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1.  The relationship between the number of cardiologists and clinical practice patterns in acute heart failure: a cross-sectional observational study 
BMJ Open  2014;4(12):e005988.
Despite the increasing burden of acute heart failure (AHF) on healthcare systems, the association between centralised cardiovascular specialist care and the quality of AHF care remains unknown. We examine the relationship between the number of cardiologists per hospital and hospital practice variations.
Design, setting and participants
In a retrospective observational study, we analysed 38 668 patients with AHF admitted to 546 Japanese acute care hospitals between 2010 and 2011 using the Diagnosis Procedure Combination administrative claims database. Sample hospitals were categorised into four groups according to the number of cardiologists per facility (none, 1–4, 5–9 and ≥10). To confirm the capability of administrative data to identify patients with AHF, the ≥10 cardiologists group was compared with two recent clinical registries in Japan.
Main outcome measures
Using multivariable logistic regression models, patient risk-adjusted in-hospital mortality rates and age-sex-adjusted ORs of various AHF therapies were calculated and compared among four hospital groups.
The ≥10 cardiologists group of hospitals from the administrative database had similar major underlying disease incidence and therapeutic practices to those of the clinical registry hospitals. Age-adjusted and sex-adjusted ORs of various AHF therapies in the four hospital groups revealed wide practice variations associated with the number of cardiologists. Adjusted in-hospital mortality demonstrated a negative association with the number of cardiologists. In addition, the different hospital-level distribution patterns of specific therapeutic practices illustrated the diffusion process of therapies across facilities.
Wide practice variations in AHF care were associated with the number of cardiologists per facility, indicating a possible relationship between the quality of AHF care and manpower resources. The provision of recommended therapies increased together with the number of cardiologists.
PMCID: PMC4281546  PMID: 25550294
2.  Development of a risk-adjusted in-hospital mortality prediction model for community-acquired pneumonia: a retrospective analysis using a Japanese administrative database 
BMC Pulmonary Medicine  2014;14(1):203.
Community-acquired pneumonia (CAP) is a common cause of patient hospitalization and death, and its burden on the healthcare system is increasing in aging societies. Here, we develop and internally validate risk-adjustment models and scoring systems for predicting mortality in CAP patients to enable more precise measurements of hospital performance.
Using a multicenter administrative claims database, we analyzed 35,297 patients hospitalized for CAP who had been discharged between April 1, 2012 and September 30, 2013 from 303 acute care hospitals in Japan. We developed hierarchical logistic regression models to analyze predictors of in-hospital mortality, and validated the models using the bootstrap method. Discrimination of the models was assessed using c-statistics. Additionally, we developed scoring systems based on predictors identified in the regression models.
The 30-day in-hospital mortality rate was 5.8%. Predictors of in-hospital mortality included advanced age, high blood urea nitrogen level or dehydration, orientation disturbance, respiratory failure, low blood pressure, high C-reactive protein levels or high degree of pneumonic infiltration, cancer, and use of mechanical ventilation or vasopressors. Our models showed high levels of discrimination for mortality prediction, with a c-statistic of 0.89 (95% confidence interval: 0.89-0.90) in the bootstrap-corrected model. The scoring system based on 8 selected variables also showed good discrimination, with a c-statistic of 0.87 (95% confidence interval: 0.86-0.88).
Our mortality prediction models using administrative data showed good discriminatory power in CAP patients. These risk-adjustment models may support improvements in quality of care through accurate hospital evaluations and inter-hospital comparisons.
PMCID: PMC4279890  PMID: 25514976
Community-acquired pneumonia; Risk-adjusted mortality; Prognosis prediction model; Severity index; Scoring system; Administrative database
3.  Can Experience Improve Hospital Management? 
PLoS ONE  2014;9(9):e106884.
Experience curve effects were first observed in the industrial arena as demonstrations of the relationship between experience and efficiency. These relationships were largely determined by improvements in management efficiency and quality of care. In the health care industry, volume-outcome relationships have been established with respect to quality of care improvement, but little is known about the effects of experience on management efficiency. Here, we examine the relationship between experience and hospital management in Japanese hospitals.
The study sample comprised individuals who had undergone surgery for unruptured abdominal aortic aneurysms and had been discharged from participant hospitals between April 1, 2006 and December 31, 2008. We analyzed the association between case volume (both at the hospital and surgeon level) and postoperative complications using multilevel logistic regression analysis. Multilevel log-linear regression analyses were performed to investigate the associations between case volume and length of stay (LOS) before and after surgery.
We analyzed 909 patients and 849 patients using the hospital-level and surgeon-level analytical models, respectively. The odds ratio of postoperative complication occurrence for an increase of one surgery annually was 0.981 (P<0.001) at the hospital level and 0.982 (P<0.001) at the surgeon level. The log-linear regression analyses showed that shorter postoperative LOS was significantly associated with high hospital-level case volume (coefficient for an increase of one surgery: −0.006, P = 0.009) and surgeon-level case volume (coefficient for an increase of one surgery: −0.011, P = 0.022). Although an increase of one surgery annually at the hospital level was statistically associated with a reduction of preoperative LOS by 1.1% (P = 0.006), there was no significant association detected between surgeon-level case volume and preoperative LOS (P = 0.504).
Experience at the hospital level may contribute to the improvement of hospital management efficiency.
PMCID: PMC4175069  PMID: 25250813
4.  Survival analyses of postoperative lung cancer patients: an investigation using Japanese administrative data 
SpringerPlus  2014;3:217.
Long-term survival rates of cancer patients represent important information for policymakers and providers, but analyses from voluntary cancer registries in Japan may not reflect the overall situation. In 2003, the Diagnosis Procedure Combination Per-Diem Payment System (DPC/PDPS) for hospital reimbursement was introduced in Japan; more than half of Japan’s acute care beds are currently covered under this system. Administrative data produced under the DPC system include claims data and clinical summaries for each admission. Due to the large amount of data spanning multiple institutions, this database may have applications in providing a more general and inclusive overview of healthcare. Here, we investigate the use of administrative data for analyses of long-term survival in cancer patients. We analyzed postoperative survival in 7,064 patients with primary non-small cell lung cancer admitted to 102 hospitals between April 2008 and March 2013 using DPC data. Survival was defined at the last date of examination or discharge within the study period, and the event was mortality during the same period. Overall survival rates for different cancer stages were calculated using the Kaplan-Meier method. Additionally, survival rates of cancer patients at clinical stage IA were compared between low- and high-volume hospitals using the Log-rank test. Postoperative 5-year survival for patients at stage IA was 85.8% (95% CI = 78.6%–93.0%). High-volume hospitals had higher survival rates than hospitals with lower volume. Our findings using large-scale administrative data were similar to previous clinical registry reports, showing potential applications as a new method in analyzing up-to-date healthcare information.
PMCID: PMC4018473  PMID: 24826376
Lung cancer; Survival analysis; Administrative data; Japan
5.  Widening disparity in the geographic distribution of pediatricians in Japan 
The shortage of physicians in Japan is a serious concern, particularly in specialties like pediatrics. The purpose of this study was to investigate recent changes in the geographic distribution of pediatricians and the factors underlying this change.
We investigated the numerical changes in the pediatrician workforce (2002 to 2007) per 100,000 of the population under the age of 15 years in 369 secondary medical areas throughout Japan, using attributive variables such as population size, social and economic status, and pediatric service delivery. We performed principal component analysis and multiple regression analysis.
We obtained two principal components: one that reflected the degree of urbanization and another that reflected the volume of pediatric service delivery. Only the first component score was positively correlated with an increased pediatrician workforce per 100,000 of the population under the age of 15 years. We classified the secondary medical areas into four groups using component scores. The increase in pediatrician workforce during this period was primarily absorbed into the two groups with higher levels of urbanization, whereas the two rural groups exhibited little increase. Pediatricians aged 50 to 59 years increased in all four groups, whereas pediatricians aged 30 to 39 years decreased in the two rural groups and increased in the two urban groups.
The trends of the pediatrician workforce increase generally kept pace with urbanization, but were not associated with the original pediatrician workforce supply. The geographic distribution of pediatricians showed rapid concentration in urban areas. This trend was particularly pronounced among female pediatricians and those aged 30 to 39 years. Given that aging pediatricians in rural areas are not being replaced by younger doctors, these areas will likely face new crises when senior physicians retire.
PMCID: PMC4222807  PMID: 24267031
Geographic distribution; Pediatrician; Physician; Workforce; Japan
6.  Association of Geographical Factors With Administration of Tissue Plasminogen Activator for Acute Ischemic Stroke 
Intravenous tissue plasminogen activator (tPA) is an effective treatment for acute ischemic stroke if administered within a few hours of stroke onset. Because of this time restriction, tPA administration remains infrequent. Ambulance use is an effective strategy for increasing tPA administration but may be influenced by geographical factors. The objectives of this study are to investigate the relationship between tPA administration and ambulance use and to examine how patient travel distance and population density affect tPA utilization.
Methods and Results
We analyzed administrative claims data from 114 194 acute ischemic stroke cases admitted to 603 hospitals between July 2010 and March 2012. Mixed‐effects logistic regression models of patients nested within hospitals with a random intercept were generated to analyze possible predictive factors (including patient characteristics, ambulance use, and driving time from home to hospital) of tPA administration for different population density categories to investigate differences in these factors in various regional backgrounds. Approximately 5.1% (5797/114 194) of patients received tPA. The composition of baseline characteristics varied among the population density categories, but adjustment for covariates resulted in all factors having similar associations with tPA administration in every category. The administration of tPA was associated with patient age and severity of stroke symptoms, but driving time showed no association. Ambulance use was significantly associated with tPA administration even after adjustment for covariates.
The association between ambulance use and tPA administration suggests the importance of calling an ambulance for suspected stroke. Promoting ambulance use for acute ischemic stroke patients may increase tPA use.
PMCID: PMC3835241  PMID: 24045119
emergency medical services; health services research; ischemic stroke; tissue‐type plasminogen activator
7.  The impact of acute organ dysfunction on patients' mortality with severe sepsis 
Severe sepsis leads to organ failure and results in high mortality. Organ dysfunction is an independent prognostic factor for intensive care unit (ICU) mortality. The objective of the present study was to determine the effect of acute organ dysfunction for ICU mortality in patients with severe sepsis using administrative data.
Materials and Methods:
A multicenter cross-sectional study was performed in 2008. The study was conducted in 112 teaching hospitals in Japan. All cases with severe sepsis in ICU were identified from administrative data.
Administrative data acquired for 4196 severe septic cases of 75,069 cases entered in the ICU were used to assess patient outcomes. Cardiovascular dysfunction was identified as the most major organ dysfunction (73.0%), and the followings were respiratory dysfunction (69.4%) and renal dysfunction (39.0%), respectively. The ICU mortality and 28-day means 28-day from ICU entry. were 18.8% and 27.7%, respectively. After adjustment for age, gender, and severity of illness, the hazard ratio of 2, 3, and ≥4, the organ dysfunctions for one organ failure on ICU mortality was 1.6, 2.0, and 2.7, respectively.
We showed that the number of organ dysfunction was a useful indicator for ICU mortality on administrative data. The hepatic dysfunction was the highest mortality among organ dysfunctions. The hazard ratio of ICU death in severe septic patients with multiple organ dysfunctions was average 2.2 times higher than severe septic patients with single organ dysfunction.
PMCID: PMC3127295  PMID: 21772676
Intensive care units; multicenter study; multiple organ failure; mortality; sepsis
8.  Lag time in an incident reporting system at a university hospital in Japan 
Quality & Safety in Health Care  2007;16(2):101-104.
Delays and underreporting limit the success of hospital incident reporting systems, but little is known about the causes or implications of delayed reporting.
Setting and methods
The authors examined 6880 incident reports filed by physicians and nurses for three years at a national university hospital in Japan and evaluated the lag time between each incident and the submission of a report.
Although physicians and nurses reported nearly equal numbers of events resulting in major injury (32 v 31), physicians reported far fewer minor incidents (430 v 6387) and far fewer incidents overall (462 v 6418). In univariate analyses, lag time was significantly longer for physicians than nurses (3.79 v 2.20 days; p<0.001). In multivariate analysis, physicians had adjusted reporting lag time 75% longer than nurses (p<0.001) and lag time for major injuries was 18% shorter than for minor injuries (p = 0.011). Adjusted lag time in 2002 and 2004 were 34% longer than in 2003 (p<0.001).
Physicians report fewer incidents than nurses and take longer to report them. Quantitative evaluation of lag time may facilitate improvements in incident reporting systems by distinguishing institutional obstacles to physician reporting from physicians' lesser willingness to report.
PMCID: PMC2653144  PMID: 17403754
9.  The association of the number of comorbidities and complications with length of stay, hospital mortality and LOS high outlier, based on administrative data 
With greater concern for efficient resource allocation and profiling of medical care, a case-mix classification was applied for the per-diem payment system in Japan. Many questions remain, one of which is the role of comorbidity and complication (CC) in grouping logic. We examined the association of the number of CC with the length of hospital stay (LOS) and hospital mortality as well as the proportion of LOS high outliers in 19 major diagnostic categories (MDCs).
This study was a secondary data analysis embedded in a government research project, including anonymous claims and clinical data during a 4-month period from July 2002. Every 19 MDC, LOS, hospital mortality or proportion of LOS high outliers was compared by the number of CC and presence of any procedures.
From 82 special function hospitals, 241,268 patients were enrolled in this study. Among all patients, 50.5% were identified without any CCs, 32.4% with one or two, 13.4% with three or four, and 3.7% with over five CCs. The overall mean LOS was 22.15 days and hospital mortality 26.05 cases per 1,000 admissions. In any MDC, LOS and the proportion of outliers increased as the number of CC rose. The mortality rate increased prominently in the respiratory system and the hematology system.
This study demonstrated that the occurrence of more CC caused longer LOS and higher mortality in some major disease categories. Further study will clarify the association of the weighted CC with resource use through controlling procedures specific for MDC.
PMCID: PMC2698257  PMID: 19568897
Comorbidity; Complication; Resource use; Mortality; Case mix
10.  Measuring hospital-wide activity volume for patient safety and infection control: a multi-centre study in Japan 
In Japan, as in many other countries, several quality and safety assurance measures have been implemented since the 1990's. This has occurred in spite of cost containment efforts. Although government and hospital decision-makers demand comprehensive analysis of these activities at the hospital-wide level, there have been few studies that actually quantify them. Therefore, the aims of this study were to measure hospital-wide activities for patient safety and infection control through a systematic framework, and to identify the incremental volume of these activities implemented over the last five years.
Using the conceptual framework of incremental activity corresponding to incremental cost, we defined the scope of patient safety and infection control activities. We then drafted a questionnaire to analyze these realms. After implementing the questionnaire, we conducted several in-person interviews with managers and other staff in charge of patient safety and infection control in seven acute care teaching hospitals in Japan.
At most hospitals, nurses and clerical employees acted as the main figures in patient safety practices. The annual amount of activity ranged from 14,557 to 72,996 person-hours (per 100 beds: 6,240; per 100 staff: 3,323) across participant hospitals. Pharmacists performed more incremental activities than their proportional share. With respect to infection control activities, the annual volume ranged from 3,015 to 12,196 person-hours (per 100 beds: 1,141; per 100 staff: 613). For infection control, medical doctors and nurses tended to perform somewhat more of the duties relative to their share.
We developed a systematic framework to quantify hospital-wide activities for patient safety and infection control. We also assessed the incremental volume of these activities in Japanese hospitals under the reimbursement containment policy. Government and hospital decision makers can benefit from this type of analytic framework and its empirical findings.
PMCID: PMC2020483  PMID: 17764578
11.  Functional mapping of hospitals by diagnosis-dominant case-mix analysis 
Principles and methods for the allocation of healthcare resources among healthcare providers have long been health policy research issues in many countries. Healthcare reforms including the development of a new case-mix system, Diagnosis Procedure Combination (DPC), and the introduction of a DPC-based payment system are currently underway in Japan, and a methodology for adequately assessing the functions of healthcare providers is needed to determine healthcare resource allocations.
By two-dimensional mapping of the rarity and complexity of diagnoses for patients receiving treatment, we were able to quantitatively demonstrate differences in the functions of different healthcare service provider groups.
On average, inpatients had diseases that were 3.6-times rarer than those seen in outpatients, while major teaching hospitals treated inpatients with diseases 3.0-times rarer on average than those seen at small hospitals.
We created and evaluated a new indicator for DPC, the diagnosis-dominant case-mix system developed in Japan, whereby the system was used to assess the functions of healthcare service providers. The results suggest that it is possible to apply the case-mix system to the integrated evaluation of outpatient and inpatient healthcare services and to the appropriate allocation of healthcare resources among health service providers.
PMCID: PMC1854890  PMID: 17425788
12.  Why are physicians not persuaded by scientific evidence? A grounded theory interview study 
The government-led "evidence-based guidelines for cataract treatment" labelled pirenoxine and glutathione eye drops, which have been regarded as the standard care for cataracts in Japan, as lacking evidence of effectiveness, causing great upset among ophthalmologists and professional ophthalmology societies. This study investigated the reasons why such "scientific evidence of treatment effectiveness" is not easily accepted by physicians, and thus, why they do not change their clinical practices to reflect such evidence.
We conducted a qualitative study based on grounded theory to explore physicians' awareness of "scientific evidence" and evidence-supported treatment in relation to pirenoxine and glutathione eye drops, and to identify current barriers to the implementation of evidence-based policies in clinical practice. Interviews were conducted with 35 ophthalmologists and 3 general practitioners on their prescribing behaviours, perceptions of eye drop effectiveness, attitudes toward the eye drop guideline recommendations, and their perceptions of "scientific evidence."
Although few physicians believed that eye drops are remarkably effective, the majority of participants reported that they prescribed eye drops to patients who asked for them, and that such patients accounted for a considerable proportion of those with cataracts. Physicians seldom attempted to explain to patients the limitations of effectiveness or to encourage them to stop taking the eye drops. Physicians also acknowledged the benefits of prescribing such drugs, which ultimately outweighed any uncertainty of their effectiveness. These benefits included economic incentives and a desire to be appreciated by patients. Changes in clinical practice were considered to bring little benefit to physicians or patients. Government approval, rarity of side effects, and low cost of the drops also encouraged prescription.
Physicians occasionally provide treatment without expecting remarkable therapeutic effectiveness, as exemplified by the use of eye drops. This finding highlights that scientific evidence alone cannot easily change physicians' clinical practices, unless evidence-based practices are accepted by the general public and supported by health policy.
PMCID: PMC1555581  PMID: 16872522
13.  Impact of treatment policies on patient outcomes and resource utilization in acute cholecystitis in Japanese hospitals 
Although currently available evidence predominantly recommends early laparoscopic cholecystectomy (LC) for the treatment of acute cholecystitis, this strategy has not been widely adopted in Japan. Herein, we describe a hospital-based study of patients with acute cholecystitis in 9 Japanese teaching hospitals in order to evaluate the impact of different institutional strategies in treating acute cholecystitis on overall patient outcomes and medical resource utilization.
From an administrative database and chart review, we identified 228 patients diagnosed with acute cholecystitis who underwent cholecystectomy between April 2001 and June 2003. In order to examine the relationship between hospitals' propensity to perform LC and patient outcomes and/or medical resource utilization, we divided the hospitals into three groups according to the observed to expected ratio of performing LC (LC propensity), and compared the postoperative complication rate, length of hospitalization (LOS), and medical charges.
No hospital adopted the policy of early surgery, and the mean overall LOS among the subjects was 30.9 days. The use of laparoscopic surgery varied widely across the hospitals; the adjusted rates of LC to total cholecystectomies ranged from 9.5% to 77%. Although intra-operative complication rate was significantly higher among patients whom LC was initially attempted when compared to those whom OC was initially attempted (9.7% vs. 0%), there was no significant association between LC propensity and postoperative complication rates. Although the postoperative time to oral intake and postoperative LOS was significantly shorter in hospitals with high use of LC, the overall LOS did not differ among hospital groups with different LC propensities. Medical charges were not associated with LC propensity.
Under the prevailing policy of delayed surgery, in terms of the postoperative complication rate and medical resource utilization, our study did not show the superiority of LC in treating acute cholecystitis patients. The timing of surgery and discharge was mainly determined by the institutional policy in Japan, rather than by the clinical course of the patient; however, considering the substantially less postoperative pain and shorter recovery time of LC compared to OC, LC should be actively applied for the treatment of acute cholecystitis. If the policy of early surgery were universally applied, the advantage of LC over OC may be more clearly demonstrated.
PMCID: PMC1488841  PMID: 16569249
14.  Patients' preferences for involvement in treatment decision making in Japan 
A number of previous studies have suggested that the Japanese have few opportunities to participate in medical decision-making, as a result both of entrenched physician paternalism and national characteristics of dependency and passivity. The hypothesis that Japanese patients would wish to participate in treatment decision-making if adequate information were provided, and the decision to be made was clearly identified, was tested by interview survey.
The subjects were diabetic patients at a single outpatient clinic in Kyoto. One of three case study vignettes (pneumonia, gangrene or cancer) was randomly assigned to each subject and, employing face-to-face interviews, the subjects were asked what their wishes would be as patients, for treatment information, participation in decision-making and family involvement.
134 patients participated in the study, representing a response rate of 90%. The overall proportions of respondents who preferred active, collaborative, and passive roles were 12%, 71%, and 17%, respectively. Respondents to the cancer vignette were less likely to prefer an active role and were more likely to prefer family involvement in decision-making compared to non-cancer vignette respondents. If a physician's recommendation conflicted with their own wishes, 60% of the respondents for each vignette answered that they would choose to respect the physician's opinion, while few respondents would give the family's preference primary importance.
Our study suggested that a majority of Japanese patients have positive attitudes towards participation in medical decision making if they are fully informed. Physicians will give greater patient satisfaction if they respond to the desire of patients for participation in decision-making.
PMCID: PMC375530  PMID: 15053839
15.  Quality of life domains in the healthy public: A trial investigation using attendants for an annual health checkup 
A trial investigation of subjects gathered for annual health checkups was performed to detect domains of quality of life in the healthy public, and to explore the changes of their demographic characteristics for the possibility of engaging them in health service activities in the community. The eligible 1,096 subjects aged 30–79 years were investigated. The period of this survey was from September to December, 1997. The subjects were questioned using ten quality of life domains which were preliminarily prepared and had been assumed to be most important in the subjects’ lives in relation to the order of priority, importance, and satisfaction levels. The first most important domain in both the male and female subjects’ lives was personal health, followed by relationships with family, though the mean importance scores for their personal health and relationships with family were almost equivalent. The mean scores for work abruptly decreased in males over 60 years of age. Also, the first large and the second relatively small principal components were extracted through principal components analysis. The proposed ten domains of quality of life are most likely valid and reliable in terms of the results analyzed and the comparison with a referred study. Relationships with family is an effective cue for health service activities in the community, and the significance of work on quality of life in the healthy public will have to be taken into account separately, especially in males.
PMCID: PMC2723422  PMID: 21432170
quality of life; healthy public; family; work; health services

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