Factors associated with prolonged length of hospital stay of elderly patients in acute care hospitals in Japan: A multilevel analysis of patients with femoral neck fracture

Real-world clinical and economic impacts of delayed rotator cuff repair surgery in Japan: analysis of a large claims database

Background

In patients with rotator cuff tears (RCTs), there is a lack of evidence regarding the impact of the timeliness of rotator cuff repair (RCR) surgery on treatment outcomes and overall healthcare burden. This study aimed to understand the impact of early vs. delayed RCR on real-world healthcare costs and resource use (HCRU) in Japan.

Methods

This study utilized JMDC health insurance claims data from January 2012 to February 2021. Patients aged ≥18 years were included if they had ≥1 inpatient or ≥2 nondiagnostic outpatient claims (≥1 month apart) for RCT (diagnosis codes S460/S468), had RCR (procedure codes K080-X) within 12 months postindex, and had 12 months post-RCR continuous enrollment. Index month was defined upon the first RCT claim, and surgery month was defined upon the first RCR. Patients were categorized as having had early (≤1 month postindex) or delayed (2-12 months postindex) RCR. RCT-related HCRU were reported for the 12-month postindex or postsurgery periods.

Results

Of 1243 RCR patients, 68.9% were male and the mean (standard deviation [SD]) age was 55.3 (8.9) years. Of 46.3% patients with an initial diagnosis of tendinosis, their RCT was diagnosed for only a mean (SD) of 5.7 (4.0) months later. The mean (SD) time from index to first RCR was 2.4 (2.3) months; 518 (41.7%) patients had early RCR. The mean total RCT-related healthcare costs were higher for patients with delayed vs. early RCR (P < .05 for both postindex and surgery). The mean (SD) postsurgery inpatient costs were higher for delayed vs. early RCR (¥1,260,066 vs. ¥1,119,381; P < .05), possibly partly driven by longer hospital stays among delayed RCR patients. Patients with delayed RCR had a higher mean number of physical therapy visits compared with early RCR, especially postsurgery (42.6 vs. 38.4; P < .05); physical therapy costs were significantly higher for delayed RCR patients, compared with early RCR, for both postindex or postsurgery periods (P < .05). During the postindex period, higher proportions of delayed vs. early RCR patients received opioids (22.1% vs. 16.2%; P < .05), nonopioid pain medications (77.7% vs. 69.5%; P < .05), cortisone injections (47.2% vs. 33.8%; P < .05), and oral cortisone (4.8% vs. 1.4%; P < .05). The mean outpatient pharmacy prescription costs were significantly higher for delayed vs. early RCR for both the postindex and postsurgery periods (both P < .05).

Conclusions

Long delays in the diagnosis or treatment of RCT in Japan may lead to higher burdens of healthcare. Patients with delayed RCR may require more prescription medications and/or PT before and after surgery. Improving the timeliness of RCT treatment could therefore reduce overall HCRU.

Effect of Combining Operating Room Nursing Based on Clinical Quantitative Assessment with WeChat Health Education on Postoperative Complications and Quality of Life of Femoral Fracture Patients Undergoing Internal Fixation

Objective

To explore the effect of combining operating room nursing based on clinical quantitative assessment with WeChat health education on postoperative complications and quality of life (QOL) of femoral fracture patients undergoing internal fixation.

Methods

Ninety femoral fracture patients treated in our hospital (July 2018 to July 2021) were chosen as the research objects and split into the control group (routine intervention) and the study group (combination of operating room nursing based on clinical quantitative assessment and WeChat health education) according to the nursing intervention modes, with 45 cases each. After nursing, the postoperative complications and QOL of patients were compared between the two groups.

Results

No statistical between-group differences in general data were observed (P > 0.05); the hospital stay, weight-bearing time, and fracture healing time were obviously shorter in the study group than in the control group (P < 0.05); 1 d after surgery, the VAS pain status was not significantly different between the two groups (P > 0.05), and 2 d and 3 d after surgery, the VAS scores were significantly lower in the study group than in the control group (P < 0.05); 1 d after surgery, the Harris scores of patients in the two groups were close and did not present statistical difference (P > 0.05), and 8 weeks after surgery, the Harris score was significantly higher in the study group than in the control group (P < 0.05); the scores on self-care agency such as self-concept, self-care skills, sense of self-care responsibility, and health knowledge level were significantly higher in the study group than in the control group (P < 0.05); compared with the control group, the probability of occurring incision infection, lung infection, pressure sore, swelling and pain, and other complications was significantly lower in the study group (P < 0.05).

Conclusion

Implementing operating room nursing based on clinical quantitative assessment combined with WeChat health education to femoral fracture patients undergoing internal fixation can effectively improve their postoperative clinical indicators, reduce their postoperative pain sensation and complication incidence, and effectively promote the joint motion range, which is conducive to enhancing their self-care agency and QOL.

Further Validation of a Novel Acute Myocardial Infarction Risk Stratification (nARS) System for Patients with Acute Myocardial Infarction

Recently, we developed a novel acute myocardial infarction (AMI) risk stratification system (nARS), which stratifies AMI patients into low- (L), intermediate- (I), and high- (H) risk groups. We have shown that the nARS shortened the length of intensive care unit (ICU) stay as well as that of hospitalization. However, the incidence of AMI-related adverse outcomes has not been fully investigated. The purpose of this study was to investigate the incidence of severe complications requiring ICU care among the 3 risk groups stratified by nARS. We retrospectively reviewed AMI patients between October 2016 and December 2018. A total of 592 patients were divided into the L- (n = 285), I- (n = 124), and H- (n = 183) risk groups. The primary endpoint was in-hospital complications requiring ICU care defined as death/cardiopulmonary arrest, shock, stroke, atrioventricular block, and respiratory failure. Among 592 patients, 239 (40.4%) developed at least 1 complication requiring ICU care, but only 28 (11.7%) developed complications in general wards. Complications requiring ICU care were most frequently observed in the H-risk group (68.9%), followed by the I-risk group (50.8%), and least in the L-risk group (17.5%) (P < 0.001). Complications requiring ICU care that occurred in the general wards were more frequently observed in the H-risk group (8.7%) compared to the I-risk (3.2%) and L-risk (2.8%) groups (P = 0.009). In conclusion, complications requiring ICU care rarely happened in the general wards, and were less in the I- and L-risk groups than in the H-risk group. These results validated the nARS, and might support the widespread use of nARS.

Models and methods for determining the optimal number of beds in hospitals and regions: a systematic scoping review

BACKGROUND

Determining the optimal number of hospital beds is a complex and challenging endeavor and requires models and techniques which are sensitive to the multi-level, uncertain, and dynamic variables involved. This study identifies and characterizes extant models and methods that can be used to determine the required number of beds at hospital and regional levels, comparing their advantages and challenges.

METHODS

A systematic search was conducted using Web of Science, Scopus, Embase and PubMed databases, with the search terms hospital bed capacity, hospital bed need, hospital, bed size, model, and method.

RESULTS

Twenty-three studies met the criteria to be included in the review. Of these studies, a total of 11 models and 5 methods were identified, mainly designed to determine hospital bed capacity at the regional level. Common determinants of the required number of hospital beds in these models included demographic changes, average length of stay, admission rates, and bed occupancy rates.

CONCLUSIONS

There are no specific norms for the required number of beds at hospital and regional levels, but some of the identified models and methods may be used to estimate this number in different contexts. Moreover, it is important to consider alternative approaches to planning hospital capacity like care pathways to fix the limitations of "bed numbers".

Novel Acute Myocardial Infarction Risk Stratification (nARS) System Reduces the Length of Hospitalization for Acute Myocardial Infarction

BACKGROUND

The novel Acute Myocardial Infarction (AMI) Risk Stratification (nARS) system was recently developed based on original criteria. The use of nARS may reduce the length of hospitalization.

METHODS AND RESULTS

We allocated 560 AMI patients into the pre-nARS group (before adopting nARS) or the nARS group. Patients in the nARS group were subdivided into the low (L), intermediate (I), and high (H) risk groups, whereas patients in the pre-nARS group were subdivided into the equivalent L (eL), equivalent I (eI), or equivalent H (eH) risk groups based on the nARS criteria. Length of coronary care unit (CCU) stay was significantly shorter in the nARS group (2.8±3.5 days) compared with the pre-nARS group (4.4±5.4 days; P<0.001). Length of hospital stay was also shorter in the nARS group (9.4±8.9 days) compared with the pre-nARS group (13.4±12.8 days; P<0.001). Length of CCU stay was significantly shorter in the L (1.1±1.0 days), I (2.8±3.5 days), and H (5.0±4.8 days) risk groups compared with corresponding eL (2.2±1.1 days), eI (4.4±5.4 days), and eH (7.1±7.8 days) risk groups.

CONCLUSIONS

Length of CCU and hospital stay were significantly shorter in the nARS group compared with the pre-nARS group. The use of nARS may save medical resources in the treatment of AMI in the regional health-care system.

Payment systems and hospital length of stay: a bunching-based evidence

Despite the huge attention on the long average hospital length of stay (LOS) in Japan, there are limited empirical studies on the impacts of the payment systems on LOS. In order to shed new light on this issue, we focus on the fact that reimbursement for hospital care is linked to the number of patient bed-days, where a "day" is defined as the period from one midnight to the next. This "midnight-to-midnight" definition may incentivize health care providers to manipulate hospital acceptance times in emergency patients, as patients admitted before midnight would have an additional day for reimbursement when compared with those admitted after midnight. We test this hypothesis using administrative data of emergency transportations in Japan from 2008 to 2011 (N = 2,146,498). The results indicate that there is a significant bunching in the number of acceptances at the emergency hospital around midnight; the number heaps a few minutes before midnight, but suddenly drops just after midnight. Given that the occurrence of emergency episode is random and the density is smooth during nighttime, bunching in the number of hospital acceptances around midnight suggests that hospital care providers shift the hospital acceptance times forward by hurrying-up to accept the patients. This manipulation clearly leads to longer LOS by one bed-day. In addition, the manipulation is observed in the prefectures where private hospitals mainly provide emergency medical services, suggesting hospital ownership is associated with the manipulation of hospital acceptance time.

Is There an Influence of Surgeon's Experience on the Clinical Course in Patients With a Proximal Femoral Fracture?

OBJECTIVES

Teaching of surgical procedures is of paramount importance. However, it can affect patients outcome. The aim of this study was to evaluate if teaching of hip fracture surgery is an independent predictor for negative in-hospital outcome.

DESIGN AND SETTING

Retrospectively, we analyzed all hip fracture patients between 2008 and 2013 recorded in a national quality measurement database (AQC). Inclusion criteria were proximal femoral fracture (ICD-10 diagnostic codes S72.00-S72.11), surgical care of those fracture and a documented teaching status of the intervention. Variables were sought in bivariate and multivariate analyses. Teaching status was entered in multiple regression analysis models for in-hospital death, complications and length of stay while controlling for confounders.

PARTICIPANTS

In the 6-year study period, a total of 4397 patients at a mean age of 80 years met the inclusion criteria. Totally, 48% (n = 2107) of the procedures were conducted as teaching interventions. The rest of our examined cases (n = 2290) were conducted as nonteaching procedures.

RESULTS

There was no association between teaching and mortality, but complications (odds ratio = 1.3; 95% CI: 1.04-1.5; p = 0.018) and prolonged hospitalization (standardized beta = 0.045, p = 0.002) were more likely to occur in the teaching group while controlling for confounders.

CONCLUSIONS

There appears to be no effect of the educational status on the in-hospital death in patients with a proximal femoral fracture. However, teaching was an independent predictor of complications and longer length of stay. Although the differences were significant, the clinical outcome was comparable in both groups, thus justifying the benefits of resident teaching.

The relationship between workload and length of stay in Singapore

Prior studies link higher workload with longer length of stay (LOS) in the US. Unlike U.S. hospitals, Singaporean hospitals, like other major hospitals in the Asia-Pacific, are partially occupied by patients with non-acute needs due to insufficient alternative facilities. We examined the association between workload and length of stay (LOS) and the impact of workload on 30-day re-hospitalization and inpatient mortality rates in retrospective cohort in this setting. We defined workload as the daily number of patients per physician team. 13,097 hospitalizations of 10,000 patients were included. We found that higher workload was associated with shorter LOS (coefficient, -0.044 [95%CI, -0.083, -0.01]), especially for patients with longer stays (hazard ratios, not significantly greater than 1 before Day 4, 1.04 [95%CI, 1.01, 1.07] at Day 4 and 1.16 [95%CI, 1.10, 1.24] at Day 10), without affecting inpatient mortality (odds ratio (OR), 1.03 [95%CI, 0.99, 1.05]) or 30-day re-hospitalization (OR, 1.01 [95%CI, 0.99, 1.04]). This result differs from studies in the US and may reflect regional differences in the use of acute hospital beds for non-acute needs.

Factors Predicting Length of Hospital Stay and Extended Care Facility Admission After Hindfoot Arthrodesis Procedures

Delayed identification of patients requiring admission to extended care facilities (ECFs) can lead to greater healthcare costs through an increased length of hospital stay (LOHS). Previous studies of hip and knee arthroplasty identified factors associated with a likely discharge to an ECF. These issues have not been extensively studied for major hindfoot procedures. We conducted a retrospective review of 198 cases treated during a 3-year period to identify the risk factors for an extended LOHS and ECF admission after ankle arthrodesis, triple arthrodesis, pantalar arthrodesis, and subtalar arthrodesis. The primary outcomes were LOHS and ECF admission. The independent predictors included age, sex, body mass index, housing status, American Society of Anesthesiologists class, diabetes and/or diabetic neuropathy, health insurance, fixation type, and perioperative infection. Stepwise multiple regression analysis was used to determine which variables were related to a longer LOHS. Nonparametric discriminant function analysis was used to identify the preoperative factors that best predicted ECF admission. A longer LOHS was significantly related to postoperative ECF admission, Centers for Medicare and Medicaid Services (CMS) insurance, diabetic neuropathy, external fixation, and infection. ECF admission was required for 34 of 198 patients (17.2%). Discriminant analysis found that older age, living alone, external fixation, and CMS insurance predicted a greater probability of ECF admission. The function accurately classified 94% of ECF admissions and 80% of non-ECF admission patients. ECF admission and CMS insurance extended the LOHS, likely owing to the administrative process of arranging an ECF discharge. If externally validated, the function we have derived could provide preoperative identification of likely ECF discharge candidates and reduce costs by shortening the LOHS.

Artificial neural networks to predict future bone mineral density and bone loss rate in Japanese postmenopausal women

Objective

Predictions of the future bone mineral density and bone loss rate are important to tailor medicine for women with osteoporosis, because of the possible presence of personal risk factors affecting the severity of osteoporosis in the future. We investigated whether it was possible to predict bone mineral density and bone loss rate in the future using artificial neural networks.

Results

A total of 135 women over 50 years old residing in T town of Wakayama Prefecture, Japan were analyzed to establish a statistical model. Artificial neural networks models were constructed using the two variables of bone mineral density and bone loss rate. The multiple correlation coefficients between the actual and measured values for lumbar and femoral bone mineral densities in 2003 showed R² = 0.929 and R² = 0.880, respectively, by linear regression analyses, while the values for bone loss rates in lumbar and femoral bone mineral densities were R² = 0.694 and R² = 0.609, respectively. Statistical models by artificial neural networks were superior to those by multiple regression analyses. The prediction of future bone mineral density values estimated by artificial neural networks was considered to be useful as a tool to tailor medicine for the early diagnosis of and intervention for women osteoporosis with women.

Electronic supplementary material

The online version of this article (10.1186/s13104-017-2910-4) contains supplementary material, which is available to authorized users.

Time trends in hospital stay after hip fracture in Canada, 2004-2012: database study

Changes in bed management and access policy aimed to shorten Canadian hip fracture hospital stay. Secular trends in hip fracture total, preoperative, and postoperative stay are unknown. Hip fracture stay shortened from 2004 to 2012, mostly from shortening postoperative stay. This may reflect changes in bed management rather than access policy.

PURPOSE

To compare the probability of discharge by time after patient admission to hospital with first-time hip fracture over a period of nine calendar years.

METHODS

We retrieved acute hospitalization records for 169,595 patients 65 years and older, who were admitted to an acute care hospital with hip fracture between 2004 and 2012 in Canada (outside of Quebec). The main outcome measure was cumulative incidence of discharge by inpatient day, accounting for competing events that end hospital stay.

RESULTS

The probability of surgical discharge within 30 days of admission increased from 57.2 % in 2004 to 67.3 % in 2012. The probability of undergoing surgery on day of admission or day after fluctuated around 58.5 % over the study period. For postoperative stay, the discharge probability increased from 6.8 to 12.2 % at day 4 after surgery and from 57.2 to 66.6 % at day 21 after surgery, between 2004 and 2012. The differences across years persisted after adjustment for characteristics of patients, fracture, comorbidity, treatment, type and timing of surgery, and access to care.

CONCLUSIONS

Hospital stay following hip fracture shortened substantially between 2004 and 2012 in Canada, mostly due to shortening of postoperative stays. Shorter hospital stays may reflect changes in bed management protocols rather than in access policy.

Risk factors for hospital re-presentation among older adults following fragility fractures: protocol for a systematic review

BACKGROUND

After being discharged from hospital following the acute management of a fragility fracture, older adults may re-present to hospital emergency departments in the post-discharge period. Early re-presentation to hospital, which includes hospital readmissions, and emergency department presentations without admission may be considered undesirable for individuals, hospital institutions and society. The identification of modifiable risk factors for hospital re-representation following initial fracture management may prove useful for informing policy or practice initiatives that seek to minimise the need for older adults to re-present to hospital early after they have been discharged from their initial inpatient care. The purpose of this systematic review is to identify correlates of hospital re-presentation in older patients who have been discharged from hospital following clinical management of fragility fractures.

METHODS/DESIGN

The review will follow the PRISMA-P reporting guidelines for systematic reviews. Four electronic databases (PubMed, CINAHL, Embase, and Scopus) will be searched. A suite of search terms will identify peer-reviewed articles that have examined the correlates of hospital re-presentation in older adults (mean age of 65 years or older) who have been discharged from hospital following treatment for fragility fractures. The Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies will be used to assess the quality of the studies. The strength of evidence will be assessed through best evidence synthesis. Clinical and methodological heterogeneity across studies is likely to impede meta-analyses.

DISCUSSION

The best evidence synthesis will outline correlates of hospital re-presentations in this clinical group. This synthesis will take into account potential risks of bias for each study, while permitting inclusion of findings from a range of quantitative study designs. It is anticipated that findings from the review will be useful in identifying potentially modifiable risk factors that have relevance in policy, practice and research priorities to improve the management of patients with fragility fractures.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015019379.

Effects of Establishing a Department of General Internal Medicine on the Length of Hospitalization

OBJECTIVE

This study aimed to evaluate the effects of establishing a Department of General Internal Medicine (DGIM) on the length of hospitalization. We evaluated the length of hospitalization associated with diseases for which full-time specialists were not available and were instead treated by physicians of the DGIM after its establishment.

METHODS

A retrospective cohort study was conducted with a review of the subjects' medical records. The subjects included patients ≥16 years of age who were hospitalized with pneumonia or cerebral infarction and treated by a physician with a specialty in internal medicine as the disease outside their specialty prior to DGIM establishment (October 1, 2006 to September 30, 2008) or by a physician of the DGIM after its establishment (October 1, 2009 to September 30, 2011). The primary outcome was the change in the length of hospitalization. The length of hospitalization for heart failure, which was treated by specialists (cardiologists) in both study periods, was also examined for comparison.

RESULTS

We evaluated 322 and 423 cases of pneumonia treated before and after the establishment of the DGIM, as well as 223 and 229 cases of cerebral infarction and 132 and 206 cases of heart failure, respectively. The length of hospitalization before and after establishment of the DGIM was 21.6 and 16.0 days for the pneumonia patients (p<0.001) and 24.2 and 19.9 days for the cerebral infarction patients (p<0.001), respectively. On the other hand, the change in the length of hospitalization for the heart failure patients was not statistically significant (19.9 vs. 17.6 days; p=0.281).

CONCLUSION

The establishment of the DGIM reduced the length of hospitalization associated with diseases for which full-time specialists were not available by over 17%.

Regional variations in in-hospital mortality, care processes, and spending in acute ischemic stroke patients in Japan

BACKGROUND

Little is known about the regional variations in ischemic stroke care in Japan. This study investigates the regional variations and associations among outcomes, care processes, spending, and physician workforce availability in acute ischemic stroke care.

METHODS

Using administrative claims data from National Claims Database, we identified National Health Insurance beneficiaries aged 65 years and older and Long Life Medical Care System beneficiaries from 9 prefectures who had been hospitalized for acute ischemic stroke between April 2010 and March 2012. Patients were grouped according to their subprefectural regions of residence known as secondary medical areas (SMAs). Performances in 8 outcome and process of care measures were analyzed in each SMA. Multilevel regression models with 2 levels (patient and regional) were used to analyze age- and sex-adjusted in-hospital mortality, hospitalization spending, and tissue plasminogen activator (tPA) utilization rate. The associations between regional supply of physicians for stroke care and the various quality measures were investigated.

RESULTS

We analyzed 49,440 acute ischemic stroke patients. The regional variations among SMAs in in-hospital mortality, spending, and tPA utilization were 3.2-, 1.7-, and 5.9-fold, respectively. Higher physician supply was significantly associated with lower in-hospital mortality and higher spending. Additionally, spending had a significantly negative correlation with regional continuity of care planning rate but a significantly positive correlation with rehabilitation rate.

CONCLUSIONS

The study revealed substantial regional variations in Japanese ischemic stroke care. Improving the allocative efficiency of physicians and establishing continuity of care networks may be useful in mitigating regional disparities and reconstructing the stroke care system.