Multivariate analysis of factors influencing length of hospitalization and medical costs of cholecystectomy for acute cholecystitis in Japan: a national database analysis.

Little information is available on the factors influencing length of stay (LOS) in hospital and medical costs during hospitalization associated with cholecystectomy for acute cholecystitis. We determined the independent factors affecting LOS and medical costs of patients who underwent cholecystectomy for acute cholecystitis based on data from the Diagnosis Procedure Combination (DPC) database. In 2008, a total of 2176 patients with acute cholecystitis were referred for cholecystectomy to 624 hospitals in Japan. We collected patient characteristics and data on treatments for acute cholecystitis using the DPC database and identified independent factors affecting LOS and medical costs during hospitalization using multiple linear regression models. Analysis revealed that early cholecystectomy was significantly associated with a decrease in LOS, whereas longer preoperative antimicrobial therapy was significantly associated with an increase of LOS: the standardized coefficient for early cholecystectomy was -0.372 and that for preoperative antimicrobial therapy was 0.353 (P < 0.001). These procedures were also significant independent factors with regard to medical costs during hospitalization: the standardized coefficient for early cholecystectomy was -0.391 and that for preoperative antimicrobial therapy was 0.335 (P < 0.001). Early cholecystectomy significantly reduces the LOS and medical costs of cholecystectomy for acute cholecystitis, while preoperative antimicrobial therapy increases LOS and medical costs during hospitalization. These results highlight the need for health care implementations such as promotion of early cholecystectomy, appropriate use of antimicrobial drugs, and centralization of patients with cholecystectomy for acute cholecystitis in Japan.

Assessing the impact of diabetes-related comorbidities and care on the hospitalization costs for patients with diabetes mellitus in Japan.

OBJECTIVE: Because diabetes mellitus (DM) has been highlighted in several healthcare sectors, variations in the case mix of DM should be evaluated to promote effective disease management. Using a Japanese administrative database (2003), we investigated the impact of DM-related comorbidities and of their relevant care processes on healthcare costs incurred during hospitalization. METHODS: Of 283,771 hospital admissions across 174 acute care hospitals, 27,853 patients with DM were analyzed. The following variables were analyzed according to age (<65 or ≥65 years), the presence of comorbidities, demographic characteristics, procedure-related complications, insulin use, surgical procedures (percutaneous minimally invasive intervention, hemodialysis, ventilation, and rehabilitation), length of stay (LOS), and total charge (TC; US$1=Y90). Multivariate analyses were applied to investigate the effects of DM-related complications and care processes associated with DM on TC. RESULTS: The mortality and procedure-related complication rates were 2.1% and 2.7%, respectively. There were significant differences in the frequencies of comorbidities by age category. Among DM-related comorbidities, peripheral vascular disease had the greatest impact on increasing the LOS or TC. Minimally invasive procedures, hemodialysis, ventilation, and procedure-related complications were significant determinants of TC. Hemodialysis and invasive surgical procedures were independent predictors of procedure-related complications. CONCLUSIONS: DM-related comorbidities and care process representative of the DM case mix were responsible for variations in healthcare costs during hospitalization.

Multivariate analysis of factors influencing medical costs of acute pancreatitis hospitalizations based on a national administrative database.

BACKGROUND: Little information is available on the analysis of medical costs of acute pancreatitis hospitalizations. AIM: This study aimed to determine the factors affecting medical costs of patients with acute pancreatitis during hospitalization using a Japanese administrative database. METHODS: A total of 7193 patients with acute pancreatitis were referred to 776 hospitals. We defined "patients with high medical costs" as patients whose medical costs exceeded the 90th percentile in medical costs during hospitalization and identified the independent factors for patients with high medical costs with and without controlling for length of stay. RESULTS: Multiple logistic regression analysis demonstrated that necrosectomy was the most significant factor for medical costs of acute pancreatitis during hospitalization. The odds ratio of necrosectomy was 33.64 (95% confidence interval, 14.14-80.03; p<0.001). Use of an intensive care unit was the most significant factor for medical costs after controlling for LOS. The OR of an ICU was 6.44 (95% CI, 4.72-8.81; p<0.001). CONCLUSION: This study demonstrated that necrosectomy and use of an ICU significantly affected the medical costs of acute pancreatitis hospitalization. These results highlight the need for health care implementations to reduce medical costs whilst maintaining the quality of patient care, and targeting patients with severe acute pancreatitis.

Early crystalloid fluid volume management in acute pancreatitis: association with mortality and organ failure.

AIMS: Guidelines recommend aggressive fluid resuscitation in patients with acute pancreatitis (AP) to minimize organ failure. This study aimed to determine whether early crystalloid fluid management is associated with mortality and/or critical care. METHODS: 9,489 AP patients aged ≥18 years were categorized into four study groups: ventilation, hemodialysis, a combination of ventilation and hemodialysis, and neither ventilation nor hemodialysis. We analyzed demographics, mortality, comorbidities, complications, AP severity, surgery of the biliary/pancreatic system, and fluid volume (FV) during the initial 48 h (FV48) and during hospitalization (FVH), and calculated the FV ratio (FVR) as FV48/FVH. The impact of FV48 and FVR on mortality and the care process was assessed according to AP severity. RESULTS: 1.1% of AP patients received ventilation, 1.7% received hemodialysis and 1.0% received both treatments. FV48 and FVR were higher in patients requiring ventilation compared with those not requiring ventilation. A high FV48 increased mortality and a high FVR decreased mortality in patients with severe AP. A high FV48 required ventilation in patients with severe AP, which was independently associated with mortality. CONCLUSION: Since relatively too much or too little early FV is associated with mortality, FV should be continuously monitored and managed according to AP severity. and IAP.

Relationships of age, cholecystectomy approach and timing with the surgical and functional outcomes of elderly patients with cholecystitis.

BACKGROUND: Safety confirmation has led to calls for laparoscopic cholecystectomy (LC) to prevail in elderly patients, but the functional changes after LC have not been sufficiently compared with open cholecystectomy (OC). Using an administrative database, we reassessed the quality of cholecystectomy approach and timing of cholecystectomy for elderly patients with cholecystitis. METHODS: A total of 2552 patients aged ≥60 years who underwent cholecystectomy for cholecystitis were enrolled. Variables included demographics, comorbidities, complications, preoperative bile duct scrutiny, cholecystectomy timing (<48, 48-96, >96 h), functional status estimated by the Barthel index, teaching status, postoperative length of stay (LOS) and total charges (TC). The impacts of age, OC and timing on LOS, TC, complications and functional changes were assessed by mixed linear regression analyses using propensity score-matched cohorts for LC and OC. RESULTS: The patients comprised 1742 LC and 810 OC patients across 122 hospitals. The mean ages and octogenarian proportions were 70.1 years and 10.6% for LC and 72.9 years and 20.5% for OC. Advancing age, males and acute inflammation were more frequently associated with OC. Longer LOS, higher TC and more complications were observed for OC. Age was a predictor of functional changes but not complications. Octogenarians and complications were associated with longer LOS, higher TC and more functional deterioration. Earlier cholecystectomy was only associated with lower TC. CONCLUSIONS: Octogenarians were likely to have OC and functional deterioration. Since OC was a predictor of resource use and complications, strategies to complete earlier LC and prevent complications are required for octogenarians.

An observational study using a national administrative database to determine the impact of hospital volume on compliance with clinical practice guidelines.

BACKGROUND: Little information is available on the relationship between hospital volume and compliance with clinical practice guidelines (CPGs). OBJECTIVES: To investigate the relationship between hospital volume and compliance with CPGs using a Japanese administrative database. DESIGN AND SUBJECTS: This was an observational study that included 60,842 patients with acute cholangitis from 829 hospitals in Japan. MEASURES: Hospital volume was categorized into the following 3 groups based on the number of cases of acute cholangitis during the study period: low-volume hospitals (LVHs; n = 20,869), medium-volume hospitals (MVHs; n = 18,387), and high-volume hospitals (HVHs; n = 21,586). We further collected patient data with regard to CPGs for acute cholangitis, and counted the number of recommendations that had been complied with for each patient. CPGs compliance score was defined as the rate of compliance with these recommendations for each patient (range, 0-10). Aggregated CPGs compliance score was measured according to hospital volume. RESULTS: Mean CPGs compliance score in HVHs was significantly higher than that in MVHs and LVHs (6.8 ± 1.6 vs. 5.6 ± 1.5 vs. 3.9 ± 1.4, respectively; P < 0.001). Multiple linear regression analysis revealed that hospital volume was most significantly associated with CPGs compliance score. The standardized coefficient for CPGs compliance score in HVHs was 0.689, whereas that of MVHs was 0.366 (P < 0.001). CONCLUSIONS: This study demonstrated that hospital volume was significantly associated with compliance with CPGs and that the Japanese administrative database was a viable tool for the monitoring of compliance with CPGs.

Reconsidering the value of rehabilitation for patients with cerebrovascular disease in Japanese acute health care hospitals.

OBJECTIVES: The 21st century has an increasing elderly population at risk of cerebrovascular disease (CVD). Efficient care for recovering functional status is emphasized among policy makers. We investigated whether rehabilitation and its early initiation provided for CVD patients produced functional recovery in acute care hospitals. METHODS: Using a Japanese administrative database during a 4-month interval from 2004 to 2008 in patients ages ≥ 15 years, we measured the demographics, consciousness level at admission, comorbidities, complications, procedures, ventilation administration, initiation day of rehabilitation, and hospital characteristics. Outcomes included total charges (TC) and functional status measured by the Barthel index (BI). Multivariate analysis measured the impact of rehabilitation and its early initiation on outcomes. To reduce the selection bias of rehabilitation and the ecological fallacy, we used propensity score matching and the linear mixed model. RESULTS: Excluding 488 deceased patients, we analyzed 45,014 CVD patients. Rehabilitation at a generalized unit produced greater BI improvement than no rehabilitation or at intensive care units. A longer hospitalization, but not a 1-day delay of rehabilitation initiation, resulted in less BI improvement and more TC. A higher patient volume and academic hospitals were associated with more TC but not with BI improvement. CONCLUSIONS: Rehabilitation, but not the timing of rehabilitation, might accompany functional recovery in acute care hospitals. Because the hospital mix or medical units can explain the variation in the quality of rehabilitation, policy makers, along with monitoring unnecessary long hospitalizations, should encourage a referral policy for rehabilitation-intensive facilities and develop effective rehabilitation using technology to optimize functional outcomes.

Contribution of case-mix classification to profiling hospital characteristics and productivity.

Case-mix classification has made it possible to analyze acute care delivery case volumes and resources. Data arising from observed differences have a role in planning health policy. Aggregated length of hospital stay (LOS) and total charges (TC) as measures of resource use were calculated from 34 case-mix groups at 469 hospitals (1,721,274 eligible patients). The difference between mean resource use of all hospitals and the mean resource use of each hospital was subdivided into three components: amount of variation attributable to hospital practice behavior (efficiency); amount attributable to hospital case-mix (complexity); and amount attributable to the interaction. Hospital characteristics were teaching status (academic or community), ownership, disease coverage, patients, and hospital volume. Multivariate analysis was employed to determine the impact of hospital characteristics on efficiency. Mean LOS and TC were greater for academic than community hospitals. Academic hospitals were least associated with LOS and TC efficiency. Low disease coverage was a predictor of TC efficiency while low patient volume was a predictor of unnecessarily long hospital stays. There was an inverse correlation between complexity and efficiency for both LOS and TC. Policy makers should acknowledge that differentiation of hospital function needs careful consideration when measuring efficiency.

Do interventions to prevent lifestyle-related diseases reduce healthcare expenditures? A randomized controlled clinical trial.

BACKGROUND: In 2008, the Japanese government implemented a program of health lifestyle interventions to reduce health care expenditure. This study evaluated whether these interventions decreased health care expenditures. METHODS: The study enrolled 99 participants insured by Japanese National Health Insurance, who, in our previous study conducted in 2004, were allocated by random sampling into an intervention group (50 participants) and a control group (49 participants). In the intervention group, we used a health support method that facilitated the attainment of goals established by each participant. The control group received instruction in exercise, as well as health support using publically available media. Although 3 participants in the intervention group and 9 participants in the control group did not participate in a follow-up health examination 1 year after the intervention, the health care expenditures of all initial participants were assessed. Expenditures before and after the intervention were compared within and between groups. Data on health care expenditures were obtained from inpatient, outpatient, pharmacy, and dental health insurance claims. RESULTS: After the intervention, the pharmacy and dental expenditures were significantly higher in the intervention group, while the pharmacy expenditure was significantly higher in the control group. However, there was no significant difference in any medical expenditure item between the intervention and control groups before or after the intervention. CONCLUSIONS: No significant differences were observed in short-term medical expenses for any medical expenditure item after a lifestyle intervention.

Community-based appraisal of laparoscopic abdominal surgery in Japan.

BACKGROUND: Despite the prevalence of laparoscopic surgery (LS), community-based appraisal of its benefit over open surgery (OS) has not been performed. This can be measured by increased total charge (TC) spent and decreased length of stay (LOS), which are indicative of greater resource use and opportunistic cost reduction. We prioritized the value of LS for eight abdominal procedures. MATERIALS AND METHODS: We used a Japanese administrative database for the 6 mo leading up to December 2007. Study procedures were appendectomy, cholecystectomy, choledocholithotomy, herniorrhaphy, colectomy, partial or total gastrectomy, and small bowel resection (SBR) in adults. We analyzed patient demographics, mortality, comorbidity, complications, use of chemotherapy or postoperative pain control, hospital teaching status, postoperative LOS, and TCs. The impact of LS was determined using multivariate analysis on the propensity-score-matched cohorts of LS and OS. RESULTS: Herniorrhaphy was most frequently performed (24,088 cases), whereas SBR was performed least (3404). LS was performed most often in cholecystectomy (81%) and least in herniorrhaphy (3.7%). LS did not increase complications in any procedure. Laparoscopic cholecystectomy and SBR were associated with shorter LOS and lower TC, whereas laparoscopic herniorrhaphy increased LOS and TC. Laparoscopic appendectomy and partial gastrectomy reduced LOS and increased TC. CONCLUSIONS: LS safety was confirmed. Laparoscopic cholecystectomy or SBR might have advantages, whereas laparoscopic was no better than open herniorrhaphy and might be decided by patient's preference. Considering the variation in the decremental opportunistic cost produced by incremental medical expenses observed among the procedures, policymakers should determine an appropriate reimbursement schedule.

Quantitative assessment of the advantages of laparoscopic gastrectomy and the impact of volume-related hospital characteristics on resource use and outcomes of gastrectomy patients in Japan.

OBJECTIVE: In this community-based study, we assessed the advantages of laparoscopic gastrectomy (LG) and the impact of volume-related hospital characteristics on gastrectomy care. BACKGROUND: The quality of gastrectomy care and the potential effects of volume-related hospital characteristics on gastrectomy care have not been comprehensively evaluated to date. METHODS: We used a Japanese administrative database of 17,761 patients across 258 hospitals delivering both open gastrectomy and LG during 6-month periods in 2006, 2007, and 2008. We examined patient demographics, principal diagnosis, comorbidities, and complications, hospital patient volume, proportion of LG procedures accomplished, teaching status and care processes, length of hospital stay, total charge, and operative time. Multivariate analyses were used to compare LG with open gastrectomy in terms of mortality, complications, operative or postoperative blood transfusion, resource use and operative time. RESULTS: LG was performed in 3,914 (22%) patients and was associated with significantly shorter length of hospital stay, lower total charge, and longer operative time. Higher hospital volume was associated with less mortality, lower frequency of transfusion, shorter length of hospital stay, lower total charge, and shorter operative time. Higher procedures accomplished were associated with fewer complications, higher frequency of transfusion, greater resource use, and longer operative time. CONCLUSIONS: Laparoscopic gastrectomy offers significant economic advantages over open gastrectomy. However, LG was associated with increased operative time and required greater blood transfusion volume once indicated, which might drive gastrectomy care to use more prudent approaches in hospitals with higher procedures accomplished rates. Stakeholders should recognize the wide variation in hospital practices, skill training and efficient gastrectomy care, in addition to the volume-quality relationship.

Probability of survival, early critical care process, and resource use in trauma patients.

BACKGROUND: Trauma Injury Severity Score is a frequently used prediction model for mortality. However, few studies have assessed the probability of survival (Ps) and early resource use after trauma. We studied the impact of Ps on early critical care or costs to test its applicability to efficient trauma care. METHODS: The relationship between Ps in 8207 trauma patients and patients' demographics, organ injured, comorbidities, use of critical care, and total charges during the initial 48 hours was analyzed using multiple regression analyses. RESULTS: Significant differences were observed among study variables across different Ps. A large variability in total charges was observed and explained by critical care, which Ps was significantly associated with. CONCLUSIONS: Trauma Injury Severity Score offers a tool for estimating resource use and might improve monitoring of early trauma care quality. Measuring the combined effect of Trauma Injury Severity Score and injured organs would refine the methodology for evaluating the trauma care system.

Contribution of bile duct drainage on resource use and clinical outcome of open or laparoscopic cholecystectomy in Japan.

AIMS: Laparoscopic cholecystectomy (LC) is replacing conventional open cholecystectomy (OC) as a preferred surgical method for treating complicated biliary tract disorders. However, there have been few studies assessing the impact of staged bile duct drainage (BDD) on costs and clinical outcomes for either surgical approach. This study evaluated the impact of surgical technique and BDD on resource utilization and complication rates. METHODS: This study included 2778 cholecystectomy patients treated for benign biliary tract diseases in 80 academic and 81 community hospitals. For both OC and LC patients, the following variables were analysed: demographics, clinical data, length of stay (LOS), total charges (TC; US$), procedure-related complications and hospital type. Multivariate analyses were used to determine the impact of BDD on LOS, TC and complication rates. RESULTS: Of the 2778 cholecystectomy patients in the study, 2255 (81.2%) underwent LC. Inflammation was diagnosed in 55.6% of OC patients and 36.0% of LC patients. Complication was 9.4% in OC cases and 4.7% in LC cases. BDD was performed in 14.5% of OC cases and in 7.6% of LC cases. Diagnosis of inflammation, presence of co-morbidities and BDD each had a significant impact on LOS and TC. After risk adjustment, LC was associated with a reduction in LOS and TC, while BDD resulted in greater LOS and TC. LC and BDD were significantly associated with complications. CONCLUSIONS: The study suggested that BDD utilized more resources and had higher rates of complications. LC remains an appropriate procedure for cholecystectomy patients. Further study will be needed to evaluate the effect of pre-operative or post-operative BDD on quality of care.

Quantitative comparison of the difficulty of performing laparoscopic colectomy at different tumor locations.

BACKGROUND: Laparoscopic approaches of colectomy for colonic cancer are increasingly surpassing the mainstream open colectomy approach. Impact of disease variables, such as tumor location, has not been adequately measured in quality improvement initiatives. Quantitative analysis concerning the difficulty performing these procedures and differences in postoperative care depending on tumor site will contribute to the development of training programs and to the assessment of quality of care strategies. METHODS: A total of 3,765 cases received laparoscopic colectomy (LC). Patient demographics, weighted comorbidities, procedure-related complications, stapling devices, operating room (OR) time, postoperative length of hospital stay (LOS), or total charges (TC) were categorized and compared based on tumor location: cecum to ascending, transverse, descending, and sigmoid colon. Multivariate analyses determined the impact of tumor location on postoperative LOS, TC, OR time, and complications. RESULTS: Sigmoid colon was the most frequent tumor placement (40.5%). Significant differences in age, gender, frequency of blood transfusion, use of stapling devices, OR time, and postoperative LOS were observed among tumor locations. Transverse colon was the most significant determinant of postoperative LOS and TC, whereas descending colon tumors correlated with increased OR time. Greater OR time was associated with more postoperative resource use and complications. CONCLUSIONS: Tumor location, complications, and OR time affected postoperative resource use, whereas greater OR time signified an increased occurrence of complications. Developers of LC training programs or healthcare policy makers should consider the quantitative impact of tumor locations when attempting to improve effective skill training or to survey the quality of LC performance.

Difference in resource utilization between patients with acute and chronic heart failure from Japanese administrative database.

BACKGROUND: Many studies have reported economic evaluation of evolving agents or therapies for patients with heart failure (HF). However, little is known whether the disease progression category (acute or chronic HF) would be considered as a risk adjustment in health service research. OBJECTIVES: This study profiles the difference in resource use or medical care for acute versus chronic HF. METHODS: This study analyzed 17,912 HF patients treated in 62 academic hospitals and 351 community hospitals. Study variables included demographic variables, comorbid status, physical activity or disease progression at admission, procedures and laboratory tests, type and dose of heart-related medications, length of stay (LOS), and total charges (TC; 1 US$= 100 yen) for acute and chronic HF. The independent contributions of disease progression categories on LOS and TC were identified using multivariate analysis. RESULTS: We identified 9813 chronic and 8099 acute HF patients. Median LOS was 18 days for both chronic and acute HF, whereas TC was US$5731 and US$6447, respectively. Regression analysis revealed that acute HF was associated with a slightly greater TC, whereas performance of procedures was the most prominent factor. As NYHA class was the next most influential factor, class 3 or 4 resulted in longer LOS or greater TC, than did class 1. CONCLUSIONS: This study suggests that acute HF increased resource use slightly, whereas use of some practices indicated in critical care was affected more by the procedures performed. Disease progression category should remain an indicator for appropriateness of medical care.

Development and analysis of a nationwide cost database of acute-care hospitals in Japan.

OBJECTIVES: Understanding of hospital cost is crucial to achieve an ideal balance between the assurance and improvement of patient safety and quality, and efficient use of finite resources. However, neither a standardized calculation methodology nor a large-scale database of costs in acute-care hospitals exists in Japan. This study aims to develop a standardized methodology, construct a nationwide cost database in Japan, analyse the characteristics of the database and examine the relationship between the cost and the charge from the viewpoint of an appropriate reflection of the cost to the price. METHOD: We designed the costing framework, gathered the data for patients discharged from 139 acute-care hospitals in Japan between July 2004 and October 2004 and constructed a database containing information on 284,730 patients. The characteristics of the database and the relationship between the cost and the charge were investigated. RESULTS: In the nationwide database we constructed, a wide range in the average cost per hospitalization and average cost per diem was observed. A wide variation of cost components was seen across major diagnostic categories. Moreover, there was a high correlation between the cost and the charge (Correlation coefficient = 0.94). CONCLUSIONS: After designing a costing framework, a nationwide database comprised of individual case-level costs with components for acute-care hospitals in Japan was successfully developed. We hope this study contributes to appropriate decision making and helps motivate further research geared towards efficient hospital management and a rational payment system in Japan.

Impact of timing of cholecystectomy and bile duct interventions on quality of cholecystitis care.

BACKGROUND: Laparoscopic cholecystectomy (LC), with or without staged bile duct interventions (BDIs), is increasingly used in acute cholecystitis. However, few studies have concurrently evaluated the timing of cholecystectomy procedures and BDIs, and quality of cholecystectomy care in cholecystitis patients. We investigated the effects of timing of BDIs and cholecystectomy on resource utilization, in order to assess the suitability of procedure timing or approach as quality indicators. METHODS: In 2006, 5914 cholecystectomy patients were treated for cholecystitis at 423 hospitals in Japan. We analyzed patient demographics, BDIs (including endoscopic retrograde cholangiopancreatography, percutaneous gallbladder or common bile duct drainage, endoscopic sphincterotomy, and extraction of choledocholithiasis), procedure-related complications, hospital teaching status, postoperative length of stay (LOS) and charges (TC). Multivariate analysis was used to measure the impact of study variables on LOS, TC and complications. RESULTS: Open cholecystectomy (OC) was performed in 1318 patients and LC in 4596. Acute inflammation was diagnosed in 52% of OC and 28% of LC patients. The incidence of complications was 8.1% for OC and 5.5% for LC. BDIs were more frequent in LC patients, especially preoperatively. Early cholecystectomy was associated with lower resource use. Postoperative BDIs had a significant impact on LOS and complications. Laparoscopic early cholecystectomy was associated with fewer postoperative BDIs. Hospital variation was found among postoperative resource use and outcomes. CONCLUSIONS: Delayed cholecystectomy and postoperative BDIs are not recommended. Use of postoperative BDIs might be a promising quality indicator for monitoring quality of preoperative care when performing early laparoscopic cholecystectomy in cholecystitis patients.

Differences in practice patterns and costs between small cell and non-small cell lung cancer patients in Japan.

Many reports exist regarding the economic evaluation of evolving chemotherapeutic regimens or diagnostic images for lung cancer (LC) patients. However, it is not clear whether clinical information, such as pathological diagnosis or cancer stage, should be considered as a risk adjustment in lung cancer. This study compared the cost and practice patterns between small cell lung carcinoma (SCLC) and non-small cell lung carcinoma (NSCLC) patients. 6,060 LC patients treated at 58 academic hospitals and 14,507 at 257 community hospitals were analyzed. Study variables included demographic variables, comorbid status, cancer stage, use of imaging and surgical procedures, type of adjuvant therapy (chemotherapy, radiation or chemo-radiation), use of ten chemotherapeutic agents, length of stay (LOS), and total charges (TC; US$1 = 100 yen) in SCLC and NSCLC patients. The impact of pathological diagnosis on LOS and TC was investigated using multivariate analysis. We identified 3,571 SCLC and 16,996 NSCLC patients. The proportion of demographic and practice-process variables differed significantly between SCLC and NSCLC patients, including diagnostic imaging, adjuvant therapy and surgical procedures. Median LOS and TC were 20 days and US$6,015 for SCLC and 18 days and US$6,993 for NSCLC patients, respectively (p < 0.001 for each variable). Regression analysis revealed that pathological diagnosis was not correlated with TC. Physicians should acknowledge that pathological diagnosis dose not accounts for any variation in cost of LC patients but that should remain as an indicator of appropriate care like selection of chemotherapeutic agents.

The effect of age and procedure on resource use for patients with cerebrovascular disease.

OBJECTIVE: Many studies have described the impact of population ageing on health care expenditures, but few have assessed its impact on specific diseases adjusted for severity and procedure. This study examined the relationship between an ageing population and resource use in patients with cerebrovascular disease (CVD). METHODS: A total of 13,856 CVD patients were treated in 82 academic and 92 community hospitals. Demographic variables, clinical variables, length of stay (LOS) and total charges were analysed by age group (under 65 years, 65-74 years and 75 years or older). The independent effects of age on LOS and total charge were determined using multivariate analysis. RESULTS: There were 5172 (37%) patients under 65 years of age, 4096 (30%) 65-74 years and 4588 (33%) 75 years or older. Intracranial infarction or ischaemia was diagnosed in 69% of the patients, haemorrhage in 23% and subarachnoid haemorrhage in 9%. The overall mortality was 6% (5% in under 65 years, 5% in 65-74 years and 9% in 75 years or older; P<0.001). There were significant differences in the proportion of procedures performed in each age category. Age and procedure were significantly associated with LOS, particularly the latter. Age had no significant association with total charge, but procedure was highly associated. CONCLUSIONS: Ageing has no significant impact on total charge. Instead policy-makers should acknowledge the effect of procedures on health care costs, conduct economic evaluations and monitor use of procedures.

Does income influence demand for medical services despite Japan's "Health Care for All" policy?

OBJECTIVES: We examined the impact of household income on the use of medical services in Japan, where there is a "health care for all" policy, with important, centralized influence by the national government designed to ensure universal access. METHODS AND SUBJECTS: All healthcare societies operating in 2003 were included in the study, representing 14,776,193 insured adults and 15,496,752 insured dependents. The mean case rate (the average number of monthly bills per patient), the mean number of service days per person, and the mean medical cost per person served as indicators of medical service use. Multiple regression analysis was performed by the forced entry method using case rate, the number of service days, and medical cost as outcome variables, and average monthly salary, dependent ratio, average age, and premium rate as the explanatory variables. RESULTS: In the multiple regression analyses, average monthly salary showed a high positive correlation of outpatient and dental indicators, including case rate, the number of service days, and medical cost. If the average monthly salary were reduced 20 percent lower than the mean, the estimated changes (95 percent CI) in case rate for the insured were -7.49 (-8.14 approximately -6.84) percent for outpatient visits and -8.16 (-8.77 approximately -7.56) percent for dental services. CONCLUSIONS: Average monthly salary intensifies the effects of copayments on the case rate, the number of service days, and medical cost in the "Employees Health Insurance" in Japan. Thus, a low salary appears to discourage patients from seeking medical and dental services.