Cost-effectiveness analysis of adult living-donor liver transplantation in Japan

AIM

Living-donor liver transplantation (LDLT) is a highly effective life-saving procedure; however, it requires substantial medical resources, and the cost-effectiveness of LDLT versus conservative management (CM) for adult patients with end-stage liver disease (ESLD) remains unclear in Japan.

METHODS

We performed a cost-effectiveness analysis using the Diagnostic Procedure Combination (DPC) data from the nationwide database of the DPC research group. We selected adult patients (18 years or older) who were admitted or discharged between 2010 and 2021 with a diagnosis of ESLD with Child-Pugh class C or B. A decision tree and Markov model were constructed, and all event probabilities were computed in 3-month cycles over a 10-year period. The willingness-to-pay per quality-adjusted life-year (QALY) was set at 5 million Japanese yen (JPY) (49,801 US dollars [USD]) from the perspective of the public health-care payer.

RESULTS

After propensity score matching, we identified 1297 and 111,849 patients in the LDLT and CM groups, respectively. The incremental cost-effectiveness ratio for LDLT versus CM for Child-Pugh classes C and B was 2.08 million JPY/QALY (20,708 USD/QALY) and 5.24 million JPY/QALY (52,153 USD/QALY), respectively. The cost-effectiveness acceptability curves showed the probabilities of being below the willingness-to-pay of 49,801 USD/QALY as 95.4% in class C and 48.5% in class B. Tornado diagrams revealed all variables in class C were below 49,801 USD/QALY while their ranges included or exceeded 49,801 USD/QALY in class B.

CONCLUSIONS

Living-donor liver transplantation for adult patients with Child-Pugh class C was cost-effective compared with CM, whereas LDLT versus CM for class B patients was not cost-effective in Japan.

A panel vector autoregression analysis for the dynamics of medical and long-term care expenditures

Although medical and long-term care expenditures for older adults are closely related, providing rigorous statistical analysis for their dynamic relationship is challenging. In this research, we propose a novel approach using the panel vector autoregression model to reveal the realized patterns of the interdependence. As an empirical application, we analyze monthly panel data on individuals in a city of Japan, where social insurance covers many formal services for long-term care. Our estimation results indicate the existence of intertemporal transition from expensive acute medical care to reasonable at-home medical care, then to at-home long-term care. Under this context, the enhancement of formal long-term care sector in Japan might have played an important role in the suppression of the total care cost in spite for its rapid aging over the past 2 decades. Additionally, we find that daycare plays multiple roles in Japanese long-term care, such as respite and rehabilitation, but there is no considerable transition from outpatient rehabilitation to daycare in the long-term care sector.

Presenteeism and social interaction in the "new normal" in Japan: a longitudinal questionnaire study

BACKGROUND

Although social interaction and social support during the "new normal" due to coronavirus disease 2019 (COVID-19) may be related to presenteeism, the effect between these factors has not been clear for Japanese workers. The aim of this study was to describe the presenteeism of Japanese workers with reference to social interaction and social support following the lifestyle changes due to COVID-19 and to assess whether social interaction and social support affected their presenteeism.

METHODS

The data were obtained from internet panel surveys from October 2020. Descriptive statistics were calculated, and multiple linear regression was conducted using the data from the first, fourth and fifth surveys, which were conducted during October to November 2020, July to August 2021, and September to October 2021, respectively. To measure presenteeism, questions from "absenteeism and presenteeism questions of the World Health Organization's Heath and Work Performance Questionnaire", short version in Japanese was utilized. Multiple linear regressions were conducted to investigate the effects of social interaction and social support-related factors on presenteeism.

RESULTS

A total of 3,407 participants were included in the analysis. The mean score of absolute presenteeism from the fifth survey was 58.07 (SD = 19.71). More time spent talking with family, a larger number of social supporters and a higher satisfaction level for social support were associated with a higher absolute presenteeism score.

CONCLUSIONS

Our results suggested that social support reduced the presenteeism of the Japanese workers during the "new normal" due to the COVID-19 pandemic. Social interaction with family also relieved presenteeism.

Effects of hospitalist co-management for hip fractures

BACKGROUND

Early surgery is recommended for patients with hip fractures. Average time to surgery in Japan is 3.8 days. Such delay could be caused by the burden of preoperative assessment and management of geriatric comorbidities upon orthopedic surgeons. Hospitalist co-management has potential benefits in comprehensive perioperative care that could positively affect time to surgery in patients with hip fractures. We compare clinical outcomes of patients with hip fractures managed by orthopedic surgeon-led care (conventional group) vs. those of patients with hip fractures managed by hospitalist co-management.

METHODS

In this single-center retrospective cohort study, time to surgery was assessed with interrupted time series analyses. Whole length of hospital stay, length of hospital stay after surgery, complications during hospitalization, 30-day readmission, initiation of osteoporosis treatment and adherence to guidelines for deep vein thrombosis prophylaxis were also evaluated with Chi-square or Fisher's exact tests.

RESULTS

The conventional group comprised 332 patients and the co-management group 418 patients. Interrupted time series analyses revealed an immediate reduction of time to surgery by 1.2 days (95%CI, -1.9 to -0.4, P = 0.003) with the start of co-management. Whole length of hospital stay and length of hospital stay after surgery tended to be shorter, but without statistical significance. Intermediate to severe complications and 30-day readmission were not significantly different between the groups. In the co-management group, the rate of initiation of osteoporosis treatment (46.4% vs. 6.3%, P < 0.001) and adherence rate to guidelines for deep vein thrombosis prophylaxis (99.3% vs. 88%, P < 0.001) were significantly higher than those in the conventional group.

CONCLUSIONS

Hospitalist co-management for elderly patients with hip fractures led to significantly shorter time to surgery than conventional orthopedic surgeon-led care, and had advantages in other clinical indicators.

Cost-effectiveness of endovascular therapy for acute stroke with a large ischemic region in Japan: impact of the Alberta Stroke Program Early CT Score on cost-effectiveness

BACKGROUND

Although randomized clinical trials (RCTs) demonstrated short-term benefits of endovascular therapy (EVT) for acute ischemic stroke (AIS) with a large ischemic region, little is known about the long-term cost-effectiveness or its difference by the extent of the ischemic areas. We aimed to assess the cost-effectiveness of EVT for AIS involving a large ischemic region from the perspective of Japanese health insurance payers, and analyze it using the Alberta Stroke Program Early CT Score (ASPECTS).

METHODS

The Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan Large Ischemic Core Trial (RESCUE-Japan LIMIT) was a RCT enrolling AIS patients with ASPECTS of 3-5 initially determined by the treating neurologist primarily using MRI. The hypothetical cohort and treatment efficacy were derived from the RESCUE-Japan LIMIT. Costs were calculated using the national health insurance tariff. We stratified the cohort into two subgroups based on ASPECTS of ≤3 and 4-5 as determined by the imaging committee, because heterogeneity was observed in treatment efficacy. EVT was considered cost-effective if the incremental cost-effectiveness ratio (ICER) was below the willingness-to-pay of 5 000 000 Japanese yen (JPY)/quality-adjusted life year (QALY).

RESULTS

EVT was cost-effective among the RESCUE-Japan LIMIT population (ICER 4 826 911 JPY/QALY). The ICER among those with ASPECTS of ≤3 and 4-5 was 19 396 253 and 561 582 JPY/QALY, respectively.

CONCLUSION

EVT was cost-effective for patients with AIS involving a large ischemic region with ASPECTS of 3-5 initially determined by the treating neurologist in Japan. However, the ICER was over 5 000 000 JPY/QALY among those with an ASPECTS of ≤3 as determined by the imaging committee.

Factors Associated With Postoperative Decisional Regret in Patients Undergoing Gastrointestinal Cancer Surgery: A Prospective Cohort Study

BACKGROUND

Surgery is recommended as the first-line treatment option to cure resectable gastrointestinal (GI) cancer. However, patients occasionally feel postoperative regret after surgery. To date, it is not clear which factors are associated with patient regret after GI cancer surgery. The aim of this study was to investigate factors related to postoperative decision regret in patients undergoing surgery for GI cancer.

METHODS

The present prospective study used questionnaires to analyze postoperative decision regret in patients undergoing GI cancer surgery in our institution between February and July 2020. Decision regret that patients felt after surgery was quantitatively measured using the decision regret scale (DRS). Multivariable linear regression models were used to examine factors related to postoperative decision regret.

RESULTS

Among 70 patients analyzed, the median (interquartile range) DRS score was 10.0 (.0-25.0). Multivariable analysis showed that preoperative Trust in Physician Scale score (partial regression coefficient (B) = -.77; 95% confidence interval (CI) = -1.13 to -.41; P < .001) and postoperative complications (B = 9.17; 95% CI = 2.20 to 16.15; P = .0011) were significantly associated with DRS score.

DISCUSSION

Preoperative trust in physician and postoperative complications were significantly associated with postoperative decision regret in patients undergoing surgery for GI cancer. Although patients may regret their choice of surgery when postoperative complications occur, trust in their physician may help reduce feelings of regret.

Effects of hospitalist co-management on rate of initiation of osteoporosis treatment in patients with vertebral compression fractures: Retrospective cohort study

BACKGROUND

Vertebral compression fractures are common in elderly people and most are due to osteoporosis. Osteoporosis treatment is effective for secondary prophylaxis, so initiation is recommended. Despite the clear benefits, the rate of initiation of osteoporosis treatment is very low. It is reported to be due to several factors including insufficient systems-based approaches for hospitals and post-acute care. Hospitalists, who are physicians dedicated to the treatment of patients in hospital and whose activity is generalist rather than specialized, are reported to be associated with higher-quality inpatient care because of, among other things, closer adherence to guidelines. Co-management by hospitalists for patients with vertebral compression fractures has potential benefits towards improving the outcomes. We compared the rate of initiation of osteoporosis treatment for patients with vertebral compression fractures between conventional orthopedic surgeon-led care (conventional group) and hospitalist co-management care (co-management group).

METHODS

This is a single-center retrospective cohort study to evaluate the rate of initiation of osteoporosis treatment and reasons for non-initiation of osteoporosis treatment. Other clinical indicators were also evaluated, including length of hospital stay, preventable complications during hospitalization, and rate of 30-day readmission.

RESULTS

We identified 55 patients in the conventional group and 93 patients in the co-management group. The rate of initiation of osteoporosis treatment was higher in the co-management group (45.2% vs. 3.6%, OR 21.5; 95%CI 5.12-192.0; P < 0.01). Most of the patients with non-initiation in the co-management group had reasons for it described in the medical records, but in the conventional group the reasons were unknown. There was no significant difference in length of hospital stay, preventable complications during hospitalization, or 30-day readmission between the groups.

CONCLUSIONS

Hospitalist co-management of patients with vertebral compression fractures showed significantly higher rate of initiation of osteoporosis treatment than conventional orthopedic surgeon-led care.

Identification of complications requiring interventions after gastrointestinal cancer surgery from real-world data: An external validation study

Background

Recently, real-world data have been recognized to have a significant role for research and quality improvement worldwide. The decision on the existence or nonexistence of postoperative complications is complex in clinical practice. This multicenter validation study aimed to evaluate the accuracy of identification of patients who underwent gastrointestinal (GI) cancer surgery and extraction of postoperative complications from Japanese administrative claims data.

Methods

We compared data extracted from both the Diagnosis Procedure Combination (DPC) and chart review of patients who underwent GI cancer surgery from April 2016 to March 2019. Using data of 658 patients at Kyoto University Hospital, we developed algorithms for the extraction of patients and postoperative complications requiring interventions, which included an invasive procedure, reoperation, mechanical ventilation, hemodialysis, intensive care unit management, and in-hospital mortality. The accuracy of the algorithms was externally validated using the data of 1708 patients at two other hospitals.

Results

In the overall validation set, 1694 of 1708 eligible patients were correctly extracted by DPC (sensitivity 0.992 and positive predictive value 0.992). All postoperative complications requiring interventions had a sensitivity of >0.798 and a specificity of almost 1.000. The overall sensitivity and specificity of Clavien-Dindo ≥grade IIIb complications was 1.000 and 0.995, respectively.

Conclusion

Patients undergoing GI cancer surgery and postoperative complications requiring interventions can be accurately identified using the real-world data. This multicenter external validation study may contribute to future research on hospital quality improvement or to a large-scale comparison study among nationwide hospitals using real-world data.

The total number of patients with any of four major fragility fractures decreased during the first wave of the COVID-19 epidemic in Japan, commencing before the state of emergency declaration, which was not as enforceable as lockdown

Durin g the first wave of the COVID-19 epidemic, the total number of patients with any of the four major fragility fractures, including both inpatients and first-visit outpatients, began to decline shortly before the state of emergency was declared, rather than immediately after it was declared.

PURPOSE

This study aimed to investigate the impact of public health measures in the first wave of the COVID-19 epidemic on the occurrence of major fragility fractures (MFFs).

METHODS

Patients aged 50 years or older who were hospitalized or had an initial visit as an outpatient for an MFF, defined as a proximal femoral fracture (PFF), vertebral fragility fracture (VFF), distal radius fracture (DRF), or a proximal humeral fracture (PHF), were included in this study. Three-phase interrupted time-series analyses were performed to evaluate the impact of the voluntary event cancellation request in late February 2020 and the emergency declaration in early April 2020 on changes in the total number of patients, including inpatients and first-visit outpatients.

RESULTS

A total of 166,560 patients with MFFs were included (92,767 PFFs, 26,158 VFFs, 33,869 DRFs, and 13,766 PHFs). From the end of February, in seven prefectures with high proportions of urbanization, decreasing trends were estimated for level changes and slope changes in the total number of patients with any of the four MFFs (level change: PFF; point estimate; - 13.5 (95% CI; - 43.4, 16.5), VFF; - 15.3 (- 32.2, 1.5), DRF; - 16.1 (- 39.9, 7.6), PHF; - 1.9 (- 13.6, 9.8), slope change: PFF; - 4.8 (- 14.0, 4.4), VFF; - 3.0 (- 8.1, 2.2), DRF; - 0.6 (- 7.9, 6.7), PHF; - 2.4 (- 6.0, 1.2)).

CONCLUSION

The findings suggested that the total number of patients with any of the four MFFs did not begin to decline from early April 2020 after the state of emergency was declared but earlier, in late February 2020.

The Japanese Guide affected the prescription of steroids for COVID-19 inpatients during the COVID-19 epidemic in Japan

Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, guidance ("Japanese Guide") has been published by a working group of several academic societies and announced by the Ministry of Health, Labour, and Welfare. Steroids as a candidate treatment for COVID-19 were noted in the Japanese Guide. However, the prescription details for steroids, and whether the Japanese Guide changed its clinical practice, were unclear. This study aimed to examine the impact of the Japanese Guide on the trends in the prescription of steroids for COVID-19 inpatients in Japan. We selected our study population using Diagnostic Procedure Combination (DPC) data from hospitals participating in the Quality Indicator/Improvement Project (QIP). The inclusion criteria were patients discharged from hospital between January 2020 and December 2020, who had been diagnosed with COVID-19, and were aged 18 years or older. The epidemiological characteristics of cases and the proportion of steroid prescriptions were described on a weekly basis. The same analysis was performed for subgroups classified by disease severity. The study population comprised 8603 cases (410 severe cases, 2231 moderate II cases, and 5962 moderate I/mild cases). The maximum proportion of cases prescribed with dexamethasone increased remarkably from 2.5 to 35.2% in the study population before and after week 29 (July 2020), when dexamethasone was included in the guidance. These increases were 7.7% to 58.7% in severe cases, 5.0% to 57.2% in moderate II cases, and 1.1% to 19.2% in moderate I/mild cases. Although the proportion of cases prescribed prednisolone and methylprednisolone decreased in moderate II and moderate I/mild cases, it remained high in severe cases. We showed the trends of steroid prescriptions in COVID-19 inpatients. The results showed that guidance can influence drug treatment provided during an emerging infectious disease pandemic.

Regional disparities in Dementia-free Life Expectancy in Japan: An ecological study, using the Japanese long-term care insurance claims database

BACKGROUND

The number of people with dementia increases in an aging society; therefore, promoting policies for dementia throughout the community is crucial to creating a dementia-friendly society. Understanding the status of older adults with dementia in each region of Japan will be a helpful indicator. We calculated Dementia-free Life Expectancy and aimed to examine regional disparities and their associated factors.

METHODS

We calculated Dementia-free Life Expectancy and Life Expectancy with Dementia for each secondary medical area in Japan based on the Degree of Independence in Daily Living for the Demented Elderly, using data extracted from the Japanese long-term care insurance claims database. We then conducted a partial least squares regression analysis, the objective variables being Dementia-free Life Expectancy and Life Expectancy with Dementia for both sexes at age 65, and explanatory regional-level variables included demographic, socioeconomic, and healthcare resources variables.

RESULTS

The mean estimated regional-level Dementia-free Life Expectancy at age 65 was 17.33 years (95% confidence interval [CI] 17.27-17.38) for males and 20.05 years (95% CI 19.99-20.11) for females. Three latent components identified by partial least squares regression analysis represented urbanicity, socioeconomic conditions, and health services-related factors of the secondary medical areas. The second component explained the most variation in Dementia-free Life Expectancy of the three, indicating that higher socioeconomic status was associated with longer Dementia-free Life Expectancy.

CONCLUSIONS

There were regional disparities in secondary medical area level Dementia-free Life Expectancy. Our results suggest that socioeconomic conditions are more related to Dementia-free Life Expectancy than urbanicity and health services-related factors.

Clinical decision-making using an assessment protocol of swallowing function after aspiration pneumonia: a comparative retrospective study

Objective: Aspiration pneumonia is a challenge in Japan, with many elderly citizens; however, there are insufficient experts on swallowing. Non-expert doctors may suspend oral intake for an overly long period because of the fear of further aspiration. We devised and modified an assessment protocol for swallowing function with reference to the Japanese and American practical guidelines for dysphagia. This study aimed to demonstrate clinical decision-making using the protocol by reporting the results of decisions on the safe and timely restart of adequate food intake for patients with aspiration pneumonia. Patients and Methods: This comparative retrospective study included 101 patients hospitalized with aspiration pneumonia between April 2015 and November 2017. We compared the parameters of patients for whom decisions on resumption of oral intake were aided by our protocol against those of patients from the previous year when the protocol was not used. We counted the days until either resumption of oral intake or events of aspiration/choking. Results: The duration of days until oral intake in the two groups was 1.64 ± 2.34 days in the protocol group (56 patients) and 2.09 ± 2.30 days in the control group (45 patients) (P=0.52). The adverse events of aspiration/choking were less frequent in the protocol group (5 vs. 15, odds ratio (OR) 0.32, P<0.001) as compared to the control group. The protocol group showed a significant reduction in aspiration/choking (OR 0.19, P<0.01). Conclusion: Clinical decision-making based on the protocol seems to help non-expert doctors make informed decisions regarding resuming oral intake after aspiration pneumonia.

Impact of policy alterations on elective percutaneous coronary interventions in Japan

OBJECTIVE

Establishing appropriate percutaneous coronary intervention (PCI) in stable angina pectoris (SAP) has become a distinctive performance measure worldwide. Clinical guidelines call for documenting ischaemia in patients with SAP prior to elective PCI. The Japanese Ministry of Health, Labour and Welfare introduced a new reimbursement policy in April 2018 to promote the appropriate and judicious implementation of PCI. The 2018 reimbursement changes clarified the required proof of ischaemia. Tests to evaluate functional ischaemia and coronary stenosis have been added as a requirement for reimbursement. We examined whether this reimbursement revision had an impact on PCI procedures for SAP in Japan.

METHODS

We used administrative claims data in Japan's Diagnosis Procedure Combination database from April 2014 through March 2020. We used interrupted time series analyses with a control to ascertain the impacts on elective PCI procedures before and after the Japanese reimbursement revision. The primary outcome was the change in elective PCI procedures per month. Emergent PCI procedures served as a control group.

RESULTS

A total of 773 240 PCI procedures were identified between April 2014 and March 2020: 388 817 and 180 462 elective PCIs before and after the reimbursement revision, respectively. After the 2018 reimbursement revision, significant trend changes were found in elective PCI procedures per month (-106.3, 95% CI -155.8 to -56.8, p<0.01), while the number of emergent PCIs remained stable throughout the study period.

CONCLUSIONS

After revising the reimbursement tariff for elective PCIs in 2018, there was a significant reduction in elective PCI procedures per month.

Role of hospitalists in Japan for heart failure in the elderly: single center retrospective cohort study

OBJECTIVE

In Japan, the benefits of hospitalist physician-led care after heart failure have not been sufficiently demonstrated. We evaluated quality of care by the general internal medicine hospitalist (GIM-H) system for patients after acute heart failure and compared it with care by cardiologists.

METHODS

This retrospective cohort study enrolled adult patients from within a two-year period who were admitted to our institution for heart failure. Primary outcome measures were medico-economic indicators: length of hospital stay and medical costs. Secondary outcomes included readmission within 30 days of discharge, death within 30 days of admission, rate of prescription of ACEI/ARB and beta-blockers for heart failure with reduced left ventricular ejection fraction, and the percentage of patients receiving bespoke written treatment plans after discharge. This was thought to represent quality of heart failure-specific care. Outcomes between the groups were compared by adjusting for background factors using a propensity score.

RESULTS

We enrolled 404 patients, and 81 were assigned to each group after matching (mean age: 86 years, female: 64.2%, mean left ventricular ejection fraction: 53.2%). The GIM-H-treated group had a significantly shorter hospital stay (13.7 days vs. 21.8 days, P < 0.001), a significantly lower total medical cost (618,805 JPY vs. 867,857 JPY, P < 0.05) but a higher medical cost per day (48,010 JPY vs 42,813 JPY, P < 0.05) than the cardiologist-treated group. Other indicators were not significantly different.

CONCLUSIONS

: GIM-H physicians in Japan are suggested to be useful and effective in care of patients with heart failure. The hospitalist system may positively impact the health economic outcomes of such patients.

Impact of the cefazolin shortage on the selection and cost of parenteral antibiotics during the supply disruption period in Japan: A controlled interrupted time series analysis

BACKGROUND

A serious shortage of cefazolin (CEZ) occurred in Japan in 2019. We compared the impact of the CEZ shortage on the selection of parenteral antibiotics at affected and non-affected hospitals.

METHODS

The data were extracted from a nationwide Japanese administrative database and included all hospitalized cases between April 2016 and December 2020. We defined 'hospitals with shortage' as those hospitals with a statistically significant decrease in the use of CEZ during the supply disruption period compared to the same months of the previous year; other hospitals as 'hospitals without shortage'. We determined the proportion of each selected parenteral antibiotic use to the sum of all selected antibiotic use in the two groups of hospitals during the supply disruption period and during the same months of the previous year. A controlled interrupted time series (CITS) analysis was conducted to estimate the impact of the CEZ shortage on each antibiotic use and the cost of all parenteral antibiotics per patient day in hospitals with shortage as compared to those without shortage.

RESULTS

In the hospitals with shortage, the proportion of CEZ use to the sum of all selected antibiotics decreased (23.5-11.1%). The decrease in CEZ use was mainly offset by the use of ceftriaxone, ceftriaxone, and ampicillin/sulbactam. The CITS analysis showed a statistically significant increase in the use of broader-spectrum beta-lactams and clindamycin during the supply disruption period (flomoxef up 58.1%, cefotiam up 63.1%, cefmetazole up 14.5%, ceftriaxone up 13.9%, and clindamycin up 20.1%). The analysis showed no statistically significant change in the cost of all parenteral antibiotics per patient day.

CONCLUSIONS

During the CEZ supply disruption, there was a statistically significant increase in the use of broader-spectrum beta-lactams and clindamycin in hospitals with shortage compared with those without shortage.

Development and validation of prediction models for the discharge destination of elderly patients with aspiration pneumonia

BACKGROUND

Discharge planning enhances the safe and timely transfer of inpatients between facilities. Predicting the discharge destination of inpatients with aspiration pneumonia is important for discharge planning. We aimed to develop and validate prediction models for the discharge destination of elderly patients with aspiration pneumonia.

METHODS

Using a nationwide inpatient database, we identified aspiration pneumonia cases for patients aged ≥65 years who had been admitted to hospital from their home or from a nursing home between April 2020 and March 2021. We divided the cases into derivation and validation cohorts according to the location of the admitting hospital. We developed two prediction models by dividing the cases based on the patient's place of residence prior to admission, one model to predict the home discharge of cases admitted from home and the other to predict the home or to a nursing home discharge of cases admitted from a nursing home. The models were internally validated with bootstrapping and internal-externally validated using a validation cohort. Nomograms that could be used easily in clinical practice were also created.

RESULTS

The derivation cohort included 19,746 cases admitted from home and 14,359 cases admitted from a nursing home. Of the former, 10,760 (54.5%) cases were discharged home; from the latter, 7,071 (49.2%) were discharged to either home or a nursing home. The validation cohort included 6,262 cases admitted from home and 6,352 cases admitted from a nursing home. In the internal-external validation, the C-statistics of the final model for the cases admitted from home and the cases admitted from a nursing home were 0.71 and 0.67, respectively.

CONCLUSIONS

We developed and validated new prediction models for the discharge of elderly patients with aspiration pneumonia either to home or to a nursing home. Our models and nomograms could facilitate the early implementation of discharge planning.

Impact of the hospital volume and setting on postoperative complications of surgery for gastroenterological cancers in a regional area of Western Japan

PURPOSE

A research subgroup was established by the Japanese Society of Gastroenterological Surgery to improve the health care quality in the Chushikoku area of Western Japan.

METHODS

The records of four surgical procedures were extracted from the Japanese National Clinical Database and analyzed retrospectively to establish the association between hospital characteristics, defined using a combination of hospital case-volume and patients' hospital travel distance, and the incidences of perioperative complications of ≥ Grade 3 of the Clavien-Dindo classification after gastroenterological surgery.

RESULTS

This study analyzed 11,515 cases of distal gastrectomy for gastric cancer, 4,705 cases of total gastrectomy for gastric cancer, 4,996 cases of right hemicolectomy for colon cancer, and 5,243 cases of lower anterior resection for rectal cancer, with composite outcome incidences of 5.6%, 10.2%, 5.5%, and 10.7%, respectively. After adjusting for patient characteristics and surgical procedures, no association was identified between the hospital category and surgical outcomes.

CONCLUSION

The findings of our study of the Chushikoku region did not provide positive support for the consolidation and centralization of hospitals, based solely on hospital case volume. Our grouping was unique in that we included patient travel distance in the analysis, but further investigations from other perspectives are needed.

Quantification of Internal Medicine Resident Inpatient Care Using the Diagnosis Procedure Combination Database

Objective Quantification of patient encounters during internal medicine residency training is challenging. At present, there are no established strategies for evaluating the whole inpatient experience in Japan. We hypothesized that the Diagnosis Procedure Combination (DPC) database, which is widely used in Japan, might be a useful tool for such an evaluation. Methods We analyzed DPC-based patient encounters of five senior residents with different types of training. One of the diseases on receipt computation data, including the four main diseases and at most eight comorbidities, was matched with each category in the Online system for Standardized Log of Evaluation and Registration of specialty training system (J-OSLER), and the match ratios were assessed. The accumulation of each disease classified into J-OSLER categories was also assessed. Monthly extra working hours and total patient-days per resident were evaluated using a Pearson correlation analysis. Results Two residents with two-year rotations in the general internal medicine department showed high numbers of patient encounters and the highest matching ratio with J-OSLER (approximately 60% with 4 major diseases, 91% with all diseases). There was a moderately positive correlation between the total patient-days and extra working hours in these residents, but no such correlation was noted in the rate of monthly patient encounters and extra working hours among residents as a whole. Conclusion The DPC-based quantification of patient encounters during residency training appears effective in evaluating the coverage of the current J-OSLER list. Owing to its wide availability and generalization, this matching method may be useful as a universal tool for assessing internal medicine programs.

Measuring the quality of life of long-term care service users in Japan: a cross-sectional questionnaire study

BACKGROUND

In Japan's super-aging society, the number of long-term care service providers is increasing, and the quality of care is a matter of concern. One aspect of the quality of care is the user's quality of life. The questionnaires EQ-5D and WHO-5 are representative indicators of quality of life. Herein, we aimed to measure the quality of life in long-term care service users in Japan and to clarify the relationship between quality of life and the level of care required.

METHODS

A questionnaire study was conducted in 106 facilities of 22 corporations. In addition to the EQ-5D and WHO-5, sex, age, and the level of care required were assessed by descriptive statistics. Bonferroni's multiple comparison test was used to analyze each quality of life score, and the differences by sex and age were analyzed multiple regression analyses, with each quality of life score as the objective variable.

RESULTS

Of 4647 cases collected, 2830 were analyzed, with no missing data. Both indicators tended to be lower than the general older population. Those scores tended to be higher in females than males (EQ-5D: males, 0.58 ± 0.26; females, 0.60 ± 0.24; P = 0.06 and WHO-5: males, 13.8 ± 5.92; females 14.9 ± 5.70; P < 0.001). In terms of age, those under 65 years old with specific diseases had lower EQ-5D scores than those in other age groups (P < 0.001); however, WHO-5 scores did not differ by age. Multiple regression analysis showed a significant association between the EQ-5D score and level of care required, except for support-required level 1, which tended to worsen as the level of care required increased. Conversely, the WHO-5 score was significantly lower for care need levels 2, 4, and 5.

CONCLUSIONS

The quality of life of long-term care service users was worse than that of the general older population, it tended to be low among males and those under 65 years old with specific diseases. Furthermore, it gradually decreased as the level of care required increased. It is important to monitor users' quality of life as a quality indicator of care, to improve and manage it.

Medium-term impacts of the waves of the COVID-19 epidemic on treatments for non-COVID-19 patients in intensive care units: A retrospective cohort study in Japan

Background

Maintaining critical care for non-Coronavirus-disease-2019 (non-COVID-19) patients is a key pillar of tackling the impact of the COVID-19 pandemic. This study aimed to reveal the medium-term impacts of the COVID-19 epidemic on case volumes and quality of intensive care for critically ill non-COVID-19 patients.

Methods

Administrative data were used to investigate the trends in case volumes of admissions to intensive care units (ICUs) compared with the previous years. Standardized mortality ratios (SMRs) of non-COVID-19 ICU patients were calculated in each wave of the COVID-19 epidemic in Japan.

Results

The ratios of new ICU admissions of non-COVID-19 patients to those in the corresponding months before the epidemic: 21% in May 2020, 8% in August 2020, 9% in February 2021, and 14% in May 2021, approximately concurrent with the peaks in COVID-19 infections. The decrease was greatest for new ICU admissions of non-COVID patients receiving invasive mechanical ventilation (IMV) on the first day of ICU admission: 26%, 15%, 19%, and 19% in the first, second, third, and fourth waves, respectively. No statistically significant change in SMR was observed in any wave of the epidemic; SMRs were 0.990 (95% uncertainty interval (UI), 0.962–1.019), 0.979 (95% UI, 0.953–1.006), 0.996 (95% UI, 0.980–1.013), and 0.989 (95% UI, 0.964–1.014), in the first, second, third, and fourth waves of the epidemic, respectively.

Conclusions

Compared to the previous years, the number of non-COVID-19 ICU patients continuously decreased over the medium term during the COVID-19 epidemic. The decrease in case volumes was larger in non-COVID-19 ICU patients initially receiving IMV than those undergoing other initial treatments. The standardized in-hospital mortality of non-COVID-19 ICU patients did not change in any waves of the epidemic.

Efficiency of the Japanese Hospitalist System for Patients with Urinary Tract Infection: A Propensity-matched Analysis

Objective The hospitalist system in the United States has been considered successful in terms of the quality of care and cost effectiveness. In Japan, however, its efficacy has not yet been extensively examined. This study examined the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population using treatment of urinary tract infection as an example. Methods We analyzed 271 patients whose most resource-consuming diagnosis at admission was urinary tract infection between April 2017 and March 2019. Propensity-matched analyses were performed to compare health care economics and the quality of care between the hospitalist system and the conventional system. Results In matched pairs, care by the hospitalist system was associated with a significantly shorter length of stay than that by the conventional system. The quality of care (oral antibiotics switch rate, rate of appropriate antibiotics change based on urine or blood culture results, detection rate of urinary tract infection etiology and the number of laboratory tests) was also considered to be favorably impacted by the hospitalist system. Although not statistically significant, hospital costs tended to be lower with the hospitalist system than with the conventional system. The mortality rate and 30-day readmission were also not significantly different between the groups. Conclusion The hospitalist system had a favorable impact on the quality of care and length of stay without increasing readmission in patients with urinary tract infection. This study is further evidence of the strong potential for the positive impact of an implemented hospitalist system in Japan.

Regional medical inter-institutional cooperation in medical provider network constructed using patient claims data from Japan

The aging world population requires a sustainable and high-quality healthcare system. To examine the efficiency of medical cooperation, medical provider and physician networks were constructed using patient claims data. Previous studies have shown that these networks contain information on medical cooperation. However, the usage patterns of multiple medical providers in a series of medical services have not been considered. In addition, these studies used only general network features to represent medical cooperation, but their expressive ability was low. To overcome these limitations, we analyzed the medical provider network to examine its overall contribution to the quality of healthcare provided by cooperation between medical providers in a series of medical services. This study focused on: i) the method of feature extraction from the network, ii) incorporation of the usage pattern of medical providers, and iii) expressive ability of the statistical model. Femoral neck fractures were selected as the target disease. To build the medical provider networks, we analyzed the patient claims data from a single prefecture in Japan between January 1, 2014 and December 31, 2019. We considered four types of models. Models 1 and 2 use node strength and linear regression, with Model 2 also incorporating patient age as an input. Models 3 and 4 use feature representation by node2vec with linear regression and regression tree ensemble, a machine learning method. The results showed that medical providers with higher levels of cooperation reduce the duration of hospital stay. The overall contribution of the medical cooperation to the duration of hospital stay extracted from the medical provider network using node2vec is approximately 20%, which is approximately 20 times higher than the model using strength.

Social and behavioral factors related to blood pressure measurement: A cross-sectional study in Bhutan

Cardiovascular disease is a leading cause of death in the Kingdom of Bhutan, and early detection of hypertension is critical for preventing cardiovascular disease. However, health-seeking behavior, including blood pressure measurement, is infrequently investigated in Bhutan. Therefore, this study investigated factors related to blood pressure measurement in Bhutan. We performed a secondary data analysis of a target population of 1,962 individuals using data from the “2014 Bhutan STEPS survey data”as a cross-sectional study. Approximately 26% of those with hypertension who were detected during the STEPS survey had never had their blood pressure measured. Previous blood pressure measurement was significantly associated with age and working status in men (self-employed [odds ratio (OR): 0.219, 95% CI: 0.133–0.361], non-working [OR: 0.114, 95% CI: 0.050–0.263], employee [OR: 1.000]). Previous blood pressure measurement was significantly associated with higher income in women (Quartile-2 [OR: 1.984, 95% CI: 1.209–3.255], Quartile-1 [OR: 2.161, 95% CI: 1.415–3.299], Quartile-4 [OR: 1.000]). A family history of hypertension (OR: 2.019, 95% CI: 1.549–2.243) increased the likelihood of having experienced a blood pressure measurement in both men and women. Multivariate logistic regression showed that people with unhealthy lifestyles (high salt intake [adjusted odds ratio (AOR): 0.247, 95% confidence interval (CI): 0.068–0.893], tobacco use [AOR: 0.538, 95% CI: 0.380–0.761]) had a decreased likelihood of previous blood pressure measurement. To promote the early detection of hypertension in Bhutan, we suggest that more attention be paid to low-income women, non-working, self-employed, and low-income men, and a reduction of barriers to blood pressure measurement. Before the STEPS survey, a substantial number of hypertensive people had never had their blood pressure measured or were unconcerned about their health. As a result, we propose that early blood pressure monitoring and treatment for people with hypertension or at higher risk of hypertension be given increased emphasis.

Multidisciplinary Team Deprescribing Intervention for Polypharmacy in Elderly Orthopedic Inpatients: A Propensity Score-matched Analysis of a Retrospective Cohort Study

Objective This study evaluated the effectiveness of a multidisciplinary team deprescribing intervention to reduce polypharmacy and potentially inappropriate medications (PIMs) in elderly orthopedic inpatients. Methods In this single-center retrospective observational study, orthopedic inpatients ≥75 years old and prescribed ≥6 different medications were enrolled as participants. Interventions comprised multidisciplinary team-led polypharmacy screening and suggestions regarding deprescribing any unnecessary medications during hospital stays. The primary outcome was reduction in the mean number of regular medicines and PIMs. Secondary outcomes included falls, delirium, and other adverse events during hospitalization as well as emergency department visits or unplanned hospital admissions within six months after discharge. Results After propensity score matching, 184 patients (intervention group, n=92; control group, n=92) were included in the analysis. The mean patient age was 83 years old. The mean number of prescribed medications and PIMs at admission were similar in both groups. The mean change in the number of regular medicines was -1.4 [standard deviation (SD), 2.3] in the intervention group and +0.2 (SD, 1.8) in the control group (p<0.001). The mean change in the number of PIMs was -0.5 (SD, 0.9) in the intervention group and +0.1 (SD, 0.8) in the control group (p<0.001). In-hospital adverse events other than falls and delirium were significantly less common in the deprescribing intervention group than in the control group. Conclusion Deprescribing intervention by our multidisciplinary team seems to have been effective in reducing the number of prescribed medicines and PIMs in elderly orthopedic inpatients, with some accompanying reduction in certain adverse events.

Hospitalization for ischemic stroke was affected more in independent cases than in dependent cases during the COVID-19 pandemic: An interrupted time series analysis

Background

The pandemic of the coronavirus disease 2019 (COVID-19) has affected health care systems globally. The aim of our study is to assess the impact of the COVID-19 pandemic on the number of hospital admissions for ischemic stroke by severity in Japan.

Methods

We analysed administrative (Diagnosis Procedure Combination—DPC) data for cases of inpatients aged 18 years and older who were diagnosed with ischemic stroke and admitted during the period April 1 2018 to June 27 2020. Levels of change of the weekly number of inpatient cases with ischemic stroke diagnosis after the declaration of state of emergency were assessed using interrupted time-series (ITS) analysis. The numbers of patients with various characteristics and treatment approaches were compared. We also performed an ITS analysis for each group (“independent” or “dependent”) divided based on components of activities of daily living (ADL) and level of consciousness at hospital admission.

Results

A total of 170,294 cases in 567 hospitals were included. The ITS analysis showed a significant decrease in the weekly number of ischemic stroke cases hospitalized (estimated decrease: −156 cases; 95% confidence interval (CI): −209 to −104), which corresponds to −10.4% (95% CI: −13.6 to −7.1). The proportion of decline in the independent group (−21.3%; 95% CI: −26.0 to −16.2) was larger than that in the dependent group (−8.6%; 95% CI: −11.7 to −5.4).

Conclusions

Our results show a marked reduction in hospital admissions due to ischemic stroke after the declaration of the state of emergency for the COVID-19 pandemic. The independent cases were affected more in proportion than dependent cases.

Medium-Term Impact of the Coronavirus Disease 2019 Pandemic on the Practice of Percutaneous Coronary Interventions in Japan

Aims: Declines in cardiovascular diseases during the first surge of coronavirus disease 2019 (COVID-19) have been reported. With the repeating surges of COVID-19, we aim to investigate the medium-term impact of the COVID-19 pandemic on the practice of percutaneous coronary interventions (PCIs).

Methods: We performed a descriptive analysis of rates of PCIs, utilizing administrative data in Japan. Changes in the proportion of severe cases and in-hospital mortality since the start of the COVID-19 pandemic were investigated using interrupted time series (ITS) analyses.

Results: From April 2018 to February 2021, 38,696 and 28,585 cases of elective and emergency PCIs, respectively, were identified. The rates of PCIs decreased during the first and third COVID-19 surges. The ratios of monthly rates of elective PCIs to that in the corresponding months during the previous 2 years were 50.3% in May 2020 and 76.1% in January 2021. The decrease in rates of emergency PCIs was smaller than that of elective PCIs. The ITS analyses did not identify any significant changes in the proportion of severe cases and in-hospital mortality.

Conclusions: We found that the impacts of COVID-19 on PCIs were larger in the first surge than in the subsequent and larger in the elective than in the emergency; this continued over the medium-term. During the COVID-19 pandemic, in-hospital mortality of cases undertaking emergency PCIs did not change.

Effects of the COVID-19 pandemic on heart failure hospitalizations in Japan: interrupted time series analysis

Aims

The Coronavirus Disease 2019 (COVID‐19) pandemic has had unprecedented effects on health care utilization for acute cardiovascular diseases. Although hospitalizations for acute coronary syndrome decreased during the COVID‐19 pandemic, there is a paucity of data on the trends and management of heart failure (HF) cases. Furthermore, concerns have been raised that angiotensin‐converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) may increase susceptibility to COVID‐19. This study aimed to elucidate changes in HF hospitalizations from the COVID‐19 state of emergency in Japan and investigated changes in the prescription of ACEIs and ARBs, and in‐hospital mortality.

Methods and results

We performed an interrupted time series analysis of HF hospitalizations in Japan to verify the impacts of the COVID‐19 state of emergency. Changes in the weekly volume of HF hospitalizations were taken as the primary outcome measure. Between 1 April 2018 and 4 July 2020, 109 429 HF cases required admission. After the state of emergency, an immediate decrease was observed in HF cases per week [−3.6%; 95% confidence interval (CI): −0.3% to −6.7%, P = 0.03]. There was no significant change in the prescription of ACEIs or ARBs after the state of emergency (4.2%; 95% CI: −0.3% to 8.9%, P = 0.07). The COVID‐19 pandemic had no effect on in‐hospital mortality among HF patients (5.3%; 95% CI: −4.9% to 16.6%, P = 0.32).

Conclusions

We demonstrated a decline in HF hospitalizations during the COVID‐19 pandemic in Japan, with no clear evidence of a negative effect on the prescription of ACEIs and ARBs or in‐hospital mortality.

Physical restraint of dementia patients in acute care hospitals during the COVID-19 pandemic: A cohort analysis in Japan

Introduction

The coronavirus disease (COVID-19) pandemic has caused unprecedented challenges for the medical staff worldwide, especially for those in hospitals where COVID-19-positive patients are hospitalized. The announcement of COVID-19 hospital restrictions by the Japanese government has led to several limitations in hospital care, including an increased use of physical restraints, which could affect the care of elderly dementia patients. However, few studies have empirically validated the impact of physical restraint use during the COVID-19 pandemic. We aimed to evaluate the impact of regulatory changes, consequent to the pandemic, on physical restraint use among elderly dementia patients in acute care hospitals.

Methods

In this retrospective study, we extracted the data of elderly patients (aged > 64 years) who received dementia care in acute care hospitals between January 6, 2019, and July 4, 2020. We divided patients into two groups depending on whether they were admitted to hospitals that received COVID-19-positive patients. We calculated descriptive statistics to compare the trend in 2-week intervals and conducted an interrupted time-series analysis to validate the changes in the use of physical restraint.

Results

In hospitals that received COVID-19-positive patients, the number of patients who were physically restrained per 1,000 hospital admissions increased after the government’s announcement, with a maximum incidence of 501.4 per 1,000 hospital admissions between the 73rd and 74th week after the announcement. Additionally, a significant increase in the use of physical restraints for elderly dementia patients was noted (p = 0.004) in hospitals that received COVID-19-positive patients. Elderly dementia patients who required personal care experienced a significant increase in the use of physical restraints during the COVID-19 pandemic.

Conclusion

Understanding the causes and mechanisms underlying an increased use of physical restraints for dementia patients can help design more effective care protocols for similar future situations.

Impact of the Clinical Trials Act on noncommercial clinical research in Japan: An interrupted time-series analysis

BACKGROUND

The number of new noncommercial clinical studies conducted in Japan declined within the first year of the implementation of the Clinical Trials Act (CTA) on April 1, 2018. This study aimed to examine the impact of the CTA's enforcement on the number of new noncommercial clinical studies registered in the Japanese Clinical Trial Registry.

METHODS

An interrupted time-series design was used in the analysis, which was conducted from April 2015 to March 2019. We collected data for studies registered in the Clinical Trial Registry, managed by the University Hospital Medical Information Network.

RESULTS

In total, 35,811 studies were registered; of these, 16,455 fulfilled the eligibility criteria. The difference in the trend of monthly number of new studies after CTA enforcement decreased significantly by 15.0 (95% CI, -18.7 to -11.3), and the level decreased by 40.8 (95% CI, -68.2 to -13.3) from the pre-enforcement to the post-enforcement period. Multigroup analyses indicated that the act exerted a significant effect on the trend of new clinical studies, particularly those with smaller sample sizes, interventional study designs, and nonprofit funding sponsors.

CONCLUSIONS

The number of Japanese noncommercial clinical studies declined significantly following implementation of the CTA. It is necessary to establish a system to promote clinical studies in Japan while ensuring transparency and safety.

Patient Safety Activity Under the Social Insurance Medical Fee Schedule in Japan: An Overview of the 2010 Nationwide Survey

OBJECTIVES

Little is known about patient safety performance under the social insurance medical fee schedule in Japan. The Health Ministry in Japan introduced the preferential patient safety countermeasure fee (PPSCF) to promote patient safety in 2006 and revised the PPSCF system in 2010. This study aims to address the patient safety performance status at hospitals implementing the PPSCF.

METHODS

A nationwide questionnaire survey targeting 2674 hospitals with the PPSCF was performed in 2010 to 2011. The 627 participant hospitals were divided into the following three groups: 178 hospitals implementing PPSCF 1 with 400 beds or more (group A), 286 hospitals implementing PPSCF 1 with 399 beds or fewer (group B), and 163 hospitals implementing PPSCF 2 (group C).

RESULTS

The mean numbers (standard errors) of patient safety managers were 1.45 (0.07) in group A, 1.12 (0.04) in group B, and 0.37 (0.12) in group C (P < 0.001). The participation number and rates of all staff for the patient safety seminar were 1721 (167) and 1.64 (0.10) in group A, 580 (26) and 1.94 (0.09) in group B, and 349 (31) and 1.98 (0.17) in group C (P < 0.001, P = 0.105).These results can be explained because hospitals with PPSCF 1 (groups A and B) must assign at least one full-time patient safety manager, whereas hospitals with PPSCF 2 (group C) are not required to do so. Patient safety performance at hospitals with PPSCF 1 was more active than that at hospitals with PPSCF 2. However, when the values were converted to per capita or per 100 beds, there were no differences across the three groups.

CONCLUSIONS

The PPSCF encourages hospitals to perform actions for patient safety by providing incentives under the social insurance medical fee schedule in Japan.

Individual and Nationwide Costs for Cancer Care During the First Year After Diagnosis Among Children, Adolescents, and Young Adults in Japan

PURPOSE

There has been limited information on the economic evaluation of children, adolescents, and young adults (AYAs) with cancer. The aim of this study was to estimate the individual and nationwide costs for cancer care during the first year after diagnosis among children and AYAs in Japan.

MATERIALS AND METHODS

We estimated the direct health care costs for children (0-14 years old) and AYAs (15-29 years old) from the perspective of the public payer. Children and AYAs with newly diagnosed cancer between April 2016 and March 2018 were identified from the Diagnosis Procedure Combination Study Group database to calculate the cost per patient. The nationwide cost was estimated by the bottom-up approach, using stratification by age group, sex, and cancer classification, based on Population Estimates and Cancer Statistics data.

RESULTS

A total of 2,939 children and 5,512 AYAs were identified. The median 1-year cost per patient after diagnosis was 2,832,840 (interquartile range, 927,490-9,222,780) JPY (in USD: median, 28,047; interquartile range, 9,183-91,310). The median 1-year cost per patient was higher in children than in AYAs in all cancer classifications. Leukemia, treatment in cancer centers, and early death as well as longer hospital stay were identified to have an impact on 1-year cost per patient after diagnosis. The 1-year nationwide cost after diagnosis was estimated as 34.83 × 10⁹ JPY (344.8 × 10⁶ USD).

CONCLUSION

We showed that cancer treatments for both children and AYAs were highly cost-intensive in Japan. Our results suggest the need for further financial and policy evaluation.

Gender with marital status, cultural differences, and vulnerability to hypertension: Findings from the national survey for noncommunicable disease risk factors and mental health using WHO STEPS in Bhutan

Cardiovascular disease is the leading cause of death in the Kingdom of Bhutan. Thus, the early detection and prevention of hypertension is critical for reducing cardiovascular disease. However, the influence of sociocultural factors on vulnerability to hypertension needs further investigation. This study performed secondary data analysis on 1,909 individuals in a cross-sectional study (the National survey for noncommunicable disease risk factors and mental health using World Health Organization (WHO) STEPS approach in Bhutan- 2014). Multivariate logistic regression demonstrated a significant association between gender with marital status and hypertension. Women had a higher odds ratio than men (Ref) when married (AOR: 1.27, 95% confidence intervals (CI): 1.23-1.31), and when separated, divorced, or widowed (AOR: 1.18, 95% CI: 1.12-1.26). People who speak the Tshanglakha language scored the highest odds (AOR: 1.24, 95% CI: 1.20-1.27), followed by Lhotshamkha (AOR: 1.09, 95% CI: 1.06-1.12) and Dzongkha (Ref) after adjusting for various social and biomedical factors. Additionally, tobacco use displayed decreased odds for hypertension. To promote the early detection and prevention of hypertension, these cultural factors should be considered even within small geographic areas, such as Bhutan. It is necessary to strengthen hypertension preventive strategies for people who speak Tshanglakha and Lhotshamkha. Furthermore, careful consideration should be given to preventing hypertension among adults aged 40 years or more, women who are married, separated, divorced, or widowed, and men who never married in Bhutan.

Optimising antimicrobial use in humans - review of current evidence and an interdisciplinary consensus on key priorities for research

Addressing the silent pandemic of antimicrobial resistance (AMR) is a focus of the 2021 G7 meeting. A major driver of AMR and poor clinical outcomes is suboptimal antimicrobial use. Current research in AMR is inequitably focused on new drug development. To achieve antimicrobial security we need to balance AMR research efforts between development of new agents and strategies to preserve the efficacy and maximise effectiveness of existing agents. Combining a review of current evidence and multistage engagement with diverse international stakeholders (including those in healthcare, public health, research, patient advocacy and policy) we identified research priorities for optimising antimicrobial use in humans across four broad themes: policy and strategic planning; medicines management and prescribing systems; technology to optimise prescribing; and context, culture and behaviours. Sustainable progress depends on: developing economic and contextually appropriate interventions; facilitating better use of data and prescribing systems across healthcare settings; supporting appropriate and scalable technological innovation. Implementing this strategy for AMR research on the optimisation of antimicrobial use in humans could contribute to equitable global health security.

Paraplegia After Open Surgical Repair Versus Thoracic Endovascular Aortic Repair for Thoracic Aortic Disease: A Retrospective Analysis of Japanese Administrative Data

OBJECTIVES

To comparatively examine the risk of postoperative paraplegia between open surgical descending aortic repair and thoracic endovascular aortic repair (TEVAR) among patients with thoracic aortic disease.

DESIGN

Retrospective cohort study.

SETTING

Acute-care hospitals in Japan.

PARTICIPANTS

A total of 6,202 patients diagnosed with thoracic aortic disease.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The main outcome of this study was the incidence of postoperative paraplegia. Multiple logistic regression models, using inverse probability of treatment weighting and an instrumental variable (ratio of TEVAR use to open surgical repair and TEVAR uses), showed that the odds ratios of paraplegia for TEVAR (relative to open surgical descending aortic repair) were 0.81 (95% confidence interval: 0.42-1.59; p = 0.55) in the inverse probability of treatment-weighted model and 0.88 (0.42-1.86; p = 0.75) in the instrumental-variable model.

CONCLUSIONS

There were no statistical differences in the risk of paraplegia between open surgical repair and TEVAR in patients with thoracic aortic disease. Improved perioperative management for open surgical repair may have contributed to the similarly low incidence of paraplegia in these two surgery types.

The impact of the COVID-19 epidemic on hospital admissions for alcohol-related liver disease and pancreatitis in Japan

During the coronavirus disease 2019 (COVID-19) pandemic, there have been health concerns related to alcohol use and misuse. We aimed to examine the population-level change in cases of alcohol-related liver disease and pancreatitis that required admission during the COVID-19 epidemic by interrupted time series (ITS) analysis using claims data. We defined the period from April 2020, when the Japanese government declared a state of emergency, as the beginning of the COVID-19 epidemic. This ITS analysis included 3,026,389 overall admissions and 10,242 admissions for alcohol-related liver disease or pancreatitis from 257 hospitals between July 2018 and June 2020. The rate of admissions per 1000 admissions during the COVID-19 epidemic period (April 2020-June 2020) was 1.2 times (rate ratio: 1.22, 95% confidence interval: 1.12-1.33) compared to the pre-epidemic period. Analyses stratified by sex revealed that the increases in admission rates of alcohol-related liver disease or pancreatitis for females were higher than for males during the COVID-19 epidemic period. The COVID-19 epidemic in Japan might associates an increase in hospital admissions for alcohol-related liver disease and pancreatitis. Our study could support the concern of alcohol consumption and health problems during the COVID-19 pandemic.

Trajectories of end-of-life medical and long-term care expenditures for older adults in Japan: retrospective longitudinal study using a large-scale linked database of medical and long-term care claims

BACKGROUND

An accurate understanding of the current state of end-of-life care is important for healthcare planning. The objectives of this study were to examine the trajectories of end-of-life medical and long-term care expenditures and associated factors.

METHODS

This was a retrospective longitudinal study using a large-scale linked database of medical and long-term care claims-National Health Insurance, Advanced Elderly Medical Insurance, and long-term care insurance-covering Prefecture A in Japan. Patients aged ≥70 years who died between April 1, 2016, and March 31, 2017, were included (N = 16,084 patients; mean age = 85.1 ± 7.5 years; 7804 men (48.5%) and 8280 women (51.5%)). The outcome measures were medical expenditures (inpatient, outpatient, and prescription), long-term care expenditures, and total healthcare expenditures (the sum of medical and long-term care expenditures) during the 60 months before the date of death. We calculated each patient's monthly medical and long-term care expenditures for 60 months before the date of death and applied group-based trajectory modeling to identify distinct trajectories. Factors associated with spending trajectories were examined via multinomial logistic regression analyses. Explanatory variables included age, sex, diseases, and the medical services used.

RESULTS

We identified six distinct spending trajectories for the total healthcare expenditures: high persistent (45.6%), medium-to-high persistent (26.1%), early rise then high persistent (9.8%), late rise (6.4%), low persistent then very late rise (i.e., when spending starts increasing later than "late rise"; 6.4%), and progressive increase (5.7%). Factors associated with the high-persistent trajectory were chronic illnesses, various organ failures, neurodegenerative diseases, fractures, and tube feeding. The trajectory pattern of medical expenditures was similar to that of total healthcare expenditures; however, a different pattern was seen for long-term care expenditures.

CONCLUSIONS

Regarding combined medical and long-term care spending of the last 5 years, most patients belonged to a pattern in which the healthcare expenditures remained high, and a combination of multiple factors contributed to these patterns. This finding can offer healthcare providers a longer-term perspective on end-of-life care.

Surgical volume reduction and the announcement of triage during the 1st wave of the COVID-19 pandemic in Japan: a cohort study using an interrupted time series analysis

Purpose

The coronavirus disease (COVID-19) pandemic has caused unprecedented challenges for surgical staffs to minimize exposure to COVID-19 or save medical resources without harmful patient outcomes, in accordance with the statement of each surgical society. No research has empirically validated declines in surgical volume in Japan, based on the usage of surgical triage. We aimed to identify whether the announcement of surgical priorities by each Japanese surgical society may have affected the surgical volume decline during the 1st wave of this pandemic.

Methods

We extracted 490,719 available cases of patients aged > 15 years who underwent elective major surgeries between July 1, 2018, and June 30, 2020. After the categorization of surgical specialities, we calculated descriptive statistics to compare the year-over-year trend and conducted an interrupted time series analysis to validate the decline of each surgical procedure.

Results

Monthly surgical cases of eight surgical specialities, especially ophthalmology and ear/nose/throat surgeries, decreased from April 2020 and reached a minimum in May 2020. An interrupted time series analysis showed no significant trends in oncological and critical surgeries.

Conclusion

Non-critical surgeries showed obvious and statistically significant declines in case volume during the 1st wave of the COVID-19 pandemic according to the statement of each surgical society in Japan.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00595-021-02286-6.

Hospitalization of mild cases of community-acquired pneumonia decreased more than severe cases during the COVID-19 pandemic

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has affected all healthcare systems. This study aimed to assess the impact of the COVID-19 pandemic on the number and severity of cases of community-acquired pneumonia (CAP) in Japan.

METHODS

Using claims data from the Quality Indicator/Improvement Project (QIP) database, urgent cases of inpatients for CAP from 01 August 2018 to 30 July 2020 were included. The monthly ratios of inpatient cases were compared from August 2018 to July 2019 and August 2019 to July 2020 as a year-over-year comparison. These ratios were also compared according to the "A-DROP" severity score, and an interrupted time series (ITS) analysis was performed to evaluate the impact of the COVID-19 pandemic on the monthly number of inpatient cases.

RESULTS

This study included a total of 67,900 inpatient cases for CAP in 262 hospitals. During the COVID-19 pandemic (defined as the period between March and July 2020) the number of inpatient cases for CAP drastically decreased compared with the same period in the previous year (-48.1%), despite a temporary reduction in the number of other urgent admissions. The number of inpatient cases decreased according to the severity of pneumonia. Milder cases showed a greater decrease in the year-over-year ratio than severe ones: mild -55.2%, moderate -45.8%, severe -39.4%, and extremely severe -33.2%. The ITS analysis showed that the COVID-19 pandemic significantly reduced the monthly number of inpatient cases for CAP (estimated decrease: -1233 cases; 95% CI -521 to -1955).

CONCLUSIONS

This study showed a significant reduction in the number of inpatient cases for CAP during the COVID-19 pandemic in Japan. The milder cases showed a greater decrease in the year-over-year ratio of the number of inpatient cases.

Trends, Treatment Approaches, and In-Hospital Mortality for Acute Coronary Syndrome in Japan During the Coronavirus Disease 2019 Pandemic

Aim: The coronavirus disease 2019 (COVID-19) pandemic has left negative spillover effects on the entire health care system. Previous studies have suggested significant declines in cases of acute coronary syndrome (ACS) and primary percutaneous coronary intervention (PCI) during the COVID-19 pandemic.

Methods: We performed a quasi-experimental, retrospective cohort study of ACS hospitalisations by using a multi-institutional administrative claims database in Japan. We used interrupted time series analyses to ascertain impacts on cases, treatment approaches, and in-hospital mortality before and after Japan’s state of emergency to respond to COVID-19. The primary outcome was the change in ACS cases per week.

Results: A total of 30,198 ACS cases (including 21,612 acute myocardial infarction and 8,586 unstable angina) were confirmed between 1^st July 2018 and 30^th June 2020. After the state of emergency, an immediate decrease was observed in ACS cases per week (-18.3%; 95% confidence interval, -13.1 to -23.5%). No significant differences were found in the severity of Killip classification (P=0.51) or cases of fibrinolytic therapy (P=0.74). The impact of the COVID-19 pandemic on in-hospital mortality in ACS patients was no longer observed after adjustment for clinical characteristics (adjusted odds ratio, 0.93; 95% confidence interval, 0.78 to 1.12;P=0.49).

Conclusions: We demonstrated the characteristics and trends of ACS cases in a Japanese population by applying interrupted time series analyses. Our findings provide significant insights into the association between COVID-19 and decreases in ACS hospitalisations during the pandemic.

Effects of periodontal management for patients with type 2 diabetes on healthcare expenditure, hospitalization and worsening of diabetes: an observational study using medical, dental and pharmacy claims data in Japan

AIMS

To investigate the effects of regular periodontal management for people with type 2 diabetes on total healthcare expenditure, hospitalization and the introduction of insulin.

MATERIALS AND METHODS

We collected data of individuals who were prescribed diabetes medications during the fiscal year 2015 from the claims database of a prefecture in Japan. We fitted generalized linear models that had sex, age, comorbidities and the status of periodontal management during the previous two years as predictors.

RESULTS

A total of 16,583 individuals were enrolled. The annual healthcare expenditure in the third year was 4% less (adjusted multiplier 0.96, 95% confidence interval [CI] 0.92-1.00) in the group receiving periodontal management every year. The adjusted odds ratio (aOR) for all-cause hospitalization was 0.90 (95% CI: 0.82-0.98). The aOR of introducing insulin in the third year for those who had not been prescribed insulin during the previous two years (n = 13,222) was 0.77 (95% CI: 0.64-0.92) in the group receiving periodontal management every year.

CONCLUSION

Regular periodontal management for diabetic people was associated with reduced healthcare expenditure, all-cause hospitalization and the introduction of insulin therapy.

Intra-operative autologous blood donation for cardiovascular surgeries in Japan: A retrospective cohort study

Intra-operative autologous blood donation is a blood conservation technique with limited evidence. We evaluated the association between intra-operative autologous blood donation and decrease in peri-operative transfusion in cardiovascular surgery based on evidence from a Japanese administrative database. We extracted the data of patients who had undergone cardiovascular surgery from the Diagnosis Procedure Combination database in Japan (2016–2019). Based on the surgery type, we examined the association of intra-operative autologous blood donation with the transfusion rate and amount of blood used in cardiac and aortic surgeries using multilevel propensity score matching. We enrolled 32,433 and 4,267 patients who underwent cardiac and aortic surgeries and received 5.0% and 6.7% intra-operative autologous blood donation with mean volumes of 557.68 mL and 616.96 mL, respectively. The red blood cell transfusion rates of the control and intra-operative autologous blood donation groups were 60.6% and 38.4%, respectively, in the cardiac surgery cohort (p < .001) and 91.4%, and 83.8%, respectively, in the aortic surgery cohort (p = .037). The transfusion amounts for the control and intra-operative autologous blood donation groups were 5.9 and 3.5 units of red blood cells, respectively, for cardiac surgery patients (p < .001) and 11.9 and 7.9 units, respectively, for aortic surgery patients (p < .001). Intra-operative autologous blood donation could reduce the transfusion rate or amount of red blood cells and fresh frozen plasma for patients undergoing index cardiovascular surgery and could be an effective blood transfusion strategy in cardiovascular surgery for Japanese patients.

Nationwide multicenter questionnaire surveys on countermeasures against antimicrobial resistance and infections in hospitals

BACKGROUND

The goals of the National Action Plan on Antimicrobial Resistance (AMR) of Japan include "implementing appropriate infection prevention and control" and "appropriate use of antimicrobials," which are relevant to healthcare facilities. Specifically, linking efforts between existing infection control teams and antimicrobial stewardship programs was suggested to be important. Previous studies reported that human resources, such as full-time equivalents of infection control practitioners, were related to improvements in antimicrobial stewardship.

METHODS

We posted questionnaires to all teaching hospitals (n = 1017) regarding hospital countermeasures against AMR and infections. To evaluate changes over time, surveys were conducted twice (1st survey: Nov 2016, 2nd survey: Feb 2018). A latent transition analysis (LTA) was performed to identify latent statuses, which refer to underlying subgroups of hospitals, and effects of the number of members in infection control teams per bed on being in the better statuses.

RESULTS

The number of valid responses was 678 (response rate, 66.7%) for the 1st survey and 559 (55.0%) for the 2nd survey. More than 99% of participating hospitals had infection control teams, with differences in activity among hospitals. Roughly 70% had their own intervention criteria for antibiotics therapies, whereas only about 60 and 50% had criteria established for the use of anti-methicillin-resistant Staphylococcus aureus antibiotics and broad-spectrum antibiotics, respectively. Only 50 and 40% of hospitals conducted surveillance of catheter-associated urinary tract infections and ventilator-associated pneumonia, respectively. Less than 50% of hospitals used maximal barrier precautions for central line catheter insertion. The LTA identified five latent statuses. The membership probability of the most favorable status in the 2nd study period was slightly increased from the 1st study period (23.6 to 25.3%). However, the increase in the least favorable status was higher (26.3 to 31.8%). Results of the LTA did not support a relationship between increasing the number of infection control practitioners per bed, which is reportedly related to improvements in antimicrobial stewardship, and being in more favorable latent statuses.

CONCLUSIONS

Our results suggest the need for more comprehensive antimicrobial stewardship programs and increased surveillance activities for healthcare-associated infections to improve antimicrobial stewardship and infection control in hospitals.

Stages of a transtheoretical model as predictors for the decline of estimated glomerular filtration rate: a retrospective cohort study

Background

The transtheoretical model (TTM) is composed of the multiple stages according to patient’s consciousness and is believed to lead people to realize the importance of healthier behaviors. We examined the association of TTM stages with the decline of estimated glomerular filtration rate (eGFR).

Methods

We used the annual health checkup data and health insurance claims data of the Japan Health Insurance Association in Kyoto Prefecture between April 2012 and March 2016. TTM stages of change obtained from questionnaires at the first health checkup and categorized into six groups. The primary outcome was defined as a more than 30% decline in eGFR from the first health checkup. We fitted multivariable Cox proportional-hazards model for time-to-event analyses adjusting for age, sex, eGFR, body mass index, blood pressure, blood sugar, dyslipidemia, uric acid, urinary protein, and existence of kidney diseases at first health checkup.

Results

We analyzed 239,755 employees and the mean follow-up was 2.9 (standard deviation, 1.2) years. As compared with the stage 1 group, the risk of eGFR decline was significantly low in the stage 3 group (hazard ratio [HR] 0.77; 95% confidence interval [CI], 0.65–0.91); stage 4 group (HR 0.80; 95% CI, 0.65–0.98); and stage 5 group (HR 0.79; 95% CI, 0.66–0.95).

Conclusion

Compared with the precontemplation stage (stage 1), the preparation, action and maintenance stages (stages 3, 4, and 5), were associated with a lower risk of eGFR decline.

Impact of rehabilitation start time on functional outcomes after stroke

OBJECTIVE

To investigate the optimum rehabilitation start timing for improved functional outcomes after stroke in Japan.

DESIGN

A retrospective database study.

SUBJECTS

A total of 140,655 patients with stroke from 1,161 acute hospitals in Japan. Only data for those patients who were discharged alive was included in the analysis.

METHODS

Activities of daily living were assessed. Comparisons were made using the rehabilitation start day after hospital admission. Reference day 2 was compared with days 1, 3, 4, 5, and 6 or later. Modified Rankin Scale at time of discharge was used as the primary outcome. In addition, cases of ischaemic stroke and haemorrhagic stroke were analysed as separate subgroups.

RESULTS

Univariate and multivariate logistic regression analyses showed that starting rehabilitation on day 2 resulted in a better outcome than starting on day 3 or later. There was no significant difference in outcome between starting rehabilitation on days 1 and 2 in all cases and subgroup of patient with infarction stroke. For a subgroup of patients with haemorrhagic stroke, starting rehabilitation on day 2 resulted in a better outcome than starting on day 1.

CONCLUSION

Starting post-stroke rehabilitation on the day of admission or second day of hospitalization may be the optimum timing for functional outcomes. However, for haemorrhagic stroke, starting rehabilitation on the second day of hospitalization may be more effective than on the day of admission.

Early impact of school closure and social distancing for COVID-19 on the number of inpatients with childhood non-COVID-19 acute infections in Japan

Many countries have implemented school closures as part of social distancing measures intended to control the spread of coronavirus disease 2019 (COVID-19). The aim of this study was to assess the early impact of nationwide school closure (March-May 2020) and social distancing for COVID-19 on the number of inpatients with major childhood infectious diseases in Japan. Using data from the Diagnosis Procedure Combination system in Japan, we identified patients aged 15 years or younger with admissions for a diagnosis of upper respiratory tract infection (URTI), lower respiratory tract infection (LRTI), influenza, gastrointestinal infection (GII), appendicitis, urinary tract infection (UTI), or skin and soft tissue infection (SSTI) between July 2018 and June 2020. Changes in the trend of the weekly number of inpatients between the two periods were assessed using interrupted time-series analysis. A total of 75,053 patients in 210 hospitals were included. The overall weekly number of inpatients was decreased by 52.5%, 77.4%, and by 83.4% in the last week of March, April, and May 2020, respectively, when compared on a year-on-year basis. The estimated impact was a reduction of 581 (standard error 42.9) inpatients per week in the post-school-closure period (p < 0.001). The main part of the reduction was for pre-school children. Remarkable decreases in the number of inpatients with URI, LRTI, and GII were observed, while there were relatively mild changes in the other groups.Conclusion: We confirmed a marked reduction in the number of inpatients with childhood non-COVID-19 acute infections in the post-school-closure period. What is Known: • Most countries have implemented social distancing measures to limit the spread of the novel coronavirus disease 2019 (COVID-19). • A large decrease in pediatric emergency visits has been reported from several countries after the social distancing. What is New: • Based on administrative claims data, a marked reduction in the number of inpatients for childhood non-COVID-19 acute infections was found in the post-school-closure period in Japan. • The magnitude of the reduction was different between the disease groups.

Code-Sharing in Cost-of-Illness Calculations: An Application to Antibiotic-Resistant Bloodstream Infections

Background: More data-driven evidence is needed on the cost of antibiotic resistance. Both Japan and England have large surveillance and administrative datasets. Code sharing of costing models enables reduced duplication of effort in research.

Objective: To estimate the burden of antibiotic-resistant Staphylococcus aureus bloodstream infections (BSIs) in Japan, utilizing code that was written to estimate the hospital burden of antibiotic-resistant Escherichia coli BSIs in England. Additionally, the process in which the code-sharing and application was performed is detailed, to aid future such use of code-sharing in health economics.

Methods: National administrative data sources were linked with voluntary surveillance data within the Japan case study. R software code, which created multistate models to estimate the excess length of stay associated with different exposures of interest, was adapted from previous use and run on this dataset. Unit costs were applied to estimate healthcare system burden in 2017 international dollars (I$).

Results: Clear supporting documentation alongside open-access code, licensing, and formal communication channels, helped the re-application of costing code from the English setting within the Japanese setting. From the Japanese healthcare system perspective, it was estimated that there was an excess cost of I$6,392 per S. aureus BSI, whilst oxacillin resistance was associated with an additional I$8,155.

Conclusions:S. aureus resistance profiles other than methicillin may substantially impact hospital costs. The sharing of costing models within the field of antibiotic resistance is a feasible way to increase burden evidence efficiently, allowing for decision makers (with appropriate data available) to gain rapid cost-of-illness estimates.

Factors affecting the use of clinical practice guidelines by hospital physicians: the interplay of IT infrastructure and physician attitudes

Background

Compliance with clinical practice guidelines (CPGs) remains insufficient around the world, despite frequent updates and continuing efforts to disseminate and implement these guidelines through a variety of strategies. We describe the current status of young resident physician practices towards CPGs and investigate the multiple factors associated with the active use of CPGs, including the physician’s knowledge, attitudes, behaviours, CPG-related education received, and the hospital’s IT infrastructures. The aim is to identify a more effective point for intervention to promote CPG implementation.

Methods

We conducted a questionnaire survey among resident physicians working at 111 hospitals across Japan in 2015 and used results with hospital IT score data collected from a prior survey. Multivariable logistic regression analysis was performed to examine the determinants of frequent use of CPGs (defined at least once per week). The independent variables were selected based on physician demographics, clinical speciality and careers, daily knowledge and behaviour items, CPG-related education received, digital preference, and hospital IT score (high/medium/low), with and without interaction terms.

Results

Responses from 535 resident physicians, at 61 hospitals, were analysed. The median hospital IT score was 6 out of a possible 10 points. Physicians who had learned about CPGs tended to work at hospitals with medium to high IT scores, had easier access to paywalled medical databases, and had better knowledge of the guideline network ‘Minds’. In addition, these physicians tended to use CPGs electronically. A physician’s behaviour towards using CPGs for therapeutic decision-making was strongly associated with frequent use of CPGs (odds ratio [95% CI] 6.1 [3.6–10.4]), which indicated that a physician’s habit strongly promotes CPG use. Moreover, CPG-related education was associated with active use of CPGs (OR1.7 [1.1–2.5]). The interaction effects between individual digital preferences and higher hospital IT score were also observed for frequent CPG use (OR2.9 [0.9–8.8]).

Conclusions

A physician’s habitual behaviours, CPG-related education, and a combination of individual digital preference and superior hospital IT infrastructure are key to bridging the gap between the use and implementation of CPGs.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s13012-020-01056-1.