Language：English   Publishing type：Research paper (scientific journal)   Publisher：Wiley  

DOI： 10.1111/apa.17489

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The results of observational studies using real-world data, known as real-world evidence, have gradually started to be used in drug development and decision-making by policymakers. A good quality management system-a comprehensive system of process, data, and documentation to ensure quality-is important in obtaining real-world evidence. A risk-based approach is a common quality management system used in interventional studies. We used a quality management system and risk-based approach in an observational study on a designated intractable disease. Our multidisciplinary team assessed the risks of the real-world data study comprehensively and systematically. When using real-world data and evidence to support regulatory decisions, both the quality of the database and the validity of the outcome are important. We followed the seven steps of the risk-based approach for both database selection and research planning. We scored the risk of two candidate databases and chose the Japanese National Database of designated intractable diseases for this study. We also conducted a quantitative assessment of risks associated with research planning. After prioritizing the risks, we revised the research plan and outcomes to reflect the risk-based approach. We concluded that implementing a risk-based approach is feasible for an observational study using real-world data. Evaluating both database selection and research planning is important. A risk-based approach can be essential to obtain robust real-world evidence.

DOI： 10.1007/s43441-024-00695-6

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OBJECTIVES: With the increasing use of direct oral anticoagulants (DOACs), managing these agents around endoscopic submucosal dissection (ESD) is crucial. However, due to the need for a large number of cases, studies examining the timing of resumption are lacking, resulting in varied recommendations across international guidelines. We aimed to perform a comparative study about the resumption timing of DOACs after colorectal ESD using a nationwide database in Japan. METHODS: We conducted a retrospective cohort study on colorectal ESD using the Diagnosis Procedure Combination database from 2012 to 2023. Patients using anticoagulants other than DOACs were excluded, and only those who resumed DOACs within 3 days were included. From eligible patients, we divided them into early (the day after ESD) and delayed (2 to 3 days after ESD) resumption groups. We used inverse probability of treatment weighting (IPTW) to assess the delayed bleeding and thromboembolic events within 30 days. Delayed bleeding was defined as bleeding requiring endoscopic hemostasis or blood transfusion after ESD. RESULTS: Of 176,139 colorectal ESDs, 3,550 involved DOAC users, with 2,698 (76%) categorized as early resumption and 852 (24%) categorized as delayed resumption groups. After IPTW adjustment, the early resumption group did not significantly increase delayed bleeding compared to the delayed resumption group (OR, 1.05; 95% CI, 0.78-1.42; P = 0.73). However, it significantly reduced the risk of thromboembolic events (OR, 0.45; 95% CI, 0.25-0.82; P < 0.01). CONCLUSIONS: Resuming DOACs the day after colorectal ESD was associated with reduced thromboembolic events without significant increase in risk of delayed bleeding.

DOI： 10.14309/ajg.0000000000003050

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BACKGROUND: Severe respiratory failure requires numerous interventions and its clinical implementation changes over time. We aimed to clarify the clinical practice and prognosis of severe respiratory failure and its changes over time. METHODS: In a nationwide Japanese administrative database from 2016 to 2019, we identified nonoperative patients with severe respiratory failure without congestive heart failure as the main diagnosis who received mechanical ventilation (MV) for more than four days. We examined trends in patient characteristics, adjunctive interventions, and prognosis. RESULTS: Among 66,905 patients included in this study, patients received antibiotics (90%), high-dose corticosteroids (14%), low-dose corticosteroids (18%), and 51% were admitted to the critical care unit. Hospital mortality was 35%. Median mechanical ventilation lasted 10 days. Tracheostomy occurred in 23% of cases. Median critical care and hospital stays were 10 and 25 days, respectively. Among survivors, 23% had mechanical ventilation dependency at hospital discharge. Large relative changes in adjunctive therapies included fentanyl (30%-38%), rocuronium (4.4%-6.7%), vasopressin (3.8%-6.0%), early rehabilitation (27%-38%), extracorporeal membrane oxygenation (0.7%-1.2%), dopamine (15%-10%), and sivelestat (8.6%-3.5%). No notable changes were seen in mechanical ventilation duration, tracheostomy, critical care unit stay, hospital stay, or ventilator dependency at discharge, except for a slight reduction in hospital mortality (36%-34%). CONCLUSIONS: Several adjunctive therapies for severe respiratory failure changed from 2016 to 2019, with an increase in evidence-based practices and a slight decrease in hospital mortality.

DOI： 10.1016/j.resinv.2024.07.003

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DOI： 10.1007/s12928-024-01003-7

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OBJECTIVES: We aimed to develop and validate a simple scoring system to predict in-hospital mortality after endoscopic variceal ligation (EVL) for esophageal variceal bleeding. METHODS: Data from a 13-year study involving 46 Japanese institutions were split into development (initial 7 years) and validation (last 6 years) cohorts. The study subjects were patients hospitalized for esophageal variceal bleeding and treated with EVL. Variable selection was performed using least absolute shrinkage and selection operator regression, targeting in-hospital all-cause mortality as the outcome. We developed the Hospital Outcome Prediction following Endoscopic Variceal Ligation (HOPE-EVL) score from β coefficients of multivariate logistic regression and assessed its discrimination and calibration. RESULTS: The study included 980 patients: 536 in the development cohort and 444 in the validation cohort. In-hospital mortality was 13.6% and 10.1% for the respective cohorts. The scoring system used five variables: systolic blood pressure (<80 mmHg: 2 points), Glasgow Coma Scale (≤12: 1 point), total bilirubin (≥5 mg/dL: 1 point), creatinine (≥1.5 mg/dL: 1 point), and albumin (<2.8 g/dL: 1 point). The risk groups (low: 0-1, middle: 2-3, high: ≥4) in the validation cohort corresponded to observed and predicted mortality probabilities of 2.0% and 2.5%, 19.0% and 22.9%, and 57.6% and 71.9%, respectively. In this cohort, the HOPE-EVL score demonstrated excellent discrimination ability (area under the curve [AUC] 0.890; 95% confidence interval [CI] 0.850-0.930) compared with the Model for End-stage Liver Disease score (AUC 0.853; 95% CI 0.794-0.912) and the Child-Pugh score (AUC 0.798; 95% CI 0.727-0.869). CONCLUSIONS: The HOPE-EVL score practically and effectively predicts in-hospital mortality. This score could facilitate the appropriate allocation of resources and effective communication with patients and their families.

DOI： 10.1111/den.14773

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Baishideng Publishing Group Inc.  

BACKGROUND

Esophageal variceal bleeding is a severe complication associated with liver cirrhosis and typically necessitates endoscopic hemostasis. The current standard treatment is endoscopic variceal ligation (EVL), and Western guidelines recommend antibiotic prophylaxis following hemostasis. However, given the improvements in prognosis for variceal bleeding due to advancements in the management of bleeding and treatments of liver cirrhosis and the global concerns regarding the emergence of multidrug-resistant bacteria, there is a need to reassess the use of routine antibiotic prophylaxis after hemostasis.

AIM

To evaluate the effectiveness of antibiotic prophylaxis in patients treated for EVL.

METHODS

We conducted a 13-year observational study using the Tokushukai medical database across 46 hospitals. Patients were divided into the prophylaxis group (received antibiotics on admission or the next day) and the non-prophylaxis group (did not receive antibiotics within one day of admission). The primary outcome was composed of 6-wk mortality, 4-wk rebleeding, and 4-wk spontaneous bacterial peritonitis (SBP). The secondary outcomes were each individual result and in-hospital mortality. A logistic regression with inverse probability of treatment weighting was used. A subgroup analysis was conducted based on the Child-Pugh classification to determine its influence on the primary outcome measures, while sensitivity analyses for antibiotic type and duration were also performed.

RESULTS

Among 980 patients, 790 were included (prophylaxis: 232, non-prophylaxis: 558). Most patients were males under the age of 65 years with a median Child-Pugh score of 8. The composite primary outcomes occurred in 11.2% of patients in the prophylaxis group and 9.5% in the non-prophylaxis group. No significant differences in outcomes were observed between the groups (adjusted odds ratio, 1.11; 95% confidence interval, 0.61-1.99; P = 0.74). Individual outcomes such as 6-wk mortality, 4-wk rebleeding, 4-wk onset of SBP, and in-hospital mortality were not significantly different between the groups. The primary outcome did not differ between the Child-Pugh subgroups. Similar results were observed in the sensitivity analyses.

CONCLUSION

No significant benefit to antibiotic prophylaxis for esophageal variceal bleeding treated with EVL was detected in this study. Global reassessment of routine antibiotic prophylaxis is imperative.

DOI： 10.3748/wjg.v30.i3.238

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BACKGROUND: Patients with refractory cardiogenic shock (CS) necessitating peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) often require an intra-aortic balloon pump (IABP) or Impella for unloading; however, comparative effectiveness data are currently lacking.Methods and Results: Using Diagnosis Procedure Combination data from approximately 1,200 Japanese acute care hospitals (April 2018-March 2022), we identified 940 patients aged ≥18 years with CS necessitating peripheral VA-ECMO along with IABP (ECMO-IABP; n=801) or Impella (ECPella; n=139) within 48 h of admission. Propensity score matching (126 pairs) indicated comparable in-hospital mortality between the ECPella and ECMO-IABP groups (50.8% vs. 50.0%, respectively; P=1.000). However, the ECPella cohort was on mechanical ventilator support for longer (median [interquartile range] 11.5 [5.0-20.8] vs. 9.0 [4.0-16.8] days; P=0.008) and had a longer hospital stay (median [interquartile range] 32.5 [12.0-59.0] vs. 23.0 [6.3-43.0] days; P=0.017) than the ECMO-IABP cohort. In addition, medical costs were higher for the ECPella than ECMO-IABP group (median [interquartile range] 9.09 [7.20-12.20] vs. 5.23 [3.41-7.00] million Japanese yen; P<0.001). CONCLUSIONS: Our nationwide study could not demonstrate compelling evidence to support the superior efficacy of Impella over IABP in reducing in-hospital mortality among patients with CS necessitating VA-ECMO. Further investigations are imperative to determine the clinical situations in which the potential effect of Impella can be maximized.

DOI： 10.1253/circj.CJ-23-0758

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Language：English   Publisher：SOCIETY FOR FREE RADICAL RESEARCH JAPAN  

Gastrointestinal bleeding (GIB) is a significant public health concern, predominantly associated with high morbidity. However, there have been no reports investigating the trends of GIB in Japan using nationwide data. This study aims to identify current trends and issues in the management of GIB by assessing Japan’s national data. We analyzed National Database sampling data from 2012 to 2019, evaluating annual hospitalization rates for major six types of GIB including hemorrhagic gastric ulcers, duodenal ulcers, esophageal variceal bleeding, colonic diverticular bleeding, ischemic colitis, and rectal ulcers. In this study, hospitalization rates per 100,000 indicated a marked decline in hemorrhagic gastric ulcers, approximately two-thirds from 41.5 to 27.9, whereas rates for colonic diverticular bleeding more than doubled, escalating from 15.1 to 34.0. Ischemic colitis rates increased 1.6 times, from 20.8 to 34.9. In 2017, the hospitalization rate per 100,000 for colonic diverticular bleeding and ischemic colitis surpassed those for hemorrhagic gastric ulcers (31.1, 31.3, and 31.0, respectively). No significant changes were observed for duodenal ulcers, esophageal variceal bleeding, or rectal ulcers. The findings of this study underscore a pivotal shift in hospitalization frequencies from upper GIB to lower GIB in 2017, indicating a potential shift in clinical focus and resource allocation.

DOI： 10.3164/jcbn.23-111

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DOI： 10.1007/s00535-023-02066-8

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BACKGROUND: The end-of-life (EOL) status, including age at death and treatment details, of patients with adult congenital heart disease (ACHD) remains unclear. This study investigated the EOL status of patients with ACHD using a nationwide Japanese database.Methods and Results: Data on the last hospitalization of 26,438 patients with ACHD aged ≥15 years, admitted between 2013 and 2017, were included. Disease complexity (simple, moderate, or great) was classified using International Classification of Diseases, 10th Revision codes. Of the 853 deaths, 831 patients with classifiable disease complexity were evaluated for EOL status. The median age at death of patients in the simple, moderate, and great disease complexity groups was 77.0, 66.5, and 39.0 years , respectively. The treatments administered before death to patients in the simple, moderate, and great complexity groups included cardiopulmonary resuscitation (30.1%, 35.7%, and 41.9%, respectively), percutaneous cardiopulmonary support (7.2%, 16.5%, and 16.3%, respectively), and mechanical ventilation (58.7%, 72.2%, and 75.6%, respectively). Overall, 70% of patients died outside of specialized facilities, with >25% dying after ≥31 days of hospitalization. CONCLUSIONS: Nationwide data showed that patients with ACHD with greater disease complexity died at a younger age and underwent more invasive treatments before death, with many dying after ≥1 month of hospitalization. Discussing EOL options with patients at the appropriate time is important, particularly for patients with greater disease complexity.

DOI： 10.1253/circj.CJ-23-0537

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BACKGROUND: Subcutaneous implantable cardioverter defibrillators (S-ICDs) are occasionally used in combination with other cardiac implantable electronic devices (CIEDs). However, whether the incidence of inappropriate shock increases in patients with S-ICDs and concomitant CIEDs remains unclear. This study aimed to investigate the association between the concomitant use of CIEDs and the incidence of inappropriate shock in patients with current-generation S-ICDs. METHODS: A total of 127 consecutive patients received an S-ICD. Patients were assigned to two groups depending on concomitant use of CIEDs at the time of S-ICD implantation: patients without other CIEDs (non-combined group, 106 patients) and patients with other CIEDs (combined group, 21 patients). CIEDs included pacemakers, implantable cardioverter defibrillators, cardiac resynchronization therapy pacemakers, and cardiac resynchronization therapy defibrillators. The primary outcome was inappropriate shock, defined as a shock other than ventricular arrhythmia. Hazard ratios and 95% confidence intervals were calculated using a time-varying Cox proportional hazards model which was adjusted for age because age differed between the groups and could be a confounder. RESULTS: During a median follow-up period of 2.2 years (interquartile range, 1.0-3.4 years), inappropriate shock events occurred in 17 (16%) and five (19%) patients of the non-combined and combined groups, respectively. While the age-adjusted hazard ratio for inappropriate shock was 24% higher in the combined than in the non-combined group (hazard ratio = 1.24, 95% confidence interval, 0.39-3.97), this difference was insignificant (p = .71). CONCLUSION: The incidence of inappropriate shock did not differ between patients with and without concomitant use of CIEDs, suggesting that S-ICDs could potentially be combined with other CIEDs without increasing the number of inappropriate shocks. Further studies are warranted to confirm the safety and feasibility of concomitant use of S-ICDs and CIEDs.

DOI： 10.1111/pace.14887

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Language：Japanese   Publisher：(一社)日本消化器内視鏡学会  

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INTRODUCTION: In general, caesarean sections are performed under spinal anaesthesia. Hypotension after spinal anaesthesia adversely affects both the mother and fetus. Although several studies have used pulse oximetry-derived indices, such as pulse perfusion index (PI) and Pleth variability index (PVI), to predict hypotension after spinal anaesthesia, the predictive ability of the PI and PVI remain controversial. METHODS AND ANALYSIS: We prepared this protocol following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We will conduct searches of MEDLINE, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Clinicaltrial.gov, European Union Clinical Trials Register (EU-CTR), WHO International Clinical Trials Registry Platform (ICTRP) and University Hospital Medical Information Network Clinical Trials Registry (UMIN) from inception until 8 October 2022. We will include retrospective and prospective observational studies and randomised controlled trials that evaluated the predictive ability of PI and PVI for hypotension after spinal anaesthesia for caesarean section, published in any language. We will exclude case reports, case series and animal studies. Two authors will independently scan and select eligible studies and perform data extraction and assessment of risk of bias. We will estimate predictive ability of PI and PVI as indices of hypotension after spinal anaesthesia for caesarean section using the Reitsma-type bivariate random-effects synthesis model and the hierarchical summary receiver operating characteristic curve. We will assess the quality of evidence using the Grading of Recommendation Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: Ethics approval is not required as the systematic review will use existing published data. The results will be submitted for publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42022362596.

DOI： 10.1136/bmjopen-2022-069309

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BACKGROUND: Acute esophageal mucosal lesions (AEMLs) are an underrecognized and largely unexplored disease. Endoscopic findings are similar, and a higher percentage of AEML could be misdiagnosed as reflux esophagitis Los Angeles classification grade D (RE-D). These diseases could have different pathologies and require different treatments. AIM: To compare AEML and RE-D to confirm that the two diseases are different from each other and to clarify the clinical features of AEML. METHODS: We selected emergency endoscopic cases of upper gastrointestinal bleeding with circumferential esophageal mucosal injury and classified them into AEML and RE-D groups according to the mucosal injury's shape on the oral side. We examined patient background, blood sampling data, comorbidities at onset, endoscopic characteristics, and outcomes in each group. RESULTS: Among the emergency cases, the AEML and RE-D groups had 105 (3.1%) and 48 (1.4%) cases, respectively. Multiple variables exhibited significantly different results, indicating that these two diseases are distinct. The clinical features of AEML consisted of more comorbidities [risk ratio (RR): 3.10; 95% confidence interval (CI): 1.68-5.71; P < 0.001] and less endoscopic hemostasis compared with RE-D (RR: 0.25; 95%CI: 0.10-0.63; P < 0.001). Mortality during hospitalization was higher in the AEML group (RR: 3.43; 95%CI: 0.82-14.40; P = 0.094), and stenosis developed only in the AEML group. CONCLUSION: AEML and RE-D were clearly distinct diseases with different clinical features. AEML may be more common than assumed, and the potential for its presence should be taken into account in cases of upper gastrointestinal bleeding with comorbidities.

DOI： 10.4240/wjgs.v15.i3.408

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BACKGROUND: Current guidelines recommend colonoscopy within 24 h for acute lower gastrointestinal bleeding; however, the evidence in support for colonic diverticular hemorrhage (CDH) indications remains insufficient. AIM: To investigate the effectiveness of early colonoscopy on the length of hospital stay for CDH patients. METHODS: We conducted a single-center retrospective cohort study. Patients who underwent colonoscopy within 24 h of presentation (early group) were compared with those who underwent colonoscopy beyond 24 h of presentation (elective group). The primary outcome was the length of hospital stay, and secondary outcomes were the identification of stigmata of recent hemorrhage (SRH), rebleeding, red blood cell transfusion more than 4 units, and interventional radiology and abdominal surgery after colonoscopy. RESULTS: We identified 574 CDH cases. Patients were divided into the early (n = 328) and elective (n = 226) groups. After propensity score matching, 191 pairs were generated. The length of hospital stay did not significantly differ between the two groups (early group vs elective group; median, 7 vs 8 d; P = 0.10). The early group had a significantly high identification of SRH (risk difference, 11.6%; 95%CI: 2.7 to 20.3; P = 0.02). No significant differences were found in the rebleeding (risk difference, 4.7%; 95%CI: -4.1 to 13.5; P = 0.35), red blood cell transfusion more than 4 units (risk difference, 1.6%; 95%CI: -7.5 to 10.6; P = 0.82), and interventional radiology and abdominal surgery rate after colonoscopy (risk difference, 0.5%; 95%CI: -2.2 to 3.2; P = 1.00). CONCLUSION: Early colonoscopy within 24 h, on arrival for CDH, could not improve the length of hospital stay.

DOI： 10.4253/wjge.v14.i12.759

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OBJECTIVES: SARS-CoV-2 infection (COVID-19) has affected tertiary medical institutions and primary care. Admission for ambulatory care sensitive conditions (ACSCs) is an important indicator of primary care quality. However, no nationwide study, especially in Asia, has examined the association between admissions for ACSCs and local surges in COVID-19. This study aimed to examine how the number of admissions for ACSCs has changed in Japan between the areas with higher and lower rates of COVID-19 infection. DESIGN: This was a retrospective two-stage cross-sectional study. We employed a difference-in-difference design to compare the number of hospital admissions for ACSCs between the areas with higher and lower rates of COVID-19 infection in Japan. SETTING: The study used a nationwide database in Japan. PARTICIPANTS: All patients were aged 20 years and above and were admitted due to ACSCs during the study period between March and September 2019 (before the pandemic) and between March and September 2020 (during the pandemic). RESULTS: The total number of ACSC admissions was 464 560 (276 530 in 2019 and 188 030 in 2020). The change in the number of admissions for ACSCs per 100 000 was not statistically significant between the areas with higher and lower rates of COVID-19 infection: 7.50 (95% CI -87.02 to 102.01). In addition, in acute, chronic and preventable ACSCs, the number of admissions per 100 000 individuals did not change significantly. CONCLUSION: Although admissions for ACSCs decreased during the COVID-19 pandemic, there was no significant change between the areas with higher and lower rates of COVID-19 infection. This implies that the COVID-19 pandemic affected the areas with higher infection rates and the areas with lower rates.

DOI： 10.1136/fmch-2022-001736

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Background: Psoriasis is a known risk factor for acute myocardial infarction (AMI). However, the associations between psoriasis and short-term outcomes of AMI remain controversial. Objective: To compare the short-term outcomes of AMI patients with and without psoriasis accounting for patient background characteristics and site-specific effects. Methods: We identified patients with AMI between July 2010 and March 2020, using a Japanese national inpatient database. We matched patients with and without psoriasis to generate a 1:10 matched-pair cohort matched for sex, hospital, and fiscal year at admission. Multivariable regression analyses with adjustment for background characteristics including age and Killip class at admission were conducted to compare short-term outcomes of AMI. Results: In this study of AMI patients with psoriasis (n = 455) and without psoriasis (n = 438,534), 30-day in-hospital mortality was 5.6%. Patients with psoriasis had higher proportions of comorbidities than patients without psoriasis. Multivariable regression analyses in the matched-pair cohort revealed that psoriasis was significantly associated with decreased 30-day in-hospital mortality (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.08-0.85). Limitations: Retrospective study design without data on psoriasis severity. Conclusion: The matched-pair cohort analyses with adjustment for patient background characteristics and site-specific effects revealed decreased in-hospital mortality in AMI patients with psoriasis.

DOI： 10.1016/j.jdin.2022.04.007

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：BMJ  

Objectives

Continuity of care is a core dimension of primary care, and better continuity is associated with better patient outcomes. Therefore, care fragmentation can be an indicator to assess the quality of primary care, especially in countries without formal gatekeeping system, such as Japan. Thus, this study aimed to describe care fragmentation among older adults in an ageing city in Japan.

Design

Cross-sectional study.

Setting

The most populated basic municipality in Japan.

Participants

Older adults aged 75 years and older.

Interventions

This study used a health claims database, including older adults who visited medical facilities at least four times a year in an urban city in Japan. The Fragmentation of Care Index (FCI) was used as an indicator of fragmentation. The FCI was developed from the Continuity of Care Index and is based on the total number of visits, different institutions visited and proportion of visits to each institution. We employed Tobit regression analysis to examine the association between the FCI and age, sex, type of insurance and most frequently visited facility.

Results

The total number of participants was 413 600. The median age of the study population was 81 years, and 41.6% were men. The study population visited an average of 3.42 clinics/hospitals, and the maximum number of visited institutions was 20. The proportion of patients with FCI &gt;0 was 85.0%, with a mean of 0.583. Multivariable analysis showed that patients receiving public assistance had a lower FCI compared with patients not receiving public assistance, with a coefficient of 0.137.

Conclusions

To our knowledge, this is the first study to demonstrate care fragmentation in Japan. Over 80% of the participants visited two or more medical facilities, and their mean FCI was 0.583. The FCI could be a basic indicator for assessing the quality of primary care.

DOI： 10.1136/bmjopen-2022-061921

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Wiley  

AIM: Urbanization and ageing are worldwide issues for healthcare providers. In particular, older adults aged 90 years and older have increased cognitive impairment and lower daily functioning than younger adults. However, the healthcare use of the oldest old remains unclear. This study aimed to describe the healthcare use of the oldest old compared with younger older adults in a city using the ecology of medical care model. METHODS: We conducted a cross-sectional study. This study targeted all residents aged 75 years and older registered in a city in Japan for one year. We described healthcare use per 1000 inhabitants over a 1-month period and included: outpatient visits, emergency department visits, hospitalizations, home visits, home care services, and facility services. We also compared healthcare use among older adults aged 75-89 years and 90 years and older. RESULTS: We described the healthcare use of 454 366 (male/female: 186 177/268 189) older adults. The numbers of persons per 1000 residents who used healthcare resources at least once in 1 month (75-89 years/90 years and older) were: outpatient clinic visits, 622/570; hospital outpatient visits, 300/263; advanced treatment hospital outpatient visits, 16/6; emergency department visits, 10/27; hospitalizations, 45/96; advanced treatment hospital hospitalizations, 2/1; planned home visits, 36/228; urgent home visits, 6/38; home care services, 173/533; and facility services, 32/178. CONCLUSIONS: The results revealed that older adults over 90 years had more hospitalizations, emergency department visits and home visits, and used facility/home care services more compared with older adults aged 75-89 years. The results provide a useful benchmark for healthcare use estimation. Geriatr Gerontol Int 2022; 22: 483-489.

DOI： 10.1111/ggi.14387

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In patients with atrial septal defect (ASD), atrial left-to-right shunting causes left atrial (LA) remodeling and dysfunction, leading to atrial fibrillation (AF). In adults with ASD and concomitant AF, LA function should be evaluated after ASD closure plus AF radiofrequency catheter ablation (RFCA).This multicenter retrospective cohort study included patients who underwent transcatheter ASD closure at one of the four leading hospitals. Patients with a history of AF also underwent preceding RFCA. The association between AF history and LA ejection fraction (EF) (indicating LA global function) at 6-12 months following ASD closure was evaluated. To account for differences in baseline characteristics between patients with and without a history of AF, we conducted the following statistical methods: (1) multivariate regression analysis in the prepropensity score (PS)-matched cohort and (2) univariate comparisons in the PS-matched cohort.Overall, this study included 231 patients (30 with AF history, 201 without). Multiple regression analysis showed that AF history was independently associated with impaired LAEF (β = -10.425, P < 0.001, model created prior to propensity matching). A one-to-one PS matching (25 pairs) showed that the LAEF at 6-12 months following ASD closure was significantly impaired in patients with ASD and AF history compared to that in patients without history of AF (median LAEF, 37.5% (interquartile range [IQR] 29.4%-48.5%) versus 52.3 [IQR 50.0%-56.6%]; P < 0.001).LA function was impaired in patients with ASD and a history of AF at 6-12 months after successful transcatheter ASD closure and on maintenance of sinus rhythm by RFCA.

DOI： 10.1536/ihj.22-265

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


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


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


</sec><sec>
<title>Conclusions</title>
Appropriate patient selection and management by specialized tertiary institutions may contribute to positive outcomes in pregnancies in women with CHD.


</sec>

DOI： 10.1186/s12872-021-02222-z

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Other Link： https://link.springer.com/article/10.1186/s12872-021-02222-z/fulltext.html

Language：English   Publishing type：Research paper (scientific journal)  

BACKGROUND: Postoperative respiratory failure is a serious problem in the anaesthetic management of patients with myasthenia gravis who undergo thymectomy. Although the classical recommendation is to avoid neuromuscular blockers, there is no strong evidence to support it. OBJECTIVES: To evaluate the postoperative outcomes in patients with myasthenia gravis after thymectomy when anaesthetic management included rocuronium reversed with sugammadex. DESIGN: A retrospective cohort study. SETTING: Nationwide acute in-patient care database. PATIENTS: A total of 1143 patients with myasthenia gravis who underwent thymectomy were included. Data were collected from the medical insurance claims data of acute care in-patient hospitals. MAIN OUTCOME MEASURES: The postoperative complications when rocuronium reversed with sugammadex was compared against no muscle relaxant use using propensity score matching. The primary outcomes were the rates of in-hospital mortality, plasma exchange following thymectomy and the use of immunoglobulins. The secondary outcomes were the length of stay in the high dependency/ICUs, the total length of hospital stay and the duration and type of respiratory support following thymectomy. RESULTS: There were no significant differences between the propensity score matched groups in terms of plasma exchange [relative risk, 0.96; 95% confidence interval (CI), 0.64 to 1.43] and use of immunoglobulins (relative risk, 1.09; 95% CI, 0.60 to 1.97). The length of hospital stay was significantly shorter in patients in whom rocuronium and sugammadex were used: 29.0 vs. 35.4 days, P = 0.035. CONCLUSIONS: Anaesthetic management with rocuronium reversed by sugammadex was not associated with increased risk of respiratory complications. These findings could help in the anaesthetic management of patients with myasthenia gravis.

DOI： 10.1097/EJA.0000000000001500

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BACKGROUND: Because generalized pustular psoriasis (GPP) is uncommon, there are few studies reporting treatments and outcomes for large numbers of patients. OBJECTIVE: To report treatments and outcomes in a large cohort of hospitalized patients with GPP. METHODS: Using a Japanese national inpatient database, we identified 1516 patients with GPP who required hospitalization from July 2010 to March 2019. We categorized patients into three medication groups: biologics (n = 294), oral agents without biologics (n = 948), or systemic corticosteroids only (n = 274). We investigated their characteristics, treatments, and outcomes. RESULTS: Mean age was 66 years (interquartile range: 52-77 years); 50 patients (3.3%) were admitted to the intensive care unit, 125 (8.2%) required blood pressure support, and 63 (4.2%) died. Patients receiving biologics were younger and had fewer comorbidities and lower in-hospital mortality (1.0% [biologics group] vs. 3.7% [oral-agents group] vs. 9.1% [corticosteroids-only group], p < .001) and morbidity (5.4% vs. 8.2% vs. 12%, p = .02). Among those who received biologics, IL-17 inhibitor use increased over time and showed comparable in-hospital mortality and morbidity to that of TNF inhibitors. LIMITATIONS: Retrospective study design. Some patients received multiple medications. CONCLUSION: Biologic treatments showed favorable outcomes compared with other treatments.

DOI： 10.1016/j.jaad.2021.06.008

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DOI： 10.1016/j.apmr.2020.09.380

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Language：Japanese   Publisher：(一社)日本疫学会  

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：WILEY  

Background and Aim: Intestinal strictures in Crohn's disease (CD) have a high rate of repeated surgery. As alternatives to surgery, endoscopic balloon dilatation (EBD), immunomodulators (IMs), and antitumor necrosis factor alpha (anti-TNFα) have been proposed. We aimed to assess the effectiveness of the combined therapy with anti-TNFα and EBD in preventing intestinal stricture recurrence and surgery in patients with CD. Methods: This retrospective cohort study included patients from the nationwide administrative database in Japan who were hospitalized and underwent at least one EBD between 1 April 2010 and 31 March 2017. The effectiveness of anti-TNFα was evaluated by performing survival analysis for the primary outcome. We selected the inverse probability of treatment weighting method for adjustment of covariates. As an exploratory analysis, we evaluated the association of anti-TNFα initiation timing with intestinal stricture recurrence. Results: The anti-TNFα exposed group had a significantly lower risk of intestinal stricture recurrence than that of the anti-TNFα nonexposed group (hazard ratio = 0.38, 95% confidence interval 0.31-0.48, P < 0.001). Surgery-free rate was shown to have the same tendency. Anti-TNFα therapy initiation before or after EBD resulted in a lower risk of intestinal stricture recurrence than that of simultaneous treatment. Conclusion: The combined therapy with anti-TNFα and EBD could have preventive effects for intestinal stricture recurrence and surgery in hospitalized patients with CD. In particular, anti-TNFα initiation may be recommended before or after EBD, not immediately after EBD. With respect to EBD, it is important to clarify the effectiveness of combination therapy with several new medication treatments, such as biologics.

DOI： 10.1002/jgh3.12329

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OBJECTIVE: To examine the associations of 3 major hospital discharge services covered under health insurance (discharge planning, rehabilitation discharge instruction, and coordination with community care) with potentially avoidable readmissions (PARs) within 30 days in older adults after rehabilitation in acute care hospitals in Tokyo, Japan. DESIGN: Retrospective cohort study using a large-scale medical claims database of all Tokyo residents aged ≥75 years. SETTING: Acute care hospitals. PARTICIPANTS: Patients who underwent rehabilitation and were discharged to home (N=31,247; mean age in years ± SD, 84.1±5.7) between October 2013 and July 2014. INTERVENTIONS: None. MAIN OUTCOME MEASURE: 30-day PAR. RESULTS: Among the patients, 883 (2.9%) experienced 30-day PAR. A multivariable logistic generalized estimating equation model (with a logit link function and binominal sampling distribution) that adjusted for patient characteristics and clustering within hospitals showed that the discharge services were not significantly associated with 30-day PAR. The odds ratios were 0.962 (95% confidence interval [CI], 0.805-1.151) for discharge planning, 1.060 (95% CI, 0.916-1.227) for rehabilitation discharge instruction, and 1.118 (95% CI, 0.817-1.529) for coordination with community care. In contrast, the odds of 30-day PAR among patients with home medical care services were 1.431 times higher than those of patients without these services (P<.001), and the odds of 30-day PAR among patients with a higher number (median or higher) of rehabilitation units were 2.031 times higher than those of patients with a lower number (below median) (P<.001). Also, the odds of 30-day PAR among patients with a higher Hospital Frailty Risk Score (median or higher) were 1.252 times higher than those of patients with a lower score (below median) (P=.001). CONCLUSIONS: The insurance-covered discharge services were not associated with 30-day PAR, and the development of comprehensive transitional care programs through the integration of existing discharge services may help to reduce such readmissions.

DOI： 10.1016/j.apmr.2019.11.019

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AIM: To determine the patterns of concomitant drug use for chronic diseases and examine the risk factors of polypharmacy in older outpatients. METHODS: Data were extracted from an anonymized health insurance claims database of a public insurance program for older adults in Tokyo, Japan. We analyzed individuals aged ≥75 years who had visited an outpatient clinic, and were regularly prescribed orally administered drugs for chronic diseases for ≥14 days between May and August 2014. The prescription patterns for 16 main drug types were studied using exploratory factor analysis, and the risk factors of polypharmacy, defined as the concomitant prescription of five or more drugs, were identified using multivariate logistic regression models. RESULTS: A total of 1 094 199 outpatients were analyzed (mean age 81.8 years, 38.4% men). We identified five prescription patterns that explained almost 40% of all observed variance: edema/heart failure/atrial fibrillation-related drugs, insomnia/anxiety-related drugs, pain-related drugs, lifestyle disease-related drugs and dementia-related drugs. The significant risk factors of polypharmacy included men, octogenarians and nonagenarians, higher number of medical institutions visited, use of physician home visits, and hospitalization during the study period. The main drug types most strongly associated with polypharmacy were analgesics, diuretics and antidiabetics. CONCLUSIONS: Polypharmacy was found to be prevalent in older outpatients aged ≥75 years in Tokyo. These findings might provide useful evidence that can contribute to the development of practical countermeasures against adverse events associated with polypharmacy in clinical practice. Geriatr Gerontol Int 2020; 20: 304-311.

DOI： 10.1111/ggi.13880

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The Japanese government encourages older adults to participate in annual health checkups designed to detect lifestyle diseases such as hypertension, diabetes, and dyslipidemia. However, individuals who are already being treated for these diseases are unlikely to benefit from health checkup participation. This retrospective cohort study of older adults evaluated the associations of pharmacological treatments for these diseases with health checkup participation and identified the disease control factors among patients receiving treatments. Using medical claims data and health checkup data between September 2013 and August 2014 from 820,215 older adults aged ≥ 75 years residing in Tokyo, Japan, we examined the associations between pharmacological treatments and health checkup participation using binary logistic regression analysis. Next, patients receiving pharmacological treatments were categorized into intensive, moderate, or limited disease control based on their blood pressure, hemoglobin A1c levels, and lipid levels; multinomial logistic regression analyses were used to identify the disease control factors. The results showed that patients receiving pharmacological treatments were more likely (odds ratio: 1.374; P < 0.001) to participate in health checkups than patients not receiving treatments. Patients with intensive disease control were more likely to be aged ≥ 90 years and use home medical care than patients with moderate control. Our findings suggest that it may be beneficial to shift the focus of health checkups from simply identifying at-risk patients to also supporting disease management. Information obtained from databases that link medical claims and health checkup data may improve evaluations of disease control in older adults and help to streamline healthcare systems.

DOI： 10.1016/j.pmedr.2019.101033

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：WILEY  

As Japan's population continues to age rapidly, the national government has implemented several measures to improve the efficiency of healthcare services and to control rising medical expenses for older patients. One such measure was the revision of the medical fee schedule for physician home visits in April 2014, in which eligibility for these visits was restricted to patients who are unable to visit outpatient clinics without assistance. Through an investigation of patients who were receiving physician home visits in Tokyo, this study examines whether this fee schedule revision resulted in an increase in patients who transitioned from home visits to outpatient care. In a retrospective analysis of health insurance claims data, we examined 80,914 Tokyo residents aged 75 years or older who had received at least one physician home visit between January and May 2014. The study period was divided into four periods (January-February, February-March, March-April, and April-May), and we examined the number of patients receiving home visits in the index month of each period who subsequently transitioned to outpatient care in the following month. Potential factors associated with this transition to outpatient care were examined using a generalised estimating equation. The March-April period that included the fee schedule revision was significantly associated with a higher number of patients who transitioned from home visits in the index month to outpatient care in the following month (odds ratio: 4.46, p < 0.001) than the other periods. In addition, patients receiving home visits at residential facilities were more likely to transition to outpatient care (odds ratio: 10.40, p < 0.001). These findings indicate that the fee schedule revision resulted in an increase in patients who ceased physician home visits and began visiting outpatient clinics for treatment.

DOI： 10.1111/hsc.12707

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Publishing type：Research paper (scientific journal)   Publisher：Elsevier BV  

DOI： 10.1016/j.healthpol.2018.12.006

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INTRODUCTION: Multimorbidity, the co-occurrence of 2 or more disorders in a patient, can complicate treatment planning and affect health outcomes. Improvements in prevention and management strategies for patients with 3 or more or more co-occurring chronic diseases requires an understanding of the epidemiology of common 3-way disease patterns and their interactions. Our study aimed to describe these common 3-way disease patterns and examine the factors associated with the co-occurrence of 3 or more diseases in elderly Japanese patients. METHODS: We included all Japanese citizens aged 75 or older living in Tokyo who used medical care between September 2013 and August 2014 (N = 1,311,116) in our analysis. The 15 most common 3-way patterns of 22 target diseases according to sex and age were identified from among all possible combinations by using an anonymized medical claims database. We examined the associations of sociodemographic characteristics and health care use with the presence of 1 or 2 co-occurring diseases and 3 or more co-occurring diseases by using multinomial logistic regression. RESULTS: Approximately 65% of patients had 3 or more co-occurring diseases. The most common 3-way pattern was hypertension, coronary heart disease, and peptic ulcer disease in men (12.4%) and hypertension, dyslipidemia, and peptic ulcer disease in women (12.8%). The prevalence of 3 or more diseases was positively associated with men, patients aged 85 to 90, the use of home medical care services, the number of outpatient facilities visited, and hospital admissions. CONCLUSION: The common 3-way disease patterns and multimorbidity factors identified in our study may facilitate the recognition of high-risk patients and support the development of clinical guidelines for multimorbidity.

DOI： 10.5888/pcd16.180170

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Language：Japanese   Publisher：厚生労働統計協会  

目的 東京都は人口密度が高く、交通網が発達していることから、隣県の医療機関が都内への訪問診療に参入している可能性が考えられる。東京都における在宅医療のあり方を検討する際には、都内の医療機関だけでなく、都外医療機関から訪問診療を受けている患者数と医療機関数の把握も必要であるが、その実態は明らかにされていない。そこで本研究は、東京都後期高齢者医療広域連合の被保険者である75歳以上の高齢者のうち、2014年8月に訪問診療を受けた患者を対象に、在宅医療提供医療機関の所在地を把握し、都外医療機関から訪問診療を受けた患者数とその特徴を分析することを目的とした。方法 本研究で使用したデータは、東京都後期高齢者医療広域連合から提供された匿名化済み医科レセプトデータである。2014年8月に訪問診療を受けた75歳以上の在宅医療患者を分析対象とした。まず、二次保健医療圏別に在宅医療患者数を把握し、75歳以上の全被保険者数に占める在宅医療者の割合を、性、年齢階級別に集計した。次に、保険証住所地の二次保健医療圏別に、訪問診療提供医療機関の所在地を把握し、都外医療機関から訪問診療を受けた患者数を把握した。最後に、都外医療機関による訪問診療を受けた患者特性をχ2検定と多重ロジスティック回帰分析を用いて検討した。結果 都内に保険証住所地がある75歳以上の在宅医療患者(2014年8月診療分)は71,312人(全被保険者の5.4%)で、うち11,085人(全在宅医療患者の15.5%)が都外医療機関から訪問診療を受けていた。都外医療機関の所在地は神奈川県、埼玉県、千葉県がほとんどであった。居住系施設等で訪問診療を受けた患者は、その27.1%が都外医療機関による訪問で、居住系施設等への同時訪問は都外医療機関による訪問診療提供と極めて強く関連していた(調整済みオッズ比18.0,P<0.001)。結論 東京都における在宅医療の提供体制を検討する際、都外医療機関による在宅医療の提供を把握すると同時に、在宅医療患者の実際の居住地を都道府県や市区町村レベルで把握可能な仕組みを構築し、在宅医療の需要と提供医療機関数の過大評価を避ける必要がある。(著者抄録)

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Language：Japanese   Publisher：(一社)日本老年医学会  

目的:高齢の在宅医療患者にとって、退院直後の再入院は療養環境の急激な変化を伴うことから心身への負担は大きく、有害事象の発生リスクも高めるため、再入院の予防は重要である。退院直後の再入院の発生と個人要因との関連を検討した研究は多いが、医療施設要因との関連を検討した研究は少ない。本研究は、在宅医療の提供体制の観点から退院直後の再入院予防策を検討するため、東京都後期高齢者医療広域連合から提供を受けたレセプトデータを用いて、在宅医療患者の退院後30日以内の再入院に関連する個人要因及び医療施設要因を明らかにする。方法:分析対象者は、在宅医療患者のうち、平成25年9月〜平成26年7月に入院し、退院後に入院前と同じ施設から在宅医療を受けた7,213名(平均年齢87.0±6.0歳、女性:69.5%)である。退院後30日以内の再入院に関連する個人要因及び医療施設要因(入院受入れ施設の病床数、在宅医療提供施設の病診区分及び在宅療養支援診療所/在宅療養支援病院「在支診/在支病」であるか否か等)を一般化推定方程式(応答変数:二項分布、リンク関数:ロジット)で分析した。結果:退院後30日以内に再入院した患者の割合は11.2%であった。一般化推定方程式の結果、退院後30日以内の再入院ありと関連したのは、男性、悪性新生物、緊急入院利用であった。医療施設要因では、在宅医療提供施設が在支診/在支病の場合(調整済オッズ比:0.205,p値<0.001)、診療所を基準にすると入院医療施設が200床以上の病院(調整済オッズ比:0.447,p値<0.001)で再入院抑制と関連していた。結論:在支診/在支病のような24時間対応可能な在宅医療の提供体制は、退院直後の再入院を抑制する要因(往診など)を包含している可能性が示唆された。在支診/在支病による訪問診療が再入院抑制に働く機序を明らかにする必要がある。(著者抄録)

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Language：Japanese   Publishing type：Research paper (scientific journal)  

AIM: To improve preventive strategies for readmission within 30 days after discharge among older patients receiving home medical care services, we examined the associations between readmission within 30 days and the medical institute factors among patients over 75 years of age. METHODS: All patients over 75 years of age receiving home medical care services and who had been admitted to hospital or clinic and discharged between September 2013 and July 2014 in Tokyo, Japan, were participants of this study (n=7,213). The primary outcome was readmission within 30 days after discharge. We performed generalized estimating equations (GEEs) using a model with logit link and binominal sampling distribution to examine the associations of sociodemographic variables, the prevalence of chronic diseases and medical institute factors with readmission within 30 days. RESULTS: Approximately 11.2% of the patients receiving home medical care services who had been discharged were readmitted within 30 days after discharge. Men, cancer patients, and emergency admission were positively associated with readmission within 30 days according to the GEEs. The rate of readmission within 30 days was lower in patients receiving home medical care services at home care support clinics/hospitals after discharge (adjusted odds ratio [aOR] = 0.205, p value < 0.001) and in patients discharged from hospitals with over 200 beds (aOR = 0.447, p value < 0.001, vs. clinics) than in others. CONCLUSION: Home care support clinics/hospitals, which can provide home medical care services around the clock, may help reduce the rate of readmission within 30 days.

DOI： 10.3143/geriatrics.55.612

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Springer Verlag  

Adult-onset Still's disease (AOSD) is a rare disease, and large epidemiological studies of this disease are limited. Furthermore, it has been difficult to show the incidence and characteristics of severe AOSD complications due to the rarity of this disease. The aim of our study was to describe the demographics of AOSD and the incidence and characteristics of severe complications. Using a large Japanese administrative database, we identified hospitalized patients with AOSD and described the demographics. We also calculated the incidence of severe complications (i.e., macrophage activation syndrome [MAS] and disseminated intravascular coagulation [DIC]) and in-hospital mortality in AOSD patients, and then analyzed the age-controlled difference between men and women. We identified 513 patients with AOSD (mean age: 53.1 years; women 64.1 %). According to the age distribution, there was no distinct peak age. The thirties and the sixties were relatively large age groups. There were 76 patients of AOSD with MAS or DIC observed in this study. The incidence of severe complications was 14.8 %, 95 % CI [11.9, 18.2]. Women were more likely to have severe complications than men after controlling for age (odds ratio: 2.07; [1.14, 3.73]; p = 0.014). AOSD does not predominantly affect young adults in our study population. Elderly AOSD patients can be observed more than before due to global population aging. Severe complications are more likely to occur in women than in men.

DOI： 10.1007/s00296-016-3546-8

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Elsevier Ireland Ltd  

BACKGROUND: Little is known about the use of multiple prescribers for benzodiazepines, which might reflect fragmented patient care and increases the risk of hospital admission for drug dependence or poisoning. Therefore, we aimed to identify the prevalence, prescribed quantities, and trajectory of multiple prescriber episodes for benzodiazepines. METHODS: We conducted a 2-year cohort study of 1178,361 recipients aged 0-74 years using a large health insurance claims database in Japan. We quantified multiple prescriber episodes for benzodiazepines occurring in ambulatory care settings in a baseline and subsequent year by (1) counting the number of unique providers within a 12-month period, (2) calculating the maximum number of unique providers within a single month, and (3) identifying consecutive overlapping prescriptions of over 30 days duration. RESULTS: Among 58,314 patients with a benzodiazepine prescription during the baseline year, 282 (0.5%) filled prescriptions from four or more providers within a 12-month period, 439 (0.8%) filled prescriptions from three or more providers within a single month, and 757 (1.3%) filled consecutive overlapping prescriptions. The odds for multiple prescriber episodes were significantly higher among patients with multiple chronic conditions. Consecutive overlapping prescriptions had the best accuracy to detect patients with potentially questionable prescribed quantities as well as to predict those with multiple prescriber episodes in the subsequent year. CONCLUSIONS: These results highlight the need for pharmacists to increase their involvement in prescription oversight and for health insurance agencies to implement a prescription monitoring program to screen for patients with multiple prescriber episodes for benzodiazepines.

DOI： 10.1016/j.drugalcdep.2015.11.010

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Springer New York LLC  

In Japan, an “Integrated Community Care” model has been introduced into the public long-term care insurance (LTCI) system to help persons ageing in place. The aim of the present study was to examine the association between the development of an Integrated Community Care system and the number of nursing home placements under the LTCI program among municipal governments in Japan. Development of the Integrated Community Care system was assessed by a paper questionnaire distributed to each municipality. The annual number of elderly nursing home placements was obtained from published national statistics data over a 10-year period from 2001 to 2010. The sample consisted of 612 municipalities (35.1 % of all municipalities) that responded to the questionnaire. A multilevel linear regression analysis for panel data revealed significantly smaller annual numbers of nursing home placements per 1000 elderly persons among municipalities that had larger number of agencies joining in multiple service networks of the Integrated Community Care system. A significantly greater number of nursing home placements was also observed among municipalities that had a larger elderly population rate, lower annual number of elderly individuals in intermediate care per 1000 elderly persons, and smaller number of elderly individuals in congregate housings per 1000 elderly persons. The national “ageing in place” policy should explore a revised model of the Integrated Community Care system that is applicable for areas with limited resources.

DOI： 10.1007/s12126-014-9215-x

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：PUBLIC LIBRARY SCIENCE  

OBJECTIVES: To assess the value of organized care by comparing the clinical outcomes and healthcare expenditure between the conventional Japanese "integrated care across specialties within one hospital" mode of providing healthcare and the prospective approach of "organized care across separate facilities within a community". DESIGN: Retrospective cohort study. SETTING: Two groups of hospitals were categorized according to healthcare delivery approach: the first group included 3 hospitals autonomously providing integrated care across specialties, and the second group included 4 acute care hospitals and 7 rehabilitative care hospitals providing organized care across separate facilities. PARTICIPANTS: Patients aged 65 years and above who had undergone hip fracture surgery. MEASUREMENTS: Regression models adjusting for patient characteristics and clinical variables were used to investigate the impact of organized care on the improvements to the mobility capability of patients before and after hospitalization and the differences in healthcare resource utilization. RESULTS: The sample for analysis included 837 hip fracture surgery cases. The proportion of patients with either unchanged or improved mobility capability was not statistically associated with the healthcare delivery approaches. Total adjusted mean healthcare expenditure for integrated care and organized care were US$28,360 (95% confidence interval: 27,787-28,972) and US$21,951 (21,511-22,420), respectively, indicating an average increase of US$6,409 in organized care. CONCLUSION: Our cost-consequence analysis underscores the need to further investigate the actual contribution of organized care to the provision of efficient and high-quality healthcare.

DOI： 10.1371/journal.pone.0133694

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Language：Japanese   Publisher：(株)星和書店  

本研究は、生活保護受給者における向精神薬の多剤処方の地域差を検討することを目的とした。2011〜2012年の医療扶助実態調査における調剤レセプト2,285,106件をデータ源とした。向精神薬の多剤処方割合が全国平均よりも29〜55%高い地域は、北海道、山形県、岐阜県、大阪府、奈良県と和歌山県の6地域であった。多剤処方割合の最も高い地域と低い地域の間には11倍の差がみられた。人口あたりの生活保護人員数が多い地域と精神病床を有する病院が少ない地域は、向精神薬の多剤処方割合が高いことが示された。2011年と比較した2012年の多剤処方のオッズが20%よりも減少した地域は、川越市、千葉市、兵庫県の3地域であった。向精神薬の多剤処方の状況を定期的にモニタリングするための体制を構築し、地域の実情に応じた対策を進めることが望まれる。(著者抄録)

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Language：English   Publishing type：Research paper (international conference proceedings)   Publisher：IOS Press  

DOI： 10.3233/978-1-61499-432-9-1211

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Objectives: This study aimed to describe the clinical and procedural characteristics of drug poisoning, to examine procedural differences between drug poisoning repeaters and non-repeaters, and to estimate the costs of drug poisoning. Methods: A retrospective cohort study of a nationally representative sample of 6585 inpatients with drug poisoning was conducted, using the administrative database of the Diagnosis Procedure Combination/Per-Diem Payment System in 2008. Results: Although only 3% of patients required surgery and 65% were discharged from the hospitals within 3 days, greater than 30% were admitted to tertiary emergency care (i.e., high-level emergency care) centers that provide care to severely ill and trauma patients who require intensive care. Only 30% of patients received psychiatric consultation during hospitalization. In addition, repeaters were less likely to be admitted to hospitals by ambulance (67% vs. 76%) and more likely to be discharged within 3 days (77% vs. 65%) than non-repeaters. The annual economic burden of drug poisoning in Japan was $66 million (\7.7 billion), with the population aged 20-39 years accounting for 50% of these costs. Conclusion: This study highlights the need for optimally allocating resources and improving prevention strategies. © 2012 Elsevier Inc.

DOI： 10.1016/j.genhosppsych.2012.07.009

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Language：Japanese   Publisher：Japan Society for Healthcare Administration  

Promotion of regional referral systems, such as regional cooperative critical-paths, enables patients to effectively and safely receive medical care, while benefiting from the advancement and specialization of technology. On the other hand, the influence of the promotion of referral systems on accessibility, such as trends in the movement of patients has scarcely been elucidated.<br>Therefore, the purpose of this study was (1) to visualize the areas from which patients are drawn to hospitals, and (2) to elucidate changes in accessibility by transferring patients to convalescent hospitals using geographic information system (GIS), in acute care hospitals in regions with advanced regional cooperation.<br>In this study, substantial areas covered by acute care hospitals were wider than secondary medical areas, and 32.5% patients were transferred to convalescent hospitals outside the secondary medical areas. Geographic dissociation between secondary medical areas established by the Medical Service Act and the actual areas covered by hospitals were clarified. It was suggested that the evaluation of accessibility using GIS can be utilized in developing health resources reflecting the actual state of health care and in making health plans.

DOI： 10.11303/jsha.49.173

CiNii Books

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Other Link： https://jlc.jst.go.jp/DN/JALC/10007677440?from=CiNii

Language：English   Publishing type：Research paper (scientific journal)  

OBJECTIVE: To compare the clinical and procedural characteristics of emergency hospital admissions for drug poisoning and major diseases. DESIGN: Retrospective observational study. SETTING: Discharged patients from 855 acute care hospitals from 1 July to 31 December in 2008 in Japan. RESULTS: There were a total of 1 157 893 emergency hospital admissions. Among the top 100 causes, drug poisoning was ranked higher in terms of the percentage of patients using ambulance services (74.1%; second) and tertiary emergency medical services (37.8%; first). Despite higher utilisation of emergency care resources, drug poisoning ranked lower in terms of the median length of stay (2 days; 100th), percentage of requirement for surgical procedures (1.7%; 91st) and inhospital mortality ratio (0.3%; 74th). CONCLUSIONS: Drug poisoning is unique among the top 100 causes of emergency admissions. Our findings suggest that drug poisoning imposes a greater burden on emergency care resources but has a less severe clinical course than other causes of admissions. Future research should focus on strategies to reduce the burden of drug poisoning on emergency medical systems.

DOI： 10.1136/bmjopen-2012-001857

Scopus

PubMed

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Language：Japanese   Publisher：(一社)日本プライマリ・ケア連合学会  

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Language：Japanese   Publisher：(一社)日本成人先天性心疾患学会  

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Language：Japanese   Publisher：(NPO)日本高血圧学会  

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Language：Japanese   Publisher：(一社)日本プライマリ・ケア連合学会  

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Language：Japanese   Publisher：(一社)日本プライマリ・ケア連合学会  

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Language：Japanese   Publisher：(一社)日本総合病院精神医学会  

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Language：Japanese   Publisher：(株)星和書店  

承認後の医薬品安全性監視の新たな手法の1つとして、医療情報データベースを用いた副作用のシグナル検出が世界各国で実施されている。本邦でも、平成30年4月より、承認された医薬品の安全性と有効性を実証する再審査に、現行の市販後調査の補完として医療情報データベースの使用が可能になった。医療情報データベースを用いた医薬品安全性監視は、これまでの自発報告で指摘されていた欠点を補うものとなる可能性がある一方で、その結果の解釈にはデータベース研究特有の課題を認識する必要がある。今後、医薬品安全性監視において、医療情報データの利活用、ならびにデータネットワークの構築がさらなる進展を遂げていくと思われるが、現時点では、従来の自発報告による安全性評価を完全に代替するものではなく、補完的役割であるという認識が妥当であると考えられる。今後の研究の推進のためにも、妥当性研究の実施が重要となるだろう。(著者抄録)

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Language：Japanese   Publisher：(株)医学書院  

＜文献概要＞【背景】平成30(2018)年度診療報酬改定では,外来で維持期リハビリテーションを受けている患者(外来維持期リハビリテーション患者)は介護保険下のリハビリテーション(介護保険リハビリテーション)に移行予定だが,介護保険リハビリテーションの提供量に余裕がないと,移行できない者が現れる.【目的】外来維持期リハビリテーション・外来リハビリテーションからの移行予定患者数と介護保険リハビリテーションの利用者数を二次医療圏域別に比較し,75歳以上のすべての移行予定患者を介護保険リハビリテーションで受け入れることができるかどうか検討する.【方法】東京都後期高齢者医療広域連合より匿名化後に提供を受けた医科レセプトデータ(2014年8月診療分)から移行予定患者数(A)を推計した.介護保険リハビリテーション利用者数(B)に対する介護保険リハビリテーション利用予定者数(A+B)の増加比を二次医療圏域別に算出した.【結果】増加比が最も大きかった二次医療圏域は島嶼部で1.85倍,次いで区南部で1.39倍だった.【結語】75歳以上のすべての移行予定患者を介護保険リハビリテーションで受け入れることは厳しいと考えられる二次医療圏域が存在した.

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Other Link： https://search.jamas.or.jp/index.php?module=Default&action=Link&pub_year=2018&ichushi_jid=J00780&link_issn=&doc_id=20180911130016&doc_link_id=10.11477%2Fmf.1552201421&url=https%3A%2F%2Fdoi.org%2F10.11477%2Fmf.1552201421&type=%88%E3%8F%91.jp_%83I%81%5B%83%8B%83A%83N%83Z%83X&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00024_2.gif

Language：Japanese   Publisher：(一社)日本薬剤疫学会  

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Language：Japanese   Publisher：医療経済研究機構  

CiNii Books

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Language：Japanese  

DOI： 10.3143/geriatrics.54.186

J-GLOBAL

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Language：Japanese   Publisher：(公社)日本精神神経学会  

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Language：Japanese  

J-GLOBAL

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Language：Japanese   Publisher：(一社)日本医療・病院管理学会  

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Language：Japanese  

CiNii Books

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Other Link： http://search.jamas.or.jp/link/ui/2014243211

Language：Japanese   Publisher：(公社)日本精神神経学会  

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Language：Japanese   Publisher：(公社)日本精神神経学会  

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Language：Japanese   Publisher：日本臨床精神神経薬理学会・日本神経精神薬理学会  

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