Kenshi Hayashida

Development and analysis of a nationwide cost database of acute‐care hospitals in Japan

OBJECTIVES Understanding of hospital cost is crucial to achieve an ideal balance between the assurance and improvement of patient safety and quality, and efficient use of finite resources. However, neither a standardized calculation methodology nor a large-scale database of costs in acute-care hospitals exists in Japan. This study aims to develop a standardized methodology, construct a nationwide cost database in Japan, analyse the characteristics of the database and examine the relationship between the cost and the charge from the viewpoint of an appropriate reflection of the cost to the price. METHOD We designed the costing framework, gathered the data for patients discharged from 139 acute-care hospitals in Japan between July 2004 and October 2004 and constructed a database containing information on 284,730 patients. The characteristics of the database and the relationship between the cost and the charge were investigated. RESULTS In the nationwide database we constructed, a wide range in the average cost per hospitalization and average cost per diem was observed. A wide variation of cost components was seen across major diagnostic categories. Moreover, there was a high correlation between the cost and the charge (Correlation coefficient = 0.94). CONCLUSIONS After designing a costing framework, a nationwide database comprised of individual case-level costs with components for acute-care hospitals in Japan was successfully developed. We hope this study contributes to appropriate decision making and helps motivate further research geared towards efficient hospital management and a rational payment system in Japan.

Factors associated with system-level activities for patient safety and infection control

Abstract Objective We examined the relationship between hospital structural characteristics and system-level activities for patient safety and infection control, for use in designing an incentive structure to promote patient safety. Methods This study utilized a questionnaire to collect institutional data about hospital infrastructure and volume of patient safety activities from all 1039 teaching hospitals in Japan. The patient safety activities were focused on meetings and conferences, internal audits, staff education and training, incident reporting and infection surveillance. Generalized linear modeling was used. Results Of the 1039 hospitals surveyed, 418 (40.2%) hospitals participated. The amount of activities significantly increased by over 30% in hospitals with dedicated patient safety and infection control full-time staff (P <0.001 and P <0.01, respectively). High profit margins also predicted the increase of patient safety programs (P <0.01). Perceived lack of administrative leadership was associated with reduced volume of activities (P <0.05), and the economic burden of safety programs was found to be disproportionately large for small hospitals (P <0.05). Conclusions Hospitals with increased resources had greater spread of patient safety and infection control activities. To promote patient safety programs in hospitals, it is imperative that policy makers require the assignment of dedicated full-time staff to patient safety. Economic support for hospitals will also be required to assure that safety programs are sustainable.

Profiling hospital performance of laparoscopic cholecystectomy based on the administrative data of four teaching hospitals in Japan.

Over the last decade in Japan, laparoscopic cholecystectomy (LC) has replaced traditional open cholecystectomy as the standard of elective surgery for cholelithiasis. The laparoscopic approach has a clinical course relatively easier to standardize among the different types of intraabdominal surgery. However, significant practice variation is suspected in Japan, but there has been little demonstration or discussion based on empirical data. Through the analysis of 1589 elective LC cases from four leading teaching hospitals in Japan between 1996 and 2000, this study aims to demonstrate the surgical variations and to investigate their determinants regarding the length of hospital stay and the health care charge. Substantially and significantly large variation existed among the hospitals in terms of the length of hospital stay and the total health care charge, even after the differences in patient factors were adjusted. Particularly, the combined drug and exam charge per day was strikingly different among the four hospitals, which indicated that the daily process also varied widely, as did the total course of inpatient care. In addition, intra-hospital variation was also remained very large even after adjusting for all the potential correlates studied. This study alarmingly points out great room for improvement in the efficiency of health care resource use and potentially in the quality of care through standardization of LC. It has serious implications for the national policy and individual providers under the on-going health care reforms directed toward higher efficiency and quality.

Influence of Verification Bias on the Assessment of MRI in the Diagnosis of Meniscal Tear

OBJECTIVE Previous studies of the sensitivity and specificity of MRI in the diagnosis of meniscal tear have not included correction for verification bias. The purpose of this study was to investigate the extent to which verification bias affected assessment of the utility of MRI in the diagnosis of meniscal tear. MATERIALS AND METHODS The patients included in the study were outpatients who from April 2006 through July 2008 consecutively visited a single institution for MRI of the meniscus for evaluation of knee pain. For patients who underwent arthroscopy in addition to MRI, the sensitivity and specificity of MRI were calculated. Global sensitivity analysis of data on patients who did not undergo arthroscopy was performed to estimate the influence of verification bias. Global sensitivity analysis is a method for graphically determining whether a particular pair of sensitivity and specificity estimates is compatible with observed data. RESULTS Eighty-two patients (23%) underwent arthroscopic verification. The sensitivity and specificity of MRI were 85% and 31%. When the possibility of meniscal tears in patients who did not undergo arthroscopy was subjected to global sensitivity analysis, the sensitivity of MRI ranged from 29% to 95% and the specificity ranged from 3% to 92%. All combinations of sensitivity and specificity produced a butterfly-shaped curve, but the base case was not inside the curve. CONCLUSION Verification bias greatly affected assessment of the utility of MRI in the diagnosis of meniscal tear. Sensitivity and specificity from previous studies may be incompatible with our data owing to verification bias.

Cost of hospital-wide activities to improve patient safety and infection control: A multi-centre study in Japan

OBJECTIVE The aim of this study was to assess the financial costs to hospitals for the implementation of hospital-wide patient safety and infection control programs. METHODS We conducted questionnaire surveys and structured interviews in seven acute-care teaching hospitals with an established reputation for their efforts towards improving patient safety. We defined the scope of patient safety activities by use of an incremental activity measure between 1999 and 2004. Hospital-wide incremental manpower, material, and financial resources to implement patient safety programs were measured. RESULTS The total incremental activities were 19,414-78,540 person-hours per year. The estimated incremental costs of activities for patient safety and infection control were calculated as US

Management patterns and healthcare costs for hospitalized patients with cerebral infarction

1.100-2.335 million per year, equivalent to the employment of 17-40 full-time healthcare staff. The ratio of estimated costs to total medical revenue ranged from 0.55% to 2.57%. Smaller hospitals tend to shoulder a higher burden compared to larger hospitals. CONCLUSIONS Our study provides a framework for measuring hospital-wide activities for patient safety. Study findings suggest that the total amount of resources is so great that cost-effective and evidence-based health policy is needed to assure the sustainability of hospital safety programs.

Contribution of case-mix classification to profiling hospital characteristics and productivity.

OBJECTIVES Although evidence shows the importance of specialized intensive care of patients with cerebral infarction, it is not well known whether resources are generously applied in the initial period and how patterns of medical resource utilization are associated with characteristics of providers and patient outcomes. In this study, we analyzed changing patterns of daily medical cost using administrative healthcare claim data and identified a management pattern in each case. METHODS We used Japans administrative data to identify medical costs on a day-to-day basis. Data of 3136 patients with acute cerebral infarction from 14 medical institutions were included in the analyses. Using the data, we calculated the costs from the perspective of the third-party payer. Institutions were divided into three groups according to the distribution of medical costs in the first 2 days, and patient background, treatment process, and outcomes were compared across the groups. RESULTS Medical cost was not necessarily intensively allocated during the early hospitalization period. Wide variations were observed in medical cost utilization patterns across institutions. The differences in medical cost for the initial hospitalization period appears to be more influenced by ICU utilization and management policies of institutions than the clinical condition of patients. CONCLUSIONS We proposed a methodology that uses administrative claim data to examine management patterns of ischemic stroke. We believe that the use of our method, in conjunction with accurate and detailed clinical data, can help elucidate the relationship among acute-period medical resource utilization, process of care, and patient outcomes.

Difference in lifetime medical expenditures between male smokers and non-smokers

Case-mix classification has made it possible to analyze acute care delivery case volumes and resources. Data arising from observed differences have a role in planning health policy. Aggregated length of hospital stay (LOS) and total charges (TC) as measures of resource use were calculated from 34 case-mix groups at 469 hospitals (1,721,274 eligible patients). The difference between mean resource use of all hospitals and the mean resource use of each hospital was subdivided into three components: amount of variation attributable to hospital practice behavior (efficiency); amount attributable to hospital case-mix (complexity); and amount attributable to the interaction. Hospital characteristics were teaching status (academic or community), ownership, disease coverage, patients, and hospital volume. Multivariate analysis was employed to determine the impact of hospital characteristics on efficiency. Mean LOS and TC were greater for academic than community hospitals. Academic hospitals were least associated with LOS and TC efficiency. Low disease coverage was a predictor of TC efficiency while low patient volume was a predictor of unnecessarily long hospital stays. There was an inverse correlation between complexity and efficiency for both LOS and TC. Policy makers should acknowledge that differentiation of hospital function needs careful consideration when measuring efficiency.

Evaluation of resource allocation and supply-demand balance in clinical practice with high-cost technologies.

OBJECTIVES It is controversial whether smokers have higher lifetime medical expenditures than non-smokers, because smokers have high annual medical expenditures but comparatively short lives. We examined differences in lifetime medical expenditures between them. METHODS We constructed life tables for male smokers and non-smokers from 40 years of age. We calculated average annual medical expenditures of them categorized by survivors and deceased, which were used to examine differences in lifetime medical expenditures between them and perform sensitivity analyses. RESULTS Smokers had a higher mortality rate, shorter life expectancy, and generally higher annual medical expenditures than non-smokers. We also observed tendencies for smokers to have higher inpatient expenditures, but non-smokers to have higher outpatient expenditures. Although non-smokers had lower long-term cumulative medical expenditures between 64 and 81 years of age, their lifetime medical expenditures were higher by a minimal amount. Sensitivity analyses did not change this result. CONCLUSIONS Smoking may not cause increases in lifetime medical expenditures because smokers had lower lifetime medical expenditures than non-smokers. However, it was clear that smokers, especially survivors, often had higher annual medical expenditures than non-smokers. The importance of tobacco control is still relevant.

The subjective incremental cost of informed consent and documentation in hospital care: a multicentre questionnaire survey in Japan.

RATIONALE, AIMS AND OBJECTIVES Japan has one of the highest numbers of high-cost medical devices installed relative to its population. While evaluations of the distribution of these devices traditionally involve simple population-based assessments, an indicator that includes the demand of these devices would more accurately reflect the situation. The purpose of this study was to develop an indicator of the supply-demand balance of such devices, using examples of magnetic resonance imaging scanners (MRI) and extracorporeal shockwave lithotripters (ESWL), and to investigate the relationship between this indicator, personnel distribution statuses and operating statuses at the prefectural level. METHODS Using data from nation-wide surveys and claims data from 16 hospitals, we developed an indicator based on the ratio of the supplied number of device units to the number of device units in demand for MRI and ESWL. The latter value was based on patient volume and utilization proportion. Correlation analyses were conducted between the supply-demand balances of these devices, personal distribution and operating statuses. RESULTS Comparisons between our indicator and conventional population-based indicators revealed that 15% and 30% of prefectures were at risk of underestimating the availability of MRI and ESWL, respectively. The numbers of specialist personnel/device units showed significant, negative correlations with our indicators in both devices. CONCLUSIONS Utilization-based analyses of health care resource placement and utilization status provide a more accurate indication than simple population-based assessments, and can assist decision makers in reviewing gaps between health policy and management. Such an indicator therefore has the potential to be a tool in helping to improve the efficiency of the allocation and placement of such devices.