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The present study aimed to investigate the postoperative mortality due to all surgeries at the prefectural level using a nationwide diagnosis procedure combination (DPC) database in Japan and to evaluate the data according to temporal changes and regional differences. Data were provided in accordance with the guidelines indicated on the Ministry of Health, Labor and Welfare, Japan. The number of cases and in-hospital mortality were calculated for each representative surgery for each hospitalization according to fiscal year of discharge from 2011 to 2018 and according to prefecture. Values of ≥10 in each aggregated data cell were presented. The aggregated result data contain 474,154 records, with about 2,000 different surgical codes. More than 10 mortalities were recorded in only 16,890 data cells, which can be used in the mortality analysis. In the analyses of artificial head insertion, cerebral aneurysm neck clipping, coronary artery and aortic bypass grafting, and tracheotomy, regional differences and a declining trend were observed in some categories. In addition to considering categories that can be used in the analysis, careful consideration must be given to the inclusion of background context such as the quality of care.

We assessed the effect of rotavirus vaccination coverage on the number of inpatients with gastroenteritis of all ages in Japan. We identified patients admitted with all-cause gastroenteritis during 2011-2019 using data from the Diagnosis Procedure Combination system in Japan. We used generalized estimating equations with a Poisson distribution, using hospital codes as a cluster variable to estimate the impact of rotavirus vaccination coverage by prefecture on monthly numbers of inpatients with all-cause gastroenteritis. We analyzed 294,108 hospitalizations across 569 hospitals. Higher rotavirus vaccination coverage was associated with reduced gastroenteritis hospitalizations compared with the reference category of vaccination coverage <40% (e.g., for coverage >80%, adjusted incidence rate ratio was 0.87 [95% CI 0.83-0.90]). Our results show that achieving higher rotavirus vaccination coverage among infants could benefit the entire population by reducing overall hospitalizations for gastroenteritis for all age groups.

Objectives: The cause of chronic kidney disease (CKD) remains uncertain in the majority of affected individuals, but the influence of socioeconomic status on CKD progression has recently gained attention. We compared the risk of CKD progression among 18 occupational classifications using an annual health checkup database.Methods: We used the annual health checkup data and health insurance claims data of the Japan Health Insurance Association in Kyoto prefecture between April 2012 and March 2016. The primary outcome for survival analysis was defined as a more than 30% change in the estimated glomerular filtration rate (eGFR) from the first health checkup. We used the Cox proportional hazards model for time-to-event analyses to estimate the hazard ratios and 95% CIs for the primary outcome, adjusting for age, sex, eGFR, body mass index, blood pressure, blood sugar, dyslipidemia, uric acid, urinary protein, and existence of kidney disease at first health checkup.Results: We analyzed 239 506 employees, and 1736 (0.7%) individuals whose eGFR had decreased by 30% or more; the mean follow-up period was 2.8 years. When we compared the risk with that for “manufacturing,” 5 categories of industries (“information and communications”; “transport and postal services”; “accommodations, eating and drinking services”; “living-related and personal services and amusement service”; “medical, health care and welfare”) were associated with a decline in the increased risk of eGFR after adjusting for the confounding factors and/or mediators.Conclusions: We provide evidence that the risk of CKD progression depends on occupational type. Further research is needed to confirm the mechanism and causal relationships involved.

Summary In Japan, the publication of the Fracture Liaison Service Clinical Standard (FLS-CS) had no apparent effect on the implementation of secondary fracture prevention, but the introduction of a new management fee for secondary fracture prevention significantly promoted the implementation of secondary fracture prevention for the target disease. Background Secondary fracture prevention is important for managing fragility fractures. In Japan, the FLS-CS was published in 2019, alongside the introduction of a new management fee for secondary fracture prevention, launched in 2022 for patients who underwent surgery for hip fracture. FLS programs were hospital-based. This study evaluated the impact of these interventions on the implementation of secondary fracture prevention during hospitalization for fragility fractures. Methods Using claims data from the Quality Indicator/Improvement Project database, patients aged 50 years or older with hip fracture who underwent surgery or with vertebral fractures were included. The publication of FLS-CS was the first intervention, followed by the introduction of the management fee as the second intervention. To evaluate the impact of these interventions, we performed an interrupted time series analysis separately for hip and vertebral fractures. Results For hip fractures, there was no immediate change after the first intervention, and the monthly rate of change decreased (incidence rate ratio [IRR]: 0.985, 95% confidence interval [CI]: 0.979–0.991). After the second intervention, there was an immediate increase (IRR: 1.890, 1.761–2.029), and the monthly rate of change also increased (IRR: 1.050, 1.044–1.056). For vertebral fractures, the proportion of change increased only immediately after the second intervention (IRR: 1.148, 1.038–1.270). Conclusion The publication of FLS-CS had no apparent effect on the implementation of secondary fracture prevention in patients with either hip or vertebral fractures. Conversely, the introduction of the management fee had the effect of increasing that for the target disease.

Background: The transtheoretical model (TTM) is composed of the multiple stages according to patient’s consciousness and is believed to lead people to realize the importance of healthier behaviors. We examined the association of TTM stages with the decline of estimated glomerular filtration rate (eGFR).Methods: We used the annual health checkup data and health insurance claims data of the Japan Health Insurance Association in Kyoto Prefecture between April 2012 and March 2016. TTM stages of change obtained from questionnaires at the first health checkup and categorized into six groups. The primary outcome was defined as a more than 30% decline in eGFR from the first health checkup. We fitted multivariable Cox proportional-hazards model for time-to-event analyses adjusting for age, sex, eGFR, body mass index, blood pressure, blood sugar, dyslipidemia, uric acid, urinary protein, and existence of kidney diseases at first health checkup.Results: We analyzed 239,755 employees and the mean follow-up was 2.9 (standard deviation, 1.2) years. As compared with the stage 1 group, the risk of eGFR decline was significantly low in the stage 3 group (hazard ratio [HR] 0.77; 95% confidence interval [CI], 0.65–0.91); stage 4 group (HR 0.80; 95% CI, 0.65–0.98); and stage 5 group (HR 0.79; 95% CI, 0.66–0.95).Conclusion: Compared with the precontemplation stage (stage 1), the preparation, action and maintenance stages (stages 3, 4, and 5), were associated with a lower risk of eGFR decline.

During the coronavirus disease 2019 (COVID-19) pandemic, there have been health concerns related to alcohol use and misuse. We aimed to examine the population-level change in cases of alcohol-related liver disease and pancreatitis that required admission during the COVID-19 epidemic by interrupted time series (ITS) analysis using claims data. We defined the period from April 2020, when the Japanese government declared a state of emergency, as the beginning of the COVID-19 epidemic. This ITS analysis included 3,026,389 overall admissions and 10,242 admissions for alcohol-related liver disease or pancreatitis from 257 hospitals between July 2018 and June 2020. The rate of admissions per 1000 admissions during the COVID-19 epidemic period (April 2020–June 2020) was 1.2 times (rate ratio: 1.22, 95% confidence interval: 1.12–1.33) compared to the pre-epidemic period. Analyses stratified by sex revealed that the increases in admission rates of alcohol-related liver disease or pancreatitis for females were higher than for males during the COVID-19 epidemic period. The COVID-19 epidemic in Japan might associates an increase in hospital admissions for alcohol-related liver disease and pancreatitis. Our study could support the concern of alcohol consumption and health problems during the COVID-19 pandemic.

BackgroundEarly mobilisation of intensive care unit (ICU) patients has been recommended in clinical practice guidelines. Therefore, the Japanese universal health insurance system introduced an additional fee for early mobilisation and/or rehabilitation, which can be claimed by hospitals when starting rehabilitation of ICU patients within 48 hours after their ICU admission. However, the effect of this fee is unknown.ObjectiveTo measure the proportion of ICU patients who received early rehabilitation and the impact on length of ICU stay, the length of hospital stay and discharged to home after the introduction of the financial incentive (additional fee for early mobilisation and/or rehabilitation).Design/methodsWe included patients who were admitted to ICU within 2 days of hospitalisation between April 2016 and January 2020. We conducted interrupted time series analyses to assess the effects of the introduction of the financial incentive.ResultsThe proportion of patients who received early rehabilitation immediately increased after the introduction of the financial incentive (rate ratio (RR) 1.293, 95% CI 1.240 to 1.349). The RR for proportion of patients received early rehabilitation was 1.008 (95% CI 1.005 to 1.011) in the period after the introduction of the financial incentive compared with period before its introduction. There was no statistically significant change in the mean length of ICU stay, the mean length of hospital stay and the proportion of patients who were discharged to home.ConclusionAfter the introduction of the financial incentive, the proportion of ICU patients who received early rehabilitation increased. However, the effects of the financial incentive on the length of ICU stay, the length of hospital stay and the proportion of patients who were discharged to home were limited.

To determine the most reliable comorbidity measure, we adapted and validated outcome-specific comorbidity scores to predict mortality and hospital charges using the comorbidities composing the Charlson and Elixhauser measures and the combination of these two used in developing Gagne's combined comorbidity scores (CC, EC, and GC, respectively). We divided cases of patients discharged in 2016–17 from the Diagnosis Procedure Combination database (n = 2,671,749) into two: one to derive weights for the scores, and the other for validation. We further validated them in subgroups, such as that with a selected diagnosis. The c-statistics of the models predicting in-hospital mortality using new mortality scores using the CC, EC, and GC were 0.780, 0.795, and 0.794, respectively. Among them, that using the EC showed the best calibration. To predict hospital charges and the length of hospital stay (LOS), the models using variables indicating the GC performed the best. The performances of the mortality and expenditure scores were considerably different in predicting each outcome. The new score using the EC performed the best in predicting in-hospital mortality for most situations. For hospital charges and the LOS, the binary variables of the GC showed the best results. The outcome-specific comorbidity scores should be considered for different outcomes.

IntroductionSurgical volume is widely used as an indicator to assess surgical burden in many areas; however, it has a risk of neglecting the differences of individual operations. Moreover, the characteristics of operations differ between rural and urban areas. Fewer but more varied operations are performed in rural settings than in urban settings. A new indicator, the person-time-adjusted surgical volume, was developed by integrating surgical volume, operative time and the surgeon’s workforce in each operation. This innovative measure expands the use of surgical volume in healthcare strategies, providing a promising tool for evaluating the surgical workforce on a timely basis.MethodsThe new indicator of surgical volume, person-time-adjusted surgical volume, was developed using weighted standard operative time and the standard number of surgeons. All statistical data were derived from three published sources. Rural and local city area data were grouped together as regional areas, on the prefectural basis (n=47) and compared with the data from the urban areas of the secondary medical area (n=48) in Japan. The surgical volume of gastrointestinal surgeries and surgeon density in each area was collected and analysed. All analyses used the person-time-adjusted surgical volume per surgeon to account for differences between medical areas.ResultsA negative association was found between the person-time-adjusted surgical volume and surgeon density. Regional areas had more person-time-adjusted surgical volume per surgeon than urban areas. A decrease in surgeon density resulted in an increased rate of person-time adjusted surgical volume in regional areas, which was a 10-fold increase in person-time-adjusted surgical volume per surgeon with decreasing surgeon density in regional areas. This suggests that surgeons in rural and local areas have a higher risk of overworking or burnout than those in urban areas.ConclusionThe person-time-adjusted surgical volume is useful for evaluating surgical burden and visualising the gap in underprivileged areas.

Background Although many countries have reformed public hospitals to reduce the imbalance of resources, there is limited information on the impact of hospital restructuring on communities and the regional healthcare system. The present study aimed to examine the effects of public hospital restructuring on the admission of elderly residents. Methods We analyzed a public hospital restructuring case in a secondary medical service area (SMSA) in Japan using administrative claims data. All consecutive patients aged 65 years or older who resided in the SMSA and were admitted to a hospital or visited a hospital between 36 months prior and 48 months after the restructuring were included. Effects of the restructuring on monthly admissions within the SMSA were evaluated using a segmented Poisson regression model and interrupted time-series analysis. Results A total of 58,929 admissions were analyzed. After the restructuring, admissions within the SMSA increased and reached the same level of admissions outside the SMSA. Interrupted time-series analyses revealed level (incidence rate ratio (IRR) 1.097, 95% confidence intervals (CI) 1.039–1.159, + 10.3% in two months) and slope (IRR 1.005, 95% CI 1.003–1.007, + 7 per month) changes in monthly admissions within the SMSA after the restructuring. Conclusions Monthly admissions of elderly residents within the SMSA increased after hospital restructuring, underscoring the importance of examining admissions within the neighborhood when assessing the impact of public hospital restructuring.