Factors associated with the introduction of visiting-pharmacist services in older adults in Japan: A nested case-control study

AIM

To investigate the factors associated with introducing visiting-pharmacist services for community-dwelling older adults in Japan.

METHODS

We conducted a nested case-control study using claims data in a cohort from a city in Tokyo. Patients aged ≥65 years who received visiting-pharmacist services for the first time between April 2014 and March 2020 were considered case patients. A maximum of four controls to each case patient were randomly selected on the basis of sex, age, health insurance systems, and month-year. Medical and long-term care service usage and patient condition were assessed using claims data from the index and preceding months, along with long-term care needs certification data. Multivariable conditional logistic regression analysis was conducted to estimate the adjusted odds ratios with 95% confidence intervals for factors associated with visiting-pharmacist service introduction.

RESULTS

A total of 22 949 participants (4591 cases and 18 358 controls) were included, with a median age of 85 years; 59.3% were women. The adjusted odds ratios (95% confidence intervals) of the three most related factors were 27.61 (23.98-31.80) for physicians' home visits, 5.83 (5.08-6.70) for hospitalization, and 4.97 (4.16-5.95) for designated-facility admission. Factors such as prescribing ≧10 medications, visiting nursing, and cancer were positively associated. In contrast, low household income and a high need for support due to cognitive function or disability were negatively associated.

CONCLUSIONS

This study provides insights into the introduction of visiting-pharmacist services for older adults in Japan. Geriatr Gerontol Int 2024; 24: 344-351.

Association of coexistence of frailty and depressive symptoms with mortality in community-dwelling older adults: Kashiwa Cohort Study

OBJECTIVES

This study aimed to determine the longitudinal associations of the coexistence of frailty and depressive symptoms with mortality among older adults.

METHODS

The study participants were community-dwelling older adults aged ≥65 years who participated in the baseline survey of the Kashiwa Cohort Study in Japan in 2012. We used Fried's frailty phenotype criteria to classify participants as non-frail (score = 0), pre-frail (1 or 2), or frail (≥3). Depressive symptoms were assessed using the GDS-15 (≥6 points). Cox proportional hazards models were used to evaluate the association of co-occurring frailty and depressive symptoms with all-cause mortality, after adjusting for sociodemographic and clinical characteristics.

RESULTS

The study included 1920 participants, including 810 non-frail, 921 pre-frail, and 189 frail older adults, of which 9.0 %, 15.7 %, and 36.0 %, respectively, had depressive symptoms. Ninety-one (4.7 %) participants died during the average follow-up period of 4.8 years. Compared with non-frail participants without depressive symptoms, frail participants had greater adjusted hazard ratios for mortality: 2.47 (95 % CI, 1.16 to 5.25) for frail participants without depressive symptoms and 4.34 (95 % CI, 1.95 to 9.65) for frail participants with depressive symptoms. However, no statistically significant associations were observed in non-frail or pre-frail participants irrespective of depressive symptoms.

CONCLUSION

Frail older adults with depressive symptoms have a substantially greater risk of mortality. Screening for depressive symptoms and frailty in older adults should be incorporated into health checkups and clinical practice to identify high-risk populations.

Contrast-enhanced CT rim sign may predict vestibular schwannoma adhesion and postoperative complications

AIM

To investigate the clinical and radiological features to predict adhesion between vestibular schwannoma (VS) and brain tissue which is a critical risk factor for postoperative infarction and residual tumour.

MATERIAL AND METHODS

One hundred and seven consecutive VS surgeries were analysed. After excluding cases without contrast-enhanced (CE) computed tomography (CT), Koos grades 1 and 2, and cases with incomplete clinical data, 44 patients were finally included in the study. Enhancement of the tumour capsule on the brainstem side on CE-CT was defined as the CE-CT rim sign, which was analysed along with clinical characteristics, including tumour adhesion and postoperative complications.

RESULTS

Eight patients exhibited CE-CT rim signs; 17 had tumour adhesions. Four patients had postoperative infarction at the ipsilateral middle cerebellar peduncle; 18 exhibited postoperative infarction and/or residual tumour at the middle cerebellar peduncle. The CE-CT rim sign significantly correlated with tumour adhesion, postoperative infarction, and postoperative infarction and/or residual tumour in the cerebellar peduncle. Univariate regression analysis revealed that the CE-CT rim sign significantly correlated with tumour adhesion (odds ratio [OR] 6.81, 95% confidence interval [CI] 1.18-39.25, p=0.032) and postoperative infarction and/or residual tumour at the cerebellar peduncle (OR 6.00, 95% CI 1.04-34.31, p=0.044).

CONCLUSION

The CE-CT rim sign was identified in 18.2% of patients with VS and significantly correlated with tumour adhesion and postoperative complications, such as postoperative infarction and residual tumour. This study highlights the importance of the preoperative CE-CT rim sign in VS, which is predictive of tumour adhesion and postoperative complications.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Toward developing care outcome quality indicators for home care for older people: A prospective cohort study in Japan

INTRODUCTION

Care quality in Japan's long-term care (LTC) agencies, including home care, is the responsibility primarily of individual agencies, and the evaluation of service processes and outcomes is minimal.

OBJECTIVES

To describe the development of quality indicators for LTC (QIs-LTC) in Japan.

METHODS

QIs-LTC were developed through literature review and expert panel discussions and then were piloted and used in a 2-year longitudinal survey. The survey (launched in September 2019) targeted older people receiving home care (n = 1450), their family members (n = 880), their professional home care providers (n = 577), and managers of home care agencies (n = 122).

RESULTS

Across eight domains (maintaining dignity, minimizing symptoms and disease deterioration, maintaining nutritional status, maintaining bladder/bowel control, encouraging physical activities, experiencing sound sleep, maintaining serenity and contentedness, and maintaining family's well-being), 24 care quality objectives were set with 24 outcome QIs-LTC and 144 process QIs-LTC. In the survey, 84.8% of clients were using home care nursing, 26.3% were living alone, and 39.5% had dementia. In the month preceding the data collection, 13.9% of clients had a new disease or worsening of an existing disease, 8.8% were hospitalized at least once, and 47.9% did not participate in activities of interest. About 20% of clients' families were unable to spend time peacefully, and 52.8% were exhausted from the client's care.

CONCLUSIONS

The QIs-LTC developed in the current study are generic and client- and family-centered. They encompass objective and subjective information and would facilitate standardized monitoring if adopted and comparison between LTC settings, including home care. In addition, future research directives are outlined. Geriatr Gerontol Int 2023; 23: 383-394.

[The pulmonary rehabilitation utilization rate among older people with chronic obstructive pulmonary disease in Japan: A retrospective study using medical and long-term care insurance claims data]

AIM

This study aimed to improve the understanding of the utilization rates and the characteristics of users of pulmonary rehabilitation (PR) among people with chronic obstructive pulmonary disease.

METHODS

We used medical and long-term care claims data from between April 2012 and March 2013 from Kashiwa city in Chiba prefecture, Japan. The study participants included patients of ≥63 years of age, who had received outpatient treatment for COPD (ICD-10 codes: J41-J44) two or more times during the study period, and who had been prescribed two or more COPD-related drugs. We extracted data on inpatient and outpatient PR using respiratory rehabilitation fee (I) (II) codes, and on home-based PR using home-care rehabilitation or nursing codes from medical insurance or long-term care insurance data.

RESULTS

The mean age of the patients was 76.8 years (total participation: n = 2,708). There were 61 (2.3%) inpatient PR users, 25 (0.9%) outpatient PR users, and 101 (3.8%) home-based PR users. The median duration of usage by the inpatient, outpatient and home-based PR users was 1 month, 2 months, and 11 months, respectively. The mean age of non-PR and outpatient PR users was 76 years, while that of the inpatient PR users and home-based PR users was approximately 80 years. Approximately 20-30% of non-PR users and outpatient PR users were certified for long-term care. In contrast, approximately half of the inpatient users and almost all of the home-based PR users were certified for long-term care.

CONCLUSIONS

Since the PR utilization rates were low in both hospital-based and home-based settings, it is necessary to take measures to disseminate each PR based on the characteristics of the intervention duration and service users.

Use of Homecare Nursing and Sense of Security Among Family Caregivers of Older Adults

Having a sense of security for living at home is essential to continue living at home and it is important to develop a community care system that enables high sense of security. Because frail to dependent older adults often accompany various conditions that require medical attention, receiving homecare nursing might allow the family caregiver to feel safe in living at home. Therefore we examined whether receiving homecare nursing service contributes to a higher family caregiver sense of security. We conducted a questionnaire survey regarding older adults who were 75 years and older with at least some sort of community care services, and their family caregivers (n=776). Family sense of security was measured using 5 items (e.g., “I feel secure about my relative living at home with help of available services”), rated on 5-point Likert scales. Characteristics of older adults were obtained from their nurses or care managers. The mean age of the older adults was 85.8 years, 58% female, and 8 % living alone. The mean total family sense of security was 20.6 (standard deviation = 3.7) out of 25. In multiple regression analysis, the family sense of security was positively associated with the use of homecare nursing (β= 0.09, p=0.020), adjusting for participants’ age, stability of their medical conditions, level of activities of daily living, use of medical procedures, living arrangements, and house call physician services. Homecare provided by nurses could contribute to longer staying at home among older adults by way of the higher family sense of security.

Self-management activities of older people with chronic obstructive pulmonary disease by types of healthcare services utilised: A cross-sectional questionnaire study

AIMS AND DESIGN

Various healthcare services in Japan provide self-management interventions for older people with chronic obstructive pulmonary disease (COPD). To examine the influence of healthcare service utilisation on self-management activities, we conducted a cross-sectional survey of older people with COPD who received care through outpatient clinics (OC), outpatient rehabilitation centres (OR) or home care (HC) services.

METHODS

The survey consisted of 34 originally developed self-report questions about three types of self-management activities: (a) strategies to minimise dyspnoea, (b) appropriate activities to maintain physical and mental health status and (c) communication with healthcare professionals or family members. We compared self-management activities in each setting (OC, OR and HC) using logistic regression analyses, controlling for dyspnoea level and age, which we chose as representative variables of disease severity.

RESULTS

Among the total sample (n = 81; mean age: 78.2 years old), participants in the HC group (n = 25) had the most severe level of COPD, followed by those in the OR (n = 31) and OC (n = 12) groups. Compared with participants from the OC group, more participants from the OR and HC groups reported self-management activities, such as "moving body corresponding to breathing" (OR: adjusted odds ratio [AOR], 6.71; HC: AOR, 6.98), "trying not to move quickly" (OR: AOR, 5.46), "avoiding suffocating movements" (HC: AOR, 7.37), "getting an influenza vaccination"(OR: AOR, 8.12; HC: AOR, 7.81), "stretching exercise" (OR: AOR, 6.42; HC: AOR, 16.76), "muscle training" (OR: AOR, 8.49; HC: AOR, 9.73) and "discussing lifestyle goals with healthcare professionals" (HC: AOR, 5.75) after controlling for dyspnoea level and age.

CONCLUSIONS

Some self-management activities (such as breathing techniques and home exercise) were associated with the use of OR or HC services, an effect persisting after adjusting for degree of breathlessness and age.

IMPLICATIONS FOR PRACTICE

Findings suggest that we should provide additional services such as OR and HC besides OC to older people with COPD who are unable to practice self-management activities. We need to consider strategies to provide effective self-management intervention in each healthcare service setting according to the unique characteristics of each setting.

Probing spin correlations using angle-resolved photoemission in a coupled metallic/Mott insulator system

A nearly free electron metal and a Mott insulating state can be thought of as opposite ends of the spectrum of possibilities for the motion of electrons in a solid. Understanding their interaction lies at the heart of the correlated electron problem. In the magnetic oxide metal PdCrO₂, nearly free and Mott-localized electrons exist in alternating layers, forming natural heterostructures. Using angle-resolved photoemission spectroscopy, quantitatively supported by a strong coupling analysis, we show that the coupling between these layers leads to an "intertwined" excitation that is a convolution of the charge spectrum of the metallic layer and the spin susceptibility of the Mott layer. Our findings establish PdCrO₂ as a model system in which to probe Kondo lattice physics and also open new routes to use the a priori nonmagnetic probe of photoemission to gain insights into the spin susceptibility of correlated electron materials.

HEALTH PROMOTION A NEW APPROACH TO DEVELOP GERONTOLOGICAL NURSING CARE QUALITY INDICATORS

While the inter-RAI, a comprehensive geriatric assessment tool, contains standardized system for assessing quality of care, there are limitations for its everyday use. Limitations include large number of items, lack of apparent process indicators, and limited symptoms and disease-related information. A new approach was introduced to develop gerontological nursing quality indicators that were targeted at long-term care. We plan to develop staff-friendly indicators, which can be extracted from regular routine client records. A group of nurse researchers discussed essential domains of elderly persons’ life quality, based on nursing theory literature, that nurses strive to maintain. Several outcome indicators were derived out of the domains, and process quality indicators were developed based on literature review. We identified nine domains based on Gordon’s functional health patterns: 1) minimizing symptoms and disease deterioration, 2) maintaining nutritional status, 3) controlling bowel movements, 4) encouraging physical activities, 5) promoting sound sleep, 6) minimizing dementia symptoms, 7) maintaining dignity, and 8) reducing family stress. We then developed 17 outcome indicators; each domain included one to four outcome indicators (e.g., maintaining nutritional status has three indicators: no aspiration, no weight loss by 3% or more, and no dehydration). Process indicators that covered regular assessment (e.g., swallowing evaluation), preventive interventions (e.g., adjusting body positions during a meal), and interventions for the problems (e.g., food texture modification) were determined. These indicators may be useful to assess gerontological nursing quality. We are planning to conduct expert panel and individual client surveys to assess its usability.

Ultrasonographic findings can identify 'pseudoprogression' under nivolumab therapy

'Pseudoprogression' is often seen in patients with melanomas who are treated with immune checkpoint inhibitors such as nivolumab or ipilimumab. We sometimes evaluate metastatic lesions by imaging tests such as computed tomography (CT) or positron emission tomography-CT. 'Pseudoprogression' usually occurs upon the initial administration, which may make it difficult for the physician to determine the disease condition. In our two cases of metastatic melanoma treated with nivolumab (antiprogrammed cell death-1 antibody), we examined the ultrasonography (US) of target lesions that could be accessed from the body surface, such as those of the regional lymph node or subcutaneous metastasis. In both cases, the US revealed a lesion approximately 10% greater in size after 40-50 days of nivolumab administration, even though the blood flow inside the tumour was reduced by about 20% within 50 days. From about 100 days after blood flow reduction was detected by US, the tumours began to decrease in size. However, contrast CT was unable to detect the association between tumour size and tumour blood flow. The present cases suggest that US could be a powerful tool for differentiating between 'pseudoprogression' and real progressive disease in patients treated with cancer immunotherapies such as those involving immune checkpoint inhibitors. The misdiagnosis of progressive disease can lead to unnecessary alterations to the current treatment. Therefore, the US findings in our study could be clinically useful and educational for physicians.