Complications after peripherally inserted central catheter versus central venous catheter implantation in intensive care unit: propensity score analysis using a nationwide database

BACKGROUND

It remains unclear whether peripherally inserted central catheters (PICCs) are superior to central venous catheters (CVCs); therefore, we compared post-implantation complications between CVC and PICC groups.

RESEARCH DESIGN AND METHODS

Patients who received CVCs or PICCs between April 2010 and March 2018 were identified from the Diagnosis Procedure Combination database, a national inpatient database in Japan. The outcomes of interest included catheter infection, pulmonary embolism, deep vein thrombosis, and phlebitis. Propensity score overlap weighting was used to balance patient backgrounds. Outcomes were compared using logistic regression analyses.

RESULTS

We identified 164,185 eligible patients, including 161,605 (98.4%) and 2,580 (1.6%) in the CVC and PICC groups, respectively. The PICC group was more likely to have overall complications (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.32-2.19), pulmonary embolism (OR, 2.32; 95% CI, 1.38-3.89), deep vein thrombosis (OR, 1.86; 95% CI, 1.16-2.99), and phlebitis (OR, 1.72; 95% CI, 1.27-2.32) than the CVC group. There was no significant intergroup difference in catheter infection (OR, 1.09; 95% CI, 0.39-3.04).

CONCLUSIONS

Patients with PICCs had a significantly greater incidence of complications than did those with CVCs. Further research is necessary to explore the factors contributing to these complications.

Antimicrobial Prophylaxis With Ampicillin-sulbactam Compared With Cefazolin for Esophagectomy: Nationwide Inpatient Database Study in Japan

OBJECTIVE

To assess the effect of antimicrobial prophylaxis with ampicillin-sulbactam (ABPC/SBT) compared with cefazolin (CEZ) on the short-term outcomes after esophagectomy.

BACKGROUND

CEZ is widely used for antimicrobial prophylaxis in esophagectomy without procedure-specific evidence, whereas ABPC/SBT is preferred in some hospitals to target both aerobic and anaerobic oral bacteria.

METHODS

Data of patients who underwent esophagectomy for cancer between July 2010 and March 2019 were extracted from a nationwide Japanese inpatient database. Overlap propensity score weighting was conducted to compare the short-term outcomes [including surgical site infection (SSI), anastomotic leakage, and respiratory failure] between antimicrobial prophylaxis with CEZ and ABPC/SBT after adjusting for potential confounders. Sensitivity analyses were also performed using propensity score matching and instrumental variable analyses.

RESULTS

Among 17,772 eligible patients, 16,077 (90.5%) and 1695 (9.5%) patients were administered CEZ and ABPC/SBT, respectively. SSI, anastomotic leakage, and respiratory failure occurred in 2971 (16.7%), 2604 (14.7%), and 2754 patients (15.5%), respectively. After overlap weighting, ABPC/SBT was significantly associated with a reduction in SSI [odds ratio 0.51 (95% CI: 0.43-0.60)], anastomotic leakage [0.51 (0.43-0.61)], and respiratory failure [0.66 (0.57-0.77)]. ABPC/SBT was also associated with reduced respiratory complications, postoperative length of stay, and total hospitalization costs. The proportion of Clostridioides difficile colitis and noninfectious complications did not differ between the groups. Propensity score matching and instrumental variable analyses demonstrated equivalent results.

CONCLUSIONS

The administration of ABPC/SBT as antimicrobial prophylaxis for esophagectomy was associated with better short-term postoperative outcomes compared with CEZ.

Effect of Intraoperative Tranexamic Acid on Perioperative Major Hemorrhage Requiring Transfusion in Patients Undergoing Elective Spine Surgery: A Propensity Score-Matched Analysis Using a National Inpatient Database

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

This study aimed to examine whether the use of intravenous TXA in elective spine surgery is associated with reduced perioperative massive hemorrhage requiring transfusion.

METHODS

We extracted all patients who underwent decompression with or without fusion surgery for the cervical, thoracic, and lumbar spine between April 2012 and March 2019. The primary outcome was the occurrence of massive hemorrhage requiring transfusion, defined as at least 560 mL of blood transfusion within 2 days of spine surgery or the requirement of additional blood transfusion from 3-7 days postoperatively. Secondary outcomes were the occurrence of thrombotic complications (pulmonary embolism, acute coronary syndrome, and stroke) and postoperative hematoma requiring additional surgery.

RESULTS

We identified 83,821 eligible patients, with 9747 (12%) patients in the TXA group. Overall, massive hemorrhage requiring transfusion occurred in 781 (.9%) patients. Propensity score matching yielded 8394 pairs. In the matched cohort, the TXA group had a lower proportion of massive hemorrhage requiring transfusion than the control group (.7% vs 1.1%; P = .002). There was no significant difference in the occurrence of thrombotic complications and postoperative hematoma requiring additional surgery between both groups. The multivariable regression analysis also showed that the use of TXA was associated with significantly lower proportions of massive hemorrhage requiring transfusion (odds ratio, .62; 95% confidence interval, .43-.90; P = .012).

CONCLUSIONS

In this analysis using real-world data, TXA use in elective spinal surgery was associated with reduced perioperative massive hemorrhage requiring transfusion without increasing thrombotic complications.

LEVEL OF EVIDENCE

Prognostic Level Ⅲ.

Endoscopic surgery versus craniotomy for spontaneous intracerebral hemorrhage in the late elderly patients

OBJECTIVES

To compare the prognosis of late elderly patients with spontaneous intracerebral hemorrhage (ICH) treated by endoscopic evacuation and craniotomy MATERIALS AND METHODS: Using the Diagnosis Procedure Combination database, we identified patients aged ≥ 75 years who underwent surgery for spontaneous ICH within 48 hours after admission between April 2014 and March 2018. Eligible patients were classified into two groups according to the type of surgery (endoscopic surgery and craniotomy). Propensity-score matching weight analysis was conducted to compare the good neurological outcome modified Rankin Scale (mRS) score (0-4) at discharge as the primary endpoint between the two groups. Secondary endpoints were postoperative meningitis, tracheostomy, reoperation within 3 days and total hospitalization costs.

RESULTS

Among the 5,396 eligible patients, endoscopic surgery and craniotomy were performed in 895 and 4,501 patients, respectively. In the propensity-score matching weight analysis, all covariates were well balanced. The proportions of patients with a good prognosis (mRS score at discharge: 0-4) did not significantly differ between the surgical procedures (42.1% vs. 42.8%, p = 0.828). The proportions of meningitis, tracheostomy and reoperation were not significantly different between the two groups. Hospitalization costs were significantly higher in the craniotomy group than in the endoscopic surgery group (25,536 vs. 29,603 US dollars, p = 0.012).

CONCLUSIONS

Inhospital outcomes did not differ between endoscopic and open surgeries for spontaneous ICH in the late-stage elderly patients aged ≥75 years. Hospitalization costs were significantly higher in the craniotomy group, suggesting that endoscopic surgery may be more acceptable.

Proportion of early extubation and short-term outcomes after esophagectomy: a retrospective cohort study

BACKGROUND

The proportion of early extubation after esophagectomy varies among hospitals; however, the impact on clinical outcomes is unclear. The aim of this retrospective study was to evaluate associations between the proportion of early extubation in hospitals and short-term outcomes after esophagectomy. Because there is no consensus regarding the optimal timing for extubation, the authors considered that hospitals' early extubation proportion reflects the hospital-level extubation strategy.

MATERIALS AND METHODS

Data of patients who underwent oncologic esophagectomy (July 2010-March 2019) were extracted from a Japanese nationwide inpatient database. The proportion of patients who underwent early extubation (extubation on the day of surgery) at each hospital was assessed and grouped by quartiles: very low- (<11%), low- (11-37%), medium- (38-83%), and high-proportion (≥84%) hospitals. The primary outcome was respiratory complications; secondary outcomes included reintubation, anastomotic leakage, other major complications, and hospitalization costs. Multivariable regression analyses were performed, adjusting for patient demographics, cancer treatments, and hospital characteristics. A restricted cubic spline analysis was also performed for the primary outcome.

RESULTS

Among 37 983 eligible patients across 545 hospitals, early extubation was performed in 17 931 (47%) patients. Early extubation proportions ranged from 0-100% across hospitals. Respiratory complications occurred in 10 270 patients (27%). Multivariable regression analyses showed that high- and medium-proportion hospitals were significantly associated with decreased respiratory complications [odds ratio, 0.46 (95% CI, 0.36-0.58) and 0.43 (0.31-0.60), respectively], reintubation, and hospitalization costs when compared with very low-proportion hospitals. The risk of anastomotic leakage and other major complications did not differ among groups. The restricted cubic spline analysis demonstrated a significant inverse dose-dependent association between the early extubation proportion and the risk of respiratory complications.

CONCLUSION

A higher proportion of early extubation in a hospital was associated with a lower occurrence of respiratory complications, highlighting a potential benefit of early extubation after esophagectomy.

Facility staffing associated with potentially avoidable hospitalizations in nursing home residents in Japan: a retrospective cohort study

BACKGROUND

Wide variations in facility staffing may lead to differences in care, and consequently, adverse outcomes such as hospitalizations. However, few studies focused on types of occupations. Therefore, we aimed to examine the association between a wide variety of facility staffing and potentially avoidable hospitalizations of nursing home residents in Japan.

METHODS

In this retrospective cohort study using long-term care and medical insurance claims data in Ibaraki Prefecture from April 2018 to March 2019, we identified individuals aged 65 years and above who were newly admitted to nursing homes. In addition, facility characteristic data were obtained from the long-term care insurance service disclosure system. Subsequently, we conducted a multivariable Cox regression analysis and evaluated the association between facility staffing and potentially avoidable hospitalizations.

RESULTS

A total of 2909 residents from 235 nursing homes were included. The cumulative incidence of potentially avoidable hospitalizations at 180 days was 14.2% (95% confidence interval [CI] 12.7-15.8). Facilities with full-time physicians (adjusted hazard ratio [HR]: 0.59, 95% CI: 0.37-0.94) and a higher number of dietitians (HR: 0.72, 95% CI: 0.54-0.97) were significantly associated with a lower likelihood of potentially avoidable hospitalizations. In contrast, having nurses or trained caregivers during the night shift (HR: 1.72, 95% CI: 1.25-2.36) and a higher number of care managers (HR: 1.37, 95% CI: 1.03-1.83) were significantly associated with a high probability of potentially avoidable hospitalizations.

CONCLUSIONS

We revealed that variations in facility staffing were associated with potentially avoidable hospitalizations. The results suggest that optimal allocation of human resources, such as dietitians and physicians, may be essential to reduce potentially avoidable hospitalizations. To provide appropriate care to nursing home residents, it is necessary to establish a system to effectively allocate limited resources. Further research is warranted on the causal relationship between staff allocation and unnecessary hospitalizations, considering the confounding factors.

Outcomes After Endoscopic Evacuation Versus Evacuation Using Craniotomy or Stereotactic Aspiration for Spontaneous Intracerebral Hemorrhage: Analysis Using a Japanese Nationwide Database

BACKGROUND

Various surgical methods are available for managing large intracerebral hemorrhage. This study compared the prognosis of patients with spontaneous intracerebral hemorrhage who underwent endoscopic evacuation, stereotactic aspiration, and craniotomy by using a nationwide inpatient database in Japan.

METHODS

Using the Diagnosis Procedure Combination database, we identified patients who underwent surgery for spontaneous intracerebral hemorrhage within 48 h after admission between April 2014 and March 2018. Eligible patients were classified into three groups according to the type of surgery (endoscopic surgery, stereotactic surgery, and craniotomy). Propensity score matching weight analysis was conducted to compare poor modified Rankin Scale score at discharge (severe disability or death) and hospitalization cost among the groups.

RESULTS

Among 17,860 eligible patients, craniotomy, stereotactic surgery, and endoscopic surgery were performed in 14,354, 474, and 3,032 patients, respectively. In the matching weight analysis, all covariates were well balanced. Compared with the endoscopic surgery group, the proportion of poor prognosis (modified Rankin Scale score at discharge of 5 or 6) was significantly higher in craniotomy groups (odds ratio 2.51, 95% confidence interval 1.11-5.68; p = 0.028). Subgroup analysis based on hemorrhage location and consciousness level at the time of admission showed no significant difference between the surgical procedures. Hospitalization costs were significantly higher in the craniotomy group than in the endoscopic surgery group (difference US $9,724, 95% confidence interval 2,169-17,259; p = 0.011).

CONCLUSIONS

Endoscopic surgery for spontaneous intracerebral hemorrhage was associated with improved prognosis compared with craniotomy at the hospital discharge. Future large-scale clinical trials are needed to evaluate the optimal surgical techniques for intracerebral hemorrhage.

Impact of Prophylactic Corticosteroid Use on In-hospital Mortality and Respiratory Failure After Esophagectomy for Esophageal Cancer: Nationwide Inpatient Data Study in Japan

OBJECTIVE

To assess the effect of preoperative prophylactic corticosteroid use on short-term outcomes after oncologic esophagectomy.

BACKGROUND

Previous studies have shown that prophylactic corticosteroid use may decrease the risk of respiratory failure following esophagectomy by attenuating the perioperative systemic inflammation response. However, its effectiveness has been controversial, and its impact on mortality remains unknown.

METHODS

Data of patients who underwent oncologic esophagectomy between July 2010 and March 2019 were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting, propensity score matching, and instrumental variable analyses were performed to investigate the associations between prophylactic corticosteroid use and short-term outcomes, such as in-hospital mortality and respiratory failure, adjusting for potential confounders.

RESULTS

Among 35,501 eligible patients, prophylactic corticosteroids were used in 22,620 (63.7%) patients. In-hospital mortality, respiratory failure, and severe respiratory failure occurred in 924 (2.6%), 5440 (15.3%), and 2861 (8.1%) patients, respectively. In stabilized inverse probability of treatment weighting analyses, corticosteroids were significantly associated with decreased in-hospital mortality [odds ratio (OR)=0.80; 95% confidence interval (CI): 0.69-0.93], respiratory failure (OR=0.84; 95% CI: 0.79-0.90), and severe respiratory failure (OR=0.87; 95% CI: 0.80-0.95). Corticosteroids were also associated with decreased postoperative length of stay and total hospitalization costs. The proportion of anastomotic leakage did not differ with the use of Propensity score matching and instrumental variable analysis demonstrated similar results.

CONCLUSIONS

Prophylactic corticosteroid use in oncologic esophagectomy was associated with lower in-hospital mortality as well as decreased respiratory failure and severe respiratory failure, suggesting a potential benefit for preoperative corticosteroid use in esophagectomy.

All-Cause Readmission or Potentially Avoidable Readmission: Which Is More Predictable Using Frailty, Comorbidities, and ADL?

Background and Objectives

Readmission-related health care reforms have shifted their focus from all-cause readmissions (ACR) to potentially avoidable readmissions (PAR). However, little is known about the utility of analytic tools from administrative data in predicting PAR. This study determined whether 30-day ACR or 30-day PAR is more predictable using tools that assess frailty, comorbidities, and activities of daily living (ADL) from administrative data.

Research Design and Methods

This retrospective cohort study was conducted at a large general acute care hospital in Tokyo, Japan. We analyzed patients aged ≥70 years who had been admitted to and discharged from the subject hospital between July 2016 and February 2021. Using administrative data, we assessed each patient's Hospital Frailty Risk Score, Charlson Comorbidity Index, and Barthel Index on admission. To determine the influence of each tool on readmission predictions, we constructed logistic regression models with different combinations of independent variables for predicting unplanned ACR and PAR within 30 days of discharge.

Results

Among 16 313 study patients, 4.1% experienced 30-day ACR and 1.8% experienced 30-day PAR. The full model (including sex, age, annual household income, frailty, comorbidities, and ADL as independent variables) for 30-day PAR showed better discrimination (C-statistic: 0.79, 95% confidence interval: 0.77-0.82) than the full model for 30-day ACR (0.73, 0.71-0.75). The other prediction models for 30-day PAR also had consistently better discrimination than their corresponding models for 30-day ACR.

Discussion and Implications

PAR is more predictable than ACR when using tools that assess frailty, comorbidities, and ADL from administrative data. Our PAR prediction model may contribute to the accurate identification of at-risk patients in clinical settings who would benefit from transitional care interventions.

Impact of Body Mass Index on Major Complications, Multiple Complications, In-hospital Mortality, and Failure to Rescue After Esophagectomy for Esophageal Cancer: A Nationwide Inpatient Database Study in Japan

OBJECTIVE

To examine the association of BMI with mortality and related outcomes after oncologic esophagectomy.

SUMMARY BACKGROUND DATA

Previous studies showed that high BMI was a risk factor for anastomotic leakage and low BMI was a risk factor for respiratory complications after esophagectomy. However, the association between BMI and in-hospital mortality after oncologic esophagectomy remains unclear.

METHODS

Data for patients who underwent esophagectomy for esophageal cancer between July 2010 and March 2019 were extracted from a Japanese nationwide inpatient database. Multivariate regression analyses and restricted cubic spline analyses were used to investigate the associations between BMI and short-term outcomes, adjusting for potential confounders.

RESULTS

Among 39,406 eligible patients, in-hospital mortality, major complications, and multiple complications (≥2 major complications) occurred in 1069 (2.7%), 14,824 (37.6%), and 3621 (9.2%), respectively. Compared with normal weight (18.5-22.9 kg/m 2 ), severe underweight (<16.0 kg/m 2 ), mild/moderate underweight (16.0-18.4 kg/m 2 ), and obese (≥27.5 kg/m 2 )were significantly associated with higher in-hospital mortality [odds ratio 2.20 (95% confidence interval 1.65-2.94), 1.25 (1.01-1.49), and 1.48 (1.05-2.09), respectively]. BMI showed U-shaped dose-response associations with mortality, major complications, and multiple complications. BMI also showed a reverse J-shaped association with failure to rescue (death after major complications).

CONCLUSIONS

Both high BMI and low BMI were associated with mortality, major complications and multiple complications after esophagectomy for esophageal cancer. Patients with low BMI were more likely to die once a major complication occurred. The present results can assist with risk stratification in patients undergoing oncologic esophagectomy.

Weight loss during neoadjuvant therapy and short-term outcomes after esophagectomy: a retrospective cohort study

BACKGROUND

Neoadjuvant therapy (NAT) has become common worldwide for resectable advanced esophageal cancer and frequently involves weight loss. Although failure to rescue (death after major complications) is known as an emerging surgical quality measure, little is known about the impact of weight loss during NAT on failure to rescue. This retrospective study aimed to investigate the association of weight loss during NAT and short-term outcomes, including failure to rescue after esophagectomy.

MATERIALS AND METHODS

Patients who underwent esophagectomy after NAT between July 2010 and March 2019 were identified from a Japanese nationwide inpatient database. Based on quartiles of percent weight change during NAT, patients were grouped into four categories of gain, stable, small loss, and loss (>4.5%). The primary outcomes were failure to rescue and in-hospital mortality. The secondary outcomes were major complications, respiratory complications, anastomotic leakage, and total hospitalization costs. Multivariable regression analyses were used to compare outcomes between the groups, adjusting for potential confounders, including baseline BMI.

RESULTS

Among 15 159 eligible patients, in-hospital mortality and failure to rescue occurred in 302 (2.0%) and 302/5698 (5.3%) patients, respectively. Weight loss (>4.5%) compared to gain was associated with increased failure to rescue and in-hospital mortality [odds ratios 1.55 (95% CI: 1.10-2.20) and 1.53 (1.10-2.12), respectively]. Weight loss was also associated with increased total hospitalizations costs, but not with major complications, respiratory complications, and anastomotic leakage. In subgroup analyses, regardless of baseline BMI, weight loss (>4.8% in nonunderweight or >3.1% in underweight) was a risk factor for failure to rescue and in-hospital mortality.

CONCLUSION

Weight loss during NAT was associated with failure to rescue and in-hospital mortality after esophagectomy, independent of baseline BMI. This emphasizes the importance of weight loss measurement during NAT to assess the risk for a subsequent esophagectomy.

Trend in the Numbers of Hospitalized Patients With Varicella, Herpes Zoster, and Ischemic Stroke in Japanese Individuals <20 Years of Age Before and After Implementation of Universal Varicella Vaccination

Several studies have shown an association between varicella-zoster virus infection and ischemic stroke. We analyzed the trends in the numbers of patients with varicella, herpes zoster and ischemic stroke before and after the universal vaccination program using a Japanese database of hospitalized patients. The number of patients with varicella decreased but those of herpes zoster and ischemic stroke did not change.

The Effect of Business Operating Systems on Nursing Home Termination

Objectives: Nursing home terminations have increased worldwide due to rising costs, staffing shortages, and the coronavirus disease pandemic. However, little is known about the impact that business operating systems have on nursing home termination. Methods: This study used the National Long-term Care database, which comprised 7,842 operating nursing homes in January 2018. Nursing home termination was identified when nursing homes discontinued provision of long-term care services to all residents between January 2018 and December 2020. Business operating systems that were reimbursed by the LTC insurance system were the exposure of interest. The logistic regression model for nursing home termination included a series of organizational, internal, and external factors as covariates. Results: From 2018 to 2020, 83 (1.1%) nursing homes were terminated. The proportion of reimbursed nursing homes varied greatly depending on the type of business operating systems. Implementing physical function training and improving working conditions were significantly associated with a lower risk of nursing home termination. Conclusion: Financial incentives to several business operating systems are an effective way to build a sustainable environment for nursing homes to continue to exist.

Early postoperative non-steroidal anti-inflammatory drugs and anastomotic leakage after oesophagectomy

BACKGROUND

Previous studies have suggested that postoperative non-steroidal anti-inflammatory drug (NSAID) use may increase the risk of anastomotic leakage after colorectal surgery. However, the association between NSAIDs and anastomotic leakage after oesophagectomy is unclear. The aim of this retrospective study was to assess the effect of early postoperative NSAID use on anastomotic leakage after oesophagectomy.

METHODS

The Data of patients who underwent oesophagectomy for cancer between July 2010 and March 2019 were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting (IPTW), propensity score matching, and instrumental variable analyses were performed to investigate the association between NSAID use in the early postoperative period (defined as the day of and the day after surgery) and short-term outcomes, adjusting for potential confounders. The primary outcome was anastomotic leakage. The secondary outcomes were acute kidney injury, gastrointestinal bleeding, and mortality.

RESULTS

Among 39 418 eligible patients, early postoperative NSAIDs were used by 16 211 individuals (41 per cent). Anastomotic leakage occurred in 5729 patients (15 per cent). In stabilized IPTW analyses, NSAIDs were not associated with anastomotic leakage (odds ratio 1.04, 95 per cent c.i. 0.97 to 1.10). The proportions of acute kidney injury and gastrointestinal bleeding, as well as 30-day mortality and in-hospital mortality, did not differ according to NSAID use. Propensity score matching and instrumental variable analyses demonstrated similar results.

CONCLUSION

Early postoperative NSAID use was not associated with anastomotic leakage or other complications in patients who underwent oesophagectomy.

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.

Development and validation of a risk score to predict the frequent emergency house calls among older people who receive regular home visits

Background

The demand for home healthcare is increasing in Japan, and a 24-hour on-call system could be a burden for primary care physicians. Identifying high-risk patients who need frequent emergency house calls could help physicians prepare and allocate medical resources. The aim of the present study was to develop a risk score to predict the frequent emergency house calls in patients who receive regular home visits.

Methods

We conducted a retrospective cohort study with linked medical and long-term care claims data from two Japanese cities. Participants were ≥ 65 years of age and had newly started regular home visits between July 2014 and March 2018 in Tsukuba city and between July 2012 and March 2017 in Kashiwa city. We followed up with patients a year after they began the regular home visits or until the month following the end of the regular home visits if this was completed within 1 year. We calculated the average number of emergency house calls per month by dividing the total number of emergency house calls by the number of months that each person received regular home visits (1–13 months). The primary outcome was the “frequent” emergency house calls, defined as its use once per month or more, on average, during the observation period. We used the least absolute shrinkage and selection operator (LASSO) logistic regression with 10-fold cross-validation to build the model from 19 candidate variables. The predictive performance was assessed with the area under the curve (AUC).

Results

Among 4888 eligible patients, frequent emergency house calls were observed in 13.0% of participants (634/4888). The risk score included three variables with the following point assignments: home oxygen therapy (3 points); long-term care need level 4–5 (1 point); cancer (4 points). While the AUC of a model that included all candidate variables was 0.734, the AUC of the 3-risk score model was 0.707, suggesting good discrimination.

Conclusions

This easy-to-use risk score would be useful for assessing high-risk patients and would allow the burden on primary care physicians to be reduced through measures such as clustering high-risk patients in well-equipped medical facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01742-7.

Short-Term Outcomes of Epidural Analgesia in Minimally Invasive Esophagectomy for Esophageal Cancer: Nationwide Inpatient Data Study in Japan

BACKGROUND

Studies have shown that epidural analgesia (EDA) is associated with a decreased risk of pneumonia and anastomotic leakage after esophagectomy, and several guidelines strongly recommend EDA use after esophagectomy. However, the benefit of EDA use in minimally invasive esophagectomy (MIE) remains unclear.

OBJECTIVE

The aim of this retrospective study was to compare the short-term outcomes between patients with and without EDA undergoing MIE for esophageal cancer.

METHODS

Data of patients who underwent oncologic MIE (April 2014-March 2019) were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting (IPTW), propensity score matching, and instrumental variable analyses were performed to investigate the associations between EDA use and short-term outcomes, adjusting for potential confounders.

RESULTS

Among 12,688 eligible patients, EDA was used in 9954 (78.5%) patients. In-hospital mortality, respiratory complications, and anastomotic leakage occurred in 230 (1.8%), 2139 (16.9%), and 1557 (12.3%) patients, respectively. In stabilized IPTW, EDA use was significantly associated with decreased in-hospital mortality (odds ratio [OR] 0.46 [95% confidence interval 0.34-0.61]), respiratory complications (OR 0.74 [0.66-0.84]), and anastomotic leakage (OR 0.77 [0.67-0.88]). EDA use was also associated with decreased prolonged mechanical ventilation, unplanned intubation, nonsteroidal anti-inflammatory drug use, acetaminophen use, postoperative length of stay, and total hospitalization costs and increased vasopressor use. One-to-three propensity score matching and instrumental variable analyses demonstrated equivalent results.

CONCLUSIONS

EDA use in oncologic MIE was associated with low in-hospital mortality as well as decreased respiratory complications, and anastomotic leakage, suggesting the potential advantage of EDA use in MIE.

Perioperative outcomes of laparoscopically assisted anorectoplasty versus conventional procedures for anorectal malformation: a retrospective nationwide database study

PURPOSE

This study aimed to compare the perioperative outcomes of laparoscopically assisted anorectoplasty (LAARP) and conventional procedures (CPs) for anorectal malformation (ARM) using a national inpatient database in Japan.

METHODS

Using the Diagnosis Procedure Combination database, we identified patients who underwent anorectoplasty for high- or intermediate-type ARMs from 2010 to 2019. Primary outcomes were postoperative rectal prolapse, anal stenosis, and general complications. Secondary outcomes were the duration of anesthesia and length of hospital stay. We performed 1:2 propensity score-matched analyses to compare the outcomes between the LAARP and CP groups.

RESULTS

We identified 1005 eligible patients, comprising 286 and 719 patients who underwent LAARP and CP, respectively. The propensity score-matched groups included 281 patients with LAARP and 562 with CP. The LAARP group showed a higher proportion of rectal prolapse (21.4% vs. 8.5%; odds ratio, 2.91; 95% confidence interval [CI], 1.89-4.48; p < 0.001) and longer duration of anesthesia (462 min vs. 365 min; difference, 90 min; 95% CI 43-137; p < 0.001) than the CP group. No significant differences were found in other outcomes.

CONCLUSION

LAARP had worse outcomes than CP in terms of rectal prolapse. Thus, we propose that LAARP may require technical refinement to improve patient outcomes.

Effect of nintedanib on acute exacerbations of fibrosing interstitial lung diseases: A national database study in Japan

Introduction

Acute exacerbation (AE) is a life-threatening event in patients with fibrosing interstitial lung diseases (ILDs). Although nintedanib reduces AE incidence, its effectiveness during AE is unclear.

Methods

Using data from the Diagnosis Procedure Combination database (September 2015–March 2020), we identified patients with fibrosing ILDs who received intravenous injection of a high-dose corticosteroid within 3 days post-admission and analysed their first hospitalisation. We performed overlap propensity score weighting to compare in-hospital outcomes between patients who received nintedanib within 14 days post-admission and those who did not. The primary and secondary outcomes were in-hospital mortality and length of hospitalisation in the patients discharged alive, respectively.

Results

Among the 6235 identified patients, 353 patients received nintedanib within 14 days post-admission. In-hospital mortality occurred in 13.7% and 6.0% patients in the control (n=5882) and nintedanib-treated (n=353) patients, respectively. The mean length of hospitalisation was 39.9 and 30.4 days in the control and nintedanib-treated patients, respectively. After overlap propensity score weighting, nintedanib treatment was significantly associated with lower in-hospital mortality in the adjusted cohort (odds ratio, 0.43; 95% confidence interval, 0.27–0.70; p=0.001). The mean length of hospitalisation in nintedanib-treated patients (30.7 days) was significantly shorter than that in the control group (37.5 days, p<0.001).

Conclusions

Nintedanib initiation during AE was significantly associated with a lower risk of in-hospital death and shorter length of hospitalisation in patients with fibrosing ILDs. Our results elucidate the potential role of nintedanib in the treatment of AE in patients with fibrosing ILDs. Further prospective studies are warranted.

Regional variation in long-term care spending in Japan

Background

Health inequalities are widening in Japan, and thus, it is important to understand whether (and to what extent) there is a regional variation in long-term care (LTC) spending across municipalities. This study assesses regional variation in LTC spending and identifies the drivers of such variation.

Methods

We conducted a cross-sectional study using publicly available municipality-level data across Japan in 2019, in which the unit of analysis was municipality. The outcome of interest was per-capita LTC spending, which was estimated by dividing total LTC spending in a municipality by the number of older adults (people aged ≥ 65). To further identify drivers of regional variation in LTC spending, we conducted linear regression of per-capita spending against a series of demand, supply, and structural factors. Shapley decomposition approach was used to highlight the contribution of each independent variable to the goodness of fit of the regression model.

Results

In Fiscal 2019, per-capita LTC spending varied from 133.1 to 549.9 thousand yen (max/min ratio 4.1) across the 1460 municipalities analyzed, showing considerable regional variation. The included covariates explained 84.0% of the total variance in LTC spending, and demand-determined variance was remarkably high, which contributed more than 85.7% of the overall R². Specifically, the highest contributing factor was the proportion of severe care-need level and care level certification rate.

Conclusions

Our results demonstrate that, even after adjusting for different municipalities’ age and sex distribution, there is a large variation in LTC spending. Furthermore, our findings highlight that, to reduce the spending gap between municipalities, the issues underlying large variations in LTC spending across municipalities must be identified and addressed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14194-6.

Trends in surgical procedures for spontaneous intracerebral hemorrhage in Japan

OBJECTIVES

Minimally invasive surgery for spontaneous intracerebral hemorrhage (ICH) has become increasingly popular in recent years. However, there are no reports on the recent trends in surgical procedures for spontaneous ICH. To investigate current trends in surgical methods for spontaneous ICH using a nationwide inpatient database from Japan.

MATERIALS AND METHODS

Patients who underwent surgery for spontaneous ICH between April 2014 and March 2018 were identified in a nationwide inpatient database from Japan. We examined patient characteristics, diagnoses, types of surgery, complications, and discharge status.

RESULTS

We identified 21,129 inpatients who underwent surgery for spontaneous ICH. The procedures were as follows: 16,256 (76.9%) transcranial hemorrhage evacuations, 3722 (17.6%) endoscopic hemorrhage evacuations, and 1151 (5.4%) stereotactic aspirations of hemorrhage. Patients tended to receive transcranial hemorrhage evacuations in hospitals with fewer surgical cases. The proportions of endoscopic hemorrhage evacuations increased annually, whereas those of stereotactic surgery decreased. The proportions of transcranial surgery remained almost unchanged. Tracheostomy and hospitalization costs were lower in the stereotactic aspirations of hemorrhage group, and the proportions of reoperation were higher in the endoscopic hemorrhage evacuations group.

CONCLUSIONS

The use of endoscopic surgery for spontaneous ICH has increased in Japan. This study can form the basis of future clinical investigations into spontaneous ICH surgery.

Implementation and costs of housing adaptations among older adults with different functional limitations in Japan

Background

Accessible housing is crucial to maintain a good quality of life for older adults with functional limitations, and housing adaptations are instrumental in resolving accessibility problems. It is unclear to what extent older adults, who have a high risk of further functional decline, use housing adaptation grants acquired through the long-term care (LTC) insurance systems. This study aimed to examine the utilization of housing adaptation grants in terms of implementation and costs, for older adults with different types of functional limitations related to accessibility problems.

Methods

The study sample included individuals from a suburban city in the Tokyo metropolitan area who were certified for care support levels (indicative of the need for preventive care) for the first time between 2010 and 2018 (N = 10,372). We followed the study participants over 12 months since the care needs certification. We matched and utilized three datasets containing the same individual’s data: 1) care needs certification for LTC insurance, 2) insurance premium levels, and 3) LTC insurance claims. We conducted a multivariable logistic regression analysis to estimate the likelihood of individuals with different functional limitations of having housing adaptations implemented. Afterward, we conducted a subgroup analysis of only older adults implementing housing adaptation grants to compare costs between groups with different functional limitations using the Mann–Whitney U and Kruskal–Wallis tests.

Results

Housing adaptations were implemented among 15.6% (n = 1,622) of the study sample, and the median cost per individual was 1,287 USD. Individuals with lower extremity impairment or poor balance were more likely to implement housing adaptations (adjusted odds ratio (AOR) = 1.290 to AOR = 2.176), while those with visual impairment or lower cognitive function were less likely to implement housing adaptations (AOR = 0.553 to AOR = 0.861). Costs were significantly lower for individuals with visual impairment (1,180 USD) compared to others (1,300 USD).

Conclusion

Older adults with visual or cognitive limitations may not receive appropriate housing adaptations, despite their high risk of accessibility problems. Housing adaptation grants should include various types of services that meet the needs of older people with different disabilities, and the results indicate there may be a need to improve the system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03100-9.

Risk factors for severe lower extremity ischemia following venoarterial extracorporeal membrane oxygenation: an analysis using a nationwide inpatient database

Objectives

Venoarterial extracorporeal membrane oxygenation is increasingly being used as a life-saving modality in critically ill patients. Despite its necessity, severe lower extremity ischemia associated with venoarterial extracorporeal membrane oxygenation remains a potentially devastating complication. We aimed to investigate the incidence and risk factors for severe lower extremity ischemia requiring fasciotomy or amputation following venoarterial extracorporeal membrane oxygenation.

Methods

All patients who received venoarterial extracorporeal membrane oxygenation during hospitalization were identified in a Japanese national inpatient database from July 1, 2010 to March 31, 2018. The primary outcome was occurrence of severe lower extremity ischemia that required fasciotomy or amputation. We used cause-specific proportional hazard models to examine the associations between potential risk factors and outcomes. We also performed a competing-risk analysis to estimate the cause-specific HR for severe lower extremity ischemia using a multivariable competing-risk Cox proportional hazard model with adjustment for potential risk factors.

Results

A total of 29 231 patients who underwent venoarterial extracorporeal membrane oxygenation during hospitalization were identified. Of these, 98 patients (0.3%) had lower extremity ischemia requiring fasciotomy or amputation. The young group (≤18 years) had a significantly higher proportion of severe lower extremity ischemia cases than the adult (19-59 years) and elderly (≥60 years) groups (1.4%, 0.5%, and 0.2%, respectively; p<0.001). In a multivariable competing-risk Cox proportional hazards regression model, younger age (HR 3.06; 95% CI 1.33 to 7.02; p<0.008) and consciousness disturbance on admission (HR 2.53; 95% CI 1.60 to 3.99; p<0.001) were significantly associated with higher likelihood of severe lower extremity ischemia.

Conclusion

In this study using a nationwide database, younger age and consciousness disturbance on admission were associated with higher risk of severe lower extremity ischemia following venoarterial extracorporeal membrane oxygenation.

Level of evidence

Level Ⅲ-prognostic and epidemiological.

Incidence and outcomes of in-hospital cardiac arrest in Japan 2011-2017: a nationwide inpatient database study

Background

Although numerous studies have investigated out-of-hospital cardiac arrest, few studies have been conducted on in-hospital cardiac arrest (IHCA). Knowledge of the nationwide epidemiology of IHCA in Japan, with its super-aging society, is important to understand the current situation of IHCA and to establish evidenced-based medicine in the future. The present study aimed to determine the incidence and outcomes of IHCA and their trends in Japan.

Methods

This observational cohort study was performed using a national administrative inpatient database for more than 1600 acute-care hospitals covering about 50% of all acute-care hospital beds in Japan from April 2011 to March 2018. We defined cardiac arrest patients who received cardiopulmonary resuscitation (chest compression) during hospitalization as IHCA. We excluded out-of-hospital cardiac arrest patients from the source population. The incidence of IHCA per 1000 hospital admissions and survival to discharge rate was reported with trend analyses by calendar year 2011–2017.

Results

Among 53,871,101 hospitalized patients without out-of-hospital cardiac arrest patients in 1626 hospitals, 2,136,038 (4.0%) had cardiac arrest. Of them, 274,664 (12.9%) received cardiopulmonary resuscitation at least once during hospitalization and were identified as IHCA, and 1,861,374 (87.1%) did not receive cardiopulmonary resuscitation. The incidence of IHCA per 1000 hospital admissions was 5.1, with a significant decreasing trend from 6.1 in 2011 to 4.6 in 2017 (P for trend = 0.033). Our estimated incidence can be translated to approximately 87,000 IHCA cases in Japan each year. The percentage of IHCA patients among cardiac arrest patients was 12.9%, with a significant decreasing trend from 14.0% in 2011 to 12.2% in 2017 (P for trend = 0.006). The overall rate of survival to discharge was 12.7%, with a significant increasing trend from 10.5% in 2011 to 14.0% in 2017 (P for trend < 0.001).

Conclusions

We found substantial associations between mortality and loss of health and IHCA in Japan. The incidence of IHCA showed a decreasing trend over time, the percentage of treated cardiac arrest patients also had a decreasing trend, and the overall survival to discharge rate improved over time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-022-00601-y.

Effectiveness of early rehabilitation following aortic surgery: a nationwide inpatient database study

OBJECTIVE

Exercise immediately after aortic surgery is controversial with limited evidence. The present study aimed to assess whether early rehabilitation commencing within 3 days of aortic surgery improves physical functions at discharge more than usual care in patients after aortic surgery.

METHODS

We used the Japanese Diagnosis Procedure Combination database, a nationwide inpatient database from more than 1600 acute care hospitals that covers approximately 75% of all intensive care unit (ICU) beds in Japan. We identified patients who underwent open or endovascular aortic surgery and were admitted to the ICU between July 2010 and March 2018. Patients beginning rehabilitation within 3 days of aortic surgery were defined as the early rehabilitation group and the remaining patients as the usual care group. We used inverse probability of treatment weighting analyses to compare outcomes between the two groups.

RESULTS

Among 121,024 eligible patients, there were 44,746 (37.0%) in the early rehabilitation group and 76,278 (63.0%) in the usual care group. In inverse probability of treatment weighting analyses, Barthel index scores at discharge were significantly higher in the early rehabilitation group than in the usual care group (difference, 4.0; 95% confidence interval, 2.8-5.2). The early rehabilitation group had significantly lower in-hospital mortality, lower total hospitalization costs, shorter ICU stay, and shorter hospital stay than the usual care group.

CONCLUSION

Early rehabilitation within 3 days of aortic surgery was associated with improved physical functions at discharge, shorter ICU and hospital stays, and lower hospitalization costs without increased mortality.

Postoperative outcomes of cancer surgery in patients with and without kidney failure with dialysis therapy: A matched-pair cohort study

Background

The difference in outcomes of cancer surgery between patients with and without kidney failure with dialysis therapy (KFDT) remains uncertain.

Methods

Using 2010–18 data in a national inpatient database in Japan, we identified patients who had undergone resection of colorectal, lung, gastric or breast cancer. We matched selected patient characteristics, type of cancer, surgical procedure and hospital of up to four patients without KFDT to each patient with KFDT. We assessed 30-day mortality and postoperative complications.

Results

Through matching, we identified 2248 patients with KFDT (807 with colorectal, 579 with lung, 500 with gastric and 362 with breast cancer) and 8210 patients without KFDT (2851 with colorectal, 2216 with lung, 1756 with gastric and 1387 with breast cancer). Postoperative complications occurred in a higher proportion of patients with KFDT than of those without KFDT after colorectal {20.3% versus 14.6%; risk difference (RD): 5.7% [95% confidence interval (95% CI) 2.6%–8.8%]}, lung [18.0% versus 12.9%; RD: 5.1% (95% CI 1.6%–8.4%)], gastric [25.0% versus 13.2%; RD: 11.8% (95% CI 7.6%–16.2%)] and breast cancer surgery [7.5% versus 3.5%; RD: 3.9% (95% CI 1.1%–6.9%)]. Patients with KFDT had a higher 30-day mortality than those without KFDT after gastric cancer surgery [1.6% versus 0.3%; RD: 1.3% (95% CI 0.1%–2.3%)]. Heart failure and ischemic heart disease occurred more frequently in patients with KFDT.

Conclusions

Patients with KFDT had higher rates of postoperative complications and 30-day mortality; however, RDs varied between cancer types. The higher rates of postoperative complications in patients with KFDT were mainly attributable to cardiovascular complications.

Clinical Characteristics and Incidences of Benign and Malignant Insulinoma Using a National Inpatient Database in Japan

CONTEXT

Insulinoma is the most common pancreatic functional neuroendocrine neoplasm, yet little information on recent clinical practice in patients with insulinoma, especially malignant insulinoma, is available.

OBJECTIVE

This work aims to clarify the characteristics and practice patterns in patients with insulinoma using a national inpatient database.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified patients with insulinoma admitted between 2010 and 2018. We compared background characteristics and therapeutic interventions between patients with benign and malignant insulinoma. We also estimated the incidence of insulinoma using the number of patients with newly diagnosed insulinoma in 2012.

RESULTS

We identified 844 patients with benign insulinoma and 102 patients with malignant insulinoma. Patients with malignant insulinoma were younger (median, 55.5 vs 66.0 years, P < .001) and less likely to be female (55.9% vs 65.3%, P = .061) than patients with benign insulinoma. Analysis of therapeutic interventions revealed that patients with malignant insulinoma more frequently received medications (71.6% vs 49.6%, P < .001) but less frequently underwent pancreatic surgery (57.8% vs 72.0%, P = .003). Older patients were a smaller proportion of those undergoing surgery and a larger proportion of those managed with medications without surgery (P < .001). The incidence of insulinoma was estimated to be 3.27 (95% CI, 2.93-3.61) individuals per million Japanese adult population per year.

CONCLUSION

The present study using a nationwide database had a larger sample size than previous studies and revealed definitive differences in patient characteristics and therapeutic patterns between benign and malignant insulinoma.

The impact of additional payments on functional decline among long-term care health facility residents in Japan

Background

Additional payment approach has been one of the most important incentives in long-term care (LTC) systems for the past 20 years in Japan.

Objective

To estimate the effect of additional payments on functional decline in long-term care health facility (LTCHF) residents of Japan.

Design

A 24-month retrospective cohort study.

Setting and subjects

Residents aged ≥65 years who were newly admitted to LTCHFs in the 2014 fiscal year.

Methods

National LTC claims data were linked to the survey of institutions and establishments for LTC. Competing risk regression was performed with functional decline as the primary outcome, and additional payments as exposure, controlling for individual and facility characteristics. The level of LTC needs certified in the LTC insurance system was applied as a proxy of functional ability. Death, hospitalisation, discharge to home and transfer to other LTC facilities were treated as competing events. Individual- and facility-level additional payments were presented as binary variables: being reimbursed or not during the follow-up period.

Results

At baseline, 146,311 residents from 3,724 LTCHFs were included. The vast majority of additional payments were associated with a lower risk of functional decline at follow-up. At the individual level, additional payment for pre/post admission instructions had the strongest association with a lower risk of functional decline. Despite this, only 8% of residents were reimbursed for this additional payment. At the facility level, residents in LTCHFs with additional payments for support for home-life resumption and nutritional management were associated with a decreased risk of functional decline.

Conclusions

The results of our study may be of particular interest to policymakers in monitoring and evaluating additional payment approaches and provide insight into improving quality of care.

Characteristics associated with hospitalization within 30 days of geriatric intermediate care facility admission

AIM

To identify facility-level characteristics associated with hospitalization within 30 days after admission to a geriatric intermediate care facility (GICF) (30-day hospitalization) in Japan.

METHODS

This retrospective cohort study used nationwide long-term care insurance claims data and a national survey of long-term geriatric care facilities. The study population was residents admitted to GICFs between October 2016 and February 2018. The outcome variable was 30-day hospitalization. The independent variables were facility-level characteristics such as level of healthcare professionals.

RESULTS

The final sample for analysis comprised 282 991 residents of mean age ± SD, 85.8 ± 7.2 years, of whom 12 814 (4.5%) experienced 30-day hospitalization. In a multivariable logistic generalized estimating equation model adjusted for facility- and resident-level characteristics, and clustering GICFs, the odds of 30-day hospitalization were 0.906 times lower (95% confidence interval [CI] 0.857-0.958) among residents in a GICF with dental hygienist than in those in a facility without. Furthermore, the risk of 30-day hospitalization was lower among residents who had been admitted to a GICF with higher staffing levels of pharmacists (adjusted odds ratio [aOR] 0.941, 95% CI 0.899-0.985), registered nurses (aOR 0.931, 95% CI 0.880-0.986), care workers (aOR 0.920, 95% CI 0.879-0.964) and speech-language pathologists (aOR 0.926, 95% CI 0.874-0.982) than in those who had been admitted to a GICF with fewer of these healthcare professionals.

CONCLUSIONS

Transitional care including dental hygienist or higher staffing levels of pharmacists, registered nurses, care workers and speech-language pathologists may be a more effective way to prevent 30-day hospitalization. Geriatr Gerontol Int 2021; 21: 1010-1017.

Intravenous cyclophosphamide in acute exacerbation of rheumatoid arthritis-related interstitial lung disease: A propensity-matched analysis using a nationwide inpatient database

OBJECTIVES

We aimed to investigate the effect of intravenous cyclophosphamide (CYC) as the initial therapy in patients with acute exacerbation of rheumatoid arthritis-related interstitial lung disease.

METHODS

This was a retrospective observational study. Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018, we identified patients with acute exacerbation of rheumatoid arthritis-related interstitial lung disease (RA-ILD) who received high-dose methylprednisolone within 3 days after admission. RA-ILD was defined as having either the diagnosis of RA-ILD or the diagnoses of both RA and ILD, based on the ICD-10 codes recorded by attending physicians. Patients were divided into two groups: those receiving intravenous CYC within 3 days after admission (CYC group) and those who did not (control group). One-to-four propensity-score matching analyses were performed.

RESULTS

A total of 6130 eligible patients were included. After propensity score matching, 129 patients in the CYC group and 516 patients in the control group were further analyzed. 90-day in-hospital mortality, defined as all-cause mortality during hospitalization within 90 days after admission, was not significantly different between the CYC and control groups (50.4% versus 42.2%, hazard ratio 1.20, 95% confidence interval 0.91-1.58). A larger proportion of patients in the CYC group received platelet transfusion than that in the control group (7.0% versus 2.3%, odds ratio 3.05, 95% confidence interval 1.20-7.73).

CONCLUSION

In this retrospective database study, the initial therapy with CYC did not show a survival benefit in patients with acute exacerbation of RA-ILD. CYC was associated with a larger proportion of platelet transfusion.

Early rehabilitation after acute myocardial infarction: A nationwide inpatient database study

BACKGROUND

The effects and safety of early rehabilitation in intensive care units (ICU) remain unclear for patients after acute myocardial infarction (AMI).

METHODS

Using Japanese Diagnosis Procedure Combination inpatient data between July 2010 and March 2018, we identified 31,603 adult patients with AMI who underwent percutaneous coronary intervention on the day of admission and who were admitted to the ICU for more than three consecutive days. Patients who started a rehabilitation program within three days of ICU admission were included in the early rehabilitation group, while others were included in the usual care group. The primary outcome was activities of daily living (ADL) at discharge, as measured using the Barthel Index score. We conducted inverse probability of treatment weighting analyses.

RESULTS

The data of 31,603 patients were examined, 5,147 of whom were assigned to the early rehabilitation group. In the weighted cohort, the Barthel Index score at discharge was not significantly different between the two groups. The early rehabilitation group had a significantly shorter hospital stay, shorter ICU stay, and lower total hospitalization costs.

CONCLUSIONS

No correlations were observed between early rehabilitation and ADL at discharge. However, the present results suggest that early rehabilitation is safe and associated with lower hospital costs and shorter hospital stays after AMI.

Risk of drug-induced interstitial lung disease in hospitalised patients: a nested case-control study

INTRODUCTION

Information on drug-induced interstitial lung disease (DILD) is limited due to its low incidence. This study investigated the frequencies of drug categories with potential risk in patients developing DILD during hospitalisation and analysed the risk of developing DILD associated with each of these drugs.

METHODS

Using a Japanese national inpatient database, we identified patients without interstitial pneumonia on admission who developed DILD and required corticosteroid therapy during hospitalisation from July 2010 to March 2016. We conducted a nested case-control study; four controls from the entire non-DILD patient cohort were matched to each DILD case on age, sex, main diagnosis, admission year and hospital. We defined 42 classified categories of drugs with 216 generic names as drugs with potential risk of DILD, and we identified the use of these drugs during hospitalisation for each patient. We analysed the association between each drug category and DILD development using conditional logistic regression analyses.

RESULTS

We retrospectively identified 2342 patients who developed DILD. After one-to-four case-control matching, 1541 case patients were matched with 5677 control patients. Six drug categories were significantly associated with the increased occurrence of DILD. These included epidermal growth factor receptor inhibitors (OR: 16.84, 95% CI 9.32 to 30.41) and class III antiarrhythmic drugs (OR: 7.01, 95% CI 3.86 to 12.73). Statins were associated with reduced risk of DILD (OR: 0.68, 95% CI 0.50 to 0.92).

CONCLUSIONS

We demonstrated significant associations between various drug categories and DILD. Our findings provide useful information on drug categories with potential risk to help physicians prevent and treat DILD.

Preoperative use of pirfenidone and reduced risk of postoperative severe respiratory complications in patients with idiopathic pulmonary fibrosis: Propensity score-matched analysis using a nationwide database in Japan

BACKGROUND AND OBJECTIVE

Patients with idiopathic pulmonary fibrosis (IPF) often develop postoperative severe respiratory complications such as acute exacerbation. Pirfenidone, an oral anti-fibrotic drug, may reduce the incidence of such complications. However, the preventive effect of pirfenidone on postoperative severe respiratory complications remains unclear.

METHODS

We identified patients with IPF who underwent surgery with general anaesthesia from July 2010 to March 2018 using the Diagnosis Procedure Combination database. We compared the occurrence of postoperative severe respiratory complications (receiving mechanical ventilation under endotracheal intubation and/or intravenous infusion of a high-dose corticosteroid and in-hospital death within 30 days after surgery) between patients who did and did not receive preoperative treatment with pirfenidone. Pearson's chi-square test and logistic regression analysis fitted with a generalized estimating equation were conducted in 1:4 propensity score-matched patients.

RESULTS

Among 631 patients identified, 19% were treated with pirfenidone before surgery. The 30-day mortality rate was 3.1% and 1.7% in the control patients (n = 510) and pirfenidone-treated patients (n = 121), respectively. In the propensity score-matched population, preoperative treatment with pirfenidone was significantly associated with a lower proportion of postoperative severe respiratory complications (OR: 0.24; 95% CI: 0.07-0.76; p = 0.015).

CONCLUSION

In this Japanese nationwide cohort, preoperative treatment with pirfenidone was significantly associated with a lower risk of postoperative severe respiratory complications in patients with IPF. Preoperative pirfenidone may thus be useful in preventing postoperative severe respiratory complications in patients with IPF who are planning to undergo surgery with general anaesthesia.

Comparison of fracture risk between proton pump inhibitors and histamine-2 receptor antagonists in ANCA-associated vasculitis patients: a nested case-control study

OBJECTIVE

Whether acid suppressants [proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs)] are associated with bone fractures in patients with ANCA-associated vasculitis (AAV) treated with glucocorticoids remains unclear. This study compared PPIs with H2RAs in terms of the risk of bone fractures in patients with AAV who received in-hospital induction therapy with glucocorticoids.

METHODS

We retrospectively identified 149 patients with fractures among 22 821 patients newly diagnosed with AAV in 1730 hospitals using a nationwide inpatient database from July 2010 to March 2018. We conducted 1:4 case-control matching. Age, sex, duration of AAV treatment and fiscal year were matched between the cases and controls. A conditional logistic regression analysis was conducted to assess the association between acid suppressants and fractures.

RESULTS

Of all enrolled patients with fractures, the median age was 77 years, and 99 (66%) were female. The median duration from AAV treatment to fracture was 52 days. The proportion of patients using PPIs was 91.3% (136 of 149) and 80.2% (478 of 596) in the case and control groups, respectively. Compared with H2RA use, PPI use was significantly associated with fractures after adjustment for age, sex, BMI, smoking habit, Charlson comorbidity index, renal failure, bisphosphonate and same fiscal year according to a multivariate analysis (adjusted odds ratio, 3.76; 95% CI: 1.37, 10.3).

CONCLUSION

PPI users had a higher risk of fractures than H2RA users among mostly advanced-age patients with AAV with remission induction therapy.

Effect of Early Rehabilitation on Physical Function in Patients Undergoing Coronary Artery Bypass Grafting: A Nationwide Inpatient Database Study

It is unclear when to begin rehabilitation after coronary artery bypass grafting (CABG) in the intensive care unit (ICU). Using the Japanese Diagnosis Procedure Combination inpatient database from 2010 to 2018, we identified adult patients who underwent a CABG and who were admitted to the ICU for ≥3 consecutive days from the date of their CABG. Patients who started any rehabilitation program prescribed by physicians or therapists within 3 days of CABG were defined as the early rehabilitation group, and the remaining patients were defined as the usual care group. We identified 30,568 eligible patients, with 13,150 (43%) patients in the early rehabilitation group. An inverse probability of treatment weighting analyses showed that the Barthel Index score at discharge in the early rehabilitation group was significantly higher than that in the usual care group (difference: 3.2; 95% confidence interval: 1.5–4.8). The early rehabilitation group had significantly lower in-hospital mortality, total hospitalization costs, length of ICU stay, and hospital stay vs. the usual care group. Our results suggested that early rehabilitation by physicians or therapists beginning within 3 days of CABG was safe, as suggested by the low mortality and improved physical function in patients who underwent CABG.

Outcomes of laparoscopic versus open pancreatoduodenectomy: A nationwide retrospective cohort study

BACKGROUND

Whether laparoscopic pancreatoduodenectomy is a feasible treatment option equivalent to open pancreatoduodenectomy remains unclear. Using a nationwide inpatient database, we investigated the postoperative outcomes of laparoscopic pancreatoduodenectomy versus open pancreatoduodenectomy.

METHODS

We conducted a retrospective cohort study using a nationwide inpatient database in Japan. We included patients who underwent pancreatoduodenectomy from April 2016 to March 2018. One-to-four propensity score matching was used to compare in-hospital mortality, postoperative complications, perioperative findings, and total hospitalization costs between the 2 groups. We also compared outcomes between laparoscopic pancreatoduodenectomy and open pancreatoduodenectomy in low- and high-volume hospitals.

RESULTS

We identified 2,100 eligible patients. The laparoscopic pancreatoduodenectomy group contained higher proportions of younger patients and patients with fewer comorbidities compared with the open pancreatoduodenectomy group. Using propensity score matching, 95 patients in the laparoscopic pancreatoduodenectomy group were matched with 380 patients in the open pancreatoduodenectomy group. No significant differences in in-hospital mortality or postoperative complication rates were found between the groups. Compared with the open pancreatoduodenectomy group, the laparoscopic pancreatoduodenectomy group showed a longer duration of anesthesia (639 vs 497 minutes; P < .001), higher proportion of unplanned mechanical ventilation (10% vs 3%; P = .007), and higher total hospitalization costs (32,242 vs 24,657 US dollars; P < .001). The subgroup analyses showed that laparoscopic pancreatoduodenectomy was associated with a higher proportion of unplanned mechanical ventilation than open pancreatoduodenectomy but only in low-volume hospitals.

CONCLUSION

This study demonstrated almost no advantage of laparoscopic pancreatoduodenectomy over open pancreatoduodenectomy. Our results suggest that laparoscopic pancreatoduodenectomy can be an alternative option for open pancreatoduodenectomy only in high-volume hospitals.

Assessing Housing Accessibility for Older Adults in Japan: A Content Validity Study

Scientifically validated tools to assess housing accessibility for older adults in Japan have been lacking. To address this, a rigorous procedure of adapting an existing housing assessment tool—the Housing Enabler, developed in Sweden—for valid use in Japan was conducted. The original tool was translated into the Japanese language, using established translation procedures. In the process, researchers checked the appropriateness of technical terms and adjusted specifications to be in accordance with Japanese standards. An expert panel approach was used to validate the content of the Japanese Housing Enabler. Thirteen certified occupational therapists, architects and care-managers (average experience=14.5 years) participated as experts in the content validity study. They rated each item with regard to relevance for assessing housing accessibility in Japan, on a scale from 1(=Not relevant) to 4(= Highly relevant). They suggested adjustments and additions that they found to be relevant to capture particularities of Japanese housing and building design. After individual ratings, the experts gathered for consensus discussions on suggested revisions of the item list. As a result, the number of items was substantially increased (from 161 to 283). A content validity index (CVI) was calculated for each item (i.e., the proportion of experts rating the relevance as at least 3). Using a recommended threshold of CVI ≥0.78, more than 90% of the items were considered relevant, thus supporting the content validity. However, the large amount of items might jeopardize the feasibility of the instrument. Further studies are needed to evaluate feasibility, criterion-related validity and aspects of reliability.

Mortality and morbidity following postoperative use of short-term, low-dose quetiapine vs risperidone in patients with diabetes: Analysis using a national inpatient database

PURPOSE

Short-term, low-dose quetiapine is used to treat postoperative delirium and insomnia. Quetiapine is contraindicated for patients with diabetes in Japan because there have been several case reports of diabetic ketoacidosis (DKA) in patients receiving long-term, high-dose quetiapine. However, because safety of short-term, low-dose quetiapine remains controversial, it is prescribed for patients with diabetes in real-world clinical practice. The present study aimed to compare in-hospital mortality and morbidity between short-term, low-dose quetiapine and risperidone in postoperative patients with diabetes.

METHODS

We used a national inpatient database in Japan to perform a retrospective cohort study. We identified hospitalized patients with diabetes who underwent scheduled elective surgery and received oral quetiapine 200 mg/d or less or oral risperidone 4 mg/d or less within 7 days of surgery between July 2010 and March 2018. We performed one-to-one propensity score-matched analyses to compare outcomes between patients with quetiapine and risperidone. The primary outcome was in-hospital mortality. The secondary outcome was infectious complications (pneumonia, urinary tract infection, surgical site infection, and sepsis).

RESULTS

Propensity score matching created 665 pairs of patients who received quetiapine or risperidone. The primary outcome was observed in 19 (2.9%) of the quetiapine group and 11 (1.7%) of the risperidone group (relative risk, 1.27; 95% confidence interval, 0.97-1.68; P = .14). The secondary outcome did not differ significantly between the groups.

CONCLUSION

In terms of mortality and infectious outcomes, safety of quetiapine and risperidone may be comparable.

Associations of Hospital Discharge Services With Potentially Avoidable Readmissions Within 30 Days Among Older Adults After Rehabilitation in Acute Care Hospitals in Tokyo, Japan

OBJECTIVE

To examine the associations of 3 major hospital discharge services covered under health insurance (discharge planning, rehabilitation discharge instruction, and coordination with community care) with potentially avoidable readmissions (PARs) within 30 days in older adults after rehabilitation in acute care hospitals in Tokyo, Japan.

DESIGN

Retrospective cohort study using a large-scale medical claims database of all Tokyo residents aged ≥75 years.

SETTING

Acute care hospitals.

PARTICIPANTS

Patients who underwent rehabilitation and were discharged to home (N=31,247; mean age in years ± SD, 84.1±5.7) between October 2013 and July 2014.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

30-day PAR.

RESULTS

Among the patients, 883 (2.9%) experienced 30-day PAR. A multivariable logistic generalized estimating equation model (with a logit link function and binominal sampling distribution) that adjusted for patient characteristics and clustering within hospitals showed that the discharge services were not significantly associated with 30-day PAR. The odds ratios were 0.962 (95% confidence interval [CI], 0.805-1.151) for discharge planning, 1.060 (95% CI, 0.916-1.227) for rehabilitation discharge instruction, and 1.118 (95% CI, 0.817-1.529) for coordination with community care. In contrast, the odds of 30-day PAR among patients with home medical care services were 1.431 times higher than those of patients without these services (P<.001), and the odds of 30-day PAR among patients with a higher number (median or higher) of rehabilitation units were 2.031 times higher than those of patients with a lower number (below median) (P<.001). Also, the odds of 30-day PAR among patients with a higher Hospital Frailty Risk Score (median or higher) were 1.252 times higher than those of patients with a lower score (below median) (P=.001).

CONCLUSIONS

The insurance-covered discharge services were not associated with 30-day PAR, and the development of comprehensive transitional care programs through the integration of existing discharge services may help to reduce such readmissions.

Association between rehabilitation during hospitalization and perinatal outcomes among pregnant women with threatened preterm birth

OBJECTIVE

This study conducted a nationwide retrospective cohort study to evaluate whether rehabilitation for pregnant women during long-term hospitalization is associated with adverse perinatal events.

METHODS

We performed a retrospective cohort study using a diagnosis procedure combination (DPC) database, a national inpatient database for acute-care inpatients in Japan. Hospitalized pregnant women diagnosed with threatened preterm birth, who stayed in the hospital for 7 days or longer from July 2010 to March 2017 in Japan were identified. One-to-four propensity score-matched analyses were performed to compare perinatal outcomes between patients with and without rehabilitation during hospitalization. The primary outcome was preterm birth (<35/0 weeks of gestation) during hospitalization.

RESULTS

Of the 141,705 eligible patients, 351 (0.25%) received any type of rehabilitation during hospitalization. One-to-four propensity score matching created a rehabilitation group (n = 338) and a nonrehabilitation group (n = 1352). The propensity-matched analysis showed that the proportion of preterm births in the rehabilitation group was lower than that in the nonrehabilitation group (5.9% versus 8.9%; risk difference: -3.0%; 95% confidence interval (CI): -5.9 to -0.03).

CONCLUSIONS

This retrospective nationwide study suggests that rehabilitation for hospitalized patients with threatened preterm birth may reduce the risk of preterm birth.

BRIEF RATIONALE

In this nationwide study, we suggest that rehabilitation for long-term hospitalized patients with threatened preterm birth may reduce the risk of preterm birth.

Postoperative evaluation of changes in extracranial-intracranial bypass graft using superficial temporal artery duplex ultrasonography

BACKGROUND AND PURPOSE

Extracranial-intracranial (ECIC) bypass grafts have been assessed postoperatively by various neuroradiologic techniques. The aim of this prospective study was to evaluate postoperative changes in ECIC bypass graft by using superficial temporal artery duplex ultrasonography (STDU). Furthermore, this study assessed the ability of STDU to predict cerebrovascular reserve capacity (CVR).

MATERIALS AND METHODS

Forty-five consecutive patients who underwent ECIC bypass procedure for atherosclerotic internal carotid artery occlusion were enrolled in this prospective study. All patients underwent single-photon emission CT and STDU preoperatively, 14 days after, 3 months after, 1 year after, and 2 years after ECIC bypass.

RESULTS

The diameter and flow velocities of the ipsilateral superficial temporal artery (STA), and regional cerebral blood flow (rCBF) showed increase during the first 2 weeks and then remained stable, whereas CVR showed a constant improvement up to 2 years after surgery. The STA diameter and mean STA flow velocity correlated significantly with CVR at 1 year after surgery (r2 = 0.1232 and r2 = 0.08716, respectively; P < .05). A cutoff value of 1.8 mm STA diameter was determined as the most reliable value to predict CVR greater than 10% at 1 year after surgery. The positive predictive value was calculated as 96.6%, the negative predictive value as 43.8%, the sensitivity as 75.7%, the specificity as 87.5%, and the likelihood ratio as 6.056.

CONCLUSIONS

ECIC bypass grafts can be assessed postoperatively in a noninvasive fashion with STDU. This technique provides information regarding patency as well as quantitative assessment of bypass function. Moreover, STDU is useful to predict CVR improvement.

Unique evolution of Bivalvia arginine kinases

The clams Pseudocardium, Solen, Corbicula and Ensis possess a unique form of arginine kinase (AK) with a molecular mass of 80 kDa and an unusual two-domain structure, a result of gene duplication and subsequent fusion. These AKs also lack two functionally important amino acid residues, Asp(62) and Arg(193), which are strictly conserved in other 40-kDa AKs and are assumed to be key residues for stabilizing the substrate-bound structure. However, these AKs show higher enzyme activity. The cDNA-derived amino acid sequences of 40-kDa AKs from the blood clam Scapharca broughtonii and the oyster Crassostrea gigas were determined. While Asp(62) and Arg(193) are conserved in Scapharca AK, these two key residues are replaced by Asn and Lys, respectively, in Crassostrea AK. The native enzyme from Crassostrea and both of the recombinant enzymes show an enzyme activity similar to that of two-domain clam AKs and at least twofold higher than that of other molluskan AKs. Although the replacement of Asp(62) or Arg(193) by Gly in normal AK causes a considerable decrease in V(max) (6-15% of wild-type enzyme) and a two- to threefold increase in K(m) for arginine, the same replacement in Scapharca AK had no pronounced effect on enzyme activity. Together with the observation that bivalve AKs are phylogenetically distinct from other molluskan AKs, these results suggest that bivalve AKs have undergone a unique molecular evolution; the characteristic stabilizing function of residues 62 and 193 has been lost and, consequently, the enzyme shows higher activity than normal.