Association between spatial access and hospitalization for ambulatory care sensitive conditions: A retrospective cohort study using claims data.

Background: Hospitalization for ambulatory care sensitive conditions (ACSCs) is potentially preventable with timely and effective primary care but may increase owing to poor access. Spatial access inequalities exist between Japan and other countries. This retrospective cohort study examined the association between admission for ACSC and spatial accessibility to primary care. Methods: We used claims data and spatial data of 50-74 years-old beneficiaries of the National Health Insurance program in a large city in Japan from April 2013-March 2014 and followed them until March 2015. We used a multilevel Poisson regression model to assess the association between the number of ACSC admissions, the distance to the nearest clinic, and the number of physicians in a given area, adjusting for age, gender, comorbidities, number of visits, and household income. Results: Among 126,666 eligible beneficiaries (mean age 65.8 years, 54% were women), 1,793 (1.4%) were hospitalized for ACSCs. The ACSC admission rate was significantly higher in those with a distance to the nearest clinic of >1 km than in those with <0.3 km (incident rate ratio [IRR] 1.32, 95% confidence interval [CI] 1.03-1.69). In the stratified analyses, a longer distance to the nearest clinic was associated with higher ACSC admission rates among women (≥0.3 km and <0.5 km: IRR 1.48, 95% CI 1.01-2.17; ≥0.5 km and <1 km: IRR 1.74, 95% CI 1.19-2.56; >1 km: IRR 1.98, 95% CI 1.29-3.03, respectively) and those aged ≥65 years (≥0.3 km and <0.5 km: IRR 1.38, 95% CI 1.07-1.79; ≥0.5 km and <1 km: IRR 1.38, 95% CI 1.06-1.80; >1 km: IRR 1.48, 95% CI 1.10-1.98). Conclusion: Unfavorable spatial access was associated with ACSC admissions, particularly among women and older adults.

Long- and Short-Term Trends in Outpatient Attendance by Speciality in Japan: A Joinpoint Regression Analysis in the Context of the COVID-19 Pandemic.

The COVID-19 pandemic resulted in a decline in outpatient attendance. Therefore, this study aimed to clarify long- and short-term clinic attendance trends by speciality in Japan between 2009 and 2021. A retrospective observational study of Japan's claims between 2009 and 2021 was conducted using the Estimated Medical Expenses Database. The number of monthly outpatient claims in clinics was used as a proxy indicator for monthly outpatient attendance, and specialities were categorised into internal medicine, paediatrics, surgery, orthopaedics, dermatology, obstetrics and gynaecology, ophthalmology, otolaryngology, and dentistry. The annually summarised age-standardised proportions and the percentage of change were calculated. Joinpoint regression analysis was used to evaluate long-term secular trends. The data set included 4,975,464,894 outpatient claims. A long-term statistically significant decrease was observed in outpatient attendance in internal medicine, paediatrics, surgery, ophthalmology, and otolaryngology during the pandemic. From March 2020 to December 2021, which includes the COVID-19 pandemic period, outpatient attendance in paediatrics, surgery, and otolaryngology decreased in all months compared with that of the corresponding months in 2019. For some specialities, the impact of the pandemic was substantial, even in the context of long-term trends. Speciality-specific preparedness is required to ensure essential outpatient services in future public health emergencies.

Association between mandatory cognitive testing for license renewal and motor vehicle collisions and road injuries.

BACKGROUND: We examined whether the policy amendment from March 2017 for a cognitive screening test for older drivers at driver's license renewal was associated with the decreased risk of motor vehicle collisions for drivers and the increased risk of injuries for pedestrians and cyclists among older people. METHODS: This was a controlled interrupted time-series study. We used police-reported data on the number of collisions as drivers and injuries as pedestrians and cyclists among people aged 70 years or older in Japan from July 2012 to December 2019. As the outcome measures, we used the ratio of the monthly number of collisions per population among drivers of three groups aged 75 years or older (75-79, 80-84, and ≥85 years), who were targeted or exposed by the policy, to that among drivers aged 70 to 74 years, who were unaffected or unexposed by the policy and would serve as controls. The ratio of pedestrian and cyclist injuries was also calculated, as previous studies have shown a concomitant increase in these injuries after the introduction of cognitive screening for driver's licenses. RESULTS: During the study period, there were 602,885 collisions as drivers and 196,889 injuries as pedestrians and cyclists among people aged 70 years or older. After the policy amendment in March 2017, collisions decreased among male drivers, and injuries increased among some age subgroups in both sexes. Cumulative estimated changes in the numbers of collisions and injuries from March 2017 to December 2019 were -3670 (95% confidence interval: -5125, -2104) and 959 (95% confidence interval: 24, 1834), respectively. CONCLUSIONS: Following the policy amendment, there was a decrease in motor vehicle collisions as drivers and an increase in road injuries as pedestrians and cyclists among older people.

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.

Hospitalizations for Ambulatory Care Sensitive Conditions in a Large City of Japan: a Descriptive Analysis Using Claims Data.

BACKGROUND: Hospitalization for ambulatory care sensitive conditions (ACSCs) is an indicator of the quality of primary care in different health systems. In Japan, where patients can choose any healthcare facility with universal health coverage (UHC), data on these admissions are unknown. OBJECTIVE: To describe the current situation of ACSC admissions in a city of Japan. DESIGN: Retrospective observational study using claims data. PARTICIPANTS: Beneficiaries aged 0-74 years of the National Health Insurance (NHI) program in a large city in the Greater Tokyo Area. We extracted ACSC admissions from all inpatient claims between April 2013 and March 2017. MAIN MEASURES: We calculated age- and sex-specific annual ACSC admission rates for three categories: acute, chronic, and vaccine-preventable. We estimated the age-adjusted admission rates by ACSC category according to administrative districts and rate ratios using Poisson regression models. We also estimated medical expenditures and lengths of stay for ACSC admissions. KEY RESULTS: Of 91,350 hospitalization episodes, we identified 7666 (8.4%) that were ACSC admissions. Males had higher annual ACSC admission rates than females (p < 0.001), especially for chronic ACSCs. Admission rates were lowest in those aged 15-39 years and higher in the youngest (0-4 years) and oldest (70-74 years) age groups. Age-adjusted chronic ACSC admission rates were lower in a newly developed area (rate ratio [RR]: 0.79, 95% confidence interval [CI]: 0.71-0.87) and higher in a residential area (RR: 1.14, 95% CI: 1.04-1.24) than in the center of the city. Total medical expenditures for all ACSC admissions accounted for 5.8% of the total inpatient expenditures of NHI in the city. CONCLUSIONS: ACSC admission rates in Japan were higher for males than for females and showed a U-shaped trend in terms of age, as in other countries with UHC, and deferred by region. This study provided possible factors to reduce ACSC admissions.

Change in Eyelid Closure in Spontaneous Blinking After Static Eyelid Reconstruction Surgery for Patients With Facial Paralysis.

BACKGROUND: Static eyelid reconstruction surgery, such as ptosis repair or brow lift, is widely performed for patients with facial paralysis. Complications include exposure keratitis and possible vision loss mainly due to eyelid closure impairment in spontaneous blinking. However, no quantitative evaluation data has been available regarding postoperative closure deterioration. METHODS: To elucidate factors associated with postoperative eyelid closure impairment, a retrospective study was performed for 51 patients who underwent an initial static eyelid reconstruction surgery from October 2017 to August 2020. A static eyelid reconstruction surgery consisted of either 1 or more of the following: (1) levator advancement, (2) brow lift, and (3) orbicularis oculi myectomy. Eyelid closure ratios (0% for complete closure impairment and 100% for perfect closure) at spontaneous blinks were measured on 6 occasions: before operation and at postoperative 1, 3, 6, 9, and 12 months. Comparison was made between preoperative and postoperative values by using mixed-effects model. RESULTS: Overall, average closure ratio was significantly increased. However, 10 patients had >10% closure ratio decreases at at least 1 postoperative measurement point, and all those patients had undergone brow lift procedures. CONCLUSIONS: Although eyelid closure at spontaneous blinks may, contrary to assumptions, generally be improved after static eyelid reconstruction surgery, brow lift was suggested to be associated with eyelid closure impairment.

Effect of annual road safety publicity and enforcement campaign on road fatalities in Japan: a time series study from 1949 to 2019.

BACKGROUND: In 1948, Japan started a short-term publicity and enforcement campaign for traffic safety nationwide, and since 1952, the campaign has been conducted twice a year for 10 days. We aimed to quantify the short-term effect of the spring sessions of the campaign, which were conducted in different months in different years, on road fatalities in Japan using data from 1949 to 2019. METHODS: We obtained national police data on the monthly number of road deaths and conducted a time series regression analysis with three steps: smoothing the long-term patterns with the natural cubic spline function, calculating the ratio of the monthly number of deaths to the corresponding smoothed value, and regressing the ratio on the number of months from January 1949 and the binary variable for the conduct of spring sessions. We repeated the analysis for four subperiods (1949-1964, 1965-1989, 1990-2004 and 2005-2019). RESULTS: During the study period, there were 632577 road deaths. Our analysis revealed that the spring sessions changed the number of deaths per day by -2.5% (95% CI -4.1% to -0.9%) in the months when they were conducted. In the four subperiods, the estimated changes were -4.5% (95% CI -8.9% to -0.1%), -2.6% (95% CI -5.0% to -0.1%), -0.1% (95% CI -2.9 to 2.7) and -3.5% (95% CI -7.9 to 0.9). CONCLUSIONS: Road fatalities were reduced in the months when the spring sessions of the campaign were conducted, but the reduction was modest. The effect might have been somewhat larger until 1964, when Japan was a middle-income country.

Reduced Road Injuries While Commuting Due to Heavy Snowfall and Ensuing Modal Shifts Among Junior High School Students in Japan.

BACKGROUND: Modal shifts in transport may reduce overall road injuries. Cyclist junior high school students are at a high risk of road injuries while commuting in Japan, and injuries among junior high school students could be reduced if the cyclists switch to other transport modes. METHODS: We estimated the change in the incidence of road deaths and serious injuries while commuting in months with heavy snowfall, when cyclists are likely to switch to other transport modes. Using police data on the monthly number of road injuries while commuting among junior high school students in Japan between 2004 and 2013 and corresponding population statistics and snowfall data, we calculated the monthly injury rate (number of deaths and serious injuries divided by population) at the prefecture level. We conducted Poisson regression analysis to estimate the change in the rate in months with a snowfall of ≥100 cm, compared to months without snowfall. RESULTS: A total of 3,164 deaths and serious injuries occurred during 2004 to 2013. The injury rate among cyclists was almost zero in months with a snowfall of ≥100 cm. That among cyclists and pedestrians in these months was reduced by 68% (95% confidence interval, 43-82%). CONCLUSION: In months with heavy snowfall, road injuries while commuting were reduced due to the near-elimination of cycling injuries among junior high school students in Japan. Switching from cycling to other transport modes would reduce overall road injuries among this population, and inducing modal shifts can be an important tool for road safety.

Prognosis of high-risk human papillomavirus-related cervical lesions: A hidden Markov model analysis of a single-center cohort in Japan.

INTRODUCTION: Previous studies have shown that individuals with human papillomavirus (HPV)-related cervical lesions have different prognoses according to the HPV genotype. However, these studies failed to account for possible diagnostic misclassification. In this retrospective cohort study, we aimed to clarify the natural course of cervical lesions according to HPV genotype to account for any diagnostic misclassification. MATERIALS AND METHODS: Our cohort included 729 patients classified as having cervical intraepithelial neoplasia (CIN). HPV was genotyped in all patients, who were followed up or treated for cervical lesions at the University of Tokyo Hospital from October 1, 2008 to March 31, 2015. Hidden Markov models were applied to estimate the diagnostic misclassification probabilities of the current diagnostic practice (histology and cytology) and the transitions between true states. We then simulated two-year transition probabilities between true cervical states according to HPV genotype. RESULTS: Compared with lesions in patients with other HPV genotypes, lesions in HPV 16-positive patients were estimated to be more likely to increase in severity (i.e., CIN3/cancer); over 2 years, 17.7% (95% confidence interval [CI], 9.3%-29.3%) and 27.8% (95% CI, 16.6%-43.5%) of those with HPV 16 progressed to CIN3/cancer from the true states of CIN1 and CIN2, respectively, whereas 55%-70% of CIN1/2 patients infected with HPV 52/58 remained in the CIN1/2 category. Misclassification was estimated to occur at a rate of 3%-38% in the current diagnostic practice. CONCLUSION: This study contributes robust evidence to current literature on cervical lesion prognosis according to HPV genotype and quantifies the diagnostic misclassification of true cervical lesions.

Knowledge, Experience, and Perceptions of Generic Drugs among Middle-Aged Adults and their Willingness-to-Pay: A Nationwide Online Survey in Japan.

Promoting generic drugs can reduce the financial burden on patients and improve healthcare finances. The insurers have been conducting promotional efforts, such as direct-mail campaigns, but little is known about the public's perception of generic drugs and effective message strategies for promotion. In 2018, we conducted a web-based survey of middle-aged Japanese men and women that investigated: (i) their perceptions of generic drugs, (ii) the association between perceptions and willingness-to-pay for brand-name drugs relative to generic drugs, and (iii) potentially effective forms of information provision to alter individuals' perceptions. Of the 1,005 respondents, over half perceived generic drugs as having the same level of efficacy and safety as brand-name drugs. While willingness-to-pay was dispersed among respondents, two factors were associated with small willingness-to-pay: (a) perceiving generic drugs as having the same level of efficacy and safety as brand-name drugs and (b) perceiving that promoting the use of generic drugs is important for controlling medical expenditures. Moreover, presenting potential savings over five years by choosing generic drugs was a potentially effective tool for altering perceptions, relative to showing monthly savings. Our findings suggest that certain parts of the population still have high willingness-to-pay for brand-name drugs, and strategic communication to alter perception could be effective in promoting the use of generic drugs among those who are price-inelastic.

Claims-based algorithms for common chronic conditions were efficiently constructed using machine learning methods.

Identification of medical conditions using claims data is generally conducted with algorithms based on subject-matter knowledge. However, these claims-based algorithms (CBAs) are highly dependent on the knowledge level and not necessarily optimized for target conditions. We investigated whether machine learning methods can supplement researchers' knowledge of target conditions in building CBAs. Retrospective cohort study using a claims database combined with annual health check-up results of employees' health insurance programs for fiscal year 2016-17 in Japan (study population for hypertension, N = 631,289; diabetes, N = 152,368; dyslipidemia, N = 614,434). We constructed CBAs with logistic regression, k-nearest neighbor, support vector machine, penalized logistic regression, tree-based model, and neural network for identifying patients with three common chronic conditions: hypertension, diabetes, and dyslipidemia. We then compared their association measures using a completely hold-out test set (25% of the study population). Among the test cohorts of 157,822, 38,092, and 153,608 enrollees for hypertension, diabetes, and dyslipidemia, 25.4%, 8.4%, and 38.7% of them had a diagnosis of the corresponding condition. The areas under the receiver operating characteristic curve (AUCs) of the logistic regression with/without subject-matter knowledge about the target condition were .923/.921 for hypertension, .957/.938 for diabetes, and .739/.747 for dyslipidemia. The logistic lasso, logistic elastic-net, and tree-based methods yielded AUCs comparable to those of the logistic regression with subject-matter knowledge: .923-.931 for hypertension; .958-.966 for diabetes; .747-.773 for dyslipidemia. We found that machine learning methods can attain AUCs comparable to the conventional knowledge-based method in building CBAs.

Dementia and patient outcomes after hip surgery in older patients: A retrospective observational study using nationwide administrative data in Japan.

OBJECTIVE: To investigate whether dementia is associated with incidence of adverse events and longer hospital stays in older adults who underwent hip surgery, after adjusting for individual social and nursing care environment. DESIGN AND SETTING: Retrospective observational study using the linked data between the Japanese Diagnosis Procedure Combination database and the reports of the medical functions of hospital beds database in Japan (April 2016-March 2017). PARTICIPANTS: A total of 48,797 individuals aged 65 and older who underwent hip surgery and were discharged during the study period. METHODS: Outcomes included in-hospital death, in-hospital pneumonia, in-hospital fracture, and longer hospital stay. We performed two-level, multilevel models adjusting for individual and hospital characteristics. RESULTS: Among all participants, 20,638 individuals (42.3%) had dementia. The incidence of adverse events for those with and without dementia included in-hospital death: 2.11% and 1.11%, in-hospital pneumonia: 0.15% and 0.07%, and in-hospital fracture: 3.76% and 3.05%, respectively. The median (inter quartile range) length of hospital stay for those with and without dementia were 26 (19-39) and 25 (19-37) days, respectively. Overall, the odds ratios (95% confidence interval (CI)) of dementia for in-hospital death, in-hospital pneumonia, and in-hospital fracture were 1.12 (0.95-1.33), 0.95 (0.51-1.80), and 1.08 (0.92-1.25), respectively. Dementia was not associated with the length of hospital stay (% change) (-0.7%, 95% CI -1.6-0.3%). Admission from home, discharge to home, and lower nurse staffing were associated with prolonged hospital stays. CONCLUSIONS: Although adverse events are more likely to occur in older adults with dementia than in those without dementia after hip surgery, we found no evidence of an association between dementia and adverse events or the length of hospital stay after adjusting for individual social and nursing care environment.

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.

Japan's Slow Response to Improve Access to Inpatient Care for COVID-19 Patients.

The coronavirus disease 2019 (COVID-19) pandemic has exposed various weaknesses in national healthcare systems across the globe. In Japan, this includes the inability to promptly mobilize the resources needed to provide inpatient care in response to the rapidly increasing number of patients. Combined with unclear entry points to healthcare, particularly in emergency cases, this has led to a situation in which access to healthcare is rapidly deteriorating. This study examined problems in Japan's healthcare delivery system. While Japan's healthcare resources (e.g., hospital beds and medical personnel) are comparable to those found in other high-income countries, progress has been slow in securing beds for COVID-19 patients. In addition, the number of beds has only recently reached the levels seen in Western countries. Factors related to slow resource allocation include dispersed existing medical resources (mainly in the private sector), the lack of collaboration mechanisms among private-dominant healthcare providers and public health agencies, an inadequate legal framework for resource mobilization, the insufficient quantification of existing resources, and undesignated entry points to healthcare systems. To better prepare for future disasters, including the next wave of COVID-19, Japan urgently needs to restructure its legal framework to promptly mobilize resources, accurately quantify existing resources, introduce coordination mechanisms with functional differentiations among all community stakeholders, and clearly designate entry points to healthcare.

Treatment of latent tuberculosis infection in patients receiving biologic agents.

INTRODUCTION: Treatment of latent tuberculosis infection is recommended in patients receiving biologics. However, evidence is weak regarding the efficacy of treatment regimens in this population, and the real-world practice pattern has not been elucidated. METHODS: Using a large-scale health insurance claims database in Japan, we identified patients who started treatment of immune-mediated inflammatory diseases with tumor necrosis factor inhibitors or other biologics. Treatment with isoniazid within 12 months of starting a biologic was summarized to evaluate the duration of treatment for latent tuberculosis infection and the time between start of isoniazid and initiation of a biologic. RESULTS: Among 2064 patients starting biologics, 10% received treatment for latent tuberculosis infection with isoniazid. Among the patients with biologics and isoniazid, isoniazid was started in the same month as initiating biologics or 1 month before in 82%. In addition to the recommended 6- and 9-month treatments, 20% of patients were receiving isoniazid at 12 months after starting treatment and 20% received a prescription for 350 days or more. CONCLUSIONS: In patients starting biologics, treatment for latent tuberculosis infection was provided for different durations, including not only the recommended periods but also longer periods. Research on safety and effectiveness of the treatment in this population is necessary.

Tuberculosis screening and management of latent tuberculosis infection prior to biologic treatment in patients with immune-mediated inflammatory diseases: A longitudinal population-based analysis using claims data.

BACKGROUND AND AIM: Screening for tuberculosis before treating with biologic agents is recommended in patients with immune-mediated inflammatory diseases (IMIDs). We conducted this study to identify adherence to the recommended practice in a real-world setting in Japan. METHODS: We used a community-based insurance claims database in a city in the Greater Tokyo Area in Japan. Between July 2012 and January 2019, we enrolled patients with IMIDs in the age range 15 to 74 years who had initiated biologic therapy. Tuberculosis screening was defined as (a) interferon-γ release assay and/or a tuberculin skin test (IGRA/TST) and (b) IGRA/TST and X-ray and/or CT scan (X-ray/CT) within 2 months before starting biologic agents. We analyzed the proportions of patients who underwent tuberculosis screening and their association with the patient- and treatment-related factors and treatment for latent tuberculosis infection (LTBI). RESULTS: Of 421 patients presumed to have initiated biologic therapy, 202 (48%) underwent IGRA/TST and 169 (40%) underwent IGRA/TST and X-ray/CT. Patients aged 65 to 74 years were more likely to undergo tuberculosis screening than those aged 45 to 64 years. Compared to infliximab, IGRA/TST was less frequently performed in patients treated with etanercept, adalimumab, golimumab, abatacept, and tocilizumab. Treatment for LTBI was provided to 67 (16%) patients. Proportions of patients receiving LTBI treatment did not significantly differ according to the screening status. CONCLUSION: There was low adherence to the recommendations for tuberculosis screening and prophylactic treatment before biologic therapy. It is necessary to continue alerting clinical practitioners to the importance of screening for tuberculosis and treatment for LTBI.