Analysis of the Evidence-practice Gap to Facilitate Proper Medical Care for the Elderly: Investigation, using Databases, of Utilization Measures for National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB)

As Japan becomes a super-aging society, presentation of the best ways to provide medical care for the elderly, and the direction of that care, are important national issues. Elderly people have multi-morbidity with numerous medical conditions and use many medical resources for complex treatment patterns. This increases the likelihood of inappropriate medical practices and an evidence-practice gap. The present study aimed to: derive findings that are applicable to policy from an elucidation of the actual state of medical care for the elderly; establish a foundation for the utilization of National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB), and present measures for the utilization of existing databases in parallel with NDB validation. Cross-sectional and retrospective cohort studies were conducted using the NDB built by the Ministry of Health, Labor and Welfare of Japan, private health insurance claims databases, and the Kyoto University Hospital database (including related hospitals). Medical practices (drug prescription, interventional procedures, testing) related to four issues—potential inappropriate medication, cancer therapy, chronic kidney disease treatment, and end-of-life care—will be described. The relationships between these issues and clinical outcomes (death, initiation of dialysis and other adverse events) will be evaluated, if possible

Reliability, validity, and responsiveness of the Japanese version of the Neck Pain and Disability Scale

Abstract Background Until recently, no Japanese versions have existed of the more popular, patient-reported disability questionnaires for neck pain. This study aimed to test the reliability, validity, and responsiveness of the Japanese version of the Neck Pain and Disability Scale (NPDS), one of the most widely used questionnaires in patients with neck pain. Methods In this validation study, 167 outpatients with neck pain participated. Patients received the NPDS and the Medical Outcome Study Short Form 36-item Health Survey (SF-36), and used Visual Analog Scales (VASs) to assess pain and global health. To examine test-retest reliability, patients who were considered stable by clinicians were given the NPDS 2 weeks after baseline. To examine responsiveness, patients who had not undergone treatment at the time of the first data collection or had no change in treatment over 3 months were studied again 2 weeks after starting a new medication or physical therapy. Results Of the 167 participants, 143 completed the questionnaires (85.6%). Factor analysis showed two factors, defined as neck-pain-related disability (factor 1) and neck-related pain (factor 2). Cronbach's a coefficient for factor 1, factor 2, and total score was 0.94, 0.93, and 0.96. The intra-class correlation coefficients for the 19 more stable patients were 0.79, 0.88, and 0.87. For concurrent validity, the correlation between NPDS subscales and total score and SF-36 subscale scores ranged from r = -0.54 to -0.22 (p \ 0.01). Correlations between the NPDS subscales and total score and VAS of pain ranged from 0.56 to 0.77 (p \ 0.01) and those for VAS of global health ranged from 0.48 to 0.63 (p \ 0.01). The NPDS subscales and total scores of the 41 patients retested after treatment were significantly improved. Electronic supplementary material The online version of this articl

Intermittent infusions of carperitide or inotoropes in out-patients with advanced heart failure.

[Background]: The ambulatory treatment of advanced heart failure (HF) with intermittent infusions of inotropes or natriuretic peptide chosen immediately before each infusion has not been described. [Methods]: Between May 2005 and July 2009, we treated 11 patients presenting with advanced HF, who received a total of 369 infusions of carperitide, olprinone, dopamine, or dobutamine, once or twice weekly. The pharmaceutical was selected before each infusion based on the systolic blood pressure (BP). [Results]: Carperitide, olprinone, and catecholamines were administered to 8 (73 infusions of 0.030 ± 0.004 μg/kg/min for 3.3 ± 0.8 h), 4 (18 infusions of 0.070 ± 0.017 μg/kg/min for 3.3 ± 0.5 h), and 6 patients (278 infusions of 3.6 ± 1.9 μg/kg/min for 2.8 ± 1.0 h), respectively. No adverse effect requiring cessation of infusion was observed. Over a mean follow-up of 29.3 ± 28.8 months (range 2–104), 4 patients died, all from cardiac causes. The Kaplan–Meier cumulative survival rate was 69.3% at 20 months (median follow-up). Compared with the pre-infusion period, the duration and number of hospitalizations for management of HF were decreased by 73.9% (p = 0.017), and 51.9% (p = 0.007), respectively, during the treatment period, and the overall medical costs by 56.9% (p = 0.021). [Conclusions]: In this study population, intermittent drug infusions selected from inotropes or natriuretic peptide based on the baseline systolic BP significantly decreased the length and number of hospitalizations and costs, without increasing mortality. These results indicate that intermittent infusions might be one of the therapeutic options in advanced HF

Fukushima after the Great East Japan Earthquake: lessons for developing responsive and resilient health systems

Background: On 11 March 2011, the Great East Japan Earthquake, followed by a tsunami and nuclear–reactor meltdowns, produced one of the most severe disasters in the history of Japan. The adverse impact of this ‘triple disaster’ on the health of local populations and the health system was substantial. In this study we examine population–level health indicator changes that accompanied the disaster, and discuss options for re–designing Fukushima’s health system, and by extension that of Japan, to enhance its responsiveness and resilience to current and future shocks. Methods: We used country–level (Japan–average) or prefecture–level data (2005–2014) available from the portal site of Official Statistics of Japan for Fukushima, Miyagi, and Iwate, the prefectures that were most affected by the disaster, to compare trends before (2005–2010) and after (2011–2014) the ‘disaster’. We made time–trend line plots to describe changes over time in age–adjusted cause–specific mortality rates in each prefecture. Findings: All three prefectures, and in particular Fukushima, had lower socio–economic indicators, an older population, lower productivity and gross domestic product per capita, and less higher–level industry than the Japan average. All three prefectures were ‘medically underserved’, with fewer physicians, nurses, ambulance calls and clinics per 100 000 residents than the Japan average. Even before the disaster, age–adjusted all–cause mortality in Fukushima was in general higher than the national rates. After the triple disaster we found that the mortality rate due to myocardial infarction increased substantially in Fukushima while it decreased nationwide. Compared to Japan average, spikes in mortality due to lung disease (all three prefectures), stroke (Iwate and Miyagi), and all–cause mortality (Miyagi and Fukushima) were also observed post–disaster. The cause–specific mortality rate from cancer followed similar trends in all three prefectures to those in Japan as a whole. Although we found a sharp rise in ambulance calls in Iwate and Miyagi, we did not see such a rise in Fukushima: a finding which may indicate limited responsiveness to acute demand because of pre–existing restricted capacity in emergency ambulance services. Conclusions: We analyze changes in indicators of health and health systems infrastructure in Fukushima before and five years following the disaster, and explored health systems’ strengths and vulnerabilities. Spikes in mortality rates for selected non–infectious conditions common among older individuals were observed compared to the national trends. The results suggest that poorer reserves in the health care delivery system in Fukushima limited its capacity to effectively meet sudden unexpected increases in demand generated by the disaster

Low testosterone levels, depressive symptoms, and falls in older men: a cross-sectional study.

While several studies have cited a potential association between testosterone deficiency and risk of falls among community-dwelling older men, evidence for such an association is conflicting. Depressive symptoms, which occasionally accompany testosterone deficiency but which are often neglected as associated symptoms, may actually provoke falls independent of or jointly with testosterone deficiency. We examined the association between testosterone levels, depressive symptoms, and falls, and assessed the joint effect of testosterone levels and depressive symptoms on falls among older men.Data for this cross-sectional study were obtained from 869 men aged over 60 years who participated in health check-ups conducted in 2010 from 2 Japanese municipalities. Salivary testosterone (sT) levels were measured using an enzyme-linked immunosorbent assay, and depressive symptoms were assessed via the short form of the Center for Epidemiologic Studies Depression Scale. Self-reported "any fall" over the 1-month period. Among the total of 482 participants analyzed (median age, 70 years), 10.8% reported any fall. On comparison between 90th percentile sT levels and lower levels, our logistic regression model with restricted cubic splines showed that lower sT levels were associated with an increased likelihood of suffering any fall after adjustment for sociodemographic characteristics, comorbidities, and mobility function. For example, 5th percentile sT was associated with any fall [adjusted odds ratio (OR), 4.23; 95% confidence interval (CI), 1.66–10.8]. Depressive symptoms were also strongly associated with any fall [adjusted OR, 3.49 (95% CI, 1.52–8.04)]. We noted no apparent interaction of sT and depressive symptoms with falls (P = .079), suggesting that the joint effect of testosterone deficiency and depressive symptoms on falls was multiplicative. Indeed, compared with a combination of 90th percentile sT values and no depressive symptoms, adjusted OR for any fall in a combination involving 5th percentile sT and depressive symptoms was 14.8-fold (95% CI, 3.76–58.0). Our findings indicated that both relatively low testosterone levels and presence of depressive symptoms were independently associated with falls among older men. Causality of these associations should be confirmed in future prospective studies

Overactive bladder symptom severity is associated with falls in community-dwelling adults: LOHAS study.

[Objectives] To examine the association between overactive bladder (OAB) symptom severity and falls and the contribution of OAB symptoms to falls in a community-dwelling population. [Design] Cross-sectional study. [Setting] 2 Japanese municipalities. [Participants] A total of 2505 residents aged over 40 years, who participated in health check-ups conducted in 2010. OAB symptom assessed via overactive bladder symptom score (OABSS) was divided into six categories based on distribution and Japanese clinical guidelines. Mobility problems and depressive symptoms were assessed via the Timed Up and Go test and the short form of the Center for Epidemiologic Studies Depression Scale, respectively. [Primary outcome measures] Self-reported any fall and frequent fall (≥2) over the 1-month period. Independent contributions to any fall and frequent falls were assessed via logistic regression to generate population-attributable fractions (PAFs), assuming separate causal relationships between OAB symptoms, mobility problems and depressive symptoms and any or frequent falls. [Results] Among the total 1350 participants (mean age: 68.3 years) analysed, any fall and frequent falls were reported by 12.7% and 4.4%, respectively. Compared with no OABSS score, moderate-to-severe OAB and mild OAB were associated with any fall (adjusted ORs 2.37 (95% CI 1.12 to 4.98) and 2.51 (95% CI 1.14 to 5.52), respectively). Moderate-to-severe OAB was also strongly associated with frequent falls (adjusted OR 6.90 (95% CI 1.50 to 31.6)). Adjusted PAFs of OAB symptoms were 40.7% (95% CI 0.7% to 64.6%) for any fall and 67.7% (95% CI −23.1% to 91.5%) for frequent falls. Further, these point estimates were similar to or larger than those of mobility problems and depressive symptoms. [Conclusions] An association does indeed exist between OAB symptom severity and falls, and OAB symptoms might be important contributors to falls among community-dwelling adults. Further longitudinal studies are warranted to examine whether or not OAB symptoms predict risk of future falls and fall-related injuries