Shiga University of Medical Science

Urban-rural healthcare disparities remain a global challenge, driven by the concentration of medical resources in urban centers. We developed a circulation-based model integrating medical resource allocation, education, and digital health. Since 2020, this program has been implemented in Hokkaido, Japan. This study examines its structure and outcomes.

The model includes physician and trainee rotation, structured referral pathways, community-based medical education, and digital infrastructure. A three-tier system was established: Esashi (primary/secondary care), Hakodate (tertiary center), and Sapporo (education and physician dispatch hub). Outcomes were assessed in three domains: health outcomes, financial sustainability, and educational outcomes. Educational outcomes were based on a previously published study in the same cohort.

Health outcomes showed overall improvement, with the standardized mortality ratio decreasing from 103.4 to 98.3 in males and from 104.8 to 100.5 in females, although these changes were not statistically significant. Pneumonia-related SMR decreased significantly in both males and females. Financial indicators improved, with inpatient revenue per patient increasing significantly from 26,553 to 38,478 JPY. In addition, medical students reported increased confidence in clinical competencies.

This model improved health, financial, and educational outcomes by coordinating physician mobility, tiered regional collaboration, and digital connectivity.(195words).

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) prevent cardiovascular events in patients with diabetic kidney disease (DKD). However, limited data exist regarding the change in B-type natriuretic peptide (BNP) after treatment. This study investigated whether SGLT2i are associated with a greater BNP reduction than other antidiabetic drugs and identified the predictors of BNP reduction following SGLT2i.

Using the Japanese nationwide database, we compared BNP levels before and 30-365 days after initiation of antidiabetic medication in 1818 patients with DKD (71 ± 12 years, 68% men, BNP 71 [27-190] pg/mL, estimated glomerular filtration rate (eGFR) 51 ± 22 mL/min/1.73 m²).

BNP reduction, defined as a reduction of >10%, occurred in 474 (50.5%) of 939 patients treated with SGLT2i and 339 (38.6%) of 879 treated with other antidiabetic drugs. SGLT2i was associated with BNP level reduction in a multivariable logistic regression analysis (odds ratio, 1.497 [1.206-1.859]; p < 0.001). This association was consistent across eGFR, proteinuria, and multiple BNP endpoints. Concomitant use of loop diuretics was associated with a lower rate of BNP reduction after SGLT2i.

Compared with other antidiabetic drugs, SGLT2i was substantially associated with BNP reduction in a broad spectrum of DKD.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are treatment options for Type 2 diabetes (T2D), but their efficacy in patients with heart failure with reduced ejection fraction (HFrEF) remains unclear. We evaluated the association of GLP-1 RAs added to guideline-directed medical therapy (GDMT) with all-cause death and hospitalization in patients with HFrEF and T2D.

We conducted a retrospective cohort study using the TriNetX platform. Patients with HFrEF and T2D were identified between 2018 and 2023 (N = 579,171). Of these, 3,379 received all of GDMTs with GLP-1 RAs, and 14,712 received all of GDMTs without GLP-1 RAs. After propensity score matching, 3,158 patients were included in each group. Primary outcome was all-cause death over 18 months; secondary outcome was hospitalization.

All of GDMTs with GLP-1 RAs were associated with a lower risk of all-cause death than all of GDMTs without GLP-1 RAs (10.5 % vs. 14.4 %; hazard ratio [HR], 0.71; 95 % confidence interval [CI], 0.62-0.83). Hospitalization did not differ significantly between groups (63.7 % vs. 60.1 %; HR, 1.05; 95 % CI, 0.98-1.12).

In patients with HFrEF and T2D, all of GDMTs with GLP-1 RAs were associated with a lower risk of all-cause death than all of GDMTs without GLP-1 RAs.