Haruko Noguchi

Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients

Context Renal insufficiency increases the risk for cardiovascular disease, but whether it affects survival after myocardial infarction is unknown. Contribution This large cohort study of Medicare beneficiaries hospitalized between April 1994 and July 1995 revealed the following: 1-year postmyocardial infarction mortality for no, mild, and moderate renal insufficiency was 24%, 46%, and 66%, respectively. Moderate renal insufficiency was more common in black and male patients and in patients with diabetes or previous stroke. Patients with moderate renal insufficiency received aspirin, -blockers, thrombolytic therapy, angiography, and angioplasty less often than patients with mild or no renal insufficiency. Implications Patients with moderate renal insufficiency have increased mortality after myocardial infarction. They also get fewer effective treatments for myocardial infarction, which may explain the higher death rate. The Editors Patients with end-stage renal disease who require dialysis have markedly increased mortality after myocardial infarction compared with other patients. One-year mortality in these patients is approximately 60% (1-3). After myocardial infarction, these patients are also unlikely to receive aggressive therapy, such as thrombolytic therapy and primary angioplasty, although these treatments have been associated with improved survival in these patients (4). Patients with renal insufficiency have a greater risk for cardiovascular disease events (5, 6), but the association between mild and moderate renal insufficiency and survival after myocardial infarction has not been evaluated in-depth (1, 7). Two earlier studies have included measures of renal function in prediction models for death after myocardial infarction. Normand and colleagues (8) incorporated both blood urea nitrogen and creatinine levels into a multivariate prediction model for 30-day mortality after myocardial infarction. Jacobs and colleagues included urea nitrogen levels as one of seven categories of predictors for death after hospital admission for acute coronary syndromes (9). However, studies have not compared survival after myocardial infarction among patients with and without renal insufficiency. In addition, the use of medical treatments and procedures after myocardial infarction among patients with and without renal insufficiency, and their association with survival, has not been studied. We hypothesized that patients with mild and moderate renal insufficiency would have substantially greater 1-year mortality than patients with no renal insufficiency. We also hypothesized that patients with renal insufficiency would be less likely to receive therapeutic interventions known to improve survival after myocardial infarction, such as -blockers, aspirin, angiotensin-converting enzyme (ACE) inhibitors, thrombolytic therapy, and primary angioplasty. Using data from the Cooperative Cardiovascular Project, we evaluated the treatment of patients with no renal insufficiency and patients with mild and moderate renal insufficiency. We also determined the independent association of renal insufficiency with survival after myocardial infarction. Methods Patients The Cooperative Cardiovascular Project collected data from all elderly (age 65 years) Medicare beneficiaries who were admitted between April 1994 and July 1995 to an acute-care hospital and discharged with the diagnosis of acute myocardial infarction (International Classification of Diseases, Ninth Revision, diagnosis code 410) (10). The diagnosis was confirmed by review of the medical records for each patient and required a serum creatine kinaseMB index greater than 5%; an elevated serum lactate dehydrogenase level with lactate dehydrogenase-1 greater than or equal to lactate dehydrogenase-2; or two of the following three criteria: chest pain, serum creatine kinase level more than twice the normal value, or electrocardiographic evidence of acute myocardial infarction (11). A total of 139 567 patients had confirmed myocardial infarction. Only the initial hospitalization for myocardial infarction during the period of evaluation was included. We excluded 6790 patients with severe renal insufficiency (serum creatinine level 4.0 mg/dL [354 mol/L]) or estimated creatinine clearance less than 0.17 mL/sec. We also excluded 10 570 patients (8.1%) for whom information on body weight was not available to estimate creatinine clearance. Measurements Within the Cooperative Cardiovascular Project, trained medical record abstracters collected the following data for each patient: date and location of hospitalization, demographic characteristics, comorbid conditions, severity of illness measures, electrocardiogram findings, laboratory values, results from invasive and noninvasive cardiac studies, contraindications to therapy, in-hospital treatments, and discharge medications (9). The reliability of the data abstraction process has been demonstrated (10, 12). We classified renal function using both the admission serum creatinine level and the estimated creatinine clearance. We defined no renal insufficiency as a serum creatinine level less than 1.5 mg/dL (<132 mol/L), mild renal insufficiency as a serum creatinine level between 1.5 and 2.4 mg/dL (132 to 212 mol/L), and moderate renal insufficiency as a serum creatinine level between 2.5 and 3.9 mg/dL (221 to 345 mol/L). We estimated creatinine clearance by using the CockroftGault equation (13) and divided patients into tertiles. Data on serum creatinine levels were available for all patients. Data on mortality during the first year after hospital admission were obtained from Social Security Administration records. Statistical Analysis We compared the characteristics and treatments of patients with no renal insufficiency, mild renal insufficiency, and moderate renal insufficiency using analysis of variance and chi-square tests. We compared the proportions of patients treated with -blockers among all patients in each category of renal function and in just the patients without relative contraindications to -blockers (previous heart failure, diabetes, chronic obstructive pulmonary disease, and pulmonary edema at presentation). We compared use of ACE inhibitors among all patients and then restricted the comparison to patients with hypertension or diabetes. For thrombolytic therapy, we compared treatment as a proportion of all patients treated and as a proportion of ideal patients treated. Ideal candidates were defined by ST-segment elevation or left bundle-branch block on the electrocardiogram; onset of chest pain within 6 hours of presentation; age of 80 years or younger; and the absence of peptic ulcer disease, chronic liver disease, metastatic cancer, and terminal illness (14). To determine the association of renal function with survival after myocardial infarction, we constructed KaplanMeier curves for the three groups of serum creatinine levels (and the tertiles of creatinine clearance); statistical significance was assessed by using the log-rank test. We repeated these analyses within subgroups of patients who presented without pulmonary edema or cardiogenic shock (Killip class I and class II) to determine whether the association of renal function with 1-year survival persisted among patients with less severe myocardial infarctions. We used Cox proportional-hazards models to determine whether mild and moderate renal insufficiency were independent predictors of 1-year mortality (15). These models were adjusted for patient demographic characteristics (age, sex, race, rural or urban setting, and region of the United States); comorbid conditions (history of diabetes mellitus, hypertension, hypercholesterolemia, tobacco use, congestive heart failure, stroke, peripheral vascular disease, angina, myocardial infarction, percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery, chronic obstructive pulmonary disease, dementia, inability to ambulate, depression, and incontinence); severity of clinical presentation (Killip class, electrocardiogram findings, heart rate, mean arterial blood pressure, alertness and orientation according to the Glasgow coma scale, duration of chest pain, and blood urea nitrogen level [< 30 mg/dL; <10.7 mmol/L as urea or 30 mg/dL; 10.7 mmol/L as urea]); hospital characteristics (capability to do coronary angiography and revascularization; volume of myocardial infarction admissions); in-hospital treatments (aspirin, -blockers, ACE inhibitors, thrombolytic therapy, intravenous nitroglycerin, coronary angiography, percutaneous transluminal coronary angioplasty, and coronary artery bypass graft surgery); and discharge medications (aspirin, -blockers, calcium-channel blockers, and ACE inhibitors). We evaluated the inclusion of a categorical variable for each hospital (n = 4200) in a 10% sample of our data set, but it had little effect on the association of renal function with survival after myocardial infarction. We also checked for violations of linearity by examining augmented models, which included quadratic terms for continuous predictors. We tested the validity of the proportional hazards assumption by determining whether the risk estimates for the renal function categories varied significantly over time. Because we found a significant interaction of the risk for renal function over time, we elected to explore stratified models over time. We separately evaluated the association of our renal function categories with survival after myocardial infarction for the following time intervals: months 1, 2 to 3, 4 to 6, 7 to 9, and 10 to 12. Because the association of renal insufficiency with mortality was the same for months 7 to 9 and 10 to 12, we combined these follow-up intervals. We confirmed that there were no residual violations of the proportional hazards assumption within each time strata by again testing for the presence of an interaction of each renal function predictor with time in predicting mor

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

Japans 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. Japans strategy for long-term care could offer lessons for other nations.

Comparison of the effects of angiotensin converting-enzyme inhibitors and beta blockers on survival in elderly patients with reduced left ventricular function after myocardial infarction

PURPOSE Angiotensin converting-enzyme (ACE) inhibitors decrease mortality after myocardial infarction among patients with depressed left ventricular function. Beta blockers may also improve survival in these patients. We compared the relative effects of these agents on the survival of elderly patients with a left ventricular ejection fraction less than 40% after myocardial infarction. SUBJECTS AND METHODS The Cooperative Cardiovascular Project collected data on patients aged 65 years and older who were admitted with myocardial infarction from April 1994 to July 1995, including 20,902 with a measured left ventricular ejection fraction less than 40% before discharge. Using proportional hazard regression models that adjusted for patient characteristics and in-hospital treatments, we compared survival among patients discharged on ACE inhibitors, beta blockers, both medications, or neither medication. RESULTS Among patients surviving hospitalization with reduced left ventricular function, 9,108 (44%) were discharged on ACE inhibitors, 2,613 (13%) on beta blockers, 3,309 (16%) on both medications, and 5,872 (28%) on neither medication. Patients treated with ACE inhibitors were more likely to have a prior diagnosis of heart failure and less likely to have undergone revascularization, whereas those treated with beta blockers were more often treated with thrombolytic therapy and aspirin. Patients treated with ACE inhibitors [hazard ratio (HR = 0.80), 0.80; 95% confidence interval (CI), 0.73 to 0.87] or beta blockers (HR = 0.76, 0.76; 95% CI, 0.64 to 0.90) had lower adjusted 1-year mortality than those who were not treated with either medication. The combination of both medications was associated with additional benefit (HR = 0.68, 0.68; 95% CI, 0.59 to 0.80). The relative benefit of each medication was greatest among patients with an ejection fraction less than 30%, a serum creatinine level 2.0 mg/dL or greater, or both. To prevent a death within a year, the number of patients who needed to be treated with both medications varied from 5 to 15, depending on ejection fraction and renal function. CONCLUSION ACE inhibitors and beta blockers were associated with similar improvements in survival among elderly patients with reduced left ventricular ejection fraction after myocardial infarction. Our results suggest that patients who can tolerate both medications gain additional benefit from the combination.

How Possibly Do Leisure and Social Activities Impact Mental Health of Middle-Aged Adults in Japan?: An Evidence from a National Longitudinal Survey

Objectives This study aimed to investigate longitudinal relations between leisure and social activities and mental health status, considering the presence or absence of other persons in the activity as an additional variable, among middle-aged adults in Japan. This study used nationally representative data in Japan with a five-year follow-up period. Methods This study focused on 16,642 middle-aged adults, age 50–59 at baseline, from a population-based, six-year panel survey conducted by the Japanese Ministry of Health, Labour and Welfare. To investigate the relations between two leisure activities (‘hobbies or cultural activities’ and ‘exercise or sports’) and four social activities (‘community events’, ‘support for children’, ‘support for elderly individuals’ and ‘other social activities’) at baseline and mental health status at follow-up, multiple logistic regression analysis was used. We also used multiple logistic regression analysis to investigate the association between ways of participating in these activities (‘by oneself’, ‘with others’, or ‘both’ (both ‘by oneself’ and ‘with others’)) at baseline and mental health status at follow-up. Results Involvement in both leisure activity categories, but not in social activities, was significantly and positively related to mental health status in both men and women. Furthermore, in men, both ‘hobbies or cultural activities’ and ‘exercise or sports’ were significantly related to mental health status only when conducted ‘with others’. In women, the effects of ‘hobbies or cultural activities’ on mental health status were no differences regardless of the ways of participating, while the result of ‘exercise or sports’ was same as that in men. Conclusions Leisure activities appear to benefit mental health status among this age group, whereas specific social activities do not. Moreover, participation in leisure activities would be effective especially if others are present. These findings should be useful for preventing the deterioration of mental health status in middle-aged adults in Japan.

Health benefits of reduced patient cost sharing in Japan

OBJECTIVE To assess the effect on out-of-pocket medical spending and physical and mental health of Japans reduction in health-care cost sharing from 30% to 10% when people turn 70 years of age. METHODS Study data came from a 2007 nationally-representative cross-sectional survey of 10 293 adults aged 64 to 75 years. Physical health was assessed using a 16-point scale based on self-reported data on general health, mobility, self-care, activities of daily living and pain. Mental health was assessed using a 24-point scale based on the Kessler-6 instrument for nonspecific psychological distress. The effect of reduced cost sharing was estimated using a regression discontinuity design. FINDINGS For adults aged 70 to 75 years whose income made them ineligible for reduced cost sharing, neither out-of-pocket spending nor health outcomes differed from the values expected on the basis of the trend observed in 64- to 69-year-olds. However, for eligible adults aged 70 to 75 years, out-of-pocket spending was significantly lower (P < 0.001) and mental health was significantly better (P < 0.001) than expected. These differences emerged abruptly at the age of 70 years. Moreover, the mental health benefits were similar in individuals who were and were not using health-care services (P = 0.502 for interaction). The improvement in physical health after the age of 70 years in adults eligible for reduced cost-sharing tended to be greater than in non-eligible adults (P = 0.084). CONCLUSION Reduced cost sharing was associated with lower out-of-pocket medical spending and improved mental health in older Japanese adults.

Regional variations in medical expenditure and hospitalization days for heart attack patients in Japan: evidence from the Tokai Acute Myocardial Study (TAMIS)

In Japan, the use of percutaneous transluminal coronary angioplasty (PTCA) for the treatment of acute myocardial infarction (AMI) is extraordinarily frequent, resulting in large medical expenditure. Using chart-based data and exploiting regional variations, we explore what factors explain the frequent use of PTCA, employing propensity score matching to estimate the average treatment effects on hospital expenditure and hospital days. We find that the probability of receiving PTCA is affected by the density of medical resources in a region. Moreover, expenditure is higher for treated patients while there are no significant differences in hospitalization days, implying that the frequent use of PTCA is economically motivated.

Does Marriage Make Us Healthier? Inter-Country Comparative Evidence from China, Japan, and Korea.

Objectives This study focuses on East Asian countries and investigates the difference in the marriage premium on the health-marriage protection effect (MPE) between younger and older generations and the intra-couple education concordance effect (ECE) on the health of married individuals. This study used inter-country comparative data from China, Japan, and Korea. Methods This study focused on individuals (n = 7,938) in China, Japan, and Korea who were sampled from the 2010 East Asian Social Survey. To investigate MPE and ECE, four health indicators were utilized: a physical and mental components summary (PCS and MCS), self-rated health status (Dself), and happiness level (Dhappy). Ordinary least squares regression was conducted by country- and gender-specific subsamples. Results We found that the MPE on PCS, MCS, and Dself was more significant for the older generation than for the younger generation in both China and Japan, whereas the results were inconclusive in Korea. With regard to the ECE on happiness (Dhappy), for both men and women, couples tend to be happier when both the husband and the wife are well educated (“higher balanced marriage”) compared to couples with a lower level of educational achievement (“lower balanced marriage”). Significant benefits from a “higher balanced marriage” on MCS and Dself were observed for women only. In contrast, no statistically significant differences in health status were observed between “higher balanced marriage” couples and couples with different levels of educational achievements (“upward marriage” or “downward marriage”). Conclusions This study found that (1) the MPE was more significant for the older generation, and (2) the health gap, particularly the happiness gap, between higher- and lower-balanced married couples was significant. The inter-country comparative findings are useful to explain how the role of marriage (and therefore of family) on health has been diluted due to the progress of industrialization and modernization.

Mental Health of Parents as Caregivers of Children with Disabilities: Based on Japanese Nationwide Survey

The number of children with disability is increasing gradually in Japan. Previous researches in other countries have reported that parents as caregivers (CGs) of children with disability have mental health problems, but the actual situation has not been examined nationwide in Japan so far. The aim of this study was to evaluate the association between mental health of CGs who had children with disability and characteristics of children, CGs, and household based on the nation-wide survey. This study utilized data from 2010 Comprehensive Survey of the Living Conditions, and defined children with disability aged 6 to 17. Individual data of children and CGs were linked, and 549 pairs of them were extracted. The Japanese version of Kessler 6 (K6) was used to assess mental health status of caregiver, scored 5 and over represented to general psychological distress. Logistic regression was used to evaluate the associations of interest. The almost half (44.4%) of CGs had psychological distress (k6 score; 5 +) in nationwide, and 8.9% of CGs might have serious mental illness (K6 score; 13+). After adjusting covariates of child, CG, and household factors, CG having a current symptom (OR, 95% CI: 3.26, 1.97–5.39), CGs activity restriction (OR, 95% CI: 2.95, 1.38–6.32), low social support (OR, 95%CI: 9.31, 1.85–46.8), three generation family (OR, 95% CI: 0.49, 0.26–0.92), and lower 25% tile group of monthly household expenditure (OR, 95% CI:1.92, 1.05–3.54), were significantly associated with psychological distress of CGs. This study encourages health care providers to pay more attentions toward parents mental health, especially for in case of having low social support, and lower income family. Further research should examine the detailed information of childs disease and disability, medical service use, and quality and quantity of social support in nationwide to straighten the system for supporting services of both children with disabilities and their CGs.

Nonprofit wage premium in the Japanese child care market: evidence from employer-employee matched data

Using unique employer–employee matched data, this study reveals the existence of a nonprofit wage premium in Japans child care industry. Nonprofits reward experienced workers with higher education, associated with the quality of care, more than their for-profit counterparts.

Disability, poverty, and role of the basic livelihood security system on health services utilization among the elderly in South Korea

With rapid aging, many of the elderly suffer from poverty and high healthcare needs. In Korea, there is a means-tested and non-contributory public assistance, the National Basic Livelihood Security System (NBLSS). The purpose of this study is to show older populations condition of disability and poverty, to evaluate the impact of NBLSS on health services utilization, and to examine the differential effect of the NBLSS by disability status among the elderly. This study used the Korea Welfare Panel Study data 2005-2014 with the final sample of 40,365, who were 65 years and older. The participants were divided into people with mild disability, severe disability, and without disability according to the Korean disability registration system. The income-level was defined to the low-income with NBLSS, the low-income without NBLSS, and the middle and high income, using the relative poverty line as a proxy of the low-income. The dependent variables were the number of outpatient visits and inpatient days, experience of home care services, total healthcare expenditure, and financial burden of healthcare expenditure. We performed Generalized Estimating Equations population-averaged model using the ten years of panel data. The result showed that within the same disability status, the low-income without NBLSS group used the least amount of inpatient care, but their financial burden of health expenditure was the highest among the three income groups. The regression model showed that if the elderly with severe disability were in the low-income without NBLSS, they reduced the outpatient and inpatient days; but their financial burden of healthcare became intensified. This study shows that the low-income elderly with disability but without adequate social protection are the most disadvantaged group. Policy is called for to mitigate the difficulties of this vulnerable population.