Effects of the per diem prospective payment system with DRG-like grouping system (DPC/PDPS) on resource usage and healthcare quality in Japan

Adjunctive Corticosteroids decreased the risk of mortality of non-HIV Pneumocystis Pneumonia

OBJECTIVES

A mortality rate of non-human immunodeficiency virus-infected pneumocystis pneumonia (non-HIV PCP) is 30-60%. But the effectiveness of adjunctive corticosteroids with trimethoprim-sulfamethoxazole has been unclear, and we examined whether it lowered risk of mortality in non-HIV PCP.

METHODS

We did an observational study of adult non-HIV PCP patients from April 2010 through March 2016, using Japanese nationwide healthcare records of the Diagnostic Procedure Combination database (DPC). The risk was estimated by the time-dependent Cox regression analyses with inverse probability weights.

RESULT

1299 eligible non-HIV PCP patients were identified. 737 patients were severe respiratory status (partial pressure of oxygen in arterial blood [PaO₂] ≤60mm Hg) and 562 were moderate (PaO₂ >60mm Hg) at hospital admission. Among patients with severe respiratory status, the adjunctive corticosteroids was associated with lower risk of 60-day mortality (HR 0.71; 95% confidence interval [CI], 0.55-0.91), and significantly decreased mortality rates (24.7% vs 36.6%, P=0.006). In contrast, no significant differences were observed in the risk of 60-day mortality (HR 1.17; 95% CI, 0.73-1.86) and the mortality rate (10.9% vs 9.1%, P=0.516) among patients with moderate respiratory status.

CONCLUSION

The adjunctive corticosteroids were associated with lower risk of 60-day mortality in severe non-HIV PCP patients.

Effect of methicillin-resistant Staphylococcus aureus in Japan

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is the most common antimicrobial-resistant organism identified in Japanese health care facilities. This study analyzed the clinical and economic burdens attributable to methicillin resistance in S aureus in Japanese hospitals.

METHODS

We retrospectively investigated data from 14,905 inpatients of 57 hospitals combined with data from nosocomial infection surveillance and administrative claim databases. The participants were inpatients with admission from April 1, 2014, to discharge on March 31, 2016. The outcomes were evaluated according to length of stay, hospital charges, and in-hospital mortality. We compared the disease burden of MRSA infections with methicillin-susceptible S aureus (MSSA) infections based on patients' characteristics and onset periods.

RESULTS

We categorized 7,188 and 7,717 patients into MRSA and MSSA groups, respectively. The adjusted effects of the MRSA group were 1.03-fold (95% confidence interval [CI] 1.01-1.05) and 1.04-fold (95% CI, 1.01-1.06), respectively, with an odds ratio of 1.14 (95% CI, 1.02-1.27).

CONCLUSIONS

The results of this study found that patient severity and onset delays were positively associated with both MRSA and burden and that the effect of methicillin resistance remained significant after adjustment.

Impact of Comorbidities on Survival in Gastric, Colorectal, and Lung Cancer Patients

BACKGROUND

The presence of comorbidities in cancer patients may influence treatment decisions and prognoses. This study aimed to examine the impact of comorbidities on overall survival in Japanese patients diagnosed with major solid tumors.

METHODS

To obtain patient-level information on clinical conditions and vital status, we performed a record linkage of population-based cancer registry data from Osaka Prefecture, Japan and administrative data produced under the Diagnosis Procedure Combination (DPC) system. The study population comprised patients who received a primary diagnosis of gastric, colorectal, or lung cancer between 2010 and 2012 at any of five cancer centers. We employed the Charlson Comorbidity Index (CCI) score to quantify the impact of comorbidities on survival. The association between CCI score and survival for each cancer site was analyzed using Cox proportional hazards regression models for all-cause mortality, after adjusting for patient sex, age at cancer diagnosis, and cancer stage.

RESULTS

A total of 2,609 patients with a median follow-up duration of 1,372 days were analyzed. The most frequent CCI score among the patients was 0 (77.7%), followed by 2 (14.3%). After adjusting for the covariates, we detected a significant association between CCI score and all-cause mortality. The hazard ratios per one-point increase in CCI score were 1.12 (95% confidence interval [CI], 1.02-1.23), 1.20 (95% CI, 1.08-1.34), and 1.14 (95% CI, 1.04-1.24) for gastric, colorectal, and lung cancer, respectively.

CONCLUSIONS

Comorbidities have a negative prognostic impact on overall survival in cancer patients, and should be assessed as risk factors for mortality when reporting outcomes.

The Effect of Diagnosis-Related Group Payment System on Quality of Care in the Field of Obstetrics and Gynecology among Korean Tertiary Hospitals

PURPOSE

To examine changes in clinical practice patterns following the introduction of diagnosis-related groups (DRGs) under the fee-for-service payment system in July 2013 among Korean tertiary hospitals and to evaluate its effect on the quality of hospital care.

MATERIALS AND METHODS

Using the 2012-2014 administrative database from National Health Insurance Service claim data, we reviewed medical information for 160400 patients who underwent cesarean sections (C-secs), hysterectomies, or adnexectomies at 43 tertiary hospitals. We compared changes in several variables, including length of stay, spillover, readmission rate, and the number of simultaneous and emergency operations, from before to after introduction of the DRGs.

RESULTS

DRGs significantly reduced the length of stay of patients undergoing C-secs, hysterectomies, and adnexectomies (8.0±6.9 vs. 6.0±2.3 days, 7.4±3.5 vs. 6.4±2.7 days, 6.3±3.6 vs. 6.2±4.0 days, respectively, all p<0.001). Readmission rates decreased after introduction of DRGs (2.13% vs. 1.19% for C-secs, 4.51% vs. 3.05% for hysterectomies, 4.77% vs. 2.65% for adnexectomies, all p<0.001). Spillover rates did not change. Simultaneous surgeries, such as colpopexy and transobturator-tape procedures, during hysterectomies decreased, while colporrhaphy during hysterectomies and adnexectomies or myomectomies during C-secs did not change. The number of emergency operations for hysterectomies and adnexectomies decreased.

CONCLUSION

Implementation of DRGs in the field of obstetrics and gynecology among Korean tertiary hospitals led to reductions in the length of stay without increasing outpatient visits and readmission rates. The number of simultaneous surgeries requiring expensive operative instruments and emergency operations decreased after introduction of the DRGs.

Cost of illness of ischemic heart disease in Japan: a time trend and future projections

Background

Ischemic heart disease (IHD/ICD10: I20-I25) is the second leading cause of deaths in Japan and accounts for 40% of deaths due to heart diseases. This study aimed to calculate the economic burden of IHD using the cost of illness (COI) method and to identify key factors that drive the change of the economic burden of IHD.

Methods

We calculated the cost of illness (COI) every 3 years from 1996 to 2014 using governmental statistics. We then predicted the COI for every 3 years starting from 2017 up to 2029 using the fixed and variable model estimations. Only the estimated future population was used as a variable in the fixed model estimation. By contrast, variable model estimation considered the time trend of health-related indicators over the past 18 years. We derived the COI from the sum of direct and indirect costs (morbidity and mortality).

Results

The past estimation of COI slightly increased from 1493.8 billion yen in 1996 to 1708.3 billion yen in 2014. Future forecasts indicated that it would decrease from 1619.0 billion yen in 2017 to 1220.5 billion yen in 2029.

Conclusion

The past estimation showed that the COI of IHD increased; in the mixed model, the COI was predicted to decrease with the continuing trend of health-related indicators. The COI of IHD in the future projection showed that, although the average age of death increased by social aging, the influence of the number of deaths and mortality cost decreased.

A trend analysis of surgical operations under a global payment system in Tehran, Iran (2005-2015)

Background

Global payment system is a first example of per-case payment system that contains 60 commonly used surgical operations for which payment is based on the average cost per case in Iran.

Objective

The aim of the study was to determine the amount of reduction, increase or no change in the trend of global operations.

Methods

In this retrospective longitudinal study, data on the 60 primary global surgery codes was gathered from Tehran Health Insurance Organization within the ten-year period of 2005–2015 separately, for each month. Out of 60 surgery codes, only acceptable data for 46 codes were available based on the insurance documents sent by medical centers. A quantitative analysis of time series through Regression Analysis Model using STATA software v.11 was performed.

Results

Some global surgery codes had an upward trend and some were downwards. Of N Codes, N83, N20, N28, N63, and N93 had an upward trend (p<0.05) and N32, N43, N81 and N90 showed a significant downward trend (p<0.05). Similarly, all H Codes except for H18 had a significant upward trend (p<0.000). As such, K Codes including K45, K56 and K81 had an increasing movement. S Codes also experienced both increasing and decreasing trends. However, none of the O Codes changed according to time. Other global surgical codes like C61, E07, M51, L60, J98 (p<0.000), I84 (p<0.031) and I86 (p<0.000) shown upward and downward trends. Total global surgeries trend was significantly upwards (B=24.26109, p<0.000).

Conclusion

The varying trend of global surgeries can partly reflect the behavior of service providers in order to increase their profits and minimize their costs.

Nationwide Increase in Cryptorchidism After the Fukushima Nuclear Accident

OBJECTIVE

To estimate the change of discharge rate after cryptorchidism surgery between pre- and postdisaster in Japan. Cryptorchidism cannot be diagnosed before birth and is not a factor that would influence a woman's decision to seek an abortion. Therefore, this disease is considered suitable for assessing how the Great East Japan Earthquake and the subsequent Fukushima Daiichi nuclear accident (2011) influenced congenital diseases.

MATERIALS AND METHODS

We obtained cryptorchidism discharge data collected over 6 years from hospitals that were included in an impact assessment survey of the Diagnosis Procedure Combination survey database in Japan and used these data to estimate the discharge rate after cryptorchidism surgery before and after the disaster. The 94 hospitals in Japan that participated in Diagnosis Procedure Combination system and had 10 or more discharges after cryptorchidism surgery within successive 6 years covering pre- and postdisaster period (FY2010-FY2015) were involved. The change in discharge rate between pre- and postdisaster was analyzed using a Bayesian generalized linear mixed model.

RESULTS

Nationwide, a 13.4% (95% credible interval 4.7%-23.0%) increase in discharge rates was estimated. The results of all sensitivity analyses were similar to the reported main results.

CONCLUSION

The discharge rate of cryptorchidism was increased nationwide. The rates of low-weight babies or preterm births, risk factors of cryptorchidism, were almost constant during the study period, and age distribution of the surgery was also not changed, which suggested that the other factors that associated with the disaster increased the incidence of cryptorchidism.

Effects of a new medical insurance payment system for hospice patients in palliative care programs in Korea

BACKGROUND

This study investigates the effects of a new medical insurance payment system for hospice patients in palliative care programs and analyzes length of survival (LoS) determinants.

METHOD

At the Pusan National University Hospital hospice center, between January 2015 and April 2016, 276 patients were hospitalized with several diagnosed types of terminal stage cancer. This study separated patients into two groups, "old" and "new," by admission date, considering the new system has been applied from July 15, 2015. The study subsequently compared LoS, total cost, and out-of-pocket expenses for the two groups.

RESULTS

Overall, 142 patients applied to the new medical insurance payment system group, while the old medical insurance payment system included 134 patients. The results do not show a significantly negative difference in LoS for the new system group (p = 0.054). Total cost is higher within the new group (p <  0.001); however, the new system registers lower patient out-of-pocket expenses (p <  0.001).

CONCLUSION

The novelty of this study is proving that the new medical insurance payment system is not inferior to the classic one in terms of LoS. The total cost of the new system increased due to a multidisciplinary approach toward palliative care. However, out-of-pocket expenses for patients overall decreased, easing their financial burden.

Association between re-admission rate and hospital characteristics for ischemic heart disease

OBJECTIVE

Hospital re-admission is considered an important marker of patient health outcomes and healthcare system performance. Korea introduced the Korean Diagnosis Procedure Combination (KDPC) for all regional public hospitals in July 2012. This study examined re-admission rates within 30 days to assess whether the hospital payment system is associated with the re-admission rate, focusing on ischemic heart disease.

METHODS

A cross-sectional study was conducted using national claims data for 2013. We analyzed data of patients with a major diagnosis of ischemic heart disease who were admitted to general hospitals with more than 500 beds in Korea. Of the eight general hospitals, two that have been operating under the new Korean payment system were public hospitals using the KDPC, and the remaining six were private general hospitals with fee for service (FFS) systems. Multiple logistic regression analysis was used to identify associations between re-admission rate and hospital characteristics.

RESULTS

The study analyzed 4,290 cases (889 cases in KDPC and 3,401 cases in FFS). The 30-day unplanned re-admission rate was higher in KDPC than in FFS (7.9% vs 5.6%, respectively). The unplanned re-admission odds ratios of KDPC was 1.74.

CONCLUSIONS

KDPC had higher 30-day unplanned re-admissions rates than did FFS.

Estimated expenditures for hip fractures using merged healthcare insurance data for individuals aged ≥ 75 years and long-term care insurance claims data in Japan

Little is known about hip fracture expenditure in Japan. Using claims data obtained from a core city near Tokyo, we estimated the mean healthcare expenditure and monthly long-term care expenditure post-hip fracture to be ¥2,600,000 (US$29,500) and ¥113,000 (US$1290), respectively.

PURPOSE

We aimed to estimate healthcare and long-term care expenditures post-hip fracture in Japan.

METHODS

Healthcare insurance claims data for adults aged ≥  75 years were merged with long-term care insurance claims data. We analyzed the data of hip fracture patients who were admitted to non-diagnosis procedure combination/per-diem payment system (DPC/PDPS) hospitals in a core city near Tokyo between April 2012 and September 2013. We estimated healthcare expenditure, namely, the difference between total payments 6 months pre- and 6 months post-hip fracture, and monthly long-term care expenditure for those who did not use long-term care insurance pre-hip fracture, but who commenced long-term care insurance post-hip fracture. We also performed multiple linear regressions to examine the associations of healthcare or long-term care expenditure with various factors.

RESULTS

The estimated mean healthcare (n = 78) and monthly long-term care (n = 42) expenditures post-hip fracture were ¥2,600,000 (US$29,500) and ¥113,000 (US$1290), respectively. In multiple linear regressions, healthcare expenditure was positively associated with longer duration of hospital stay (p = 0.036), and negatively associated with higher Charlson Comorbidity Index scores (p = 0.015). Monthly long-term care expenditure was positively associated with higher care-needs level post-hip fracture (p = 0.022), and usage of institutional care services (p < 0.001).

CONCLUSIONS

This is the first study to estimate healthcare and long-term care expenditures post-hip fracture using claims data in Japan. Further studies are needed that include healthcare claims data at both DPC/PDPS and non-DPC/PDPS hospitals to capture the lifelong course of long-term care required post-hip fracture.

Evaluation of economic burden of colonic surgical site infection at a Japanese hospital

BACKGROUND

Several reports have been published regarding cost increases attributable to surgical site infections (SSIs) in Europe and the USA. However, such studies have been limited in Japan.

AIM

To evaluate the economic burden of colorectal SSIs on hospitals in Japan.

METHODS

This study was undertaken at a Japanese university hospital. Amongst 265 patients who had undergone colorectal surgery in the Department of Coloproctological Surgery between November 2014 and March 2016, 16 patients who developed SSIs and could be allocated a diagnosis procedure combination code were selected as SSI cases. Individual SSI cases were matched to non-SSI cases based on a combination of surgical category, age band, sex, wound class, presence of stoma and risk index. Median length of stay (LOS) and piecework reference cost were compared between SSI episodes and non-SSI episodes.

FINDINGS

The median LOS for patients with SSI and without SSI was 25.5 [interquartile range (IQR) 21.5-39.3] and 16.5 (IQR 12.5-18.5) days, respectively (P<0.01). The median piecework reference cost for patients with SSI and without SSI was ¥842,155 (IQR ¥716,423-1,388,968) and ¥575,795 (IQR ¥529,638-680,105), respectively (P<0.01).

CONCLUSION

SSIs led to a significant increase in LOS and economic burden. Although the SSI episodes appear to be more profitable than the non-SSI episodes, the economic profit for SSI episodes was less than that for non-SSI episodes in the observation period, when opportunity costs were taken into account.

Charting a path forward: policy analysis of China's evolved DRG-based hospital payment system

Background

At present, the diagnosis-related groups-based prospective payment system (DRG-PPS) that has been implemented in China is merely a prototype called the simplified DRG-PPS, which is known as the ‘ceiling price for a single disease’. Given that studies on the effects of a simplified DRG-PPS in China have usually been controversial, we aim to synthesize evidence examining whether DRGs can reduce medical costs and length of stay (LOS) in China.

Methods

Data were searched from both Chinese [Wan Fang and China National Knowledge Infrastructure Database (CNKI)] and international databases (Web of Science and PubMed), as well as the official websites of Chinese health departments in the 2004–2016 period. Only studies with a design that included both experimental (with DRG-PPS implementation) and control groups (without DRG-PPS implementation) were included in the review.

Results

The studies were based on inpatient samples from public hospitals distributed in 12 provinces of mainland China. Among them, 80.95% (17/21) revealed that hospitalization costs could be reduced significantly, and 50.00% (8/16) indicated that length of stay could be decreased significantly. In addition, the government reports showed the enormous differences in pricing standards and LOS in various provinces, even for the same disease.

Conclusions

We conclude that the simplified DRGs are useful in controlling hospitalization costs, but they fail to reduce LOS. Much work remains to be done in China to improve the simplified DRG-PPS.

Estimating the disease burden of methicillin-resistant Staphylococcus aureus in Japan: Retrospective database study of Japanese hospitals

OBJECTIVES

The nationwide impact of antimicrobial-resistant infections on healthcare facilities throughout Japan has yet to be examined. This study aimed to estimate the disease burden of methicillin-resistant Staphylococcus aureus (MRSA) infections in Japanese hospitals.

DESIGN

Retrospective analysis of inpatients comparing outcomes between subjects with and without MRSA infection.

DATA SOURCE

A nationwide administrative claims database.

SETTING

1133 acute care hospitals throughout Japan.

PARTICIPANTS

All surgical and non-surgical inpatients who were discharged between April 1, 2014 and March 31, 2015.

MAIN OUTCOME MEASURES

Disease burden was assessed using hospitalization costs, length of stay, and in-hospital mortality. Using a unique method of infection identification, we categorized patients into an anti-MRSA drug group and a control group based on anti-MRSA drug utilization. To estimate the burden of MRSA infections, we calculated the differences in outcome measures between these two groups. The estimates were extrapolated to all 1584 acute care hospitals in Japan that have adopted a prospective payment system.

RESULTS

We categorized 93 838 patients into the anti-MRSA drug group and 2 181 827 patients into the control group. The mean hospitalization costs, length of stay, and in-hospital mortality of the anti-MRSA drug group were US$33 548, 75.7 days, and 22.9%, respectively; these values were 3.43, 2.95, and 3.66 times that of the control group, respectively. When extrapolated to the 1584 hospitals, the total incremental burden of MRSA was estimated to be US$2 billion (3.41% of total hospitalization costs), 4.34 million days (3.02% of total length of stay), and 14.3 thousand deaths (3.62% of total mortality).

CONCLUSIONS

This study quantified the approximate disease burden of MRSA infections in Japan. These findings can inform policymakers on the burden of antimicrobial-resistant infections and support the application of infection prevention programs.

Differences between determinants of in-hospital mortality and hospitalisation costs for patients with acute heart failure: a nationwide observational study from Japan

OBJECTIVES

Although current case-mix classifications in prospective payment systems were developed to estimate patient resource usage, whether these classifications reflect clinical outcomes remains unknown. The efficient management of acute heart failure (AHF) with high mortality is becoming more important in many countries as its prevalence and associated costs are rapidly increasing. Here, we investigate the determinants of in-hospital mortality and hospitalisation costs to clarify the impact of severity factors on these outcomes in patients with AHF, and examine the level of agreement between the predicted values of mortality and costs.

DESIGN

Cross-sectional observational study.

SETTING AND PARTICIPANTS

A total of 19 926 patients with AHF from 261 acute care hospitals in Japan were analysed using administrative claims data.

MAIN OUTCOME MEASURES

Multivariable logistic regression analysis and linear regression analysis were performed to examine the determinants of in-hospital mortality and hospitalisation costs, respectively. The independent variables were grouped into patient condition on admission, postadmission procedures indicating disease severity (eg, intra-aortic balloon pumping) and other high-cost procedures (eg, single-photon emission CT). These groups of independent variables were cumulatively added to the models, and their effects on the models' abilities to predict the respective outcomes were examined. The level of agreement between the quartiles of predicted mortality and predicted costs was analysed using Cohen's κ coefficient.

RESULTS

In-hospital mortality was associated with patient's condition on admission and severity-indicating procedures (C-statistics 0.870), whereas hospitalisation costs were associated with severity-indicating procedures and high-cost procedures (R² 0.32). There were substantial differences in determinants between the outcomes. In addition, there was no consistent relationship observed (κ=0.016, p<0.0001) between the quartiles of in-hospital mortality and hospitalisation costs.

CONCLUSIONS

The determinants of mortality and costs for hospitalised patients with AHF were generally different. Our results indicate that the same case-mix classifications should not be used to predict both these outcomes.

Mixed-method research protocol: defining and operationalizing patient-related complexity of nursing care in acute care hospitals

AIM

To define the concept of patient-related complexity of nursing care in acute care hospitals and to operationalize it in a questionnaire.

BACKGROUND

The concept of patient-related complexity of nursing care in acute care hospitals has not been conclusively defined in the literature. The operationalization in a corresponding questionnaire is necessary, given the increased significance of the topic, due to shortened lengths of stay and increased patient morbidity.

DESIGN

Hybrid model of concept development and embedded mixed-methods design.

METHODS

The theoretical phase of the hybrid model involved a literature review and the development of a working definition. In the fieldwork phase of 2015 and 2016, an embedded mixed-methods design was applied with complexity assessments of all patients at five Swiss hospitals using our newly operationalized questionnaire 'Complexity of Nursing Care' over 1 month. These data will be analysed with structural equation modelling. Twelve qualitative case studies will be embedded. They will be analysed using a structured process of constructing case studies and content analysis. In the final analytic phase, the quantitative and qualitative data will be merged and added to the results of the theoretical phase for a common interpretation. Cantonal Ethics Committee Zurich judged the research programme as unproblematic in December 2014 and May 2015.

DISCUSSION

Following the phases of the hybrid model and using an embedded mixed-methods design can reach an in-depth understanding of patient-related complexity of nursing care in acute care hospitals, a final version of the questionnaire and an acknowledged definition of the concept.

Differential Effects of Declining Rates in a Per Diem Payment System

The paper demonstrates differential effects of a prospective payment system with declining per diem rates, dependent on the percentiles of length of stay. The analysis uses dynamic panel data estimates and a recent nationwide administrative database for major diagnostic categories in 1068 Japanese hospitals in 2006-2012 to show that average length of stay significantly increases for hospitals in percentiles 0-25 of the pre-reform length of stay and significantly decreases for hospitals in percentiles 51-100. The decline of the average length of stay is larger for hospitals in higher percentiles of the length of stay. Hospitals in percentiles 51-100 significantly increase their rate of nonemergency/unanticipated readmissions within 42 days after discharge. The decline in the length of total episode of treatment is smaller for hospitals in percentiles 0-25. The findings are robust in terms of the choice of a cohort of hospitals joining the reform. The paper discusses applicability of 'best practice' rate-setting to help improve the performance of hospitals in the lowest quartile of average length of stay. Copyright © 2015 John Wiley & Sons, Ltd.

Reducing Length of Hospital Stay Does Not Increase Readmission Rates in Early-Stage Gastric, Colon, and Lung Cancer Surgical Cases in Japanese Acute Care Hospitals

Background

The Japanese government has worked to reduce the length of hospital stay by introducing a per-diem hospital payment system that financially incentivizes the timely discharge of patients. However, there are concerns that excessively reducing length of stay may reduce healthcare quality, such as increasing readmission rates. The objective of this study was to investigate the temporal changes in length of stay and readmission rates as quality indicators in Japanese acute care hospitals.

Methods

We used an administrative claims database under the Diagnosis Procedure Combination Per-Diem Payment System for Japanese hospitals. Using this database, we selected hospitals that provided data continuously from July 2010 to March 2014 to enable analyses of temporal changes in length of stay and readmission rates. We selected stage I (T1N0M0) gastric, colon, and lung cancer surgical patients who had been discharged alive from the index hospitalization. The outcome measures were length of stay during the index hospitalization and unplanned emergency readmissions within 30 days after discharge.

Results

From among 804 hospitals, we analyzed 42,585, 15,467, and 40,156 surgical patients for gastric, colon, and lung cancer, respectively. Length of stay was reduced by approximately 0.5 days per year. In contrast, readmission rates were generally stable at approximately 2% or had decreased slightly over the 4-year period.

Conclusions

In early-stage gastric, colon, and lung cancer surgical patients in Japan, reductions in length of stay did not result in increased readmission rates.

Current Trends and Healthcare Resource Usage in the Hospital Treatment of Primary Malignant Brain Tumor in Japan: A National Survey Using the Diagnostic Procedure Combination Database (J-ASPECT Study-Brain Tumor)

We conducted this study to clarify the current trends and healthcare resource usage in the treatment of inpatients with primary malignant brain tumors. The Diagnostic Procedure Combination (DPC) data of all inpatients treated between 2013 and 2014 in the 370 core and branch hospitals enrolled in the Japanese Neurosurgical Society training program were collected. DPC is a discharge abstract and administrative claims database of inpatients. We assessed 6,142 primary, malignant brain tumor patients. Patient information, diagnostic information, treatment procedure, and healthcare resource usage were analyzed. Chemotherapy was the most frequent treatment (27% of cases), followed by surgery (13%) and surgery + chemo-radiotherapy (11%). Temozolomide (TMZ), the most frequently used chemotherapeutic drug, was administered to 1,236 patients. Concomitant TMZ and radiotherapy was administered to 816 patients, and was performed according to the Stupp regimen in many cases. The mean length of hospital stay (LOS) was 16 days, and the mean medical cost was 1,077,690 yen. The average medical cost of TMZ-only treatment was 1,138,620 yen whilst it was 4,424,300 yen in concomitant TMZ patients. The LOS was significantly shorter in high-volume than in low-volume hospitals, and the medical cost was higher in hospitals treating 21–50 patients compared to those treating 1–10 patients. However, the direct medical cost of TMZ treatment was the same across different volume hospitals. This is the first report of current trends and healthcare resource usage in the treatment of primary malignant brain tumor inpatients in the TMZ era in Japan.

Impact of payment system change from per-case to per-diem on high severity patient's length of stay

A new payment system, the diagnosis-related group (DRG) system, and Korean diagnosis procedure combination (KDPC, per-diem) payment system were officially introduced in 2002 and in 2012, respectively. We evaluated the impact of payment system change from per-case to per-diem on high severity patient's length of stay (LOS).Claim data was used. A total of 36,240 case admissions and 72,480 control admissions were included in the analysis. Segmented regression analysis of interrupted time series between cases and controls was conducted. Hospitals that consistently participated in the DRG payment system and changed to the KDPC payment system were defined as case hospitals. Hospitals that consistently participated in the DRG payment system were defined as control hospitals.LOS increased by 0.025 days per month (P = 0.0055) for 3 surgical diagnosis-related admissions due to the bundled payment system change. LOS among emergency admissions also increased and showed an increasing tendency under the KDPC. The LOS increase was observed specifically for complex procedure admissions and high severity cases (CCI 0, 1: 0.022, P = 0.0142; CCI 2, 3: 0.026, P = 0.0288; CCI ≥ 4: 0.055, P = 0.0003).Although both payment systems are optimized to decrease LOS, incentives to reduce LOS are stronger under the DRG system than under the KDPC system. It is worth noting that too strong incentive for reducing LOS is suitable to high severity cases.

Factor Analysis Influencing Postoperative Hospital Stay and Medical Costs for Patients with Definite, Suspected, or Unmatched Diagnosis of Acute Cholecystitis according to the Tokyo Guidelines 2013

Purpose. To identify significant independent preoperative factors influencing postoperative hospital stay (PHS) and medical costs (MC) in 171 patients who underwent cholecystectomy for benign gallbladder diseases and had definite, suspected, or unmatched acute cholecystitis (AC) diagnosis according to the Tokyo Guidelines 2013 (TG13). Methods. The 171 patients were classified according to the combination of diagnostic criteria including local signs of inflammation (A), systemic signs of inflammation (B), and imaging findings (C): A+ B+ C (definite diagnosis, n = 84), A+ B (suspected diagnosis, n = 25), (A or B) + C (n = 10), A (n = 41), and B (n = 11). Results. The A+ B + C and (A or B) + C groups had equivalent PHS and MC, suggesting that imaging findings were essential for AC diagnosis. PHS and MC were significantly increased in the order of severity grades based on TG13. Performance status (PS), white blood cell count, and severity grade were identified as preoperative factors influencing PHS by multivariate analysis, and significant independent preoperative factors influencing MC were age, PS, preoperative biliary drainage, hospital stay before surgery, albumin, and severity grade. Conclusion. PS and severity grade significantly influenced prolonged PHS and increased MC.

Readmission rates of South Korean psychiatric inpatients by inpatient volumes per psychiatrist

BACKGROUND

Readmission rates of psychiatric inpatients are higher in South Korea than other Organization for Economic Co-operation and Development (OECD) countries. In addition, the solution for readmission control is deficient based on the characteristics of the South Korean National Health Insurance (NHI) system. Therefore, it is necessary to identify ways to reduce psychiatric inpatient readmissions. This study investigated the relationship between inpatient volume per psychiatrist and the readmission rate of psychiatric inpatients in South Korea.

METHOD

We used NHI claim data (N = 37,796) from 53 hospitals to analyze readmission within 30 days for five diagnosis (organic mental disorders, mental and behavioral disorders due to psychoactive substance use, schizophrenia, mood disorders, neurotic disorders, and stress-related and somatoform disorders) between 2010 and 2013. We performed χ2 and analysis of variance tests to investigate associations between patient and hospital-level variables and readmission within 30 days. Finally, generalized estimating equation (GEE) models were analyzed to examine possible associations with readmission.

RESULTS

Readmissions within 30 days accounted for 1,598 (4.5 %) claims. Multilevel analysis demonstrated that inpatient volume per psychiatrist were inversely related with readmission within 30 days (low odds ratio [OR]: 0.38, 95 % confidence interval [CI]: 0.28-0.51; mid-low OR: 0.48, 95 % CI: 0.36-0.63; mid-high OR: 0.55, 95 % CI: 0.44-0.69; Q4 = ref). The subgroup analysis by diagnosis revealed that both "schizophrenia, schizotypal, and delusional disorders" and "mood disorders" had inverse relationships with readmission risk for all volume groups.

CONCLUSIONS

We observed an inverse association between inpatient volume per psychiatrist and the 30-day readmission rate of psychiatric inpatients, suggesting that it could be a useful quality indicator in mental health care.

Early results of pediatric appendicitis after adoption of diagnosis-related group-based payment system in South Korea

Purpose

As an alternative to the existing fee-for-service (FFS) system, a diagnosis-related group (DRG)-based payment system has been suggested. The aim of this study was to investigate the early results of pediatric appendicitis treatment under the DRG system, focusing on health care expenditure and quality of health care services.

Patients and methods

The medical records of 60 patients, 30 patients before (FFS group), and 30 patients after adoption of the DRG system (DRG), were reviewed retrospectively.

Results

Mean hospital stay was shortened, but the complication and readmission rates did not worsen in the DRG. Overall health care expenditure and self-payment decreased from Korean Won (KRW) 2,499,935 and KRW 985,540, respectively, in the FFS group to KRW 2,386,552 and KRW 492,920, respectively, in the DRG. The insurer’s payment increased from KRW 1,514,395 in the FFS group to KRW 1,893,632 in the DRG. For patients in the DRG, calculation by the DRG system yielded greater overall expenditure (KRW 2,020,209 vs KRW 2,386,552) but lower self-payment (KRW 577,803 vs KRW 492,920) than calculation by the FFS system.

Conclusion

The DRG system worked well in pediatric patients with acute appendicitis in terms of cost-effectiveness over the short term. The gradual burden on the national health insurance fund should be taken into consideration.

What causes international variations in length of stay: a comparative analysis for two inpatient conditions in Japanese and Canadian hospitals

Hospital average length of stay varies considerably between countries. However, there is limited patient-level research identifying or discounting possible reasons for these differences. This study compares the length of stay of patients in Japan, where it is the longest in the OECD, and Canada, where length of stay is closer to the OECD mean. Administrative patient-level data, including age, gender, co-morbidities, intervention, discharge plan, outcome and length of stay were collected from two Japanese and two Ontario, Canada hospitals for two diagnoses: colorectal cancer surgery and acute myocardial infarction. Analyses examined linkages between patient characteristics, hospitals and countries and length of stay. When controlling for patient demographic characteristics, the incidence of co-morbidities and discharge plan practices, Japanese length of stay tended to be significantly longer than that in Canada for both diagnoses. Mortality rates were not significantly different; however, the readmission rate (28 days or less) for acute myocardial infarction was higher in the Canadian hospitals. The findings indicate that non-clinical factors contribute to sustained international differences in length of stay. These factors may include professional or cultural norms, differing payment schemes and access to long-term care facilities. The study also introduces a protocol that can be used for international patient-level comparisons that can enable effective policy and management learning.

The Impact of Patient Profiles and Procedures on Hospitalization Costs through Length of Stay in Community-Acquired Pneumonia Patients Based on a Japanese Administrative Database

Background

Community-acquired pneumonia is a common cause of patient hospitalization, and its burden on health care systems is increasing in aging societies. In this study, we aimed to investigate the factors that affect hospitalization costs in community-acquired pneumonia patients while considering the intermediate influence of patient length of stay.

Methods

Using a multi-institutional administrative claims database, we analyzed 30,041 patients hospitalized for community-acquired pneumonia who had been discharged between April 1, 2012 and September 30, 2013 from 289 acute care hospitals in Japan. Possible factors associated with hospitalization costs were investigated using structural equation modeling with length of stay as an intermediate variable. We calculated the direct, indirect (through length of stay), and total effects of the candidate factors on hospitalization costs in the model. Lastly, we calculated the ratio of indirect effects to direct effects for each factor.

Results

The structural equation model showed that higher disease severities (using A-DROP, Barthel Index, and Charlson Comorbidity Index scores), use of mechanical ventilation, and tube feeding were associated with higher hospitalization costs, regardless of the intermediate influence of length of stay. The severity factors were also associated with longer length of stay durations. The ratio of indirect effects to direct effects on total hospitalization costs showed that the former was greater than the latter in the factors, except in the use of mechanical ventilation.

Conclusions

Our structural equation modeling analysis indicated that patient profiles and procedures impacted on hospitalization costs both directly and indirectly. Furthermore, the profiles were generally shown to have greater indirect effects (through length of stay) on hospitalization costs than direct effects. These findings may be useful in supporting the more appropriate distribution of health care resources.

National trends in hospital length of stay for acute myocardial infarction in China

BACKGROUND

China is experiencing increasing burden of acute myocardial infarction (AMI) in the face of limited medical resources. Hospital length of stay (LOS) is an important indicator of resource utilization.

METHODS

We used data from the Retrospective AMI Study within the China Patient-centered Evaluative Assessment of Cardiac Events, a nationally representative sample of patients hospitalized for AMI during 2001, 2006, and 2011. Hospital-level variation in risk-standardized LOS (RS-LOS) for AMI, accounting for differences in case mix and year, was examined with two-level generalized linear mixed models. A generalized estimating equation model was used to evaluate hospital characteristics associated with LOS. Absolute differences in RS-LOS and 95% confidence intervals were reported.

RESULTS

The weighted median and mean LOS were 13 and 14.6 days, respectively, in 2001 (n = 1,901), 11 and 12.6 days in 2006 (n = 3,553), and 11 and 11.9 days in 2011 (n = 7,252). There was substantial hospital level variation in RS-LOS across the 160 hospitals, ranging from 9.2 to 18.1 days. Hospitals in the Central regions had on average 1.6 days (p = 0.02) shorter RS-LOS than those in the Eastern regions. All other hospital characteristics relating to capacity for AMI treatment were not associated with LOS.

CONCLUSIONS

Despite a marked decline over the past decade, the mean LOS for AMI in China in 2011 remained long compared with international standards. Inter-hospital variation is substantial even after adjusting for case mix. Further improvement of AMI care in Chinese hospitals is critical to further shorten LOS and reduce unnecessary hospital variation.

The relationship between the number of cardiologists and clinical practice patterns in acute heart failure: a cross-sectional observational study

OBJECTIVES

Despite the increasing burden of acute heart failure (AHF) on healthcare systems, the association between centralised cardiovascular specialist care and the quality of AHF care remains unknown. We examine the relationship between the number of cardiologists per hospital and hospital practice variations.

DESIGN, SETTING AND PARTICIPANTS

In a retrospective observational study, we analysed 38,668 patients with AHF admitted to 546 Japanese acute care hospitals between 2010 and 2011 using the Diagnosis Procedure Combination administrative claims database. Sample hospitals were categorised into four groups according to the number of cardiologists per facility (none, 1-4, 5-9 and ≥10). To confirm the capability of administrative data to identify patients with AHF, the ≥10 cardiologists group was compared with two recent clinical registries in Japan.

MAIN OUTCOME MEASURES

Using multivariable logistic regression models, patient risk-adjusted in-hospital mortality rates and age-sex-adjusted ORs of various AHF therapies were calculated and compared among four hospital groups.

RESULTS

The ≥10 cardiologists group of hospitals from the administrative database had similar major underlying disease incidence and therapeutic practices to those of the clinical registry hospitals. Age-adjusted and sex-adjusted ORs of various AHF therapies in the four hospital groups revealed wide practice variations associated with the number of cardiologists. Adjusted in-hospital mortality demonstrated a negative association with the number of cardiologists. In addition, the different hospital-level distribution patterns of specific therapeutic practices illustrated the diffusion process of therapies across facilities.

CONCLUSIONS

Wide practice variations in AHF care were associated with the number of cardiologists per facility, indicating a possible relationship between the quality of AHF care and manpower resources. The provision of recommended therapies increased together with the number of cardiologists.

Development of a risk-adjusted in-hospital mortality prediction model for community-acquired pneumonia: a retrospective analysis using a Japanese administrative database

Background

Community-acquired pneumonia (CAP) is a common cause of patient hospitalization and death, and its burden on the healthcare system is increasing in aging societies. Here, we develop and internally validate risk-adjustment models and scoring systems for predicting mortality in CAP patients to enable more precise measurements of hospital performance.

Methods

Using a multicenter administrative claims database, we analyzed 35,297 patients hospitalized for CAP who had been discharged between April 1, 2012 and September 30, 2013 from 303 acute care hospitals in Japan. We developed hierarchical logistic regression models to analyze predictors of in-hospital mortality, and validated the models using the bootstrap method. Discrimination of the models was assessed using c-statistics. Additionally, we developed scoring systems based on predictors identified in the regression models.

Results

The 30-day in-hospital mortality rate was 5.8%. Predictors of in-hospital mortality included advanced age, high blood urea nitrogen level or dehydration, orientation disturbance, respiratory failure, low blood pressure, high C-reactive protein levels or high degree of pneumonic infiltration, cancer, and use of mechanical ventilation or vasopressors. Our models showed high levels of discrimination for mortality prediction, with a c-statistic of 0.89 (95% confidence interval: 0.89-0.90) in the bootstrap-corrected model. The scoring system based on 8 selected variables also showed good discrimination, with a c-statistic of 0.87 (95% confidence interval: 0.86-0.88).

Conclusions

Our mortality prediction models using administrative data showed good discriminatory power in CAP patients. These risk-adjustment models may support improvements in quality of care through accurate hospital evaluations and inter-hospital comparisons.

Disparities associated with breast reconstruction in Japan

BACKGROUND

With increasing rates of postmastectomy breast reconstruction, it has been suggested that there is an insufficient supply of services that meet patient demands. This study aimed to identify potential disparities in, and variables associated with, postmastectomy reconstruction in Japan.

METHODS

Using 20,257 Japanese breast cancer discharge data from 2010, the authors identified 1616 breast cancer patients, with tumor-node-metastasis classification of malignant tumors T1~4 and N0M0, between 20 and 59 years of age. Factors influencing the use of immediate breast reconstruction of either autogenous tissue or tissue expander placement were analyzed using multinomial logistic regression comparing no reconstruction to either autogenous tissue or tissue expander placement.

RESULTS

The immediate breast reconstruction rate was 11.2 percent among the study patients. The rate of autogenous method use was 49 percent and the rate of tissue expander use was 51 percent. Tissue expander placement was performed primarily in patients who resided in cities (OR, 2.4; 95 percent confidence interval, 1.5 to 4.1) and was performed at city hospitals. Patients who lived in rural areas primarily underwent autogenous tissue reconstruction, traveled to city hospitals to undergo surgery (OR, 2.0; 95 percent confidence interval, 1.0 to 4.0), and had normal body mass index (OR, 1.9; 95 percent confidence interval, 1.1 to 3.1).

CONCLUSIONS

The authors identified potential disparities associated with breast reconstruction. These disparities might be due to limited surgery methods and might have excluded some patients because of their age, physical, and economic status. Uneven distribution of plastic surgeons might have required patients to travel for breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Development and validation of an acute heart failure-specific mortality predictive model based on administrative data

BACKGROUND

Acute heart failure (AHF) with its high in-hospital mortality is an increasing burden on healthcare systems worldwide, and comparing hospital performance is required for improving hospital management efficiency. However, it is difficult to distinguish patient severity from individual hospital care effects. The aim of this study was to develop a risk adjustment model to predict in-hospital mortality for AHF using routinely available administrative data.

METHODS

Administrative data were extracted from 86 acute care hospitals in Japan. We identified 8620 hospitalized patients with AHF from April 2010 to March 2011. Multivariable logistic regression analyses were conducted to analyze various patient factors that might affect mortality. Two predictive models (models 1 and 2; without and with New York Heart Association functional class, respectively) were developed and bootstrapping was used for internal validation. Expected mortality rates were then calculated for each hospital by applying model 2.

RESULTS

The overall in-hospital mortality rate was 7.1%. Factors independently associated with higher in-hospital mortality included advanced age, New York Heart Association class, and severe respiratory failure. In contrast, comorbid hypertension, ischemic heart disease, and atrial fibrillation/flutter were found to be associated with lower in-hospital mortality. Both model 1 and model 2 demonstrated good discrimination with c-statistics of 0.76 (95% confidence interval, 0.74-0.78) and 0.80 (95% confidence interval, 0.78-0.82), respectively, and good calibration after bootstrap correction, with better results in model 2.

CONCLUSIONS

Factors identifiable from administrative data were able to accurately predict in-hospital mortality. Application of our model might facilitate risk adjustment for AHF and can contribute to hospital evaluations.

Reforming reimbursement of public hospitals in Greece during the economic crisis: Implementation of a DRG system

OBJECTIVES

Until recently, in-patient NHS hospital care in Greece was reimbursed via an anachronistic and under-priced retrospective per diem system, which has been held primarily responsible for continuous budget deficits. The purpose of this paper is to present the efforts of the Ministry of Health (MoH) to implement a new DRG-based payment system.

METHODS

As in many countries, the decision was to adopt a patient classification from abroad and to refine it for use in Greece with national data. Pricing was achieved with a combination of activity-based costing with data from selected Greek hospitals, and "imported" cost weights. Data collection, IT support and monitoring are provided via ESY.net, a web-based facility developed and implemented by the MoH.

RESULTS

After an initial pilot testing of the classification in 20 hospitals, complete DRG reimbursement data was reported by 113 hospitals (85% of total) for the fourth quarter of 2011. The recorded monthly increase in patient discharges billed with the new system and in revenue implies increasing adaptability by the hospitals. However, the unfavorable inlier vs. outlier distribution of discharges and revenue observed in some health regions signifies the need for corrective actions.

CONCLUSIONS

The importance of this reimbursement reform is discussed in light of the current crisis faced by the Greek economy. There is yet much to be done and many projects are currently in progress to support this effort; however the first cost containment results are encouraging.