Time Trend of Outcomes for Severe Acute Pancreatitis After Publication of Japanese Guidelines Based on a National Administrative Database.

OBJECTIVES: This study aimed to investigate the recent time trend of outcomes for severe acute pancreatitis after publication of Japanese guidelines based on a national administrative database. METHODS: A total of 10,400 patients with severe acute pancreatitis were referred to 1021 hospitals between 2010 and 2012 in Japan. We collected patients' data from the administrative database to compare in-hospital mortality (within 28 days and overall), length of stay (LOS), and medical costs during hospitalization. The study periods were categorized into 3 groups according to fiscal year: 2010 (n = 2698), 2011 (n = 3842), and 2012 (n = 3860). RESULTS: In-hospital mortality within 28 days and overall in-hospital mortality were significantly decreased according to fiscal year (6.3% [2010] vs 5.7% [2011] vs 4.5% [2012], P = 0.005; 7.6% vs 7.1% vs 5.6%, P = 0.002, respectively). However, mean LOS and medical costs were not different between fiscal years (27.0 vs 27.1 vs 26.9 days, P = 0.218; 13,998.0 vs 14,156.4 vs 14,319.2 USD, P = 0.232, respectively). CONCLUSIONS: This study shows that mortality of severe acute pancreatitis was reduced according to the time course, whereas LOS or medical costs were stable after publication of the Japanese guidelines.

Recent Change in Treatment of Disseminated Intravascular Coagulation in Japan: An Epidemiological Study Based on a National Administrative Database.

This study investigated the time trends and hospital factors affecting the use of drugs for infectious disease-associated disseminated intravascular coagulation (DIC) based on a national administrative database. A total of 14 324 patients with infectious disease-associated DIC were referred to 1041 hospitals from 2010 to 2012 in Japan. Patients' data were collected from the administrative database to determine time trends and hospital factors affecting the use of drugs for DIC. Three study periods were established, namely, the fiscal years 2010 (n = 3308), 2011 (n = 5403), and 2012 (n = 5613). The use of antithrombin, heparin, protease inhibitors, and recombinant human soluble thrombomodulin (rhs-TM) for DIC was evaluated. The frequency of use of antithrombin, heparin, and protease inhibitors decreased while that of rhs-TM significantly increased from 2010 to 2012 in Japan (25.1% in 2010, 43.1% in 2011, and 56.8% in 2012; P < .001, respectively). Logistic regression showed that the study period was associated with the use of rhs-TM in patients with DIC. The odds ratio (OR) for 2011 was 2.34 (95% confidence interval [CI], 2.12-2.58; P < .001) whereas that for 2012 was 4.34 (95% CI, 3.94-4.79; P < .001). A large hospital size was the most significant factor associated with the use of rhs-TM in patients with DIC (OR, 3.14; 95% CI, 2.68-3.66; P < .001). The use of rhs-TM has dramatically increased. A large hospital size was significantly associated with the increased use of rhs-TM in patients with DIC from 2010 to 2012 in Japan.

Influence of comorbidity on outcomes of older patients with acute pancreatitis based on a national administrative database.

BACKGROUND: Little information is available on the influence of comorbidities on outcomes of older patients with acute pancreatitis. This study aimed to investigate the influence of comorbidities on outcomes of older patients with acute pancreatitis using data from a national Japanese administrative database. METHODS: A total of 14 322 older patients (≥70 years) with acute pancreatitis were referred to 1090 hospitals between 2010 and 2012 in Japan. We collected patients' data from the administrative database to compare the in-hospital mortality and length of stay of older patients with acute pancreatitis. The patients were categorized into four groups according to comorbidity level using the Charlson Comorbidity Index (CCI): none (CCI score=0; n=6890); mild (1; n=3874); moderate (2; n=2192) and severe (≥3; n=1366). RESULTS: Multiple logistic and linear regression analyses revealed that severe comorbidity was significantly associated with higher in-hospital mortality and longer length of stay [odds ratio (OR)=2.26; 95% confidence interval (CI): 1.75-2.92, P<0.001 and coefficient 4.37 days; 95% CI: 2.89-5.85, P<0.001, respectively]. In addition, cardiovascular and renal diseases were the most significant comorbidities affecting outcomes of the older patients. ORs of cardiovascular and renal diseases for mortality were 1.44 (95% CI: 1.13-1.85, P=0.003) and 2.69 (95% CI: 1.88-3.85, P<0.001), respectively, and coefficients for length of stay were 3.01 days (95% CI: 1.34-4.67, P<0.001) and 3.72 days (95% CI: 1.01-6.42, P=0.007), respectively. CONCLUSION: This study demonstrated that comorbidities significantly influenced outcomes of older patients with acute pancreatitis and cardiovascular and renal comorbidities were significant factors affecting outcomes.

Effects of proton pump inhibitor on outcomes of patients with severe acute pancreatitis based on a national administrative database.

OBJECTIVE: This study aimed to investigate whether proton pump inhibitors (PPIs) affect the outcomes of patients with severe acute pancreatitis based on a national administrative database. METHODS: A total of 10,400 patients with severe acute pancreatitis were referred to 1021 hospitals between 2010 and 2012 in Japan. Patients were divided into two groups: patients who used PPIs (n = 3879) and those without PPIs (n = 6521). We collected patients' data from the administrative database to compare in-hospital mortality within 7, 14, and 28 days, and overall in-hospital mortality between groups, using propensity score analysis to adjust for treatment selection bias. RESULTS: Multiple logistic regression showed that use of PPIs did not affect in-hospital mortality within 7 and 14 days. The odds ratio (OR) for mortality within 7 days was 1.14 (95% confidence interval [CI]: 0.91-1.42, p = 0.236) while that within 14 days was 1.10 (95% CI: 0.89-1.35, p = 0.349). No significant association was observed for in-hospital mortality within 28 days and overall in-hospital mortality (OR for within 28 days: 1.12, 95% CI: 0.92-1.37, p = 0.224; OR for overall in-hospital mortality: 1.42, 95% CI: 0.97-1.87, p = 0.065). CONCLUSIONS: This study shows that use of PPIs does not affect clinical outcomes of patients with severe acute pancreatitis. Prospective or randomized studies are needed to confirm the efficacy of PPIs on outcomes of patients with severe acute pancreatitis in the future.

Circumstance of endoscopic and laparoscopic treatments for gastric cancer in Japan: A review of epidemiological studies using a national administrative database.

Currently, endoscopic submucosal dissection (ESD) and laparoscopic gastrectomy (LG) have become widely accepted and increasingly play important roles in the treatment of gastric cancer. Data from an administrative database associated with the diagnosis procedure combination (DPC) system have revealed some circumstances of ESD and LG in Japan. Some studies demonstrated that medical costs or length of stay of patients receiving ESD for gastric cancer had become significantly reduced while length of hospitalization and costs were significantly increased in older patients. With respect to LG, some recent reports have shown that this has been a cost-beneficial treatment for patients compared with open gastrectomy while simultaneous LG and cholecystectomy is a safe procedure for patients with both gastric cancer and gallbladder stones. These epidemiological studies using the administrative database in the DPC system closely reflect clinical circumstances of endoscopic and surgical treatment for gastric cancer in Japan. However, DPC database does not contain detailed clinical data such as histological types and lesion size of gastric cancer. The link between the DPC database and another detailed clinical database may be vital for future research into endoscopic and laparoscopic treatments for gastric cancer.

Effect of dementia on outcomes of elderly patients with hemorrhagic peptic ulcer disease based on a national administrative database.

BACKGROUND: Little information is available on the effect of dementia on outcomes of elderly patients with hemorrhagic peptic ulcer disease at the population level. AIMS: This study aimed to investigate the effect of dementia on outcomes of elderly patients with hemorrhagic peptic ulcer based on a national administrative database. METHODS: A total of 14,569 elderly patients (≥80 years) who were treated by endoscopic hemostasis for hemorrhagic peptic ulcer were referred to 1073 hospitals between 2010 and 2012 in Japan. We collected patients' data from the administrative database to compare clinical and medical economic outcomes of elderly patients with hemorrhagic peptic ulcers. Patients were divided into two groups according to the presence of dementia: patients with dementia (n = 695) and those without dementia (n = 13,874). RESULTS: There were no significant differences in in-hospital mortality within 30 days and overall mortality between the groups (odds ratio; OR 1.00, 95 % confidence interval; CI 0.68-1.46, p = 0.986 and OR 1.02, 95 % CI 0.74-1.41, p = 0.877). However, the length of stay (LOS) and medical costs during hospitalization were significantly higher in patients with dementia compared with those without dementia. The unstandardized coefficient for LOS was 3.12 days (95 % CI 1.58-4.67 days, p < 0.001), whereas that for medical costs was 1171.7 US dollars (95 % CI 533.8-1809.5 US dollars, p < 0.001). CONCLUSIONS: Length of stay and medical costs during hospitalization are significantly increased in elderly patients with dementia undergoing endoscopic hemostasis for hemorrhagic peptic ulcer disease.

Effect of hospital volume on outcomes of laparoscopic appendectomy for acute appendicitis: an observational study.

BACKGROUND: This study investigated the effect of hospital volume on outcomes of laparoscopic appendectomy for acute appendicitis. METHODS: In total, 30,525 patients who underwent laparoscopic appendectomy for acute appendicitis were referred to 825 hospitals in Japan from 2010 to 2012. We compared appendectomy-related complications, length of stay (LOS), and medical costs in relation to hospital volume. For this study period, hospitals were categorized as low-volume hospitals (LVHs, <50 cases), medium-volume hospitals (MVHs, 50-100 cases), or high-volume hospitals (HVHs, >100 cases). RESULTS: Significant differences in appendectomy-related complications were observed among the LVHs, MVHs, and HVHs (6.9, 7.2, and 6.0 %, respectively; p = 0.001). Multiple logistic regression revealed that HVHs were associated with a lower relative risk of appendectomy-related complications than were LVHs and MVHs (odds ratio [OR], 0.84; 95 % confidence interval [CI], 0.74-0.95; p = 0.006). Multiple linear regression showed that HVHs were associated with shorter LOS and lower medical costs than were LVHs and MVHs. The unstandardized coefficient for LOS was -0.92 days (95 % CI, -1.07 to -0.78; p < 0.001), whereas that for medical costs was - $167.4 (95 % CI, -256.2 to -78.6; p < 0.001). CONCLUSIONS: Hospital volume was significantly associated with laparoscopic appendectomy outcomes.

Observational study to compare antithrombin and thrombomodulin for disseminated intravascular coagulation.

BACKGROUND: There have been no studies comparing the effects of antithrombin (AT-III) and recombinant human soluble thrombomodulin (rhs-TM) on outcomes in patients with disseminated intravascular coagulation (DIC) associated with infectious diseases. OBJECTIVE: The aim of this observational study is to compare AT-III and rhs-TM in terms of outcomes such as mortality, length of hospitalization, and medical costs in patients with DIC associated with infectious diseases based on a Japanese administrative database. SETTING: A total of 7,535 patients with DIC associated with infectious diseases in 886 hospitals from 2010 to 2012 in Japan. Methods We collected patients' data from the administrative database to compare clinical and medical economic outcomes of patients with DIC. Patients were divided into two groups according to treatment of DIC: AT-III (n = 3,601) and rhs-TM (n = 3,934). MAIN OUTCOMES MEASURE: In-hospital mortality (within 14 days, within 28 days, and overall mortality), length of stay (LOS), and medical costs during hospitalization. RESULTS: Multilevel logistic regression analysis showed that there were no significant differences with regard to in-hospital mortality between AT-III and rhs-TM within 14 days (odds ratio (OR) of rhs-TM 0.97, 95 % confidence interval (CI) 0.85-1.11, p = 0.744), within 28 days (OR 1.00, 95 % CI 0.89-1.13, p = 0.919), and overall (OR 0.95, 95 % CI 0.85-1.07, p = 0.470). However, multilevel linear regression analysis revealed that use of rhs-TM significantly decreased LOS and medical costs during hospitalization. The coefficient for LOS was -2.92 days (95 % CI -4.79 to -1.04 days; p = 0.002) whereas that for medical costs during hospitalization was -798.3 Euro (95 % CI -1,515.7 to -81.0 Euro; p = 0.029). CONCLUSION: This study demonstrated no significant difference in in-hospital mortality between AT-III and rhs-TM. However, use of rhs-TM was significantly associated with decreased LOS and medical costs during hospitalization in patients with DIC associated with infectious diseases.

Influence of hospital volume on outcomes of laparoscopic gastrectomy for gastric cancer in patients with comorbidity in Japan.

OBJECTIVE: Little information is available on the relationship between hospital volume and the outcomes of laparoscopic gastrectomy for gastric cancer in patients with comorbidity. This study aimed to investigate the influence of hospital volume on patient outcomes of laparoscopic gastrectomy for gastric cancer in patients with comorbidity using a national administrative database. METHODS: A total of 5941 comorbid patients treated with laparoscopic gastrectomy for gastric cancer were referred to 741 hospitals in Japan. We collected patients' data from the administrative database to compare laparoscopy-related complications, in-hospital mortality, length of stay (LOS), and medical costs during hospitalization in relation to hospital volume. Hospital volume was categorized into two groups: low (<40 cases in 3 years; n = 4111) and high (≥ 40 cases; n = 1830). RESULTS: There were no significant differences between the groups in laparoscopy-related complications and in-hospital mortality (p = 0.684 and p = 0.200, respectively). However, significant variations in mean LOS and medical costs were observed between hospital volume categories (26.1 days vs. 20.2 days and 16,163.9 US dollars vs. 14,345.9 US dollars, respectively; p < 0.001). Multiple linear regressions revealed that higher hospital volume was significantly associated with shorter LOS and lower medical costs during hospitalization. The unstandardized coefficient for LOS was -4.62 days (95% confidence interval = -5.63--3.60, p < 0.001), whereas that for medical costs was -1424.1 US dollars (95% confidence interval = -1962.5--885.6, p < 0.001). CONCLUSION: Hospital volume was significantly associated with a decrease of LOS and medical costs of comorbid patients undergoing laparoscopic gastrectomy for gastric cancer.

Impact of regional clinical pathways on the length of stay in hospital among stroke patients in Japan.

BACKGROUND: Clinical pathways are care plans used by health providers to describe essential steps in the care of patients with specific medical conditions. Clinical implementation of the regional clinical pathways in Japan has spread, and the 2008 fee schedule included a new "regional inter-provider care planning fee" for stroke. However, no evidence regarding the efficacy of the regional clinical pathways for stroke has appeared. OBJECTIVES: We examined the association of regional clinical pathways on the length of in-hospital stay in patients with stroke. We also examined whether a variation in the length of in-hospital stay for stroke patients between hospitals exists, and if so, the impact of regional clinical pathways on this variation. RESEARCH DESIGN: Cross-sectional analysis using the Diagnosis Procedure Combination database for the period April 2011 to March of 2012. SUBJECTS: A total of 117,180 patients with the diagnosis "cerebral infarction," coded as I63 in ICD10. MEASURES: Associations of the use of a regional clinical pathway with the length of in-hospital stay (LOS) were estimated by multilevel regression models using a 2-level structure of individuals nested within the 1011 hospitals. The models added both patient-level factors and hospital-level factors that are potentially associated with LOS. RESULTS: Hospitals administering a regional clinical pathway had a significantly shorter LOS (9.1 d) than hospitals that did not. Approximately 12% of the variation in LOS between hospitals is possibly explained by whether hospitals implement regional clinical pathways. Application of regional clinical pathways at the individual level is associated with a 7.2-day decrease in LOS at the individual level. CONCLUSIONS: These findings suggest that the regional clinical pathways are potentially effective in improving the management of stroke patients and in promoting the consistency of care between hospitals.

The recent time trend of outcomes of disseminated intravascular coagulation in Japan: an observational study based on a national administrative database.

The aim of this study is to investigate the recent trend over time of outcomes of patients with disseminated intravascular coagulation (DIC) based on the Japanese administrative database. A total of 34,711 patients with DIC had been referred to 1,092 hospitals from 2010 to 2012 in Japan. We collected patients' data from the administrative database to compare in-hospital mortality within 14 and 28 days between periods. The study periods were categorized into three groups: 2010 (n = 8,382), 2011 (n = 13,372), and 2012 (n = 12,957). These analyses were performed according to the underlying diseases associated with DIC. The in-hospital mortality within 14 or 28 days of DIC patients with infectious diseases decreased between 2010 and 2012 (within 14 days: 20.4 vs. 18.1 vs. 17.9 %, P = 0.009; within 28 days: 31.1 vs. 28.7 vs. 27.7%, P = 0.003; respectively). Multiple logistic regressions also showed that the period was associated with in-hospital mortality of DIC patients with infectious diseases. The odds ratios of 2011 and 2012 for in-hospital mortality within 14 days were 0.86 [95% confidence intervals (CI) 0.77-0.97] and 0.84 (95% CI 0.75-0.94) whereas those for in-hospital mortality within 28 days were 0.89 (95% CI 0.81-0.98) and 0.83 (95% CI 0.76-0.92), respectively. However, there were no significant differences in mortality of patients with DIC associated with other underlying diseases between 2010 and 2012. This study demonstrated that in-hospital mortality of DIC patients with infectious diseases gradually improved between 2010 and 2012 in Japan.

Age-related differences in outcomes and etiologies of acute abdominal pain based on a national administrative database.

Acute abdominal pain is one of the most frequent causes of admission to emergency departments. However, there is a shortage of detail information showing the difference of outcomes or etiology of acute abdominal pain according to age. We therefore conducted an epidemiological analysis to reveal the difference between age on outcomes and etiology of acute abdominal pain using an administrative database associated with the Diagnosis Procedure Combination (DPC) system. We obtained discharge data relating to 12,209 patients with acute abdominal pain from 931 DPC participation hospitals between 2009 and 2011 in Japan. We compared length of hospital stay (LOS), in-hospital mortality, and etiology of acute abdominal pain between age categories. Patients were divided into five age groups as follows: < 20 (n = 1,106), 20-39 (n = 3,353), 40-59 (n = 2,925), 60-79 (n = 3,144), and ≥ 80 years (n = 1,681). Longer LOS and higher in-hospital mortality were observed in patients aged ≥ 80 years (p < 0.001). Regarding etiologies of acute abdominal pain, intestinal infection or acute appendicitis were more frequent in patients aged < 20 or 20-39 years, while ileus or cholelithiasis were more frequent in patients aged 60-79 or ≥ 80 years in both male and female patients (p < 0.001). This study demonstrated the significant differences between age with regard to the patient outcomes and etiology of acute abdominal pain. The current findings highlight the importance of improving the quality of medical care for patients with acute abdominal pain.

Endoscopic submucosal dissection for gastric cancer: the influence of hospital volume on complications and length of stay.

BACKGROUND: Little information is available about the relationship between hospital volume and the clinical outcome of endoscopic submucosal dissection (ESD) for gastric cancer. The purpose of this study was to investigate the influence of hospital volume on clinical outcomes of ESD using a national administrative database. METHODS: A total of 27,385 patients treated with ESD for gastric cancer were referred to 867 hospitals between 2009 and 2011 in Japan. We collected patients' data from the administrative database to compare ESD-related complications and length of stay (LOS) in relation to hospital volume. Hospital volume was categorized into three groups based on the number of cases treated over the study period: low-volume hospitals (LVHs, <50 cases), medium-volume hospitals (MVHs, 50-100 cases), and high-volume hospitals (HVHs, >100 cases). These analyses were performed for each location of gastric cancer [upper (cardia and fundus), middle (body), and lower third (antrum and pylorus)]. RESULTS: Significant differences in ESD-related complications among the three hospital volume categories were observed for upper gastric cancer (6.5 % in LVHs vs. 5.2 % in MVHs vs. 3.4 % in HVHs; p = 0.017). Multiple logistic regression revealed that HVHs were significantly associated with decreased relative risk of ESD-related complications in upper gastric cancer (odds ratio for HVHs 0.51; 95 % confidence interval, 0.31-0.83, p = 0.007). However, no significant differences for ESD-related complications were seen for middle and lower gastric cancers among the different hospital volume categories (p > 0.05). Additionally, hospital volume was significantly associated with a decreasing LOS for all locations of gastric cancers (p < 0.001). CONCLUSIONS: The present study has demonstrated that hospital volume was mainly associated with clinical outcome in patients with ESD for upper gastric cancer. Further studies for successive monitoring of outcomes of ESD should be conducted in the near future.

Time trend of medical economic outcomes of endoscopic submucosal dissection for gastric cancer in Japan: a national database analysis.

BACKGROUND: Little information is available on the analysis of chronological changes in medical economic outcomes of endoscopic submucosal dissection (ESD) for gastric cancer. This study aimed to investigate the recent time trend of medical economic outcomes of ESD for gastric cancer based on the Japanese administrative database. METHODS: A total of 32,943 patients treated with ESD for gastric cancer were referred to 907 hospitals from 2009 to 2011 in Japan. We collected patients' data from the administrative database to compare ESD-related complications, risk-adjusted length of stay (LOS), and medical costs during hospitalization. The study periods were categorized into three groups: 2009 (n = 9,727), 2010 (n = 11,052), and 2011 (n = 12,164). RESULTS: No significant difference was observed in ESD-related complications between three study periods (p = 0.496). However, mean LOS and medical costs during hospitalization of patients with ESD were significantly lower in 2011 than in 2009 and 2010 (p < 0.001). Multiple linear regression analysis showed that patients who received ESD in 2011 had a significantly shorter LOS and lower medical costs during hospitalization compared with those in 2009. The unstandardized coefficient of patients with ESD in 2011 for LOS was -0.78 days [95 % confidence interval (CI), -0.89 to -0.65; p ≤ 0.001], while that of those for medical costs during hospitalization was -290.5 US dollars (95 % CI, -392.3 to -188.8; p ≤ 0.001). CONCLUSIONS: This study showed that the complication rate of ESD was stable, whereas the LOS and medical costs of patients were significantly reduced from 2009 to 2011.

Effects of additional laparoscopic cholecystectomy on outcomes of laparoscopic gastrectomy in patients with gastric cancer based on a national administrative database.

BACKGROUND: Little information is available on the effects of adding laparoscopic cholecystectomy to laparoscopic gastrectomy on outcomes of patients with gastric cancer. The aim of this study is to investigate the effects of adding laparoscopic cholecystectomy to laparoscopic gastrectomy on outcomes in patients with gastric cancer using a national administrative database. METHODS: A total of 14,006 patients treated with laparoscopic gastrectomy for gastric cancer were referred to 744 hospitals in Japan between 2009 and 2011. Patients were divided into two groups, those who also underwent simultaneous laparoscopic cholecystectomy for gallbladder stones (n = 1484) and those who underwent laparoscopic gastrectomy alone (n = 12,522). Laparoscopy-related complications, in-hospital mortality, length of stay, and medical costs during hospitalization were compared in the patient groups. RESULTS: Multiple logistic regression analysis revealed that adding laparoscopic cholecystectomy did not affect laparoscopy-related complications (odds ratio, 1.02; 95% confidence interval [CI], 0.84-1.24; P = 0.788) or in-hospital mortality (odds ratio, 1.16; 95% CI, 0.49-2.76; P = 0.727). Multiple linear regression analysis also showed that adding laparoscopic cholecystectomy did not affect the length of stay (unstandardized coefficient, 0.37 d; 95% CI, -0.47 to 1.22 d; P = 0.389). However, adding laparoscopic cholecystectomy was associated with significantly increased medical costs during hospitalization (unstandardized coefficient, $1256.0 (95% CI, $806.2-$1705.9; P < 0.001). CONCLUSIONS: This study demonstrated that adding laparoscopic cholecystectomy did not affect outcomes of patients undergoing laparoscopic gastrectomy for gastric cancer, although medical costs during hospitalization were significantly increased.

Endoscopic submucosal dissection for gastric cancer in elderly Japanese patients: an observational study of financial costs of treatment based on a national administrative database.

OBJECTIVE: There is currently little information on the medical economic outcomes of endoscopic submucosal dissection (ESD) for gastric cancer (GC) in elderly patients. This study therefore aimed to investigate the medical economic outcomes of ESD in elderly patients with GC using a national administrative database. METHODS: A total of 27 385 patients treated with ESD for GC were referred to 867 hospitals in Japan from 2009 to 2011. We collected data from the national administrative database and divided them into two groups according to age: elderly patients (≥80 years; n = 5525) and non-elderly patients (<80 years; n = 21 860). We compared ESD-related complications, risk-adjusted length of stay (LOS) and medical costs during hospitalization between elderly and non-elderly patients. RESULTS: There was no significant difference in ESD-related complications between elderly and non-elderly patients (4.3% vs 3.9%, P = 0.152). However, significant differences were observed in mean LOS and medical costs during hospitalization between the two groups (P < 0.001). Multiple linear regression analysis showed that elderly patients experienced a significantly longer LOS and higher medical costs. The unstandardized coefficient for LOS in elderly patients was 2.71 days (95% confidence interval [CI] 2.59-2.84, P < 0.001), while that for medical costs during hospitalization was USD952.1 (95% CI 847.7-1056.5, P < 0.001). CONCLUSIONS: LOS and medical costs during hospitalization were significantly higher in elderly patients undergoing ESD for GC than in non-elderly patients, although there was no difference in the incidence of ESD-related complications.

Multivariate analysis of factors influencing length of hospitalization and medical costs of cholecystectomy for acute cholecystitis in Japan: a national database analysis.

Little information is available on the factors influencing length of stay (LOS) in hospital and medical costs during hospitalization associated with cholecystectomy for acute cholecystitis. We determined the independent factors affecting LOS and medical costs of patients who underwent cholecystectomy for acute cholecystitis based on data from the Diagnosis Procedure Combination (DPC) database. In 2008, a total of 2176 patients with acute cholecystitis were referred for cholecystectomy to 624 hospitals in Japan. We collected patient characteristics and data on treatments for acute cholecystitis using the DPC database and identified independent factors affecting LOS and medical costs during hospitalization using multiple linear regression models. Analysis revealed that early cholecystectomy was significantly associated with a decrease in LOS, whereas longer preoperative antimicrobial therapy was significantly associated with an increase of LOS: the standardized coefficient for early cholecystectomy was -0.372 and that for preoperative antimicrobial therapy was 0.353 (P < 0.001). These procedures were also significant independent factors with regard to medical costs during hospitalization: the standardized coefficient for early cholecystectomy was -0.391 and that for preoperative antimicrobial therapy was 0.335 (P < 0.001). Early cholecystectomy significantly reduces the LOS and medical costs of cholecystectomy for acute cholecystitis, while preoperative antimicrobial therapy increases LOS and medical costs during hospitalization. These results highlight the need for health care implementations such as promotion of early cholecystectomy, appropriate use of antimicrobial drugs, and centralization of patients with cholecystectomy for acute cholecystitis in Japan.

Association between ambulance distance to hospitals and mortality from acute diseases in Japan: national database analysis.

OBJECTIVE: The aim of this study was to evaluate the relationship between ambulance distance to hospitals and mortality from acute diseases using the national database in Japan. DESIGN: Geospatial ecological study. SETTING: We collected the data of transport distance to hospitals from the Diagnosis Procedure Combination database and that of mortality per 100 000 from some acute diseases from the database of life tables by the Ministry of Health, Labour and Welfare in Japan. PARTICIPANTS: A total of 108 314 patients (40 882 patients with acute myocardial infarction, 31 632 patients with brain infarction, 4992 patients with subarachnoid hemorrhage, and 30 808 patients with pneumonia) were referred in Japan in 2008. MAIN OUTCOME MEASURES: We evaluated the association between the mean transport distance to hospitals and the mortality from acute diseases using simple linear regression analysis. This correlation was evaluated separately for each acute disease. RESULTS: The mean transport distances to hospitals were 8.1 km for acute myocardial infarction, 8.3 km for brain infarction, 9.5 km for subarachnoid hemorrhage, and 7.6 km for pneumonia, whereas the mortalities per 100,000 were 34.6 for acute myocardial infarction, 60.4 for brain infarction, 11.2 for subarachnoid hemorrhage, and 91.6 for pneumonia. Simple linear regression analysis revealed significant positive correlations between transport distance and mortality per 100,000 for acute myocardial infarction and brain infarction (R2 = 0.315 and 0.398, P < .001, respectively). Otherwise, moderate positive correlations between transport distance and mortality per 100,000 were shown for subarachnoid hemorrhage and pneumonia (R2 = 0.112, P < .012 and .233, P < .001, respectively). CONCLUSIONS: This study suggests that the ambulance distance to hospitals significantly influences the risk of mortality for some acute diseases in Japan. Further studies are needed to confirm this association.

TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos).

Since the publication of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07), diagnostic criteria and severity assessment criteria for acute cholangitis have been presented and extensively used as the primary standard all over the world. However, it has been found that there are crucial limitations in these criteria. The diagnostic criteria of TG07 do not have enough sensitivity and specificity, and its severity assessment criteria are unsuitable for clinical use. A working team for the revision of TG07 was organized in June, 2010, and these criteria have been updated through clinical implementation and its assessment by means of multi-center analysis. The diagnostic criteria of acute cholangitis have been revised as criteria to establish the diagnosis where cholestasis and inflammation demonstrated by clinical signs or blood test in addition to biliary manifestations demonstrated by imaging are present. The diagnostic criteria of the updated Tokyo Guidelines (TG13) have high sensitivity (87.6 %) and high specificity (77.7 %). TG13 has better diagnostic capacity than TG07. Severity assessment is classified as follows: Grade III: associated with organ failure; Grade II: early biliary drainage should be conducted; Grade1: others. As for the severity assessment criteria of TG07, separating Grade II and Grade I at the time of diagnosis was impossible, so they were unsuitable for clinical practice. Therefore, the severity assessment criteria of TG13 have been revised so as not to lose the timing of biliary drainage or treatment for etiology. Based on evidence, five predictive factors for poor prognosis in acute cholangitis--hyperbilirubinemia, high fever, leukocytosis, elderly patient and hypoalbuminemia--have been extracted. Grade II can be diagnosed if two of these five factors are present. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis.

In 2007, the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were first published in the Journal of Hepato-Biliary-Pancreatic Surgery. The fundamental policy of TG07 was to achieve the objectives of TG07 through the development of consensus among specialists in this field throughout the world. Considering such a situation, validation and feedback from the clinicians' viewpoints were indispensable. What had been pointed out from clinical practice was the low diagnostic sensitivity of TG07 for acute cholangitis and the presence of divergence between severity assessment and clinical judgment for acute cholangitis. In June 2010, we set up the Tokyo Guidelines Revision Committee for the revision of TG07 (TGRC) and started the validation of TG07. We also set up new diagnostic criteria and severity assessment criteria by retrospectively analyzing cases of acute cholangitis and cholecystitis, including cases of non-inflammatory biliary disease, collected from multiple institutions. TGRC held meetings a total of 35 times as well as international email exchanges with co-authors abroad. On June 9 and September 6, 2011, and on April 11, 2012, we held three International Meetings for the Clinical Assessment and Revision of Tokyo Guidelines. Through these meetings, the final draft of the updated Tokyo Guidelines (TG13) was prepared on the basis of the evidence from retrospective multi-center analyses. To be specific, discussion took place involving the revised new diagnostic criteria, and the new severity assessment criteria, new flowcharts of the management of acute cholangitis and cholecystitis, recommended medical care for which new evidence had been added, new recommendations for gallbladder drainage and antimicrobial therapy, and the role of surgical intervention. Management bundles for acute cholangitis and cholecystitis were introduced for effective dissemination with the level of evidence and the grade of recommendations. GRADE systems were utilized to provide the level of evidence and the grade of recommendations. TG13 improved the diagnostic sensitivity for acute cholangitis and cholecystitis, and presented criteria with extremely low false positive rates adapted for clinical practice. Furthermore, severity assessment criteria adapted for clinical use, flowcharts, and many new diagnostic and therapeutic modalities were presented. The bundles for the management of acute cholangitis and cholecystitis are presented in a separate section in TG13. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.