Antimicrobial Prophylaxis With Ampicillin-sulbactam Compared With Cefazolin for Esophagectomy: Nationwide Inpatient Database Study in Japan.

OBJECTIVE: To assess the effect of antimicrobial prophylaxis with ampicillin-sulbactam (ABPC/SBT) compared with cefazolin (CEZ) on the short-term outcomes after esophagectomy. BACKGROUND: CEZ is widely used for antimicrobial prophylaxis in esophagectomy without procedure-specific evidence, whereas ABPC/SBT is preferred in some hospitals to target both aerobic and anaerobic oral bacteria. METHODS: Data of patients who underwent esophagectomy for cancer between July 2010 and March 2019 were extracted from a nationwide Japanese inpatient database. Overlap propensity score weighting was conducted to compare the short-term outcomes [including surgical site infection (SSI), anastomotic leakage, and respiratory failure] between antimicrobial prophylaxis with CEZ and ABPC/SBT after adjusting for potential confounders. Sensitivity analyses were also performed using propensity score matching and instrumental variable analyses. RESULTS: Among 17,772 eligible patients, 16,077 (90.5%) and 1695 (9.5%) patients were administered CEZ and ABPC/SBT, respectively. SSI, anastomotic leakage, and respiratory failure occurred in 2971 (16.7%), 2604 (14.7%), and 2754 patients (15.5%), respectively. After overlap weighting, ABPC/SBT was significantly associated with a reduction in SSI [odds ratio 0.51 (95% CI: 0.43-0.60)], anastomotic leakage [0.51 (0.43-0.61)], and respiratory failure [0.66 (0.57-0.77)]. ABPC/SBT was also associated with reduced respiratory complications, postoperative length of stay, and total hospitalization costs. The proportion of Clostridioides difficile colitis and noninfectious complications did not differ between the groups. Propensity score matching and instrumental variable analyses demonstrated equivalent results. CONCLUSIONS: The administration of ABPC/SBT as antimicrobial prophylaxis for esophagectomy was associated with better short-term postoperative outcomes compared with CEZ.

Impact of Body Mass Index on Major Complications, Multiple Complications, In-hospital Mortality, and Failure to Rescue After Esophagectomy for Esophageal Cancer: A Nationwide Inpatient Database Study in Japan.

OBJECTIVE: To examine the association of BMI with mortality and related outcomes after oncologic esophagectomy. SUMMARY BACKGROUND DATA: Previous studies showed that high BMI was a risk factor for anastomotic leakage and low BMI was a risk factor for respiratory complications after esophagectomy. However, the association between BMI and in-hospital mortality after oncologic esophagectomy remains unclear. METHODS: Data for patients who underwent esophagectomy for esophageal cancer between July 2010 and March 2019 were extracted from a Japanese nationwide inpatient database. Multivariate regression analyses and restricted cubic spline analyses were used to investigate the associations between BMI and short-term outcomes, adjusting for potential confounders. RESULTS: Among 39,406 eligible patients, in-hospital mortality, major complications, and multiple complications (≥2 major complications) occurred in 1069 (2.7%), 14,824 (37.6%), and 3621 (9.2%), respectively. Compared with normal weight (18.5-22.9 kg/m 2 ), severe underweight (<16.0 kg/m 2 ), mild/moderate underweight (16.0-18.4 kg/m 2 ), and obese (≥27.5 kg/m 2 )were significantly associated with higher in-hospital mortality [odds ratio 2.20 (95% confidence interval 1.65-2.94), 1.25 (1.01-1.49), and 1.48 (1.05-2.09), respectively]. BMI showed U-shaped dose-response associations with mortality, major complications, and multiple complications. BMI also showed a reverse J-shaped association with failure to rescue (death after major complications). CONCLUSIONS: Both high BMI and low BMI were associated with mortality, major complications and multiple complications after esophagectomy for esophageal cancer. Patients with low BMI were more likely to die once a major complication occurred. The present results can assist with risk stratification in patients undergoing oncologic esophagectomy.

Impact of Prophylactic Corticosteroid Use on In-hospital Mortality and Respiratory Failure After Esophagectomy for Esophageal Cancer: Nationwide Inpatient Data Study in Japan.

OBJECTIVE: To assess the effect of preoperative prophylactic corticosteroid use on short-term outcomes after oncologic esophagectomy. BACKGROUND: Previous studies have shown that prophylactic corticosteroid use may decrease the risk of respiratory failure following esophagectomy by attenuating the perioperative systemic inflammation response. However, its effectiveness has been controversial, and its impact on mortality remains unknown. METHODS: Data of patients who underwent oncologic esophagectomy between July 2010 and March 2019 were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting, propensity score matching, and instrumental variable analyses were performed to investigate the associations between prophylactic corticosteroid use and short-term outcomes, such as in-hospital mortality and respiratory failure, adjusting for potential confounders. RESULTS: Among 35,501 eligible patients, prophylactic corticosteroids were used in 22,620 (63.7%) patients. In-hospital mortality, respiratory failure, and severe respiratory failure occurred in 924 (2.6%), 5440 (15.3%), and 2861 (8.1%) patients, respectively. In stabilized inverse probability of treatment weighting analyses, corticosteroids were significantly associated with decreased in-hospital mortality [odds ratio (OR)=0.80; 95% confidence interval (CI): 0.69-0.93], respiratory failure (OR=0.84; 95% CI: 0.79-0.90), and severe respiratory failure (OR=0.87; 95% CI: 0.80-0.95). Corticosteroids were also associated with decreased postoperative length of stay and total hospitalization costs. The proportion of anastomotic leakage did not differ with the use of Propensity score matching and instrumental variable analysis demonstrated similar results. CONCLUSIONS: Prophylactic corticosteroid use in oncologic esophagectomy was associated with lower in-hospital mortality as well as decreased respiratory failure and severe respiratory failure, suggesting a potential benefit for preoperative corticosteroid use in esophagectomy.

Early postoperative non-steroidal anti-inflammatory drugs and anastomotic leakage after oesophagectomy.

BACKGROUND: Previous studies have suggested that postoperative non-steroidal anti-inflammatory drug (NSAID) use may increase the risk of anastomotic leakage after colorectal surgery. However, the association between NSAIDs and anastomotic leakage after oesophagectomy is unclear. The aim of this retrospective study was to assess the effect of early postoperative NSAID use on anastomotic leakage after oesophagectomy. METHODS: The Data of patients who underwent oesophagectomy for cancer between July 2010 and March 2019 were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting (IPTW), propensity score matching, and instrumental variable analyses were performed to investigate the association between NSAID use in the early postoperative period (defined as the day of and the day after surgery) and short-term outcomes, adjusting for potential confounders. The primary outcome was anastomotic leakage. The secondary outcomes were acute kidney injury, gastrointestinal bleeding, and mortality. RESULTS: Among 39 418 eligible patients, early postoperative NSAIDs were used by 16 211 individuals (41 per cent). Anastomotic leakage occurred in 5729 patients (15 per cent). In stabilized IPTW analyses, NSAIDs were not associated with anastomotic leakage (odds ratio 1.04, 95 per cent c.i. 0.97 to 1.10). The proportions of acute kidney injury and gastrointestinal bleeding, as well as 30-day mortality and in-hospital mortality, did not differ according to NSAID use. Propensity score matching and instrumental variable analyses demonstrated similar results. CONCLUSION: Early postoperative NSAID use was not associated with anastomotic leakage or other complications in patients who underwent oesophagectomy.

Facility staffing associated with potentially avoidable hospitalizations in nursing home residents in Japan: a retrospective cohort study.

BACKGROUND: Wide variations in facility staffing may lead to differences in care, and consequently, adverse outcomes such as hospitalizations. However, few studies focused on types of occupations. Therefore, we aimed to examine the association between a wide variety of facility staffing and potentially avoidable hospitalizations of nursing home residents in Japan. METHODS: In this retrospective cohort study using long-term care and medical insurance claims data in Ibaraki Prefecture from April 2018 to March 2019, we identified individuals aged 65 years and above who were newly admitted to nursing homes. In addition, facility characteristic data were obtained from the long-term care insurance service disclosure system. Subsequently, we conducted a multivariable Cox regression analysis and evaluated the association between facility staffing and potentially avoidable hospitalizations. RESULTS: A total of 2909 residents from 235 nursing homes were included. The cumulative incidence of potentially avoidable hospitalizations at 180 days was 14.2% (95% confidence interval [CI] 12.7-15.8). Facilities with full-time physicians (adjusted hazard ratio [HR]: 0.59, 95% CI: 0.37-0.94) and a higher number of dietitians (HR: 0.72, 95% CI: 0.54-0.97) were significantly associated with a lower likelihood of potentially avoidable hospitalizations. In contrast, having nurses or trained caregivers during the night shift (HR: 1.72, 95% CI: 1.25-2.36) and a higher number of care managers (HR: 1.37, 95% CI: 1.03-1.83) were significantly associated with a high probability of potentially avoidable hospitalizations. CONCLUSIONS: We revealed that variations in facility staffing were associated with potentially avoidable hospitalizations. The results suggest that optimal allocation of human resources, such as dietitians and physicians, may be essential to reduce potentially avoidable hospitalizations. To provide appropriate care to nursing home residents, it is necessary to establish a system to effectively allocate limited resources. Further research is warranted on the causal relationship between staff allocation and unnecessary hospitalizations, considering the confounding factors.

Outcomes After Endoscopic Evacuation Versus Evacuation Using Craniotomy or Stereotactic Aspiration for Spontaneous Intracerebral Hemorrhage: Analysis Using a Japanese Nationwide Database.

BACKGROUND: Various surgical methods are available for managing large intracerebral hemorrhage. This study compared the prognosis of patients with spontaneous intracerebral hemorrhage who underwent endoscopic evacuation, stereotactic aspiration, and craniotomy by using a nationwide inpatient database in Japan. METHODS: Using the Diagnosis Procedure Combination database, we identified patients who underwent surgery for spontaneous intracerebral hemorrhage within 48 h after admission between April 2014 and March 2018. Eligible patients were classified into three groups according to the type of surgery (endoscopic surgery, stereotactic surgery, and craniotomy). Propensity score matching weight analysis was conducted to compare poor modified Rankin Scale score at discharge (severe disability or death) and hospitalization cost among the groups. RESULTS: Among 17,860 eligible patients, craniotomy, stereotactic surgery, and endoscopic surgery were performed in 14,354, 474, and 3,032 patients, respectively. In the matching weight analysis, all covariates were well balanced. Compared with the endoscopic surgery group, the proportion of poor prognosis (modified Rankin Scale score at discharge of 5 or 6) was significantly higher in craniotomy groups (odds ratio 2.51, 95% confidence interval 1.11-5.68; p = 0.028). Subgroup analysis based on hemorrhage location and consciousness level at the time of admission showed no significant difference between the surgical procedures. Hospitalization costs were significantly higher in the craniotomy group than in the endoscopic surgery group (difference US $9,724, 95% confidence interval 2,169-17,259; p = 0.011). CONCLUSIONS: Endoscopic surgery for spontaneous intracerebral hemorrhage was associated with improved prognosis compared with craniotomy at the hospital discharge. Future large-scale clinical trials are needed to evaluate the optimal surgical techniques for intracerebral hemorrhage.

Endoscopic surgery versus craniotomy for spontaneous intracerebral hemorrhage in the late elderly patients.

OBJECTIVES: To compare the prognosis of late elderly patients with spontaneous intracerebral hemorrhage (ICH) treated by endoscopic evacuation and craniotomy MATERIALS AND METHODS: Using the Diagnosis Procedure Combination database, we identified patients aged ≥ 75 years who underwent surgery for spontaneous ICH within 48 hours after admission between April 2014 and March 2018. Eligible patients were classified into two groups according to the type of surgery (endoscopic surgery and craniotomy). Propensity-score matching weight analysis was conducted to compare the good neurological outcome modified Rankin Scale (mRS) score (0-4) at discharge as the primary endpoint between the two groups. Secondary endpoints were postoperative meningitis, tracheostomy, reoperation within 3 days and total hospitalization costs. RESULTS: Among the 5,396 eligible patients, endoscopic surgery and craniotomy were performed in 895 and 4,501 patients, respectively. In the propensity-score matching weight analysis, all covariates were well balanced. The proportions of patients with a good prognosis (mRS score at discharge: 0-4) did not significantly differ between the surgical procedures (42.1% vs. 42.8%, p = 0.828). The proportions of meningitis, tracheostomy and reoperation were not significantly different between the two groups. Hospitalization costs were significantly higher in the craniotomy group than in the endoscopic surgery group (25,536 vs. 29,603 US dollars, p = 0.012). CONCLUSIONS: Inhospital outcomes did not differ between endoscopic and open surgeries for spontaneous ICH in the late-stage elderly patients aged ≥75 years. Hospitalization costs were significantly higher in the craniotomy group, suggesting that endoscopic surgery may be more acceptable.

Short-Term Outcomes of Epidural Analgesia in Minimally Invasive Esophagectomy for Esophageal Cancer: Nationwide Inpatient Data Study in Japan.

BACKGROUND: Studies have shown that epidural analgesia (EDA) is associated with a decreased risk of pneumonia and anastomotic leakage after esophagectomy, and several guidelines strongly recommend EDA use after esophagectomy. However, the benefit of EDA use in minimally invasive esophagectomy (MIE) remains unclear. OBJECTIVE: The aim of this retrospective study was to compare the short-term outcomes between patients with and without EDA undergoing MIE for esophageal cancer. METHODS: Data of patients who underwent oncologic MIE (April 2014-March 2019) were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting (IPTW), propensity score matching, and instrumental variable analyses were performed to investigate the associations between EDA use and short-term outcomes, adjusting for potential confounders. RESULTS: Among 12,688 eligible patients, EDA was used in 9954 (78.5%) patients. In-hospital mortality, respiratory complications, and anastomotic leakage occurred in 230 (1.8%), 2139 (16.9%), and 1557 (12.3%) patients, respectively. In stabilized IPTW, EDA use was significantly associated with decreased in-hospital mortality (odds ratio [OR] 0.46 [95% confidence interval 0.34-0.61]), respiratory complications (OR 0.74 [0.66-0.84]), and anastomotic leakage (OR 0.77 [0.67-0.88]). EDA use was also associated with decreased prolonged mechanical ventilation, unplanned intubation, nonsteroidal anti-inflammatory drug use, acetaminophen use, postoperative length of stay, and total hospitalization costs and increased vasopressor use. One-to-three propensity score matching and instrumental variable analyses demonstrated equivalent results. CONCLUSIONS: EDA use in oncologic MIE was associated with low in-hospital mortality as well as decreased respiratory complications, and anastomotic leakage, suggesting the potential advantage of EDA use in MIE.

Effects of Early Postdischarge Rehabilitation Services on Care Needs-Level Deterioration in Older Adults With Functional Impairment: A Propensity Score-Matched Study.

OBJECTIVE: To examine the effects of early postdischarge rehabilitation on care needs-level deterioration in older Japanese patients. DESIGN: Propensity score-matched retrospective cohort study. SETTING: A secondary data analysis was conducted using medical and long-term care insurance claims data from a suburban city in Japan. PARTICIPANTS: We analyzed patients (N=2746) aged 65 years or older who were discharged from hospital to home between April 2012 and March 2014 and had care needs certification indicating functional impairment. INTERVENTIONS: The provision of early rehabilitation services by rehabilitation therapists within 1 month of discharge. Propensity score matching was used to control for differences in characteristics between patients with and without early rehabilitation services. MAIN OUTCOME MEASURES: Any deterioration in care needs level during the 12-month period after discharge. Cox proportional hazards analyses were conducted to identify the association between the exposure and outcome variables after matching. RESULTS: Among 2746 patients, 573 (20.9%) used early rehabilitation services. Care needs-level deterioration occurred in 508 patients (incidence: 18.3 per 1000 person-months), of which 76 used early rehabilitation services (12.3 per 1000 person-months) and 432 did not use early rehabilitation services (20.0 per 1000 person-months). One-to-one propensity score matching produced 566 matched pairs that adjusted for the differences in all covariables. In these matched pairs, the hazard of care needs-level deterioration was significantly lower among patients who used early rehabilitation services (hazard ratio=0.712, 95% CI, 0.529-0.958). A Kaplan-Meier survival analysis showed similar results (log-rank: P=.023). CONCLUSIONS: Early rehabilitation services provided by rehabilitation therapists after hospital discharge appeared effective in preventing care needs-level deterioration, and involving rehabilitation therapists in transitional care may aid the optimization of health care for older Japanese adults with functional impairment.

Implementation and costs of housing adaptations among older adults with different functional limitations in Japan.

BACKGROUND: Accessible housing is crucial to maintain a good quality of life for older adults with functional limitations, and housing adaptations are instrumental in resolving accessibility problems. It is unclear to what extent older adults, who have a high risk of further functional decline, use housing adaptation grants acquired through the long-term care (LTC) insurance systems. This study aimed to examine the utilization of housing adaptation grants in terms of implementation and costs, for older adults with different types of functional limitations related to accessibility problems. METHODS: The study sample included individuals from a suburban city in the Tokyo metropolitan area who were certified for care support levels (indicative of the need for preventive care) for the first time between 2010 and 2018 (N = 10,372). We followed the study participants over 12 months since the care needs certification. We matched and utilized three datasets containing the same individual's data: 1) care needs certification for LTC insurance, 2) insurance premium levels, and 3) LTC insurance claims. We conducted a multivariable logistic regression analysis to estimate the likelihood of individuals with different functional limitations of having housing adaptations implemented. Afterward, we conducted a subgroup analysis of only older adults implementing housing adaptation grants to compare costs between groups with different functional limitations using the Mann-Whitney U and Kruskal-Wallis tests. RESULTS: Housing adaptations were implemented among 15.6% (n = 1,622) of the study sample, and the median cost per individual was 1,287 USD. Individuals with lower extremity impairment or poor balance were more likely to implement housing adaptations (adjusted odds ratio (AOR) = 1.290 to AOR = 2.176), while those with visual impairment or lower cognitive function were less likely to implement housing adaptations (AOR = 0.553 to AOR = 0.861). Costs were significantly lower for individuals with visual impairment (1,180 USD) compared to others (1,300 USD). CONCLUSION: Older adults with visual or cognitive limitations may not receive appropriate housing adaptations, despite their high risk of accessibility problems. Housing adaptation grants should include various types of services that meet the needs of older people with different disabilities, and the results indicate there may be a need to improve the system.

Regional variation in long-term care spending in Japan.

BACKGROUND: Health inequalities are widening in Japan, and thus, it is important to understand whether (and to what extent) there is a regional variation in long-term care (LTC) spending across municipalities. This study assesses regional variation in LTC spending and identifies the drivers of such variation. METHODS: We conducted a cross-sectional study using publicly available municipality-level data across Japan in 2019, in which the unit of analysis was municipality. The outcome of interest was per-capita LTC spending, which was estimated by dividing total LTC spending in a municipality by the number of older adults (people aged ≥ 65). To further identify drivers of regional variation in LTC spending, we conducted linear regression of per-capita spending against a series of demand, supply, and structural factors. Shapley decomposition approach was used to highlight the contribution of each independent variable to the goodness of fit of the regression model. RESULTS: In Fiscal 2019, per-capita LTC spending varied from 133.1 to 549.9 thousand yen (max/min ratio 4.1) across the 1460 municipalities analyzed, showing considerable regional variation. The included covariates explained 84.0% of the total variance in LTC spending, and demand-determined variance was remarkably high, which contributed more than 85.7% of the overall R2. Specifically, the highest contributing factor was the proportion of severe care-need level and care level certification rate. CONCLUSIONS: Our results demonstrate that, even after adjusting for different municipalities' age and sex distribution, there is a large variation in LTC spending. Furthermore, our findings highlight that, to reduce the spending gap between municipalities, the issues underlying large variations in LTC spending across municipalities must be identified and addressed.

Perioperative outcomes of laparoscopically assisted anorectoplasty versus conventional procedures for anorectal malformation: a retrospective nationwide database study.

PURPOSE: This study aimed to compare the perioperative outcomes of laparoscopically assisted anorectoplasty (LAARP) and conventional procedures (CPs) for anorectal malformation (ARM) using a national inpatient database in Japan. METHODS: Using the Diagnosis Procedure Combination database, we identified patients who underwent anorectoplasty for high- or intermediate-type ARMs from 2010 to 2019. Primary outcomes were postoperative rectal prolapse, anal stenosis, and general complications. Secondary outcomes were the duration of anesthesia and length of hospital stay. We performed 1:2 propensity score-matched analyses to compare the outcomes between the LAARP and CP groups. RESULTS: We identified 1005 eligible patients, comprising 286 and 719 patients who underwent LAARP and CP, respectively. The propensity score-matched groups included 281 patients with LAARP and 562 with CP. The LAARP group showed a higher proportion of rectal prolapse (21.4% vs. 8.5%; odds ratio, 2.91; 95% confidence interval [CI], 1.89-4.48; p < 0.001) and longer duration of anesthesia (462 min vs. 365 min; difference, 90 min; 95% CI 43-137; p < 0.001) than the CP group. No significant differences were found in other outcomes. CONCLUSION: LAARP had worse outcomes than CP in terms of rectal prolapse. Thus, we propose that LAARP may require technical refinement to improve patient outcomes.

Trends in surgical procedures for spontaneous intracerebral hemorrhage in Japan.

OBJECTIVES: Minimally invasive surgery for spontaneous intracerebral hemorrhage (ICH) has become increasingly popular in recent years. However, there are no reports on the recent trends in surgical procedures for spontaneous ICH. To investigate current trends in surgical methods for spontaneous ICH using a nationwide inpatient database from Japan. MATERIALS AND METHODS: Patients who underwent surgery for spontaneous ICH between April 2014 and March 2018 were identified in a nationwide inpatient database from Japan. We examined patient characteristics, diagnoses, types of surgery, complications, and discharge status. RESULTS: We identified 21,129 inpatients who underwent surgery for spontaneous ICH. The procedures were as follows: 16,256 (76.9%) transcranial hemorrhage evacuations, 3722 (17.6%) endoscopic hemorrhage evacuations, and 1151 (5.4%) stereotactic aspirations of hemorrhage. Patients tended to receive transcranial hemorrhage evacuations in hospitals with fewer surgical cases. The proportions of endoscopic hemorrhage evacuations increased annually, whereas those of stereotactic surgery decreased. The proportions of transcranial surgery remained almost unchanged. Tracheostomy and hospitalization costs were lower in the stereotactic aspirations of hemorrhage group, and the proportions of reoperation were higher in the endoscopic hemorrhage evacuations group. CONCLUSIONS: The use of endoscopic surgery for spontaneous ICH has increased in Japan. This study can form the basis of future clinical investigations into spontaneous ICH surgery.

Risk of drug-induced interstitial lung disease in hospitalised patients: a nested case-control study.

INTRODUCTION: Information on drug-induced interstitial lung disease (DILD) is limited due to its low incidence. This study investigated the frequencies of drug categories with potential risk in patients developing DILD during hospitalisation and analysed the risk of developing DILD associated with each of these drugs. METHODS: Using a Japanese national inpatient database, we identified patients without interstitial pneumonia on admission who developed DILD and required corticosteroid therapy during hospitalisation from July 2010 to March 2016. We conducted a nested case-control study; four controls from the entire non-DILD patient cohort were matched to each DILD case on age, sex, main diagnosis, admission year and hospital. We defined 42 classified categories of drugs with 216 generic names as drugs with potential risk of DILD, and we identified the use of these drugs during hospitalisation for each patient. We analysed the association between each drug category and DILD development using conditional logistic regression analyses. RESULTS: We retrospectively identified 2342 patients who developed DILD. After one-to-four case-control matching, 1541 case patients were matched with 5677 control patients. Six drug categories were significantly associated with the increased occurrence of DILD. These included epidermal growth factor receptor inhibitors (OR: 16.84, 95% CI 9.32 to 30.41) and class III antiarrhythmic drugs (OR: 7.01, 95% CI 3.86 to 12.73). Statins were associated with reduced risk of DILD (OR: 0.68, 95% CI 0.50 to 0.92). CONCLUSIONS: We demonstrated significant associations between various drug categories and DILD. Our findings provide useful information on drug categories with potential risk to help physicians prevent and treat DILD.

Comparison of fracture risk between proton pump inhibitors and histamine-2 receptor antagonists in ANCA-associated vasculitis patients: a nested case-control study.

OBJECTIVE: Whether acid suppressants [proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs)] are associated with bone fractures in patients with ANCA-associated vasculitis (AAV) treated with glucocorticoids remains unclear. This study compared PPIs with H2RAs in terms of the risk of bone fractures in patients with AAV who received in-hospital induction therapy with glucocorticoids. METHODS: We retrospectively identified 149 patients with fractures among 22 821 patients newly diagnosed with AAV in 1730 hospitals using a nationwide inpatient database from July 2010 to March 2018. We conducted 1:4 case-control matching. Age, sex, duration of AAV treatment and fiscal year were matched between the cases and controls. A conditional logistic regression analysis was conducted to assess the association between acid suppressants and fractures. RESULTS: Of all enrolled patients with fractures, the median age was 77 years, and 99 (66%) were female. The median duration from AAV treatment to fracture was 52 days. The proportion of patients using PPIs was 91.3% (136 of 149) and 80.2% (478 of 596) in the case and control groups, respectively. Compared with H2RA use, PPI use was significantly associated with fractures after adjustment for age, sex, BMI, smoking habit, Charlson comorbidity index, renal failure, bisphosphonate and same fiscal year according to a multivariate analysis (adjusted odds ratio, 3.76; 95% CI: 1.37, 10.3). CONCLUSION: PPI users had a higher risk of fractures than H2RA users among mostly advanced-age patients with AAV with remission induction therapy.

The impact of additional payments on functional decline among long-term care health facility residents in Japan.

BACKGROUND: Additional payment approach has been one of the most important incentives in long-term care (LTC) systems for the past 20 years in Japan. OBJECTIVE: To estimate the effect of additional payments on functional decline in long-term care health facility (LTCHF) residents of Japan. DESIGN: A 24-month retrospective cohort study. SETTING AND SUBJECTS: Residents aged ≥65 years who were newly admitted to LTCHFs in the 2014 fiscal year. METHODS: National LTC claims data were linked to the survey of institutions and establishments for LTC. Competing risk regression was performed with functional decline as the primary outcome, and additional payments as exposure, controlling for individual and facility characteristics. The level of LTC needs certified in the LTC insurance system was applied as a proxy of functional ability. Death, hospitalisation, discharge to home and transfer to other LTC facilities were treated as competing events. Individual- and facility-level additional payments were presented as binary variables: being reimbursed or not during the follow-up period. RESULTS: At baseline, 146,311 residents from 3,724 LTCHFs were included. The vast majority of additional payments were associated with a lower risk of functional decline at follow-up. At the individual level, additional payment for pre/post admission instructions had the strongest association with a lower risk of functional decline. Despite this, only 8% of residents were reimbursed for this additional payment. At the facility level, residents in LTCHFs with additional payments for support for home-life resumption and nutritional management were associated with a decreased risk of functional decline. CONCLUSIONS: The results of our study may be of particular interest to policymakers in monitoring and evaluating additional payment approaches and provide insight into improving quality of care.

Preoperative use of pirfenidone and reduced risk of postoperative severe respiratory complications in patients with idiopathic pulmonary fibrosis: Propensity score-matched analysis using a nationwide database in Japan.

BACKGROUND AND OBJECTIVE: Patients with idiopathic pulmonary fibrosis (IPF) often develop postoperative severe respiratory complications such as acute exacerbation. Pirfenidone, an oral anti-fibrotic drug, may reduce the incidence of such complications. However, the preventive effect of pirfenidone on postoperative severe respiratory complications remains unclear. METHODS: We identified patients with IPF who underwent surgery with general anaesthesia from July 2010 to March 2018 using the Diagnosis Procedure Combination database. We compared the occurrence of postoperative severe respiratory complications (receiving mechanical ventilation under endotracheal intubation and/or intravenous infusion of a high-dose corticosteroid and in-hospital death within 30 days after surgery) between patients who did and did not receive preoperative treatment with pirfenidone. Pearson's chi-square test and logistic regression analysis fitted with a generalized estimating equation were conducted in 1:4 propensity score-matched patients. RESULTS: Among 631 patients identified, 19% were treated with pirfenidone before surgery. The 30-day mortality rate was 3.1% and 1.7% in the control patients (n = 510) and pirfenidone-treated patients (n = 121), respectively. In the propensity score-matched population, preoperative treatment with pirfenidone was significantly associated with a lower proportion of postoperative severe respiratory complications (OR: 0.24; 95% CI: 0.07-0.76; p = 0.015). CONCLUSION: In this Japanese nationwide cohort, preoperative treatment with pirfenidone was significantly associated with a lower risk of postoperative severe respiratory complications in patients with IPF. Preoperative pirfenidone may thus be useful in preventing postoperative severe respiratory complications in patients with IPF who are planning to undergo surgery with general anaesthesia.

Mortality and morbidity following postoperative use of short-term, low-dose quetiapine vs risperidone in patients with diabetes: Analysis using a national inpatient database.

PURPOSE: Short-term, low-dose quetiapine is used to treat postoperative delirium and insomnia. Quetiapine is contraindicated for patients with diabetes in Japan because there have been several case reports of diabetic ketoacidosis (DKA) in patients receiving long-term, high-dose quetiapine. However, because safety of short-term, low-dose quetiapine remains controversial, it is prescribed for patients with diabetes in real-world clinical practice. The present study aimed to compare in-hospital mortality and morbidity between short-term, low-dose quetiapine and risperidone in postoperative patients with diabetes. METHODS: We used a national inpatient database in Japan to perform a retrospective cohort study. We identified hospitalized patients with diabetes who underwent scheduled elective surgery and received oral quetiapine 200 mg/d or less or oral risperidone 4 mg/d or less within 7 days of surgery between July 2010 and March 2018. We performed one-to-one propensity score-matched analyses to compare outcomes between patients with quetiapine and risperidone. The primary outcome was in-hospital mortality. The secondary outcome was infectious complications (pneumonia, urinary tract infection, surgical site infection, and sepsis). RESULTS: Propensity score matching created 665 pairs of patients who received quetiapine or risperidone. The primary outcome was observed in 19 (2.9%) of the quetiapine group and 11 (1.7%) of the risperidone group (relative risk, 1.27; 95% confidence interval, 0.97-1.68; P = .14). The secondary outcome did not differ significantly between the groups. CONCLUSION: In terms of mortality and infectious outcomes, safety of quetiapine and risperidone may be comparable.

Associations of Hospital Discharge Services With Potentially Avoidable Readmissions Within 30 Days Among Older Adults After Rehabilitation in Acute Care Hospitals in Tokyo, Japan.

OBJECTIVE: To examine the associations of 3 major hospital discharge services covered under health insurance (discharge planning, rehabilitation discharge instruction, and coordination with community care) with potentially avoidable readmissions (PARs) within 30 days in older adults after rehabilitation in acute care hospitals in Tokyo, Japan. DESIGN: Retrospective cohort study using a large-scale medical claims database of all Tokyo residents aged ≥75 years. SETTING: Acute care hospitals. PARTICIPANTS: Patients who underwent rehabilitation and were discharged to home (N=31,247; mean age in years ± SD, 84.1±5.7) between October 2013 and July 2014. INTERVENTIONS: None. MAIN OUTCOME MEASURE: 30-day PAR. RESULTS: Among the patients, 883 (2.9%) experienced 30-day PAR. A multivariable logistic generalized estimating equation model (with a logit link function and binominal sampling distribution) that adjusted for patient characteristics and clustering within hospitals showed that the discharge services were not significantly associated with 30-day PAR. The odds ratios were 0.962 (95% confidence interval [CI], 0.805-1.151) for discharge planning, 1.060 (95% CI, 0.916-1.227) for rehabilitation discharge instruction, and 1.118 (95% CI, 0.817-1.529) for coordination with community care. In contrast, the odds of 30-day PAR among patients with home medical care services were 1.431 times higher than those of patients without these services (P<.001), and the odds of 30-day PAR among patients with a higher number (median or higher) of rehabilitation units were 2.031 times higher than those of patients with a lower number (below median) (P<.001). Also, the odds of 30-day PAR among patients with a higher Hospital Frailty Risk Score (median or higher) were 1.252 times higher than those of patients with a lower score (below median) (P=.001). CONCLUSIONS: The insurance-covered discharge services were not associated with 30-day PAR, and the development of comprehensive transitional care programs through the integration of existing discharge services may help to reduce such readmissions.

Intensive In-Hospital Rehabilitation After Hip Fracture Surgery and Activities of Daily Living in Patients With Dementia: Retrospective Analysis of a Nationwide Inpatient Database.

OBJECTIVES: To examine the effects of earlier, more frequent, and larger daily amounts of postoperative rehabilitation on activities of daily living (ADL) after hip fracture surgery in patients with dementia. DESIGN: Retrospective cohort study. SETTING: A total of 1053 acute-care hospitals. PARTICIPANTS: Patients aged ≥65 years with dementia at admission underwent hip fracture surgery and received postoperative rehabilitation from April 1, 2014 to March 31, 2016 (N=43,206). INTERVENTIONS: Three rehabilitation variables as key independent variables: (1) the interval from surgery to starting rehabilitation (days); (2) the frequency of postoperative rehabilitation (days per week); and (3) the average daily units of postoperative rehabilitation (minutes per daily rehabilitation). MAIN OUTCOME MEASURE: ADLs based on the Barthel Index (BI) at discharge from acute-care hospitals. RESULTS: In the multivariable linear regression analysis, delayed rehabilitation was significantly associated with a lower BI at discharge (for each day of the interval increase, BI at discharge was 0.38 lower; 95% confidence interval [CI], 0.21-0.54), and a significant increase in the BI at discharge was observed in patients who underwent more frequent rehabilitation (BI [95% CI] was 2.62 [0.99-4.25], 5.83 [4.28-7.38], 7.56 [5.95-9.16], and 9.16 [7.34-10.97] higher for frequencies of 3.1-4.0, 4.1-5.0, 5.1-6.0, and >6.0 days per week, respectively) and larger daily amounts of rehabilitation (4.37 [3.69-5.06] and 6.60 [5.63-7.57] higher for 40-59 and ≥60 minutes per day, respectively). CONCLUSIONS: These results suggest that earlier, more frequent, and larger daily amounts of postoperative rehabilitation in acute-care hospitals are independently associated with better recovery in ADL at discharge from acute-care hospitals after hip fracture surgery in patients with dementia.