<title>Abstract</title><sec>
<title>Background</title>
Japan has promoted end-of-life care at home and in long-term care facilities, and the total proportion of in-hospital deaths has decreased recently. However, the difference in trends of in-hospital deaths by the cause of death remains unclear. We investigated the variation in trends of in-hospital deaths among older adults with long-term care from 2007 to 2017, by cause of death and place of care.


</sec><sec>
<title>Methods</title>
Using the national long-term care insurance registry, long-term care claims data, and national death records, we identified people aged 65 years or older who died between 2007 and 2017 and used long-term care services in the month before death. Using a joinpoint regression model, we evaluated time trends of the proportion of in-hospital deaths by cause of death (cancer, heart diseases, cerebrovascular diseases, pneumonia, and senility) and place of care (home, long-term care health facility, or long-term care welfare facility).


</sec><sec>
<title>Results</title>
Of the 3,261,839 participants, the mean age was 87.0 ± 8.0 years, and 59.2% were female. Overall, the proportion of in-hospital deaths decreased from 66.2% in 2007 to 55.3% in 2017. By cause of death, the proportion of in-hospital deaths remained the highest for pneumonia (81.6% in 2007 and 77.2% in 2017) and lowest for senility (25.5% in 2007 and 20.0% in 2017) in all types of places of care. The joinpoint regression analysis showed the steepest decline among those who died of senility, especially among long-term care health facility residents.


</sec><sec>
<title>Conclusions</title>
The findings of this nationwide study suggest that there was a decreasing trend of in-hospital deaths among older adults, although the speed of decline and absolute values varied widely depending on the cause of death and place of care.


</sec>

目的 介護保険総合データベース(介護DB)の導入により,悉皆的な介護保険研究が可能になった。反面,介護DBでは死亡情報が含まれず他データとの突合も制限されているため,死亡に関する研究は実施困難である。本研究では,統計法に基いて入手した介護保険受給者台帳(受給者台帳)と人口動態統計死亡票(死亡票)を用いて,受給者台帳の受給資格喪失記録を死亡の代理変数として使用することの妥当性を評価した。方法 受給者台帳に記録された受給者情報の月次断面を2007年4月から2017年3月まで累積し,介護度が自立または年齢が65歳未満の者を除外した510,751,798件を研究対象とした。受給者台帳の異動区分コードが終了の場合を受給資格喪失とし,これと死亡票とを確定的マッチング(性別,生年月日,死亡年月日,居住市区町村)で突合できた場合を死亡例として,受給資格喪失の死亡に対する検査特性(感度,特異度,陽性反応的中率,陰性反応的中率)を算出した。結果 受給者台帳510,751,798件中の5,986,991件(1.17%)で受給資格喪失となり,うち5,295,961件の死亡が特定された。受給資格喪失の死亡に対する感度は100%,特異度は99.9%,陽性反応的中率は88.5%,陰性反応的中率は100%だった。陽性反応的中率を層別化すると,2012年以前は85～88%程度,2013年以降は91%前後,男性(91.9%)は女性(85.9%)よりも高く,年齢階級(65-69歳:80.6%,70-74歳:86.7%,75-79歳:86.4%,80-84歳:86.7%,85-89歳:88.0%,90-94歳:90.6%,95歳以上:93.4%)や要介護度(要支援1・2含む要支援:72.2%,要介護1:79.7%,要介護2:85.9%,要介護3:89.3%,要介護4:92.3%,要介護5:94.0%)とともに上昇した。結論 受給資格喪失を死亡の代理変数として用いると偽陽性が1割程度発生するため,受給資格喪失を死亡率そのものの推計に用いるのは適切ではない。しかし曝露因子間の交絡の影響や曝露因子の死亡への効果が過小評価される可能性があることに留意すれば,受給資格喪失を死亡の代理変数としてアウトカムに用いることは許容できると考えられた。(著者抄録)

Abstract

In clinical trials, smoking‐cessation aids (SCAs) have proven to be effective at improving the odds of smoking cessation. Because of the effectiveness of SCAs in these settings, many countries have adopted the coverage of SCAs to reduce tobacco use. However, the effect of such coverage on tobacco use is ambiguous. On one hand, the coverage may have the intended effect and reduce tobacco use. On the other hand, the coverage may cause beneficiaries to participate in tobacco use more as the drug coverage protects beneficiaries from future costs associated with tobacco use. To understand the effect of SCA coverage, we examine it using 2008–2012 Canadian Tobacco Use Monitoring Survey and a difference‐in‐differences approach. We find that SCA coverage increases cigarette and cigarillo use. Moreover, the effect of SCA coverage on tobacco use is stronger in men and in those with at least a college education. Our results point to the unintended consequences of the coverage of SCAs on tobacco use.

Abstract

Countries seeking to move away from a purely fee‐for‐service (FFS) system may consider a hybrid approach whereby only some procedures are paid by FFS while others are paid prospectively. Yet little evidence exists whether such a hybrid payment system contains overall costs without adverse influences on health outcomes. In 2003, Japan experienced a reform from FFS to a hybrid payment system in which only some inpatient procedures were paid prospectively. We exploit this reform to test how such a hybrid system affects overall costs and health outcomes. Briefly, we find that healthcare providers responded opportunistically to the reform, moving some procedures out of the bundled inpatient setting to FFS services, leading to no reduction in cost. There was some evidence of a moderate deterioration in health outcomes, in terms of a decline in the probability of symptoms being cured at discharge. In sum, our results suggest that in some cases, a hybrid payment system can be non‐superior to either FFS or prospective payment system.

OBJECTIVES: To analyze the association of an incentivization program to promote death outside of hospitals with changes in place of death. DESIGN: A longitudinal observational study using national databases. SETTING AND PARTICIPANTS: Participants comprised Japanese decedents (≥65 years) who had used long-term care insurance services and died between April 2007 and March 2014. METHODS: Using a database of Japanese long-term care insurance service claims, subjects were divided into community-dwelling and residential aged care (RAC) facility groups. Based on national death records, change in place of death after the Japanese government initiated incentivization program was observed using logistic regression. RESULTS: Hospital deaths decreased by 8.7% over time, mainly due to an increase in RAC facility deaths. The incentivization program was more associated with decreased in-hospital deaths for older adults in RAC facilities than community-dwelling older adults. CONCLUSIONS AND IMPLICATIONS: In Japan, the proportion of in-hospital deaths of frail older adults decreased since the health services system introduced the incentivization program for end-of-life care outside of hospitals. The shift of place of death from hospitals to different locations was more prominent among residents of RAC facilities, where informal care from laymen was required less, than among community residents.

<title>Abstract</title><sec>
<title>Background</title>
It is unclear how formal long-term care (LTC) availability affects formal /informal caregiving patterns and caregiver health. We tested the impact of reduced formal LTC availability on formal LTC service use, intensity of informal caregiving, and caregiver health.


</sec><sec>
<title>Methods</title>
Using a representative, repeated cross-sectional sample of Japanese caregivers providing care to co-resident family members from 2001 to 2016, we applied a difference-in-differences approach by observing caregivers before and after the major reform of the public Japanese LTC insurance (LTCI) in 2006. The reform reduced coverage benefits for non-institutionalized older persons with low care needs, but not for those with high care needs. We analyzed 12,764 caregivers aged ≥30 years (mean age 64.3 ± 11.8 years, 73.5% women) and measured indicators of formal LTC use, hours of informal caregiving, and caregiver self-reported health outcomes after propensity score matching to balance caregivers’ background characteristics.


</sec><sec>
<title>Results</title>
We found the 2006 LTCI reform relatively reduced the use of formal LTC services and relatively increased the percentage of experiencing long hours of informal caregiving (&gt; 3 h per day) among the caregivers for seniors with low care needs compared to those for seniors with high care needs. The effects of the LTCI reform for the caregivers for seniors with low care needs were 2.2 percentage point higher on caregivers’ experiencing poor self-rated health (95% confidence interval [CI]: 0.7–3.7; <italic>p</italic> = 0.01), 2.7 percentage point higher on experiencing symptoms of a depressive state (95%CI: 0.5–4.8; <italic>p</italic> = 0.03), and 4.7 percentage point higher on experiencing symptoms of musculoskeletal diseases (95%CI, 3.6–5.7; <italic>p</italic> &lt; 0.001), compared to those for seniors with high care needs.


</sec><sec>
<title>Conclusions</title>
Reduced formal care availability under the Japanese LTCI reform increased hours of informal caregiving corresponding to reduced use of formal LTC and deteriorated multiple dimensions of caregiver health. Our findings may highlight the importance of enhancing the availability of formal LTC services for caregiver health.


</sec>

Japan's healthcare expenditures, which are largely publicly funded, have been growing dramatically due to the rapid aging of the population as well as the innovation and diffusion of new medical technologies. Annual costs for surgical treatments are estimated to be approximately USD 20 billion. Using unique longitudinal clinical data at the individual surgeon level, this study aims to estimate the technical efficiency of surgical treatments across surgical specialties in a high-volume Japanese teaching hospital by employing stochastic frontier analysis (SFA) with production frontier models. We simultaneously examine the impacts of potential determinants that are likely to affect inefficiency in operating rooms. Our empirical results show a relatively high average technical efficiency of surgical production, with modest disparity across surgical specialties. We also demonstrate that an increase in the number of operations performed by a surgeon significantly reduces operating room inefficiency, whereas the revision of the fee-for-service schedule for surgical treatments does not have a significant impact on inefficiency. In addition, we find higher technical efficiency among surgeons who perform multiple daily surgeries than those who perform a single operation in a day. We suggest that it is important for hospital management to retain efficient surgeons and physicians and provide efficient healthcare services given the competitive Japanese healthcare market.

•We determined the relationship between long hours of care and the assistance in each activity of daily living (ADL) element.•The assistance in wiping of the body, dressing and toileting were significantly associated with longer hours of care .•To support caregivers effectively, it is important to consider the kinds of ADL elements of the care recipients.

<sec><title>Objective</title>Because married couples have many environmental influences in common, spouses may develop similar diseases. This study aimed to determine the concordance of hypertension, diabetes and dyslipidaemia, which are major risk factors for cardiovascular disease, among married couples in Japan.

</sec><sec><title>Research design and methods</title>We conducted a cross-sectional study of married couples who were both aged ≥40 years using the 2016 Comprehensive Survey of Living Conditions, which is a Japanese national survey. We first determined the proportions of wives and husbands who were receiving therapy for each of the diseases of interest. We then conducted logistic regression analyses using the wives undergoing therapy for each disease as outcomes and the husbands undergoing therapy for the same disease as the principal exposure, adjusting for covariates.

</sec><sec><title>Results</title>The subjects of the analyses were 86 941 married couples. The wives of male patients were significantly more likely to be receiving therapy for the same disease. Logistic regression revealed that when husbands were undergoing therapy for these diseases their wives had ORs (95% CIs) of 1.79 (1.72–1.86) for hypertension, 1.45 (1.34–1.58) for diabetes, 2.58 (2.41–2.75) for dyslipidaemia and 1.87 (1.80–1.93) for any of these diseases.

</sec><sec><title>Conclusions</title>If men have hypertension, diabetes or dyslipidaemia, their wives were also more susceptible to the same disease. Medical professionals and couples may need to recognise these results and consider couple-based interventions to help the prevention, early detection and treatment of these diseases.

</sec>

<title>Abstract</title>
<sec>
<title>Background</title>
Japan, with the oldest population in the world, faces a financial challenge caused by rising long-term care (LTC) expenditure. For policymakers to address this, it is important that we have a better understanding of how individual and regional characteristics affect LTC expenditure.


</sec>
<sec>
<title>Methods</title>
We linked national LTC insurance (LTCI) claim data, covering the entire population who used LTCI services in Japan, with municipality data on an individual level. Individuals 65 years and older (n=3 876 068) who had used LTCI benefits at least once in the fiscal year (FY) 2016 were included. We examined the associations of individual and municipality characteristics regarding supply and demand of healthcare with the LTC expenditures on facility care, home and community care, and total care (the sum of both types of care), after adjusting for regional differences in LTC extra charges.


</sec>
<sec>
<title>Results</title>
The following variables were associated with higher total expenditure; at the individual level: female, a higher care-need level, a lower income (0% co-payments) or a facility service user; at the municipality level: municipalities locating in metropolitan areas, with a higher proportion of single elderly households, more doctors per 1000 citizens, more nursing homes per 100 000 LTC benefit users or more outpatient medical spending per citizen ≥75 years old.


</sec>
<sec>
<title>Conclusions</title>
As we are able to identify several individual and municipality characteristics associated with higher LTC expenditure in Japan, the study offers insights into dealing with the rapidly growing LTC expenditure.


</sec>

<title>Abstract</title>
<sec>
<title>Background</title>
With the increase of overall life expectancy in Japan, effective and beneficial lifestyle approaches and practices are crucial for individuals to have a long, productive and healthy life. Although previous studies suggest that exercise or sports, especially when performed with others, from midlife level have a positive impact on enhancing healthy life expectancy, there is paucity of information regarding these contexts and possible associations. The present study intends to clarify the relationship between engagement in exercise or sports among middle-aged persons and healthy life expectancy through an ecological study in all prefectures in Japan.


</sec>
<sec>
<title>Methods</title>
We tabulated (1) the ratios of middle-aged individuals engaged in exercise or sports and (2) the different methods by which they are engaged in exercise or sports for each prefecture by using data from the 2005–2010 Longitudinal Survey of Middle-aged and Elderly Persons by the Ministry of Health, Labour and Welfare of Japan. Weighted multiple linear regression analyses were performed by sex, using healthy life expectancy in 2010 of each prefecture calculated by Hashimoto (2013) as a criterion variable; indices of (1) and (2) of each year as explanatory variables; and age, living conditions, employment, and chronic diseases as adjusted variables.


</sec>
<sec>
<title>Results</title>
For middle-aged males, the ratio of those engaged in exercise or sports in each year from 2005 to 2010 was positively correlated with healthy life expectancy; this relationship was found in the ratio of middle-aged engaging in exercise or sports “with families or friends”. For females, such a relationship could only be found in the ratio of middle-aged females engaged in exercise or sports in 2008, and those engaging in exercise or sports “with families or friends” in 2006, 2008 and 2010.


</sec>
<sec>
<title>Conclusion</title>
Prefectures with a higher ratio of middle-aged individuals engaging in exercise or sports, especially when done with families or friends, have longer healthy life expectancies. This was particularly evident for males. Thus, exercise or sports with families or friends in midlife seems to be more effective in promoting healthy life expectancy for males than females in Japan.


</sec>

Implementing smoking bans is a worldwide common practice for tobacco control. However, if the policy prohibits smoking partially rather than comprehensively, it may increase nonsmokers’ exposure to secondhand smoke (SHS) in nonprohibited places. This paper investigates how a partial smoking ban affected nonsmokers’ SHS exposure (measured by frequency of having exposure to SHS in days per month) in households, workplaces, and restaurants by examining the case of a partial smoking ban introduced in a large Japanese prefecture in 2013. Using data from the National Health and Nutrition Survey (NHNS) in 2010, 2013, and 2016 (n = 30,244) and the Comprehensive Survey of Living Conditions (CSLC) from 2001 to 2016 (n = 2,366,896), this paper employs a difference-in-differences (DID) approach. We found that the partial smoking ban significantly increased their SHS exposure in households and workplaces by 2.64 days and 4.70 days per month, respectively, while it did not change nonsmokers’ SHS exposure in restaurants. The results imply that the smoking ban displaced smokers from public places to private places. We also found that neither smokers’ smoking status nor smoking intensity changed significantly after implementing the partial smoking ban. Comprehensive smoking bans are needed to better protect nonsmokers from SHS exposure.

OBJECTIVE: To evaluate how cardiovascular diseases harm labor force participation (LFP) among the Japanese population and verify the validity of plasma biomarkers as instrumental variables of cardiovascular diseases after adjusting for a broad set of confounders including dietary intake. DESIGN: Using nationally representative repeated cross-sectional surveys in Japan, the Comprehensive Survey of Living Conditions and National Health and Nutrition Survey, with plasma biomarkers as instrumental variables for quasi-randomization. SETTING: Onset of cardiovascular diseases in those receiving regular treatment for hypertension, intracerebral hemorrhage, intracerebral infarction, angina pectoris, myocardial infarction, or other types of cardiovascular diseases. PARTICIPANTS: A total of 65,615 persons aged ≥ 20 years (35,037 women and 30,578 men) who completed a survey conducted every three years from 1995 through 2013. MAIN OUTCOME MEASURES: Respondent employment and weekly working hours during each survey year. RESULTS: Cardiovascular diseases significantly and remarkably reduced the probability of working by 15.4% (95% CI: -30.6% to -0.2%). The reduction in working probability was detected for women only. Respondents aged ≥ 40 years were less likely to work once diagnosed and the reduction was enlarged for those aged ≥ 65 years, while those aged < 40 years appeared to be unaffected. Probability of engaging in manual labor significantly decreased once diagnosed; however, no impact was found for cognitive occupations. Among employed respondents, the adverse effects of cardiovascular diseases decreased working hours by five hours per week. Validity of the biomarker instrumental variables was generally verified. CONCLUSIONS: A vicious circle is suggested between LFP and unfavorable health. However, the effects vary across age, sex, and occupation type, even after adjusting for causal effects, which could cause a downward bias in LFP impact. ATTRIBUTES: cardiovascular disease, labor force participation, instrumental variable method as quasi-randomization, plasma biomarker, Comprehensive Survey of Living Conditions, National Health and Nutrition Survey.

In this study, we examine the effect of a remedial education program in language arts and mathematics for third and fourth-grade students with low previous academic performance. Utilizing a unique panel data set constructed from the administrative data of public elementary schools in Adachi ward in Japan, we estimate the impact of remedial program participation on the subsequent test scores in Japanese language arts and mathematics. This paper utilizes the variations in placement policies of schools as an instrument to identify the effect of the remedial education program, controlling for selection biases. Our estimation results indicate that the remedial education programs had positive effects on test scores of Japanese language arts by 0.13 of a standard deviation, while no statistically significant effect was found for mathematics test scores. The results suggest that the participants increased awareness of the importance of study practices and hours of study as well.

Objective The aim of this nationwide study was to estimate the duration of formal long-term care, provided by Japanese long-term care insurance (LTCI) services, among frail Japanese elderly people living in the community.Methods The study subjects were 2,188,397 (men: 579,422, women: 1,124,022, age≥65 years) beneficiaries who used LTCI services for community living in June 2013. The duration of LTCI services for community living per diem per capita was estimated by converting the benefit amount to duration of care using the code for service in claims bills according to gender and care levels, which are a nationally certified classification of individual needs for long-term care (care level 1: lowest need, care level 5: highest need). Subsequently, LTCI services for community living were categorized into respite services and community services. Community services were further subcategorized into home visiting services and daycare services.Results The overall average duration of formal care per diem per capita for men and women were 97.4 and 112.7 minutes for care level 1, 118.3 and 149.1 for care level 2, 186.9 and 246.4 for care level 3, 215.2 and 273.2 for care level 4, and 213.1 and 261.4 for care level 5, respectively. Length of respite services increased gradually with care level, whereas duration of community services peaked at care level 3 and decreased at care levels 4 and 5. With regard to the community service subcategories, duration of home visiting services increased with care level, but duration of daycare services peaked at care level 3.Conclusion Although the care levels in the LCTI system are designed to assess the need for formal care in terms of duration of care, our results suggest that the use of formal LTCI services for community living is not vertically equitable. Services that efficiently increase duration of formal care for those with higher needs for care may improve the equity and sustainability of formal long-term care services for community living.

Aim: To determine the resident and facility characteristics associated with residents’ care-need level deterioration in long-term care welfare facilities in Japan. Methods: A nationally representative sample of 358 886 residents who lived in 3774 long-term care welfare facilities for at least 1 year from October 2012 was obtained from long-term care insurance claims data. Facility characteristics were linked with a survey of institutions and establishments for long-term care in 2012. We used a multilevel logistic regression according to the inclusion and exclusion of lost to follow-up to define the resident and facility characteristics associated with resident care-need level deteriorations (lost to follow-up: the majority were hospitalized residents or had died
were treated as deterioration in the including loss to follow-up model). Results: Adjusting for the covariates, at the resident level, older age and lower care-need level at baseline were more likely to show deterioration in the care-need level. At the facility level, metropolitan facilities, unit model (all private room settings) and mixed-model facilities (partly private room settings) were less likely to experience care-need level deterioration. A higher proportion of registered nurses among all nurses was negatively related to care-need level deterioration only in the model including lost to follow-up. A higher proportion of registered dietitians among all dietitians and the facilities in business for fewer years were negatively associated with care-need level deterioration only in the model excluding lost to follow-up. Conclusions: The present study could help identify residents who are at risk of care-need level deterioration, and could contribute to improvements in provider quality performance and enhance competence in the market. Geriatr Gerontol Int 2018
18: 758–766.

The present study examines the relationships between changes in bonding and bridging types of social capital and depressive states among middle-aged adults in Japan using a nationally representative sample. Data was collected from a nationwide, population-based survey conducted from 2005 to 2013 in nine annual waves. A total of 16,737 middle-aged men and 17,768 middle-aged women provided data. They reported about depressive states, measured by Kessler 6 scores, and bonding and bridging types of social capital, measured by reported participation in different social activities. Latent growth modeling was conducted to examine relations between changes in bonding and bridging types of social capital and depressive states within individuals across the nine waves. The results showed that, for both men and women, increases in bonding social capital were associated with decreases in depressive states, while changes in bridging social capital were not related to changes in depressive states. In addition, the results showed that changes in bonding social capital, but not bonding social capital at the baseline, affected changes in depressive states. Future studies should take changes in social capital as an independent variable into consideration.

目的 重度要介護高齢者の在宅日数は、地域別に算出することで地域包括ケアシステムの達成状況の評価指標となりうる。本研究の目的は、全国介護レセプトデータを用いて在宅日数を都道府県別に算出し、観察期間前後の打ち切り(以下、観察の打ち切り)を考慮して地域を比較する指標としての可能性を示すことである。方法 厚生労働省の承認を受けて8年間の全国介護レセプトデータを用いた。対象者は65歳以上で要介護4または5の認定を受け、要支援または要介護認定を受けていた期間に介護保険サービスを利用した者とした。観察期間における在宅日数が0日の対象者を在宅ゼロ群、在宅日数が1日以上の対象者を在宅群とし、在宅ゼロ群の人数の割合(以下、在宅ゼロ者割合)および在宅群の在宅日数平均値(以下、平均在宅日数)を算出した。次に在宅群を、打ち切りなし群、開始時打ち切り群、終了時打ち切り群、両側打ち切り群に分類して在宅日数を算出し、各群の割合を都道府県別に算出した。また、在宅ゼロ者割合と、平均在宅日数を都道府県別に算出し、両者の相関係数および散布図を示した。さらに、特定施設入居者生活介護等のサービス利用期間も在宅で生活した期間とした在宅日数(以下、介護保険在宅日数)を算出し、在宅日数との比較を行った。結果 対象地域は1,630市区町村(全市区町村の93.6%)で、対象者数は3,598,809人であった。在宅ゼロ者割合は37.8%、平均在宅日数は362.6日であった。打ち切りなし群、開始時打ち切り群、終了時打ち切り群、両側打ち切り群の人数(割合)はそれぞれ1,653,443人(45.9%)、240,136人(6.7%)、331,533人(9.2%)、15,013人(0.4%)、在宅日数平均値は247.8日、672.1日、610.6日、2570.9日であり、各群の人数の割合は都道府県により異なっていた。都道府県別の在宅ゼロ者割合の最大値と最小値は54.2%、30.3%で、平均在宅日数の最大値と最小値は475.5日、292.4日であった。在宅ゼロ者割合と平均在宅日数の相関係数は-0.55であった。在宅日数と介護保険在宅日数の差は、都道府県によって異なっていた。結論 在宅ゼロ者割合および平均在宅日数は、「観察の打ち切り」の影響を考慮する必要があるものの、両者を組み合わせることにより、地域の指標として利用可能であると考えられた。(著者抄録)

We evaluate a spillover effect of the Japanese public long-term care insurance (LTCI) as a policy to stimulate family caregivers’ labor force participation. Using nationally representative data from 1995 to 2013, we apply difference-in-difference propensity score matching to investigate the spillover effect in two periods: before and after the introduction of the LTCI in 2000 and before and after its major amendment in 2006. Our results show that the LTCI introduction has significant and positive spillover effects on family caregivers’ labor force participation and the effects vary by gender and age. In contrast, the LTCI amendment is found to have generally negative spillover effects on their labor force participation. We draw attention to these spillover effects, as expanding labor market supply to sustain the economy would be a priority for Japan and other rapidly aging countries in the coming decades.

AimThe effects of family caregiving, especially long-hours caregiving, on coronary heart disease (CHD) are debatable. We examined the impact of family caregiving on incident non-fatal CHD.
MethodsWe used data from the Longitudinal Survey of Middle-Aged and Elderly Persons from 2005 to 2010, a nationwide panel survey for Japanese people aged 50-59 years in 2005 (baseline). After we excluded non-respondents and people with missing key variables at baseline, 25 121 individuals without CHD, stroke or cancer were followed up for a mean of 4.6 years. The exposure was assessed at baseline by three indicators: (i) family caregiving; (ii) hours spent caregiving; and (iii) kinship type of care recipient. The non-fatal CHD incidence was identified according to questionnaire responses from 2006 to 2010.
ResultsCox's proportional hazards analysis did not show a statistically significant association between family caregiving and incident non-fatal CHD (hazard ratio [HR] 1.13, 95% confidence interval [CI] 0.92-1.40). Caregivers who spent 20-69 h per week on care showed a statistically significant increased risk for non-fatal CHD (HR 1.78, 95% CI 1.23-2.58) compared with non-caregivers; whereas this increased risk was statistically significant only among women (HR 1.98, 95% CI 1.27-3.08), but not among men (HR 1.35, 95% CI 0.67-2.71). Kinship type of care recipient did not make a significant difference to the effects of family caregiving on incident non-fatal CHD.
ConclusionsLong-hours family caregiving could be an independent risk factor for incident non-fatal CHD among middle-aged women in Japan. Geriatr Gerontol Int 2017; 17: 2109-2115.

Financial support for children's medical expenses has been introduced in many countries. Limited work has been done on price elasticity in children's healthcare demand, especially in countries other than the United States. Moreover, it remains unclear how the effects of a change in the cost sharing rate on healthcare demand would differ by medical condition. We investigated the impact of an increase in the cost sharing rate on medical service utilization among school children as a whole and for each of nine common conditions, applying a difference-in-differences approach. The study period ranged from April 1, 2012, to March 30, 2014. Participants were elementary school children in an urban area who were eligible for National Health Insurance (a community-based public insurance) during the study period and who were enrolled in the 2nd, 3rd, or 4th grade in April 2013. We collected observations from 2896 persons and 69,504 (2896 x 24 months) person-months. When elementary school children were promoted to the 4th grade, they became disqualified for a municipal medical subsidy. The control group was the children promoted to the 2nd or the 3rd grade, who remained eligible for the subsidy. All data were obtained from health insurance claims. We identified the nine most common medical conditions among the subject children, and stratified the analyses by the condition diagnosed. We found that an increase in the cost sharing rate reduced outpatient service utilization as a whole. Also, we observed an increase in inpatient service utilization, not because of worsened health conditions, but rather due to substitution of inpatient service for outpatient service. The reductions in outpatient service were heterogeneous across medical conditions; declines were sharper for mild or chronic conditions. These findings may help to characterize how a change in cost sharing rate affects health outcomes in children. (C) 2017 Elsevier Ltd. All rights reserved.

Objective Changes in mortality inequalities across socioeconomic groups have been a substantial public health concern worldwide. We investigated changes in absolute/relative mortality inequalities across occupations, and the contribution of different diseases to inequalities in tandem with the restructuring of the Japanese economy.
Methods Using complete Japanese national death registries from 5 year intervals (1980-2010), all cause and cause specific age standardised mortality rates (ASMR per 100 000 people standardised using the Japanese standard population in 1985, aged 30-59 years) across 12 occupations were computed. Absolute and relative inequalities were measured in ASMR differences (RDs) and ASMR ratios (RRs) among occupations in comparison with manufacturing workers (reference). We also estimated the changing contribution of different diseases by calculating the differences in ASMR change between 1995 and 2010 for occupations and reference.
Results All cause ASMRs tended to decrease in both sexes over the three decades except for male managers (increased by 71% points, 1995-2010). RDs across occupations were reduced for both sexes (civil servants 233.5 to -1.9 for men; sales workers 63.3 to 4.5 for women) but RRs increased for some occupations (professional workers 1.38 to 1.70; service workers 2.35 to 3.73) for men and decreased for women from 1980 to 2010. Male relative inequalities widened among farmer, fishery and service workers, because the percentage declines were smaller in these occupations. Cerebrovascular disease and cancer were the main causes of the decrease in mortality inequalities among sexes but the incidence of suicide increased among men, thereby increasing sex related inequalities.
Conclusions Absolute inequality trends in mortality across occupations decreased in both sexes, while relative inequality trends were heterogeneous in Japan. The main drivers of narrowing and widening mortality inequalities were cerebrovascular disease and suicide, respectively. Future public health efforts will benefit from eliminating residual inequalities in mortality by considering the contribution of the causes of death and socioeconomic status stratification.

This paper examines the causal effects of retirement on health investment behavior among Japanese permanent employees. We find that the Japanese employees participate less in unhealthy habits (smoking and drinking) after retiring from their permanent employment, and after completely ceasing to work, they further increase participation in healthy life habits (regular exercise). We also find gender differences in these responses. (C) 2017 Elsevier B.V. All rights reserved.

It is widely documented that psychological distress is negatively associated with social networks involvement. However, despite the theoretical postulations that social networks are crucial for alleviating psychological distress, no study has yet empirically confirmed the causality of this relationship. Thus, we used the random-effects generalized least squares method to investigate the effect of one- and two-year lagged values for involvement in social networks on psychological distress. Nine years of longitudinal data were extracted from a nationally representative survey in Japan ("The Longitudinal Survey of Middle-aged and Older Persons"). We utilized the Kessler 6 (K6) score to measure psychological distress among 15,242 respondents aged 50-59 years in the baseline year (2005), and stratified participants into three layers of social networks: inner (well-established friendship ties and participating in hobby activates), intermediary (neighborly ties), and outer (involvement in community activities). We found highly significant and negative associations between all three layers and K6 scores, with the strongest association being for the inner layer. We further observed that one-year lagged involvement in the inner and intermediary layers led to significantly lower K6 scores. However, the protective influences of social networks generally diminished over time. In addition, the protective influences of social network involvement on psychological distress were stronger for women than for men. Furthermore, involvement in social networks was especially important for improving mental health among people with psychological distress. These findings would be important for policymaking to prevent mental health deterioration among middle-aged adults in Japan. (C) 2017 Elsevier Ltd. All rights reserved.

Background: Depressive symptoms are a leading cause of disability and emotional suffering, particularly in old age. However, evidence on depression and old age in developing countries remains largely ignored. The aim of this study was to examine the relation between health behavior and social conditions with depression among dependent community-dwelling older persons in the Republic of Chile.
Methods: This is a cross-sectional and inferential study, using nationally representative secondary data. Two models used logistic regression on 640 dependent community-dwelling older persons from all over Chile, who personally answered a depression assessment, excluding those taking antidepressants. The geriatric depression scale (GDS-15) was used as outcome. The first model aims at any kind of depression (GDS 5&gt;). The second aims at severe depression (GDS 10&gt;). As exposure, we used the health behavior and social conditions of the older persons. Socio-demographic and physical conditions were used as adjustment.
Results: 44.5% of the older persons presented depressive symptoms. Among them, 11% had severe depression. Logistic regression showed that significant detrimental factors for being depressed in both models were visiting the doctor five times or over because of acute diseases, feeling uncomfortable with their living arrangement, and feeling discriminated. On the other hand, every additional day of physical exercise and living alone had a beneficial and detrimental effect only in model one.
Conclusion: Analyses on ways to support older persons living alone and the promotion of physical exercise to avoid depression are needed, along with a deeper understanding of the comfort with their living arrangement. Finally, ways to address the discrimination among older persons should be further explored.

Objective Previous studies conducted in Japan targeted only mothers who cared for children with disabilities, and lacked reference subjects, such as mothers of children without disabilities. The aim of this study was to examine the association between raising one or two children with a disability and maternal psychological distress compared to mothers of children without a disability, and to assess differences among partnered mothers living with grandparent(s), partnered mothers without grandparent(s), and single mothers. Methods This study utilized data from the Comprehensive Survey of Living Conditions (CSLC) in 2010. We merged the data of the children (aged six and over), mothers, and fathers. This study obtained 33,739 study subjects as a triad of a child (33,110 children without disabilities and 629 children with disabilities), mother, and father. The Japanese version of Kessler 6 (K6) was used to assess the psychological distress of mothers. Multivariate logistic regression was performed to assess the independent association of a child with a disability on maternal psychological distress after controlling for the basic characteristics of the children, mothers, and households. Results This study reported that raising one or two children with disabilities was significantly related to maternal psychological distress (odds ratio: 1.72 for one child, 2.85 for two children) compared to mothers of children without disability. After stratifying the analyses by family structure, significant associations remained among mothers in two-parent families but not for mothers in three-generation families and single mothers due to a small number of children with disabilities in these families. Conclusions This study reported the significant association between raising a child with a disability and maternal psychological distress in comparison to mothers of children without disabilities. Attention should be paid to not only single mothers, but also partnered mothers in two-parent families who have a child with a disability. It is important for health professionals to focus on the mental health of every mother of a child with a disability and to assess their needs for psychological support.

<p>目的 本稿では，介護予防事業に参加している高齢者の属性を明らかにし，介護予防事業の一環として北海道網走市が実施している高齢者サロンが，高齢者の身体的・精神的な健康を改善するという仮説の検証を行う。</p><p>方法 本稿では，当該自治体において2013年と2014年の 2 月 1 日に実施された「高齢者の生活と健康に関する調査」の個票を用いる。網走市の介護予防事業（通称「ふれあいの家」事業）の参加者のうち，協力が得られ，かつ当該調査に対し，2013年と2014年の両年に回答した者を参加群（N=157）とする。非参加群は，網走市在住の65歳以上高齢者から無作為抽出した者のうち，同じく当該調査に両年とも回答をした者（N=252人）とする。分析方法は，参加群・非参加群間での選択バイアスを調整するため，傾向スコア法を用いた。共変量は，2013年の性別・年齢・同居家族の有無・配偶者の有無・就労の有無・1 カ月の生活費・最短の「ふれあいの家」までの距離・主観的健康感・老研式活動能力指標・K6・通院の有無とした。アウトカムは，2014年における，主観的健康感・老研式活動能力指標・K6・通院の有無である。</p><p>結果 ベースラインである2013年の基本属性を見ると，非参加群と比べ，参加群では，「ふれあいの家」までの距離が近く，年齢層が高い女性が多い。また，1 カ月の生活費が 2 万円ほど高い傾向にある。しかし，同居家族の有無や配偶者の有無については，両群で有意差はなかった。なお，健康指標に関しては，参加群の方が非参加群より健康的であることがわかった。傾向スコア法による推定の結果，介護予防事業は，参加群の方が非参加群と比べ，2014年における K6 が1.713ポイント改善していることから，網走市における当該事業が，参加者の精神面での健康には寄与していることが明らかになった。</p><p>結論 本稿が得た結果から，網走市における，コミュニティの構成員を主体とする介護予防事業には一定の効果があることがわかった。これは，社会参加によって築かれた近隣住民との良好な関係が精神面で良い影響を与えているのかもしれない。他方，身体的な健康に対する効果については観察されなかったが，本稿の観察期間は 2 年間と極めて短期間であり，また，当該介護事業が住民主体の活動であることから，中・長期的な専門家による介入と経過観察が必要である可能性が示唆された。</p>

This study investigated the effects of leisure and social activities on the ability of middle-aged adults to maintain activities of daily living (ADL), and whether performing these activities alone or with others contributed to the ability to perform ADL. The study used nationally representative longitudinal data of 22,770 adults in Japan, aged 50-59 years, who did not have limitations in performing ADL at the beginning of the 5-year survey period. The study considered six activity categories: two leisure activities ("hobbies or cultural activities" and "exercise or sports") and four social activities ("community events," "support for children," "support for elderly individuals," and "other social activities"). Multiple logistic regression analysis was used to examine the relation between participation in these categories at baseline and difficulties in ADL at the 5-year follow-up. The association between the extent of social interaction during these activities ("by oneself," "with others," or "both") and difficulties in ADL was also investigated. The analysis yielded significant negative correlations between "exercise or sports" and difficulties in ADL for both men and women, and between "hobbies or cultural activities" and difficulties in ADL for women. However, these significant relationships occurred only when activities were conducted "with others." The present findings might help prevent deterioration in middle-aged adults' performance of ADL in Japan.

AimThe objective of the present study was to verify how socioeconomic and physical/mental health status would be associated with activity limitations by age and sex among older adults, using nationally representative cross-sectional data in Japan.
MethodsThe present study focused on 8373 older adults aged 65 years or older extracted from the Comprehensive Survey of Living Conditions conducted in 2007 by the Japanese Ministry of Health, Labor and Welfare. Univariate and multiple logistic regression analyses and population-attributable risk were applied to validate the relationships of socioeconomic and physical/mental health status with activity limitations among the total population, and by age groups (young-old or old-old) and sex.
ResultsMental health showed the highest odds ratio and population-attributable risk in the total population. In addition, low back pain was associated with activity limitations regardless of age and sex. Other musculoskeletal diseases, such as arthropathy and osteoporosis, were related to activity limitations for women, regardless of age, whereas cardiovascular diseases, including angina pectoris/myocardial infarction and cerebral stroke, were associated with activity limitations for men in any age group. There were no statistically significant correlations between socioeconomic status and activity limitations in any groups.
ConclusionMental health was the most important factor of activity limitations in Japanese older adults. Furthermore, low back pain regardless of age and sex, other musculoskeletal diseases only for women and cardiovascular diseases mainly for men could also be significant risk factors to activity limitations. Therefore, preventive approaches of activity limitations considering sex differences are important for older adults in Japan.

Objectives
This study focuses on East Asian countries and investigates the difference in the marriage premium on the health-marriage protection effect (MPE) between younger and older generations and the intra-couple education concordance effect (ECE) on the health of married individuals. This study used inter-country comparative data from China, Japan, and Korea.
Methods
This study focused on individuals (n = 7,938) in China, Japan, and Korea who were sampled from the 2010 East Asian Social Survey. To investigate MPE and ECE, four health indicators were utilized: a physical and mental components summary (PCS and MCS), self-rated health status (Dself), and happiness level (Dhappy). Ordinary least squares regression was conducted by country-and gender-specific subsamples.
Results
We found that the MPE on PCS, MCS, and Dself was more significant for the older generation than for the younger generation in both China and Japan, whereas the results were inconclusive in Korea. With regard to the ECE on happiness (Dhappy), for both men and women, couples tend to be happier when both the husband and the wife are well educated ("higher balanced marriage") compared to couples with a lower level of educational achievement ("lower balanced marriage"). Significant benefits from a "higher balanced marriage" on MCS and Dself were observed for women only. In contrast, no statistically significant differences in health status were observed between "higher balanced marriage" couples and couples with different levels of educational achievements ("upward marriage" or "downward marriage").
Conclusions
This study found that (1) the MPE was more significant for the older generation, and (2) the health gap, particularly the happiness gap, between higher-and lower-balanced married couples was significant. The inter-country comparative findings are useful to explain how the role of marriage (and therefore of family) on health has been diluted due to the progress of industrialization and modernization.

The number of children with disability is increasing gradually in Japan. Previous researches in other countries have reported that parents as caregivers (CGs) of children with disability have mental health problems, but the actual situation has not been examined nationwide in Japan so far. The aim of this study was to evaluate the association between mental health of CGs who had children with disability and characteristics of children, CGs, and household based on the nation-wide survey. This study utilized data from 2010 Comprehensive Survey of the Living Conditions, and defined children with disability aged 6 to 17. Individual data of children and CGs were linked, and 549 pairs of them were extracted. The Japanese version of Kessler 6 (K6) was used to assess mental health status of caregiver, scored 5 and over represented to general psychological distress. Logistic regression was used to evaluate the associations of interest. The almost half (44.4%) of CGs had psychological distress (k6 score; 5 +) in nationwide, and 8.9% of CGs might have serious mental illness (K6 score; 13 +). After adjusting covariates of child, CG, and household factors, CG having a current symptom (OR, 95% CI: 3.26, 1.97-5.39), CG's activity restriction (OR, 95% CI: 2.95, 1.38-6.32), low social support (OR, 95% CI: 9.31, 1.85-46.8), three generation family (OR, 95% CI: 0.49, 0.26-0.92), and lower 25% tile group of monthly household expenditure (OR, 95% CI: 1.92, 1.05-3.54), were significantly associated with psychological distress of CGs. This study encourages health care providers to pay more attentions toward parent's mental health, especially for in case of having low social support, and lower income family. Further research should examine the detailed information of child's disease and disability, medical service use, and quality and quantity of social support in nationwide to straighten the system for supporting services of both children with disabilities and their CGs.

Objectives
This study aimed to investigate longitudinal relations between leisure and social activities and mental health status, considering the presence or absence of other persons in the activity as an additional variable, among middle-aged adults in Japan. This study used nationally representative data in Japan with a five-year follow-up period.
Methods
This study focused on 16,642 middle-aged adults, age 50-59 at baseline, from a population-based, six-year panel survey conducted by the Japanese Ministry of Health, Labour and Welfare. To investigate the relations between two leisure activities ('hobbies or cultural activities' and 'exercise or sports') and four social activities ('community events', 'support for children', 'support for elderly individuals' and 'other social activities') at baseline and mental health status at follow-up, multiple logistic regression analysis was used. We also used multiple logistic regression analysis to investigate the association between ways of participating in these activities ('by oneself', 'with others', or 'both' (both 'by oneself' and 'with others')) at baseline and mental health status at follow-up.
Results
Involvement in both leisure activity categories, but not in social activities, was significantly and positively related to mental health status in both men and women.
Furthermore, in men, both 'hobbies or cultural activities' and 'exercise or sports' were significantly related to mental health status only when conducted 'with others'. In women, the effects of 'hobbies or cultural activities' on mental health status were no differences regardless of the ways of participating, while the result of 'exercise or sports' was same as that in men.
Conclusions
Leisure activities appear to benefit mental health status among this age group, whereas specific social activities do not. Moreover, participation in leisure activities would be effective especially if others are present. These findings should be useful for preventing the deterioration of mental health status in middle-aged adults in Japan.

This study examines how the 2000 and 2006 revisions of the fee-for-service system have affected patient–nurse ratios and the average length of hospital stays in Japan. The empirical results show that hospitals are quite responsive to changes in price policy. The fee revisions have certainly achieved the policy objectives of reducing patient–nurse ratios and the length of hospital stays. As a result, hospitals have responded by greatly increasing the number of expensive beds for acute care. However, this was not exactly predicted by the Japanese government, which has aimed to reallocate health-care resources, such as beds, to subacute or long-term care.

We explore the causal relationship between hospital length of stay (LOS) and re-hospitalization for Acute Myocardial Infarction (AMI) patients in Japan, where the average LOS is the longest among OECD countries. Using chart-based data, we address the endogeneity between LOS and re-hospitalization probability by using an exogenous variation based on Rokuyo (the six basic labels allocated to each day), which is found to be irrelevant to admission day but relevant to discharge day. While we do find a significant and positive association between LOS and re-hospitalization probability in the OLS estimation, we do not find a significant relationship once LOS is instrumented by Rokuyo in various instrumental variable estimations. This implies that additional stay that was induced owing to patient's choice of preferred Rokuyo at discharge has no effect on re-hospitalization probability.

Mental health problems during pregnancy and postpartum periods are one of
the alarming health issues among women in Japan. This study analyzed data
on the Japanese version of the Kessler 6 (K6), specific psychosocial
stressors, and working status of pregnant and puerperium women (n=1126)
from respondents in the Comprehensive Survey of People’s Living
Conditions (CSPLC) conducted in 2007 by Ministry of Health, Labour and
Welfare in Japan. Multiple logistic analyses showed the significant
associations between mental health and psychosocial stressors: “family
relationship,” “pregnancy and birth,” and “incomes/ family budgets/ debts”,
regardless of “employed” or “unemployed”. After stratified by working
status, whereas “one’s job” stressor had an association with mental health
only for employed females, stressors for “one’s disease/long -term care” and
“housework” had associations only for unemployed ones. For employed
women, the primary factor for mental health was “family relationship”
stressor. Although mental health status measured by K6 was not different
between employed or unemployed female population, primary stressors
related mental health was revealed to differ with working status. Especially,
“family relationship” stressor was the highest risk factor of mental health in
employed women. More importantly, the results provided evidence on the
differences in associations between mental health and specific psychosocial
stressors by working status. Psychosocial risk assessments and interventions
on working status among pregnant and puerperium women should be
imperative to pay attention for social politics.

Objective To assess the effect on out-of-pocket medical spending and physical and mental health of Japan's reduction in health-care cost sharing from 30% to 10% when people turn 70 years of age.
Methods Study data came from a 2007 nationally-representative cross-sectional survey of 10 293 adults aged 64 to 75 years. Physical health was assessed using a 16-point scale based on self-reported data on general health, mobility, self-care, activities of daily living and pain. Mental health was assessed using a 24-point scale based on the Kessler-6 instrument for nonspecific psychological distress. The effect of reduced cost sharing was estimated using a regression discontinuity design.
Findings For adults aged 70 to 75 years whose income made them ineligible for reduced cost sharing, neither out-of-pocket spending nor health outcomes differed from the values expected on the basis of the trend observed in 64- to 69-year-olds. However, for eligible adults aged 70 to 75 years, out-of-pocket spending was significantly lower (P&lt;0.001) and mental health was significantly better (P&lt;0.001) than expected. These differences emerged abruptly at the age of 70 years. Moreover, the mental health benefits were similar in individuals who were and were not using health-care services (P=0.502 for interaction). The improvement in physical health after the age of 70 years in adults eligible for reduced cost-sharing tended to be greater than in non-eligible adults (P=0.084).
Conclusion Reduced cost sharing was associated with lower out-of-pocket medical spending and improved mental health in older Japanese adults.

Objectives Scale development of health-related quality of life (HRQOL) measures, including physical and mental health measures, among public datasets from Japan is needed for comparative studies on health conditions among different age, gender, and socio-economic subgroups. Multi-attributable scales of continuous/discrete variables on HRQOL could be more flexible for different kinds of epidemiologic and socio-econometric studies rather than single-item measures. The objectives of this study were to create multi-dimensional scales for physical, mental, and summary health measures and to describe the age-related trends of these scales in Japan. Methods We utilized data from the 2007 Comprehensive Survey of the Living Conditions of People on Health and Welfare (LCPHW: Kokumin Seikatsu Kiso Chosa) (n = 383,745) to measure physical health (0 = worst score, 16 = best score) by summarizing four items: general health status, bedridden status/mobility, self-care/usual activities, and pain (0 = worst score, 4 = best score for each item). Mental health was measured using a Japanese version of K6 (0 = worst score, 4 = best score, modified from original version in which 24 = worst score and 0 = best score). We then created a summary health scale using the simple sum of physical and mental health (0 = worst score, 20 = best score). The reliability and validity of the scales were evaluated and their age-related trends described. Results The internal consistency reliability of the physical and summary health scales was not sufficiently high (Cronbach's α = 0.64 and 0.67, respectively) and the agerelated trend was smooth and monotonous. The internal consistency reliability of the mental health scale (K6) was high (Cronbach's α = 0.90), while the age-related trend peaked at age 65-74 years. Conclusions While K6 was a measure with high reliability for describing mental health, use of the physical and summary health scale in the Japanese population requires further discussion. Additional validation tests of the summary scales also need to be performed, in which our methodology is applied to other data sets that include strict diagnostic results based on a structural interview. © The Japanese Society for Hygiene 2011.

Japan&apos;s population is ageing rapidly because of long life expectancy and a low birth rate, while traditional supports for elderly people are eroding. In response, the Japanese Government initiated mandatory public long-term care insurance (LTCI) in 2000, to help older people to lead more independent lives and to relieve the burdens of family carers. LTCI operates on social insurance principles, with benefits provided irrespective of income or family situation; it is unusually generous in terms of both coverage and benefits. Only services are provided, not cash allowances, and recipients can choose their services and providers. Analysis of national survey data before and after the programme started shows increased use of formal care at lower cost to households, with mixed results for the wellbeing of carers. Challenges to the success of the system include dissatisfaction with home-based care, provision of necessary support for family carers, and fiscal sustainability. Japan&apos;s strategy for long-term care could offer lessons for other nations.

Japan's health indices such as life expectancy at birth are among the best in the world. However, at 8.5% the proportion of gross domestic product spent on health is 20th among Organisation for Economic Co-operation and Development countries in 2008 and half as much as that in the USA. Costs have been contained by the nationally uniform fee schedule, in which the global revision rate is set first and item-by-item revisions are then made. Although the structural and process dimensions of quality seem to be poor, the characteristics of the health-care system are primarily attributable to how physicians and hospitals have developed in the country, and not to the cost-containment policy. However, outcomes such as postsurgical mortality rates are as good as those reported for other developed countries. Japan's basic policy has been a combination of tight control of the conditions of payment, but a laissezfaire approach to how services are delivered; this combination has led to a scarcity of professional governance and accountability. In view of the structural problems facing the health-care system, the balance should be shifted towards increased freedom of payment conditions by simplification of reimbursement rules, but tightened control of service delivery by strengthening of regional health planning, both of which should be supported through public monitoring of providers' performance. Japan's experience of good health and low cost suggests that the priority in health policy should initially be improvement of access and prevention of impoverishment from health care, after which efficiency and quality of services should then be pursued.

雑誌掲載版

Following the introduction of the long-term care insurance scheme and deregulation of the market for at-home care services, Japan experienced a substantial increase in expenditure on care for the elderly. Using household-level survey data, we empirically examine whether the increase in care expenditure is associated with supplier density springing from the rise in the number of care providers following deregulation. We provide weak evidence that supplier density in the at-home care market is positively correlated with probability to use care or expenditure on care. Moreover, we find no link between the share of for-profit providers and the demand for at-home care services. (C) 2009 Elsevier B.V. All rights reserved.

The Technological Change in Health Care Research Network collected unique patient-level data on three procedures for treatment of heart attack patients (catheterization, coronary artery bypass grafts and percutaneous transluminal coronary angioplasty) for 17 countries over a 15-year period to examine the impact of economic and institutional factors on technology adoption. Specific institutional factors are shown to be important to the uptake of these technologies. Health-care systems characterized as public contract systems and reimbursement systems have higher adoption rates than public-integrated health-care systems. Central control of funding of investments is negatively associated with adoption rates and the impact is of the same magnitude as the overall health-care system classification. GDP per capita also has a strong role in initial adoption. The impact of income and institutional characteristics on the utilization rates of the three procedures diminishes over time. Copyright (C) 2008 John Wiley, & Sons, Ltd.

We empirically examine how the decision to purchase private health insurance and hospitalization are made
based on labor income, socio-demographic factors, and private health insurance. The increase in household labor income
and wealth has a positive effect on purchasing private health insurance. This suggests a supplementary effect for public
health insurance under the strict control of a two-tier healthcare coverage system. Our results support the hypothesis that
moral hazard presents for the costs paid to private health insurance by households. A strong positive association with the
risk of hospitalization causes individuals to change their health behavior after purchasing private health insurance leading
to lower costs in the ill health status and acquire less preventive measures. Thus, moral hazard exists in Japanese health
insurance market. Unlike the previous study, adverse selection based on our results is not negligible in the case of
hospitalization in Japan. The positive effect indicates that the higher the risk of illness with households, the more
insurance policies a household possesses. The results support our hypotheses that the decision to purchase health
insurance in case of death in an insured household in a hospital is attributed to the initial health stock of the household.
This means that households purchase private health insurance when there is a high probability of hospitalization with
claimed insuWe empirically examine how the decision to purchase private health insurance and hospitalization are made
based on labor income, socio-demographic factors, and private health insurance. The increase in household labor income
and wealth has a positive effect on purchasing private health insurance. This suggests a supplementary effect for public
health insurance under the strict control of a two-tier healthcare coverage system. Our results support the hypothesis that
moral hazard presents for the costs paid to private health insurance by households. A strong positive association with the
risk of hospitalization causes individuals to change their health behavior after purchasing private health insurance leading
to lower costs in the ill health status and acquire less preventive measures. Thus, moral hazard exists in Japanese health
insurance market. Unlike the previous study, adverse selection based on our results is not negligible in the case of
hospitalization in Japan. The positive effect indicates that the higher the risk of illness with households, the more
insurance policies a household possesses. The results support our hypotheses that the decision to purchase health
insurance in case of death in an insured household in a hospital is attributed to the initial health stock of the household.
This means that households purchase private health insurance when there is a high probability of hospitalization with
claimed insurance on death. The benefits from private health insurance policies for hospitalization provide incentives for
individuals to purchase health insurance that are a reflection of adverse selection against private health insurance. rance on death. The benefits from private health insurance policies for hospitalization provide incentives for
individuals to purchase health insurance that are a reflection of adverse selection against private health insurance.

本研究の目的は，「消費生活に関するパネル調査」（財団法人家計経済研究所）を用いて，世帯資産と所得を中心とした社会経済的状況が出産・育児期における女性の心理的健康に与える影響について実証的分析を行うことにある．動学同時決定パネル推定の結果，①世帯資産の変化率および世帯資産は，出産・育児期の女性の心理的健康状態に対して有意な影響がない； ②年間世帯所得の増加は心理的健康状態を有意に改善するが，効果は非常に小さい； ③推定モデルにかかわりなく，退職は女性の心理的健康状態に対してポジティブに，出産はネガティブに作用し，退職と出産の心理的健康尺度に与える効果の大きさは，世帯所得の効果よりもはるかに大きい； ④夫の親との同居は妻の心理的健康状態にネガティブに，夫の学歴の高さはポジティブに作用する，という結果を得た．以上の結果から，比較的若年層の女性の健康に対する効果は世帯の経済資源よりも非経済的要因の方が重要であり，現代社会で多様な役割を担っている女性にとって，就学前児童を抱えながらの就業継続が最も大きな心理的負担となっていることがわかった．The object of this study is to evaluate effects of socioeconomic status on psychological health in Japanese females in 20s-40s, using "Japanese Panel Survey of Consumers" conducted by the Institute for Research on Household Economics. The dynamic panel data estimation shows that (1) family assets have no impacts on female psychological health status; (2) household annual income has a significant positive effect on female health, however the size of effect is very negligible; (3) non-economic events and status such as retirement, birth, living with spouse's parents, and spouse's educational attainment have more significant impacts on female psychological health condition than do family assets or income.

In Japan, the, use of percutaneous transluminal coronary angioplasty (PTCA) for the treatment of acute myocardial infarction (AMI) is extraordinarily frequent, resulting in large medical expenditure. Using chart-based data and exploiting regional variations, we explore what factors explain the frequent use of PTCA, employing propensity score matching to estimate the average treatment effects on hospital expenditure and hospital days. We find that the probability of receiving PTCA is affected by the density of medical resources in a region. Moreover, expenditure is higher for treated patients while there are no significant differences in hospitalization days, implying that the frequent use of PTCA is economically motivated.

This study takes advantage of the introduction of Japan's public long-term care insurance scheme in 2000 as a unique natural experiment to evaluate how the socialization of long-term care affects female labor participation. Our difference-in-differences estimates suggest that the introduction of the scheme had no effect on female labor market participation in 2001, but a large and positive effect in 2002. The new long-term care scheme raised the probability that female caregivers were employed by 8 percentage points and, on average, the number of days per week and hours per day worked by female caregivers by 10-20 percent age points. (C) 2006 Elsevier B.V. All rights reserved.

Innovation of medical technology is a major driving force behind the increase in medical expenditures in developed countries. Previous studies identified that the diffusion of medical technology varied across countries according to the characteristics of regulatory policy and payment systems. Based on Roger's diffusion of innovation theory, this study purported to see how local practice norms, the evolving nature of diffusing technology, and local clinical needs in addition to differences in politico-economic systems would affect the process of innovation diffusion. Taking a case of coronary stenting, an innovative therapeutic technology in early 1990s, we provided a case study of hospital-based data between two teaching high-tech hospitals in Japan and the US for discussion. Stenting began to be widely used in both countries when complementary new technology modified its clinical efficacy, but the diffusion process still differed between the two hospitals due to (1) distinctive payment systems for hospitals and physicians, (2) practice norms in favor of percutaneous intervention rather than bypass surgery that was shaped by payment incentives and cultural attitudes, and (3) local patient's clinical characteristics that the technology had to be tailored for. The case study described the diffusion of stent technology as a dynamic process between patients, physicians, hospitals, health care systems, and technology under global and local conditions. (c) 2006 Elsevier Ireland Ltd. All rights reserved.

CONTEXT: Most older adults who die in Japan do so in the hospital without receiving hospice or palliative care. While there are some hospices in Japan, little is known about the care they provide to the elderly. OBJECTIVE: To clarify how the care of dying patients differs in a hospice and a geriatric hospital in Japan. DESIGN: Cohort study. SETTING: A hospice and a geriatric hospital in Japan. PARTICIPANTS: One hundred ninety-one inpatients aged 65 or older. MAIN OUTCOME: Areas of our interest: (1) gender and age; (2) primary disease(s) and cause of death; (3) observed symptoms/conditions and medical treatment or care conducted within 48 hours prior to death; (4) the actual topics leading to disclosure; and (5) whether or not advance directives had been given. RESULTS: The X2 test determined that there were statistically significant differences between a geriatric hospital and a hospice, with respect to mean age, diagnoses on admission, primary cause of death, symptoms/conditions, and the practice of medical interventions. However, controlling for patient characteristics and assuming a bivariate distribution between the probabilities of choosing a facility and of undergoing a medical procedure, we found that patients at the hospice were more likely to undergo treatment with opioids, urethral catheter, and oral medicine; such patients were less likely to undergo oxygen inhalation, total parenteral nutrition, and other intravenous drips. CONCLUSION: The hospice examined in this study was similar to the approach regarding medical treatments observed at the geriatric hospital.

The purpose of this paper is to investigate how to establish an education program for preschool teachers that will help them develop hearty and sympathetic body awareness when interacting with children. Lately, numbers of studies have proved that interactive physical synchronization" plays a significant role in the ability of preschool teachers to develop their "adaptable and compassionate body attentiveness." This study qualitatively examines the effectiveness of the empirical model we developed in a previous study of 223 students who completed training programs for preschool teachers at three universities. The empirical results were based on a multidimensional scaling method; they show that a specific professional training program might be effective in helping preschool teachers to achieve a higher degree of interactive physical synchronization, in particular, with respect to indicators representing "intersubjectivity" and "physical sensitivity."

The main objects of this paper are to introduce how to organize the dance therapy session intended for inpatients of a collaborative psychiatric hospital in Ibaragi prefecture; and to develop an outcome measurement of the session on their interactive physical communication through expressive bady movements. In order to develop the quantitative model assessing how patients' interactive physical communication is promoted through the sessions, we collect 20 principal indicators based on our previous studies on "interactive physical synchronization (kyoshin)" on expressive body movements. We apply a hierarchical cluster method (called multidimensional scaling method) evaluating the degree of interactive physical communication for 7 male and 17 female patients through the dance thrapy performed four-times from January through March in 2004. Cosequently, we found that our therapy program would motivate patients to achieve their creative and unique expressive body movements and it would lead them to higher degree of interactive physical communication. Also, we foud that the quantitative model is applicable to locate relative relation between "activity" and "passivity" among patients.

The main object of this study is to examine the life course and attitude of alumni that would be notably influenced by what they had learned and experienced in Toyo-Eiwa University. We prepared a unique socio-economic and opinion survey on entire 3, 192 alumni, conducted on unregistered basis in June, 2003. Five hundred forty-two (17.9%) alumni responded to the survey and 19 alumni allowed us for having further hearings from them. Note that the response rate in this study is not high enough to come to any definite conclusions capable to represent their behavior and thoughts after the graduation. However, we still believe that some results provide significant and useful resource for us to review how the college education has been affecting the choices and attitudes at various stages of their life. The survey consists of four main subjects ; (1) the degree of satisfaction with the college life and the sense of self-respect as Toyo-Eiwa alumni ; (2) individual demographic characteristics (e. g., age and family status including marriage/divorce status, and birth, etc) ; (3) the history of socioeconomic status (e. g., current and past employment status, wage, working hours, qualifications, living status, and health status, etc) ; and (4) the attitude of life course (e. g., marriage, family life, and various social activities, etc). Our results reveal that most alumni who responded to the survey feel impressed and affected by what they studied and experienced in their college-age. They have been trying to survive with self-respect as Toyo-Eiwa alumni, under the socio-economic circumstances getting severer through 1 990's. Finally, we are really grateful for alumni who spent long hours to complete our survey sheet, in particular, for those who kindly agreed to further face-to-face interview conducted by some undergraduates. Without their collaboration and a number of useful remarks on this study, we would not have been capable to continue and accomplish the research.

Background: Patients with end-stage renal disease are known to have decreased survival after myocardial infarction, but the association of less severe renal dysfunction with survival after myocardial infarction is unknown.
Objectives: To determine how patients with renal insufficiency are treated during hospitalization for myocardial infarction and to determine the association of renal insufficiency with survival after myocardial infarction.
Design: Cohort study.
Setting: All nongovernment hospitals in the United States.
Patients: 130 099 elderly patients with myocardial infarction hospitalized between April 1994 and July 1995.
Measurements: Patients were categorized according to initial serum creatinine level: no renal insufficiency (creatinine level &lt; 1.5 mg/dL [&lt;132 mumol/L];. n = 82 455), mild renal insufficiency (creatinine level, 1.5 to 2.4 mg/dL [132 to 212 mumol/L]; n = 36 756), or moderate renal insufficiency (creatinine level, 2.5 to 3.9 mg/dL (221 to 345 mumol/L); n = 10 888). Vital status up to 1 year after discharge was obtained from Social Security records.
Results: Compared with patients with no renal insufficiency, patients with moderate renal insufficiency were less likely to receive aspirin, beta-blockers, thrombolytic therapy, angiography, and angioplasty during hospitalization. One-year mortality was 24% in patients with no renal insufficiency, 46% in patients with mild renal insufficiency, and 66% in patients with moderate renal insufficiency (P &lt; 0.001). After adjustment for patient and treatment characteristics, mild (hazard ratio, 1.68 [95% CI, 1.63 to 1.73]) and moderate (hazard ratio, 2.35 [CI 2.26 to 2.45]) renal insufficiency were associated with substantially elevated risk for death during the first month of follow-up. This increased mortality risk continued until 6 months after myocardial infarction.
Conclusions: Renal insufficiency was an independent risk factor for death in elderly patients after myocardial infarction. Targeted interventions may be needed to improve treatment for this high-risk population.

Objective. To determine the effect of treatment by a cardiologist on mortality of elderly patients with acute myocardial infarction (AMI, heart attack), accounting for both measured confounding using risk-adjustment techniques and residual unmeasured confounding with instrumental variables (TV) methods.
Data Sources/Study Setting. Medical chart data and longitudinal administrative hospital records and death records were obtained for 161,558 patients aged greater than or equal to 65 admitted to a nonfederal acute care hospital with AMI from April 1994 to July 1995. Our principal measure of significant cardiologist treatment was whether a patient was admitted by a cardiologist. We use supplemental data to explore whether our analysis would differ substantially using alternative definitions of significant cardiologist treatment.
Study Design. This retrospective cohort study compared results using least squares (LS) multivariate regression with results from IV methods that accounted for additional unmeasured patient characteristics. Primary outcomes were 30-day and one-year mortality, and secondary outcomes included treatment with medications and revascularization procedures.
Data Collection/Extraction Methods. Medical charts for the initial hospital stay of each AMI patient underwent a comprehensive abstraction, including dates of hospitalization, admitting physician, demographic characteristics, comorbid conditions, severity of clinical presentation, electrocardiographic and other diagnostic test results, contraindications to therapy, and treatments before and after AMI.
Principal Findings. Patients admitted by cardiologists had fewer comorbid conditions and less severe AMIs. These patients had a 10 percent (95 percent CI: 9.5-10.8 percent) lower absolute mortality rate at one year. After multivariate adjustment with LS regression, the adjusted mortality difference was 2 percent (95 percent CI: 1.4-2.6 percent). Using IV methods to provide additional adjustment for unmeasured differences in risk, we found an even smaller, statistically insignificant association between physician specialty and one-year mortality, relative risk (RR) 0.96 (0.88-1.04). Patients admitted by a cardiologist were also significantly more likely to have a cardiologist consultation within the first day of admission and during the initial hospital stay, and also had a significantly larger share of their physician bills for inpatient treatment from cardiologists. IV analysis of treatments showed that patients treated by cardiologists were more likely to undergo revascularization procedures and to receive thrombolytic therapy, aspirin, and calcium channel-blockers, but less likely to receive beta-blockers.
Conclusions. In a large population of elderly patients with AMI, we found significant treatment differences but no significant incremental mortality benefit associated with treatment by cardiologists.

Context: Angiotensin-converting enzyme (ACE) inhibitors have been shown to decrease mortality in patients with myocardial infarction and depressed left ventricular function, but physicians may be reluctant to prescribe ACE inhibitors to patients with concomitant renal insufficiency.
Objective: To evaluate whether patients with depressed left, ventricular ejection fraction following acute myocardial infarction have a similar reduction in mortality from ACE inhibitors regardless of their renal function.
Design: Retrospective cohort study using medical record data.
Setting: All nonfederal acute care hospitals.
Patients: A cohort of 20902 Medicare beneficiaries aged 65 years and older directly admitted to the hospital from February 1, 1994, through July 30, 1995, and with a documented left ventricular ejection fraction of less than 40% measured by echocardiography, radionuclide scintigraphy, or angiography following a confirmed acute myocardial infarction.
Main Outcome Measures: One-year survival for patients who received or who did not receive an ACE inhibitor at hospital discharge, stratified by the patient's level of renal function.
Results: For the entire cohort, the receipt of an ACE inhibitor on hospital discharge was associated with greater 1-year survival (hazards ratio, 0.84; 95% confidence interval, 0.77-0.91) after adjusting for patient demographic characteristics, comorbidity, severity of illness (including left ventricular ejection fraction), and the receipt of other therapies. In stratified models, the receipt of an ACE inhibitor was associated with a 37% (16%-52%) lower mortality for patients who had poor renal function (serum creatinine level,&lt;265 mu mol/L [&lt;3 mg/dL]) and a 16% (8%-23%) lower mortality for patients who had better renal function. Use of aspirin therapy attenuated the benefit of ACE inhibitors in patients with poor renal function.
Conclusions: Moderate renal insufficiency should not be considered a contraindication to the use of ACE inhibitors in patients with depressed left ventricular ejection fraction following myocardial infarction. Use of aspirin therapy may attenuate the benefit of ACE inhibitors in patients with high serum creatinine levels; therefore, further studies are needed to determine whether treatment with aspirin, alternative antiplatelet agents, or anticoagulation is indicated for these patients.