Capturing the trends in hospital standardized mortality ratios for pneumonia: a retrospective observational study in Japan (2010 to 2018).

BACKGROUND: Pneumonia has a high human toll and a substantial economic burden in developed countries like Japan, where the crude mortality rate was 77.7 per 100,000 people in 2017. As this trend is going to continue with increasing number of the elderly multi-morbid population in Japan; monitoring performance over time is a social need to alleviate the disease burden. The study objective was to determine the characteristics of hospital standardized mortality ratios (HSMRs) for pneumonia in Japan from 2010 to 2018 to describe this trend. METHODS: Data of the DPC (Diagnostic Procedures Combination) database were used, which is an administrative claims and discharge summary database for acute care in-patients in Japan. HSMRs were calculated using the actual and expected numbers of in-hospital deaths, the latter of which was calculated using logistic regression model, with a number of explanatory variables, e.g., age, sex, urgency of admission, mode of transportation, patient volume per month in each hospital, A-DROP score, and Charlson comorbidity index (CCI). We constructed two HSMR models: a single-year model, which included hospitals with > 10 in-patients per month and, a 9-year model, which included those hospitals with complete 9-year data. Predictive accuracy of the logistic models was assessed using c-index (area under receiver operating curve). RESULTS: Total 230,372 patients were included for the analysis over the 9-year study period. Calculated HSMRs showed wide variation among hospitals. The proportion of hospitals with HSMR less than 100 increased from 36.4% in 2010 to 60.6% in 2018. Both models showed good predictive ability with a c-statistic of 0.762 for the 9-year model, and no less than 0.717 for the single-year model. CONCLUSION: This study denoted that HSMRs of pneumonia can be calculated using DPC data in Japan and revealed significant variations among hospitals with comparable case-mixes. Therefore, HSMR can be used as yet another measure to help improve quality of care over time if other indicators are examined in parallel and to get a clear picture of where hospitals excel and lack.

The structure of the quality of clinical practice guidelines with the items and overall assessment in AGREE II: a regression analysis.

BACKGROUND: The Appraisal of Guidelines for Research & Evaluation (AGREE) II has been widely used to evaluate the quality of clinical practice guidelines (CPGs). While the relationship between the overall assessment of CPGs and scores of six domains were reported in previous studies, the relationship between items constituting these domains and the overall assessment has not been analyzed. This study aims to investigate the relationship between the score of each item and the overall assessment and identify items that could influence the overall assessment. METHODS: All Japanese CPGs developed using the evidence-based medicine method and published from 2011 to 2015 were used. They were independently evaluated by three appraisers using AGREE II. The evaluation results were analyzed using regression analysis to evaluate the influence of 6 domains and 23 items on the overall assessment. RESULTS: A total of 206 CPGs were obtained. All domains and all items except one were significantly correlated to the overall assessment. Regression analysis revealed that Domain 3 (Rigour of Development), Domain 4 (Clarity of Presentation), Domain 5 (Applicability), and Domain 6 (Editorial Independence) had influence on the overall assessment. Additionally, four items of AGREE II, clear selection of evidence (Item 8), specific/unambiguous recommendations (Item 15), advice/tools for implementing recommendations (Item 19), and conflicts of interest (Item 22), significantly influenced the overall assessment and explained 72.1% of the variance. CONCLUSIONS: These four items may highlight the areas for improvement in developing CPGs.

Trends in hospital standardized mortality ratios for stroke in Japan between 2012 and 2016: a retrospective observational study.

OBJECTIVE: Stroke is one of the leading causes of death and disability, and imposes a major healthcare burden. The aim of this study was to determine the characteristics of hospital standardized mortality ratios (HSMRs) for stroke in Japan for the year 2012-16 to describe the trend. DESIGN: Retrospective observational study. SETTING: Data from the Japanese administrative database. PARTICIPANTS: All hospital admissions for stroke were identified from diagnostic procedures combination (DPC) database from 2012 to 2016. MAIN OUTCOME MEASURES: HSMR was calculated using the actual number of in-hospital deaths and expected deaths. To obtain the expected death number, a logistic regression model was developed to get the coefficient with a number of explanatory variables. Predictive accuracy of the logistic models was assessed using c-index and calibration was evaluated using the Hosmer-Lemeshow test. RESULTS: A total of 63 084 patients admitted for stroke from January 2012 to December 2016 were analyzed. HSMRs showed declining tendency over these 5 years, suggesting stroke-related mortality has been improving. While the HSMRs varied from year to year, a wide variation was also seen among the different hospitals in Japan. The proportion of hospitals with HSMR less than 100 increased from 41.0% in 2012 to 59.0% in 2016. CONCLUSION: This study demonstrated that HSMR can be calculated using DPC data and found wide variation in HSMR of stroke among hospitals in Japan and enabled us to image the trend. By examining these trends, facilities, authorities and provinces can initiate designs that will ultimately lead to an upgraded healthcare delivery system.

Quality assessment of clinical practice guidelines using the AGREE instrument in Japan: A time trend analysis.

BACKGROUND: Clinical practice guidelines (CPGs) are representative methods for promoting the standardization of healthcare and improvement of its quality. Few studies have investigated changes in the quality of CPGs published in a country over time. Our aim was to investigate changes in the quality of CPGs over time in the context of the available infrastructure for CPG development, public interest in healthcare quality, and healthcare providers' responses to this interest. METHODS: All CPGs pertaining to evidence-based medicine (EBM) issued between 2000 and 2014 in Japan (n = 373) were evaluated using the Japanese version of the Appraisal of Guidelines for Research and Evaluation (AGREE) I. Additionally, time trends in quality were analyzed. Using a cut-off point based on the publication year of CPG development literature, the evaluated CPGs were classified into those published until 2008 (pre-2008) and those published since 2009 (post-2008). Subsequently, we compared these groups in terms of 1) first edition CPGs and its second editions, and 2) patients' version of CPGs. RESULTS: Scores on all six domains of AGREE I improved each year. A comparison of the first- and second-edition of CPGs (n = 64) showed that scores on all domains improved significantly after revision. Significant improvement was observed in three domains (#2 stakeholder involvement, #3 rigor of development, and #4 clarity of presentation) in the pre-2008 group and in all domains in the post-2008 group. The comparison between the pre- and post-2008 groups in terms of CPGs for patients showed that the score increased in only one domain (#1 scope and purpose). CONCLUSIONS: The number of published CPGs has been increasing and the quality of CPGs, as assessed using the AGREE I instrument, has been improving. These changes seem to be influenced by improvements in social infrastructure, such as the publication of CPG development procedures, availability of CPG preparation methodology training, and increase in CPG-related skills.

Cost of illness of leukemia in Japan - Trend analysis and future projections.

BACKGROUND: Leukemia is a deadly hematological malignancy that usually affects all age groups and imposes significant burden on public funds and society. The objective of this study was to analyze the cost of illness (COI) of leukemia, and to mark out the underlying driving factors, in Japan. METHODS: COI method was applied to the data from government statistics. We first summed up the direct and indirect costs from 1996 to 2014; then future COI for the year 2017-2029 was projected. RESULTS: Calculated COI showed an upward trend with a 13% increase from 1996 to 2014 (270-305 billion yen). Increased COI was attributed to an increase in direct costs. Although mortality cost accounted for the largest proportion of COI, but followed a downward trend. Decreased mortality costs reflected the effects of aging. Mortality cost per person also decreased, however, the percentage of mortality cost for individuals ≥65 years of age increased consistently from 1996 to 2014. If a similar trend in health-related indicators continue, COI would remain stable from 2017 to 2029 regardless of models. CONCLUSION: COI of leukemia increased from 1996 to 2014, but was projected to decrease in foreseeable future. With advancement of new therapies, leukemia has become potentially curable and require long-term care; so direct cost and morbidity cost will remain unchanged. This reveal the further continuing burden on public funds. Thus, the information obtained from this study can be regarded as beneficial to future policy making with respect to government policies in Japan.

Cost of illness of ischemic heart disease in Japan: a time trend and future projections.

BACKGROUND: Ischemic heart disease (IHD/ICD10: I20-I25) is the second leading cause of deaths in Japan and accounts for 40% of deaths due to heart diseases. This study aimed to calculate the economic burden of IHD using the cost of illness (COI) method and to identify key factors that drive the change of the economic burden of IHD. METHODS: We calculated the cost of illness (COI) every 3 years from 1996 to 2014 using governmental statistics. We then predicted the COI for every 3 years starting from 2017 up to 2029 using the fixed and variable model estimations. Only the estimated future population was used as a variable in the fixed model estimation. By contrast, variable model estimation considered the time trend of health-related indicators over the past 18 years. We derived the COI from the sum of direct and indirect costs (morbidity and mortality). RESULTS: The past estimation of COI slightly increased from 1493.8 billion yen in 1996 to 1708.3 billion yen in 2014. Future forecasts indicated that it would decrease from 1619.0 billion yen in 2017 to 1220.5 billion yen in 2029. CONCLUSION: The past estimation showed that the COI of IHD increased; in the mixed model, the COI was predicted to decrease with the continuing trend of health-related indicators. The COI of IHD in the future projection showed that, although the average age of death increased by social aging, the influence of the number of deaths and mortality cost decreased.