Differences in management and outcomes of acute myocardial infarction among four general hospitals in Japan

Impact of timing of bile duct interventions on resource use and clinical outcome of cholecystectomy patients in Japan

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.

Contribution of bile duct drainage on resource use and clinical outcome of open or laparoscopic cholecystectomy in Japan

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.

Difference in resource utilization between patients with acute and chronic heart failure from Japanese administrative database

BACKGROUND

Many studies have reported economic evaluation of evolving agents or therapies for patients with heart failure (HF). However, little is known whether the disease progression category (acute or chronic HF) would be considered as a risk adjustment in health service research.

OBJECTIVES

This study profiles the difference in resource use or medical care for acute versus chronic HF.

METHODS

This study analyzed 17,912 HF patients treated in 62 academic hospitals and 351 community hospitals. Study variables included demographic variables, comorbid status, physical activity or disease progression at admission, procedures and laboratory tests, type and dose of heart-related medications, length of stay (LOS), and total charges (TC; 1 US$= 100 yen) for acute and chronic HF. The independent contributions of disease progression categories on LOS and TC were identified using multivariate analysis.

RESULTS

We identified 9813 chronic and 8099 acute HF patients. Median LOS was 18 days for both chronic and acute HF, whereas TC was US$5731 and US$6447, respectively. Regression analysis revealed that acute HF was associated with a slightly greater TC, whereas performance of procedures was the most prominent factor. As NYHA class was the next most influential factor, class 3 or 4 resulted in longer LOS or greater TC, than did class 1.

CONCLUSIONS

This study suggests that acute HF increased resource use slightly, whereas use of some practices indicated in critical care was affected more by the procedures performed. Disease progression category should remain an indicator for appropriateness of medical care.

Impact of age and procedure on resource use for patients with ischemic heart disease

OBJECTIVES

Impact of age on healthcare expenditures should be assessed by targeting on specific diseases and controlling for procedures and severity of illness. Relationship between age and resource use in patients receiving acute care medicine for ischemic heart disease (IHD) was examined.

METHODS

We analyzed 19,874 IHD patients treated in 82 academic and 92 community hospitals. Length of stay (LOS), total charges (TC), and high outliers of LOS and TC were analyzed for every age group (under 65 years, 65-74 years, 75 years or older). Independent effects of age on LOS, TC, and high outliers of LOS and TC were determined using multivariate analysis.

RESULTS

7863 (39.6%) patients were under 65 years, 7181 (36.1%) between 65 years and 74 years, and 4830 (24.3%) aged 75 years or older. Proportion of angina or non-medical treatment was significantly different among three age categories (angina 72%, 75%, 71.4%; non-medical 37.3%, 40.9%, 38.9%, respectively). Significant association with LOS or TC was identified in patients receiving coronary artery bypass graft surgery with percutaneous intracoronary intervention, who were most associated with TC high outlier.

CONCLUSIONS

Age had a modest impact on resource use, as compared with procedures. Policy makers need to acknowledge the impact of procedures on healthcare spending.

What is the empirical evidence that hospitals with higher-risk adjusted mortality rates provide poorer quality care? A systematic review of the literature

Background

Despite increasing interest and publication of risk-adjusted hospital mortality rates, the relationship with underlying quality of care remains unclear. We undertook a systematic review to ascertain the extent to which variations in risk-adjusted mortality rates were associated with differences in quality of care.

Methods

We identified studies in which risk-adjusted mortality and quality of care had been reported in more than one hospital. We adopted an iterative search strategy using three databases – Medline, HealthSTAR and CINAHL from 1966, 1975 and 1982 respectively. We identified potentially relevant studies on the basis of the title or abstract. We obtained these papers and included those which met our inclusion criteria.

Results

From an initial yield of 6,456 papers, 36 studies met the inclusion criteria. Several of these studies considered more than one process-versus-risk-adjusted mortality relationship. In total we found 51 such relationships in a widen range of clinical conditions using a variety of methods. A positive correlation between better quality of care and risk-adjusted mortality was found in under half the relationships (26/51 51%) but the remainder showed no correlation (16/51 31%) or a paradoxical correlation (9/51 18%).

Conclusion

The general notion that hospitals with higher risk-adjusted mortality have poorer quality of care is neither consistent nor reliable.

Identification of uncomplicated patients with acute myocardial infarction undergoing percutaneous coronary intervention: are these patients suitable for early discharge?

BACKGROUND

The hospital stay after acute myocardial infarction (AMI) is still extremely long in Japan and does not correspond with disease severity. The purpose of the present study was to identify a subgroup of AMI patients suitable for early discharge.

METHODS AND RESULTS

A total of 3,739 AMI patients treated with percutaneous coronary intervention (PCI) within 24 h after onset, who enrolled Osaka Acute Coronary Insufficiency Study between April 1998 and March 2004, were studied. Patients showing no complications within the first 7 days (n=1,786) were considered to be eligible for early discharge. In these patients, multivariate logistic regression analysis selected prior myocardial infarction, left anterior descending coronary artery disease and failed PCI as independent predictors of major complications from day 8 to discharge. Patients without any predictor had significant lower rates of major complications from day 8 to 6 months after discharge than those with 1 or more predictors. Furthermore, in the present study there were no deaths in patients without any predictors.

CONCLUSION

Patients who either do not have serious complications during the first 7 days or any predictor are at very low risk of major complications from day 8 to 6 months after discharge. These carefully selected patients may be suitable for early (day 8) hospital discharge after AMI.

Longitudinal Study of Acute Myocardial Infarction in the Southeast Osaka District From 1988 to 2002

BACKGROUND

Data on clinical characteristics, long-term mortality rates, and factors influencing outcome of acute myocardial infarction (AMI) based on an unselected cohort in the percutaneous coronary intervention (PCI) era are still limited in Japan.

METHODS AND RESULTS

In the present study 415 consecutive patients with AMI who were admitted to hospital within 24 h of symptom onset between January 1988 and December 2002 were studied. There was a marked seasonal variation of AMI with a minimum in summer and a maximum in winter, as well as a marked circadian variation with a significant morning peak. Overall, 45.8% of patients were treated with primary PCI. Increased age and female sex were negatively associated with the probability of undergoing PCI. During the follow-up period (mean duration, 4.01+/-3.41 years), the unadjusted long-term all-cause mortality rate was 21.4%. Multivariate Cox regression analysis showed that age, prior cerebrovascular disease, renal failure, Killip > or =2, and ventricular tachycardia/fibrillation were independent predictors of worse long-term mortality after AMI. Furthermore, the use of PCI was independently associated with favorable long-term survival after AMI.

CONCLUSIONS

Although PCI was associated with a favorable long-term mortality, it remains underused in subsets of patients and increased use may further reduce the long-term mortality rate in Japanese AMI patients.

Predictors of Length of Hospital Stay After Acute Myocardial Infarction in Japan

BACKGROUND

In Western countries, the length of hospital stay after acute myocardial infarction (AMI) has decreased dramatically during the past 3 decades and is now approximately 1 week. However, epidemiological data concerning the length of hospital stay, its predictors and trends based on a large-scale sample are still limited in Japan.

METHODS AND RESULTS

The study group comprised 4,113 surviving AMI patients who were enrolled in the Osaka Acute Coronary Insufficiency Study from April 1998 to March 2003. The mean length of hospital stay was 31.2 days. Clinical factors (patient characteristics, severity of infarction, therapy, and in-hospital complications) only explained 26% of the variation in hospital stay. The mean hospital stay was significantly longer in 1998 than in 2002. In 2002, occupational status and admission to a high-volume hospital were independent predictors of a shorter hospital stay, but this association was not observed in 1998.

CONCLUSIONS

The hospital stay is still extremely long in Japan and clinical factors do not provide an explanation. The findings of the present study suggest that the hospital stay could be reduced in some patients with AMI, but randomized studies are needed to examine the feasibility of early discharge.