An observational study using a national administrative database to determine the impact of hospital volume on compliance with clinical practice guidelines

Recombinant Human Soluble Thrombomodulin Contributes to a Reduction In-Hospital Mortality of Acute Cholangitis with Disseminated Intravascular Coagulation: A Propensity Score Analyses of a Japanese Nationwide Database

The anti-DIC biological agent, recombinant human soluble thrombomodulin (rhTM), is being used clinically for DIC treatment in Japan. Patients with acute cholangitis associated with DIC are severe and require improved treatment. In addition, although clinical efficacy of rhTM in patients with acute cholangitis and DIC is expected, its efficacy is controversial. Thus, it is useful to evaluate rhTM in patients with acute cholangitis with DIC. This study aimed to validate the hypothesis that rhTM use improves in-hospital mortality in patients with acute cholangitis with DIC. A propensity score-matching analysis using a nationwide administrative database, the Japanese Diagnosis Procedure Combination Inpatient Database from April 2012 to March 2018, was performed. This database includes administrative claims data for all inpatients discharged from more than 1,000 participating hospitals, covering 92% of all tertiary-care emergency hospitals in Japan. Eligible patients (n = 2,865) were categorized into the rhTM (n = 1,636) or control groups (n = 1,229). Propensity score-matching created a matched cohort of 910 pairs with and without rhTM. In-hospital mortality between the groups in the unmatched analysis showed no significant difference (rhTM vs. control; 10.8% vs. 12.2%; p = 0.227). However, in-hospital mortality between the groups in the propensity score-matched analysis showed a significant difference (rhTM vs. control; 9.5% vs. 12.9%; p = 0.021). These results demonstrated that the rhTM group had significantly lower in-hospital mortality for patients with acute cholangitis with DIC. We propose that rhTM should be used for the treatment of patients with acute cholangitis with DIC.

The Effect of Anesthetic Type on Outcomes of Hip Fracture Surgery: A Nationwide Population-Based Study

Hip fractures are a global public health problem. During surgery following hip fractures, both general and regional anesthesia are used, but which type of anesthesia offers a better outcome remains controversial. There has been little research evaluating different anesthetic types on mortality and readmission rates for hip fracture surgery using nationwide population-based data.We used nationwide population-based data to examine the effect of anesthetic type on mortality and readmission rates for hip fracture surgery.Retrospective observational study.General acute care hospitals throughout Taiwan.A total of 17,189 patients hospitalized for hip fracture surgery in 2011.Generalized estimating equation models with propensity score weighting were performed after adjustment for patient, surgeon, and hospital characteristics to examine the associations of anesthesia type with 30-day all-cause mortality, 30-day all-cause readmission, and 30-day specific-cause readmission (including surgical site infection, sepsis, acute respiratory failure, acute stroke, acute myocardial infarction, acute renal failure, deep vein thrombosis, pneumonia, and urinary tract infection).Of 17,189 patients, 11,153 (64.9%) received regional anesthesia and 6036 (35.1%) received general anesthesia. Overall, the 30-day mortality rate was 1.7%, and the 30-day readmission rate was 12.3%. Regional anesthesia was not associated with decreased 30-day all-cause mortality (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.67-1.18, P = 0.409), but associated with decreased 30-day all-cause readmission and surgical site infection readmission relative to general anesthesia (OR 0.83, 95% CI 0.75-0.93, P = 0.001 and OR 0.69, 95% CI 0.49-0.97, P = 0.031).Regional anesthesia is not associated with 30-day mortality, but is associated with lower 30-day all-cause and surgical site infection readmission compared with general anesthesia for hip fracture surgery.

Effect of hospital volume on outcomes of laparoscopic appendectomy for acute appendicitis: an observational study

BACKGROUND

This study investigated the effect of hospital volume on outcomes of laparoscopic appendectomy for acute appendicitis.

METHODS

In total, 30,525 patients who underwent laparoscopic appendectomy for acute appendicitis were referred to 825 hospitals in Japan from 2010 to 2012. We compared appendectomy-related complications, length of stay (LOS), and medical costs in relation to hospital volume. For this study period, hospitals were categorized as low-volume hospitals (LVHs, <50 cases), medium-volume hospitals (MVHs, 50-100 cases), or high-volume hospitals (HVHs, >100 cases).

RESULTS

Significant differences in appendectomy-related complications were observed among the LVHs, MVHs, and HVHs (6.9, 7.2, and 6.0 %, respectively; p = 0.001). Multiple logistic regression revealed that HVHs were associated with a lower relative risk of appendectomy-related complications than were LVHs and MVHs (odds ratio [OR], 0.84; 95 % confidence interval [CI], 0.74-0.95; p = 0.006). Multiple linear regression showed that HVHs were associated with shorter LOS and lower medical costs than were LVHs and MVHs. The unstandardized coefficient for LOS was -0.92 days (95 % CI, -1.07 to -0.78; p < 0.001), whereas that for medical costs was - $167.4 (95 % CI, -256.2 to -78.6; p < 0.001).

CONCLUSIONS

Hospital volume was significantly associated with laparoscopic appendectomy outcomes.

Influence of hospital volume on outcomes of laparoscopic gastrectomy for gastric cancer in patients with comorbidity in Japan

OBJECTIVE

Little information is available on the relationship between hospital volume and the outcomes of laparoscopic gastrectomy for gastric cancer in patients with comorbidity. This study aimed to investigate the influence of hospital volume on patient outcomes of laparoscopic gastrectomy for gastric cancer in patients with comorbidity using a national administrative database.

METHODS

A total of 5941 comorbid patients treated with laparoscopic gastrectomy for gastric cancer were referred to 741 hospitals in Japan. We collected patients' data from the administrative database to compare laparoscopy-related complications, in-hospital mortality, length of stay (LOS), and medical costs during hospitalization in relation to hospital volume. Hospital volume was categorized into two groups: low (<40 cases in 3 years; n = 4111) and high (≥ 40 cases; n = 1830).

RESULTS

There were no significant differences between the groups in laparoscopy-related complications and in-hospital mortality (p = 0.684 and p = 0.200, respectively). However, significant variations in mean LOS and medical costs were observed between hospital volume categories (26.1 days vs. 20.2 days and 16,163.9 US dollars vs. 14,345.9 US dollars, respectively; p < 0.001). Multiple linear regressions revealed that higher hospital volume was significantly associated with shorter LOS and lower medical costs during hospitalization. The unstandardized coefficient for LOS was -4.62 days (95% confidence interval = -5.63--3.60, p < 0.001), whereas that for medical costs was -1424.1 US dollars (95% confidence interval = -1962.5--885.6, p < 0.001).

CONCLUSION

Hospital volume was significantly associated with a decrease of LOS and medical costs of comorbid patients undergoing laparoscopic gastrectomy for gastric cancer.

The recent time trend of outcomes of disseminated intravascular coagulation in Japan: an observational study based on a national administrative database

The aim of this study is to investigate the recent trend over time of outcomes of patients with disseminated intravascular coagulation (DIC) based on the Japanese administrative database. A total of 34,711 patients with DIC had been referred to 1,092 hospitals from 2010 to 2012 in Japan. We collected patients' data from the administrative database to compare in-hospital mortality within 14 and 28 days between periods. The study periods were categorized into three groups: 2010 (n = 8,382), 2011 (n = 13,372), and 2012 (n = 12,957). These analyses were performed according to the underlying diseases associated with DIC. The in-hospital mortality within 14 or 28 days of DIC patients with infectious diseases decreased between 2010 and 2012 (within 14 days: 20.4 vs. 18.1 vs. 17.9 %, P = 0.009; within 28 days: 31.1 vs. 28.7 vs. 27.7%, P = 0.003; respectively). Multiple logistic regressions also showed that the period was associated with in-hospital mortality of DIC patients with infectious diseases. The odds ratios of 2011 and 2012 for in-hospital mortality within 14 days were 0.86 [95% confidence intervals (CI) 0.77-0.97] and 0.84 (95% CI 0.75-0.94) whereas those for in-hospital mortality within 28 days were 0.89 (95% CI 0.81-0.98) and 0.83 (95% CI 0.76-0.92), respectively. However, there were no significant differences in mortality of patients with DIC associated with other underlying diseases between 2010 and 2012. This study demonstrated that in-hospital mortality of DIC patients with infectious diseases gradually improved between 2010 and 2012 in Japan.

Institutional characteristics associated with receipt of emergency care for obstructive pyelonephritis at community hospitals

PURPOSE

Delivering the recommended care is an important quality measure that has been insufficiently studied in urology. Obstructive pyelonephritis is a suitable case study for this focus because many patients do not receive such care, although guidelines advocate decompression. We determined the influence of hospital factors, particularly familiarity with urolithiasis, on the likelihood of decompression in such patients.

MATERIALS AND METHODS

We used the NIS from 2002 to 2011 to retrospectively identify patients admitted to community hospitals with severe infection and ureteral calculi. Hospital familiarity with nephrolithiasis was estimated by calculating hospital stone volume (divided into quartiles) and hospital treatment intensity (the decompression rate in patients with ureteral calculi and no infection). After calculating national estimates we performed logistic regression to determine the association between the receipt of decompression and hospital stone volume, controlling for treatment intensity and other covariates thought to be associated with receiving recommended care.

RESULTS

Of an estimated 107,848 patients with obstructive pyelonephritis 27.4% failed to undergo decompression. Discrepancies were greatest between hospitals with the highest and lowest stone volumes (76% vs 25%, OR 2.77, 95% CI 1.94-3.96, p <0.01) as well as high and low treatment intensity (78% vs 37%, p <0.01).

CONCLUSIONS

High hospital stone volume and treatment intensity were associated with an increased likelihood of receiving decompression. Such findings might be useful to identify hospitals and regions where access to quality urological care should be augmented.

Association between hospital case volume and mortality in non-elderly pneumonia patients stratified by severity: a retrospective cohort study

Background

The characteristics and aetiology of pneumonia in the non-elderly population is distinct from that in the elderly population. While a few studies have reported an inverse association between hospital case volume and clinical outcome in elderly pneumonia patients, the evidence is lacking in a younger population. In addition, the relationship between volume and outcome may be different in severe pneumonia cases than in mild cases. In this context, we tested two hypotheses: 1) non-elderly pneumonia patients treated at hospitals with larger case volume have better clinical outcome compared with those treated at lower case volume hospitals; 2) the volume-outcome relationship differs by the severity of the pneumonia.

Methods

We conducted the study using the Japanese Diagnosis Procedure Combination database. Patients aged 18–64 years discharged from the participating hospitals between July to December 2010 were included. The hospitals were categorized into four groups (very-low, low, medium, high) based on volume quartiles. The association between hospital case volume and in-hospital mortality was evaluated using multivariate logistic regression with generalized estimating equations adjusting for pneumonia severity, patient demographics and comorbidity score, and hospital academic status. We further analyzed the relationship by modified A-DROP pneumonia severity score calculated using the four severity indices: dehydration, low oxygen saturation, orientation disturbance, and decreased systolic blood pressure.

Results

We identified 8,293 cases of pneumonia at 896 hospitals across Japan, with 273 in-hospital deaths (3.3%). In the overall population, no significant association between hospital volume and in-hospital mortality was observed. However, when stratified by pneumonia severity score, higher hospital volume was associated with lower in-hospital mortality at the intermediate severity level (modified A-DROP score = 2) (odds ratio (OR) of very low vs. high: 2.70; 95% confidence interval (CI): 1.12–6.55, OR of low vs. high: 2.40; 95% CI:0.99–5.83). No significant association was observed for other severity strata.

Conclusions

Hospital case volume was inversely associated with in-hospital mortality in non-elderly pneumonia patients with intermediate pneumonia severity. Our result suggests room for potential improvement in the quality of care in hospitals with lower volume, to improve treatment outcomes particularly in patients admitted with intermediate pneumonia severity.

Endoscopic submucosal dissection for gastric cancer: the influence of hospital volume on complications and length of stay

BACKGROUND

Little information is available about the relationship between hospital volume and the clinical outcome of endoscopic submucosal dissection (ESD) for gastric cancer. The purpose of this study was to investigate the influence of hospital volume on clinical outcomes of ESD using a national administrative database.

METHODS

A total of 27,385 patients treated with ESD for gastric cancer were referred to 867 hospitals between 2009 and 2011 in Japan. We collected patients' data from the administrative database to compare ESD-related complications and length of stay (LOS) in relation to hospital volume. Hospital volume was categorized into three groups based on the number of cases treated over the study period: low-volume hospitals (LVHs, <50 cases), medium-volume hospitals (MVHs, 50-100 cases), and high-volume hospitals (HVHs, >100 cases). These analyses were performed for each location of gastric cancer [upper (cardia and fundus), middle (body), and lower third (antrum and pylorus)].

RESULTS

Significant differences in ESD-related complications among the three hospital volume categories were observed for upper gastric cancer (6.5 % in LVHs vs. 5.2 % in MVHs vs. 3.4 % in HVHs; p = 0.017). Multiple logistic regression revealed that HVHs were significantly associated with decreased relative risk of ESD-related complications in upper gastric cancer (odds ratio for HVHs 0.51; 95 % confidence interval, 0.31-0.83, p = 0.007). However, no significant differences for ESD-related complications were seen for middle and lower gastric cancers among the different hospital volume categories (p > 0.05). Additionally, hospital volume was significantly associated with a decreasing LOS for all locations of gastric cancers (p < 0.001).

CONCLUSIONS

The present study has demonstrated that hospital volume was mainly associated with clinical outcome in patients with ESD for upper gastric cancer. Further studies for successive monitoring of outcomes of ESD should be conducted in the near future.

Time trend of medical economic outcomes of endoscopic submucosal dissection for gastric cancer in Japan: a national database analysis

BACKGROUND

Little information is available on the analysis of chronological changes in medical economic outcomes of endoscopic submucosal dissection (ESD) for gastric cancer. This study aimed to investigate the recent time trend of medical economic outcomes of ESD for gastric cancer based on the Japanese administrative database.

METHODS

A total of 32,943 patients treated with ESD for gastric cancer were referred to 907 hospitals from 2009 to 2011 in Japan. We collected patients' data from the administrative database to compare ESD-related complications, risk-adjusted length of stay (LOS), and medical costs during hospitalization. The study periods were categorized into three groups: 2009 (n = 9,727), 2010 (n = 11,052), and 2011 (n = 12,164).

RESULTS

No significant difference was observed in ESD-related complications between three study periods (p = 0.496). However, mean LOS and medical costs during hospitalization of patients with ESD were significantly lower in 2011 than in 2009 and 2010 (p < 0.001). Multiple linear regression analysis showed that patients who received ESD in 2011 had a significantly shorter LOS and lower medical costs during hospitalization compared with those in 2009. The unstandardized coefficient of patients with ESD in 2011 for LOS was -0.78 days [95 % confidence interval (CI), -0.89 to -0.65; p ≤ 0.001], while that of those for medical costs during hospitalization was -290.5 US dollars (95 % CI, -392.3 to -188.8; p ≤ 0.001).

CONCLUSIONS

This study showed that the complication rate of ESD was stable, whereas the LOS and medical costs of patients were significantly reduced from 2009 to 2011.

Endoscopic submucosal dissection for gastric cancer in elderly Japanese patients: an observational study of financial costs of treatment based on a national administrative database

OBJECTIVE

There is currently little information on the medical economic outcomes of endoscopic submucosal dissection (ESD) for gastric cancer (GC) in elderly patients. This study therefore aimed to investigate the medical economic outcomes of ESD in elderly patients with GC using a national administrative database.

METHODS

A total of 27 385 patients treated with ESD for GC were referred to 867 hospitals in Japan from 2009 to 2011. We collected data from the national administrative database and divided them into two groups according to age: elderly patients (≥80 years; n = 5525) and non-elderly patients (<80 years; n = 21 860). We compared ESD-related complications, risk-adjusted length of stay (LOS) and medical costs during hospitalization between elderly and non-elderly patients.

RESULTS

There was no significant difference in ESD-related complications between elderly and non-elderly patients (4.3% vs 3.9%, P = 0.152). However, significant differences were observed in mean LOS and medical costs during hospitalization between the two groups (P < 0.001). Multiple linear regression analysis showed that elderly patients experienced a significantly longer LOS and higher medical costs. The unstandardized coefficient for LOS in elderly patients was 2.71 days (95% confidence interval [CI] 2.59-2.84, P < 0.001), while that for medical costs during hospitalization was USD952.1 (95% CI 847.7-1056.5, P < 0.001).

CONCLUSIONS

LOS and medical costs during hospitalization were significantly higher in elderly patients undergoing ESD for GC than in non-elderly patients, although there was no difference in the incidence of ESD-related complications.

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

BACKGROUND

Little information is available on the effects of adding laparoscopic cholecystectomy to laparoscopic gastrectomy on outcomes of patients with gastric cancer. The aim of this study is to investigate the effects of adding laparoscopic cholecystectomy to laparoscopic gastrectomy on outcomes in patients with gastric cancer using a national administrative database.

METHODS

A total of 14,006 patients treated with laparoscopic gastrectomy for gastric cancer were referred to 744 hospitals in Japan between 2009 and 2011. Patients were divided into two groups, those who also underwent simultaneous laparoscopic cholecystectomy for gallbladder stones (n = 1484) and those who underwent laparoscopic gastrectomy alone (n = 12,522). Laparoscopy-related complications, in-hospital mortality, length of stay, and medical costs during hospitalization were compared in the patient groups.

RESULTS

Multiple logistic regression analysis revealed that adding laparoscopic cholecystectomy did not affect laparoscopy-related complications (odds ratio, 1.02; 95% confidence interval [CI], 0.84-1.24; P = 0.788) or in-hospital mortality (odds ratio, 1.16; 95% CI, 0.49-2.76; P = 0.727). Multiple linear regression analysis also showed that adding laparoscopic cholecystectomy did not affect the length of stay (unstandardized coefficient, 0.37 d; 95% CI, -0.47 to 1.22 d; P = 0.389). However, adding laparoscopic cholecystectomy was associated with significantly increased medical costs during hospitalization (unstandardized coefficient, $1256.0 (95% CI, $806.2-$1705.9; P < 0.001).

CONCLUSIONS

This study demonstrated that adding laparoscopic cholecystectomy did not affect outcomes of patients undergoing laparoscopic gastrectomy for gastric cancer, although medical costs during hospitalization were significantly increased.

Impact of guideline-concordant microbiological testing on outcomes of pneumonia

OBJECTIVE

Clinical practice guidelines recommend standardized diagnostic microbiological testing for community-acquired pneumonia on hospital admission, although evidence of its impact on quality is limited. This study evaluated the relationship between guideline-concordant microbiological testing (GCMT) and both in-hospital mortality and length of stay.

DESIGN

/st> Retrospective cohort study using a multicenter claims-based inpatient database linked to a government hospital census database in Japan.

SETTING AND PARTICIPANTS

/st> Patients who were diagnosed with and treated for pneumonia, and were discharged between 1 July 2010 and 30 September 2011 (n = 65 145).

METHODS

and

MAIN OUTCOME MEASURES

/st> GCMT was defined to include sputum tests, blood cultures and urine antigen tests conducted on the first day of hospitalization. We examined the association between 30-day in-hospital mortality and both the performance of each test and the number of tests performed using multivariable logistic regression analysis, adjusting for patient demographics, pneumonia severity and hospital characteristics. Length of stay was analyzed using a Cox proportional hazards model.

RESULTS

/st> Simultaneous conduct of all three tests was significantly associated with reduced 30-day mortality (odds ratio: 0.64; 95% confidence interval (CI): 0.56-0.74) and with increased likelihood of discharge (hazard ratio: 1.04; 95% CI: 1.00-1.07), after adjusting for patient and hospital characteristics. The association was more marked as the level of disease severity increased.

CONCLUSIONS

/st> Performance of GCMT was significantly associated with lower mortality and shorter length of stay. These results suggest that hospitals should assure performance of GCMT in patients with severe community-acquired pneumonia.

Association between ambulance distance to hospitals and mortality from acute diseases in Japan: national database analysis

OBJECTIVE

The aim of this study was to evaluate the relationship between ambulance distance to hospitals and mortality from acute diseases using the national database in Japan.

DESIGN

Geospatial ecological study.

SETTING

We collected the data of transport distance to hospitals from the Diagnosis Procedure Combination database and that of mortality per 100 000 from some acute diseases from the database of life tables by the Ministry of Health, Labour and Welfare in Japan.

PARTICIPANTS

A total of 108 314 patients (40 882 patients with acute myocardial infarction, 31 632 patients with brain infarction, 4992 patients with subarachnoid hemorrhage, and 30 808 patients with pneumonia) were referred in Japan in 2008.

MAIN OUTCOME MEASURES

We evaluated the association between the mean transport distance to hospitals and the mortality from acute diseases using simple linear regression analysis. This correlation was evaluated separately for each acute disease.

RESULTS

The mean transport distances to hospitals were 8.1 km for acute myocardial infarction, 8.3 km for brain infarction, 9.5 km for subarachnoid hemorrhage, and 7.6 km for pneumonia, whereas the mortalities per 100,000 were 34.6 for acute myocardial infarction, 60.4 for brain infarction, 11.2 for subarachnoid hemorrhage, and 91.6 for pneumonia. Simple linear regression analysis revealed significant positive correlations between transport distance and mortality per 100,000 for acute myocardial infarction and brain infarction (R2 = 0.315 and 0.398, P < .001, respectively). Otherwise, moderate positive correlations between transport distance and mortality per 100,000 were shown for subarachnoid hemorrhage and pneumonia (R2 = 0.112, P < .012 and .233, P < .001, respectively).

CONCLUSIONS

This study suggests that the ambulance distance to hospitals significantly influences the risk of mortality for some acute diseases in Japan. Further studies are needed to confirm this association.

Multivariate analysis of factors influencing length of hospitalization and medical costs of cholecystectomy for acute cholecystitis in Japan: a national database analysis

Little information is available on the factors influencing length of stay (LOS) in hospital and medical costs during hospitalization associated with cholecystectomy for acute cholecystitis. We determined the independent factors affecting LOS and medical costs of patients who underwent cholecystectomy for acute cholecystitis based on data from the Diagnosis Procedure Combination (DPC) database. In 2008, a total of 2176 patients with acute cholecystitis were referred for cholecystectomy to 624 hospitals in Japan. We collected patient characteristics and data on treatments for acute cholecystitis using the DPC database and identified independent factors affecting LOS and medical costs during hospitalization using multiple linear regression models. Analysis revealed that early cholecystectomy was significantly associated with a decrease in LOS, whereas longer preoperative antimicrobial therapy was significantly associated with an increase of LOS: the standardized coefficient for early cholecystectomy was -0.372 and that for preoperative antimicrobial therapy was 0.353 (P < 0.001). These procedures were also significant independent factors with regard to medical costs during hospitalization: the standardized coefficient for early cholecystectomy was -0.391 and that for preoperative antimicrobial therapy was 0.335 (P < 0.001). Early cholecystectomy significantly reduces the LOS and medical costs of cholecystectomy for acute cholecystitis, while preoperative antimicrobial therapy increases LOS and medical costs during hospitalization. These results highlight the need for health care implementations such as promotion of early cholecystectomy, appropriate use of antimicrobial drugs, and centralization of patients with cholecystectomy for acute cholecystitis in Japan.

TG13 management bundles for acute cholangitis and cholecystitis

Bundles that define mandatory items or procedures to be performed in clinical practice have been increasingly used in guidelines in recent years. Observance of bundles enables improvement of the prognosis of target diseases as well as guideline preparation. There were no bundles adopted in the Tokyo Guidelines 2007, but the updated Tokyo Guidelines 2013 (TG13) have adopted this useful tool. Items or procedures strongly recommended in clinical practice have been prepared in the practical guidelines and presented as management bundles. TG13 defined the mandatory items for the management of acute cholangitis and acute cholecystitis. Critical parts of the bundles in TG13 include diagnostic process, severity assessment, transfer of patients if necessary, therapeutic approach, and time course. Their observance should improve the prognosis of acute cholangitis and cholecystitis. When utilizing TG13 management bundles, further clinical research needs to be conducted to evaluate the effectiveness and outcomes of the bundles. It is also expected that the present report will lead to evidence construction and contribute to further updating of the Tokyo Guidelines. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

Association between hospital volume and outcomes of elderly and non-elderly patients with acute biliary diseases: a national administrative database analysis

AIM

This study aimed to investigate the relationship between hospital volume and clinical outcomes of elderly and non-elderly patients with acute biliary diseases using data from a national administrative database.

METHODS

Overall, 26720 elderly and 33774 non-elderly patients with acute biliary diseases were referred to 820 hospitals in Japan. Hospital volume was categorized into three groups based on the case numbers during the study period: low-volume, medium-volume and high-volume. We compared the risk-adjusted length of stay (LOS) and in-hospital mortality in relation to hospital volume. These analyses were stratified according to the presence of invasive treatments for acute biliary diseases.

RESULTS

Multiple linear regression analyses showed that increased hospital volume was significantly associated with shorter LOS in both elderly and non-elderly patients with and without invasive treatments. Increased hospital volume was significantly associated with decreased relative risk of in-hospital mortality in elderly patients. The odds ratio for high-volume hospitals was 0.672 in elderly patients without invasive treatments (95% confidence interval [CI] 0.533-0.847, P=0.001) and 0.715 in those with invasive treatments (95% C, 0.566-0.904, P=0.005). However, no significant differences for in-hospital mortality were seen in non-elderly patients with and without invasive treatments.

CONCLUSION

  This study has highlighted that higher volume hospitals significantly reduced LOS and in-hospital mortality for elderly patients with acute biliary diseases, but not non-elderly patients. The current results are of value for elderly healthcare policy decision-making, and highlight the need for further studies into the quality of care for elderly patients.

The impact of rural hospital closures on equity of commuting time for haemodialysis patients: simulation analysis using the capacity-distance model

Background

Frequent and long-term commuting is a requirement for dialysis patients. Accessibility thus affects their quality of lives. In this paper, a new model for accessibility measurement is proposed in which both geographic distance and facility capacity are taken into account. Simulation of closure of rural facilities and that of capacity transfer between urban and rural facilities are conducted to evaluate the impacts of these phenomena on equity of accessibility among dialysis patients.

Methods

Post code information as of August 2011 of all the 7,374 patients certified by municipalities of Hiroshima prefecture as having first or third grade renal disability were collected. Information on post code and the maximum number of outpatients (capacity) of all the 98 dialysis facilities were also collected. Using geographic information systems, patient commuting times were calculated in two models: one that takes into account road distance (distance model), and the other that takes into account both the road distance and facility capacity (capacity-distance model). Simulations of closures of rural and urban facilities were then conducted.

Results

The median commuting time among rural patients was more than twice as long as that among urban patients (15 versus 7 minutes, p < 0.001). In the capacity-distance model 36.1% of patients commuted to the facilities which were different from the facilities in the distance model, creating a substantial gap of commuting time between the two models. In the simulation, when five rural public facilitiess were closed, Gini coefficient of commuting times among the patients increased by 16%, indicating a substantial worsening of equity, and the number of patients with commuting times longer than 90 minutes increased by 72 times. In contrast, closure of four urban public facilities with similar capacities did not affect these values.

Conclusions

Closures of dialysis facilities in rural areas have a substantially larger impact on equity of commuting times among dialysis patients than closures of urban facilities. The accessibility simulations using thecapacity-distance model will provide an analytic framework upon which rational resource distribution policies might be planned.

The influence of diabetes mellitus on short-term outcomes of patients with bleeding peptic ulcers

PURPOSE

Little information is available on the influence of diabetes mellitus on the short-term clinical outcomes of patients with bleeding peptic ulcers. The aim of this study is to investigate whether diabetes mellitus influences the short-term clinical outcomes of patients with bleeding peptic ulcers using a Japanese national administrative database.

MATERIALS AND METHODS

A total of 4863 patients treated by endoscopic hemostasis on admission for bleeding peptic ulcers were referred to 586 participating hospitals in Japan. We collected their data to compare the risk-adjusted length of stay (LOS) and in-hospital mortality of patients with and without diabetes mellitus within 30 days. Patients were divided into two groups: patients with diabetes mellitus (n=434) and patients without diabetes mellitus (n=4429).

RESULTS

Mean LOS in patients with diabetes mellitus was significantly longer than those without diabetes mellitus (15.8 days vs. 12.5 days, p<0.001). Also, higher in-hospital mortality within 30 days was observed in patients with diabetes mellitus compared with those without diabetes mellitus (2.7% vs. 1.1%, p=0.004). Multiple linear regression analysis revealed that diabetes mellitus was significantly associated with an increase in risk-adjusted LOS. The standardized coefficient was 0.036 days (p=0.01). Furthermore, the analysis revealed that diabetes mellitus significantly increased the risk of in-hospital mortality within 30 days (odds ratio=2.285, 95% CI=1.161-4.497, p=0.017).

CONCLUSION

This study demonstrated that presence of diabetes mellitus significantly influences the short-term clinical outcomes of patients with bleeding peptic ulcers.

Multivariate analysis of factors influencing medical costs of acute pancreatitis hospitalizations based on a national administrative database

BACKGROUND

Little information is available on the analysis of medical costs of acute pancreatitis hospitalizations.

AIM

This study aimed to determine the factors affecting medical costs of patients with acute pancreatitis during hospitalization using a Japanese administrative database.

METHODS

A total of 7193 patients with acute pancreatitis were referred to 776 hospitals. We defined "patients with high medical costs" as patients whose medical costs exceeded the 90th percentile in medical costs during hospitalization and identified the independent factors for patients with high medical costs with and without controlling for length of stay.

RESULTS

Multiple logistic regression analysis demonstrated that necrosectomy was the most significant factor for medical costs of acute pancreatitis during hospitalization. The odds ratio of necrosectomy was 33.64 (95% confidence interval, 14.14-80.03; p<0.001). Use of an intensive care unit was the most significant factor for medical costs after controlling for LOS. The OR of an ICU was 6.44 (95% CI, 4.72-8.81; p<0.001).

CONCLUSION

This study demonstrated that necrosectomy and use of an ICU significantly affected the medical costs of acute pancreatitis hospitalization. These results highlight the need for health care implementations to reduce medical costs whilst maintaining the quality of patient care, and targeting patients with severe acute pancreatitis.

Effect of hospital volume on clinical outcome in patients with acute pancreatitis, based on a national administrative database

OBJECTIVE

This study aimed to investigate the relationship between hospital volume and clinical outcome in patients with acute pancreatitis, using a Japanese national administrative database.

METHODS

A total of 7007 patients with acute pancreatitis were referred to776 hospitals in Japan. Patient data were corrected according to the severity of acute pancreatitis to allow the comparison of risk-adjusted in-hospital mortality and length of stay in relation to hospital volume. Hospital volume was categorized based on the number of cases during the study period into low-volume (<10 cases), medium-volume (10-16 cases), and high-volume hospitals (HVHs, >16 cases).

RESULTS

Increased hospital volume was significantly associated with decreased relative risk of in-hospital mortality in both patients with mild and those with severe acute pancreatitis. The odds ratios for HVHs were 0.424 (95% confidence interval [CI], 0.228-0.787; P = 0.007) and 0.338 (95% CI, 0.138-0.826; P = 0.017), respectively. Hospital volume was also significantly associated with shorter length of stay in patients with mild acute pancreatitis. The unstandardized coefficient for HVHs was -0.978 days (95% CI, -1.909 to -0.048; P = 0.039).

CONCLUSIONS

This study demonstrated that hospital volume influences the clinical outcome in both patients with mild and those with severe acute pancreatitis.

Cost containment and quality of care in Japan: is there a trade-off?

Japan's health indices such as life expectancy at birth are among the best in the world. However, at 8·5% the proportion of gross domestic product spent on health is 20th among Organisation for Economic Co-operation and Development countries in 2008 and half as much as that in the USA. Costs have been contained by the nationally uniform fee schedule, in which the global revision rate is set first and item-by-item revisions are then made. Although the structural and process dimensions of quality seem to be poor, the characteristics of the health-care system are primarily attributable to how physicians and hospitals have developed in the country, and not to the cost-containment policy. However, outcomes such as postsurgical mortality rates are as good as those reported for other developed countries. Japan's basic policy has been a combination of tight control of the conditions of payment, but a laissez-faire approach to how services are delivered; this combination has led to a scarcity of professional governance and accountability. In view of the structural problems facing the health-care system, the balance should be shifted towards increased freedom of payment conditions by simplification of reimbursement rules, but tightened control of service delivery by strengthening of regional health planning, both of which should be supported through public monitoring of providers' performance. Japan's experience of good health and low cost suggests that the priority in health policy should initially be improvement of access and prevention of impoverishment from health care, after which efficiency and quality of services should then be pursued.

[Practical use of DPC information for occupational health consultation]

BACKGROUND

The Diagnosis Procedure Combination (DPC) is a national administrative case-mix classification system for acute inpatient care which was launched in Japan in 2003. This system was designed to increase the standardization and transparency of medical information. The system has collected medical information in a unified format nationwide from acute hospitals. Significant parts of the data has been published by Ministry of Health, Labour and Welfare, including average length of hospital stay and number of patients by disease and hospital. This information is valuable for medical consultation in occupational health settings.

OBJECTIVES

This article provides an overview of the DPC system and how to utilize the data from the perspective of occupational health practitioners.