Akira Babazono

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.

A comparison of international health outcomes and health care spending

Does increased spending improve health outcomes? We analyzed 1988 data from OECD countries to determine how key health care indexes correlate with health care outcomes. Total health care spending per capita and outpatient and inpatient utilization are not related to health outcomes. How our resources are allocated seems to be more important than how much money is actually spent.

Can Stress Management at the Workplace Prevent Depression? A Randomized Controlled Trial

Background: Stress, mental health and depression at the workplace have emerged as common and significant problems. The effectiveness of a stress-management program at the workplace was investigated. Methods: The effectiveness of a stress-management program was examined in workers at a highly stressful workplace using a randomized controlled trial. The 58 workers in the office were randomly assigned into a stress-management group (n = 28) and a control group (n = 30). The stress-management program included lectures on the perception of stress, measures to cope with it, stress-management recording sheets, and e-mail counseling. This program was based on the cognitive behavioral approach. The stress-management program was carried out for 3 months, and perceived work-related stress and psychological symptoms were evaluated using: General Health Questionnaire (GHQ)-30, Center for Epidemiologic Study for Depression (CES-D), the Questionnaire of Work-Related Stress and the Effort-Reward Imbalance Questionnaire. Twenty-one out of the 28 in the stress-management group and all in the control group were successfully followed up. Results: In the stress-management group, a significant improvement in the depressive symptoms was observed, compared with the control group in CES-D (p = 0.003 by two-tailed paired t-test, and p = 0.042 by repeated measure analysis of variance). In the multiple regression analysis, the effect of stress management on depressive symptoms at follow-up was significant (p = 0.041), controlling for potential confounding factors. However, the alleviation of perceived occupational stress was limited. Conclusions: A stress-management program based on the cognitive behavioral approach at the workplace may have potential for the prevention of depression.

The high-risk and population strategy for occupational health promotion (HIPOP-OHP) study: study design and cardiovascular risk factors at the baseline survey.

In order to establish the methodology of a population strategy for improving cardiovascular risk factors, we have planned the High-risk and Population Strategy for Occupational Health Promotion Study (HIPOP-OHP study). This study is a nonrandomized control trial in approximately 6500 participants in six intervention and six control companies. Our population strategy is based on three factors, nutrition, physical activity, and smoking. For each factor, a researchers working team was organized and has been supporting the intervention. A standardized method to obtain comparable data has also been established. In the baseline survey, urinary sodium excretion in male subjects was higher, and urinary potassium excretion was lower in both genders in the intervention group compared to the control group. The prevalence of hypertension for both genders was also higher in the intervention group. Male subjects in the intervention group had higher serum total cholesterol than controls, while high-density lipoprotein cholesterol was lower in both genders in the intervention group compared to the control group. These differences were reflected by our finding that the predicted relative risk of coronary heart disease for male subjects was significantly higher in the intervention group (relative risk, RR: 1.17; 95% confidence interval, 95% CI.: 1.09, 1.25) and significantly lower in the control group (RR: 0.93; 95% CI.: 0.89, 0.98) compared to a model Japanese population. Similar results were observed in the female subjects. Taken together, these findings indicate that it is possible to compare trends of predicted relative risk for coronary heart disease between two groups.

Time to Systemic Metastases in Patients with Posterior Uveal Melanoma

A total of 116 patients, all of whom had systemic metastases from posterior uveal melanoma, were evaluated to identify potential indicators for time to systemic metastasis. In the multivariate Cox proportional hazards model with clinically available variables, the age at initial treatment for uveal melanoma, gender and diameter of the primary tumor were revealed to be independent predictive factors for time to systemic metastasis. Age older than 60 years, male gender, and diameter of the primary uveal melanoma more than 10 mm were proved to be independent unfavorable factors. The estimated median time to systemic metastasis for the most unfavorable group (age > 60, male, diameter > 10 mm) was 20.2 months in contrast with 76.1 months for the most favorable group (age < or = 60, female, diameter < or = 10 mm). Although the results of this study cannot be applied to all patients with posterior uveal melanoma, predictive factors for time to systemic metastasis in those patients who have recurred supplement the information obtained from prognostic factors for the likelihood of metastasis or survival. They contribute not only to our understanding of the biology of metastasizing posterior uveal melanoma, but also in developing appropriate strategies for follow-up and treatment.

Minamata disease: catastrophic poisoning due to a failed public health response.

We present the history of Minamata disease in a chronological order from the public health point of view. Because the appropriate public health response – to investigate and control the outbreak – as set out in the Food Sanitation Act was not conducted, no one knew how many became ill following the outbreak. Exposure could not be stopped. In our discussion, we offer two reasons as to why the Japanese public health agencies did not apply the Act: social circumstances in the 1950s and 1960s that placed emphasis on industrial development, and the Japanese medical community’s lack of knowledge about the Act. The history of Minamata disease shows us the consequences when public health responses are not implemented. Minamata disease should be an invaluable lesson for future public health responses.

Does smoking cessation improve mental health

There is a possibility that cessation of smoking improves mental health, but there are no studies that have demonstrated this. A cohort study was performed for 1 year in 18 males who spontaneously stopped smoking (cessation group) and 173 who continued to smoke (smoking group). The mental health state was evaluated using the Japanese version of the 30‐item General Health Questionnaire (GHQ‐30) before the cessation of smoking and 6 months and 1 year after smoking cessation. Changes in the GHQ score were compared between the cessation and smoking groups. In order to control the effects of confounding factors, multiple regression analyses were performed using the GHQ score after 6 months and 1 year as dependent variables. The GHQ score in the cessation group significantly decreased 6 months and 1 year after smoking cessation (P < 0.04 and 0.01, respectively, by paired t‐test). In the smoking group, the GHQ score slightly decreased. Repeated measure analysis of variance revealed that the decrease in the GHQ score in the cessation group was significantly larger than in the smoking group. Multiple regression analysis revealed significant effects of smoking cessation on mental health after controlling for other confounding factors. It can be concluded that smoking cessation may improve mental health.

A case–control study of the relationships among silica exposure, gastric cancer, and esophageal cancer

BACKGROUND We examined the effect of silica exposure on gastric and esophageal cancer mortality using a cancer control series in a population setting. METHODS Cases and controls were restricted to male subjects and were drawn from death certificates in the Tobi area of Japan. A control group was selected from a series of deaths due to colon cancer, and cancers of other organs. The Japanese death certificate system is comprehensive because all deaths must be reported to the local office and death certificates are written by medical doctors. Age and smoking habits adjusted the Mantel-Haenszel odds ratios were estimated. RESULTS For gastric cancer, the age-, smoking-adjusted odds ratios were 1.22 (95% CI 0.74-2.01) for colon cancer and the other cancer control for silica exposure work, and 1. 36 (95% CI 0.76-2.43) for silicosis. For esophageal cancer, the age- and smoking-adjusted odds ratios were 1.53 (95% CI 0.59-3.96) for the cancer control for silica exposure, and 2.33 (95% CI 0.87-6.23) for silicosis, respectively. CONCLUSIONS The results suggest that gastric and esophageal cancer were related to silica exposure and silicosis in the study area, although they did not reach a statistically significant level because of the small sample size. The estimated odds ratios were higher for esophageal cancer and silicotic patients.

A Meta-Analysis on the Relationship between Pneumoconiosis and Lung Cancer

A Meta‐Analysis on the Relationship between Pneumoconiosis and Lung Cancer: Toshihide Tsuda, et al. Department of Hygiene and Preventive Medicine, Okayama University Medical School—An excess of lung cancer deaths among pneumoconiosis patients has been noted for many years but there has not been agreement on the excess of lung cancer deaths among pneumoconiosis patients in Japan. A meta‐analysis on the relationship between silicosis/pneumoconiosis and lung cancer mortality was conducted, by using 36 mortality studies published from 1980 to 1994. MEDLINE and other information sources were used for the information retrieval. After the critical appraisal, 32 eligible studies were identified. Study estimates were then pooled by using both the fixed effect model and the random effect model. An excess of lung cancer mortality among people with silicosis/pneumoconiosis was shown in all 32 studies. Although homogeneity among the studies was rejected (p<0.05) because the shape of the funnel plots assumed a symmetrical pyramidal shape, the summary rate ratio was estimated. The estimated rate ratio was 2.74 (95 percent confidence interval 2.60‐2.90) in all 32 studies, and 2.77 (2.61‐2.94) in 25 cohort studies. The random effect model results were almost the same as the fixed model results. The estimates in the Japanese studies were a little higher than the overall estimates, which indicated that lung cancer mortality was about three times higher among silicotic patients than among people in the control. This indicated a causal‐relationship between silicosis and lung cancer. This means that lung cancer should be regarded as one of the important complications of silicosis/pneumoconiosis. We recommend further research on the relationship between silica exposure and lung cancer.

Patient-motivated prevention of lifestyle-related disease in Japan: A randomized, controlled clinical trial

BackgroundPreventing lifestyle-related disease requires realistic, cost-effective programs that patients will embrace. We sought to determine whether patient-motivated lifestyle changes would better enhance healthcare outcomes compared with usual care. In addition, we performed an incremental cost-identification analysis of the intervention.MethodsParticipants were members of the National Health Insurance in Umi Town, Fukuoka Prefecture, Japan. Ninety-nine patients consented to participate in the study and were then randomized into the Patient-motivated Health Promotion Program group (intervention group) or the conventional support group (control group). The intervention group had a support team — consisting of qualified dietitians, health exercise instructors, and public health nurses — who encouraged patients to set their own goals and to select their own lifestyle improvements. Follow-up support was performed twice during the first year. These follow-up interventions were made in the patients’ homes. The control group received the results of their health examinations and instructions on how to enhance exercise via leaflets only. The control group did not receive services from support staff or have the benefit of the two home visits. All patients underwent health center visits for blood testing and reindoctrination, which were conducted at the end of 4, 6, and 12 months. Main outcome measures included changes in vegetable intake and physical activity (measured as number of steps taken per day). Other health measures included bodyweight, body mass index, blood pressure, cholesterol levels, and General Health Questionnaire.ResultsThe intervention program significantly increased the number of steps per day, increased the likelihood of consuming ≥2 servings of any type of vegetable, and increased the likelihood of consuming green and yellow vegetables after 1 year compared with the control group. However, there were no significant differences between groups with respect to measures of bodyweight, body mass index, blood pressure, cholesterol levels, and General Health Questionnaire score after 1 year. The incremental cost per person-year and the adjusted incremental cost per person-year were ¥27 495 (