Characteristics of the patients consulted with emergency medicine physicians at a large-scale COVID-19 vaccination center: Prospective observational study.

OBJECTIVE: We aimed to clarify the characteristics of patients consulted by the medical staff with emergency medicine (EM) physicians after vaccination and EM physicians transferred to an outside hospital. DESIGN: The Japanese Self-Defense Force established a large-scale coronavirus disease 2019 (COVID-19) vaccination center. Overall, 1,306,928 citizens received the Moderna vaccine, which targeted the first and second vaccinations between May 24, 2021 and November 30, 2021. EM physicians were always available in the emergency room (ER). The medical staff could consult the patients with EM physicians; however, the criteria were ambiguous. We conducted signal detection analysis on the patients who experienced adverse events to detect characteristics. RESULTS: Of the 3,312 patients experienced adverse events after vaccination, the medical staff consulted 344 with EM physicians. The patients whose respiratory rate and systolic blood pressure (BP) were more than 18 per minute and 162 mmHg, respectively, were considerably consulted. In addition, the patients whose systolic BP was more than 186.5 mmHg were transferred to an outside hospital. No patients were seriously ill or died after being transferred to an outside hospital. CONCLUSIONS: The medical staff consulted the patients with a high respiratory rate or BP with EM physicians. In addition to BP, the respiratory rate would also be necessary as a finding that suggests a patient's severity after vaccination. Therefore, it appears safer that EM physicians are always available to ensure the recipients' safety when running a new large-scale vaccination center against unknown diseases, such as COVID-19.

Lifestyle Pathways Affecting Children's Mental Health in Japan during the COVID-19 Pandemic.

The recent prolonged COVID-19 pandemic has worsened the daily lives of preschoolers and elementary school children worldwide. Although these changes may have affected their mental health, the full picture still remains unknown. Since March 2020, Japan has intermittently experienced several COVID-19 waves. This survey was conducted between February and March 2022. In this study, we investigated the pathways by which specific lifestyle factors (such as exercise, sleep, diet, and life skills) affect physical/psychosocial health (PPH) in 1183 preschoolers (3-5 years old) and 3156 elementary school children (6-11 years old) in Toyama Prefecture, Japan. These pathways were examined using a path analysis. Consequently, "life skills" was found to be the factor most strongly associated with PPH in both preschoolers and elementary school children (p < 0.001). Furthermore, it was associated with the physical activity score and with PPH via physical activity. Moreover, both boys' and girls' mental health declined with age among elementary school children (p < 0.001). The results of the current study may be helpful for early interventions (around the start of elementary school) at home and at school to improve children's mental health during the COVID-19 pandemic.

National trends in the outcomes of subarachnoid haemorrhage and the prognostic influence of stroke centre capability in Japan: retrospective cohort study.

OBJECTIVES: To examine the national, 6-year trends in in-hospital clinical outcomes of patients with subarachnoid haemorrhage (SAH) who underwent clipping or coiling and the prognostic influence of temporal trends in the Comprehensive Stroke Center (CSC) capabilities on patient outcomes in Japan. DESIGN: Retrospective study. SETTING: Six hundred and thirty-one primary care institutions in Japan. PARTICIPANTS: Forty-five thousand and eleven patients with SAH who were urgently hospitalised, identified using the J-ASPECT Diagnosis Procedure Combination database. PRIMARY AND SECONDARY OUTCOME MEASURES: Annual number of patients with SAH who remained untreated, or who received clipping or coiling, in-hospital mortality and poor functional outcomes (modified Rankin Scale: 3-6) at discharge. Each CSC was assessed using a validated scoring system (CSC score: 1-25 points). RESULTS: In the overall cohort, in-hospital mortality decreased (year for trend, OR (95% CI): 0.97 (0.96 to 0.99)), while the proportion of poor functional outcomes remained unchanged (1.00 (0.98 to 1.02)). The proportion of patients who underwent clipping gradually decreased from 46.6% to 38.5%, while that of those who received coiling and those left untreated gradually increased from 16.9% to 22.6% and 35.4% to 38%, respectively. In-hospital mortality of coiled (0.94 (0.89 to 0.98)) and untreated (0.93 (0.90 to 0.96)) patients decreased, whereas that of clipped patients remained stable. CSC score improvement was associated with increased use of coiling (per 1-point increase, 1.14 (1.08 to 1.20)) but not with short-term patient outcomes regardless of treatment modality. CONCLUSIONS: The 6-year trends indicated lower in-hospital mortality for patients with SAH (attributable to better outcomes), increased use of coiling and multidisciplinary care for untreated patients. Further increasing CSC capabilities may improve overall outcomes, mainly by increasing the use of coiling. Additional studies are necessary to determine the effect of confounders such as aneurysm complexity on outcomes of clipped patients in the modern endovascular era.

Joint effect of cognitive decline and walking ability on incidence of wandering behavior in older adults with dementia: A cohort study.

OBJECTIVES: Wandering behavior is one of the most troublesome behavioral disturbances in dementia. Inconsistent associations between physical function and wandering behavior were reported, and the effect of cognitive decline may be different according to walking ability. The purposes of this study are to investigate whether high walking ability is a risk factor for wandering behavior and to investigate the interaction of walking ability and cognitive function with wandering behavior in older adults with dementia. METHODS: This retrospective cohort study included 3979 elderly adults with dementia. The association of cognitive function and walking ability with incidence of wandering behavior during a 5-year follow-up period were examined using a generalized linear model, and relative excess risk due to interaction (RERI) was calculated. RESULTS: Severe cognitive decline and high walking ability were associated with a higher risk for wandering behavior. Additionally, some joint effects of cognitive decline and walking ability decline were higher than the sum of its individual effects (RERI [95% confidence interval], severe cognitive decline × 'walk with help': 1.58 [0.35, 2.81]; severe cognitive decline × 'independent': 3.09 [1.05, 5.14]). CONCLUSIONS: Effects of cognitive decline and walking ability on incidence of wandering behavior were observed, and the effects varied depending on their combination.

Influence of hospital capabilities and prehospital time on outcomes of thrombectomy for stroke in Japan from 2013 to 2016.

To determine whether increasing thrombectomy-capable hospitals with moderate comprehensive stroke center (CSC) capabilities is a valid alternative to centralization of those with high CSC capabilities. This retrospective, nationwide, observational study used data from the J-ASPECT database linked to national emergency medical service (EMS) records, captured during 2013-2016. We compared the influence of mechanical thrombectomy (MT) use, the CSC score, and the total EMS response time on the modified Rankin Scale score at discharge among patients with acute ischemic stroke transported by ambulance, in phases I (2013-2014, 1461 patients) and II (2015-2016, 3259 patients). We used ordinal logistic regression analyses to analyze outcomes. From phase I to II, MTs increased from 2.7 to 5.5%, and full-time endovascular physicians per hospital decreased. The CSC score and EMS response time remained unchanged. In phase I, higher CSC scores were associated with better outcomes (1-point increase, odds ratio [95% confidence interval]: 0.951 [0.915-0.989]) and longer EMS response time was associated with worse outcomes (1-min increase, 1.007 [1.001-1.013]). In phase II, neither influenced the outcomes. During the transitional shortage of thrombectomy-capable hospitals, increasing hospitals with moderate CSC scores may increase nationwide access to MT, improving outcomes.

Radiation Emergency Medical Preparedness in Japan: A Survey of Nuclear Emergency Core Hospitals.

OBJECTIVE: Based on experiences following the Great East Japan Earthquake and nuclear power plant accident in 2011, Nuclear Emergency Core Hospitals (NECHs) were designated as centers for radiation disaster management in Japan. This study aimed to investigate their current status and identify areas for improvement. METHODS: This cross-sectional study was conducted in October 2018. Demographic data were collected by a questionnaire with free text responses about attitudes toward NECHs. Considerations regarding risk communications during a radiation disaster were analyzed using qualitative text mining analysis. RESULTS: A total of 36 hospitals participated in this study. Only 31% of NECHs anticipated a radiation disaster. The importance of business continuity plans and risk communications was shown. Text analysis identified 7 important categories for health care workers during a radiation disaster, including media response, communications to hospital staff, risk communications, radiation effects on children, planning for a radiation disaster in the region, rumors, and the role in the region. CONCLUSION: The radiation disaster medical system and NECHs in Japan were surveyed. The importance of risk communications, planning for a radiation disaster in each region, and the role in the region are identified as issues that need to be addressed.

Heatstroke predictions by machine learning, weather information, and an all-population registry for 12-hour heatstroke alerts.

This study aims to develop and validate prediction models for the number of all heatstroke cases, and heatstrokes of hospital admission and death cases per city per 12 h, using multiple weather information and a population-based database for heatstroke patients in 16 Japanese cities (corresponding to around a 10,000,000 population size). In the testing dataset, mean absolute percentage error of generalized linear models with wet bulb globe temperature as the only predictor and the optimal models, respectively, are 43.0% and 14.8% for spikes in the number of all heatstroke cases, and 37.7% and 10.6% for spikes in the number of heatstrokes of hospital admission and death cases. The optimal models predict the spikes in the number of heatstrokes well by machine learning methods including non-linear multivariable predictors and/or under-sampling and bagging. Here, we develop prediction models whose predictive performances are high enough to be implemented in public health settings.

Dentists' Legal Liability and Duty of Explanation in Dental Malpractice Litigation in Japan.

INTRODUCTION: Dental litigation accounts for approximately 10% of medical cases in Japan. This study sought to identify factors related to dentists' legal liability in Japan, including their duty to explain procedures and treatments to their patients. METHODS: We analysed court decisions in 166 dental malpractice cases litigated in Japan between 1978 and 2017. To identify factors related to the legal liability of dentists, an analysis was performed to evaluate the associations among patient characteristics, dentist characteristics, litigation, and dentists' explanatory behaviour. RESULTS: Of the 36 cases related to dentist liability, the study identified 23 cases (63.9%) of litigation in which the dentists were found to be in violation of their duty to provide an explanation. Regarding the severity of injury, the ratio of death and permanent disability was significantly higher in decisions in which the purpose of the explanation was something other than obtaining the patient's consent compared with decisions to obtain the patient's consent (P = .014). CONCLUSIONS: In cases in which the dentist was found legally responsible, the proportion of cases involving procedural negligence with the explanation of medical guidance was significantly higher. Dentists should pay careful attention not only to the patient's consent but also to their explanations, including "medical guidance." Moreover, they should recognise that inappropriate explanations correlate with serious errors.

Employing multiple-attribute utility technology to evaluate publicity activities for cancer information and counseling programs in Japan.

BACKGROUND: Cancer Information and Support Centers (CISCs), which are set up at designated cancer care hospitals (DCCHs) according to the national cancer control programs in Japan, are expected to provide cancer patients and their families with information and counseling, but their public recognition remains low. Therefore, it is necessary to evaluate the publicity activities of CISCs. METHODS: In this study, we evaluated two types of activities for publicizing CISCs conducted inside and outside one of the DCCHs ('Inside Activity' and 'Outside Activity', respectively) by multi-attribute utility technology (MAUT). Seven types of stakeholders, including physicians (n = 5), nurses (n = 4), CISC cancer counselors (n = 5), executives (n = 5), office department staff (n = 5), and licensed social insurance consultants in the hospital (n = 5), as well as patients and citizens (n = 19) were involved in the evaluation. RESULTS: Eight goals of the program for publicizing CISCs were determined. The utility score for each goal was separately calculated for Inside Activity and Outside Activity, and those of the eight goals were summed up to obtain an overall utility score for each activity. Finally, no substantial difference in overall utility score was found between the activity types (Inside Activity = 82.00 vs. Outside Activity = 81.18). CONCLUSIONS: It is implied that omitting or reducing either activity should be avoided in streamlining publicity activities at the CISCs. Despite the limited external validity of the finding, the methodology presented in this study is widely applicable to evaluate other multifaceted programs under an increasingly tight budget in the oncology setting. As the MAUT approach enables us to obtain numerical data for priority settings, it will contribute to rationalized healthcare management, especially in the oncology setting in which objective evaluations of the national cancer-related control programs are lacking and a broad range of stakeholders is involved.

Pathway linking physical activity, sleep duration, and breakfast consumption with the physical/psychosocial health of schoolchildren.

The relationship between certain lifestyle habits and schoolchildren's health has previously been reported on, but the exact pathway of the effects lifestyle habits have on physical/psychosocial health (PPH) has not been investigated nor has the relative influence of different habits on schoolchildren's health. In this study, schoolchildren were recruited from a primary school in Toyama Prefecture, Japan (n = 576), and the relevant data were collected in June/July 2017. Path analysis was used to examine the relationships of lifestyle habits and physical fitness with PPH among schoolchildren in grades 1-4 and 5-6. Body weight and total fitness scores were found to be not related to the children's PPH. The pathway via which lifestyle habits influenced PPH was determined successfully. Among children in grades 1-4, sex (p < .05), age (p < .01), and breakfast intake (p < .05) were related to PPH. Among schoolchildren in grades 5-6, the duration of sleep (p < .05) was related to PPH. Thus, factors related to schoolchildren's PPH vary by school grade. The identification of the predictors of the PPH of schoolchildren should inform the design of tailored, grade-specific health promotion interventions in Japanese elementary schools.

Incidence and Mortality of Dementia-Related Missing and Their Associated Factors: An Ecological Study in Japan.

BACKGROUND: Dementia-related missing and subsequent deaths are becoming serious problems with increases in people with dementia. However, there are no sufficient studies investigating the incidence rate, the mortality rate, and their risk factors. METHODS: An ecological study aggregated at the Japanese prefectural level was conducted. Dementia-related missing persons cases and deaths in 2018 were extracted from the statistics of the National Police Agency in Japan. We extracted variables about older adults' characteristics, care, and safety as candidate variables considered to be relevant to dementia-related missing persons cases and deaths. Associations of the candidate variables with the incidence and mortality rates were analyzed using the generalized linear model (family: quasi-poisson, link: log) adjusted for confounding factors (proportion of older adults and gross prefectural product). RESULTS: The incidence rate and mortality rate per 100,000 person-year was 21.72 and 0.652 in Japan, respectively. One facility increase in the number of nursing care facilities for older adults per 100,000 persons aged 65-years-old or more was associated with a 7.9% (95% confidence interval [CI], 3.3-12.4%) decrease in the incidence rate. One increase in the number of public health nurses per 100,000 persons was associated with a 3.2% (95% CI, 1.6-4.9%) decrease in the incidence rate. A ten percent increase in the proportion of people who live in an urban area was associated with a 20.3% (95% CI, 8.7-33.2%) increase in the incidence rate and a 12.9% (95% CI, 5.6-19.8%) decrease in the mortality rate. CONCLUSIONS: Identified associated factors may be useful for managing or predicting dementia-related missing persons cases and associated deaths.

Medical malpractice litigation related to choking accidents in older people in Japan.

OBJECTIVE: To analyse malpractice litigation cases in Japan and identify the factors related to choking accidents in older people. BACKGROUND: Choking while eating is common in older people and has potentially severe consequences. METHODS: This study analysed court decisions related to choking accidents occurring in Japan between 2000 and 2015 that involved the death of an older person or permanent severe choking-related injury. A database of court decisions (n = 23) was constructed according to patient and caregiver characteristics, and nursing services. An analysis was performed on caregiver liability, and to identify factors related to choking accidents. RESULTS: The court ruled that the caregiver was liable in 10 of the 23 cases. Liability was related to appropriate food choices, failure to monitor of eating or the non-performance of resuscitation after an accident. Prior knowledge of aspiration (P < .001), inappropriate assistance during the meal (P < .001), and inappropriate emergency treatment (P = .028) were more likely to be present in cases in which caregivers were judged liable than in those in which they were not. CONCLUSIONS: Lack of appropriate assistance during the meal was the factor most strongly associated with a court ruling of caregiver liability for choking accidents in older people.

Temporal trends and geographical disparities in comprehensive stroke centre capabilities in Japan from 2010 to 2018.

OBJECTIVES: Comprehensive stroke centre (CSC) capabilities are associated with reduced in-hospital mortality due to acute stroke. However, it remains unclear whether there are improving trends in the CSC capabilities or how hospital-related factors determine quality improvement. This study examined whether CSC capabilities changed in Japan between 2010 and 2018 and and whether any changes were influenced by hospital characteristics. DESIGN: A hospital-based cross-sectional study. SETTING: We sent out questionnaires to the training institutions of the Japan Neurosurgical Society and Japan Stroke Society in 2010, 2014 and 2018. PARTICIPANTS: 749 hospitals in 2010, 532 hospitals in 2014 and 786 hospitals in 2018 participated in the J-ASPECT study, a nationwide survey of acute stroke care capacity for proper designation of a comprehensive stroke centre in Japan. MAIN OUTCOME MEASURES: CSC capabilities were assessed using the validated scoring system (CSC score: 1-25 points) in 2010, 2014 and 2018 survey. The effect of hospital characteristics was examined using multiple logistic regression analysis. RESULTS: Among the 323 hospitals that responded to all surveys, the implementation of 13 recommended items increased. The CSC score (median and IQR) was 16 (13-19), 18 (14-20) and 19 (15-21) for 2010, 2014 and 2018, respectively (p<0.001). There was a ≥20% increase in six items (eg, endovascular physicians, stroke unit and interventional coverage 24/7), and a ≤20% decrease in community education. A lower baseline CSC score (OR: 0.82, 95% CI 0.75 to 0.9), the number of beds≥500 (OR: 3.9, 95% CI 1.2 to 13.0) and the number of stroke physicians (7-9) (OR: 2.6, 95% CI 1.1 to 6.3) were associated with improved CSC capabilities, independent of geographical location. CONCLUSIONS: There was a significant improvement in CSC capabilities between 2010 and 2018, which was mainly related to the availability of endovascular treatment and multidisciplinary care. Our findings may be useful to determine which hospitals should be targeted to improve CSC capabilities in a defined area.

Effect of treatment modality and cerebral vasospasm agent on patient outcomes after aneurysmal subarachnoid hemorrhage in the elderly aged 75 years and older.

OBJECTIVE: We sought to examine whether the effect of treatment modality and drugs for cerebral vasospasm on clinical outcomes differs between elderly and non-elderly subarachnoid hemorrhage (SAH) patients in Japan. METHODS: We analyzed the J-ASPECT Study Diagnosis Procedure Combination database (n = 17,343) that underwent clipping or coiling between 2010 and 2014 in 579 hospitals. We stratified patients into two groups according to their age (elderly [≥75 years old], n = 3,885; non-elderly, n = 13,458). We analyzed the effect of treatment modality and anti-vasospasm agents (fasudil hydrochloride, ozagrel sodium, cilostazol, statin, eicosapentaenoic acid [EPA], and edaravone) on in-hospital poor outcomes (mRS 3-6 at discharge) and mortality using multivariable analysis. RESULTS: The elderly patients were more likely to be female, have impaired levels of consciousness and comorbidity, and less likely to be treated with clipping and anti-vasospasm agents, except for ozagrel sodium and statin. In-hospital mortality and poor outcomes were higher in the elderly (15.8% vs. 8.5%, 71.7% vs. 36.5%). Coiling was associated with higher mortality (odds ratio 1.43, 95% confidence interval 1.2-1.7) despite a lower proportion of poor outcomes (0.84, 0.75-0.94) in the non-elderly, in contrast to no effect on clinical outcomes in the elderly. A comparable effect of anti-vasospasm agents on mortality was observed between non-elderly and elderly for fasudil hydrochloride (non-elderly: 0.20, 0.17-0.24), statin (0.63, 0.50-0.79), ozagrel sodium (0.72, 0.60-0.86), and cilostazol (0.63, 0.51-0.77). Poor outcomes were inversely associated with fasudil hydrochloride (0.59, 0.51-0.68), statin (0.84, 0.75-0.94), and EPA (0.83, 0.72-0.94) use in the non-elderly. No effect of these agents on poor outcomes was observed in the elderly. CONCLUSIONS: In contrast to the non-elderly, no effect of treatment modality on clinical outcomes were observed in the elderly. A comparable effect of anti-vasospasm agents was observed on mortality, but not on functional outcomes, between the non-elderly and elderly.

Effects of case volume and comprehensive stroke center capabilities on patient outcomes of clipping and coiling for subarachnoid hemorrhage.

OBJECTIVE: Improved outcomes in patients with subarachnoid hemorrhage (SAH) treated at high-volume centers have been reported. The authors sought to examine whether hospital case volume and comprehensive stroke center (CSC) capabilities affect outcomes in patients treated with clipping or coiling for SAH. METHODS: The authors conducted a nationwide retrospective cohort study in 27,490 SAH patients who underwent clipping or coiling in 621 institutions between 2010 and 2015 and whose data were collected from the Japanese nationwide J-ASPECT Diagnosis Procedure Combination database. The CSC capabilities of each hospital were assessed by use of a validated scoring system based on answers to a previously reported 25-item questionnaire (CSC score 1-25 points). Hospitals were classified into quartiles based on CSC scores and case volumes of clipping or coiling for SAH. RESULTS: Overall, the absolute risk reductions associated with high versus low case volumes and high versus low CSC scores were relatively small. Nevertheless, in patients who underwent clipping, a high case volume (> 14 cases/yr) was significantly associated with reduced in-hospital mortality (Q1 as control, Q4 OR 0.71, 95% CI 0.55-0.90) but not with short-term poor outcome. In patients who underwent coiling, a high case volume (> 9 cases/yr) was associated with reduced in-hospital mortality (Q4 OR 0.69, 95% CI 0.53-0.90) and short-term poor outcomes (Q3 [> 5 cases/yr] OR 0.75, 95% CI 0.59-0.96 vs Q4 OR 0.65, 95% CI 0.51-0.82). A high CSC score (> 19 points) was significantly associated with reduced in-hospital mortality for clipping (OR 0.68, 95% CI 0.54-0.86) but not coiling treatment. There was no association between CSC capabilities and short-term poor outcomes. CONCLUSIONS: The effects of case volume and CSC capabilities on in-hospital mortality and short-term functional outcomes in SAH patients differed between patients undergoing clipping and those undergoing coiling. In the modern endovascular era, better outcomes of clipping may be achieved in facilities with high CSC capabilities.

National trends in outcomes of ischemic stroke and prognostic influence of stroke center capability in Japan, 2010-2016.

BACKGROUND: Limited national-level information on temporal trends in comprehensive stroke center capabilities and their effects on acute ischemic stroke patients exists. AIMS: To examine trends in in-hospital outcomes of acute ischemic stroke patients and the prognostic influence of temporal changes in comprehensive stroke center capabilities in Japan. METHODS: This retrospective study used the J-ASPECT Diagnosis Procedure Combination database and identified 372,978 acute ischemic stroke patients hospitalized in 650 institutions between 2010 and 2016. Temporal trends in patient outcomes and recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy usage were examined. Facility comprehensive stroke center capabilities were assessed using a validated scoring system (comprehensive stroke center score: 1-25 points) in 2010 and 2014. The prognostic influence of temporal comprehensive stroke center score changes on in-hospital mortality and poor outcomes (modified Rankin Scale: 3-6) at discharge were examined using hierarchical logistic regression models. RESULTS: Over time, stroke severity at admission decreased, whereas median age, sex ratio, and comorbidities remained stable. The median comprehensive stroke center score increased from 16 to 17 points. After adjusting for age, sex, comorbidities, consciousness level, and facility comprehensive stroke center score, proportion of in-hospital mortality and poor outcomes at discharge decreased (from 7.6% to 5.0%, and from 48.7% to 43.1%, respectively). The preceding comprehensive stroke center score increase (in 2010-2014) was independently associated with reduced in-hospital mortality and poor outcomes, and increased rt-PA and mechanical thrombectomy use (odds ratio (95% confidence interval): 0.97 (0.95-0.99), 0.97 (0.95-0.998), 1.07 (1.04-1.10), and 1.21 (1.14-1.28), respectively). CONCLUSIONS: This nationwide study revealed six-year trends in better patient outcomes and increased use of rt-PA and mechanical thrombectomy in acute ischemic stroke. In addition to lesser stroke severity, preceding improvement of comprehensive stroke center capabilities was an independent factor associated with such trends, suggesting importance of comprehensive stroke center capabilities as a prognostic indicator of acute stroke care.

Development of Quality Indicators of Stroke Centers and Feasibility of Their Measurement Using a Nationwide Insurance Claims Database in Japan　­ J-ASPECT Study ­

BACKGROUND: We aimed to develop quality indicators (QIs) related to primary and comprehensive stroke care and examine the feasibility of their measurement using the existing Diagnosis Procedure Combination (DPC) database. METHODS AND RESULTS: We conducted a systematic review of domestic and international studies using the modified Delphi method. Feasibility of measuring the QI adherence rates was examined using a DPC-based nationwide stroke database (396,350 patients admitted during 2013-2015 to 558 hospitals participating in the J-ASPECT study). Associations between adherence rates of these QIs and hospital characteristics were analyzed using hierarchical logistic regression analysis. We developed 17 and 12 measures as QIs for primary and comprehensive stroke care, respectively. We found that measurement of the adherence rates of the developed QIs using the existing DPC database was feasible for the 6 QIs (primary stroke care: early and discharge antithrombotic drugs, mean 54.6% and 58.7%; discharge anticoagulation for atrial fibrillation, 64.4%; discharge antihypertensive agents, 51.7%; comprehensive stroke care: fasudil hydrochloride or ozagrel sodium for vasospasm prevention, 86.9%; death complications of diagnostic neuroangiography, 0.4%). We found wide inter-hospital variation in QI adherence rates based on hospital characteristics. CONCLUSIONS: We developed QIs for primary and comprehensive stroke care. The DPC database may allow efficient data collection at low cost and decreased burden to evaluate the developed QIs.

Impact of the consumption tax rate increase on out-of-hospital cardiac arrest in Japan: an interrupted time series analysis.

OBJECTIVES: The Japanese government increased the consumption tax rate from 5% to 8% on 1 April 2014. The impact of this policy on the incidence of out-of-hospital cardiac arrest (OHCA) is unknown. Thus, we aimed to evaluate a potential association between the consumption tax rate increase and OHCA. DESIGN: An interrupted time series design. SETTING: National registry data for all cases of OHCA in Japan. PARTICIPANTS: All OHCA cases of presumed cardiac origin in Japan between January 2005 and December 2016. PRIMARY OUTCOME MEASURE: We used a quasiexperimental design with interrupted time series analysis to investigate whether the consumption tax rate increase was associated with changes in OHCA trends after adjusting for baseline trends. The effective date of the consumption tax rate increase (1 April 2014) was used to split the OHCA data into categories of before and after the change. RESULTS: In total, 808 055 OHCAs of presumed cardiac origin were reported during the study period. Prior to the consumption tax rate increase, the mean monthly OHCA rate was 5.12 cases per 100 000 population (mean monthly count: 5483.45). After adjusting for underlying trends, there was a substantial step change in the incidence of OHCAs (relative risk (RR): 0.921; 95% CI 0.889 to 0.955). CONCLUSIONS: The implementation of the consumption tax rate increase was associated with a significant decrease in the incidence of OHCAs in Japan.

The Influence of Age on the Outcomes of Traumatic Brain Injury: Findings from a Japanese Nationwide Survey (J-ASPECT Study-Traumatic Brain Injury).

BACKGROUND: The epidemiology of patients with traumatic brain injury (TBI) has changed dramatically over recent decades as a result of rapid advances in aging societies. We assessed the influence of age on outcomes of patients with TBI and sought to identify prognostic factors for in-hospital mortality of TBI among elderly patients. METHODS: Using a nationwide database, we analyzed data from 5651 patients with TBI. Univariate analysis was conducted to compare patient demographics, neurologic status on admission, radiologic findings, systemic complication rates, length of hospital stay, in-hospital mortality, and home discharge rates between elderly and nonelderly groups. Multivariable analysis was conducted to determine prognostic factors for in-hospital mortality among elderly patients. RESULTS: Overall in-hospital mortality was significantly higher in elderly patients (12.8% vs. 19.3%; P < 0.001). In-hospital mortality of elderly patients with mild TBI increased significantly at >7 days after admission, whereas that of elderly patients with moderate or severe TBI was significantly higher immediately after admission. Age (odds ratio [OR], 1.62; P = 0.024), male sex (OR, 1.30; P = 0.004), Japan Coma Scale score on admission (OR, 5.95, P < 0.001), and incidence of acute subdural hematoma (OR, 1.89; P < 0.001) were associated with in-hospital mortality in elderly patients with TBI. CONCLUSIONS: Elderly patients with TBI showed significantly higher in-hospital mortality. Delayed increases in in-hospital mortality were observed among elderly patients with mild TBI. Level of consciousness on admission was the strongest predictor of in-hospital mortality among elderly patients.