Evidence‐based prescription of corticosteroids for COVID‐19 patients: A comparison between general medicine and other specialty in Japan

Abstract Background The difference of evidence‐based prescription for COVID‐19 patients between general medicine and other specialty in Japan is unclear. Methods A retrospective observational study using a hospital‐based administrative database was conducted for the differences between departments for prescriptions of glucocorticoids in COVID‐19 patients. Results Of 65,156 patients, 23,348 met indication for glucocorticoids. General medicine physicians in Japan were more likely to prescribe corticosteroids for COVID‐19 patients than other departments after its evidence was published (adjusted odds ratio, 1.32; p < 0.001; 95% confidence interval, 1.11–1.56). Conclusions General medicine physicians were more likely to practice evidence‐based care for COVID‐19 patients.


| INTRODUC TI ON
It is crucial to determine the quality of general care for COVID-19 patients to assess patient outcomes. In several countries, general practitioners had to contribute as the mainstay of outpatient and inpatient care because infectious disease specialists and respiratory physicians could not treat all patients during the COVID-19 pandemic. 1,2 Numerous clinical trials have been conducted to date, with the aim of establishing an effective treatment. In particular, the report of an absolute risk reduction in 28-day mortality by administering dexamethasone to COVID-19 hospitalized patients requiring oxygen therapy and mechanical ventilation on June 16, 2020, was a breakthrough. 3 In the United Kingdom, based on this scientific evidence, the administration rate of corticosteroids to eligible patients increased from 27.5% in the week before June 16, 2020, to 75%-80% in January 2021, and the successful implementation of new treatment methods with a high evidence level was recognized, mainly in general medicine departments. 4 However, the circumstances surrounding the implementation of corticosteroids in COVID-19 patients by general medicine departments in Japan are unclear. Potential inequalities in treatment according to specialty during pandemics are critical to individuals, communities, and nations. Therefore, we aimed to elucidate the quality of general care for COVID-19 patients. We examined the past situation of glucocorticoid prescription for COVID-19 patients after solid evidence had been published and whether there were differences by specialty in Japan during this pandemic.

| ME THODS
The current study used the largest nationwide hospital adminis-

| Variables
The data used in this study included demographics, clinical characteristics, corticosteroid use, and departmental characteristics (general medicine, respiratory medicine, emergency medicine, internal medicine, pediatrics, cardiology, and gastroenterology) ( Table 1). We followed the Japanese Medical Specialty Organization for specialty classification by the physicians. 6 Standard descriptive statistics were used to calculate the number, percentage, mean, median, and interquartile range (IQR) for each piece of data. The chi-square test or Fisher's exact test was used for comparisons of categorical data. For continuous variables, t-tests or Reference Manual). All tests were two tailed, and statistical significance was set at p < 0.05.This study was approved by the appropriate ethics committee.

| DISCUSS ION
This is the first study to analyze corticosteroid prescription and the department of admission for COVID-19 patients using a large Japanese database. We found that the general medicine department was significantly more likely to use corticosteroids in COVID-19 patients requiring oxygen therapy and mechanical ventilation at the time of admission than other departments. In addition to individual behavioral change, factors involved in decision-making must be considered when implementing new therapeutic interventions, and in several cases, the complexity of the intervention and difficulty in reaching consensus with others have been identified as barriers. 7 In previous studies, the Department of General Medicine collaborated with nurses and other frontline care team members during COVID-19 treatment, which facilitated consensus building regarding new healthcare delivery methods and information sharing. 8,9 This may have been a factor in the rapid introduction of corticosteroids with a high level of evidence and decision-making based on scientific evidence.
This study had several limitations. First, it only analyzed data from COVID-19 patients in DPC-registered hospitals in Japan. This is an inadequate sample size compared with the number of patients published by the MHLW. 10 Second, because of the characteristics of the data described above, there may be insufficient assessment of the expertise of physicians involved in the prescription of corticosteroids.
In conclusion, we evaluated the characteristics of corticosteroid prescriptions for COVID-19 patients after data on treatment with a high level of evidence was published and found that general medicine departments prescribed more corticosteroids for COVID-19 patients than other departments. This was a result of the application of treatment by general medicine departments immediately after data with high level of evidence regarding the treatment were published.

ACK N OWLED G M ENTS
We thank the team members, Dr.

PATI E NT CO N S E NT S TATE M E NT
None.

CLI N I C A L TR I A L R EG I S TR ATI O N
None.

CO N FLI C T O F I NTE R E S T
The authors have stated explicitly that there are no conflicts of interest in connection with this article.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.