Predictors of hospital mortality and multidrug-resistant pathogens in hospitalized pneumonia patients residing in the community

Background and objective

The 2019 ATS/ADSA guidelines for adult community-acquired pneumonia (CAP) eliminated healthcare-associated pneumonia (HCAP) and considered it to be a form of CAP. This concept, however, was based on studies with relatively small sample sizes.

Methods

We investigated the risk factors of 30-day mortality, and methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa infections in patients with pneumonia coming from the community using the Diagnosis Procedure Combination database, a nationwide discharge database of acute care hospitals. Furthermore, we compared these factors between CAP and HCAP.

Results

A total of 272,337 patients aged ≥20 years with pneumonia were grouped into 145,082 CAP patients and 127,255 HCAP patients. The 30-day mortality rate (8.9 % vs.3.3 %), MRSA infection (2.4 % vs. 1.4 %), and Pseudomonas aeruginosa infection (1.6 % vs. 1.0 %) were significantly higher in HCAP than in CAP patients. Multivariable logistic regression analysis showed that 12 of 13 identified predictors of mortality (i.e., high age, male, underweight, non-ambulatory status, bedsore, dehydration, respiratory failure, consciousness disturbance, hypotension, admitted in critical care, comorbidity of heart failure, and chronic obstructive pulmonary disease) were identical in CAP and HCAP patients. Similarly, five of six distinct risk factors for MRSA infection, and three of three for Pseudomonas aeruginosa infection were identical between the patients.

Conclusion

The risk factors for mortality and MRSA or Pseudomonas aeruginosa infection were almost identical in patients with CAP and HCAP. The assessment of individual risk factors for mortality and MRSA or Pseudomonas aeruginosa infection in CAP and abandoning categorization as HCAP can improve and simplify empiric therapy.

Nationwide epidemiology and clinical practice patterns of pediatric urinary tract infections: application of multivariate time-series clustering

BACKGROUND

The nationwide epidemiology and clinical practice patterns for younger children hospitalized with urinary tract infections (UTIs) were unclear.

METHODS

We conducted a retrospective observational study consisting of 32,653 children aged < 36 months who were hospitalized with UTIs from 856 medical facilities during fiscal years 2011-2018 using a nationally representative inpatient database in Japan. We investigated the epidemiology of UTIs and changes in clinical practice patterns (e.g., antibiotic use) over 8 years. A machine learning algorithm of multivariate time-series clustering with dynamic time warping was used to classify the hospitals based on antibiotic use for UTIs.

RESULTS

We observed marked male predominance among children aged < 6 months, slight female predominance among children aged > 12 months, and summer seasonality among children hospitalized with UTIs. Most physicians selected intravenous second- or third-generation cephalosporins as the empiric therapy for treating UTIs, which was switched to oral antibiotics during hospitalizations for 80% of inpatients. Whereas total antibiotic use was constant over the 8 years, broad-spectrum antibiotic use decreased gradually from 5.4 in 2011 to 2.5 days of therapy per 100 patient-days in 2018. The time-series clustering distinctively classified 5 clusters of hospitals based on antibiotic use patterns and identified hospital clusters that preferred to use broad-spectrum antibiotics (e.g., antipseudomonal penicillin and carbapenem).

CONCLUSIONS

Our study provided novel insight into the epidemiology and practice patterns for pediatric UTIs. Time-series clustering can be useful to identify the hospitals with aberrant practice patterns to further promote antimicrobial stewardship. A higher resolution version of the Graphical abstract is available as Supplementary information.

Financial incentives for infection prevention and antimicrobial stewardship to reduce antibiotic use: Japan's nationwide observational study

BACKGROUND

The Japanese government introduced financial incentives to reduce nationwide antibiotic use in hospital settings.

AIM

This study aimed to determine whether the nationwide financial incentives for creating infection prevention and control (IPC) teams introduced in 2012 and antimicrobial stewardship (ASP) teams introduced in 2018 were associated with changes in antibiotic use and health resource utilization at a national level.

METHODS

We conducted time-series analyses and a difference-in-differences study consisting of 3,057,517 inpatients with infectious diseases from 472 medical facilities during fiscal years 2011-2018 using a nationally representative inpatient database in Japan. The primary outcome was the days of therapy (DOT) of antibiotic use per 100 patient-days (PDs). The secondary outcomes consisted of types of antibiotic used, health resource utilization, and mortality.

RESULTS

A total of 5,201,304 financial incentives were observed during 2012-2018, which resulted in a total of 12.1 billion JPY (≈110 million USD). Time-series analyses found decreasing trends in total antibiotic use (79.3-72.5 DOTs/100 PDs (8.6% reduction)) and carbapenem use (9.0-7.0 DOTs/100 PDs (7.8% reduction)) from 2011 to 2018 without adversely affecting other healthcare outcomes (e.g., mortality). In the difference-in-differences analyses, we did not observe meaningful changes in total antibiotic use between the incentivized and unincentivized hospitals for ASP teams, except for the northern part of Japan. No dose-response relationships were observed between the amount of financial incentives and reductions in antibiotic use during 2011-2019.

CONCLUSIONS

Further research and efforts are needed to accelerate antimicrobial stewardship in hospital settings in Japan.

Incremental medical cost of delirium in elderly patients with cognitive impairment: analysis of a nationwide administrative database in Japan

OBJECTIVES

Delirium is a neuropsychiatric disorder that commonly occurs in elderly patients with cognitive impairment. The economic burden of delirium in Japan has not been well characterised. In this study, we assessed incremental medical costs of delirium in hospitalised elderly Japanese patients with cognitive impairment.

DESIGN

Retrospective, cross-sectional, observational study.

SETTING

Administrative data collected from acute care hospitals in Japan between April 2012 and September 2020.

PARTICIPANTS

Hospitalised patients ≥65 years old with cognitive impairment were categorised into groups-with and without delirium. Delirium was identified using a delirium identification algorithm based on the International Classification of Diseases 10^th Revision codes or antipsychotic prescriptions.

OUTCOME MEASURES

Total medical costs during hospitalisation were compared between the groups using a generalised linear model.

RESULTS

The study identified 297 600 hospitalised patients ≥65 years of age with cognitive impairment: 39 836 had delirium and 257 764 did not. Patient characteristics such as age, sex, inpatient department and comorbidities were similar between groups. Mean (SD) unadjusted total medical cost during hospitalisation was 979 907.7 (871 366.4) yen for patients with delirium and 816 137.0 (794 745.9) yen for patients without delirium. Adjusted total medical cost was significantly greater for patients with delirium compared with those without delirium (cost ratio=1.09, 95% CI: 1.09 to 1.10; p<0.001). Subgroup analyses revealed significantly higher total medical costs for patients with delirium compared with those without delirium in most subgroups except patients with hemiplegia or paraplegia.

CONCLUSIONS

Medical costs during hospitalisation were significantly higher for patients with delirium compared with those without delirium in elderly Japanese patients with cognitive impairment, regardless of patient subgroups such as age, sex, intensive care unit admission and most comorbidities. These findings suggest that delirium prevention strategies are critical to reducing the economic burden as well as psychological/physiological burden in cognitively impaired elderly patients in Japan.

Impact of COVID-19 infection rates on admissions for ambulatory care sensitive conditions: nationwide difference-in-difference design in Japan

OBJECTIVES

SARS-CoV-2 infection (COVID-19) has affected tertiary medical institutions and primary care. Admission for ambulatory care sensitive conditions (ACSCs) is an important indicator of primary care quality. However, no nationwide study, especially in Asia, has examined the association between admissions for ACSCs and local surges in COVID-19. This study aimed to examine how the number of admissions for ACSCs has changed in Japan between the areas with higher and lower rates of COVID-19 infection.

DESIGN

This was a retrospective two-stage cross-sectional study. We employed a difference-in-difference design to compare the number of hospital admissions for ACSCs between the areas with higher and lower rates of COVID-19 infection in Japan.

SETTING

The study used a nationwide database in Japan.

PARTICIPANTS

All patients were aged 20 years and above and were admitted due to ACSCs during the study period between March and September 2019 (before the pandemic) and between March and September 2020 (during the pandemic).

RESULTS

The total number of ACSC admissions was 464 560 (276 530 in 2019 and 188 030 in 2020). The change in the number of admissions for ACSCs per 100 000 was not statistically significant between the areas with higher and lower rates of COVID-19 infection: 7.50 (95% CI -87.02 to 102.01). In addition, in acute, chronic and preventable ACSCs, the number of admissions per 100 000 individuals did not change significantly.

CONCLUSION

Although admissions for ACSCs decreased during the COVID-19 pandemic, there was no significant change between the areas with higher and lower rates of COVID-19 infection. This implies that the COVID-19 pandemic affected the areas with higher infection rates and the areas with lower rates.

Evaluating the Hospital Standardized Home-Transition Ratios for Cerebral Infarction in Japan: A Retrospective Observational Study from 2016 through 2020

Discharge to home is considered appropriate as a treatment goal for diseases that often leave disabilities such as cerebral infarction. Previous studies showed differences in risk-adjusted in-hospital mortality and readmission rates; however, studies assessing the rate of hospital-to-home transition are limited. We developed and calculated the hospital standardized home-transition ratio (HSHR) using Japanese administrative claims data from 2016–2020 to measure the quality of in-hospital care for cerebral infarction. Overall, 24,529 inpatients at 35 hospitals were included. All variables used in the analyses were associated with transition to another hospital or facility for inpatients, and evaluation of the HSHR model showed good predictive ability with c-statistics (area under curve, 0.73 standard deviation; 95% confidence interval, 0.72–0.73). All HSHRs of each consecutive year were significantly correlated. HSHRs for cerebral infarction can be calculated using Japanese administrative claims data. It was found that there is a need for support for low HSHR hospitals because hospitals with high/low HSHR were likely to produce the same results in the following year. HSHRs can be used as a new quality indicator of in-hospital care and may contribute to assessing and improving the quality of care.

Hospital-level characteristics of the standardised mortality ratio for ischemic heart disease: a retrospective observational study using Japanese administrative claim data from 2012 to 2019

Background

Ischemic heart disease (IHD) is one of the leading causes of mortality worldwide and imposes a heavy burden on patients. Previous studies have indicated that the optimal care for IHD during hospitalisation may reduce the risk of in-hospital mortality. The standardised mortality ratio (SMR) is an indicator for assessing the risk-adjusted in-hospital mortality ratio based on case-mix. This indicator can crucially identify hospitals that can be changed to improve patient safety and the quality of care. This study aimed to determine the hospital-level characteristics of the SMR for IHD in Japan.

Methods

This study was designed as a retrospective observational study using the Japanese administrative claim data from 2012 to 2019. The data of all hospital admissions with a primary diagnosis of IHD (ICD-10, I20-I25) were used. Patients with complete variables data were included in this study. Hospitals with less than 200 IHD inpatients in each 2-year period were excluded. The SMR was defined as the ratio of the observed number of in-hospital deaths to the expected number of in-hospital deaths multiplied by 100.The observed number of in-hospital deaths was the sum of the actual number of in-hospital deaths at that hospital, and the expected number of in-hospital deaths was the sum of the probabilities of in-hospital deaths. Ratios of in-hospital mortality was risk-adjusted using multivariable logistic regression analyses. The c-statistic and Hosmer-Lemeshow test were used to evaluate the predictive accuracy of the logistic models. Changes in SMRs in each consecutive period were assessed using Spearman's correlation coefficient.

Results

A total of 64,831 were admitted patients with IHD in 27 hospitals as complete submission data. The SMRs showed wide variation among hospitals, ranging from 35.4 to 197.6, and analysis models indicated good predictive ability with a c-statistic of 0.93 (95% CI [0.92-0.94]) and Hosmer-Lemeshow test of 0.30. The results of chi-square tests and t-tests for all variables to assess the association with in-hospital mortality were P < 0.001. In the analysis of trends in each consecutive period, the SMRs showed positive correlations.

Conclusions

This study denoted that the SMRs for IHD could be calculated using Japanese administrative claim data. The SMR for IHD might contribute to the development of more appropriate benchmarking systems for hospitals to improve quality of care.

Association between nurse aide staffing and patient mortality after major cancer surgeries in acute care settings: A retrospective cohort study

This study examined the association between adding nurse aides and patient mortality in acute care settings. We conducted a retrospective cohort study using a national healthcare administrative claims database. We identified patients who underwent planned surgery for six types of cancer from 2010 to 2017. Multivariable logistic analyses were used to examine the association between the nurse aide staffing level and patient outcomes. The primary outcomes were failure to rescue and 30-day hospital mortality. We examined 330 666 in-hospital patients. The median number of nurse aides per 100 occupied beds was 6.60 (interquartile range, 4.61-8.43). In the multivariable analysis, nurse aide staffing level was not significantly associated with failure to rescue or 30-day hospital mortality. The Japanese government provides economic incentives to hospitals that hire more nurse aides, expecting that a higher nurse aide staffing level will help licensed nurses concentrate on the tasks that need their specialties. However, our findings suggest that adding nurse aides may not be associated with lower rates of failure to rescue or 30-day hospital mortality in acute care settings.

Additional effect of azithromycin over β-lactam alone for severe community-acquired pneumonia-associated acute respiratory distress syndrome: a retrospective cohort study

Background

Community-acquired pneumonia (CAP) is the most common cause of acute respiratory distress syndrome (ARDS). Although previous studies have suggested that macrolide therapy is beneficial for ARDS, its benefit for severe CAP-associated ARDS remains uncertain. Previous studies were limited in that they had a small sample size and included patients with non-pulmonary ARDS and those with pulmonary ARDS. This study aimed to investigate the additional effect of azithromycin when used with β-lactam compared with the effect of β-lactam alone in mechanically ventilated patients with CAP-associated ARDS.

Methods

We identified mechanically ventilated patients with CAP-associated ARDS between July 2010 and March 2015 using data in the Diagnosis Procedure Combination database, a Japanese nationwide inpatient database. We performed propensity score matching analysis to assess 28-day mortality and in-hospital mortality in mechanically ventilated patients with CAP-associated ARDS who received β-lactam with and without azithromycin within hospital 2 days after admission. The inverse probability of treatment weighting analysis was also conducted.

Results

Eligible patients (n = 1257) were divided into the azithromycin group (n = 226) and the control group (n = 1031). The one-to-four propensity score matching analysis included 139 azithromycin users and 556 non-users. No significant difference was observed between the groups with respect to 28-day mortality (34.5% vs. 37.6%, p = 0.556) or in-hospital mortality (46.0% vs. 49.1%, p = 0.569). The inverse probability of treatment weighting analysis showed similar results.

Conclusions

Compared with treatment with β-lactam alone, treatment with azithromycin plus β-lactam had no significant additional effect on 28-day mortality or in-hospital mortality in mechanically ventilated patients with CAP-associated ARDS. To the best of our knowledge, this study is the first to determine the effect of azithromycin in mechanically ventilated patients with CAP-associated ARDS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41479-021-00093-8.

Association of body mass index with Clostridioides difficile infection among older patients with pneumonia in Japan

AIM

Obesity is reported to be a risk factor for Clostridioides difficile infection. However, obesity rarely occurs in older Asian patients, and the effects of obesity on health and disease are different in Asian and Western countries. This study aimed to assess the association between body mass index and C. difficile infection risk among older patients with pneumonia in Japan.

METHODS

This retrospective observational cohort study used data from the nationwide database of acute hospital inpatients' data in Japan between July 2014 and March 2016. All patients aged ≥65 years admitted with a primary diagnosis of pneumonia were enrolled. Risk factors for C. difficile infection were determined by logistic regression analysis, including known risks as covariates.

RESULTS

Among 221 242 pneumonia patients, 611 developed C. difficile infection. Underweight patients (body mass index <18.5 kg/m² ) showed higher odds for C. difficile infection (odds ratio 1.38, 95% confidence interval 1.17-1.62, P < 0.001) than normal weight patients (body mass index 18.5-24.9 kg/m² ), whereas overweight patients (body mass index ≥25 kg/m² ) showed lower odds (odds ratio 0.63, 95% confidence interval 0.45-0.89, P < 0.01).

CONCLUSIONS

Body mass index was associated with C. difficile infection in older pneumonia patients in Japan. Underweight was a risk factor, whereas overweight was a protective factor for C. difficile infection. Geriatr Gerontol Int 2021; ••: ••-••.

Dose-response association between nurse staffing and patient outcomes following major cancer surgeries using a nationwide inpatient database in Japan

AIMS AND OBJECTIVES

To examine the non-linear dose-response associations between nurse staffing levels and patient outcomes using a nationwide inpatient database in Japan.

BACKGROUND

Previous studies showed that higher nurse staffing levels were associated with better patient outcomes. However, it remains unclear whether there are thresholds for the associations between higher nurse staffing levels and improved patient outcomes.

DESIGNS

Retrospective observational study design following the STROBE guideline.

METHODS

We identified all patients aged ≥20 years who underwent one of six major cancer surgeries between July 2010 and March 2018 using data from the Diagnosis Procedure Combination database, a nationwide database for acute-care inpatients in Japan. Restricted cubic spline regression analyses, the statistical method that allows non-linear functional form, were performed with several scenarios of cut-off points to examine the dose-response associations between patient-to-nurse ratio per shift and failure to rescue, 30-day in-hospital mortality and postoperative complications.

RESULTS

Among 645,687 patients, restricted cubic spline regression analyses showed insignificant associations of patient-to-nurse ratio with failure to rescue and 30-day in-hospital mortality with no threshold, but a reverse J-shaped association with postoperative complications with a threshold of patient-to-nurse ratio per shift of 5.4.

CONCLUSIONS

In terms of postoperative complications, additional registered nurses were associated with decreased postoperative complications. However, this incremental benefit of additional registered nurses may disappear if hospitals allocate five to six number of registered nurses in general wards.

RELEVANCE TO CLINICAL PRACTICE

This study suggested that additional registered nurses over one per five to six patients may not bring the incremental benefit to decrease postoperative complications.

Association between the duration of physical restraint and pulmonary embolism in psychiatric patients: A nested case-control study using a Japanese nationwide database

BACKGROUND

Pulmonary embolism is the most life-threatening adverse event following physical restraint. However, little is known about the associaton between the duration of physical restraint and pulmonary embolism in psychiatric patients.

OBJECTIVE

The purpose of this study is to evaluate whether more total days of physical restraint is associated with a higher risk of pulmonary embolism.

METHOD

This is a retrospective nested case-control study using a Japanese nationwide administrative inpatient database. We identified patients who were admitted to psychiatric departments from July 2010 to March 2017. One-to-four case-control matching was performed with patients with and without pulmonary embolism. We performed multivariable conditional logistic regression analyses to assess the odds ratios of total days of physical restraint regarding pulmonary embolism.

RESULTS

We identified 223,285 eligible psychiatric patients; 132 (0.059%) patients developed pulmonary embolism during hospitalization. Overall, 13.2% of the psychiatric patients experienced physical restraint for at least 1 day. More total days of physical restraint was significantly associated with a higher risk of pulmonary embolism.

CONCLUSIONS

Longer exposure to physical restraint may increase the risk of pulmonary embolism in psychiatric patients.

Characteristics and Trends of the Hospital Standardized Readmission Ratios for Pneumonia: A Retrospective Observational Study Using Japanese Administrative Claims Data from 2010 to 2018

Previous studies indicated that optimal care for pneumonia during hospitalization might reduce the risk of in-hospital mortality and subsequent readmission. This study was a retrospective observational study using Japanese administrative claims data from April 2010 to March 2019. We analyzed data from 167,120 inpatients with pneumonia ≥15 years old in the benchmarking project managed by All Japan Hospital Association. Hospital-level risk-adjusted ratios of 30-day readmission for pneumonia were calculated using multivariable logistic regression analyses. The Spearman’s correlation coefficient was used to assess the correlation in each consecutive period. In the analysis using complete 9-year data including 54,756 inpatients, the hospital standardized readmission ratios (HSRRs) showed wide variation among hospitals and improvement trend (r = −0.18, p = 0.03). In the analyses of trends in each consecutive period, the HSRRS were positively correlated between ‘2010–2012’ and ‘2013–2015’ (r = 0.255, p = 0.010), and ‘2013–2015’ and ‘2016–2018’ (r = 0.603, p < 0.001). This study denoted the HSRRs for pneumonia could be calculated using Japanese administrative claims data. The HSRRs significantly varied among hospitals with comparable case-mix, and could relatively evaluate the quality of preventing readmission including long-term trends. The HSRRs can be used as yet another measure to help improve quality of care over time if other indicators are examined in parallel.

Development of a General Statistical Analytical System Using Nationally Standardized Medical Information

In Japan, since the Next Generation Medical Infrastructure Act regarding anonymized medical data contributing to R&D came into force in 2018, it is expected to exploit medical data for R&D. The Millennial Medical Record Project has been collected a large amount of standardized medical data of a number of hospitals stored in a database under the act. In order for users to widely exploit the medical data when carrying out trial-and-error, there is a difficulty of data access because of a highly secured management of non-anonymous medical data. To solve the data access problem, we develop a general statistical analytical system for executing a variety of statistical significance tests with statistical power analysis in an environment of trial-and-error for users' analyses without programming. In the analytical system, the front-end is a registration form as the input and the analysis results as the output on Microsoft Excel, and the back-end is based on Python, R and SQL. Although the fixed registration form covers limited application for the analysis, since the analysis results using the stored Millennial Medical Record data is provided in a short time without collecting the necessary data for the analysis, the exploitation of medical data could widely and rapidly promote by medical experts/researchers in the manner of trial-and-error. The developed system could apply to make protocols for clinical research and clinical trial, and the potential to discover real-world evidence could be increased.

Short-Term Associations of Ambient Fine Particulate Matter (PM2.5) with All-Cause Hospital Admissions and Total Charges in 12 Japanese Cities

The short-term association between ambient particulate matter ≤2.5 microns in diameter (PM_2.5) and hospital admissions is not fully understood. Studies of this association with hospital admission costs are also scarce, especially in entire hospitalized populations. We examined the association between ambient PM_2.5 and all-cause hospital admissions, the corresponding total charges, and the total charges per patient by analyzing the hospital admission data of 2 years from 628 hospitals in 12 cities in Japan. We used generalized additive models with quasi-Poisson regression for hospital admissions and generalized additive models with log-linear regression for total charges and total charges per patient. We first estimated city-specific results and the combined results by random-effect models. A total of 2,017,750 hospital admissions were identified. A 10 µg/m³ increase in the 2 day moving average was associated with a 0.56% (95% CI: 0.14–0.99%) increase in all-cause hospital admissions and a 1.17% (95% CI: 0.44–1.90%) increase in total charges, and a 10 µg/m³ increase in the prior 2 days was associated with a 0.75% (95% CI: 0.34–1.16%) increase in total charges per patient. Short-term exposure to ambient PM_2.5 was associated with increased all-cause hospital admissions, total charges, and total charges per patient.

Current trends in diabetes mellitus database research in Japan

With the widespread use of electronic medical records and administrative claims databases, analytic results from so-called real-world data have become increasingly important in healthcare decision-making. Diabetes mellitus is a heterogeneous condition that involves a broad spectrum of patients. Real-world database studies have been recognised as a powerful tool to understand the impact of current practices on clinical courses and outcomes, such as long-term glucose control, development of microvascular or macro-vascular diseases, and mortality. Diabetes is also a major global health issue and poses a significant social and economic burden worldwide. Therefore, it is critical to understand the epidemiology, clinical course, treatment reality, and long-term outcomes of diabetes to determine realistic solutions to a variety of disease-related issues that we are facing. In the present review, we summarise the healthcare system and large-scale databases currently available in Japan, introduce the results from recent database studies involving Japanese patients with diabetes, and discuss future opportunities and challenges for the use of databases in the management of diabetes.

Associations between early parenteral nutrition and in-hospital outcomes in underweight patients with gastrointestinal surgery

BACKGROUND & AIMS

Guidelines recommend early parenteral nutrition for malnourished patients. However, the effectiveness of early parenteral nutrition in underweight patients has not been established. This study aimed to determine whether in-hospital outcomes were associated with early parenteral nutrition in underweight gastrointestinal surgery patients with short-term contraindications to early enteral nutrition.

METHODS

We identified underweight adult gastrointestinal surgery patients with short-term contraindications to early enteral nutrition using the Japanese Diagnosis Procedure Combination database from July 2010 to March 2018. We performed propensity-score overlap weighting to compare in-hospital outcomes between patients with and without early parenteral nutrition. The primary outcome was length of hospital stay. The secondary outcomes were total hospitalization cost, hospital-acquired pneumonia, hospital-acquired urinary tract infection, central line-associated bloodstream infection, and all-cause 28-day in-hospital mortality.

RESULTS

We identified 31,898 eligible patients. Early parenteral nutrition was associated with longer hospital stay (19.2 vs. 18.4 days; difference, 0.7 days; 95% CI, 0.1 to 1.4). There were no differences between the patients with and without early parenteral nutrition in total hospitalization cost (difference, US$60; 95% CI, -277 to 397), hospital-acquired pneumonia (risk difference, -0.11%; 95% CI, -0.78 to 0.55), hospital-acquired urinary tract infection (risk difference, 0.03%; 95% CI, -0.08 to 0.14), central line-associated bloodstream infection (risk difference, 0.08%; 95% CI, -0.02 to 0.18), and all-cause 28-day in-hospital mortality (risk difference, 0.31%; 95% CI, -0.07 to 0.69).

CONCLUSIONS

Early parenteral nutrition for underweight gastrointestinal surgery patients with short-term contraindications to early enteral nutrition was associated with longer hospital stay.

Identification of risk factors for mortality and delayed oral dietary intake in patients with open drainage due to deep neck infections: Nationwide study using a Japanese inpatient database

BACKGROUNDS

Data on risk factors for deep neck infection including descending necrotizing mediastinitis (DNM) have been limited. Using a nationwide database, the aim was identifying the factors related to patient death and delay in recovering oral intake.

METHODS

Data of 4949 patients were extracted from a Japanese inpatient database between 2012 and 2017. The main outcome was survival at discharge. In a subgroup analysis of the 4949 patients with survival, the second outcome was delay in the interval between admission and full recovery of oral intake.

RESULTS

Only a few factors (advanced-age, ventilation) were associated with both mortality and delayed oral dietary intake by logistic regression analyses. Conversely, several factors including DNM (adjusted-odds ratio [OR] 1.41) and repeated surgery (adjusted-OR 1.70) were significantly related only to delayed oral dietary intake.

CONCLUSIONS

Although DNM was not necessarily related to mortality, patients with DNM should receive careful attention to avoid delayed oral dietary intake.

High-dose versus low-dose intravenous immunoglobulin for treatment of children with Kawasaki disease weighing 25 kg or more

Little is known whether 2-g/kg IVIG is necessary for older children with Kawasaki disease (KD), because they could have more complications and financial burden. The purpose of this study was to compare outcomes between high- and low-dose IVIG in KD children with higher body weight (25 kg or more), using a national inpatient database in Japan from 2010 to 2017. We identified those receiving 2-g/kg and 1-g/kg IVIG as an initial treatment. Outcomes included the proportions of coronary artery abnormality (CAA) formation, IVIG resistance, adverse effects, length of stay, and medical costs. A propensity score matching analysis was conducted to compare the outcomes between the groups. We identified 1332 patients with KD and created 4:1 propensity score-matched pairs between high- and low-dose IVIG groups. There were no significant differences in the proportions of CAA (5.3% vs. 4.1%; p = 0.587), IVIG resistance, and length of stay. Medical costs were significantly higher in the high-dose group than in the low-dose group (p < 0.001).Conclusion: No significant difference was shown between the high- and low-dose IVIG groups in the proportions of outcomes, while medical costs were higher in the high-dose group. Further studies are needed to ascertain the appropriate IVIG dose in older patients with KD. What is Known: • For treatments of Kawasaki disease at any age in the acute phase, 2-g/kg single-dose intravenous immunoglobulin and aspirin have been the most recommended to reduce fever early and prevent complications of coronary artery abnormalities. What is New: • There was no significant difference in outcomes between children with Kawasaki disease weighing ≥ 25 kg treated with high-dose or low-dose IVIG in terms of coronary artery abnormalities, IVIG resistance, adverse effects, and length of stay, except for medical costs.

Measuring Quality of Care for Ischemic Stroke Treated With Acute Reperfusion Therapy in Japan - The Close The Gap-Stroke

BACKGROUND

In Japan there is no consensus on how to efficiently measure quality indicators (QIs), defined as a standard of care, for acute ischemic stroke (AIS). Using information from a health insurance claims database and electronic medical records, we evaluated the feasibility and validity of measuring QIs for AIS patients who received intravenous recombinant tissue plasminogen activator (IV rt-PA) or endovascular therapy (EVT).Methods and Results:AIS patients receiving rt-PA or EVT between 2013 and 2015 were identified. We selected 17 AIS QI measures for primary stroke centers (PSCs) and 8 for comprehensive stroke centers (CSCs). Defined QIs were calculated for each hospital and then averaged. In total, the data of 8,206 patients (rt-PA 83.7%, EVT 34.9%) from 172 hospitals were obtained. Median National Institute of Health Stroke Scale score at admission was 14, and 37.7% of the patients were functionally independent at discharge. All target QIs were successfully measured with fewer missing values, and the accuracy of preset data was about 90%. Adherence rates were low (<50%) in 5 QI measures among PSCs, including door-to-needle time ≤1 h, and in 1 QI measure among CSCs (door-to-brain and vascular imaging time ≤30 min).

CONCLUSIONS

Measuring QIs for AIS by this novel approach was feasible and reliable in the provision of a national benchmark.

National trends in appropriate antibiotics use among pediatric inpatients with uncomplicated lower respiratory tract infections in Japan

BACKGROUND

Japan was ranked as the worst country of 36 high-income countries in terms of oral antibiotic consumptions for children. Knowing the patterns and variations of antibiotic use for pediatric inpatients with uncomplicated respiratory infections is an important step to promote judicious antibiotic use.

METHODS

Discharge records were extracted for children aged between 3 months and 15 years with acute lower respiratory tract infections for the fiscal years 2010-2014 using a national inpatient database in Japan. We investigated the trends in antibiotic use using mixed effect regression models and ascertained variations and clustering of the practice patterns across different hospitals using unsupervised machine learning methodology.

RESULTS

A total of 280,298 children were included in the study. Total and broad-spectrum antibiotic use, except for fluoroquinolone, showed decreasing trends from 2010 to 2014. Additionally, the proportions of patients who received no antibiotics or only penicillin increased from 17.1% to 9.9% in 2010 to 24.5% and 13.7% in 2014, respectively. Cluster analysis showed that only one-quarter of hospitals used no antibiotics for 28.8% of children and only penicillin for 53.7% of children. In the remaining clusters of hospitals, the piperacillin, 3rd generation cephalosporins, and penicillin beta-lactamase inhibitors were used for 68.5%, 68.5%, and 69.6% of the patients who received antibiotics.

CONCLUSIONS

Slightly increasing trends in narrow-spectrum antibiotics were observed. However, the treatment strategy in only one-quarter of hospitals was consistent with the current recommendations. Hospital level interventions to promote and monitor antibiotic use could be helpful to improve antibiotic use for pediatric inpatients.

Histamine-2 receptor antagonists versus proton pump inhibitors for septic shock after lower gastrointestinal tract perforation: a retrospective cohort study using a national inpatient database

Background

Studies have shown the potential benefit of stress ulcer prophylaxis including histamine-2 receptor antagonists (H2RA) and proton pump inhibitors (PPI) in critically ill patients. However, the adverse effects of stress ulcer prophylaxis such as Clostridioides difficile infection (CDI) and hospital-acquired pneumonia have been reported. Abdominal septic shock is associated with increased risk of bleeding, CDI, and pneumonia; however, which ulcer prophylaxis might be associated with better outcomes in patients with septic shock after lower gastrointestinal tract perforation is unknown.

Methods

In this retrospective cohort study using the Japanese Diagnosis Procedure Combination database from July 2010 to March 2015, we identified patients aged 18 years or older who received open abdominal surgery for lower gastrointestinal tract perforation and who used vasopressors and antibiotics within 2 days of admission. We performed propensity score matching and inverse probability of treatment weighting (IPTW) to compare the outcomes between patients who received H2RA and those who received PPI within 2 days of admission. The outcomes included gastrointestinal bleeding requiring endoscopic hemostasis within 28 days of admission, 28-day mortality, CDI, and hospital-acquired pneumonia.

Results

The propensity score matching created 1088 pairs of patients who received H2RA or PPI within 2 days of admission. There were no significant differences between the H2RA and PPI groups regarding gastrointestinal bleeding requiring endoscopic hemostasis within 28 days of admission (0.74% vs 1.3%, risk ratio 0.57 (0.24–1.4), and P = 0.284), 28-day mortality (11.3% vs 12.9%, risk ratio 0.88 (0.68–1.1), and P = 0.386), CDI (0.64% vs 0.46%, risk ratio 1.4 (0.45–4.4), and P = 0.774), and hospital-acquired pneumonia (3.0% vs 4.3%, risk ratio 0.70 (0.45–1.1), and P = 0.138). IPTW analysis showed similar results.

Conclusions

There were no significant differences in gastrointestinal bleeding requiring endoscopic hemostasis within 28 days of admission, 28-day mortality, CDI, and hospital-acquired pneumonia between H2RA and PPI in patients with septic shock after lower gastrointestinal tract perforation.

Association between early antibiotic treatment and clinical outcomes in children hospitalized for asthma exacerbation

BACKGROUND

Professional society guidelines recommend against routine early antibiotic use in the treatment of asthma exacerbation without comorbid bacterial infection. However, high antibiotic prescribing rates have been reported in developed countries.

OBJECTIVE

We sought to assess the effectiveness of this strategy in the routine care of children.

METHODS

Using data on 48,743 children hospitalized for asthma exacerbation with no indication of bacterial infection during the period 2010 to 2018, we conducted a retrospective cohort study to compare clinical outcomes and resource utilization between children who received early antibiotic treatment and those who did not.

RESULTS

Overall, 19,866 children (41%) received early antibiotic treatment. According to the propensity score matching analysis, children with early antibiotic treatment had longer hospital stay (mean difference, 0.21 days; 95% CI, 0.18-0.28), higher hospitalization costs (mean difference, $83.5; 95% CI, 62.9-104.0), and higher risk of probiotic use (risk ratio, 2.01; 95% CI, 1.81-2.23) than children who did not receive early antibiotic therapy. Similar results were found from inverse probability of treatment weighting, g-computation, and instrumental variable methods and sensitivity analyses. The risks of mechanical ventilation and 30-day readmission were similar between the groups or slightly higher in the treated group, depending on the statistical models.

CONCLUSIONS

Antibiotic therapy may be associated with prolonged hospital stay, elevated hospitalization costs, and high risk of probiotic use without improving treatment failure and readmission. Our findings highlight the need for reducing inappropriate antibiotic use among children hospitalized for asthma.

Trends in hospital standardized mortality ratios for stroke in Japan between 2012 and 2016: a retrospective observational study

OBJECTIVE

Stroke is one of the leading causes of death and disability, and imposes a major healthcare burden. The aim of this study was to determine the characteristics of hospital standardized mortality ratios (HSMRs) for stroke in Japan for the year 2012-16 to describe the trend.

DESIGN

Retrospective observational study.

SETTING

Data from the Japanese administrative database.

PARTICIPANTS

All hospital admissions for stroke were identified from diagnostic procedures combination (DPC) database from 2012 to 2016.

MAIN OUTCOME MEASURES

HSMR was calculated using the actual number of in-hospital deaths and expected deaths. To obtain the expected death number, a logistic regression model was developed to get the coefficient with a number of explanatory variables. Predictive accuracy of the logistic models was assessed using c-index and calibration was evaluated using the Hosmer-Lemeshow test.

RESULTS

A total of 63 084 patients admitted for stroke from January 2012 to December 2016 were analyzed. HSMRs showed declining tendency over these 5 years, suggesting stroke-related mortality has been improving. While the HSMRs varied from year to year, a wide variation was also seen among the different hospitals in Japan. The proportion of hospitals with HSMR less than 100 increased from 41.0% in 2012 to 59.0% in 2016.

CONCLUSION

This study demonstrated that HSMR can be calculated using DPC data and found wide variation in HSMR of stroke among hospitals in Japan and enabled us to image the trend. By examining these trends, facilities, authorities and provinces can initiate designs that will ultimately lead to an upgraded healthcare delivery system.

Development of the predicted and standardized carbapenem usage metric: Analysis of the Japanese Diagnosis Procedure Combination payment system data

This study aimed to develop a metric for standardized and predicted carbapenem consumption using the Diagnosis Procedure Combination payment system database and patients' characteristics. Based on Diagnosis Procedure Combination data analysis, the developed metric will provide useful benchmarks that stewardship programs can use to help drive improvements.

The effect of antithrombin added to recombinant human-soluble thrombomodulin for severe community-acquired pneumonia-associated disseminated intravascular coagulation: a retrospective cohort study using a nationwide inpatient database

Background

Studies showed potential benefits of recombinant human-soluble thrombomodulin (rhTM) and antithrombin for treating sepsis associated disseminated intravascular coagulation. However, benefits of their combination have been inconclusive.

Methods

Using a nationwide inpatient database in Japan, we performed propensity-score matched analyses to compare outcomes between rhTM combined with antithrombin and rhTM alone for severe community-acquired pneumonia associated disseminated intravascular coagulation from July 2010 to March 2015. The outcomes included in-hospital mortality and requirement of red cell transfusion.

Results

Propensity score matching created 189 pairs of patients who received rhTM combined with antithrombin or rhTM alone within 2 days of admission. There was no significant difference between the two groups for in-hospital mortality (40.2% vs. 45.5%). Patients treated with rhTM and antithrombin were more likely to require red cell transfusion than those treated with rhTM alone (37.0% vs. 25.9%).

Conclusions

Compared with rhTM alone, combination of rhTM with antithrombin for severe community-acquired pneumonia-associated disseminated intravascular coagulation may be ineffective for reducing mortality and may increase bleeding.

Capturing the trends in hospital standardized mortality ratios for pneumonia: a retrospective observational study in Japan (2010 to 2018)

Background

Pneumonia has a high human toll and a substantial economic burden in developed countries like Japan, where the crude mortality rate was 77.7 per 100,000 people in 2017. As this trend is going to continue with increasing number of the elderly multi-morbid population in Japan; monitoring performance over time is a social need to alleviate the disease burden. The study objective was to determine the characteristics of hospital standardized mortality ratios (HSMRs) for pneumonia in Japan from 2010 to 2018 to describe this trend.

Methods

Data of the DPC (Diagnostic Procedures Combination) database were used, which is an administrative claims and discharge summary database for acute care in-patients in Japan. HSMRs were calculated using the actual and expected numbers of in-hospital deaths, the latter of which was calculated using logistic regression model, with a number of explanatory variables, e.g., age, sex, urgency of admission, mode of transportation, patient volume per month in each hospital, A-DROP score, and Charlson comorbidity index (CCI). We constructed two HSMR models: a single-year model, which included hospitals with > 10 in-patients per month and, a 9-year model, which included those hospitals with complete 9-year data. Predictive accuracy of the logistic models was assessed using c-index (area under receiver operating curve).

Results

Total 230,372 patients were included for the analysis over the 9-year study period. Calculated HSMRs showed wide variation among hospitals. The proportion of hospitals with HSMR less than 100 increased from 36.4% in 2010 to 60.6% in 2018. Both models showed good predictive ability with a c-statistic of 0.762 for the 9-year model, and no less than 0.717 for the single-year model.

Conclusion

This study denoted that HSMRs of pneumonia can be calculated using DPC data in Japan and revealed significant variations among hospitals with comparable case-mixes. Therefore, HSMR can be used as yet another measure to help improve quality of care over time if other indicators are examined in parallel and to get a clear picture of where hospitals excel and lack.

Nasogastric Tube Feeding Versus Total Parenteral Nutrition in Older Dysphagic Patients with Pneumonia: Retrospective Cohort Study

OBJECTIVES

Many older patients with pneumonia cannot intake orally after admission and may need nutritional care such as nasogastric tube feeding or total parenteral nutrition. This study sought to compare in-hospital outcomes between patients receiving nasogastric tube feeding and total parenteral nutrition.

DESIGN

This is a retrospective cohort study.

SETTING

A hospital-based database constructed by the Diagnosis Procedure Combination survey data comprising more than 100 acute-care hospitals.

PARTICIPANTS

The study included consecutive older inpatients aged >65 years admitted to participating hospitals with a diagnosis of pneumonia from 2014 through 2017.

MEASUREMENTS

We compared patients who received total parenteral nutrition and those who received nasogastric tube feeding in terms of characteristics and outcomes.

RESULTS

Among the included inpatients, a total of 336 (73.2%) patients received total parenteral nutrition and 123 (26.8%) patients received nasogastric tube feeding. Patients with nasogastric tube feeding had less in-hospital mortality (13.8% vs 27.1%, p = 0.003) and a smaller number of complications (mean; 0.71 vs 1.44, p <0.001), shorter length of hospital stay (mean; 27.6 vs 48.9, p <0.001), more discharges home (72.4% vs 35.1%, p <0.001), and more discharges without oral intake (65.9% vs 45.8%, p <0.001) than patients with total parenteral nutrition. The same results were obtained in propensity score analysis.

CONCLUSIONS

Older patients with pneumonia treated with total parenteral nutrition were significantly more likely to have higher in-hospital mortality than those receiving nasogastric tube feeding.

The Impact of Changes in Clinical Guideline on Practice Patterns and Healthcare Utilizations for Kawasaki Disease in Japan

Objective: Previous studies showed the efficacy of glucocorticoids on prevention of coronary artery lesions (CAL) among Kawasaki disease (KD) patients, and clinical guideline for KD in Japan was changed regarding glucocorticoid use in 2012. However, little is known regarding how the guideline change had impacts on healthcare utilizations and clinical outcomes. Methods: We conducted a retrospective observational study using national inpatient database in Japan among KD patients aged under 18 years during 2010-2015. Recent trends in practice patterns were analyzed, and we divided the hospitals into four groups based on glucocorticoid use: (1) consistently using hospital, (2) started using hospital, (3) stopped using hospital, and (4) never using hospital. Then, we compared healthcare utilizations and risks of coronary artery lesions before and after the guideline change. Results: We identified 24,517 inpatients with KD. From 2010 to 2014, use of glucocorticoid increased from 8.9 to 17.4% of KD inpatients. All types of hospitals showed reduction in coronary artery lesions, but the reduction was the most prominent in hospitals that started using glucocorticoid therapy after clinical guideline change in 2012 (adjusted OR, 0.22; 95%CI, 0.07-0.68). Also, Glucocorticoid consistently using hospitals, started using hospitals, and never using hospitals showed reductions in hospitalization costs, whereas hospitals that stopped using glucocorticoids after clinical guideline change had elevated healthcare costs as opposed to natural trends observed in other groups. Guideline complying hospitals had the greatest reductions in healthcare costs. Conclusions: The early stage glucocorticoid use could be a cost-saving strategy for treatment for KD patients without increasing risks of CAL.

Japanese Herbal Kampo Hochu-Ekki-To or Juzen-Taiho-To after Surgery for Hip Fracture Does Not Reduce Infectious Complications

Background

Infectious complications after hip fracture surgery are common in the elderly. Although experimental studies have suggested that kampo medicine, Hochu-ekki-to and Juzen-taiho-to, can prevent infectious complications, only a few small clinical studies have been published to date.

Primary Study Objective

The aim of the present study is to investigate the impact of Hochu-ekki-to or Juzen-taiho-to on postoperative infectious complications in patients undergoing surgery for hip fracture.

Methods and Design

In this retrospective cohort study using a nationwide inpatient database in Japan, we performed propensity score matching to compare patients who did or did not receive kampo medicine after surgery for hip fracture.

Settings

A nationwide inpatient database.

Participants

Patients who did or did not receive kampo medicine after surgery for hip fracture.

Intervention

Kampo medicine after surgery for hip fracture.

Primary Outcome Measures

Infectious complications.

Results

The proportions of postoperative infectious complications were not significantly different between the 424 propensity-matched pairs with and without kampo medicine (11 versus 8, P = 0.644).

Conclusion

The present study suggests that Hochu-ekki-to or Juzen-taiho-to postoperatively is not associated with decreased occurrence of infectious complications in patients who underwent surgery for hip fracture.

Risks and Benefits of Stress Ulcer Prophylaxis for Patients With Severe Sepsis

OBJECTIVES

The Surviving Sepsis Campaign Guidelines recommend stress ulcer prophylaxis for patients with severe sepsis who have bleeding risks. Although sepsis has been considered as a risk factor for gastrointestinal bleeding, the effect of stress ulcer prophylaxis has not been studied in patients with severe sepsis. Furthermore, stress ulcer prophylaxis may be associated with an increased risk of hospital-acquired pneumonia or Clostridium difficile infection. The aim of this study was to investigate the risks and benefits of stress ulcer prophylaxis for patients with severe sepsis.

DESIGN

Retrospective cohort study.

SETTING

Five hundred twenty-six acute care hospitals in Japan.

PATIENTS

A total of 70,862 patients with severe sepsis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One-to-one propensity score matching created 15,651 pairs of patients who received stress ulcer prophylaxis within 2 days of admission and those who did not. Patient characteristics were well balanced between the two groups. No significant differences were seen between the stress ulcer prophylaxis group and the control group with regard to gastrointestinal bleeding requiring endoscopic hemostasis (0.6% vs 0.5%; p = 0.208), 30-day mortality (16.4% vs 16.9%; p = 0.249), and Clostridium difficile infection (1.4% vs 1.3%; p = 0.588). The stress ulcer prophylaxis group had a significantly higher proportion of hospital-acquired pneumonia (3.9% vs 3.3%; p = 0.012) compared with the control group.

CONCLUSIONS

Since the rate of gastrointestinal bleeding requiring endoscopic hemostasis is not different comparing patients with and without stress ulcer prophylaxis, and the increase in hospital-acquired pneumonia is significant, routine stress ulcer prophylaxis for patients with severe sepsis may be unnecessary.

Association between advanced practice nursing and 30-day mortality in mechanically ventilated critically ill patients: A retrospective cohort study

PURPOSE

Little is known about the association between advanced practice nursing and mortality. The aim of this study was to evaluate whether the presence of advanced practice nurses (APN), that is, certified nurse (CN) and certified nurse specialist (CNS) in intensive care, is associated with 30-day mortality for mechanically ventilated critically ill patients.

MATERIALS AND METHODS

Using a Japanese national in-patient database, we identified 45,620 patients who were admitted to an intensive care unit (ICU) and received mechanical ventilation within 2 days of hospital admission between 1 April 2014 and 31 March 2015. We assessed the association between the number of CN/CNSs per 10 adult ICU beds and 30-day mortality.

RESULTS

We examined 8955 patients in 134 hospitals without CN/CNSs and 36,665 in 284 hospitals with CN/CNSs. Overall, the number of CN/CNSs per 10 adult ICU beds ranged from 0 to 7.5. In the multivariable analysis, the number of CN/CNSs per 10 adult ICU beds was significantly associated with a reduction in 30-day mortality (adjusted odds ratio 0.97; 95% confidence interval, 0.94-1.00; P=0.023).

CONCLUSIONS

Our findings show that APNs may play an important role in improving patient outcome in the adult ICU.

Status and Future Perspectives of Utilizing Big Data in Neurosurgical and Stroke Research

The management, analysis, and integration of Big Data have received increasing attention in healthcare research as well as in medical bioinformatics. The J-ASPECT study is the first nationwide survey in Japan on the real-world setting of stroke care using data obtained from the diagnosis procedure combination-based payment system. The J-ASPECT study demonstrated a significant association between comprehensive stroke care (CSC) capacity and the hospital volume of stroke interventions in Japan; further, it showed that CSC capabilities were associated with reduced in-hospital mortality rates. Our study aims to create new evidence and insight from ‘real world’ neurosurgical practice and stroke care in Japan using Big Data. The final aim of this study is to develop effective methods to bridge the evidence-practice gap in acute stroke healthcare. In this study, the authors describe the status and future perspectives of the development of a new method of stroke registry as a powerful tool for acute stroke care research.

Increase in avoidable hospital admissions after the Great East Japan Earthquake

BACKGROUND

The Great East Japan Earthquake and subsequent tsunami and nuclear disaster on 11 March 2011 had a short-term influence on the increase in emergency department visits and hospital admissions due to various diseases. However, it remains unclear whether the earthquake and tsunami disaster affected the long-term health conditions of people in the affected areas.

METHODS

Using a national inpatient database in Japan, we investigated people's ambulatory care sensitive conditions (ACSCs), which are defined as conditions for which effective management and treatment should prevent admission to a hospital. We compared the number of admissions for ACSCs before-quake (July 2010 to February 2011) with after-quake (July 2012 to February 2013) periods in the disaster area compared with other areas using a difference-in-differences design. Linear regression models with the interaction between periods and areas were used to estimate the impact of the earthquake on admissions for ACSCs.

RESULTS

No significant difference in difference was seen in preventable ACSCs (where immunisation and other interventions can prevent illness) or chronic ACSCs (where effective care can prevent flare-ups), while acute ACSCs (where early intervention can prevent more serious progression) increased significantly (3.3 admissions per 100 000 population; 95% CI 0.4 to 6.3; p=0.028).

CONCLUSIONS

Preventable and chronic ACSCs may have increased just after the earthquake and then immediately decreased. However, avoidable admissions due to acute ACSCs remained high in the long term after the earthquake and tsunami disaster.

Cerebral infarction after intraarterial and intravenous chemoradiotherapy for head and neck cancer: A retrospective analysis using a Japanese inpatient database

BACKGROUND

The occurrence of cerebral infarction after intraarterial chemoradiotherapy (CRT) remains uncertain.

METHODS

We conducted a retrospective cohort study using the Diagnosis Procedure Combination (DPC) database from 2010 to 2013. We performed a 1:4 propensity score-matched analysis between patients undergoing intraarterial or intravenous CRT, and determined the association between cerebral infarction and intraarterial CRT.

RESULTS

Among patients with head and neck cancer receiving platinum-based chemotherapy and concurrent radiotherapy, we identified 776 patients with intraarterial CRT and 7157 with intravenous CRT. The occurrence of cerebral infarction was significantly higher in the intraarterial CRT group than in the intravenous CRT group: 1.4% (11 of 775) versus 0.4% (12 of 3100; p = .002). There was no significant difference in mucosal toxicity or febrile neutropenia.

CONCLUSION

About 10% of patients received intraarterial CRT. Intraarterial CRT was associated with a higher incidence of cerebral infarction than was intravenous CRT. This result is useful when considering the procedure-related risks and the potential benefits of intraarterial CRT. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1354-1358, 2016.

Factors Associated With Neck Hematoma After Thyroidectomy: A Retrospective Analysis Using a Japanese Inpatient Database

To identify risk factors for post-thyroidectomy hematoma requiring airway intervention or surgery ("wound hematoma") and determine post-thyroidectomy time to intervention. Post-thyroidectomy hematoma is rare but potentially lethal. Information on wound hematoma in a nationwide clinical setting is scarce.Using the Japanese Diagnosis Procedure Combination database, we extracted data from records of patients undergoing thyroidectomy from July 2010 to March 2014. Patients with clinical stage IV cancer or those with bilateral neck dissection were excluded because they could have undergone planned tracheotomy on the day of thyroidectomy. We assessed the association between background characteristics and wound hematoma ≤2 days post-thyroidectomy, using multivariable logistic regression analysis. Among 51,968 patients from 880 hospitals, wound hematoma occurred in 920 (1.8%) ≤2 days post-thyroidectomy and in 203 (0.4%) ≥3 days post-thyroidectomy (in-hospital mortality = 0.05%). Factors significantly associated with wound hematoma ≤2 days post-thyroidectomy were male sex (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.30-1.77); higher age (OR 1.01, 95% CI 1.00-1.02); overweight or obese (OR 1.22, 95% CI 1.04-1.44); type of surgery (partial thyroidectomy for benign tumor compared with: total thyroidectomy, benign tumor [OR 1.95, 95% CI 1.45-2.63]; partial thyroidectomy, malignant tumor [OR 1.21, 95% CI 1.00-1.46]; total thyroidectomy, malignant tumor [OR 2.49, 95% CI 1.82-3.49]; and thyroidectomy for Graves disease [OR 3.88, 95% CI 2.59-5.82]); neck dissection (OR, 1.53, 95% CI 1.05-2.23); antithrombotic agents (OR 1.58, 95% CI 1.15-2.17); and blood transfusion (OR 5.33, 95% CI 2.39-11.91). Closer monitoring of airway and neck is recommended for patients with risk factors, and further cautious monitoring beyond 3 days post-thyroidectomy.

Factors associated with prolonged duration of post-tympanoplasty local treatment in adult chronic otitis media patients: A retrospective observational study using a Japanese inpatient database

OBJECTIVE

The occurrence of persistent infection following tympanoplasty has been reported in many studies, and it is important to know the risks for site infection after tympanoplasty. In this study, we aimed to explore the factors affecting early wound complications after tympanoplasty for chronic otitis media.

METHODS

We conducted a retrospective cohort study using the Diagnosis Procedure Combination database. Data on a total of 13,094 adult patients from 420 acute-care hospitals who received tympanoplasty for chronic otitis media from 2010 to 2013 were extracted. The duration (days) of postsurgical local wound treatment was measured as an outcome, because this duration was assumed to be prolonged by the existence of wound infection. The associations between treatment duration and background characteristics (age, sex, body mass index, smoking status, diabetes mellitus, use of antithrombotic agents, with or without cholesteatoma, duration of anesthesia, academic hospital or not, and hospital volume) were assessed by multivariable linear regression analyses, fitted with a generalized estimating equation to adjust for within-hospital clustering.

RESULTS

The median treatment duration in each hospital was 8 days (interquartile range: 7-11). Factors significantly associated with longer treatment duration were: older age (0.2 days for 10-year increase), use of antithrombotic agents during hospitalization (1.8 days), and prolonged duration of anesthesia (vs. <120min of anesthesia, additional 1, 2, 3, and 4 days for 120-179, 180-239, 240-299, and ≥300min of anesthesia, respectively). Body mass index and smoking status were not significantly associated with treatment duration.

CONCLUSIONS

Older age, antithrombotic agents during hospitalization, and longer anesthesia time were independently associated with early local wound complications after tympanoplasty for chronic otitis media.

Variation in Risk-Standardized Mortality of Stroke among Hospitals in Japan

Despite recent advances in care, stroke remains a life-threatening disease. Little is known about current hospital mortality with stroke and how it varies by hospital in a national clinical setting in Japan. Using the Diagnosis Procedure Combination database (a national inpatient database in Japan), we identified patients aged ≥ 20 years who were admitted to the hospital with a primary diagnosis of stroke within 3 days of stroke onset from April 2012 to March 2013. We constructed a multivariable logistic regression model to predict in-hospital death for each patient with patient-level factors, including age, sex, type of stroke, Japan Coma Scale, and modified Rankin Scale. We defined risk-standardized mortality ratio as the ratio of the actual number of in-hospital deaths to the expected number of such deaths for each hospital. A hospital-level multivariable linear regression was modeled to analyze the association between risk-standardized mortality ratio and hospital-level factors. We performed a patient-level Cox regression analysis to examine the association of in-hospital death with both patient-level and hospital-level factors. Of 176,753 eligible patients from 894 hospitals, overall in-hospital mortality was 10.8%. The risk-standardized mortality ratio for stroke varied widely among the hospitals; the proportions of hospitals with risk-standardized mortality ratio categories of ≤ 0.50, 0.51-1.00, 1.01-1.50, 1.51-2.00, and >2.00 were 3.9%, 47.9%, 41.4%, 5.2%, and 1.5%, respectively. Academic status, presence of a stroke care unit, higher hospital volume and availability of endovascular therapy had a significantly lower risk-standardized mortality ratio; distance from the patient's residence to the hospital was not associated with the risk-standardized mortality ratio. Our results suggest that stroke-ready hospitals play an important role in improving stroke mortality in Japan.

Effect of Japanese Herbal Kampo Medicine Goreisan on Reoperation Rates after Burr-Hole Surgery for Chronic Subdural Hematoma: Analysis of a National Inpatient Database

Goreisan is a herbal Kampo medicine used for treating chronic subdural hematoma (CSDH) in Japan. Experimental studies have suggested that Goreisan exerts a hydrogogue effect, but clinical evidence for the effectiveness of Goreisan in CSDH is currently lacking. Using a national Japanese inpatient database, we examined the association between Goreisan use and reoperation rates after burr-hole surgery for CSDH. We identified 36,020 patients, including 3,889 Goreisan users and 32,131 nonusers. Propensity scores of receiving Goreisan were calculated based on hospital characteristics and patient backgrounds (age, sex, body mass index, activities of daily living, consciousness level, comorbidities, antithrombotic agent use, mannitol infusion, and corticosteroid infusion). One-to-one propensity-score matching created 3,879 pairs of Goreisan users and nonusers. Propensity-matched analysis revealed that Goreisan use was significantly associated with a lower reoperation rate (4.8%) compared with nonuse (6.2%) (risk difference, −1.4%; 95% confidence interval (CI), −2.4% to −0.38%). The number needed to prevent one reoperation was 72 (95% CI, 41–265). Instrumental-variable analysis showed similar results to the propensity-matched analysis. These results suggest that Goreisan use reduced the need for reoperation after burr-hole surgery for CSDH.

Complication rates after functional endoscopic sinus surgery: analysis of 50,734 Japanese patients

OBJECTIVE

The complication rates associated with different types of functional endoscopic sinus surgery (FESS) remain to be fully examined.

STUDY DESIGN

Retrospective cohort study.

METHODS

We extracted data from the Japanese Diagnosis Procedure Combination database on 50,734 patients (aged ≥ 16 years) who underwent FESS for chronic rhinosinusitis between 2007 and 2013. We focused on specific types of surgery and stratified the patients into three groups: group 1 (single sinus surgery), group 2 (multiple sinus surgery), and group 3 (whole sinus surgery). Patient characteristics and early postoperative complications including cerebrospinal fluid (CSF) leakage, orbital injury, severe hemorrhage, and toxic shock syndrome (TSS) that occurred during 1 to 2 weeks of each hospitalization were compared. Multivariable logistic regression analysis was performed to assess the association between overall complication rate and background characteristics, with adjustment for within-hospital clustering.

RESULTS

The overall complication rate was 0.50%; the rates of CSF leakage, orbital injury, hemorrhage requiring surgery, blood transfusion, and TSS were 0.09%, 0.09%, 0.10%, 0.18%, and 0.02%, respectively. Ethmoidectomy combined with sphenoidotomy was associated with higher overall complication rates (1.40%). The rate of orbital injury was highest in group 2, whereas that of other complications did not differ significantly among the groups. Extent of FESS showed no significant association with overall complication rate.

CONCLUSION

More extensive FESS was not associated with increased rates of postoperative CSF leakage, hemorrhage, or TSS. Multiple sinus surgery was associated with a higher rate of orbital injury. The extent of surgery did not significantly affect the overall complication rate.

LEVEL OF EVIDENCE

2b.

Carperitide Increases the Need for Renal Replacement Therapy After Cardiovascular Surgery

OBJECTIVES

Acute kidney injury is a common complication after aortic surgery. Carperitide, a human atrial natriuretic peptide, was reported to be effective for preventing acute kidney injury after cardiac surgery. However, most studies were from single centers, and results of meta-analyses are subject to publication bias. The aim of the present study was to investigate whether carperitide preserved renal function in patients undergoing cardiovascular surgery.

DESIGN

Retrospective cohort study.

SETTING

Participating hospitals (N = 281) in a national database from 2010 to 2013.

PARTICIPANTS

Adult patients (N = 47,032) who underwent cardiovascular surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The main intervention variable investigated was the use of carperitide on the day of surgery. Assessed outcomes included receiving renal replacement therapy within 21 days of surgery and in-hospital mortality. Data were available for 47,032 patients, of whom 2,186 (4.6%) received carperitide on the day of surgery. Multivariate logistic regression analysis revealed that carperitide was significantly associated with a greater likelihood of receiving renal replacement therapy within 21 days of surgery, but not with in-hospital mortality.

CONCLUSIONS

In patients undergoing cardiovascular surgery, carperitide significantly increased the odds of receiving renal replacement therapy within 21 days after surgery.