Risk of postoperative pneumonia after extubation with the positive pressure versus normal pressure technique: a single-center retrospective observational study.

PURPOSE: A normal pressure extubation technique (no lung inflation before extubation), proposed by the Japanese Society of Anesthesiologists to prevent droplet infection during the coronavirus disease 2019 (COVID-19) pandemic, could theoretically increase postoperative pneumonia incidence compared with a positive pressure extubation technique (lung inflation before extubation). However, the normal pressure extubation technique has not been adequately evaluated. This study compared postoperative pneumonia incidence between positive and normal pressure extubation techniques using a dataset from the University of Tsukuba Hospital. METHODS: In our hospital, the extubation methods changed from positive to normal pressure extubation techniques on March 3, 2020 due to the COVID-19 pandemic. Thus, we compared the risk of postoperative pneumonia between the positive (April 1, 2017 to December 31, 2019) and normal pressure extubation techniques (March 3, 2020 to March 31, 2022) using propensity score analyses. Postoperative pneumonia was defined using the International Classification of Diseases, 10th Edition (ICD-10) codes (J13-J18), and we reviewed the medical records of patients flagged with these ICD-10 codes (preoperative pneumonia and ICD-10 codes for prophylactic antibiotic prescriptions for pneumonia). RESULTS: We identified 20,011 surgeries, including 11,920 in the positive pressure extubation group (mean age 48.2 years, standard deviation [SD] 25.2 years) and 8,091 in the normal pressure extubation group (mean age 47.8 years, SD 25.8 years). The postoperative pneumonia incidences were 0.19% (23/11,920) and 0.17% (14/8,091) in the positive and normal pressure extubation groups, respectively. The propensity score analysis using inverse probability weighting revealed no significant difference in postoperative pneumonia incidence between the two groups (adjusted odds ratio 0.98, 95% confidence interval 0.50 to 1.91, P = 0.94). CONCLUSIONS: These results indicated no increased risk of postoperative pneumonia associated with the normal pressure extubation technique compared with the positive pressure extubation technique. CLINICAL TRIAL NUMBER: Clinical trial number: UMIN000048589 https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000055364.

The Effect of Home Care Support Clinics on Hospital Readmission in Heart Failure Patients in Japan.

BACKGROUND: Heart failure is common and is associated with high rates of hospitalization. Home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in Japan in 2006 and 2012, respectively. OBJECTIVE: This study aimed to examine the effect of post-discharge care by conventional or enhanced HCSCs on readmission, compared with general clinics. DESIGN: Retrospective cohort study using the Japanese nationwide health insurance claims database. PARTICIPANTS: Participants were ≥65 years of age, admitted for heart failure and discharged between July 2014 and August 2015 and received a home visit within a month following the discharge (n=12,393). MAIN MEASURES: The exposure was the type of medical facility that provides post-discharge home healthcare: general clinics, conventional HCSCs, and enhanced HCSCs. The primary outcome was all-cause readmission for 6 months after the first visit; the incidence of emergency house calls was a secondary outcome. We used a competing risk regression using the Fine and Gray method, in which death was regarded as a competing event. KEY RESULTS: At 6 months, readmissions were lower in conventional (38%) or enhanced HCSCs (38%) than general clinics (43%). The adjusted subdistribution hazard ratio (sHR) of readmission was 0.87 (95% CI: 0.78-0.96) for conventional and 0.86 (0.78-0.96) for enhanced HCSCs. Emergency house calls increased with conventional (sHR: 1.77, 95% CI:1.57-2.00) and enhanced HCSCs (sHR: 1.93, 95% CI: 1.71-2.17). CONCLUSIONS: Older Japanese patients with heart failure receiving post-discharge home healthcare by conventional or enhanced HCSCs had lower readmission rates, possibly due to compensation with more emergency house calls. Conventional and enhanced HCSCs may be effective in reducing the risk of rehospitalization. Further studies are necessary to confirm the medical functions performed by HCSCs.

[Maturation and Development of the"All Japan E-Learning Cloud of the Training Program for Oncology Professionals].

This paper reports the 5-year operational status of the third phase of the"All Japan E-Learning Cloud of the Training Program for Oncology Professionals"by tabulating the viewing trends of available lecture contents. In this phase, the goal was to train cancer genome medical professionals in this new, advanced medical technology field as well as train personnel to treat rarely encountered pediatric, adolescent/young adult, and other life stage cancers. Additionally, new lecture items have been added to the e-learning cloud in collaboration with 7 oncology specialist centers, contributing to the development of human capital in cancer care(including graduate student education)and faculty development for local medical professionals.

The relationship between long working hours and depression among first-year residents in Japan.

BACKGROUND: In Japan, some residents develop mental health problems. In previous studies, it was reported that long working hours might be a cause of stress reaction such as depression. There were some reports that compared residents with 80 or more working hours with those with less than 80 working hours. However, many residents are practically detained for extra-long time, designated as 100 h or more per week, for medical practice, training, self-study, etc. There have been few reports on extra-long hours of work. This study evaluated the working environment and the amount of stress experienced by first-year residents, and examined the relationship between long working hours and depression, especially in the group of extra-long working hours. METHODS: The study included 1241 first-year residents employed at 250 training hospitals in 2011. A self-report questionnaire was administered at the beginning of the residency and 3 months later to collect data on demographics, depressive symptoms, and training conditions (e.g., duration of work, sleep, disposable time, and night shift). Depressive symptoms were rated using the Center for Epidemiologic Studies Depression Scale. RESULTS: The mean duration of work per week was 79.4 h, with 97 residents (7.8%) working 100 h or more. At 3 months, clinically significant depressive symptoms were reported by 45.5% of residents working 100 or more h per week, which proportion was significantly greater than that for respondents working less than 60 h (P < 0.001). Multivariate logistic regression analysis showed that a working week of 80 to 99.9 h was associated with a 2.83 fold higher risk and 100 h or more was associated with a 6.96-fold higher risk of developing depressive symptoms compared with a working week of less than 60 h. CONCLUSION: Working excessively long hours was significantly associated with development of depressive symptoms. Proper management of resident physicians' working hours is critical to maintaining their physical and mental health and to improve the quality of care they provide.

Can we predict future depression in residents before the start of clinical training?

CONTEXT: Depression among medical residents is a very serious problem. It is, however, very difficult to detect signs of depression early, despite the severity and frequency of depression. We designed a nationwide longitudinal study to investigate whether the Sense of Coherence (SOC) Scale, an indicator of ability to cope with stress, could predict future depressive symptoms among medical residents. METHODS: We distributed self-administered questionnaires to first-year residents in 251 postgraduate education hospitals just before the start of their clinical training. The questionnaire contained the Center for Epidemiologic Studies Depression (CES-D) Scale (a screening tool for depression), the SOC Scale, and items on demographic factors. After 3 months, we again distributed questionnaires to residents who had responded to the first survey. The second questionnaire contained the CES-D Scale and items on the respondents' working conditions. We categorised respondents into three groups according to their SOC scores and analysed the relationships between the three SOC groups (low, middle and high scores) and the occurrence of depressive symptoms at the follow-up survey. RESULTS: In all, 1738 of 2935 residents (59.2%) responded to the first survey. Of these, 1245 residents (71.6%) also responded to the follow-up survey. A total of 189 residents were excluded because they screened positive for depressive symptoms at the first survey. Data for a further 36 were excluded because they were incomplete. At the follow-up survey, 238 of the remaining 1020 residents (23.3%) had new-onset depressive symptoms. These included 61 (41.2%) respondents in the low SOC group, 159 (22.3%) in the middle SOC group, and 18 (11.3%) in the high SOC group (p < 0.01). The odds ratio of the low SOC group for new-onset depressive symptoms, adjusted for demographic factors, baseline CES-D score and mean working time, was 3.11 (95% confidence interval 1.48-6.53), using the high SOC group as the reference. CONCLUSIONS: The SOC score was significantly related to future depressive symptoms among medical residents. The SOC Scale might be a useful and easy-to-use predictor of future depression.

Objective Evaluation of Gaze Location Patterns Using Eye Tracking During Cystoscopy and Artificial Intelligence-Assisted Lesion Detection.

Background: The diagnostic accuracy of cystoscopy varies according to the knowledge and experience of the performing physician. In this study, we evaluated the difference in cystoscopic gaze location patterns between medical students and urologists and assessed the differences in their eye movements when simultaneously observing conventional cystoscopic images and images with lesions detected by artificial intelligence (AI). Methodology: Eye-tracking measurements were performed, and observation patterns of participants (24 medical students and 10 urologists) viewing images from routine cystoscopic videos were analyzed. The cystoscopic video was captured preoperatively in a case of initial-onset noninvasive bladder cancer with three low-lying papillary tumors in the posterior, anterior, and neck areas (urothelial carcinoma, high grade, and pTa). The viewpoint coordinates and stop times during observation were obtained using a noncontact type of gaze tracking and gaze measurement system for screen-based gaze tracking. In addition, observation patterns of medical students and urologists during parallel observation of conventional cystoscopic videos and AI-assisted lesion detection videos were compared. Results: Compared with medical students, urologists exhibited a significantly higher degree of stationary gaze entropy when viewing cystoscopic images (p < 0.05), suggesting that urologists with expertise in identifying lesions efficiently observed a broader range of bladder mucosal surfaces on the screen, presumably with the conscious intent of identifying pathologic changes. When the participants observed conventional and AI-assisted lesion detection images side by side, contrary to urologists, medical students showed a higher proportion of attention directed toward AI-detected lesion images. Conclusion: Eye-tracking measurements during cystoscopic image assessment revealed that experienced specialists efficiently observed a wide range of video screens during cystoscopy. In addition, this study revealed how lesion images detected by AI are viewed. Observation patterns of observers' gaze may have implications for assessing and improving proficiency and serving educational purposes. To the best of our knowledge, this is the first study to utilize eye tracking in cystoscopy. University of Tsukuba Hospital, clinical research reference number R02-122.

Integrated Electronic Health Record of Multidisciplinary Professionals Throughout the Cancer Care Pathway: A Pilot Study Exploring Patient-Centered Information in Breast Cancer Patients.

Purpose: The aim of this pilot study was to first aggregate and then integrate the medical records of various healthcare professionals involved with breast cancer patients to reveal if and how patient-centered information is documented in multidisciplinary cancer care. Patients and Methods: We aggregated 20 types of medical records from various healthcare professionals such as physicians, nurses and allied healthcare professionals (AHPs) throughout three breast cancer patients' care pathways in a department of breast surgery at a university hospital. Purposeful sampling was used, and three cases were examined. The number of integrated type of records was 14, 14, 17 in case 1, 2 and 3, respectively. We manually annotated and analyzed them exploratively using a thematic analysis. The tags were produced using both a deductive template approach and a data-driven inductive approach. All records were then given tags. We defined patient-centered information related tags and biomedical information related tags and then analyzed for if and how patient-centered information was documented. Results: The number of patient-centered information related tags accounted for 30%, 30% and 20% of the total in case 1, 2 and 3, respectively. In all cases, patient-centered information was distributed across various medical records. The Progress Note written by doctors provided much of the patient-centered information, while other records contained information not described elsewhere in the Progress Notes. The records of nurses and AHPs included more patient-centered information than the doctors' notes. Each piece of patient-centered information was documented in fragments providing from each of the healthcare professionals' viewpoints. Conclusion: The documented information throughout the breast cancer care pathway in the cases examined was dominated by biomedical information. However, our findings suggest that integrating fragmented patient-centered information from various healthcare professionals' medical records produces holistic patient-centered information from multiple perspectives and thus may facilitate an enhanced multidisciplinary patient-centered care.

An important paradigm shift within healthcare is the shift toward patient-centered care and away from disease-centered treatment. Patient-centered care is based on shared decision-making, respecting an individual patient's preferences, needs and values, and considering social context and best available research evidence to improve the quality of care. A multidisciplinary team (MDT) approach plays an important role in patient-centered care and MDTs are already adopted into daily oncology practices in many countries, especially in breast cancer care. Previous studies have shown that an effective MDT needs more patient-centered information but often that patient-centered information is notably absent from medical records. We investigated if and how patient-centered information such as psychosocial entries exists in patient records. For this purpose, we performed an exploratory pilot study in which the patient records of three patients with breast cancer, including two patients with advanced stage disease, were studied throughout their care pathway. We observed that the documentation of patient-centered information was fragmented and scattered across various medical records written by multidisciplinary professionals. Moreover, these pieces of scattered information were recorded from different perspectives and viewpoints. Our findings point to a significant role that healthcare informatics could play, as integrating the various healthcare professionals' electronic health record could likely produce multifaceted and more holistic patient-centered information which could be shared and used in shared decision-making and MDTs with a view to considering both patient and clinical perspectives, potentially improving the quality of care.

Toward a Patient-Centered Care Supporting System: Integration of Multidisciplinary Health Records in Breast Cancer Care.

An important paradigm shift within healthcare is the shift toward patient-centered care (PCC). Multidisciplinary team meetings (MDTM) are considered essential for PCC, despite being considered time-consuming and expensive. Patient-centered information (PCI) is known to improve the quality of care. This study investigated where and how the PCI of multidisciplinary professionals' health records exists, and to explore the possibility of a sustainable PCC-supporting healthcare system. We performed an exploratory pilot study of the patient records of three patients with breast cancer. We observed that PCI was documented throughout the care pathway in the cases examined. However, we also found that these data were fragmented and scattered across various medical records, and they were also from different point of views and patient care perspectives. PCI was founded to be less accessible than traditional medical records and was even hard to find using a manual search. We therefore propose that preparing PCI for MDTM may be one of the obvious burdens for healthcare professionals (HPs). We do however believe that integrating PCI from multiple professionals' records likely plays an important function in a shift towards PCC and serves to improve not only the quality of care but also the HPs' experiences without additional burden and could contribute to a more sustainable health care system.

Association between types of home healthcare and emergency house calls, hospitalization, and end-of-life care in Japan.

BACKGROUND: To meet the increasing demand for home healthcare in Japan, as part of the national healthcare system, home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in 2006 and 2012 respectively. This study aimed to evaluate whether HCSCs has succeeded in providing 24-h home care services through the end of life. METHODS: A retrospective cohort study was conducted using the national database in Japan. Participants were ≥ 65 years of age, had newly started regular home visits between July 2014 and September 2015, and used general clinics, conventional HCSCs, or enhanced HCSCs. Each patient was followed up for 6 months after the first visit. The outcome measures were (i) emergency house call(s), (ii) hospitalization(s), and (iii) end-of-life care defined as in-home death. Multivariable logistic regression analyses were performed for statistical analysis. RESULTS: The analysis included 160,674 patients, including 13,477, 64,616, and 82,581 patients receiving regular home visits by general clinics, conventional HCSCs, and enhanced HCSCs respectively. Compared to general clinics, the use of conventional and enhanced HCSCs was associated with an increased likelihood of emergency house calls (adjusted odds ratio [aOR] and 95% confidence intervals [CIs] of 1.62 [1.56-1.69] and 1.86 [1.79-1.93], respectively) and a decreased likelihood of hospitalizations (aOR [95% CIs] of 0.86 [0.82-0.90] and 0.88 [0.84-0.92] respectively). Among 39,082 patients who died during the follow-up period, conventional and enhanced HCSCs had more in-home deaths (aOR [95% CIs] of 1.46 [1.33-1.59] and 1.60 [1.46-1.74], respectively) compared to general clinics. CONCLUSIONS: HCSCs (especially enhanced HCSCs) provided more emergency house calls, reduced hospitalization, and enabled expected deaths at home, suggesting that further promotion of HCSCs (especially enhanced HSCSs) would be advantageous.

Hospital-Level Variation in Cardiac Rehabilitation After Myocardial Infarction in Japan During Fiscal Years 2014-2015 Using the National Database.

Background: Cardiac rehabilitation (CR) is an evidence-based medical service for patients with acute myocardial infarction (AMI); however, its implementation is inadequate. We investigated the provision status and equality of CR by hospitals in Japan using a comprehensive nationwide claims database. Methods and Results: We analyzed data from the National Database of Health Insurance Claims and Specific Health Checkups in Japan for the period April 2014-March 2016. We identified patients aged ≥20 years with postintervention AMI. We calculated hospital-level proportions of inpatient and outpatient CR participation. The equality of hospital-level proportions of inpatient and outpatient CR participation was evaluated using the Gini coefficient. We included 35,298 patients from 813 hospitals for the analysis of inpatients and 33,328 patients from 799 hospitals for the analysis of outpatients. The median hospital-level proportions of inpatient and outpatient CR participation were 73.3% and 1.8%, respectively. The distribution of inpatient CR participation was bimodal; the Gini coefficients of inpatient and outpatient CR participation were 0.37 and 0.73, respectively. Although there were statistically significant differences in the hospital-level proportion of CR participation for several hospital factors, CR certification status for reimbursement was the only visually evident factor affecting the distribution of CR participation. Conclusions: The distributions of inpatient and outpatient CR participation by hospitals were suboptimal. Further research is warranted to determine future strategies.

Medical expenditures for fragility hip fracture in Japan: a study using the nationwide health insurance claims database.

Using the nationwide health insurance claims database in Japan, we estimated total annual medical expenditures for fragility hip fracture across the population at 329.2 billion yen (2.99 billion US dollars). Long-term care expenditures were not included. Fragility hip fracture imposes a considerable health economic burden on society in Japan. PURPOSE: Fragility hip fracture imposes a substantial health economic burden on society globally. We aimed to estimate medical expenditures for fragility hip fracture using the nationwide health insurance claims database in Japan. METHODS: We included adults aged 60 and over without prior hip fracture who were admitted for fragility hip fracture (i.e., femoral neck or extracapsular) between October 2014 and October 2015 (13 months). Fragility hip fracture was identified through newly assigned disease codes for fracture and procedure codes associated with the fracture. As a proxy for medical expenditures per patient, incremental payments were calculated (i.e., the difference between the total payments 6 months before and after fragility hip fracture). The total payments included health insurance reimbursements and copayments for inpatient and outpatient services. Long-term care expenditures were not included in this study. RESULTS: We identified 142,361 individuals (28,868 male and 113,493 female) with fragility hip fracture. Mean medical expenditures for fragility hip fracture per patient were 2,550,000 yen (¥) (23,180 US dollars [$]; ¥110 = $1) in male and ¥2,494,000 ($22,670) in female patients, respectively. Total annual medical expenditures for fragility hip fracture across the population were 329.2 billion yen (2.99 billion US dollars): 67.96 billion yen (620 million US dollars) in male and 261.24 billion yen (2.37 billion US dollars) in female patients, respectively. CONCLUSION: This is the first study to estimate medical expenditures for hip fracture using the nationwide health insurance claims database, which represents almost all health insurance claims in Japan. Fragility hip fracture inflicts a considerable health economic burden on society in Japan.