Person: Tsugawa, Yusuke
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Tsugawa
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Yusuke
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Tsugawa, Yusuke
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Publication Educational environment and the improvement in the General Medicine In‐training Examination score(John Wiley and Sons Inc., 2017) Nishizaki, Yuji; Mizuno, Atsushi; Shinozaki, Tomohiro; Okubo, Tomoya; Tsugawa, Yusuke; Shimizu, Taro; Konishi, Ryota; Yamamoto, Yu; Yanagisawa, Naotake; Shiojiri, Toshiaki; Tokuda, YasuharuPublication Association of bariatric surgery with risk of acute care use for hypertension-related disease in obese adults: population-based self-controlled case series study(BioMed Central, 2017) Shimada, Yuichi J.; Tsugawa, Yusuke; Iso, Hiroyasu; Brown, David; Hasegawa, KoheiBackground: 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. Electronic supplementary material The online version of this article (doi:10.1186/s12916-017-0914-5) contains supplementary material, which is available to authorized users.Publication Regional health expenditure and health outcomes after out-of-hospital cardiac arrest in Japan: an observational study(BMJ Publishing Group, 2015) Tsugawa, Yusuke; Hasegawa, Kohei; Hiraide, Atsushi; Jha, AshishObjectives: Japan is considering policies to set the target health expenditure level for each region, a policy approach that has been considered in many other countries. The objective of this study was to examine the relationship between regional health expenditure and health outcomes after out-of-hospital cardiac arrest (OHCA), which incorporates the qualities of prehospital, in-hospital and posthospital care systems. Design: We examined the association between prefecture-level per capita health expenditure and patients’ health outcomes after OHCA. Setting: We used a nationwide, population-based registry system of OHCAs that captured all cases with OHCA resuscitated by emergency responders in Japan from 2005 to 2011. Participants: All patients with OHCA aged 1–100 years were analysed. Outcome measures The patients’ 1-month survival rate, and favourable neurological outcome (defined as cerebral performance category 1–2) at 1-month. Results: Among 618 154 cases with OHCA, the risk-adjusted 1-month survival rate varied from 3.3% (95% CI 2.9% to 3.7%) to 8.4% (95% CI 7.7% to 9.1%) across prefectures. The risk-adjusted probabilities of favourable neurological outcome ranged from 1.6% (95% CI 1.4% to 1.9%) to 3.7% (95% CI 3.4% to 3.9%). Compared with prefectures with lowest tertile health expenditure, 1-month survival rate was significantly higher in medium-spending (adjusted OR 1.31, 95% CI 1.03 to 1.66, p=0.03) and high-spending prefectures (adjusted OR 1.30, 95% CI 1.03 to 1.64, p=0.02), after adjusting for patient characteristics. There was no difference in the survival between medium-spending and high-spending regions. We observed similar patterns for favourable neurological outcome. Additional adjustment for regional per capita income did not affect our overall findings. Conclusions: We observed a wide variation in the health outcomes after OHCA across regions. Low-spending regions had significantly worse health outcomes compared with medium-spending or high-spending regions, but no difference was observed between medium-spending and high-spending regions. Our findings suggest that focusing on the median spending may be the optimum that allows for saving money without compromising patient outcomes.Publication Variation in Quality and Costs of Care Across Physicians and Its Determinants(2016-05-06) Tsugawa, Yusuke; Jha, Ashish K.; Jena, Anupam B.; Newhouse, Joseph P.; Zaslavsky, Alan M.This dissertation evaluates one of the key determinants of health care quality and costs – practice patterns of physicians. For decades, rapid health care spending growth and suboptimal quality of care have been fundamental issues of the U.S. health care system. A large body of literature has demonstrated substantial geographic variation in health care utilization without concomitant improvement in patient outcomes in higher spending regions. This literature has spurred debate about whether current levels of health care utilization are indeed socially wasteful – i.e., generate higher spending with no improvement in patient outcomes. While informative, however, this literature has not investigated variation due to individual physician behaviors, despite the central role of physicians as key decision makers in health care. In fact, surprisingly little is known about how individual physicians vary in their care, the determinants of that care, and the implications of that variation for patient outcomes. This dissertation attempts to shed light on these questions by analyzing the productivity of health care spending at the physician level. Chapter 1 investigates the proportion of service use variation that can be explained by variation in individual physician practice patterns, and examines the impact of that variation on patient outcomes. I analyze data on Medicare beneficiaries hospitalized with medical conditions treated by general internists. Using a cross-classified multilevel model, I find that variation in spending across physicians exceeds variation across hospitals (10.9% and 6.2% of overall spending, respectively). As for evaluating the impact of between-physician variation in spending on patient outcomes, I exploit a natural experiment of physicians who specialize in hospital-based care – hospitalist physicians. Hospitalists routinely work in shifts and therefore patients are plausibly quasi-randomized to these physicians within a hospital based on physician work schedule. Among 272,979 hospitalizations treated by 8,489 hospitalists, hospitalists in the highest-spending quartile had lower 30-day patient mortality than hospitalists in the lowest quartile within the same hospital, despite similar patient characteristics (adjusted mortality rate 10.7% vs. 11.2%; adjusted odds ratio 0.94, 95%CI: 0.90 to 0.98, p=0.002). I observe no relationship between physician spending and patients’ readmission rates. Given larger variation in spending across physicians than across hospitals, our findings suggest that policies focused on individual physicians may be as or more effective than those targeted toward hospitals or regions. Moreover, interventions targeted at high-spending physicians to reduce spending, without accounting for their quality of care, may have the unintended consequence of negatively impacting patients’ health. Chapter 2 begins my evaluation of the upstream determinants of variation in quality of care across physicians with a special focus on physicians’ years in practice. Physicians with longer years in practice may accumulate, or conversely exhibit obsolescence of, knowledge and skills. However, the association between physicians’ years in practice and patient outcomes is poorly understood. Using data on Medicare beneficiaries aged 65 years or older hospitalized during 2011-2013 with a medical condition, I investigate the association between hospitalist physicians’ years since residency completion and patient outcomes, adjusting for patient and physician characteristics and hospital-specific fixed effects. I again rely on quasi-randomization of patients to hospitalists to circumvent the possibility that physicians with greater years in practice may treat patients that are sicker on unobserved dimensions. Of 386,159 hospitalizations treated by 14,650 hospitalists, hospitalists in practice longer had higher patient mortality than hospitalists in practice for fewer years, despite similar patient characteristics. Each additional 10 years in practice was associated with 0.5% increase (95% CI: 0.3% to 0.7%, p<0.001) in patients’ mortality. Significant effects were present for low- and medium-volume physicians, but not high-volume physicians. Readmissions and costs of care were not meaningfully associated with physician years in practice. This study has implications for recent debates in the medical community regarding how best to ensure maintenance of clinical skills over a physician’s career. Our findings suggest that evaluating patient outcomes, particularly among older physicians with low-to-medium patient volume, may be necessary to guarantee that quality care provided by physicians is high throughout their careers. Chapter 3 assesses another upstream determinant of between-physician variation in quality of care – physician sex. 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. While physician sex is not a modifiable factor, understanding whether quality of care differs between male and female physicians is critically important, as it allows us to further investigate which aspects of practice patterns that vary between male and female physicians lead to better patient outcomes. Using nationally representative data on Medicare beneficiaries in 2012-2013, I examine the association between physician sex and patient outcomes among general internists. Despite similar observed illness severity of patients, female physicians have lower 30-day patient mortality (adjusted mortality rate 10.9% vs 11.4%; adjusted risk difference -0.5%, 95%CI: -0.7% to -0.4%, p<0.001) and lower 30-day readmissions (adjusted readmission rate 15.1% vs 15.8%; adjusted risk difference -0.7%, 95%CI: -0.8% to -0.5, p<0.001) within same hospital. These findings are unaffected when restricting analyses to hospitalist physicians for whom patients are plausibly randomized. Although the exact mechanism underlying these differences remains unclear, understanding why these differences in care quality exist, and what we might do to alleviate them, is critical to ensuring that all patients get high quality care.Publication Impact of inpatient caseload, emergency department duties, and online learning resource on General Medicine In-Training Examination scores in Japan(Dove Medical Press, 2015) Kinoshita, Kensuke; Tsugawa, Yusuke; Shimizu, Taro; Tanoue, Yusuke; Konishi, Ryota; Nishizaki, Yuji; Shiojiri, Toshiaki; Tokuda, YasuharuBackground: Both clinical workload and access to learning resource are important components of educational environment and may have effects on clinical knowledge of residents. Methods: We conducted a survey with a clinical knowledge evaluation involving postgraduate year (PGY)-1 and -2 resident physicians at teaching hospitals offering 2-year postgraduate training programs required for residents in Japan, using the General Medicine In-Training Examination (GM-ITE). An individual-level analysis was conducted to examine the impact of the number of assigned patients and emergency department (ED) duty on the residents’ GM-ITE scores by fitting a multivariable generalized estimating equations. In hospital-level analysis, we evaluated the relationship between for the number of UpToDate reviews for each hospital and for the hospitals’ mean GM-ITE score. Results: A total of 431 PGY-1 and 618 PGY-2 residents participated. Residents with four or five times per month of the ED duties exhibited the highest mean scores compared to those with greater or fewer ED duties. Those with largest number of inpatients in charge exhibited the highest mean scores compared to the residents with fewer inpatients in charge. Hospitals with the greater UpToDate topic viewing showed significantly greater mean score. Conclusion: Appropriate ED workload and inpatient caseload, as well as use of evidence-based electronic resources, were associated with greater clinical knowledge of residents.