Epidemiologic evaluation of pulmonary paragonimiasis in Japan using a Japanese nationwide administrative database.

BACKGROUND: Paragonimiasis is a parasitic disease primarily contracted through consumption of undercooked freshwater crustaceans or wild boar meat. Large-scale nationwide epidemiological data on paragonimiasis are lacking. In this study, we aimed to investigate the nationwide epidemiology of hospitalized patients with paragonimiasis in Japan using a comprehensive nationwide Japanese administrative database. METHODS: We evaluated the Japanese Diagnosis Procedure Combination (DPC) data of patients diagnosed with pulmonary paragonimiasis between April 1, 2012 and March 30, 2020. The patients' address and information, including age, sex, treatment (medication: praziquantel; surgery: open thoracotomy or intracranial mass extirpation), Japan coma scale, comorbidities, and length of hospital stay, were extracted. RESULTS: Of the 49.6 million hospitalized patients, data were extracted on 73 patients with paragonimiasis, of whom 36 were male and 37 were female. The mean age was 49.7 years and the mean length of stay was 12.5 days. The most frequent comorbidity was pleural effusion (31.5 %), followed by pneumothorax (13.7 %). The sites of ectopic paragonimiasis in organs other than the lung included the liver (5.5 %), skin (4.1 %), and brain (2.7 %). Geographically, most patients were from the Kyushu region (54.8 %), followed by the Kanto region (22.0 %). Fukuoka Prefecture had the highest number of patients (22.0 %) by prefecture. During the study period, an average of 9.1 patients/year were hospitalized with lung paragonimiasis in Japan. CONCLUSION: Paragonimiasis has not completely disappeared in Japan; thus, physicians should be aware of paragonimiasis in the Kyushu region, especially in the Fukuoka Prefecture.

The Current Status of Suicide and Medical Care System in Japan: An Analysis of 81,407 Patients Using the Diagnosis Procedure Combination Database.

Japan has a high suicide mortality rate compared to other developed countries. To reduce suicide mortality in Japan, it is important to systematically analyze factors related to death of patients with suicide attempt. This study aimed to analyze the characteristics of patients with suicide attempt, and the factors related to their death using the Diagnosis Procedure Combination (DPC) data- a nationally representative inpatient database. We collected 81,407 cases of suicide attempt from 2016 to 2018 from DPC data and performed a multilevel logistic analysis of factors associated with death discharges. The analysis results showed that patients who received psychiatric liaison care had a lower mortality rate, but only 0.6% of surviving patients received psychiatric liaison care after admission. The odds ratio (OR) of death was high for hanging (28.86; p < 0.001) and jumping (16.28; p < 0.001), compared to wrist cutting. Patients without a psychiatric diagnosis were more likely to choose means such as hanging (14.1%) than those with a psychiatric disorder. The weekend cases had a higher OR of death than weekday (Wednesday as reference) cases (Friday 1.14, p = 0.011; Saturday 1.60, p < 0.001; Sunday 1.67, p < 0.001). Based on these findings, we suggest that improving the availability and quality of psychiatric care in acute care hospitals and primary care settings, as well as enhancing the emergency department system on weekends, could help reduce the mortality of suicide attempts.

Analysis of the risk factors of mortality in elderly patients with hip fracture using a combined database of medical and long-term care insurance claims data.

BACKGROUND: The present study evaluated the risk of mortality in elderly hip fracture, focusing on comorbidities and nursing care levels. METHODS: The present study was an observational cohort study that used a combined database of medical and long-term care insurance (LTCI) claims data from one prefecture in Japan between 2011 and 2016. In total, 6125 patients aged 65 years and older were selected from acute care hospitals with a diagnosis of "hip fracture" between March 2011 and March 2012. The impact of long-term care insurance claim evaluation levels and comorbidities at recruitment time was investigated using this dataset. These patients were followed up monthly until March 2016. Based on this person-month dataset, survival analysis was performed with death as the endpoint. Cases in which receipt data were missing during the middle of the observation period and cases in which the patient survived at the end of the observation period were censored. RESULTS: The number of deaths during the observation period was 635 (10.4%). The impact of comorbidities and nursing care level on mortality were both significant as follows: high nursing care level before the fracture (hazard ratio: 1.09, P < 0.001), comorbidities of malignant diseases (HR: 1.45, P < 0.001), heart disease (hazard ratio: 1.20, P = 0.037), pneumonia (hazard ratio: 1.27, P < 0.001), chronic obstructive pulmonary disease (hazard ratio: 1.28, P = 0.026), renal failure (hazard ratio: 1.44, P < 0.001), and dementia (hazard ratio: 1.27, P = 0.013). CONCLUSION: The results of this study showed that a high level of nursing care and presence of comorbidities such as malignant diseases, heart diseases, pneumonia, chronic obstructive pulmonary disease, renal failure, and dementia increased mortality in elderly patients with hip fracture. Furthermore, this study showed the usefulness of a combined database of medical and LTCI claims data for clinical and health service-related research in the field of orthopedics.

Epidemiological Study of Hospital Admissions for Food-Induced Anaphylaxis Using the Japanese Diagnosis Procedure Combination Database.

BACKGROUND: Food allergies are common among children, and food-induced anaphylaxis (FIA) is a serious disease with a risk of death; however, there is yet to be a large-scale epidemiological study on causative foods in Japan. The purpose of this study was to identify foods that cause FIA in Japan. METHODS: We identified 9,079 patients from the Japanese Diagnosis Procedure Combination Database who were admitted for treatment for FIA from April 1, 2014 through March 31, 2017. We extracted data on patient sex, age, use of epinephrine injections on the first day, prescription for epinephrine self-injection on the day of discharge, length of stay, readmission, and causative foods. RESULTS: The most common causative food was eggs, followed by wheat, milk, peanuts, and buckwheat. The most common causative food in each age group was eggs among 0-3-year-olds, milk among 4-6-year-olds, peanuts among 7-19-year-olds, and wheat among those aged 20 years and older. Epinephrine was used at admission among about 40%, 50%, and over 60% of cases in which the causative food was eggs; wheat, milk and peanuts; and buckwheat, respectively. The proportion of cases with a prescription for epinephrine self-injection at discharge was highest among those in which the causative food was wheat, followed by peanuts, buckwheat, milk, and eggs. CONCLUSIONS: FIA due to peanuts has become as common in Japan as it is in the West. These results suggest the importance of taking measures to prevent peanut allergies because children cannot make adequate decisions regarding food.

Mortality changes for patients with pneumococcal pneumonia from 2012 to 2017 in Japan.

INTRODUCTION: Pneumococcal pneumonia has a high morbidity and mortality in adults, especially those ≥65 years old. In the past decade, pneumococcal vaccination programs have been initiated worldwide, however, few data concerning mortality changes are available in pneumococcal pneumonia patients and there are no reports clarifying these current changes in Japan. METHODS: Japanese patients ≥65 years old hospitalized with pneumococcal pneumonia between April 2012 and March 2018 were analyzed using the Diagnostic Procedure Combination database. In-hospital mortality was evaluated, and the odds ratios for this outcome in each fiscal year compared with that in 2012 was analyzed using multivariable logistic regression models. RESULTS: Between 2012 and 2017, data of 47,375 pneumococcal pneumonia patients ≥65 years old were extracted. The incidence per 1000 person-years for in-hospital mortality was 60.4 in 2012, 56.8 in 2013, 63.2 in 2014, 56.1 in 2015, 73.0 in 2016, and 67.4 in 2017 and the odds ratios for in-hospital mortality in 2013, 2014, 2015, 2016, and 2017 compared with that in 2012 were 1.00, 1.05, 1.04, 1.06, and 0.98, respectively. There were no significant differences between 2012 and each year from 2013 to 2017. Low BMI; low ADL score; high A-DROP score; comorbid malignancy and heart failure; the coexistence of invasive pneumococcal infection; and the use of invasive mechanical ventilation were independent risk factors for in-hospital mortality. CONCLUSIONS: There were no changes in in-hospital mortality in pneumococcal pneumonia patients between 2012 or each year from 2013 to 2017 and further epidemiological observations are necessary.

Effects of additive corticosteroid therapy on 90-day survival in patients with community-onset pneumonia.

INTRODUCTION: Systemic corticosteroid therapy is occasionally used as an additive therapy, especially for patients with severe pneumonia. However, its recommendation for use in patients with pneumonia varies worldwide, and its efficacy is unclear. METHODS: Adult Japanese patients hospitalized with community-onset pneumonia between January and December 2012 were analyzed using the Diagnostic Procedure Combination database. The patients were classified into mild-to-moderate and severe groups using the A-DROP (age, dehydration, respiration, orientation, and blood pressure) system. The 90-day survival rate was evaluated between the presence or absence of corticosteroid treatment using the Kaplan-Meier method in the overall, mild-to-moderate and severe groups, respectively. The patients' clinical characteristics were adjusted between the two groups using the inverse probability of treatment weighting method. RESULTS: Among 123,811, 110,534 patients were classified as mild-to-moderate grade (corticosteroid group: 8,465, non-corticosteroid group: 102,069) and 13,277 patients were classified as severe grade (corticosteroid group: 1,338, non-corticosteroid group: 11,939). The 90-day survival rate was higher in the non-corticosteroid group than in the corticosteroid group in patients with pneumonia of overall grade (weighted hazard ratio [HR]: 1.36; P < 0.001) and those with mild-to-moderate grade (weighted HR: 1.46; P < 0.001). However, there were no significant differences in the outcomes between the two groups in those with severe grade (weighted HR: 1.08; P = 0.38). CONCLUSIONS: Additive systemic corticosteroid therapy may be related to poor 90-day prognosis in patients with mild-to-moderate grade community-onset pneumonia, although it may not be positively associated with its prognosis in those with severe grade.

COVID-19 vaccination coverage by company size and the effects of workplace vaccination program in Japan: a cohort study.

BACKGROUND: Vaccination is considered the most effective control measure against COVID-19. Vaccine hesitancy and equitable vaccine allocation are important challenges to disseminating developed vaccines. To promote COVID-19 vaccination coverage, the government of Japan established the workplace vaccination program. However, while it appears that the program was effective in overcoming vaccine hesitancy, the program may have hindered the equitable allocation of vaccines because it mainly focused on employees of large companies. We investigated the relationship between company size and COVID-19 vaccination completion status of employees and the impact of the workplace vaccination program on this relationship. METHODS: We conducted an internet-based prospective cohort study from December 2020 (baseline) to December 2021. The data were collected using a self-administered questionnaire survey. Briefly, 27,036 workers completed the questionnaire at baseline and 18,560 at follow-up. After excluding ineligible respondents, we finally analyzed the data from 15,829 participants. At baseline, the participants were asked about the size of the company they worked for, and at follow-up they were asked about the month in which they received their second COVID-19 vaccine dose and the availability of a company-arranged vaccination opportunity. RESULTS: In each month throughout the observation period, the odds of having received a second COVID-19 vaccine dose were significantly lower for small-company employees than for large-company employees in the sex- and age-adjusted model. This difference decreased after adjusting for socioeconomic factors, and there was no significant difference after adjusting for the availability of a company-arranged vaccination opportunity. CONCLUSIONS: The workplace vaccination program implemented in Japan to control the COVID-19 pandemic may have been effective in overcoming vaccine hesitancy in workers; however, it may have caused an inequitable allocation of vaccines between companies of different sizes. Because people who worked for small companies were less likely to be vaccinated, it will be necessary to enhance support of vaccination for this population in the event of future infectious disease outbreaks. TRIAL REGISTRATION: Not applicable.

The role of heparin bridging in lung cancer surgery: a nationwide database analysis.

PURPOSE: There is little evidence to demonstrate the impact of heparin bridging (HB) in major surgery. This study aimed to evaluate the benefits and risks of HB in lung cancer surgery by comparing HB and non-HB (NHB) groups. METHODS: We extracted patients who were taking an anticoagulant, were diagnosed with lung cancer, and underwent lung resection between April 2014 and March 2018 from a nationwide database in Japan. We compared the HB and NHB groups to determine the benefits and risks of HB. The proportion of postoperative thromboembolism and bleeding events between the HB and NHB groups was the primary outcome. We performed propensity score matching to remove any HB assignment bias. RESULTS: We selected 2416 patients, and among these, 1068 patients had HB and 1348 did not. Propensity score matching extracted 1500 patients: 750 with HB and 750 without HB. After matching, a Chi-square test showed no significant difference in the incidence of postoperative thromboembolism (1.5% vs 0.9%, p value = 0.343) and bleeding events (5.9% vs 4.0%, p value = 0.124) between the two groups. CONCLUSIONS: There was no significant difference in the incidence of postoperative thromboembolism and bleeding in the patients with and those without HB.

Early Enteral Nutrition is Related to Decreased In-hospital Mortality and Hospitalization in Patients with Acute Pancreatitis: Data from the Japanese Diagnosis Procedure Combination Database.

Management of early nutrition plays an important role in the treatment of acute pancreatitis patients, but the sample sizes of randomized control trials that have compared enteral and parental nutrition were small. From the data of Diagnostic Procedure Combination, we identified patients who had been diagnosed with acute pancreatitis and discharged from the hospital between 2014 and 2015. We compared the length of hospital stay and hospital mortality among patients with acute pancreatitis that was managed with and without enteral nutrition within 7 days from hospitalization. The results showed a significant decrease in the in-hospital mortality rate of 56% (odds ratio 0.444, 95% confidence interval [CI] 0.358 - 0.551, P < 0.001) and length of hospital stay by 8.6 days (95% CI -9.05 - -8.13, P < 0.001) when enteral nutrition was administered within 7 days. According to multivariate analysis, early enteral nutrition was independently associated with in-hospital mortality rate and length of hospitalization. Enteral nutrition is an important management method for the treatment of acute pancreatitis patients.

Effectiveness of regional clinical pathways on postoperative length of stay for hip fracture patients: A retrospective observational study using the Japanese Diagnosis Procedure Combination database.

BACKGROUND: Regional clinical pathways, a new type of clinical pathway, are practiced with the aim of standardizing and optimizing medical care by cooperation among multiple medical institutions in a region. However, current evaluation of the effectiveness of regional clinical pathways for hip fracture, a major health problem requiring hospitalization for orthopedic surgery, is insufficient. This study aimed to determine the association between regional clinical pathways and postoperative hospital length of stay (LOS) among hip fracture patients. In particular, we focused on the variation in postoperative LOS of hip fracture patients among hospitals and the contribution of regional clinical pathways to this variation. METHODS: Using data from the Diagnosis Procedure Combination (DPC) database in Japan from April 2011 to March 2013, patients who were diagnosed with "fracture of head and neck of femur" (ICD10 code S72.0) or "pertrochanteric fracture" (S72.1) and received "bipolar hip arthroplasty" or "open reduction and internal fixation" were extracted. A total of 110,133 patients were included. Associations between regional clinical pathways and postoperative LOS were analyzed using cross-sectional analysis with multilevel regression models. RESULTS: Hospitals that implemented a regional clinical pathway showed a significant reduction (13 days) in the postoperative LOS of hip fracture patients. We found a 16% inter-hospital variation in postoperative LOS, which might be explained by hospital-level implementation of regional clinical pathways. Application of regional clinical pathways at the patient level resulted in a 4-day decrease in postoperative LOS. CONCLUSIONS: Implementation of regional clinical pathways for hip fracture patients at the hospital level was associated with reduced postoperative LOS, regardless of whether or not pathways were implemented at the patient level. This suggests that regional clinical pathways are effective for patient care management in hospitals.

[Development of a Method for Assignment Control in Randomized Controlled Trials].

Randomized controlled trials (RCT) are the most reliable study design for causality estimation in medical research. Proper implementation of the process of randomization is necessary to ensure the reliability of RCT. In order to do so, 1) generation of randomization sequence, 2) allocation concealment, and 3) allocation must be properly implemented. Methods such as the central secretariat method, the envelope method, and the sequentially numbered container method are adopted to secure proper implementation. For investigator-initiated clinical research and relatively small-scale clinical research, the envelope method and the sequentially numbered container method are often adopted because of budgetary reasons, but these methods do not assure the implementation of proper RCT. Therefore, we designed an assignment management note system as a new method to manage the assignment of RCT that can be implemented in small scale clinical research. In this paper, we compare the assignment management note system with the conventional method from the viewpoint of the procedure necessary for the proper implementation of RCT, and discuss the advantages and limitations of the assignment management note system.

Efficacy of Antimicrobial Catheters for Prevention of Catheter-Associated Urinary Tract Infection in Acute Cerebral Infarction.

BACKGROUND: Catheter-associated urinary tract infection (CAUTI) is a common nosocomial infection. However, the effectiveness of antimicrobial catheters in reducing CAUTI in cerebral infarction patients is unknown. The purpose of this study was to determine whether antimicrobial catheters protect against CAUTI in cerebral infarction patients. METHODS: We identified 27,548 patients from the Japanese Diagnosis Procedure Combination Database who had been admitted from April 1, 2012 through March 31, 2014 for acute management of cerebral infarction and had used at least an indwelling urethral catheter. We extracted data on patient sex, age, comorbidity, length of stay, activities of daily living (ADL), surgery, hospital case volume, and catheter type. We defined CAUTI as a urinary tract infection arising during admission. We performed multi-level logistic regression analysis to analyze the reduction in CAUTI using antimicrobial catheters. RESULTS: The rate of CAUTI was 8.8% and 8.3% in the control and antimicrobial catheter groups, respectively. Significant risk factors for CAUTI were age, diabetes requiring insulin therapy, low ADL score, and long hospitalization. Incidence rate was significantly lower in operated cases and those treated with tissue plasminogen activator. For all cases overall, the use of an antimicrobial catheter was not associated with a lower CAUTI rate. However, use was associated with a lower rate of CAUTI in diabetic patients on insulin. CONCLUSIONS: Antimicrobial catheter use was not associated with a lower incidence rate of CAUTI in acute cerebral infarction patients. However, stratified analysis suggested that use was associated with a lower incidence in diabetic patients on insulin.

The relationship between high-dose corticosteroid treatment and mortality in acute respiratory distress syndrome: a retrospective and observational study using a nationwide administrative database in Japan.

BACKGROUND: In the 1980s, randomized-controlled trials showed that high-dose corticosteroid treatment did not improve the mortality of acute respiratory distress syndrome (ARDS). However, while the diagnostic criteria for ARDS have since changed, and supportive therapies have been improved, no randomized-controlled trials have revisited this issue since 1987; thus, the effect of high-dose corticosteroid treatment may be different in this era. We evaluated the effect of high-dose corticosteroid treatment in patients with ARDS using a nationwide administrative database in Japan in a retrospective and observational study. METHODS: This study was performed with a large population using the 2012 Japanese nationwide administrative database (diagnostic procedure combination). We evaluated the mortality of ARDS patients receiving or not receiving high-dose corticosteroid treatment within 7 days of hospital admission. We employed propensity score weighting with a Cox proportional hazards model in order to minimize the bias associated with the retrospective collection of data on baseline characteristics and compared the mortality between the high-dose and non-high-dose corticosteroid groups. RESULTS: Data from 2707 patients were used; 927 patients were treated with high-dose corticosteroid and 1780 patients were treated without high-dose corticosteroid, within 7 days of admission. After adjusting for confounds, mortality rates within 3 months were significantly higher in the high-dose corticosteroid group compared to the non-high-dose corticosteroid group (weighted hazard ratio: 1.59; 95% CI: 1.37-1.84; P <  0.001). CONCLUSIONS: Our results suggest that high-dose corticosteroid treatment does not improve the prognosis of patients with ARDS, even in this era. However, this study has limitations owing to its retrospective and observational design.

Coexisting infectious diseases on admission as a risk factor for mechanical ventilation in patients with Guillain-Barré syndrome.

BACKGROUND: The aim of this study was to investigate patient characteristics on admission to hospital that increase the risk of subsequent mechanical ventilation (MV) use for patients with Guillain-Barré syndrome (GBS). METHODS: We extracted data from the Japanese Diagnosis Procedure Combination (DPC) database for 4132 GBS patients admitted to hospital. Clinical characteristics of GBS patients with and without MV were compared. Multivariate logistic regression analyses were performed to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for the associations of requirement for MV with coexisting infectious diseases, after adjustment for potential confounding variables, age, sex, hospital type, and ambulance transportation. RESULTS: In total, 281 patients required MV, and 493 patients had coexisting respiratory diseases on admission. After adjustment for covariates and stratification by coexisting respiratory diseases, multivariate logistic regression analysis revealed that coexisting cytomegaloviral (CMV) disease (OR 8.81; 95% CI, 2.34-33.1) and herpes simplex viral (HSV) infections (OR 4.83; 95% CI, 1.16-20.1) were significantly associated with the requirement for MV in the group without coexisting respiratory diseases. CONCLUSION: Our findings suggest that coexisting CMV and HSV infections on admission might be significantly associated with increased risk of respiratory failure in GBS patients.

Efficacy of early sivelestat administration on acute lung injury and acute respiratory distress syndrome.

BACKGROUND AND OBJECTIVE: The efficacy of sivelestat, a neutrophil elastase inhibitor, for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) remains controversial. We investigated the role of sivelestat in ALI/ARDS patients on mortality as an end point between the sivelestat group and the non-sivelestat group within 7 days of admission. METHODS: This study was performed using the Japanese nationwide administrative database (Diagnostic Procedure Combination; DPC) in 2012. We employed the propensity score weighting method with a Cox proportional hazards model to compare the mortality between the sivelestat group and the non-sivelestat group. RESULTS: A total of 4276 patients were eligible for this study; 1997 patients were treated with sivelestat and 2279 patients did not receive sivelestat within 7 days of admission. After adjusting for confounds, the mortality within 3 months was significantly lower in the sivelestat group compared with the non-sivelestat group (weighted hazard ratio: 0.83; 95% CI: 0.75-0.93; P < 0.002). Multiple regression analysis revealed that younger age, absence of cancer, no need for haemodialysis and no use of high-dose methylprednisolone were significantly correlated with treatment success (survive). CONCLUSION: These results of this retrospective and observational study suggest that administration of sivelestat within 7 days of admission may improve the prognosis of patients with ALI/ARDS. To our knowledge, this is the largest study to evaluate the efficacy of sivelestat on ALI/ARDS.

Effects of proton pump inhibitor on outcomes of patients with severe acute pancreatitis based on a national administrative database.

OBJECTIVE: This study aimed to investigate whether proton pump inhibitors (PPIs) affect the outcomes of patients with severe acute pancreatitis based on a national administrative database. METHODS: A total of 10,400 patients with severe acute pancreatitis were referred to 1021 hospitals between 2010 and 2012 in Japan. Patients were divided into two groups: patients who used PPIs (n = 3879) and those without PPIs (n = 6521). We collected patients' data from the administrative database to compare in-hospital mortality within 7, 14, and 28 days, and overall in-hospital mortality between groups, using propensity score analysis to adjust for treatment selection bias. RESULTS: Multiple logistic regression showed that use of PPIs did not affect in-hospital mortality within 7 and 14 days. The odds ratio (OR) for mortality within 7 days was 1.14 (95% confidence interval [CI]: 0.91-1.42, p = 0.236) while that within 14 days was 1.10 (95% CI: 0.89-1.35, p = 0.349). No significant association was observed for in-hospital mortality within 28 days and overall in-hospital mortality (OR for within 28 days: 1.12, 95% CI: 0.92-1.37, p = 0.224; OR for overall in-hospital mortality: 1.42, 95% CI: 0.97-1.87, p = 0.065). CONCLUSIONS: This study shows that use of PPIs does not affect clinical outcomes of patients with severe acute pancreatitis. Prospective or randomized studies are needed to confirm the efficacy of PPIs on outcomes of patients with severe acute pancreatitis in the future.

Effect of dementia on outcomes of elderly patients with hemorrhagic peptic ulcer disease based on a national administrative database.

BACKGROUND: Little information is available on the effect of dementia on outcomes of elderly patients with hemorrhagic peptic ulcer disease at the population level. AIMS: This study aimed to investigate the effect of dementia on outcomes of elderly patients with hemorrhagic peptic ulcer based on a national administrative database. METHODS: A total of 14,569 elderly patients (≥80 years) who were treated by endoscopic hemostasis for hemorrhagic peptic ulcer were referred to 1073 hospitals between 2010 and 2012 in Japan. We collected patients' data from the administrative database to compare clinical and medical economic outcomes of elderly patients with hemorrhagic peptic ulcers. Patients were divided into two groups according to the presence of dementia: patients with dementia (n = 695) and those without dementia (n = 13,874). RESULTS: There were no significant differences in in-hospital mortality within 30 days and overall mortality between the groups (odds ratio; OR 1.00, 95 % confidence interval; CI 0.68-1.46, p = 0.986 and OR 1.02, 95 % CI 0.74-1.41, p = 0.877). However, the length of stay (LOS) and medical costs during hospitalization were significantly higher in patients with dementia compared with those without dementia. The unstandardized coefficient for LOS was 3.12 days (95 % CI 1.58-4.67 days, p < 0.001), whereas that for medical costs was 1171.7 US dollars (95 % CI 533.8-1809.5 US dollars, p < 0.001). CONCLUSIONS: Length of stay and medical costs during hospitalization are significantly increased in elderly patients with dementia undergoing endoscopic hemostasis for hemorrhagic peptic ulcer disease.

Influence of comorbidity on outcomes of older patients with acute pancreatitis based on a national administrative database.

BACKGROUND: Little information is available on the influence of comorbidities on outcomes of older patients with acute pancreatitis. This study aimed to investigate the influence of comorbidities on outcomes of older patients with acute pancreatitis using data from a national Japanese administrative database. METHODS: A total of 14 322 older patients (≥70 years) with acute pancreatitis were referred to 1090 hospitals between 2010 and 2012 in Japan. We collected patients' data from the administrative database to compare the in-hospital mortality and length of stay of older patients with acute pancreatitis. The patients were categorized into four groups according to comorbidity level using the Charlson Comorbidity Index (CCI): none (CCI score=0; n=6890); mild (1; n=3874); moderate (2; n=2192) and severe (≥3; n=1366). RESULTS: Multiple logistic and linear regression analyses revealed that severe comorbidity was significantly associated with higher in-hospital mortality and longer length of stay [odds ratio (OR)=2.26; 95% confidence interval (CI): 1.75-2.92, P<0.001 and coefficient 4.37 days; 95% CI: 2.89-5.85, P<0.001, respectively]. In addition, cardiovascular and renal diseases were the most significant comorbidities affecting outcomes of the older patients. ORs of cardiovascular and renal diseases for mortality were 1.44 (95% CI: 1.13-1.85, P=0.003) and 2.69 (95% CI: 1.88-3.85, P<0.001), respectively, and coefficients for length of stay were 3.01 days (95% CI: 1.34-4.67, P<0.001) and 3.72 days (95% CI: 1.01-6.42, P=0.007), respectively. CONCLUSION: This study demonstrated that comorbidities significantly influenced outcomes of older patients with acute pancreatitis and cardiovascular and renal comorbidities were significant factors affecting outcomes.

Impact of regional clinical pathways on the length of stay in hospital among stroke patients in Japan.

BACKGROUND: Clinical pathways are care plans used by health providers to describe essential steps in the care of patients with specific medical conditions. Clinical implementation of the regional clinical pathways in Japan has spread, and the 2008 fee schedule included a new "regional inter-provider care planning fee" for stroke. However, no evidence regarding the efficacy of the regional clinical pathways for stroke has appeared. OBJECTIVES: We examined the association of regional clinical pathways on the length of in-hospital stay in patients with stroke. We also examined whether a variation in the length of in-hospital stay for stroke patients between hospitals exists, and if so, the impact of regional clinical pathways on this variation. RESEARCH DESIGN: Cross-sectional analysis using the Diagnosis Procedure Combination database for the period April 2011 to March of 2012. SUBJECTS: A total of 117,180 patients with the diagnosis "cerebral infarction," coded as I63 in ICD10. MEASURES: Associations of the use of a regional clinical pathway with the length of in-hospital stay (LOS) were estimated by multilevel regression models using a 2-level structure of individuals nested within the 1011 hospitals. The models added both patient-level factors and hospital-level factors that are potentially associated with LOS. RESULTS: Hospitals administering a regional clinical pathway had a significantly shorter LOS (9.1 d) than hospitals that did not. Approximately 12% of the variation in LOS between hospitals is possibly explained by whether hospitals implement regional clinical pathways. Application of regional clinical pathways at the individual level is associated with a 7.2-day decrease in LOS at the individual level. CONCLUSIONS: These findings suggest that the regional clinical pathways are potentially effective in improving the management of stroke patients and in promoting the consistency of care between hospitals.

Effects of additional laparoscopic cholecystectomy on outcomes of laparoscopic gastrectomy in patients with gastric cancer based on a national administrative database.

BACKGROUND: Little information is available on the effects of adding laparoscopic cholecystectomy to laparoscopic gastrectomy on outcomes of patients with gastric cancer. The aim of this study is to investigate the effects of adding laparoscopic cholecystectomy to laparoscopic gastrectomy on outcomes in patients with gastric cancer using a national administrative database. METHODS: A total of 14,006 patients treated with laparoscopic gastrectomy for gastric cancer were referred to 744 hospitals in Japan between 2009 and 2011. Patients were divided into two groups, those who also underwent simultaneous laparoscopic cholecystectomy for gallbladder stones (n = 1484) and those who underwent laparoscopic gastrectomy alone (n = 12,522). Laparoscopy-related complications, in-hospital mortality, length of stay, and medical costs during hospitalization were compared in the patient groups. RESULTS: Multiple logistic regression analysis revealed that adding laparoscopic cholecystectomy did not affect laparoscopy-related complications (odds ratio, 1.02; 95% confidence interval [CI], 0.84-1.24; P = 0.788) or in-hospital mortality (odds ratio, 1.16; 95% CI, 0.49-2.76; P = 0.727). Multiple linear regression analysis also showed that adding laparoscopic cholecystectomy did not affect the length of stay (unstandardized coefficient, 0.37 d; 95% CI, -0.47 to 1.22 d; P = 0.389). However, adding laparoscopic cholecystectomy was associated with significantly increased medical costs during hospitalization (unstandardized coefficient, $1256.0 (95% CI, $806.2-$1705.9; P < 0.001). CONCLUSIONS: This study demonstrated that adding laparoscopic cholecystectomy did not affect outcomes of patients undergoing laparoscopic gastrectomy for gastric cancer, although medical costs during hospitalization were significantly increased.