The revised index for social engagement (RISE) in long-term care facilities: reliability and validity in Japan.

BACKGROUND: This study aimed to establish the validity and reliability of a revised index for social engagement (RISE) in the Japanese context. METHODS: We analysed the data of 1377 participants over 65 years of age who had been admitted to two types of long-term care facilities (LTCF) in Japan: four health facilities for older adults and eight nursing homes. Resident level data based on the Japanese version of the interRAI assessment instrument were collected from 623 residents in the former and 754 in the latter. From these data, we calculated RISE by adding six dichotomous items on social engagement in the assessment form. Factorial validity was evaluated by exploratory factorial analysis and confirmatory factor analysis, convergent validity by the correlation between average activity time and the RISE score, and discriminant validity by the correlation between cognitive levels and the RISE scores. Lastly, we assessed internal consistency using Cronbach's alpha. RESULTS: We identified a two-factor model in the exploratory factorial analysis with a factor loading >0.40, except for one RISE item. The confirmatory factor analysis confirmed that the two-factor model had appropriate model fits. The correlation between time involved in activities and the RISE score was r = 0.45, while the correlation between cognitive function and the RISE score was r = -0.32. The convergent and discriminant validities supported the use of Japanese LTCF. Cronbach's alpha ranged 0.70-0.72. CONCLUSIONS: Although further revision may be needed to improve factorial validity, RISE is reliable and valid for assessing social engagement of older adults admitted to LTCF in Japan. By using the Japanese version of RISE, the positive aspects of social functioning can be appropriately assessed and provide more evidence for improving the quality of care in LTCF.

A Cost Projection of Scheduled Physician Home-Visit Services in Japan: 2014 to 2064.

This study predicts the volume and spending on scheduled physician home-visit (SPHV) services over five decades. This model-based evaluation study considered the following scenarios in Japan: (1) change in services-delivery; (2) technology-assisted services; (3) a combination of (1) and (2). The model predicted that the volume and spending on SPHV will increase as the population and working-age population decline. Scenario analysis indicated that a combined strategy could reduce the relative rate of spending to less than 2.00 in 2064, indicating that home health-care service reforms through changes in services-delivery and cost-reduction through technology-assisted services are promising in countries facing aging population.

Japan: achieving UHC by regulating payment.

The triple goals of Universal Health Coverage (UHC) are to cover the whole population, to reduce patients' costs, and to expand coverage to all effective services, equitably available to all. This paper analyses the experience of Japan in achieving these goals, focusing on the central role played by the payment system. The payment system, or fee schedule, sets the price of services and pharmaceuticals, as well as the conditions that providers must comply with in order to receive payment. The fee schedule was first introduced following the enactment of social health insurance (SHI) in 1922. Initially, the SHI program covered only manual workers, who comprised a mere 3% of the population. However, the fee schedule of the largest SHI plan was subsequently adopted by all other SHI plans. From 1958, there has been only one fee schedule. Population coverage was achieved in 1961 by mandating all residing in Japan to enroll in SHI, thereby making everyone entitled to all the services and pharmaceuticals listed in the fee schedule. Next, co-insurance was capped to an affordable level by the introduction of catastrophic coverage in 1973. Lastly, extra billing and balance billing were explicitly restricted in 1984. The key to achieving and sustaining UHC goals in Japan lies in being able to contain costs and reallocate resources by revising the fee schedule.

Moving towards universal health coverage: lessons from 11 country studies.

In recent years, many countries have adopted universal health coverage (UHC) as a national aspiration. In response to increasing demand for a systematic assessment of global experiences with UHC, the Government of Japan and the World Bank collaborated on a 2-year multicountry research programme to analyse the processes of moving towards UHC. The programme included 11 countries (Bangladesh, Brazil, Ethiopia, France, Ghana, Indonesia, Japan, Peru, Thailand, Turkey, and Vietnam), representing diverse geographical, economic, and historical contexts. The study identified common challenges and opportunities and useful insights for how to move towards UHC. The study showed that UHC is a complex process, fraught with challenges, many possible pathways, and various pitfalls--but is also feasible and achievable. Movement towards UHC is a long-term policy engagement that needs both technical knowledge and political know-how. Technical solutions need to be accompanied by pragmatic and innovative strategies that address the national political economy context.

Real-world cost analysis of chemotherapy for colorectal cancer in Japan: detailed costs of various regimens during the entire course of chemotherapy.

BACKGROUND: Various chemotherapy regimens for advanced colorectal cancer have been introduced to clinical practice in Japan over the past decade. The cost profiles of these regimens, however, remain unclear in Japan. To explore the detailed costs of different regimens used to treat advanced colorectal cancer during the entire course of chemotherapy in patients treated in a practical setting, we conducted a so-called "real-world" cost analysis. METHOD: A detailed cost analysis was performed retrospectively. Patients with advanced colorectal cancer who had received chemotherapy in a practical healthcare setting from July 2004 through October 2010 were extracted from the ordering system database of Showa University Hospital. Direct medical costs of chemotherapy regimens were calculated from the hospital billing data of the patients. The analysis was conducted from a payer's perspective. RESULTS: A total of 30 patients with advanced colorectal cancer were identified. Twenty patients received up to second-line treatment, and 8 received up to third-line treatment. The regimens identified from among all courses of treatment in all patients were 13 oxaliplatin-based regimens, 31 irinotecan-based regimens, and 11 regimens including molecular targeted agents. The average (95% confidence interval [95% CI]) monthly cost during the overall period from the beginning of treatment to the end of treatment was 308,363 (258,792 to 357,933) Japanese yen (JPY). According to the type of regimen, the average monthly cost was 418,463 (357,413 to 479,513) JPY for oxaliplatin-based regimens, 215,499 (188,359 to 242,639) JPY for irinotecan-based regimens, and 705,460 (586,733 to 824,187) JPY for regimens including molecular targeted agents. Anticancer drug costs and hospital fees accounted for 50 to 77% and 11 to 25% of the overall costs of chemotherapy, respectively. CONCLUSION: The costs of irinotecan-based regimens were lower than those of oxaliplatin-based regimens and regimens including molecular targeted agents in Japan. Using a lower cost regimen for first-line treatment can potentially reduce the overall cost of chemotherapy. The main cost drivers were the anticancer drug costs and hospitalization costs.

Controlling Spending For Health Care And Long-Term Care: Japan's Experience With A Rapidly Aging Society.

As the Japanese population has aged rapidly, Japan's experience has implications for other high-income countries, including the United States. The aging of Japan's population, coupled with the government's decision to implement a public long-term care insurance program in 2000, has increased the nation's expenditures. In acute care, costs have been relatively contained by biennially revising the fee schedule for all physician and hospital services and by lowering pharmaceutical prices. The fee schedule not only sets prices but also controls volume by setting the conditions of billing for each item. This fee schedule is applied to all social health insurance plans (which enroll all permanent residents of Japan) and to virtually all providers. In contrast, despite the use of a similar fee schedule, spending in long-term care insurance has increased more than spending in health care. This is both because long-term care became an entitlement and because aging has had a greater impact on long-term care insurance spending than on health insurance spending. In this article we analyze Japanese expenditure data to provide essential information to the US as the percentage of its population ages sixty-five and older continues to rise. A key lesson that the US can learn from Japan's experience is that as its population ages, the need for long-term care will increase, necessitating better control of acute care spending.

Cost containment and quality of care in Japan: is there a trade-off?

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 laissez-faire 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.

Population ageing and wellbeing: lessons from Japan's long-term care insurance policy.

Japan'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's strategy for long-term care could offer lessons for other nations.

Future of Japan's system of good health at low cost with equity: beyond universal coverage.

Japan's premier health accomplishment in the past 50 years has been the achievement of good population health at low cost and increased equity between different population groups. The development of Japan's policies for universal coverage are similar to the policy debates that many countries are having in their own contexts. The financial sustainability of Japan's universal coverage is under threat from demographic, economic, and political factors. Furthermore, a series of crises-both natural and nuclear-after the magnitude 9·0 Great East Japan Earthquake on March 11, 2011, has shaken up the entire Japanese social system that was developed and built after World War 2, and shown existing structural problems in the Japanese health system. Here, we propose four major reforms to assure the sustainability and equity of Japan's health accomplishments in the past 50 years-implement a human-security value-based reform; redefine the role of the central and local governments; improve the quality of health care; and commit to global health. Now is the time for rebirth of Japan and its health system.

Japanese universal health coverage: evolution, achievements, and challenges.

Japan shows the advantages and limitations of pursuing universal health coverage by establishment of employee-based and community-based social health insurance. On the positive side, almost everyone came to be insured in 1961; the enforcement of the same fee schedule for all plans and almost all providers has maintained equity and contained costs; and the co-payment rate has become the same for all, except for elderly people and children. This equity has been achieved by provision of subsidies from general revenues to plans that enrol people with low incomes, and enforcement of cross-subsidisation among the plans to finance the costs of health care for elderly people. On the negative side, the fragmentation of enrolment into 3500 plans has led to a more than a three-times difference in the proportion of income paid as premiums, and the emerging issue of the uninsured population. We advocate consolidation of all plans within prefectures to maintain universal and equitable coverage in view of the ageing society and changes in employment patterns. Countries planning to achieve universal coverage by social health insurance based on employment and residential status should be aware of the limitations of such plans.

Pricing Services: An Underutilized Policy Instrument for Access and Quality.

We aim to introduce the readers of this special collection to the importance of pricing health and long-term care services, a topic covered in 2 recent joint World Health Organization/Organization for Economic Co-operation and Development (WHO/OECD) publications. The special issue will focus on country experiences in pricing setting and regulation, best practices, and areas for future research.

COP27: The Prospects and Challenges for the Middle East and North Africa (MENA).

In line with the global trend, the Middle East and North Africa (MENA) region has been growing vulnerable to the direct and indirect health effects of climate change including death tolls due to climatological disasters and diseases sensitive to climate change since the industrial revolution. Regarding the limited capacity of MENA countries to adapt and respond to these effects, and also after relative failures of the previous negotiation in Glasgow, in the upcoming COP27 in Egypt, the heads of the region's parties are determined to take advantage of the opportunity to host MENA to mitigate and prevent the worst effects of climate change. This would be achieved through mobilizing international partners to support climate resilience, a major economic transformation, and put health policy and management in a strategic position to contribute to thinking and action on these pressing matters, at least to avoid or minimize the future adverse consequences.

Predictors of dying at home for patients receiving nursing services in Japan: A retrospective study comparing cancer and non-cancer deaths.

BACKGROUND: The combined effects of the patient's and the family's preferences for death at home have in determining the actual site of death has not been fully investigated. We explored this issue on patients who had been receiving end-of-life care from Visiting Nurse Stations (VNS). In Japan, it has been the government's policy to promote end-of-life care at home by expanding the use of VNS services. METHODS: A retrospective national survey of a random sample of 2,000 out of the 5,224 VNS was made in January 2005. Questionnaires were mailed to VNS asking the respondents to fill in the questionnaire for each patient who had died either at home or at the hospital from July to December of 2004. Logistic regression analysis was respectively carried out to examine the factors related to dying at home for cancer and non-cancer patients. RESULTS: We obtained valid responses from 1,016 VNS (50.8%). The total number of patients who had died in the selected period was 4,175 (cancer: 1,664; non-cancer: 2,511). Compared to cancer patients, non-cancer patients were older and had more impairment in activities of daily living (ADL) and cognitive performance, and a longer duration of care. The factor having the greatest impact for dying at home was that of both the patient and the family expressing such preferences [cancer: OR (95% CI) = 57.00 (38.79-83.76); non-cancer: OR (95% CI) = 12.33 (9.51-15.99)]. The Odds ratio was greater compared with cases in which only the family had expressed such a preference and in which only the patient had expressed such a preference. ADL or cognitive impairment and the fact that their physician was based at a clinic, and not at a hospital, had modest effects on dying at home. CONCLUSIONS: Dying at home was more likely when both the patient and the family had expressed such preferences, than when the patient alone or the family alone had done so, in both cancer and non-cancer patients. Health care professionals should try to elicit the patient's and family's preferences on where they would wish to die, following which they should then take appropriate measures to achieve this outcome.

Should the provision of home help services be contained?: validation of the new preventive care policy in Japan.

BACKGROUND: To maintain the sustainability of public long-term care insurance (LTCI) in Japan, a preventive care policy was introduced in 2006 that seeks to promote active improvement in functional status of elderly people who need only light care. This policy promotes the use of day care services to facilitate functional improvement, and contains the use of home help services that provide instrumental activity of daily living (IADL) support. However, the validity of this approach remains to be demonstrated. METHODS: Subjects comprised 241 people aged 65 years and over who had recently been certified as being eligible for the lightest eligibility level and had began using either home help or day care services between April 2007 and October 2008 in a suburban city of Tokyo. A retrospective cohort study was conducted ending October 2009 to assess changes in the LTCI eligibility level of these subjects. Cox's proportional hazards model was used to calculate the relative risk of declining in function to eligibility Level 4 among users of the respective services. RESULTS: Multivariate analysis adjusted for factors related to service use demonstrated that the risk of decline in functional status was lower for users of home help services than for users of day care services (HR = 0.55, 95% CI: 0.31-0.98). The same result was obtained when stratified by whether the subject lived with family or not. Furthermore, those who used two or more hours of home help services did not show an increase in risk of decline when compared with those who used less than two hours. CONCLUSIONS: No evidence was obtained to support the effectiveness of the policy of promoting day care services and containing home help services for those requiring light care.

Impact of home and community-based services on hospitalisation and institutionalisation among individuals eligible for long-term care insurance in Japan.

BACKGROUND: This population-based retrospective cohort study aimed to clarify the impact of home and community-based services on the hospitalisation and institutionalisation of individuals certified as eligible for long-term care insurance (LTCI) benefits. METHODS: Health insurance data and LTCI data were combined into a database of 1,020 individuals in two farming communities in Hokkaido who were enrolled in Citizen's Health Insurance. They had not received long-term care services prior to April 1, 2000 and were newly certified as eligible for Long-Term Care Insurance benefits between April 1, 2000 and February 29, 2008. The analysis covered 565 subjects who had not been hospitalised or institutionalised at the time of first certification of LTCI benefits. The adjusted hazard ratios (HRs) of hospitalisation or institutionalisation or death after the initial certification were calculated using the Cox proportional hazard model. The predictors were age, sex, eligibility level, area of residence, income, year of initial certification and average monthly outpatient medical expenditures, in addition to average monthly total home and community-based services expenditures (analysis 1), the use or no use of each type of service (analysis 2), and average monthly expenditures for home-visit and day-care types of services, the use or no use of respite care, and the use or no use of rental services for assistive devices (analysis 3). RESULTS: Users of home and community-based services were less likely than non-users to be hospitalised or institutionalised. Among the types of services, users of respite care (HR: 0.71, 95% confidence interval [CI]: 0.55-0.93) and rental services for assistive devices (HR: 0.70, 95% CI: 0.54-0.92) were less likely to be hospitalised or institutionalised than non-users. For those with relatively light needs, users of day care were also less likely to be hospitalised or institutionalized than non-users (HR: 0.77, 95% CI: 0.61-0.98). CONCLUSIONS: Respite care, rental services for assistive devices and day care are effective in preventing hospitalisation and institutionalisation. Our results suggest that home and community-based services contribute to the goal of the LTCI system of encouraging individuals certified as needing long-term care to live independently at home for as long as possible.

Use of physical restraints and antipsychotic medications in nursing homes: a cross-national study.

OBJECTIVES: This study compares inter- and intra-country differences in the prevalence of physical restraints and antipsychotic medications in nursing homes, and examines aggregated resident conditions and organizational characteristics correlated with these treatments. METHODS: Population-based, cross-sectional data were collected using a standardized Resident Assessment Instrument (RAI) from 14,504 long-term care facilities providing nursing home level services in five countries participating in the interRAI consortium, including Canada, Finland, Hong Kong (Special Administrative Region, China), Switzerland, and the United States. Facility-level prevalence rates of physical restraints and antipsychotic use were examined both between and within the study countries. RESULTS: The prevalence of physical restraint use varied more than five-fold across the study countries, from an average 6% in Switzerland, 9% in the US, 20% in Hong Kong, 28% in Finland, and over 31% in Canada. The prevalence of antipsychotic use ranged from 11% in Hong Kong, between 26-27% in Canada and the US, 34% in Switzerland, and nearly 38% in Finland. Within each country, substantial variations existed across facilities in both physical restraint and antipsychotic use rates. In all countries, neither facility case mix nor organizational characteristics were particularly predictive of the prevalence of either treatment. CONCLUSIONS: There exists large, unexplained variability in the prevalence of physical restraint and antipsychotic use in nursing home facilities both between and within countries. Since restraints and antipsychotics are associated with adverse outcomes, it is important to understand the idiosyncratic factors specific to each country that contribute to variation in use rates.

Relationship between interRAI HC and the ICF: opportunity for operationalizing the ICF.

BACKGROUND: The International Classification of Functioning, Disability and Health (ICF) is embraced as a framework to conceptualize human functioning and disability. Health professionals choose measures to represent the domains of the framework. The ICF coding classification is an administrative system but multiple studies have linked diverse clinical assessments to ICF codes. InterRAI-HC (home care) is an assessment designed to assist planning of care for patients receiving home care. Examining the relationship between the ICF and the interRAI HC is of particular interest because the interRAI assessments are widely used in clinical practice and research, are computerized, and uploaded to databases that serve multiple purposes including public reporting of quality in Canada and internationally. The objective of this study was to examine the relationship between the interRAI HC (home care) assessment and the ICF. Specifically, the goal was to determine the proportion of interRAI HC items that can be linked to each of the major domains of the ICF (Body Function, Body Structure, Activities and Participation, and the Environmental Factors), the chapters and the specific ICF codes. METHODS: Three coders who were familiar with both the home care assessment and the ICF independently assigned ICF codes to inter-RAI HC items. Subsequently, a series of teleconference meetings were held to reach consensus on the primary code and much later consensus was used to finalize codes for additional items added to the interRAI HC. RESULTS: Following exclusion of administrative and diagnostic sections, 175 interRAI items were examined for potential assignment of codes. Of these 52 were assigned codes related to body function, 43 to activities and participation, 34 to environment, 1 to body structure, 17 to not coded, and 26 to not defined. Considering all 3-digit ICF codes, interRAI items addressed 43.2% of Body Function and 50.6% of Activities and Participation codes. CONCLUSION: The conceptual overlap in content, offers an excellent opportunity to operationalize the ICF domains and the codes particularly in the areas of Body Function and Activities and Participation. Use of measures such as the interRAI assessments with common elements across settings facilitates standardized reporting for organizations, regions and nations.

Financing Long-term Care: Lessons From Japan.

Long-term care (LTC) must be carefully delineated when expenditures are compared across countries because how LTC services are defined and delivered differ in each country. LTC's objectives are to compensate for functional decline and mitigate the care burden of the family. Governments have tended to focus on the poor but Germany opted to make LTC universally available in 1995/1996. The applicant's level of dependence is assessed by the medical team of the social insurance plan. Japan basically followed this model but, unlike Germany where those eligible may opt for cash benefits, they are limited to services. Benefits are set more generously in Japan because, prior to its implementation in 2000, health insurance had covered long-stays in hospitals and there had been major expansions of social services. These service levels had to be maintained and be made universally available for all those meeting the eligibility criteria. As a result, efforts to contain costs after the implementation of the LTC Insurance have had only marginal effects. This indicates it would be more efficient and equitable to introduce public LTC Insurance at an early stage before benefits have expanded as a result of ad hoc policy decisions.

[Utility-based evaluation of the quality of life of patient's with gastric cancer who receive chemotherapy--comparison of patients' quality of life between oral TS-1 and conventional injectable combination therapy].

We tried to clarify the applicability of "utility" for the evaluation of patient's QOL with gastric cancer after chemotherapy and attempted to compare differences in QOL after treatment with the oral antitumor agent TS-1 or with a conventional injectable combination. Three items, moving activity, pain, and gastrointestinal symptoms, were employed as indicators of patient QOL, and then the assessment of utility was compared based on the expected outcomes that 9 pharmacists working on a ward, 9 nurses working on a neurosurgery ward, and 9 nurses working on a gastrointestinal surgery ward estimated directly using the three methods of standard gamble, time trade-off, and rating scale according to predictive scenarios based on each scenario. The QOL of patients who received the two different types of chemotherapy were also compared as the average utilities from the direct estimation depending on patient conditions as used for chart review. Furthermore, the average utilities were compared with the utility of the mapping method, which can be estimated by applying a utility-converting table defined in the EQ-5D survey. The average utility from each practitioner using the direct estimation revealed that the assessed utility from nurses working on a neurosurgery ward was higher than those of the pharmacists. The average utility obtained using the standard gamble method was higher than those using the rating scale and time trade-off methods. The average utility in the TS-1 therapy group was 0.84-0.94, and that in the conventional injectable therapy group was 0.52-0.79 (p<0.05). The result suggests that utility is applicable for estimation of gastric cancer patient QOL after chemotherapy, and that TS-1 therapy is superior to the traditional injectable combination therapy.

Decreasing Use of Percutaneous Endoscopic Gastrostomy Tube Feeding in Japan.

OBJECTIVES: To identify trends in percutaneous endoscopic gastrostomy (PEG) tube placement and intravenous hyperalimentation (IVH) in nonhospital settings (as a potential alternative to tube feeding for nutrition) and to summarize published reports concerning the decision-making process for PEG placement. DESIGN: National survey and systematic review. SETTING: Japan. PARTICIPANTS: All Japanese people. MEASUREMENTS: Data on numbers of individuals with a PEG tube and IVH were obtained from the website of the Japanese Ministry of Health, Labour, and Welfare and published reports concerning the decision-making process for PEG placement in Japan were summarized. RESULTS: The number of PEG tube placements peaked in 2007 and has been decreasing since Japan experienced the Great East Japan Earthquake in 2011. A further decline was seen in 2015 after the Japanese Ministry of Health, Labour and Welfare revised the fee schedule in 2014. More than half of individuals who had tubes were aged 80 and older during the years observed. In contrast, the number of individuals receiving IVH was lowest in the same year as PEG tube placement peaked and has been increasing ever since. Four studies reported that the decision-making process included consideration of not only the underlying disease, but also the individual's age and social barriers and the physician's personal philosophy. CONCLUSION: The number of PEG tube placements has been decreasing since its peak in 2007, and the number of individuals receiving IVH has been increasing. Many factors influence the decision-making process for PEG tube placement. Physicians in Japan may be realizing that there is little evidence to support the use of tube feeding in frail elderly adults.