Number of consulting medical institutions and risk of polypharmacy in community-dwelling older people under a healthcare system with free access: a cross-sectional study in Japan.

BACKGROUND: Under the Japanese free access healthcare system, patients are allowed to consult multiple medical institutions (including clinics and hospitals for general or specialist consultation) without primary care referral. This potentially increases the risk of polypharmacy. We examined the association between the number of consulting medical institutions and polypharmacy under a healthcare system with free access. METHODS: Via a self-administered questionnaire, we identified people aged ≥65 years with ≥1 disease and ≥1 consulting medical institution in a Japanese city in 2016. The exposure of interest was the number of consulting medical institutions (1, 2, or ≥3) and the outcome was polypharmacy (use of ≥6 types of drugs). We performed a multivariate logistic regression analysis, adjusting for age, sex, household economy, and the number and type of comorbidities. To minimize confounding effects, we also performed propensity-score-matched analysis, categorizing patients into two groups: 1 and ≥2 consulting medical institutions. RESULTS: Of 993 eligible individuals (mean (standard deviation) age: 75.1 (6.5) years, men: 52.6%), 15.7% (156/993) showed polypharmacy. Proportions of polypharmacy were 9.7% (50/516), 16.6% (55/332), and 35.2% (51/145) for people who consulted 1, 2, and ≥3 medical institutions, respectively. Relative to people who consulted 1 medical institution, adjusted odds ratios (95% confidence intervals) for polypharmacy were 1.50 (0.94-2.37) and 3.34 (1.98-5.65) for those who consulted 2 and ≥3 medical institutions, respectively. In propensity score matching, of 516 and 477 patients who consulted 1 and ≥2 medical institutions, 307 pairs were generated. The proportion of polypharmacy was 10.8% (33/307) and 17.3% (53/307), respectively (P = 0.020). The odds ratio for polypharmacy (≥2 vs. 1 consulting medical institution) was 1.73 (95% confidence interval 1.09-2.76). CONCLUSIONS: Patients who consulted more medical institutions were more likely to show polypharmacy. The results could encourage physicians and pharmacists to collect medication information more actively and conduct appropriate medication reviews. Strengthening primary care is needed to address the polypharmacy issue, especially in countries with healthcare systems with free access.

[Introduction of long-term care insurance: changes in service usage].

OBJECTIVES: With the aging of the population, Japan's long-term care system has shifted from a welfare-placement system to a social-insurance system, which is a precedent of policies for the elderly. We examined how individuals who used care services before the implementation of long-term care insurance (LTCI) (previous service users) currently use the LTCI services, with a focus on the processes of service use. METHODS: Panel data were obtained from the Nihon University Japanese Longitudinal Study of Aging database. These data were collected by interviews conducted before (November 1999 and March 2000) and after (November 2001 and December 2001) the establishment of LTCI. Among the 3992 individuals who participated in these interviews, 416 of the previous service users, aged ≥65 years, were sampled. The outcome measures were the processes of using LTCI services (application for LTCI, certification of long-term care need, and contract with LTCI service providers). Logistic regression analysis was performed to identify individual factors associated with the process of application for LTCI. RESULTS: There were 133 LTCI users among the 416 previous service users (32.0%). Of the service processes used, 45.5% of previous service users were applicants, 85.7% of the applicants were certified individuals, and 88.7% of those certified used services with service contracts. The application process was significantly easier for individuals with disease (odds ratio[OR], 8.34 : 95% confidence interval [CI], 1.86-37.46), those dependent for their instrumental activities of daily living (IADL) (OR, 11.21 : 95% CI, 5.22-24.07), those with an equivalent income of <1.25 million yen (OR, 2.72 : 95% CI, 1.30-5.69), and those who had used respite care (OR, 3.29 : 95% CI, 1.16-9.35) previously. In contrast, the application process was significantly difficult for community rehabilitation users (OR, 0.38 : 95% CI, 0.17-0.82). CONCLUSION: Only half of the previous service users were applicants, and they had severe diseases or were more dependent for their IADL. Our findings suggest that many individuals who were functionally independent were covered under the welfare-placement system. Additionally, low-income individuals did not refrain from applying.