Validation of claims data to identify death among aged persons utilizing enrollment data from health insurance unions

Variability in Short-term Mortality Following Repair of Ruptured Abdominal Aortic Aneurysms Across Centers and Physicians

BACKGROUND

Variation in the care management of repairs for ruptured infrarenal abdominal aortic aneurysms (rAAA) between centers and physicians, e.g., the procedural volumes may explain differences in mortality outcomes. First, we quantified the center and physician variability associated with 30- and 90-day mortality risk following open (rOSR) and endovascular (rEVAR) aneurysm repair. Second, we explored wheter part of this variability was attributable to procedural volume at the center and physician level.

METHODS

Two cohorts including rOSR and rEVAR procedures between 2013-2019 were analyzed from the Vascular Quality Initiative database. Thirty- and 90-day all-cause mortality was derived from linked Medicare claims data. The median odds ratio (MOR, median mortality risk from low- to high-risk cluster) and intraclass correlation (ICC, variability attributable to each cluster) for 30- and 90-day mortality risk associated with center and physician variability were derived using patient-level adjusted multilevel logistic regression models. Procedural volume was calculated at the center and physician levels and stratified by quartiles. The models were sequentially adjusted for volumes, and the difference in ICC (without vs. with accounting for volume) was calculated to describe the center and physician variability in mortality risk attributable to volumes.

RESULTS

We included 450 rOSRs (mean age=74.5±7.6 years; 23.5% female) and 752 rEVARs (76.4±8.4 years; 26.1% female). Following rOSRs, the 30- and 90-day mortality rates were 32.9% and 38.7%. No variability across centers and physicians was noted (30- and 90-day MORs ≈ 1 and ICCs ≈ 0%). Neither center nor physician volume was associated with 30-day(P=.477 and P=.796) or 90-day mortality (P=.098 and P=.559). Following rEVAR, the 30- and 90-day mortality rate was 21.3% and 25.5%, respectively. Significant center variability (30-day MOR=1.82 95%CI 1.33-2.22 and ICC=11% 95%CI 2%-36%; 90-day MOR=1.76 95%CI 1.37-2.09 and ICC=10% 95%CI 3%-30%), but negligeable variability across physicians (30- and 90-day MORs≈1 and ICCs ≈ 0%) were noted. Neither center nor physician volume was associated with 30- (P=.076 and P=.336) nor 90-day mortality risk (P=.066 and P=.584). The center variability attributable to procedural volumes was negligeable (difference in ICCs: 1% for 30-day; 0% for 90-day mortality).

CONCLUSION

Variability in practice from center-to-center was associated with short-term mortality outcomes in rEVAR, but not for rOSR. Physician variability was not associated with short-term mortality for rOSR or rEVAR. Annualized center and physician volumes did not significantly explain these associations. Further work is needed to identify center-level factors affecting the quality of care and outcomes for ruptured AAA.

Claims-based Frailty Index in Japanese Older Adults: A Cohort Study Using LIFE Study Data

BACKGROUND

We aimed to assess whether the United States-developed Claims-based Frailty Index (CFI) can be implemented in Japanese older adults using claims data.

METHODS

We used the monthly claims data and certification of long-term care (LTC) insurance data of residents from 12 municipalities from April 2014 to March 2019. The 12 months from first recording was defined as the "baseline period," and the time thereafter as the "follow-up period". Participants aged ≥65 years were included, and those with no certified LTC insurance or who died at baseline were excluded. New certification of LTC insurance and all-cause mortality during the follow-up period were defined as outcome events. CFI categorization consisted of three steps including: 1) using 12 months deficit-accumulation approach that assigned different weights to each of the 52 items; 2) the accumulated score to derive the CFI; and 3) categorizing the CFI as "robust" (<0.15), "prefrail" (0.15-0.24), and "frail" (≥0.25). Kaplan-Meier survival curves and Cox proportional hazard models were used to determine the association between CFI and outcomes. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated.

RESULTS

There were 519,941 participants in total. After adjusting for covariates, the severe CFI category had a high risk of certification of LTC insurance (prefrail: HR 1.33; 95% CI, 1.27-1.39 and frail: HR 1.60; 95% CI, 1.53-1.68) and all-cause mortality (prefrail: HR 1.44; 95% CI, 1.29-1.60 and frail: HR 1.84; 95% CI, 1.66-2.05).

CONCLUSION

This study suggests that CFI can be implemented in Japanese claims data to predict the certification of LTC insurance and mortality.

Drug prescribing changes in the last year of life among homebound older adults: national retrospective cohort study

OBJECTIVES

This study aimed to evaluate the prescription patterns of drugs during the last year of life in homebound older adults who received home medical care.

METHODS

We used a nationwide claims database in Japan and selected older adults aged ≥75 years who received home medical care services from ≥12 months before their death. We evaluated medications prescribed 12 months before death (month 12), 3 months before death (month 3) and in the last month of life (month 1). We explored the factors associated with the decreased number of cardiovascular preventive drugs from month 12 to both month 3 and month 1.

RESULTS

A total of 118 661 participants were included, and the majority were aged ≥90 years and women. The prevalence of cardiovascular preventive drugs decreased but remained common in month 1, which included antihypertensives (34.7%), antiplatelets (15.9%), oral anticoagulants (7.6%), antidiabetic drugs (7.3%) and lipid-lowering drugs (6.1%). The relative decrease from month 12 to month 1 was the largest for lipid-lowering drugs (44.8%) and the smallest for oral anticoagulants (13.6%). Among other drugs, laxatives (enema), antiemetics, oral corticosteroids, analgesics, expectorants, bronchodilators and antibiotics showed a large relative increase. Older age, duration of home medical care services for <1 year and diagnoses of cancer, dementia and Parkinson's disease were associated with a greater likelihood of a decreased number of cardiovascular preventive drugs.

CONCLUSIONS

There is room for deprescribing to avoid inappropriate polypharmacy by balancing preventive and symptom management drugs in those receiving home medical care with a limited life expectancy.

Studies of Health Insurance Claims Data in Japan: A Scoping Review

BACKGROUND

Health insurance claims data are used in various research fields; however, an overview on how they are used in healthcare research is scarce in Japan. Therefore, we conducted a scoping review to systematically map the relevant studies using Japanese claims data.

METHODS

MEDLINE, EMBASE, and Ichushi-Web were searched up to April 2021 for studies using Japanese healthcare claims data. We abstracted the data on study characteristics and summarized target diseases and research themes by the types of claims database. Moreover, we described the results of studies that aimed to compare health insurance claims data with other data sources narratively.

RESULTS

A total of 1,493 studies were included. Overall, the most common disease classifications were "Diseases of the circulatory system" (18.8%, n = 281), "Endocrine, nutritional, and metabolic diseases" (11.5%, n = 171; mostly diabetes), and "Neoplasms" (10.9%, n = 162), and the most common research themes were "medical treatment status" (30.0%, n = 448), "intervention effect" (29.9%, n = 447), and "clinical epidemiology, course of diseases" (27.9%, n = 417). Frequent diseases and themes varied by type of claims databases. A total of 19 studies aimed to assess the validity of the claims-based definition, and 21 aimed to compare the results of claims data with other data sources. Most studies that assessed the validity of claims data compared to medical records were hospital-based, with a small number of institutions.

CONCLUSIONS

Claims data are used in various research areas and will increasingly provide important evidence for healthcare policy in Japan. It is important to use previous claims database studies and share information on methodology among researchers, including validation studies, while informing policymakers about the applicability of claims data for healthcare planning and management.

Validation studies of Japanese administrative health care data: A scoping review

PURPOSE

Large-scale administrative health care databases are increasingly being utilized for research. However, there has not been much literature that validated administrative data in Japan; a previous review identified six validation studies published between 2011 and 2017. We conducted a literature review of studies that assessed the validity of Japanese administrative health care data.

METHODS

We searched for studies published by March 2022 that compared individual-level administrative data with a reference standard from another data source, as well as studies that validated administrative data using other data within the same database. The eligible studies were also summarized based on characteristics which included data types, settings, reference standard used, numbers of patients, and conditions validated.

RESULTS

There were 36 eligible studies, including 29 that used external reference standard and seven that validated administrative data using other data within the same database. Chart review was the reference standard in 21 studies (range of the numbers of patients, 72-1674; 11 studies conducted in single institutions and nine studies in 2-5 institutions). Five studies used a disease registry as the reference standard. Diagnoses of cardiovascular diseases, cancer, and diabetes were frequently evaluated.

CONCLUSIONS

Validation studies are being conducted at an increasing rate in Japan, although most of them are small scale. Further large-scale comprehensive validation studies are necessary to effectively utilize the databases for research.

Association between types of home healthcare and emergency house calls, hospitalization, and end-of-life care in Japan

BACKGROUND

To meet the increasing demand for home healthcare in Japan, as part of the national healthcare system, home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in 2006 and 2012 respectively. This study aimed to evaluate whether HCSCs has succeeded in providing 24-h home care services through the end of life.

METHODS

A retrospective cohort study was conducted using the national database in Japan. Participants were ≥ 65 years of age, had newly started regular home visits between July 2014 and September 2015, and used general clinics, conventional HCSCs, or enhanced HCSCs. Each patient was followed up for 6 months after the first visit. The outcome measures were (i) emergency house call(s), (ii) hospitalization(s), and (iii) end-of-life care defined as in-home death. Multivariable logistic regression analyses were performed for statistical analysis.

RESULTS

The analysis included 160,674 patients, including 13,477, 64,616, and 82,581 patients receiving regular home visits by general clinics, conventional HCSCs, and enhanced HCSCs respectively. Compared to general clinics, the use of conventional and enhanced HCSCs was associated with an increased likelihood of emergency house calls (adjusted odds ratio [aOR] and 95% confidence intervals [CIs] of 1.62 [1.56-1.69] and 1.86 [1.79-1.93], respectively) and a decreased likelihood of hospitalizations (aOR [95% CIs] of 0.86 [0.82-0.90] and 0.88 [0.84-0.92] respectively). Among 39,082 patients who died during the follow-up period, conventional and enhanced HCSCs had more in-home deaths (aOR [95% CIs] of 1.46 [1.33-1.59] and 1.60 [1.46-1.74], respectively) compared to general clinics.

CONCLUSIONS

HCSCs (especially enhanced HCSCs) provided more emergency house calls, reduced hospitalization, and enabled expected deaths at home, suggesting that further promotion of HCSCs (especially enhanced HSCSs) would be advantageous.

Prevalence of multimorbidity and its associations with hospitalisation or death in Japan 2014-2019: a retrospective cohort study using nationwide medical claims data in the middle-aged generation

OBJECTIVE

To describe the prevalence of multimorbidity and its associations with clinical outcomes across age groups.

DESIGN

Retrospective cohort study using nationwide medical claims data.

SETTING

Carried out in Japan between April 2014 and March 2019.

PARTICIPANTS

N=246 671 Japanese individuals aged 20-74 enrolled in the health insurance were included into the baseline data set for fiscal year (FY) 2014. Of those, N=181 959 individuals were included into the cohort data set spanning FY2014-FY2018.

EXPOSURES

Multimorbidity was defined as having ≥2 of 15 chronic conditions according to the International Classification of Diseases 10th Revision codes of the Charlson Comorbidity Index.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome: the standardised prevalence of multimorbidity across age groups was evaluated using data from FY2014 and extrapolated to the Japanese total population.

SECONDARY OUTCOME

hospitalisation or death events were traced by month using medical claims data and insurer enrolment data. Associations between multimorbidity and 5-year hospitalisation and/or death events across age groups were analysed using a Cox regression model.

RESULTS

The standardised prevalence rate of multimorbidity in the nationwide Japanese total population was estimated to 26.1%. The prevalence rate with age was increased, approximately 5% (ages 20-29), 10% (30-39), 20% (40-49), 30% (50-59), 50% (60-69) and 60% (70-74). Compared with individuals aged 20-39 without multimorbidity, those with multimorbidity had a higher incidence of clinical events in any age group (HR=2.43 (95% CI 2.30 to 2.56) in ages 20-39, HR=2.55 (95% CI 2.47 to 2.63) in ages 40-59 and HR=3.41 (95% CI 3.23 to 3.53) in ages ≥60). The difference in the incidence of clinical events between multimorbidity and no multimorbidity was larger than that between age groups.

CONCLUSIONS

Multimorbidity is already prevalent in the middle-aged generation and is associated with poor clinical outcomes. These findings underscore the significance of multimorbidity and highlight the urgent need for preventive intervention at the public healthcare level.

Association between exercise and risk of fractures in new-onset type 2 diabetes: a retrospective cohort study

In this population-based retrospective cohort study, exercising before and after the diagnosis of type 2 diabetes was significantly associated with lower risk of fractures. This result suggested that exercising might be effective in reducing fracture risk.

PURPOSE

Patients with diabetes have a significantly higher risk of fractures. We aimed to investigate the association between exercise and fracture risk in new-onset type 2 diabetes.

METHODS

This retrospective cohort study using the Korean National Health Insurance Service database included 170,148 patients with new-onset type 2 diabetes who underwent two cycles of health checkup between 2009-2012 and 2011-2014. The patients were classified into four groups (non-exercising, newly exercising, previously exercising, and continuously exercising) and followed up until the date of fracture, death, or December 31, 2018. Hip fractures, vertebral fractures, and any fractures were defined using diagnostic codes.

RESULTS

The proportions of non-exercising, newly exercising, previously exercising, and continuously exercising patients were 65.1%, 15.7%, 10.9%, and 8.3%, respectively. Continuously exercising patients showed the lowest risk for fractures, followed by newly exercising patients using the non-exercising group as a reference. The adjusted hazard ratios (95% confidence intervals) for hip fracture, vertebral fracture, and any fracture were 0.69 (0.50-0.94), 0.73 (0.63-0.84), and 0.90 (0.83-0.97), respectively, in the continuously exercising group and 0.76 (0.61-0.95), 0.85 (0.76-0.94), and 0.93 (0.88-0.98) in the newly exercising group. The risk was lower in patients who lost less than 5% of their body weight than in those who lost 5% or more.

CONCLUSION

Exercising was associated with lower risk of fractures in newly diagnosed diabetes. However, exercise accompanied by excessive weight loss may not have a significant association with a lower risk of fractures.

The Effect of Home Care Support Clinics on Hospital Readmission in Heart Failure Patients in Japan

BACKGROUND

Heart failure is common and is associated with high rates of hospitalization. Home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in Japan in 2006 and 2012, respectively.

OBJECTIVE

This study aimed to examine the effect of post-discharge care by conventional or enhanced HCSCs on readmission, compared with general clinics.

DESIGN

Retrospective cohort study using the Japanese nationwide health insurance claims database.

PARTICIPANTS

Participants were ≥65 years of age, admitted for heart failure and discharged between July 2014 and August 2015 and received a home visit within a month following the discharge (n=12,393).

MAIN MEASURES

The exposure was the type of medical facility that provides post-discharge home healthcare: general clinics, conventional HCSCs, and enhanced HCSCs. The primary outcome was all-cause readmission for 6 months after the first visit; the incidence of emergency house calls was a secondary outcome. We used a competing risk regression using the Fine and Gray method, in which death was regarded as a competing event.

KEY RESULTS

At 6 months, readmissions were lower in conventional (38%) or enhanced HCSCs (38%) than general clinics (43%). The adjusted subdistribution hazard ratio (sHR) of readmission was 0.87 (95% CI: 0.78-0.96) for conventional and 0.86 (0.78-0.96) for enhanced HCSCs. Emergency house calls increased with conventional (sHR: 1.77, 95% CI:1.57-2.00) and enhanced HCSCs (sHR: 1.93, 95% CI: 1.71-2.17).

CONCLUSIONS

Older Japanese patients with heart failure receiving post-discharge home healthcare by conventional or enhanced HCSCs had lower readmission rates, possibly due to compensation with more emergency house calls. Conventional and enhanced HCSCs may be effective in reducing the risk of rehospitalization. Further studies are necessary to confirm the medical functions performed by HCSCs.

Validation study on definition of cause of death in Japanese claims data

Identifying the cause of death is important for the study of end-of-life patients using claims data in Japan. However, the validity of how cause of death is identified using claims data remains unknown. Therefore, this study aimed to verify the validity of the method used to identify the cause of death based on Japanese claims data. Our study population included patients who died at two institutions between January 1, 2018 and December 31, 2019. Claims data consisted of medical data and Diagnosis Procedure Combination (DPC) data, and five definitions developed from disease classification in each dataset were compared with death certificates. Nine causes of death, including cancer, were included in the study. The definition with the highest positive predictive values (PPVs) and sensitivities in this study was the combination of "main disease" in both medical and DPC data. For cancer, these definitions had PPVs and sensitivities of > 90%. For heart disease, these definitions had PPVs of > 50% and sensitivities of > 70%. For cerebrovascular disease, these definitions had PPVs of > 80% and sensitivities of> 70%. For other causes of death, PPVs and sensitivities were < 50% for most definitions. Based on these results, we recommend definitions with a combination of "main disease" in both medical and DPC data for cancer and cerebrovascular disease. However, a clear argument cannot be made for other causes of death because of the small sample size. Therefore, the results of this study can be used with confidence for cancer and cerebrovascular disease but should be used with caution for other causes of death.

Contemporary use of SGLT2 inhibitors in heart failure patients with diabetes mellitus: a comparison of DPP4 inhibitors in a nationwide electric health database of the superaged society

BACKGROUND

There is a lack of recent data reflecting the actual use of sodium-glucose cotransporter-2 (SGLT2) inhibitors for heart failure (HF) and type 2 diabetes (DM) in the superaged society. The present study investigated the association between the use of SGLT2 inhibitors and one-year prognosis in patients hospitalized across a broad spectrum of HF patients with DM in the superaged society using the Nationwide Electric Health Database in Japan.

METHODS

The patients hospitalized with the first episode of acute HF were identified from the National Database of Health Insurance Claims and Specific Health Checkups of Japan between April 2014 and March 2019. A cohort of 2,277 users of SGLT2 inhibitors and 41,410 users of the active comparator, dipeptidyl peptidase-4 (DPP4) inhibitors were compared. A propensity score-matched cohort study of 2,101 users of each inhibitor was also conducted. A multivariable multilevel mixed-effects survival model was conducted with adjustments, and hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated.

RESULTS

Among 300,398 patients discharged with HF in 4,176 hospitals, 216,016 (71.9%) were 75 years or older, and 60,999 (20.3%) took antidiabetic medications. Among them, the patients treated with SGLT2 inhibitors were younger and had a more severe status than those treated with DPP4 inhibitors. Kaplan-Meier analysis showed that patients treated with SGLT2 inhibitors had a lower mortality risk and HF readmission. In propensity-matched cohorts, SGLT2 inhibitor use was associated with a lower risk of mortality and HF readmission than DPP-4 inhibitor use (HR [95% CI]; 0.70 [0.56, 0.89] and 0.52 [0.45, 0.61], respectively). Very elderly (≥ 75 years) patients showed similar results. Favorable effects were also observed across all age groups, including ≥ 75 years, in patients with coronary artery disease or atrial fibrillation and with concomitant β-blocker, diuretics, or insulin.

CONCLUSION

The use of SGLT2 inhibitors at discharge was associated with a lower risk of one-year mortality and HF readmission in patients across a broad spectrum of HF with DM in the superaged society. The findings further support the benefits of using SGLT2 inhibitors in very elderly HF care and complement the current evidence.

Accuracy of algorithms to identify patients with a diagnosis of major cancers and cancer-related adverse events in an administrative database: a validation study in an acute care hospital in Japan

OBJECTIVES

Validation studies in oncology are limited in Japan. This study was conducted to evaluate the accuracy of diagnosis and adverse event (AE) definitions for specific cancers in a Japanese health administrative real-world database (RWD).

DESIGN AND SETTING

Retrospective observational validation study to assess the diagnostic accuracy of electronic medical records (EMRs) and claim coding regarding oncology diagnosis and AEs based on medical record review in the RWD. The sensitivity and positive predictive value (PPV) with 95% CIs were calculated.

PARTICIPANTS

The validation cohort included patients with lung (n=2257), breast (n=1121), colorectal (n=1773), ovarian (n=216) and bladder (n=575) cancer who visited the hospital between January 2014 and December 2018, and those with prostate cancer (n=3491) visiting between January 2009 and December 2018, who were identified using EMRs.

OUTCOMES

Key outcomes included primary diagnosis, deaths and AEs.

RESULTS

For primary diagnosis, sensitivity and PPV for the respective cancers were as follows: lung, 100.0% (96.6 to 100.0) and 81.0% (74.9 to 86.2); breast, 100.0% (96.3 to 100.0) and 74.0% (67.3 to 79.9); colorectal, 100.0% (96.6 to 100.0) and 80.5% (74.3 to 85.8); ovarian, 89.8% (77.8 to 96.6) and 75.9% (62.8 to 86.1); bladder, 78.6% (63.2 to 89.7) and 67.3% (52.5 to 0.1); prostate, 100.0% (93.2 to 100.0) and 79.0% (69.7 to 86.5). Sensitivity and PPV for death were as follows: lung, 97.0% (84.2 to 99.9) and 100.0% (84.2 to 100.0); breast, 100.0% (1.3 to 100.0) and 100.0% (1.3 to 100.0); colorectal, 100.0% (28.4 to 100.0) and 100.0% (28.4 to 100.0); ovarian, 100.0% (35.9 to 100.0) and 100.0% (35.9 to 100.0); bladder, 100.0% (9.4-100.0) and 100.0% (9.4 to 100.0); prostate, 75.0% (19.4 to 99.4) and 100.0% (19.4 to 100.0). Overall, PPV tended to be low, with the definition based on International Classification of Diseases, 10th revision alone for AEs.

CONCLUSION

Diagnostic accuracy was not so high, and therefore needs to be further investigated.

TRIAL REGISTRATION NUMBER

University Hospital Medical Information Network (UMIN) Clinical Trials Registry (UMIN000039345).

Endovascular versus open repair in patients with abdominal aortic aneurysm: a claims-based data analysis in Japan

Objectives

Endovascular aortic repair (EVAR) evolved through competition with open aortic repair (OAR) as a safe and effective treatment option for appropriately selected patients with abdominal aortic aneurysm (AAA). Although endoleaks are the most common reason for post-EVAR reintervention, compliance with lifelong regular follow-up imaging remains a challenge.

Design

Retrospective data analysis.

Setting

The Japan Medical Data Center (JMDC), a claims database with anonymous data linkage across hospitals, consists of corporate employees and their families of ≤75 years of age.

Participants

The analysis included participants in the JMDC who underwent EVAR or OAR for intact (iAAA) or ruptured (rAAA) AAA. Patients with less than 6 months of records before the aortic repair were excluded.

Main outcome measures

Overall survival and reintervention rates.

Results

We identified 986 cases (837 iAAA and 149 rAAA) from JMDC with first aortic repairs between January 2015 and December 2020. The number of patients, median age (years (IQR)), follow-up (months) and post-procedure CT scan (times per year) were as follows: iAAA (OAR: n=593, 62.0 (57.0–67.0), 26.0, 1.6, EVAR: n=244, 65.0 (31.0–69.0), 17.0, 2.2), rAAA (OAR: n=110, 59.0 (53.0–59.0), 16.0, 2.1, EVAR: n=39, 62.0 (31.0–67.0), 18.0, 2.4). Reintervention rate was significantly higher among EVAR than OAR in rAAA (15.4% vs 8.2%, p=0.04). In iAAA, there were no group difference after 5 years (7.8% vs 11.0%, p=0.28), even though EVAR had initial advantage. There were no differences in mortality rate between EVAR and OAR for either rAAA or iAAA.

Conclusions

Claims-based analysis in Japan showed no statistically significant difference in 5-year survival rates of the OAR and EVAR groups. However, the reintervention rate of EVAR in rAAA was significantly higher, suggesting the need for regular post-EVAR follow-up with imaging. Therefore, international collaborations for long-term outcome studies with real-world data are warranted.

Medical expenditures for fragility hip fracture in Japan: a study using the nationwide health insurance claims database

Using the nationwide health insurance claims database in Japan, we estimated total annual medical expenditures for fragility hip fracture across the population at 329.2 billion yen (2.99 billion US dollars). Long-term care expenditures were not included. Fragility hip fracture imposes a considerable health economic burden on society in Japan.

PURPOSE

Fragility hip fracture imposes a substantial health economic burden on society globally. We aimed to estimate medical expenditures for fragility hip fracture using the nationwide health insurance claims database in Japan.

METHODS

We included adults aged 60 and over without prior hip fracture who were admitted for fragility hip fracture (i.e., femoral neck or extracapsular) between October 2014 and October 2015 (13 months). Fragility hip fracture was identified through newly assigned disease codes for fracture and procedure codes associated with the fracture. As a proxy for medical expenditures per patient, incremental payments were calculated (i.e., the difference between the total payments 6 months before and after fragility hip fracture). The total payments included health insurance reimbursements and copayments for inpatient and outpatient services. Long-term care expenditures were not included in this study.

RESULTS

We identified 142,361 individuals (28,868 male and 113,493 female) with fragility hip fracture. Mean medical expenditures for fragility hip fracture per patient were 2,550,000 yen (¥) (23,180 US dollars [$]; ¥110 = $1) in male and ¥2,494,000 ($22,670) in female patients, respectively. Total annual medical expenditures for fragility hip fracture across the population were 329.2 billion yen (2.99 billion US dollars): 67.96 billion yen (620 million US dollars) in male and 261.24 billion yen (2.37 billion US dollars) in female patients, respectively.

CONCLUSION

This is the first study to estimate medical expenditures for hip fracture using the nationwide health insurance claims database, which represents almost all health insurance claims in Japan. Fragility hip fracture inflicts a considerable health economic burden on society in Japan.

Association between pre-admission anticoagulation and in-hospital death, venous thromboembolism, and major bleeding among hospitalized COVID-19 patients in Japan

Purpose

The coagulation activation leads to thrombotic complications such as venous thromboembolism (VTE) in patients with coronavirus disease‐2019 (COVID‐19). Prophylactic anticoagulation therapy has been recommended for hospitalized COVID‐19 patients in clinical guidelines. This retrospective cohort study aimed to examine the association between pre‐admission anticoagulation treatment and three outcomes: in‐hospital death, VTE, and major bleeding among hospitalized COVID‐19 patients in Japan.

Methods

Using a large‐scale claims database built by the Medical Data Vision Co. in Japan, we identified patients hospitalized for COVID‐19 who had outpatient prescription data at least once within 3 months before being hospitalized. Exposure was set as pre‐admission anticoagulation treatment (direct oral anticoagulant or vitamin K antagonist), and outcomes were in‐hospital death, VTE, and major bleeding. We conducted multivariable logistic regression analyses, adjusting for a single summarized score (a propensity score of receiving pre‐admission anticoagulation) for VTE and major bleeding, due to the small number of outcomes.

Results

Among the 2612 analytic patients, 179 (6.9%) had pre‐admission anticoagulation. Crude incidence proportions were 13.4% versus 8.5% for in‐hospital death, 0.56% versus 0.58% for VTE, and 2.2% versus 1.1% for major bleeding among patients with and without pre‐admission anticoagulation, respectively. Adjusted odds ratios (95% confidence intervals) were 1.25 (0.75–2.08) for in‐hospital death, 0.21 (0.02–1.97) for VTE, and 2.63 (0.80–8.65) for major bleeding. Several sensitivity analyses did not change the results.

Conclusions

We found no evidence that pre‐admission anticoagulation treatment was associated with in‐hospital death. However, a larger sample size may be needed to conclude its effect on VTE and major bleeding.

Key Characteristics of Database Studies on Drug Effectiveness in the Postmarketing Stage: A Systematic Review

BACKGROUND

In recent years, real-world data (RWD) have been actively used in the field of pharmaceutical research. Database (DB) study, one of the observational studies using RWD, is a comprehensive, continuous, and rapid research method that plays an important role in the postmarketing stage of drugs, although the interpretation of the results may be limited. DB studies are often focused on drug safety, and previous research reviewing DB studies on drug effectiveness across different disease areas have been limited.

OBJECTIVE

The objective of this review was to reveal the current status of DB studies on drug effectiveness in various therapeutic areas and to provide information that allows researchers to consider conducting appropriate DB studies on drug effectiveness in the postmarketing stage.

METHODS

For this systematic review, we searched Embase and MEDLINE for DB studies on drug effectiveness published between 1 January 2018 and 31 December 2019. We reviewed the title, abstract, and methods to identify studies on drug effectiveness using medical information DBs, and excluded non-medical studies, studies on non-drug, and studies on drug safety, actual use, or cost outcomes that did not include any effectiveness outcomes. The name and type of the DB (administrative claims DB, clinical DB, pharmacy DB, and DB linkage), study design, comparison group, type of outcome, and presence or absence of reference to the outcome definition were extracted and summarized according to disease areas.

RESULTS

We obtained 225 articles on DB studies on drug effectiveness using DBs that integrate large-scale medical data for secondary use across different disease areas. Among the DB classifications, administrative claims DBs (70%, 158/225) were most commonly used, while pharmacy DBs were used in only three studies. The largest number of reported studies were associated with cardiovascular, respiratory, and infectious diseases. Outcomes were often inpatient diagnosis, and some ideas included defining effectiveness based on drug use. While various outcomes were uniformly used in studies for the treatment of infectious diseases and respiratory organs, death (overall survival [OS]) and drug continuation (progression-free survival [PFS]) in patients with cancer, laboratory values in the endocrine system (mainly diabetes) were used as the main outcomes. Outcome validation within the article was limited. New user design (32%, 73/225), propensity score analysis (58%, 131/225), and sensitivity analysis (40%, 90/225) were used as measures to reduce bias in these studies. Sixty-eight studies (30%, 68/225) were supported by pharmaceutical companies.

CONCLUSIONS

This systematic review summarized the status of cross-disease research articles on DB studies on drug effectiveness. While considering the strengths and limitations of DB studies, we hope that our comprehensive results would help to promote appropriate DB studies on drug effectiveness in the postmarketing stage.

Associations of kidney tests at medical facilities and health checkups with incidence of end-stage kidney disease: a retrospective cohort study

No study has assessed the association between no health checkup and end-stage kidney disease (ESKD). This retrospective cohort study, including 69,147 adults aged ≥ 40 years in Japan who were insured by the National Health Insurance and the Late-Stage Medical Care System for the Elderly, assessed the associations of kidney tests at medical facilities and health checkups with incident ESKD. The main exposure was the histories of kidney tests using dipstick urinalysis and/or serum creatinine measurement at medical facilities and checkups in the past year: “checkups,” “no kidney test (without checkup),” and “kidney tests (without checkup)” groups. During the median observational period of 5.0 years, ESKD was observed in 246 (0.8%) men and 124 (0.3%) women. The “no kidney test” group was associated with ESKD in men (adjusted subhazard ratio of “no kidney test” vs. “checkups”: 1.66 [95% confidence interval, 1.04–2.65], but not in women. Age-specific subgroup analyses identified the “no kidney test” group as a high-risk population of ESKD in elderly men (1.30 [0.70–2.41] and 2.72 [1.39–5.33] in men aged 40–74 and ≥ 75 years, respectively). Elderly men with no kidney test at medical facilities and no health checkup were at higher risk of ESKD.

Validity of diagnoses and procedures in Japanese dental claims data

BACKGROUND

Dental claims data have been used for epidemiological studies without establishing the validity of the recorded diagnoses or procedures. The present study aimed to examine the accuracy of diagnoses, procedures, operation time, and the number of teeth recorded in dental claims data.

METHODS

We reviewed the charts of 200 patients who visited and 100 patients who were hospitalized in the Department of General Dentistry, Orthodontics, and Oral and Maxillofacial Surgery in an academic hospital between August 2012 and December 2017. The sensitivity and specificity of the dental claims data for five diseases and 15 procedures were evaluated. We assessed the difference in the number of teeth and duration of general anesthesia between claims data and chart reviews.

RESULTS

Sensitivity was more than 86% for six out of seven diagnoses except for pericoronitis (67%). Specificity ranged from 72% (periodontal disease) to 100% (oral cancer for inpatient). The sensitivity of procedures ranged from 10% (scaling for inpatient) to 100%, and the specificity ranged from 6% (food intake on the day of the surgery) to 100%. The mean (standard deviation [SD]) number of teeth in the chart review was 22.6 (6.8), and in the dental claims was 21.6 (8.6). The mean (SD) operation time was 171.2 (120.3) minutes, while the duration of general anesthesia was 270.9 (171.3) minutes.

CONCLUSIONS

The present study is the first study to validate dental claims data, and indicates the extent of usefulness of each diagnosis and procedure for future dental research using administrative data.

Economic Status and Mortality in Patients with Alzheimer's Disease in Japan: The Longevity Improvement and Fair Evidence Study

OBJECTIVES

As more countries are implementing measures to address Alzheimer's disease (AD), it is essential to update the available knowledge on the relationship between economic status and mortality in patients with AD. This study examined the influence of economic status on mortality in Japanese individuals with AD using a medical claims dataset.

DESIGN

This was a retrospective cohort study.

SETTING AND PARTICIPANTS

Medical claims data from April 2014 to March 2019 were obtained from 13 local cities participating in the Longevity Improvement and Fair Evidence study. The inclusion criteria were patients aged 65 years and older who were newly diagnosed with AD during the study period.

METHODS

The outcome was death during the follow-up period. We assessed economic status by household income (middle to high income and low income); data were obtained from the use of the Medical Expenditure Ceiling Application and Standard Copayment Reduction Card (fee reduction card) when receiving an AD diagnosis, as an indicator of low-income status. We performed multivariate Cox proportional hazards analyses to examine the relationship between economic status and mortality; the model was adjusted for age, sex, the Charlson comorbidity index, and antidementia drug use.

RESULTS

We identified 39,081 newly diagnosed patients with AD from the Longevity Improvement and Fair Evidence study database (mean age, 83.6 years; female, 67.1%). Of these, 3189 individuals were identified as having a low-income status. After adjusting for possible confounders, low-income status was associated with mortality (hazard ratio, 1.95; 95% confidence interval, 1.84-2.07).

CONCLUSIONS AND IMPLICATIONS

Low-income status was associated with substantially poorer prognoses in new AD cases, indicating a need for a thorough examination of medical and nursing care services utilized by low-income individuals with AD and to explore improvement strategies.

Current Status, Challenges, and Future Perspectives of Real-World Data and Real-World Evidence in Japan

Abstract

The aim of this article is to help develop a common understanding of the current status, challenges, and future perspectives of real-world data (RWD) and real-world evidence (RWE) in Japan. RWD and RWE are very widely used terms, but standardized definitions are lacking. Given broad and growing applications of RWD/RWE from the perspective of clinical development and medical affairs, the PhRMA Japan Medical Affairs Committee Working Group 1 have proposed the following definitions: “RWD are the data relating to patient health status and/or the delivery of health care routinely collected from a variety of sources” and “RWE is the evidence derived from analysis of RWD.” The key challenges for RWD and RWE in Japan include restricted access and linkage of RWD, as well as a lack of universally accepted methodological approaches, which reduces the potential for patient and healthcare benefits. These challenges for RWD/RWE are by no means unique to Japan and similar challenges exist for countries in Europe and the USA. The quality of data and analysis, study design, and the transparency of reporting should be discussed more to ensure credibility and acceptance by decision-makers as the demand for RWD and RWE increases. The future developments around Japan’s RWD and RWE are expected to include improved RWD access, data linkage, and increased acceptance by decision-makers, all supported by innovative technology. Improvements in RWD access and database linkage will enable both public and private sectors to assemble more comprehensive health information in Japan.

Video abstract

Validity of claims-based algorithms for selected cancers in Japan: Results from the VALIDATE-J study

Purpose

Real‐world data from large administrative claims databases in Japan have recently become available, but limited evidence exists to support their validity. VALIDATE‐J validated claims‐based algorithms for selected cancers in Japan.

Methods

VALIDATE‐J was a multicenter, cross‐sectional, retrospective study. Disease‐identifying algorithms were used to identify cancers diagnosed between January or March 2012 and December 2016 using claims data from two hospitals in Japan. Positive predictive values (PPVs), specificity, and sensitivity were calculated for prevalent (regardless of baseline cancer‐free period) and incident (12‐month cancer‐free period; with claims and registry periods in the same month) cases, using hospital cancer registry data as gold standard.

Results

22 108 cancers were identified in the hospital claims databases. PPVs (number of registry cases) for prevalent/incident cases were: any malignancy 79.0% (25 934)/73.1% (18 119); colorectal 84.4% (3519)/65.6% (2340); gastric 87.4% (3534)/76.8% (2279); lung 88.1% (2066)/79.9% (1636); breast 86.4% (4959)/59.9% (3185); pancreatic 87.1% (582)/80.4% (508); melanoma 48.7% (46)/42.9% (36); and lymphoma 83.6% (1457)/77.8% (1035). Specificity ranged from 98.3% to 100% (prevalent)/99.5% to 100% (incident); sensitivity ranged from 39.1% to 67.6% (prevalent)/12.5% to 31.4% (incident). PPVs of claims‐based algorithms for several cancers in patients ≥66 years of age were slightly higher than those in a US Medicare population.

Conclusions

VALIDATE‐J demonstrated high specificity and modest‐to‐moderate sensitivity for claims‐based algorithms of most malignancies using Japanese claims data. Use of claims‐based algorithms will enable identification of patient populations from claims databases, while avoiding direct patient identification. Further research is needed to confirm the generalizability of our results and applicability to specific subgroups of patient populations.

Elucidating variations in outcomes among older end-stage renal disease patients on hemodialysis in Fukuoka Prefecture, Japan

Variations in health care outcomes and services potentially indicate resource allocation inefficiency. Therefore, this study was conducted to examine variations in mortality and hospitalization cases among end-stage renal disease (ESRD) patients receiving hemodialysis (HD) care from medical facilities located in 13 secondary medical care areas (SMAs) of Fukuoka prefecture, Japan. The research was designed as a retrospective, cross-sectional study using insurance claims data. The subjects of the study were older patients (over 65 years old) insured by the Fukuoka prefecture’s Latter-Stage Elderly Healthcare Insurance. Using an electronic claims database, we identified patients with chronic kidney disease (CKD) who had received HD care from April 1, 2017 to March 31, 2018. The CKD status was identified using International Classification of Disease, 10th revision code, and HD maintenance status was ascertained using specific insurance procedure codes. A total of 5,243 patients met our inclusion criteria and their records were subsequently reviewed. About 73% (n = 3,809) of patients had admission records during the period studied. Thus, the data regarding hospital length of stay (LOS) and admission costs were analyzed separately. Significant differences in terms of increased risks in hospitalization were evident in a number of SMAs. An increase in mortality risk due to heart failure and malignancy was observed in two separate SMAs. Also, analyzed LOS, total hospitalization cost, and cost per day according to SMAs showed statistically significant variations. The findings highlight the magnitude of the burden of CKD and ESRD in the community. The high prevalence of ESRD, associated mortality, and hospitalized HD patients signal the need for clinicians to assume broader roles in measures against chronic kidney disease through involvement in community awareness programs. To improve patient outcomes, improvement of regional health care provision, the level of medical care, and the development of existing human resources are needed.

Data resource profile: JMDC claims database sourced from health insurance societies

JMDC, Inc. (JMDC) has created a database, using data collected from health insurance societies in Japan, consisting of ledgers of insureds, claims (for hospitalization, outpatient treatment, drug preparation, and dental treatment), and health checkup results. The earliest data are from the claims in January 2005, except dental claims from December 2009 and health checkup results from April 2008. Currently (the end of June 2020), the number of insureds included is approximately 9.8 million. This database is unique for Japan and has the following characteristics: (a) the basic population can be ascertained; (b) standardization is carried out using a dictionary; and (c) anonymized individual IDs can be followed on the basis of a time-series over various periods, with the earliest starting date being January 2005. However, it has certain limitations, in that the disease status and test results cannot be ascertained, and there is insufficient access to data for elderly people.

Decreased Administration of Life-Sustaining Treatment just before Death among Older Inpatients in Japan: A Time-Trend Analysis from 2012 through 2014 Based on a Nationally Representative Sample

The administration of intensive end-of-life care just before death in older patients has become a major policy concern, as it increases medical costs; however, care intensity does not necessarily indicate quality. This study aimed to describe the temporal trends in the administration of life-sustaining treatments (LSTs) and intensive care unit (ICU) admissions just before death in older inpatients in Japan. We utilized the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB). Inpatients who were aged ≥65 years and died in October of 2012, 2013, or 2014 were analyzed. The numbers of decedents in 2012, 2013, and 2014 were 3362, 3473, and 3516, respectively. The frequencies of receiving cardiopulmonary resuscitation (CPR) (11.0% to 8.3%), mechanical ventilation (MV) (13.1% to 9.8%), central venous catheter (CVC) insertion (10.6% to 7.8%), and ICU admission (9.1% to 7.8%), declined between 2012 and 2014. After adjusting for age, sex, and type of ward, the declining trends persisted for CPR, MV, and CVC insertion relative to the frequencies in 2012. Our results indicate that the administration of LST just before death in older inpatients in Japan decreased from 2012 to 2014.

Reduction in inequalities in health insurance coverage and healthcare utilization among older adults in the Philippines after mandatory national health insurance coverage: trend analysis for 2003-2017

BACKGROUND

Health policies in the Philippines have evolved in response to increasing health demands of older adults. However, there is a lack of research on equity among the ageing population in low-middle income countries. The objective of this study was to identify the trends in National Health Insurance Program (NHIP) coverage and healthcare utilization among older adults in the Philippines for the period from 2003 to 2017, during which NHIP expansion policies were implemented, focusing on reductions in socio-economic inequalities.

METHODS

A literature search of policies for older adults and an analysis of four Philippine National Demographic and Health Surveys (2003, 2008, 2013, and 2017) with data from 25,217 older adults who were 60 years or older were performed. The major outcome variables were NHIP coverage, self-reported illness, outpatient healthcare utilization, and inpatient healthcare utilization. Inequalities in NHIP coverage and healthcare utilization according to wealth were evaluated by calculating the concentration index for individual years, followed by a regression-based decomposition analysis.

RESULTS

NHIP coverage among older adults increased from 9.4 (2003) to 87.6% (2017). Although inequalities according to wealth quintile were observed in all four surveys (all P < 0.001), the concentration index declined from 0.3000 (2003) to 0.0247 (2017), showing reduced inequalities in NHIP coverage over time as observed for self-reported illness and healthcare utilization. NHIP coverage expansion for older adults in 2014 enabled equal opportunity for access to healthcare.

CONCLUSION

The passage of mandatory NHIP coverage for older Filipino adults in 2014 was followed by a reduction in inequality in NHIP coverage and healthcare utilization according to wealth.