Association between hospital case volume and maternal adverse events in patients with placental abruption: An analysis using a Japanese national inpatient database

OBJECTIVE

To clarify the relationship between the prognosis of patients with placental abruption (PA) and the healthcare delivery system using data from a large national inpatient database in Japan.

METHODS

Using the Diagnosis Procedure Combination database, we conducted a retrospective cohort study with the data of patients in almost 1000 hospitals with the primary diagnosis of PA who were hospitalized from April 2014 to March 2021. We divided the hospitals into four groups based on the number of deliveries per month. We performed multilevel logistic regression analysis to analyze the relationship between hospital case volume and maternal end-organ injury (MEOI).

RESULTS

Altogether, 8222 patients were included for analysis; among whom, 3575 (44%) were transferred by ambulance. MEOI was noted in 977 patients (12%) with no obvious difference by hospital case volume. Ambulance transfer, age, gestational weeks at admission, delivery on the first day of hospitalization, and history of eclampsia were significantly associated with a higher incidence of MEOI, but the hospital case volume was not.

CONCLUSION

Using a Japanese administrative database, our study shows that hospital case volume was not significantly associated with the severity of maternal illness among patients with PA.

Surgical outcomes of robot-assisted radical cystectomy in octogenarian or older patients: A Japanese nationwide study

OBJECTIVE

To evaluate the surgical outcomes of robot-assisted radical cystectomy (RARC) in octogenarian or older patients based on a Japanese nationwide database.

METHODS

The diagnosis procedure combination database was used to extract the data on radical cystectomy cases. Surgical outcomes of RARC in octogenarian or older patients (older group) were initially compared to those of patients younger than 80 years (younger group). Then, the surgical outcomes of RARC in the older group were compared to those of open radical cystectomy (ORC) and laparoscopic radical cystectomy (LRC) in the same age group.

RESULTS

Between 2018 and 2021, 478 RARC cases in the older group and 2257 RARC cases in the younger group were identified. In the older group, ileal conduit, neobladder, and other urinary diversions were carried out in 352 (73.6%), 22 (4.6%), and 104 (21.8%) patients, respectively. In the older group, when compared with the younger group, the complication rate (24.9%), blood transfusion rate (41.4%), and in-hospital mortality (1.4%) were equivalent, while significantly shorter anesthesia time and longer length of stay were observed in the older group (521.0 ± 140.4 min vs. 595.1 ± 141.71 min, p < 0.01, and 32.9 ± 16.8 days vs. 30.6 ± 17.8 days, p = 0.01, respectively). In the comparison of the surgical outcomes of older patients receiving RARC to those receiving ORC (n = 746) and LRC (n = 375), the RARC group had the lowest complication rate and the shortest length of stay, while the shortest anesthesia time was noted in the ORC group.

CONCLUSION

The feasibility of RARC for octogenarian or older patients was demonstrated by the nationwide database study.

Impact of Administering Intravenous Azithromycin within 7 Days of Hospitalization for Influenza Virus Pneumonia: A Propensity Score Analysis Using a Nationwide Administrative Database

The potential antimicrobial and anti-inflammatory effectiveness of azithromycin against severe influenza is yet unclear. We retrospectively investigated the effect of intravenous azithromycin administration within 7 days of hospitalization in patients with influenza virus pneumonia and respiratory failure. Using Japan's national administrative database, we enrolled and classified 5066 patients with influenza virus pneumonia into severe, moderate, and mild groups based on their respiratory status within 7 days of hospitalization. The primary endpoints were total, 30-day, and 90-day mortality rates. The secondary endpoints were the duration of intensive-care unit management, invasive mechanical ventilation, and hospital stay. The inverse probability of the treatment weighting method with estimated propensity scores was used to minimize data collection bias. Use of intravenous azithromycin was proportional to the severity of respiratory failure (mild: 1.0%, moderate: 3.1%, severe: 14.8%). In the severe group, the 30-day mortality rate was significantly lower with azithromycin (26.49% vs. 36.65%, p = 0.038). In the moderate group, the mean duration of invasive mechanical ventilation after day 8 was shorter with azithromycin; there were no significant differences in other endpoints between the severe and moderate groups. These results suggest that intravenous azithromycin has favorable effects in patients with influenza virus pneumonia using mechanical ventilation or oxygen.

Trends of radical cystectomy and comparisons of surgical outcomes among surgical approaches focusing on robot-assisted radical cystectomy: A Japanese nationwide database study

OBJECTIVE

To clarify the trends in radical cystectomy and to compare surgical outcomes among surgical approaches focusing on robot-assisted radical cystectomy based on a Japanese nationwide database.

METHODS

The Diagnosis Procedure Combination database was used to extract data on radical cystectomy cases. Trends in open radical cystectomy, laparoscopic radical cystectomy, minimum incision endoscopic radical cystectomy, and robot-assisted radical cystectomy between April 2012 and March 2021 were evaluated. Basic characteristics and peri-operative indicators were compared among the four groups. Propensity score matching was applied to assess the differences between open radical cystectomy and robot-assisted radical cystectomy.

RESULTS

During the study period, a decreasing number of open radical cystectomies and an increasing number of minimally invasive radical cystectomies were shown in the total cohort of 28 345 cases. The number of robot-assisted radical cystectomies rapidly increased after government approval in 2018. Minimally invasive radical cystectomies, including robot-assisted radical cystectomies, had a significantly lower complication rate, a shorter length of stay, and a lower blood transfusion rate, but a longer anesthesia time than open radical cystectomies. In the propensity score matching analysis comparing the surgical outcomes of robot-assisted radical cystectomy and open radical cystectomy, similar results were demonstrated, and blood transfusion rates were equivalent.

CONCLUSION

For the past decade, the number of minimally invasive radical cystectomies has steadily increased without compromised surgical outcomes, except for anesthesia time. Robot-assisted radical cystectomies in particular rapidly became widespread in Japan after government approval in 2018 and became a standard surgery within the first 3 years.

The Relationship Between Preoperative Frailty Risk as Assessed by the Hospital Frailty Risk Score and the Outcome at Discharge in Coronary Artery Bypass Grafting (CABG) Patients: A Retrospective Observational Study Using the Diagnosis Procedure Combination Database

The relationship between the Hospital Frailty Risk Score (HFRS)-based frailty risk and outcomes after coronary artery bypass grafting (CABG) is yet unclear. The objective of this study was to investigate the relationship between preoperative frailty risk as assessed by the HFRS and postoperative outcomes in patients undergoing CABG. This observational study used the diagnosis procedure combination (DPC) system in Japan (2014-2017). In total, 35,015 adults aged ≥ 65 years and diagnosed with angina pectoris and acute myocardial infarction who had undergone CABG were enrolled. We investigated the association between the HFRS-based frailty risk and the home discharge rate, as well as the prevalence of complications. Multilevel logistic regression analysis revealed that having an HFRS ≥ 5 was a determinant of lower home discharge rate (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.49-0.74, P <0.01), aspiration pneumonia (OR 2.25, 95%CI 1.27-3.96, P <0.01) and disuse syndrome (OR 1.90, 95%CI 1.23-2.94, P <0.01). Preoperative stratification of frailty risk using HFRS may help in predicting postoperative progress and in planning postoperative rehabilitation.

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.

Existing Data Sources for Clinical Epidemiology: Database of the National Hospital Organization in Japan

This review introduces the National Hospital Organization (NHO) database in Japan. The NHO has maintained two databases through a system of data collection from 140 hospitals in the NHO. National Hospital Organization Clinical Data Archives (NCDA) is collecting clinical information in real time from the electronic medical records since January 2016, and Medical Information Analysis (MIA) databank is collecting daily insurance claims data since April 2010. The NHO database covers more than 8 million patients in 140 hospitals throughout Japan. The database consists of the information of patient profiles, hospital admission and discharge, diagnosis with ICD-10 codes, text data from medical chart, daily health insurance claims such as medical procedures, medications or surgeries, vital signs and laboratory data, and so on. The NHO database includes a wide variety of diseases and settings, including acute, chronic and intractable diseases, emergency medical services, disaster medicine, response to emerging infectious disease outbreaks, medical care according to health policies such as psychiatry, tuberculosis, or muscular dystrophy, and health systems in sparsely populated non-urban areas. Among several common diseases, the database has representativeness in terms of age distribution compared with the Patient Survey 2017 by the Ministry of Health, Labour and Welfare. Interested researchers can contact (700-dbproject@mail.hosp.go.jp) the NHO database division to obtain more information about the NHO database for utilization.

A Smartphone Application as a Telemedicine Tool for Stroke Care Management

Since smartphone applications are revolutionizing telemedicine, a new application specifically for stroke care (JOIN) was designed. Addition of the JOIN smartphone application to the stroke treatment workflow in our hospital was assessed. JOIN has key functions that may improve the care of stroke patients, including the ability to (1) exchange information such as patient data and medical images in real-time throughout the entire process of patient management; (2) track each step of the protocol from door to discharge; and (3) facilitate real-time interaction of all team members via text, audio, and a video chat system. Two periods, 2.7 years before the implementation of JOIN (Pre-JOIN) with 37 patients and 2.2 years after (Post-JOIN) with 54 patients, were compared, and the workflow for all 91 patients who had a cerebral infarction and were treated with tissue plasminogen activator (tPA) and/or thrombectomy between October 2012 and July 2017 was reviewed. There were noticeable reductions in overall patient management time, including times for door-to-imaging, starting tPA treatment, and endovascular intervention with JOIN. Staff members were unanimously satisfied with JOIN, due to the increased efficiency of information exchange and the ability for real-time discussions with different professionals when needed. No significant changes in patient outcomes (as assessed by modified Rankin Scale [mRS] scores) at 3 months and in the total cost for the treatment were observed. A smartphone-based application with the capability of sharing information instantaneously among healthcare professionals facilitated time-sensitive, acute care of ischemic stroke patients.

Efficacy of Antimicrobial Catheters for Prevention of Catheter-Associated Urinary Tract Infection in Acute Cerebral Infarction

Background

Catheter-associated urinary tract infection (CAUTI) is a common nosocomial infection. However, the effectiveness of antimicrobial catheters in reducing CAUTI in cerebral infarction patients is unknown. The purpose of this study was to determine whether antimicrobial catheters protect against CAUTI in cerebral infarction patients.

Methods

We identified 27,548 patients from the Japanese Diagnosis Procedure Combination Database who had been admitted from April 1, 2012 through March 31, 2014 for acute management of cerebral infarction and had used at least an indwelling urethral catheter. We extracted data on patient sex, age, comorbidity, length of stay, activities of daily living (ADL), surgery, hospital case volume, and catheter type. We defined CAUTI as a urinary tract infection arising during admission. We performed multi-level logistic regression analysis to analyze the reduction in CAUTI using antimicrobial catheters.

Results

The rate of CAUTI was 8.8% and 8.3% in the control and antimicrobial catheter groups, respectively. Significant risk factors for CAUTI were age, diabetes requiring insulin therapy, low ADL score, and long hospitalization. Incidence rate was significantly lower in operated cases and those treated with tissue plasminogen activator. For all cases overall, the use of an antimicrobial catheter was not associated with a lower CAUTI rate. However, use was associated with a lower rate of CAUTI in diabetic patients on insulin.

Conclusions

Antimicrobial catheter use was not associated with a lower incidence rate of CAUTI in acute cerebral infarction patients. However, stratified analysis suggested that use was associated with a lower incidence in diabetic patients on insulin.

Factors affecting prolonged length of stay in psychiatric patients in Japan: A retrospective observational study

AIM

Hospital length of stay (LOS) is one of the stratified measures of health-care efficiency and is commonly used to assess performance of psychiatric care. The aim of this study was to identify risk factors for prolonged LOS of psychiatric patients.

METHODS

We retrospectively analyzed adult psychiatric patients (ICD-10; F00-F99) between April 2012 and March 2014 in the Japanese Diagnosis Procedure Combination database. We examined factors affecting prolonged LOS using multivariable logistic regression analysis. Subgroup analyses of the logistic regression were undertaken according to two diagnostic groups (F20-F29 and F30-F39).

RESULTS

A total of 34 326 patients admitted to and discharged from psychiatric beds were included. Older age, lower Global Assessment of Functioning score, involuntary commitment, several psychiatric services, certain other patient factors, academic hospitals, public hospitals, and higher density of psychiatric beds were significantly associated with prolonged LOS. Hospital patient volume was significantly associated with shorter LOS. In the subgroup analyses, most of these factors were consistent although some were not associated with prolonged LOS.

CONCLUSION

Not only clinical factors but also institutional characteristics were associated with prolonged LOS. Our study provided useful information for improvement in psychiatric services and indicated the need to consider the division of roles between healthcare/welfare institutions and psychiatric-related resource allocation. Interventions should be considered for achieving shorter LOS for psychiatric patients.

Mortality-Reducing Effect of Rehabilitation for COPD: Observational Propensity-Matched Cohort Study Using a Nationwide Database

BACKGROUND

In the course of therapy of patients with COPD, non-pharmacologic treatment, such as rehabilitation, plays an important role. Although some studies have provided concrete evidence of the effectiveness of rehabilitation in improving functional outcomes in subjects with COPD, evidence of its mortality-reducing effect has been insufficient. In the present study, we examined whether rehabilitation had positive effects on in-hospital mortality of subjects with COPD.

METHODS

We used the Japanese Diagnosis Procedure Combination nationwide administrative claims database. This was a retrospective cohort study, and there were 18,037 eligible subjects with COPD from 1,055 hospitals. The main outcome was in-hospital mortality rates. A one-to-one propensity score matching method was used to compare hospital mortality rates after admission between rehabilitation and non-rehabilitation groups.

RESULTS

A total of 3,356 pairs of subjects were selected from the rehabilitation and non-rehabilitation groups (n = 6,712). Subjects in the rehabilitation program showed a reduction in the odds of mortality (odds ratio = 0.80, 95% CI 0.65-1.00, P = .045). In the subgroup analyses, the rehabilitation group had a lower in-hospital mortality in the pre-obese subgroup (body mass index 25.0-29.9) than the non-rehabilitation group (P = .02). Although not significant, the rehabilitation group showed a relatively low in-hospital mortality in the Hugh-Jones dyspnea scale class 5 subgroup (P = .066).

CONCLUSIONS

This large nationwide cohort study showed that rehabilitation indeed contributed to a reduction of in-hospital mortality. These findings underscore the importance of adopting rehabilitation as part of the treatment of COPD.

Variceal hemorrhage: Analysis of 9987 cases from a Japanese nationwide database

AIM

Gastroesophageal variceal hemorrhage is an important complication of cirrhosis. We investigated the in-hospital mortality and its risk factors after variceal hemorrhage in a large sample population, using a nationwide Japanese database.

METHODS

Data on the patients with variceal hemorrhage were collected for a total of 39 months from a nationwide administrative database covering approximately 1000 hospitals in Japan. The risk factors for fatal outcome after variceal hemorrhage were analyzed with receiver-operator curves (ROC) and univariate and multivariate logistic regression. Comorbidities were assessed with the Charlson Comorbidity Index.

RESULTS

We identified 9987 patients with variceal hemorrhage from a total of 20.3 million inpatients in the database. The median age was 63 years and 68.8% were male. The overall in-hospital mortality was 16.8% (1676 cases). In univariate analysis, Child-Pugh class was the strongest predictor; the area under the ROC of Child-Pugh score for predicting in-hospital mortality was 0.802. In multivariate analysis, increased in-hospital mortality was significantly associated with male sex (vs female: odds ratio [OR] = 1.19, P = 0.01), older age, Child-Pugh class B or C (B vs A: OR = 2.80, P < 0.001; C vs A: OR = 20.1, P < 0.001) and higher Charlson Comorbidity Index (≥6 vs ≤5; OR = 1.29, P < 0.001).

CONCLUSION

In spite of recent advances in the treatment of variceal hemorrhage, the in-hospital mortality remained as high as 16%. Poor liver function was the most important predictor, suggesting that liver failure after variceal hemorrhage might have been the cause of death.