Optimal age to discontinue long-term surveillance of intraductal papillary mucinous neoplasms: comparative cost-effectiveness of surveillance by age.

OBJECTIVE: Current guidelines recommend long-term image-based surveillance for patients with low-risk intraductal papillary mucinous neoplasms (IPMNs). This simulation study aimed to examine the comparative cost-effectiveness of continued versus discontinued surveillance at different ages and define the optimal age to stop surveillance. DESIGN: We constructed a Markov model with a lifetime horizon to simulate the clinical course of patients with IPMNs receiving imaging-based surveillance. We calculated incremental cost-effectiveness ratios (ICERs) for continued versus discontinued surveillance at different ages to stop surveillance, stratified by sex and IPMN types (branch-duct vs mixed-type). We determined the optimal age to stop surveillance as the lowest age at which the ICER exceeded the willingness-to-pay threshold of US$100 000 per quality-adjusted life year. To estimate model parameters, we used a clinical cohort of 3000 patients with IPMNs and a national database including 40 166 patients with pancreatic cancer receiving pancreatectomy as well as published data. RESULTS: In male patients, the optimal age to stop surveillance was 76-78 years irrespective of the IPMN types, compared with 70, 73, 81, and 84 years for female patients with branch-duct IPMNs <20 mm, =20-29 mm, ≥30 mm and mixed-type IPMNs, respectively. The suggested ages became younger according to an increasing level of comorbidities. In cases with high comorbidity burden, the ICERs were above the willingness-to-pay threshold irrespective of sex and the size of branch-duct IPMNs. CONCLUSIONS: The cost-effectiveness of long-term IPMN surveillance depended on sex, IPMN types, and comorbidity levels, suggesting the potential to personalise patient management from the health economic perspective.

Machine Learning-based Models for Outpatient Prescription of Kampo Formulations: An Analysis of a Health Insurance Claims Database.

BACKGROUND: Despite the widespread practice of Japanese traditional Kampo medicine, the characteristics of patients receiving various Kampo formulations have not been documented in detail. We applied a machine learning model to a health insurance claims database to identify the factors associated with the use of Kampo formulations. METHODS: A 10% sample of enrollees of the JMDC Claims Database in 2018 and 2019 was used to create the training and testing sets, respectively. Logistic regression analyses with lasso regularization were performed in the training set to construct models with prescriptions of 10 commonly used Kampo formulations in 1 year as the dependent variable and data of the preceding year as independent variables. Models were applied to the testing set to calculate the C-statistics. Additionally, the performance of simplified scores using 10 or 5 variables were evaluated. RESULTS: There were 338,924 and 399,174 enrollees in the training and testing sets, respectively. The commonly prescribed Kampo formulations included kakkonto, bakumondoto, and shoseityuto. Based on the lasso models, the C-statistics ranged from 0.643 (maoto) to 0.888 (tokishakuyakusan). The models identified both the common determinants of different Kampo formulations and the specific characteristics associated with particular Kampo formulations. The simplified scores were slightly inferior to full models. CONCLUSION: Lasso regression models showed good performance for explaining various Kampo prescriptions from claims data. The models identified the characteristics associated with Kampo formulation use.

A post-marketing safety assessment of COVID-19 mRNA vaccination for serious adverse outcomes using administrative claims data linked with vaccination registry in a city of Japan.

INTRODUCTION: The safety profiles of COVID-19 vaccines are incompletely evaluated in Japan. OBJECTIVES: To examine the risk of serious adverse effects after COVID-19 mRNA vaccination (BNT162b2 and mRNA-1273) in cohort studies and self-controlled case series (SCCS). METHODS: Using an administrative claims database linked with the COVID-19 vaccination registry in a city in Japan between September 2020 and September 2021, we identified health insurance enrolees aged ≥ 18 years. We evaluated the risk of acute myocardial infarction, appendicitis, Bell's palsy, convulsions/seizures, disseminated intravascular coagulation, immune thrombocytopenia, pulmonary embolism, haemorrhagic or ischemic stroke, venous thromboembolism, and all-cause mortality, 21 days following any COVID-19 mRNA vaccination, compared with non-vaccination periods. For the cohort studies, we estimated incidence rate ratios (IRRs) by Poisson regression and rate differences (IRDs) by weighted least-squares regression, adjusting for sex, age, and Charlson comorbidity index. We applied a modified SCCS design to appropriately treat outcome-dependent exposures. For the modified SCCS, we estimated within-subject IRRs by weighted conditional Poisson regression. Subgroup analyses stratified by sex and age were also conducted. RESULTS: We identified 184,491 enrolees [male: 87,218; mean (standard deviation) age: 64.2 (19.5) years] with 136,667 first and 127,322 s dose vaccinations. The risks of any outcomes did not increase in any analyses, except for the fact that the modified SCCS indicated an increased risk of pulmonary embolism after the first dose in women (within-subject IRR [95%CI]: 3.97 [1.18-13.32]). CONCLUSION: The findings suggested that the COVID-19 mRNA vaccine was generally safe, whilst a signal of pulmonary embolism following the first dose of the COVID-19 mRNA vaccine was observed.

Association of Operative Day of the Week with the Length of Stay and Total Hospitalization Costs in Patients with Partial Mastectomy: A Nationwide Database Study in Japan.

Introduction: Length of stay (LOS) is a major concern while optimizing medical resources and costs. Hence, factors influencing LOS should be investigated. In Japan, breast cancer surgery generally involves several days of hospitalization for observation, despite few complications. We hypothesized that the day of surgery (weekday; Monday-Friday) affects LOS. Methods: Using a Japanese nationwide database, we retrospectively identified 146,610 patients who underwent partial mastectomy for stage 0-III breast cancer from July 2010 to March 2017. We conducted multivariable linear and logistic regression analyses adjusting for background characteristics (such as comorbidities and hospital characteristics) with a generalized estimating equation for within-hospital clustering to compare postoperative and total LOS, total hospitalization costs, and postoperative complications between the groups for whom the surgery was performed on different days of the week. Results: In total, whereas the median postoperative LOS was 4 days (interquartile range, 3-6 days), the median total LOS was 6 days (5-8 days). The median total hospitalization cost was 6,189 US dollars (5,609-6,668 US dollars), and postoperative complications occurred in 3.3% of cases. Despite no significant difference in postoperative complications, Monday-Wednesday surgeries showed significantly shorter postoperative LOS than Friday surgeries (-0.11 days [95% confidence interval, -0.14 to -0.07] on Monday with reference to Friday). Nevertheless, Monday surgeries showed significantly increased total LOS (0.69 days [0.64-0.74]) and hospitalization costs (93 US dollars [71-116]) in comparison with Friday surgeries. Conclusions: The operative day of the week was associated with increased LOS and cost, with no difference in postoperative complications after partial mastectomy. Surgeries on Monday involved longer preoperative hospital stays and higher total hospitalization costs than those on other weekdays.

Cost-effectiveness analysis of trastuzumab monotherapy versus adjuvant chemotherapy plus trastuzumab in elderly patients with HER2-positive early breast cancer.

BACKGROUND: In elderly patients with human epidermal growth factor 2-positive breast cancer, adjuvant chemotherapy was associated with decreased quality of life, with relatively small benefits for prognosis. We examined the cost-effectiveness of trastuzumab monotherapy versus adjuvant chemotherapy plus trastuzumab in elderly patients with human epidermal growth factor 2-positive breast cancer. METHODS: A Markov model was developed to evaluate the costs and benefits of trastuzumab monotherapy over adjuvant chemotherapy plus trastuzumab for elderly patients with human epidermal growth factor 2-positive breast cancer. We built the model with a yearly cycle over a 20-year time horizon and five health states: disease-free, relapse, post-relapse, metastasis and death. The parameters in the model were based on a previous randomized controlled trial and a nationwide administrative database in Japan. The incremental cost-effectiveness ratio, expressed as Japanese yen per the quality-adjusted life-years, was estimated from the perspective of health care payers. One-way deterministic sensitivity analysis and probabilistic sensitivity analysis with Monte-Carlo simulations of 10 000 samples were conducted. RESULTS: The incremental cost-effectiveness ratio of trastuzumab monotherapy over adjuvant chemotherapy plus trastuzumab was $\sim$1.8 million Japanese yen /quality-adjusted life-year. The one-way deterministic sensitivity analysis showed that transition probability from disease-free to metastasis status and cost of metastasis status had the greatest influence on the incremental cost-effectiveness ratio. More than half the estimates in the probabilistic sensitivity analysis were located below a threshold of willingness-to-pay of 5 million Japanese yen /quality-adjusted life-year. CONCLUSION: In this first comparative cost-effectiveness analysis of adjuvant chemotherapy plus trastuzumab versus trastuzumab monotherapy in the elderly, the latter was found favorable for elderly patients with human epidermal growth factor 2-positive breast cancer.

In-hospital mortality associated with community-acquired pneumonia due to methicillin-resistant Staphylococcus aureus: a matched-pair cohort study.

BACKGROUND: It remains unclear whether methicillin-resistant Staphylococcus aureus (MRSA) pneumonia is associated with higher mortality compared with non-MRSA pneumonia. This study's objective was to compare outcomes including in-hospital mortality and healthcare costs during hospitalisation between patients with MRSA pneumonia and those with non-MRSA pneumonia. METHODS: Using a national inpatient database in Japan, we conducted a 1:4 matched-pair cohort study of inpatients with community-acquired pneumonia from 1 April 2012 to 31 March 2014. In-hospital outcomes (mortality, length of stay and healthcare costs during hospitalisation) were compared between patients with and without MRSA infection. We performed multiple imputation using chained equations followed by multivariable regression analyses fitted with generalised estimating equations to account for clustering within matched pairs. All-cause in-hospital mortality and healthcare costs during hospitalisation were compared for pneumonia patients with and without MRSA infection. RESULTS: Of 450,317 inpatients with community-acquired pneumonia, 3102 patients with MRSA pneumonia were matched with 12,320 patients with non-MRSA pneumonia. The MRSA pneumonia patients had higher mortality, longer hospital stays and higher costs. Multivariable logistic regression analysis revealed that MRSA pneumonia was significantly associated with higher in-hospital mortality compared with non-MRSA pneumonia (adjusted odds ratio = 1.94; 95% confidence interval: 1.72-2.18; p < 0.001). Healthcare costs during hospitalisation were significantly higher for patients with MRSA pneumonia than for those with non-MRSA pneumonia (difference = USD 8502; 95% confidence interval: USD 7959-9045; p < 0.001). CONCLUSIONS: MRSA infection was associated with higher in-hospital mortality and higher healthcare costs during hospitalisation, suggesting that preventing MRSA pneumonia is essential.

Association between ambulance use and hospitalization costs among heart failure patients.

Heart failure is the main cause of hospitalization, which burdens the healthcare system. Although many hospitalizations for heart failure follow ambulance use, it is unknown whether ambulance use increases hospitalization costs. Using the Diagnosis Procedure Combination database in Japan, we examined all hospitalizations of patients with heart failure from April 2014 to March 2015. Patients were divided into those with and those without ambulance use. We performed a multiple regression analysis to examine the association between ambulance use and total hospitalization costs, adjusting for age, sex, length of day, and activities of daily living. We identified 126,067 hospitalizations for heart failure. The percentages of ambulance use were 29%, 27%, 30%, and 50% among patients with NYHA Functional Classification I, II, III, and IV, respectively. For patients categorized as NYHA I (n = 9,700), multiple linear regression analysis revealed that ambulance use was significantly associated with higher hospitalization cost (coefficient 723 USD; 95% confidence interval 109-1337; p = 0.021). Even for heart failure patients with NYHA I, ambulances were frequently used. Ambulance use was independently associated with increased hospital costs. Future research is needed on transitional care to limit unnecessary ambulance use.

Early Initiation of Feeding and In-Hospital Outcomes in Patients Hospitalized for Acute Heart Failure.

Extensive data on early nutrition support for patients requiring critical care are available. However, whether early initiation of feeding could be beneficial for patients hospitalized for acute heart failure (HF) remains unclear. We sought to compare outcomes of early and delayed initiation of feeding for hospitalized patients with acute HF using a nationwide inpatient database. We retrospectively analyzed data from the Diagnosis Procedure Combination database. We included patients hospitalized for HF between January 2010 and March 2018. We excluded patients with length of hospital stay ≤2 days, those patients who underwent major procedures under general anesthesia, and those requiring advanced mechanical supports within 2 days after admission including intubation, intra-aortic balloon pumping, and extracorporeal membrane oxygenation. Propensity score matching and instrumental variable analyses were conducted to compare in-hospital mortality, complications and length of stay between the early and delayed feeding groups. Among 432,620 eligible patients, 403,442 patients (93%) received early initiation of feeding (within 2 days after admission) and 29,178 patients (7%) received delayed initiation of feeding. Propensity score matching created 29,153 pairs and delayed initiation of feeding was associated with higher in-hospital mortality (odds ratio 1.32; 95% confidence interval 1.26 to 1.39), longer hospital stay and higher incidence of pneumonia and sepsis. The instrumental variable analysis also showed patients with delayed initiation of feeding had higher in-hospital mortality (odds ratio 1.34; 95% confidence interval 1.28 to 1.40). In conclusion, our analysis suggested a potential benefit of early initiation of feeding for in-hospital outcomes in hospitalized patients hospitalized for acute HF. Further investigations are required to confirm our results and to clarify the underlying mechanisms.

Association between early antibiotic treatment and clinical outcomes in children hospitalized for asthma exacerbation.

BACKGROUND: Professional society guidelines recommend against routine early antibiotic use in the treatment of asthma exacerbation without comorbid bacterial infection. However, high antibiotic prescribing rates have been reported in developed countries. OBJECTIVE: We sought to assess the effectiveness of this strategy in the routine care of children. METHODS: Using data on 48,743 children hospitalized for asthma exacerbation with no indication of bacterial infection during the period 2010 to 2018, we conducted a retrospective cohort study to compare clinical outcomes and resource utilization between children who received early antibiotic treatment and those who did not. RESULTS: Overall, 19,866 children (41%) received early antibiotic treatment. According to the propensity score matching analysis, children with early antibiotic treatment had longer hospital stay (mean difference, 0.21 days; 95% CI, 0.18-0.28), higher hospitalization costs (mean difference, $83.5; 95% CI, 62.9-104.0), and higher risk of probiotic use (risk ratio, 2.01; 95% CI, 1.81-2.23) than children who did not receive early antibiotic therapy. Similar results were found from inverse probability of treatment weighting, g-computation, and instrumental variable methods and sensitivity analyses. The risks of mechanical ventilation and 30-day readmission were similar between the groups or slightly higher in the treated group, depending on the statistical models. CONCLUSIONS: Antibiotic therapy may be associated with prolonged hospital stay, elevated hospitalization costs, and high risk of probiotic use without improving treatment failure and readmission. Our findings highlight the need for reducing inappropriate antibiotic use among children hospitalized for asthma.

Recent Practice Patterns and Variations in Children Hospitalized for Asthma Exacerbation in Japan.

BACKGROUND: High antibiotic prescribing rates for adults with an asthma exacerbation have been reported in developed countries, but few studies have assessed the variation of antibiotic and adjunctive treatment in the routine care of children. OBJECTIVE: We evaluated the trends in health resource utilization for children hospitalized for asthma exacerbation, ascertained the variations of practices across hospitals and geographic location, and classified these different patterns at hospital levels. METHODS: Using data on Japanese children hospitalized for asthma exacerbation with no indication of bacterial infection during 2010-2018, we conducted a retrospective observational study to assess the trends in initial treatment patterns and their variations. Mixed-effect generalized linear models were used to investigate the treatment trends. Hierarchical cluster analyses were performed to classify the treatment variations across hospitals. RESULTS: Overall, 54,981 children were eligible for the study. Proportions of antibiotic use decreased from 47.2% in 2010 to 26.9% in 2018. Similarly, utilization of antitussives, antihistamines, and methylxanthine showed decreasing trends over the period, whereas the use of mucolytics and ambroxol increased. These treatment variations were more considerable in hospital levels than in 47 prefecture levels. Hierarchical cluster analyses classified these patterns into 6 groups, mostly based on mediator release inhibitor, ambroxol, and antitussives. CONCLUSIONS: Wide variations in antibiotics and adjunctive treatments were observed across hospital levels. Our findings support the improvement in reducing inappropriate antibiotic use and highlight the need for comparative effectiveness research of the adjunctive treatments among children hospitalized for asthma.

Effects of Prophylactic Antibiotics on Length of Stay and Total Costs for Pediatric Acute Pancreatitis: A Nationwide Database Study in Japan.

OBJECTIVES: Acute pancreatitis (AP) guidelines for adult patients do not recommend routine prophylactic use of antibiotics because of no clinical merit on mortality, infectious complications, or length of stay. Although the mortality of pediatric AP is low, no studies have explored the rationale for antibiotic use in pediatric patients. The aim of this study was to evaluate the effects of early prophylactic antibiotics on length of stay and total costs in pediatric patients. METHODS: Using the Japanese Diagnosis Procedure Combination database from 2010 to 2017, we used the stabilized inverse probability of treatment weighting method using propensity scores to balance the background characteristics in the antibiotics group and the control group, and compared length of stay and total costs between the groups. RESULTS: We found significant differences between the antibiotics group (n = 652) and the control group (n = 467) in length of stay (11 days vs 9 days; percent difference, 15.4%; 95% confidence interval, 5.0%-26.8%) and total costs (US $4085 vs US $3648; percent difference, 19.8%; 95% confidence interval, 8.0%-32.9%). CONCLUSIONS: Prophylactic antibiotics were associated with longer length of stay and higher total costs. Our results do not support routine use of prophylactic antibiotics in pediatric AP populations.

Impact of Body Mass Index on Outcomes After Breast Cancer Surgery: Nationwide Inpatient Database Study in Japan.

BACKGROUND: Recent studies have shown better postoperative outcomes in mildly obese patients, a phenomenon called the obesity paradox. In the field of breast cancer surgery, however, previous studies have only shown an association between obesity and worse postoperative outcomes using multivariable analysis; the obesity paradox has not been investigated in patients undergoing breast cancer surgery. PATIENTS AND METHODS: We identified patients who underwent mastectomy for stage 0 to III breast cancer from July 2010 to March 2017 using a Japanese nationwide inpatient database. We used restricted cubic spline analyses to investigate potential nonlinear associations between body mass index (BMI) and outcomes (postoperative complications, 30-day readmission, duration of anesthesia, length of hospital stay, and hospitalization costs). We also performed multivariable regression analyses for the outcomes. RESULTS: Among 239,108 eligible patients, 25.6% had a BMI of > 25.0 kg/m2. BMI showed U-shaped associations with postoperative complications, length of stay, and hospitalization costs, and a linear association with duration of anesthesia. The proportion of postoperative complications was lowest at a BMI of around 22.0 kg/m2, while the length of stay was shortest and total costs were lowest at a BMI of around 20.0 kg/m2. Compared to a BMI of 22.0 kg/m2, a BMI of > 30.0 kg/m2 was significantly associated with greater postoperative complications, 30-day readmission, duration of anesthesia, length of stay, and hospitalization costs. CONCLUSION: Restricted cubic spline analyses displayed U-shaped associations between BMI and in-hospital complications, length of stay, and hospitalization costs, but none of the associations showed the obesity paradox.

Association between the number of hospital admissions and in-hospital outcomes in patients with heart failure.

Readmission to the hospital is a major issue in clinical care for patients with heart failure (HF). However, the impact of the number of hospital admissions due to worsened HF is not fully understood. We sought to clarify the association between the number of hospital admissions due to worsened HF and patient outcomes. We studied 331,259 patients (median age was 81 years, and 175,286 patients (52.9%) were men) hospitalized for HF between January 2010 and March 2018 using the Japanese Diagnosis Procedure Combination Database, a national inpatient database. Patients were categorized into five groups based on the number of times they were admitted: once (n = 264,583), twice (n = 42,385), three times (n = 13,205), four times (n = 5347), and five or more times (n = 5739). The patients with larger numbers of admissions were more likely to have comorbidities and to use inotropic agents. The interval period between hospitalizations was shortened with an increasing number of hospital admissions, whereas the length of hospital stay was prolonged with an increasing number of hospital admissions. Multivariable logistic regression analysis fitted with a generalized estimating equation showed that an increased number of hospital admissions was independently associated with higher in-hospital mortality. In conclusion, readmission to the hospital due to worsened HF was still common, and in-hospital mortality was higher in those with larger numbers of readmissions, suggesting a clinical significance of the number of readmissions in patients with HF.

Epinephrine autoinjector prescription patterns for severe anaphylactic patients in Japan: A retrospective analysis of health insurance claims data.

BACKGROUND: Current guidelines recommend that any patient who has experienced anaphylaxis should be prescribed one or more epinephrine autoinjectors (EAI) for immediate self-treatment. However, the etiology of anaphylaxis and prescription patterns of EAI have not been widely examined in Japan. METHODS: This was a retrospective cohort study using a large Japanese claims database (JMDC, Tokyo, Japan). We included patients with severe anaphylaxis who received epinephrine in a hospital or outpatient clinic from 2011 to 2016. We extracted patients who were prescribed EAIs and examined the annual trend of EAI prescription rates and refill patterns. RESULTS: We identified 1255 eligible patients. Among them, 361 patients (28.8%) were prescribed EAIs within 30 days after their initial severe anaphylactic episode. In patients who were prescribed EAIs, 65.9% were prescribed EAIs from the same facility in which initial treatment was given for severe anaphylaxis. The prescription rates of EAI significantly increased from 11.1% in 2011 to 30.9% in 2016. Among patients with initial EAI prescriptions, 97.3% refilled their EAI prescriptions at least once and 40.5% refilled their prescriptions annually during the 3 year follow up period. CONCLUSIONS: EAI prescription rates were relatively low in patients who experienced severe anaphylaxis in Japan. Physicians should prescribe EAIs to all patients who were treated for anaphylaxis under their care and avoid delegating the responsibility of prescribing EAIs to other facilities. Initial prescription of EAIs can result in improved regular refill and dissemination practices.

Recent treatment patterns and variations for pediatric acute encephalopathy in Japan.

BACKGROUND: Treatments for pediatric acute encephalopathy are largely empiric with limited evidence to support. This study investigated recent trends in clinical practice patterns for pediatric acute encephalopathy at a national level. METHOD: Discharge records were extracted for children with acute encephalopathy for the fiscal years 2010-2015 using a national inpatient database in Japan. We ascertained the secular trends in medications, diagnostic and therapeutic procedures, healthcare costs, in-hospital mortality, and length of hospital stays (LOS), using mixed effect linear or logistic regression models. We also ascertained variations and clustering of the practice patterns across different hospitals using hierarchical cluster analyses. RESULTS: A total of 4692 eligible inpatients were identified. From 2010 to 2015, we observed increasing trends in hospitalization costs, corticosteroid and edaravone use and a decreasing trend in LOS. Despite changes in treatments, the rates of home respiratory support and in-hospital mortality were constant during the study period. Hierarchical cluster analyses showed that 6 hospital groups showed largely different therapeutic strategies to the same disease regardless of mortality rates. Hospitals with more intensive treatment practices were likely to have higher mortality, while hospitals with less intensive treatment practices were likely to have the lower mortality. However, hospitals in one group (group 1) had less intensive treatment practice even though they had the highest mortality. CONCLUSIONS: We provided novel insights into the recent trends in treatments for pediatric acute encephalopathy. Therapeutic strategies varied between hospitals, suggesting the importance of pursuing evidence-based treatment strategy and promoting standardized practices to pediatric acute encephalopathy.

Risk Management of Aneurysmal Subarachnoid Hemorrhage by Age and Treatment Method from a Nationwide Database in Japan.

OBJECTIVE: There has been no precise guide for treatment management of aneurysmal subarachnoid hemorrhage (aSAH) based on the patient's age and treatment method. This study clarifies each risk management for aSAH according to age and treatment method listed in a nationwide database. METHODS: We compared 2 groups of patients (nonelderly, <65 years; elderly, ≥65 years) who underwent surgical clipping or endovascular coiling and were registered in a nationwide database in Japan from 2010 to 2015. The odds ratio (OR) and 95% confidence interval (CI) of each risk factor were calculated through multivariate logistic regression analysis for poor outcome according to a modified Rankin Scale score >2 at discharge for each group. RESULTS: In all groups, the risk factors for poor outcome were older age, male sex, neurologic grade on admission, diabetes mellitus, and use of anticoagulation drugs. Inverse risk factors were a high-volume hospital, academic hospital, hypertension, and use of an antiplatelet drug (OR, 0.63-0.81; 95% CI, 0.56-0.88). Chronic heart disease was also a risk factor, but use of a statin drug (OR, 0.85-0.87; 95% CI, 0.76-0.97) and location other than on the anterior communicating artery (OR, 0.74-0.80; 95% CI, 0.67-0.91) were inverse risks in both the elderly and the endovascular coiling groups. CONCLUSIONS: Management for patients with aneurysmal subarachnoid hemorrhage was recommended in high-volume and academic institutes with the administration of antiplatelet drugs and consideration of several risk factors. Elderly patients undergoing endovascular coiling might be better given a statin drug, and patients with chronic heart failure or an anterior communicating artery aneurysm should be treated more carefully.

Recent trends in practice patterns and impact of corticosteroid use on pediatric Mycoplasma pneumoniae-related respiratory infections.

BACKGROUND: Mycoplasma pneumoniae is a major pathogen causing community-acquired pneumonia/bronchitis in children, and macrolide-resistant strains are increasing in East Asian countries. Recent practice patterns, especially for antibiotic selection, and benefits of corticosteroid treatment in pediatric Mycoplasma pneumoniae infections remain unclear. METHODS: Using the Japanese Diagnosis Procedure Combination inpatient database, we analyzed recent trends in antibiotic selection and corticosteroid use for pediatric Mycoplasma pneumoniae-related respiratory infections, using multivariable mixed effects logistic regressions. In addition, we compared hospital utilization and readmission between children who received corticosteroids and those who did not, using propensity-score matching and instrumental variable analyses. RESULTS: Overall, 51,633 inpatients were identified. From 2010 to 2014, the use of macrolides and lincosamides decreased from 62.8% to 50.6% and from 25.6% to 13.7% respectively (Ptrend < 0.001), whereas fluoroquinolone use increased from 4.6% to 22.6% (Ptrend < 0.001). Tetracycline use did not demonstrate a significant change in trend. Propensity score matching analysis showed that hospital stay in the steroid group was 0.90 days longer than in the non-steroid group (95% confidence interval, 0.84-0.96). Total hospitalization cost was higher in the steroid compared to the non-steroid group (57.6 US dollars; 95% CI, 48.8-66.8). A significant difference in 30-day readmission risk was observed between the steroid (1.6%) and non-steroid (1.2%) groups (risk difference 0.4%; 95% CI, 0.1-0.7%). Similar results were observed on instrumental variable analyses. CONCLUSIONS: Increasing trends in fluoroquinolone use and decreasing trends in macrolide use were observed. Our study did not prove the benefits of corticosteroid use. Further studies are required to confirm the clinical benefits of corticosteroid treatment.

Recent trends in practice patterns and comparisons between immunoglobulin and corticosteroid in pediatric immune thrombocytopenia.

The clinical benefits and practice patterns of different pharmacologic regimes in acute pediatric immune thrombocytopenia (ITP) remain unclear in Japan. Using a national inpatient database, we analyzed recent trends in practice patterns for acute pediatric ITP, and compared risks of 6-month readmission, total hospitalization costs, and lengths of hospital stay between ITP children treated with intravenous immunoglobulin (IVIG) and corticosteroid, using inverse probability weighting analyses. From 2010 to 2014, the proportions of IVIG use increased from 43.4 to 66.0% (P trend < 0.001), while the proportions of corticosteroid use and watchful waiting decreased from 16.4 to 10% and from 28.6 to 14.3%, respectively (P trend < 0.001). No significant difference in 6-month readmission risk was observed between IVIG and corticosteroid (p = 0.28). Total length of hospital stay in the corticosteroid group was 3.5 days longer than that in IVIG (95% confidence interval, 2.1-4.6 days), whereas total hospitalization cost was greater in IVIG than in corticosteroid (difference, ¥ 207,994; 95% confidence interval, ¥ 149586-¥ 280728). A trend toward increased IVIG use was observed during the study period. Total hospitalization cost was considerably greater in the IVIG than in the corticosteroid group, whereas readmission risks were similar in both groups.