The Evaluation of Hospitalist Care for Patients with Aspiration Pneumonia Using Risk-adjusted Performance Indicators Developed from a Nationwide Inpatient Database.

Background High-quality evidence proving the superiority of hospitalist services is lacking. We developed risk-adjusted performance indicators from a multilevel prediction model using a nationwide inpatient database to evaluate hospitalist medical care for patients with aspiration pneumonia. Methods We extracted cases diagnosed with aspiration pneumonia between 2014 and 2021 from the Diagnosis Procedure Combination (DPC) database. Hospital-level risk-adjusted performance indicators were the observed-to-expected ratio of the following outcomes using a multilevel prediction model containing both patient- and hospital-level variables: death or transfer in poor condition within 30 days (poor outcome), in-hospital death within 30 days, and discharges within the 25th and 50th percentiles for length of stay defined by the DPC system. Using the predicted numbers of each outcome without random intercept as denominators of both indicators, the numerators of Indicator 1 were observed numbers of each outcome, while those in Indicator 2 were "smoothed" predicted numbers of outcomes estimated by the fitted model with random intercept. The ratio of the number of outcomes for each hospital to the mean number of outcomes among participating hospitals was used as a reference. We applied these indicators to Takatsuki General Hospital (TGH) as a working example. Results A total of 526,245 patients were analyzed. Compared with indicator 1, indicator 2 showed greater stability in the mean ratio and bootstrapping confidence interval (CI). Indicator 2 of poor outcome and discharges within the 25th percentile in 2017 at TGH were 1.110 (95% CI 0.784-1.375) and 1.458 (95% CI 1.272-1.597), respectively. Conclusions Utilizing a nationwide inpatient database, we developed risk-adjusted performance indicators using a multilevel prediction model to evaluate hospitalist medical care for patients with aspiration pneumonia. Given the reliable results shown in the working example, these indicators have potential benefits for the accurate evaluation of the quality of medical care.

Operating table stability and patient safety during an earthquake based on the results of a shaking table experiment.

Background: The damage that may be caused to the operating table and patients under general anaesthesia when a large earthquake occurs is unclear. We aimed to evaluate the movement and damage to operating tables and patients under general anaesthesia during an earthquake. Methods: An operating table with a manikin resembling a patient on it was placed on a shaking table, and seismic waves were input into the shaking table. The effects of seismic waves were evaluated by altering surgical positions (supine and head-down positions), operating tables, flooring material, seismic waves, and output. We observed the movement of the operating table and measured the acceleration of the operating table and manikin head. Results: Under 90% output of long-period seismic waves, the operating table with the supine manikin was overturned. Under experimental conditions that did not cause rocking, shaking such as tilting of the operating table caused stronger acceleration in the manikin's head than in the operating table. There was no clear relationship between operating table rocking and maximum acceleration as a result of programmed seismic waves. In long-period earthquakes, rocking and overturning occurred >60 s after the onset of shaking, whereas in direct earthquakes, rocking occurred within 10 s. Conclusions: An earthquake could cause strong acceleration of the patient's head under general anaesthesia, and operating tables may overturn or shake violently. Regarding patient safety, further measures to prevent overturning should be considered.

Defining the Standard of the Terminology of the Mechanical Ventilation Data in Japan.

To effectively use data from intensive care unit patient information systems at multiple hospitals, it is necessary to standardize the data into a well-ordered form. However, terms often vary between devices. We designed a mechanical ventilation concept model and applied data to that model using existing tools and expert opinions. The JSICM glossary was revised based on this study.

Clinical decision-making using an assessment protocol of swallowing function after aspiration pneumonia: a comparative retrospective study.

Objective: Aspiration pneumonia is a challenge in Japan, with many elderly citizens; however, there are insufficient experts on swallowing. Non-expert doctors may suspend oral intake for an overly long period because of the fear of further aspiration. We devised and modified an assessment protocol for swallowing function with reference to the Japanese and American practical guidelines for dysphagia. This study aimed to demonstrate clinical decision-making using the protocol by reporting the results of decisions on the safe and timely restart of adequate food intake for patients with aspiration pneumonia. Patients and Methods: This comparative retrospective study included 101 patients hospitalized with aspiration pneumonia between April 2015 and November 2017. We compared the parameters of patients for whom decisions on resumption of oral intake were aided by our protocol against those of patients from the previous year when the protocol was not used. We counted the days until either resumption of oral intake or events of aspiration/choking. Results: The duration of days until oral intake in the two groups was 1.64 ± 2.34 days in the protocol group (56 patients) and 2.09 ± 2.30 days in the control group (45 patients) (P=0.52). The adverse events of aspiration/choking were less frequent in the protocol group (5 vs. 15, odds ratio (OR) 0.32, P<0.001) as compared to the control group. The protocol group showed a significant reduction in aspiration/choking (OR 0.19, P<0.01). Conclusion: Clinical decision-making based on the protocol seems to help non-expert doctors make informed decisions regarding resuming oral intake after aspiration pneumonia.

Effects of hospitalist co-management on rate of initiation of osteoporosis treatment in patients with vertebral compression fractures: Retrospective cohort study.

BACKGROUND: Vertebral compression fractures are common in elderly people and most are due to osteoporosis. Osteoporosis treatment is effective for secondary prophylaxis, so initiation is recommended. Despite the clear benefits, the rate of initiation of osteoporosis treatment is very low. It is reported to be due to several factors including insufficient systems-based approaches for hospitals and post-acute care. Hospitalists, who are physicians dedicated to the treatment of patients in hospital and whose activity is generalist rather than specialized, are reported to be associated with higher-quality inpatient care because of, among other things, closer adherence to guidelines. Co-management by hospitalists for patients with vertebral compression fractures has potential benefits towards improving the outcomes. We compared the rate of initiation of osteoporosis treatment for patients with vertebral compression fractures between conventional orthopedic surgeon-led care (conventional group) and hospitalist co-management care (co-management group). METHODS: This is a single-center retrospective cohort study to evaluate the rate of initiation of osteoporosis treatment and reasons for non-initiation of osteoporosis treatment. Other clinical indicators were also evaluated, including length of hospital stay, preventable complications during hospitalization, and rate of 30-day readmission. RESULTS: We identified 55 patients in the conventional group and 93 patients in the co-management group. The rate of initiation of osteoporosis treatment was higher in the co-management group (45.2% vs. 3.6%, OR 21.5; 95%CI 5.12-192.0; P < 0.01). Most of the patients with non-initiation in the co-management group had reasons for it described in the medical records, but in the conventional group the reasons were unknown. There was no significant difference in length of hospital stay, preventable complications during hospitalization, or 30-day readmission between the groups. CONCLUSIONS: Hospitalist co-management of patients with vertebral compression fractures showed significantly higher rate of initiation of osteoporosis treatment than conventional orthopedic surgeon-led care.

Efficiency of the Japanese Hospitalist System for Patients with Urinary Tract Infection: A Propensity-matched Analysis.

Objective The hospitalist system in the United States has been considered successful in terms of the quality of care and cost effectiveness. In Japan, however, its efficacy has not yet been extensively examined. This study examined the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population using treatment of urinary tract infection as an example. Methods We analyzed 271 patients whose most resource-consuming diagnosis at admission was urinary tract infection between April 2017 and March 2019. Propensity-matched analyses were performed to compare health care economics and the quality of care between the hospitalist system and the conventional system. Results In matched pairs, care by the hospitalist system was associated with a significantly shorter length of stay than that by the conventional system. The quality of care (oral antibiotics switch rate, rate of appropriate antibiotics change based on urine or blood culture results, detection rate of urinary tract infection etiology and the number of laboratory tests) was also considered to be favorably impacted by the hospitalist system. Although not statistically significant, hospital costs tended to be lower with the hospitalist system than with the conventional system. The mortality rate and 30-day readmission were also not significantly different between the groups. Conclusion The hospitalist system had a favorable impact on the quality of care and length of stay without increasing readmission in patients with urinary tract infection. This study is further evidence of the strong potential for the positive impact of an implemented hospitalist system in Japan.

Effects of hospitalist co-management for hip fractures.

BACKGROUND: Early surgery is recommended for patients with hip fractures. Average time to surgery in Japan is 3.8 days. Such delay could be caused by the burden of preoperative assessment and management of geriatric comorbidities upon orthopedic surgeons. Hospitalist co-management has potential benefits in comprehensive perioperative care that could positively affect time to surgery in patients with hip fractures. We compare clinical outcomes of patients with hip fractures managed by orthopedic surgeon-led care (conventional group) vs. those of patients with hip fractures managed by hospitalist co-management. METHODS: In this single-center retrospective cohort study, time to surgery was assessed with interrupted time series analyses. Whole length of hospital stay, length of hospital stay after surgery, complications during hospitalization, 30-day readmission, initiation of osteoporosis treatment and adherence to guidelines for deep vein thrombosis prophylaxis were also evaluated with Chi-square or Fisher's exact tests. RESULTS: The conventional group comprised 332 patients and the co-management group 418 patients. Interrupted time series analyses revealed an immediate reduction of time to surgery by 1.2 days (95%CI, -1.9 to -0.4, P = 0.003) with the start of co-management. Whole length of hospital stay and length of hospital stay after surgery tended to be shorter, but without statistical significance. Intermediate to severe complications and 30-day readmission were not significantly different between the groups. In the co-management group, the rate of initiation of osteoporosis treatment (46.4% vs. 6.3%, P < 0.001) and adherence rate to guidelines for deep vein thrombosis prophylaxis (99.3% vs. 88%, P < 0.001) were significantly higher than those in the conventional group. CONCLUSIONS: Hospitalist co-management for elderly patients with hip fractures led to significantly shorter time to surgery than conventional orthopedic surgeon-led care, and had advantages in other clinical indicators.

Quantification of Internal Medicine Resident Inpatient Care Using the Diagnosis Procedure Combination Database.

Objective Quantification of patient encounters during internal medicine residency training is challenging. At present, there are no established strategies for evaluating the whole inpatient experience in Japan. We hypothesized that the Diagnosis Procedure Combination (DPC) database, which is widely used in Japan, might be a useful tool for such an evaluation. Methods We analyzed DPC-based patient encounters of five senior residents with different types of training. One of the diseases on receipt computation data, including the four main diseases and at most eight comorbidities, was matched with each category in the Online system for Standardized Log of Evaluation and Registration of specialty training system (J-OSLER), and the match ratios were assessed. The accumulation of each disease classified into J-OSLER categories was also assessed. Monthly extra working hours and total patient-days per resident were evaluated using a Pearson correlation analysis. Results Two residents with two-year rotations in the general internal medicine department showed high numbers of patient encounters and the highest matching ratio with J-OSLER (approximately 60% with 4 major diseases, 91% with all diseases). There was a moderately positive correlation between the total patient-days and extra working hours in these residents, but no such correlation was noted in the rate of monthly patient encounters and extra working hours among residents as a whole. Conclusion The DPC-based quantification of patient encounters during residency training appears effective in evaluating the coverage of the current J-OSLER list. Owing to its wide availability and generalization, this matching method may be useful as a universal tool for assessing internal medicine programs.

Deciduosis of the Appendix During Pregnancy.

Acute appendicitis is an important differential diagnosis in patients with right lower quadrant pain during pregnancy. Endometriosis, a hormone-related pathology, is another possibility. Patients with endometriosis are typically symptomatic before pregnancy. Stromal endometriosis is a variant of endometriosis that presents no symptoms before pregnancy but which occasionally presents with the new onset of symptoms during pregnancy. We report the case of a 35-year-old woman in her 8th month of pregnancy who presented with impending appendiceal rupture due to deciduosis of the appendix, a progesterone-related condition, during pregnancy. This case suggests that deciduosis/stromal endometriosis should be considered as a differential diagnosis of acute abdomen during pregnancy, even if the patient is asymptomatic before pregnancy.

Impact of the Hospitalist System in Japan on the Quality of Care and Healthcare Economics.

Objective The hospitalist system is considered successful with respect to the quality of care and cost effectiveness in the United States. Studies have consistently demonstrated an improved clinical efficiency with this system. In Japan, however, the efficacy of the hospitalist system has not yet been examined. As a "super-aged society", Japan has a high number of elderly patients with multiple comorbidities who may theoretically receive better care by the hospitalist system than by the conventional system. This study investigates the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population. Methods We analyzed 274 patients ≥65 years of age in whom the most resource-consuming diagnosis at admission was aspiration pneumonia over a 1-year period. We categorized patients as those managed by hospitalists and those managed by various departments (control group) and compared the groups. Propensity score matching was used to minimize selection bias. Results For matched pairs, the length of hospital stay in the hospitalist group was shorter than that in the control group. Care by the hospitalist system was associated with significantly lower hospital costs. The quality of care (rate of switching from intravenous to oral antibiotics, duration of antibiotics therapy, number of chest X-rays and blood tests during hospitalization) was also considered to be favorably impacted by the hospitalist system. There was no statistically significant difference in the mortality rate or readmission rate between the groups. Conclusion This study showed that the hospitalist system had a favorable impact on the quality of care and cost effectiveness, suggesting the potential utility of its implementation in the Japanese medical system.

Convulsive seizure and pulmonary edema during hyperbaric oxygen therapy:A case report.

Hyperbaric oxygen therapy (HBOT) for carbon monoxide (CO) poisoning is widely performed to prevent delayed neuropsychiatric syndrome. Although HBOT can generally be performed with safety, the appropriate management of HBOT still remains unestablished. A 31-year-old man was transferred to our facility to undergo HBOT in a multiplace chamber with a diagnosis of CO poisoning. The first HBOT session ended uneventfully. During the second HBOT session, the patient suddenly experienced convulsive seizures. The accompanying doctor administered intravenous propofol to stop the convulsion and terminated the HBOT. Soon after the convulsion, the patient developed frothy secretions through the endotracheal-tube with impaired oxygenation. Head computed tomography scan showed no abnormalities, suggesting the seizure was associated with complications of HBOT. A chest X-ray revealed bilateral pulmonary edema, and echocardiography revealed normal cardiac function, indicating that the pulmonary edema resulted from HBOT or neurogenic mechanism secondary to the seizure. The patient's respiratory status improved without recurrence of the seizure and no delayed neurological sequelae was seen afterwards. Here we report unexpected rare adverse events during HBOT. Hyperbaric oxygen therapy for acute indications should be performed in multiplace chambers, with appropriate preparation and medical equipment. J. Med. Invest. 65:286-288, August, 2018.

Liver abscess with Citrobacter koseri bacteremia.

Citrobacter koseri is a rare cause of liver abscess with two reported cases in diabetic patients. We report a rare case of C. koseri liver abscess with C. koseri bacteremia in an elderly male with chronic kidney disease. He presented vomiting and weakness without any other signs. He was diagnosed with liver abscess by ultrasound, and blood culture showed C. koseri growth. The patient was treated effectively with a course of antibiotics and drainage. When C. koseri is isolated in patients with comorbidity, such as chronic kidney disease, we should consider the possibility of abscess including liver abscess and utilize a combined treatment of drainage and course of antibiotics for mixed infection.

Diagnosis of E. coli tricuspid valve endocarditis: a case report.

Escherichia coli is a rare cause of bacterial endocarditis. We report a case of an elderly man with cirrhosis who developed bacterial endocarditis due to E.coli. We review the literature that summarizes a total of 41 cases, with a predominance of elderly women, diabetics, and patients with urinary tract infections and prosthetic heart valves. E.coli bacteremia may be mistakenly attributed to a more benign source such as urosepsis and overlooked as an indication of endocarditis. A delay in diagnosis may lead to higher mortality as the opportunity for early valve replacement in appropriate cases and more prolonged courses of antibiotics may not be considered.