Excess mortality among adults with mental disorders treated in psychiatric and general medical settings: A population-based cohort study using municipal medical claims data in Japan.

OBJECTIVES: To estimate the excess mortality associated with serious mental illnesses (schizophrenia and bipolar disorder) and common mental disorders (depression and anxiety) at the population level. METHODS: We conducted a population-based, retrospective cohort study in Tsukuba, Japan. Individuals aged 20-74 years and insured for at least 12 months by the National Health Insurance or Late Elders' Health Insurance as of April 2015 were included (n = 41,618, 29% of the city's population aged 20-74 years). Individuals with mental disorders (International Classification of Diseases-10 code: F00-F99) were identified in psychiatric and general medical services using medical claims during the 12-month baseline period and classified into mutually exclusive diagnostic subgroups. Their age/sex-adjusted all-cause mortality rate ratios (aMRRs) were estimated and compared to those of individuals without mental disorders. RESULTS: Altogether, 12.0% of participants had mental disorders (general medical service: 7.2% vs. psychiatric service: 4.8%). Common mental disorders were the most prevalent (8.1%). During the median 48 months of observation, 225 deaths were observed in people with mental disorders. The aMRR was 1.98 (95%CI: 1.70-2.29) for all mental disorders, with a higher rate ratio in psychiatric service than in general medical service users (aMRR: 2.64 [2.12-3.29] vs. 1.70 [1.42-2.04]), 3.57 (2.71-4.70) for serious mental illness, with a higher rate ratio in psychiatric inpatient service than in outpatient service users (aMRR: 5.74 [3.76-8.78] vs. 2.84 [2.00-4.04]), and 1.53 (1.27-1.84) for common mental disorders. CONCLUSION: Serious and common mental disorders in psychiatric and general health services are associated with increased mortality in Japan.

Factors associated with non-initiation of osteoporosis pharmacotherapy after hip fracture: analysis of claims data in Japan.

In an analysis of claims data from a city in Japan, male patients and patients with dementia were less likely to receive osteoporosis pharmacotherapy after hip fracture. Treatment initiation rate has improved between 2014 and 2017. PURPOSE: Older adults with recent hip fractures are at a high risk of recurrent fractures. However, the post-fracture care gap has been reported globally. This study examines factors associated with pharmacotherapy non-initiation within 1 year after hip surgery. METHODS: Using medical and long-term care (LTC) claims, and LTC needs certification data in Tsukuba City, Japan, we identified individuals aged 65 years or older who had hip fractures with subsequent surgical procedures between October 1, 2014, and December 31, 2017. Patient (age, sex, dementia, and comorbidities) and health service-related characteristics (fiscal year, type of hospital, number of hospital beds, and admission to recovery phase rehabilitation wards) were examined. The association of these factors with non-pharmacotherapy for osteoporosis within 1 year after hip fracture using multivariable logistic models was analyzed. RESULTS: We identified 275 patients with hip fractures who did not receive pharmacotherapy pre-fracture. Forty percent of them received pharmacotherapy within 1 year of post-fracture. Male sex (odds ratio (OR) = 4.49 [2.14-9.44]) and dementia (OR = 1.90 [1.03-3.52]) were associated with no pharmacotherapy, whereas later fiscal year (OR = 0.64 [0.48-0.87]) and admission to rehabilitation wards (OR = 0.25 [0.14-0.46]) were associated with pharmacotherapy initiation within 1 year of post-fracture. Comorbidities were not associated with the initiation of pharmacotherapy. CONCLUSION: Pharmacotherapy for osteoporosis was less likely to be initiated after a hip fracture in male patients and patients with dementia. These patients should be considered for pharmacotherapy because they are at high risk of recurrent fractures.

Evaluation of enhanced home care support clinics regarding emergency home visits, hospitalization, and end-of-life care: a retrospective cohort study in a city of Japan.

BACKGROUND: To meet the increasing demand for home healthcare in Japan as the population ages, home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in 2006 and 2012, respectively. This study aimed to evaluate whether enhanced HCSCs fulfilled the expected role in home healthcare. METHODS: We conducted a retrospective cohort study using linked medical and long-term care claims data from a municipality in Japan. Participants were ≥ 65 years of age, had newly started regular home visits between July 2014 and March 2018, and used either conventional or enhanced HCSCs. Patients were followed up for one year after they started regular home visits or until the month following the end of the regular home visits if they ended within one year. The outcome measures were (i) emergency home visits at all hours and on nights and holidays at least once, respectively, (ii) hospitalization at least once, and (iii) end-of-life care, which was evaluated based on the place of death and whether a physician was present at the time of in-home death. Multivariable logistic regression analyses were conducted for the outcomes of emergency home visits and hospitalizations. RESULTS: The analysis included 802 patients, including 405 patients in enhanced HCSCs and 397 patients in conventional HCSCs. Enhanced HCSCs had more emergency home visits at all hours than conventional HCSCs (65.7% vs. 49.1%; adjusted odds ratio 1.70, 95% CI [1.26-2.28]), more emergency home visits on nights and holidays (33.6% vs. 16.7%; 2.20 [1.55-3.13]), and fewer hospitalizations (21.5% vs. 32.2%; 0.55 [0.39-0.76]). During the follow-up period, 229 patients (152 patients in enhanced HCSCs and 77 patients in HCSCs) died. Deaths at home were significantly more common in enhanced HCSCs than in conventional HCSCs (80.9% vs. 64.9%; p < .001), and physician-attended deaths among those who died at home were also significantly more common in enhanced HCSCs (99.2% vs. 78.0%; p < .001). CONCLUSIONS: This study confirms that enhanced HCSCs are more likely to be able to handle emergency home visits and end-of-life care at home, which are important medical functions in home healthcare. Further promotion of enhanced HCSCs would be advantageous.

Associations of polypharmacy and drugs with sedative or anticholinergic properties with the risk of long-term care needs certification among older adults in Japan: A population-based, nested case-control study.

AIM: To estimate the risk of disability associated with high-risk prescribing, such as polypharmacy and drugs with sedative or anticholinergic properties, using long-term care needs certification as a proxy of incident disability. METHODS: A case-control study nested within a cohort of older adults (89% aged ≥65 years) was carried out between 2014 and 2019 using the combined medical claims and long-term care needs certification database of Tsukuba City, Japan. We identified 2123 cases who received their first long-term care certification, and matched them to 40 295 controls based on age, sex, residential area and observation period (≥36 months). The risk of long-term care needs certification associated with high-risk prescribing exposure 7-30 months before the index month was estimated using conditional logistic regression adjusting for baseline comorbidities and health service use. RESULTS: Polypharmacy (5-9 drugs; adjusted odds ratio [aOR] 1.32, 95% confidence interval [95% CI] 1.18-1.47), hyperpolypharmacy (≥10 drugs; aOR 1.87, 95% CI 1.57-2.23) and cumulative dose of drugs with sedative or anticholinergic properties (1-364 defined daily dose [DDD]; aOR 1.07, 95% CI 0.97-1.19; 365-729 DDD; aOR 1.25, 95% CI 1.07-1.45; ≥730 DDD; aOR 1.33, 95% CI 1.19-1.62) had dose-response relationships with long-term care certification risks. CONCLUSIONS: High-risk prescribing was associated with the risk of long-term care needs certification in the general older population. Further studies are warranted to examine whether a decrease in prescribing drugs with sedative or anticholinergic properties could reduce the long-term care burden on society. Geriatr Gerontol Int 2022; 22: 497-504.

Development and validation of a risk score to predict the frequent emergency house calls among older people who receive regular home visits.

BACKGROUND: The demand for home healthcare is increasing in Japan, and a 24-hour on-call system could be a burden for primary care physicians. Identifying high-risk patients who need frequent emergency house calls could help physicians prepare and allocate medical resources. The aim of the present study was to develop a risk score to predict the frequent emergency house calls in patients who receive regular home visits. METHODS: We conducted a retrospective cohort study with linked medical and long-term care claims data from two Japanese cities. Participants were ≥ 65 years of age and had newly started regular home visits between July 2014 and March 2018 in Tsukuba city and between July 2012 and March 2017 in Kashiwa city. We followed up with patients a year after they began the regular home visits or until the month following the end of the regular home visits if this was completed within 1 year. We calculated the average number of emergency house calls per month by dividing the total number of emergency house calls by the number of months that each person received regular home visits (1-13 months). The primary outcome was the "frequent" emergency house calls, defined as its use once per month or more, on average, during the observation period. We used the least absolute shrinkage and selection operator (LASSO) logistic regression with 10-fold cross-validation to build the model from 19 candidate variables. The predictive performance was assessed with the area under the curve (AUC). RESULTS: Among 4888 eligible patients, frequent emergency house calls were observed in 13.0% of participants (634/4888). The risk score included three variables with the following point assignments: home oxygen therapy (3 points); long-term care need level 4-5 (1 point); cancer (4 points). While the AUC of a model that included all candidate variables was 0.734, the AUC of the 3-risk score model was 0.707, suggesting good discrimination. CONCLUSIONS: This easy-to-use risk score would be useful for assessing high-risk patients and would allow the burden on primary care physicians to be reduced through measures such as clustering high-risk patients in well-equipped medical facilities.

Factors Associated with Outpatient Cardiac Rehabilitation Participation in Older Patients: A Population-Based Study Using Claims Data from Two Cities in Japan.

BACKGROUND: Although outpatient cardiac rehabilitation has been shown to be effective, the participation status of older cardiac patients is unclear in real-world settings. We investigated the proportion and associated factors of outpatient cardiac rehabilitation participation among older patients with heart diseases after cardiac intervention. METHODS: We analyzed data from medical and long-term care insurance claims data from two municipalities in Japan. The data coverage period was between April 2014 and March 2019 in City A and between April 2012 and November 2016 in City B. We identified patients aged ≥65 years with post-operative acute myocardial infarction, angina pectoris, or heart valve disease. We estimated the proportion of cardiac rehabilitation participation and conducted logistic regression to identify factors (age, sex, type of cardiac disease, open-heart surgery, Charlson comorbidity index, long-term care need level, catecholamine use, inpatient cardiac rehabilitation, and hospital volume for cardiac rehabilitation) associated with outpatient cardiac rehabilitation participation. RESULTS: A total of 690 patients were included in this study. The proportion of patients receiving outpatient cardiac rehabilitation was 9.0% overall. Multivariable logistic regression analysis suggested that men (adjusted OR 3.98; 95% CI 1.69-9.37), acute myocardial infarction (adjusted OR 2.76; 95% CI 1.20-6.36; reference angina pectoris), inpatient cardiac rehabilitation (adjusted OR 17.01; 95% CI 5.33-54.24), and "hospital volume" for cardiac rehabilitation (adjusted OR 4.35; 95% CI 1.14-16.57 for high-volume hospitals; reference low-volume hospital) were independently associated with outpatient cardiac rehabilitation. CONCLUSIONS: The participation rate of outpatient cardiac rehabilitation among older post-operative cardiac patients was suboptimal. Further studies are warranted to examine its generalizability and whether a targeted approach to a group of patients who are less likely to receive outpatient cardiac rehabilitation could improve the participation rate.

Impact of duration of untreated psychosis on remission in first-episode schizophrenia in Thailand: a cohort study

ABSTRACT Background: To scale up the services for first-episode schizophrenia in Thailand, it is essential to understand to what extent health care-seeking is delayed, and how much the delay affects the treatment outcome. Objectives: To investigate the duration of untreated psychosis (DUP) and its impact on remission in first-episode schizophrenia across the country. Methods: 276 outpatients with a first-episode schizophrenia were followed for 6 months and assessed whether they fulfilled the criteria for remission at the follow-up. The proportion of those achieving remission was compared by the DUP. The impact of DUP on remission was estimated in multivariate analyses. Results: At the follow-up, 83% (71/86) of patients who had met the criteria for symptomatic remission at the baseline achieved enduring remission, whereas 63% (119/190) of patients who had not met the criteria for symptomatic remission at baseline met it at the follow-up. The shorter the DUP, the higher the proportion of those who achieved symptomatic or enduring remission at the follow-up. The impact of DUP on symptomatic remission appeared to be significant after controlling for other factors influencing remission. Conclusion: Since the DUP would influence remission of patients with schizophrenia, early detection and intervention services should be provided in Thailand.

Discovering Common Elements of Empirically Supported Self-Help Interventions for Depression in Primary Care: a Systematic Review.

BACKGROUND: Although the efficacy of self-help cognitive-behavioral therapy (CBT) for depression has been well established, its feasibility in primary care settings is limited because of time and resource constraints. The goal of this study was to identify common elements of empirically supported (i.e., proven effective in controlled research) self-help CBTs and frameworks for effective use in practice. METHODS: Randomized controlled trials (RCTs) for self-help CBTs for depression in primary care were systematically identified in Pubmed, PsycINFO, and CENTRAL. The distillation and matching model approach was used to abstract commonly used self-help techniques (practice elements). Study contexts associated with unique combinations of intervention elements were explored, including total human support dose (total face-to-face, telephone, and personalized email contact time recommended by the protocol), effective symptom domain (depression vs. general psychological distress), and severity of depression targeted by the study. Relative contribution to intervention success was estimated for individual elements and human support by conditional probability (CP, proportion of the number of times each element appeared in a successful intervention to the number of times it was used in the interventions identified by the review). RESULTS: Twenty-one interventions (12 successful) in 20 RCTs and 21 practice elements were identified. Cognitive restructuring, behavioral activation, and homework assignment were elements appearing in > 80% of successful interventions. The dose of human support was positively associated with the proportion of interventions that were successful in a significant linear fashion (CPs: interventions with no support, 0.20; 1-119 min of support, 0.60; 120 min of support, 0.83; p = 0.042). In addition, human support increased the probability of success for most of the extracted elements. Only social support activation, homework assignment, and interpersonal skills were highly successful (CPs ≥ 0.60) when minimal support was provided. DISCUSSION: These findings suggest that human support is an important component in creating an evidence-informed brief self-help program compatible with primary care settings.

Antipsychotic use and related factors among people with dementia aged 75 years or older in Japan: A comprehensive population-based estimation using medical and long-term care data.

OBJECTIVES: Antipsychotics are used to manage the behavioral and psychological symptoms of dementia (BPSD), despite their association with greater risks for mortality and cerebrovascular events. Previous studies in Japan have estimated the prevalence of antipsychotics among older adults who took antidementia drugs. Using long-term care (LTC) data, we aimed to obtain more accurate estimates of the prevalence of antipsychotics and to determine factors related to their use in older adults with dementia. METHODS: Medical and LTC claims data and LTC certification data between April 2012 and September 2013 were obtained from a middle-sized suburban city. The 1-year prevalence of antipsychotic use was estimated among individuals with probable dementia aged greater than or equal to 75 years who were prescribed antidementia drugs and/or had dementia based on LTC needs certification data. RESULTS: Of 25 919 participants, 4865 had probable dementia and 1506 were prescribed antidementia drugs. The prevalence of antipsychotics among participants with probable dementia was 10.7%, which was lower than that in those who were prescribed antidementia drugs (16.4%). Among participants with probable dementia with LTC certification data available (N = 4419), lower cognitive function (vs mild; adjusted odds ratio 2.16, 95% confidence interval 1.63-2.86), antidementia drug use (2.27, 1.84-2.81), and institutional LTC services use (2.34, 1.85-2.97) were associated with greater odds of antipsychotic use, whereas older age (greater than or equal to 92 years) was associated with lower odds (vs less than 77 years; 0.42, 0.27-0.65). CONCLUSIONS: These findings may be useful for estimating the burden of BPSD and for taking measures to reduce inappropriate antipsychotic prescription.

The association of personal importance of religion and religious service attendance with suicidal ideation by age group in the National Survey on Drug Use and Health.

Religiosity has been shown to be inversely associated with suicidal ideation, but few studies have examined associations by age group. This study aimed to examine the association between religiosity with suicidal ideation by age group. This study used a large nationally representative sample of 260,816 study participants from the National Survey on Drug Use and Health. Religiosity was defined as self-reported importance of religious beliefs and frequency of religious service attendance. The association between religiosity and suicidal ideation was assessed by multivariable logistic regression analysis stratified by age group (18-25, 26-34, 35-49, 50-64, 65 or older). The importance of religious beliefs was inversely associated with suicidal ideation in all age groups. The association was the strongest in people aged 65 or older, followed by people aged 18-25. Religious service attendance was also inversely associated with suicidal ideation in people aged 65 or more when attendance was more than 25 times per year. These findings may be helpful to understand age in relation to the relationship between religiosity and suicidal ideation. Particular attention to religiosity among older adults as a protective factor for suicidal ideation may be helpful in clinical settings.

Attitudes toward taking medication among outpatients with schizophrenia: cross-national comparison between Tokyo and Beijing.

OBJECTIVES: The aim of this study was to compare attitudes toward medication and associated factors for patients with schizophrenia in Japan and China. METHODS: Age-group matched samples were drawn from outpatients in Tokyo (N = 76) and Beijing (N = 76) according to the same inclusion/exclusion criteria. Psychotropic prescription and attitudes toward medication were measured using Drug Attitude Inventory-30 (DAI-30) and an original questionnaire regarding beliefs about psychiatric medication. Stepwise regression analysis of the DAI-30 data was performed for each group. RESULTS: Japanese subjects were prescribed significantly larger amounts of antipsychotics. Polypharmacy of antipsychotics and concurrent use of anticholinergics, anxiolytics, or hypnotics were more frequently found among subjects in Tokyo than among those in Beijing. However, subjects in Tokyo and Beijing had similar subjective responses to medication, subjective evaluation of side-effects, and complaints about overuse of psychotropics. Subjects in Tokyo complained less about physician's over-reliance on medication and were less concerned about medication cost than those in Beijing. In Tokyo, longer duration of illness and lower subjective distress caused by side effects predicted a more positive subjective response, while female gender, younger age, and lower Brief Psychiatric Rating Scale score were independently correlated with a better subjective response in Beijing. CONCLUSIONS: Subjective acceptance of multiple medications is greater for patients in Japan than those in China. Determinants of subjective response to medication varied between Japan and China.