Development and usability of a hospital standardized ADL ratio (HSAR) for elderly patients with cerebral infarction: a retrospective observational study using administrative claim data from 2012 to 2019 in Japan.

BACKGROUND: Maintenance of activities of daily living (ADL) during acute hospitalization is an important treatment goal, especially for elderly inpatients with diseases that often leave disabilities, such as cerebral infarction. However, studies assessing risk-adjusted ADL changes are limited. In this study, we developed and calculated a hospital standardized ADL ratio (HSAR) using Japanese administrative claims data to measure the quality of hospitalization care for patients with cerebral infarction. METHODS: This study was designed as a retrospective observational study using the Japanese administrative claim data from 2012 to 2019. The data of all hospital admissions with a primary diagnosis of cerebral infarction (ICD-10, I63) were used. The HSAR was defined as the ratio of the observed number of ADL maintenance patients to the expected number of ADL maintenance patients multiplied by 100, and ratio of ADL maintenance patients was risk-adjusted using multivariable logistic regression analyses. The c-statistic was used to evaluate the predictive accuracy of the logistic models. Changes in HSARs in each consecutive period were assessed using Spearman's correlation coefficient. RESULTS: A total of 36,401 patients from 22 hospitals were included in this study. All variables used in the analyses were associated with ADL maintenance, and evaluations using the HSAR model showed predictive ability with c-statistics (area under the curve, 0.89; 95% confidence interval, 0.88-0.89). CONCLUSIONS: The findings indicated a need to support hospitals with a low HSAR because hospitals with high/low HSAR were likely to produce the same results in the subsequent periods. HSAR can be used as a new quality indicator of in-hospital care and may contribute to the assessment and improvement of the quality of care.

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.

Comprehensive cost of illness of dementia in Japan: a time trend analysis based on Japanese official statistics.

OBJECTIVE: To analyze the chronological change in social burden of dementia in Japan for policy implications of appropriate resource allocation and quality improvement. DESIGN: National, population-based, observational study from 2002 to 2014. SETTING: Seven nationwide data sets from Japanese official statistics. METHOD: Comprehensive Cost of Illness method. MAIN OUTCOME MEASURES: The outcome variables included healthcare services, nursing care services, informal care (unpaid care offered by family and relatives), mortality cost and morbidity cost. RESULTS: The number of patients with dementia increased 2.50 times from 0.42 million in 2002 to 1.05 million in 2014. While the number of patients living in homes and communities increased by 3.22 times that of patients living in nursing care facilities increased by 1.42 times. The total social burden increased 2.06-2.27 times from JPY 1.84-2.42 to 3.79-5.51 trillion (JPY 1 trillion = US$ 100 billion). Regarding the total burden, the proportion of informal care provided increased from 36.6-51.9% to 37.7-57.2%. Furthermore, the proportion of primary caretakers aged ≥70 years increased from 27.6% to 37.6%. CONCLUSIONS: Owing to the promotion of 'Deinstitutionalization' (shift of nursing care site from in-facilities to in-home and in-community), 'Elderly care by the elderly,' and 'Earlier diagnosis of dementia,' the average cost per patient reduced by 0.82-0.91 times from JPY 4.37-5.77 to 3.60-5.24 million. Therefore, the management of informal care in a manner that does not exceed the acceptable limit of the patients' caretakers, while maintaining patient safety and quality of care, is imperative.

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 hepatocellular carcinoma in Japan: A time trend and future projections.

BACKGROUND: Hepatocellular carcinoma (HCC) is the fifth leading cause of death in Japan. The aim of this study was to calculate the social burden of HCC using the cost of illness (COI) method, and to identify the key factors driving changes in the economic burden of HCC. METHODS: Utilizing government-based statistical nationwide data, the cost of illness (COI) method was used to estimate the COI for 1996, 1999, 2002, 2005, 2008, and 2014 to make predictions for 2017, 2020, 2023, 2026, and 2029. The COI comprised direct and indirect costs (morbidity and mortality costs) of HCC. RESULTS: From 1996 to 2014, COI trended downward. In 2014, COI (579.2 billion JPY) was 0.71 times greater than that in 1996 (816.2 billion JPY). Mortality costs accounted for more than 70% of total COI and were a major contributing factor to the decrease in COI. It was predicted that COI would continue a downward trend until 2029, and that the rate of decline would be similar. CONCLUSIONS: COI of HCC has been decreasing since 1996. Treatment of patients infected with hepatitis C virus using newly introduced technologies has high therapeutic effectiveness, and will affect the future prevalence of HCC. These policies and technologies may accelerate the downward tendency of COI, and the relative economic burden of HCC is likely to continue to decrease.

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.

Cost of illness of non-alcoholic liver cirrhosis in Japan: A time trend analysis and future projections.

AIM: Liver cirrhosis is a preneoplastic condition to hepatocellular carcinoma that is an important worldwide public health concern, and its economic burden has been estimated in some countries. The objective of this study was to estimate and predict the cost of illness (COI) associated with non-alcoholic liver cirrhosis in Japan. METHODS: Using a COI method on available data from government statistics, we estimated the economic burden in 3-year intervals from 1996 to 2014. We then predicted the COI in 3-year intervals from 2017 to 2029 using fixed and variable model estimations. With fixed model estimation, only the estimated future population was used as a variable. Variable model estimation considered the time trends of health-related indicators throughout the past 18 years. RESULTS: The estimated COI of non-alcoholic liver cirrhosis was ¥208.1bn in 2014. The COI of non-alcoholic liver cirrhosis had a downward trend from 1996 to 2014. The predicted future COI of non-alcoholic liver cirrhosis was ¥144.3-210.5bn, ¥106.0-213.8bn, ¥88.6-213.4bn, ¥76.7-215.5bn, and ¥66.4-214.3bn in 2017, 2020, 2023, 2026, and 2029, respectively. CONCLUSIONS: The results of this study suggest that the COI of non-alcoholic liver cirrhosis in Japan has steadily decreased and will continue to decrease. Treatment of patients with hepatitis C virus infection with newly introduced technologies has high therapeutic effectiveness, which will affect the future prevalence of non-alcoholic liver cirrhosis. When interpreting the results of long-term estimation, it should be noted that the results of this study were based on present conditions.

Effects of the concentration of digestive surgical operations in regional Japan.

PURPOSE: The purpose of this study was to investigate the relationship between the concentration of digestive system surgery and outcomes at a regional level in Japan, using time-series data. METHODS: We used nationwide data from 2008 to 2013, and analyzed the ten most common surgical procedures. The unit of analysis was secondary medical areas (SMAs), which cover several municipalities and provide medical services for common diseases. The concentration of surgery in these areas was measured using the Herfindahl-Hirschman Index (HHI) and the relationship between the concentration of surgery and length of stay in hospital (LOS) was analyzed, in accordance with surgical difficulty. RESULTS: There was a downward trend in both the HHI and LOS from 2008 to 2013. SMAs showing an upward trend in the HHI (increased concentration) were associated with a greater reduction in LOS than those showing a downward trend for eight surgical procedures. For three easy surgical procedures, increased concentration of surgery was significantly associated with a reduction in LOS. After adjustment for trends in the aging population and the surgical volume in 2008, an increasing concentration for three easy surgical procedures was significantly related to a reduction in the LOS. CONCLUSION: Concentrating relatively easy surgical procedures at a regional level may be associated with a reduction in LOS.

Evaluation of clinical practice guidelines using the AGREE instrument: comparison between data obtained from AGREE I and AGREE II.

OBJECTIVE: The Appraisal of Guidelines for Research and Evaluation (AGREE) is a representative, quantitative evaluation tool for evidence-based clinical practice guidelines (CPGs). Recently, AGREE was revised (AGREE II). The continuity of evaluation data obtained from the original version (AGREE I) has not yet been demonstrated. The present study investigated the relationship between data obtained from AGREE I and AGREE II to evaluate the continuity between the two measurement tools. RESULTS: An evaluation team consisting of three trained librarians evaluated 68 CPGs issued in 2011-2012 in Japan using AGREE I and AGREE II. The correlation coefficients for the six domains were: (1) scope and purpose 0.758; (2) stakeholder involvement 0.708; (3) rigor of development 0.982; (4) clarity of presentation 0.702; (5) applicability 0.919; and (6) editorial independence 0.971. The item "Overall Guideline Assessment" was newly introduced in AGREE II. This global item had a correlation coefficient of 0.628 using the six AGREE I domains, and 0.685 using the 23 items. Our results suggest that data obtained from AGREE I can be transferred to AGREE II, and the "Overall Guideline Assessment" data can be determined with high reliability using a standardized score of the 23 items.

Informing health policy in Japan: A mixed-model estimation to compare the cost of illness of cervical cancer and endometrial cancer.

AIM: The objective of this study was to inform Japanese health policy by comparing cervical cancer and endometrial cancer from the standpoint of economic burden and examining factors affecting future changes in economic burden. METHODS: Using government-based nationwide statistical data, we used the cost-of-illness (COI) method to estimate the COI from 1996 to 2011 and predicted future estimates for 2014, 2017, and 2020. RESULTS: In 2011, the COI of cervical cancer was estimated at 159.9 billion yen and that of endometrial cancer was estimated at 99.5 billion yen. Assuming the current trends in health-related indicators, the COI of cervical cancer is predicted to temporarily decrease in 2014 and then remain constant. Meanwhile, the COI of endometrial cancer is predicted to temporarily decrease in 2014 before returning to an upward trend. CONCLUSION: The COI of both cervical cancer and endometrial cancer is estimated to remain constant or increase in the future. The average age of death from cervical cancer is predicted to remain relatively young and the high human capital value of patients who die in their sixties is the most likely explanation for the lack of decrease in future COI. As women's participation in society continues to increase, the future COI may also increase. Regarding endometrial cancer, the increase in direct costs, particularly hospitalization costs, is a likely factor resulting in the increase in the COI. This is because women are surviving longer, and thus receiving care for longer durations, because of advancements in medical care.

Cost of illness of the prostate cancer in Japan--a time-trend analysis and future projections.

BACKGROUND: The majority of patients with prostate cancer (International Classification of Diseases, 10th edition, code C61) are elderly. With Japan's rapidly society aging, both the prevalence and mortality of prostate cancer are expected to increase in the future. The objective of this study was to estimate and predict the cost of illness (COI) associated with prostate cancer in Japan. METHODS: Using a COI method based on available data from government office statistics, we estimated the COI for 2002, 2005, 2008, and 2011. We then predicted the COI for 2014, 2017, and 2020 using fixed model estimation and variable model estimation. With fixed model estimation, only estimated future population was used as a variable. Variable model estimation considered the time trend of health-related indicators in the past 15 years. We derived the COI from the sum of direct and indirect costs (morbidity and mortality). RESULTS: We found the predicted future COI of prostate cancer to be 354.7-378.3 billion yen in 2014, 370.8-421.0 billion yen in 2017, and 385.3-474.1 billion yen in 2020. Regardless of the estimation model, we found that COI would increase compared with the baseline year 2011 (307.3 billion yen). The direct costs for inpatient and outpatient treatment, laboratory tests, and drugs accounted for 60-75% of the COI of prostate cancer. CONCLUSIONS: The results of this study suggest that the COI of prostate cancer in Japan has steadily increased and is expected to rise in the future. Direct costs comprised the largest proportion of the COI and are anticipated to continue expanding; this will result in increased burden on public funds in Japan, where a universal public insurance system operates. These trends differ from those with other forms of cancer.

Cost of illness of breast cancer in Japan: trends and future projections.

BACKGROUND: Breast cancer is a major cause of death for women in Japan. The objectives of this study were to estimate and project the economic burden associated with breast cancer in Japan and identify the key factors that drive the change of the economic burden of breast cancer. METHODS: We calculated the cost of illness (COI) every 3 years from 1996 to 2020 using governmental statistics. COI was calculated by summing the direct costs, morbidity costs, and mortality costs. RESULTS: From 1996 to 2011 COI was trending upward. COI in 2011 (697 billion yen) was 1.7-times greater than that in 1996 (407 billion yen). The mortality costs accounted for approximately 65-70% of the total COI and were a major contributing factor to increase in COI. It was predicted that COI would continue to trend upwards until 2020 (699.4-743.8 billion yen depending on the model), but the rate of increase would decline. CONCLUSIONS: COI of breast cancer has been steadily increasing since 1996. While the rate of increase is expected to plateau, the average age at death from breast cancer is still less than that from other cancers, and the relative economic burden of breast cancer will continue to increase in the foreseeable future.

Cost of illness of the cervical cancer of the uterus in Japan--a time trend and future projections.

BACKGROUND: Cervical cancer is associated with high morbidity and mortality rates among young women in Japan. The objective of this study was to assess and project the economic burden associated with cervical cancer in Japan and identify factors affecting future changes in this burden on society. METHODS: Utilizing government-based statistical nationwide data, we used the cost of illness (COI) method to estimate the COIs for 1996, 1999, 2002, 2005, 2008, and 2011 to make predictions for 2014, 2017, and 2020. The COI comprised direct and indirect costs (morbidity and mortality costs). RESULTS: The COI was estimated to have increased by 66% from 96.1 billion yen in 1996 to 159.9 billion yen in 2011. The number of deaths increased, but the proportion of those aged ≥65 years as a percentage of all deaths remained mostly unchanged, with no increase in the average age at death. The mortality cost per person was estimated to have increased (31.5 million yen in 1996 vs. 43.5 million yen in 2011). Assuming that the current trend in health-related indicators continues, the COI is predicted to temporarily decrease in 2014, followed by almost no change in 2020 (the estimated COI is 145.3-164.6 billion yen). The mortality cost per person is predicted to remain almost unchanged (39.4-46.3 million yen in 2020). CONCLUSIONS: The fact that the life expectancy of affected individuals is not being prolonged and that the mortality in young individuals with a high human capital value is not decreasing may contribute to future sustainment of the COI. We believe that the results of the present study are applicable to discussions of disease control priorities.

Indium(III)-catalyzed knoevenagel condensation of aldehydes and activated methylenes using acetic anhydride as a promoter.

The combination of a catalytic amount of InCl3 and acetic anhydride remarkably promotes the Knoevenagel condensation of a variety of aldehydes and activated methylene compounds. This catalytic system accommodates aromatic aldehydes containing a variety of electron-donating and -withdrawing groups, heteroaromatic aldehydes, conjugate aldehydes, and aliphatic aldehydes. Central to successfully driving the condensation series is the formation of a geminal diacetate intermediate, which was generated in situ from an aldehyde and an acid anhydride with the assistance of an indium catalyst.

Characteristics of unit-level patient safety culture in hospitals in Japan: a cross-sectional study.

BACKGROUND: Patient safety culture (PSC) has an important role in determining safety and quality in healthcare. Currently, little is known about the status of unit-level PSC in hospitals in Japan. To develop appropriate strategies, characteristics of unit-level PSC should be investigated. Work units may be classified according to the characteristics of PSC, and common problems and appropriate strategies may be identified for each work unit category. This study aimed to clarify the characteristics of unit-level PSC in hospitals in Japan. METHODS: In 2012, a cross-sectional study was conducted at 18 hospitals in Japan. The Hospital Survey on Patient Safety Culture questionnaire, developed by the United States Agency for Healthcare Research and Quality, was distributed to all healthcare workers (n =12,076). Percent positive scores for 12 PSC sub-dimensions were calculated for each unit, and cluster analysis was used to categorise the units according to the percent positive scores. A generalised linear mixed model (GLMM) was used to analyse the results of the cluster analysis, and odds ratios (ORs) for categorisation as high-PSC units were calculated for each unit type. RESULTS: A total of 9,124 respondents (75.6%) completed the questionnaire, and valid data from 8,700 respondents (72.0%) were analysed. There were 440 units in the 18 hospitals. According to the percent positive scores for the 12 sub-dimensions, the 440 units were classified into 2 clusters: high-PSC units (n =184) and low-PSC units (n =256). Percent positive scores for all PSC sub-dimensions for high-PSC units were significantly higher than those for low-PSC units. The GLMM revealed that the combined unit type of 'Obstetrics and gynaecology ward, perinatal ward or neonatal intensive care unit' was significantly more likely to be categorised as high-PSC units (OR =9.7), and 'Long-term care ward' (OR =0.2), 'Rehabilitation unit' (OR =0.2) and 'Administration unit' (OR =0.3) were significantly less likely to be categorised as high-PSC units. CONCLUSIONS: Our study findings demonstrate that PSC varies considerably among different unit types in hospitals in Japan. Factors contributing to low PSC should be identified and possible measures for improving PSC should be developed and initiated.

Perioperative patient safety indicators and hospital surgical volumes.

BACKGROUND: Since the late 1990s, patient safety has been an important policy issue in developed countries. To evaluate the effectiveness of the activities of patient safety, it is necessary to quantitatively assess the incidence of adverse events by types of failure mode using tangible data. The purpose of this study is to calculate patient safety indicators (PSIs) using the Japanese Diagnosis Procedure Combination/per-diem payment system (DPC/PDPS) reimbursement data and to elucidate the relationship between perioperative PSIs and hospital surgical volume. METHODS: DPC/PDPS data of the Medi-Target project managed by the All Japan Hospital Association were used. An observational study was conducted where PSIs were calculated using an algorithm proposed by the US Agency for Healthcare Research and Quality. We analyzed data of 1,383,872 patients from 188 hospitals who were discharged from January 2008 to December 2010. RESULTS: Among 20 provider level PSIs, four PSIs (three perioperative PSIs and decubitus ulcer) and mortality rates of postoperative patients were related to surgical volume. Low-volume hospitals (less than 33rd percentiles surgical volume per month) had higher mortality rates (5.7%, 95% confidence interval (CI), 3.9% to 7.4%) than mid- (2.9%, 95% CI, 2.6% to 3.3%) or high-volume hospitals (2.7%, 95% CI, 2.5% to 2.9%). Low-volume hospitals had more deaths among surgical inpatients with serious treatable complications (38.5%, 95% CI, 33.7% to 43.2%) than high-volume hospitals (21.4%, 95% CI, 19.0% to 23.9%). Also Low-volume hospitals had lower proportion of difficult surgeries (54.9%, 95% CI, 50.1% to 59.8%) compared with high-volume hospitals (63.4%, 95% CI, 62.3% to 64.6%). In low-volume hospitals, limited experience may have led to insufficient care for postoperative complications. CONCLUSIONS: We demonstrated that PSIs can be calculated using DPC/PDPS data and perioperative PSIs were related to hospital surgical volume. Further investigations focusing on identifying risk factors for poor PSIs and effective support to these hospitals are needed.

Occupational stress among healthcare workers in Japan.

BACKGROUND: High distress levels in healthcare workers in Japan may deteriorate safe service provision. OBJECTIVE: To clarify job stress of healthcare workers, we compared Brief Job Stress Questionnaire (BJSQ) scores among physicians, nursing staff and administrative workers. METHODS: Healthcare workers (n=9,137) in 20 hospitals in Japan were asked to answer BJSQ. BJSQ is job stress questionnaire to measure "Job Stressors", "Stress Responses" and "Social Supports". RESULTS: The "Total Health Risk" of the healthcare workers was 10% higher than the national average. While the physicians felt the stress of the quantitative and qualitative job overload, they had support from supervisors and coworkers and showed mild "Stress Responses". The nursing staff felt the stress of the quantitative and qualitative job overload at the same level as the physicians, but they did not have sufficient support from supervisors and coworkers, and showed high "Stress Responses". The administrative workers did not have sufficient support from supervisors and coworkers, but they experienced less stress as measured by the quantitative and qualitative job overload than the physicians or the nursing staff and showed moderate "Stress Responses". CONCLUSIONS: Further studies are needed to clarify the mechanisms and the influence of other factors to the stress trait in healthcare workers.