Impact of patient characteristics and treatment procedures on hospitalization cost and length of stay in Japanese patients with influenza: A structural equation modelling approach

The Cost of Seasonal Influenza: A Systematic Literature Review on the Humanistic and Economic Burden of Influenza in Older (≥ 65 Years Old) Adults

INTRODUCTION

Adults aged ≥ 65 years contribute a large proportion of influenza-related hospitalizations and deaths due to increased risk of complications, which result in high medical costs and reduced health-related quality of life (HRQoL). Although seasonal influenza vaccines are recommended for older adults, the effectiveness of current vaccines is dependent on several factors including strain matching and recipient demographic factors. This systemic literature review aimed to explore the economic and humanistic burden of influenza in adults aged ≥ 65 years.

METHODS

An electronic database search was conducted to identify studies assessing the economic and humanistic burden of influenza, including influenza symptoms that impact the HRQoL and patient-related outcomes in adults aged ≥ 65 years. Studies were to be published in English and conducted in Germany, France, Spain, and Italy, the UK, USA, Canada, China, Japan, Brazil, Saudi Arabia, and South Africa.

RESULTS

Thirty-eight studies reported on the economic and humanistic burden of influenza in adults aged ≥ 65 years. Higher direct costs were reported for people at increased risk of influenza-related complications compared to those at low risk. Lower influenza-related total costs were found in those vaccinated with adjuvanted inactivated trivalent influenza vaccine (aTIV) compared to high-dose trivalent influenza vaccine (TIV-HD). Older age was associated with an increased occurrence and longer duration of certain influenza symptoms.

CONCLUSION

Despite the limited data identified, results show that influenza exerts a high humanistic and economic burden in older adults. Further research is required to confirm findings and to identify the unmet needs of current vaccines.

Associations of acute medical care with the transfer and acceptance functions of hospitals in a region in Japan with limited medical resources

BACKGROUND

Japan's health care system may be providing inpatient care inefficiently with a low number of physicians per hospital bed and a long average length of stay (LOS). The present study examined associations of acute medical care with hospital-level factors, such as the transfer and acceptance rates, and mediation effect of LOS, using medical service fees per day as an outcome measure for the provision of acute medical care in hospitals in a region with limited medical resources.

METHODS

To analyze the associations of acute medical care with hospital-level factors, this research used multilevel structural equation modeling (SEM) of a dataset that included 225,203 patients admitted to 99 hospitals in Fukushima, Japan. The characteristics of the patients, medical activities, and hospitals, such as the transfer and acceptance rates, were assumed to have both direct and indirect effects through LOS on medical service fees per day.

RESULTS

The final analysis used data from 165,413 patients discharged or transferred from 79 hospitals. After separating patient-level effects using multilevel SEM, the results revealed that, at the hospital level, the transfer rate had a significant and positive association with increased medical service fees per day, both directly (standardized coefficient [SC] = 0.215) and indirectly (SC = 0.057) through shortened LOS. The number of first hospitalized patients per physician had a significant and positive association with increased medical service fees per day only indirectly through shortened LOS (SC = 0.063). The acceptance rate had a significant and negative association with medical service fees per day only indirectly through prolonged LOS (SC = -0.078).

CONCLUSIONS

Hospital-level factors, such as enhanced transfer function, reduced acceptance function, and a large number of patients for treatment of acute episodes per physician, had positive associations with increased medical service fees per day, either directly or indirectly through LOS.

Comparison of patient characteristics and in-hospital mortality between patients with COVID-19 in 2020 and those with influenza in 2017-2020: a multicenter, retrospective cohort study in Japan

Background

COVID-19 has worse mortality than influenza in American and European studies, but evidence from the Western Pacific region is scarce.

Methods

Using a large-scale multicenter inpatient claims data in Japan, we identified individuals hospitalised with COVID-19 in 2020 or influenza in 2017–2020. We compared patient characteristics, supportive care, and in-hospital mortality, with multivariable logistic regression analyses for in-hospital mortality overall, by age group, and among patients with mechanical ventilation.

Findings

We identified 16,790 COVID-19 patients and 27,870 influenza patients, with the different age distribution (peak at 70–89 years in COVID-19 vs. bimodal peaks at 0–9 and 80–89 years in influenza). On admission, the use of mechanical ventilation was similar in both groups (1·4% vs. 1·4%) but higher in the COVID-19 group (3·3% vs. 2·5%; p<0·0001) during the entire hospitalisation. The crude in-hospital mortality was 5·1% (856/16,790) for COVID-19 and 2·8% (791/27,870) for influenza. Adjusted for potential confounders, the in-hospital mortality was higher for COVID-19 than for influenza (adjusted odds ratio [aOR] 1·83, 95% confidence interval [CI] 1·64–2·04). In age-stratified analyses, the aOR (95%CI) were 0·78 (0·56–1·08) and 2·05 (1·83–2·30) in patients aged 20–69 years and ≥70 years, respectively (p-for-interaction<0·0001). Among patients with mechanical ventilation, the aOR was 0·79 (0·59–1·05).

Interpretation

Patients hospitalised with COVID-19 in Japan were more likely to die than those with influenza. However, this was mainly driven by findings in older people, and there was no difference once mechanical ventilation was started.

Funding

Ministry of Health, Labour and Welfare of Japan (21AA2007).

Length of stay, hospitalisation costs and in-hospital mortality of methicillin-susceptible and methicillin-resistant Staphylococcus aureus bacteremia in Japan

OBJECTIVES

To examine the length of stay, hospitalisation costs and case fatality of methicillin-susceptible and -resistant Staphylococcus aureus (MSSA and MRSA) bacteremia in Japan.

STUDY DESIGN

Retrospective cohort study. Patients with a diagnosis of S. aureus bacteremia who were admitted to a tertiary care hospital (the National Centre for Global Health and Medicine [NCGM]) in Tokyo, Japan, between 1st January 2016 and 31st December 2020 were included in the study.

METHODS

We combined Japan Nosocomial Infections Surveillance data and Diagnosis Procedure Combination data at NCGM from 2016 to 2020. The data were stratified into MSSA and MRSA groups. Length of stay (LoS), LoS after submission of a blood culture specimen (LoS-after), hospitalisation cost, hospitalisation costs per day and clinical outcome were compared after propensity score matching.

RESULTS

Median LoS was 46 (interquartile range [IQR] 28.5-64.5) days in the MSSA group and 66 (IQR 40-91) days in the MRSA group (P = 0.020). Median LoS-after was 38 (IQR 25-62.5) days and 45 (IQR 24-63) days (P = 0.691) in the MSSA and MRSA groups, respectively. Median hospitalisation cost was significantly higher in the MRSA group (26,035 [IQR 18,154-47,362] USD) than in the MSSA group (19,823 [IQR 13,764-32,042] USD) (P = 0.036), but cost per day was not (MRSA: 528.9 [IQR 374.9-647.4] USD; MSSA: 455.6 [IQR 359.2-701.7] USD; P = 0.990). Case fatality rate was higher in the MRSA group than in the MSSA group (22/60 vs 9/60, P = 0.012).

CONCLUSIONS

Patients with MRSA bacteremia had longer LoS and higher costs than those with MSSA bacteremia. However, LoS-after and hospitalisation costs per day were not different. The longer LoS of patients in Japan compared with other countries might contribute to the higher disease burden of S. aureus bacteremia in Japan.

Epidemiology and burden of illness of seasonal influenza among the elderly in Japan: A systematic literature review and vaccine effectiveness meta-analysis

BACKGROUND

Elderly populations are particularly vulnerable to influenza and often require extensive clinical support. In Japan, nationwide passive surveillance monitors seasonal influenza but does not capture the full disease burden. We synthesized existing evidence on the epidemiology, vaccine effectiveness (VE), and economic burden of seasonal influenza in the elderly population.

METHODS

PubMed, EMBASE, and ICHUSHI were searched for articles on seasonal influenza in Japan, published between 1997 and 2018, in English or Japanese. Grey literature was also assessed. A random-effects meta-analysis characterized VE of influenza vaccines among studies reporting this information.

RESULTS

Of 1,147 identified articles, 143 met inclusion criteria. Reported incidence rates varied considerably depending on study design, season, study setting and, most importantly, case definition. In nursing homes, the maximum reported attack rate was 55.2% and in the 16 articles reporting mortality rates, case fatality rates varied from 0.009% to 14.3%. Most hospitalizations were in people aged >60; healthcare costs were partially mitigated by vaccine administration. Meta-analysis estimated overall VE of 19.1% (95% CI: 2.3% - 33.0%) with a high proportion of heterogeneity (I2 : 89.1%). There was a trend of lower VE in older people (40.1% [-57.3-77.2] in the <65 group; 12.9% [-8.0-29.8] in those 65; P = .21).

CONCLUSIONS

Despite differences between studies that make comparisons challenging, the influenza burden in elderly Japanese is significant. While vaccines are effective, current vaccination programs offer suboptimal protection. Health economic data and cost-effectiveness analyses were limited and represent areas for policy-relevant future research.

Cost-effectiveness analysis of influenza vaccination during pregnancy in Japan

BACKGROUND

Pregnant women and infants are known as high risk groups for influenza. WHO recommend pregnant women be vaccinated with inactivated influenza vaccine. In Japan, some municipalities started to give subsidy to encourage pregnant women to receive a shot on their own accord, which has made the introduction of seasonal antepartum maternal vaccination program (AMVP) into the routine vaccination list a current topic in health policy and has raised the need to evaluate the value for money of such possibility.

METHODS

We conducted a cost-effectiveness analysis to evaluate the efficiency of conducting AMVP in Japan. A decision tree model was adopted taking into consideration the duration of single-year vaccine effectiveness for infants and for mothers. The program targeted pregnant women aged 20-49 years old at or over 12 weeks gestation during October 1 through March 30. Estimated probabilities of treatments received due to influenza for pregnant/postpartum women or their infants varied by calendar time, vaccination status, and/or gestational age. Incremental cost-effectiveness ratio (ICER) compared with current no-AMVP from societal perspective was calculated. Transition probabilities, utility weights to estimate quality-adjusted life year (QALY), and disease treatment costs were either calculated or extracted from literature. Costs per vaccination was assumed at ¥3,529/US$32.1.

RESULTS

AMVP reduces disease treatment costs, while the reduction cannot offset the vaccination cost. Incremental QALYs were at 0.00009, among them 84.2% were from infants. ICER was ¥7,779,356/US$70,721 per QALY gained. One-way sensitivity analyses revealed that vaccine effectiveness for infant and costs per shot were the two main key variables affecting the ICER.

CONCLUSION

We found that vaccinating pregnant women with influenza vaccine to prevent unvaccinated infants and pregnant/postpartum women from influenza-associated disease in Japan can be cost-effective from societal perspective, under the WHO-suggested "cost-effective" criteria (1-3 times of GDP).

Antibody dynamics in Japanese paediatric patients with influenza A infection treated with neuraminidase inhibitors in a randomised trial

Neuraminidase inhibitors (NAIs) complement influenza virus infection management by helping to clear virus, alleviate symptoms, and reduce transmission. In a previous randomised study, we examined the effect of 4 NAIs on virus clearance and influenza symptoms in Japanese paediatric patients. In this second analysis, we examined the effects of NAI treatment on antibody responses and virus clearance, and the relationships between antibody responses and patients’ infection histories (previous infection; asymptomatic infection via household members of same virus type/subtype; vaccination), and between infection histories and viral kinetics. Haemagglutination inhibition (HI) antibody responses produced HI titres ≥40 by Day 14 of NAI treatment, in parallel with virus clearance (trend test P = 0.001). Comparing patients with and without influenza infection histories (directly or asymptomatic infection via household members) showed that infection history had a marked positive effect on HI antibody responses in patients vaccinated before the current influenza season (before enrolment). Current virus clearance was significantly faster in patients previously infected with the same virus type/subtype than in those not previously infected, and clearance pattern depended on the NAI. Assessment of anti-influenza effects of antiviral drugs and vaccines should consider virus and antibody dynamics in response to vaccination and natural infection histories.

Co-insurance and health care utilization in Japanese patients with rheumatoid arthritis: a discontinuity regression approach

Background

Co-insurance rates in Japan decrease when patients turn 70 years of age. We aim to compare changes in medical demand for Japanese patients with rheumatoid arthritis (RA) at age 70 prior to 2014, when there was a reduction in co-insurance rates from 30 to 10%, with changes in medical demand at age 70 after 2014 when co-insurance rates decreased from 30% to only 20%.

Methods

We used administrative data from large Japanese hospitals. We employed a discontinuity regression (RD) approach to control for unobserved endogeneity in the data.

Results

We identified a total of 7343 patients with RA, 4905 (67%) turned age 70 before April, and found that a 20% decrease in co-insurance was associated with increased utilization of more expensive biologic RA drugs, more outpatient visits and higher total medical costs. However, a 10% decrease in co-insurance for patients who turned 70 after 2014 did not significantly change demand for medical services.

Conclusions

For the younger cohort, we did not observe any changes in medical demand after a price decrease. We therefore conclude that the economic goal of cost sharing, namely a behavioural change towards lower health-care utilization, is not achieved in this particular cohort of chronic patients.

Electronic supplementary material

The online version of this article (10.1186/s12939-019-0920-7) contains supplementary material, which is available to authorized users.

Burden of illness of chemotherapy in castration-resistant prostate cancer patients in Japan: a retrospective database analysis

OBJECTIVE

The objective was to assess the burden of chemotherapy for castration-resistant prostate cancer (CRPC) in Japan.

METHODS

Utilizing a large administrative hospital database we compared a set of outcome measures 12 months before and after initiation of chemotherapy, namely total medical costs, number of outpatient visits, number of hospital admissions and number of days spent in hospital.

RESULTS

A total of 598 CRPC patients were identified in the database. Total healthcare costs increased from 143,578 Japanese Yen (JPY) per patient per month (PPPM), before chemotherapy, to 333,628 JPY after start of chemotherapy. The number of hospital admissions increased by 280%, and the number of days spent in hospital by 380%.

CONCLUSIONS

The overall costs of chemotherapy for patients diagnosed with castration-resistant prostate cancer in Japan are high. Our findings can serve as a basis for health economic evaluations.

Persistence with Biological Disease-modifying Antirheumatic Drugs and Its Associated Resource Utilization and Costs

Objective

The study assessed persistence rates of biological disease-modifying antirheumatic drugs (bDMARDs) for the treatment of rheumatoid arthritis in Japan and compared resource utilization and treatment costs between persistence and non-persistence groups.

Methods

Data were extracted from a Japanese claims database between 2009 and 2015. bDMARD-naïve patients were identified and included in the final analysis. Survival analysis was used to estimate 1-year persistence rates for current bDMARDs. Propensity score matching was applied to control for potential treatment selection bias. Resource utilization and healthcare costs were calculated 1 year before and after initiation of bDMARDs and compared between persistence and non-persistence groups.

Results

A total of 6153 bDMARD-naïve patients were identified and the overall 1-year persistence rate was 85% (95% CI 84–86). Overall, 1-year outpatient visits increased from 10 at baseline to 16 after bDMARD treatment, while the number of hospital admissions declined from 3.3 to 1.6. The non-persistence group had a larger increase in outpatient visits after bDMARD initiation compared with the persistence group (8–16 vs. 10–16, respectively) and a smaller decrease in hospital admissions (3.1–1.9 vs. 3.5–1.4, respectively). Persistence was associated with a reduction in total healthcare costs of US$760.

Conclusions

Japanese bDMARD-naïve patients with RA have a high persistence rate with those treatments. The reduction in medication costs in non-persistent patients is offset by higher hospitalization costs, making non-persistence more expensive.

Electronic supplementary material

The online version of this article (10.1007/s40801-018-0139-8) contains supplementary material, which is available to authorized users.

Treatment pathways of Japanese prostate cancer patients - A retrospective transition analysis with administrative data

BACKGROUND

Limited availability of real-world data that describe treatment patterns of Japanese prostate cancer (PCA) patients.

METHODS

A biweekly transition analysis of PCA treatment was performed for patients with PCA diagnosis and a specific treatment between 2010 and 2015. To account for different cancer stages, two patient populations were analyzed. The first group consisted of patients on medication for hormone-sensitive prostate cancer (HSPC). The second group is comprised of patients who ended up receiving specific therapy for castration-resistant prostate cancer (CRPC). For each treatment, the average of treatment duration and the portion of patients transitioning to a consecutive treatment was calculated.

RESULTS

We identified 59,626 patients from the Japanese administrative database with a PCA diagnosis and specific treatment. In the first year of our observational study 786 patients commenced a HSPC treatment and 695 received a CRPC specific therapy Among the HSPC group, we found that combination hormonal therapy, comprised of a gonadotrophin releasing hormone agonist or antagonist with an antiandrogen was more common than monotherapy. The results of the CRPC group indicated that chemotherapy administration was for a shorter time period in a real-world setting as compared to published clinical studies.

CONCLUSION

Utilizing a novel method to visualize real-world treatment pathways for PCA patients we found that real treatment pathways are in line with international guidelines.

Impact of patient characteristics and treatment procedures on hospitalization cost and length of stay in Japanese patients with influenza: A structural equation modelling approach

OBJECTIVES

Little is known about the economic burden of influenza-related hospitalizations in Japan. This study sought to identify the factors that contribute to the total healthcare costs (THCs) associated with hospitalizations due to influenza in the Japanese population.

STUDY DESIGN

A retrospective cross-sectional database analysis study.

METHODS

A structural equation modelling approach was used to analyse a nationwide Japanese hospital claims data. This study included inpatients with at least 1 confirmed diagnosis of influenza and with a hospital stay of at least 2 days, who were admitted between April 2014 and March 2015.

RESULTS

A total of 5261 Japanese inpatients with a diagnosis of influenza were included in the final analysis. The elderly (≥65 years) and the young (≤15 years) comprised more than 85% of patients. The average length of stay (LOS) was 12.5 days, and the mean THC was 5402 US dollars (US$) per hospitalization. One additional hospital day increased the THC by 314 US$. Intensive care unit hospitalizations were linked to higher costs (+4957 US$) compared to regular hospitalizations. The biggest procedure-related cost drivers, which were also impacted by LOS, were blood transfusions (+6477 US$), tube feedings (+3501 US$) and dialysis (+2992 US$).

CONCLUSIONS

In Japan, the economic burden due to influenza-related hospitalizations for both children and the elderly is considerable and is further impacted by associated comorbidities, diagnostic tests and procedures that prolong the LOS.