Koichi Nobutomo

Analysis of hospital charges for cerebral infarction stroke inpatients in Beijing, People's Republic of China

OBJECTIVE Stroke is a heavy economic burden on the individuals, society and health services in China, where health expenditure is rising rapidly. The purpose of the present study is to examine health services and demographic factors associated with inpatient charges for cerebral infarction in China, focusing on hospital charges of insured and uninsured patients. METHODS The study subjects were 545 patients with a principal diagnosis of cerebral infarction stroke who were discharged from the China-Japan Friendship Hospital from January 1, 1997 through December 31, 1998. Demographic, clinical and administrative data were retrospectively collected from the medical record and financial database. The influence of social and medical factors on total charges was analyzed with stepwise multiple regression model. RESULTS Of 545 subjects, 429 (79%) were the insured patients and 116 (21%) were the uninsured patients. Length of hospital stay (LOHS) for the insured patients (median, 32 days) was significantly longer (P<0.001) than that for the uninsured (median, 23 days). The hospital charges per discharge for the insured was significantly higher (geometric mean, 10407 yuan) (P<0.0001) than that for the uninsured patients (geometric mean, 5857 yuan). With stepwise multiple regression, factors associated independently with the hospital charge were: longer hospital stay, insurance status, increased number of head magnetic resonance imaging (MRI) and computerized tomography (CT), infection in hospital stay, and more severe condition of stroke. CONCLUSIONS Inpatient charge for cerebral infarction stroke was positively associated with being the insured. The findings suggest an overuse of health care resources in insured patients and limited use of resources by those who are not.

Analysis of hospital charges for ischemic stroke in Fukuoka, Japan

OBJECTIVES Stroke is a heavy economic burden on individuals, society, and health services in Japan, where health expenditures are rising rapidly. The objective of the present study was to examine medical services and demographic factors associated with increased inpatient charges for ischemic stroke in Japan. SUBJECTS AND METHODS The study subjects were 316 patients with a principal diagnosis of acute ischemic stroke who were discharged from the National Kyushu Medical Center Hospital from 1 July 1995 through 31 June 1999. Demographic, clinical, and administrative data were retrospectively collected from medical records and the hospital Clinical Financial Information System (CFIS). The influence of social and medical factors on total charges was analyzed using the stepwise multiple regression model. RESULTS Among the total subjects, the mean (median) length of hospital stay (LOHS) was 33 (30) days (range, 2-155 days). The mean (median) hospital charge per patient was US dollars 9020 (dollars 7974) with a range of dollars 336-54,509. The distribution of charges was 42% for fundamental, 17% for injection therapies, 13% for radiological test, 11% for other laboratory examinations, 3% for drugs, and 3% for operations. Stepwise multiple regression analysis revealed that LOHS was the key determinant of the hospital charge (partial R2=0.5993, P=0.0001). Operations (P=0.0001) and angiography (P=0.03) were also independent but less contributory determinants of the hospital charge. CONCLUSIONS LOHS was strongly, positively associated with inpatient charges for ischemic stroke in Japan. This implies that significant charge reductions are more likely to rely on shortening LOHS, which probably can be achieved by altering reimbursement policies.

Applicability of press needles to a double-blind trial: a randomized, double-blind, placebo-controlled trial.

ObjectivesOwing to a lack of a suitable needle procedure, it has been impossible to evaluate the efficacy of acupuncture in clinical studies using double-blind testing. We evaluated the applicability of a new kind of press needle (Pyonex) to a double-blind trial by comparing the press needle with a placebo (lacking the needle element). MethodsThe purpose of the study consisted of 2 phases. In the phase 1, to evaluate the applicability and efficacy of the press needles, 90 participants who had never been treated using acupuncture were randomly assigned to receive either the press needle (n=45) or a placebo (n=45). The applicability was measured using a questionnaire regarding the perception of penetration, and efficacy was measured using a visual analog scale of low back pain (LBP). When the applicability and efficacy of the press needles were confirmed in phase 1, the mechanism of LBP relief by the press needles was examined in phase 2. ResultsIn phase 1, intergroup comparisons showed no significant differences concerning the perception of penetration. In addition, for patients with LBP, the press needles reduced the subjective evaluation of LBP compared with the placebo (P<0.05). In phase 2, visual analog scale results indicated that LBP was reduced significantly more in the press needle group than in the local anesthesia group (P<0.05). DiscussionThe participants could not distinguish between the press needle and a placebo, and the data from the press needle group suggested a specific influence on patients with LBP. These findings imply that the press needle and a placebo provide an effective means of realizing a double-blind setting for clinical studies of acupuncture.

AIR POLLUTION AND CYTOLOGICAL CHANGES IN SPUTUM

The increase in sputum cellularity due to inflammatory and bronchial epithelial cells was compared in two groups of 308 and 399 subjects drawn from populations exposed to air-pollution levels common in industrialised countries. Single morning sputum specimens were examined and the differences in increased sputum cellularity between the two groups, stratified by age, sex, and tobacco consumption was assessed by the summary X2 test of Mantel-Haenszel. The group exposed to heavier air pollution had more increases in alveolar phagocytes, neutrophils, and lymphocytes, but not in eosinophils and bronchial epithelial cells. Subjects were also asked to answer a questionnaire on the symptoms of chronic bronchitis; the study showed that the inflammatory response preceded the appearance of symptoms.

Standard of care and liability in medical malpractice litigation in Japan

Although the incidence of medical malpractice litigation is increasing in Japan, it remains unclear whether medical malpractice litigation gives doctors and hospitals, an economic incentive to provide high-quality medical care by requiring that they compensate patients for harm caused by negligence. Therefore, to evaluate whether the medical malpractice litigation system contributes to the delivery of high-quality medical care, we first analyzed the decisions made in medical malpractice cases between 1986 and 1998 in ten district courts (n=421). We found the following results: (1) the probability that patients received compensation and the amount of compensation received, increased with the level of negligence, for all injury severity levels; (2) the significant predictors that a case would be decided in favor of the patient were the patients legal basis (P=0.00) and the severity of injury (P=0.02). Although, it seems that Japanese medical malpractice litigation gives doctors an economic incentive to avoid delivering substandard medical care, since both the severity of injury and negligence were significant predictors, medical litigation in Japan might in fact corrupt the compensation process by creating an adversarial atmosphere.

Sleep patterns and impulse control among Japanese junior high school students.

Adolescents with decreased impulse control exhibit behavioral problems. Lifestyles are related to impulse control. However, the relations of sleep patterns and impulse control among adolescents are unknown. Thus we examined how sleep patterns were associated with impulse control among Japanese junior high school students. Surveys were completed by a nationwide sample of 1934 students. A significant association between decreased impulse control and bedtimes after midnight was revealed. Specific lifestyle factors related to bedtimes after midnight were older age, greater numbers of hours spent watching television, lack of participation in an extracurricular activity, greater use of convenience stores, and increased attendance at cram schools. This study revealed that going to sleep after midnight was significantly related to decreased impulse control among adolescents. Data about specific lifestyle factors related to going to sleep after midnight should be useful in preventing those behaviors demonstrated by school children that derive from decreased impulse control.

The problems of medical malpractice litigation in Japan : The significant factors responsible for the tendency of patients to avoid litigation

The present research has demonstrated that the Japanese tendency to avoid medical malpractice litigation can be ascribed to Japans medical malpractice litigation system, and not the Japanese legal consciousness. From this standpoint, the present research has made clear the specific problem areas of the litigation system by looking at all cases from the last 10 years in the main district courts. The total average time taken for medical malpractice litigation is 3.0 years - much longer than the average time for normal litigation. Furthermore, the average amount of money needed to bring a medical malpractice complaint was 2,200,000 yen, far too much for the patients family to bear. We have also demonstrated to what extent the amount is inversely related to the patients age. Naturally, it is possible to bring a case without reliance on a lawyer, but in 90.0% of cases a lawyer was employed, and the success rate of litigants that had not employed a lawyer was 0%. Through the above discussion, we have show the present situation regarding time and costs in medical malpractice litigation, and it is suggested that these are the important reasons why medical malpractice disputants demonstrate a tendency to avoid litigation.

Importance of explanation before and after forensic autopsy to the bereaved family: lessons from a questionnaire study

To investigate how bereaved families felt about the explanation received before and after forensic autopsies, the authors conducted a cross-sectional survey of the bereaved families whose next of kin underwent a forensic autopsy at the two Departments of Forensic Medicine and a few bereaved families of crime victims. Of 403 questionnaires sent, 126 families responded. Among 81.5% of the respondents who received an explanation from policemen before the autopsy, 78.8% felt that the quality of the explanation was poor or improper. In Japan, the law has restricted disclosure of information from a forensic autopsy. Despite legal restrictions, 82% wanted to hear from the person who conducted the autopsy. However, police explained the results of autopsy to 65.2% of respondents. Among the families whose frustration and anger increased after autopsy, 86.4% had not been satisfied with the explanation before the autopsy. Additionally, 57.7% had not been informed on the autopsy findings at the time of the questionnaire when more than 2 years had passed after the autopsy. These results reminded us of the importance of an explanation before and shortly after a forensic autopsy for a better understanding and acceptance by bereaved families.

PREdIctING tHE dIScHARGE dEStINAtION OF REHABILItAtION PAtIENtS uSING A SIGNAL dEtEctION APPROAcH

OBJECTIVE To predict the discharge destination of rehabilitation patients using signal detection analysis. DESIGN Cross-sectional and follow-up studies. SUBJECT The subjects were 324 patients discharged from a hospital in Fukuoka, Japan, between April 2005 and March 2006 and 313 patients discharged from the same hospital between 1 April and 31 October 2006. METHODS The discharge destinations of the 324 patients were predicted using signal detection analysis. As a validation study, 7 variables identified in the first analysis were used to categorize 313 patients, organized retrospectively into 8 groups, and to calculate the home discharge rate in each group. RESULTS A patients activities with respect to daily living, key person preference, dementia, age, route taken to hospitalization, residence before hospitalization, and gender were significant predictors of his or her discharge destination. Signal detection analysis established 8 subgroups, with 17.9-99.1% of the patients returning home after discharge. As a validation study, the actual and expected rates in the 8 subgroups were compared, and no significant difference was observed between the rates in any subgroup. CONCLUSION Signal detection analysis is a useful technique for predicting the discharge destination of rehabilitation patients.

Physician and Patient Perceptions of the Physician Explanations in Medical Encounters

Although, in actual practice, physicians have to subjectively judge the level of the explanation that they provide, little is known about this judgment. Therefore, making use of 630 physician-patient pairs in Japan, we investigated the association between patient and physician evaluations of physician explanations of medical test results and diagnoses. We found that the physician’s judgment does not always agree with that of the patient, with regard to the level of explanation necessary. In addition, we first identified factors relating to the accuracy of physician judgments with regard to their explanations to patients. More studies will be necessary to verify the present findings.