Cost-Effectiveness of Behavior Modification Intervention for Patients With Chronic Kidney Disease in the FROM-J Study.

OBJECTIVES: Chronic kidney disease (CKD) is a significant public health problem. An advanced, or innovative, CKD care system of clinical practice collaboration among general physicians (GPs), nephrologists, and other healthcare workers achieved behavior modification in patients with Stage 3 CKD in the Frontier of Renal Outcome Modifications in Japan (FROM-J) study. This behavior modification intervention consisted of educational sessions on nutrition and lifestyle, as well as encouragement of patients' regular visits. The intervention contributed to slowing CKD progression. This study aimed to evaluate the cost-effectiveness of the widespread diffusion of the behavior modification intervention proven effective by the FROM-J study. METHODS: A cost-effectiveness analysis was carried out to compare the behavior modification intervention with the current practice recommended by the latest CKD clinical guidelines for GPs. A Markov model with a societal perspective under Japan's health system was constructed. We assumed that the behavior modification intervention proven effective by the FROM-J study would be initiated by GPs for targeted patient cohorts-patients aged 40-74 years with Stage 3 CKD-as a part of the innovative CKD care system. RESULTS: The incremental cost-effectiveness ratio for the behavior modification intervention compared with current guideline-based practice was calculated as 145,593 Japanese yen (¥; $1,324 United States dollars [$]) per quality-adjusted life year (QALY). CONCLUSIONS: Using the suggested value of social willingness to pay for a one-QALY gain in Japan of ¥5 million (US$45,455) as the threshold to judge cost-effectiveness, the behavior modification intervention is cost-effective. Our results suggest that diffusing the behavior modification intervention proven effective by the FROM-J study could be justifiable as an efficient use of finite healthcare resources. GPs could be encouraged to initiate this intervention by revising the National Health Insurance fee schedule and strengthening clinical guidelines regarding behavior modification interventions.

[Content analysis of newspaper reports on passive smoking regulations in Japan].

Objectives　Ever since Tokyo was awarded the privilege to host the 2020 Olympic Games, the Japanese Ministry of Health, Labour, and Welfare has worked toward implementing a ban on passive smoking. This study examined the present situation of passive smoking in Japan, and the coverage of passive smoking regulations in newspaper reports, based on a content analysis. This was followed by a comparison with the contents of the "White Paper on Tobacco," published by the Japanese Ministry of Health, Labour, and Welfare in August, 2016.Methods　In total, 182 articles published from September 7, 2013 to March 31, 2017 were collected from three major newspapers based in Tokyo (Asahi, Yomiuri, and Mainichi). The article search criteria included the presence of the following keywords in the title or main text: "passive smoking OR entire surface smoking cessation OR indoor smoking OR indoor smoking cessation OR smoking cessation in the site OR smoking cessation in the building." Online posts and articles that did not focus mainly on the regulation of passive smoking were excluded. The 37 coding categories that were developed were classified either as positive or negative (with respect to coverage of passive smoking regulations). The assessment of passive smoking in the White Paper on Tobacco informed the coding categories, to allow the evaluation of the extent to which the contents of the White Paper were reflected in newspaper reports.Results　Among the 182 articles examined, 107 addressed only the positive aspects of the regulations, while 7 addressed only the negative aspects. Further, 50 articles addressed both positive and negative aspects, while 18 addressed neither. Among those addressing both positive and negative aspects, 14 (28%) included counterarguments to the negative comments, which consistently reflected the contents of the White Paper on Tobacco.Conclusions　Majority of the articles reported only on the positive aspects of the regulations. Persuasive articles that presented both the positive and negative aspects of the issue, which included counterarguments to the negative opinions, were scarce. However, such articles were found to some degree in the editorials of newspapers. The influence of such editorials may increase if newspapers include the pros or cons of this issue, and present counterarguments. Additionally, some topics were not reported sufficiently. Thus, problems were observed in the newspaper reports regarding passive smoking regulations.

Improving health literacy in a Japanese community population-A pilot study to develop an educational programme.

OBJECTIVE: Although a growing number of interventional studies on health literacy have been conducted recently, the majority were designed in clinical settings, focusing mainly on functional health literacy. This study evaluated a programme designed to improve health literacy in a community population, with a scope of going beyond functional health literacy. METHODS: In collaboration with an Approved Specified Nonprofit organization (NPO), we evaluated a five-session programme designed to provide basic knowledge on health-care policy and systems, current issues in health care in Japan, patient roles and relationships with health-care providers and interpersonal skills. In total, 67 of 81 programme participants agreed to participate in the study, and 54 returned the completed questionnaires at baseline and at follow-up. Health literacy and trust in the medical profession were measured at baseline and at follow-up. Participants' learning through the programme was qualitatively analysed by thematic analysis. RESULTS: Quantitative examinations of the changes in health literacy and degree of trust in medical professionals between the baseline and follow-up suggested that health literacy significantly improved after implementing the programme. The thematic analysis of participants' learning throughout the programme suggested that they not only acquired knowledge and skills but also experienced a shift in their beliefs and behaviours. DISCUSSION: Providing individuals who are motivated to learn about health-care systems and collaborate with health-care providers with the necessary knowledge and skills may improve their health literacy, which could enable them to maintain and promote their health and that of their family and other people around them.

Evaluation of the Validity of a Novel CKD Assessment Checklist Used in the Frontier of Renal Outcome Modifications in Japan Study.

OBJECTIVE: This study aimed to assess the validity of a novel chronic kidney disease (CKD) evaluation checklist method used in the Frontier of Renal Outcome Modifications in Japan study. METHODS: Nineteen patients with CKD were recruited, and each patient was assessed by 2 dietitians using the checklist and provided with lifestyle modification instructions based on their assessment. We evaluated the concordance between dietitians, and we assessed the accuracy of the protein and salt intake estimates made by dietitians who only had access to patients' food diaries and verbal reports through comparison with assessments made by an independent dietitian who additionally had access to patients' meal photographs and urine collections. RESULTS: The most frequently given instructions concerned blood pressure control (46%), followed by body mass index control (28%), and potassium control (9%). The instructions provided to patients corresponded between dietitians at rates of 94% for patients' 1st evaluation and 74% for their 2nd evaluation. The evaluated items showed good agreement between dietitians except for their estimates of salt and protein intakes. The dietitians categorized salt and protein intakes into 3 groups each (<6, 6-12, and >12 g and <0.8, 0.8-1.2, and >1.2 g/kg, respectively). The concordance rates between dietitians were 77.1% and 80.8%, and Cohen's κ coefficients were 0.633 and 0.613 for salt and protein intakes, respectively. The concordance rates between the dietitians' estimates and the independent dietitian's objective assessment were 78.5% and 45.1%, and Cohen's κ coefficients were 0.616 and 0.311 for salt and protein intakes, respectively. The estimates and objective assessments were strongly correlated for salt intake, but weakly correlated for protein intake. CONCLUSION: We concluded that the checklist method was appropriate for the evaluation of CKD patients except for protein intake estimation. We hope it will be useful for the instruction of CKD patients widely in the future.

The Speckle Tracking Imaging for the Assessment of Cardiac Resynchronization Therapy (START) study.

BACKGROUND: We sought to identify the feasibility of speckle tracking echocardiography (STE) to predict cardiac resynchronization therapy (CRT) responders in a prospective multicenter study. METHODS AND RESULTS: Patients who were newly implanted with a CRT device were enrolled. Time (T) from QRS to maximum peak radial and circumferential strain (CS) in 6 segments on the left ventricular (LV) short-axis plane, and to the maximum peak of longitudinal strain in 18 segments on 3 apical LV planes was measured (Tmax). In segments with multiple peaks on the time-strain curves, time to the first peak (Tfirst) was also assessed. Difference in T between the earliest and latest segment and standard deviation (SD) of T in each strain component were assessed. CRT responders were defined as having LV end-systolic volume reduction >15% at 6 months after CRT. Clinical outcomes were assessed with a composite endpoint of death from cardiac causes or unplanned hospitalization for heart failure. Among 180 patients, 109 patients were identified as responders. Tfirst-SD of CS >116 ms was selected as the best independent predictor of CRT responders (P<0.001, hazard ratio=9.83, 95% confidence interval 3.78-25.6). In addition, Tfirst-SD of CS was associated with the clinical endpoints. CONCLUSIONS: This prospective multicenter study revealed the high feasibility of dyssynchrony assessment by STE, which may improve the ability to predict CRT responders.

First report on 30-day and operative mortality in risk model of isolated coronary artery bypass grafting in Japan.

BACKGROUND: Risk models of coronary artery bypass grafting (CABG) using a large database are useful for improving surgical quality. To obtain accurate, high-quality assessments of the surgical outcomes, each country should maintain its own database. This study was conducted to collect Japanese data and prepare a risk stratification of isolated CABG procedures using the Japan Adult Cardiovascular Surgery Database (JACVSD). METHODS: We analyzed 7133 CABG-only records from 97 participating sites throughout Japan using a data entry form with 255 variables that was sent to the JACVSD office by our Web-based data collection system. The statistical model was constructed by multiple logistic regression. Model discrimination was tested using the area under the receiver operating characteristic curve (C index). Model calibration was tested by the Hosmer-Lemeshow test. RESULTS: Of 7133 operations, 47.2% had diabetes mellitus, 14.0% were urgent, and 15.6% involved peripheral vascular disease. The observed 30-day and operative mortality rates were 2.02% and 2.72%, respectively. Significant variables with high odds ratios included emergency or salvage status (3.71), preoperative creatinine value exceeding 3.0 mg/dL (3.59), aortic valve stenosis (3.01), and moderate to severe chronic lung disease (2.86). Hosmer-Lemeshow test and C-index values for 30-day mortality were satisfactory at 0.96 and 0.85, respectively. CONCLUSIONS: The results obtained in Japan were at least as good as those reported elsewhere. The performance of our risk model also matched those of the Society of Thoracic Surgeons National Adult Cardiac Database and the European Society Database.