Effectiveness of regional clinical pathways on postoperative length of stay for hip fracture patients: A retrospective observational study using the Japanese Diagnosis Procedure Combination database

Satisfaction Survey for Regional Clinical Pathway for Stroke Patients in Acute and Rehabilitation Hospitals in Japan

Objectives

We collected opinions about the use of a stroke-specific regional clinical pathway for facilitating collaboration between acute and rehabilitation hospitals in Japan.

Methods

The study surveys were administered in acute hospitals designated as primary stroke centers and certified by the Japan Stroke Association (n=961) and in rehabilitation hospitals affiliated with the Kaifukuki Rehabilitation Ward Association (n=1237). The survey collected information on interfacility collaboration when caring for patients admitted during the acute phase following non-traumatic stroke from April 2020 to March 2021. We examined the pathway's usefulness and challenges relative to facility type using the χ² test.

Results

Of 422 acute hospitals and 223 rehabilitation hospitals that responded to our survey, 259 (62.1%) acute hospitals and 164 (85.4%) rehabilitation hospitals used the pathway. Fewer rehabilitation hospitals than acute hospitals considered that the pathway was useful (52.0% vs. 63.8%, P=0.02). Fewer rehabilitation hospitals did not experience pathway-related problems when compared with acute hospitals (38.0% vs. 55.8%, P<0.01).

Conclusions

Personnel at rehabilitation hospitals were less satisfied with the regional clinical care pathway than those in acute hospitals. These results suggest that the current stroke-specific regional clinical pathway could be improved.

Validation of Operational Definition to Identify Patients with Osteoporotic Hip Fractures in Administrative Claims Data

As incidences of osteoporotic hip fractures (OHFs) have increased, identifying OHFs has become important to establishing the medical guidelines for their management. This study was conducted to develop an operational definition to identify patients with OHFs using two diagnosis codes and eight procedure codes from health insurance claims data and to assess the operational definition’s validity through a chart review. The study extracted data on OHFs from 522 patients who underwent hip surgeries based on diagnosis codes. Orthopedic surgeons then reviewed these patients’ medical records and radiographs to identify those with true OHFs. The validities of nine different algorithms of operational definitions, developed using a combination of three levels of diagnosis codes and eight procedure codes, were assessed using various statistics. The developed operational definition showed an accuracy above 0.97 and an area under the receiver operating characteristic curve above 0.97, indicating excellent discriminative power. This study demonstrated that the operational definition that combines diagnosis and procedure codes shows a high validity in detecting OHFs and can be used as a valid tool to detect OHFs from big health claims data.

Temporal trends of medical cost and cost-effectiveness in sepsis patients: a Japanese nationwide medical claims database

Background

Sepsis is the leading cause of death worldwide. Although the mortality of sepsis patients has been decreasing over the past decade, the trend of medical costs and cost-effectiveness for sepsis treatment remains insufficiently determined.

Methods

We conducted a retrospective study using the nationwide medical claims database of sepsis patients in Japan between 2010 and 2017. After selecting sepsis patients with a combined diagnosis of presumed serious infection and organ failure, patients over the age of 20 were included in this study. We investigated the annual trend of medical costs during the study period. The primary outcome was the annual trend of the effective cost per survivor, calculated from the gross medical cost and number of survivors per year. Subsequently, we performed subgroup and multiple regression analyses to evaluate the association between the annual trend and medical costs.

Results

Among 50,490,128 adult patients with claims, a total of 1,276,678 patients with sepsis were selected from the database. Yearly gross medical costs to treat sepsis gradually increased over the decade from $3.04 billion in 2010 to $4.38 billion in 2017, whereas the total medical cost per hospitalization declined (rate = − $1075/year, p < 0.0001). While the survival rate of sepsis patients improved during the study period, the effective cost per survivor significantly decreased (rate = − $1806/year [95% CI − $2432 to − $1179], p = 0.001). In the subgroup analysis, the trend of decreasing medical cost per hospitalization remained consistent among the subpopulation of age, sex, and site of infection. After adjusting for age, sex (male), number of chronic diseases, site of infection, intensive care unit (ICU) admission, surgery, and length of hospital stay, the admission year was significantly associated with reduced medical costs.

Conclusions

We demonstrated an improvement in annual cost-effectiveness in patients with sepsis between 2010 and 2017. The annual trend of reduced costs was consistent after adjustment with the confounders altering hospital expenses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-022-00624-5.

Feasibility, acceptability, and preliminary effects of PATH FOR timely transfer of geriatric HIP fracture patients from hospital to rehabilitation to home (PATH4HIP): a protocol for a mixed method study

BACKGROUND

Hip fractures in older adults are significant contributors to severe functional decline and disability as well as hospitalization and increased health care costs. Research shows that timely referral to geriatric rehabilitation leads to better patient outcomes. Currently, a wide variability in the timing, the frequency, and the choice of appropriate setting for rehabilitation of hip fracture patients exists.

AIM

Evaluate the feasibility, acceptability, and preliminary effectiveness of PATH4HIP, a pathway intervention for timely transfer of post-operative geriatric hip fracture patients from hospital to rehabilitation to home.

METHODS

This is a single-arm, pragmatic feasibility study to measure reach, effectiveness, adoption, implementation, and maintenance of PATH4HIP, a pathway for post-operative hip fracture patients from a large academic health science center to a geriatric rehabilitation service in Ottawa, Canada. During a 6-month period, all hip fracture patients, 65 years of age or older who have undergone surgery and have met the eligibility criteria (n = 96), will be transferred to the geriatric rehabilitation service no later than post-operative day 6. Patients (n = 10-12) and clinicians who are working on the orthopedic team (n = 10-12) and on the geriatric rehabilitation service (n = 10-12) will be invited to participate in an interview to share their feedback on the intervention's feasibility and acceptability and to provide suggestions to improve PATH4HIP. Descriptive statistics will be used to summarize results of the quantitative data and content analysis will be used to analyze the qualitative data. The study will be open for recruitment from January to July 2022.

DISCUSSION

If feasible, PATH4HIP will result in the reduction of the post-operative acute care length of stay to less than or equal to 6 days, while having no detrimental effect on rehabilitation outcomes such as functional gains, or discharge destination.

Considerations for Better Management of Postoperative Pain in Light of Chronic Postoperative Pain: A Narrative Review

Chronic postoperative pain (CPOP) is prevalent, with particularly high rates in breast surgery, thoracotomy, and amputation. As the world emerges from the coronavirus disease 2019 (COVID-19) lockdowns, it is expected that there will be an increase in surgical procedures, elevating the importance of preventing CPOP in the coming years. Risk factors are emerging to better stratify patients at high risk for CPOP. Perioperative analgesia plays an important role in managing acute postoperative pain and in some cases may limit its transition to CPOP. Acute postoperative pain is adaptive, normal, expected, and has a well-defined trajectory, while CPOP is maladaptive and, as a form of chronic pain, is challenging to treat. Good analgesia, early ambulation, and rehabilitation efforts may be helpful in preventing CPOP following certain surgeries. Enhanced Recovery After Surgery (ERAS) protocols present guidance to help promote recovery and prevent CPOP.

Shorter acute hospital length of stay in hip fracture patients after surgery predicted by early surgery and mobilization

Time to surgery, early mobilization, fracture type, and ASA grades independently affect acute hospital length of stay after hip fracture surgery. Modifiable factors can be audited to reduce length of stay, and non-modifiable factors can be used for consideration of a tiered bundled payment reimbursement model.

INTRODUCTION

As hip fracture incidence rises with our ageing global population, there will be an increase in consumption of healthcare resources. We hypothesized that hospital management and patient factors can affect healthcare burden load. Using length of stay (LOS) as a surrogate for consumption, the aim of this study is to elucidate the effect of hospital management and patient-related factors on length of stay (LOS) for patients after hip fracture surgery. We studied modifiable and non-modifiable factors influencing LOS, and identification of these modifiable factors accords opportunities for mitigating these factors.

METHODS

This retrospective study examines hip fracture data from a large tertiary hospital in Singapore over the period of 2017 to 2020. Data collected on the electronic medical record included age, gender, race, marital status, payer type, ASA score, TTS, type of surgery, fracture type, POD1 mobilization, discharge position, and presence of pressure sores, and they were correlated with LOS using binary logistic regression on SAS.

RESULTS

A total of 1045 patients were included in this study with 704 females and 341 males. The mean age was 79.5 ± 8.57 years (range 60-105) with an average LOS 13.64 ± 10.0 days (range 2-114). On binary logistic regression, ASA and trochanteric fracture remains a significant non-modifiable factor for LOS with OR = 1.486 (95% CI 1.106, 1.996, p = 0.0086) and OR 1.522 (95% CI 1.149, 2.015, p = 0.0034) respectively. Significant modifiable factors were TTS > 48 h (OR = 1.819, 95% CI 1.205, 2.746, p = 0.0044) and POD1 mobilization (OR = 0.441, 95% CI 0.257, 0.756, p = 0.0029).

CONCLUSIONS

Our analysis showed TTS and POD1 are significant modifiable factors for LOS, and resources can be diverted towards them for the management of hip fracture patients and pre-empting the increasing load on our healthcare system.

Trends in the incidence and outcome of sepsis using data from a Japanese nationwide medical claims database-the Japan Sepsis Alliance (JaSA) study group

Background

Trends in the incidence and outcomes of sepsis using a Japanese nationwide database were investigated.

Methods

This was a retrospective cohort study. Adult patients, who had both presumed serious infections and acute organ dysfunction, between 2010 and 2017 were extracted using a combined method of administrative and electronic health record data from the Japanese nationwide medical claim database, which covered 71.5% of all acute care hospitals in 2017. Presumed serious infection was defined using blood culture test records and antibiotic administration. Acute organ dysfunction was defined using records of diagnosis according to the international statistical classification of diseases and related health problems, 10th revision, and records of organ support. The primary outcomes were the annual incidence of sepsis and death in sepsis per 1000 inpatients. The secondary outcomes were in-hospital mortality rate and length of hospital stay in patients with sepsis.

Results

The analyzed dataset included 50,490,128 adult inpatients admitted between 2010 and 2017. Of these, 2,043,073 (4.0%) patients had sepsis. During the 8-year period, the annual proportion of patients with sepsis across inpatients significantly increased (slope = + 0.30%/year, P < 0.0001), accounting for 4.9% of the total inpatients in 2017. The annual death rate of sepsis per 1000 inpatients significantly increased (slope = + 1.8/1000 inpatients year, P = 0.0001), accounting for 7.8 deaths per 1000 inpatients in 2017. The in-hospital mortality rate and median (interquartile range) length of hospital stay significantly decreased (P < 0.001) over the study period and were 18.3% and 27 (15–50) days in 2017, respectively.

Conclusions

The Japanese nationwide data indicate that the annual incidence of sepsis and death in inpatients with sepsis significantly increased; however, the annual mortality rates and length of hospital stay in patients with sepsis significantly decreased. The increasing incidence of sepsis and death in sepsis appear to be a significant and ongoing issue.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03762-8.

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

BACKGROUND

Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues.

AIM

To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF.

METHODS

A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence.

RESULTS

A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics).

CONCLUSION

These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

Pre-transplant Rehabilitation to Decrease the Post-transplant Length of Stay for Hematological Malignancy Patients Undergoing Allo-HSCT

Objectives:

Pre-transplant rehabilitation for hematological malignancy patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) helps improve physical capacity. However, its benefit with respect to post-transplant hospital length of stay (LOS) is unclear. Consequently, the aim of this study was to investigate the effect of pre-transplant rehabilitation on post-transplant LOS for hematological malignancy patients undergoing allo-HSCT.

Methods:

Data on patients diagnosed between April 2014 and March 2017 were collected from the Japanese Diagnosis Procedure Combination database. The patients were identified using the ICD-10 codes C81–85, C90–94, C96, and D46. Multilevel linear regression analyses were conducted to identify the effects of pre-transplant rehabilitation on post-transplant LOS (log transformed).

Results:

In total, 3614 patients were included in the study. Pre-transplant rehabilitation was associated with a significant reduction in post-transplant hospital LOS (β=–0.134, P<0.001).

Conclusions:

Pre-transplant rehabilitation may be an effective strategy for shortening the post-transplant hospital LOS in hematological malignancy patients undergoing allo-HSCT. Consequently, it may be necessary to consider starting rehabilitation before transplantation.

[An Introduction to Real-world Data and Tips for Analysing It]

Medical big data, also referred to as 'real-world data' (RWD) is defined as "data related to patient health status and/or health care delivery collected routinely from a variety of sources". This includes data from disease and drug registries, electronic health records, claims and billing data and census data collected from clinicians, hospitals, and payers. Observational studies using RWD collected during general clinical practice are considered complementary to randomized control trials. However, since this design does not allow the random assignment of patients, causal inference analyses are required. Researchers should study the protocol properly before considering the combination of study design, the characteristics of data source, calculation of the appropriate sample size and the validity of outcomes. Data definition using data code should also be considered. Furthermore, the reliability of the source studies must be considered and discussed when the article is written. This review aims to outline the methods for performing reliable observational studies using RWD.

History and Profile of Diagnosis Procedure Combination (DPC): Development of a Real Data Collection System for Acute Inpatient Care in Japan

DPC, which is an acronym for “Diagnosis Procedure Combination,” is a patient classification method developed in Japan for inpatients in the acute phase of illness. It was developed as a measuring tool intended to make acute inpatient care transparent, aiming at standardization of Japanese medical care, as well as evaluation and improvement of its quality. Subsequently, this classification method came to be used in the Japanese medical service reimbursement system for acute inpatient care and appropriate allocation of medical resources. Furthermore, it has recently contributed to the development and maintenance of an appropriate medical care provision system at a regional level, which is accomplished based on DPC data used for patient classification. In this paper, we first provide an overview of DPC. Next, we will look back at over 15 years of DPC history; in particular, we will explore how DPC has been refined to become an appropriate medical service reimbursement system. Finally, we will introduce an outline of DPC-related research, starting with research using DPC data.

Hospitalization and discharge routes of elderly hip fracture patients with and without dementia: a nationwide cross-sectional exploratory study using the Japanese Diagnostic Procedure Combination database

PURPOSE

The characteristics of elderly hip fracture patients in acute care hospitals were analyzed based on hospitalization and discharge route and the presence or absence of a dementia diagnosis.

METHODS

The study was conducted as a cross-sectional exploratory study using data from the Diagnosis Procedure Combination database in Japan from April 2014 to March 2016. Patients aged 65 years or older who had surgery for a hip fracture were identified. We subsequently extracted patients whose home, medical institution (including convalescent rehabilitation wards), or elderly care facility was both the admission and discharge route. A total of 105 122 patients were included.

RESULTS

19% of patients were diagnosed with dementia. Patients with dementia had a shorter length of acute care hospital stay than those without dementia. The hospitalization route for dementia patients was 51% at home and 40% at a care facility. Dementia patients were discharged to hospital and care facilities at 41% each. Nearly all patients received hospital-based postoperative rehabilitation regardless of dementia but patients with dementia had lower gains in activities of daily living.

CONCLUSION

Hip fracture patients with dementia have less opportunity for continuous hospital-based rehabilitation and need an environment that allows for continuous elderly care facility-based and community-based rehabilitation.IMPLICATIONS FOR REHABILITATIONIn Japan, an aging society, one in five elderly patients undergoing hip fracture surgery was diagnosed with dementia.Many hip fracture patients with dementia have a shorter length of hospital stay and may have fewer opportunities to change hospitals to receive rehabilitation.It is necessary to establish an ongoing and proactive community- and elderly care facility-based rehabilitation system for patients with hip fracture with dementia after acute care hospital discharge.

Insufficient Postoperative Rehabilitation in Patients with Both Proximal Femoral Fracture and Antecedent Mental Illness

Introduction:

Though a combination of proximal femoral fracture and mental illness is likely, the management of this combination is not well established. The aim of this study was to clarify the current disposition of acute care and rehabilitation for patients with this combination of conditions at our institution.

Methods:

We retrospectively analyzed the records of 192 patients hospitalized in the psychiatric ward who present with a proximal femoral fracture and an antecedent mental illness. We investigated walking ability prior to injury and after surgery, at discharge from our institution, using the Functional Independence Measure (FIM) score.

Results:

Although patients in the psychiatric ward demonstrated postoperative hospital stays approximately 10 days longer than those in the orthopedic ward, more than half of the patients in the psychiatric ward were discharged from our institution with a functional level of complete dependence for walking ability. In addition, nearly 90% of the patients studied were transferred to a psychiatric hospital where no physical therapy or rehabilitation was provided to the inpatients.

Conclusions:

At our institution, patients with proximal femoral fracture and antecedent mental illness tended to be discharged with complete dependence in walking ability, often to a psychiatric hospital without physical therapy or rehabilitation. We hope this paper will draw attention to the need for rehabilitation in these patients.