Otologic disease trends in Japan post-COVID-19 outbreak: A retrospective time-series analysis.

OBJECTIVE: To evaluate the potential impact of coronavirus disease 2019 (COVID-19) and vaccinations on otologic diseases, including facial nerve paralysis (including Ramsay Hunt syndrome), vestibular neuritis, sudden sensorineural hearing loss, and Meniere's disease. METHODS: In this retrospective study, we conducted a time-series analysis employing a causal impact algorithm on a large-scale inpatient database in Japan. We compared the actual number of hospitalized patients with otologic diseases to two predictions: one without any covariates and another with a covariate accounting for the reduction in the number of hospitalized patients due to lockdown measures. Additionally, we performed Granger causality tests to ensure the robustness of our findings. RESULTS: No significant increase was noted in the number of hospitalized patients with otologic diseases following the onset of the COVID-19 pandemic in the causal impact analysis. Similarly, no notable surge was observed in hospitalizations for these diseases following the introduction of the COVID-19 vaccine. The Granger causality tests results aligned with the causal impact analysis findings. CONCLUSION: Our findings indicate that COVID-19 and vaccinations had minimal discernible effects on hospitalization of patients with otologic diseases, suggesting that otologic diseases may not be significantly impacted by COVID-19 and vaccinations, which could have implications for public health policies and the allocation of healthcare resources during a pandemic. Further research and monitoring of long-term effects are warranted to validate these findings and guide healthcare decision-making.

Geographical distribution of antimicrobial exposure among very preterm and very low birth weight infants: A nationwide database study in Japan.

OBJECTIVES: To examine spatial effects in neonatal care, we conducted a retrospective cohort study to investigate the geographical distribution of antimicrobial exposure among very preterm and very low birth weight infants in Japan. STUDY DESIGN: We utilized a nationwide claims database in Japan to extract prescriptions of injectable antimicrobials for 41,423 very preterm and very low birth weight infants admitted within the first two days of life from April 2010 to March 2021. We identified frequently prescribed antimicrobials, revealed early neonatal exposure and neonatal exposure to each antimicrobial agent by 47 prefectures in Japan, and evaluated their spatial autocorrelation using global and local Moran's I statistics. We then scrutinized regional disparities in antimicrobial drug prescriptions. RESULTS: The top 10 antimicrobials prescribed to very preterm and very low birth weight infants in Japan were ampicillin, amikacin, gentamicin, cefotaxime, fluconazole, ampicillin combination, micafungin, cefmetazole, cefazolin, and vancomycin. We identified northern cold spots for fluconazole exposure and southern hot spots for ampicillin, amikacin, gentamicin, and cefmetazole exposure. Geographical heterogeneity in the selection of antibacterial and antimycotic agents was observed. CONCLUSION: Our study revealed the geographical distribution of antimicrobial exposure among very preterm and very low birth weight infants in Japan, thus disclosing its spatial effects. Further research addressing the spatial effects of neonatal care is needed to understand how drug exposure affects the outcomes of preterm infants.

Development of a set of quality indicators in paediatric and perinatal care in Japan with a modified Delphi method.

BACKGROUNDS: Few paediatric and perinatal quality indicators (QIs) have been developed in the Japanese setting, and the quality of care is not assured or validated. The aim of this study was to develop QIs in paediatric and perinatal care in Japan using an administrative database and confirm the feasibility and applicability of the indicators using a single-site practice test. METHODS: We used a RAND-modified Delphi method that integrates evidence review with expert consensus development. QI candidates were generated from clinical practice guidelines (CPGs) available in English or Japanese and existing QIs in nine selected paediatric or perinatal conditions. Consensus building was based on independent panel ratings. The performance of QIs was retrospectively assessed using data from an administrative database at the National Children's Hospital. Data between April 2018 and March 2019 were used, while data between April 2019 and March 2021 were also used for selected condition, considering the small number of patients. Each QI was calculated as follows: number of times the indicator was met/number of participants×100. RESULTS: From the literature review conducted between 2010 and 2020, 124 CPGs and 193 existing indicators were identified to generate QI candidates. Through the consensus-building process, 133 QI candidates were assessed and 79 QIs were accepted. The practice test revealed wide variations in the process-level performance of QIs in four categories: patient safety: median 43.9% (IQR 16.7%-85.6%), general paediatrics: median 98.8% (IQR 84.2%-100%), advanced paediatrics: median 94.4% (IQR 46.0%-100%) and advanced obstetrics: median 80.3% (IQR 59.6%-100%). CONCLUSIONS: We established 79 QIs for paediatric and perinatal care in Japan using an administrative database that can be applied to hospitals nationwide. The practice test confirmed the measurability of the developed QIs. Benchmarking these QIs will be an attractive approach to improving the quality of care.

Risk factors for postoperative anastomotic leakage after repair of esophageal atresia: a retrospective nationwide database study.

PURPOSE: Postoperative anastomotic leakage is the most frequent short-term complication of esophageal atresia repair in neonates. We conducted this study using a nationwide surgical database in Japan to identify the risk factors for anastomotic leakage in neonates undergoing esophageal atresia repair. METHODS: Neonates diagnosed with esophageal atresia between 2015 and 2019 were identified in the National Clinical Database. Postoperative anastomotic leakage was compared among patients to identify the potential risk factors, using univariate analysis. Multivariable logistic regression analysis included sex, gestational age, thoracoscopic repair, staged repair, and procedure time as independent variables. RESULTS: We identified 667 patients, with an overall leakage incidence of 7.8% (n = 52). Anastomotic leakage was more likely in patients who underwent staged repairs than in those who did not (21.2% vs. 5.2%, respectively) and in patients with a procedure time > 3.5 h than in those with a procedure time < 3.5 h (12.6% vs. 3.0%, respectively; p < 0.001). Multivariable logistic regression analysis identified staged repair (odds ratio [OR] 4.89, 95% confidence interval [CI] 2.22-10.16, p < 0.001) and a longer procedure time (OR 4.65, 95% CI 2.38-9.95, p < 0.001) as risk factors associated with postoperative leakage. CONCLUSION: Staged procedures and long operative times are associated with postoperative anastomotic leakage, suggesting that leakage is more likely after complex esophageal atresia repair and that such patients require refined treatment strategies.

Prescribed daily-dose-based metrics of oral antibiotic use for hospitalized children in Japan.

Objective: Defined daily-dose (DDD)-based metrics are frequently used to measure antibiotic consumption. However, they are unsuitable for the pediatric population because they are defined using the maintenance dose for 70-kg adults. Moreover, children have large body weight variations. We assessed the prescribed daily dose (PDD) and PDD-based metrics of oral antibiotics for children to develop an alternative to DDD-based metrics in Japan. Design: We performed observational study using data from the Japanese administrative claims database between April 2018 and March 2019. Methods: Of 453,001 patients (aged 1 month-15 years), 564,326 admissions to 1,159 hospitals were included. We showed the median PDD (mg/day and mg/kg/day) and PDD-based metrics for 8 antibiotics for each age category (1 month to <1 year old and 1-6, 7-12, and 13-15 years old). We also assessed the relationship between PDD-based metrics and days of therapy (DOT)-based metrics using a scatter plot and correlation. Results: In total, 86,389 patients (19.1%) were prescribed oral antibiotics; amoxicillin, macrolides, and third-generation cephalosporins were the most common. The PDD (mg/day) for each antibiotic increased with age to 7-12 years old, when an adult dose was reached. The PDD (mg/kg/day) decreased with age to 13-15 years old, due to increasing body weight. The relationship between PDD per 1,000 patient days and DOT per 1,000 patient days differed depending on the antibiotic. Conclusions: PDD-based metrics stratified by age could characterize antibiotic consumption, even with body-weight variations. Therefore, PDD-based metrics, in addition to DOT-based metrics, are helpful benchmarks for antibiotic use in children.

Pandemic-resilient target setting in colorectal cancer screening for vulnerable older population.

BACKGROUND: Colorectal cancer screening (CRCS) needs to be pandemic-resilient to avoid long-lasting shutdowns; however, realistic participation target remains unelucidated. This study aimed to identify the lowest acceptable participation rate in CRCS during a pandemic, focusing on vulnerable older populations who require urgent intervention. METHODS: This nationwide cross-sectional study included 80,946 inpatients aged 70-85 years who were first diagnosed with colorectal cancer (CRC) after 70 years of age, between April 1, 2014 and March 31, 2019, in Japan. To evaluate the association between area-level CRCS participation rate and individual early CRC detection, a multilevel logistic regression model was constructed. The mandatorily implemented screening rates were converted to the total screening rate equivalents (TSREs), which reflect the remaining contributions of voluntarily provided screenings. RESULTS: Early detections during stages 0-I were significantly observed when primary screening rate was ≥38% (TSRE) and combined follow-up rate was ≥85%. For early detection during Tis-T1, primary screening rate ≥ 38% (TSRE) and combined follow-up rate ≥ 90% were necessary. For follow-up rates ≥70% or ≥75%, there were cases where missed detection of Tis-T1 were observed. CONCLUSION: The results indicate that, even during pandemic, CRCS should achieve a primary screening rate of 38% and follow-up rate of 85% for vulnerable older populations. These values, lower than the current desirable rates, suggest the maximum possible compromise in balancing the resources between cancer screening and pandemic measures. Moreover, they also indicate the minimum target for shifting to fecal immunochemical test-focused program. Further explorations with varied CRCS settings are necessary for verification.

Current status of intensive end-of-life care in children with hematologic malignancy: a population-based study.

BACKGROUND: Adult patients with hematologic malignancies are less likely to receive palliative care and more likely to accept intensive anti-cancer treatments until end-of-life than those with solid tumors, but limited data are available regarding the quality of end-of-life care (EOLC) for children with hematologic malignancies. To improve the quality of EOLC for children with hematologic malignancies, the aims of this study were (i) to compare intensive EOLC between children with hematologic malignancies and those with solid tumors; and (ii) to describe factors associated with intensive EOLC in children with hematologic malignancies. METHODS: We retrospectively reviewed 0- to 18-year-old patients with cancer, who died in hospital between April 2012 and March 2016 in Japan using the Diagnosis Procedure Combination per-diem payment system. Indicators of intensive inpatient EOLC were defined as intensive care unit admission, cardiopulmonary resuscitation (CPR), intubation and/or mechanical ventilation, hemodialysis, or extra-corporeal membrane oxygenation in the last 30 days of life, or intravenous chemotherapy in the last 14 days. We determined factors associated with intensive EOLC using regression models. Data regarding use of blood transfusion were also obtained from the database. RESULTS: Among 1199 patients, 433 (36%) had hematological malignancies. Children with hematologic malignancies were significantly more likely than those with solid tumors to have intubation and/or mechanical ventilation (37.9% vs. 23.5%), intensive care unit admission (21.9% vs. 7.2%), CPR (14.5% vs. 7.7%), hemodialysis (13.2% vs. 3.1%) or extra-corporeal membrane oxygenation (2.5% vs. 0.4%) in their last 30 days, or intravenous chemotherapy (47.8% vs. 18.4%; all P < .01) within their last 14 days of life. Over 90% of children with hematological malignancies received a blood transfusion within the last 7 days of life. For hematological malignancies, age under 5 years was associated with CPR and ≥ 2 intensive EOLC indicators. Longer hospital stays had decreased odds of ≥ 2 intensive EOLC indicators. CONCLUSION: Children with hematologic malignancies are more likely to receive intensive EOLC compared to those with solid tumors. A younger age and shorter hospital stay might be associated with intensive EOLC in children with hematologic malignancies.

Consultation-liaison psychiatry in Japan: a nationwide retrospective observational study.

BACKGROUND: Consultation-liaison psychiatry (CLP)-professional psychiatric care provided to coordinate with surgical or medical treatment of inpatients with psychiatric disorders-was included in universal health coverage in Japan in 2012. Despite evidence of benefits of CLP, basic data and geographic distribution information regarding CLP at the national level remain unclear. This study aimed to 1) identify the geographic disparity of CLP in Japan and 2) investigate the association between number of consultations per CLP patient and region. METHODS: We retrospectively analyzed anonymized data retrieved from the Japanese administrative inpatient database regarding inpatients who were provided CLP between April 2012 and March 2017. Demographic characteristics were summarized and geographic disparity by prefecture was visualized for fiscal years 2012 and 2016; we also summarized the data according to region. Multivariate linear regression analysis was used to investigate association between the number of consultations per CLP patient and region after adjusting for covariates. RESULTS: Data from a total of 46,171 patients who received 138,866 CLP services were included. Results revealed more patients aged 75-84 years received CLPs than any other age group (29.7%) and the overall male/female ratio was 53:47 in 2016. In 2012 and 2016, 24.2 and 30.7% of CLP patients, respectively, were transferred to other hospitals; 9.7 and 8.8%, respectively, discharged due to the death. CLP services were provided in 14 prefectures in 2012 and 33 by 2016; 14 prefectures had no available CLP services. After adjusting for covariates, Tohoku (ß = - 0.220, p < 0.034), Chugoku (ß = - 0.160, p < 0.026), and Shikoku (ß = - 0.555, p < 0.001) had a significant negative correlation with the number of consultations per CLP patient compared with Hokkaido region (an adjusted R square (R2) = 0.274). CONCLUSIONS: Our study clarified the characteristics of patients in Japan who received CLPs and the geographic disparity in CLP services. Although 5 years had passed since CLP was introduced, the results imply wide availability of CLP nationally. The analysis data provided may inform future policies to improve CLP services.

Risk factors for early unplanned readmission in patients with bipolar disorder: A retrospective observational study.

OBJECTIVES: Evidence regarding the relationships between patient, hospital, and regional factors and early unplanned readmission (short-term outcome) in patients with bipolar disorder is lacking. This study aimed to examine risk factors associated with early unplanned readmission in patients with bipolar disorder. METHOD: We retrospectively analyzed adult bipolar patients (ICD-10; F31) between April 2012 and March 2014 in the Japanese Diagnosis Procedure Combination database. We examined factors affecting the 30-day unplanned readmission using multivariable logistic regression analysis. RESULTS: A total of 2688 patients admitted to psychiatric beds were included. Multivariate analysis showed that unchanged or exacerbation discharge outcome (adjusted odds ratio [aOR]: 1.93; 95% confidence interval [CI]: 1.06-3.51, p = 0.031), unplanned or urgent admission settings (aOR: 1.51; 95% CI: 1.00-2.26, p = 0.048), physical comorbidity (chronic pulmonary disease) (aOR: 4.74; 95% CI: 1.30-17.29, p = 0.018), presence of psychiatric acute-care beds (aOR: 1.72; 95% CI: 1.02-2.87, p = 0.040), and intermediate-level hospital psychiatric staffing (aOR: 1.82; 95% CI: 1.14-2.91, p = 0.012) were significantly associated with higher early unplanned readmission, while higher density of psychiatrists in the area (aOR: 0.50; 95% CI: 0.29-0.87, p = 0.014) was significantly associated with lower early unplanned readmission. CONCLUSIONS: The results suggest that not only careful management of high-risk patients but also consideration of functional differentiation in psychiatric inpatient care, psychiatric resource allocation, and follow-up support for patients with bipolar disorder are needed for reducing the early unplanned readmission rate.

Volume effect in paediatric brain tumour resection surgery: analysis of data from the Japanese national inpatient database.

BACKGROUND: Paediatric brain tumours are the second most common type of malignancies that occur during childhood. Surgical resection is usually the first step in the treatment of these patients; however, evidence pertaining to a 'volume effect' in paediatric brain tumour resection surgery and the associations among the surgical volume, clinical features and treatments are not well characterised. METHODS: Data pertaining to paediatric patients (age ≤ 15 years) who underwent brain tumour resection surgery between April 2012 and March 2016 were retrieved from the Japanese administrative inpatient database and retrospectively analysed. Demographic characteristics, therapeutic procedures and in-hospital mortality were summarised according to the hospital surgical volume. Penalised logistic regression analysis was used to investigate the association between the hospital surgical volume and in-hospital mortality. RESULTS: A total of 1354 paediatric patients were included. About 40% of the patients were in the 11- to 15-year age group. The male:female ratio was 53:47, the overall crude in-hospital mortality was 1.8% (n = 24) and the 30-day postoperative mortality was 0.4% (n = 6). The crude mortality ratio was 3.3% in the lowest quartile and 0.8% in the highest quartile by volume. After adjusting for covariates, a higher hospital surgical volume was associated with lower in-hospital mortality (compared with 1-4 surgeries per 4 years, 15-25 surgeries, odds ratio [OR]: 0.25; 95% confidence interval [CI]: 0.05-0.90, p = 0.033; ≥26 surgeries, OR: 0.31; 95% CI: 0.08-0.96, p = 0.042). CONCLUSIONS: The present study indicated a volume-outcome relationship in paediatric brain tumour resection surgery cases. Further centralisation of surgeries should be considered to achieve better outcomes.

Predictors associated with unplanned hospital readmission of medical and surgical intensive care unit survivors within 30 days of discharge.

BACKGROUND: Reducing the 30-day unplanned hospital readmission rate is a goal for physicians and policymakers in order to improve quality of care. However, data on the readmission rate of critically ill patients in Japan and knowledge of the predictors associated with readmission are lacking. We investigated predictors associated with 30-day rehospitalization for medical and surgical adult patients separately. METHODS: Patient data from 502 acute care hospitals with intensive care unit (ICU) facilities in Japan were retrospectively extracted from the Japanese Diagnosis Procedure Combination (DPC) database between April 2012 and February 2014. Factors associated with unplanned hospital readmission within 30 days of hospital discharge among medical and surgical ICU survivors were identified using multivariable logistic regression analysis. RESULTS: Of 486,651 ICU survivors, we identified 5583 unplanned hospital readmissions within 30 days of discharge following 147,423 medical hospitalizations (3.8% readmitted) and 11,142 unplanned readmissions after 339,228 surgical hospitalizations (3.3% readmitted). The majority of unplanned hospital readmissions, 60.9% of medical and 63.1% of surgical case readmissions, occurred within 15 days of discharge. For both medical and surgical patients, the Charlson comorbidity index score; category of primary diagnosis during the index admission (respiratory, gastrointestinal, and metabolic and renal); hospital length of stay; discharge to skilled nursing facilities; and having received a packed red blood cell transfusion, low-dose steroids, or renal replacement therapy were significantly associated with higher unplanned hospital readmission rates. CONCLUSIONS: From patient data extracted from a large Japanese national database, the 30-day unplanned hospital readmission rate after ICU stay was 3.4%. Further studies are required to improve readmission prediction models and to develop targeted interventions for high-risk patients.

The degree of severity and trends in hospital standardized mortality ratios in Japan between 2008 and 2012: a retrospective observational study.

OBJECTIVES: Hospital standardized mortality ratio (HSMR), an indicator that adjusts hospital mortality for case-mix differences, is used as a hospital performance measure. The aim of this study is to build a new HSMR model in Japan and examine HSMR trends according to the degree of severity. DESIGN: Observational retrospective study. SETTINGS: Data from the Japanese Administrative Database. PARTICIPANTS: A total of 3 813 492 admissions from 278 Japanese acute-care hospitals were extracted from the database (patients between 2008 and 2012, from July to December in each year). MAIN OUTCOME MEASURES: We estimated the probability of in-hospital death by fitting a logistic regression model, and assessed the performance of the models with the c-index. In each year, HSMRs were obtained by calculating the ratio of the number of observed deaths to the number of expected deaths. The HSMR trends, including trends in comorbidity subgroups defined by the Charlson comorbidity index, were analysed. RESULTS: The c-index value was 0.871 for the HSMR model. The HSMR followed a constant decreasing trend over time; it fell by 18.8% from 110.3 in 2008 to 91.5 in 2012. The reduction in HSMR was not present in the severe comorbidity group, while the reduction trend was observed in the mild comorbidity group. CONCLUSIONS: Our model demonstrated excellent discrimination without detailed clinical data. The Japanese HSMR followed a constant decreased trend, while the reduction trend was not present in the severe patients. Our study implies the need to consider severe patients for assessing hospital quality by HSMR.

Factors affecting prolonged length of stay in psychiatric patients in Japan: A retrospective observational study.

AIM: Hospital length of stay (LOS) is one of the stratified measures of health-care efficiency and is commonly used to assess performance of psychiatric care. The aim of this study was to identify risk factors for prolonged LOS of psychiatric patients. METHODS: We retrospectively analyzed adult psychiatric patients (ICD-10; F00-F99) between April 2012 and March 2014 in the Japanese Diagnosis Procedure Combination database. We examined factors affecting prolonged LOS using multivariable logistic regression analysis. Subgroup analyses of the logistic regression were undertaken according to two diagnostic groups (F20-F29 and F30-F39). RESULTS: A total of 34 326 patients admitted to and discharged from psychiatric beds were included. Older age, lower Global Assessment of Functioning score, involuntary commitment, several psychiatric services, certain other patient factors, academic hospitals, public hospitals, and higher density of psychiatric beds were significantly associated with prolonged LOS. Hospital patient volume was significantly associated with shorter LOS. In the subgroup analyses, most of these factors were consistent although some were not associated with prolonged LOS. CONCLUSION: Not only clinical factors but also institutional characteristics were associated with prolonged LOS. Our study provided useful information for improvement in psychiatric services and indicated the need to consider the division of roles between healthcare/welfare institutions and psychiatric-related resource allocation. Interventions should be considered for achieving shorter LOS for psychiatric patients.

Hospital mortality of patients aged 80 and older after surgical repair for type A acute aortic dissection in Japan.

To evaluate whether patients aged 80 and older have higher risk of hospital mortality after repair of type A acute aortic dissection (TAAAD).Emergency surgery for TAAAD in patients aged 80 and older remains a controversial issue because of its high surgical risk.Data from patients who underwent surgical repair of TAAAD between April 2011 and March 2013 were retrospectively extracted from the Japanese Diagnosis Procedure Combination database. The effect of age on hospital mortality was evaluated using multivariate logistic regression analysis.A total of 5175 patients were enrolled. The mean age of patients was 67.1 ±â€Š13.0 years, and the male:female ratio was 51:49. Patients aged 80 and older more frequently received tracheostomy than their younger counterparts (9.5% vs 5.4%, P <0.001). Intensive care unit and hospital stays were significantly longer in the elderly cohort versus the younger cohort (7.6 vs 6.7 days, P <0.001, and 42.2 vs 35.8 days, P <0.001, respectively). Logistic regression analysis showed that age ≥80 years was significantly associated with a higher risk of hospital mortality (adjusted odds ratio, 1.62; 95% confidence interval, 1.28-2.06; P <0.001). In linear regression analysis, age ≥80 years was also significantly associated with longer hospital stay (P = 0.007).In a large, nationwide, Japanese database, patients aged 80 and older were at increased risk of hospital mortality and length of hospital stay.

Preoperative factors affecting cost and length of stay for isolated off-pump coronary artery bypass grafting: hierarchical linear model analysis.

OBJECTIVE: To determine the effect of preoperative patient and hospital factors on resource use, cost and length of stay (LOS) among patients undergoing off-pump coronary artery bypass grafting (OPCAB). DESIGN: Observational retrospective study. SETTINGS: Data from the Japanese Administrative Database. PARTICIPANTS: Patients who underwent isolated, elective OPCAB between April 2011 and March 2012. PRIMARY OUTCOME MEASURES: The primary outcomes of this study were inpatient cost and LOS associated with OPCAB. A two-level hierarchical linear model was used to examine the effects of patient and hospital characteristics on inpatient costs and LOS. The independent variables were patient and hospital factors. RESULTS: We identified 2491 patients who underwent OPCAB at 268 hospitals. The mean cost of OPCAB was $40 665 ±7774, and the mean LOS was 23.4±8.2 days. The study found that select patient factors and certain comorbidities were associated with a high cost and long LOS. A high hospital OPCAB volume was associated with a low cost (-6.6%; p=0.024) as well as a short LOS (-17.6%, p<0.001). CONCLUSIONS: The hospital OPCAB volume is associated with efficient resource use. The findings of the present study indicate the need to focus on hospital elective OPCAB volume in Japan in order to improve cost and LOS.

Geographic distribution of healthcare resources, healthcare service provision, and patient flow in Japan: a cross sectional study.

Healthcare systems in developed countries are facing the challenge of dealing with changing social structures as a result of rapidly aging populations. This study examines the relationship among the geographical distribution of healthcare resources, healthcare service provision, and interregional patient flow in Japan. A cross-sectional study was performed using data from healthcare-related public surveys conducted in 2008, together with social, economic, and environmental variables. The geographical units of analysis were 348 Secondary Healthcare Service Areas, which provide and manage most healthcare services in Japan. The equity of the distribution of physicians among hospitals and clinics was evaluated using the Lorenz curve and the Gini coefficient. Multiple regression analysis was used to examine the relationships between the inpatient flow ratio and selected variables. Next, the 348 Secondary Healthcare Service Areas were divided into tertiles according to the inpatient flow ratio, and differences among these variables were examined using Bonferroni's correction for multiple comparisons. The Gini coefficient for physician distribution among hospitals was 0.209 and was 0.165 among clinics. Multiple regression analysis showed that hospital physician density, the elderly ratio, and hospital bed density were all correlated with the inpatient flow ratio (ß = 0.396, -0.576, 0.425, respectively; R(2) = 0.622, all ps < 0.001). Healthcare resources were significantly more scarce in the lowest tertile (outflow group) than in other groups in both hospitals and clinics. The provision of healthcare services was also imbalanced among tertiles. Our results imply that there is a need for reconstituting the geographical distribution of healthcare resources in Japan. Further research and healthcare-related databases are also needed to facilitate the creation of a more balanced geographical distribution and of a more effective healthcare system in Japan.

Transmitral E/A ratio decreases in association with abdominal fat accumulation in patients with impaired glucose tolerance or mild diabetes without left ventricular hypertrophy.

An abnormal left ventricular (LV) diastolic function is an early sign of diabetic cardiomyopathy, which is characterized by an impaired diastolic and/or systolic function of the left ventricle in the absence of ischemic, valvular, or hypertensive heart disease, and serves as a marker of cardiovascular risk. However, it is unclear whether LV diastolic abnormalities can be detected in patients with impaired glucose tolerance (IGT) or mild diabetes without LV hypertrophy (LVH). We examined echocardiographic data from 92 consecutive Japanese patients aged 45-79 years with or without IGT or mild diabetes in the absence of LVH. Impaired glucose tolerance or mild diabetes was defined as the presence of one or more of the following criteria: fasting plasma glucose >110 mg/dl, hemoglobin A1c >5.6%, homeostasis model assessment ratio >1.73, or the taking of oral antihyperglycemic drugs. Left ventricular hypertrophy was defined as an LV mass index (LVMI) >116 g/m(2) in men and >104 g/m(2) in women. Patients with ischemic, valvular, or hypertensive heart disease were excluded. The age, blood pressure, heart rate, and LVMI were similar between patients with (IGT/DM group, n = 43) and without IGT or mild diabetes (non-IGT/DM group, n = 49), whereas the body mass index and waist circumference (WC) were greater in the IGT/DM compared to the non-IGT/DM group (P < 0.05 and P < 0.001, respectively). The transmitral E/A ratio was lower and the deceleration time longer in the IGT/DM than in the non-IGT/DM group (both P < 0.05). Stepwise regression analysis revealed that age and WC were independent determinants of the E/A ratio. In conclusion, diastolic abnormalities without LVH can be detected in Japanese patients with IGT or mild diabetes. The E/A ratio decreases in association with abdominal fat accumulation.