Publications

2019
Shimada YJ, Gibo K, Tsugawa Y, Goto T, Yu EW, Iso H, Brown DFM, Hasegawa K. Bariatric surgery is associated with lower risk of acute care use for cardiovascular disease in obese adults. Cardiovasc Res. 2019;115 (4) :800-806.Abstract
AIMS: Studies have suggested relationships between obesity and cardiovascular disease (CVD) morbidity. However, little is known about whether substantial weight reduction affects the risk of CVD-related acute care use in obese patients with CVD. The objective of this study was to determine whether bariatric surgery is associated with decreased risk of CVD-related acute care use. METHODS AND RESULTS: We performed a self-controlled case series study of obese adults with CVD who underwent bariatric surgery, using population-based emergency department (ED), and inpatient samples in California, Florida, and Nebraska from 2005 to 2011. The primary outcome was ED visit or unplanned hospitalization for CVD. We used conditional logistic regression to compare the risk during sequential 12-month periods, using pre-surgery months 13-24 as the reference period. We identified 11 106 obese adults with CVD who underwent bariatric surgery. During the reference period, 20.6% [95% confidence interval (CI), 19.8-21.3%] of patients had an ED visit or unplanned hospitalization for CVD. The risk did not significantly change in the subsequent 12-month pre-surgery period [adjusted odds ratio (aOR) 0.98; 95% CI, 0.93-1.04; P = 0.42]. By contrast, in the first 12-month period after bariatric surgery, the risk significantly decreased (aOR 0.91; 95% CI, 0.86-0.96; P = 0.002). The risk remained reduced in the subsequent 13-24 months post-bariatric surgery (aOR 0.84; 95% CI, 0.79-0.89; P < 0.001). There was no reduction in the risk in separate obese populations that underwent non-bariatric surgery (i.e. cholecystectomy, hysterectomy). By CVD category, the risk of acute care use for coronary artery disease (CAD), heart failure (HF), and hypertension decreased after bariatric surgery, whereas that of dysrhythmia and venous thromboembolism transiently increased (Bonferroni corrected P < 0.05 for all comparisons). CONCLUSION: Bariatric surgery is associated with a lower risk of overall CVD-related ED visit or unplanned hospitalization. The decline was mainly driven by reduced risk of acute care use for CAD, HF, and hypertension after bariatric surgery.
2018
Tsugawa Y, Jena AB, Orav JE, Blumenthal DM, Tsai TC, Mehtsun WT, Jha AK. Age and sex of surgeons and mortality of older surgical patients: observational study. BMJ. 2018;361 :k1343.Abstract
OBJECTIVE: To investigate whether patients' mortality differs according to the age and sex of surgeons. DESIGN: Observational study. SETTING: US acute care hospitals. PARTICIPANTS: 100% of Medicare fee-for-service beneficiaries aged 65-99 years who underwent one of 20 major non-elective surgeries between 2011 and 2014. MAIN OUTCOME MEASURE: Operative mortality rate of patients, defined as death during hospital admission or within 30 days of the operative procedure, after adjustment for patients' and surgeons' characteristics and indicator variables for hospitals. RESULTS: 892 187 patients who were treated by 45 826 surgeons were included. Patients' mortality was lower for older surgeons than for younger surgeons: the adjusted operative mortality rates were 6.6% (95% confidence interval 6.5% to 6.7%), 6.5% (6.4% to 6.6%), 6.4% (6.3% to 6.5%), and 6.3% (6.2% to 6.5%) for surgeons aged under 40 years, 40-49 years, 50-59 years, and 60 years or over, respectively (P for trend=0.001). There was no evidence that adjusted operative mortality differed between patients treated by female versus male surgeons (adjusted mortality 6.3% for female surgeons versus 6.5% for male surgeons; adjusted odds ratio 0.97, 95% confidence interval 0.93 to 1.01). After stratification by sex of surgeon, patients' mortality declined with age of surgeon for both male and female surgeons (except for female surgeons aged 60 or older); female surgeons in their 50s had the lowest operative mortality. CONCLUSION: Using national data on Medicare beneficiaries in the US, this study found that patients treated by older surgeons had lower mortality than patients treated by younger surgeons. There was no evidence that operative mortality differed between male and female surgeons.
Tsugawa Y, Blumenthal DM, Jha AK, Orav JE, Jena AB. Association between physician medical school ranking and patient outcomes and costs of care: observational study. BMJ. 2018;362 :k3640.Abstract
OBJECTIVE: To investigate whether the (USNWR) ranking of the medical school a physician attended is associated with patient outcomes and healthcare spending. DESIGN: Observational study. SETTING: Medicare, 2011-15. PARTICIPANTS: 20% random sample of Medicare fee-for-service beneficiaries aged 65 years or older (n=996 212), who were admitted as an emergency to hospital with a medical condition and treated by general internists. MAIN OUTCOME MEASURES: Association between the USNWR ranking of the medical school a physician attended and the physician's patient outcomes (30 day mortality and 30 day readmission rates) and Medicare Part B spending, adjusted for patient and physician characteristics and hospital fixed effects (which effectively compared physicians practicing within the same hospital). A sensitivity analysis employed a natural experiment by focusing on patients treated by hospitalists, because patients are plausibly randomly assigned to hospitalists based on their specific work schedules. Alternative rankings of medical schools based on social mission score or National Institute of Health (NIH) funding were also investigated. RESULTS: 996 212 admissions treated by 30 322 physicians were examined for the analysis of mortality. When using USNWR primary care rankings, physicians who graduated from higher ranked schools had slightly lower 30 day readmission rates (adjusted rate 15.7% for top 10 schools 16.1% for schools ranked ≥50; adjusted risk difference 0.4%, 95% confidence interval 0.1% to 0.8%; P for trend=0.005) and lower spending (adjusted Part B spending $1029 (£790; €881) $1066; adjusted difference $36, 95% confidence interval $20 to $52; P for trend <0.001) compared with graduates of lower ranked schools, but no difference in 30 day mortality. When using USNWR research rankings, physicians graduating from higher ranked schools had slightly lower healthcare spending than graduates from lower ranked schools, but no differences in patient mortality or readmissions. A sensitivity analysis restricted to patients treated by hospitalists yielded similar findings. Little or no relation was found between alternative rankings (based on social mission score or NIH funding) and patient outcomes or costs of care. CONCLUSIONS: Overall, little or no relation was found between the USNWR ranking of the medical school from which a physician graduated and subsequent patient mortality or readmission rates. Physicians who graduated from highly ranked medical schools had slightly lower spending than graduates of lower ranked schools.
Goto A, Tsugawa Y, Fujimori K. Factors Associated With Intention of Future Pregnancy Among Women Affected by the Fukushima Nuclear Accident: Analysis of Fukushima Health Management Survey Data From 2012 to 2014. J Epidemiol. 2018.Abstract
BACKGROUND: Little is known about the association between the anxiety toward the effects of radiation on reproduction caused by the Fukushima nuclear accident and the birth rate of people in Fukushima. Therefore, we examined changes and associated factors of future pregnancy intention among mothers in Fukushima Prefecture. METHODS: Using data from three postal surveys among women who registered their pregnancies in the prefecture (N = 6,751 in 2012, N = 6,871 in 2013, and N = 6,725 in 2014), we analyzed the factors associated with women's intention of future pregnancy using multivariable logistic regression models. RESULTS: The proportion of mothers with pregnancy intention increased from 53.5% in 2012 to 57.9% in 2014, especially among multiparas (P for trend <0.001). Factors inversely associated with pregnancy intention of both groups were older maternal age (adjusted odds ratio [aOR] 0.92 for primipara and 0.87 for multipara), poor subjective health (aOR 0.75 and 0.81, respectively), and presence of depressive symptoms (aOR 0.71 and 0.79, respectively) (P < 0.01 for all items). In addition, not living with husband (aOR 0.24), dissatisfaction with obstetrical care (aOR 0.89) and child abnormalities (aOR 0.72) were inversely associated with pregnancy intention among primiparas, while receiving infertility treatment (aOR 2.05) was positively associated among multiparas (P < 0.01 for all items). A separate analysis of 2012 and 2013 data showed that concern about radiation contamination of breast milk was associated with pregnancy intention among primiparas (aOR 0.61, P < 0.001). CONCLUSIONS: Mothers' concern about radiation was associated with lower pregnancy intention, especially among primiparas. Providing quality obstetrical and mental health care and parenting support may be the keys to maintaining the temporal increase in fertility.
Goto T, Tsugawa Y, Faridi MK, Camargo CA, Hasegawa K. Reduced Risk of Acute Exacerbation of COPD After Bariatric Surgery: A Self-Controlled Case Series Study. Chest. 2018;153 (3) :611-617.Abstract
BACKGROUND: Obesity is common among individuals with COPD and associated with increased COPD morbidities. However, little is known about the impact of weight reduction on COPD-related outcomes in patients who are obese. METHODS: Using the population-based ED and inpatient sample in three US states (California, Florida, and Nebraska), we performed a self-controlled case series study of 481 adults who were obese (40-65 years of age) with COPD who underwent bariatric surgery. The primary outcome was an ED visit or hospitalization for acute exacerbation of COPD (AECOPD) from 2005 through 2011. We compared each patient's risk of the outcome during sequential 12-month periods using presurgery months 13 through 24 as the reference period. RESULTS: During the 13 to 24 months before bariatric surgery (ie, reference period), 28% (95% CI, 24%-32%) of patients had an ED visit or hospitalization for AECOPD. In the subsequent 12-month presurgery period, the risk did not change materially (31%; 95% CI, 27%-35%), with an adjusted OR (aOR) of 1.16 (95% CI, 0.88-1.53; P = .29). By contrast, during the first 12 months after bariatric surgery, the risk declined significantly (12%; 95% CI, 9%-15%; aOR, 0.35; 95% CI, 0.25-0.49; P < .001). Likewise, in the subsequent period of 13 to 24 months after bariatric surgery, the risk remained significantly low (13%; 95% CI, 11%-17%; aOR, 0.39; 95% CI, 0.28-0.55; P < .001). CONCLUSIONS: The risk of an ED visit or hospitalization for AECOPD substantially decreased after bariatric surgery in patients who are obese. This observation suggests the effectiveness of substantial weight reduction on COPD morbidity.
2017
Blumenthal DM, Olenski AR, Tsugawa Y, Jena AB. Association Between Treatment by Locum Tenens Internal Medicine Physicians and 30-Day Mortality Among Hospitalized Medicare Beneficiaries. JAMA. 2017;318 (21) :2119-2129.Abstract
Importance: Use of locum tenens physicians has increased in the United States, but information about their quality and costs of care is lacking. Objective: To evaluate quality and costs of care among hospitalized Medicare beneficiaries treated by locum tenens vs non-locum tenens physicians. Design, Setting, and Participants: A random sample of Medicare fee-for-service beneficiaries hospitalized during 2009-2014 was used to compare quality and costs of hospital care delivered by locum tenens and non-locum tenens internal medicine physicians. Exposures: Treatment by locum tenens general internal medicine physicians. Main Outcomes and Measures: The primary outcome was 30-day mortality. Secondary outcomes included inpatient Medicare Part B spending, length of stay, and 30-day readmissions. Differences between locum tenens and non-locum tenens physicians were estimated using multivariable logistic regression models adjusted for beneficiary clinical and demographic characteristics and hospital fixed effects, which enabled comparisons of clinical outcomes between physicians practicing within the same hospital. In prespecified subgroup analyses, outcomes were reevaluated among hospitals with different levels of intensity of locum tenens physician use. Results: Of 1 818 873 Medicare admissions treated by general internists, 38 475 (2.1%) received care from a locum tenens physician; 9.3% (4123/44 520) of general internists were temporarily covered by a locum tenens physician at some point. Differences in patient characteristics, demographics, comorbidities, and reason for admission between locum tenens and non-locum tenens physicians were not clinically relevant. Treatment by locum tenens physicians, compared with treatment by non-locum tenens physicians (n = 44 520 physicians), was not associated with a significant difference in 30-day mortality (8.83% vs 8.70%; adjusted difference, 0.14%; 95% CI, -0.18% to 0.45%). Patients treated by locum tenens physicians had significantly higher Part B spending ($1836 vs $1712; adjusted difference, $124; 95% CI, $93 to $154), significantly longer mean length of stay (5.64 days vs 5.21 days; adjusted difference, 0.43 days; 95% CI, 0.34 to 0.52), and significantly lower 30-day readmissions (22.80% vs 23.83%; adjusted difference, -1.00%; 95% CI -1.57% to -0.54%). Conclusions and Relevance: Among hospitalized Medicare beneficiaries treated by a general internist, there were no significant differences in overall 30-day mortality rates among patients treated by locum tenens compared with non-locum tenens physicians. Additional research may help determine hospital-level factors associated with the quality and costs of care related to locum tenens physicians.
Shimada YJ, Tsugawa Y, Iso H, Brown DFM, Hasegawa K. Association of bariatric surgery with risk of acute care use for hypertension-related disease in obese adults: population-based self-controlled case series study. BMC Med. 2017;15 (1) :161.Abstract
BACKGROUND: Hypertension carries a large societal burden. Obesity is known as a risk factor for hypertension. However, little is known as to whether weight loss interventions reduce the risk of hypertension-related adverse events, such as acute care use (emergency department [ED] visit and/or unplanned hospitalization). We used bariatric surgery as an instrument for investigating the effect of large weight reduction on the risk of acute care use for hypertension-related disease in obese adults with hypertension. METHODS: We performed a self-controlled case series study of obese patients with hypertension who underwent bariatric surgery using population-based ED and inpatient databases that recorded every bariatric surgery, ED visit, and hospitalization in three states (California, Florida, and Nebraska) from 2005 to 2011. The primary outcome was acute care use for hypertension-related disease. We used conditional logistic regression to compare each patient's risk of the outcome event during sequential 12-month periods, using pre-surgery months 13-24 as the reference period. RESULTS: We identified 980 obese patients with hypertension who underwent bariatric surgery. The median age was 48 years (interquartile range, 40-56 years), 74% were female, and 55% were non-Hispanic white. During the reference period, 17.8% (95% confidence interval [CI], 15.4-20.2%) had a primary outcome event. The risk remained unchanged in the subsequent 12-month pre-surgery period (18.2% [95% CI, 15.7-20.6%]; adjusted odds ratio [aOR] 1.02 [95% CI, 0.83-1.27]; P = 0.83). In the first 12-month period after bariatric surgery, the risk significantly decreased (10.5% [8.6-12.4%]; aOR 0.58 [95% CI, 0.45-0.74]; P < 0.0001). Similarly, the risk remained significantly reduced in the 13-24 months after bariatric surgery (12.9% [95% CI, 10.8-15.0%]; aOR 0.71 [95% CI, 0.57-0.90]; P = 0.005). By contrast, there was no significant reduction in the risk among obese patients who underwent non-bariatric surgery (i.e., cholecystectomy, hysterectomy, spinal fusion, or mastectomy). CONCLUSIONS: In this population-based study of obese adults with hypertension, we found that the risk of acute care use for hypertension-related disease decreased by 40% after bariatric surgery. The data provide the best evidence on the effectiveness of substantial weight loss on hypertension-related morbidities, underscoring the importance of discussing options for weight reduction when treating obese patients with hypertension.
Nishizaki Y, Mizuno A, Shinozaki T, Okubo T, Tsugawa Y, Shimizu T, Konishi R, Yamamoto Y, Yanagisawa N, Shiojiri T, et al. Educational environment and the improvement in the General Medicine In-training Examination score. J Gen Fam Med. 2017;18 (5) :312-314.
Tsugawa Y, Jena AB, Jha AK. Limitations Concerning the Association of Physician Sex and Patient Outcomes-Reply. JAMA Intern Med. 2017;177 (7) :1058-1059.
Tsugawa Y, Hashimoto K, Tabuchi T, Shibuya K. What can Japan learn from tobacco control in the UK?. Lancet. 2017;390 (10098) :933-934.
Shimada YJ, Tsugawa Y, Camargo CA, Brown DFM, Hasegawa K. Effect of Bariatric Surgery on Emergency Department Visits and Hospitalizations for Atrial Fibrillation. Am J Cardiol. 2017;120 (6) :947-952.Abstract
Atrial fibrillation (AF) and obesity are major health problems in the United States. However, little is known about whether bariatric surgery affects AF-related morbidities. This study investigated whether bariatric surgery is associated with short-term and long-term changes in the risk of emergency department (ED) visits or hospitalizations for AF. We performed a self-controlled case series study of obese adults with AF who underwent bariatric surgery by using population-based ED and inpatient databases in California, Florida, and Nebraska from 2005 to 2011. The primary outcome was ED visit or hospitalization for AF. We used conditional logistic regression to compare each patient's risk of the outcome event during sequential 12-month periods, using presurgery months 13 to 24 as a reference period. Our sample consisted of 523 obese adults with AF who underwent bariatric surgery. The median age was 57 years (interquartile range 48 to 64 years), 59% were female, and 84% were non-Hispanic white. During the reference period, 15.9% (95% confidence interval [CI] 12.7% to 19.0%) of patients had an ED visit or hospitalization for AF. The risk remained similar in the subsequent 12-month presurgery period (adjusted OR [aOR] 1.29 [95% CI, 0.94 to 1.76] p = 0.11). In contrast, the risk significantly increased within 12 months after bariatric surgery (aOR 1.53 [95% CI 1.13 to 2.07] p = 0.006). The risk remained elevated during 13-24 months after bariatric surgery (aOR 1.41 [95% CI, 1.03 to 1.91] p = 0.03). In conclusion, this population-based study demonstrated that bariatric surgery was associated with an increased risk of AF episodes requiring an ED visit or hospitalization for at least 2 years after surgery among obese patients with AF.
Sakai Bizmark R, Chang R-KR, Tsugawa Y, Zangwill KM, Kawachi I. Impact of AHA's 2007 guideline change on incidence of infective endocarditis in infants and children. Am Heart J. 2017;189 :110-119.Abstract
Use a nationally representative sample to assess impacts of new clinical guidelines issued by the American Heart Association (AHA) in 2007 for many types of invasive procedures, with recommendations for significant decreases in antimicrobial prophylaxis use. STUDY DESIGN: Interrupted time series analyses of pediatric hospitalizations for Infective Endocarditis (IE), using the Nationwide Inpatient Sample (NIS) ICD-9-CM diagnostic codes, identified IE hospitalizations for patients <18 years old from 2001 to 2012. Changes in IE incidence before and after 2007 AHA guidelines were evaluated, with differences in IE clinical severity assessed using in-hospital mortality and length of stay. Analyses were stratified by pathogen type and age group (0-9 y/o and 10-17 y/o). RESULTS: With 3,748 patients in the study, we observed rising trends in IE incidence, but no significant difference between pre- and post-guideline. There was a significant trend increase for IE due to viridans group streptococci (VGS) for ages >10 years old, comparing pre-guideline to post-guideline periods, but not in children 0-9 years of age. Neither in-hospital mortality nor length of stay changed significantly during study. CONCLUSIONS: The data did not demonstrate an impact of the 2007 guideline changes on overall incidence of pediatric IE. However, a significant increase in disease incidence trend due to VGS was observed for the 10-17 year-old group, compared pre- and post-guideline.
Nomura S, Sakamoto H, Glenn S, Tsugawa Y, Abe SK, Rahman MM, Brown JC, Ezoe S, Fitzmaurice C, Inokuchi T, et al. Population health and regional variations of disease burden in Japan, 1990-2015: a systematic subnational analysis for the Global Burden of Disease Study 2015. Lancet. 2017;390 (10101) :1521-1538.Abstract
BACKGROUND: Japan has entered the era of super-ageing and advanced health transition, which is increasingly putting pressure on the sustainability of its health system. The level and pace of this health transition might vary across regions within Japan and concern is growing about increasing regional variations in disease burden. The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) provides a comprehensive, comparable framework. We used data from GBD 2015 with the aim to quantify the burden of disease and injuries, and to attribute risk factors in Japan at a subnational, prefecture-level. METHODS: We used data from GBD 2015 for 315 causes and 79 risk factors of death, disease, and injury incidence and prevalence to measure the burden of diseases and injuries in Japan and in the 47 Japanese prefectures from 1990 to 2015. We extracted data from GBD 2015 to assess mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), life expectancy, and healthy life expectancy (HALE) in Japan and its 47 prefectures. We split extracted data by prefecture and applied GBD methods to generate estimates of burden, and attributable burden due to known risk factors. We examined the prefecture-level relationships of common health system inputs (eg, health expenditure and workforces) to the GBD outputs in 2015 to address underlying determinants of regional health variations. FINDINGS: Life expectancy at birth in Japan increased by 4·2 years from 79·0 years (95% uncertainty interval [UI] 79·0 to 79·0) to 83·2 years (83·1 to 83·2) between 1990 and 2015. However, the gaps between prefectures with the lowest and highest life expectancies and HALE have widened, from 2·5 to 3·1 years and from 2·3 to 2·7 years, respectively, from 1990 to 2015. Although overall age-standardised death rates decreased by 29·0% (28·7 to 29·3) from 1990 to 2015, the rates of mortality decline in this period substantially varied across the prefectures, ranging from -32·4% (-34·8 to -30·0) to -22·0% (-20·4 to -20·1). During the same time period, the rate of age-standardised DALYs was reduced overall by 19·8% (17·9 to 22·0). The reduction in rates of age-standardised YLDs was very small by 3·5% (2·6 to 4·3). The pace of reduction in mortality and DALYs in many leading causes has largely levelled off since 2005. Known risk factors accounted for 34·5% (32·4 to 36·9) of DALYs; the two leading behavioural risk factors were unhealthy diets and tobacco smoking in 2015. The common health system inputs were not associated with age-standardised death and DALY rates in 2015. INTERPRETATION: Japan has been successful overall in reducing mortality and disability from most major diseases. However, progress has slowed down and health variations between prefectures is growing. In view of the limited association between the prefecture-level health system inputs and health outcomes, the potential sources of regional variations, including subnational health system performance, urgently need assessment. FUNDING: Bill & Melinda Gates Foundation, Japan Ministry of Education, Science, Sports and Culture, Japan Ministry of Health, Labour and Welfare, AXA CR Fixed Income Fund and AXA Research Fund.
Tsugawa Y, Newhouse JP, Zaslavsky AM, Blumenthal DM, Jena AB. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ. 2017;357 :j1797.Abstract
 To investigate whether outcomes of patients who were admitted to hospital differ between those treated by younger and older physicians. Observational study. US acute care hospitals. 20% random sample of Medicare fee-for-service beneficiaries aged ≥65 admitted to hospital with a medical condition in 2011-14 and treated by hospitalist physicians to whom they were assigned based on scheduled work shifts. To assess the generalizability of findings, analyses also included patients treated by general internists including both hospitalists and non-hospitalists. 30 day mortality and readmissions and costs of care.  736 537 admissions managed by 18 854 hospitalist physicians (median age 41) were included. Patients' characteristics were similar across physician ages. After adjustment for characteristics of patients and physicians and hospital fixed effects (effectively comparing physicians within the same hospital), patients' adjusted 30 day mortality rates were 10.8% for physicians aged <40 (95% confidence interval 10.7% to 10.9%), 11.1% for physicians aged 40-49 (11.0% to 11.3%), 11.3% for physicians aged 50-59 (11.1% to 11.5%), and 12.1% for physicians aged ≥60 (11.6% to 12.5%). Among physicians with a high volume of patients, however, there was no association between physician age and patient mortality. Readmissions did not vary with physician age, while costs of care were slightly higher among older physicians. Similar patterns were observed among general internists and in several sensitivity analyses. Within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those physicians treating high volumes of patients.
Tsugawa Y, Jha AK, Newhouse JP, Zaslavsky AM, Jena AB. Variation in Physician Spending and Association With Patient Outcomes. JAMA Intern Med. 2017;177 (5) :675-682.Abstract
Importance: While the substantial variation in health care spending across regions and hospitals is well known, key clinical decisions are ultimately made by physicians. However, the degree to which spending varies across physicians and the clinical consequences of that variation are unknown. Objective: To investigate variation in spending across physicians and its association with patient outcomes. Design, Setting, and Participants: For this retrospective data analysis, we analyzed a 20% random sample of Medicare fee-for-service beneficiaries 65 years and older who were hospitalized with a nonelective medical condition and treated by a general internist between January 1, 2011, and December 31, 2014. We first quantified the proportion of variation in Medicare Part B spending attributable to hospitals, physicians, and patients. We then examined the association between physician spending and patient outcomes, adjusted for patient and physician characteristics and hospital fixed effects (effectively comparing physicians within the same hospital). Our primary analysis focused on hospitalist physicians, whose patients are plausibly quasirandomized within a hospital based on physician work schedule. A secondary analysis focused on general internists overall. To ensure that patient illness severity did not directly affect physician spending estimates, we calculated physicians' spending levels in 2011 through 2012 and examined outcomes of their patients in 2013 and 2014. Exposures: Physicians' adjusted Part B spending level in 2011 through 2012. Main Outcomes and Measures: Patients' 30-day mortality and readmission rates in 2013 and 2014. Results: To determine the amount of variation across physicians we included 485 016 hospitalizations treated by 21 963 physicians at 2837 acute care hospitals for the analysis of hospitalists and 839 512 hospitalizations treated by 50 079 physicians at 3195 acute care hospitals for the analysis of general internists. Variation in spending across physicians within hospital was larger than variation across hospitals (for hospitalists, 8.4% across physicians vs 7.0% across hospitals; for general internists, 10.5% across physicians vs 6.2% across hospitals). Higher physician spending was not associated with lower 30-day mortality (adjusted odds ratio [aOR] for additional $100 in physician spending, 1.00; 95% CI, 0.98-1.01; P = .47) or readmissions (aOR, 1.00; 95% CI, 0.99-1.01; P = .54) for hospitalists within the same hospital. We observed similar patterns among general internists. Conclusions and Relevance: Health care spending varies more across individual physicians than across hospitals. However, higher physician spending is not associated with better outcomes of hospitalized patients. Our findings suggest policies targeting both physicians and hospitals may be more effective in reducing wasteful spending than policies focusing solely on hospitals.
Shimada YJ, Tsugawa Y, Iso H, Brown DFM, Hasegawa K. Association between bariatric surgery and rate of hospitalisations for stable angina pectoris in obese adults. Heart. 2017;103 (13) :1009-1014.Abstract
OBJECTIVE: Obesity and stable angina pectoris (SAP) are important public health problems in the USA. However, little is known about whether weight reduction affects the rate of SAP-related morbidities. This study was designed to test the hypothesis that bariatric surgery is associated with a lower rate of hospitalisations for SAP in obese adults. METHODS: We performed a self-controlled case series study of obese adults with SAP who underwent bariatric surgery using a population-based inpatient database in three states (California, Florida and Nebraska) from 2005 to 2011. The primary outcome was hospitalisation for SAP. We used conditional logistic regression to compare the rate of the outcome event during sequential 12-month periods, using presurgery months 13-24 as a reference period. RESULTS: Our sample consisted of 953 patients with SAP who underwent bariatric surgery. The median age was 57 years, 51% were women, and 78% were non-Hispanic white. During the reference period, 25.3% (95%CI, 22.5% to 28.1%) had a hospitalisation for SAP. The rate remained stable in the subsequent 12-month presurgery period (adjusted OR (aOR) 0.84 (95% CI, 0.69 to 1.02); p=0.07). In the first 12-month period after bariatric surgery, we observed a significantly lower rate (9.1% (95% CI, 7.3% to 11.0%); aOR 0.33 (95% CI, 0.26 to 0.43); p<0.0001). Similarly, the rate remained significantly lower in the subsequent 13-24 months after bariatric surgery (8.7% (95% CI, 6.9% to 10.5%); aOR 0.31 (95% CI, 0.24 to 0.41); p<0.0001). CONCLUSION: In this population-based study of obese adults with SAP, we found that the rate of hospitalisations for SAP was lower by two-thirds after bariatric surgery.
Goto Y, Goto T, Hagiwara Y, Tsugawa Y, Watase H, Okamoto H, Hasegawa K. Techniques and outcomes of emergency airway management in Japan: An analysis of two multicentre prospective observational studies, 2010-2016. Resuscitation. 2017;114 :14-20.Abstract
OBJECTIVES: Continuous surveillance of emergency airway management practice is imperative in improving quality of care and patient safety. We aimed to investigate the changes in the practice of emergency airway management and the related outcomes in the emergency departments (EDs) in Japan. METHODS: We conducted an analysis of the data from two prospective, observational, multicentre registries of emergency airway management-the Japanese Emergency Airway Network (JEAN)-1 and -2 Registries from April 2010 through May 2016. RESULTS: We recorded 10,927 ED intubations (capture rate, 96%); 10,875 paediatric and adult patients were eligible for our analysis. The rate of rapid sequence intubation (RSI) use as the initial intubation method significantly increased from 28% in 2010 to 53% in 2016 (P=0.03). Likewise, the rate of video laryngoscope (VL) use as the first intubation device increased significantly from 2% in 2010 to 40% in 2016 (P<0.001), with a significant decrease in the rate of direct laryngoscope use from 97% in 2010 to 58% in 2016 (P<0.001). Concurrent with these changes, the overall first-attempt success rate also increased from 68% in 2010 to 74% in 2016 (P=0.02). By contrast, the rate of adverse events did not change significantly over time (P=0.06). CONCLUSION: By using data from two large, multicentre, prospective registries, we characterised the current emergency airway management practice, and identified their changes in Japan. The data demonstrated significant increases in the rate of RSI and VL use on the first attempt and the first-attempt success rate over the 6-year study period.
Tsugawa Y, Jena AB, Orav JE, Jha AK. Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study. BMJ. 2017;356 :j273.Abstract
OBJECTIVE:  To determine whether patient outcomes differ between general internists who graduated from a medical school outside the United States and those who graduated from a US medical school. DESIGN:  Observational study. SETTING:  Medicare, USA. PARTICIPANTS:  20% national sample of data for Medicare fee-for-service beneficiaries aged 65 years or older admitted to hospital with a medical condition in 2011-14 and treated by international or US medical graduates who were general internists. The study sample for mortality analysis included 1 215 490 admissions to the hospital treated by 44 227 general internists. MAIN OUTCOME MEASURES:  Patients' 30 day mortality and readmission rates, and costs of care per hospital admission, with adjustment for patient and physician characteristics and hospital fixed effects (effectively comparing physicians within the same hospital). As a sensitivity analysis, we focused on physicians who specialize in the care of patients admitted to hospital ("hospitalists"), who typically work in shifts and whose patients are plausibly quasi-randomized based on the physicians' work schedules. RESULTS:  Compared with patients treated by US graduates, patients treated by international graduates had slightly more chronic conditions. After adjustment for patient and physician characteristics and hospital fixed effects, patients treated by international graduates had lower mortality (adjusted mortality 11.2% v 11.6%; adjusted odds ratio 0.95, 95% confidence interval 0.93 to 0.96; P<0.001) and slightly higher costs of care per admission (adjusted costs $1145 (£950; €1080) v $1098; adjusted difference $47, 95% confidence interval $39 to $55, P<0.001). Readmission rates did not differ between the two types of graduates. Similar differences in patient outcomes were observed among hospitalists. Differences in patient mortality were not explained by differences in length of stay, spending level, or discharge location. CONCLUSIONS:  Data on older Medicare patients admitted to hospital in the US showed that patients treated by international graduates had lower mortality than patients cared for by US graduates.
Tsugawa Y, Jena AB, Figueroa JF, Orav JE, Blumenthal DM, Jha AK. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Intern Med. 2017;177 (2) :206-213.Abstract
Importance: Studies have found differences in practice patterns between male and female physicians, with female physicians more likely to adhere to clinical guidelines and evidence-based practice. However, whether patient outcomes differ between male and female physicians is largely unknown. Objective: To determine whether mortality and readmission rates differ between patients treated by male or female physicians. Design, Setting, and Participants: We analyzed a 20% random sample of Medicare fee-for-service beneficiaries 65 years or older hospitalized with a medical condition and treated by general internists from January 1, 2011, to December 31, 2014. We examined the association between physician sex and 30-day mortality and readmission rates, adjusted for patient and physician characteristics and hospital fixed effects (effectively comparing female and male physicians within the same hospital). As a sensitivity analysis, we examined only physicians focusing on hospital care (hospitalists), among whom patients are plausibly quasi-randomized to physicians based on the physician's specific work schedules. We also investigated whether differences in patient outcomes varied by specific condition or by underlying severity of illness. Main Outcomes and Measures: Patients' 30-day mortality and readmission rates. Results: A total of 1 583 028 hospitalizations were used for analyses of 30-day mortality (mean [SD] patient age, 80.2 [8.5] years; 621 412 men and 961 616 women) and 1 540 797 were used for analyses of readmission (mean [SD] patient age, 80.1 [8.5] years; 602 115 men and 938 682 women). Patients treated by female physicians had lower 30-day mortality (adjusted mortality, 11.07% vs 11.49%; adjusted risk difference, -0.43%; 95% CI, -0.57% to -0.28%; P < .001; number needed to treat to prevent 1 death, 233) and lower 30-day readmissions (adjusted readmissions, 15.02% vs 15.57%; adjusted risk difference, -0.55%; 95% CI, -0.71% to -0.39%; P < .001; number needed to treat to prevent 1 readmission, 182) than patients cared for by male physicians, after accounting for potential confounders. Our findings were unaffected when restricting analyses to patients treated by hospitalists. Differences persisted across 8 common medical conditions and across patients' severity of illness. Conclusions and Relevance: Elderly hospitalized patients treated by female internists have lower mortality and readmissions compared with those cared for by male internists. These findings suggest that the differences in practice patterns between male and female physicians, as suggested in previous studies, may have important clinical implications for patient outcomes.
2016
Wang DE, Tsugawa Y, Jha AK. Patient Experience and Health Care Quality-Reply. JAMA Intern Med. 2016;176 (10) :1575-1576.

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