Japan's Dental Care Facing Population Aging: How Universal Coverage Responds to the Changing Needs of the Elderly.

Although universal health coverage (UHC) is pursued by many countries, not all countries with UHC include dental care in their benefits. Japan, with its long-held tradition of UHC, covers dental care as an essential benefit, and the majority of dental care services are provided to all patients with minimal copayment. Being under UHC, the scope of services as well as prices are regulated by the uniform fee schedule, and dentists submit claims according to the uniform format and fee schedule. The author analyzed the publicly available dental health insurance claims data as well as a sampling survey on dental hygiene to illustrate how Japan's dental care is responding to the challenges from population aging. A marked improvement was found in dental health status in the elderly population as measured by improved tooth-specific survival. The improvement may be attributable to the universal coverage of dental care, as evidenced by the steady increase in home visits by dentists/dental hygienists as well as home oral rehabilitation services.

Infant, neonatal, and postneonatal mortality trends in a disaster region and in Japan, 2002-2012: a multi-attribute compositional study.

BACKGROUND: The reductions achieved in infant mortality in Japan are globally regarded as remarkable. However, no studies in Japan have classified infant mortality trends into neonatal and postneonatal or considered regional issues. This study aimed to explore trends in neonatal and postneonatal deaths, both overall for Japan and in a region affected by a natural disaster. METHODS: Drawing on national infant death data, we used a multi-attribute compositional study design to examine all infant deaths occurring in a region affected by a disaster (Tohoku, which consists of Iwate, Miyagi, and Fukushima) between 2002 and 2012. We used conjoint analysis to clarify the associations between infant and maternal characteristics and age of infant death. RESULTS: We obtained data of a total of 31,012 infant deaths between 2002 and 2012, which included 1450 from Tohoku. Infant mortality rates in Japan overall declined over the period but increased in 2011. There were more postneonatal (29-364 days post-birth) than neonatal (0-28 days post-birth) deaths. Infant deaths in Tohoku declined slightly overall, with a fluctuation in 2011. In Tohoku, the trends in postneonatal death rates were similar; the overall rates for males increased, but those for females decreased in 2011. We found that the cause and place of infant death differed by gender for neonatal and postneonatal deaths in both Japan in general and Tohoku. The conjoint analysis showed that most variables affected the age of postneonatal death. The factor with the largest influence on the variation in infant death age was gestational week (55.5%). A maternal gestational week ≤36 was linked to an average age at death of 43.4 days, and > 37 was linked to an average of 83.7 days. CONCLUSIONS: In Japan, infant death rates have declined steadily over the past 10 years. The recent trends indicated that postneonatal death rates were higher than neonatal rates, especially in Tohoku. However, not much attention has been focused on postneonatal deaths in Japan. Our findings may help health planners to prioritise work on the factors that are linked to infant deaths in the neonatal and postneonatal periods. TRIAL REGISTRATION: Not applicable.

Differences in infant and child mortality before and after the Great East Japan Earthquake and Tsunami: a large population-based ecological study.

OBJECTIVES: To examine associations between access to medical care, geological data, and infant and child mortality in the area of North-Eastern Japan that was impacted by the Great East Japan Earthquake and Tsunami (GEJET) in 2011. DESIGN: A population-based ecological study using publicly available data. SETTING: Twenty secondary medical areas (SMAs) in the disaster-affected zones in the north-eastern prefectures of Japan (Iwate, Fukushima and Miyagi). PARTICIPANTS: Children younger than 10 years who died in the 20 SMAs between 2008 and 2014 (n=1 748). Primary and secondary outcome measures: Multiple regression analysis for infant and child mortality rate. The mean values were applied for infant and child mortality rates and other factors before GEJET (2008-2010) and after GEJET (2012-2014). RESULTS: Between 2008 and 2014, the most common cause of death among children younger than 10 years was accidents. The mortality rate per 100 000 persons was 39.1±41.2 before 2011, 226.7±43.4 in 2011 and 31.4±39.1 after 2011. Regression analysis revealed that the mortality rate was positively associated with low age in each period, while the coastal zone was negatively associated with fewer disaster base hospitals in 2011. By contrast, the number of obstetrics and gynaecology centres (ß=-189.9, p=0.02) and public health nurses (ß=-1.7, p=0.01) was negatively associated with mortality rate per person in 2011. CONCLUSIONS: In 2011, the mortality rate among children younger than 10 years was 6.4 times higher than that before and after 2011. Residence in a coastal zone was significantly associated with higher child mortality rates.

Japan turns pro-life: recent change in reproductive health policy and challenges by new technologies.

Japan, known as a pro-choice country in terms of abortion, is currently facing the increase of "selective abortions" thanks to new prenatal screening. Efforts to restrict proliferation of new technology has not been successful and it is likely that Japan will turn pro-life by strictly enforcing the Maternity Protection Act (MPA), which prohibits abortions due to "fetal cause".

Linkage rate between data from health checks and health insurance claims in the Japan National Database.

BACKGROUND: Japan's National Database (NDB) includes data on health checks and health insurance claims, is linkable using hash functions, and is available for research use. However, the linkage rate between health check and health insurance claims data has not been investigated. METHODS: Linkage rate was evaluated by comparing observed medical and pharmaceutical charges among health check recipients in fiscal year (FY) 2009 (N = 21 588 883) with expected charges from the same population when record linkage was complete. Using the NDB, observed charges were estimated from the first published result of linking health check recipients in FY2009 and their health insurance claims in FY2010. Expected charges were estimated by combining 3 publicly available datasets, including data from the Medical Care Benefit Survey and an ad-hoc report by the Japan Health Insurance Association. RESULTS: Only 14.9% of expected charges were linked by the NDB. The linkage rate was higher for women than for men (18.2% vs 12.4%) and for elderly adults as compared with younger adults (>25% vs <10%). CONCLUSIONS: The linkage rate in the NDB was so low that any research linking health check and health insurance claims will not be reliable. Causes for the low linkage rate include differences between health check and health insurance claims data in name format (eg, insertion of a space between family and given names) and date of birth (Japanese vs Gregorian calendar). Investigation of the causes for the low linkage rate and measures for improvement are urgently needed.

Cohort analysis of incidence/mortality of liver cancer in Japan through logistic curve fitting.

Incidence/mortality of liver cancer follow logistic curves because there is a limit reflecting the prevalence of hepatitis virus carriers in the cohort. The author fitted logistic curves to incidence/mortality data covering the nine five-year cohorts born in 1911-1955 of both sexes. Goodness-of-fit of logistic curves was sufficiently precise to be used for future predictions. Younger cohorts born in 1936 or later were predicted to show constant decline in incidence/mortality in the future. The male cohort born in 1931-35 showed an elevated incidence/mortality of liver cancer early in their lives supporting the previous claim that this particular cohort had suffered massive HCV infection due to nation-wide drug abuse in the 1950s. Declining case-fatality observed in younger cohorts suggested improved treatment of liver cancer. This study demonstrated that incidence/mortality of liver cancer follow logistic curves and fitted logistic formulae can be used for future prediction. Given the predicted decline of incidence/mortality in younger cohorts, liver cancer is likely to be lost to history in the not-so-distant future.

A mathematical model to predict the risk of hepatitis B infection through needle/syringe sharing in mass vaccination.

BACKGROUND: The Japanese Government settled a class litigation case with hepatitis B virus (HBV) carriers who claim to have been infected through needle/syringe sharing in childhood mass vaccination with a blanket compensation agreement. However, it is difficult to estimate how many of the present HBV carriers were infected horizontally from mass vaccination and how many were infected vertically from mothers. METHODS: A mathematical model to predict the risk of infection through needle/syringe sharing in mass vaccination was proposed and a formula was developed. The formula was presented in a logarithmic graph enabling users to estimate how many people will be infected if a needle/syringe is shared by how many people for how many times under certain probability of infection. The formula was then applied to the historical data of mass tuberculin skin tests (TSTs) and BCG inoculation, from which a best estimate of how much needle/syringe sharing was practiced in different birth cohorts was determined. RESULTS: For the oldest cohort born between 1951 and 1955, the prevalence of HBV carriers-0.65% at birth through vertical transmission-more than doubled in 1995 (1.46%) through horizontal transmission. If the probability of infection through needle/syringe sharing is assumed to be 10%, it is theoretically likely that an average of five or more people shared a needle/syringe four times to achieve the prevalence of HBV carriers in 1995. However, for the youngest cohort born between 1981 and 1985, the effects of needle/syringe sharing were negligible because the later prevalence of HBV carriers was lower than the prevalence at birth. CONCLUSIONS: More than half of the HBV carriers born in the early 1950s might have contracted the disease by mass vaccinations. Japan's experience needs to be shared with other countries as a caution in conducting mass vaccination programs under scarce needle/syringe supply (291 words).

Prevalence of bile duct cancer among printing industry workers in comparison with other industries.

OBJECTIVES: The aim of this study was to assess the risk of developing bile duct cancer among workers in the other printing industry in comparison with workers in all industries in general. METHODS: Prevalence of bile duct cancer was compared between workers in the printing industry and age-standardized controls in all other industries using the claims database of the Japan Health Insurance Association, which insures workers of small-medium sized employers of all industries. RESULTS: Young (aged 30-49) male workers in the printing industry showed an elevated but insignificant standardized prevalence rate ratio (SPRR) for bile duct cancer in comparison with workers in all other industries (SPRR: 1.78; 95%CI: 0.63-5.00). The risk was higher for intrahepatic bile duct cancer but remained insignificant (SPRR: 3.03; 95%CI: 0.52-17.56). CONCLUSIONS: The sharply elevated risk of bile duct cancer observed among proof-printing workers of a printing factory in Osaka may not be generalizable to workers in the printing industry nationwide.

Effects of health guidance on outpatient and pharmacy expenditures: a disease- and drug-specific 3-year observational study using propensity-score matching.

BACKGROUND: Evidence is lacking on whether health guidance for metabolic syndrome reduces health care expenditures. The author used propensity-score matching to evaluate the effects of health guidance on health care expenditure. METHODS: Men who did and did not receive health guidance from a health insurance society (approximately 60 000 covered lives) were matched (n = 397 respectively) using propensity scores. Health insurance claims were compared using cumulative health care expenditures for metabolic syndrome-related outpatient medical care and drug costs for the period from the initial consultation to 3 years later. RESULTS: No difference was observed between intervention and control groups in cumulative outpatient charges or drug costs related to metabolic syndrome. However, regression analysis using the Tobit model showed that health guidance resulted in a small, nonsignificant reduction in health care expenditure. CONCLUSIONS: Health guidance for metabolic syndrome did not reduce outpatient charges or drug costs related to metabolic syndrome during the 3-year period after the intervention. Findings from Tobit regression suggest that health guidance might eventually result in savings, but this hypothesis remains untested.

A comparison of disease-specific medical expenditures in Japan using the principal diagnosis method and the proportional distribution method.

BACKGROUND: There are technical limitations to handling all the information mentioned in health insurance claims (HICs) in Japan. Therefore, conventional methods for estimating disease-specific medical expenditures assume that all medical care expenditures in a given HIC are spent on only one principal diagnosis even when the HIC contains multiple diagnoses. OBJECTIVES: To estimate the disease-specific medical expenditures that consider all diagnosis on a given HIC. METHODS: Data were obtained from 169 622 outpatient HICs in May 2006 from health insurance provided by the employer. We compared the estimated disease-specific medical expenditures of the conventional method with a proportional distribution method (PDM), which considers all diagnoses on the HICs. RESULTS: For diabetes mellitus and other diseases of the digestive system, the proportion of principal diagnoses among total diagnoses was 52.4% (4849/9251) and 19.6% (2614/13331), respectively. In addition, the ratio of the estimated disease-specific medical expenditures between the conventional method and the PDM method was 1.49 for diabetes mellitus and 0.64 for other diseases of the digestive system. The estimation of disease-specific medical expenditures using the conventional method may therefore have overestimated the expenditures on the disease category typically selected as the principal diagnosis and underestimated the expenditures on the disease category less likely to be selected as the principal diagnosis. CONCLUSIONS: The conventional method for estimation of disease-specific medical expenditures should be improved by utilizing all the diagnoses information on HICs.

Estimating medical expenditures spent on rule-out diagnoses in Japan.

BACKGROUND: According to the regulations concerning reimbursement rules for the uniform coverage scheme in Japan's health insurance system, rule-out diagnoses must be included in a health insurance claim (HIC) to ensure reimbursement for clinical procedures whose results show that a suspected disease is not present. However, estimations of disease-specific medical expenditure by conventional methods have not considered the information on rule-out diagnoses. OBJECTIVES: To estimate disease-specific medical expenditure for rule-out diagnoses. METHODS: Data were obtained from 169,622 outpatient HICs in May 2006 from corporate health insurance societies. We used the proportional distribution method to estimate medical expenditure for each of the major disease categories defined by the Classification of Diseases for the use of Social Insurance, which is based on the International Statistical Classification of Diseases and Related Health Problems, 10th Revision. RESULTS: There were 442,010 diagnoses on the HICs, of which 20,330 (4.60%) were rule-out diagnoses. Rule-out diagnoses accounted for 8.5% of total medical expenditure. The proportion of medical expenditure spent on rule-out diagnoses varied across the major diseases categories, and it was estimated that more than one-third (36.9%) of the medical expenditure on neoplasm is spent on rule-out diagnoses. CONCLUSIONS: The existence of rule-out diagnoses affects the estimation of disease-specific medical expenditure. Therefore, the estimation of disease-specific medical expenditure and evaluation of prevention and treatment programmes should be improved by utilizing information on rule-out diagnoses.

Integrated care through disease-oriented clinical care pathways: experience from Japan's regional health planning initiatives.

INTRODUCTION: In April 2008, Japan launched a radical reform in regional health planning that emphasized the development of disease-oriented clinical care pathways. These 'inter-provider critical paths' have sought to ensure effective integration of various providers ranging among primary care practitioners, acute care hospitals, rehabilitation hospitals, long-term care facilities and home care. DESCRIPTION OF POLICY PRACTICE: All 47 prefectures in Japan developed their Regional Health Plans pursuant to the guideline requiring that these should include at least four diseases: diabetes, acute myocardial infarction, cerebrovascular accident and cancer. To illustrate the care pathways developed, this paper describes the guideline referring to strokes and provides examples of the new Regional Health Plans as well as examples of disease-oriented inter-provider clinical paths. In particular, the paper examines the development of information sharing through electronic health records (EHR) to enhance effective integration among providers is discussed. DISCUSSION AND CONCLUSION: Japan's reform in 2008 is unique in that the concept of 'disease-oriented regional inter-provider critical paths' was adopted as a national policy and all 47 prefectures developed their Regional Health Plans simultaneously. How much the new regional health planning policy has improved the quality and outcome of care remains to be seen and will be evaluated in 2013 after the five-year planned period of implementation has concluded. Whilst electronic health records appear to be a useful tool in supporting care integration they do not guarantee success in the application of an inter-provider critical path.

[Outpatient antimicrobial drug use and antimicrobial resistance frequency in Suwa area, Nagano, Japan].

A cross-sectional study was conducted to determine antimicrobial use and to analyze the correlation to resistant bacteria. Records on antimicrobial prescriptions in Suwa area, Nagano prefecture, were collected from December 2009 to May 2010 from a national health insurance database system. Records on antimicrobial-resistant bacteria during the same period were collected from area hospitals. Data was then compared to data published in Europe. The target population was 31,505, or 27.1% of the total area population. More antimicrobials were prescribed in an outpatient setting rather for inpatients. Total outpatient antimicrobial use was 9.34 defined daily dose (DDD) per 1,000 subject days. Macrolides, lincosamides, and streptogramins (MLS) was the most prescribed drug group, followed by beta-lactams other than penicillin and quinolone. The quinolone-resistance rate among Escherichia coli in this area was within a predictable range based on European data, although that of macrolide-resistance among Streptococcus pneumoniae exceeded the predictable range. The health insurance system electronic database proved useful in collecting data on antimicrobial use for curbing action against antimicrobial resistance, including antimicrobial stewardship.

A statistical analysis of 'rule-out' diagnoses in outpatient health insurance claims in Japan.

BACKGROUND: As each clinical procedure must be justified by a corresponding diagnosis in Japanese health insurance claim (HIC), unconfirmed diagnoses marked as rule-out diagnoses will be written on an HIC. However, little is known about the statistical profiles of such rule-out diagnoses. OBJECTIVES: To illustrate the basic statistical profiles of rule-out diagnoses. METHODS: We analysed all the diagnoses on 169 622 outpatient HICs in May 2006 from corporate health insurance societies. The proportions of additional diagnoses and rule-out diagnoses in each of the major disease categories defined by the Classification of Diseases for the use of Social Insurance, which is based on the International Statistical Classification of Diseases and Related Health Problems 10th Revision were calculated. RESULTS: There were 442 010 diagnoses on the HICs, of which 96 253 (21.8%) were principal diagnoses and 345 757 (78.2%) were additional diagnoses. Of the principal diagnoses, 1022 (1.1%) were rule-out diagnoses. Of the additional diagnoses, 19 308 (5.6%) were rule-out diagnoses. The percentage of rule-out diagnoses in the additional diagnosis category was significantly higher than that in the principal diagnosis category. Among the major disease categories, neoplasms showed the highest percentage of rule-out diagnoses for both principal diagnosis and additional diagnosis. CONCLUSIONS: The existence of rule-out diagnoses affects the results of statistics based on HIC data. Japanese statistics based on HIC data should be improved by utilizing the information on rule-out diagnoses.

Is oseltamivir (Tamiflu) safe? Re-examining the Tamiflu 'ado' from Japan.

Reports that oseltamivir causes abnormal behaviors in influenza patients and, thereby, increases the risk of injuries or death alerted the world. Such reports came almost exclusively from Japan, which consumes more than 75% of the world supply, even before the novel influenza pandemic started. The Japanese government will not revoke its warning issued in March 2007 against the use of oseltamivir in teenagers despite the accumulating evidence that such abnormal behaviors are part of generic symptoms of influenza-like delirium and not attributable to certain drugs. The author analyzes the background of the 'ado' by compiling the various sources of information, some of which have not been readily available to the international audience and explains why Japan is incapable of producing firm evidence to draw a definite conclusion. The author also alarms the potential risk of sudden death related to oseltamivir and foresees how the problem may be solved in the future.

Declining accuracy in disease classification on health insurance claims: should we reconsider classification by principal diagnosis?

BACKGROUND: An ideal classification should have maximum intercategory variance and minimal intracategory variance. Health insurance claims typically include multiple diagnoses and are classified into different disease categories by choosing principal diagnoses. The accuracy of classification based on principal diagnoses was evaluated by comparing intercategory and intracategory variance of per-claim costs and the trend in accuracy was reviewed. METHODS: Means and standard deviations of log-transformed per-claim costs were estimated from outpatient claims data from the National Health Insurance Medical Benefit Surveys of 1995 to 2007, a period during which only the ICD10 classification was applied. Intercategory and intracategory variances were calculated for each of 38 mutually exclusive disease categories and the percentage of intercategory variance to overall variance was calculated to assess the trend in accuracy of classification. RESULTS: A declining trend in the percentage of intercategory variance was observed: from 19.5% in 1995 to 10% in 2007. This suggests that there was a decline in the accuracy of disease classification in discriminating per-claim costs for different disease categories. The declining trend temporarily reversed in 2002, when hospitals and clinics were directed to assign the principal diagnosis. However, this reversal was only temporary and the declining trend appears to be consistent. CONCLUSIONS: Classification of health insurance claims based on principal diagnoses is becoming progressively less accurate in discriminating per-claim costs. Researchers who estimate disease-specific health care costs using health insurance claims must therefore proceed with caution.

Mortality in East Asian countries in the pre-war period: a quasi-experimental study on healthy immigrant effects.

Life tables of East Asian countries in the prewar period (1926-30) provide a rare quasi-experimental study on immigration. Age and sex-specific mortality of four East Asian countries/regions namely Japan, Korea, Taiwan and Kwanton province of China in the prewar period (1926-30) were drawn from life tables and vital statistics of that time. Mortality curves of these countries/regions were compared to illustrate healthy immigrant effects and racial disposition. Expatriate Japanese men of working age (20-35) had a slightly lower age-specific mortality than indigenous Japanese, suggesting a healthy migrant effect. Also, "humps" in the mortality curves around twenty years of age due to tuberculosis were observed in expatriate Japanese in all three foreign countries/ regions but not in local residents. Mild healthy immigrant effects were observed in expatriate Japanese men of working age. Susceptibility to tuberculosis was attributable to racial disposition rather than to environmental factors.

Do individualized health promotional programs reduce health care expenditure? A systematic review of controlled trials in the "Health-Up" model projects of the National Health Insurance.

OBJECTIVES: The aim was to summarize the outcomes of the controlled trials in the "Health-Up" model projects of the National Health Insurance to quantify the effects of individualized health promotional programs (IHPPs) on outpatient and pharmaceutical health care expenditure. METHODS: Reports submitted to the Ministry of Health, Labor & Welfare by municipalities participating in the projects were reviewed and monthly per-capita outpatient and pharmaceutical expenditures were extracted. Comparisons were made between the intervention and control groups as to temporal changes between one year before and the one year after the programs. Temporal changes were evaluated with reference to effect ratio with 95% CI. RESULTS: A total of 31 programs conducted in 17 municipalities were included in the review. A total of 2,947 people participated in the IHPPs and 6,666 people were assigned to the control group in a randomized or matched manner. IHPPs varied widely as to the effects on health care expenditures: Sixteen programs demonstrated reduction effects (ER < 1), of which two were statistically significant, while fifteen programs demonstrated inflationary effects (ER > 1), of which two were significant. Overall, per capita health care expenditure of all participants increased by 4.7% (95% CI: 1.003-1.094) or 6,697 yen above the controls. The pooled ER was 1.044 (95% CI: 1.000-1.091) indicating a 4.4% inflation of the per capita health care expenditure of participants compared to the controls during the year after the interventions. CONCLUSIONS: Overall, IHPPs demonstrated slight but significant inflationary effects on outpatient and pharmaceutical health care expenditures. Follow-up studies must be conducted to adjudicate the long-term effects of IHPPs on health care expenditure.