Association of Bystander Interventions With Neurologically Intact Survival Among Patients With Bystander-Witnessed Out-of-Hospital Cardiac Arrest in Japan

IMPORTANCE

Neurologically intact survival after out-of-hospital cardiac arrest (OHCA) has been increasing in Japan. However, associations between increased prehospital care, including bystander interventions and increases in survival, have not been well estimated.

OBJECTIVE

To estimate the associations between bystander interventions and changes in neurologically intact survival among patients with OHCA in Japan.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective descriptive study using data from Japan's nationwide OHCA registry, which started in January 2005. The registry includes all patients with OHCA transported to the hospital by emergency medical services (EMS) and recorded patients' characteristics, prehospital interventions, and outcomes. Participants were 167,912 patients with bystander-witnessed OHCA of presumed cardiac origin in the registry between January 2005 and December 2012.

EXPOSURES

Prehospital interventions by bystander, including defibrillation using public-access automated external defibrillators and chest compression.

MAIN OUTCOMES AND MEASURES

Neurologically intact survival was defined as Glasgow-Pittsburgh cerebral performance category score 1 or 2 and overall performance category scores 1 or 2 at 1 month or at discharge. The association between the interventions and neurologically intact survival was evaluated.

RESULTS

From 2005 to 2012, the number of bystander-witnessed OHCAs of presumed cardiac origin increased from 17,882 (14.0 per 100,000 persons [95% CI, 13.8-14.2]) to 23,797 (18.7 per 100,000 persons [95% CI, 18.4-18.9]), and neurologically intact survival increased from 587 cases (age-adjusted proportion, 3.3% [95% CI, 3.0%-3.5%]) to 1710 cases (8.2% [95% CI, 7.8%-8.6%]). The rates of bystander chest compression increased from 38.6% to 50.9%, bystander-only defibrillation increased from 0.1% to 2.3%, bystander defibrillation combined with EMS defibrillation increased from 0.1% to 1.4%, and EMS-only defibrillation decreased from 26.6% to 23.5%. Performance of bystander chest compression, compared with no bystander chest compression, was associated with increased neurologically intact survival (8.4% [6594 survivors/78,592 cases] vs 4.1% [3595 survivors/88,720 cases]; odds ratio [OR], 1.52 [95% CI, 1.45-1.60]). Compared with EMS-only defibrillation (15.0% [6445 survivors/42,916 cases]), bystander-only defibrillation (40.7% [931 survivors/2287 cases]) was associated with increased neurologically intact survival (OR, 2.24 [95% CI, 1.93-2.61]), as was combined bystander and EMS defibrillation (30.5% [444 survivors/1456 cases]; OR, 1.50 [95% CI, 1.31-1.71]), whereas no defibrillation (2.0% [2369 survivors/120,653 cases]) was associated with reduced survival (OR, 0.43 [95% CI, 0.39-0.48]).

CONCLUSIONS AND RELEVANCE

In Japan, between 2005 and 2012, the rates of bystander chest compression and bystander defibrillation increased and were associated with increased odds of neurologically intact survival.

The profile of Japanese Association for Acute Medicine - out-of-hospital cardiac arrest registry in 2014-2015

Aim

To describe the registry design of the Japanese Association for Acute Medicine – out‐of‐hospital cardiac arrest (JAAM‐OHCA) Registry as well as its profile on hospital information, patient and emergency medical service characteristics, and in‐hospital procedures and outcomes among patients with OHCA who were transported to the participating institutions.

Methods

The special committee aiming to improve the survival after OHCA by providing evidence‐based therapeutic strategies and emergency medical systems from the JAAM has launched a multicenter, prospective registry that enrolled OHCA patients who were transported to critical care medical centers or hospitals with an emergency care department. The primary outcome was a favorable neurological status 1 month after OHCA.

Results

Between June 2014 and December 2015, a total of 12,024 eligible patients with OHCA were registered in 73 participating institutions. The mean age of the patients was 69.2 years, and 61.0% of them were male. The first documented shockable rhythm on arrival of emergency medical services was 9.0%. After hospital arrival, 9.4% underwent defibrillation, 68.9% tracheal intubation, 3.7% extracorporeal cardiopulmonary resuscitation, 3.0% intra‐aortic balloon pumping, 6.4% coronary angiography, 3.0% percutaneous coronary intervention, 6.4% targeted temperature management, and 81.1% adrenaline administration. The proportion of cerebral performance category 1 or 2 at 1 month after OHCA was 3.9% among adult patients and 5.5% among pediatric patients.

Conclusions

The special committee of the JAAM launched the JAAM‐OHCA Registry in June 2014 and continuously gathers data on OHCA patients. This registry can provide valuable information to establish appropriate therapeutic strategies for OHCA patients in the near future.

Evaluation of pre-hospital administration of adrenaline (epinephrine) by emergency medical services for patients with out of hospital cardiac arrest in Japan: controlled propensity matched retrospective cohort study

OBJECTIVES

To evaluate the effectiveness of pre-hospital adrenaline (epinephrine) administered by emergency medical services to patients with out of hospital cardiac arrest.

DESIGN

Controlled propensity matched retrospective cohort study, in which pairs of patients with or without (control) adrenaline were created with a sequential risk set matching based on time dependent propensity score.

SETTING

Japan's nationwide registry database of patients with out of hospital cardiac arrest registered between January 2007 and December 2010.

PARTICIPANTS

Among patients aged 15-94 with out of hospital cardiac arrest witnessed by a bystander, we created 1990 pairs of patients with and without adrenaline with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) and 9058 pairs among those with non-VF/VT.

MAIN OUTCOME MEASURES

Overall and neurologically intact survival at one month or at discharge, whichever was earlier.

RESULTS

After propensity matching, pre-hospital administration of adrenaline by emergency medical services was associated with a higher proportion of overall survival (17.0% v 13.4%; unadjusted odds ratio 1.34, 95% confidence interval 1.12 to 1.60) but not with neurologically intact survival (6.6% v 6.6%; 1.01, 0.78 to 1.30) among those with VF/VT; and higher proportions of overall survival (4.0% v 2.4%; odds ratio 1.72, 1.45 to 2.04) and neurologically intact survival (0.7% v 0.4%; 1.57, 1.04 to 2.37) among those with non-VF/VT.

CONCLUSIONS

Pre-hospital administration of adrenaline by emergency medical services improves the long term outcome in patients with out of hospital cardiac arrest, although the absolute increase of neurologically intact survival was minimal.

Association between timing of epinephrine administration and intact neurologic survival following out-of-hospital cardiac arrest in Japan: a population-based prospective observational study

OBJECTIVES

This study aimed to investigate whether early epinephrine administration in out-of-hospital cardiopulmonary arrest (OHCA) patients was associated with improved outcomes and to address the selection bias inherent in observational studies (more severe cases are more likely to receive epinephrine).

METHODS

This was a retrospective analysis of prospectively collected population-based data of adult bystander-witnessed OHCA patients from a nationwide Japanese registry between January 2007 and December 2008. To address selection bias, those who attained early return of spontaneous circulation (ROSC) without epinephrine administration were excluded, leaving 49,165 patients in the analysis. The outcomes were intact neurologic survival, defined as survival with cerebral performance category score 1 or 2, and any survival at 1 month or at discharge (whichever was earlier). The primary predictor was the time from the start of cardiopulmonary resuscitation (CPR) by emergency medical services (EMS) to first epinephrine administration, with early epinephrine defined as within 10 minutes.

RESULTS

Multivariate logistic regression analysis showed that cardiac origin OHCA patients who received early epinephrine (≤ 10 minutes) had significantly higher rates of intact neurologic survival (odds ratio [OR]=1.39, 95% confidence interval [CI]=1.08 to 1.78) and any survival (OR=1.73, 95% CI=1.46 to 2.04) than those who did not receive early epinephrine, after adjusting for potential confounders. Results for noncardiac OHCA patients were similar.

CONCLUSIONS

Early epinephrine administration may be associated with higher rates of intact neurologic survival and any survival in adult bystander-witnessed OHCA patients. This article provides a potential method to address the selection bias inherent in observational studies that examine the effects of drug administration in OHCA patients.

Quality of care for diabetes patients using National Health Insurance claims data in Japan

BACKGROUND

Assessment of the quality of care is a key element in current diabetes care. However, the quality of care for diabetes patients in Japan has rarely been reported.

OBJECTIVES

To assess the quality of diabetes care in two communities in Japan by using National Health Insurance claims data.

METHODS

We analysed claim data of 13,650 beneficiaries of National Health Insurance in two communities in Japan from May 2006 to April 2007. Diabetes cases were identified by using a case detection algorism. Our main outcome measures were three process quality indicators: (1) haemoglobin A1c (HbA1c) testing; (2) annual eye examination; and (3) annual nephropathy screening, recommended in the existing clinical guidelines. We calculated the performance rate of each quality indicator and examined the effects of demographic characteristics and co-morbid conditions.

RESULTS

We identified 636 diabetes cases. Of these, 97.0% had at least one HbA1c test, and 69.8% had ≥ 4 tests during the study period. The odds ratios (ORs) for ≥ 4 HbA1c tests were lower in subgroups aged 75-79 (OR 0.58, 95% confidence interval 0.35-0.96), and aged ≥ 80 (OR 0.54, 95% confidence interval 0.32-0.88) compared with the subgroup aged <70 after adjusting for other patient characteristics. The annual rate for eye examinations and nephropathy screenings were 20.8% and 5.8% respectively.

CONCLUSIONS

We found high performance rates for HbA1c testing, while the annual rates for eye examinations and nephropathy screenings were suboptimal. Using administrative data would facilitate more comprehensive assessment of the quality of care in Japan.

Process quality of diabetes care under favorable access to healthcare: a 2-year longitudinal study using claims data in Japan

OBJECTIVE

To investigate the process quality of diabetes care provided to patients under universal health insurance coverage.

RESEARCH DESIGN AND METHODS

Using claim data for 570 363 beneficiaries aged 20-69 years who were covered by Health Insurance Societies between April 2010 and March 2012, we identified patients with type 2 diabetes who made follow-up visits at least every 3 months in the first year (subject-identification year). We assessed patient adherence to follow-up visits in the second year (quality-reporting year), calculated the proportion of patients that completed routine examinations for glycemic control and complications, and evaluated associations between characteristics of patients and quality indicators using multivariable logistic regression models.

RESULTS

We identified 12 909 patients with diabetes; in the subject-identification year, 1415 (11.0%) had prescriptions for insulin injections, 6049 (46.9%) had prescriptions for oral antihyperglycemic agents, and 5445 (42.2%) had no diabetes-related prescriptions. Among patients using medication, 474 (6.4%) dropped out in the quality-reporting year. The adjusted percentages of quality indicators among patients using oral antihyperglycemic agents were 95.8% for glycated hemoglobin, 35.6% for eye examinations, 15.4% for urine microalbumin excretion, and 90.6% for serum lipids; the percentages among patients taking insulin were the same or higher. Annual testing for glycated hemoglobin was less frequent in patients aged 40-49 years than in patients aged 60-69 years (OR 0.77; 95% CI 0.66 to 0.91). Fewer men than women (OR 0.59; 95% CI 0.54 to 0.64), and fewer patients aged 40-49 years than those aged 60-69 years (OR 0.56; 95% CI 0.50 to 0.63) tended to complete routine eye examinations.

CONCLUSIONS

Screening for retinopathy and nephropathy was less frequent than required despite favorable conditions for access to healthcare in Japan. Suboptimal quality of care appeared to depend on provider factors as well as patient factors, such as limited access to retinopathy prevention among working-age men with diabetes.

Association between local-level resources for home care and home deaths: A nationwide spatial analysis in Japan

Aim

Little is known about whether and how local-level resources regarding home care are associated with the prevalence of home deaths. We aimed to investigate whether geographic patterns of the resources for home care were associated with the prevalence of home deaths, taking spatial variation into consideration.

Methods

We conducted an ecological cross-sectional study in Japan using nationwide data in 2014. The areal unit was the municipality, the smallest administrative unit in Japan. We investigated the association between the percentage of home deaths and the resources of home care support clinics with available 24-hour-a-day functions, considering the geographic effect of neighboring municipalities by applying a geographically weighted regression model.

Results

The mean and standard deviation of the percentages of home deaths were 11.4% (5.0%), and those of the number of home care support clinics per 10,000 elderly population were 3.4 (3.7). The percentages of home deaths in neighboring municipalities tended to be significantly correlated (Moran’s I 0.34, p<0.001). Adjusting for the number of hospital beds, total population, and the socio-economic status of municipality, the results of an ordinary least squares regression model showed a positive correlation between the percentage of home deaths and the local resources for home care support clinics per 10,000 elderly population (regression coefficient 0.15, 95% confidence interval 0.07, 0.22), while the existence of spatial autocorrelation of the residual was suggested (Moran’s I of the residual 0.227, p<0.001). The geographically weighted regression model showed local regression coefficients varying across municipalities with a better model fit over the analogous ordinary least squares model (adjusted R² 0.414 vs. 0.131).

Conclusion

Home deaths were more prevalent in municipalities with greater home care resources. This association was geographically varied and further strengthened in some areas.

Impact of long-hours family caregiving on non-fatal coronary heart disease risk in middle-aged people: Results from a longitudinal nationwide survey in Japan

AIM

The effects of family caregiving, especially long-hours caregiving, on coronary heart disease (CHD) are debatable. We examined the impact of family caregiving on incident non-fatal CHD.

METHODS

We used data from the Longitudinal Survey of Middle-Aged and Elderly Persons from 2005 to 2010, a nationwide panel survey for Japanese people aged 50-59 years in 2005 (baseline). After we excluded non-respondents and people with missing key variables at baseline, 25 121 individuals without CHD, stroke or cancer were followed up for a mean of 4.6 years. The exposure was assessed at baseline by three indicators: (i) family caregiving; (ii) hours spent caregiving; and (iii) kinship type of care recipient. The non-fatal CHD incidence was identified according to questionnaire responses from 2006 to 2010.

RESULTS

Cox's proportional hazards analysis did not show a statistically significant association between family caregiving and incident non-fatal CHD (hazard ratio [HR] 1.13, 95% confidence interval [CI] 0.92-1.40). Caregivers who spent 20-69 h per week on care showed a statistically significant increased risk for non-fatal CHD (HR 1.78, 95% CI 1.23-2.58) compared with non-caregivers; whereas this increased risk was statistically significant only among women (HR 1.98, 95% CI 1.27-3.08), but not among men (HR 1.35, 95% CI 0.67-2.71). Kinship type of care recipient did not make a significant difference to the effects of family caregiving on incident non-fatal CHD.

CONCLUSIONS

Long-hours family caregiving could be an independent risk factor for incident non-fatal CHD among middle-aged women in Japan. Geriatr Gerontol Int 2017; 17: 2109-2115.

The association between higher nurse staffing standards in the fee schedules and the geographic distribution of hospital nurses: A cross-sectional study using nationwide administrative data

BACKGROUND

In Japan, the revision of the fee schedules in 2006 introduced a new category of general care ward for more advanced care, with a higher staffing standard, a patient-to-nurse ratio of 7:1. Previous studies have suggested that these changes worsened inequalities in the geographic distribution of nurses, but there have been few quantitative studies evaluating this effect. This study aimed to investigate the association between the distribution of 7:1 beds and the geographic distribution of hospital nursing staffs.

METHODS

We conducted a secondary data analysis of hospital reimbursement reports in 2012 in Japan. The study units were secondary medical areas (SMAs) in Japan, which are roughly comparable to hospital service areas in the United States. The outcome variable was the nurse density per 100,000 population in each SMA. The 7:1 bed density per 100,000 population was the main independent variable. To investigate the association between the nurse density and 7:1 bed density, adjusting for other variables, we applied a multiple linear regression model, with nurse density as an outcome variable, and the bed densities by functional category of inpatient ward as independent variables, adding other variables related to socio-economic status and nurse workforce. To investigate whether 7:1 bed density made the largest contribution to the nurse density, compared to other bed densities, we estimated the standardized regression coefficients.

RESULTS

There were 344 SMAs in the study period, of which 343 were used because of data availability. There were approximately 553,600 full time equivalent nurses working in inpatient wards in hospitals. The mean (standard deviation) of the full time equivalent nurse density was 426.4 (147.5) and for 7:1 bed density, the figures were 271.9 (185.9). The 7:1 bed density ranged from 0.0 to 1,295.5. After adjusting for the possible confounders, there were more hospital nurses in the areas with higher densities of 7:1 beds (standardized regression coefficient 0.62, 95% confidence interval 0.56-0.68).

CONCLUSION

We found that the 7:1 nurse staffing standard made the largest contribution to the geographic distribution of hospital nurses, adjusted for socio-economic status and nurse workforce-related factors.

Emergency and disaster preparedness for chronically ill patients: a review of recommendations

Recent disasters, especially those in developed countries, have highlighted the importance of disaster preparedness measures for chronic diseases. A number of surviving patients experienced the exacerbation of a chronic illness, such as hypertension, diabetes, cancer, and chronic respiratory diseases, due to disaster-related stress, interruption of care, or both; for some patients, these exacerbations resulted in death. Here, we review reports from recent disasters in developed countries and summarize the recommendations for disaster preparedness of chronically ill patients. A considerable number of recommendations based on the lessons learned from recent disasters have been developed, and they provide practical and essential steps to prevent treatment interruption during and after a disaster. To improve preparedness efforts, we suggest that health care providers should be aware of the following three suggestions: 1) recommendations should be evidence-based; 2) recommendations should contain consistent messages; and 3) recommendations should be feasible.

Cesarean delivery rates for overall and multiple pregnancies in Japan: A descriptive study using nationwide health insurance claims data

AIM

Due to the lack of national perinatal registries, population-wide descriptive statistics on cesarean deliveries in Japan are unknown. We aim to describe cesarean deliveries for overall and multiple pregnancies using the Japan National Database of health insurance claims.

METHODS

We calculated the national and prefectural cesarean delivery rates for overall and multiple pregnancies in 2014. We described maternal morbidities (e.g., blood transfusion) and the place and type of the institutions providing prenatal and perinatal care.

RESULTS

The national cesarean delivery rates were 18.6% overall and 82.7% for women with multiple pregnancies. Prefectural cesarean delivery rates for overall and multiple pregnancies varied from 12.5% to 24.2% and from 49.2% to 100%, respectively, showing a moderate positive correlation (r = 0.59, p < 0.001). Overall, 1.4% of cesarean patients received an allogeneic blood transfusion, compared to 3.2% for those with multiple pregnancies. In addition, 65.9% of overall cesarean deliveries occurred at hospitals with ≥20 beds, whereas 94.6% of cesarean patients with multiple pregnancies delivered at hospitals. Older patients were more likely to receive their cesarean section at a different institution than their first visit within the same prefecture, but trans-prefectural movement during pregnancy covered by health insurance was most frequent among those in their early thirties: 7.0% overall and 10.7% for multiple pregnancies.

CONCLUSIONS

The overall cesarean delivery rate in Japan was optimal, but the rate was high for multiple pregnancies, with large regional differences. Data on patient movement across institutions and areas would help to improve the perinatal care system.

Multistate Markov Model to Predict the Prognosis of High-Risk Human Papillomavirus-Related Cervical Lesions

Cervical intraepithelial neoplasia (CIN) has a natural history of bidirectional transition between different states. Therefore, conventional statistical models assuming a unidirectional disease progression may oversimplify CIN fate. We applied a continuous-time multistate Markov model to predict this CIN fate by addressing the probability of transitions between multiple states according to the genotypes of high-risk human papillomavirus (HPV). This retrospective cohort comprised 6022 observations in 737 patients (195 normal, 259 CIN1, and 283 CIN2 patients at the time of entry in the cohort). Patients were followed up or treated at the University of Tokyo Hospital between 2008 and 2015. Our model captured the prevalence trend satisfactory, particularly for up to two years. The estimated probabilities for 2-year transition to CIN3 or more were the highest in HPV 16-positive patients (13%, 30%, and 42% from normal, CIN1, and CIN2, respectively) compared with those in the other genotype-positive patients (3.1%-9.6%, 7.6%-16%, and 21%-32% from normal, CIN1, and CIN2, respectively). Approximately 40% of HPV 52- or 58-related CINs remained at CIN1 and CIN2. The Markov model highlights the differences in transition and progression patterns between high-risk HPV-related CINs. HPV genotype-based management may be desirable for patients with cervical lesions.

In-hospital mortality and length of hospital stay with craniotomy versus craniectomy for acute subdural hemorrhage: a multicenter, propensity score-matched analysis

OBJECTIVE

The optimal surgical treatment for acute subdural hemorrhage (ASDH) remains controversial. The purpose of this study was to compare outcomes in patients who underwent craniotomy with those in patients who underwent decompressive craniectomy for the treatment of ASDH.

METHODS

Using the Japan Trauma Data Bank, a nationwide trauma registry, the authors identified patients aged ≥ 18 years with ASDH who underwent surgical evacuation after blunt head trauma between 2004 and 2015. Logistic regression analysis was used to estimate a propensity score to predict decompressive craniectomy use. They then used propensity score-matched analysis to compare patients who underwent craniotomy with those who underwent decompressive craniectomy. To identify the potential benefits and disadvantages of decompressive craniectomy among different subgroups, they estimated the interactions between treatment and the subgroups using logistic regression analysis.

RESULTS

Of 236,698 patients who were registered in the database, 1788 were eligible for propensity score-matched analysis. The final analysis included 514 patients who underwent craniotomy and 514 patients who underwent decompressive craniectomy. The in-hospital mortality did not differ significantly between the groups (41.6% for the craniotomy group vs 39.1% for the decompressive craniectomy group; absolute difference -2.5%; 95% CI -8.5% to 3.5%). The length of hospital stay was significantly longer in patients who underwent decompressive craniectomy (median 23 days [IQR 4-52 days] vs 30 days [IQR 7-60 days], p = 0.005). Subgroup analyses demonstrated qualitative interactions between decompressive craniectomy and the patient subgroups, suggesting that patients who were more severely injured (Glasgow Coma Scale score < 9 and probability of survival < 0.64) and those involved in high-energy injuries may be good candidates for decompressive craniectomy.

CONCLUSIONS

The results of this study showed that overall, decompressive craniectomy did not appear to be superior to craniotomy in ASDH treatment in terms of in-hospital mortality. In contrast, there were significant differences in the effectiveness of decompressive craniectomy between the subgroups. Thus, future studies should prioritize the identification of a subset of patients who will possibly benefit from the performance of each of the procedures.

Trends in dental visits during the state of emergency for COVID-19 in Japan: a retrospective observational study

OBJECTIVES

To determine national medium-term trends in dental visits during three COVID-19 emergency declaration periods in Japan and to analyse how these trends varied according to prefectural emergency measures and COVID-19 incidence.

DESIGN AND SETTING

A retrospective observational study of Japan's dental claims from January 2017 to December 2021.

DATA SOURCES

Data from a monthly report by the Health Insurance Claims Review and Reimbursement Services (HICRRS) in Japan. HICRRS handles the claims of employer-based health insurance.

DATA ANALYSIS

We determined the number of monthly dental claims nationwide from January 2017 to December 2021 and the percentage change in the number of monthly dental claims based on the difference in the COVID-19 alert level between the three emergency declaration periods in 2020-2021 and the corresponding periods in 2019. Results were analysed using descriptive statistics, multiple regression model, graphical figures, and narrative synthesis.

OUTCOME MEASURES

The main outcome was the change in the number of dental visits between the emergency declaration periods in 2020-2021 and the corresponding periods in 2019. We also assessed the difference in the number of dental visits based on the COVID-19 alert level.

RESULTS

The data set included a total of 736 946 088 dental claims. Until the end of 2021, the greatest decrease in monthly dental claims was in April 2020, which was 22.3% lower than that in April 2019. As indicated by the coefficient in the regression model, the percentage change in monthly dental claims decreased by 5.01% (95% CI -8.27 to -1.74) depending on the difference between the prefectures designated as being under special precautions and other prefectures.

CONCLUSIONS

The decrease in dental visits was greater during the first state of emergency, ie, April-May 2020, and in prefectures designated as being under special precautions. Further efforts to promote appropriate dental visits at different alert levels are necessary.

Area-Wide Traffic-Calming Zone 30 Policy of Japan and Incidence of Road Traffic Injuries Among Cyclists and Pedestrians

Objectives. To quantify the impact of the "Zone 30" policy introduced in September 2011 on the incidence of cyclist and pedestrian injuries in Japan.Methods. This was an interrupted time-series study. We used the data of cyclist and pedestrian injuries recorded by the Japanese police between 2005 and 2016. We evaluated the monthly number of deaths and serious injuries per person-time on narrow roads (width < 5.5 m, subjected to the policy) compared with that on wide roads (≥ 5.5 m) to control for secular trends. We regressed the injury rate ratio on 2 predictors: the numbers of months after January 2005 and after September 2011. Using the regression results, we estimated the number of deaths and serious injuries prevented.Results. There were 266 939 deaths and serious injuries. By 2016, the cumulative changes in the rate ratio spanned from -0.26 to -0.046, depending on sex and age, and an estimated number of 1704 (95% confidence interval = 1293, 2198) injuries were prevented.Conclusions. The policy had a large preventive impact on cyclist and pedestrian deaths and serious injuries at the national level.

Can income-based co-payment rates improve disparity? The case of the choice between brand-name and generic drugs

BACKGROUND

Higher income population tend to prefer brand-name to generic drugs, which may cause disparity in access to brand-name drugs among income groups. A potential policy that can resolve such disparity is imposing a greater co-payment rate on high-income enrollees. However, the effects of such policy are unknown. We examined how patients' choice between brand-name and generic drugs are affected by the unique income-based co-payment rates in Japan; 10% for general enrollees and 30% for those with high income among the elderly aged 75 and over.

METHODS

We drew on cross-sectional price variation among commonly prescribed 311 drugs using health insurance claims data from a large prefecture in Japan between October 2013 and September 2014 to identify between-income-group differences in responses to differentiated payments.

RESULTS

Running 311 multivariate logistic regression models controlling individual demographics, the median estimate indicated that high-income group was 3% (odds ratio = 0.97) less likely to choose a generic drug than the general-income group and the interquartile estimates ranged 0.92-1.02. The multivariate feasible generalized least squares model indicated high-income group's higher likelihood to choose brand-name drugs than the general-income group without co-payment rate differentiation (p < 0.001). Such gap in the likelihood was attenuated by 0.4% (p = 0.027) with an US$1 increase in the difference in additional payment/month for brand-name drugs between income groups - no gap with US$10 additional payment/month. This attenuation was observed in drugs for chronic diseases only, not for acute diseases.

CONCLUSIONS

Income-based co-payment rates appeared to reduce disparity in access to brand-name drugs across income groups, in addition to reducing total medical expenditure among high-income group who shifted from brand-name drugs to generic ones due to larger drug price differences.

Impact of a direct-to-consumer information campaign on prescription patterns for overactive bladder

Background

Direct-to-consumer information (DTCI) campaign is a new medium to inform and empower patients in their decision-making without directly promoting specific drugs. However, little is known about the impact of DTCI campaigns, expanding rapidly in developed countries, on changes in prescription patterns. We sought to determine whether a DTCI campaign on overactive bladder increases the prescription rate for overactive bladder treatment drugs.

Methods

We performed a 3-year retrospective cohort study of 1332 participants who were diagnosed overactive bladder but not prescribed treatment drugs prior to the examined DTCI campaign (exposure), using the health insurance claims dataset of the Japan Medical Data Center (November 19, 2010 to November 18, 2013). The DTCI campaign for overactive bladder included television, Internet, and print advertising (November 19, 2011 to December 22, 2011). We divided the study period into Pre-Campaign Year (2010–2011), Year 1 (2011–2012), and Year 2 (2012–2013). Each year began on November 19 and included Period 1 (weeks 1–5) through Period 10 (weeks 46–50). The main outcome was first-time prescription of the treatment drug for each patient, measured by 5-week periods. Using Period 10 in the Pre-Campaign Year as the referent period, we applied the Cox proportional hazard model for each period. Additionally, we performed the interrupted time series analysis (ITSA) for the first-time prescription rate per 5-week period.

Results

Following the DTCI campaign, patients were about seven times more likely to receive a first prescription of a treatment drug during Period 4 in Year 1 (hazard ratio 7.09; 95% CI, 2.11–23.8; p-value<.01) compared with the reference period. Similar increases were also observed for subsequent Periods 5 and 6 in Year 1. The ITSA confirmed the DTCI campaign impact on the level of prescription rate (one-time increase in the regression-intercept) that increased by 1128.1 [per standardized 100,000 persons] (p < .05) during Period 4 in Year 1.

Conclusions

The examined DTCI campaign appeared to increase the prescription rate among patients with overactive bladder for 15 weeks with a 15-week delay. Clinical outcomes of the patients with targeted diseases need to be monitored after DTCI campaigns by a future study.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3147-1) contains supplementary material, which is available to authorized users.

Structure and process of dementia care and patient outcomes after hip surgery in elderly people with dementia: A retrospective observational study in Japan

BACKGROUND

Japan introduced the financial incentives for dementia special care at hospitals in the fee schedule in April 2016.

OBJECTIVE

To investigate whether the financial incentives for dementia special care contributed to better patient outcomes after hip surgery for older adults with dementia.

DESIGN

Retrospective observational study using the Diagnosis Procedure Combination database and the Reporting on medical functions of hospital beds data.

SETTING

Acute care hospitals adopting the Diagnosis Procedure Combination system in Japan.

PARTICIPANTS

A total of 20,393 eligible patients aged 65 years or older with dementia who underwent hip surgeries and discharged from 405 hospitals from April 2016 to March 2017.

METHODS

There are two levels of dementia care quality categories in the financial incentives for dementia special care as follows: Type 1 requires a multidisciplinary team with geriatric and dementia care expertise and Type 2 requires to assign trained nurses who underwent dementia training at every general ward. The outcomes were in-hospital mortality, readmission within 30 days, and length of hospital stay. We performed generalized estimating equation model or logistic generalized estimating equation models adjusting for individual and hospital characteristics.

RESULTS

Among the 405 hospitals, the numbers of hospitals without dementia care incentive, those with Type 1, and those with Type 2 were 207, 99, and, 99, respectively. Overall, the prevalence of in-hospital death and readmission within 30 days was 2.01% and 2.70%, respectively. Overall, the mean (standard deviation, SD) length of hospital stay was 32.0 (20.0) days. There were no significant associations between dementia special care and in-hospital mortality in Type 1 (adjusted OR [odds ratio] =0.87, 95% confidence interval [CI] = 0.66-1.16) and Type 2 (adjusted OR = 1.18, 95% CI = 0.92-1.52), and readmission within 30 days in Type 1 (adjusted OR = 1.11, 95% CI = 0.89-1.38) and Type 2 (adjusted OR = 1.03, 95% CI = 0.83-1.29). Length of hospital stay was not significantly different among hospitals with and without incentive, Type 1 (coefficient -0.23, 95% CI = -2.64-2.18.), and Type 2 (coefficient 0.87, 95% CI = -1.54-3.28). An increase in patient-to-nurse ratio was significantly associated with 2.25 days longer length of hospital stay (95% CI 1.00-3.51).

CONCLUSION

Dementia care incentive was not associated with better outcomes in elderly with dementia who underwent hip surgery in Japan, but the worse nurse workload was associated with longer length of hospital stay. Further long-term assessment is necessary.