Perspectives on the optimal timing of advance care planning among Japanese patients undergoing dialysis and clinicians: a cross-sectional study.

KEY MESSAGES: The majority of dialysis patients and clinicians favor early advance care planning in our sample. Yet, there is a disconnect: only 11% of patients discussed future care with their clinicians. Our findings indicate Japanese dialysis patients and clinicians support proactive advance care planning at or before dialysis initiation. BACKGROUND: Little is known about the optimal timing of discussions about advance care planning among dialysis patients and clinicians engaged in dialysis care. We aimed to explore the preferred timing for advance care planning and assess actual participation in advance care planning among dialysis patients and their clinicians. METHODS: A scenario-based survey on Japanese patients aged ≥65 years on dialysis and clinicians involved in their dialysis care was performed. Participants were asked if they would feel prepared to engage in advance care planning with their clinicians, offering a choice among four hypothetical stages within the illness trajectory, extending from the initiation of dialysis to a later phase characterized by the patient's extreme frailty. RESULTS: Overall, 181 patients and 128 clinicians participated in the study. Among these, 131 (72%) patients, and 84 (66%) clinicians indicated that they would prefer to initiate advance care planning around the time of dialysis initiation. Only 20 patients (11%) indicated that they had participated in advance care planning with at least one clinician, including 11 (6%) who indicated that they had discussed their preferences around life-sustaining treatments and 8 (4%) who had discussed their preferences around dialysis continuation. CONCLUSIONS: While fewer than 11% of patients undergoing dialysis and their clinicians enrolled in our study had participated in advance care planning, most indicated that they would be comfortable initiating the discussion around the time of dialysis initiation. These findings suggest untapped opportunities to engage patients in advance care planning early in the course of their dialysis.

Real-world experience implementing Advance Care Planning in the Asia-Pacific: ACP in Japan.

Promoting Advance Care Planning (ACP) in the super-aged society of Japan has become increasingly important for supporting older adults to continue to live in the community until the end of life. To promote ACP further in Japan, Japanese family-centered decision-making and high-context culture need to be taken into account. Therefore, we describe the environmental and historical backgrounds surrounding ACP in Japan, and based on the results, introduce research and education programs regarding its implementation.

Association between resilience and advance care planning during the COVID-19 pandemic in Japan: a nationwide cross-sectional study.

Advance care planning (ACP) is essential for end-of-life care, especially during the novel coronavirus disease 2019 (COVID-19) pandemic, and resilience is critical to deal with pandemic-related stressors. Therefore, we investigated the association between resilience ability and ACP discussions during the COVID-19 pandemic. A nationwide web-based survey was conducted in July 2021 in Japan. We analyzed the respondents' ability to bounce back from stress (bouncing-back ability), positive stress coping (e.g., "seeking social support", "planning"), and negative stress coping (e.g., "avoidance", "alcohol and drug use") in relation to ACP discussions using multivariable logistic regression models. In total, 2000 responses (86% participation rate) were received (mean age: 51.8 ± 16.7). Normal and high bouncing-back ability (adjusted odds ratio [AOR]: 1.69, 95% CI: 1.03-2.79; AOR: 2.07, 95% CI: 1.18-3.65, respectively) were significantly associated with the occurrence of ACP discussions. Seeking social support and planning were significantly associated with ACP discussions, whereas avoidance and alcohol and drug use were not. Both bouncing-back ability and positive stress coping were significantly associated with the occurrence of ACP discussions during the COVID-19 pandemic in Japan. These findings could be useful for aiding health-care providers involved in ACP discussions during the COVID-19 pandemic.

Development and Initial Psychometric Validation of the COVID-19 Pandemic Burden Index for Healthcare Workers.

BACKGROUND: The burden of COVID-19 on healthcare workers (HCWs) is reported to be increasing, yet the psychometric scales now in use evaluate only single aspects; few measure the pandemic-specific burden on HCWs comprehensively. OBJECTIVE: To develop a scale to quantify the physical, mental, and socioeconomic burden of the COVID-19 pandemic on HCWs. DESIGN: Scale development and cross-sectional survey. PARTICIPANTS: Consenting HCWs aged ≥20. MAIN MEASURES: Development of an item-list based on literature reviews and HCW panel input, evaluation of content validity and item selection using the Delphi method, psychometric testing conducted on HCWs, validity assessment by factor analyses and hypothesis verification, internal consistency evaluation by Cronbach's alpha, test-retest analysis, and interpretability assessment. KEY RESULTS: Through the Delphi process, a 29-item pilot scale was generated. In psychometric testing, data from 863 HCWs contributed to the development of the final version of this scale, called Pandemic Burden Index twenty for HCWs (PBI-20), a 20-item scale to measure six domains: fatigue, fear of infection, inadequacy as a medical professional, mental health concerns, prejudice or discrimination, and anxiety about one's livelihood and daily life. Factor analysis showed each factor corresponded to the six domains of this scale. Hypothesis verification showed the PBI-20 total score to be moderately to highly correlated with the Short Form 36 vitality score and mental health score and with intention of turnover. The PBI-20 had good internal consistency (Cronbach's alpha 0.92). Test-retest analysis showed the intraclass correlation coefficient to be 0.70 and the minimal important change to be -7.0. CONCLUSIONS: The psychometrically sound questionnaire we developed to measure pandemic-specific burdens for HCWs provides an understanding of comprehensive burdens on HCWs and may serve to evaluate interventions to reduce the burdens.

Culturally Adapted Consensus Definition and Action Guideline: Japan's Advance Care Planning.

CONTEXT: A conceptual framework for advance care planning is lacking in societies like Japan's valuing family-centered decision-making. OBJECTIVES: A consensus definition of advance care planning with action guideline adapted to Japanese society. METHODS: We conducted a multidisciplinary modified Delphi study 2020-2022. Thirty physicians, 10 healthcare and bioethics researchers, six nurses, three patient care managers, three medical social workers, three law experts, and a chaplain evaluated, in 7 rounds (including two web-based surveys where the consensus level was defined as ratings by ≥70% of panelists of 7-9 on a nine-point Likert scale), brief sentences delineating the definition, scope, subjects, and action guideline for advance care planning in Japan. RESULTS: The resulting 29-item set attained the target consensus level, with 72%-96% of item ratings 7-9. Advance care planning was defined as "an individual's thinking about and discussing with their family and other people close to them, with the support as necessary of healthcare providers who have established a trusting relationship with them, preparations for the future, including the way of life and medical treatment and care that they wish to have in the future." This definition/action guideline specifically included support for individuals hesitant to express opinions to develop and express preparations for the future. CONCLUSION: Adaptation of advance care planning to Japanese culture by consciously enhancing and supporting individuals' autonomous decision-making may facilitate its spread and establishment in Japan and other societies with family-centered decision-making cultures.

Door-to-oral time and in-hospital outcomes in older adults with aspiration pneumonia undergoing dysphagia rehabilitation.

BACKGROUND & AIMS: Aspiration pneumonia (AP) is a public health concern among older adults. Previous studies have reported the association between oral intake initiation within 48 h after hospital admission and better in-hospital outcomes among patients with AP. We investigated the association between initiation of oral intake within 24 h and in-hospital outcomes of older patients with AP undergoing dysphagia rehabilitation. METHODS: This retrospective cohort study was conducted from April 2015 to September 2020. Door-to-oral time (D2O) was defined as the time from hospital arrival to the first oral intake and was divided into early (within 24 h), middle (between 24 and 48 h), and late (over 48 h). We examined the associations between D2O and in-hospital outcomes: discharge with oral intake (by logistic regression analysis), length of stay, and days from the first oral intake to discharge (by fitting the general linear models with robust variance estimation). RESULTS: Among the 398 patients with AP, 142 (35.7%) were classified into early, 111 (27.9%) into middle, and 145 (36.4%) into late groups. Compared with the late group, we found insufficient evidence that early D2O was associated with a greater likelihood of discharge with oral intake (adjusted odds ratio = 1.09; 95% confidence interval [95% CI]: 0.50 to 2.38). The early group was associated with a shorter length of stay (adjusted length difference [aLD] = -7.14 days; 95% CI: -10.80 to -3.42) but not with shorter days from first oral intake to discharge (aLD = -3.34 days; 95% CI: -6.91 to 0.24). CONCLUSIONS: While D2O within 24 h among patients with AP was not associated with a decreased likelihood of discharge with oral intake, it was associated with a shorter length of stay. To improve outcomes without compromising the quality of AP care, early oral intake should be decided based on careful swallowing function assessment.

Usefulness of a mobile phone application for respiratory rate measurement in adult patients.

AIMS: Respiratory rate measurement is one of the core nursing skills for early detection of deterioration of a patient's condition. Nevertheless, it is sometimes bothersome to visually measure respiratory rate over 1 min. Respiratory rate measurement using a mobile phone application "RRate" has been reported to be accurate and completed in a short time. However, it has only been investigated in children. The aim of this study was to validate the "RRate" compared with the 1-min method in adult patients. METHODS: This was a cross-sectional study in the setting of a nursing school. Videos of the movement of the thorax during respiration of adult patients were made. Nursing students watched these videos and measured respiratory rate with each method. Bland-Altman analysis was used to calculate bias and limits of agreement. The times taken for the measurements were compared using a t test. RESULTS: A total of 59 nursing students participated. When compared to the reference measurement, the one measured using "RRate" and the one measured over 1 min showed a bias of 0.40 breaths per minute and 0.65 breaths per minute, limits of agreement of -2.86 to 3.67 breaths per minute and -2.11 to 3.41 breaths per minute, respectively. The mean measurement time for "RRate" was 22.8 s (95% CI 13.9-36.6), which was significantly shorter than the 65.8 s (95% CI 61.0-73.2) for the measurement over 1 min (p < .001). CONCLUSIONS: Respiratory rate can be measured accurately in a shorter time using a mobile phone application in adult patients.

Usefulness of computed tomography in the diagnosis of acute pyelonephritis in older patients suspected of infection with unknown focus.

BACKGROUND: In older adults, the diagnosis of acute pyelonephritis is challenging because of non-specific symptoms and false-positive urine test results. Few studies have investigated the diagnostic performance of computed tomography (CT) signs. PURPOSE: To evaluate the diagnostic performance of CT signs for acute pyelonephritis in older patients suspected of infection with unknown focus. MATERIAL AND METHODS: This cross-sectional study was conducted between 2015 and 2018. Patients aged ≥65 years who underwent blood cultures, urine culture, and non-contrast or contrast-enhanced CT on admission were included. Cases with clinically presumable infection focus before CT were excluded. Two radiologists blinded to clinical information independently reviewed five CT signs: perirenal fat stranding; pelvicalyceal wall thickening and enhancement; renal enlargement; thickening of Gerota's fascia; and area(s) of decreased attenuation. The final diagnoses were made by a clinical expert panel. RESULTS: Among 473 eligible patients, 61 were diagnosed with acute pyelonephritis. When the laterality of findings between the left and right kidneys were considered, the positive and negative likelihood ratios of perirenal fat stranding were 4.0 (95% confidence interval [CI] = 2.3-7.0) and 0.8 (95% CI = 0.7-0.9) in non-contrast CT, respectively. The other signs in non-contrast CT showed similar diagnostic performance with positive and negative likelihood ratios of 3.5-11.3 and 0.8-0.9, respectively. CONCLUSION: CT signs can help physicians diagnose acute pyelonephritis in older patients suspected of infection with unknown focus.

Association between religious beliefs and discussions regarding advance care planning: A nationwide survey.

BACKGROUND: The relationship between advance care planning and religious beliefs, which are important for palliative care, is controversial in Western countries and has not been verified in Asian countries. AIM: To investigate the association between advance care planning discussions and religious beliefs in Japan. DESIGN: A nationwide survey conducted in 2016 using a quota sampling method to obtain a representative sample of Japan's general population. SETTING/PARTICIPANTS: We analyzed responses from 3167 adults aged 20-84 years (mean age ± standard deviation, 50.9 ± 16.8 years). The outcome was measured by asking whether the respondents had ever discussed advance care planning, and the main exposure by whether they had any religious beliefs or affiliations, and if so, their degree of devoutness. We analyzed religious beliefs, affiliations, and devoutness in relation to the occurrence of discussions using multivariable logistic regression models adjusted for possible sociodemographic covariates. RESULTS: Compared with respondents without, those with religious beliefs had significantly higher odds of having had discussions (adjusted odds ratio: 1.45, 95% confidence interval: 1.22-1.73). The devoutness of religious belief was proportional to the propensity of the occurrence of discussions (p for trend < 0.001). In addition, Buddhists and Christians had higher odds of having had discussions than did nonbelievers. CONCLUSION: The results suggest that holding religious beliefs, especially in Japanese Buddhism and Christianity, facilitates advance care planning discussions among Japanese adults, and thus, may help health-care providers identify those prioritized for facilitating engagement in advance care planning, especially in palliative and spiritual care settings.

Healthcare Providers' Perceptions on the Timing of Initial Advance Care Planning Discussions in Japan: a Mixed-Methods Study.

BACKGROUND: Most adult patients are willing to discuss advance care planning before the onset of any illness. There might be differences in preferences for timing when it comes to initiating advance care planning discussions by healthcare providers with patients. OBJECTIVE: To identify healthcare providers' willingness to initiate advance care planning discussions in Japan. DESIGN: A mixed-methods questionnaire comprising three case scenarios based on three different illness trajectories. PARTICIPANTS: The study participants were physicians and nurses employed in four community hospitals in Japan. MAIN MEASURES: Percentages of physicians' and nurses' willingness to initiate advance care planning discussions at four stages of patients' illness trajectory were quantitatively determined, and perceptions on preferred timing were qualitatively identified. KEY RESULTS: From 108 physician and 123 nurse respondents (response rate: 99%), 291 physician and 362 nurse responses about three case scenarios were obtained. Overall, 51.2% of physicians and 65.5% of nurses (p < 0.001) accepted discussion before illness. Less than one-third of physicians considered advance care planning a "wise precaution," while about two-thirds of nurses did. Additionally, more than half of both physicians and nurses preferred to postpone advance care planning until the patient's imminent death. CONCLUSIONS: Physicians are less willing than nurses to begin advance care planning discussions before patients' health has deteriorated though most prefer to wait until the patients are close to death. Healthcare providers' attitudes toward advance care planning will need to be addressed to improve rates of completion in Japan.

Association between the use of physical restraint and functional decline among older inpatients admitted with pneumonia in an acute care hospital: A retrospective cohort study.

AIM: This study was conducted to investigate the association between the use of physical restraint and functional decline in older inpatients admitted with pneumonia in an acute care setting. Although several adverse effects related to restraint use have been reported, few researchers have examined this subject in acute care settings. METHODS: This retrospective cohort study was conducted at a 471-bed, acute care hospital in Japan. Patients 65 years old and older who were admitted with pneumonia between April 2015 and September 2017 were included. The use of restraints (belts and/or mittens) was recorded for every 8-hour shift. The number of shifts during which each patient was restrained was used as an explanatory variable. The primary outcome was the Katz ADL score at discharge. We used multiple linear regression analysis to adjust for confounding factors. RESULTS: Of 403 patients, 94 required physical restraints. The mean age was 84.5 years (standard deviation [SD] 8.2); 44.4% were women. The mean Katz score on admission was 2.7 (SD 2.4). For multiple linear regression analysis, the coefficient of the number of restraints used was -0.024 (95% confidence interval: -0.044, -0.003, p = .022). Consequently, the restraint use for 13.9 days was associated with the decrease in the Katz score by 1.0. CONCLUSIONS: Results suggest that physical restraint use is associated with functional decline among older inpatients admitted with pneumonia in acute care settings.

Association between direct interpersonal involvement with a dying family member and discussions regarding advance care planning among Japanese older adults.

AIM: There is growing recognition of the need to hold advance care planning discussions. Older adults who have direct interpersonal involvement with dying family members might begin to consider their own end-of-life care. This study examined the associations between experiences of being with a dying family member and advance care planning discussions among Japanese older adults. METHODS: This study examined data from a previous self-administered questionnaire survey carried out among outpatients aged ≥65 years. All participants were visitors of a community hospital in Japan, with data being collected over a 1-week period in July 2016. The main exposure was experiences of being with dying family members, while the outcome was advance care planning discussions with the family members and/or their physician. We analyzed the associations between experiences of being with dying family members and advance care planning discussions through log-binomial regression models adjusted for possible sociodemographic confounders. RESULTS: Of the 302 respondents included for analysis, 96 (32%) had experiences of being with dying family members, while 179 (59%) held advance care planning discussions. Respondents with said experiences were more likely to have discussions than those without experiences (fully adjusted prevalence ratio 1.31, 95% confidence interval 1.04-1.65). Subgroup analyses showed no significant interaction effects between experiences of being with dying family members and the covariates. CONCLUSIONS: Direct interpersonal involvement with dying family members might facilitate advance care planning discussions among Japanese older adults. Our results should help healthcare providers recognize individuals who are unlikely to have discussions. Geriatr Gerontol Int 2021; 21: 197-202.

How Psychosocial Factors Contribute to Japanese Older Adults' Initiation of Advance Care Planning Discussions: A Qualitative Study.

Objectives: This study aimed to reveal the features of older adults' advance care planning (ACP) discussions by identifying psychosocial factors related to their discussions in Japan, where people value family-centered decision making. Methods: A qualitative study using in-depth interviews was conducted with 39 participants (aged ≥65 years) recruited from the outpatient department of a community hospital in Fukushima, Japan. Data were analyzed using the grounded theory approach. Results: Through experiences of family caregiving, participants became aware of their own feelings about the end of life. Equal relationship with family members was important for lowering the threshold for having discussions. Some participants and their families in the same generation reached agreements on ACP; however, they were willing to yield to children's decision making despite these discussions. Discussions: These findings provide insights into the psychosocial factors in relation to ACP discussions and support for the role of ACP discussions in the family-centered decision-making culture.

Experience as an Informal Caregiver and Discussions Regarding Advance Care Planning in Japan.

CONTEXT: Advance care planning (ACP) is vital for end-of-life care management. Experiences as informal family caregivers might act as a catalyst to promote ACP. OBJECTIVES: We investigated the association between ACP discussions and caregiving experiences. METHODS: A nationwide survey in Japan was conducted in December 2016 using a quota sampling method to select a sample representative of the general Japanese population. The responses of 3167 individuals aged 20-84 years (mean age: 50.9 ± 16.8) were analyzed. The outcome was measured by asking if respondents had ever engaged in ACP discussions. The exposure was measured by asking whether and for how long respondents had experience as informal caregivers for family members. We analyzed informal caregiving experience related to the occurrence of ACP discussions using multivariable logistic regression models that adjusted for possible covariates. RESULTS: Respondents with informal caregiving experience had significantly higher odds of having ACP discussions than those without caregiving experience (adjusted odds ratio: 1.93, 95% CI = 1.63, 2.29). Stronger effects were identified in younger adults (aged 20-65 years) and those with a higher education level (education duration > 12 years) than in older adults (aged ≥65 years) and those with a lower education level, respectively. CONCLUSION: Experiences as informal caregivers for family members may facilitate ACP discussions among Japanese adults, especially younger adults with higher educational attainment. Our findings may help health-care providers screen those at risk for inadequate ACP discussions, and informal caregiving experience should be considered when health-care providers initiate discussions of end-of-life care.

Patients' preferences and factors influencing initial advance care planning discussions' timing: A cross-cultural mixed-methods study.

BACKGROUND: Although advance care planning discussions are increasingly accepted worldwide, their ideal timing is uncertain and cultural factors may pertain. AIM: To evaluate timing and factors affecting initiation of advance care planning discussions for adult patients in Japan and Taiwan. DESIGN: Mixed-methods questionnaire survey to quantitatively determine percentages of patients willing to initiate advance care planning discussions at four stages of illness trajectory ranging from healthy to undeniably ill, and to identify qualitative perceptions underlying preferred timing. SETTING/PARTICIPANTS: Patients aged 40-75 years visiting outpatient departments at four Japanese and two Taiwanese hospitals were randomly recruited. RESULTS: Overall (of 700 respondents), 72% (of 365) in Japan and 84% (of 335) in Taiwan (p < 0.001) accepted discussion before illness. In Japan, factors associated with willingness before illness were younger age and rejection of life-sustaining treatments; in Taiwan, older age, stronger social support, and rejection of life-sustaining treatments. Four main categories of attitudes were extracted: the most common welcomed discussion as a wise precaution, responses in this first category outnumbered preference for postponement of discussion until imminent end of life, acceptance of the universal inevitability of death, and preference for discussion at healthcare providers' initiative. CONCLUSION: The majority of patients are willing to begin discussion before their health is severely compromised; about one out of five patients are unwilling to begin until clearly facing death. To promote advance care planning, healthcare providers must be mindful of patients' preferences and factors associated with acceptance and reluctance to initiate advance care planning.

Added value of inflammatory markers to vital signs to predict mortality in patients suspected of severe infection.

OBJECTIVE: To evaluate the added value of inflammatory markers to vital signs to predict mortality in patients suspected of severe infection. METHODS: This study was conducted at an acute care hospital (471-bed capacity). Consecutive adult patients suspected of severe infection who presented to either ambulatory care or the emergency department from April 2015 to March 2017 were retrospectively evaluated. A prognostic model for predicting 30-day in-hospital mortality based on previously established vital signs (systolic blood pressure, respiratory rate, and mental status) was compared with an extended model that also included four inflammatory markers (C-reactive protein, neutrophil-lymphocyte ratio, mean platelet volume, and red cell distribution width). Measures of interest were model fit, discrimination, and the net percentage of correctly reclassified individuals at the pre-specified threshold of 10% risk. RESULTS: Of the 1015 patients included, 66 (6.5%) died. The extended model including inflammatory markers performed significantly better than the vital sign model (likelihood ratio test: p < 0.001), and the c-index increased from 0.69 (range 0.67-0.70) to 0.76 (range 0.75-0.77) (p = 0.01). All included markers except C-reactive protein showed significant contribution to the model improvement. Among those who died, 9.1% (95% CI -2.8-21.8) were correctly reclassified by the extended model at the 10% threshold. CONCLUSIONS: The inflammatory markers except C-reactive protein showed added predictive value to vital signs. Future studies should focus on developing and validating prediction models for use in individualized predictions including both vital signs and the significant markers.

Association between social networks and discussions regarding advance care planning among Japanese older adults.

BACKGROUND: Older adults' discussions with family, or with physicians, or with both, about advance care planning (ACP) are increasingly regarded as important for the management of end-of-life care, and yet the factors that induce older adults to engage in ACP discussions are poorly understood. For example, in older adults, is stronger connectedness with family and friends (stronger "networks") associated with ACP discussions? By facilitating, or by impeding ACP discussions? We sought to evaluate the associations between ACP discussions and social networks in Japanese older adults. METHODS: In July 2016 we conducted a cross-sectional survey on 355 community-dwelling patients aged ≥65 years visiting community hospital clinics in Fukushima, Japan. We used the Lubben Social Network Scale (LSNS-6, the shortest available LSNS scale) to assess social networks and recorded two components of social network structure, marital status (dichotomized as "married" vs. "single / other") and living status ("living with others" vs. "living alone"). One item asked if patients had had ACP discussions. We analyzed the LSNS-6 social network and marital and living status data in relation to the occurrence of ACP discussions using multiple logistic regression models with adjustments for possible confounding factors. RESULTS: Respondents' social network was "limited" in 16% of cases; 61% had had ACP discussions. Respondents with a limited social network had a significantly lower tendency to have had ACP discussions than respondents with an "adequate" social network (adjusted odds ratio [AOR]: 0.35; 95% confidence interval [CI]: 0.18-0.66; P < 0.001). Marital status and living status were not significantly associated with ACP discussion. CONCLUSIONS: Among Japanese older adults, weaker social networks may be associated with a lower tendency to discuss ACP. Our findings may help practitioners to quickly screen populations at risk for inadequate ACP discussion by using the LSNS-6.

Determinants of incentive preferences for health behavior change in Japan.

Interest in the use of incentives to promote health behavior change has been growing worldwide. However, to develop an effective incentive program, accurate information regarding individual preferences is essential. Therefore, the aim of this study was to clarify determinants of incentive preferences for health behavior change. A self-completed questionnaire survey regarding incentives for health behavior change was conducted in a Japanese village in 2015. The outcome measures were individual preferences for features of incentives, including item, frequency, type and value. The types of incentives were defined as follows: assured-type (given for participation); effort-type (given if participants make some kind of effort); and outcome-type (given if participants make achievements decided a priori). The associations with respondents' sex, age, presence of lifestyle-related disease and stage in the transtheoretical model of health behavior change were investigated using multivariate analysis. A total of 1469 residents responded to the survey. Significant associations with preference for different incentive features were found as follows: for monetary items, female and elderly; for high frequency, female and maintenance stage; for effort-type, male, action stage and contemplation stage; and for outcome-type, maintenance stage and action stage. Our results appeared to identify determinants of incentive preferences for health behavior change. These findings are expected to promote the development of an incentive program more in tune with individual preferences.

Development and validation of a prediction model for functional decline in older medical inpatients.

OBJECTIVE: To prevent functional decline in older inpatients, identification of high-risk patients is crucial. The aim of this study was to develop and validate a prediction model to assess the risk of functional decline in older medical inpatients. METHODS: In this retrospective cohort study, patients ≥65 years admitted acutely to medical wards were included. The healthcare database of 246 acute care hospitals (n = 229,913) was used for derivation, and two acute care hospitals (n = 1767 and 5443, respectively) were used for validation. Data were collected using a national administrative claims and discharge database. Functional decline was defined as a decline of the Katz score at discharge compared with on admission. RESULTS: About 6% of patients in the derivation cohort and 9% and 2% in each validation cohort developed functional decline. A model with 7 items, age, body mass index, living in a nursing home, ambulance use, need for assistance in walking, dementia, and bedsore, was developed. On internal validation, it demonstrated a c-statistic of 0.77 (95% confidence interval (CI) = 0.767-0.771) and good fit on the calibration plot. On external validation, the c-statistics were 0.79 (95% CI = 0.77-0.81) and 0.75 (95% CI = 0.73-0.77) for each cohort, respectively. Calibration plots showed good fit in one cohort and overestimation in the other one. CONCLUSIONS: A prediction model for functional decline in older medical inpatients was derived and validated. It is expected that use of the model would lead to early identification of high-risk patients and introducing early intervention.

Association between daily salt intake of 3-year-old children and that of their mothers: A cross-sectional study.

This study investigated the association between the daily salt intake of 3-year-old children and that of their mothers. A total of 641 children were studied. The daily salt intake of the children and their mothers was estimated by morning and spot urine methods, respectively. In the multivariable analysis, a 1 g higher maternal daily salt intake was associated with a 0.14 g (95% confidence interval [CI], 0.07-0.22, P < .001) higher salt intake of her children. In the secondary analysis, the odds ratios for excess salt intake of children were 1.61 (95% CI, 1.01-2.55, P = .045) and 1.81 (95% CI, 1.12-2.91, P = .015) for 9.7-11.5 g and 11.5 g or more of maternal daily salt intake, respectively. Our findings could help to convince mothers of the importance of appropriate salt intake, not only for themselves but also for their children.