Effectiveness of monthly and bimonthly follow-up of patients with well-controlled type 2 diabetes: a propensity score matched cohort study.

BACKGROUND: On average, patients in Japan with type 2 diabetes mellitus have a clinical consultation every month, although evidence for a favorable follow-up interval is lacking. This study investigated whether the follow-up interval can be extended by comparing the clinical outcomes and cost for monthly versus bimonthly follow-up of patients with well-controlled diabetes mellitus. METHODS: We combined administrative claims data from the National Health Insurance and the Health Checkups Program data of Tsu city, Japan between 2011 and 2014 to conduct a retrospective cohort study of patients with well-controlled type 2 diabetes mellitus. Propensity scores were used to assemble a matched-pairs cohort from patients who had monthly and bimonthly follow-up. Equivalence between two groups was assessed by designating the proportion of patients who maintained good control of their diabetes in the subsequent year as a primary outcome. The proportion achieving target blood pressure and lipid levels, favorable lifestyle, and annual cost were compared as secondary outcomes. RESULTS: Of 12,145 participants, 693 with monthly follow-up and 693 with bimonthly follow-up were matched using propensity scores. In the monthly follow-up group 654 (94.4%) remained under good diabetic control, versus 658 (95.0%) in the bimonthly group (difference: 0.6%; 95% confidence interval: - 1.8 to 2.9%). All secondary outcomes were equivalent for the monthly and bimonthly follow-up groups except the proportion achieving target blood pressure, the proportion engaging in regular exercise, and annual cost. CONCLUSIONS: For patients with well-controlled diabetes mellitus, although frequent follow-up by a physician does not affect the control of blood glucose level in the subsequent year, the annual treatment cost becomes much higher. We suggest that patients with well-controlled diabetes can be followed up less often.

Verification bias in assessment of the utility of MRI in the diagnosis of cruciate ligament tears.

OBJECTIVE: The purpose of this study was to investigate the extent to which verification bias affects the sensitivity and specificity of MRI in the diagnosis of cruciate ligament tears. MATERIALS AND METHODS: Consecutively registered outpatients who underwent MRI evaluation of the knee were included in the study. The sensitivity and specificity of MRI were calculated for patients whose diagnosis was verified with arthroscopy. For patients who did not undergo arthroscopy, the effect of verification bias was estimated with global sensitivity analysis, a technique of graphic representation of whether a particular combination of sensitivity and specificity estimates is compatible with the observed data. RESULTS: Among the 356 patients included in the study, 82 patients (23%) had the MRI findings verified at arthroscopy. The sensitivity and specificity of MRI among patients who underwent arthroscopy were 38% and 90%. For patients whose disease status was not verified with arthroscopy, the influence of verification bias was estimated with global sensitivity analysis. The sensitivity of MRI ranged from 3% to 73%, and the specificity from 63% to 98%. The region comprising all possible combinations of sensitivity and specificity had a butterfly shape. The sensitivity and specificity pair estimated from cases verified with arthroscopy was included in this region. CONCLUSION: Verification bias did not greatly affect assessment of the diagnostic utility of MRI in the evaluation of cruciate ligament tears. The high specificity previously reported for MRI can be considered valid, but the sensitivity may not be as reliable.

Influence of verification bias on the assessment of MRI in the diagnosis of meniscal tear.

OBJECTIVE: Previous studies of the sensitivity and specificity of MRI in the diagnosis of meniscal tear have not included correction for verification bias. The purpose of this study was to investigate the extent to which verification bias affected assessment of the utility of MRI in the diagnosis of meniscal tear. MATERIALS AND METHODS: The patients included in the study were outpatients who from April 2006 through July 2008 consecutively visited a single institution for MRI of the meniscus for evaluation of knee pain. For patients who underwent arthroscopy in addition to MRI, the sensitivity and specificity of MRI were calculated. Global sensitivity analysis of data on patients who did not undergo arthroscopy was performed to estimate the influence of verification bias. Global sensitivity analysis is a method for graphically determining whether a particular pair of sensitivity and specificity estimates is compatible with observed data. RESULTS: Eighty-two patients (23%) underwent arthroscopic verification. The sensitivity and specificity of MRI were 85% and 31%. When the possibility of meniscal tears in patients who did not undergo arthroscopy was subjected to global sensitivity analysis, the sensitivity of MRI ranged from 29% to 95% and the specificity ranged from 3% to 92%. All combinations of sensitivity and specificity produced a butterfly-shaped curve, but the base case was not inside the curve. CONCLUSION: Verification bias greatly affected assessment of the utility of MRI in the diagnosis of meniscal tear. Sensitivity and specificity from previous studies may be incompatible with our data owing to verification bias.

Primary chemotherapy patterns for ovarian cancer treatment in Japan.

AIMS: Evidence-based clinical practices can improve patient outcomes, especially in the area of chemotherapy. In Japan, it is not known how well physicians adhere to evidence-based chemotherapy guidelines. This study aimed to assess physician compliance with national guidelines for ovarian cancer primary chemotherapy in Japan. METHODS: Using an administrative database, we analyzed 209 cases of surgical laparotomy without neoadjuvant chemotherapy as the primary intervention for adnexal cancer. Cases were identified across seven teaching hospitals between 2003 and 2006. RESULTS: Of the 136 patients receiving inpatient chemotherapy, 101 cases (74%) were treated with platinum-taxane therapy. In five hospitals, platinum-taxane therapy was used in more than 75% of patients, compared to 56% and 32% in the other two hospitals, respectively. The proportion of patients receiving paclitaxel and carboplatin concomitant therapy (TC therapy) was 67%, although significant variation was noted between hospitals (range 32% to 94%, P < 0.001). Of the 91 patients receiving TC therapy, 59 (65%) were given full-dose monthly regimens, while 32 cases (35%) were treated with divided doses weekly. Weekly TC therapy was more frequently provided in hospitals with a low volume of patients receiving TC therapy. Patients under the age of 65 receiving inpatient chemotherapy were more likely to receive full-dose regimens than patients 65 or older (68% vs 43%, P = 0.005). Publication of national treatment guidelines did not appear to substantially impact chemotherapy practice patterns. CONCLUSIONS: Adherence to standardized chemotherapy was comparable to rates in European countries, although rates among hospitals differed significantly. Elderly patients were more likely to receive divided-dose regimens.

Work stress and workload of full-time anesthesiologists in acute care hospitals in Japan.

PURPOSE: The number of anesthesiologists per population in Japan is small compared with that in Europe and North America. While there is a growing concern that hard work causes anesthesiologists' fatigue and may compromise patient safety, the workload and physical stress, as well as the impact of staff support on physicians' stress have not been assessed in detail. The goal of this study was to evaluate the working environment, anesthesia workload, and occupational stress of anesthesiologists in Japan. METHODS: A questionnaire survey was performed targeting 1010 members of the Japanese Society of Anesthesiologists working as anesthesiologists affiliated with acute care hospitals in Japan. Data on background information, working environment, operation anesthesia duties, and stress were collected, and the relationship of work stress with background, environment, and anesthesia duties was evaluated by linear regression analysis. RESULTS: Responses were obtained from 383 full-time anesthesiologists (response rate, 43.9%). The total anesthesia time per week was 23.6 h on average. The work stress score was 114.3 +/- 30.2 (mean +/- SD) when the average workers' work stress score in Japan was 100. The work stress score was significantly associated with "years of experience" (with experience < 10 years considered as the reference; 10-19 years: beta = -0.18, P = 0.02, > or = 20 years: beta = -0.15, P = 0.04), "hospital with > or = 500 beds" (with a hospital with < or = 299 beds considered as the reference; beta = 0.15, P = 0.04), "total time of anesthesia per week" (beta = 0.18, P.02), "estimated annual cases managed by an anesthesiologist" (beta = 0.12, P = 0.04) and "no-support stress" (beta = 0.21, P < 0.01) on linear regression analysis (R(2) = 0.12). CONCLUSION: Our results provide a quantitative assessment of the duties of anesthesiologists and show that work stress among anesthesiologists is related to workload and other factors.

Association between patient age and hospitalization resource use in a teaching hospital in Japan.

OBJECTIVES: This study examined the association between patient age and cumulative resource use during a 1-year period among patients in a Japanese hospital, as well as the equality of resource distribution between age groups. METHODS: We analyzed the administrative data for 9695 patients 35 years or older at a tertiary hospital. Multiple linear regression models were used to identify factors associated with cumulative resource use, including total charges, diagnostic examination charges, and drug charges, during a 1-year period. Gini coefficients were estimated to examine equality of cumulative resource use between age groups. RESULTS: Multiple linear regression analyses revealed a quadratic relationship between age and cumulative charges for all fees, diagnostic examinations, and drugs among surviving patients. However, age did not significantly associate with cumulative resource use among non-surviving patients. On the other hand, the cumulative duration of hospitalization (natural log-transformed) was strongly associated with resource use among all patients, both surviving and non-surviving. Cumulative resource use for inpatients was substantially unequal, but these inequalities of resource use did not correspond to age divisions. CONCLUSIONS: No linear association was found between patient age and cumulative resource use during a 1-year period among either surviving or non-surviving patients on multivariate regression analyses and the inequality of resource use among non-surviving patients differed by age group.

Management patterns and healthcare costs for hospitalized patients with cerebral infarction.

OBJECTIVES: Although evidence shows the importance of specialized intensive care of patients with cerebral infarction, it is not well known whether resources are generously applied in the initial period and how patterns of medical resource utilization are associated with characteristics of providers and patient outcomes. In this study, we analyzed changing patterns of daily medical cost using administrative healthcare claim data and identified a management pattern in each case. METHODS: We used Japan's administrative data to identify medical costs on a day-to-day basis. Data of 3136 patients with acute cerebral infarction from 14 medical institutions were included in the analyses. Using the data, we calculated the costs from the perspective of the third-party payer. Institutions were divided into three groups according to the distribution of medical costs in the first 2 days, and patient background, treatment process, and outcomes were compared across the groups. RESULTS: Medical cost was not necessarily intensively allocated during the early hospitalization period. Wide variations were observed in medical cost utilization patterns across institutions. The differences in medical cost for the initial hospitalization period appears to be more influenced by ICU utilization and management policies of institutions than the clinical condition of patients. CONCLUSIONS: We proposed a methodology that uses administrative claim data to examine management patterns of ischemic stroke. We believe that the use of our method, in conjunction with accurate and detailed clinical data, can help elucidate the relationship among acute-period medical resource utilization, process of care, and patient outcomes.

Early diagnosis of pancreatic necrosis based on perfusion CT to predict the severity of acute pancreatitis.

BACKGROUND: Perfusion CT can diagnose pancreatic necrosis in early stage of severe acute pancreatitis, accurately. However, no study to date has examined whether early diagnosis of pancreatic necrosis is useful in predicting persistent organ failure (POF). METHODS: We performed a multi-center prospective observational cohort study to investigate whether perfusion CT can predict the development of POF in the early stage of AP, based on early diagnosis of the development of pancreatic necrosis (PN). From 2009 to 2012, we examined patients showing potential early signs of severe AP (n = 78) on admission. Diagnoses for the development of PN were made prospectively by on-site physicians on the admission based on perfusion CT (diagnosis 1). Blinded retrospective reviews were performed by radiologists A and B, having 8 and 13 years of experience as radiologists (diagnosis 2 and 3), respectively. Positive diagnosis for the development of PN were assumed equivalent to positive predictions for the development of POF. We then calculated the area under the curve (AUC) of the receiver operating characteristic for POF predictions. RESULTS: Fourteen (17.9%) and 23 patients (29.5%) developed PN and POF, respectively. For diagnoses 1, 2, and 3, AUCs for POF predictions were 74, 68, and 73, respectively. CONCLUSIONS: Perfusion CT diagnoses pancreatic necrosis and on that basis predicts the development of POF; http://www.umin.ac.jp/ctr/index-j.htm,UMIN000001926 .

Medical student abuse during clinical clerkships in Japan.

OBJECTIVE: To assess the prevalence of medical student abuse during clinical clerkships in Japan. DESIGN: A cross-sectional questionnaire survey. SETTING: Six medical schools in Japan. PARTICIPANTS: Final year (sixth-year) and fifth-year medical students in the period from September 2003 to January 2004. From a total of 559 students solicited, 304 (54.4%) returned the questionnaire, and 276 (49.4%: 178 male and 98 female) completed it. MEASUREMENTS: Prevalence of medical student abuse in 5 categories: verbal abuse, physical abuse, academic abuse, sexual harassment, and gender discrimination; differences in abusive experience between male and female students; types of alleged abusers; reporting abusive experiences to authorities; and emotional effects of abusive experiences. RESULTS: Medical student abuse was reported by 68.5% of the respondents. Verbal abuse was the most frequently experienced abuse (male students 52.8%, female students 63.3%). Sexual harassment was experienced significantly more often (P<.001) by female students (54.1%) than by male students (14.6%). Faculty members were most often reported as abusers (45.2% of cases). Abuse occurred most frequently during surgical rotations (42.0% of cases), followed by internal medicine (25.1%) and anesthesia rotations (21.8%). Very few abused students reported their abusive experiences to authorities (8.5%). The most frequent emotional response to abuse was anger (27.1% of cases). CONCLUSIONS: Although experience of abuse during clinical clerkships is common among medical students in Japan, the concept of "medical student abuse" is not yet familiar to Japanese. To improve the learning environment, medical educators need to take action to resolve this serious issue.

Impact of treatment policies on patient outcomes and resource utilization in acute cholecystitis in Japanese hospitals.

BACKGROUND: Although currently available evidence predominantly recommends early laparoscopic cholecystectomy (LC) for the treatment of acute cholecystitis, this strategy has not been widely adopted in Japan. Herein, we describe a hospital-based study of patients with acute cholecystitis in 9 Japanese teaching hospitals in order to evaluate the impact of different institutional strategies in treating acute cholecystitis on overall patient outcomes and medical resource utilization. METHODS: From an administrative database and chart review, we identified 228 patients diagnosed with acute cholecystitis who underwent cholecystectomy between April 2001 and June 2003. In order to examine the relationship between hospitals' propensity to perform LC and patient outcomes and/or medical resource utilization, we divided the hospitals into three groups according to the observed to expected ratio of performing LC (LC propensity), and compared the postoperative complication rate, length of hospitalization (LOS), and medical charges. RESULTS: No hospital adopted the policy of early surgery, and the mean overall LOS among the subjects was 30.9 days. The use of laparoscopic surgery varied widely across the hospitals; the adjusted rates of LC to total cholecystectomies ranged from 9.5% to 77%. Although intra-operative complication rate was significantly higher among patients whom LC was initially attempted when compared to those whom OC was initially attempted (9.7% vs. 0%), there was no significant association between LC propensity and postoperative complication rates. Although the postoperative time to oral intake and postoperative LOS was significantly shorter in hospitals with high use of LC, the overall LOS did not differ among hospital groups with different LC propensities. Medical charges were not associated with LC propensity. CONCLUSION: Under the prevailing policy of delayed surgery, in terms of the postoperative complication rate and medical resource utilization, our study did not show the superiority of LC in treating acute cholecystitis patients. The timing of surgery and discharge was mainly determined by the institutional policy in Japan, rather than by the clinical course of the patient; however, considering the substantially less postoperative pain and shorter recovery time of LC compared to OC, LC should be actively applied for the treatment of acute cholecystitis. If the policy of early surgery were universally applied, the advantage of LC over OC may be more clearly demonstrated.

Why are physicians not persuaded by scientific evidence? A grounded theory interview study.

BACKGROUND: The government-led "evidence-based guidelines for cataract treatment" labelled pirenoxine and glutathione eye drops, which have been regarded as the standard care for cataracts in Japan, as lacking evidence of effectiveness, causing great upset among ophthalmologists and professional ophthalmology societies. This study investigated the reasons why such "scientific evidence of treatment effectiveness" is not easily accepted by physicians, and thus, why they do not change their clinical practices to reflect such evidence. METHODS: We conducted a qualitative study based on grounded theory to explore physicians' awareness of "scientific evidence" and evidence-supported treatment in relation to pirenoxine and glutathione eye drops, and to identify current barriers to the implementation of evidence-based policies in clinical practice. Interviews were conducted with 35 ophthalmologists and 3 general practitioners on their prescribing behaviours, perceptions of eye drop effectiveness, attitudes toward the eye drop guideline recommendations, and their perceptions of "scientific evidence." RESULTS: Although few physicians believed that eye drops are remarkably effective, the majority of participants reported that they prescribed eye drops to patients who asked for them, and that such patients accounted for a considerable proportion of those with cataracts. Physicians seldom attempted to explain to patients the limitations of effectiveness or to encourage them to stop taking the eye drops. Physicians also acknowledged the benefits of prescribing such drugs, which ultimately outweighed any uncertainty of their effectiveness. These benefits included economic incentives and a desire to be appreciated by patients. Changes in clinical practice were considered to bring little benefit to physicians or patients. Government approval, rarity of side effects, and low cost of the drops also encouraged prescription. CONCLUSION: Physicians occasionally provide treatment without expecting remarkable therapeutic effectiveness, as exemplified by the use of eye drops. This finding highlights that scientific evidence alone cannot easily change physicians' clinical practices, unless evidence-based practices are accepted by the general public and supported by health policy.

Supplier-Induced Demand for Chronic Disease Care in Japan: Multilevel Analysis of the Association between Physician Density and Physician-Patient Encounter Frequency.

BACKGROUND: There are currently large regional variations in the frequency of physician-patient encounters for the treatment of chronic lifestyle diseases in Japan. These variations may be influenced by competition among physicians, and supplier-induced demand (SID) in health care can occur when physicians manipulate their patients' demand for medical services to increase the use of health care. OBJECTIVES: To analyze patient data to investigate the presence of SID in the treatment of chronic diseases at the regional level in Japan. METHODS: We tested the hypothesis that clinic and hospital physicians in areas of high competition (high physician density) are more likely to recommend a sooner follow-up consultation than do those in areas of lower competition (lower physician density). Using random-effects multilevel models, we analyzed patient survey data and administrative claims data to estimate the effects of physician density on encounter frequency and medical charges. In the analysis of claims data, we used the mean drug administration period as a proxy for the frequency of physician-initiated encounters. RESULTS: Our analysis showed that encounter frequency was significantly associated with clinic physician density, but there were no consistent associations with hospital physician density. Increases in physician density were significantly associated with increases in both clinic and hospital medical charges, and these associations were independent from encounter frequency. CONCLUSIONS: The results of our study indicate the presence of SID in Japan. Further studies should investigate whether more frequent physician-patient encounters provide clinical advantages to patients.

Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015.

BACKGROUND: Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines. METHODS: A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines. RESULTS: Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles. CONCLUSIONS: The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.

Patients' preferences for involvement in treatment decision making in Japan.

BACKGROUND: A number of previous studies have suggested that the Japanese have few opportunities to participate in medical decision-making, as a result both of entrenched physician paternalism and national characteristics of dependency and passivity. The hypothesis that Japanese patients would wish to participate in treatment decision-making if adequate information were provided, and the decision to be made was clearly identified, was tested by interview survey. METHODS: The subjects were diabetic patients at a single outpatient clinic in Kyoto. One of three case study vignettes (pneumonia, gangrene or cancer) was randomly assigned to each subject and, employing face-to-face interviews, the subjects were asked what their wishes would be as patients, for treatment information, participation in decision-making and family involvement. RESULTS: 134 patients participated in the study, representing a response rate of 90%. The overall proportions of respondents who preferred active, collaborative, and passive roles were 12%, 71%, and 17%, respectively. Respondents to the cancer vignette were less likely to prefer an active role and were more likely to prefer family involvement in decision-making compared to non-cancer vignette respondents. If a physician's recommendation conflicted with their own wishes, 60% of the respondents for each vignette answered that they would choose to respect the physician's opinion, while few respondents would give the family's preference primary importance. CONCLUSIONS: Our study suggested that a majority of Japanese patients have positive attitudes towards participation in medical decision making if they are fully informed. Physicians will give greater patient satisfaction if they respond to the desire of patients for participation in decision-making.

Attitudes of the Japanese public and doctors towards use of archived information and samples without informed consent: preliminary findings based on focus group interviews.

BACKGROUND: The purpose of this study is to explore laypersons' attitudes toward the use of archived (existing) materials such as medical records and biological samples and to compare them with the attitudes of physicians who are involved in medical research. METHODS: Three focus group interviews were conducted, in which seven Japanese male members of the general public, seven female members of the general public and seven physicians participated. RESULTS: It was revealed that the lay public expressed diverse attitudes towards the use of archived information and samples without informed consent. Protecting a subject's privacy, maintaining confidentiality, and communicating the outcomes of studies to research subjects were regarded as essential preconditions if researchers were to have access to archived information and samples used for research without the specific informed consent of the subjects who provided the material. Although participating physicians thought that some kind of prior permission from subjects was desirable, they pointed out the difficulties involved in obtaining individual informed consent in each case. CONCLUSIONS: The present preliminary study indicates that the lay public and medical professionals may have different attitudes towards the use of archived information and samples without specific informed consent. This hypothesis, however, is derived from our focus groups interviews, and requires validation through research using a larger sample.

Factors associated with prolonged length of hospital stay of elderly patients in acute care hospitals in Japan: a multilevel analysis of patients with femoral neck fracture.

OBJECTIVE: To analyze possible factors associated with prolonged length of stay (LOS) in hip fracture patients in Japan, such as the availability of beds in medical and nursing care facilities at the community level, as well as patient factors, clinical factors and hospital structural characteristics. METHODS: The sample for analysis consisted of 8318 hip fracture cases from 199 hospitals throughout Japan. We conducted multilevel analyses to investigate whether LOS and the discharge destinations of patients are associated with the availability and utilization of medical and nursing care resources in the communities where each hospital is located. RESULTS: After adjusting for patient factors, clinical factors and hospital structural characteristics, a higher number of long-term care beds at the community level was observed to be significantly correlated with both shorter LOS and increased rate of discharge to other facilities. DISCUSSION AND CONCLUSION: Although the Japanese government is attempting to reduce acute care hospital LOS and the number of long-term care beds in order to reduce health care costs, the results of this study suggest that a reduction in the number of long-term care beds would not necessarily reduce the LOS of acute care hospitals, and may instead exacerbate the problem.

Effects of the per diem prospective payment system with DRG-like grouping system (DPC/PDPS) on resource usage and healthcare quality in Japan.

OBJECTIVES: In 2003, Japan introduced the prospective payment system (PPS) with diagnosis-related groups (DRG) rearranged grouping system called the diagnostic procedure combination/per-diem payment system (DPC/PDPS). Even after eight years, little is known about the effects of DPC/PDPS. The purpose of this study was to examine the effects of DPC/PDPS on resource usage and healthcare quality. METHODS: Using 2001-2009 (fiscal year) administrative data of acute myocardial infarction patients, four indices, including inpatient total accumulated medical charges, length of stay (LOS), mortality rate, and readmission rate, were compared between patients reimbursed by DPC/PDPS or by fee-for-service. RESULTS: DPC/PDPS significantly reduced total accumulated medical charges by $1061 (95% confidence interval [CI], -2007, -116) and LOS by 2.29 days (95% CI, -3.71, -0.88) after risk adjustment. However, mortality rate (Odds ratio [OR], 0.94; 95% CI, 0.73, 1.21) was unchanged. Furthermore, DPC/PDPS increased the readmission rate (OR, 1.37; 95% CI, 1.03, 1.82). CONCLUSIONS: This study showed that DPC/PDPS was associated with reduced resource usage, but not improved healthcare quality, as with DRG/PPSs in other countries. To achieve successful healthcare reform, further discussion on additional motives will be required.

Healthcare-associated infections in acute ischaemic stroke patients from 36 Japanese hospitals: risk-adjusted economic and clinical outcomes.

BACKGROUND: Healthcare-associated infections are a major cause for worsening in ischaemic stroke patients. In addition to increased morbidity and mortality, healthcare-associated infections also result in a potentially preventable increase in economic costs. AIMS: The aim of this study was to identify healthcare-associated infection incidence in ischaemic stroke patients in Japanese hospitals, and to conduct a risk-adjusted analysis of the associated economic and clinical outcomes. METHODS: Healthcare-associated infections were identified in 36 Japanese hospitals using an administrative database. Identification was carried out using a combination of International Classification of Diseases-10 codes and antibiotic utilisation patterns that indicated the presence of an infection. Risk-adjusted hospital charges and length of stay were calculated using multiple linear regression analyses correcting for patient and hospital factors. A logistic regression model was used to analyse the association between healthcare-associated infection infection and mortality. RESULTS: There was an overall healthcare-associated infection incidence of 16·4%, with an interhospital range of 4·7-28·3%. After risk-adjustment, infected cases paid an additional US$3,067 per admission (interhospital range US$434-US$7,151) and were hospitalised for an additional 16·3-days (interhospital range: 5·1-25·1-days) when compared with uninfected patients. Healthcare-associated infections also had a strongly significant association with increased mortality (odds ratio=23·2, 95% confidence intervals: 12·5-43·2). CONCLUSIONS: We observed a wide range of healthcare-associated infection incidence between the hospitals. Healthcare-associated infections were found to be significantly associated with increased hospital charges, length of stay, and mortality. Furthermore, the use of risk-adjusted multi-institutional comparisons allowed us to analyse individual performance levels in both infection and cost control.

An outcome prediction model for adult intensive care.

OBJECTIVE: To develop a prediction model of 28-day mortality in adult intensive care units using administrative data. DESIGN, SETTING AND PARTICIPANTS: We obtained data from 33 ICUs in Japan on all adult patients discharged from ICUs in 2007. Three predictive models were developed using (i) the five variables of the Critical Care Outcome Prediction Equation (COPE) model (age, unplanned admission, mechanical ventilation, hospital category and primary diagnosis) (the C model); (ii) 11 variables, including the COPE variables and six additional variables (sex, reason for ICU entry, time between hospital admission and ICU entry, use of fresh frozen plasma or a platelet preparation, dialysis, and use of pressors/vasoconstrictors (the P+ model); and (iii) ten of the 11 variables, excluding primary diagnosis (the P- model). Data for 6758 patients were stratified at the hospital level and randomly divided into test and validation datasets. Using the test dataset, five, 10 or nine variables were subjected to multiple logistic regression analysis (sex was excluded [P > 0.05]). MAIN OUTCOME MEASURE: Mortality at 28 days after the first ICU day. RESULTS: Areas under the Receiver Operating Characteristic curve (AUROCs) for the test dataset in the C, P+ and P- models were 0.84, 0.89 and 0.87, respectively. Predicted mortality for the validation dataset gave Hosmer-Lemeshow chi2 values of 12.91 (P = 0.12), 10.76 (P = 0.22) and 13.52 (P = 0.1), respectively, and AUROCs of 0.84, 0.89 and 0.90, respectively. CONCLUSIONS: Our P- model is robust and does not depend on disease identification. This is an advantage, as errors can arise in coding of primary diagnoses. Our model may facilitate mortality prediction based on administrative data collected on ICU patients.