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Differences between determinants of in-hospital mortality and hospitalisation costs for patients with acute heart failure: a nationwide observational study from Japan
  1. Noriko Sasaki,
  2. Susumu Kunisawa,
  3. Hiroshi Ikai,
  4. Yuichi Imanaka
  1. Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Kyoto, Japan
  1. Correspondence to Dr Yuichi Imanaka; imanaka-y{at}


Objectives Although current case-mix classifications in prospective payment systems were developed to estimate patient resource usage, whether these classifications reflect clinical outcomes remains unknown. The efficient management of acute heart failure (AHF) with high mortality is becoming more important in many countries as its prevalence and associated costs are rapidly increasing. Here, we investigate the determinants of in-hospital mortality and hospitalisation costs to clarify the impact of severity factors on these outcomes in patients with AHF, and examine the level of agreement between the predicted values of mortality and costs.

Design Cross-sectional observational study.

Setting and participants A total of 19 926 patients with AHF from 261 acute care hospitals in Japan were analysed using administrative claims data.

Main outcome measures Multivariable logistic regression analysis and linear regression analysis were performed to examine the determinants of in-hospital mortality and hospitalisation costs, respectively. The independent variables were grouped into patient condition on admission, postadmission procedures indicating disease severity (eg, intra-aortic balloon pumping) and other high-cost procedures (eg, single-photon emission CT). These groups of independent variables were cumulatively added to the models, and their effects on the models' abilities to predict the respective outcomes were examined. The level of agreement between the quartiles of predicted mortality and predicted costs was analysed using Cohen's κ coefficient.

Results In-hospital mortality was associated with patient's condition on admission and severity-indicating procedures (C-statistics 0.870), whereas hospitalisation costs were associated with severity-indicating procedures and high-cost procedures (R2 0.32). There were substantial differences in determinants between the outcomes. In addition, there was no consistent relationship observed (κ=0.016, p<0.0001) between the quartiles of in-hospital mortality and hospitalisation costs.

Conclusions The determinants of mortality and costs for hospitalised patients with AHF were generally different. Our results indicate that the same case-mix classifications should not be used to predict both these outcomes.

  • Case-mix classification
  • in-hospital mortality
  • hospitalization costs
  • resource utilization

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  • Contributors NS and YI had full access to all the data, were involved in the study design and wrote the manuscript. NS, SK, HI and YI acquired, analysed and interpreted the data, as well as performed the statistical analyses. YI acquired funding for the study. All authors were involved in critical revisions and approval of the final manuscript.

  • Funding This research was financially supported in part by a Health Sciences Research Grant from the Ministry of Health, Labour and Welfare of Japan (H27-iryo-ippan-001), a Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science ([A]16H02634), and a Health, Labour and Welfare Policy Research Grant (H28-seisaku-shitei-009).

  • Competing interests None declared.

  • Ethics approval This study was approved by the Ethics Committee of Kyoto University Graduate School and Faculty of Medicine, Japan.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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