Perspectives of value-based policy making in child health care in Japan.

In Japan, epidemiological transition has profoundly influenced the priorities of child healthcare. As pediatric care is shifting from a disease-driven curative approach to an integrated approach, the value of child health care now needs to be redefined with an integrated scope. With the trend to emphasize a rational judgement on the social value in terms of resource allocation and health policy, a value-based approach is necessary for child health care. This study aims to provide an overview and perspective of value-based policy making in child health care, under a context of epidemiological transition, health care system and social changes. The current methodology scheme of CEA and outcome evaluation has limitations, not meeting the urgent need of the application. The outcomes of child health care are no longer limited in clinical and health indicators such as survival rate, cure rate and health related quality of life, but also various aspects other than health, such as education, well-being of children and their primary caregivers, especially when treatment of diseases is no longer the dominant role of health care. Such the evaluation should reflect the impacts of the integrated approach in a long-term scope.

Accessibility of pediatric inpatient services in Japan.

In Japan, all citizens are covered by the national insurance system. Children's medical expenses are subsidized by local government co-payments. This removed most economic barriers to visiting medical facilities, geographical obstacles to pediatric medical services remain, including distance to medical facilities and transportation time. However, information on geographic accessibility of pediatric inpatient services is scarce. In this study, I calculated the proportion of children resident in areas accessible to pediatric inpatient service providers within 30 and 60 minutes by automobile. Calculations were based on addresses of hospitals that met criteria for high reimbursement for secondary and tertiary pediatric inpatient services, data for residential blocks, and data for the average velocity of an automobile. In total, 88.0% of children lived within 30 minutes of these hospitals and 95.2% of children lived within 60 minutes. The percentage of children with such access was higher in regions with high population density (e.g., Kanto and Kinki) compared with regions with low population density (e.g., Hokkaido, Tohoku, and Shikoku). Furthermore, regions with high population density also had high rates of children that lived within reach of hospitals with at least five full-time pediatricians.

Inter-Regional Differences in Travel Time to the Nearest Nursery for Children with Mild Acute Illness in Japan.

Access to day-care services for children with mild acute illness is important for working parents, because infants and toddlers often suddenly become ill, and most Japanese nursery schools do not accept children with even mild illnesses. Actual travel time to nurseries providing such day-care services is one of the indicators for measuring accessibility. However, this variable has not been well analyzed in previous work. To clarify practical access to such nurseries, this study used a car navigation algorithm to calculate the percentage of the population of children in Japan who can access nurseries providing services for children with mild acute illnesses within 15 to 30 minutes and compared this with the proportion of children living within a linear distance of 10 km of such nurseries. Of the 4,987,706 children younger than 5 years in 2015, 51.7% lived in areas from which the nearest nursery for children with mild acute illness was accessible within 0-15 minutes by automobile. In addition, 81.5% lived within 0-30 minutes of such nurseries, and the same percentage (81.5%) lived within a linear distance of 10 km of such nurseries. Both calculation methods (travel time and linear distance) showed inter-regional differences in accessibility, and the proportion of children with access to these nurseries was higher in heavily populated regions (e.g., Kanto and Kinki) than in less populated regions (e.g., Hokkaido and Tohoku). Children and caregivers throughout Japan should have equal access to these nurseries, because the national government subsidizes such services.

Children's access to major hospitals estimated to provide pediatric inpatient services 24 h a day in Japan.

To measure the geographic accessibility of pediatric inpatient medical services in Japan, the proportion of children who lived within 5, 10, 20, and 30 km of the nearest hospital providing inpatient services for children and staffed by at least five full-time equivalent pediatricians was calculated. Geographic information systems were used to assess the location of the hospitals, and the latitude, longitude, and child population of 219,100 residential "blocks" in Japan. The population and proportion of children in over- and under-populated prefectures were compared to show differences in accessibility. CONCLUSION: Of the 15.88 million children in Japan, 14.72 million (92.7%) lived within 30 km of the nearest hospital with at least five full-time equivalent pediatricians. They could therefore probably reach it within 1 h by car. However, the proportion of children living further than 30 km away varied across under- and over-populated prefecture groups. More than half of the 1.16 million children who lived in areas more than 30 km from the nearest hospital were in the 12 prefectures with the lowest population densities. Plans for medical provision for children should therefore be formulated differently for over- and under-populated prefectures, with provision made for improved transport from remote areas. What is Known: • The number of pediatricians and hospitals with pediatric departments is surveyed by Japanese health authorities, and the statistics on medical resources in each prefecture are published on the Japanese government's website. • Accessibility of medical services for children has not been well analyzed in Japan. What is New: • In total, 92.7% of Japanese children lived within 30 km of the nearest major hospital providing pediatric inpatient services. • More than half of the remaining children were residents of the 12 prefectures with the lowest population density.

Unequal Accessibility of Nurseries for Sick Children in Over- and Under-Populated Areas of Japan.

Infants and toddlers are prone to rapidly contracting illnesses, which are usually attributed to infectious diseases. Most nurseries and schools in Japan, however, refuse to accept children even with mild illnesses. For working parents, a sick child may therefore create new problems as the situation requires new day-care arrangements. To support such families, the Japanese government subsidizes construction and management of nurseries that operate especially for sick children. However, it has not been known whether most families are able to access such nurseries. To clarify the accessibility of these services, I calculated the distance to the nurseries from each of the 211,012 "blocks" (small residential areas with a median of 0.18 km2) in Japan and determined the proportion of children aged 0-4 years who lived within 3, 5, 10, 20 or 30 km of the nearest such nursery. Overall, 82.1% of these children lived within 10 km. However, the proportion was lower in northern parts of Japan such as Hokkaido and Tohoku, which have expansive land areas and low population and pediatric department densities. The proportion of children who lived within that same distance of the nearest nursery was also much lower in small towns and villages with 10,000 or fewer residents. Nurseries for sick children were not evenly distributed, and children and their caregivers in under-populated areas had to travel further to access these facilities. As the national government subsidizes such services, children and caregivers throughout Japan should have equal access to them.

Labor law violations in Japanese public hospitals from March 2002 to March 2011.

BACKGROUND: According to the Japan Pediatric Society, the mean extra work hours of hospital pediatricians in 2010 was approximately 80 h per month, which is the certification criterion for Karoshi (death from overwork), but there is no precise picture of personnel management at hospitals because the labor authorities do not disclose detailed statistics concerning labor law violations to the public. METHODS: Most local governments have a disclosure system, and the local governments that operate public hospitals were requested to disclose warning documents issued by the labor authorities from March 2002 to March 2011. RESULTS: A total of 208/369 public hospitals (56.4%) with ≥200 beds in Japan were warned of labor law violations. Offenses included exceeding the limit of working hours (177 hospitals) and non-payment of increased wages for night and holiday work (98 hospitals). CONCLUSIONS: Many public hospitals in Japan did not always pay workers including physicians for increased workload because they do not regard night and holiday duties as work hours.

Emergency transport for Japanese children with non-life-threatening conditions.

BACKGROUND: Emergency rooms in Japan are overused by children with non-life-threatening conditions, and utilization of emergency transport for children in Japan should also be analyzed. METHODS: Utilization rates of emergency transport per 1000 live births or 1000 children from 1985 to 2008 in Japan were calculated from national data of emergency transport, child population and annual live births. RESULTS: Emergency transport per 1000 preschool-age (28 days-6 years old) and school-age (7-17 years old) children rose, and that for newborn babies (0-27 days old) per 1000 live births grew from 1985 to 2008. The utilization rates, however, did not grow homogeneously among the different severity groups. The rates of transport for children who needed no hospitalization or those for children who needed inpatient care <3 weeks rose in each of the three age groups. The rates for patients who were dead on arrival or who needed hospitalization ≥ 3 weeks, however, declined in all the age groups. CONCLUSIONS: Emergency transport per 1000 live births or 1000 children grew from 1985 to 2008. The utilization rates, however, did not grow homogeneously among different severity groups. The rates for children with non-life-threatening conditions rose, while those for children dead on arrival or with severe conditions declined in the past two decades.

Are city population and the number of emergency medical facilities correlated?

BACKGROUND: The shortage of physicians is reported in the small cities in Japan, but the mal-distribution of physicians and emergency medical facilities has not been fully investigated. METHODS: Survey of Medical Institutions, 2005, Survey of Physicians, Dentists and Pharmacists, 2004, and 2005 Population Census of Japan were used. The relationships between city population and the numbers of medical resources such as emergency medical facilities, physicians and pediatricians were analyzed. RESULTS: The population and the number of emergency medical facilities of 895 cities were strongly correlated (r = 0.800, P = 0.000), and the numbers of the physicians and pediatricians had strong relationships to city population. CONCLUSION: All the cities cannot provide 24 h emergency services, therefore access time to medical facilities should be shortened by the construction of a transportation network instead of dispatching physicians to remote districts.

Are long physician working hours harmful to patient safety?

BACKGROUND: Pediatricians of Japanese hospitals including not only residents but also attending physicians work long hours, and 8% work for >79 h per week. Most of them work consecutively for >or=32 h when they are on call. The aim of the present study was to evaluate the effect of long work hours on patient safety. METHODS: The electronic databases MEDLINE and EMBASE to searched identify the English- and Japanese-language literature for studies on work hours, medical errors, patient safety, and malpractice for years 1966-2005. Studies that analyzed the relationship between physician work hours and outcomes directly related to patient safety were selected. RESULTS: Seven studies met the criteria. Four studies suggest that reduction of work hours has a favorable effect on patient safety indicators. In the other three studies no significant changes of the indicators were observed, but no report found that shorter work hours were harmful to patient safety. CONCLUSION: Decrease of physician work hours is not harmful but favorable to patient safety.