Tetsuya Otsubo

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.

Association of healthcare expenditures with aggressive versus palliative care for cancer patients at the end of life: a cross-sectional study using claims data in Japan

BACKGROUND End-of-life (EOL) care imposes heavy economic burdens on patients and health insurers. Little is known about the association between the types of EOL care and healthcare costs for cancer patients across various providers. OBJECTIVE To explore the association of healthcare expenditures with benchmarking indicators of aggressive versus palliative care among terminally ill cancer patients, from the perspective of health insurers. DESIGN Cross-sectional retrospective study using health insurance claims data. SETTING participants Cancer patients who had died in Kyoto prefecture, Japan, between April 2009 and May 2010. Main outcome measure Claims data were analyzed using multilevel generalized linear models to examine whether aggressive care and palliative care were associated with expenditures during the last 3 months of life, after adjusting for patient characteristics, hospital characteristics and other non-indicator procedures. RESULTS We analyzed 3143 decedents from 54 hospitals. Median expenditure per patient during the last 3 months was US

Impact of hospital case volume on quality of end-of-life care in terminal cancer patients

13 030. Higher expenditures were associated with the aggressive care indicators of higher mortality at acute-care hospitals and use of chemotherapy in the last month of life, as well as with the palliative care indicators of increased hospice care and opioid use in the last 3 months of life. However, increased physician home care in the last 3 months was associated with lower expenditure. CONCLUSIONS Indicators of both aggressive and palliative EOL care were associated with higher healthcare expenditures. These results may support the coherent development of measures to optimize aggressive care and reduce the financial burdens of terminal cancer care.

Derivation and Validation of In-Hospital Mortality Prediction Models in Ischaemic Stroke Patients Using Administrative Data

BACKGROUND Quality of end-of-life (EOL) care is gaining increasing attention. However, the relationship between hospital case volume and performance of benchmark quality indicators is not well characterized. The aim of this study was to determine whether hospital case volume affects EOL care for terminal cancer patients. METHODS We conducted a retrospective cross-sectional study using claims data of patients who died of cancer at acute-care hospitals in Kyoto prefecture, Japan, between March 2009 and May 2010. Hospitals were grouped into tertiles based on the number of terminal cancer cases. We used multilevel logistic regression models to examine the association of the following quality indicators with the tertiles: opioid use during the last 2 months of life (indicating good quality of care), provision of intensive care unit (ICU) service or life-sustaining treatments during the last month of life (poor quality), and chemotherapy during the last month of life (poor quality). RESULTS The final sample for analysis consisted of 3294 decedents from 88 hospitals. Significant associations between hospital case volume and quality of EOL care were identified after adjusting for patient and hospital characteristics. Small- and medium-volume hospitals were found to be less likely to administer opioids, and medium-volume hospitals were more likely to provide ICU service or life-sustaining treatments when compared with large-volume hospitals. No significant association between chemotherapy use and case volume was observed. CONCLUSIONS The results showed that the case volume of terminally ill cancer patients was associated with several aspects of quality of EOL care.

Association of Geographical Factors With Administration of Tissue Plasminogen Activator for Acute Ischemic Stroke

Background: Stroke and other cerebrovascular diseases are a major cause of death and disability. Predicting in-hospital mortality in ischaemic stroke patients can help to identify high-risk patients and guide treatment approaches. Chart reviews provide important clinical information for mortality prediction, but are laborious and limiting in sample sizes. Administrative data allow for large-scale multi-institutional analyses but lack the necessary clinical information for outcome research. However, administrative claims data in Japan has seen the recent inclusion of patient consciousness and disability information, which may allow more accurate mortality prediction using administrative data alone. The aim of this study was to derive and validate models to predict in-hospital mortality in patients admitted for ischaemic stroke using administrative data. Methods: The sample consisted of 21,445 patients from 176 Japanese hospitals, who were randomly divided into derivation and validation subgroups. Multivariable logistic regression models were developed using 7- and 30-day and overall in-hospital mortality as dependent variables. Independent variables included patient age, sex, comorbidities upon admission, Japan Coma Scale (JCS) score, Barthel Index score, modified Rankin Scale (mRS) score, and admissions after hours and on weekends/public holidays. Models were developed in the derivation subgroup, and coefficients from these models were applied to the validation subgroup. Predictive ability was analysed using C-statistics; calibration was evaluated with Hosmer-Lemeshow χ2 tests. Results: All three models showed predictive abilities similar or surpassing that of chart review-based models. The C-statistics were highest in the 7-day in-hospital mortality prediction model, at 0.906 and 0.901 in the derivation and validation subgroups, respectively. For the 30-day in-hospital mortality prediction models, the C-statistics for the derivation and validation subgroups were 0.893 and 0.872, respectively; in overall in-hospital mortality prediction these values were 0.883 and 0.876. Conclusions: In this study, we have derived and validated in-hospital mortality prediction models for three different time spans using a large population of ischaemic stroke patients in a multi-institutional analysis. The recent inclusion of JCS, Barthel Index, and mRS scores in Japanese administrative data has allowed the prediction of in-hospital mortality with accuracy comparable to that of chart review analyses. The models developed using administrative data had consistently high predictive abilities for all models in both the derivation and validation subgroups. These results have implications in the role of administrative data in future mortality prediction analyses.

Quality of care and in-hospital resource use in acute myocardial infarction: Evidence from Japan

Background 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. Conclusion 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.

Decentralization and centralization of healthcare resources: Investigating the associations of hospital competition and number of cardiologists per hospital with mortality and resource utilization in Japan

OBJECTIVES To determine the association between quality of care in process and outcome measures and in-hospital resource use among patients admitted for acute myocardial infarction (AMI) in Japan. METHODS We analyzed 23,512 AMI patients across 150 hospitals in Japan between April 2008 and March 2011. The exposure measure was inpatient hospital resource use, which was calculated from the sum of all hospital fees for healthcare services provided to AMI patients. Hospitals were then categorized into quartiles based on a risk-adjusted in-hospital resource use index. Quality of care was assessed using three process measures (in-hospital prescription of aspirin, β-blockers, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers) and two outcome measures (7-day and 30-day in-hospital mortality). Process and outcome measures were analyzed with multilevel logistic regression models that adjusted for patient and hospital characteristics. RESULTS No significant differences in process measures were observed across the quartiles of in-hospital resource use. In contrast, hospitals with the lowest resource use were significantly associated with poorer outcomes (7-day in-hospital mortality OR: 1.851 [95% CI 1.327-2.582]; 30-day in-hospital mortality OR: 1.706 [95% CI 1.259-2.312]) than hospitals with higher resource use. CONCLUSION Poorer quality of care in outcome measures was significantly associated with lower resource utilization among AMI patients in Japanese hospitals, but process measures did not show similar associations.

Healthcare‐associated infections in acute ischaemic stroke patients from 36 Japanese hospitals: risk‐adjusted economic and clinical outcomes

OBJECTIVE To investigate the associations of hospital competition and number of cardiologists per hospital (indicating the decentralization and centralization of healthcare resources, respectively) with 30-day in-hospital mortality, healthcare spending, and length of stay (LOS) among patients with acute myocardial infarction (AMI) in Japan. METHODS We collected data from 23,197 AMI patients admitted to 172 hospitals between 2008 and 2011. Hospital competition and number of cardiologists per hospital were analyzed as exposure variables in multilevel regression models for in-hospital mortality, healthcare spending, and LOS. Other covariates included patient, hospital, and regional variables; as well as the use of percutaneous coronary intervention (PCI). RESULTS Hospitals in competitive regions and hospitals with a higher number of cardiologists were both associated lower in-hospital mortality. Additionally, hospitals in competition regions were also associated with longer LOS durations, whereas hospitals with more cardiologists had higher spending. The use of PCI was also associated with reduced mortality, increased spending and increased LOS. CONCLUSIONS Centralization of cardiologists at the hospital level and decentralization of acute hospitals at the regional level may be contributing factors for improving the quality of care in Japan. Policymakers need to strike a balance between these two approaches to improve healthcare provision and quality.

The effect of centralization of health care services on travel time and its equality

Background Healthcare-associated infections are a major cause for worsening in ischaemic stroke patients. In addition to increased morbidity and mortality, healthcare-associated infections also result in a potentially preventable increase in economic costs. Aims The aim of this study was to identify healthcare-associated infection incidence in ischaemic stroke patients in Japanese hospitals, and to conduct a risk-adjusted analysis of the associated economic and clinical outcomes. Methods Healthcare-associated infections were identified in 36 Japanese hospitals using an administrative database. Identification was carried out using a combination of International Classification of Diseases-10 codes and antibiotic utilisation patterns that indicated the presence of an infection. Risk-adjusted hospital charges and length of stay were calculated using multiple linear regression analyses correcting for patient and hospital factors. A logistic regression model was used to analyse the association between healthcare-associated infection infection and mortality. Results There was an overall healthcare-associated infection incidence of 16·4 %, with an interhospital range of 4·7–28·3%. After risk-adjustment, infected cases paid an additional US

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

3 067 per admission (interhospital range US