Incidence of opportunistic infections in patients with rheumatoid arthritis treated with different molecular-targeted drugs: A population-based retrospective cohort study

OBJECTIVES

We compared the incidences of four opportunistic infections (OIs) in patients with rheumatoid arthritis (RA) treated with molecular-targeted drugs from big claims data.

MATERIALS AND METHODS

We identified 205,906 patients with RA who were prescribed molecular-targeted drugs in 2010-17 from the National Database of Japan and calculated the incidence of four OIs (Pneumocystis pneumonia, tuberculosis, nontuberculous mycobacterial infection, and herpes zoster).

RESULTS

The total number of Pneumocystis pneumonia, tuberculosis, nontuberculous mycobacterial infection, and herpes zoster patients with biological disease-modifying antirheumatic drugs or tofacitinib treatment history in RA was 765, 1158, 834, and 18,336, respectively. The incidence rates of each OI for all biological disease-modifying antirheumatic drugs were 0.14, 0.14, 0.09, and 2.40 per 100 person-years, respectively, while for tofacitinib they were 0.22, 0.22, 0.07, and 7.00 per 100 person-years. No big difference was observed among biological disease-modifying antirheumatic drugs. All OIs showed higher incidence in those >65 years, but Pneumocystis pneumonia, nontuberculous mycobacterial infection, and herpes zoster showed no difference between those 65-74 years old and those >75 years old. The median of occurrence was the third, seventh, ninth, and thirteenth month after treatment, respectively.

CONCLUSIONS

We counted real incidence rates of OIs for the whole nation from big claims data.

Seasonal exacerbation of rheumatoid arthritis detected by big claims data analysis: A retrospective population study

OBJECTIVES

The objective of the study was to determine the seasonal changes in the initiation of biological disease-modifying antirheumatic drugs (bDMARDs) and methotrexate (MTX) using big claims data.

METHODS

We counted the monthly number of initial administrations of each bDMARD and MTX in patients with rheumatoid arthritis (RA) between April 2010 and March 2017. Data were collected from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. This database covers more than 95% of Japanese citizens. Seasonal changes in the number of initiations were determined. Patient claims were also classified according to drugs, districts, gender, and ages.

RESULTS

The initiation of bDMARDs and MTX administration varied according to the season in a sine curve shape, with the highest numbers in May to July and the lowest numbers in November to January. The same changing pattern was observed among each bDMARD, district, gender, and age groups particularly when the number was on the higher side.

CONCLUSION

We noted an apparent seasonal change in the number of bDMARDs initiated, with a peak during spring, suggesting an exacerbation of RA in the spring in Japan. These changes are overlooked in daily practice and are only visible using big data.

Effects of Arterial Stiffness on Cerebral WM Integrity in Older Adults: A Neurite Orientation Dispersion and Density Imaging and Magnetization Transfer Saturation Imaging Study

BACKGROUND AND PURPOSE

Arterial stiffness is reported to be able to cause axonal demyelination or degeneration. The present study aimed to use advanced MR imaging techniques to examine the effect of arterial stiffness on the WM microstructure among older adults.

MATERIALS AND METHODS

Arterial stiffness was measured using the cardio-ankle vascular elasticity index (CAVI). The high-CAVI (mean CAVI ≥ 9 points) and the low-CAVI groups (mean CAVI < 9 points) were created. The neuronal fiber integrity of the WM was evaluated by neurite orientation dispersion and density imaging and magnetization transfer saturation imaging. Tract-Based Spatial Statistics and the tracts-of-interest analysis were performed. Specific WM regions (corpus callosum, internal capsule, anterior thalamic radiation, corona radiata, superior longitudinal fasciculus, forceps minor, and inferior fronto-occipital fasciculus) were selected in the tracts-of-interest analysis.

RESULTS

In Tract-Based Spatial Statistics, the high-CAVI group showed a significantly lower myelin volume fraction value in the broad WM and significantly higher radial diffusivity and isotropic volume fraction values in the corpus callosum, forceps minor, inferior fronto-occipital fasciculus, internal capsule, corona radiata, and anterior thalamic radiation than the low-CAVI group. In tracts-of-interest analysis using multivariate linear regression, significant associations were found between the mean CAVI and radial diffusivity in the anterior thalamic radiation and the corona radiata; isotropic volume fraction in the anterior thalamic radiation and the corona radiata; and myelin volume fraction in the superior longitudinal fasciculus (P < .05). Additionally, partial correlation coefficients were observed for the significant associations of executive function with radial diffusivity and myelin volume fraction (P < .05).

CONCLUSIONS

Arterial stiffness could be associated with demyelination rather than axonal degeneration.

An Investigation of Water Diffusivity Changes along the Perivascular Space in Elderly Subjects with Hypertension

BACKGROUND AND PURPOSE

Hypertension may be related to alterations of the glymphatic system, a waste metabolite drainage system in the brain. We aimed to investigate analysis along the perivascular space index changes in elderly subjects with hypertension.

MATERIALS AND METHODS

Diffusion-weighted images were acquired from 126 subjects, including 63 subjects with hypertension (25 men and 38 women; mean age, 72.45 years) and 63 age- and sex-matched controls (25 men and 38 women; mean age, 72.16 years). We calculated the analysis along the perivascular space index as a ratio of the mean of x-axis diffusivities in the projection and association areas to the mean of y-axis diffusivity in the projection area and z-axis diffusivity in the association area. The left, right, and mean analysis along the perivascular space indices of both hemispheres were compared between the hypertension and control groups using a Mann-Whitney U test. The Spearman correlation coefficient was used to assess the correlation between the left, right, and mean ALPS indices and blood pressure and pulse pressure.

RESULTS

The left (P = .011) and mean (P = .024) analysis along the perivascular space indices of the hypertension group were significantly lower than that of the control group. The left, right, and mean analysis along the perivascular space indices of all subjects were significantly negatively correlated with blood pressure values (r = -0.200 to -0.278, P = .002-0.046) and pulse pressure values (r = -0.221 to -0.245, P = .006-0.013).

CONCLUSIONS

Our results are consistent with a model in which hypertension causes glymphatic dysfunction.

Trend in Prescription and Treatment Retention of Molecular-Targeted Drugs in 121,131 Japanese Patients With Rheumatoid Arthritis: A Population-Based Real-World Study

OBJECTIVES

To describe the real-world prescription and treatment retention of molecular-targeted drugs for rheumatoid arthritis (RA) in Japan.

MATERIALS AND METHODS

204,416 patients with RA prescribed at least one of the eight molecular-targeted drugs in 7 years from the National Database of Health Insurance Claims and Specific Health Checkups of Japan covering 98.3% of the Japanese population. The retention rate of each drug as well as head-to head comparisons were estimated by Kaplan-Meier method.

RESULTS

121,131 RA patients were prescribed any molecular-targeted drug for the first time, while 36,633 uses of molecular-targeted drug switched from another (switch use). The overall retention rates of molecular-targeted drugs at 12, 36, and 60 months were 0.64, 0.42, and 0.32 for the naïve use and 0.59, 0.40, and 0.31 for the switch use, respectively. Non-tumor necrosis factor (TNF)-inhibitor molecular-targeted drugs, particularly tocilizumab and tofacitinib, had higher retention rates than TNF inhibitors for both naïve and switch uses regardless of the previous drug, and showed higher retention rates in head-to-head comparisons between eight molecular-targeted drugs.

CONCLUSIONS

Our data reveal that the real-world drug retention is overall lower than previously reported and higher with non-TNF inhibitors than with TNF inhibitors.

Living alone combined with physical frailty or cognitive frailty is independent risk factor of outcomes in the patients with acute heart failure after discharge

Background

Living status is an important factor to manage the conditions of acute heart failure (AHF) patients after discharge. In patients with heart failure (HF), a frailty is a common and serious complication. However, the association between living alone and the outcome in HF patients have not been well described.

Purpose

The purpose of this study is to identify the association between living alone and following outcomes. Furthermore, we reveal the impact of living alone combined with physical or cognitive frailty in AHF patient after discharge.

Methods

We have enrolled 1117 discharged patients with AHF in the Kitakawachi Clinical Background and Outcome of Heart Failure Registry (KICKOFF Registry; 13 hospitals in a city in Japan) from April 2015 to January 2017. The KICKOFF Registry is a prospective multicenter community-based cohort of AHF patients. We defined physical frailty as impossible outdoor walking and cognitive frailty as dementia. We divided into three groups, living without alone (non-alone, n=898), living alone without frailty (alone without frailty, n=148) and living alone with physical or cognitive frailty (alone with frailty, n=71). We compared the clinical characteristics and outcomes between three groups. We defined a primary outcome as a composite endpoint that included all-cause mortality and hospitalization for HF.

Results

During the follow-up period whose median was 573 days, a total of 548 patients (49.1%) had the composite endpoint, and the highest proportion of the composite endpoint was in alone with frailty, 63.4%. This was followed by 49.2% in non-alone, and 41.2% in alone without frailty. In the Kaplan-Meier analyses, the composite endpoint was a significantly higher in alone with frailty than the other groups (Figure A), but there was no significant difference between all patients with living alone and those without living alone (Figure B). After adjustment by gender, age, and the other co-morbidities (HF, coronary artery disease, valvular disease, hypertension, diabetes, atrial fibrillation and chronic kidney disease) in the Cox proportional hazard model, the composite endpoint hazard ratio (HR) increased significantly in the factor of alone with frailty when compared with the others (adjusted HR, 1.38; 95% confidence interval, 1.00–1.86; p=0.048).

Conclusion

In this study, the patients with only living alone have not independently prognostic impact, but those with living alone combined physical frailty or cognitive frailty have independently prognostic impact after discharged AHF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This research was supported by research funding from Nakajima Steel Pipe Company Limited.

P2263Prognostic impact of perceived social isolation in patients with heart failure

Background

Perceived social isolation (SI), the subjective sense of feelings of loneliness or isolation, has a negative impact on health outcomes, particularly in older adults. Although SI may also contribute to poor prognosis in patients with HF, evidence on the relationship between SI and outcomes in patients with HF is limited.

Purpose

The aim of this study was to investigate the relationship between SI and hospital readmission in patients with HF.

Methods

This study was a single center prospective cohort study. We consecutively enrolled 203 patients (mean age 72.9±11.7) who admitted for acute HF or exacerbation of chronic HF. At hospital discharge, we assessed perceived SI by using Lubben Social Network Scale - 6 (LSNS-6). Lower scores in LSNS-6 represents greater SI. Study outcome was rehospitalization for worsening HF within 180 days after discharge. We selected the optimal cutoff point of LSNS-6 that predict a worse outcome by the receiver operating characteristic (ROC) curve analysis. We investigate the association between SI and 180-days HF rehospitalization by using Cox proportional-hazard models, controlling for potential confounding factors.

Results

During follow up, A total of 40events (19.7%) were observed. The optimal cut-off point of LSNS-6 score was 17 points (the area under the ROC curve: 0.62, p<0.05, sensitivity: 82.5%, specificity 42.4%). Kaplan-Meier survival curves showed that those patients with greater SI (LSNS-6≤17) presented significantly higher HF rehospitalization rate (Figure). After adjusting for several pre-existing prognostic factors, LSNS-6≤17 was independently associated with HF rehospitalization (hazard ratio2.15,95% confidence interval 1.00–4.89).

Conclusion

The present study shows that SI is a independent predictor of HF rehospitalization in patients with HF. Assessing SI in the clinical practice with a brief screening tool may help identify patients with heart failure at greater risk of rehospitalization.

P6332Prevalence and prognostic impact of sarcopenia identified according to Asia Working Group for Sarcopenia definition in non-dependent elderly patients with heart failure

Background

Sarcopenia is a geriatric syndrome characterized by loss of muscle mass and muscle function. As the population ages, there is a growing worldwide interest in the intersection of sarcopenia and heart failure (HF). However, estimates of the prevalence of sarcopenia in HF vary widely because of difference in diagnostic criteria. Although the Asian Working Group of Sarcopenia (AWGS) has announced a consensus on the diagnostic criteria of sarcopenia in Asian people, the prevalence and prognostic impact of sarcopenia based on AWGS criteria in patients with HF remains unclear.

Purpose

The aim of this study was to investigate the prevalence and predictive value of sarcopenia identified according to AWGS definition in non-dependent elderly patients with HF.

Methods

This study was a prospective, single-center cohort study in Japan. We consecutively enrolled 274 patients, aged 65 years or older, hospitalized due to acute HF or acute exacerbation of chronic HF and who were able to walk at least 20 m at discharge. Patients with severe cognitive or psychiatric disorders were excluded. Patients with implantable cardiac pacemaker or cardioverter defibrillator were also excluded because skeletal muscle mass was estimated by using bioimpedance analysis. At hospital discharge, we collected data on age, gender, left ventricular ejection fraction, brain natriuretic peptide, estimate glomerular filtration rate, body mass index and sarcopenia. Sarcopenia was diagnosed according to the AWGS criteria: low skeletal muscle index (<7.0 kg/m2 in men, <5.7 kg/m2 in women) and either slow usual walking speed (<0.8 m/s) or low handgrip strength (<26 kg in men, <17 kg in women). Study outcome was rehospitalization for worsening HF within 180 days after discharge. We assessed the independent association between sarcopenia and HF rehospitalization by using multivariate Cox proportional hazards regression analysis.

Results

In this study, a total of 199 patents (43.4%) fulfilled sarcopenia criteria at discharge. During follow-up, 57 patients (20.8%) readmitted for HF. Kaplan-Meier survival curves showed that patients with sarcopenia had significantly lower event-free survival than those without sarcopenia (Figure). After adjusting for other prognostic factors, sarcopenia was independently associated with HF rehospitalization (hazard ratio: 2.31, 95% confidence interval: 1.20–4.53).

Conclusion

Based on AWGS criteria, sarcopenia is highly prevalent even among non-dependent elderly HF patients, and is an independent strong predictor of rehospitalization for worsening HF. AWGS criteria for sarcopenia may be useful for risk prediction in HF.

P6360Prognostic value of polypharmacy in patients with heart failure

Background

Polypharmacy creates an increased patient's burden by drug-drug interactions and poor adherence. However, there are very few studies available evaluating the association of polypharmacy with hospital readmission in patients with heart failure (HF).

Purpose

The aim of this study was to investigate the impact of polypharmacy on hospital readmission for HF.

Methods

We enrolled 1253 patients who were hospitalized with acute heart failure (AHF) or acute exacerbation of chronic heart failure in the Kitakawachi Clinical Background and Outcome of Heart Failure Registry (KICKOFF Registry) from April 2015 to July 2018 (age 78.1±11.5 years, male 51.4%). Our Registry is a prospective multicenter community-based cohort study of HF patients in Japan. The inclusion criteria for the registry was a diagnosis of HF during hospitalization according to the Framingham criteria, and there were no exclusion criteria. From data at discharge, we collected data on clinical characteristics, medication schedule, and social backgrounds. We defined polypharmacy as the use of seven or more medications. The primary end point was HF rehospitalization within 1 year after discharge. Cox proportional hazards regression analysis was used to describe the association between polypharmacy and 1-year HF rehospitalization, controlling for potential confounding factors.

Results

In this study, the prevalence of polypharmacy was 59.7% of all patients. Patients with polypharmacy were more likely to have comorbidities such as hypertension, dyslipidemia, diabetes, chronic kidney disease, coronary artery disease and dementia. They also had lower EF (50.9±0.64 vs 53.6±0.80, p<0.01), compared to patients without polypharmacy. There was no significant difference in age, gender and BMI, compared to patients without polypharmacy. During the follow-up period, a total of 278 patients (24.9%) were readmitted for HF. In Kaplan-Meier analyses, hospital readmission for HF during 1-year follow-up was significantly higher in patients with polypharmacy (p<0.01) (figure). After adjusting for gender, age, EF, and the other co-morbidities, polypharmacy was independently associated with higher risk of rehospitalization for HF (hazard ratio 1.28, 95% confidence interval, 1.07–1.52, p<0.01).

Conclusion

Polypharmacy is an independent predictor of hospital readmission for HF. Our study suggests the need for developing an effective strategy to choose the appropriate drugs in patients with HF.

Acknowledgement/Funding

Nakajima Steel Pipe

Comparing the effectiveness of biological disease-modifying antirheumatic drugs using real-world data

OBJECTIVES

The objective of this study is to compare the effectiveness of biological disease-modifying antirheumatic drugs (bDMARDs) by analyzing claims data of 13 Japanese national university hospitals.

METHODS

We evaluated 4970 cases of rheumatoid arthritis treated with bDMARDs from the Clinical Information Statistical Analysis database, which has collected and integrated 13 Japanese national university hospitals' claims data for 10 years. We surveyed the medications and calculated the retention rates of bDMARDs using the Kaplan-Meier method and differentiated the effectiveness between the two bDMARDs by comparing the retention rates after switching from one drug to another.

RESULTS

Of the 4970 cases, 1364 switched bDMARDs at least once. Tocilizumab (TCZ) reported the highest retention rate, whereas abatacept (ABT) revealed a similar rate compared with only naïve cases. The retention rate curves were higher in cases on TCZ that switched from the other bDMARDs than those in the reversed cases. Following TCZ, ABT and etanercept indicated better results than the other bDMARDs.

CONCLUSION

We could compare the effectiveness among bDMARDs by differentiating the retention rates from big claims data. TCZ reported higher retention rates in both naïve and switched cases than other bDMARDs.

Discussion of “Attitude of Physi -cians Towards Automatic Alerting in Computerized Physician Order Entry Systems”

With these comments on the paper “Attitude of Physicians Towards Automatic Alerting in Computerized Physician Order Entry Systems”, written by Martin Jung and co authors, with Dr. Elske Ammenwerth as senior author [1], the journal wants to stimulate a broad discussion on computerized physi cian order entry systems. An international group of experts have been invited by the editor of Methods to comment on this paper. Each of the invited commentaries forms one section of this paper.

Commentaries on “Informatics and Medicine: From Molecules to Populations”

Objective: To discuss interdisciplinary research and education in the context of informatics and medicine by commenting on the paper of Kuhn et al. “Informatics and Medicine: From Molecules to Populations”.

Method: Inviting an international group of experts in biomedical and health informatics and related disciplines to comment on this paper.

Results and Conclusions: The commentaries include a wide range of reasoned arguments and original position statements which, while strongly endorsing the educational needs identified by Kuhn et al., also point out fundamental challenges that are very specific to the unusual combination of scientific, technological, personal and social problems characterizing biomedical informatics. They point to the ultimate objectives of managing difficult human health problems, which are unlikely to yield to technological solutions alone. The psychological, societal, and environmental components of health and disease are emphasized by several of the commentators, setting the stage for further debate and constructive suggestions.

Automatic DPC Code Selection from Electronic Medical Records

Objectives: We extracted index terms related to diseases recorded in hospital discharge summaries and examined the capability of the vector space model to select a suitable diagnosis with these terms.

Methods: By morphological analysis, we extracted index terms and constructed an original dictionary for the discharge summary analysis. We chose 125 different DPC (Japanese DRG system) codes for the diseases, each of which had more than 20 cases. We divided them into two groups. One group consisted of 5927 cases from 2004 fiscal year and was used to generate the document vector space according to the DPC. The other group of 3187 cases was collected to verify the automatic DPC selection by using data from 2005 fiscal year. The top 200 extracted index terms for each disease were used to calculate the weight of each disease.

Results: The DPC code obtained by the calculated similarity was compared with the original codes of patients for 125 DPCs of 3187 cases. Eighty percent of the cases matched the diagnosis of the DPC (first six digits) and 56% of the cases completely matched all 14 digits of the DPC.

Conclusions: We demonstrated that we could extract suitable terms for each disease and obtain characteristics, such as the diagnosis, from the calculated vectors. This technique can be used to measure the qualification of discharge summaries and to integrate discharge summaries among different facilities. By the text mining technique, we can characterize the contents of electronic discharge summaries and deduce diagnoses with the data.

Estimation and Evaluation of Future Demand and Supply of Healthcare Services Based on a Patient Access Area Model

Accessibility to healthcare service providers, the quantity, and the quality of them are important for national health. In this study, we focused on geographic accessibility to estimate and evaluate future demand and supply of healthcare services. We constructed a simulation model called the patient access area model (PAAM), which simulates patients’ access time to healthcare service institutions using a geographic information system (GIS). Using this model, to evaluate the balance of future healthcare services demand and supply in small areas, we estimated the number of inpatients every five years in each area and compared it with the number of hospital beds within a one-hour drive from each area. In an experiment with the Tokyo metropolitan area as a target area, when we assumed hospital bed availability to be 80%, it was predicted that over 78,000 inpatients would not receive inpatient care in 2030. However, this number would decrease if we lowered the rate of inpatient care by 10% and the average length of the hospital stay. Using this model, recommendations can be made regarding what action should be undertaken and by when to prevent a dramatic increase in healthcare demand. This method can help plan the geographical resource allocation in healthcare services for healthcare policy.

Quality Requirements for Electronic Health Record Systems*. A Japanese-German Information Management Perspective

BACKGROUND

For more than 30 years, there has been close cooperation between Japanese and German scientists with regard to information systems in health care. Collaboration has been formalized by an agreement between the respective scientific associations. Following this agreement, two joint workshops took place to explore the similarities and differences of electronic health record systems (EHRS) against the background of the two national healthcare systems that share many commonalities.

OBJECTIVES

To establish a framework and requirements for the quality of EHRS that may also serve as a basis for comparing different EHRS.

METHODS

Donabedian's three dimensions of quality of medical care were adapted to the outcome, process, and structural quality of EHRS and their management. These quality dimensions were proposed before the first workshop of EHRS experts and enriched during the discussions.

RESULTS

The Quality Requirements Framework of EHRS (QRF-EHRS) was defined and complemented by requirements for high quality EHRS. The framework integrates three quality dimensions (outcome, process, and structural quality), three layers of information systems (processes and data, applications, and physical tools) and three dimensions of information management (strategic, tactical, and operational information management).

CONCLUSIONS

Describing and comparing the quality of EHRS is in fact a multidimensional problem as given by the QRF-EHRS framework. This framework will be utilized to compare Japanese and German EHRS, notably those that were presented at the second workshop.

Overview of recent trans-institutional health network projects in Japan and Germany

Worldwide populations are aging and countries have to prepare for the effects of demographic change in health care. Health information exchange (HIE), which is the process of moving patient information across health care providers electronically, can help overcome health data fragmentation and open opportunities to improve patient care in terms of quality, economy and efficiency. Since Japan and Germany are among the first countries strongly impacted by demographic changes of aging populations, we report on current developments about health information systems carrying out HIE based on case studies in both countries. Four projects that address the improvement of HIE within a defined region have been selected and investigated: the German project of the Lower Saxony Bank of Health and the Japanese projects Chiba ITnet, Nagasaki AjisaiNet and the National Disaster and Backup System of Japan. The project descriptions are based on relevant English publications, on-site visits and interviews with developers and users. The projects are introduced in terms of their basic architecture and implementation, their present status and future objectives. The projects' developments are still in progress and all have to cope with significant challenges before they will be able to provide a fully working trans-institutional health network solution.

Using geographic information systems to simulate patient access areas

We constructed a simulation model with a geographic information system (GIS) to predict the future shortage of beds in the Tokyo Metropolitan Area. With a grid square method, we calculated patient numbers for every 500 square meters of the Tokyo Metropolitan Area until 2040 and estimated whether those in need could be admitted to hospitals within an hour's drive from their homes. The simulation demonstrates that after 2025 many patients may not be able to find hospitals within this time framework. The situation will be especially serious in the center of Tokyo and along the railway lines, where many senior citizens reside. We can now apply this innovative GIS method in many fields and especially for the precise estimation of future demands for and supply of medical assistance.

Discussion of "Attitude of physicians towards automatic alerting in computerized physician order entry systems"

With these comments on the paper "Attitude of Physicians Towards Automatic Alerting in Computerized Physician Order Entry Systems", written by Martin Jung and co-authors, with Dr. Elske Ammenwerth as senior author [1], the journal wants to stimulate a broad discussion on computerized physician order entry systems. An international group of experts have been invited by the editor of Methods to comment on this paper. Each of the invited commentaries forms one section of this paper.

[A new attempt to promote home medical care in Kashiwa city-usefulness of information and communication technology with seamless multidisciplinary cooperation]

Due to the rapidly increasing super-aging society, medical policy in Japan should be redefined. Therefore, the medical and nursing home care system should now be revised greatly. We need to change the current principle that is based on cure only. The patients should receive hospitable care closely connected with their life in their home-town(region)throughout their lifetime. This is termed as "home medical care system". Here, we promote patient-centered medical home care, which implements the chronic and/or End-Of-Life care models, in Kashiwa city, Chiba prefecture. This system is a promising framework for primary care transformation. There is a need for a multidisciplinary team-based care system using information and communication technology(ICT)with smooth and seamless cooperation. However, increased awareness among the workers engaged in home medical care is first required.

Data analysis and data mining: current issues in biomedical informatics

BACKGROUND

Medicine and biomedical sciences have become data-intensive fields, which, at the same time, enable the application of data-driven approaches and require sophisticated data analysis and data mining methods. Biomedical informatics provides a proper interdisciplinary context to integrate data and knowledge when processing available information, with the aim of giving effective decision-making support in clinics and translational research.

OBJECTIVES

To reflect on different perspectives related to the role of data analysis and data mining in biomedical informatics.

METHODS

On the occasion of the 50th year of Methods of Information in Medicine a symposium was organized, which reflected on opportunities, challenges and priorities of organizing, representing and analysing data, information and knowledge in biomedicine and health care. The contributions of experts with a variety of backgrounds in the area of biomedical data analysis have been collected as one outcome of this symposium, in order to provide a broad, though coherent, overview of some of the most interesting aspects of the field.

RESULTS

The paper presents sections on data accumulation and data-driven approaches in medical informatics, data and knowledge integration, statistical issues for the evaluation of data mining models, translational bioinformatics and bioinformatics aspects of genetic epidemiology.

CONCLUSIONS

Biomedical informatics represents a natural framework to properly and effectively apply data analysis and data mining methods in a decision-making context. In the future, it will be necessary to preserve the inclusive nature of the field and to foster an increasing sharing of data and methods between researchers.

Auto-Selection of DPC Codes from Discharge Summaries by Text Mining in Several Hospitals and Analysis of Differences in Discharge Summaries

Recently, Electronic Medical Record (EMR) systems have become popular in Japan, and numerous discharge summaries are being stored electronically, although they have not yet been reutilized. We performed text mining by using the term frequencyinverse document frequency method along with a morphological analysis of the discharge summaries from 3 hospitals (the Chiba University Hospital, St. Luke’s International Hospital, and the Saga University Hospital). We found differences in the styles of the summaries between hospitals, while the rates of properly classified Diagnosis Procedure Combination (DPC) codes were almost the same. Beyond the different styles for the discharge summaries, the text mining method was able to obtain appropriate extracts of the proper DPC codes. An improvement was observed by using the integrated model data between the hospitals. It appeared that a large database containing data from many hospitals could improve the precision of text mining.

[Home medical care center project for an aging society]

We have to create a new paradigm for home medical care system towards a historical increase of elderly population in Japan. Tokyo University and Chiba University have been collaborating to erect a home medical care support center in Kashiwa, Chiba prefecture. We have been constructing a support center as well as a home care doctor system, and also created a teaching course for GPs to learn a home care doctor activity. We have also been constructing a regional network system called IT Net in Chiba, which connects all the entire medical and care staff. We will expand this model in many places and to instruct medical students and residents there in the near future.

Japanese EMRs and IT in Medicine: Expansion, Integration, and Reuse of Data

Objectives

The prevalence of electronic medical record in Japan varies according to the size of the hospital which is 62.5% in major hospitals, 21.7% in medium, 9.1% in small size hospitals, and 16.5% in clinics. The complete paperless system is very limited, though some major hospitals are aiming at this system. Several regional network systems which connect different platforms of EMRs, have been developing in many districts, while the final picture of a regional network has not been clearly proposed. To develop a whole electronic health record or personal health records system from the regional network data, we have several obstacles to overcome such as standardization, a privacy act, unique national health number.

Methods

Some experimental trials have just been started. The reuse of the accumulated data has also just been initiated. We exploited text mining systems (term frequency-inverse document frequency method) to find similar cases and auto-audit Japanese diagnosis related group (DRG) coding by using discharge summaries.

Results

The same or even a more extreme phenomenon of huge data accumulation is occurring in genetic research and confluence of multi-disciplines of informatics is the next step, which has an enormous accumulation of data and discoveries of the relations beyond the dimension of each informatics.

Conclusions

We need another approach to science apart from the conventional method, and data-driven approach with data mining techniques must be brought in for each field. Informaticians have new important roles as coordinators to link up numerous phenomena over dimensions.

Auto-selection of DRG codes from discharge summaries by text mining in several hospitals: analysis of difference of discharge summaries

Recently, electronic medical record (EMR) systems have become popular in Japan, and number of discharge summaries is stored electronically, though they have not been reutilized yet. We performed text mining with Tf-idf method and morphological analysis in the discharge summaries from three Hospitals (Chiba University Hospital, St. Luke's International Hospital and Saga University Hospital). We showed differences in the styles of summaries, between hospitals, while the rate of properly classified DPC (Diagnosis Procedure Combination) codes were almost the same. Beyond different styles of the discharge summaries, text mining method could obtain proper extracts of proper DPC codes. Improvement was observed by using integrated model data between the hospitals. It seemed that huge database which contains the data of many hospitals can improve the precision of text mining.

Comparing a Japanese and a German hospital information system

OBJECTIVES

To examine the architectural differences and similarities of a Japanese and German hospital information system (HIS) in a case study. This cross-cultural comparison, which focuses on structural quality characteristics, offers the chance to get new insights into different HIS architectures, which possibly cannot be obtained by inner-country comparisons.

METHODS

A reference model for the domain layer of hospital information systems containing the typical enterprise functions of a hospital provides the basis of comparison for the two different hospital information systems. 3LGM(2) models, which describe the two HISs and which are based on that reference model, are used to assess several structural quality criteria. Four of these criteria are introduced in detail.

RESULTS

The two examined HISs are different in terms of the four structural quality criteria examined. Whereas the centralized architecture of the hospital information system at Chiba University Hospital causes only few functional redundancies and leads to a low implementation of communication standards, the hospital information system at the University Hospital of Leipzig, having a decentralized architecture, exhibits more functional redundancies and a higher use of communication standards.

CONCLUSIONS

Using a model-based comparison, it was possible to detect remarkable differences between the observed hospital information systems of completely different cultural areas. However, the usability of 3LGM(2) models for comparisons has to be improved in order to apply key figures and to assess or benchmark the structural quality of health information systems architectures more thoroughly.

[Recent investigations on the basis of pathogenesis of SLE and new therapeutic approaches]

Systemic lupus erythematosus (SLE) is a multisystem, autoimmune, connective-tissue disorder with a broad range of clinical presentations. SLE predominantly affects women, especially from ethnic groups with African and Asian ancestry. This disorder is a chronic illness that can be life threatening when major organs are affected, but more commonly results in debilitating condition and affects employment and fertility. This article summarizes the recent advances in our understanding of the genetics, epidemiology and pathogenesis of SLE. In addition, progress in the assessment and management of serious complications such as lupus nephritis and CNS lupus is reviewed. New therapeutic approaches, such as low-dose cyclophosphamide regimens, mycophenolate mofetil and biological agents are also discussed.

Commentaries on "Informatics and medicine: from molecules to populations"

OBJECTIVE

To discuss interdisciplinary research and education in the context of informatics and medicine by commenting on the paper of Kuhn et al. "Informatics and Medicine: From Molecules to Populations".

METHOD

Inviting an international group of experts in biomedical and health informatics and related disciplines to comment on this paper.

RESULTS AND CONCLUSIONS

The commentaries include a wide range of reasoned arguments and original position statements which, while strongly endorsing the educational needs identified by Kuhn et al., also point out fundamental challenges that are very specific to the unusual combination of scientific, technological, personal and social problems characterizing biomedical informatics. They point to the ultimate objectives of managing difficult human health problems, which are unlikely to yield to technological solutions alone. The psychological, societal, and environmental components of health and disease are emphasized by several of the commentators, setting the stage for further debate and constructive suggestions.

Temporal abstraction and data mining with visualization of laboratory data

To analyze the laboratory data by data mining, user-centered universal tools have not been available in medicine. We analyzed 1,565,877 laboratory data of 771 patients with viral hepatitis in order to find the difference of the temporal changes in laboratory test data between Hepatitis B and Hepatitis C by the combination of temporal abstraction and data mining. The data for one patient is temporal for more than 5 years. After pretreatment the data was converted to abstract patterns and then selected into sets of data combination and rules to identify Hepatitis B or C by D2MS and LUPC which were originally produced by ourselves. Not only data pattern, but also temporal relations were considered as a part of the rules. In the course of evaluating the results by domain experts, even though there were not so remarkable hypotheses, visualization tools made it easier for them to understand the relations of the complicated rules.

[Age and gender difference in rheumatology]

Most collagen diseases are more common in women except polyarteritis nodosa, but aging makes this gender difference smaller in some of the diseases. In systemic lupus erythematosus the incidence difference between men and women diminishes while Sjogren syndrome is more common in women at all ages. Diabetes mellitus and hyperlipidemia are also very common complications with steroid treatment. DM is more common in those aged over 45 years old. On the contrary, hyperlipidemia is common at all ages with the peak in those 45-54 years old and only 22% over 75 years old have hyperlipidemia. According to the introduction of aggressive therapy for rheumatoid arthritis, complications in the elderly should be carefully managed.

[Collagen diseases with opportunistic infections]

Treatment of opportunistic infections emerging in collagen diseases is very important as well as the therapy of original diseases. Lung tuberculosis, Pneumocystis carinii and lung fungal infections are main opportunistic infections. There is effective prophylaxis against them, though the cases for their administration should be carefully chosen because of their adverse effects. We have administrated INH and ST (Sulphomethoxazole and Trimethoprim) more than 15 years as the prophylaxis against tuberculosis and P. carinii to the cases who are treated more than 60 mg of prednisolone per day as an initial dose until less than 30 mg per day and completely succeeded. Infliximab treatment has been reported that it often induces tuberculosis in abroad and lots of occurrence was anticipated in Japan where high incidence of tuberculosis is observed. So far, however, there are only few patients, maybe due to the selection of the patients and actively utilizing prophylaxis.

[EMI net--electronic medical record sharing in local community for home care medicine]

An electronic medical information network (EMI net) includes patient records from more than 40 facilities in Matsudo City and it is now used especially to improve the communication between doctors and nurses who visit patients' home. This fact suggests the importance of a medical information sharing system in a local area for home care medicine. An infrastructure connecting facilities to share the database of the patient records is essential for home care medicine performed by a multidisciplinary team beyond one medical facility.

[EMI net--electronic medical record sharing in local community for home care medicine]

An electronic medical information network (EMI net) includes patient records from more than 40 facilities in Matsudo City and it is now used especially to improve the communication between doctors and nurses who visit patients' homes. This fact suggests the importance of a medical information sharing system in a local area for home care medicine. An infrastructure connecting facilities to share the database of the patient records is essential for home care medicine performed by a multidisciplinary team beyond one medical facility.

[Introduction of a community network system to visiting care]

A community-based electronic medical record sharing network system (EMI net) was developed in Matsudo City. This system facilitates communication between GPs and visiting nurses in charge of patients under homecare and it has proved useful from the view point of visiting nurses. For example nurses can read the information input by visiting GPs timely, share common view on the patients with GPs, and write a report illustrated with photographs at any time. Moreover, they can communicate with GPs through E-mail. On the other hand, EMI net remains to be improved in a few aspects, such as the need of a system to indicate a record has been read by GPs and to decrease the labor for entering data. We plan to increase the services provided by EMI net by enrolling other facilities.