Clinical Studies using Diagnosis Procedure Combination (DPC) Database

Transcription

1 Clinical Studies using Diagnosis Procedure Combination (DPC) Database Hideo Yasunaga, MD, PhD Department of Health Management and Policy, Graduate School of Medicine, University of Tokyo 1

2 What is DPC? Japanese version of Diagnosis Related Groups Diagnosis Procedure Combination (DPC) is a diagnosis-dominant case-mix system, comprised of 18 major diagnostic categories (MDC), 520 diagnostic groups, and 2,347 case-mix groups.

3 18 Major Diagnosis Group MDC 01 Central nervous system MDC 02 Eyes MDC 03 Ears, Nose and Throat MDC 04 Respiratory system MDC 05 Cardiovascular system

4 520 Diagnosis Groups Major Diagnosis Group 05 (Cardiovascular system) Acute Myocardiac Infarction Angina Pectoris Cardiomyopathy Valvular Diseases

5 2,347 DPC (Acute myocardiac infarction) AMI, tpa, Coronary stent xx03x3xx AMI, IABP, CABG xx02x4xx

6 The DPC Database The DPC Database is a patient discharge and administrative claims database. Data are compiled between July and December each year by the DPC Research Group (Chief: Shinya Matsuda MD, PhD) funded by the Ministry of Health, Labour and Welfare, Japan.

7 Administrative Claims Database in the US (1)Nationwide Inpatient Sample (NIS) Database -includes 8 million patients per year from 1,044 hospitals in 40 states, representing approx. 20% of all inpatients in the US. (2) Medicare Claim Database -includes all patients 65 yrs -linked with Surveillance, Epidemiology and End Results (SEER) program of cancer registries (SEER-Medicare Linked Database).

8 Japanese DPC Database includes around 3 million inpatients per half a year, representing approx. 45% of all acute care inpatients in Japan.

9 Data The database include patient information on -Diagnoses coded with the ICD-10 codes -Procedures -Comorbidities at admission ( 入 院 時 併 存 症 ) -Complications after admission ( 入 院 後 合 併 症 ) -Drugs and Devices used -In-hospital mortality( 在 院 死 亡 ) -Length of stay( 在 院 日 数 ) -Costs 9

10 -Cancer stage, Chemotherapy, Radiotherapy -Coma Scale -ASA, NYHA, Hugh-Jones, Child-Pugh -Burn Index -Pregnancy -Smoking index etc.

11 Clinical Statistics using the DPC Database 11

12 Operative Mortality following Cancer Surgery 2007 (がん 手 術 後 の 在 院 死 亡 率 ) N inhospital death % Lung 17, % Esophagus 3, % Stomach 31, % Liver 10, % Pancreas 6, % Colon 27, % Rectum 17, % Kidney 8, % Bladder 2, % Prostate 7, % Uterus 7, %

13 Operative Mortality following Cancer Surgery yrs 60-69yrs 70-79yrs 80yrs Lung 0.5% 0.7% 1.3% 2.1% Esophagus 2.7% 3.3% 7.3% 10.0% Stomach 0.6% 1.0% 1.8% 3.9% Liver 1.6% 2.3% 3.7% 4.5% Pancreas 1.4% 2.9% 4.0% 6.6% Colon 1.0% 1.3% 2.2% 4.6% Rectum 0.6% 1.0% 2.5% 4.6% Bladder 0.0% 1.4% 3.0% 3.1% Uterus 0.3% 0.2% 0.6% 1.0%

14 Surgical Volume and Operative Outcomes ( 手 術 件 数 と 手 術 成 績 ) Studies have indicated that higher operative caseload volume is associated with lower surgical mortality after complex surgical procedures. However, little is known about the relationship between operative volume and postoperative complications.

15 Postoperative complications following Nephrectomy for Renal Cancer (n=7988) Urinary tract infection 117 (1.5%) Ileus 103 (1.3%) Surgical site infection 97 (1.2%) Cardiac events 87 (1.1%) Sepsis 63 (0.8%) Respiratory complications 58 (0.7%) Renal failure 46 (0.6%) Venous thromboembolism 44 (0.4%) Pancreatitis 21 (0.3%) Stroke 17 (0.2%) Peritonitis 14 (0.2%) Overall, 595 patients (7.4%) had at least one complication. The in-hospital rate of death was 0.84% (n=67).

16 Age and Outcomes

17 Hospital volume and outcomes *Hospital volume: the annual number of nephrectomy perfomed at each hospital

18 Multivariate regression

19 Incidence of Malignant Hyperthermia( 悪 性 高 熱 ) Malignant hyperthermia (MH) is a life-threatening pharmacogenetic disease that occurs during general anesthesia. A potential risk of MH is the use of volatile anesthetic agents ( 揮 発 性 麻 酔 薬 ) and muscle relaxants ( 筋 弛 緩 薬 ). The true incidence of MH remains unclear because of a paucity of universal reporting.

20 Incidence of MH determined with the DPC database 17 MH detected among 1,238,171 patients undergoing general anesthesia. N % MH Incidence (per million) Total 1,238, % Volatile agents Sevoflurane 932, % Isoflurane 33, % Halothane % Enflurane % Muscle Relaxants Suxamethonium 19, % Vecuronium 782, % Pancuroneum 11, % Rocuronium 246, % Propofol 949, %

21 DES was introduced in September 2004 in Japan. Impact of Drug-eluting Stents (DES) on Treatment Option Mix for Coronary Artery Disease in Japan Coronary artery bypass grafting (CABG) -on-pump CABG -off-pump CABG Percutaneous coronary intervention (PCI) -Bare metal stent (BMS) -Drug-eluting stent (DES)

22 4-year trend in proportions of therapeutic options for Angina Pectoris from 144 hospital in July, PCI:percutaneous coronary intervention, CABG:coronary artery bypass grafting DES:drug eluting stents,bms:bare metal stents

23 DES not only replaced BMS, but also expanded patients eligibility for PCI. Increase in PCI was concurrent with a temporary reduction in on-pump CABG but in the increase in off-pump CABG. 23

24 The Effect of Mechanical Thromboprophylaxis for Pulmonary Embolism following Abdominal Cancer Surgery ( 腹 部 がん 手 術 後 の 肺 塞 栓 症 に 対 する 間 欠 的 空 気 圧 迫 装 置 による 予 防 効 果 ) 24

25 Incidence of Perioperative Pulmonary Embolism in the groups with and without mechanical prophylaxis No prophylaxis Mechanical prophylaxis N PE % N PE % Overall 18, % 52, % Gastrectomy % % Colectomy % % Rectal surgery % % Hepatectomy % % Nephrectomy % % Prostatectomy % % Hysterectomy % %

26 Duration of anesthesia 180 Logistic regression odds ratio 95% confidence interval Reference > Thromboprophylaxis None Mechanical thromboprophylaxis Reference p

27 Measles in Japan, America was declared free from endemic measles transmission in In Europe, 29,000 measles infections were reported in In Japan, measles outbreaks occurred in 2001 and Measles sometimes accompanies diverse complications, including pneumonia, otitis media, and central nervous system involvement. We searched for measles-related complications and hospitalizations in Japan in , using the DPC Database.

28 Measles Complications Age (years) All Any complication (%) Pneumonia (%) Encephalitis (%) Meningitis (%) Intestinal complications (%) Conjunctivitis (%) Otitis media (%) Other complications (%)

29 Age Distribution Age distribution revealed two peaks in 4 and years old. Measles-mumps-rubella (MMR)vaccine failure in late 1980s and early 1990s could be associated with the high incidence in patients aged years.

30 Venomous snake bites in Japan About 15% of 3000 species of snakes worldwide are venomous, including rattlesnakes, cottonmouths and copperheads in North America, cobras, mambas and kraits in tropical zones, and mamushi (A. blomhoffii) and habu (T. flavoviridis) in Japan. Crotalidae species (pit vipers) with a triangular head, elliptical pupils, and retractable fangs (NEJM2002;347:347-56)

31 Mamushi and Habu bites (N=1,670) July Aug Sep Oct Nov Dec

32 n % Region Northern area Hokkaido Tohoku Central area Kanto Chubu Western area Kinki Chugoku Shikoku Southern area Kyushu Okinawa islands

33 Snake venom increases capillary membrane permeability, which leads to extravasation of electrolytes, albumin, and red blood cells into the bite site. Edema, hypoalbuminemia, and hemoconcentration can result in hypovolemic shock and acute renal failure. n % Local complications Wound infection Compartment syndrome Systemic complications Shock Disseminated intravascular coagulation Rhabdomyolysis Acute renal failure Death 3 0.2

34 Health service researches using the DPC database Researchers can utilize the DPC database to identify, track, and analyze national trends in healthcare utilization, access, outcomes and costs. The data can be utilized to make a better allocation of healthcare resources.

35 Framework for clinical epidemiological studies using the DPC database Clinical experts Epidemiologists Discussion Study Design Paperwork Data extraction Data screening Analysis

36 Development of the DPC database Increase in the coverage rate Improvement of usability for researchers Linkage with other database -Outpatient database -Cancer registry -Long-term care database