Yasuki Kobayashi

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.

The new cooperative medical scheme in China

The New Cooperative Medical Scheme (NCMS) is a heavily subsidized voluntary health insurance program established in 2003 to reduce the risk of catastrophic health spending for rural residents in China. In this review, we present the current collection of knowledge available regarding the performance of NCMS on the aspects of revenue collection, risk pooling, reimbursement rules and provider payment. The available evidence suggests that NCMS has substantially improved health care access and utilization among the participants; however, it appears to have no statistically significant effect on average household out-of-pocket health spending and catastrophic expenditure risk. As NCMS is rolled out to other counties, it must be careful to generalize the findings reported in the published papers and reports, because the early pilot counties were not randomly selected and there are a lot of local adaptations. In addition, we expect that NCMS could be an important opportunity to establish some trust-based institutions in the best interest of the participants to monitor provider quality and control cost inflation. Rigorous evaluations, based on richer and latest micro-level data, could considerably strengthen the evidence base for the performance and impact of NCMS.

Different time trends of caloric and fat intake between statin users and nonusers among US adults: gluttony in the time of statins?

IMPORTANCE Both dietary modification and use of statins can lower blood cholesterol. The increase in caloric intake among the general population is reported to have plateaued in the last decade, but no study has examined the relationship between the time trends of caloric intake and statin use. OBJECTIVE To examine the difference in the temporal trends of caloric and fat intake between statin users and nonusers among US adults. DESIGN, SETTING, AND PARTICIPANTS A repeated cross-sectional study in a nationally representative sample of 27,886 US adults, 20 years or older, from the National Health and Nutrition Examination Survey, 1999 through 2010. EXPOSURES Statin use. MAIN OUTCOMES AND MEASURES Caloric and fat intake measured through 24-hour dietary recall. Generalized linear models with interaction term between survey cycle and statin use were constructed to investigate the time trends of dietary intake for statin users and nonusers after adjustment for possible confounders. We calculated model-adjusted caloric and fat intake using these models and examined if the time trends differed by statin use. Body mass index (BMI) changes were also compared between statin users and nonusers. RESULTS In the 1999-2000 period, the caloric intake was significantly less for statin users compared with nonusers (2000 vs 2179 kcal/d; P = .007). The difference between the groups became smaller as time went by, and there was no statistical difference after the 2005-2006 period. Among statin users, caloric intake in the 2009-2010 period was 9.6% higher (95% CI, 1.8-18.1; P = .02) than that in the 1999-2000 period. In contrast, no significant change was observed among nonusers during the same study period. Statin users also consumed significantly less fat in the 1999-2000 period (71.7 vs 81.2 g/d; P = .003). Fat intake increased 14.4% among statin users (95% CI, 3.8-26.1; P = .007) while not changing significantly among nonusers. Also, BMI increased more among statin users (+1.3) than among nonusers (+0.4) in the adjusted model (P = .02). CONCLUSIONS AND RELEVANCE Caloric and fat intake have increased among statin users over time, which was not true for nonusers. The increase in BMI was faster for statin users than for nonusers. Efforts aimed at dietary control among statin users may be becoming less intensive. The importance of dietary composition may need to be reemphasized for statin users.

Assessment of Urinary Cotinine as a Marker of Nicotine Absorption from Tobacco Leaves: A Study on Tobacco Farmers in Malaysia

Assessment of Urinary Cotinine as a Marker of Nicotine Absorption from Tobacco Leaves: A Study on Tobacco Farmers in Malaysia: Mayumi Onuki, et al. Department of Public Health, Graduate School of Medicine, The University of Tokyo—To assess dermal absorption of nicotine from tobacco leaves in relation to Green Tobacco Sickness (GTS), urinary cotinine concentrations were measured in 80 male tobacco‐growing farmers and in 40 healthy males (controls) who did not handle wet tobacco leaves in Kelantan, Malaysia. Among non‐smokers, urinary cotinine levels in farmers were significantly higher than those of controls; farmers with urinary cotinine of 50 ng/ml/m2 or above showed eye symptoms more frequently than those below this level (p<0.05). Farmers who did not wear protective equipment had subjective symptoms more frequently than those who used the equipment (p<0.05); some of these symptoms were seen more frequently in organophosphate (Tamaron) users than in non‐users. As tobacco farmers evidence a risk of nicotine poisoning from tobacco leaves, assessment including GTS together with effects of pesticides will be necessary.

Urbanization and physician maldistribution: a longitudinal study in Japan

BackgroundThe relative shortage of physicians in Japans rural areas is an important issue in health policy. In the 1970s, the Japanese government began a policy to increase the number of medical students and to achieve a better distribution of physicians. Beginning in 1985, however, admissions to medical school were reduced to prevent a future oversupply of physicians. In 2007, medical school entrants equaled just 92% of their 1982 peers. The urban annual population growth rate is positive and the rural is negative, a trend that may affect denominator populations and physician distribution.MethodsOur data cover six time points and span a decade: 1998, 2000, 2002, 2004, 2006, and 2008. The spatial units for analysis are the secondary tier of medical care (STM) as defined by the Medical Service Law and related legislation. We examined trends in the geographic disparities in population and physician distribution among 348 STMs in Japan. We compared populations and the number of physicians per 100,000 populations in each STM. To measure maldistribution quantitatively, we calculated Gini coefficients for physician distribution.ResultsBetween 1998 and 2008, the total population and the number of practicing physicians for every 100,000 people increased by 0.95% and 13.6%, respectively. However, the inequality of physician distribution remained constant, although small and mostly rural areas experienced an increase in physician to population ratios. In contrast, as the maldistribution of population escalated during the same period, the Gini coefficient of population rose. Although the absolute number of practicing physicians in small STMs decreased, the fall in the denominator population of the STMs resulted in an increase in the number of practicing physicians per population in those located in rural areas.ConclusionsA policy that increased the number of physicians and the physician to population ratios between 1998 and 2008 in all geographic areas of Japan, irrespective of size, did not lead to a more equal geographical distribution of physicians. The ratios of physicians to population in small rural STMs increased because of concurrent trends in urbanization and not because of a rise in the number of practicing physicians.

Determinants of out-of-pocket health expenditure in China: analysis using China Health and Nutrition Survey data.

BackgroundWithin total health expenditure, the share of out-of-pocket health expenditure by individuals has increased in the past 25 years in China, from 20% in 1980 to 49% in 2006, with a peak of 59% in 2000. Medical issues have become a larger concern than any other issue for households.ObjectiveTo estimate the determinants of individual out-of-pocket health expenditure in China.MethodsWe used a subsample of 9860 adults aged ≥18 years from the 2004 China Health and Nutrition Survey. To control for potential sample selection bias, the Heckman selection model was used to analyse individuals’ health expenditure decisions, which is based on a sample that excludes individuals who do not report paying for healthcare.ResultsOf the sampled population, 24.6% reported recent illness, 80.6% of whom sought care; 82.3% of those who sought care reported the amount of health spending. The average out-of-pocket health expenditure was Chinese Yuan (Y) 502 (Y100 =

Degree of agreement between weight perception and body mass index of Japanese workers: MY Health Up Study.

US12.2 in 2004). Illness perceived as ‘quite serious’ and self-reported poor health status had the highest coefficients (2.012 [p < 0.01] and 3.351 [p < 0.01], respectively). People spent more on healthcare with increasing age, especially over the age of 65 years, with a coefficient of 1.171 (p < 0.01). Those who had chronic disease, earned higher incomes, resided in urban areas, lived in the middle or eastern region, or lived in a household with a head having a middle school or higher education paid more for healthcare. In the model examining disaggregated effects of insurance programmes, the coefficients were positive, except for commercial insurance, and the coefficient for labour insurance was significant.ConclusionPerceived severity of illness and self-reported health status are the most important factors when determining out-of-pocket health expenditure. The effect of aging is substantial. China should develop appropriate medical relief policies for the elderly to help them gain access to necessary healthcare services. Certain types of insurance programmes tend to increase out-of-pocket health expenditures, which highlights the need to continuously monitor and rigorously evaluate the impact of ongoing health insurance reform in China.

The effect of aging on functional decline among older Japanese living in a community: a 5-year longitudinal data analysis

Degree of Agreement between Weight Perception and Body Mass Index of Japanese Workers: MY Health Up Study: Mariko Inoue, et al. Department of Public Health, Graduate School of Medicine, University of Tokyo—The objective of this study was to assess the degree of agreement between body mass index (BMI) and weight perception of Japanese office workers between the ages of 20 and 65. We sent 43,064 self‐administered health‐related questionnaires to all employees of a financial firm in Japan in October 2004. The questionnaire asked the respondents for their height, weight, and their weight perception. The kappa coefficient was calculated to investigate the degree of agreement between the BMI calculated using the self‐reported data and weight perception for three categories. Of the questionnaires, 34,921 (81.1%) were returned and 33,514 responses (77.8%) were used for the analysis. Based on Japanese obesity criteria, 2,202 men (31.2%) and 5,145 women (19.5%) were obese; and 179 men (2.5%) and 2,769 women (10.5%) were underweight. The kappa coefficient was 0.374 for men and 0.297 for women. The kappa coefficients for different age groups—twenties, thirties, forties, fifties, and sixties (up to 65)—were respectively as follows: 0.315, 0.355, 0.374, 0.406, and 0.425 for men; and 0.194, 0.275, 0.285, 0.334, and 0.355 for women. In conclusion, the degree of agreement between BMI and weight perception differed by age and sex. The degree of agreement was smaller among women than among men and the degree of agreement among younger women was weaker than among older women.

Functional transitions and active life expectancy for older Japanese living in a community

Background and aims: Using longitudinal data analyses, we examined the effects of aging on functional decline, based on activities of daily living (ADL) and instrumental activities of daily living (IADL) during a 5-year follow-up among older people living in a community in Japan. Methods: The baseline survey in July 1988 involved all elderly residents aged 60 or older in Saku City, Nagano, Japan (N=13418). All survivors of this cohort were asked to participate in follow-up surveys conducted in 1989, 1990, 1991, 1992 and 1993. Five items of ADL and five of IADL were measured on each survey. A generalized estimating equations (GEE) analysis was used to examine the effects of aging on the increase of the proportion of subjects with functional dependence. Results: These results indicated that the proportion of subjects who were dependent in ADL increased during the 5-year period by 2.2 times (p<0.001) and the proportion of those who were dependent in either ADL or IADL increased during the same period by 1.8 times (p<0.001 ). Gender did not appear to be significantly associated with functional decline. Conclusions: The GEE analysis in this study identified the statistically significant effect of aging on the increase of the proportion of subjects with functional dependence based on ADL and IADL.

Association of periodontitis with increased white blood cell count and blood pressure.

We examined functional transitions in both the activities of daily living (ADL), and instrumental activities of daily living (IADL), over a 1-year interval among older Japanese living in a community, then estimated their physically active life expectancy (PALE) and instrumentally active life expectancy (IALE). In 1992, all residents aged 65 or older who lived in Saku City, Nagano, Japan, were followed-up over the 1-year interval. A self-administrated questionnaire, which involved age, sex, five ADL items, and five IADL items, was used for each survey in both 1992 and 1993. Of the baseline cohort (n=10,098), we received 9533 analyzable questionnaires at the follow-up survey in 1993. During the follow-up, 92 and 87% of subjects who were initially independent in ADL and IADL remained independent, respectively. PALE for men and women were estimated to be 16.0 and 18.9 at 65 years of age, respectively. IALE for men and for women were estimated to be 12.8 and 14.6 at the age of 65, respectively. Proportions of the PALE to total life expectancy (TLE) at any age did not greatly differ between men and women; however, men had a slightly larger proportion of IALE to TLE at any given age than women.