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

Do the diagnosis-related group payment reforms have a negative impact?-an empirical study from Western China

Background

The first Diagnosis-Related Group (DRG) Reimbursement pilots in China, which started in 2019, marked an essential step in cost control and service efficiency in Chinese hospitals, but some adverse effects inevitably emerged during the implementation of DRG in TCM (traditional Chinese medicine) hospitals. This study aims to explore the positive and negative effects of DRG payment reform and provide a reference for the reform of medical insurance payments in countries that retain traditional medicine.

Methods

Longitudinal data from two hospitals, Qingyang City Hospital of TCM and Tianshui City Hospital of TCM, were retrieved from China's Gansu Health for All Big Data Platform from June 2016 to June 2022, and the policy effects were assessed using the difference-in-differences (DID) method and mediated-effects model.

Results

The DRG reform reduced hospitalization costs, diagnostic costs, drug costs, and nursing costs by 6.5, 4.2, 7.9, and 26.2%, respectively, in the treatment group hospitals (p < 0.01), but increased the hospitalization times by 17.5% (p < 0.01); there was a "reimbursement bias" for patients with different types of medical insurance. In the treatment group hospitals, the primary beneficiaries of the reform were urban employees' basic medical insurance patients, whose costs decreased by 4.9% (p < 0.01), with a non-significant effect on out-of-pocket payment patients and free medical care patients; the hospitals in the treatment group tended to reduce the use of Chinese medicine unique diagnostic and therapeutic means and increase the proportion of western medicine treatments under the pressure of the supremacy of costs.

Conclusion

The reform of the DRG payment method has positively impacted the cost control of TCM hospitals, but it has also had some adverse effects. This poses a challenge and prompts a thought about how TCM hospitals can maintain their distinctive advantages by optimizing the design of the DRG system at present.

Impact of a new case-based payment scheme on volume distribution across public hospitals in Zhejiang, China: does 'Same disease, same price' matter

BACKGROUND

With the implementation of the hierarchical medical system (HMS) in China, Zhejiang Province introduced an innovative payment scheme called "payment method by disease types with point counting". This scheme was initially adopted in Jinhua in July 2017, and was later integrated with the "same disease, same price" policy in Hangzhou in January 2020. This study aimed to investigate the impact of these reforms on the distribution of health service volume.

METHODS

Data were obtained from 104 hospitals, including 12 tertiary and 14 secondary hospitals from each of four regions: Jinhua (intervention) vs. Taizhou (control), and Hangzhou (intervention) vs. Ningbo (control). A total of 3848 observation points were examined using two sets of controlled interrupted time series analyses to assess the effects of this new case-based payment, without and with "same disease, same price", on the proportion of discharges, total medical revenue and hospitalization revenue. The Herfindahl-Hirschman Index (HHI) were analyzed to evaluate changes in market competition.

RESULTS

Following the introduction of the new case-based payment without "same disease, same price", secondary hospitals in Jinhua experienced a significant decline in the proportion of discharges (β6 = -0.1074, p = 0.047), total medical revenue (β6 = -0.0729, p = 0.026), and hospitalization revenue (β6 = -0.1062, p = 0.037) compared to those in Taizhou, while tertiary hospitals showed a non-significant increase. After incorporating "same disease, same price", the proportion of discharges (β6 = 0.2015, p = 0.031), total medical revenue (β6 = 0.1101, p = 0.041) and hospitalization revenue (β6 = 0.1248, p = 0.032) in Hangzhou's secondary hospitals increased compared with Ningbo's, yet the differences in both the level and trend changes between tertiary hospitals in the two cities were not statistically significant. The HHI in Jinhua (β7 = 0.0011, p = 0.043) presented an upward trend during the pilot period of the case-based payment, while the HHI in Hangzhou (β6 = -0.0234, p = 0.021) decreased immediately after the introduction of "same disease, same price".

CONCLUSION

This new case-based payment scheme may worsen the disproportionate distribution of service volume across hospitals of different levels. While "same disease, same price" shows potential benefits, further evidence is needed to assess its effectiveness in promoting HMS. Policymakers should consider hospital interests in payment design and address unintended strategic behaviors.

Relationship between hospital surgical volume and the perioperative esophagectomy costs for esophageal cancer: a nationwide administrative claims database study

BACKGROUND

Numerous studies have described positive relationships between hospital volume (HV) and clinical outcomes in highly complex procedures, including esophagectomies. Although the centralization of surgery has been considered a possible solution for improving clinical outcomes, the HV impact on perioperative healthcare costs is unknown. This study aimed to determine the relationship between HV and perioperative healthcare costs for patients undergoing esophagectomy for esophageal cancer.

METHODS

This retrospective, nationwide cohort study used Japanese Administrative Claims Database data. Data on esophagectomies performed nationwide in 2015 were extracted. The outcome measure was perioperative healthcare costs per person from the perspective of the insurer. The healthcare costs in outpatient or inpatient settings of any hospital and clinic where patients received treatment were summed up from the month the surgery was performed to 3 months after. Linear regression analyses were conducted to assess the risk-adjusted effects of the HV category (1-4/5-9/10-14/15-) on perioperative costs.

RESULTS

A total of 5232 patients underwent an esophagectomy at 584 hospitals. The overall perioperative cost was 20.834 billion Japanese yen (JPY). The median perioperative costs per person for each HV category (1-4/5-9/10-14/15-) were 3.728 (709 patients), 3.740 (658 patients), 3.760 (512 patients), and 3.760 (3253 patients) million JPY, respectively (P = 0.676). Multivariate analyses revealed that each HV category had no significant impact on perioperative costs.

CONCLUSIONS

There were no significant differences in the perioperative costs between high- and low-volume centers. Esophageal cancer surgery centralization may be achievable without increasing healthcare costs.

The Impact of a New Case-Based Payment System on Quality of Care: A Difference-in-Differences Analysis in China

Purpose

China has developed and widely piloted a new case-based payment, ie, the "Diagnosis-Intervention Packet" (DIP) payment, which has a granular classification system. We evaluated the impact of DIP payment on the quality of care in a large pilot city in China and explored potential mechanisms of quality change.

Methods

The city started to implement DIP payment with a hospital-level cap on July 1, 2019. Using a 5% random sample of discharge records from July 2017 to June 2021, we employed a difference-in-differences approach to compare two mortality measures (in-hospital mortality, mortality of surgical patients), two readmission measures (all-cause readmission within 30 days, readmission with the same principal diagnosis within 30 days) and a patient safety measure (operation associated complications or adverse event) in 13 pilot hospitals and 27 non-pilot hospitals before and after DIP payment reform.

Results

Of 122,637 discharge records included, 43,023 (35.1%) were from pilot hospitals. After DIP payment, the readmission rate within 30 days and readmission rate with the same principal diagnosis in pilot hospitals decreased significantly by 3.2 percentage points (P <0.001) and 1.8 percentage points (P <0.001), respectively. The in-hospital mortality rate, the mortality rate of surgical patients, and the rate of operation-associated complications or adverse events did not have significant changes. The decrease in quality measures was primarily driven by tertiary hospitals, was more obvious over time after the policy adoption, and was more pronounced in groups with higher intensity of care.

Conclusion

This study indicated that DIP payment with a cap in the study city was associated with improved quality of care among patients in pilot hospitals. The provider's behavior of increasing the intensity of care, especially for more severe patients, may partially contribute to the results.

Management and outcomes of heart failure hospitalization among older adults in the United States and Japan

AIMS

Despite advances in therapies, the disease burden of heart failure (HF) has been rising globally. International comparisons of HF management and outcomes may reveal care patterns that improve outcomes. Accordingly, we examined clinical management and patient outcomes in older adults hospitalized for acute HF in the United States (US) and Japan.

METHODS

We identified patients aged >65 who were hospitalized for HF in 2013 using US Medicare data and the Japanese Registry of Acute Decompensated Heart Failure (JROADHF). We described patient characteristics, management, and healthcare utilization and compared outcomes using multivariable Cox regression during and after HF hospitalization.

RESULTS

Among 11 193 Japanese and 120 289 US patients, age and sex distributions were similar, but US patients had higher comorbidity rates. The length of stay was longer in Japan (median 18 vs. 5 days). While Medicare patients had higher use of implantable cardioverter defibrillator or cardiac resynchronization therapy during hospitalization (1.32% vs. 0.6%), Japanese patients were more likely to receive cardiovascular medications at discharge and to undergo cardiac rehabilitation within 3 months of HF admission (31% vs. 1.6%). Physician follow-up within 30 days was higher in Japan (77% vs. 57%). Cardiovascular readmission, cardiovascular mortality and all-cause mortality were 2.1-3.7 times higher in the US patients. The per-day cost of hospitalization was lower in Japan ($516 vs. $1323).

CONCLUSIONS

We observed notable differences in the management, outcomes and costs of HF hospitalization between the US and Japan. Large differences in length of hospitalization, cardiac rehabilitation rate and outcomes warrant further research to determine the optimal length of stay and assess the benefits of inpatient cardiac rehabilitation to reduce rehospitalization and mortality.

Safety of advanced laparoscopic hepatectomy for elderly patients: a Japanese nationwide analysis

BACKGROUND

Although basic laparoscopic hepatectomy (LH) has become the standard procedure for hepatectomy, the safety of advanced LH remains to be clarified, especially in elderly patients. We investigated the safety of advanced LH in elderly Japanese patients.

METHODS

Elderly patients (≥ 65 years) who underwent advanced LH between 2016 and 2021 were analyzed using a nationwide claims database in Japan. The perioperative outcomes of patients who underwent open hepatectomy (OH group) or LH (LH group) were compared using propensity score matching (PSM). The primary outcome was in-hospital mortality. The E-value method was performed to assess the strength of the outcome point estimates against possible unmeasured confounding factors.

RESULTS

Among 5,021 patients, eligible patients were classified into the OH (n = 4,152) and LH (n = 527) groups. The median patient age was 74 years in both groups. Hepatocellular carcinoma and metastatic liver tumors were the major indications for hepatectomy (OH: 52.5% versus 30.6%; LH: 60.7% versus 26.4%). After PSM, in-hospital mortality rates for OH and LH were 1.7 and 0.76%, respectively. The risk ratio was 0.45 (95% confidence interval, 0.16-1.25; E-value = 3.87). Compared with OH, LH was associated with a longer anesthesia time (411 versus 432 min), lower rate of blood product use (red blood concentrate: 33.5% versus 20.3%; fresh frozen plasma: 29.2% versus 17.1%), and shorter hospital stay (13 versus 12 days).

CONCLUSIONS

In elderly patients, the safety of advanced LH was similar to that of advanced OH, or might be better in Japan under the current policy of hospital accreditation.

Statistical Analysis of the Factors that Affect Postoperative Length of Hospital Stay after Unruptured Intracranial Aneurysm Treatment in Japan: A 20-year Nationwide Multicenter Study

Treatment strategies for unruptured intracranial aneurysms (UIAs) should be carefully considered with reference to rupture and complication rates. It is also important to minimize the length of hospital stay (LOS) and to ensure a high quality of medical care. In this study, we aim to clarify the factors that affect the LOS of patients treated for UIAs using the Inpatient Clinico-Occupational Database of the Rosai Hospital Group (ICOD-R). This was a nationwide-multicenter study based on ICOD-R data from 2000 to 2019. Patients diagnosed with UIAs who were treated with clipping or coiling were included in the study. Multivariate analysis was performed to identify the factors affecting LOS. LOS was also compared between groups classified by surgical procedure or treatment period. We identified 3294 patients on the database who underwent clipping or coiling of UIAs during the study period. Multivariate analysis revealed hospital admission during the early 2000s and the late 2010s, age, and treating institution to be significantly correlated with LOS (p < 0.05). There was a significant difference between the mean LOS of the clipping group (20.3 days) and the coiling group (9.65 days) (p < 0.001). Compared by treatment period, LOS significantly shortened over time. Our results suggest that the type of treatment, time of treatment, patient age, and the treating institution affect postoperative LOS for UIAs. Although coiling was found to lead to a lower average LOS than clipping, treatment selection should take the characteristics of each patient's aneurysm into consideration.

Statistical Insight into China's Indigenous Diagnosis-Related-Group System Evolution

The use of Diagnosis-Related Groups (DRG) is a prevalent payment system employed to control hospitalization costs and improve medical efficiency. China has developed an indigenized DRG payment system including Single Disease Payment (SDP), DRGs, and Big Data Diagnosis-Intervention Packet (DIP). In this study, we took cholecystitis as an example, drawing on both primary and secondary data to verify the effectiveness of China's indigenized DRG system and to introduce the evolution of DRGs in China. Primary data were gathered from Qilu Hospital in 2019-2021. Secondary data were collected from published literature from 2004-2016. Only studies with both pre-SDP/DRG and post-SDP/DRG groups were included. Among the studies included, 92.9% (13/14) reported a significant reduction in hospitalization costs after the implementation of SDP while other studies identified length of stay (LOS) and age as the most significant influential factors in SDP. Furthermore, we elaborated the efficiency of DRGs using data from 2738 inpatients in Qilu hospital. Moreover, 60% (6/10) of the studies from the databases also showed the efficiency of DRGs in different regions. SDP is efficient in saving hospitalization costs, but its implementation is limited. DRGs have a broader scope of application, but their effectiveness remains to be validated. DIP is a brand new concept in China, and more data are needed to assess its efficiency.

Hospital response to Activity-Based Funding and price incentives: Evidence from Ireland

Activity-Based Funding (ABF) is a funding policy incentivising hospitals to deliver more efficient care. ABF can be complemented by additional price incentives to further drive hospital efficiency. In 2016, ABF was introduced for public patients admitted to Irish public hospitals. Additionally, a price incentive to perform laparoscopic cholecystectomy as day-case surgery was introduced in 2018. Private patient activity in public hospitals was subject to neither ABF nor price incentive. Using national Hospital In-Patient-Enquiry activity data 2013-2019, we evaluated the impact of ABF and the price incentive for laparoscopic cholecystectomy surgery in Ireland. We exploit variation in hospital payment for public and private patients treated in public acute Irish hospitals and employ a Propensity Score Matching Difference-in-Differences approach. We estimate the funding change impacts across outcomes measuring the proportion of day-case admissions and length of stay. We found no significant impact for either outcomes linked to ABF introduction. Similarly, no impacts linked to the price incentive were observed. It appears providers of laparoscopic cholecystectomy in Irish public hospitals did not react to the new funding mechanisms. The implementation of the funding policies did not improve hospital efficiency. Further strengthening of these new funding mechanisms are required to deliver more efficient care.

Does prospective payment influence quality of care? A systematic review of the literature

In the light of rising health expenditures, the cost-efficient provision of high-quality inpatient care is on the agenda of policy-makers worldwide. In the last decades, prospective payment systems (PPS) for inpatient care were used as an instrument to contain costs and increase transparency of provided services. It is well documented in the literature that prospective payment has an impact on structure and processes of inpatient care. However, less is known about its effect on key outcome indicators of quality of care. In this systematic review, we synthesize evidence from studies investigating how financial incentives induced by PPS affect indicators of outcome quality domains of care, i.e. health status and user evaluation outcomes. We conduct a review of evidence published in English, German, French, Portuguese and Spanish language produced since 1983 and synthesize results of the studies narratively by comparing direction of effects and statistical significance of different PPS interventions. We included 64 studies, where 10 are of high, 18 of moderate and 36 of low quality. The most commonly observed PPS intervention is the introduction of per-case payment with prospectively set reimbursement rates. Abstracting evidence on mortality, readmission, complications, discharge disposition and discharge destination, we find the evidence to be inconclusive. Thus, claims that PPS either cause great harm or significantly improve the quality of care are not supported by our findings. Further, the results suggest that reductions of length of stay and shifting treatment to post-acute care facilities may occur in the course of PPS implementations. Accordingly, decision-makers should avoid low capacity in this area.

Cost Sharing and Cost Shifting Mechanisms under a per Diem Payment System in a County of China

Cost sharing and cost shifting mechanisms are of vital importance in a prospective payment system. This paper employed the difference-in-differences method to estimate the impacts of a per diem system with inverted-U-shape rates on medical costs and the length of stay based on data from a health insurance institution. The supply side cost sharing mechanism worked so that the new payment system significantly reduced medical costs by 17.59 percent while the average length of stay varied little. After further analyzing the mechanism, we found that heterogeneous effects emerged mainly due to the special rates design. The reform decreased the cases that incurred relatively high medical costs and lengths of stay. However, cost shifting existed so that physicians could be motivated to provide unnecessary services to the patients who should have been discharged before the average length of stay. Therefore, payment rates in the per diem system require a sophisticated design to constrain its distortion to medical service provision even though medical expenditures were successfully contained.

Medical insurance payment schemes and patient medical expenses: a cross-sectional study of lung cancer patients in urban China

BACKGROUND

As the main cause of cancer death, lung cancer imposes seriously health and economic burdens on individuals, families, and the health system. In China, there is no national study analyzing the hospitalization expenditures of different payment methods by lung cancer inpatients. Based on the 2010-2016 database of insured urban resident lung cancer inpatients from the China Medical Insurance Research Association (CHIRA), this paper aims to investigate the characteristics and cost of hospitalized lung cancer patient, to examine the differences in hospital expenses and patient out-of-pocket (OOP) expenses under four medical insurance payment methods: fee-for-service (FFS), per-diem payments, capitation payments (CAP) and case-based payments, and to explore the medical insurance payment method that can be conducive to controlling the cost of lung cancer.

METHOD

This is a 2010-2016, 7-year cross-sectional study. CHIRA data are not available to researchers after 2016. The Medical Insurance Database of CHIRA was screened using the international disease classification system to yield 28,200 inpatients diagnosed with lung cancer (ICD-10: C34, C34.0, C34.1, C34.2, C34.3, C34.8, C34.9). The study includes descriptive analysis and regression analysis based on generalized linear models (GLM).

RESULTS

The average patient age was 63.4 years and the average length of hospital stay (ALOS) was 14.2 day; 60.7% of patients were from tertiary hospitals; and 45% were insured by FFS. The per-diem payment had the lowest hospital expenses (RMB7496.00/US$1176.87), while CAP had the lowest OOP expenses (RMB1328.18/US$208.52). Compared with FFS hospital expenses, per-diem was 21.3% lower (95% CI = -0.265, -0.215) and case-based payment was 8.4% lower (95% CI = -0.151, -0.024). Compared with the FFS, OOP expenses, per-diem payments were 9.2% lower (95% CI = -0.130, -0.063) and CAP was 15.1% lower (95% CI = -0.151, -0.024).

CONCLUSION

For lung cancer patients, per-diem payment generated the lowest hospital expenses, while CAP meant patients bore the lowest OOP costs. Policy makers are suggested to give priority to case-based payments to achieve a tripartite balance among medical insurers, hospitals, and insured members. We also recommend future studies comparing the disparities of various diseases for the cause of different medical insurance schemes.

Impact of Diagnosis-Related Groups on Inpatient Quality of Health Care: A Systematic Review and Meta-Analysis

The aim of this meta-analysis was to comprehensively evaluate the effectiveness of Diagnosis-related group (DRG) based payment on inpatient quality of care. A comprehensive literature search was conducted in PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science from their inception to December 30, 2022. Included studies reported associations between DRGs-based payment and length of stay (LOS), re-admission within 30 days and mortality. Two reviewers screened the studies independently, extracted data of interest and assessed the risk of bias of eligible studies. Stata 13.0 was used in the meta-analysis. A total of 29 studies with 36 214 219 enrolled patients were analyzed. Meta-analysis showed that DRG-based payment was effective in LOS decrease (pooled effect: SMD = -0.25, 95% CI = -0.37 to -0.12, Z = 3.81, P < .001), but showed no significant overall effect in re-admission within 30 days (RR = 0.79, 95% CI = 0.62-1.01, Z = 1.89, P = .058) and mortality (RR = 0.91, 95% CI = 0.72-1.15, Z = 0.82, P = .411). DRG-based payment demonstrated statistically significant superiority over cost-based payment in terms of LOS reduction. However, owing to limitations in the quantity and quality of the included studies, an adequately powered study is necessary to consolidate these findings.

Evaluation of the condition of inpatients in acute care hospitals in Japan: A retrospective multicenter descriptive study

This retrospective, multicenter, descriptive study aimed to evaluate the conditions of inpatients in acute care hospitals using the Severity of a Patient's Condition and Extent of a Patient's Need for Medical/Nursing Care tool. The study included 4 234 253 patients admitted to acute care hospitals in Japan between April 2019 and March 2020. Electrocardiographic monitoring, provision of respiratory care, and administration of antiarrhythmic agent injections and treatment were performed in a sterile room for >20%, >10%, and <1% of patient-days, respectively. More than 40% of inpatients needed support with performing activities of daily living, such as dressing and undressing, turning over, and oral care. The proportion of patients requiring daily medical/nursing care was generally high at the beginning of hospitalization, gradually decreased, and subsequently increased. Patients in acute care hospitals in Japan were not hospitalized unnecessarily early or for inappropriately long periods, and the efficiency of medical care improved over time. The Severity of a Patient's Condition and Extent of a Patient's Need for Medical/Nursing Care tool is useful for evaluating patient conditions in acute care hospitals.

A comparison of four quasi-experimental methods: an analysis of the introduction of activity-based funding in Ireland

Background

Health services research often relies on quasi-experimental study designs in the estimation of treatment effects of a policy change or an intervention. The aim of this study is to compare some of the commonly used non-experimental methods in estimating intervention effects, and to highlight their relative strengths and weaknesses. We estimate the effects of Activity-Based Funding, a hospital financing reform of Irish public hospitals, introduced in 2016.

Methods

We estimate and compare four analytical methods: Interrupted time series analysis, Difference-in-Differences, Propensity Score Matching Difference-in-Differences and the Synthetic Control method. Specifically, we focus on the comparison between the control-treatment methods and the non-control-treatment approach, interrupted time series analysis. Our empirical example evaluated the length of stay impact post hip replacement surgery, following the introduction of Activity-Based Funding in Ireland. We also contribute to the very limited research reporting the impacts of Activity-Based-Funding within the Irish context.

Results

Interrupted time-series analysis produced statistically significant results different in interpretation, while the Difference-in-Differences, Propensity Score Matching Difference-in-Differences and Synthetic Control methods incorporating control groups, suggested no statistically significant intervention effect, on patient length of stay.

Conclusion

Our analysis confirms that different analytical methods for estimating intervention effects provide different assessments of the intervention effects. It is crucial that researchers employ appropriate designs which incorporate a counterfactual framework. Such methods tend to be more robust and provide a stronger basis for evidence-based policy-making.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08657-0.

Can case-based payment contain healthcare costs? - A curious case from China

We adopted a difference-in-difference (DID) design to evaluate the impact of a case-based payment pilot in Tianjin, China on hospital admission, utilization of varied therapeutic regimes, and the associated costs. We used claim data of all admissions of angina and acute myocardial infarction during July 2015 to June 2018, 18 months before and after the program. Our analyses were supported by convincing common trends tests and a couple of sensitivity analyses. As intended, for patients who received percutaneous coronary stenting (PCS) and were counted in the case-based payment system, we showed that the program decreased length-of-stay, per-admission spending, and out-of-pocket spending by 20.8%, 14.2%, and 95.5%, respectively, but did not increase readmissions. However, when considering all patients who suffered from the two types of coronary heart diseases, we found that the program otherwise increased per-admission spending by nearly 11%. As a result, the program took a perverse effect in increasing monthly spending for the health insurance scheme and the society by 1005.6 thousand USD (47·5%) and 1095·7 thousand USD (34·7%), respectively. Increases in hospital admissions, and proportion of performing PCS accounted for 66·7% and 39·2% of the rise, respectively. In addition, our analysis provided evidence of health providers' cream-skimming behaviors, including selecting younger patients with lower CCI in the case-based system, up-coding complications, and keeping higher cost patients in the fee-for-service payment system. We draw lessons that case-based payment may make an unintended impact that increases healthcare costs when incentives are not properly designed.

Temporal trends of medical cost and cost-effectiveness in sepsis patients: a Japanese nationwide medical claims database

Background

Sepsis is the leading cause of death worldwide. Although the mortality of sepsis patients has been decreasing over the past decade, the trend of medical costs and cost-effectiveness for sepsis treatment remains insufficiently determined.

Methods

We conducted a retrospective study using the nationwide medical claims database of sepsis patients in Japan between 2010 and 2017. After selecting sepsis patients with a combined diagnosis of presumed serious infection and organ failure, patients over the age of 20 were included in this study. We investigated the annual trend of medical costs during the study period. The primary outcome was the annual trend of the effective cost per survivor, calculated from the gross medical cost and number of survivors per year. Subsequently, we performed subgroup and multiple regression analyses to evaluate the association between the annual trend and medical costs.

Results

Among 50,490,128 adult patients with claims, a total of 1,276,678 patients with sepsis were selected from the database. Yearly gross medical costs to treat sepsis gradually increased over the decade from $3.04 billion in 2010 to $4.38 billion in 2017, whereas the total medical cost per hospitalization declined (rate = − $1075/year, p < 0.0001). While the survival rate of sepsis patients improved during the study period, the effective cost per survivor significantly decreased (rate = − $1806/year [95% CI − $2432 to − $1179], p = 0.001). In the subgroup analysis, the trend of decreasing medical cost per hospitalization remained consistent among the subpopulation of age, sex, and site of infection. After adjusting for age, sex (male), number of chronic diseases, site of infection, intensive care unit (ICU) admission, surgery, and length of hospital stay, the admission year was significantly associated with reduced medical costs.

Conclusions

We demonstrated an improvement in annual cost-effectiveness in patients with sepsis between 2010 and 2017. The annual trend of reduced costs was consistent after adjustment with the confounders altering hospital expenses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-022-00624-5.

Existing Data Sources for Clinical Epidemiology: Database of the National Hospital Organization in Japan

This review introduces the National Hospital Organization (NHO) database in Japan. The NHO has maintained two databases through a system of data collection from 140 hospitals in the NHO. National Hospital Organization Clinical Data Archives (NCDA) is collecting clinical information in real time from the electronic medical records since January 2016, and Medical Information Analysis (MIA) databank is collecting daily insurance claims data since April 2010. The NHO database covers more than 8 million patients in 140 hospitals throughout Japan. The database consists of the information of patient profiles, hospital admission and discharge, diagnosis with ICD-10 codes, text data from medical chart, daily health insurance claims such as medical procedures, medications or surgeries, vital signs and laboratory data, and so on. The NHO database includes a wide variety of diseases and settings, including acute, chronic and intractable diseases, emergency medical services, disaster medicine, response to emerging infectious disease outbreaks, medical care according to health policies such as psychiatry, tuberculosis, or muscular dystrophy, and health systems in sparsely populated non-urban areas. Among several common diseases, the database has representativeness in terms of age distribution compared with the Patient Survey 2017 by the Ministry of Health, Labour and Welfare. Interested researchers can contact (700-dbproject@mail.hosp.go.jp) the NHO database division to obtain more information about the NHO database for utilization.

Physician perspectives on the implications of the diagnosis-related groups for medical practice in Turkey: A qualitative study

Hospital reimbursement models might have unintended consequences for medical practice. In Turkey, a mixed reimbursement scheme, based on the diagnosis‐related group (DRG) model and global budget, was gradually introduced as part of the country's 2003 healthcare reforms. This article examines the impacts of the DRG model on medical practice in Turkey, as perceived by physicians working in public and private hospitals. This study draws on an analysis of 14 interviews with physicians. The findings reveal that the implementation of the DRG has transformed medical practice into a process of cost‐benefit optimisation which involves balancing the income and expenses of hospitals against patients' medical needs. To mitigate the negative effects of the DRG, the current model may need to be reformed, particularly to grant exemptions from the standard reimbursement structure for patients who are experiencing complications and/or multiple health conditions.

The diagnosis‐related group has transformed medical practice in Turkey into a process of optimisation.

Physicians are responsible for balancing hospital budgets against patients' medical needs under the current reimbursement model.

Limited reimbursements for most of healthcare services hinder effective medical practice.

Physicians agree upon the need to increase hospital reimbursement levels by the Social Security Institution.

Analysis of the Effects of Electronic Medical Records and a Payment Scheme on the Length of Hospital Stay

Objectives: This study analyzed the effects of computerization of medical information systems and a hospital payment scheme on medical care outcomes. Specifically, we examined the effects of Electronic Medical Records (EMRs) and a diagnosis procedure combination/per-diem payment scheme (DPC/PDPS) on the average length of hospital stay (ALOS).Methods: Post-intervention changes in the monthly ALOS were measured using an interrupted time-series analysis.Results: The level changes observed in the monthly ALOS immediately post-DPC/PDPS were –1.942 (95% confidence interval [CI], –2.856 to –1.028), –1.885 (95% CI, –3.176 to –0.593), –1.581 (95% CI, –3.081 to –0.082) and –2.461 (95% CI, –3.817 to 1.105) days in all ages, <50, 50–64, and ≥65 years, respectively. During the post-DPC/PDPS period, trends of 0.107 (95% CI, 0.069 to 0.144), 0.048 (95% CI, –0.006 to 0.101), 0.183 (95% CI, 0.122 to 0.245) and 0.110 (95% CI, 0.054 to 0.167) days/month, respectively, were observed. During the post-EMR period, trends of –0.053 (95% CI, –0.080 to –0.027), –0.093 (95% CI, –0.135 to –0.052), and –0.049 (95% CI, –0.087 to –0.012) days/month were seen for all ages, 50–64 and ≥65 years, respectively.Conclusions: The increasing post-DPC/PDPS trends offset the decline in ALOS observed immediately post-DPC/PDPS, and the observed ALOS was longer than the counterfactual at the end of the DPC/PDPS study periods. Conversely, due to the downward trend seen after EMR introduction, the actual ALOS at the end of the EMR study period was shorter than the counterfactual, suggesting that EMRs might be more effective than the DPC/PDPS in sustainably reducing the LOS.

Payment mechanism and hospital admission: New evidence from Thailand healthcare reform

In 2007, Thailand's Civil Servant Medical Benefit Scheme (CSMBS), one of the three main public health insurers, adopted a new payment mechanism for hospital admission. There has been a shift from fee-for-service toward Diagnostic Related Group (DRG)-based payment that transfers financial risk from the government to health care providers. This study investigates the effects of this policy change on hospital admission, frequency of admission, length of stay (LOS), type of hospital admitted, and out-of-pocket (OOP) inpatient medical expenditure. By employing nationally representative micro-level data (Health and Welfare surveys) and difference-in-difference approach, this study finds a 1 percentage point decline in hospitalization, a 10% higher chance of admission at community hospitals (the lowest level inpatient public health care facility), and a 7% less chance of admission at higher level public health care facilities like general hospitals. No significant change was observed in LOS, frequency of admission, or OOP inpatient medical expenditure associated with the post-2007 payment mechanism change. Our results emphasize the effectiveness of a close-ended payment mechanism for health care in developing countries. This study also adds to the limited literature on using micro-level data to investigate payment mechanism change in the context of low- and middle-income countries.

Outcomes of women with congenital heart disease admitted to acute-care hospitals for delivery in Japan: a retrospective cohort study using nationwide Japanese diagnosis procedure combination database

Background

The number of women with congenital heart disease (CHD) who are of childbearing age is increasing due to advancements in medical management. Nonetheless, data on the outcomes of delivery in women with CHD remain limited. Therefore, we conducted a retrospective cohort study using a nationwide database of deliveries by women with CHD.

Methods

Deliveries by women with CHD discharged from acute-care hospitals between April 2017 and March 2018 were identified based on the Diagnosis Procedure Combination database which covers almost all acute-care hospitals in Japan. By using this database, we tried to include relatively high-risk deliveries by women with CHD. Subjects were divided into three groups according to the underlying disease complexity: simple, moderate, and great complexity. The clinical characteristics and incidence of peripartum cardiovascular events were compared among the three groups.

Results

A total of 249 deliveries from 107 hospitals were included. The largest facility had 29 deliveries per year. Given the uncertainty of underlying cardiac anomalies, 48 women were excluded, and the remaining 201 women (median age, 32 years) were analyzed. In-hospital maternal death, use of extracorporeal membrane oxygenation, intra-aortic balloon pump, pacemaker, and direct current cardioversion were not observed. Nine patients (4.5%) required intravenous diuretic administration. However, the difference in the frequency of diuretic use was not significant among the three groups (simple, 1.9%; moderate, 7.2%; great, 6.9%; P = 0.204). One participant required valve replacement surgery at 22 days after a successful cesarean section. As the disease complexity increased, deliveries occurred more frequently at university hospitals (simple, 41.7%; moderate, 52.2%; great, 72.4%; P = 0.013) and the length of hospitalization was significantly longer, with median durations of 9.0 (interquartile range [IQR] 7.0–11.0) days, 10.0 (IQR 8.0–24.0) days, and 11.0 (IQR 8.0–36.0) days in the simple, moderate, and great complexity groups, respectively (P = 0.002).

Conclusions

Appropriate patient selection and management by specialized tertiary institutions may contribute to positive outcomes in pregnancies in women with CHD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02222-z.

Healthcare Warranty Policies Optimization for Chronic Diseases Based on Delay Time Concept

Warranties for healthcare can be greatly beneficial for cost reductions and improvements in patient satisfaction. Under healthcare warranties, healthcare providers receive a lump sum payment for the entire care episode, which covers a bundle of healthcare services, including treatment decisions during initial hospitalization and subsequent readmissions, as well as disease-monitoring plans composed of periodic follow-ups. Higher treatment intensities and more radical monitoring strategies result in higher medical costs, but high treatment intensities reduce the baseline readmission rates. This study intends to provide a systematic optimization framework for healthcare warranty policies. In this paper, the proposed model allows healthcare providers to determine the optimal combination of treatment decisions and disease-monitoring policies to minimize the total expected healthcare warranty cost over the prespecified period. Given the nature of the disease progression, we introduced a delay time model to simulate the progression of chronic diseases. Based on this, we formulated an accumulated age model to measure the effect of follow-up on the patient's readmission risk. By means of the proposed model, the optimal treatment intensity and the monitoring policy can be derived. A case study of pediatric type 1 diabetes mellitus is presented to illustrate the applicability of the proposed model. The findings could form the basis of developing effective healthcare warranty policies for patients with chronic diseases.

Changes to Hospital Inpatient Volume After Newspaper Reporting of Medical Errors

OBJECTIVE

The aim of this study was to investigate the influence of medical error case reporting by national newspapers on inpatient volume at acute care hospitals.

DESIGN

A case-control study was conducted using the article databases of 3 major Japanese newspapers with nationwide circulation between fiscal years 2012 and 2013. Data on inpatient volume at acute care hospitals were obtained from a Japanese government survey between fiscal years 2011 and 2014. Panel data were constructed and analyzed using a difference-in-differences design.

SETTING

Acute care hospitals in Japan.

PARTICIPANTS

Hospitals named in articles that included the terms "medical error" and "hospital" were designated case hospitals, which were matched with control hospitals using corresponding locations, nurse-to-patient ratios, and bed numbers.

EXPOSURE

Medical error case reporting in newspapers.

MAIN OUTCOME MEASURES

Changes to hospital inpatient volume after error reports.

RESULTS

The sample comprised 40 case hospitals and 40 control hospitals. Difference-in-differences analyses indicated that newspaper reporting of medical errors was not significantly associated (P = 0.122) with overall inpatient volume.

CONCLUSIONS

Medical error case reporting by newspapers showed no influence on inpatient volume. Hospitals therefore have little incentive to respond adequately and proactively to medical errors. There may be a need for government intervention to improve the posterror response and encourage better health care safety.

Detecting Undifferentiation of Tertiary and County Hospitals in China in Adoption of DRG Instrument

(1) Background: Undifferentiated function for medical institutes in different levels had been a barrier to China’s healthcare reform. Thus, this study aimed to detect medical services that were capable offered both in tertiary and county hospitals in China and discuss the process of detection. (2) Method: Data of 2 tertiary hospitals that were city level and 12 county-level hospitals from one city in China were collected and grouped into diagnosis-related groups (DRGs). A strategy with four steps was devised by considering the aspects of service volume, in-hospital mortality rate, in-hospital adverse events rate, and inpatient cost. Additionally, a comparison of each indicator was made between city- versus county-level hospitals. (3) Results: There were no differences in service quality between the two levels of hospitals while county hospitals had lower average inpatient costs in 129 DRGs that covered 39.5% of all cases. About CNY 0.26 billion would be saved if certain cases were paid at county-level prices. (4) Conclusion: The study proposed a strategy with four steps that could help in locating the range of diseases in which patients’ admission suffered from the problem of undifferentiation between hospitals’ functions to reduce the irrational growth of healthcare expenditure.

Impacts of Diagnosis-Related Groups Payment on the Healthcare Providers' Behavior in China: A Cross-Sectional Study Among Physicians

Purpose

Currently, China is piloting diagnosis-related groups (DRG) payment system in 30 cities. The main aim of this study was to explore the respondents' impressions regarding the hospitals' policies and physicians' behavior change brought by the DRG payment system, and investigate whether and how the hospitals' policies affect the physicians' behavior.

Methods

We distributed questionnaires designed for this study to 200 physicians. Data analysis consisted of descriptive statistics, T-test, and network analysis.

Results

Respondents stated that the hospitals had adopted several policies in response to DRG payment and DRG payment could reduce overtreatment and improve efficiency. However, it also led to several negative effects including an increased explanation to the patients, hindering new technologies, case splitting, and cherry picking. In addition, there was no evidence that harmful effects such as refusing patients and premature discharge existed. Overall, the benefits outweighed the drawbacks of DRG. Moreover, the hospitals' policies could effectively change physician behaviors. Our results indicated that promoting the implementation of clinical pathways had the most positive impact, while limiting costs and length of stay is not recommended.

Conclusion

In general, Chinese physicians who participated in the questionnaire possessed relatively positive attitudes towards the DRG payment system. Nevertheless, some of the negative impacts cannot be ignored. Meanwhile, the hospitals' policies should be implemented with adequate consideration of the impact on physicians' behavior.

Analytical methods to assess the impacts of activity-based funding (ABF): a scoping review

BACKGROUND

Activity-Based Funding (ABF) has been implemented across many countries as a means to incentivise efficient hospital care delivery and resource use. Previous reviews have assessed the impact of ABF implementation on a range of outcomes across health systems. However, no comprehensive review of the methods used to generate this evidence has been undertaken. The aim of this review is to identify and assess the analytical methods employed in research on ABF hospital performance outcomes.

METHODS

We conducted a scoping review in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Five academic databases and reference lists of included studies were used to identify studies assessing the impact of ABF on hospital performance outcomes. Peer-reviewed quantitative studies published between 2000 and 2019 considering ABF implementation outside the U.S. were included. Qualitative studies, policy discussions and commentaries were excluded. Abstracts and full text studies were double screened to ensure consistency. All analytical approaches and their relative strengths and weaknesses were charted and summarised.

RESULTS

We identified 19 studies that assessed hospital performance outcomes from introduction of ABF in England, Korea, Norway, Portugal, Israel, the Netherlands, Canada, Italy, Japan, Belgium, China, and Austria. Quasi-experimental methods were used across most reviewed studies. The most commonly used assessment methods were different forms of interrupted time series analyses. Few studies used difference-in-differences or similar methods to compare outcome changes over time relative to comparator groups. The main hospital performance outcome measures examined were case numbers, length of stay, mortality and readmission.

CONCLUSIONS

Non-experimental study designs continue to be the most widely used method in the assessment of ABF impacts. Quasi-experimental approaches examining the impact of ABF implementation on outcomes relative to comparator groups not subject to the reform should be applied where possible to facilitate identification of effects. These approaches provide a more robust evidence-base for informing future financing reform and policy.

Current trend in treatment of glioblastoma in Japan: a national survey using the diagnostic procedure combination database (J-ASPECT study-glioblastoma)

Background

In the treatment for glioblastoma (GBM), treatment modalities, such as bevacizumab (BEV) and carmustine wafers implants have been approved in Japan since 2013. However, it is unclear whether such a trend in treatment complexity can accelerate treatment centralization. The aim of this study was to reveal the current trend in the treatment of GBM in Japan.

Methods

We used diagnostic procedure combination (DPC) database to analyze the data of 1,774 patients from 305 institutions between April 2016 and March 2019. To analyze the situations associated with first-line BEV use during concurrent TMZ (temozolomide)-radiotherapy, we compared TMZ alone and TMZ–BEV groups.

Results

Of the 1,774 patients with GBM, tumor removal by craniotomy was performed in 1,572 (88.6%) patients, and stereotactic biopsy was performed in 156 (8.8%) patients. A total of 1,229 (69.3%) patients underwent radiotherapy, and 1,287 (72.5%) patients underwent chemotherapy. TMZ alone was administered to 878 (68.2%) and TMZ combined with BEV in 381 (29.6%) patients. In the TMZ–BEV group, as compared to the TMZ-alone group, the rate of discharge to home was significantly lower (P = 0.0044), and the rate of stereotactic biopsy was significantly higher (P < 0.0001). No significant difference was observed in the distribution of patients between the TMZ alone and TMZ–BEV groups depending on the scale of institution (P = 0.1240).

Conclusion

First-line BEV administration seems to be selected properly regardless of the institutional scale. This Japan-wide study of GBM treatment revealed that high level and newly introduced treatments have been steadily generalized in Japanese institutions.

Short-Term Associations of Ambient Fine Particulate Matter (PM2.5) with All-Cause Hospital Admissions and Total Charges in 12 Japanese Cities

The short-term association between ambient particulate matter ≤2.5 microns in diameter (PM_2.5) and hospital admissions is not fully understood. Studies of this association with hospital admission costs are also scarce, especially in entire hospitalized populations. We examined the association between ambient PM_2.5 and all-cause hospital admissions, the corresponding total charges, and the total charges per patient by analyzing the hospital admission data of 2 years from 628 hospitals in 12 cities in Japan. We used generalized additive models with quasi-Poisson regression for hospital admissions and generalized additive models with log-linear regression for total charges and total charges per patient. We first estimated city-specific results and the combined results by random-effect models. A total of 2,017,750 hospital admissions were identified. A 10 µg/m³ increase in the 2 day moving average was associated with a 0.56% (95% CI: 0.14–0.99%) increase in all-cause hospital admissions and a 1.17% (95% CI: 0.44–1.90%) increase in total charges, and a 10 µg/m³ increase in the prior 2 days was associated with a 0.75% (95% CI: 0.34–1.16%) increase in total charges per patient. Short-term exposure to ambient PM_2.5 was associated with increased all-cause hospital admissions, total charges, and total charges per patient.

Hospitalization of mild cases of community-acquired pneumonia decreased more than severe cases during the COVID-19 pandemic

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has affected all healthcare systems. This study aimed to assess the impact of the COVID-19 pandemic on the number and severity of cases of community-acquired pneumonia (CAP) in Japan.

METHODS

Using claims data from the Quality Indicator/Improvement Project (QIP) database, urgent cases of inpatients for CAP from 01 August 2018 to 30 July 2020 were included. The monthly ratios of inpatient cases were compared from August 2018 to July 2019 and August 2019 to July 2020 as a year-over-year comparison. These ratios were also compared according to the "A-DROP" severity score, and an interrupted time series (ITS) analysis was performed to evaluate the impact of the COVID-19 pandemic on the monthly number of inpatient cases.

RESULTS

This study included a total of 67,900 inpatient cases for CAP in 262 hospitals. During the COVID-19 pandemic (defined as the period between March and July 2020) the number of inpatient cases for CAP drastically decreased compared with the same period in the previous year (-48.1%), despite a temporary reduction in the number of other urgent admissions. The number of inpatient cases decreased according to the severity of pneumonia. Milder cases showed a greater decrease in the year-over-year ratio than severe ones: mild -55.2%, moderate -45.8%, severe -39.4%, and extremely severe -33.2%. The ITS analysis showed that the COVID-19 pandemic significantly reduced the monthly number of inpatient cases for CAP (estimated decrease: -1233 cases; 95% CI -521 to -1955).

CONCLUSIONS

This study showed a significant reduction in the number of inpatient cases for CAP during the COVID-19 pandemic in Japan. The milder cases showed a greater decrease in the year-over-year ratio of the number of inpatient cases.

The best of both worlds? The economic effects of a hybrid fee-for-service and prospective payment reimbursement system

Countries seeking to move away from a purely fee-for-service (FFS) system may consider a hybrid approach whereby only some procedures are paid by FFS while others are paid prospectively. Yet little evidence exists whether such a hybrid payment system contains overall costs without adverse influences on health outcomes. In 2003, Japan experienced a reform from FFS to a hybrid payment system in which only some inpatient procedures were paid prospectively. We exploit this reform to test how such a hybrid system affects overall costs and health outcomes. Briefly, we find that healthcare providers responded opportunistically to the reform, moving some procedures out of the bundled inpatient setting to FFS services, leading to no reduction in cost. There was some evidence of a moderate deterioration in health outcomes, in terms of a decline in the probability of symptoms being cured at discharge. In sum, our results suggest that in some cases, a hybrid payment system can be non-superior to either FFS or prospective payment system.

Changes in the Penetration Rate of Biosimilar Infliximab Within Japan Using a Japanese Claims Database

Purpose

Infliximab, which was approved in 2002, had its first biosimilar launched in 2014 across Japan. However, the penetration rate of this biosimilar remains unclear given the limited data regarding its current clinical use throughout Japan. This study was conducted to describe the current clinical characteristics of patients receiving infliximab and the penetration rate of the reference infliximab and/or biosimilar infliximab using a Japanese administrative claims database.

Patients and Methods

This retrospective, descriptive study utilized the Japan Medical Data Vision database, a nationwide hospital-based database. Data on patients receiving infliximab recorded from April 2008 to March 2019 were extracted from the database. Patient characteristics of the reference and biosimilar infliximab groups and penetration rates according to fiscal year, target diseases diagnosis, and subsidy for intractable diseases were examined.

Results

A total of 9735 patients were extracted for analysis, among whom 92% (n=8950) and 8% (n=785) received only reference infliximab and its biosimilar, respectively. Both groups exhibited similar clinical characteristics. The biosimilar penetration rate increased from 0.8% in 2014 to 22.5% in 2018, with overall penetration rates throughout the period according to diagnosis (with or without subsidy) being 14.4% (with, 4.1%; without, 16.4%), 4.7% (with, 3.7%; without, 10.6%), 5.7% (with, 4.5%; without, 13.5%), and 7.5% (with, 4.4%; without, 8.2%) for rheumatoid arthritis, Crohn’s disease, ulcerative colitis, and psoriasis, respectively.

Conclusion

Biosimilar infliximab is prescribed for patients with similar characteristics to reference infliximab. Despite the increasing penetration rates according to target disease, they remain much lower among patients receiving subsidy for intractable disease than among those who do not.

Early impact of school closure and social distancing for COVID-19 on the number of inpatients with childhood non-COVID-19 acute infections in Japan

Many countries have implemented school closures as part of social distancing measures intended to control the spread of coronavirus disease 2019 (COVID-19). The aim of this study was to assess the early impact of nationwide school closure (March-May 2020) and social distancing for COVID-19 on the number of inpatients with major childhood infectious diseases in Japan. Using data from the Diagnosis Procedure Combination system in Japan, we identified patients aged 15 years or younger with admissions for a diagnosis of upper respiratory tract infection (URTI), lower respiratory tract infection (LRTI), influenza, gastrointestinal infection (GII), appendicitis, urinary tract infection (UTI), or skin and soft tissue infection (SSTI) between July 2018 and June 2020. Changes in the trend of the weekly number of inpatients between the two periods were assessed using interrupted time-series analysis. A total of 75,053 patients in 210 hospitals were included. The overall weekly number of inpatients was decreased by 52.5%, 77.4%, and by 83.4% in the last week of March, April, and May 2020, respectively, when compared on a year-on-year basis. The estimated impact was a reduction of 581 (standard error 42.9) inpatients per week in the post-school-closure period (p < 0.001). The main part of the reduction was for pre-school children. Remarkable decreases in the number of inpatients with URI, LRTI, and GII were observed, while there were relatively mild changes in the other groups.Conclusion: We confirmed a marked reduction in the number of inpatients with childhood non-COVID-19 acute infections in the post-school-closure period. What is Known: • Most countries have implemented social distancing measures to limit the spread of the novel coronavirus disease 2019 (COVID-19). • A large decrease in pediatric emergency visits has been reported from several countries after the social distancing. What is New: • Based on administrative claims data, a marked reduction in the number of inpatients for childhood non-COVID-19 acute infections was found in the post-school-closure period in Japan. • The magnitude of the reduction was different between the disease groups.

Update on Chemotherapeutic Approaches and Management of Bevacizumab Usage for Glioblastoma

Glioblastoma, the most common primary brain tumor in adults, has one of the most dismal prognoses in cancer. In 2009, bevacizumab was approved for recurrent glioblastoma in the USA. To evaluate the clinical impact of bevacizumab as a first-line drug for glioblastoma, two randomized clinical trials, AVAglio and RTOG 0825, were performed. Bevacizumab was found to improve progression-free survival (PFS) and was reported to be beneficial for maintaining patient performance status as an initial treatment. These outcomes led to bevacizumab approval in Japan in 2013 as an insurance-covered first-line drug for glioblastoma concurrently with its second-line application. However, prolongation of overall survival was not evinced in these clinical trials; hence, the clinical benefit of bevacizumab for newly diagnosed glioblastomas remains controversial. A recent meta-analysis of randomized controlled trials of bevacizumab combined with temozolomide in recurrent glioblastoma also showed an effect only on PFS, and the benefit of bevacizumab even for recurrent glioblastoma is controversial. Here, we discuss the clinical impact of bevacizumab for glioblastoma treatment by reviewing previous clinical trials and real-world evidence by focusing on Japanese experiences. Moreover, the efficacy and safety of bevacizumab are summarized, and we provide suggestions for updating the approaches and management of bevacizumab.

Characteristics and related factors of emergency department visits, readmission, and hospital transfers of inpatients under a DRG-based payment system: A nationwide cohort study

Objectives

Taiwan has implemented the Diagnosis Related Groups (DRGs) since 2010, and the quality of care under the DRG-Based Payment System is concerned. This study aimed to examine the characteristics, related factors, and time distribution of emergency department (ED) visits, readmission, and hospital transfers of inpatients under the DRG-Based Payment System for each Major Diagnostic Category (MDC).

Methods

We conducted a retrospective cohort study using data from the National Health Insurance Research Database (NHIRD) from 2012 to 2013 in Taiwan. Multilevel logistic regression analysis was used to examine the factors related to ED visits, readmissions, and hospital transfers of patients under the DRG-Based Payment System.

Results

In this study, 103,779 inpatients were under the DRG-Based Payment System. Among these inpatients, 4.66% visited the ED within 14 days after their discharge. The factors associated with the increased risk of ED visits within 14 days included age, lower monthly salary, urbanization of residence area, comorbidity index, MDCs, and hospital ownership (p < 0.05). In terms of MDCs, Diseases and Disorders of the Kidney and Urinary Tract (MDC11) conferred the highest risk of ED visits within 14 days (OR = 4.95, 95% CI: 2.69–9.10). Of the inpatients, 6.97% were readmitted within 30 days. The factors associated with the increased risk of readmission included gender, age, lower monthly salary, comorbidity index, MDCs, and hospital ownership (p < 0.05). In terms of MDCs, the inpatients with Pregnancy, Childbirth and the Puerperium (MDC14) had the highest risk of readmission within 30 days (OR = 20.43, 95% CI: 13.32–31.34). Among the inpatients readmitted within 30 days, 75.05% of them were readmitted within 14 days. Only 0.16% of the inpatients were transferred to other hospitals.

Conclusion

The study shows a significant correlation between Major Diagnostic Categories in surgery and ED visits, readmission, and hospital transfers. The results suggested that the main reasons for the high risk may need further investigation for MDCs in ED visits, readmissions, and hospital transfers.

Factors affecting the use of clinical practice guidelines by hospital physicians: the interplay of IT infrastructure and physician attitudes

Background

Compliance with clinical practice guidelines (CPGs) remains insufficient around the world, despite frequent updates and continuing efforts to disseminate and implement these guidelines through a variety of strategies. We describe the current status of young resident physician practices towards CPGs and investigate the multiple factors associated with the active use of CPGs, including the physician’s knowledge, attitudes, behaviours, CPG-related education received, and the hospital’s IT infrastructures. The aim is to identify a more effective point for intervention to promote CPG implementation.

Methods

We conducted a questionnaire survey among resident physicians working at 111 hospitals across Japan in 2015 and used results with hospital IT score data collected from a prior survey. Multivariable logistic regression analysis was performed to examine the determinants of frequent use of CPGs (defined at least once per week). The independent variables were selected based on physician demographics, clinical speciality and careers, daily knowledge and behaviour items, CPG-related education received, digital preference, and hospital IT score (high/medium/low), with and without interaction terms.

Results

Responses from 535 resident physicians, at 61 hospitals, were analysed. The median hospital IT score was 6 out of a possible 10 points. Physicians who had learned about CPGs tended to work at hospitals with medium to high IT scores, had easier access to paywalled medical databases, and had better knowledge of the guideline network ‘Minds’. In addition, these physicians tended to use CPGs electronically. A physician’s behaviour towards using CPGs for therapeutic decision-making was strongly associated with frequent use of CPGs (odds ratio [95% CI] 6.1 [3.6–10.4]), which indicated that a physician’s habit strongly promotes CPG use. Moreover, CPG-related education was associated with active use of CPGs (OR1.7 [1.1–2.5]). The interaction effects between individual digital preferences and higher hospital IT score were also observed for frequent CPG use (OR2.9 [0.9–8.8]).

Conclusions

A physician’s habitual behaviours, CPG-related education, and a combination of individual digital preference and superior hospital IT infrastructure are key to bridging the gap between the use and implementation of CPGs.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s13012-020-01056-1.

History and Profile of Diagnosis Procedure Combination (DPC): Development of a Real Data Collection System for Acute Inpatient Care in Japan

DPC, which is an acronym for “Diagnosis Procedure Combination,” is a patient classification method developed in Japan for inpatients in the acute phase of illness. It was developed as a measuring tool intended to make acute inpatient care transparent, aiming at standardization of Japanese medical care, as well as evaluation and improvement of its quality. Subsequently, this classification method came to be used in the Japanese medical service reimbursement system for acute inpatient care and appropriate allocation of medical resources. Furthermore, it has recently contributed to the development and maintenance of an appropriate medical care provision system at a regional level, which is accomplished based on DPC data used for patient classification. In this paper, we first provide an overview of DPC. Next, we will look back at over 15 years of DPC history; in particular, we will explore how DPC has been refined to become an appropriate medical service reimbursement system. Finally, we will introduce an outline of DPC-related research, starting with research using DPC data.

Prediction model for prolonged length of stay in patients with community-acquired pneumonia based on Japanese administrative data

BACKGROUND

The length of hospital stay in community-acquired pneumonia patients is closely associated with medical costs, the burden of which is increasing in aging societies. Herein, we developed and validated models for predicting prolonged length of stay in community-acquired pneumonia patients to support efficient care in these patients.

METHODS

We obtained data of 32,916 patients hospitalized for pneumonia who were discharged between 2012 and 2013 from 304 acute care hospitals in Japan. Logistic regression models were developed with prolonged length of stay as the outcome and patient characteristics as predictors. The models were internally validated using bootstrapping and externally validated using pneumonia patients discharged in 2014.

RESULTS

The median length of stay was 11 (interquartile range, 8-17) days. The following were significant predictors of prolonged length of stay (odds ratio >1.6): age ≥75 years, Barthel index score ≤6, fraction of inspired oxygen ≥35%, Japan Coma Scale score of 100-300, anemia, muscle wasting and atrophy, bedsores, dysphasia, and methicillin-resistant Staphylococcus aureus infection. Our validation models had a c-statistic of 0.78 (95% confidence interval, 0.77-0.79) and a calibration slope of 0.98.

CONCLUSIONS

Our prediction models may help policymakers in developing strategies for the optimal management of community-acquired pneumonia patients with a focus on patients at a high risk of prolonged length of stay.

Current status of the management and outcomes of acute aortic dissection in Japan: Analyses of nationwide Japanese Registry of All Cardiac and Vascular Diseases-Diagnostic Procedure Combination data

Background:

Despite recent advances in the diagnosis and management, the mortality of acute aortic dissection remains high. This study aims to clarify the current status of the management and outcome of acute aortic dissection in Japan.

Methods:

A total of 18,348 patients with acute aortic dissection (type A: 10,131, type B: 8217) in the Japanese Registry of All Cardiac and Vascular Diseases database between April 2012–March 2015 were studied. Characteristics, clinical presentation, management, and in-hospital outcomes were analyzed.

Results:

Seasonal onset variation (autumn- and winter-dominant) was found in both types. More than 90% of patients underwent computed tomography for primary diagnosis. The overall in-hospital mortality of types A and B was 24.3% and 4.5%, respectively. The mortality in type A patients managed surgically was significantly lower than in those not receiving surgery (11.8% (799/6788) vs 49.7% (1663/3343); p&lt;0.001). The number of cases managed endovascularly in type B increased 2.2-fold during the period, and although not statistically significant, the mortality gradually decreased (5.2% to 4.1%, p=0.49). Type A showed significantly longer length of hospitalization (median 28 days) and more than five times higher medical costs (6.26 million Japanese yen) than those in type B. The mean Barthel index at discharge was favorable in both type A (89.0±22.6) and type B (92.6±19.0). More than two-thirds of type A patients and nearly 90% of type B patients were directly discharged home.

Conclusions:

This nationwide study elucidated the clinical features and outcomes in contemporary patients with acute aortic dissections in real-world clinical practice in Japan.

Effect of adjuvant chemotherapy on survival benefit in stage III colon cancer patients stratified by age: a Japanese real-world cohort study

Background

Adjuvant chemotherapy is relatively underused in older patients with colon cancer in Japan, and its age-specific effects on clinical outcomes remain unclear. This study aimed to assess the effect of adjuvant chemotherapy on survival benefit in stage III colon cancer patients stratified by age in a Japanese real-world setting.

Methods

In this multi-center retrospective cohort study, we analyzed patient-level information through a record linkage of population-based cancer registry data and administrative claims data. The study population comprised patients aged ≥18 years who received a pathological diagnosis of stage III colon cancer and underwent curative resection between 2010 and 2014 at 36 cancer care hospitals in Osaka Prefecture, Japan. Patients were divided into two groups based on age at diagnosis (< 75 and ≥ 75 years). The effect of adjuvant chemotherapy was analyzed using Cox proportional hazards regression models for all-cause mortality with inverse probability weighting of propensity scores. Adjusted hazard ratios were estimated for both age groups.

Results

A total of 783 patients were analyzed; 476 (60.8%) were aged < 75 years and 307 (39.2%) were aged ≥75 years. The proportion of older patients who received adjuvant chemotherapy (36.8%) was substantially lower than that of younger patients (73.3%). In addition, the effect of adjuvant chemotherapy was different between the age groups: the adjusted hazard ratio was 0.56 (95% confidence interval: 0.33–0.94, P = 0.027) in younger patients and 1.07 (0.66–1.74, P = 0.78) in older patients.

Conclusions

The clinical effectiveness of adjuvant chemotherapy in older patients with stage III colon cancer appears limited under current utilization practices.

Validation of the instrument "Complexity of Nursing Care"-A mixed-methods study

Aims

This study aimed to psychometrically test the instrument "Complexity of Nursing Care" and to broaden the understanding of the instrument's psychometrics and applicability.

Design

Embedded mixed-methods design.

Methods

We performed a cross-sectional study assessing all stationary patients of five Swiss hospitals daily for up to 5 days with the instrument "Complexity of Nursing Care" over a 1-month period in 2015. The scale's psychometrics were analysed using partial least square structural equation modelling. In the qualitative study section, we completed 12 case studies and analysed them case-wise and across cases. Quantitative and qualitative results were synthesized in tables.

Results

Structural equation modelling confirmed a reflective-formative second-order model of the instrument with good psychometric properties leading to a formula for the calculation of a complexity score. Qualitative results evolved descriptions of low and high extent of complexity. Narrative considerations of two raters deepened the understanding of the inter-rater reliability.

Beijing's diagnosis-related group payment reform pilot: Impact on quality of acute myocardial infarction care

In 2012, China's first diagnosis-related group (DRG) payment system was piloted in Beijing. This study explored whether this payment pilot improved quality and reduced costs of acute myocardial infarction (AMI) care in hospitals implementing DRG payment as compared to control hospitals. A difference-in-difference study design was used with regression and considered several quality indicators including aspirin at arrival, aspirin at discharge, β-blocker at arrival, β-blocker at discharge, statin at discharge, in-hospital mortality, and 30-day readmission rates. DRG payment mechanisms without specific mechanisms to promote care quality did not improve quality of AMI care. Future studies should study the impact of cost control mechanisms together with quality improvement efforts to assess how quality of care may be improved within the Chinese healthcare system. These lessons would be helpful to share with lower-middle-income countries undergoing rapid development that are transitioning to a significantly higher burden of non-communicable diseases.

Does hospital information technology infrastructure promote the implementation of clinical practice guidelines? A multicentre observational study of Japanese hospitals

OBJECTIVES

It remains unclear whether insufficient information technology (IT) infrastructure in hospitals hinders implementation of clinical practice guidelines (CPGs) and affects healthcare quality. The objectives of this study were to describe the present state of IT infrastructure provided in acute care hospitals across Japan and to investigate its association with healthcare quality.

METHODS

A questionnaire survey of hospital administrators was conducted in 2015 to gather information on hospital-level policies and elements of IT infrastructure. The number of positive responses by each respondent to the survey items was tallied. Next, a composite quality indicator (QI) score of hospital adherence to CPGs for perioperative antibiotic prophylaxis was calculated using administrative claims data. Based on this QI score, we performed a chi-squared automatic interaction detection (CHAID) analysis to identify correlates of hospital healthcare quality. The independent variables included hospital size and teaching status in addition to hospital policies and elements of IT infrastructure.

RESULTS

Wide variations were observed in the availability of various IT infrastructure elements across hospitals, especially in local area network availability and access to paid evidence databases. The CHAID analysis showed that hospitals with a high level of access to paid databases (p<0.05) and internet (p<0.05) were strongly associated with increased care quality in larger or teaching hospitals.

CONCLUSIONS

Hospitals with superior IT infrastructure may provide higher-quality care. This allows clinicians to easily access the latest information on evidence-based medicine and facilitate the dissemination of CPGs. The systematic improvement of hospital IT infrastructure may promote CPG use and narrow the evidence-practice gaps.

Large hospital variation in the utilization of Post-procedural CT to detect pulmonary embolism/Deep Vein Thrombosis in Patients Undergoing Total Knee or Hip Replacement Surgery: Japanese Nationwide Diagnosis Procedure Combination Database Study

OBJECTIVE

The purpose of the study was to investigate variation in the use of in-hospital CT for venous thromboembolism (VTE) detection after total knee or hip replacement (TKR/THR) among surgical patients, using a nationwide Japanese in-hospital administrative database.

METHODS

This retrospective study using a national administrative database (4/2012-3/2013) extracted patients who underwent TKR/THR surgeries at hospitals meeting the annual case-volume threshold of ≥ 30. Hospitals were categorized into three equally sized groups by frequency of postoperative CT use (low, middle, and high CT use group) to compare baseline patient-level and hospital-level characteristics. To further investigate between-hospital variation in CT usage, we fitted a hierarchical logistic regression model including hospital-specific random intercepts and fixed patient- and hospital-level effects. The intra class correlation coefficient was used to measure the amount of variability in CT use attributable to between-hospital variation.

RESULTS

A total of 39,127 patients discharged from 447 hospitals met the inclusion criteria. The median hospital stay was 25 days (interquartile range, 20 - 32) and 7,599 (19.4%) patients underwent CT for VTE. CT utilization varied greatly among the hospitals; the crude frequency ranged from 0 to 100 % (median, 7.3 %; interquartile range, 1.8 - 18.3 %). After adjustment for known hospital- and patient-level factors related to CT use, 47 % of the variation in CT use remained attributable to the behavior of individual hospitals.

CONCLUSION

We observed large inter hospital variability in the utilization of post-procedure CT for VTE detection in this Japanese TKR/THR cohort, suggesting that CT utilization is not optimized across the nation.

ADVANCES IN KNOWLEDGE

We observed significant variability in the utilization of post-procedure CT for VTE detection among inpatients who underwent TKR/THR surgeries in a large sample of Japanese hospitals. The large variation suggests that CT utilization is not optimized across the nation, and that there may be potential overutilization of the technology in the highest CT use hospitals.

Hospitalization period and direct medical cost in patients using warfarin or novel oral anti-coagulants after a cerebral embolism

Background Warfarin has been used in Japan for a long time in patients after cerebral embolism to prevent recurrence. Recently, several novel oral anti-coagulants (NOACs) have been approved for use and are gradually replacing warfarin. However, it remains unclear whether warfarin and other NOACs differ from each other with respect to drug costs and length of stay (LOS) during treatment in Japan. Objective To assess differences in LOS and direct medical cost between patients after cerebral embolism treated with warfarin and those treated with NOACs. Setting Thirteen acute care hospitals in Japan. Method For hospitalized patients with cerebral embolisms who were treated with NOACs and/or warfarin between April 2012 and March 2014, we assessed LOS for patients with warfarin and NOAC using log-rank test, and stratified proportional hazard regression. Also, we assess direct medical cost using paired-t test. Main Outcome measure LOS and medical cost after first treatment with warfarin and NOAC. Results The median LOS for NOACs-treated patients was 12.5 days and that for warfarin treated patients was 19.0 days while the corresponding mean medical costs were USD 7151 ± 6228 [JPY 736,546 ± 641,437] and USD 8950 ± 5891 [JPY 921,830 ± 606,765]. The drug cost for NOACs-treated patients was higher but costs for laboratory-test and hospitalization were lower than those for warfarin-treated patients. Conclusions For NOAC-treated patients, LOS was shorter, and medical cost during hospitalization tended to be lower than those for warfarin-treated patients, whereas NOACs prices were higher than warfarin price.