Implementation rate of diabetic self-management education and support for Japanese people with diabetes using the National Database.

People with diabetes are encouraged to receive diabetes self-management education and support (DSMES) appropriately. However, in Japan, the implementation rates of DSMES are not known. DSMES implementation rates were calculated using the National Database of claims data, which included nearly all insurance-covered medical procedures. The study enrolled participants who received regular antidiabetic medications between April 2017 and March 2018. The implementation rates of DSMES-related care were calculated by characteristics, visiting medical facilities and prefectures. In 4,465,513 participants receiving antidiabetic medications (men, 57.8%; insulin use, 14.1%), nutrition guidance (5.6%) was the most frequently provided care type. Insulin users and participants visiting Japan Diabetes Society-certified and large medical institutions had higher implementation rates of nutrition guidance. DSMES-related care might not be provided adequately for Japanese people with diabetes. Further studies are needed to develop an optimal diabetes care system.

Literature Review of Studies Using the National Database of the Health Insurance Claims of Japan (NDB): Limitations and Strategies in Using the NDB for Research.

The use of the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) for research has increased over time. Researchers need to understand the characteristics of the data to generate quality-assured evidence from the NDB. In this review, we mapped and characterized the limitations and related strategies using the NDB for research based on the descriptions of published NDB studies. To find studies that used Japanese healthcare claims data, we searched MEDLINE, EMBASE, and Ichushi-Web up to June 2023. Additionally, we hand-searched the NDB data publication list from the Ministry of Health, Labour and Welfare (2017-2023). We abstracted data based on the NDB data type, research themes, age of the study sample or population, targeted disease, and the limitations and strategies in the NDB studies. Ultimately, 267 studies were included. Overall, the most common research theme was describing and estimating the prescriptions and treatment patterns (125 studies, 46.8%). There was a variation in the frequency of themes according to the type of NDB data. We identified the following categories of limitations: (1) lack of information on confounders/covariates, outcomes, and other clinical content, (2) limitations regarding patients not included in the NDB, (3) misclassification of data, (4) lack of unique identifiers and register of beneficiaries, and (5) others. Although the included studies noted several limitations of using the NDB for research, they also provided some strategies to address them. Organizing the limitations of NDB in research and the related strategies across research fields can help support high-quality NDB studies.

Studies of Health Insurance Claims Data in Japan: A Scoping Review.

Background: Health insurance claims data are used in various research fields; however, an overview on how they are used in healthcare research is scarce in Japan. Therefore, we conducted a scoping review to systematically map the relevant studies using Japanese claims data. Methods: MEDLINE, EMBASE, and Ichushi-Web were searched up to April 2021 for studies using Japanese healthcare claims data. We abstracted the data on study characteristics and summarized target diseases and research themes by the types of claims database. Moreover, we described the results of studies that aimed to compare health insurance claims data with other data sources narratively. Results: A total of 1,493 studies were included. Overall, the most common disease classifications were "Diseases of the circulatory system" (18.8%, n = 281), "Endocrine, nutritional, and metabolic diseases" (11.5%, n = 171; mostly diabetes), and "Neoplasms" (10.9%, n = 162), and the most common research themes were "medical treatment status" (30.0%, n = 448), "intervention effect" (29.9%, n = 447), and "clinical epidemiology, course of diseases" (27.9%, n = 417). Frequent diseases and themes varied by type of claims databases. A total of 19 studies aimed to assess the validity of the claims-based definition, and 21 aimed to compare the results of claims data with other data sources. Most studies that assessed the validity of claims data compared to medical records were hospital-based, with a small number of institutions. Conclusions: Claims data are used in various research areas and will increasingly provide important evidence for healthcare policy in Japan. It is important to use previous claims database studies and share information on methodology among researchers, including validation studies, while informing policymakers about the applicability of claims data for healthcare planning and management.

Different incidences of diabetic retinopathy requiring treatment since diagnosis according to the course of diabetes diagnosis: a retrospective cohort study.

We aimed to estimate the cumulative incidence of treatment-requiring diabetic retinopathy since clinical diagnosis of diabetes based on the course of diagnosis in a retrospective cohort study using Japan's medical claims and health checkup data (JMDC Claims Database; 2009-2020). We included patients whose diabetes was first diagnosed at medical facilities (hospitals/clinics). We grouped them by health checkup participation before diagnosis, health checkup results, and antidiabetic medication promptly after the diagnosis. The incidence of treatment-requiring diabetic retinopathy (laser photocoagulation, intraocular injection, or vitrectomy) was compared among the groups. Of 126,696 patients, those who started an antidiabetic medication promptly after diabetes diagnosis without a recent health checkup faced the highest risk of treatment-requiring diabetic retinopathy (1-/5-year cumulative incidence: 3.1%/6.0%). This increased risk was consistently observed across various analyses, including the Cox proportional hazard model, sensitivity analysis restricting to those with an eye examination, and sensitivity analysis using vitrectomy as the outcome. Among patients with HbA1c ≥ 6.5% at recent health checkups, those who promptly started an antidiabetic medication had a higher risk (1.4%/3.8%) than those who did not (0.7%/2.7%). Taking the information about the course of diabetes diagnosis is important to manage risk stratification for diabetic retinopathy appropriately.

Patient referral flow between physician and ophthalmologist visits for diabetic retinopathy screening among Japanese patients with diabetes: A retrospective cross-sectional cohort study using the National Database.

AIMS/INTRODUCTION: Regular screening for diabetic retinopathy is essential. This study aimed to show the process and current situation of diabetic retinopathy screening prescribed by physicians (internists) and ophthalmologists for Japanese patients with diabetes. MATERIALS AND METHODS: This retrospective cohort study used data from the Japanese National Database of Insurance Claims between April 2016 and March 2018. Ophthalmology visits and fundus examinations are defined using specific medical procedure codes. The proportion of ophthalmology visits for patients with diabetic medication and for fundus examination among those who visited ophthalmologists was calculated in the fiscal year 2017. A modified Poisson regression analysis was carried out to identify factors associated with retinopathy screening. Similarly, quality indicators by prefectures were also calculated. RESULTS: Among 4,408,585 patients receiving diabetic medications (57.8% men, 14.1% insulin use), 47.4% visited the ophthalmology department and 96.9% of those underwent fundus examination. Regression analysis showed that female sex, older age, insulin use, medical facilities with Japan Diabetes Society certification and large medical facilities were predictors of fundus examination. By prefecture, the ophthalmology consultation rate and the fundus examination ranged 38.5-51.0% and 92.1-98.7%, respectively. CONCLUSIONS: Less than half of the patients who were prescribed antidiabetic medication by their physicians visited an ophthalmologist. However, most of the patients who visited an ophthalmologist had a fundus examination carried out. A similar tendency was noted for each prefecture. It is essential to reaffirm the necessity of recommending ophthalmologic examinations to physicians and healthcare professionals who care for patients with diabetes.

Proportion of subsequent clinic visits among persons without regular clinic visits who were screened as having hyperglycemia: A retrospective cohort study.

AIMS/INTRODUCTION: We aimed to examine the proportion of subsequent clinic visits for persons screened as having hyperglycemia based on glycated hemoglobin (HbA1c) levels at screening and the presence/absence of hyperglycemia at health checkups before 1 year of the screening among those without previous diabetes-related medical care and attending regular clinic visits. MATERIALS AND METHODS: This retrospective cohort study used the 2016-2020 data of Japanese health checkups and claims. The study analyzed 8,834 adult beneficiaries aged 20-59 years without regular clinic visits who had never received diabetes-related medical care and whose recent health checkups showed hyperglycemia. The rates of 6-month subsequent clinic visits after health checkups were evaluated according to HbA1c levels and the presence/absence of hyperglycemia at checkups a year before. RESULTS: The overall clinic visit rate was 21.0%. The HbA1c-specific rates were 17.0, 26.7, 25.4 and 28.4% for <7.0, 7.0-7.4, 7.5-7.9 and ≥8.0% (64 mmol/mol), respectively. Persons with hyperglycemia at a previous screening had lower clinic visit rates than those without hyperglycemia, particularly in the HbA1c category of <7.0% (14.4% vs 18.5%; P < 0.001) and 7.0-7.4% (23.6% vs 35.1%; P < 0.001). CONCLUSIONS: The overall rate of subsequent clinic visits among those without previous regular clinic visits was <30%, including for participants with HbA1c ≥8.0%. Persons with previously detected hyperglycemia had lower clinic visit rates, despite requiring more health counseling. Our findings might be useful for designing a tailored approach to encourage high-risk individuals to seek diabetes care through clinic visits.

Incidence of interventions for diabetic retinopathy and serious lower-limb complications and its related factors in patients with type 2 diabetes using a real-world large claims database.

Aims: To examine the incidence of interventions for diabetic retinopathy and serious limb complications and to elucidate the patient attributes related to the incidence of each intervention based on real-world claims data from Japan. Materials and methods: A retrospective longitudinal study design involving a 9 year (2009-2018) claims database obtained from the JMDC Inc. Patients with type 2 diabetes aged 20-74 years taking antidiabetic medications were divided into two groups: "patients with newly initiated antidiabetic medication" (Group 1, n = 47,201) and "patients with continuing antidiabetic medication" (Group 2, n = 82,332). The incidence rate for each intervention was analyzed. We also divided Group 1 into the former and latter periods and investigated temporal changes. Results: The incidences of the first retinopathy intervention (laser photocoagulation, vitrectomy, or intraocular injection), vitrectomy, and lower-limb amputations in Group 1 were 7.46, 2.37, and 0.31 /1000 person-years, respectively. Those in Group 2 were about 1.2-1.5 times higher. Older age, insulin use, and being dependents rather than insured persons were associated with a higher incidence in both groups after adjustment. While the incidence of the interventions for retinopathy hardly changed during the observation period, that of lower-limb amputations decreased by 40%, with less statistical significance (p = 0.11). Conclusions: We showed the incidences of the first retinopathy interventions and lower-limb amputations and their secular trends in patients with diabetes, stratified by whether the antidiabetic medication was newly initiated or not. Older age, insulin use, and being dependents were risk factors of these interventions for diabetic complications. Supplementary Information: The online version contains supplementary material available at 10.1007/s13340-021-00566-7.

Lack of Awareness of Own Hypercholesterolemia or Statin Medication among Adult Statin Users in the United States: Prevalence and Patient Characteristics in a Repeated Cross-Sectional Study.

Knowledge of a patient's medication is important in treating hyperlipidemia; however, little is known about this in practice. We carried out a repeated cross-sectional study to analyze a nationally representative sample of US adult statin users from the National Health and Nutrition Examination Survey, 1999−2018. We used medication bottle checks and self-reported survey data to estimate the percentage of individuals who are unaware of their hypercholesterolemia, type of medication, or how to take their medication. We used logistic regression to examine their characteristics. We included 8798 statin users; however, 17.6% were unaware of their hypercholesterolemia or statin use. Being older, male, non-Hispanic Black, taking a wider range of prescription medications, and previous diabetes or cardiovascular disease diagnosis were associated with lack of awareness. Serum low-density lipoprotein cholesterol level was lower among those lacking awareness (85.5 vs. 100.7 mg/dL; p < 0.001). Many of those unaware of drug type had been given little information about statins; 34.0% had no diagnosis of diabetes or cardiovascular disease, and of these, 27.1% were >75 years old. Roughly one in six lacked awareness, but no association was found with hypercholesterolemia control. Healthcare providers should ascertain a patient's understanding and consider the risks and benefits of statin medication.

Association between diabetes and adjuvant chemotherapy implementation in patients with stage III colorectal cancer.

AIMS/INTRODUCTION: Among colorectal cancer (CRC) patients, pre-existing diabetes is suggested to influence poor prognosis, but the impact on adjuvant chemotherapy implementation is largely unknown. We aimed to compare the implementation rate of adjuvant chemotherapy between CRC patients with and without pre-existing diabetes in a retrospective cohort study. MATERIALS AND METHODS: Colorectal cancer diagnosis information was obtained from the hospital-based cancer registry of patients with stage III CRC who underwent curative surgery in 2013 in Japan (n = 6,344). Health claims data were used to identify diabetes and chemotherapy. We examined the association between diabetes and the implementation rate of adjuvant chemotherapy using a generalized linear model adjusted for age, sex, updated Charlson Comorbidity Index, hospital type and prefecture. Furthermore, we applied a mediation analysis to examine the extent to which postoperative complications mediated the association. RESULTS: Of the 6,344 patients, 1,266 (20.0%) had diabetes. The mean ages were 68.2 and 71.3 years for patients without and with diabetes, respectively. Compared with those without diabetes, patients with diabetes were less likely to receive adjuvant chemotherapy (crude rate 58.9 and 49.8%; adjusted percentage point difference 4.6; 95% confidence interval 1.7-7.5). The difference was evident for patients aged <80 years, and larger for platinum-containing regimens than others. Mediation analysis showed that postoperative complications explained 9.1% of the inverse association between diabetes and adjuvant chemotherapy implementation. CONCLUSIONS: We observed that patients with stage III CRC and diabetes are less likely to receive adjuvant chemotherapy than those without diabetes, and postoperative complications might partially account for the association.

The age of death in Japanese patients with type 2 and type 1 diabetes: A descriptive epidemiological study.

This study clarified the age of death in patients with or without diabetes using the largest health insurance database in Japan. This population-based retrospective cohort study was performed using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) data. The ages of death between people with and without diabetes were compared. A total of 142,277,986 patients (74,488,962 women and 67,789,024 men) over 6 years, including 4,647,016 females, and 6,507,817 males with diabetes, were included. 2,786,071 females and 2,975,876 males died over 6 years, including 652,699 females and 954,655 males with diabetes. The average age of death in patients with diabetes was 2.6 years less than that of patients without diabetes. This descriptive epidemiological study illustrated the difference in age at death of patients with and without diabetes.

How are new drugs disseminated in Japan? Analysis using the National Database of Health Insurance Claims of Japan.

Drug lag refers to the difference in the time of a new drug's approval in different countries; the dissemination of the new drug after approval within the countries is another problem. We examined the nationwide dissemination of 11 cancer drugs approved in Japan between 2011 and 2015 using the National Database of Health Insurance Claims data. We extracted data on the number of cancer drug prescriptions from 47 prefectures and associated demographic information, such as age and sex. Eight diabetes drugs were also examined for comparison. We observed a lag between the marketing approval date of the drugs and their first use. To further explore the rise and pattern of each drug's dissemination, we analyzed the trend of the cumulative number and total of new prescriptions for each prefecture. The results showed that the first month of new cancer drug prescriptions varied across prefectures. On average, they lagged by up to 2 months in the slowest prefectures, whereas the variation was almost nonexistent for diabetes drugs. The patterns of dissemination varied more among cancer drugs across the seven Japanese geographical regions. After the initial prescription, the number of prescriptions showed a steep rise for most cancer drugs, whereas the increase was gradual for diabetes drugs. In conclusion, the dissemination of cancer drugs had a greater lag time than that of diabetes drugs. Further research is needed to explore the causative factors to ensure that all effective drugs are equally accessible for those who need them.

Retrospective nationwide study on the trends in first-line antidiabetic medication for patients with type 2 diabetes in Japan.

AIMS/INTRODUCTION: To investigate the national trend in the prescription of first-line non-insulin antidiabetic agents and total medical costs (TMCs) after prescribing the drug in Japanese patients with type 2 diabetes. MATERIALS AND METHODS: Using the National Database of Health Insurance Claims and Specific Health Check-ups of Japan covering almost the entire Japanese population, we calculated the proportion of each antidiabetic drug from 2014 to 2017, and determined the factors associated with drug selection. The TMCs in the first year after starting the drugs were calculated, and factors associated with the costs were also determined. RESULTS: Among 1,136,723 new users of antidiabetic agents, dipeptidyl peptidase-4 inhibitors were the most prescribed (65.1%), followed by biguanides (15.9%) and sodium-glucose cotransporter 2 inhibitors (7.6%). Sodium-glucose cotransporter 2 inhibitor and biguanide use increased during 2014-2017 (2.2%-11.4% and 13.7%-17.2%, respectively), whereas the others decreased. Biguanides were not prescribed at all in 38.2% of non-Japan Diabetes Society-certified facilities. The TMCs were the lowest among those who started with biguanides. Fiscal year, age, sex, facility, number of beds and comorbidities were associated with drug choice and TMCs. There were wide regional variations in the drug choice, but not in the TMCs. CONCLUSIONS: Unlike in the USA and Europe, dipeptidyl peptidase-4 inhibitor is the most prescribed first-line medication for type 2 diabetes patients in Japan, while there is a wide variation in the drug choice by facility-type and prefecture.

Factors associated with the degree of glycemic deterioration among patients with type 2 diabetes who dropped out of diabetes care: A longitudinal analysis using medical claims and health checkup data in Japan.

AIMS/INTRODUCTION: To identify factors associated with worsening glycemic control after discontinuing diabetes care among patients with type 2 diabetes. MATERIALS AND METHODS: This retrospective cohort study combined medical claims and health checkup data between January 2005 and April 2018. Adult Japanese workers with type 2 diabetes who had dropped out from diabetes care for ≥4 months after receiving ≥18 months of non-intermittent care and had health checkup information both before and after the dropout were included. Factors associated with changes in HbA1c during the dropout period were identified using multiple linear regression analyses and depicting restricted cubic spline (RCS) curves. RESULTS: A total of 1,125 patients (mean age: 51.2 years, baseline HbA1c: 6.8%, and number of males: 93.7%) whose follow-up HbA1c increased to 7.6% after a mean 9.3-month dropout period were included. Deterioration in HbA1c was associated with higher baseline HbA1c and sulfonylurea or insulin use. The RCS curves illustrated that patients without antidiabetic medication had small changes in HbA1c (+0.5% from a baseline HbA1c of 7.0%), whereas those using sulfonylureas or insulin had an approximately 2% or more increase in HbA1c even when maintaining reasonable glycemic control before dropping out. CONCLUSIONS: Overall in this study, glycemic control worsened during treatment interruptions among patients who were mainly male employees. However, changes in HbA1c greatly varied based on baseline HbA1c and antidiabetic medication type. Caring for patients at risk of worsening glycemic control due to treatment dropout, especially those using sulfonylurea and insulin, is imperative.

Variation in process quality measures of diabetes care by region and institution in Japan during 2015-2016: An observational study of nationwide claims data.

AIMS: To calculate process quality measures of diabetes care in Japan using nationwide exclusive claims database. METHODS: Using the National Database of health insurance claims during 2015-2016, the proportions of outpatients who received recommended examinations at least annually among those with regular antidiabetic medication were calculated as quality indicators, reported altogether and by prefecture and institutional certification (from the Japan Diabetes Society). Distributions of institutional-level quality indicators were also reported. RESULTS: Among 4,154,452 outpatients, 96.7% underwent HbA1c or glycated albumin examination. Retinopathy examination was conducted among 46.5% of patients [prefecture (range): 37.5%-51.0%, institutional certification: 44.8% (without) vs. 59.8% (with)]. Urinary qualitative examination was conducted among 67.3% of patients at institutions with <200 beds (prefecture: 54.1%-81.9%, institutional certification: 66.8% vs. 92.8%), whereas urinary quantitative albumin or protein examination was conducted among 19.4% of patients (prefecture: 10.8%-31.6%, institutional certification: 18.7% vs. 54.8%). Distributions of institutional-level quality indicators showed that most institutions without institutional certification seldomly order urinary quantitative examination. CONCLUSIONS: Although the quality indicator for glycaemic control examination was favourable, some aspects of diabetes care were suboptimal and varied greatly by prefecture and institution; individual and organisational efforts to improve quality of diabetes care would be needed in Japan.

Expectations of and recommendations for a cancer survivorship guideline in Japan: a literature review of guidelines for cancer survivorship.

BACKGROUND: Optimal cancer survivorship care needs its comprehensive guidelines. We aimed to identify English and Japanese guidelines that include cancer survivorship in their title, the issues highlighted in such guidelines, and any existing oncology practice guidelines in Japan that address these issues. METHODS: This literature review was performed in three stages. First, guidelines published in English or Japanese that included cancer survivorship in the title were identified. Then, the issues that each cancer survivorship guideline addressed were defined. Lastly, Japanese guidelines that include survivorship issues were sought. RESULTS: Six guidelines published in English addressed 31 cancer survivorship issues. No specific cancer survivorship guideline was available in Japanese. Thirty-four Japanese guidelines mentioned cancer survivorship issues. These guidelines addressed screening/surveillance for detecting recurrence or secondary cancer but did not address coordination of care, implications for practice, or inclusion of family. At present, Japanese guidelines poorly address the issue of promotion of a healthy lifestyle in cancer survivors. Also, poorly addressed were long-term and late effects such as pain, psychological distress, fatigue, cognitive dysfunction, cardiovascular effects (including anthracycline-induced cardiac toxicity), sleep disorders, and sexual dysfunction in cancer survivors. CONCLUSION: There is a need for guidelines on optimal coordination of care between oncologists and other health care providers to support patients along the cancer care continuum and specifically to encourage a healthy lifestyle as part of cancer survivorship. The development of a comprehensive Japanese guideline that addresses these issues would help to improve the clinical outcome for cancer survivors in Japan.

Sweet taste disorder and vascular complications in patients with abnormal glucose tolerance.

BACKGROUND: It remains unknown whether taste disorders can be a risk factor for micro- and macro-vascular diseases in patients with abnormal glucose tolerance. METHODS: A cross-sectional study in a nationally representative samples of 848 and 849 US adults (aged ≥40years) with diabetes or prediabetes who had sweet and salt taste disorders, respectively, from the National Health and Nutrition Examination Survey 2011-2012. RESULTS: Among the study population, 5.7% had sweet taste disorder and 8.6% had salt taste disorder. These data correspond to approximately 1.5 million and 1.8 million individuals with abnormal glucose tolerance aged 40years or older in the US population, respectively. In the adjusted model, sweet taste disorder was significantly associated with complication of ischemic heart disease (adjusted odds ratio [OR], 2.45; 95% confidence interval [CI], 1.03-5.81; P=0.04). Moreover, sweet taste disorder in patients with diabetes was significantly associated with diabetic retinopathy (adjusted OR, 2.89; 95% CI, 1.09-7.69; P=0.03) and diabetic nephropathy (adjusted OR, 3.17; 95% CI, 1.07-9.36; P=0.03). Meanwhile, salt taste disorder was not significantly associated with diabetic retinopathy, diabetic nephropathy, ischemic heart disease, or stroke. Total sugar intake was significantly higher in patients with sweet taste disorder than in those without it, whereas total daily intake of carbohydrate did not differ significantly. No significant association was observed between salt taste disorder and daily intake of sodium after multivariate analysis. CONCLUSIONS: Sweet taste disorder in patients with abnormal glucose tolerance was associated with increased sugar intake and vascular complications.