Development and usability of a hospital standardized ADL ratio (HSAR) for elderly patients with cerebral infarction: a retrospective observational study using administrative claim data from 2012 to 2019 in Japan.

BACKGROUND: Maintenance of activities of daily living (ADL) during acute hospitalization is an important treatment goal, especially for elderly inpatients with diseases that often leave disabilities, such as cerebral infarction. However, studies assessing risk-adjusted ADL changes are limited. In this study, we developed and calculated a hospital standardized ADL ratio (HSAR) using Japanese administrative claims data to measure the quality of hospitalization care for patients with cerebral infarction. METHODS: This study was designed as a retrospective observational study using the Japanese administrative claim data from 2012 to 2019. The data of all hospital admissions with a primary diagnosis of cerebral infarction (ICD-10, I63) were used. The HSAR was defined as the ratio of the observed number of ADL maintenance patients to the expected number of ADL maintenance patients multiplied by 100, and ratio of ADL maintenance patients was risk-adjusted using multivariable logistic regression analyses. The c-statistic was used to evaluate the predictive accuracy of the logistic models. Changes in HSARs in each consecutive period were assessed using Spearman's correlation coefficient. RESULTS: A total of 36,401 patients from 22 hospitals were included in this study. All variables used in the analyses were associated with ADL maintenance, and evaluations using the HSAR model showed predictive ability with c-statistics (area under the curve, 0.89; 95% confidence interval, 0.88-0.89). CONCLUSIONS: The findings indicated a need to support hospitals with a low HSAR because hospitals with high/low HSAR were likely to produce the same results in the subsequent periods. HSAR can be used as a new quality indicator of in-hospital care and may contribute to the assessment and improvement of the quality of care.

Cost of illness for colorectal cancer in Japan - a time trend and future projections (1996-2035) based on governmental statistics.

BACKGROUND: In Japan, the crude mortality rate of colorectal cancer is the second highest among men and highest among women by site. We aimed to calculate the social burden of colorectal cancer using the cost of illness (COI) method and identify the main factors that drove changes in the COI. METHODS: From 1996 to 2020, the COI was estimated by summing direct, morbidity, and mortality costs. In addition, the COI by 2035 was projected by fitting approximate curves obtained from historical data to health-related indicators by sex and age. Future projections of the number of patients by the stage of disease were also made to explore the factors that changed the COI. RESULTS: The number of deaths and incidence from colorectal cancer was expected to continue increasing due to population aging. However, the COI was projected to rise from 850.3 billion yen in 1996 to 1.451 trillion yen in 2020, and peaked at 1.478 trillion yen in 2023 before it declined. CONCLUSION: Although the increased number of deaths associated with population aging increased COI, it was expected that the COI would decrease around 2023 due to a decrease in the human capital value of the deceased. In addition, the mortality rate was expected to decrease in the future due to an increase in the percentage of early detection of colorectal cancer via widespread screening and advances in medical technology.

Cost of illness in a super-aged society-comparison of breast, lung, and prostate cancer in Japan.

BACKGROUND: Aging increases the disease burden because of an increase in disease prevalence and mortality among older individuals. This could influence the perception of the social burden of different diseases and treatment prioritization within national healthcare services. Cancer is a disease with a high disease burden in Japan; however, the age-specific frequency and age-specific mortality rates differ according to site. In this study, we evaluated the relationship between the aging of the Japanese society and the disease burden by comparing the features of three cancers with different age-specific frequency rates in Japan. Furthermore, we made projections for the future to determine how the social burden of these cancers will change. METHODS: We calculated the social burden of breast, lung, and prostate cancers by adding the direct, morbidity, and mortality costs. Estimates were made using the cost of illness (COI) method. For future projections, approximate curves were fitted for mortality rate, number of hospital admissions per population, number of outpatient visits per population, and average length of hospital stay according to sex and age. RESULTS: The COI of breast, lung, and prostate cancers in 2017 was 903.7, 1,547.6, and 390.8 billion yen, respectively. Although the COI of breast and prostate cancers was projected to increase, that of lung cancer COI was expected to decrease. In 2017, the average age at death was 68.8, 76.8, and 80.7 years for breast, lung, and prostate cancers, respectively. CONCLUSIONS: Patients with breast cancer die earlier than those with other types of cancer. The COI of breast cancer ("young cancer") was projected to increase slightly because of an increase in mortality costs, whereas that of prostate cancer ("aged cancer") was projected to increase because of an increase in direct costs. The COI of lung cancer ("aging cancer") was expected to decrease in 2020, despite the increase in deaths, as the impact of the decrease in human capital value outweighed that of the increase in deaths. Our findings will help prioritize future policymaking, such as cancer control research grants.

Trends in the development process of clinical practice guidelines: a questionnaire survey for the guideline development groups in Japan.

BACKGROUND: Clinical practice guidelines (CPGs) are representative methods for promoting healthcare standardization and improving its quality. Previous studies on the CPG (published by 2006) development process in Japan reported that the involvement of experts and patients, efficient evidence collection and appraisal, and paucity of evidence on Japanese patients should be improved for the efficient CPG development. This study aimed to clarify the trends of CPG development process in Japan, focusing on the involvement of experts and patients, efficient evidence collection and appraisal, and paucity of Japanese evidence. METHODS: A cross-sectional questionnaire survey was conducted for CPG development groups to collect information on the development activities of the CPGs published from 2012 to 2019. These CPGs were identified from the Japanese guideline clearinghouse. The questionnaire included the questions on composing the group, securing funding sources, collecting and appraising the research evidence, and the difficulties in the CPG development process. The questionnaires were distributed to the chairpersons of the CPG development groups through postal mail from November 2020 to January 2021. Combining the data from the current survey with those of previous studies reporting the development process of CPGs published by 2011, we analyzed the trend in the CPG development process. RESULTS: Of the total 265 CPGs included in the analysis, 164 (response rate: 41.4%) were from the current survey and 101 (response rate: 44.5%) were from previous studies. Among these, 40 (15.1%) were published by 2005, 47 (17.7%) in 2006-2010, 77 (29.1%) in 2011-2015, and 101 (38.1%) in 2016-2019. The proportion of CPGs involving methodologists did not increase through the publication periods. The proportion of CPGs involving patients almost doubled from the first period (15.9%) to the fourth period (32.4%). The yield rates of the articles did not change through the publication periods. The difficulty in "Coping with the paucity of Japanese evidence" has been improving consistently (69.2% in the first period to 37.4% in the fourth period). CONCLUSIONS: Our results suggest the need for methodological improvement in the efficient collection and appraisal of evidence and in the system assigning experts to the CPG development groups.

Cost of illness of liver diseases in Japan.

INTRODUCTION AND OBJECTIVES: Liver disease is characterized by the progression from hepatitis to cirrhosis, followed by liver cancer, i.e., a disease with a higher mortality rate as the disease progresses. To estimate the cost of illness (COI) of liver diseases, including viral hepatitis, cirrhosis, and liver cancer, and to determine the overall effect of expensive but effective direct-acting antivirals on the COI of liver diseases. PATIENTS OR MATERIALS AND METHODS: Using a COI method from available government statistics data, we estimated the economic burden at 3-year intervals from 2002 to 2017. RESULTS: The total COI of liver diseases was 1402 billion JPY in 2017. The COI of viral hepatitis, cirrhosis, and liver cancer showed a downward trend. Conversely, other liver diseases, including alcoholic liver disease and nonalcoholic steatohepatitis (NASH), showed an upward trend. The COI of hepatitis C continued to decline despite a sharp increase in drug unit prices between 2014 and 2017. CONCLUSIONS: The COI of liver diseases in Japan has been decreasing for the past 15 years. In the future, a further reduction in patients with hepatitis C is expected, and even if the incidence of NASH and alcoholic liver disease increases, that of cirrhosis and liver cancer will likely continue to decrease.

Capturing the trends in hospital standardized mortality ratios for pneumonia: a retrospective observational study in Japan (2010 to 2018).

BACKGROUND: Pneumonia has a high human toll and a substantial economic burden in developed countries like Japan, where the crude mortality rate was 77.7 per 100,000 people in 2017. As this trend is going to continue with increasing number of the elderly multi-morbid population in Japan; monitoring performance over time is a social need to alleviate the disease burden. The study objective was to determine the characteristics of hospital standardized mortality ratios (HSMRs) for pneumonia in Japan from 2010 to 2018 to describe this trend. METHODS: Data of the DPC (Diagnostic Procedures Combination) database were used, which is an administrative claims and discharge summary database for acute care in-patients in Japan. HSMRs were calculated using the actual and expected numbers of in-hospital deaths, the latter of which was calculated using logistic regression model, with a number of explanatory variables, e.g., age, sex, urgency of admission, mode of transportation, patient volume per month in each hospital, A-DROP score, and Charlson comorbidity index (CCI). We constructed two HSMR models: a single-year model, which included hospitals with > 10 in-patients per month and, a 9-year model, which included those hospitals with complete 9-year data. Predictive accuracy of the logistic models was assessed using c-index (area under receiver operating curve). RESULTS: Total 230,372 patients were included for the analysis over the 9-year study period. Calculated HSMRs showed wide variation among hospitals. The proportion of hospitals with HSMR less than 100 increased from 36.4% in 2010 to 60.6% in 2018. Both models showed good predictive ability with a c-statistic of 0.762 for the 9-year model, and no less than 0.717 for the single-year model. CONCLUSION: This study denoted that HSMRs of pneumonia can be calculated using DPC data in Japan and revealed significant variations among hospitals with comparable case-mixes. Therefore, HSMR can be used as yet another measure to help improve quality of care over time if other indicators are examined in parallel and to get a clear picture of where hospitals excel and lack.

The structure of the quality of clinical practice guidelines with the items and overall assessment in AGREE II: a regression analysis.

BACKGROUND: The Appraisal of Guidelines for Research & Evaluation (AGREE) II has been widely used to evaluate the quality of clinical practice guidelines (CPGs). While the relationship between the overall assessment of CPGs and scores of six domains were reported in previous studies, the relationship between items constituting these domains and the overall assessment has not been analyzed. This study aims to investigate the relationship between the score of each item and the overall assessment and identify items that could influence the overall assessment. METHODS: All Japanese CPGs developed using the evidence-based medicine method and published from 2011 to 2015 were used. They were independently evaluated by three appraisers using AGREE II. The evaluation results were analyzed using regression analysis to evaluate the influence of 6 domains and 23 items on the overall assessment. RESULTS: A total of 206 CPGs were obtained. All domains and all items except one were significantly correlated to the overall assessment. Regression analysis revealed that Domain 3 (Rigour of Development), Domain 4 (Clarity of Presentation), Domain 5 (Applicability), and Domain 6 (Editorial Independence) had influence on the overall assessment. Additionally, four items of AGREE II, clear selection of evidence (Item 8), specific/unambiguous recommendations (Item 15), advice/tools for implementing recommendations (Item 19), and conflicts of interest (Item 22), significantly influenced the overall assessment and explained 72.1% of the variance. CONCLUSIONS: These four items may highlight the areas for improvement in developing CPGs.

Trends in hospital standardized mortality ratios for stroke in Japan between 2012 and 2016: a retrospective observational study.

OBJECTIVE: Stroke is one of the leading causes of death and disability, and imposes a major healthcare burden. The aim of this study was to determine the characteristics of hospital standardized mortality ratios (HSMRs) for stroke in Japan for the year 2012-16 to describe the trend. DESIGN: Retrospective observational study. SETTING: Data from the Japanese administrative database. PARTICIPANTS: All hospital admissions for stroke were identified from diagnostic procedures combination (DPC) database from 2012 to 2016. MAIN OUTCOME MEASURES: HSMR was calculated using the actual number of in-hospital deaths and expected deaths. To obtain the expected death number, a logistic regression model was developed to get the coefficient with a number of explanatory variables. Predictive accuracy of the logistic models was assessed using c-index and calibration was evaluated using the Hosmer-Lemeshow test. RESULTS: A total of 63 084 patients admitted for stroke from January 2012 to December 2016 were analyzed. HSMRs showed declining tendency over these 5 years, suggesting stroke-related mortality has been improving. While the HSMRs varied from year to year, a wide variation was also seen among the different hospitals in Japan. The proportion of hospitals with HSMR less than 100 increased from 41.0% in 2012 to 59.0% in 2016. CONCLUSION: This study demonstrated that HSMR can be calculated using DPC data and found wide variation in HSMR of stroke among hospitals in Japan and enabled us to image the trend. By examining these trends, facilities, authorities and provinces can initiate designs that will ultimately lead to an upgraded healthcare delivery system.

Comprehensive cost of illness of dementia in Japan: a time trend analysis based on Japanese official statistics.

OBJECTIVE: To analyze the chronological change in social burden of dementia in Japan for policy implications of appropriate resource allocation and quality improvement. DESIGN: National, population-based, observational study from 2002 to 2014. SETTING: Seven nationwide data sets from Japanese official statistics. METHOD: Comprehensive Cost of Illness method. MAIN OUTCOME MEASURES: The outcome variables included healthcare services, nursing care services, informal care (unpaid care offered by family and relatives), mortality cost and morbidity cost. RESULTS: The number of patients with dementia increased 2.50 times from 0.42 million in 2002 to 1.05 million in 2014. While the number of patients living in homes and communities increased by 3.22 times that of patients living in nursing care facilities increased by 1.42 times. The total social burden increased 2.06-2.27 times from JPY 1.84-2.42 to 3.79-5.51 trillion (JPY 1 trillion = US$ 100 billion). Regarding the total burden, the proportion of informal care provided increased from 36.6-51.9% to 37.7-57.2%. Furthermore, the proportion of primary caretakers aged ≥70 years increased from 27.6% to 37.6%. CONCLUSIONS: Owing to the promotion of 'Deinstitutionalization' (shift of nursing care site from in-facilities to in-home and in-community), 'Elderly care by the elderly,' and 'Earlier diagnosis of dementia,' the average cost per patient reduced by 0.82-0.91 times from JPY 4.37-5.77 to 3.60-5.24 million. Therefore, the management of informal care in a manner that does not exceed the acceptable limit of the patients' caretakers, while maintaining patient safety and quality of care, is imperative.

Cost of illness of non-alcoholic liver cirrhosis in Japan: A time trend analysis and future projections.

AIM: Liver cirrhosis is a preneoplastic condition to hepatocellular carcinoma that is an important worldwide public health concern, and its economic burden has been estimated in some countries. The objective of this study was to estimate and predict the cost of illness (COI) associated with non-alcoholic liver cirrhosis in Japan. METHODS: Using a COI method on available data from government statistics, we estimated the economic burden in 3-year intervals from 1996 to 2014. We then predicted the COI in 3-year intervals from 2017 to 2029 using fixed and variable model estimations. With fixed model estimation, only the estimated future population was used as a variable. Variable model estimation considered the time trends of health-related indicators throughout the past 18 years. RESULTS: The estimated COI of non-alcoholic liver cirrhosis was ¥208.1bn in 2014. The COI of non-alcoholic liver cirrhosis had a downward trend from 1996 to 2014. The predicted future COI of non-alcoholic liver cirrhosis was ¥144.3-210.5bn, ¥106.0-213.8bn, ¥88.6-213.4bn, ¥76.7-215.5bn, and ¥66.4-214.3bn in 2017, 2020, 2023, 2026, and 2029, respectively. CONCLUSIONS: The results of this study suggest that the COI of non-alcoholic liver cirrhosis in Japan has steadily decreased and will continue to decrease. Treatment of patients with hepatitis C virus infection with newly introduced technologies has high therapeutic effectiveness, which will affect the future prevalence of non-alcoholic liver cirrhosis. When interpreting the results of long-term estimation, it should be noted that the results of this study were based on present conditions.

Effects of the concentration of digestive surgical operations in regional Japan.

PURPOSE: The purpose of this study was to investigate the relationship between the concentration of digestive system surgery and outcomes at a regional level in Japan, using time-series data. METHODS: We used nationwide data from 2008 to 2013, and analyzed the ten most common surgical procedures. The unit of analysis was secondary medical areas (SMAs), which cover several municipalities and provide medical services for common diseases. The concentration of surgery in these areas was measured using the Herfindahl-Hirschman Index (HHI) and the relationship between the concentration of surgery and length of stay in hospital (LOS) was analyzed, in accordance with surgical difficulty. RESULTS: There was a downward trend in both the HHI and LOS from 2008 to 2013. SMAs showing an upward trend in the HHI (increased concentration) were associated with a greater reduction in LOS than those showing a downward trend for eight surgical procedures. For three easy surgical procedures, increased concentration of surgery was significantly associated with a reduction in LOS. After adjustment for trends in the aging population and the surgical volume in 2008, an increasing concentration for three easy surgical procedures was significantly related to a reduction in the LOS. CONCLUSION: Concentrating relatively easy surgical procedures at a regional level may be associated with a reduction in LOS.

Cost of illness of ischemic heart disease in Japan: a time trend and future projections.

BACKGROUND: Ischemic heart disease (IHD/ICD10: I20-I25) is the second leading cause of deaths in Japan and accounts for 40% of deaths due to heart diseases. This study aimed to calculate the economic burden of IHD using the cost of illness (COI) method and to identify key factors that drive the change of the economic burden of IHD. METHODS: We calculated the cost of illness (COI) every 3 years from 1996 to 2014 using governmental statistics. We then predicted the COI for every 3 years starting from 2017 up to 2029 using the fixed and variable model estimations. Only the estimated future population was used as a variable in the fixed model estimation. By contrast, variable model estimation considered the time trend of health-related indicators over the past 18 years. We derived the COI from the sum of direct and indirect costs (morbidity and mortality). RESULTS: The past estimation of COI slightly increased from 1493.8 billion yen in 1996 to 1708.3 billion yen in 2014. Future forecasts indicated that it would decrease from 1619.0 billion yen in 2017 to 1220.5 billion yen in 2029. CONCLUSION: The past estimation showed that the COI of IHD increased; in the mixed model, the COI was predicted to decrease with the continuing trend of health-related indicators. The COI of IHD in the future projection showed that, although the average age of death increased by social aging, the influence of the number of deaths and mortality cost decreased.

Informing health policy in Japan: A mixed-model estimation to compare the cost of illness of cervical cancer and endometrial cancer.

AIM: The objective of this study was to inform Japanese health policy by comparing cervical cancer and endometrial cancer from the standpoint of economic burden and examining factors affecting future changes in economic burden. METHODS: Using government-based nationwide statistical data, we used the cost-of-illness (COI) method to estimate the COI from 1996 to 2011 and predicted future estimates for 2014, 2017, and 2020. RESULTS: In 2011, the COI of cervical cancer was estimated at 159.9 billion yen and that of endometrial cancer was estimated at 99.5 billion yen. Assuming the current trends in health-related indicators, the COI of cervical cancer is predicted to temporarily decrease in 2014 and then remain constant. Meanwhile, the COI of endometrial cancer is predicted to temporarily decrease in 2014 before returning to an upward trend. CONCLUSION: The COI of both cervical cancer and endometrial cancer is estimated to remain constant or increase in the future. The average age of death from cervical cancer is predicted to remain relatively young and the high human capital value of patients who die in their sixties is the most likely explanation for the lack of decrease in future COI. As women's participation in society continues to increase, the future COI may also increase. Regarding endometrial cancer, the increase in direct costs, particularly hospitalization costs, is a likely factor resulting in the increase in the COI. This is because women are surviving longer, and thus receiving care for longer durations, because of advancements in medical care.

Cost of illness of the prostate cancer in Japan--a time-trend analysis and future projections.

BACKGROUND: The majority of patients with prostate cancer (International Classification of Diseases, 10th edition, code C61) are elderly. With Japan's rapidly society aging, both the prevalence and mortality of prostate cancer are expected to increase in the future. The objective of this study was to estimate and predict the cost of illness (COI) associated with prostate cancer in Japan. METHODS: Using a COI method based on available data from government office statistics, we estimated the COI for 2002, 2005, 2008, and 2011. We then predicted the COI for 2014, 2017, and 2020 using fixed model estimation and variable model estimation. With fixed model estimation, only estimated future population was used as a variable. Variable model estimation considered the time trend of health-related indicators in the past 15 years. We derived the COI from the sum of direct and indirect costs (morbidity and mortality). RESULTS: We found the predicted future COI of prostate cancer to be 354.7-378.3 billion yen in 2014, 370.8-421.0 billion yen in 2017, and 385.3-474.1 billion yen in 2020. Regardless of the estimation model, we found that COI would increase compared with the baseline year 2011 (307.3 billion yen). The direct costs for inpatient and outpatient treatment, laboratory tests, and drugs accounted for 60-75% of the COI of prostate cancer. CONCLUSIONS: The results of this study suggest that the COI of prostate cancer in Japan has steadily increased and is expected to rise in the future. Direct costs comprised the largest proportion of the COI and are anticipated to continue expanding; this will result in increased burden on public funds in Japan, where a universal public insurance system operates. These trends differ from those with other forms of cancer.

Cost of illness of the cervical cancer of the uterus in Japan--a time trend and future projections.

BACKGROUND: Cervical cancer is associated with high morbidity and mortality rates among young women in Japan. The objective of this study was to assess and project the economic burden associated with cervical cancer in Japan and identify factors affecting future changes in this burden on society. METHODS: Utilizing government-based statistical nationwide data, we used the cost of illness (COI) method to estimate the COIs for 1996, 1999, 2002, 2005, 2008, and 2011 to make predictions for 2014, 2017, and 2020. The COI comprised direct and indirect costs (morbidity and mortality costs). RESULTS: The COI was estimated to have increased by 66% from 96.1 billion yen in 1996 to 159.9 billion yen in 2011. The number of deaths increased, but the proportion of those aged ≥65 years as a percentage of all deaths remained mostly unchanged, with no increase in the average age at death. The mortality cost per person was estimated to have increased (31.5 million yen in 1996 vs. 43.5 million yen in 2011). Assuming that the current trend in health-related indicators continues, the COI is predicted to temporarily decrease in 2014, followed by almost no change in 2020 (the estimated COI is 145.3-164.6 billion yen). The mortality cost per person is predicted to remain almost unchanged (39.4-46.3 million yen in 2020). CONCLUSIONS: The fact that the life expectancy of affected individuals is not being prolonged and that the mortality in young individuals with a high human capital value is not decreasing may contribute to future sustainment of the COI. We believe that the results of the present study are applicable to discussions of disease control priorities.

Characteristics of unit-level patient safety culture in hospitals in Japan: a cross-sectional study.

BACKGROUND: Patient safety culture (PSC) has an important role in determining safety and quality in healthcare. Currently, little is known about the status of unit-level PSC in hospitals in Japan. To develop appropriate strategies, characteristics of unit-level PSC should be investigated. Work units may be classified according to the characteristics of PSC, and common problems and appropriate strategies may be identified for each work unit category. This study aimed to clarify the characteristics of unit-level PSC in hospitals in Japan. METHODS: In 2012, a cross-sectional study was conducted at 18 hospitals in Japan. The Hospital Survey on Patient Safety Culture questionnaire, developed by the United States Agency for Healthcare Research and Quality, was distributed to all healthcare workers (n =12,076). Percent positive scores for 12 PSC sub-dimensions were calculated for each unit, and cluster analysis was used to categorise the units according to the percent positive scores. A generalised linear mixed model (GLMM) was used to analyse the results of the cluster analysis, and odds ratios (ORs) for categorisation as high-PSC units were calculated for each unit type. RESULTS: A total of 9,124 respondents (75.6%) completed the questionnaire, and valid data from 8,700 respondents (72.0%) were analysed. There were 440 units in the 18 hospitals. According to the percent positive scores for the 12 sub-dimensions, the 440 units were classified into 2 clusters: high-PSC units (n =184) and low-PSC units (n =256). Percent positive scores for all PSC sub-dimensions for high-PSC units were significantly higher than those for low-PSC units. The GLMM revealed that the combined unit type of 'Obstetrics and gynaecology ward, perinatal ward or neonatal intensive care unit' was significantly more likely to be categorised as high-PSC units (OR =9.7), and 'Long-term care ward' (OR =0.2), 'Rehabilitation unit' (OR =0.2) and 'Administration unit' (OR =0.3) were significantly less likely to be categorised as high-PSC units. CONCLUSIONS: Our study findings demonstrate that PSC varies considerably among different unit types in hospitals in Japan. Factors contributing to low PSC should be identified and possible measures for improving PSC should be developed and initiated.

Cost of illness of the stomach cancer in Japan - a time trend and future projections.

BACKGROUND: Stomach cancer is one of the leading causes of cancer deaths in Japan. The objectives of this study were to estimate and project the economic burden associated with stomach cancer in Japan, and to identify the key factors that drive the economic burden of stomach cancer. METHODS: We calculated Cost of illness (COI) of 1996, 2002, 2008, 2014 and 2020 by using government office statistics and the COI method. We calculated direct cost and indirect cost (morbidity cost and mortality cost), and estimated the COI by summing them up. RESULTS: The number of deaths remained at approximately 50,000 in 1996-2008. COI was in downward trend from 1,293.5 billion yen in 1996 to 1,114.2 billion yen in 2008. Morbidity cost was 85.6 billion yen and 54.0 billion yen, mortality cost was 972.3 billion yen and 806.4 billion yen, and mortality cost per person was 19.4 million yen and 16.1 million yen in 1996 and 2008, respectively. Decrease of mortality cost that accounted for a large part of the COI (72.4% in 2008) was the major contributing factor. COI is predicted to decrease if the trend of health related indicators continues (442.8-1,056.1 billion yen depending on the model in 2020). Mortality cost per person is also predicted to decrease (9.5-12.5 million yen depending on the model in 2020). CONCLUSIONS: If the trend of health related indicators continues, it is estimated that COI of stomach cancer would decrease. "Aging", "change of the healthcare providing system" and "new medical technology" are considered as contributing factors of COI.

The characteristics of patient safety culture in Japan, Taiwan and the United States.

BACKGROUND: Quality and safety issues are receiving growing attention. Patient safety culture (PSC) plays an important role in patient safety. The characteristics of PSC in various countries, each with a different set of values, have not been determined sufficiently. The aim of this study is to investigate the characteristics of PSC in Japan, Taiwan and the U.S. METHODS: A cross-sectional survey was conducted in Japan and Taiwan using the Hospital Survey on PSC (HSOPS) questionnaire developed by the U.S. Agency for Healthcare Research and Quality (AHRQ). Data from Japan and Taiwan were also compared with the U.S. "2010 HSOPS Comparative Database" provided by AHRQ. RESULTS: Valid response rates in Japan, Taiwan and the U.S. were 66.5% (6,963/10,466), 85.7% (10,019/11,692) and 35.2% (291,341/827,424), respectively. The proportion of respondents with some experience of event reporting during the past 12 months was highest in Japan. In general, U.S. healthcare workers were likely to evaluate their PSC higher than that in Japan or Taiwan. The attitude of continuous improvement in Japan and event reporting of near misses in Taiwan were rated as low. In the U.S., staffing was rated as high. CONCLUSIONS: The results suggest that PSC varies among different countries, and the cultural setting of each country should be given special consideration in the development of effective intervention plans to improve PSC. Additional investigations with improved methodology and a common protocol are required to accurately compare PSCs among countries.

The impact of nurse working hours on patient safety culture: a cross-national survey including Japan, the United States and Chinese Taiwan using the Hospital Survey on Patient Safety Culture.

BACKGROUND: A positive patient safety culture (PSC) is one of the most critical components to improve healthcare quality and safety. The Hospital Survey on Patient Safety Culture (HSOPS), developed by the US Agency for Healthcare Research and Quality, has been used to assess PSC in 31 countries. However, little is known about the impact of nurse working hours on PSC. We hypothesized that long nurse working hours would deteriorate PSC, and that the deterioration patterns would vary between countries. Moreover, the common trends observed in Japan, the US and Chinese Taiwan may be useful to improve PSC in other countries. The purpose of this study was to clarify the impact of long nurse working hours on PSC in Japan, the US, and Chinese Taiwan using HSOPS. METHODS: The HSOPS questionnaire measures 12 sub-dimensions of PSC, with higher scores indicating a more positive PSC. Odds ratios (ORs) were calculated using a generalized linear mixed model to evaluate the impact of working hours on PSC outcome measures (patient safety grade and number of events reported). Tukey's test and Cohen's d values were used to verify the relationships between nurse working hours and the 12 sub-dimensions of PSC. RESULTS: Nurses working ≥60 h/week in Japan and the US had a significantly lower OR for patient safety grade than those working <40 h/week. In the three countries, nurses working ≥40 h/week had a significantly higher OR for the number of events reported. The mean score on 'staffing' was significantly lower in the ≥60-h group than in the <40-h group in all the three countries. The mean score for 'teamwork within units' was significantly lower in the ≥60-h group than in the <40-h group in Japan and Chinese Taiwan. CONCLUSIONS: Patient safety grade deteriorated and the number of events reported increased with long working hours. Among the 12 sub-dimensions of PSC, long working hours had an impact on 'staffing' and 'teamwork within units' in Japan, the US and Chinese Taiwan.

Difference in prioritization of patient safety interventions between experts and patient safety managers in Japan.

Although a variety of patient safety interventions have been implemented, prioritizing them in a limited resource environment is important. The intervention priorities of patient safety managers may differ from those of patient safety experts. This study aimed to clarify the difference in prioritization of interventions between experts and safety managers to better identify interventions that should be promoted in Japan. We performed a secondary data analysis of two surveys: the Delphi survey for Japanese experts and a nationwide questionnaire survey for safety managers in hospitals. Regarding the 32 interventions constituting 14 organizational-level and 18 clinical-level interventions examined in the previous studies, we assessed three correlations to examine the difference in prioritization between experts and safety managers: correlations between experts and safety managers in the three perspectives (contribution, dissemination, and priority), those between priorities of experts and safety managers at the clinical and organizational level, and those among the three perspectives in experts and safety managers. Contribution (r = 0.768) and dissemination (r = 0.689) of patient safety interventions evaluated by experts and safety managers were positively correlated, but priorities were not. Interventions with priorities that differed between experts and safety managers were identified. In experts, there was no significant correlation between contribution and priority or between dissemination and priority. For safety managers, contributions (r = 0.812) and dissemination (r = 0.691) were positively correlated with priority. Our results suggest that patient safety managers evaluated future priority based on past contributions and current dissemination, whereas experts evaluated future priority based on other factors, such as expected impacts in the future, as mentioned in the previous study. In health policymaking, promotion of patient safety interventions that were given high priority by experts, but low priority by safety managers, should be considered with possible incentives.