Japanese Diagnosis Procedure Combination Research Articles

Relative dose intensity of R-CHOP treatment and febrile neutropenia incidence: A nation-wide survey

Abstract Background No comprehensive analysis has evaluated the appropriate relative dose intensity (RDI) of R-CHOP treatment in elderly patients. This study aimed to clarify the relationships between the RDI of R-CHOP treatment and susceptibility of febrile neutropenia (FN) using a national inpatient database in Japan. Methods We identified patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL) who received the first R-CHOP treatment between July 2007 and March 2017 from the Japanese Diagnosis Procedure Combination Database. RDI was calculated according to a comparison between the actual cyclophosphamide dose and the 100%-dose cyclophosphamide. Multivariable logistic regression analysis was performed to identify factors associated with the incidence of febrile neutropenia (FN). Results FN occurred in 1,465 of the 18,095 (8.1%) patients, at a median of 10 days (IQR, 8-12) from the initiation of the chemotherapy. Compared with the >100% RDI group, multivariate analyses showed that each low-RDI group (80%≤RDI Conclusions Our study suggests that low-RDI R-CHOP treatment decreases the susceptibility of FN in patients who are over 70 years of age.

Patient characteristics and in-hospital complications of subcutaneous implantable cardioverter-defibrillator for Brugada syndrome in Japan.

BackgroundClinical features and complications of subcutaneous implantable cardioverter‐defibrillator (S‐ICD) implantation for Brugada syndrome have not been well studied.MethodsWe used the Japanese Diagnosis Procedure Combination database to retrospectively investigate patients who had undergone ICD implantation between April 2016 and March 2017. We compared the characteristics and in‐hospital complications of patients with Brugada syndrome implanted with S‐ICD or transvenous (TV)‐ICD.ResultsWe extracted 3090 patients who received ICD implantation. Among them, we identified 278 Brugada patients. The mean age was 43 ± 14.4 years and 262 (94%) were male. Of these 278 patients, 136 (49%) received S‐ICD and 142 (51%) received TV‐ICD. TV‐ICD recipients had a history of atrial fibrillation more frequently compared with S‐ICD recipients. The median (interquartile range) of length of hospital stay was not significantly different between patients with S‐ICD and TV‐ICD (13 days [10‐20.5] vs 12 days [10‐18], respectively). The prevalence of in‐hospital complications after ICD implantation was similar between the two groups. There were no patients with cardiac tamponade, hemothorax, pneumothorax, cardiovascular event, stroke, and death following the procedure during hospitalization in either group.ConclusionsShort‐term safety of S‐ICD implantation may be identical to that of TV‐ICD. Large prospective studies are warranted to compare the effects and long‐term safety of S‐ICD compared with TV‐ICD.

Extracorporeal membrane oxygenation improves outcomes of accidental hypothermia without vital signs: A nationwide observational study

AimPatients with accidental hypothermia without vital signs increasingly receive venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, there is limited knowledge regarding the efficacy of this advanced rewarming method. We aimed to determine whether VA-ECMO improved outcomes in patients with accidental hypothermia without vital signs, using a large nationwide inpatient database in Japan. MethodsUsing the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2017, we identified patients diagnosed with accidental hypothermia who received closed-chest cardiac massage in-hospital on the day of admission. Patients who received VA-ECMO on the day of admission were allocated to the VA-ECMO group, and those who received cardiopulmonary resuscitation (CPR) only were allocated to the conventional CPR group. The primary outcome was in-hospital mortality, and the secondary outcome was a Japan Coma Scale status of “alert consciousness” at discharge. Propensity score-matching analyses were performed to compare the outcomes. ResultsWe identified 1661 eligible patients during the 81-month study period, and 318 (19%) received VA-ECMO on the day of admission. Crude in-hospital mortality was 65% in the VA-ECMO group and 84% in the conventional CPR group. Propensity score-matching analyses demonstrated significantly lower in-hospital mortality (risk difference: −13%; 95% confidence interval: −21% to −5.1%) and a higher proportion of “alert consciousness” at discharge (risk difference: 8.3%; 95% confidence interval: 1.9%–15%) in the VA-ECMO group compared with the conventional CPR group. ConclusionVA-ECMO was associated with higher survival and favourable neurological outcomes compared with conventional CPR alone in patients with accidental hypothermia without vital signs.

Incidence and In-Hospital Mortality of Neonatal Disseminated Intravascular Coagulation in Japan: An Observational Study of a Nationwide Hospital Claims Database.

This study aimed to estimate the incidence and prognosis of neonatal disseminated intravascular coagulation (DIC) in Japan by analyzing data retrieved from a national administrative database. Clinically, the prognosis of DIC in neonates is poor, but there is little epidemiological data in Japan. This retrospective observational study identified patients diagnosed with neonatal DIC and who were registered in the Japanese diagnosis procedure combination (DPC) database between April 1, 2014 and March 31, 2016. The patients, who were diagnosed with neonatal DIC, included those with ICD-10 code D65 or P60 in primary and secondary diagnosis, with comorbid conditions existing at admission, and with complications occurring after admission. Of 78,073 neonates admitted to 1,474 neonatal intensive care units, 1,864 (2.4%) were diagnosed with DIC. There was no difference between sexes in incidence of DIC; the incidence of DIC was higher in extremely low birth weight infants (9.8%), and significantly higher than that in normal birth weight infants. The overall mean length of hospital stay was longer in neonates with DIC (69.5 days) than in those without DIC (32.6 days, P < 0.001). The number of deaths was 1,156 (1.5%). In-hospital mortality was significantly higher in neonates with DIC (14.1%) than in those without DIC (1.2%, P < 0.001), especially in premature babies. This nationwide study was the first report to investigate the incidence and in-hospital mortality of neonatal DIC in Japan. Neonatal DIC has a significant impact on prognosis, and its influence is greater in premature than in term infants.

Comparison of the association of risperidone and quetiapine with deteriorating performance in walking and dressing in subjects with Parkinson's disease: a retrospective cohort study using administrative claims data.

This retrospective cohort study was performed to investigate the association between risperidone and deteriorating performance in walking and dressing in subjects with Parkinson's disease using the Japanese Diagnosis Procedure Combination data. These data include inpatient claims including information from the time of admission to discharge from 89 acute phase National Hospitals in Japan. The data were evaluated by implementing the inverse probability of treatment weighting, using propensity scores estimated from the clinical characteristics of subjects prescribed risperidone or quetiapine. The generalized estimation equation was used to estimate the adjusted risk ratios (aRRs) and 95% confidence intervals (CIs). In total, 304 subjects were eligible for participation, and were hospitalized between April 2012 and March 2017 (108 and 196 for risperidone and quetiapine groups, respectively). The performance of walking deteriorated at discharge, with 22.2% and 10.2% recorded at admission for the risperidone and quetiapine groups (aRR, 1.7; 95% CI, 0.9 to 3.4), respectively. The performance of dressing also deteriorated: 24.1% and 10.7% in the risperidone and quetiapine groups (aRR, 1.9; 95% CI, 1.04 to 3.7), respectively. These results suggest an association between risperidone and deteriorating performance in dressing in subjects with Parkinson's disease in comparison with quetiapine.

Characteristics, treatments, and outcomes among patients with abdominal aortic injury in Japan: a nationwide cohort study.

BackgroundAbdominal aortic injury (AAI) is a life-threatening condition that occurs in only 0.1% of all trauma admissions. Because of its rarity, the clinical features of AAI remain unclear. We investigated the characteristics, treatments, and clinical outcomes among patients with AAI.MethodsThis retrospective cohort study was performed using the Japanese Diagnosis Procedure Combination database. We identified patients with a confirmed diagnosis of AAI with emergency admission from 1 July 2010 to 31 March 2017. Eligible patients were divided into three groups: those who were treated with no surgery or endovascular treatment (non-repair group), those who underwent surgery without endovascular treatment (open repair group), and those who received endovascular treatment without surgery (endovascular repair group).ResultsA total of 238 patients met the inclusion criteria during the study period. Of these, 191 (80.3%) were allocated to the non-repair group, 20 (8.4%) were allocated to the open repair group, and 27 (11.3%) were allocated to the endovascular repair group. The proportions of patients in the non-repair group from July 2010 to March 2012, April 2012 to March 2014, April 2014 to March 2016, and April 2016 to March 2017 were 93.5%, 75.9%, 80.6%, and 73.2%, respectively. The crude in-hospital mortality rate was 26.2%, 35.0%, and 18.5% in the non-repair, open repair, and endovascular repair group, respectively.ConclusionsIn this cohort, the proportion of non-repair for AAI decreased from 2010 to 2017, whereas the proportion of endovascular repair increased. Younger patients were more likely to undergo open repair, whereas older patients were more likely to undergo endovascular repair.

Association between intravenous contrast media exposure and non-recovery from dialysis-requiring septic acute kidney injury: a nationwide observational study.

This study aimed to examine the association between the use of intravenous contrast and non-recovery from dialysis-requiring acute kidney injury (AKI-D) and in-hospital mortality among patients with sepsis. This was a retrospective observational study using the Japanese Diagnosis Procedure Combination inpatient database between January 2011 and December 2016. We identified patients with septic AKI who began continuous renal replacement therapy (RRT) within 2-days of admission and underwent computed tomography. We compared patients with AKI-D with and without the use of intravenous contrast for computed tomography and performed propensity score matching to adjust for confounders for the association between exposure to intravenous contrast and outcomes, including a composite outcome of in-hospital mortality and RRT dependence at discharge and RRT duration. From 3782 and 6619 patients with septic AKI-D with and without intravenous contrast exposure, respectively, 3485 propensity score-matched pairs were generated. No significant differences were found in the outcomes between the propensity score-matched groups: a composite outcome of in-hospital mortality and RRT dependence, 49.6% vs. 50.2% (odds ratio (OR) 0.98; 95% CI (confidence interval) 0.88, 1.07); in-hospital mortality, 45.3% vs. 46.1% (OR 0.97; 95% CI 0.87, 1.06); RRT dependence, 4.4% vs 4.1% (OR 1.08; 95% CI 0.85, 1.31); and median (interquartile range) of RRT duration, 4 [2-11]days vs. 4 [2-11]days (P = 0.58). This large observational study did not support an association between intravenous contrast media and adverse in-hospital outcomes in patients with septic AKI-D. Further studies are warranted to assess the generalizability.

Outcomes of endoscopic sinus surgery for sinusitis-induced intracranial abscess in patients undergoing neurosurgery.

Although sinusitis-induced intracranial complications rarely occur in the current era of antibiotics, they can induce neurological symptoms or death. The authors of this study investigated the association between endoscopic sinus surgery (ESS) and outcomes in patients who had undergone neurosurgical procedures for sinusitis-induced intracranial abscess. The authors obtained data on patients with sinusitis-induced intracranial abscess from the Japanese Diagnosis Procedure Combination inpatient data for the period from 2010 to 2017. They excluded patients with fungal sinusitis, orbital complications, immunodeficiency, and malignant disease. They also excluded patients who had received antifungal agents, chemotherapy, immunosuppressants, and antidiabetic drugs. Eligible patients were divided into those with and those without neurosurgical procedures. Propensity score-adjusted regression analyses were performed to examine the association between ESS within the same hospitalization and outcomes (mortality, blood transfusion, readmission, revision neurosurgery, and length of stay). Of the 552 potentially eligible patients, 255 were treated with neurosurgical procedures, including 104 who underwent ESS within the same hospitalization and 151 who did not. ESS was not significantly associated with mortality (OR 0.54, 95% CI 0.05-5.81, p = 0.61), blood transfusion (OR 1.95, 95% CI 0.84-4.51, p = 0.12), readmission (OR 0.86, 95% CI 0.34-2.16, p = 0.75), revision neurosurgery (OR 0.65, 95% CI 0.24-1.74, p = 0.39), or length of stay (percent difference -10.8%, 95% CI -24.4% to 5.1%, p = 0.18). The present study suggests that ESS may not have significant benefits with respect to reducing mortality, blood transfusion, readmission, revision neurosurgery, or length of stay.

SUN-164 ASSOCIATION BETWEEN INTRAVENOUS CONTRAST MEDIA AND NON-RECOVERY FROM DIALYSIS-REQUIRING SEPTIC ACUTE KIDNEY INJURY IN INTENSIVE CARE UNIT PATIENTS: A NATIONWIDE OBSERVATIONAL STUDY

Although the concern of the effect of iodinated contrast media on acute kidney injury (AKI) affects physician’s decision on the usage of contrast media with computed tomography (CT), recent reports have questioned the causal relationship between administration of intravenous contrast media and the subsequent AKI, and its causal relationship is still controversial. However, there are no previous reports about whether iodinated-contrast media increase non-renal recovery in critically ill patients who require renal replacement therapy (RRT) early after admission. In this retrospective observational study using the Japanese Diagnosis Procedure Combination inpatient database during a period between July 1, 2011 and March 31, 2017, we identified patients with septic AKI who required continuous renal replacement therapy (CRRT) within 1 day after admission. Patients were divided into those who received computed tomography with intravenous contrast media and those without contrast media. We performed propensity score matching to control potential confounders and analyzed associations between exposure to intravenous contrast media and outcomes, including major adverse kidney events (MAKE) which was defined as death and RRT-dependence at discharge, and duration of RRT. A total of 9,055 patients (3293 with contrast media and 5762 without contrast media) were eligible. Propensity score matching analyses showed MAKE at discharge was not statistically different between the groups with and without contract media (49.6% vs 50.7%, p=0.441). RRT duration was median 5 days and also not significantly different between the groups. Use of intravenous contrast media was not associated with increase in MAKE or RRT duration in patients with septic dialysis-requiring AKI.

Endurological treatment trend of upper urinary urolithiasis in Japan from the Japanese Diagnosis Procedure Combination Database.

Endurological treatment trend of upper urinary urolithiasis in Japan from the Japanese Diagnosis Procedure Combination Database.

In-hospital mortality associated with transcatheter arterial embolization for treatment of hepatocellular carcinoma in patients on hemodialysis for end stage renal disease: a matched-pair cohort study using a nationwide database.

Objectives:No previous study has evaluated the risks associated with transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma in patients on hemodialysis (HD) for end stage renal disease (ESRD), because invasive treatment is rarely performed for such patients. We used a nationwide database to investigate in-hospital mortality and complication rates following TACE in patients on HD for ESRD.Methods:Using the Japanese Diagnosis Procedure Combination database, we enrolled patients on HD for ESRD who underwent TACE for hepatocellular carcinoma. For each patient, we randomly selected up to four non-dialyzed patients using a matched-pair sampling method based on the patient’s age, sex, treatment hospital, and treatment year. In-hospital mortality and complication rates were compared between dialyzed and non-dialyzed patients following TACE.Results:We compared matched pairs of 1551 dialyzed and 5585 non-dialyzed patients. Although the complication rate did not differ between the dialyzed and non-dialyzed ESRD patients [5.7% vs 5.8%, respectively; odds ratio, 0.99; 95% confidence interval (0.79–1.23); p = 0.90], the in-hospital mortality rate was significantly higher in dialyzed ESRD patients than in non-dialyzed patients [2.2% vs 0.97%, respectively; odds ratio, 2.21; 95% confidence interval (1.44–3.40); p < 0.001]. Among the dialyzed patients, the mortality rate was not significantly associated with sex, age, Charlson comorbidity index, or hospital volume.Conclusions:The in-hospital mortality rate following TACE was 2.2 % and was significantly higher in dialyzed than in non-dialyzed ESRD patients. The indications for TACE in HD-dependent patients should be considered carefully with respect to the therapeutic benefits v s risks.Advances in knowledge:In hospital mortality rate following TACE in dialyzed patients was more than twice compared to non-dialyzed patients. Post-procedural complication following TAE in ESRD onHD patients was 5.7%, and did not differ from that in non dialyzed patients.

Association between the variation in hospital beds and inpatient chemo/radiotherapy for breast cancer: A retrospective study using the Japanese Diagnosis Procedure Combination database of over 500K records.

e18008 Background: Chemo/radiotherapy for breast cancer patients does not require hospitalization in most cases. We investigated the relationship between the proportion of hospitalization for chemo/radiotherapy over total hospitalization among breast cancer cases (inpatient chemo/radiotherapy rate) and the number of hospital beds per capita using the national database in Japan. Methods: We conducted a retrospective observational study using Diagnosis Procedure Combination (DPC) database and National survey database from April 2012 to March 2016. We aggregated hospital-level data into prefecture-level data and classified the 47 prefectures into quintiles based on the number of hospital beds per capita (9-10 prefectures per quintile). Generalized estimating equations (GEE) were used for examining the relationship between the number of hospital beds and inpatient chemo/radiotherapy rate (discretionary setting) or the number of surgical operations (imperative setting). Results: Over the five-year study period, there were 561,165 records for hospitalization for breast cancer cases. The inpatient chemo/radiotherapy rate at each prefecture varied, ranging from 2.6% to 61.8% in 2016. The inpatient chemo/radiotherapy rate was significantly higher in the second highest and the highest quintile by 11.7% (95% CI 4.0-19.5%, P = 0.003) and 9.6% (95% CI 1.8-17.4%, P = 0.015), respectively, compared with the middle quintile. There was no significant difference between the lowest, second lowest and middle quintile. On the contrary, there was no significant difference in the number of surgical operations for breast cancer per capita between each quintile and middle quintile. Conclusions: We found that higher hospital beds associated with more chemo/radiotherapy in the inpatient setting. This study is a starting point for the discussion on the employment support for people with cancer and the economical utilization of the limited medical resource in the oncology field. The further studies evaluating the association between health resource and the other type of procedures are warranted.

Association of Early Systemic Corticosteroid Therapy with Mortality in Patients with Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis: A Retrospective Cohort Study Using a Nationwide Claims Database.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe dermatologic disorders with high mortality. The role of systemic corticosteroids as an adjunctive therapy for SJS or TEN remains controversial. The aim of this study was to determine whether treatment with early systemic corticosteroids impacts the in-hospital mortality of patients hospitalized with SJS or TEN. Using the Japanese Diagnosis Procedure Combination Database, a large nationwide inpatient administrative claims database, we identified inpatients aged ≥ 18years who were admitted with SJS or TEN. Treatment with early systemic corticosteroids was defined as starting treatment with systemic corticosteroids within 2days (day0 or day1) of admission. The primary outcome was in-hospital mortality. We examined the association between early systemic corticosteroids and in-hospital mortality using propensity score (PS) analyses. We identified 1846 eligible patients with SJS or TEN, including 793 patients with early systemic corticosteroid use at ≤ 2mg/kg/day, 558 patients with early systemic corticosteroid use at > 2mg/kg/day, and 495 patients without early corticosteroid use. PS matching created 235 pairs (> 2mg/kg/day vs. controls) and 332 pairs (≤ 2mg/kg/day vs. controls). Early systemic corticosteroid use was not significantly associated with lower in-hospital mortality by PS matching (> 2mg/kg/day vs. controls: relative risk [RR] 0.83, 95% confidence interval [CI] 0.37-1.85; ≤ 2mg/kg/day vs. controls: RR 0.61, 95% CI 0.28-1.36) and by inverse probability of treatment weighting (> 2mg/kg/day vs. controls: RR 0.99, 95% CI 0.45-2.19; ≤ 2mg/kg/day vs. controls: RR 0.65, 95% CI 0.29-1.47). Early systemic corticosteroid therapy for patients with SJS or TEN was not associated with lower in-hospital mortality. Further studies are needed to define the effect of corticosteroids for patients with SJS or TEN.

Association of dialysis with in-hospital disability progression and mortality in community-onset stroke.

End-stage renal disease is associated with increased risk of cerebrovascular disease, but the effect on post-stroke clinical outcomes has not been thoroughly investigated. Using the Japanese Diagnosis Procedure Combination database, which includes administrative claims and discharge abstract data, we examined the association between risk factors including dialysis therapy and in-hospital disability progression or mortality in patients with community-onset stroke. We extracted data of patients aged ≥ 20 years old who were admitted to the hospital within 3 days after onset of stroke between July 2010 and March 2013. The disability level was divided into modified Rankin Scale (mRS) 0-1, 2-3, 4-5, and 6 (death). Disability progression was defined as an increase in disability level. Odds ratios for in-hospital disability progression and mortality were calculated using logistic regression models. Of 435 403 patients, 7562 (1.7%) received dialysis therapy. The median length of stay was 21 and 20 days for patients with and without dialysis, respectively. During the hospital stay, disability progressed in 100 402 (23.1%) patients and 45 919 (10.5%) died. Patients on dialysis had a higher prevalence of disability progression (26.8%) and mortality (13.1%) compared to those without dialysis (23.0% and 10.5%, respectively). Dialysis was associated with an increased risk of in-hospital disability progression (odds ratio, 1.56; 95% confidence interval, 1.47-1.66) and mortality (odds ratio 1.70; 95% confidence interval, 1.57-1.84). These risks were comparable among subtypes of stroke. Dialysis was associated with an increased risk of in-hospital disability progression and mortality among patients with community-onset stroke, regardless of stroke subtype.

Disaster-related carbon monoxide poisoning after the Great East Japan Earthquake, 2011: a nationwide observational study.

AimTo investigate disaster‐related carbon monoxide (CO) poisoning after the Great East Japan Earthquake using a nationwide inpatient database in Japan.MethodsThis was a retrospective cohort study. We identified adult patients with CO poisoning who were registered in the Japanese Diagnosis Procedure Combination inpatient database from 2010 to 2017. We evaluated trends in the numbers of patients with CO poisoning each month from disaster (Tohoku region) and non‐disaster areas. In the disaster area, we compared the numbers of patients with CO poisoning during pre‐ and post‐earthquake periods. We also compared the numbers of CO poisonings after the earthquake (<30 days) and 1 year later.ResultsEligible patients (n = 7,814) were categorized into disaster area (n = 988) and non‐disaster area (n = 6,826) groups. The numbers of CO‐poisoned patients in the non‐disaster area showed a seasonal variation, and there was a significant peak registered on March 11 in the disaster area. In the disaster area, the number of patients with CO poisoning in the post‐earthquake period was significantly higher than that in the pre‐earthquake period (135 versus 18; odds ratio, 7.50; 95% confidence interval, 4.59–12.3). The number of patients in the post‐earthquake period was also significantly higher than that on April 9, 2012, which was one month after the annual follow‐up (135 versus 10; odds ratio, 13.5; 95% confidence interval, 7.10–25.7).ConclusionThis study showed that CO poisoning significantly increased in the affected area after the Great East Japan Earthquake, underlining the importance of providing information regarding the hazard of earthquake‐related CO poisoning.

Effects of preoperative oral management by dentists on postoperative outcomes following esophagectomy: Multilevel propensity score matching and weighting analyses using the Japanese inpatient database.

The purpose of this study was to investigate the effects of preoperative oral management (POM) by dentists on the incidence of postoperative pulmonary complications (PPCs), length of hospital stay, medical costs, and days of antibiotics administration following both open and thoracoscopic esophagectomy.Dental plaque is an established risk factor for postoperative pneumonia, which could be reduced by POM. However, few clinical guidelines for cancer treatment, including those for esophageal cancer, recommend POM as routine perioperative care.We extracted data of esophagectomy cases from the Japanese Diagnosis Procedure Combination database. We subsequently conducted propensity score (PS) analyses for multilevel data, including matching, inverse probability of treatment weighting (IPTW), and standardized mortality ratio weighting (SMRW), to estimate the effect of POM by dentists on the outcomes of esophagectomy.We analyzed 3412 esophagectomy cases of which 812 were open, and 2600 were thoracoscopic surgery. In IPTW analysis to estimate the average treatment effect, the risk difference of postoperative aspiration pneumonia ranged from -2.49% to -2.02% between the POM and control groups of both open and thoracoscopic esophagectomy cases. IPTW analyses indicated that the total medical costs of thoracoscopic esophagectomy were reduced by 221,200 to 253,100 Japanese Yen (equivalent to about $2000-$2200). In PS matching and SMRW analyses to estimate average treatment effect on treated, there was no difference in outcomes between the POM and control groups.Our results suggested that in patients undergoing open or thoracoscopic esophagectomy, POM by dentists prevented the occurrence of postoperative aspiration pneumonia. It could also reduce the total medical costs of thoracoscopic esophagectomy. Thus, POM by dentists can be considered as a routine perioperative care for all patients undergoing esophagectomy, regardless of the expected risk for PPC.

Nationwide observational study of mortality from complicated intra-abdominal infections and the role of bacterial cultures.

The benefit of taking intra-abdominal cultures during source control procedures in patients with complicated intra-abdominal infection (CIAI) is unknown. The aim of this study was to evaluate whether intra-abdominal cultures reduce the mortality rate of CIAI. The Japanese Diagnosis Procedure Combination database was used to identify adult patients with CIAI who had undergone source control procedures on the first day of admission to hospital between April 2014 and March 2016. In-hospital mortality was compared between patients who did and those who did not have intra-abdominal cultures taken. A generalized linear mixed-effect logistic regression model and a random intercept per hospital were used to adjust for baseline confounders and institutional differences. Subgroup analyses were also performed according to disease cause, site of onset and severity of CIAI. Intra-abdominal cultures were taken from 16 303 of 41 495 included patients. Multivariable logistic regression analysis showed that patients with intra-abdominal cultures had a significantly lower mortality than those without (odds ratio 0·85, 95 per cent c.i. 0·77 to 0·95). Subgroup analyses revealed statistically significant differences in mortality between patients with and without cultures among those with lower intestinal perforation, biliary tract infection/perforation, healthcare-associated CIAI and high-risk community-acquired CIAI. Intra-abdominal cultures obtained during source control procedures may reduce in-hospital mortality, especially in patients with lower intestinal perforation, biliary tract infection/perforation, or healthcare-associated or high-risk community-acquired CIAI.

Risk factors for early unplanned readmission in patients with bipolar disorder: A retrospective observational study

ObjectivesEvidence regarding the relationships between patient, hospital, and regional factors and early unplanned readmission (short-term outcome) in patients with bipolar disorder is lacking. This study aimed to examine risk factors associated with early unplanned readmission in patients with bipolar disorder. MethodWe retrospectively analyzed adult bipolar patients (ICD-10; F31) between April 2012 and March 2014 in the Japanese Diagnosis Procedure Combination database. We examined factors affecting the 30-day unplanned readmission using multivariable logistic regression analysis. ResultsA total of 2688 patients admitted to psychiatric beds were included. Multivariate analysis showed that unchanged or exacerbation discharge outcome (adjusted odds ratio [aOR]: 1.93; 95% confidence interval [CI]: 1.06–3.51, p = 0.031), unplanned or urgent admission settings (aOR: 1.51; 95% CI: 1.00–2.26, p = 0.048), physical comorbidity (chronic pulmonary disease) (aOR: 4.74; 95% CI: 1.30–17.29, p = 0.018), presence of psychiatric acute-care beds (aOR: 1.72; 95% CI: 1.02–2.87, p = 0.040), and intermediate-level hospital psychiatric staffing (aOR: 1.82; 95% CI: 1.14–2.91, p = 0.012) were significantly associated with higher early unplanned readmission, while higher density of psychiatrists in the area (aOR: 0.50; 95% CI: 0.29–0.87, p = 0.014) was significantly associated with lower early unplanned readmission. ConclusionsThe results suggest that not only careful management of high-risk patients but also consideration of functional differentiation in psychiatric inpatient care, psychiatric resource allocation, and follow-up support for patients with bipolar disorder are needed for reducing the early unplanned readmission rate.

Large hospital variation in the utilization of Post-procedural CT to detect pulmonary embolism/Deep Vein Thrombosis in Patients Undergoing Total Knee or Hip Replacement Surgery: Japanese Nationwide Diagnosis Procedure Combination Database Study.

The purpose of the study was to investigate variation in the use of in-hospital CT for venous thromboembolism (VTE) detection after total knee or hip replacement (TKR/THR) among surgical patients, using a nationwide Japanese in-hospital administrative database. This retrospective study using a national administrative database (4/2012-3/2013) extracted patients who underwent TKR/THR surgeries at hospitals meeting the annual case-volume threshold of ≥ 30. Hospitals were categorized into three equally sized groups by frequency of postoperative CT use (low, middle, and high CT use group) to compare baseline patient-level and hospital-level characteristics. To further investigate between-hospital variation in CT usage, we fitted a hierarchical logistic regression model including hospital-specific random intercepts and fixed patient- and hospital-level effects. The intra class correlation coefficient was used to measure the amount of variability in CT use attributable to between-hospital variation. A total of 39,127 patients discharged from 447 hospitals met the inclusion criteria. The median hospital stay was 25 days (interquartile range, 20 - 32) and 7,599 (19.4%) patients underwent CT for VTE. CT utilization varied greatly among the hospitals; the crude frequency ranged from 0 to 100 % (median, 7.3 %; interquartile range, 1.8 - 18.3 %). After adjustment for known hospital- and patient-level factors related to CT use, 47 % of the variation in CT use remained attributable to the behavior of individual hospitals. We observed large inter hospital variability in the utilization of post-procedure CT for VTE detection in this Japanese TKR/THR cohort, suggesting that CT utilization is not optimized across the nation. We observed significant variability in the utilization of post-procedure CT for VTE detection among inpatients who underwent TKR/THR surgeries in a large sample of Japanese hospitals. The large variation suggests that CT utilization is not optimized across the nation, and that there may be potential overutilization of the technology in the highest CT use hospitals.

Physician-manned prehospital emergency care in tertiary emergency centers in Japan.

AimUse of a physician‐manned prehospital emergency medical service (EMS) has recently become widespread in Japan. Understanding the epidemiology of critically ill patients is essential for planning national and regional physician‐manned prehospital EMS systems. However, current knowledge on patients receiving physician‐manned prehospital EMS is sparse. The present study aimed to determine the clinical features of critically ill patients with and without physician‐manned prehospital EMS, using a national inpatient database in Japan.MethodsUsing the Japanese Diagnosis Procedure Combination inpatient database, we identified all hospitalized patients transported to tertiary emergency centers by physician‐manned EMS or EMS without a physician from April 2014 to March 2015. We collected data on patient characteristics, in‐hospital mortality, admission diagnoses, advanced life support interventions, and incidence of critical illnesses.ResultsWe identified 497,911 hospitalized patients transported to tertiary emergency centers by EMS. Of these, 15,507 (3%) patients were hospitalized by physician‐manned EMS. The majority of admission diagnoses in the physician‐manned EMS group were classified “diseases of the circulatory system” (45%) and “injury, poisoning and certain other consequences of external causes” (34%). The rates of in‐hospital mortality, advanced life support interventions, and critical illnesses in the physician‐manned EMS group were 22%, 51%, and 53%, respectively. The median incidences of hospitalized patients by physician‐manned EMS, advanced life support interventions, and critical illnesses were 12, 137, and 205 per 100,000 persons per year in facilities with physician‐manned EMS, respectively.ConclusionOur study indicates that physician‐manned EMS is dispatched to a relatively small proportion of critically ill patients in Japan.