Japanese Local Governments' Dissemination Activities for Advance Care Planning: A Descriptive Analysis of a Nationwide Survey during the COVID-19 Pandemic.

This study aims to compare the awareness-raising activities between municipalities with and without focused anti-infection measures during the 2019 coronavirus disease (COVID-19) pandemic. Descriptive analysis was conducted using a nationwide self-administered questionnaire survey on municipalities' activities for residents and for healthcare providers and care workers (HCPs) in October 2022 in Japan. This study included 433 municipalities that had conducted awareness-raising activities before 2019 Fiscal Year. Workshops for residents were conducted in 85.2% of the municipalities, and they were more likely to be conducted in areas with focused anti-infection measures than those without measures (86.8% vs. 75.4%). Additionally, 85.9% of the municipalities were impacted by the pandemic; 50.1% canceled workshops, while 26.0% switched to a web-based style. Activities for HCPs were conducted in 55.2-63.7% of the municipalities, and they were more likely to be conducted in areas with focused anti-infection measures. A total of 50.6-62.1% of the municipalities changed their workshops for HCPs to a web-based style. Comparisons between areas with and without focused anti-infection measures indicated that the percentages of those impacted for all activities were not significantly different. In conclusion, awareness-raising activities in municipalities were conducted with new methods during the COVID-19 pandemic. Using information technology is essential to further promote such activities for residents.

Pulse Methylprednisolone Versus Dexamethasone in COVID-19: A Multicenter Cohort Study.

Although pulse (high-dose) methylprednisolone therapy can hypothetically control immune system flare-ups effectively, the clinical benefit of pulse methylprednisolone compared with dexamethasone in COVID-19 remains inconclusive. OBJECTIVES: To compare pulse methylprednisolone to dexamethasone as a COVID-19 treatment. DESIGN SETTING AND PARTICIPANTS: Using a Japanese multicenter database, we identified adult patients admitted for COVID-19 and discharged between January 2020 and December 2021 treated with pulse methylprednisolone (250, 500, or 1,000 mg/d) or IV dexamethasone (≥ 6 mg/d) at admission day 0 or 1. Main Outcomes and Measures: The primary outcome was in-hospital mortality. Secondary outcomes were 30-day mortality, new ICU admission, insulin initiation, fungal infection, and readmission. Multivariable logistic regression was conducted to differentiate the dose of pulse methylprednisolone (250, 500, or 1,000 mg/d). Additionally, subgroup analyses by characteristics such as the need for invasive mechanical ventilation (IMV) were also conducted. RESULTS: A total of 7,519, 197, 399, and 1,046 patients received dexamethasone, 250, 500, and 1,000 mg/d of methylprednisolone, respectively. The crude in-hospital mortality was 9.3% (702/7,519), 8.6% (17/197), 17.0% (68/399), and 16.2% (169/1,046) for the different doses, respectively. The adjusted odds ratio (95% CI) was 1.26 (0.69-2.29), 1.48 (1.07-2.04), and 1.75 (1.40-2.19) in patients starting 250, 500, and 1,000 mg/d of methylprednisolone, respectively, compared with those starting dexamethasone. In subgroup analyses, the adjusted odds ratio of in-hospital mortality was 0.78 (0.25-2.47), 1.12 (0.55-2.27), and 1.04 (0.68-1.57) in 250, 500, and 1,000 mg/d of methylprednisolone, respectively, among patients with IMV, whereas the adjusted odds ratio was 1.54 (0.77-3.08), 1.62 (1.13-2.34), and 2.14 (1.64-2.80) among patients without IMV. CONCLUSIONS AND RELEVANCE: Higher doses of pulse methylprednisolone (500 or 1,000 mg/d) may be associated with worse COVID-19 outcomes when compared with dexamethasone, especially in patients not on IMV.

The Effect of Business Operating Systems on Nursing Home Termination.

Objectives: Nursing home terminations have increased worldwide due to rising costs, staffing shortages, and the coronavirus disease pandemic. However, little is known about the impact that business operating systems have on nursing home termination. Methods: This study used the National Long-term Care database, which comprised 7,842 operating nursing homes in January 2018. Nursing home termination was identified when nursing homes discontinued provision of long-term care services to all residents between January 2018 and December 2020. Business operating systems that were reimbursed by the LTC insurance system were the exposure of interest. The logistic regression model for nursing home termination included a series of organizational, internal, and external factors as covariates. Results: From 2018 to 2020, 83 (1.1%) nursing homes were terminated. The proportion of reimbursed nursing homes varied greatly depending on the type of business operating systems. Implementing physical function training and improving working conditions were significantly associated with a lower risk of nursing home termination. Conclusion: Financial incentives to several business operating systems are an effective way to build a sustainable environment for nursing homes to continue to exist.

Comparison of the Characteristics and Outcomes of COVID-19 Patients Treated by a Hospital-at-Home Service in Japan during the Alpha and Delta Waves.

Coronavirus infections occurred in repeated waves caused by different variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), with the number of patients increasing during each wave. A private after-hours house-call (AHHC) service provides hospital-at-home (HaH) services to patients in Japan requiring oxygen when hospital beds are in short supply. This retrospective study aimed to compare the characteristics of COVID-19 patients treated by the AHHC service during the COVID-19 waves caused by the Alpha (March-June 2021) and Delta (July-December 2021) SARS-CoV-2 variants. All patients with COVID-19 treated by the AHHC service from March to December 2021 while awaiting hospitalization were included. The data were collected from medical records and follow-up telephone interviews. The AHHC service treated 55 and 273 COVID-19 patients during the Alpha and Delta waves, respectively. The patients treated during the Delta wave were significantly younger than those treated during the Alpha wave (median: 63 years and 47 years, respectively; p < 0.001). Disease severity did not differ significantly between the two waves, but the crude case-fatality rate was significantly higher during the Alpha wave (10/55, 18.2%) than during the Delta wave (4/273, 1.4%; p < 0.001). The patient characteristics and outcomes differed between the Alpha and Delta waves.

Association between pre-admission anticoagulation and in-hospital death, venous thromboembolism, and major bleeding among hospitalized COVID-19 patients in Japan.

PURPOSE: The coagulation activation leads to thrombotic complications such as venous thromboembolism (VTE) in patients with coronavirus disease-2019 (COVID-19). Prophylactic anticoagulation therapy has been recommended for hospitalized COVID-19 patients in clinical guidelines. This retrospective cohort study aimed to examine the association between pre-admission anticoagulation treatment and three outcomes: in-hospital death, VTE, and major bleeding among hospitalized COVID-19 patients in Japan. METHODS: Using a large-scale claims database built by the Medical Data Vision Co. in Japan, we identified patients hospitalized for COVID-19 who had outpatient prescription data at least once within 3 months before being hospitalized. Exposure was set as pre-admission anticoagulation treatment (direct oral anticoagulant or vitamin K antagonist), and outcomes were in-hospital death, VTE, and major bleeding. We conducted multivariable logistic regression analyses, adjusting for a single summarized score (a propensity score of receiving pre-admission anticoagulation) for VTE and major bleeding, due to the small number of outcomes. RESULTS: Among the 2612 analytic patients, 179 (6.9%) had pre-admission anticoagulation. Crude incidence proportions were 13.4% versus 8.5% for in-hospital death, 0.56% versus 0.58% for VTE, and 2.2% versus 1.1% for major bleeding among patients with and without pre-admission anticoagulation, respectively. Adjusted odds ratios (95% confidence intervals) were 1.25 (0.75-2.08) for in-hospital death, 0.21 (0.02-1.97) for VTE, and 2.63 (0.80-8.65) for major bleeding. Several sensitivity analyses did not change the results. CONCLUSIONS: We found no evidence that pre-admission anticoagulation treatment was associated with in-hospital death. However, a larger sample size may be needed to conclude its effect on VTE and major bleeding.

The role of after-hours house-call medical service in the treatment of COVID-19 patients awaiting hospital admission: A retrospective cohort study.

ABSTRACT: Due to the increasing number of coronavirus disease 2019 (COVID-19) cases in Japan, hospitals are unable to provide admission and immediate inpatient care. The after-hours house call (AHHC) service offers telephone consultations and in-home care to patients awaiting admission. Currently, there is no report on the management of COVID-19 patients when inpatient beds are insufficient.We aimed to describe the clinical characteristics and outcomes of COVID-19 patients treated by an AHHC medical service in Osaka and Tokyo, between April and May 2021 (during the fourth wave in Japan). Patients were classified into 2 groups: Moderate I and Moderate II, according to the severity of infection under Japanese guidelines. A retrospective study of the hospital records and follow-up telephone consultations was performed.The AHHC treated a total of 55 COVID-19 patients (17 with Moderate I, 38 with Moderate II disease). The median ages (interquartile range) were 63 (49-80.5) and 64 (50.8-81), respectively. In each group, approximately 30% of AHHC patients received out-of-hospital oxygen therapy for the duration of their treatment until it was no longer required. Major symptoms, including shortness of breath or difficulty breathing (47.1% and 78.9%, respectively) and fever or chills (41.2% and 76.3%, respectively) were lower in the Moderate I group than in the Moderate II group. Overall, 16.4% of patients died, with 17.6% in the Moderate I group and 15.8% in the Moderate II group.We found the proportion of mortality in patients treated by the AHHC was slightly higher to that of patients treated in Japanese hospitals. This study will provide an alternative management of patients requiring oxygen in situations where hospital beds are in short supply.

Association between Nafamostat Mesylate and In-Hospital Mortality in Patients with Coronavirus Disease 2019: A Multicenter Observational Study.

Nafamostat mesylate may be effective against coronavirus disease 2019 (COVID-19). However, it is not known whether its use is associated with reduced in-hospital mortality in clinical practice. We conducted a retrospective observational study to evaluate the effect of nafamostat mesylate in patients with COVID-19 using the Medical Data Vision Co. Ltd. hospital-based database in Japan. We compared patients with COVID-19 who were (n = 121) and were not (n = 15,738) administered nafamostat mesylate within 2 days of admission between January and December 2020. We conducted a 1:4 propensity score matching with multiple imputations for smoking status and body mass index and combined the 20 imputed propensity score-matched datasets to obtain the adjusted odds ratio for in-hospital mortality. Crude in-hospital mortality was 13.2% (16/121) and 5.0% (790/15,738), respectively. In the propensity score-matched analysis with multiple imputations, the adjusted odds ratio (use vs. no use of nafamostat mesylate) for in-hospital mortality was 1.27 (95% confidence interval: 0.61-2.64; p = 0.52). Sensitivity analyses showed similar results. The results of this retrospective observational study did not support an association between nafamostat mesylate and improved in-hospital outcomes in patients with COVID-19, although further studies with larger sample sizes are warranted to assess the generalizability of our findings.

Comparison of patient characteristics and in-hospital mortality between patients with COVID-19 in 2020 and those with influenza in 2017-2020: a multicenter, retrospective cohort study in Japan.

BACKGROUND: COVID-19 has worse mortality than influenza in American and European studies, but evidence from the Western Pacific region is scarce. METHODS: Using a large-scale multicenter inpatient claims data in Japan, we identified individuals hospitalised with COVID-19 in 2020 or influenza in 2017-2020. We compared patient characteristics, supportive care, and in-hospital mortality, with multivariable logistic regression analyses for in-hospital mortality overall, by age group, and among patients with mechanical ventilation. FINDINGS: We identified 16,790 COVID-19 patients and 27,870 influenza patients, with the different age distribution (peak at 70-89 years in COVID-19 vs. bimodal peaks at 0-9 and 80-89 years in influenza). On admission, the use of mechanical ventilation was similar in both groups (1·4% vs. 1·4%) but higher in the COVID-19 group (3·3% vs. 2·5%; p<0·0001) during the entire hospitalisation. The crude in-hospital mortality was 5·1% (856/16,790) for COVID-19 and 2·8% (791/27,870) for influenza. Adjusted for potential confounders, the in-hospital mortality was higher for COVID-19 than for influenza (adjusted odds ratio [aOR] 1·83, 95% confidence interval [CI] 1·64-2·04). In age-stratified analyses, the aOR (95%CI) were 0·78 (0·56-1·08) and 2·05 (1·83-2·30) in patients aged 20-69 years and ≥70 years, respectively (p-for-interaction<0·0001). Among patients with mechanical ventilation, the aOR was 0·79 (0·59-1·05). INTERPRETATION: Patients hospitalised with COVID-19 in Japan were more likely to die than those with influenza. However, this was mainly driven by findings in older people, and there was no difference once mechanical ventilation was started. FUNDING: Ministry of Health, Labour and Welfare of Japan (21AA2007).

Family caregiving and changes in mental health status in Japan during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had a widespread significant impact on mental health. However, the effect of providing care to family members (informal caregiving) on changes in mental health status during the pandemic remains unclear. METHODS: Using cross-sectional data from a large internet survey conducted between August and September 2020, we investigated the association of informal caregiving status with the incidence of mental health deterioration (increased loneliness, self-reported deterioration in mental health, and new suicidal ideation) in Japan during the COVID-19 pandemic. RESULTS: Among 25,482 participants (mean age 48.8 [standard deviation 17.3]; 50.3% women), 2,500 (9.8%) were providing informal care during the pandemic. After adjusting for potential confounders, informal caregivers were more likely than non-caregivers to experience increased loneliness (adjusted odds ratio [aOR] 2.16; 95% confidence interval [CI] 1.70-2.76), self-reported deterioration in mental health (aOR 1.54; 95% CI 1.14-2.08), and new incidence of suicidal ideation (aOR 3.65; 95% CI 1.92-6.92). The degree of mental health deterioration depended on the intensity of care. For example, the incidence rates of new suicidal ideation were 15.0%, 5.2%, and 3.6% for individuals who provided high-intensity caregiving, those who provided low-intensity caregiving, and non-caregivers, respectively (p-for-trend<0.001). The stratified analysis by gender showed that informal caregiving was associated with self-reported deterioration in mental health status among women (aOR 2.19; 95% CI 1.49-3.21) but not men (aOR 1.08; 95% CI 0.75-1.56). CONCLUSION: Informal caregivers were more likely to experience mental health deterioration than non-caregivers during the COVID-19 pandemic.

Patients' impressions of after-hours house-call services during the COVID-19 pandemic in Japan: a questionnaire-based observational study.

BACKGROUND: Access to healthcare has been strongly affected by the coronavirus disease 2019 (COVID-19) pandemic, which has raised concerns about the increased risk of delays in receiving medical care. This study aimed to assess the patients' impressions of after-hour house-call (AHHC) medical services during the COVID-19 pandemic using a patient questionnaire. METHODS: This was a cross-sectional observational study of anonymized medical record data and internet-based questionnaires from patients who used AHHC medical services from April 2020 to January 2021. We summarized the patients' impressions of AHHC medical services during the COVID-19 pandemic stratified by patient characteristics. The questions of the questionnaire were as follows: (i) Did you use the AHHC medical services because you suspected you had COVID-19 infection? (ii) Do you feel that the use of AHHC medical services has helped prevent transmission of COVID-19? (iii) What action would you have taken in the absence of AHHC medical services? RESULTS: A total of 1802 patients responded to the questionnaire (response rate: 11.3%). First, 700 (40.8%) of the responders indicated that they had used AHHC medical services because of suspicion of COVID-19. Second, most responders (88.8%) felt that AHHC medical services prevented transmission of COVID-19. Third, 774 (43.0%) of the responders considered that they would have visited an emergency department or called an ambulance if AHHC medical services had not been used. Furthermore, 411 (22.8%) of the responders indicated that they would remain at home or wait until working hours if AHHC medical services were not available despite having a condition that required emergency attention. CONCLUSIONS: AHHC medical services may be one of the strategies for those who refrain from seeking healthcare services, thus reducing the risk of delayed hospital visits during emergencies. Furthermore, AHHC medical services may also contribute to preventing transmission of COVID-19 by avoiding contact with other patients in the hospital.

Changes in the proportion and severity of patients with fever or common cold symptoms utilizing an after-hours house call medical service during the COVID-19 pandemic in Tokyo, Japan: a retrospective cohort study.

BACKGROUND: Trends in the characteristics and disease severity of patients using an after-hours house call (AHHC) medical service changed during the coronavirus disease (COVID-19) pandemic. However, there have been no reports on this issue since the start of the COVID-19 pandemic. This study aimed to investigate patients' tendencies to utilize an AHHC medical service for fever or common cold symptoms during the COVID-19 pandemic. METHODS: This retrospective cohort study compared the characteristics and disease severity of patients with fever or common cold symptoms utilizing an AHHC medical service offered by a single large company between the control period (December 1, 2018 to April 30, 2019) and the COVID-19 pandemic exposure period (December 1, 2019 to April 30, 2020). We also assessed the proportion of these patients in relation to all patients calling the service for any reason. RESULTS: During the control and COVID-19 pandemic exposure periods, a total of 6462 and 10,003 patients consulted the AHHC medical service, respectively. Of these, 5335 (82.6%) and 7423 (74.2%) patients had fever and common cold symptoms, respectively, during the control and COVID-19 pandemic exposure periods (P < 0.001). The corresponding median (interquartile range) ages were 8 (3-11) and 10 (4-33) years, respectively. The distribution of disease severity differed between the groups. The proportions of patients with mild, moderate, and severe illness were 71.1, 28.7, and 0.2% in the control period and 42.3, 56.7, and 0.9% in the COVID-19 pandemic exposure period, respectively (P < 0.001). CONCLUSIONS: During the COVID-19 pandemic, the proportion of patients with fever or common cold symptoms was lower than that in the control period, but disease severity was significantly higher.

Change of Use in Community Services among Disabled Older Adults during COVID-19 in Japan.

During the COVID-19 pandemic, social interactions were restricted, including community services for disabled older adults. This study aimed to describe the change of use in community services related to long-term care insurance (LTCI) during the pandemic in Japan. A retrospective descriptive study was conducted using data collected via a cloud-based management support platform for older adult care provider "Kaipoke", by a private-sector company "SMS Co., Ltd.", in which care-managers of LTCI manage their office work. Data collection occurred from July 2019 to June 2020. Study subjects were LTCI service users aged 65 years and above. Subjects were living at home. We examined changes in the number of users of LTCI services before and after the COVID-19 pandemic began, using an interrupted time-series analysis. Results indicated that the use of outpatient services was reduced; however, home-visit services were maintained. The decrease in use was significant in the seven prefectures where the infection initially spread. There are concerns that older adults or surrounding caregivers can be affected by such changes in LTC service use. It is therefore necessary to implement sustainable measures from a long-term perspective and investigate their influence as part of future studies.

Surgical mask use by healthcare personnel to prevent COVID-19 spread in a long-term care facility.

Long-term care facilities are a recognized high-risk setting for severe outcomes during the coronavirus disease 2019 (COVID-19) outbreak. This study describes a COVID-19 outbreak in a long-term care facility in Japan. The index case was a nurse who wore a surgical mask and used standard precautions. Of the 17 confirmed cases of COVID-19, 14 (14/93, 15.1%) were residents and three (3/69, 4.3%) were healthcare personnel (HCP); no visitors tested positive 0 (0/22, 0.0%). Mask utilization by HCP was not much effective in preventing COVID-19 transmission, even when interaction was not considered as being in close contact.