Contribution of case-mix classification to profiling hospital characteristics and productivity

Profiling and Benchmarking Central Nervous System Infections in an Infectious Diseases Intensive Care Unit

BACKGROUND

There is little information comparing the performance of community acquired central nervous system infections (CNSI) treatment by intensive care units (ICUs) specialized in infectious diseases with treatment at other ICUs. Our objective was to reduce these gaps, creating bases for benchmarking and future case-mix classification.

METHODS

This is a retrospective observational cohort of 785 admissions with 82 cases of CNSI admitted to the ICU of an important Brazilian referral center for infectious diseases (INI) between January 2012 and January 2019. Comparisons were made to data retrospectively collected from the 303,500 intensive care admissions from the Brazilian state health care system included in the Epimed Monitor database. Clinical, epidemiologic, and performance indicators: the standardized mortality rate (SMR) and the standardized resource use rate per ICU surviving patient (SRU) were collected.

RESULTS

Case-mix infections profile and SMR/SRU data. SUS Mixed medical/surgical ICUs: SMR = 1.26, SRU = 1.59; SUS Neurological ICUs: SMR = 1.17, SRU = 2.23; INI ICU: SMR = 1.1, SRU = 1.1; INI ICU CNSI patients: SMR = 0.95, SRU = 1.01.

CONCLUSIONS

Severe patients with CNSI can be efficiently and effectively treated in an ICU specialized in infectious diseases when compared to mixed medical/surgical and neurological ICUs from the public health system. At the same time, we provided profiling and a case-mix that can help and encourage benchmarking by other institutions and other countries.

Mortality changes for patients with pneumococcal pneumonia from 2012 to 2017 in Japan

INTRODUCTION

Pneumococcal pneumonia has a high morbidity and mortality in adults, especially those ≥65 years old. In the past decade, pneumococcal vaccination programs have been initiated worldwide, however, few data concerning mortality changes are available in pneumococcal pneumonia patients and there are no reports clarifying these current changes in Japan.

METHODS

Japanese patients ≥65 years old hospitalized with pneumococcal pneumonia between April 2012 and March 2018 were analyzed using the Diagnostic Procedure Combination database. In-hospital mortality was evaluated, and the odds ratios for this outcome in each fiscal year compared with that in 2012 was analyzed using multivariable logistic regression models.

RESULTS

Between 2012 and 2017, data of 47,375 pneumococcal pneumonia patients ≥65 years old were extracted. The incidence per 1000 person-years for in-hospital mortality was 60.4 in 2012, 56.8 in 2013, 63.2 in 2014, 56.1 in 2015, 73.0 in 2016, and 67.4 in 2017 and the odds ratios for in-hospital mortality in 2013, 2014, 2015, 2016, and 2017 compared with that in 2012 were 1.00, 1.05, 1.04, 1.06, and 0.98, respectively. There were no significant differences between 2012 and each year from 2013 to 2017. Low BMI; low ADL score; high A-DROP score; comorbid malignancy and heart failure; the coexistence of invasive pneumococcal infection; and the use of invasive mechanical ventilation were independent risk factors for in-hospital mortality.

CONCLUSIONS

There were no changes in in-hospital mortality in pneumococcal pneumonia patients between 2012 or each year from 2013 to 2017 and further epidemiological observations are necessary.

Coexisting infectious diseases on admission as a risk factor for mechanical ventilation in patients with Guillain-Barré syndrome

Background

The aim of this study was to investigate patient characteristics on admission to hospital that increase the risk of subsequent mechanical ventilation (MV) use for patients with Guillain–Barré syndrome (GBS).

Methods

We extracted data from the Japanese Diagnosis Procedure Combination (DPC) database for 4132 GBS patients admitted to hospital. Clinical characteristics of GBS patients with and without MV were compared. Multivariate logistic regression analyses were performed to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for the associations of requirement for MV with coexisting infectious diseases, after adjustment for potential confounding variables, age, sex, hospital type, and ambulance transportation.

Results

In total, 281 patients required MV, and 493 patients had coexisting respiratory diseases on admission. After adjustment for covariates and stratification by coexisting respiratory diseases, multivariate logistic regression analysis revealed that coexisting cytomegaloviral (CMV) disease (OR 8.81; 95% CI, 2.34–33.1) and herpes simplex viral (HSV) infections (OR 4.83; 95% CI, 1.16–20.1) were significantly associated with the requirement for MV in the group without coexisting respiratory diseases.

Conclusion

Our findings suggest that coexisting CMV and HSV infections on admission might be significantly associated with increased risk of respiratory failure in GBS patients.

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Subjects of this study were 4132 inpatients with Guillain–Barré syndrome.

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Data were derived from the Japanese Diagnosis Procedure Combination (DPC) database.

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Association between comorbidities and mechanical ventilation use was evaluated.

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Cytomegaloviral and herpes simplex viral infections were associated with ventilation.

Differential Effects of Declining Rates in a Per Diem Payment System

The paper demonstrates differential effects of a prospective payment system with declining per diem rates, dependent on the percentiles of length of stay. The analysis uses dynamic panel data estimates and a recent nationwide administrative database for major diagnostic categories in 1068 Japanese hospitals in 2006-2012 to show that average length of stay significantly increases for hospitals in percentiles 0-25 of the pre-reform length of stay and significantly decreases for hospitals in percentiles 51-100. The decline of the average length of stay is larger for hospitals in higher percentiles of the length of stay. Hospitals in percentiles 51-100 significantly increase their rate of nonemergency/unanticipated readmissions within 42 days after discharge. The decline in the length of total episode of treatment is smaller for hospitals in percentiles 0-25. The findings are robust in terms of the choice of a cohort of hospitals joining the reform. The paper discusses applicability of 'best practice' rate-setting to help improve the performance of hospitals in the lowest quartile of average length of stay. Copyright © 2015 John Wiley & Sons, Ltd.

Efficacy of concurrent treatments in idiopathic pulmonary fibrosis patients with a rapid progression of respiratory failure: an analysis of a national administrative database in Japan

Background

Some IPF patients show a rapid progression of respiratory failure. Most patients are treated with high-dose corticosteroids. However, no large clinical studies have investigated the prognosis or efficacy of combined treatments including high-dose corticosteroids in IPF patients with a rapid progression of respiratory failure.

Methods

We enrolled IPF patients who received mechanical ventilation and high-dose corticosteroids between April 2010 and March 2013. Records were extracted from a Japanese nationwide inpatient database. We conducted a retrospective epidemiologic and prognostic analysis.

Results

Two hundred nine patients receiving an average of 12.8 days of ventilatory support were enrolled. There were 138 (66 %) fatal cases; the median survival was 21 days. The short-term (within 30 days) and long-term (within 90 days) survival rates were 44.6 and 24.6 %, respectively. The average monthly admission rate among the IPF patients with the rapid progression of respiratory failure in the winter was significantly higher than that in spring (p = 0.018). Survival did not differ to a statistically significant extent in the different geographic areas of Japan. Survivors were significantly younger (p = 0.002) with higher rates of mild dyspnea on admission (p = 0.012), they more frequently underwent bronchoscopy (p < 0.001), and received anticoagulants (p = 0.027), co-trimoxazole (p < 0.001) and macrolide (p = 0.02) more frequently than non-survivors. A multivariate logistic analysis demonstrated that two factors were significantly associated with a poor prognosis: >80 years of age (OR = 2.94, 95 % Cl 1.044–8.303; p = 0.041) and the intravenous administration of high-dose cyclophosphamide (OR = 3.17, 95 % Cl 1.101–9.148; p = 0.033). Undergoing bronchoscopy during intubation (OR = 0.25, 95 % Cl 0.079–0.798; p = 0.019) and the administration of co-trimoxazole (OR = 0.28, 95 % Cl 0.132–0.607; p = 0.001) and macrolides (OR = 0.37, 95 % Cl 0.155–0.867; p = 0.033) were significantly associated with a good prognosis. The dosage of co-trimoxazole significantly correlated with survival.

Conclusions

Co-trimoxazole and macrolides may be a good addition to high-dose corticosteroids in the treatment of IPF patients with a rapid progression of respiratory failure.

Impact of teaching intensity and academic status on medical resource utilization by teaching hospitals in Japan

Teaching hospitals require excess medical resources to maintain high-quality care and medical education. To evaluate the appropriateness of such surplus costs, we examined the impact of teaching intensity defined as activities for postgraduate training, and academic status as functions of medical research and undergraduate teaching on medical resource utilization. Administrative data for 47,397 discharges from 40 academic and 12 non-academic teaching hospitals in Japan were collected. Hospitals were classified into three groups according to intern/resident-to-bed (IRB) ratio. Resource utilization of medical services was estimated using fee-for-service charge schedules and normalized with case mix grouping. 15-24% more resource utilization for laboratory examinations, radiological imaging, and medications were observed in hospitals with higher IRB ratios. With multivariate adjustment for case mix and academic status, higher IRB ratios were associated with 10-15% more use of radiological imaging, injections, and medications; up to 5% shorter hospital stays; and not with total resource utilization. Conversely, academic status was associated with 21-33% more laboratory examinations, radiological imaging, and medications; 13% longer hospital stays; and 10% more total resource utilization. While differences in medical resource utilization by teaching intensity may not be associated with indirect educational costs, those by academic status may be. Therefore, academic hospitals may need efficiency improvement and financial compensation.