incidence of readmission because of ACSCs. Regional medical plans to prevent avoidable readmissions should incorporate policy interventions that focus on the clinic physician workforce.

Epidemiology and volume-outcome relationship of extracorporeal membrane oxygenation for respiratory failure in Japan: A retrospective observational study using a national administrative database

Aim

To describe the epidemiology of patients on extracorporeal membrane oxygenation (ECMO) and investigate the possible association between outcomes for respiratory ECMO patients and hospital volume of ECMO treatment for any indications.

Methods

Using data from the Diagnosis Procedure Combination database, a nationwide Japanese inpatient database, between 1 July 2010 and 31 March 2018, we identified inpatients aged ≥18 years who underwent ECMO. Institutional case volume was defined as the mean annual number of ECMO cases; eligible patients were categorized into institutional case volume tertile groups. The primary outcome was in-hospital mortality. For ECMO patients with respiratory failure, the association between institutional case volume group and in-hospital mortality rate was analyzed using a multilevel logistic regression model including multiple imputation.

Results

Extracorporeal membrane oxygenation was carried out on 25,384 patients during the study period; of those, 1,227 cases were for respiratory failure. Respiratory cases were categorized into low- (<8 cases/year), medium- (8-16 cases/year), and high-volume groups (≥17 cases/year). The overall in-hospital mortality rate for respiratory ECMO was 62.5% in low-, 54.7% in medium-, and 50.4% in high-volume institutions. With reference to low-volume institutions, the adjusted odds ratios (95% confidence interval) of the medium- and high-volume institutions for in-hospital mortality were 0.72 (0.50-1.04; P = 0.082) and 0.65 (0.45-0.95; P = 0.024), respectively.

Conclusions

The present study showed that accumulating the experience of using ECMO for any indications could positively affect the outcome of ECMO treatment for respiratory failure, which suggests the effectiveness of consolidating ECMO cases in high-volume centers in Japan.

Impact of the Hospitalist System in Japan on the Quality of Care and Healthcare Economics

Objective The hospitalist system is considered successful with respect to the quality of care and cost effectiveness in the United States. Studies have consistently demonstrated an improved clinical efficiency with this system. In Japan, however, the efficacy of the hospitalist system has not yet been examined. As a "super-aged society", Japan has a high number of elderly patients with multiple comorbidities who may theoretically receive better care by the hospitalist system than by the conventional system. This study investigates the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population. Methods We analyzed 274 patients ≥65 years of age in whom the most resource-consuming diagnosis at admission was aspiration pneumonia over a 1-year period. We categorized patients as those managed by hospitalists and those managed by various departments (control group) and compared the groups. Propensity score matching was used to minimize selection bias. Results For matched pairs, the length of hospital stay in the hospitalist group was shorter than that in the control group. Care by the hospitalist system was associated with significantly lower hospital costs. The quality of care (rate of switching from intravenous to oral antibiotics, duration of antibiotics therapy, number of chest X-rays and blood tests during hospitalization) was also considered to be favorably impacted by the hospitalist system. There was no statistically significant difference in the mortality rate or readmission rate between the groups. Conclusion This study showed that the hospitalist system had a favorable impact on the quality of care and cost effectiveness, suggesting the potential utility of its implementation in the Japanese medical system.

Public needs for information disclosure on healthcare performance: Different determinants between Japan and the Netherlands

The accumulated healthcare performance data related to unwarranted practice variations are not necessarily disseminated to patients and citizens. To clarify the needs for public disclosure, we explored Japanese and Dutch citizens' preferences and values towards information disclosure and healthcare disparity.Online opt-in survey was conducted and we asked citizens their preference to know about the healthcare performance indicators of regions and hospitals, and their attitudes towards healthcare equity. After a descriptive statistical analysis, Chi-squared automatic interaction detection tree analysis was performed to explore the socio-demographic determinants which were associated with positive value for information disclosure and healthcare equity. Then, we compared the combination of attributes of the highest and the lowest subgroups of each country and compared within and between countries. Last, logistic regression analysis was performed to further evaluate the impact of each determinant.Significant differences were observed between the 2 countries (Japan [JPN] 1038; Netherlands [NL] 1040). The crucial attributes identified were age, sex, educational background, and living area (JPN), along with age and sex (NL). Japanese comprised multiple subgroups with heterogeneous values, showed relatively low interest in knowing the information, and seemed to accept healthcare inequality, especially among urban males aged 20 to 59 years. Contrarily, Dutch people mostly showed high interest in both items. Female and older respondents valued information disclosure highly across countries.To share healthcare performance knowledge and empowering the public, historical, cultural, and socio-demographic context including health literacy of citizens' subgroups should be considered in making comprehensive public reports.

Analysis of concordance with antiemetic guidelines in pediatric, adolescent, and young adult patients with cancer using a large-scale administrative database

Object

The appropriate use of antiemetics is important for the prevention of chemotherapy‐induced nausea and vomiting (CINV); however, little is known about the rate of concordance with antiemetic guidelines for CINV in the field of pediatric, adolescent, and young adult.

Methods

Using the Diagnosis Procedure Combination system in Japan, we identified patients <30 years of age who were diagnosed with cancer between July 2010 and March 2016. We have assessed concordance with the ASCO antiemetic guidelines for each emetic risk category of chemotherapeutic drugs. Furthermore, we have assessed the risk factors of discordance with the antiemetic guidelines using a logistic regression.

Results

In total, 21 106 patients who underwent chemotherapy were included. The rates of concordance with the guidelines in each emetic risk category of chemotherapeutic drugs were 51.1% in high risk, ≥18 years of age; 21.5% in high risk, <18 years of age; 32.1% in moderate risk; 52.0% in low risk; and 51.6% in minimal risk. The main reason for the discordance was underuse of antiemetics, especially steroids. The factors for discordance were younger age, use of moderate and high emetic risk chemotherapeutic drugs, hematological malignancy, and brain tumor.

Conclusion

There is substantial scope to improve the antiemetic practice and reduce the risk of discordance with the antiemetic guidelines in pediatric, adolescent, and young adult patients. The risk factors are different from those in adults. Further investigations to evaluate the causes of discordance are warranted.

Classification tree model of the personal economic burden of dementia care by related factors of both people with dementia and caregivers in Japan: a cross-sectional online survey

OBJECTIVE

The purpose of this study was to clarify the microlevel determinants of the economic burden of dementia care at home in Japanese community settings by classifying them into subgroups of factors related to people with dementia and their caregivers.

DESIGN

A cross-sectional online survey.

PARTICIPANTS

4313 panels of Japanese research company who fulfilled the following criteria: (1) aged 30 years or older, (2) non-professional caregiver of someone with dementia, (3) caring for only one person with dementia and (4) having no conflicts of interest with advertising or marketing research entities.

PRIMARY OUTCOME MEASURES

Informal care costs and out-of-pocket payments for long-term care (LTC) services.

RESULTS

From 4313 respondents, only 1383 caregivers in community-settings were included in this analysis. We conducted a χ² automatic interaction detection analysis to identify the factors related to each cost (informal care costs and out-of-pocket payments for LTC services) divided into subcategories. In the resultant classifications, informal care cost was mainly related to caregivers' employment status. When caregivers acquired family care leave, informal care costs were the highest. On the other hand, out-of-pocket payments for LTC were related to care-need levels and family economic status. Activities of Daily Living and Instrumental Activities of Daily Living functions such as bathing, toileting and cleaning were related to all costs.

CONCLUSION

This study clarified the difference in dementia care costs between classified subgroups by considering the combination of the situations of both people with dementia and their caregivers. Informal care costs were related to caregivers' employment and cohabitation status rather to the situations of people with dementia. On the other hand, out-of-pocket payments for LTC services were related to care-need levels and family economic status. These classifications will be useful in understanding which situation represents a greater economic burden and helpful in improving the sustainability of the dementia care system in Japan.

A challenge to all. A primer on inter-country differences of high-need, high-cost patients

BACKGROUND

Across countries, a small group of patients accounts for the majority of health care spending. These patients are more likely than other patients to experience problems with quality and safety in their care, suggesting that efforts targeting efficiency and quality among this population might have significant payoffs for health systems. Better understanding of similarities and differences in patient characteristics and health care use in different countries may ultimately inform further efforts to improve care for HNHC patients in these health systems.

METHODS

We conducted a cross-sectional descriptive study using one year of patient-level data on high-cost patients in seven high-income OECD member countries. Countries were selected based on availability of detailed information (large enough samples of claims, administrative, and survey data of high-cost patients). We studied concentration of spending among high-cost patients, characteristics of high-cost patients, and per capita spending on high-cost patients.

FINDINGS

Cost-concentration of the top 5% of patients varied across countries, from 41% in Japan to 60% in Canada, driven primarily by variation in the top 1% of spenders. In general, high-cost patients were more likely to be female (57.7% on average), had a significant number of multi-morbidities (up to on average 10 major diagnostic categories (ICD chapters), and had a lower socioeconomic status. Characteristics of high-cost patients varied as well: median age ranged from 62 in the Netherlands to 75 in Germany and the difference in socioeconomic status is particularly stark in the US. Lastly, utilization, particularly for inpatient care, varied with an average number of inpatient days ranging from 6.6 nights (US) to 97.7 nights in Japan.

INTERPRETATION

In this descriptive study, there is substantial variation in the cost concentration, characteristics, and per capita spending on high-cost patient populations across high-income countries. Differences in the way that health systems are structured likely explains some of this variation, which suggests the potential of cross-system learning opportunities. Our findings highlight the need for further studies including comparable performance metrics and institutional analysis.

Does hospital information technology infrastructure promote the implementation of clinical practice guidelines? A multicentre observational study of Japanese hospitals

OBJECTIVES

It remains unclear whether insufficient information technology (IT) infrastructure in hospitals hinders implementation of clinical practice guidelines (CPGs) and affects healthcare quality. The objectives of this study were to describe the present state of IT infrastructure provided in acute care hospitals across Japan and to investigate its association with healthcare quality.

METHODS

A questionnaire survey of hospital administrators was conducted in 2015 to gather information on hospital-level policies and elements of IT infrastructure. The number of positive responses by each respondent to the survey items was tallied. Next, a composite quality indicator (QI) score of hospital adherence to CPGs for perioperative antibiotic prophylaxis was calculated using administrative claims data. Based on this QI score, we performed a chi-squared automatic interaction detection (CHAID) analysis to identify correlates of hospital healthcare quality. The independent variables included hospital size and teaching status in addition to hospital policies and elements of IT infrastructure.

RESULTS

Wide variations were observed in the availability of various IT infrastructure elements across hospitals, especially in local area network availability and access to paid evidence databases. The CHAID analysis showed that hospitals with a high level of access to paid databases (p<0.05) and internet (p<0.05) were strongly associated with increased care quality in larger or teaching hospitals.

CONCLUSIONS

Hospitals with superior IT infrastructure may provide higher-quality care. This allows clinicians to easily access the latest information on evidence-based medicine and facilitate the dissemination of CPGs. The systematic improvement of hospital IT infrastructure may promote CPG use and narrow the evidence-practice gaps.

Effects of preoperative oral management by dentists on postoperative outcomes following esophagectomy: Multilevel propensity score matching and weighting analyses using the Japanese inpatient database

The purpose of this study was to investigate the effects of preoperative oral management (POM) by dentists on the incidence of postoperative pulmonary complications (PPCs), length of hospital stay, medical costs, and days of antibiotics administration following both open and thoracoscopic esophagectomy.Dental plaque is an established risk factor for postoperative pneumonia, which could be reduced by POM. However, few clinical guidelines for cancer treatment, including those for esophageal cancer, recommend POM as routine perioperative care.We extracted data of esophagectomy cases from the Japanese Diagnosis Procedure Combination database. We subsequently conducted propensity score (PS) analyses for multilevel data, including matching, inverse probability of treatment weighting (IPTW), and standardized mortality ratio weighting (SMRW), to estimate the effect of POM by dentists on the outcomes of esophagectomy.We analyzed 3412 esophagectomy cases of which 812 were open, and 2600 were thoracoscopic surgery. In IPTW analysis to estimate the average treatment effect, the risk difference of postoperative aspiration pneumonia ranged from -2.49% to -2.02% between the POM and control groups of both open and thoracoscopic esophagectomy cases. IPTW analyses indicated that the total medical costs of thoracoscopic esophagectomy were reduced by 221,200 to 253,100 Japanese Yen (equivalent to about $2000-$2200). In PS matching and SMRW analyses to estimate average treatment effect on treated, there was no difference in outcomes between the POM and control groups.Our results suggested that in patients undergoing open or thoracoscopic esophagectomy, POM by dentists prevented the occurrence of postoperative aspiration pneumonia. It could also reduce the total medical costs of thoracoscopic esophagectomy. Thus, POM by dentists can be considered as a routine perioperative care for all patients undergoing esophagectomy, regardless of the expected risk for PPC.

Comparison of surgical and conservative treatment outcomes for type a aortic dissection in elderly patients

Background

In recent years, surgical outcomes have improved, and positive reports on surgery for type A aortic dissection (AAD) in the elderly are increasing. However, the difference between surgical and conservative treatments in the elderly remains unclear. Therefore, we conducted this study to determine whether surgery should be performed for Stanford (AAD) in elderly patients.

Methods

Data of patients aged 80 years or older who were hospitalized for AAD from April 2014 to March 2016 were extracted from the Japanese national inpatient database. Outcome measures were all-cause in-hospital death, stroke, acute kidney injury and tracheotomy, and composite adverse events (consisting of all-cause in-hospital death, stroke, acute kidney injury, and tracheotomy), and we compared them between surgical and conservative treatments using propensity score matching.

Results

The study cohort included 3258 patients, with 845 matched pairs (1690 patients) in the propensity score matching. All-cause in-hospital death was significantly lower in the surgical treatment group than in the conservative treatment group before and after matching (15.6% vs. 51.1%, p < 0.001; 16.7% vs. 31.6%, p < 0.001, respectively); however, there was no significant difference in composite adverse events after matching (36.0%, conservative vs. 37.2%, surgical; p = 0.65), and adjusted odds ratio was 1.06 and 95% confidence interval was 0.86–1.29 (p = 0.61) with reference to conservative treatment.

Conclusions

All-cause in-hospital death among elderly patients with AAD was significantly lower in patients treated surgically than in those undergoing conservative treatment. However, there was no significant difference between the two groups in the event-free survival, which is important for the elderly. These findings may be used in the consideration of treatment course for elderly patients with AAD.

Electronic supplementary material

The online version of this article (10.1186/s13019-018-0814-6) contains supplementary material, which is available to authorized users.

Epidemiology of mechanically ventilated patients treated in ICU and non-ICU settings in Japan: a retrospective database study

BACKGROUND

In most countries, patients receiving mechanical ventilation (MV) are treated in intensive care units (ICUs). However, in some countries, including Japan, many patients on MV are not treated in ICUs. There are insufficient epidemiological data on these patients. Here, we sought to describe the epidemiology of patients on MV in Japan by comparing and contrasting patients on MV treated in ICUs and in non-ICU settings. A preliminary comparison of patient outcomes between ICU and non-ICU patients was a secondary objective.

METHODS

Data on adult patients receiving MV for at least 3 days in ICUs or non-ICU settings from April 2010 through March 2012 were obtained from the Quality Indicator/Improvement Project, a voluntary data-administration project covering more than 400 acute-care hospitals in Japan. We excluded patients with cancer-related diagnoses. Patient demographic data and the critical care provided were compared between groups.

RESULTS

Over the study period, 17,775 patients on MV were treated only in non-ICU settings, whereas 20,516 patients were treated at least once in ICUs (46.4% vs. 53.6%). Average age was higher in non-ICU patients than in ICU patients (72.8 vs. 70.2, P < 0.001). Mean number of ventilation days was greater in non-ICU patients (11.7 vs. 9.5, P < 0.001). Hospital mortality was higher in non-ICU patients (41.4% vs. 38.8%, P < 0.001). Standard critical care (e.g., arterial line placement, enteral nutrition, and stress-ulcer prevention) was provided significantly less often in non-ICU patients. Multivariate analysis showed that ICU admission significantly decreased hospital mortality (adjusted odds ratio 0.713, 95% CI 0.676 to 0.753).

CONCLUSIONS

A large proportion of Japanese patients on MV were treated in non-ICU settings. Analysis of administrative data indicated preliminarily that hospital mortality rates in these patients were higher in non-ICU settings than in ICUs. Prospective analyses comparing non-ICU and ICU patients on MV by severity scoring are needed.

Future projection of the physician workforce and its geographical equity in Japan: a cohort-component model

INTRODUCTION

The geographical inequity of physicians is a serious problem in Japan. However, there is little evidence of inequity in the future geographical distribution of physicians, even though the future physician supply at the national level has been estimated. In addition, possible changes in the age and sex distribution of future physicians are unclear. Thus, the purpose of this study is to project the future geographical distribution of physicians and their demographics.

METHODS

We used a cohort-component model with the following assumptions: basic population, future mortality rate, future new registration rate, and future in-migration and out-migration rates. We examined changes in the number of physicians from 2005 to 2035 in secondary medical areas (SMAs) in Japan. To clarify the trends by regional characteristics, SMAs were divided into four groups based on urban or rural status and initial physician supply (lower/higher). The number of physicians was calculated separately by sex and age strata.

RESULTS

From 2005 to 2035, the absolute number of physicians aged 25-64 will decline by 6.1% in rural areas with an initially lower physician supply, but it will increase by 37.0% in urban areas with an initially lower supply. The proportion of aged physicians will increase in all areas, especially in rural ones with an initially lower supply, where it will change from 14.4% to 31.3%. The inequity in the geographical distribution of physicians will expand despite an increase in the number of physicians in rural areas.

CONCLUSIONS

We found that the geographical disparity of physicians will worsen from 2005 to 2035. Furthermore, physicians aged 25-64 will be more concentrated in urban areas, and physicians will age more rapidly in rural places than urban ones. The regional disparity in the physician supply will worsen in the future if new and drastic measures are not taken.

Cost-Effectiveness of Second-Line Endocrine Therapies in Postmenopausal Women with Hormone Receptor-positive and Human Epidermal Growth Factor Receptor 2-negative Metastatic Breast Cancer in Japan

BACKGROUND

Exemestane (EXE), exemestane + everolimus (EXE + EVE), toremifene (TOR), and fulvestrant (FUL) are second-line endocrine therapies for postmenopausal hormone receptor-positive (HR +)/human epidermal growth factor receptor 2-negative (HER2 -) metastatic breast cancer (mBC) in Japan. Although the efficacy of these therapies has been shown in recent studies, cost-effectiveness has not yet been determined in Japan.

OBJECTIVE

This study aimed to examine the cost-effectiveness of second-line endocrine therapies for the treatment of postmenopausal women with HR + and HER2 - mBC.

METHODS

A Markov model was developed to analyze the cost-effectiveness of the therapies over a 15-year time horizon from a public healthcare payer's perspective. The efficacy and utility parameters were determined via a systematic search of the literature. Direct medical care costs were used. A discount rate of 2% was applied for costs and outcomes. Subgroup analysis was performed for non-visceral metastasis. A series of sensitivity analyses, including probabilistic sensitivity analysis (PSA) and threshold analysis were performed.

RESULTS

Base-case analyses estimated incremental cost-effectiveness ratios (ICERs) of 3 million and 6 million Japanese yen (JPY)/quality-adjusted life year (QALY) gained for TOR and FUL 500 mg relative to EXE, respectively. FUL 250 mg and EXE + EVE were dominated. The overall survival (OS) highly influenced the ICER. With a willingness-to-pay (WTP) threshold of 5 million JPY/QALY, the probability of TOR being cost-effective was the highest. Subgroup analysis in non-visceral metastasis revealed 0.4 and 10% reduction in ICER from the base-case results of FUL5 500 mg versus EXE and TOR versus EXE, respectively, while threshold analysis indicated EVE and FUL prices should be reduced 73 and 30%, respectively.

CONCLUSION

As a second-line therapy for postmenopausal women with HR +/HER2 - mBC, TOR may be cost-effective relative to other alternatives and seems to be the most favorable choice, based on a WTP threshold of 5 million JPY/QALY. FUL 250 mg is expected to be as costly and effective as EXE. The cost-effectiveness of EXE + EVE and FUL 500 mg could be improved by a large price reduction. However, the results are highly sensitive to the hazard ratio of OS. Policy makers should carefully interpret and utilize these findings.

Comparison of national strategies to reduce meticillin-resistant Staphylococcus aureus infections in Japan and England

BACKGROUND

National responses to healthcare-associated infections vary between high-income countries, but, when analysed for contextual comparability, interventions can be assessed for transferability.

AIM

To identify learning from country-level approaches to addressing meticillin-resistant Staphylococcus aureus (MRSA) in Japan and England.

METHODS

A longitudinal analysis (2000-2017), comparing epidemiological trends and policy interventions. Data from 441 textual sources concerning infection prevention and control (IPC), surveillance, and antimicrobial stewardship interventions were systematically coded for: (a) type: mandatory requirements, recommendations, or national campaigns; (b) method: restrictive, persuasive, structural in nature; (c) level of implementation: macro (national), meso (organizational), micro (individual) levels. Healthcare organizational structures and role of media were also assessed.

FINDINGS

In England significant reduction has been achieved in number of reported MRSA bloodstream infections. In Japan, in spite of reductions, MRSA remains a predominant infection. Both countries face new threats in the emergence of drug-resistant Escherichia coli. England has focused on national mandatory and structural interventions, supported by a combination of outcomes-based incentives and punitive mechanisms, and multi-disciplinary IPC hospital teams. Japan has focused on (non-mandatory) recommendations and primarily persuasive interventions, supported by process-based incentives, with voluntary surveillance. Areas for development in Japan include resourcing of dedicated data management support and implementation of national campaigns for healthcare professionals and the public.

CONCLUSION

Policy interventions need to be relevant to local epidemiological trends, while acceptable within the health system, culture, and public expectations. Cross-national learning can help inform the right mix of interventions to create sustainable and resilient systems for future infection and economic challenges.

Development of a risk score for the prediction of incident dementia in older adults using a frailty index and health checkup data: The JAGES longitudinal study

In Japan, the prevalence of dementia is expected to reach 4.7 million by 2025. This study aimed to develop a risk score for the prediction of incident dementia in community-dwelling older adults. In this longitudinal observational study, we used data from the Japan Gerontological Evaluation Study (JAGES) conducted in K City. We performed Cox regression analyses to develop three risk score models for the prediction of incident dementia in older adults using a frailty index and health checkup data. Analyses of the area under the receiver operating characteristic curve were conducted to compare the models' predictive abilities. We identified 6656 (9.2%) individuals who developed incident dementia during the observation period. The C-statistics of the risk scores ranged from 0.733 to 0.790. The risk score models were able to predict incident dementia in older adults and may help non-medical professionals detect dementia risk at an early stage.

The impact of low body mass index on postoperative outcomes in pancreatectomy patients: a retrospective analysis of Japanese administrative data

PURPOSE

To comparatively examine in-hospital mortality among different underweight body mass index (BMI) categories in pancreatic cancer patients after pancreatectomy in Japan.

METHODS

We conducted a large-scale multi-center retrospective cohort study of adult patients with pancreatic cancer who underwent pancreatectomy between April 1, 2010 and March 31, 2016. Patients were classified according to BMI as follows: normal BMI (18.50-24.99 kg/m²), mild thinness (17.00-18.49 kg/m²), moderate thinness (16.00-16.99 kg/m²), and severe thinness (< 16.00 kg/m²). A multivariable logistic regression analysis was performed with in-hospital mortality as the dependent variable and BMI groups as the main independent variable of interest.

RESULTS

We analyzed 6173 patients from 332 hospitals. The results showed that the severe thinness group had a longer postoperative hospital stay (34.4 ± 25.6 days) and higher incidence of postoperative pneumonia (5.5%) than the other groups. The generalized estimating equations accounted for patient demographics, surgical procedure, anesthetic technique, activities of daily living score, and Charlson comorbidity index as covariates. Relative to the normal BMI group, the odds ratios for in-hospital mortality were 0.57 (95% confidence interval: 0.26-1.24; P = 0.16) in the mild thinness group, 1.49 (0.64-3.48; P = 0.36) in the moderate thinness group, and 2.54 (1.05-6.08; P = 0.04) in the severe thinness group.

CONCLUSION

Severe thinness was significantly associated with a higher risk of mortality, and extremely low BMI should be considered a risk factor in pancreatectomy patients.

The personal cost of dementia care in Japan: A comparative analysis of residence types

OBJECTIVE

We aimed to quantify the personal economic burden of dementia care in Japan according to residence type.

METHODS

A cross-sectional online survey was conducted on 3841 caregivers of people with dementia. An opportunity cost approach was used to calculate informal care costs. All costs and the observed/expected (OE) ratio of costs were adjusted using patient sex, age, and care-needs levels, and compared among the residence types.

RESULTS

The mean daily informal care time was 8.2 hours, and the mean monthly informal care costs for community-dwelling people with dementia were US$1559. The OE ratio for informal care costs in community-dwelling patients was higher than in institutionalized patients.

CONCLUSION

The inclusion of informal care costs reduced the differences in total personal costs among the residence types. The economic burden of informal care should be considered when quantifying dementia care costs.

Are pension types associated with happiness in Japanese older people?: JAGES cross-sectional study

Background

Although many previous studies have examined the determinants of happiness in older adults, few have investigated the association between pension types and happiness. When compared to other conventional socioeconomic indicators, pension types may be more indicative of long-term socioeconomic status as they can reflect a person’s job history over their life course. This study examined the association between pension types and happiness in Japanese older people.

Methods

Cross-sectional survey data from the Japan Gerontological Evaluation Study were used to analyze the association between pension types and happiness. The study population comprised 120152 participants from 2013. We calculated the prevalence ratios of happiness for the different pension types using Poisson regression models that controlled for age, sex, marital status, equivalent income, wealth, education level, working status, occupation, depression, and social support.

Results

After controlling for socioeconomic indicators, the prevalence ratios (95% confidence intervals) of happiness for no pension benefits, low pension benefits, and moderate pension benefits relative to high pension benefits were 0.77 (0.73–0.81), 0.95 (0.94–0.97), and 0.98 (0.97–0.99), respectively. However, the inclusion of depression as a covariate weakened the association between pension types and happiness.

Conclusions

While pension types were associated with happiness after adjusting for other proxy measures of socioeconomic status, the association diminished following adjustment for depression. Pension types may provide rich information on socioeconomic status and depression throughout the course of life. In addition to conventional socioeconomic indicators, pension types should also be considered when assessing the determinants of happiness in older adults.

Examining changes in the equity of physician distribution in Japan: a specialty-specific longitudinal study

OBJECTIVES

In this longitudinal study, we examined changes in the geographical distribution of physicians in Japan from 2000 to 2014 by clinical specialty with adjustments for healthcare demand based on population structure.

METHODS

The Japanese population was adjusted for healthcare demand using health expenditure per capita stratified by age and sex. The numbers of physicians per 100 000 demand-adjusted population (DAP) in 2000 and 2014 were calculated for subprefectural regions known as secondary medical areas. Disparities in the geographical distribution of physicians for each specialty were assessed using Gini coefficients. A subgroup analysis was conducted by dividing the regions into four groups according to urban-rural classification and initial physician supply.

RESULTS

Over the study period, the number of physicians per 100 000 DAP decreased in all specialties assessed (internal medicine: -6.9%, surgery: -26.0%, orthopaedics: -2.1%, obstetrics/gynaecology (per female population): -17.5%) except paediatrics (+33.3%) and anaesthesiology (+21.1%). No reductions in geographical disparity were observed in any of the specialties assessed. Geographical disparity increased substantially in internal medicine, surgery and obstetrics and gynaecology(OB/GYN). Rural areas with lower initial physician supply experienced the highest decreases in physicians per 100 000 DAP for all specialties assessed except paediatrics and anaesthesiology. In contrast, urban areas with lower initial physician supply experienced the lowest decreases in physicians per 100 000 DAP in internal medicine, surgery, orthopaedics and OB/GYN, but the highest increase in anaesthesiology.

CONCLUSION

Between 2000 and 2014, the number of physicians per 100 000 DAP in Japan decreased in all specialties assessed except paediatrics and anaesthesiology. There is also a growing urban-rural disparity in physician supply in all specialties assessed except paediatrics. Additional measures may be needed to resolve these issues and improve physician distribution in Japan.

Early diagnosis of pancreatic necrosis based on perfusion CT to predict the severity of acute pancreatitis

BACKGROUND

Perfusion CT can diagnose pancreatic necrosis in early stage of severe acute pancreatitis, accurately. However, no study to date has examined whether early diagnosis of pancreatic necrosis is useful in predicting persistent organ failure (POF).

METHODS

We performed a multi-center prospective observational cohort study to investigate whether perfusion CT can predict the development of POF in the early stage of AP, based on early diagnosis of the development of pancreatic necrosis (PN). From 2009 to 2012, we examined patients showing potential early signs of severe AP (n = 78) on admission. Diagnoses for the development of PN were made prospectively by on-site physicians on the admission based on perfusion CT (diagnosis 1). Blinded retrospective reviews were performed by radiologists A and B, having 8 and 13 years of experience as radiologists (diagnosis 2 and 3), respectively. Positive diagnosis for the development of PN were assumed equivalent to positive predictions for the development of POF. We then calculated the area under the curve (AUC) of the receiver operating characteristic for POF predictions.

RESULTS

Fourteen (17.9%) and 23 patients (29.5%) developed PN and POF, respectively. For diagnoses 1, 2, and 3, AUCs for POF predictions were 74, 68, and 73, respectively.

CONCLUSIONS

Perfusion CT diagnoses pancreatic necrosis and on that basis predicts the development of POF; http://www.umin.ac.jp/ctr/index-j.htm,UMIN000001926 .

Survival analysis of increases in care needs associated with dementia and living alone among older long-term care service users in Japan

BACKGROUND

Japan is known for its long life expectancy and rapidly aging society that there are various demands of older adults need to be fulfilled with, and one of them is long-term care needs. Therefore, Japan implemented the Long-Term Care Insurance in year 2000 for citizens who are above 65-year old and citizens who are above 40-year old in needs of long-term care services. This study was undertaken to longitudinally examine the influence of dementia and living alone on care needs increases among older long-term care insurance service users in Japan.

METHODS

Long-term care insurance claims data were used to identify enrollees who applied for long-term care services between October 2010 and September 2011, and subjects were tracked until March 2015. A Kaplan-Meier survival analysis was conducted to examine increases in care needs over time in months. Cox regression models were used to examine the effects of dementia and living alone on care needs increases.

RESULTS

The cumulative survival rates before care needs increased over the 4.5-year observation period were 17.6% in the dementia group and 31.9% in the non-dementia group. After adjusting for age, sex, care needs level, and status of living alone, the risk of care needs increases was found to be 1.5 times higher in the dementia group. Living alone was not a significant risk factor of care needs increases, but people with dementia who lived alone had a higher risk of care needs increases than those without dementia.

CONCLUSION

Dementia, older age, the female sex, and lower care needs levels were associated with a higher risk of care needs increases over the study period. Among these variables, dementia had the strongest impact on care needs increases, especially in persons who lived alone.

Comparison of In-hospital Outcomes Between Transcatheter and Surgical Aortic Valve Replacement in Patients with Aortic Valve Stenosis: A Retrospective Cohort Study Using Administrative Data

OBJECTIVE

The number of surgeries for valvular heart disease performed in Japan has greatly increased over the past decade, and surgical aortic valve replacements (SAVR) constitute the vast majority of aortic valve replacement procedures. Although transcatheter aortic valve implantation (TAVI) was recently introduced, studies have yet to compare the clinical outcomes between TAVI and SAVR in the Japanese healthcare setting. This study aimed to compare in-hospital outcomes between TAVI and SAVR using a multicenter administrative database.

DESIGN

Retrospective cohort study.

SETTING

Acute care hospitals in Japan.

PARTICIPANTS

A total of 16,775 patients diagnosed with aortic valve stenosis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The main study outcome measure was in-hospital mortality. Based on multiple logistic regression analysis using inverse probability of treatment weighting, the odds ratio of in-hospital mortality for TAVI (relative to SAVR) was calculated to be 0.36 (95% confidence intervals: 0.13-0.98; p = 0.04). In patients aged 80 years or older, the odds ratio was even lower at 0.34 (95% confidence intervals: 0.15-0.73; p < 0.01). In addition, the incidences of reoperations, hemorrhagic complications, cardiac tamponade, and postoperative infections were significantly higher in the SAVR patients.

CONCLUSIONS

This large-scale multicenter comparative analysis of TAVI and SAVR in Japan indicated that TAVI produced better clinical outcomes in patients with aortic valve stenosis. The improved outcomes were particularly notable in patients aged 80 years or older.

Analysis of the evidence-practice gap to facilitate proper medical care for the elderly: investigation, using databases, of utilization measures for National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB)

As Japan becomes a super-aging society, presentation of the best ways to provide medical care for the elderly, and the direction of that care, are important national issues. Elderly people have multi-morbidity with numerous medical conditions and use many medical resources for complex treatment patterns. This increases the likelihood of inappropriate medical practices and an evidence-practice gap. The present study aimed to: derive findings that are applicable to policy from an elucidation of the actual state of medical care for the elderly; establish a foundation for the utilization of National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB), and present measures for the utilization of existing databases in parallel with NDB validation.

Cross-sectional and retrospective cohort studies were conducted using the NDB built by the Ministry of Health, Labor and Welfare of Japan, private health insurance claims databases, and the Kyoto University Hospital database (including related hospitals). Medical practices (drug prescription, interventional procedures, testing) related to four issues—potential inappropriate medication, cancer therapy, chronic kidney disease treatment, and end-of-life care—will be described. The relationships between these issues and clinical outcomes (death, initiation of dialysis and other adverse events) will be evaluated, if possible.

Differences between determinants of in-hospital mortality and hospitalisation costs for patients with acute heart failure: a nationwide observational study from Japan

OBJECTIVES

Although current case-mix classifications in prospective payment systems were developed to estimate patient resource usage, whether these classifications reflect clinical outcomes remains unknown. The efficient management of acute heart failure (AHF) with high mortality is becoming more important in many countries as its prevalence and associated costs are rapidly increasing. Here, we investigate the determinants of in-hospital mortality and hospitalisation costs to clarify the impact of severity factors on these outcomes in patients with AHF, and examine the level of agreement between the predicted values of mortality and costs.

DESIGN

Cross-sectional observational study.

SETTING AND PARTICIPANTS

A total of 19 926 patients with AHF from 261 acute care hospitals in Japan were analysed using administrative claims data.

MAIN OUTCOME MEASURES

Multivariable logistic regression analysis and linear regression analysis were performed to examine the determinants of in-hospital mortality and hospitalisation costs, respectively. The independent variables were grouped into patient condition on admission, postadmission procedures indicating disease severity (eg, intra-aortic balloon pumping) and other high-cost procedures (eg, single-photon emission CT). These groups of independent variables were cumulatively added to the models, and their effects on the models' abilities to predict the respective outcomes were examined. The level of agreement between the quartiles of predicted mortality and predicted costs was analysed using Cohen's κ coefficient.

RESULTS

In-hospital mortality was associated with patient's condition on admission and severity-indicating procedures (C-statistics 0.870), whereas hospitalisation costs were associated with severity-indicating procedures and high-cost procedures (R² 0.32). There were substantial differences in determinants between the outcomes. In addition, there was no consistent relationship observed (κ=0.016, p<0.0001) between the quartiles of in-hospital mortality and hospitalisation costs.

CONCLUSIONS

The determinants of mortality and costs for hospitalised patients with AHF were generally different. Our results indicate that the same case-mix classifications should not be used to predict both these outcomes.

Examining sufficiency and equity in the geographic distribution of physicians in Japan: a longitudinal study

OBJECTIVES

The objective of this study was to longitudinally examine the geographic distribution of physicians in Japan with adjustment for healthcare demand according to changes in population age structure.

METHODS

We examined trends in the number of physicians per 100 000 population in Japan's secondary medical areas (SMAs) from 2000 to 2014. Healthcare demand was adjusted using health expenditure per capita. Trends in the Gini coefficient and the number of SMAs with a low physician supply were analysed. A subgroup analysis was also conducted where SMAs were divided into 4 groups according to urban-rural classification and initial physician supply.

RESULTS

The time-based changes in the Gini coefficient and the number of SMAs with a low physician supply indicated that the equity in physician distribution had worsened throughout the study period. The number of physicians per 100 000 population had seemingly increased in all groups, with increases of 22.9% and 34.5% in urban groups with higher and lower initial physician supply, respectively. However, after adjusting healthcare demand, physician supply decreased by 1.3% in the former group and increased by 3.5% in the latter group. Decreases were also observed in the rural groups, where the number of physicians decreased by 4.4% in the group with a higher initial physician supply and 7.6% in the group with a lower initial physician supply.

CONCLUSIONS

Although the total number of physicians increased in Japan, demand-adjusted physician supply decreased in recent years in all areas except for urban areas with a lower initial physician supply. In addition, the equity of physician distribution had consistently deteriorated since 2000. The results indicate that failing to adjust healthcare demand will produce misleading results, and that there is a need for major reform of Japan's healthcare system to improve physician distribution.

Asymptomatic C-reactive protein elevation in neutropenic children

BACKGROUND

Febrile neutropenia (FN) can be a life-threatening complication in children with malignancies. There is no standardized preventive treatment for childhood FN, and information on C-reactive protein (CRP) elevation in afebrile patients with neutropenia (CEAN) is limited. The aim of this study was therefore to identify the association between CEAN and FN onset, and evaluate the efficacy of broad-spectrum antibiotics for FN prophylaxis.

METHODS

We retrospectively reviewed the medical records of 22 consecutive pediatric patients with hematologic malignancies (acute myeloid leukemia, n = 2; acute lymphoid leukemia, n = 20) admitted to the present institution between 2006 and 2011. CEAN was defined as CRP elevation ≥0.05 mg/dL between the two most recent blood tests with no fever. We identified CEAN before FN onset, and assessed the efficacy of broad-spectrum antibiotics for FN prevention in CEAN. FN incidence within 48 h after CEAN detection was compared between prophylactic and non-prophylactic episodes.

RESULTS

CEAN was observed before FN onset in 20 (55.6%), of 36 FN episodes. Among the 95 analyzed CEAN episodes, broad-spectrum antibiotics had been used for 30 episodes (prophylactic episodes), whereas these antibiotics had not been used in 60 episodes (non-prophylactic episodes). Prophylactic episodes had a significantly lower FN incidence than non-prophylactic episodes (6.7% and 31%, respectively, P < 0.01) within 48 h after CEAN detection. Bacteremia was observed in three non-prophylactic episodes.

CONCLUSION

Patients with CEAN are at higher risk of FN, and physicians may consider the use of broad-spectrum antibiotics to prevent FN development.

Effect of the number of request calls on the time from call to hospital arrival: a cross-sectional study of an ambulance record database in Nara prefecture, Japan

OBJECTIVES

In Japan, ambulance staff sometimes must make request calls to find hospitals that can accept patients because of an inadequate information sharing system. This study aimed to quantify effects of the number of request calls on the time interval between an emergency call and hospital arrival.

DESIGN AND SETTING

A cross-sectional study of an ambulance records database in Nara prefecture, Japan.

CASES

A total of 43 663 patients (50% women; 31.2% aged 80 years and over): (1) transported by ambulance from April 2013 to March 2014, (2) aged 15 years and over, and (3) with suspected major illness.

PRIMARY OUTCOME MEASURES

The time from call to hospital arrival, defined as the time interval from receipt of an emergency call to ambulance arrival at a hospital.

RESULTS

The mean time interval from emergency call to hospital arrival was 44.5 min, and the mean number of requests was 1.8. Multilevel linear regression analysis showed that ∼43.8% of variations in transportation times were explained by patient age, sex, season, day of the week, time, category of suspected illness, person calling for the ambulance, emergency status at request call, area and number of request calls. A higher number of request calls was associated with longer time intervals to hospital arrival (addition of 6.3 min per request call; p<0.001). In an analysis dividing areas into three groups, there were differences in transportation time for diseases needing cardiologists, neurologists, neurosurgeons and orthopaedists.

CONCLUSIONS

The study revealed 6.3 additional minutes needed in transportation time for every refusal of a request call, and also revealed disease-specific delays among specific areas. An effective system should be collaboratively established by policymakers and physicians to ensure the rapid identification of an available hospital for patient transportation in order to reduce the time from the initial emergency call to hospital arrival.

The economic burden of methicillin-resistant Staphylococcus aureus in community-onset pneumonia inpatients

BACKGROUND

The quantitative effect of multidrug-resistant bacterial infections on real-world health care resources is not clear. This study aimed to estimate the burden of methicillin-resistant Staphylococcus aureus (MRSA) infections in pneumonia inpatients in Japan.

METHODS

Using a nationwide administrative claims database, we analyzed pneumonia patients who had been hospitalized in 1,063 acute care hospitals. Patients who received anti-MRSA drugs were categorized into an anti-MRSA drug group, and the remaining patients comprised the control group. We estimated the burden of length of stay, in-hospital mortality, total antibiotic agent costs, and total hospitalization costs. Risk adjustments were conducted using propensity score matching.

RESULTS

The study sample comprised 634 patients administered anti-MRSA drugs and 87,427 control patients. In propensity score-matching analysis (1 to 1), the median length of stay, antibiotic costs, and hospitalization costs of the anti-MRSA drug group were significantly higher than those of the control group (21 days vs 14 days [P < .001], $756 vs $172 [P < .001] and $8,741 vs $5,063 [P < .001], respectively); the attributable excess of these indicators were 9.0 ± 1.6 days, $1,044 ± $101, and $5,548 ± $580, respectively.

CONCLUSIONS

These findings may serve as a reference to support further research on multidrug-resistant bacterial infections and eventually inform policy formulation.

[Measures to Raise Awareness on Home Care Medicine for Staff at an Acute Medical Care Facility - Multi-Professional Collaboration on the Strengths Dissemination Project]

Kohka Public Hospital(KPH)focuses primarily on the treatment of acute diseases. However, as the only general hospital in the medical district and established under the National Health Insurance, KPH has a mandate in comprehensive medical care. With the aim of becoming a hospital that can cope with the anticipated super-aging society, a meeting was started to raise staff awareness of home care medicine. Senior managers were placed in each team along with staff with no involvement on the issue. Initially, a SWOT analysis was conducted to understand the current status. Views raised in the meetings will be summarized, and consequent measures will be announced both internally and externally as part of the Strengths Dissemination Project. Interest in home care medicine at acute medical care hospitals is undeniably low, but the reality is that many do not know how to get involved due to the lack of exposure. It is unquestionable that the need for home care medicine and regional cooperation will rise in our nation. We must direct the attention of health care providers there and start discussions.

Reducing Length of Hospital Stay Does Not Increase Readmission Rates in Early-Stage Gastric, Colon, and Lung Cancer Surgical Cases in Japanese Acute Care Hospitals

Background

The Japanese government has worked to reduce the length of hospital stay by introducing a per-diem hospital payment system that financially incentivizes the timely discharge of patients. However, there are concerns that excessively reducing length of stay may reduce healthcare quality, such as increasing readmission rates. The objective of this study was to investigate the temporal changes in length of stay and readmission rates as quality indicators in Japanese acute care hospitals.

Methods

We used an administrative claims database under the Diagnosis Procedure Combination Per-Diem Payment System for Japanese hospitals. Using this database, we selected hospitals that provided data continuously from July 2010 to March 2014 to enable analyses of temporal changes in length of stay and readmission rates. We selected stage I (T1N0M0) gastric, colon, and lung cancer surgical patients who had been discharged alive from the index hospitalization. The outcome measures were length of stay during the index hospitalization and unplanned emergency readmissions within 30 days after discharge.

Results

From among 804 hospitals, we analyzed 42,585, 15,467, and 40,156 surgical patients for gastric, colon, and lung cancer, respectively. Length of stay was reduced by approximately 0.5 days per year. In contrast, readmission rates were generally stable at approximately 2% or had decreased slightly over the 4-year period.

Conclusions

In early-stage gastric, colon, and lung cancer surgical patients in Japan, reductions in length of stay did not result in increased readmission rates.

Oliguria without serum creatinine increase after living donor liver transplantation is associated with adverse post-operative outcomes

BACKGROUND

Acute kidney injury (AKI) is a common complication after liver transplantation and is associated with significant morbidity and mortality. Although clinical guidelines recommend defining AKI based on serum creatinine increase and oliguria, the validity and utility of the oliguric component of AKI definition remains largely unexplored. This study examined the incidence and the impact on clinical outcomes of oliguria meeting the urine output criterion of AKI in patients undergoing liver transplantation. The authors hypothesised that oliguria was an independent risk factor for adverse post-operative outcomes.

METHODS

This study retrospectively examined 320 patients who underwent living donor liver transplantation at our centre. AKI stages were allocated according to recent guidelines based on serum creatinine or urine output within 7 days of surgery.

RESULTS

The incidence of oliguria meeting the urine output criterion of AKI was 50.3%. Compared with creatinine criterion alone, incorporating oliguria into the diagnostic criteria dramatically increased the measured incidence of AKI from 39.7% to 62.2%. Compared with patients diagnosed without AKI using either criterion, oliguric patients without serum creatinine increase had significantly longer intensive care unit stays (median: 5 vs. 4 days, P = 0.016), longer hospital stays (median: 60 vs. 49 days, P = 0.014) and lower chronic kidney disease-free survival rate on post-operative day 90 (54.2% vs. 73.3%, P = 0.008).

CONCLUSION

Oliguria is common after liver transplantation, and incorporating oliguria into the diagnostic criteria dramatically increases the measured incidence of AKI. Oliguria without serum creatinine increase was significantly associated with adverse post-operative outcomes.

In-hospital mortality and treatment patterns in acute myocardial infarction patients admitted during national cardiology meeting dates

BACKGROUND

Many hospitals experience a reduction in the number of available physicians on days when national scientific meetings are conducted. This study investigates the relationship between in-hospital mortality in acute myocardial infarction (AMI) patients and admission during national cardiology meeting dates.

METHODS

Using an administrative database, we analyzed patients with AMI admitted to acute care hospitals in Japan from 2011 to 2013. There were 3 major national cardiology meetings held each year. A hierarchical logistic regression model was used to compare in-hospital mortality and treatment patterns between patients admitted on meeting dates and those admitted on identical days during the week before and after the meeting dates.

RESULTS

We identified 6,332 eligible patients, with 1,985 patients admitted during 26 meeting days and 4,347 patients admitted during 52 non-meeting days. No significant differences between meeting and non-meeting dates were observed for in-hospital mortality (7.4% vs. 8.5%, respectively; p=0.151, unadjusted odds ratio: 0.861, 95% confidence interval: 0.704-1.054) and the proportion of percutaneous coronary intervention (PCI) performed on the day of admission (75.9% vs. 76.2%, respectively; p=0.824). We also found that some low-staffed hospitals did not treat AMI patients during meeting dates.

CONCLUSION

Little or no "national meeting effect" was observed on in-hospital mortality in AMI patients, and PCI rates were similar for both meeting and non-meeting dates. Our findings also indicated that during meeting dates, AMI patients may have been consolidated to high-performance and sufficiently staffed hospitals.

Evaluation of Acute Myocardial Infarction In-hospital Mortality Using a Risk-adjustment Model Based on Japanese Administrative Data

This study aimed to develop a new risk-adjustment method to assess acute myocardial infarction (AMI) in-hospital mortality. Risk-adjustment was based on variables obtained from administrative data from Japanese hospitals, and included factors such as age, gender, primary diagnosis and co-morbidity. The infarct location was determined using the criteria of the International Classification of Diseases (10th version). Potential co-morbidity risk factors for mortality were selected based on previous studies and their critical influence analysed to identify major co-morbidities. The remaining minor co-morbidities were then divided into two groups based on their medical implications. The major co-morbidities included shock, pneumonia, cancer and chronic renal failure. The two minor co-morbidity groups also demonstrated a substantial impact on mortality. The model was then used to assess clinical performance in the participating hospitals. Our model reliably employed the available data for the risk-adjustment of AMI mortality and provides a new approach to evaluating clinical performance.