101
|
Yasumura S, Hashimoto K, Hoshoya M, Fujimori K, Wakagi Y. SP3-34 The overview and prospects of "Japan Eco & Child Study" in Fukushima. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976o.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
102
|
Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K. Early crystalloid fluid volume management in acute pancreatitis: association with mortality and organ failure. Pancreatology 2011; 11:351-61. [PMID: 21757973 DOI: 10.1159/000328965] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 04/28/2011] [Indexed: 12/11/2022]
Abstract
AIMS Guidelines recommend aggressive fluid resuscitation in patients with acute pancreatitis (AP) to minimize organ failure. This study aimed to determine whether early crystalloid fluid management is associated with mortality and/or critical care. METHODS 9,489 AP patients aged ≥18 years were categorized into four study groups: ventilation, hemodialysis, a combination of ventilation and hemodialysis, and neither ventilation nor hemodialysis. We analyzed demographics, mortality, comorbidities, complications, AP severity, surgery of the biliary/pancreatic system, and fluid volume (FV) during the initial 48 h (FV48) and during hospitalization (FVH), and calculated the FV ratio (FVR) as FV48/FVH. The impact of FV48 and FVR on mortality and the care process was assessed according to AP severity. RESULTS 1.1% of AP patients received ventilation, 1.7% received hemodialysis and 1.0% received both treatments. FV48 and FVR were higher in patients requiring ventilation compared with those not requiring ventilation. A high FV48 increased mortality and a high FVR decreased mortality in patients with severe AP. A high FV48 required ventilation in patients with severe AP, which was independently associated with mortality. CONCLUSION Since relatively too much or too little early FV is associated with mortality, FV should be continuously monitored and managed according to AP severity. and IAP.
Collapse
|
103
|
Murata A, Matsuda S, Kuwabara K, Ichimiya Y, Fujino Y, Kubo T, Fujimori K, Horiguchi H. Equivalent clinical outcomes of bleeding peptic ulcers in teaching and non-teaching hospitals: evidence for standardization of medical care in Japan. TOHOKU J EXP MED 2011; 223:1-7. [PMID: 21178323 DOI: 10.1620/tjem.223.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The clinical outcomes of treatments for several medical conditions are better in teaching hospitals than in non-teaching hospitals. However, there is only limited information for comparisons of the clinical outcomes of bleeding peptic ulcers between teaching and non-teaching hospitals. A total of 4,863 patients treated by endoscopic hemostasis on admission for bleeding peptic ulcers were evaluated in 586 hospitals of the Diagnosis Procedure Combination (DPC) system. We collected their data from the database associated with the DPC system to compare the risk-adjusted length of stay (LOS) and in-hospital mortality within 30 days with respect to the hospital characteristics. The hospitals were categorized into two groups: teaching hospitals that were certified by the Japanese Society of Gastroenterology (3,332 patients in 360 hospitals) and non-teaching hospitals (1,531 patients in 226 hospitals). There was no significant difference with regard to the mean LOS and the crude in-hospital mortality within 30 days between groups (p = 0.181 and 0.174, respectively). Multiple linear regression analyses revealed that the hospital characteristics were not associated with the risk-adjusted LOS. The standardized coefficient for non-teaching hospitals was 0.019 (p = 0.172). Multiple logistic regression analyses further showed no significant difference in the in-hospital mortality within 30 days (non-teaching hospitals, odds ratio = 1.35, 95% confidence interval = 0.786 - 2.319, p = 0.277). In conclusion, both teaching and non-teaching hospitals have equivalent qualities in management of bleeding peptic ulcers. These findings suggest that the standardization of medical treatments for bleeding peptic ulcers has become disseminated in Japan.
Collapse
|
104
|
Kuwabara K, Matsuda S, Ishikawa KB, Horiguchi H, Fujimori K. Association of operating time and gastrectomy with initiation of postoperative oral food intake. Dig Surg 2011; 28:157-62. [PMID: 21540602 DOI: 10.1159/000323626] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 11/30/2010] [Indexed: 01/13/2023]
Abstract
BACKGROUND Fast-track programs optimizing perioperative care have been initiated along with the advancement of laparoscopic colorectal surgery. To clarify that these programs were evidence based for gastrectomy cases, we assessed the effect of operating time and gastrectomy type [open partial (OPG), open total (OTG), laparoscopic partial (LPG) and laparoscopic total (LTG)] on postoperative commencement of oral food intake. METHODS Among 14,465 cases of gastrectomy across 837 hospitals, we examined the demographics, comorbidity, complications, postoperative epidural analgesia, rehabilitation and teaching status. The impact of gastrectomy type and operating time on postoperative fasting period was assessed using mixed regression models to distill off the hospital practice belief. RESULTS We identified 2,775 laparoscopic gastrectomies and 10,064 partial gastrectomies, 2,485 of which were conducted via laparoscopy. Operating time was shortest in OPG and longest in LTG. The fasting period was shortest in LPG and longest in OTG. Longer operating time prolonged the fasting period, except for LTG. Postoperative epidural analgesia and earlier rehabilitation, but not laparoscopic gastrectomy, were associated with a shortened fasting period. CONCLUSION When developing a fast-track program for gastrectomy, clinicians should recognize the impact of longer operating time and perioperative care rather than that of gastrectomy type on oral intake.
Collapse
|
105
|
Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K. Community-Based Appraisal of the Effects of Parenteral Nutrition Versus Enteral Nutrition on the Quality of Care for Patients With Acute Pancreatitis. Gastroenterology Res 2011; 4:1-8. [PMID: 27957005 PMCID: PMC5139793 DOI: 10.4021/gr289w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2011] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Enteral nutrition (EN) rather than parenteral nutrition (PN) has been advocated in treatment guidelines for acute pancreatitis (AP) as endorsed in randomized studies or meta-analyses. The findings derived from those studies would recognize the criticism of smaller sample sizes or limited patient case-mixes. To determine the generalizability of those findings, community-based appraisal on the advantages of EN over PN is required. Using a Japanese administrative database between 2006 and 2010, we determine whether EN is superior to PN in the real clinical settings. METHODS A total of 24,913 patients diagnosed with AP at admission in 1,000 hospitals were identified. Among them, we analyzed 1,803 patients of ≥ 15 years who received EN or PN for AP across 480 hospitals. Among three nutrition categories of PN only, EN only and PN with EN, we examined patient characteristics, comorbidities, complications, AP severity score determined by the Ministry of Health, Labor and Welfare, surgical procedures for the biliary/pancreatic system, use of artificially assisted ventilation and hemodialysis proxy of multiple organ failures and hospital teaching status. To identify the variables associated with PN use, a logistic regression model was used and the propensity score (PS) was calculated to control for the selection bias of patient case-mix preferring PN use. Then, we compared mortality, length of hospital stay (LOS), total charges (TC) and commencement day of oral food intake between EN and PN. RESULTS A total of 1,191 PN patients, 330 EN patients and 282 mixed EN and PN patients were identified. EN was indicated for patients with mild AP and procedures for the pancreas. PS matching analysis indicated that PN had a higher mortality compared with EN, and PN significantly increased LOS and TC compared with EN. PN deterred the commencement of oral food intake. CONCLUSIONS Community-based study has shown that EN was employed in the less severe case-mixed. Even though considering that selection bias, EN was still superior to PN in AP. Physicians should be aware of the guidelines for the advocacy of EN and need to carefully consider the indications for EN to optimize the quality of AP care.
Collapse
|
106
|
Goto M, Imura T, Inagaki A, Ogawa N, Yamaya H, Fujimori K, Kurokawa Y, Satomi S. The impact of ischemic stress on the quality of isolated pancreatic islets. Transplant Proc 2011; 42:2040-2. [PMID: 20692402 DOI: 10.1016/j.transproceed.2010.05.101] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although the ischemic stress of donated organs has been shown to have strong negative effects on islet recovery, the impact on islet quality remains uncertain. In the present study, therefore, we examined the influence of ischemic stress on the expression of inflammatory mediators among isolated islets. MATERIALS AND METHODS Islets were isolated from adult porcine pancreata subjected to 16-hour cold ischemia time (CIT) in addition to 40-minute warm ischemia time (WIT). We evaluated the islet yield, islet loss during the first 24 hours in culture, adenosine diphosphate (ADP)/adenosine triphosphate (ATP) ratio, ATP/DNA ratio, glucose-stimulated respiratory activity, in vivo bioassay, and the expression of inflammatory mediators (tissue factor [TF], [MCP-1], macrophage migration inhibitory factor) on the isolated islets. We also analyzed ATP/DNA ratios of the exocrine tissues during isolation procedures. RESULTS The islet yield, survival rate during culture, and glucose-stimulated respiratory activity were significantly lower in cases of 16-hour CIT plus 40-minute WIT compared with the control group (P < .0001, .0006, and .002, respectively). In contrast, ADP/ATP ratio as well as TF and MCP-1 expressions on the isolated islets were higher among the ischemic group (P = .005, .16, and .005, respectively). During isolation procedures, the ATP/DNA of the exocrine tissues was extremely lower in the ischemic compared to the control group (P < .0001). Notably, however, both ATP/DNA and ADP/ATP ratio of isolated islets were well preserved even in the ischemic group (P = .45 and .40). DISCUSSION These data suggest that ischemic stress during the preservation period negatively affects the energy status of exocrine tissues. Destruction of the exocrine tissues, in combination with warm ischemic stress during the isolation procedures, subsequently decreases isolated islet activity, inducing the expression of inflammatory mediators.
Collapse
|
107
|
Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K, Yasunaga H, Miyata H. Quantitative Assessment of the Advantages of Laparoscopic Gastrectomy and the Impact of Volume-Related Hospital Characteristics on Resource Use and Outcomes of Gastrectomy Patients in Japan. Ann Surg 2011; 253:64-70. [DOI: 10.1097/sla.0b013e318204e524] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|
108
|
Kubo T, Fujino Y, Murata A, Ichimiya Y, Kuwabara K, Fujimori K, Horiguchi H, Matsuda S. Prevalence of type 2 diabetes among acute inpatients and its impact on length of hospital stay in Japan. Intern Med 2011; 50:405-11. [PMID: 21372449 DOI: 10.2169/internalmedicine.50.4268] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The goal of this study was to determine the prevalence of type 2 diabetes among acute inpatients and evaluate its impact on the length of hospital stay in Japan. RESEARCH DESIGN AND METHODS The discharge records of 2,120,170 acute inpatients who were 30 years old or older and discharged between July and December of 2008 were obtained from the Japanese administrative case-mix system, Diagnosis Procedure Combination (DPC), and allocated for analysis. Type 2 diabetes was defined by E11 of the ICD-10 coding system on patient records. Other types of diabetes, including type 1 diabetes and diabetes in pregnancy (defined by ICD-10 codes E10 E12-14 and O24, respectively) were excluded from the analyses. RESULTS Type 2 diabetes was observed among 11.4% of the records, 9.9% of which were cases of diabetes as a comorbidity. Total length of hospital stay was 33,468,152 days, with diabetes patients occupying 13.9% of the total bed days. Patients with type 2 diabetes as a comorbidity had prolonged lengths of hospital stay compared to patients free from diabetes, and stratification by sex, age, surgical treatment, and disease category did not alter these results. The median length of hospital stay was 9 days among patients without diabetes and 13 days among patients with diabetes. CONCLUSION Japanese acute health care is experiencing an epidemic of type 2 diabetes, with 1 out of 10 acute inpatients suffering from the disease. Complication of type 2 diabetes is associated with prolonged length of hospital stay.
Collapse
|
109
|
Matsuda S, Fujimori K, Kuwabara K, Ishikawa KB, Fushimi K. Diagnosis Procedure Combination as an Infrastructure for the Clinical Study. ACTA ACUST UNITED AC 2011. [DOI: 10.7223/apjdm.5.81] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
110
|
Ichimiya Y, Matsuda S, Fujino Y, Kubo T, Murata A, Kuwabara K, Fujimori K, Horiguchi H. Profiling of the care processes for laryngeal cancer with the Japanese administrative database. TOHOKU J EXP MED 2011; 223:61-66. [PMID: 21222341 DOI: 10.1620/tjem.223.61] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
At present, there is a shortage of detailed data on head and neck cancer treatment in acute care hospitals in Japan. We conducted an analysis of the care process for laryngeal cancer inpatients in Japan using a national administrative database based on the case-mix system known as the Diagnosis Procedure Combination to evaluate the recent clinical situation of a relatively high incidence of head and neck cancers. We obtained discharge data relating to 2790 cases (one case = one hospitalization) involving 2319 laryngeal cancer patients from 346 acute care hospitals that participated in the Japanese national case-mix project between July and December of 2008. The details of their treatment procedures were analyzed according to the Japanese procedure codes managed by the Ministry of Health, Labour, and Welfare of Japan. There were 2156 male and 163 female patients. The median age was 69 years (range: 22-96 years). The most frequent surgical procedure was endoscopic resection which was performed for 781 cases. Chemotherapy was given in 31.6% of cases in the < 60 age group, 28.2% in the 60-79, and 14.1% in the ≥ 80. The most frequently used chemotherapy regimen was a single drug, S-1 (compound of tegafur, gimeracil and oteracil potassium), which was more frequently used in the ≥ 70 age group than in the younger age group. The Diagnosis Procedure Combination database, which collects a large volume of data from all over the country, is useful for analysis of the care process for head and neck cancers in Japan.
Collapse
|
111
|
Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K. Reconsidering the value of rehabilitation for patients with cerebrovascular disease in Japanese acute health care hospitals. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2011; 14:166-176. [PMID: 21211499 DOI: 10.1016/j.jval.2010.10.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES The 21st century has an increasing elderly population at risk of cerebrovascular disease (CVD). Efficient care for recovering functional status is emphasized among policy makers. We investigated whether rehabilitation and its early initiation provided for CVD patients produced functional recovery in acute care hospitals. METHODS Using a Japanese administrative database during a 4-month interval from 2004 to 2008 in patients ages ≥ 15 years, we measured the demographics, consciousness level at admission, comorbidities, complications, procedures, ventilation administration, initiation day of rehabilitation, and hospital characteristics. Outcomes included total charges (TC) and functional status measured by the Barthel index (BI). Multivariate analysis measured the impact of rehabilitation and its early initiation on outcomes. To reduce the selection bias of rehabilitation and the ecological fallacy, we used propensity score matching and the linear mixed model. RESULTS Excluding 488 deceased patients, we analyzed 45,014 CVD patients. Rehabilitation at a generalized unit produced greater BI improvement than no rehabilitation or at intensive care units. A longer hospitalization, but not a 1-day delay of rehabilitation initiation, resulted in less BI improvement and more TC. A higher patient volume and academic hospitals were associated with more TC but not with BI improvement. CONCLUSIONS Rehabilitation, but not the timing of rehabilitation, might accompany functional recovery in acute care hospitals. Because the hospital mix or medical units can explain the variation in the quality of rehabilitation, policy makers, along with monitoring unnecessary long hospitalizations, should encourage a referral policy for rehabilitation-intensive facilities and develop effective rehabilitation using technology to optimize functional outcomes.
Collapse
|
112
|
Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K. Relationships of age, cholecystectomy approach and timing with the surgical and functional outcomes of elderly patients with cholecystitis. Int J Surg 2011; 9:392-9. [DOI: 10.1016/j.ijsu.2011.03.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 02/08/2011] [Accepted: 03/16/2011] [Indexed: 01/28/2023]
|
113
|
Watanabe K, Imai Y, Takaya H, Nakazawa M, Chikayama T, Ando S, Mizuno Y, Sugawara K, Nakamura Y, Saitoh E, Hamaoka K, Motoya D, Fujimori K, Inao M, Nakayama N, Nagoshi S, Mochida S. A case of liver cirrhosis due to hepatits C virus infection complicating giant anorectal varices treated with balloon-occluded retrograde transvenous obliteration. Clin J Gastroenterol 2010; 4:19-23. [PMID: 26190616 DOI: 10.1007/s12328-010-0187-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 10/25/2010] [Indexed: 11/29/2022]
Abstract
A 73-year-old man with liver cirrhosis due to hepatitis C virus infection was admitted to our hospital because of massive bleeding from external varices. Colonoscopic examination revealed that giant anorectal varices had developed between the anus and rectal ampulla, and had ruptured at the perianal site. On three-dimensional computed tomography imaging, the feeding and drainage vessels of the varices were identified as the inferior mesenteric vein and right inferior hemorrhoidal vein, respectively. Endoscopic therapies were not employed for the bleeding varices, because the blood flow volume of the feeding vessel was extremely large. Balloon-occluded retrograde transvenous obliteration (B-RTO) was therefore carried out through the drainage vessels. The variceal blood flow disappeared after B-RTO therapy, and the varices decreased in size with thrombus formation verified by colonoscopy. Bleeding from the external varices also ceased. B-RTO therapy may be an effective approach for giant anorectal varices presenting as a complication in liver cirrhosis patients in whom the main drainage vessels can be determined.
Collapse
|
114
|
Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K. Community-based appraisal of laparoscopic abdominal surgery in Japan. J Surg Res 2010; 165:e1-13. [PMID: 21067779 DOI: 10.1016/j.jss.2010.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Revised: 08/08/2010] [Accepted: 09/01/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Despite the prevalence of laparoscopic surgery (LS), community-based appraisal of its benefit over open surgery (OS) has not been performed. This can be measured by increased total charge (TC) spent and decreased length of stay (LOS), which are indicative of greater resource use and opportunistic cost reduction. We prioritized the value of LS for eight abdominal procedures. MATERIALS AND METHODS We used a Japanese administrative database for the 6 mo leading up to December 2007. Study procedures were appendectomy, cholecystectomy, choledocholithotomy, herniorrhaphy, colectomy, partial or total gastrectomy, and small bowel resection (SBR) in adults. We analyzed patient demographics, mortality, comorbidity, complications, use of chemotherapy or postoperative pain control, hospital teaching status, postoperative LOS, and TCs. The impact of LS was determined using multivariate analysis on the propensity-score-matched cohorts of LS and OS. RESULTS Herniorrhaphy was most frequently performed (24,088 cases), whereas SBR was performed least (3404). LS was performed most often in cholecystectomy (81%) and least in herniorrhaphy (3.7%). LS did not increase complications in any procedure. Laparoscopic cholecystectomy and SBR were associated with shorter LOS and lower TC, whereas laparoscopic herniorrhaphy increased LOS and TC. Laparoscopic appendectomy and partial gastrectomy reduced LOS and increased TC. CONCLUSIONS LS safety was confirmed. Laparoscopic cholecystectomy or SBR might have advantages, whereas laparoscopic was no better than open herniorrhaphy and might be decided by patient's preference. Considering the variation in the decremental opportunistic cost produced by incremental medical expenses observed among the procedures, policymakers should determine an appropriate reimbursement schedule.
Collapse
|
115
|
Murata A, Matsuda S, Kuwabara K, Fujino Y, Kubo T, Fujimori K, Horiguchi H. Impact of hospital volume on clinical outcomes of endoscopic biliary drainage for acute cholangitis based on the Japanese administrative database associated with the diagnosis procedure combination system. J Gastroenterol 2010; 45:1090-6. [PMID: 20502923 DOI: 10.1007/s00535-010-0257-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Accepted: 05/01/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND We aimed to determine the relationship between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis, using the Japanese administrative database associated with the diagnosis procedure combination (DPC) system. METHODS A total of 8698 patients with endoscopic biliary drainage were referred to 654 hospitals. We corrected patients' data from the database to compare risk-adjusted length of stay (LOS) and drainage-related complications in relation to the hospital volume. Hospital volume was categorized into three groups based on number of cases during the study period: low-volume hospitals (LVHs; <16 cases), medium-volume hospitals (MVHs; 16-32 cases), and high-volume hospitals (HVHs; >32 cases). RESULTS Significant variation in mean LOS was observed between hospital volume categories (26.8 ± 22.6 days in LVHs vs. 23.3 ± 21.5 days in MVHs vs. 19.7 ± 17.2 days in HVHs, P < 0.001). There was a significant difference with regard to complications of endoscopic biliary drainage (5.6% in LVHs vs. 4.3% in MVHs vs. 3.2% in HVHs, P < 0.001). Multiple linear regression analysis revealed that hospital volume was most significantly associated with a decrease in risk-adjusted LOS. The standardized coefficient of MVHs was -0.155, whereas that of HVHs was -0.802. Multiple logistic regression analysis showed that hospital volume decreased the relative risk of drainage-related complications. The odds ratio (OR) of MVHs was 0.764 [95% confidence interval (CI), 0.604-0.965], whereas the OR of HVHs was 0.561 (95% CI, 0.434-0.725). CONCLUSIONS There was a significant association between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis.
Collapse
|
116
|
Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K. Probability of survival, early critical care process, and resource use in trauma patients. Am J Emerg Med 2010; 28:673-81. [PMID: 20637382 DOI: 10.1016/j.ajem.2009.02.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Revised: 01/28/2009] [Accepted: 02/27/2009] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Trauma Injury Severity Score is a frequently used prediction model for mortality. However, few studies have assessed the probability of survival (Ps) and early resource use after trauma. We studied the impact of Ps on early critical care or costs to test its applicability to efficient trauma care. METHODS The relationship between Ps in 8207 trauma patients and patients' demographics, organ injured, comorbidities, use of critical care, and total charges during the initial 48 hours was analyzed using multiple regression analyses. RESULTS Significant differences were observed among study variables across different Ps. A large variability in total charges was observed and explained by critical care, which Ps was significantly associated with. CONCLUSIONS Trauma Injury Severity Score offers a tool for estimating resource use and might improve monitoring of early trauma care quality. Measuring the combined effect of Trauma Injury Severity Score and injured organs would refine the methodology for evaluating the trauma care system.
Collapse
|
117
|
Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Hayashida K, Fujimori K. Impact of timing of bile duct interventions on resource use and clinical outcome of cholecystectomy patients in Japan. J Eval Clin Pract 2010; 16:802-10. [PMID: 20557412 DOI: 10.1111/j.1365-2753.2009.01205.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
AIMS Laparoscopic cholecystectomy (LC) is increasingly used for acute cholecystitis, in conjunction with staged bile duct interventions (BDIs). However, few studies have evaluated the impact of BDI timing on costs and clinical outcomes during hospitalization. This study assessed the effects of several types of BDI and their timing on resource utilization and complications. METHODS A total of 13,738 cholecystectomy patients were treated for benign gallbladder diseases in 66 academic and 376 community hospitals in Japan in 2006. Variables analysed included: BDIs including endoscopic retrograde cholangiopancreatography (ERCP), percutaneous gallbladder or common bile duct drainage (external drainage), endoscopic sphincterotomy, clearance of choledocholithiasis (internal drainage); and length of stay (LOS), total charges (TCs), procedure-related complications, and hospital function. Multivariate analysis was used to determine the impact of LC or BDIs on LOS, TCs and complications. RESULTS A total of 11,690 (85.1%) patients underwent LC. Inflammation was diagnosed in 70.7% of open cholecystectomy (OC) and 42.1% of LC patients. Complications were 7.7% in OC and 5.4% in LC patients. LC was associated with reduced LOS and TCs. BDIs were performed in more OC than LC patients. Preoperative was more costly than postoperative ERCP. Postoperative external drainage was significantly associated with LOS, TCs and complications. Advantages of pre- or postoperative internal drainage were not proven. CONCLUSIONS External drainage should be completed preoperatively. Postoperative ERCP may be preferable for bile duct scrutiny alone. Further evaluation of the timing of cholecystectomy will determine precisely the superiority of pre- or postoperative BDIs in terms of quality of care for complicated patients.
Collapse
|
118
|
Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Hayashida K, Fujimori K. Contribution of case-mix classification to profiling hospital characteristics and productivity. Int J Health Plann Manage 2010; 26:e138-150. [PMID: 20583315 DOI: 10.1002/hpm.1051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Case-mix classification has made it possible to analyze acute care delivery case volumes and resources. Data arising from observed differences have a role in planning health policy. Aggregated length of hospital stay (LOS) and total charges (TC) as measures of resource use were calculated from 34 case-mix groups at 469 hospitals (1,721,274 eligible patients). The difference between mean resource use of all hospitals and the mean resource use of each hospital was subdivided into three components: amount of variation attributable to hospital practice behavior (efficiency); amount attributable to hospital case-mix (complexity); and amount attributable to the interaction. Hospital characteristics were teaching status (academic or community), ownership, disease coverage, patients, and hospital volume. Multivariate analysis was employed to determine the impact of hospital characteristics on efficiency. Mean LOS and TC were greater for academic than community hospitals. Academic hospitals were least associated with LOS and TC efficiency. Low disease coverage was a predictor of TC efficiency while low patient volume was a predictor of unnecessarily long hospital stays. There was an inverse correlation between complexity and efficiency for both LOS and TC. Policy makers should acknowledge that differentiation of hospital function needs careful consideration when measuring efficiency.
Collapse
|
119
|
Fukushima D, Doi H, Fukushima K, Katsura K, Ogawa N, Sekiguchi S, Fujimori K, Sato A, Satomi S, Ishida K, Fukushima K. Glutamate exocrine dynamics augmented by plasma glutamine and the distribution of amino acid transporters of the rat pancreas. JOURNAL OF PHYSIOLOGY AND PHARMACOLOGY : AN OFFICIAL JOURNAL OF THE POLISH PHYSIOLOGICAL SOCIETY 2010; 61:265-271. [PMID: 20610855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Accepted: 05/25/2010] [Indexed: 05/29/2023]
Abstract
The nutritional and physiological roles of amino acid (AA)s have been investigated for individual organs. In the current study, we focused on the dynamics of glutamate and transport systems in the pancreas. We employed original procedures to obtain rat pancreatic juice (PJ) subjected to intravenous administration of alanyl-glutamine (AG) for AA analysis. The pancreatic expressions of the transporters were evaluated by immunohistochemistry. We found that glutamate was secreted into the PJ in the basal state. The intravenous administration of AG increased the concentration and total amount of glutamate excreted into the PJ. In terms of the transport systems, L-type AA transporter (LAT1) was identified exclusively in the islet cells. Glutamate transporter 1 (GLT1), glutamate-aspartate transporter (GLAST), vesicular glutamate transporter 1 (VGUT1) and cystine/glutamic acid transporter (xCT) were found in the islet cells. xCT was identified in the duct cells as well, but was not accompanied by the expression of 4F2 heavy chain (4F2hc) staining in the islets and the acinar cells, similar to neutral AA transporter (ASCT2) or b0,+-type AA transporter 1(BAT1). Excitatory AA transporter (EAAC) was identified only in the acinar cells. Glutamate was exclusively found in the acinar cells. We revealed the novel dynamics of glutamate in the rat PJ. The glutamate secretion into the PJ was augmented by plasma glutamine, indicating the de novo metabolisms of glutamate, together with the local expression of the related transporters.
Collapse
|
120
|
Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K. Quantitative comparison of the difficulty of performing laparoscopic colectomy at different tumor locations. World J Surg 2010; 34:133-9. [PMID: 20020298 DOI: 10.1007/s00268-009-0292-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Laparoscopic approaches of colectomy for colonic cancer are increasingly surpassing the mainstream open colectomy approach. Impact of disease variables, such as tumor location, has not been adequately measured in quality improvement initiatives. Quantitative analysis concerning the difficulty performing these procedures and differences in postoperative care depending on tumor site will contribute to the development of training programs and to the assessment of quality of care strategies. METHODS A total of 3,765 cases received laparoscopic colectomy (LC). Patient demographics, weighted comorbidities, procedure-related complications, stapling devices, operating room (OR) time, postoperative length of hospital stay (LOS), or total charges (TC) were categorized and compared based on tumor location: cecum to ascending, transverse, descending, and sigmoid colon. Multivariate analyses determined the impact of tumor location on postoperative LOS, TC, OR time, and complications. RESULTS Sigmoid colon was the most frequent tumor placement (40.5%). Significant differences in age, gender, frequency of blood transfusion, use of stapling devices, OR time, and postoperative LOS were observed among tumor locations. Transverse colon was the most significant determinant of postoperative LOS and TC, whereas descending colon tumors correlated with increased OR time. Greater OR time was associated with more postoperative resource use and complications. CONCLUSIONS Tumor location, complications, and OR time affected postoperative resource use, whereas greater OR time signified an increased occurrence of complications. Developers of LC training programs or healthcare policy makers should consider the quantitative impact of tumor locations when attempting to improve effective skill training or to survey the quality of LC performance.
Collapse
|
121
|
Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K. Effect of Hospital Characteristics on the Quality of Laparoscopic Gastrectomy in Japan. Gastroenterology Res 2010; 3:65-73. [PMID: 27956988 PMCID: PMC5139872 DOI: 10.4021/gr2010.04.189w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2010] [Indexed: 01/18/2023] Open
Abstract
Background Laparoscopic gastrectomy (LG) is becoming more widely indicated, although its application has not been investigated sufficiently in community-based gastrointestinal research because the small number of gastric cancers in western countries might have limited its use. However, concerns have been raised regarding variations in the quality of care with LG. To contribute to improving the efficient utilization of costly surgical innovations, we determined the impact of hospital characteristics on LG care. Methods Among 3,914 LG patients in 58 academic and 200 community hospitals between 2006 and 2008, we examined patient demographics, comorbidity, complications, partial or total gastrectomy, care process, hospital patient volume, hospital ownership and teaching status, and fiscal year. Hospital LG volume was divided into three quintile categories (lower volume, LV; intermediate volume, IV; or higher volume, HV) that consisted of an approximately equal number of patients. Dependent variables were operating time (OT), length of stay (LOS) and total charge (TC). The impact of hospital characteristics on these variables was assessed using multivariate analysis. Results Twenty-seven academic hospitals out of 193 LV hospitals treated 271 (21%) LG patients, 20 of 44 IV hospitals treated 596 (47%), and 11 of 21 HV hospitals treated 748 (55%). Although mortality or complications did not vary significantly between LV, IV and HV hospitals, the latter were associated with longer OT or LOS and more TC. More blood transfusions were required in HV hospitals once indicated. Hospital ownership or teaching status did not explain the variation in complications. Teaching and national hospitals consumed more resources, and municipal and private hospitals reduced OT more than national hospitals. Conclusions A volume-quality relationship was recognized. As intraoperative transfusion prolongs OT and results in more complications, clinical societies or policy makers should introduce this new technique concurrently with quality improvement initiatives that aim to reduce unnecessary OT at targeted institutions. Hospitals varied in terms of LOS and TC, therefore, policy makers should also monitor resource utilization to enhance the efficiency of LG care under restrictive fiscal policies.
Collapse
|
122
|
Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Hayashida K, Fujimori K. Contribution of bile duct drainage on resource use and clinical outcome of open or laparoscopic cholecystectomy in Japan. J Eval Clin Pract 2010; 16:31-8. [PMID: 20367813 DOI: 10.1111/j.1365-2753.2008.01109.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AIMS Laparoscopic cholecystectomy (LC) is replacing conventional open cholecystectomy (OC) as a preferred surgical method for treating complicated biliary tract disorders. However, there have been few studies assessing the impact of staged bile duct drainage (BDD) on costs and clinical outcomes for either surgical approach. This study evaluated the impact of surgical technique and BDD on resource utilization and complication rates. METHODS This study included 2778 cholecystectomy patients treated for benign biliary tract diseases in 80 academic and 81 community hospitals. For both OC and LC patients, the following variables were analysed: demographics, clinical data, length of stay (LOS), total charges (TC; US$), procedure-related complications and hospital type. Multivariate analyses were used to determine the impact of BDD on LOS, TC and complication rates. RESULTS Of the 2778 cholecystectomy patients in the study, 2255 (81.2%) underwent LC. Inflammation was diagnosed in 55.6% of OC patients and 36.0% of LC patients. Complication was 9.4% in OC cases and 4.7% in LC cases. BDD was performed in 14.5% of OC cases and in 7.6% of LC cases. Diagnosis of inflammation, presence of co-morbidities and BDD each had a significant impact on LOS and TC. After risk adjustment, LC was associated with a reduction in LOS and TC, while BDD resulted in greater LOS and TC. LC and BDD were significantly associated with complications. CONCLUSIONS The study suggested that BDD utilized more resources and had higher rates of complications. LC remains an appropriate procedure for cholecystectomy patients. Further study will be needed to evaluate the effect of pre-operative or post-operative BDD on quality of care.
Collapse
|
123
|
Matsuda S, Fujimori K, Fushimi K. Development of Casemix Based Evaluation System in Japan. ACTA ACUST UNITED AC 2010. [DOI: 10.7223/apjdm.4.55] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
124
|
Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K. Hospital volume and quality of laparoscopic gastrectomy in Japan. Dig Surg 2009; 26:422-9. [PMID: 19923832 DOI: 10.1159/000236904] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Accepted: 08/29/2009] [Indexed: 12/10/2022]
Abstract
BACKGROUND Laparoscopic gastrectomy (LG) has become the prevailing surgery of choice for gastric cancer, but the impact of hospital volume or operating room (OR) time has not been evaluated. An observational study was conducted to assess the quality of LG based on hospital volume and OR time. METHODS 3,054 LG patients were enrolled in 420 hospitals throughout Japan. Analyzed variables included patient demographics, complications, use of stapling devices or chemotherapy, hospital volume, and teaching status. Hospitals were categorized into high- (>or=4 LG per month), intermediate- (1-3) and low- (<1) volume hospitals. Multivariate analysis was used to measure hospital volume and OR time impact. RESULTS 259 laparoscopic total gastrectomies (LTGs) were performed. Complications were observed in 269 cases (8.8%). High-volume hospitals treated less severe cases. OR time, but not hospital volume, was associated with complications. Hospital volume, teaching status and stapling devices explained variations in OR time. CONCLUSION OR time was a more significant predictor of complications than hospital volume. OR time was consumed more in the employment of stapling devices and LTG. To promote LG efficiency, training curricula highlighting the applicability of these techniques should be considered by clinical experts.
Collapse
|
125
|
Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K. Impact of hospital case volume on the quality of laparoscopic colectomy in Japan. J Gastrointest Surg 2009; 13:1619-26. [PMID: 19582520 DOI: 10.1007/s11605-009-0956-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 06/12/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The increased use of laparoscopic colectomy for colon cancer requires the evaluation of hospital case volume, quality care, and training systems, considering the difficulty of this surgery for various tumor locations. MATERIALS AND METHODS We assessed the quality of this procedure in Japan, based on hospital case volume and tumor location. A total of 3,765 patients were enrolled across 567 hospitals between July and December 2007. We analyzed patient characteristics, postoperative surgical complications, the administration of stapling devices or chemotherapy, hospital volume and teaching status, postoperative length of stay, total charges, and operating room time. Hospitals were classified into four case-volume categories: high (> or =5 cases per month), intermediate to high (3-4), low to intermediate (1-2), and low (<1). Multivariate analysis was used to test the impact of hospital category and tumor location. RESULTS Ten high-volume hospitals performed 401 cases, while 355 low-volume hospitals did 903. Hospital case volume, operating time, and complications affected postoperative stay and total costs. Longer procedural time was an independent predictor of complications. Tumor location, case volume, and teaching status explained the variations in procedural time individually but not complications. Training systems highlighting the applicability of techniques are important to promote the quality of laparoscopic colectomy.
Collapse
|