Predictors of hospital mortality and multidrug-resistant pathogens in hospitalized pneumonia patients residing in the community.

Background and objective: The 2019 ATS/ADSA guidelines for adult community-acquired pneumonia (CAP) eliminated healthcare-associated pneumonia (HCAP) and considered it to be a form of CAP. This concept, however, was based on studies with relatively small sample sizes. Methods: We investigated the risk factors of 30-day mortality, and methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa infections in patients with pneumonia coming from the community using the Diagnosis Procedure Combination database, a nationwide discharge database of acute care hospitals. Furthermore, we compared these factors between CAP and HCAP. Results: A total of 272,337 patients aged ≥20 years with pneumonia were grouped into 145,082 CAP patients and 127,255 HCAP patients. The 30-day mortality rate (8.9 % vs.3.3 %), MRSA infection (2.4 % vs. 1.4 %), and Pseudomonas aeruginosa infection (1.6 % vs. 1.0 %) were significantly higher in HCAP than in CAP patients. Multivariable logistic regression analysis showed that 12 of 13 identified predictors of mortality (i.e., high age, male, underweight, non-ambulatory status, bedsore, dehydration, respiratory failure, consciousness disturbance, hypotension, admitted in critical care, comorbidity of heart failure, and chronic obstructive pulmonary disease) were identical in CAP and HCAP patients. Similarly, five of six distinct risk factors for MRSA infection, and three of three for Pseudomonas aeruginosa infection were identical between the patients. Conclusion: The risk factors for mortality and MRSA or Pseudomonas aeruginosa infection were almost identical in patients with CAP and HCAP. The assessment of individual risk factors for mortality and MRSA or Pseudomonas aeruginosa infection in CAP and abandoning categorization as HCAP can improve and simplify empiric therapy.

The Effects of Hospital Volume on Short-Term Outcomes of Laparoscopic Surgery for Rectal Cancer: A Large-Scale Analysis of 37,821 Cases on a Nationwide Administrative Database.

INTRODUCTION: Laparoscopic low anterior resection (L-LAR) has become widely accepted for the treatment of rectal cancer. However, little is known about the superiority of L-LAR in a real-world setting (including low-volume hospitals) and the association between the short-term outcomes and hospital volume focusing on L-LAR. METHODS: This is a retrospective cohort study. A total of 37,821 patients who underwent LAR for rectal cancer were analyzed using the Diagnosis Procedure Combination (DPC) database from January 2014 to December 2017. The short-term surgical outcomes were analyzed using a multilevel analysis. Hospital volumes were divided into quartiles, including low (1-31), middle (32-55), high (56-91), and very-high volume (92-444 resections per 4 years). The effects of hospital volume on the outcomes were investigated. RESULTS: The study population included 8,335 patients (22%) who underwent open low anterior resection (O-LAR) and 29,486 patients (78%) who underwent L-LAR. The in-hospital mortality and morbidity were consistent with previous reports. In patients who underwent L-LAR, the in-hospital mortality (0.12% vs. 0.41%; OR: 0.33; p = 0.005), the rate of reoperation (3.76% vs. 6.48%; OR: 0.67; p < 0.001), and the perioperative transfusion rate (3.81% vs. 5.90%; OR: 0.66; p < 0.001) were significantly lower in very-high-volume hospitals than in low-volume hospitals. These effects of hospital volume were not observed in O-LAR. CONCLUSIONS: Our present study demonstrates that high volume improves outcomes in patients who underwent L-LAR in a real-world setting.

Research to inform health systems' responses to rapid population ageing: a collection of studies funded by the WHO Centre for Health Development in Kobe, Japan.

Population ageing is a global phenomenon that has profound implications for all aspects of health systems development. Research is needed to understand and improve the health system response to this demographic shift, especially in low- and middle-income countries where the change is happening rapidly. This Supplement was organized by the WHO Centre for Health Development in Kobe, Japan (WHO Kobe Centre) whose mission is to promote innovation and research for equitable and sustainable universal health coverage considering the impacts of population ageing. The Supplement features 10 papers all based on studies that were funded by the WHO Kobe Centre in recent years. The studies involve a diverse set of 10 countries in the Asia Pacific (Cambodia, Japan, the Lao People's Democratic Republic, Malaysia, Mongolia, Myanmar, the Philippines, Singapore, Thailand and Viet Nam); address various aspects of the health system including service delivery, workforce development and financing; and utilize a wide range of research methods, including economic modelling, household surveys and intervention evaluations. This introductory article offers a brief description of each study's methods, key findings and implications. Collectively, the studies demonstrate the potential contribution that health systems research can make toward addressing the challenges of ensuring sustainable universal health coverage even while countries undergo rapid population ageing.

[Influence of the Deviation Value of High Schools on the Geographical Distribution of Medical Doctors in Japan: A Cross Sectional Study].

Various efforts have been made in recent years to deal with the uneven distribution of medical doctors in Japan, but very few studies have paid attention to the influence of local education level. In this study, we investigated the relationship between regional education levels and the uneven distribution of doctors. We conducted a multiple linear regression analysis, setting the number of doctors per 100 thousand population per Health Care Region (HCR) as the outcome variable, and the number of high schools whose deviation value is 60 or more, the number of clinics per 100 thousand population, the number of beds per 100 thousand people, the population aging rate, the rate of treatment (outpatient), the density of population and the existence of medical schools as the explanatory variables. As a result, we found that a HCR with a high school with a deviation value of 60 or more had a significantly higher number of physicians per 100 thousand population (P<0.05), and that two or more such high schools intensified the tendency. Similar results were obtained when using only national and public high schools, and when using the rate, rather than the number, of high schools whose deviation value is 60 or more. It is suggested that, especially in rural areas where the lack of the medical doctors is a critical issue, raising the local education level can be an effective measure to relieve the uneven distribution of doctors.

Pediatric Fulminant Myocarditis in Japan: A Retrospective Nationwide Database Study of Hospital Volume, Management Practices, and Mortality.

OBJECTIVES: Pediatric fulminant myocarditis is a subset of pediatric acute myocarditis associated with critical illness. We aimed to compare mortality and other outcomes such as length of hospital stay between pediatric fulminant myocarditis and nonfulminant myocarditis. For the subgroup of patients with fulminant myocarditis, we also aimed to describe the current management practices and evaluate the impact of clinically relevant factors, including hospital case volume, on mortality. DESIGN: Retrospective observational study using the Diagnosis Procedure Combination database from April 2012 to March 2018. SETTING: Over 1,000 acute care hospitals in Japan. PATIENTS: Patients with acute myocarditis less than 18 years old, including patients with fulminant myocarditis (i.e., those who received at least one of the following by day 7 of hospitalization: inotropes/vasopressors, mechanical circulatory support, or cardiopulmonary resuscitation). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Multivariable logistic regression analysis was conducted to investigate the association between clinically relevant factors and in-hospital mortality of patients with fulminant myocarditis. Furthermore, post hoc propensity score analyses (propensity score-adjusted, propensity score-matched, and inverse probability of treatment-weighted analyses) were performed to confirm the effect of hospital case volume on in-hospital mortality. In total, 866 pediatric patients with acute myocarditis were included, and 382 (44.1%) were categorized as fulminant myocarditis. In-hospital mortality for those with fulminant myocarditis was 24.1%. fulminant myocarditis was associated with 41.3-fold greater odds of mortality than nonfulminant myocarditis (95% CI, 14.7-115.9; p < 0.001). In the subgroup of patients with fulminant myocarditis, a higher in-hospital mortality was significantly associated with younger age (≤ 5 yr; odds ratio, 3.41; 95% CI, 1.75-6.64) and the need for either mechanical ventilation (odds ratio, 2.39; 95% CI, 1.03-5.57), cardiopulmonary resuscitation (odds ratio, 10.63; 95% CI, 5.52-20.49), or renal replacement therapy (odds ratio, 2.53; 95% CI, 1.09-5.87) by day 7. A lower in-hospital mortality rate was significantly associated with treatment at hospitals in the highest pediatric fulminant myocarditis case volume tertile (≥ 6 cases in 6 yr; odds ratio, 0.30; 95% CI, 0.13-0.68) compared with treatment at hospitals in the lowest tertile (1-2 cases in 6 yr). Post hoc propensity score analyses consistently supported the primary results. CONCLUSIONS: In-hospital mortality of pediatric fulminant myocarditis in Japan remains high. Treatment at hospitals in the highest pediatric fulminant myocarditis case volume tertile (≥ 6 cases in 6 yr) was associated with a 70% relative reduction in odds of in-hospital mortality compared with treatment at hospitals in the lowest tertile (1-2 cases in 6 yr). The reasons for such differences need further study.

An analysis of equity in treatment of hip fractures for older patients with dementia in acute care hospitals: observational study using nationwide hospital claims data in Japan.

BACKGROUND: Globally, and particularly in countries with rapidly ageing populations like Japan, there are growing concerns over the heavy burden of ill health borne by older people, and the capacity of the health system to ensure their access to quality care. Older people with dementia may face even greater barriers to appropriate care in acute care settings. Yet, studies about the care quality for older patients with dementia in acute care settings are still few. The objective of this study is to assess whether dementia status is associated with poorer treatment by examining the association of a patient's dementia status with the probability of receiving surgery and the waiting time until surgery for a hip fracture in acute care hospitals in Japan. METHODS: All patients with closed hip fracture were extracted from the Diagnosis Procedure Combination (DPC) database between April 2014 and March 2018. After excluding complicated cases, we conducted regressions with multilevel models. We used two outcome measures: (i) whether the patient received a surgery or was treated by watchful waiting; and (ii) number of waiting days until surgery after admission. RESULTS: Two hundred fourteen thousand six hundred one patients discharged from 1328 hospitals were identified. Among them, 159,173 patients received surgery. Both 80-89 year-olds (OR 0.87; 95% CI, 0.84, 0.90) and those 90 years old and above (OR 0.67; 95% CI, 0.65, 0.70) had significantly lower odds ratios for receiving surgery compared to 65-79 year-olds. Those with severe dementia had a significantly greater likelihood of receiving surgery compared to those without dementia (OR 1.21; 95% CI, 1.16, 1.25). Patients aged 90 years old and above had shorter waiting time for surgery (Coef. -0.06; 95% CI, - 0.11, - 0.01). Mild dementia did not have a statistically significant impact on the number of waiting days until surgery (P = 0.34), whereas severe dementia was associated with shorter waiting days (Coef. -0.08; 95% CI, - 0.12, - 0.03). CONCLUSIONS: These findings suggest physicians may be taking proactive measures to preserve physical function for those with severe dementia and to avoid prolonged hospitalization although there are no formal guidelines on prioritization for the aged and dementia patients.

Incidence and In-Hospital Mortality of Neonatal Disseminated Intravascular Coagulation in Japan: An Observational Study of a Nationwide Hospital Claims Database.

This study aimed to estimate the incidence and prognosis of neonatal disseminated intravascular coagulation (DIC) in Japan by analyzing data retrieved from a national administrative database. Clinically, the prognosis of DIC in neonates is poor, but there is little epidemiological data in Japan. This retrospective observational study identified patients diagnosed with neonatal DIC and who were registered in the Japanese diagnosis procedure combination (DPC) database between April 1, 2014 and March 31, 2016. The patients, who were diagnosed with neonatal DIC, included those with ICD-10 code D65 or P60 in primary and secondary diagnosis, with comorbid conditions existing at admission, and with complications occurring after admission. Of 78,073 neonates admitted to 1,474 neonatal intensive care units, 1,864 (2.4%) were diagnosed with DIC. There was no difference between sexes in incidence of DIC; the incidence of DIC was higher in extremely low birth weight infants (9.8%), and significantly higher than that in normal birth weight infants. The overall mean length of hospital stay was longer in neonates with DIC (69.5 days) than in those without DIC (32.6 days, P < 0.001). The number of deaths was 1,156 (1.5%). In-hospital mortality was significantly higher in neonates with DIC (14.1%) than in those without DIC (1.2%, P < 0.001), especially in premature babies. This nationwide study was the first report to investigate the incidence and in-hospital mortality of neonatal DIC in Japan. Neonatal DIC has a significant impact on prognosis, and its influence is greater in premature than in term infants.

Equality of Treatment for Hip Fracture Irrespective of Regional Differences in Socioeconomic Status: Analysis of Nationwide Hospital Claims Data in Japan.

Despite the wide variety of international evidence on the relationship between the socioeconomic status (SES) and health outcomes, less is known about the association between SES and healthcare provider practices. We assessed whether patients with a closed hip fracture were treated differently by hospital physicians according to the SES of their residential areas in Japan. Hip fracture is a common cause of hospitalization among the elderly, but the relationship between SES and hip fracture treatment remains unknown in Japan. We employed the Diagnosis Procedure Combination (DPC) database from April 2011 to March 2014. SES of the patient's residential area was estimated using Census-derived areal deprivation index (ADI). We performed a cross-sectional study of national claims data and analyzed it using cross-classified multilevel models. We used two outcome measures: (i) whether the patient received an operation or was treated by watchful waiting; and (ii) number of waiting days until operation following admission. We identified 95,011 patients admitted to 1,050 hospitals. Of these, 85,480 patients underwent surgery. Low SES of residential areas was not correlated with the chance of undergoing surgery (P = 0.15) but was weakly correlated with longer waiting days (coefficient, 0.03; 95% confidence interval, -0.01 to 0.06; P = 0.08). The difference of waiting days between maximum (10.4) and minimum ADI (-4.0) was marginal (0.39 days). The results indicate the SES of patient's residential area does not affect the decision of surgical treatment for hip fracture and has ignorable impact on waiting days from hospital admission to surgery.

Short-term and long-term effects of a self-managed physical activity program using a pedometer for chronic respiratory disease: a randomized controlled trial.

[Purpose] The aim of this study was to evaluate the effects of a self-managed physical activity program using a pedometer and diary on physical function, ADL, and QOL in patients with chronic respiratory disease. [Subjects and Methods] 17 outpatients with chronic respiratory disease were assessed for dyspnea, muscle strength, exercise tolerance, ADL, and QOL at baseline, after 3-, and 6-months after the start of the program. Patients were randomly assigned to "Control" or "Diary" group. In the Diary group, the number of steps was counted with a pedometer and recorded in a diary together with self-evaluation of physical activity, while patients assigned to the Control group did not use a pedometer or keep a diary. [Results] The Diary group showed significant improvement in the daily step count over time. The Diary group showed significant improvement of the dyspnea, muscle strength, and exercise tolerance at 3 months, dyspnea and muscle strength at 6 months. Significant differences found between two groups with regard to the extent of change in the muscle strength, exercise tolerance, and QOL at 3 months. [Conclusion] This study suggests that a self-managed physical activity program using a pedometer and diary can increase the level of physical activity.

Impact of regional clinical pathways on the length of stay in hospital among stroke patients in Japan.

BACKGROUND: Clinical pathways are care plans used by health providers to describe essential steps in the care of patients with specific medical conditions. Clinical implementation of the regional clinical pathways in Japan has spread, and the 2008 fee schedule included a new "regional inter-provider care planning fee" for stroke. However, no evidence regarding the efficacy of the regional clinical pathways for stroke has appeared. OBJECTIVES: We examined the association of regional clinical pathways on the length of in-hospital stay in patients with stroke. We also examined whether a variation in the length of in-hospital stay for stroke patients between hospitals exists, and if so, the impact of regional clinical pathways on this variation. RESEARCH DESIGN: Cross-sectional analysis using the Diagnosis Procedure Combination database for the period April 2011 to March of 2012. SUBJECTS: A total of 117,180 patients with the diagnosis "cerebral infarction," coded as I63 in ICD10. MEASURES: Associations of the use of a regional clinical pathway with the length of in-hospital stay (LOS) were estimated by multilevel regression models using a 2-level structure of individuals nested within the 1011 hospitals. The models added both patient-level factors and hospital-level factors that are potentially associated with LOS. RESULTS: Hospitals administering a regional clinical pathway had a significantly shorter LOS (9.1 d) than hospitals that did not. Approximately 12% of the variation in LOS between hospitals is possibly explained by whether hospitals implement regional clinical pathways. Application of regional clinical pathways at the individual level is associated with a 7.2-day decrease in LOS at the individual level. CONCLUSIONS: These findings suggest that the regional clinical pathways are potentially effective in improving the management of stroke patients and in promoting the consistency of care between hospitals.

Hepatocellular carcinoma with peritoneal dissemination which was regressed during vitamin K2 and vitamin E administration.

A 65-year-old man with positive anti-hepatitis C antibody and chronic renal failure was diagnosed as having a ruptured hepatocellular carcinoma (HCC) based on computed tomography (CT). The patient underwent transcatheter arterial embolization (TAE) for the HCC. After one more session of TAE, the patient underwent surgery. But HCC seeding peritoneally was pointed out. Vitamin K2 and vitamin E were administered as a conservative treatment. Six months after starting vitamins K2 and E, the primary tumor did not increase in size and intraperitoneal dissemination disappeared on CT with a significant decrease of alpha-fetoprotein. Even though this is only one case, combination therapy of vitamin K2 and E may induce growth suppression of HCC.