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To investigate the epidemiologic and clinical characteristics of maternal near-misses attributable to haemorrhagic stroke (HS) occurring in patients with hypertensive disorders of pregnancy (HDP), with a focus on severe neurological morbidity.A national retrospective cohort study was conducted using the national database of health insurance claims for the period 2010 to 2017. The subjects were all insured women with a diagnosis of both HDP and HS. Severe neurological morbidity requiring rehabilitation, types of HDP, types of HS, and magnesium sulphate use were tabulated.The number of women with HDP who were diagnosed with HS was 3.4 per 100,000 deliveries between 2010 and 2017. Forty percent of HDP-related HS cases had neurological morbidities requiring rehabilitation (1.4 per 100,000 deliveries), and 4.4% were in a persistent vegetative state after HS. Of the HDP cases who developed HS, 69.2% were severe HDP, of which 55.6% were without eclampsia. The most common type of HS was intracerebral haemorrhage (2.5 per 100,000 deliveries), followed by subarachnoid haemorrhage due to cerebral aneurysm (1.2 per 100,000 deliveries). The frequency of magnesium sulphate use increased in all patients with HDP-related HS in the second half of the study period (2014-2017) compared with the first half (2010-2013) (p 0.0001). This was more evident in cases of HDP-related HS with eclampsia (31.9% to 83.8%) compared to those without eclampsia (25.0% to 42.9%).Of the maternal near-miss cases due to HDP-related HS, 40.0% were rehabilitated and 69.2% were HDP without either eclampsia or severe hypertension.

Background and aim: The introduction of direct oral anticoagulants (DOACs) has greatly changed the use of anticoagulant therapy in patients with non-valvular atrial fibrillation (Af). However, few studies have reported on the current state of anticoagulant therapy at the national level. This study aimed to examine changes in the proportions of oral anticoagulant (OAC) prescriptions (4 DOACs and a vitamin K antagonist: VKA) in patients with non-valvular Af aged ≥65 years, taking into consideration the risk of cerebral infarction and bleeding.Methods: Anticoagulant prescriptions in outpatients with Af were temporally analyzed using the nationwide claims database in Japan. The proportion of anticoagulants prescribed to Af patients aged ≥65 years was determined. Trends in anticoagulant prescriptions were examined according to cerebral infarction and bleeding risk.Results: The proportion of anticoagulant prescriptions for 12,076 Af patients aged ≥65 years in Japan increased from 41% in 2011 to 56% in 2015. The proportion of prescriptions for DOACs surpassed that of VKA. An increase in DOAC prescriptions was accompanied by an increase in the proportion of anticoagulant prescriptions in each group according to the CHA2DS2-VASc and HAS-BLED scores. The proportion of anticoagulant prescriptions for patients with a high risk of developing cerebral infarction and bleeding showed a marked increase.Conclusion: Trends in anticoagulant prescriptions in patients with non-valvular AfAf in Japan showed a marked increase in DOAC prescriptions. The widespread use of DOACs greatly changes the profiles of cerebral infarction and bleeding risks, which are related to the prescription of anticoagulant therapy in patients with non-valvular Af.

Aims/Introduction Although the epidemiological relationship between hypoglycemia and increased risk of acute coronary syndrome (ACS) has been well established, the time period for increased risk of ACS after a severe hypoglycemic episode remains unknown. The present study aimed to determine the ACS risk after a severe hypoglycemic episode. Materials and Methods We carried out a retrospective population‐based cohort study based on national claims data in Japan. We retrieved data of diabetes patients aged ≥35 years collected from April 2014 to March 2016. The absolute risk of ACS was defined as the occurrence of an emergency percutaneous coronary intervention after a severe hypoglycemic episode. Results In total, data of 7,909,626 patients were included in the analysis. The absolute risk of ACS was 2.9 out of 1,000 person‐years in all patients. ACS risk in patients with severe hypoglycemic episodes was 3.0 out of 1,000 person‐years. Severe hypoglycemic episodes increased the absolute risk of ACS in patients aged ≥70 years, but not in patients aged, This study identifies the absolute risk of acute coronary syndrome in Japanese patients after they have experienced a severe hypoglycemic episode. Study results showed that acute coronary syndrome risk increased considerably within a short period after a severe hypoglycemic episode, indicating a strong association between the length of time after a severe hypoglycemic episode and acute coronary syndrome risk.

Poor implementation and variable quality of cardiac rehabilitation (CR) for coronary heart disease (CHD) have been a global concern. This nationwide study aimed to clarify the implementation of and participation in CR among CHD patients and associated factors in Japan. We conducted a retrospective cohort study using data extracted from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in 2017–2018 were included. Aspects of CR were assessed in terms of (1) participation in exercise-based CR, (2) pharmacological education, and (3) nutritional education. Of 87,829 eligible patients, 32% had participated in exercise-based CR, with a mean program length of 40 ± 71 days. CABG was associated with higher CR participation compared to PCI (OR 10.2, 95% CI 9.6–10.8). Patients living in the Kyushu region were more likely to participate in CR (OR 2.59, 95% CI 2.39–2.81). Among patients who participated in CR, 92% received pharmacological education, whereas only 67% received nutritional education. In Japan, the implementation of CR for CHD is insufficient and involved varying personal, therapeutic, and geographical factors. CR implementation needs to be promoted in the future.

The administration of intensive end-of-life care just before death in older patients has become a major policy concern, as it increases medical costs; however, care intensity does not necessarily indicate quality. This study aimed to describe the temporal trends in the administration of life-sustaining treatments (LSTs) and intensive care unit (ICU) admissions just before death in older inpatients in Japan. We utilized the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB). Inpatients who were aged ≥65 years and died in October of 2012, 2013, or 2014 were analyzed. The numbers of decedents in 2012, 2013, and 2014 were 3362, 3473, and 3516, respectively. The frequencies of receiving cardiopulmonary resuscitation (CPR) (11.0% to 8.3%), mechanical ventilation (MV) (13.1% to 9.8%), central venous catheter (CVC) insertion (10.6% to 7.8%), and ICU admission (9.1% to 7.8%), declined between 2012 and 2014. After adjusting for age, sex, and type of ward, the declining trends persisted for CPR, MV, and CVC insertion relative to the frequencies in 2012. Our results indicate that the administration of LST just before death in older inpatients in Japan decreased from 2012 to 2014.

[Background] Recognising the importance of the social determinants of health, the Japanese government introduced a health management support programme targeted at type 2 diabetes (T2D) for public assistance recipients (PAR) in 2018. However, evidence of the T2D prevalence among PAR is lacking. We aimed to estimate T2D prevalence by age and sex among PAR, compared with the prevalence among health insurance enrollees (HIE). Additionally, regional differences in T2D prevalence among PAR were examined. [Methods] This was a cross-sectional study using 1-month health insurance claims of both PAR and HIE. The Fact-finding Survey data on Medical Assistance and the National Database of Health Insurance Claims data were used. T2D prevalence among PAR and HIE were assessed by age and sex, respectively. Moreover, to examine regional differences in T2D prevalence of inpatients and outpatients among PAR, T2D crude prevalence and age-standardised prevalence were calculated by prefecture. Multilevel logistic regression analysis was also conducted at the city level. [Results] T2D crude prevalence was 7.7% in PAR (inpatients and outpatients). Among outpatients, the prevalence was 7.5% in PAR and 4.1% in HIE, respectively. The mean crude prevalence and age-standardised prevalence of T2D (inpatients and outpatients) among 47 prefectures were 7.8% and 3.9%, respectively. In the city-level analysis, the OR for the prevalence of T2D by region ranged from 0.31 to 1.51. [Conclusion] The prevalence of T2D among PAR was higher than HIE and there were regional differences in the prevalence of PAR. Measures to prevent the progression of diabetes among PAR by region are needed., 生活保護受給者の糖尿病有病実態解明 --200万人のレセプトデータ解析--. 京都大学プレスリリース. 2021-11-16.

ObjectivesTo accumulate evidence that obstacle avoidance training alone is effective in improving the locomotor ability of individuals with stroke.DesignSystematic review and meta-analysis.SettingMEDLINE, EMBASE, CENTRAL, ICTRP and PEDro were searched for related information until December 2018. Two independent reviewers extracted data. Outcome measurement data were subjected to meta-analyses using random-effects models. Data syntheses were conducted using RevMan V.5.3, and the certainty of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation approach.ParticipantsParticipants with various types and phases of stroke were included.InterventionThe usual gait training including obstacle avoidance training (interventions of any type, intensity, duration and frequency).Primary and secondary outcome measuresPrimary outcomes were gait speed, composite gait ability and objective balance ability. Secondary outcomes were subjective balance ability, gait endurance and fall incidence.ResultsTwo randomised controlled trials with a total of 49 participants were used as data sources for this study. The obstacle avoidance training (training) group had lower gait speed than the control group (mean difference (MD) 0.03, 95% CI −0.11 to 0.16, p=0.51). Further, the certainty of evidence was very low. The subjective balance ability (Activities-specific Balance Confidence scale) was not significantly different between the training and control groups (MD 6.65, 95% CI −7.59 to 20.89, p=0.36), and it showed very low certainty of evidence.ConclusionsObstacle avoidance training may have little or no effect on individuals with stroke. The failure to find the effectiveness of obstacle avoidance training alone is possibly attributable to the insufficient amount of training in the intervention and the lack of well-designed studies that measured relevant outcomes.PROSPERO registration numberCRD42017060691.

ObjectivesQuality indicators are measurable elements widely used to assess the quality of care. They are often developed from the results of systematic reviews or clinical practice guidelines. These sources are regularly updated in line with new clinical evidence, but there are few articles on updating quality indicators based on clinical practice guidelines. This study aimed to update the quality indicators developed for low-risk labour care in Japan in 2012, mainly drawing on new or updated clinical practice guidelines, and making the process clearly visible and assessable.Design and settingWe used a modified Delphi method for the update. The procedure included four steps: (1) updating the definition of low-risk labour; (2) reviewing the literature published between June 2012 and December 2015 using five guidelines and two quality indicator databases to extract potential candidate indicators; (3) formation of a multidisciplinary panel including mothers and (4) panel ratings (two rounds between February and April 2016) on the validity of the candidate indicators, and judging the validity of the previous quality indicators drawing on the new evidence.ParticipantsA multidisciplinary panel of 13 clinicians, including obstetricians, paediatricians and midwives, plus 3 non-clinician mothers.ResultsThe literature review identified 276 new recommendations from 27 clinical practice guidelines including 2 published in Japan and 21 quality indicators. We developed 13 new candidate indicators from these sources and panel recommendations, 12 of which were approved by the multidisciplinary panel. The panel also accepted all 23 existing quality indicators as still valid, resulting in a total of 35 quality indicators for low-risk labour.ConclusionsWe successfully updated the quality indicators for low-risk labour care in Japan. The procedure developed may be useful for updating other quality indicators based on new clinical practice guidelines.

Objectives Cardiac rehabilitation is underused and its quality in practice is unclear. A quality indicator is a measurable element of clinical practice performance. This study aimed to propose a set of quality indicators for cardiac rehabilitation following an acute coronary event in the Japanese population and conduct a small-size practice test to confirm feasibility and applicability of the indicators in real-world clinical practice. Design and setting This study used a modified Delphi technique (the RAND/UCLA appropriateness method), a consensus method which involves an evidence review, a face-to-face multidisciplinary panel meeting and repeated anonymous rating. Evidence to be reviewed included clinical practice guidelines available in English or Japanese and existing quality indicators. Performance of each indicator was assessed retrospectively using medical records at a university hospital in Japan. Participants 10 professionals in cardiac rehabilitation for the consensus panel. Results In the literature review, 23 clinical practice guidelines and 16 existing indicators were identified to generate potential indicators. Through the consensus-building process, a total of 30 indicators were assessed and finally 13 indicators were accepted. The practice test (n=39) revealed that 74% of patients underwent cardiac rehabilitation. Median performance of process measures was 93% (IQR 46–100%). ‘Communication with the doctor who referred the patient to cardiac rehabilitation’ and ‘continuous participation in cardiac rehabilitation’ had low performance (32% and 38%, respectively). Conclusions A modified Delphi technique identified a comprehensive set of quality indicators for cardiac rehabilitation. The single-site, small-size practice test confirmed that most of the proposed indicators were measurable in real-world clinical practice. However, some clinical processes which are not covered by national health insurance in Japan had low performance. Further studies will be needed to clarify and improve the quality of care in cardiac rehabilitation.

Background In childbirth, most deliveries are low-risk, defined as spontaneous labor at full term without special high-risk facts or complications, especially in high-resource countries where maternal and perinatal mortality rates are very low. Indeed, the majority of mothers and infants have no serious conditions during labor. However, the quality of care provided is not assured, and performance may vary by birthing facility and provider. The overuse of technology in childbirth in some parts of the world is almost certainly based on assumptions like, “something can go wrong at any minute.” There is a need to assess the quality of care provided for mothers and infants in low-risk labor. We aimed to develop specific quality indicators for low-risk labor care provided primarily by midwives in Japan. Methods We used a RAND-modified Delphi method, which integrates evidence review with expert consensus development. The procedure comprises five steps: (1) literature review, including clinical practice guidelines, to extract and develop quality indicator candidates; (2) formation of a multidisciplinary panel; (3) independent panel ratings (Round 1); (4) panel meeting and independent panel ratings (Round 2); and (5) independent panel ratings (Round 3). The three independent panel ratings (Rounds 1–3) were held between July and December 2012. Results The assembled multidisciplinary panel comprised eight clinicians (two pediatricians, three obstetricians, and three midwives) and three mothers who were nonclinicians. Evidentiary review extracted 166 key recommendations from 32 clinical practice guidelines, and 31 existing quality indicators were added. After excluding duplicate recommendations and quality indicators, the panel discussed 25 candidate indicators. Of these, 18 were adopted, one was modified, six were not adopted, and four were added during the meeting, respectively. Conclusions We established 23 quality indicators for low-risk labor care provided by midwives in labor units in Japan.

Background Cardiac rehabilitation improves quality of life and mortality in patients with ischemic heart disease, but it is underutilised and quality in practice is unknown. Quality indicators are increasingly used to quantify healthcare quality. In Japan, however, such indicators for cardiac rehabilitation have not been developed yet. Objectives The purpose of this study was to develop quality indicators considering clinical circumstances in Japan. Methods To determine quality indicator candidates, we systematically searched electronic databases and reviewed existing related guidelines indicators. Using a modified Delphi technique, a domestic multidisciplinary panel of ten experts was assembled for a face-to-face meeting. After panel members rated the candidates individually on a questionnaire, a final consensus was determined for each measure. Results A literature search identified 894 clinical guidelines and 38 existing quality indicators. Some of them were excluded due to inconsistency with a priori criteria. Then, 26 guidelines and 16 indicators were selected to create a list of indicator candidates. The panel discussed 27 candidates: six indicators were adopted, one indicator was not adopted, 20 indicators were reconstituted into four indicators, and three new additional indicators were suggested. Consequently, 13 indicators were chosen. Discussion Guideline-based quality indicator development may be time-efficient and resource saving, but further methodology research is needed. We are planning a pilot test of these indicators at multiple facilities. Implications for Guideline Developers/Users Guideline developers should take potential use as quality indicators into account for making recommendations.

Background In Japan some labour units have started services for low risk labour provided primarily by midwives with the assistance of obstetricians. However, real practices varied with facilities and quality of care has not been sufficiently assured. Objectives We aimed to develop quality indicators of low-risk labour provided primarily by midwives in Japan. Methods We systematically searched databases to select related indicators and clinical practice guidelines. Using a modified Delphi method, a multidisciplinary panel including two women who experienced labour and were not health professionals was assembled and a meeting was held. After the panel members rated the candidates individually, consensus was attained for each indicator. Results An electronic search retrieved 104 guidelines (2043 key recommendations) from which 32 guidelines (166 key recommendations) were selected. Some recommendations were excluded due to difficulties in measuring and others due to evidence against following certain guidelines. Additionally, 31 existing quality indicators were identified. The panel discussed 25 candidate indicators: 18 indicators were adopted, six indicators were not adopted, one indicator was modified. Four indicators were added later following discussion. Consequently, 23 quality indicators of care were chosen. Discussion A pilot test of these indicators at multiple facilities should contribute to future development of guideline-based quality indicators. Implications for Guideline Developers/Users Guideline developers should be more conscious in making recommendations that are potentially used as quality indicators.