Visualization and Improvement of the Quality, Efficiency, and Equity of the Healthcare System - Secondary Publication.

In a depopulating society, it is difficult to ensure sufficient resources and finances for health and health care. Thus, effective management of the reform of the healthcare system by visualizing the quality, efficiency, and equity of health care is imperative. This article presents an overview of the studies conducted by my team in this area over the past 35 years, covering the following four sections: (1) visualization of healthcare system using individual-level data, (2) healthcare system at the organizational level, (3) healthcare system at the national and regional levels, and (4) creation of a social system for health. To improve the quality, efficiency, and equity of the healthcare system as well as the social system for people's health, it is necessary to visualize the actual situation and share this information with all stakeholders to contribute to the joint management of healthcare system. On this basis, from the perspectives of each region and the nation, it is important to visualize and grasp various wider determinants of people's health and healthcare performance and to improve health care and social systems.

Presenteeism and social interaction in the "new normal" in Japan: a longitudinal questionnaire study.

BACKGROUND: Although social interaction and social support during the "new normal" due to coronavirus disease 2019 (COVID-19) may be related to presenteeism, the effect between these factors has not been clear for Japanese workers. The aim of this study was to describe the presenteeism of Japanese workers with reference to social interaction and social support following the lifestyle changes due to COVID-19 and to assess whether social interaction and social support affected their presenteeism. METHODS: The data were obtained from internet panel surveys from October 2020. Descriptive statistics were calculated, and multiple linear regression was conducted using the data from the first, fourth and fifth surveys, which were conducted during October to November 2020, July to August 2021, and September to October 2021, respectively. To measure presenteeism, questions from "absenteeism and presenteeism questions of the World Health Organization's Heath and Work Performance Questionnaire", short version in Japanese was utilized. Multiple linear regressions were conducted to investigate the effects of social interaction and social support-related factors on presenteeism. RESULTS: A total of 3,407 participants were included in the analysis. The mean score of absolute presenteeism from the fifth survey was 58.07 (SD = 19.71). More time spent talking with family, a larger number of social supporters and a higher satisfaction level for social support were associated with a higher absolute presenteeism score. CONCLUSIONS: Our results suggested that social support reduced the presenteeism of the Japanese workers during the "new normal" due to the COVID-19 pandemic. Social interaction with family also relieved presenteeism.

A panel vector autoregression analysis for the dynamics of medical and long-term care expenditures.

Although medical and long-term care expenditures for older adults are closely related, providing rigorous statistical analysis for their dynamic relationship is challenging. In this research, we propose a novel approach using the panel vector autoregression model to reveal the realized patterns of the interdependence. As an empirical application, we analyze monthly panel data on individuals in a city of Japan, where social insurance covers many formal services for long-term care. Our estimation results indicate the existence of intertemporal transition from expensive acute medical care to reasonable at-home medical care, then to at-home long-term care. Under this context, the enhancement of formal long-term care sector in Japan might have played an important role in the suppression of the total care cost in spite for its rapid aging over the past 2 decades. Additionally, we find that daycare plays multiple roles in Japanese long-term care, such as respite and rehabilitation, but there is no considerable transition from outpatient rehabilitation to daycare in the long-term care sector.

Cost-effectiveness of endovascular therapy for acute stroke with a large ischemic region in Japan: impact of the Alberta Stroke Program Early CT Score on cost-effectiveness.

BACKGROUND: Although randomized clinical trials (RCTs) demonstrated short-term benefits of endovascular therapy (EVT) for acute ischemic stroke (AIS) with a large ischemic region, little is known about the long-term cost-effectiveness or its difference by the extent of the ischemic areas. We aimed to assess the cost-effectiveness of EVT for AIS involving a large ischemic region from the perspective of Japanese health insurance payers, and analyze it using the Alberta Stroke Program Early CT Score (ASPECTS). METHODS: The Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan Large Ischemic Core Trial (RESCUE-Japan LIMIT) was a RCT enrolling AIS patients with ASPECTS of 3-5 initially determined by the treating neurologist primarily using MRI. The hypothetical cohort and treatment efficacy were derived from the RESCUE-Japan LIMIT. Costs were calculated using the national health insurance tariff. We stratified the cohort into two subgroups based on ASPECTS of ≤3 and 4-5 as determined by the imaging committee, because heterogeneity was observed in treatment efficacy. EVT was considered cost-effective if the incremental cost-effectiveness ratio (ICER) was below the willingness-to-pay of 5 000 000 Japanese yen (JPY)/quality-adjusted life year (QALY). RESULTS: EVT was cost-effective among the RESCUE-Japan LIMIT population (ICER 4 826 911 JPY/QALY). The ICER among those with ASPECTS of ≤3 and 4-5 was 19 396 253 and 561 582 JPY/QALY, respectively. CONCLUSION: EVT was cost-effective for patients with AIS involving a large ischemic region with ASPECTS of 3-5 initially determined by the treating neurologist in Japan. However, the ICER was over 5 000 000 JPY/QALY among those with an ASPECTS of ≤3 as determined by the imaging committee.

Identification of complications requiring interventions after gastrointestinal cancer surgery from real-world data: An external validation study.

Background: Recently, real-world data have been recognized to have a significant role for research and quality improvement worldwide. The decision on the existence or nonexistence of postoperative complications is complex in clinical practice. This multicenter validation study aimed to evaluate the accuracy of identification of patients who underwent gastrointestinal (GI) cancer surgery and extraction of postoperative complications from Japanese administrative claims data. Methods: We compared data extracted from both the Diagnosis Procedure Combination (DPC) and chart review of patients who underwent GI cancer surgery from April 2016 to March 2019. Using data of 658 patients at Kyoto University Hospital, we developed algorithms for the extraction of patients and postoperative complications requiring interventions, which included an invasive procedure, reoperation, mechanical ventilation, hemodialysis, intensive care unit management, and in-hospital mortality. The accuracy of the algorithms was externally validated using the data of 1708 patients at two other hospitals. Results: In the overall validation set, 1694 of 1708 eligible patients were correctly extracted by DPC (sensitivity 0.992 and positive predictive value 0.992). All postoperative complications requiring interventions had a sensitivity of >0.798 and a specificity of almost 1.000. The overall sensitivity and specificity of Clavien-Dindo ≥grade IIIb complications was 1.000 and 0.995, respectively. Conclusion: Patients undergoing GI cancer surgery and postoperative complications requiring interventions can be accurately identified using the real-world data. This multicenter external validation study may contribute to future research on hospital quality improvement or to a large-scale comparison study among nationwide hospitals using real-world data.

Cost-effectiveness analysis of adult living-donor liver transplantation in Japan.

AIM: Living-donor liver transplantation (LDLT) is a highly effective life-saving procedure; however, it requires substantial medical resources, and the cost-effectiveness of LDLT versus conservative management (CM) for adult patients with end-stage liver disease (ESLD) remains unclear in Japan. METHODS: We performed a cost-effectiveness analysis using the Diagnostic Procedure Combination (DPC) data from the nationwide database of the DPC research group. We selected adult patients (18 years or older) who were admitted or discharged between 2010 and 2021 with a diagnosis of ESLD with Child-Pugh class C or B. A decision tree and Markov model were constructed, and all event probabilities were computed in 3-month cycles over a 10-year period. The willingness-to-pay per quality-adjusted life-year (QALY) was set at 5 million Japanese yen (JPY) (49,801 US dollars [USD]) from the perspective of the public health-care payer. RESULTS: After propensity score matching, we identified 1297 and 111,849 patients in the LDLT and CM groups, respectively. The incremental cost-effectiveness ratio for LDLT versus CM for Child-Pugh classes C and B was 2.08 million JPY/QALY (20,708 USD/QALY) and 5.24 million JPY/QALY (52,153 USD/QALY), respectively. The cost-effectiveness acceptability curves showed the probabilities of being below the willingness-to-pay of 49,801 USD/QALY as 95.4% in class C and 48.5% in class B. Tornado diagrams revealed all variables in class C were below 49,801 USD/QALY while their ranges included or exceeded 49,801 USD/QALY in class B. CONCLUSIONS: Living-donor liver transplantation for adult patients with Child-Pugh class C was cost-effective compared with CM, whereas LDLT versus CM for class B patients was not cost-effective in Japan.

Factors Associated With Postoperative Decisional Regret in Patients Undergoing Gastrointestinal Cancer Surgery: A Prospective Cohort Study.

BACKGROUND: Surgery is recommended as the first-line treatment option to cure resectable gastrointestinal (GI) cancer. However, patients occasionally feel postoperative regret after surgery. To date, it is not clear which factors are associated with patient regret after GI cancer surgery. The aim of this study was to investigate factors related to postoperative decision regret in patients undergoing surgery for GI cancer. METHODS: The present prospective study used questionnaires to analyze postoperative decision regret in patients undergoing GI cancer surgery in our institution between February and July 2020. Decision regret that patients felt after surgery was quantitatively measured using the decision regret scale (DRS). Multivariable linear regression models were used to examine factors related to postoperative decision regret. RESULTS: Among 70 patients analyzed, the median (interquartile range) DRS score was 10.0 (.0-25.0). Multivariable analysis showed that preoperative Trust in Physician Scale score (partial regression coefficient (B) = -.77; 95% confidence interval (CI) = -1.13 to -.41; P < .001) and postoperative complications (B = 9.17; 95% CI = 2.20 to 16.15; P = .0011) were significantly associated with DRS score. DISCUSSION: Preoperative trust in physician and postoperative complications were significantly associated with postoperative decision regret in patients undergoing surgery for GI cancer. Although patients may regret their choice of surgery when postoperative complications occur, trust in their physician may help reduce feelings of regret.

The Japanese Guide affected the prescription of steroids for COVID-19 inpatients during the COVID-19 epidemic in Japan.

Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, guidance ("Japanese Guide") has been published by a working group of several academic societies and announced by the Ministry of Health, Labour, and Welfare. Steroids as a candidate treatment for COVID-19 were noted in the Japanese Guide. However, the prescription details for steroids, and whether the Japanese Guide changed its clinical practice, were unclear. This study aimed to examine the impact of the Japanese Guide on the trends in the prescription of steroids for COVID-19 inpatients in Japan. We selected our study population using Diagnostic Procedure Combination (DPC) data from hospitals participating in the Quality Indicator/Improvement Project (QIP). The inclusion criteria were patients discharged from hospital between January 2020 and December 2020, who had been diagnosed with COVID-19, and were aged 18 years or older. The epidemiological characteristics of cases and the proportion of steroid prescriptions were described on a weekly basis. The same analysis was performed for subgroups classified by disease severity. The study population comprised 8603 cases (410 severe cases, 2231 moderate II cases, and 5962 moderate I/mild cases). The maximum proportion of cases prescribed with dexamethasone increased remarkably from 2.5 to 35.2% in the study population before and after week 29 (July 2020), when dexamethasone was included in the guidance. These increases were 7.7% to 58.7% in severe cases, 5.0% to 57.2% in moderate II cases, and 1.1% to 19.2% in moderate I/mild cases. Although the proportion of cases prescribed prednisolone and methylprednisolone decreased in moderate II and moderate I/mild cases, it remained high in severe cases. We showed the trends of steroid prescriptions in COVID-19 inpatients. The results showed that guidance can influence drug treatment provided during an emerging infectious disease pandemic.

The total number of patients with any of four major fragility fractures decreased during the first wave of the COVID-19 epidemic in Japan, commencing before the state of emergency declaration, which was not as enforceable as lockdown.

Durin g the first wave of the COVID-19 epidemic, the total number of patients with any of the four major fragility fractures, including both inpatients and first-visit outpatients, began to decline shortly before the state of emergency was declared, rather than immediately after it was declared. PURPOSE: This study aimed to investigate the impact of public health measures in the first wave of the COVID-19 epidemic on the occurrence of major fragility fractures (MFFs). METHODS: Patients aged 50 years or older who were hospitalized or had an initial visit as an outpatient for an MFF, defined as a proximal femoral fracture (PFF), vertebral fragility fracture (VFF), distal radius fracture (DRF), or a proximal humeral fracture (PHF), were included in this study. Three-phase interrupted time-series analyses were performed to evaluate the impact of the voluntary event cancellation request in late February 2020 and the emergency declaration in early April 2020 on changes in the total number of patients, including inpatients and first-visit outpatients. RESULTS: A total of 166,560 patients with MFFs were included (92,767 PFFs, 26,158 VFFs, 33,869 DRFs, and 13,766 PHFs). From the end of February, in seven prefectures with high proportions of urbanization, decreasing trends were estimated for level changes and slope changes in the total number of patients with any of the four MFFs (level change: PFF; point estimate; - 13.5 (95% CI; - 43.4, 16.5), VFF; - 15.3 (- 32.2, 1.5), DRF; - 16.1 (- 39.9, 7.6), PHF; - 1.9 (- 13.6, 9.8), slope change: PFF; - 4.8 (- 14.0, 4.4), VFF; - 3.0 (- 8.1, 2.2), DRF; - 0.6 (- 7.9, 6.7), PHF; - 2.4 (- 6.0, 1.2)). CONCLUSION: The findings suggested that the total number of patients with any of the four MFFs did not begin to decline from early April 2020 after the state of emergency was declared but earlier, in late February 2020.

Regional disparities in Dementia-free Life Expectancy in Japan: An ecological study, using the Japanese long-term care insurance claims database.

BACKGROUND: The number of people with dementia increases in an aging society; therefore, promoting policies for dementia throughout the community is crucial to creating a dementia-friendly society. Understanding the status of older adults with dementia in each region of Japan will be a helpful indicator. We calculated Dementia-free Life Expectancy and aimed to examine regional disparities and their associated factors. METHODS: We calculated Dementia-free Life Expectancy and Life Expectancy with Dementia for each secondary medical area in Japan based on the Degree of Independence in Daily Living for the Demented Elderly, using data extracted from the Japanese long-term care insurance claims database. We then conducted a partial least squares regression analysis, the objective variables being Dementia-free Life Expectancy and Life Expectancy with Dementia for both sexes at age 65, and explanatory regional-level variables included demographic, socioeconomic, and healthcare resources variables. RESULTS: The mean estimated regional-level Dementia-free Life Expectancy at age 65 was 17.33 years (95% confidence interval [CI] 17.27-17.38) for males and 20.05 years (95% CI 19.99-20.11) for females. Three latent components identified by partial least squares regression analysis represented urbanicity, socioeconomic conditions, and health services-related factors of the secondary medical areas. The second component explained the most variation in Dementia-free Life Expectancy of the three, indicating that higher socioeconomic status was associated with longer Dementia-free Life Expectancy. CONCLUSIONS: There were regional disparities in secondary medical area level Dementia-free Life Expectancy. Our results suggest that socioeconomic conditions are more related to Dementia-free Life Expectancy than urbanicity and health services-related factors.

Clinical decision-making using an assessment protocol of swallowing function after aspiration pneumonia: a comparative retrospective study.

Objective: Aspiration pneumonia is a challenge in Japan, with many elderly citizens; however, there are insufficient experts on swallowing. Non-expert doctors may suspend oral intake for an overly long period because of the fear of further aspiration. We devised and modified an assessment protocol for swallowing function with reference to the Japanese and American practical guidelines for dysphagia. This study aimed to demonstrate clinical decision-making using the protocol by reporting the results of decisions on the safe and timely restart of adequate food intake for patients with aspiration pneumonia. Patients and Methods: This comparative retrospective study included 101 patients hospitalized with aspiration pneumonia between April 2015 and November 2017. We compared the parameters of patients for whom decisions on resumption of oral intake were aided by our protocol against those of patients from the previous year when the protocol was not used. We counted the days until either resumption of oral intake or events of aspiration/choking. Results: The duration of days until oral intake in the two groups was 1.64 ± 2.34 days in the protocol group (56 patients) and 2.09 ± 2.30 days in the control group (45 patients) (P=0.52). The adverse events of aspiration/choking were less frequent in the protocol group (5 vs. 15, odds ratio (OR) 0.32, P<0.001) as compared to the control group. The protocol group showed a significant reduction in aspiration/choking (OR 0.19, P<0.01). Conclusion: Clinical decision-making based on the protocol seems to help non-expert doctors make informed decisions regarding resuming oral intake after aspiration pneumonia.

Role of hospitalists in Japan for heart failure in the elderly: single center retrospective cohort study.

OBJECTIVE: In Japan, the benefits of hospitalist physician-led care after heart failure have not been sufficiently demonstrated. We evaluated quality of care by the general internal medicine hospitalist (GIM-H) system for patients after acute heart failure and compared it with care by cardiologists. METHODS: This retrospective cohort study enrolled adult patients from within a two-year period who were admitted to our institution for heart failure. Primary outcome measures were medico-economic indicators: length of hospital stay and medical costs. Secondary outcomes included readmission within 30 days of discharge, death within 30 days of admission, rate of prescription of ACEI/ARB and beta-blockers for heart failure with reduced left ventricular ejection fraction, and the percentage of patients receiving bespoke written treatment plans after discharge. This was thought to represent quality of heart failure-specific care. Outcomes between the groups were compared by adjusting for background factors using a propensity score. RESULTS: We enrolled 404 patients, and 81 were assigned to each group after matching (mean age: 86 years, female: 64.2%, mean left ventricular ejection fraction: 53.2%). The GIM-H-treated group had a significantly shorter hospital stay (13.7 days vs. 21.8 days, P < 0.001), a significantly lower total medical cost (618,805 JPY vs. 867,857 JPY, P < 0.05) but a higher medical cost per day (48,010 JPY vs 42,813 JPY, P < 0.05) than the cardiologist-treated group. Other indicators were not significantly different. CONCLUSIONS: : GIM-H physicians in Japan are suggested to be useful and effective in care of patients with heart failure. The hospitalist system may positively impact the health economic outcomes of such patients.

Impact of the cefazolin shortage on the selection and cost of parenteral antibiotics during the supply disruption period in Japan: A controlled interrupted time series analysis.

BACKGROUND: A serious shortage of cefazolin (CEZ) occurred in Japan in 2019. We compared the impact of the CEZ shortage on the selection of parenteral antibiotics at affected and non-affected hospitals. METHODS: The data were extracted from a nationwide Japanese administrative database and included all hospitalized cases between April 2016 and December 2020. We defined 'hospitals with shortage' as those hospitals with a statistically significant decrease in the use of CEZ during the supply disruption period compared to the same months of the previous year; other hospitals as 'hospitals without shortage'. We determined the proportion of each selected parenteral antibiotic use to the sum of all selected antibiotic use in the two groups of hospitals during the supply disruption period and during the same months of the previous year. A controlled interrupted time series (CITS) analysis was conducted to estimate the impact of the CEZ shortage on each antibiotic use and the cost of all parenteral antibiotics per patient day in hospitals with shortage as compared to those without shortage. RESULTS: In the hospitals with shortage, the proportion of CEZ use to the sum of all selected antibiotics decreased (23.5-11.1%). The decrease in CEZ use was mainly offset by the use of ceftriaxone, ceftriaxone, and ampicillin/sulbactam. The CITS analysis showed a statistically significant increase in the use of broader-spectrum beta-lactams and clindamycin during the supply disruption period (flomoxef up 58.1%, cefotiam up 63.1%, cefmetazole up 14.5%, ceftriaxone up 13.9%, and clindamycin up 20.1%). The analysis showed no statistically significant change in the cost of all parenteral antibiotics per patient day. CONCLUSIONS: During the CEZ supply disruption, there was a statistically significant increase in the use of broader-spectrum beta-lactams and clindamycin in hospitals with shortage compared with those without shortage.

Development and validation of prediction models for the discharge destination of elderly patients with aspiration pneumonia.

BACKGROUND: Discharge planning enhances the safe and timely transfer of inpatients between facilities. Predicting the discharge destination of inpatients with aspiration pneumonia is important for discharge planning. We aimed to develop and validate prediction models for the discharge destination of elderly patients with aspiration pneumonia. METHODS: Using a nationwide inpatient database, we identified aspiration pneumonia cases for patients aged ≥65 years who had been admitted to hospital from their home or from a nursing home between April 2020 and March 2021. We divided the cases into derivation and validation cohorts according to the location of the admitting hospital. We developed two prediction models by dividing the cases based on the patient's place of residence prior to admission, one model to predict the home discharge of cases admitted from home and the other to predict the home or to a nursing home discharge of cases admitted from a nursing home. The models were internally validated with bootstrapping and internal-externally validated using a validation cohort. Nomograms that could be used easily in clinical practice were also created. RESULTS: The derivation cohort included 19,746 cases admitted from home and 14,359 cases admitted from a nursing home. Of the former, 10,760 (54.5%) cases were discharged home; from the latter, 7,071 (49.2%) were discharged to either home or a nursing home. The validation cohort included 6,262 cases admitted from home and 6,352 cases admitted from a nursing home. In the internal-external validation, the C-statistics of the final model for the cases admitted from home and the cases admitted from a nursing home were 0.71 and 0.67, respectively. CONCLUSIONS: We developed and validated new prediction models for the discharge of elderly patients with aspiration pneumonia either to home or to a nursing home. Our models and nomograms could facilitate the early implementation of discharge planning.

Impact of policy alterations on elective percutaneous coronary interventions in Japan.

OBJECTIVE: Establishing appropriate percutaneous coronary intervention (PCI) in stable angina pectoris (SAP) has become a distinctive performance measure worldwide. Clinical guidelines call for documenting ischaemia in patients with SAP prior to elective PCI. The Japanese Ministry of Health, Labour and Welfare introduced a new reimbursement policy in April 2018 to promote the appropriate and judicious implementation of PCI. The 2018 reimbursement changes clarified the required proof of ischaemia. Tests to evaluate functional ischaemia and coronary stenosis have been added as a requirement for reimbursement. We examined whether this reimbursement revision had an impact on PCI procedures for SAP in Japan. METHODS: We used administrative claims data in Japan's Diagnosis Procedure Combination database from April 2014 through March 2020. We used interrupted time series analyses with a control to ascertain the impacts on elective PCI procedures before and after the Japanese reimbursement revision. The primary outcome was the change in elective PCI procedures per month. Emergent PCI procedures served as a control group. RESULTS: A total of 773 240 PCI procedures were identified between April 2014 and March 2020: 388 817 and 180 462 elective PCIs before and after the reimbursement revision, respectively. After the 2018 reimbursement revision, significant trend changes were found in elective PCI procedures per month (-106.3, 95% CI -155.8 to -56.8, p<0.01), while the number of emergent PCIs remained stable throughout the study period. CONCLUSIONS: After revising the reimbursement tariff for elective PCIs in 2018, there was a significant reduction in elective PCI procedures per month.

Efficiency of the Japanese Hospitalist System for Patients with Urinary Tract Infection: A Propensity-matched Analysis.

Objective The hospitalist system in the United States has been considered successful in terms of the quality of care and cost effectiveness. In Japan, however, its efficacy has not yet been extensively examined. This study examined the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population using treatment of urinary tract infection as an example. Methods We analyzed 271 patients whose most resource-consuming diagnosis at admission was urinary tract infection between April 2017 and March 2019. Propensity-matched analyses were performed to compare health care economics and the quality of care between the hospitalist system and the conventional system. Results In matched pairs, care by the hospitalist system was associated with a significantly shorter length of stay than that by the conventional system. The quality of care (oral antibiotics switch rate, rate of appropriate antibiotics change based on urine or blood culture results, detection rate of urinary tract infection etiology and the number of laboratory tests) was also considered to be favorably impacted by the hospitalist system. Although not statistically significant, hospital costs tended to be lower with the hospitalist system than with the conventional system. The mortality rate and 30-day readmission were also not significantly different between the groups. Conclusion The hospitalist system had a favorable impact on the quality of care and length of stay without increasing readmission in patients with urinary tract infection. This study is further evidence of the strong potential for the positive impact of an implemented hospitalist system in Japan.

Effects of hospitalist co-management on rate of initiation of osteoporosis treatment in patients with vertebral compression fractures: Retrospective cohort study.

BACKGROUND: Vertebral compression fractures are common in elderly people and most are due to osteoporosis. Osteoporosis treatment is effective for secondary prophylaxis, so initiation is recommended. Despite the clear benefits, the rate of initiation of osteoporosis treatment is very low. It is reported to be due to several factors including insufficient systems-based approaches for hospitals and post-acute care. Hospitalists, who are physicians dedicated to the treatment of patients in hospital and whose activity is generalist rather than specialized, are reported to be associated with higher-quality inpatient care because of, among other things, closer adherence to guidelines. Co-management by hospitalists for patients with vertebral compression fractures has potential benefits towards improving the outcomes. We compared the rate of initiation of osteoporosis treatment for patients with vertebral compression fractures between conventional orthopedic surgeon-led care (conventional group) and hospitalist co-management care (co-management group). METHODS: This is a single-center retrospective cohort study to evaluate the rate of initiation of osteoporosis treatment and reasons for non-initiation of osteoporosis treatment. Other clinical indicators were also evaluated, including length of hospital stay, preventable complications during hospitalization, and rate of 30-day readmission. RESULTS: We identified 55 patients in the conventional group and 93 patients in the co-management group. The rate of initiation of osteoporosis treatment was higher in the co-management group (45.2% vs. 3.6%, OR 21.5; 95%CI 5.12-192.0; P < 0.01). Most of the patients with non-initiation in the co-management group had reasons for it described in the medical records, but in the conventional group the reasons were unknown. There was no significant difference in length of hospital stay, preventable complications during hospitalization, or 30-day readmission between the groups. CONCLUSIONS: Hospitalist co-management of patients with vertebral compression fractures showed significantly higher rate of initiation of osteoporosis treatment than conventional orthopedic surgeon-led care.

Impact of the hospital volume and setting on postoperative complications of surgery for gastroenterological cancers in a regional area of Western Japan.

PURPOSE: A research subgroup was established by the Japanese Society of Gastroenterological Surgery to improve the health care quality in the Chushikoku area of Western Japan. METHODS: The records of four surgical procedures were extracted from the Japanese National Clinical Database and analyzed retrospectively to establish the association between hospital characteristics, defined using a combination of hospital case-volume and patients' hospital travel distance, and the incidences of perioperative complications of ≥ Grade 3 of the Clavien-Dindo classification after gastroenterological surgery. RESULTS: This study analyzed 11,515 cases of distal gastrectomy for gastric cancer, 4,705 cases of total gastrectomy for gastric cancer, 4,996 cases of right hemicolectomy for colon cancer, and 5,243 cases of lower anterior resection for rectal cancer, with composite outcome incidences of 5.6%, 10.2%, 5.5%, and 10.7%, respectively. After adjusting for patient characteristics and surgical procedures, no association was identified between the hospital category and surgical outcomes. CONCLUSION: The findings of our study of the Chushikoku region did not provide positive support for the consolidation and centralization of hospitals, based solely on hospital case volume. Our grouping was unique in that we included patient travel distance in the analysis, but further investigations from other perspectives are needed.