Medical expenditures of men with hypertension and/or a smoking habit: a 10-year follow-up study of National Health Insurance in Shiga, Japan

Pet ownership-related differences in medical and long-term care costs among community-dwelling older Japanese

This study examined the differences in medical and long-term care costs over 18 months between pet owners and non-owners among community-dwelling older Japanese. Pet ownership data were collected from 460 community-dwelling adults age 65 years and older. These data were matched with data from the National Health Insurance, health insurance for older people, and Long-Term Care Insurance beneficiaries for 17 months back from the survey on pet ownership. Pet-ownership group-specific trajectories in monthly medical and long-term care costs were modeled by a generalized estimating equation. Among pet owners (n = 96, 20.9%) and non-pet owners (n = 364, 79.1%) there were no significant differences in baseline demographic or health characteristics including chronic disease and self-reported long-term care level. At baseline, pet owners had estimated monthly medical costs of ¥48,054 (SE = 0.11; $418), compared to ¥42,260 (SE = 0.06; $367) for non-pet owners. The monthly medical costs did not differ significantly between the two groups during the 18-month follow-up period. At baseline, estimated monthly long-term care costs of pet owners and non-pet owners were ¥676 (SE = 0.75; $6) and ¥1,420 (SE = 0.52; $12), respectively. During the follow-up period, the non-pet owner to owner ratio of monthly long-term care costs was 1.2 at minimum and 2.3 at maximum. This study showed that monthly long-term care costs for pet owners were approximately half those of non-pet owners. Pet owners might use long-term care services less frequently, or use lighter care services.

Association of Trajectories of Higher-Level Functional Capacity with Mortality and Medical and Long-Term Care Costs Among Community-Dwelling Older Japanese

Background

Higher-level functional capacity is crucial component for independent living in later life. We used repeated-measures analysis to identify aging trajectories in higher-level functional capacity. We then determined whether these trajectories were associated with all-cause mortality and examined differences in medical and long-term care costs between trajectories among community-dwelling older Japanese.

Methods

2,675 adults aged 65-90 years participated in annual geriatric health assessments and biennial health monitoring surveys during the period from October 2001 through August 2011. The average number of follow-up assessments was 4.0, and the total number of observations was 10,609. Higher-level functional capacity, which correspond to the fourth and fifth sublevels of Lawton's hierarchical model, was assessed with the Tokyo Metropolitan Institute of Gerontology-Index of Competence (TMIG-IC).

Results

We identified four distinct trajectory patterns (high-stable, late-onset decreasing, early-onset decreasing, and low-decreasing) on the TMIG-IC through age 65-90 years. As compared with the high-stable trajectory group, participants in the late-onset decreasing, early-onset decreasing, and low-decreasing TMIG-IC trajectory groups had adjusted hazard ratios for mortality of 1.22 (95% confidence interval: 1.01-1.47), 1.90 (1.53-2.36), and 2.87 (2.14-3.84), respectively. Participants with high-stable and late-onset decreasing higher-level functional capacity trajectories had lower mean monthly medical costs and long-term care costs. In contrast, mean total costs were higher for those with low-decreasing trajectories, after excluding the large increase in such costs at the end of life.

Conclusions

People with a low-decreasing aging trajectory in higher-level functional capacity had higher risks of death and had high monthly total costs.

The associations of multimorbidity with the sum of annual medical and long-term care expenditures in Japan

BACKGROUND

The occurrence of multimorbidity (i.e., the coexistence of multiple chronic diseases) increases with age in older adults and is a growing concern worldwide. Multimorbidity has been reported to be a driving factor in the increase of medical expenditures in OECD countries. However, to the best of our knowledge, there is no published research that has examined the associations between multimorbidity and either long-term care (LTC) expenditure or the sum of medical and LTC expenditures worldwide. We, therefore, aimed to examine the associations of multimorbidity with the sum of medical and LTC expenditures for older adults in Japan.

METHODS

Medical insurance claims data for adults ≥75 years were merged with LTC insurance claims data from Kashiwa city, a suburb in the Tokyo metropolitan area, for the period between April 2012 and September 2013 to obtain an estimate of medical and LTC expenditures. We also calculated the 2011 updated and reweighted version of the Charlson Comorbidity Index (CCI) scores. Then, we performed multiple generalized linear regressions to examine the associations of CCI scores (0, 1, 2, 3, 4, or ≥ 5) with the sum of annual medical and LTC expenditures, adjusting for age, sex, and household income level.

RESULTS

The mean sum of annual medical and LTC expenditures was ¥1,086,000 (US$12,340; n = 30,042). Medical and LTC expenditures accounted for 66 and 34% of the sum, respectively. Every increase in one unit of the CCI scores was associated with a ¥257,000 (US$2920); 95% Confidence Interval: ¥242,000, 271,000 (US$2750, 3080) increase in the sum of the expenditures (p < 0.001; n = 29,915).

CONCLUSIONS

Using a merged medical and LTC claims dataset, we found that greater CCI scores were associated with a higher sum of annual medical and LTC expenditures for older adults. To the best of our knowledge, this is the first study to examine the associations of multimorbidity with LTC expenditures or the sum of medical and LTC expenditures worldwide. Our study indicated that the economic burden on society caused by multimorbidity could be better evaluated by the sum of medical and LTC expenditures, rather than medical expenditures alone.

Comorbidity Status and Annual Total Medical Expenditures in U.S. Hypertensive Adults

INTRODUCTION

The purpose of this study is to investigate comorbidity status and its impact on total medical expenditures in non-institutionalized hypertensive adults in the U.S.

METHODS

Data from the 2011-2014 Medical Expenditure Panel Survey were used. Patients were included if they had a diagnosis code for hypertension, were aged ≥18 years, and were not pregnant during the study period (N=26,049). The Elixhauser Comorbidity Index was modified to add hypertension-related comorbidities. The outcome variable was annual total medical expenditures, and a generalized linear model regression (gamma distribution with a log link function) was used. All costs were adjusted to 2014 U.S. dollars.

RESULTS

Based on the modified Elixhauser Comorbidity Index, 14.0% of patients did not have any comorbidities, 23.0% had one, 24.4% had two, and 38.7% had three or more. The five most frequent comorbidities were hyperlipidemia, diabetes, rheumatoid arthritis, depression, and chronic pulmonary disease. Estimated mean annual total medical expenditures were $3,914 (95% CI=$3,456, $4,372) for those without any comorbidity; $5,798 (95% CI=$5,384, $6,213) for those with one comorbidity; $8,333 (95% CI=$7,821, $8,844) for those with two comorbidities; and $13,920 (95% CI=$13,166, $14,674) for those with three or more comorbidities. Of the 15 most frequent comorbidities, the condition with the largest impact on expenditures for an individual person was congestive heart failure ($7,380). Hypertensive adults with stroke, coronary heart disease, diabetes, renal diseases, and hyperlipidemia had expenditures that were $6,069, $6,046, $5,039, $4,974, and $4,851 higher, respectively, than those without these conditions.

CONCLUSIONS

Comorbidities are highly prevalent among hypertensive adults, and this study shows that each comorbidity significantly increases annual total medical expenditures.

Tobacco use and household expenditures on food, education, and healthcare in low- and middle-income countries: a multilevel analysis

Background

The majority of one billion smokers worldwide live in low- and middle-income countries (LMICs) and the highest proportion of smokers in most of these countries belong to the lower socioeconomic groups. This study aimed to investigate the associations between tobacco use within households and expenditures on food, education, and healthcare in LMICs.

Methods

Using data from the World Health Survey, this cross-sectional study included a sample of 53,625 adult males aged <60 years from 40 LMICs. Multilevel, mixed-effects linear regression was used to determine the association between current tobacco use status of the main income provider (daily; occasional; no use) and three categories of (logged) household expenditures: food, education, and healthcare; controlling for age, level of education, household wealth quintile, marital status, urban–rural setting, country-level income group, and region.

Results

In the preferred random-slope models that controlled for covariates, daily tobacco use was associated with lower household expenditures on education and healthcare by 8.0 % (95 % confidence interval: −12.8 to –3.2 %) and 5.5 % (−10.7 to –0.3 %), respectively. The association between tobacco use and food expenditure was inconsistent across models.

Conclusions

Tobacco use in LMICs may have a negative influence on investment in human capital development. Addressing the tobacco use problem in LMICs could benefit not only the health and economic well-being of smokers and their immediate families but also long-run economic development at a societal level.

Impact of cardiovascular risk factors on medical expenditure: evidence from epidemiological studies analysing data on health checkups and medical insurance

Concerns have increasingly been raised about the medical economic burden in Japan, of which approximately 20% is attributable to cardiovascular disease, including coronary heart disease and stroke. Because the management of risk factors is essential for the prevention of cardiovascular disease, it is important to understand the relationship between cardiovascular risk factors and medical expenditure in the Japanese population. However, only a few Japanese epidemiological studies analysing data on health checkups and medical insurance have provided evidence on this topic. Patients with cardiovascular risk factors, including obesity, hypertension, and diabetes, may incur medical expenditures through treatment of the risk factors themselves and through procedures for associated diseases that usually require hospitalization and sometimes result in death. Untreated risk factors may cause medical expenditure surges, mainly due to long-term hospitalization, more often than risk factors preventively treated by medication. On an individual patient level, medical expenditures increase with the number of concomitant cardiovascular risk factors. For single risk factors, personal medical expenditure may increase with the severity of that factor. However, on a population level, the medical economic burden attributable to cardiovascular risk factors results largely from a single, particularly prevalent risk factor, especially from mildly-to-moderately abnormal levels of the factor. Therefore, cardiovascular risk factors require management on the basis of both a cost-effective strategy of treating high-risk patients and a population strategy for reducing both the ill health and medical economic burdens that result from cardiovascular disease.

Hypertension and medical expenditure in the Japanese population: Review of prospective studies

Hypertension is a major determinant of health and is likely to have an effect on medical economics. The economic burden due to hypertension may be attributable not only to antihypertensive medication but also to the very expensive procedures required for cases of cardiovascular disease that occur more frequently in hypertensive compared with normotensive individuals. The objective of this article was to review articles published on prospective cohort studies that measured medical expenditure attributable to hypertension in community-dwelling populations in Japan. Many medical services in these populations are provided under the medical insurance system that requires the enrolment of all Japanese residents. Personal medical expenditure attributable to hypertension increases with worsening severity of the condition. Medical expenditure was increased further in cases of hypertensive patients who have another concomitant cardiovascular risk factor. In particular, hypertension, especially moderate-to-severe untreated hypertension, increases the risk of long-term hospitalization resulting in considerably higher medical expenditure, compared with non-hospitalized cases. Therefore, assuming that the use of antihypertensive medication is essential for hypertensive patients to prevent serious vascular diseases, a cost-effective high-risk strategy needs to be considered to reduce both ill-health and the economic burden due to hypertension. However, from a population perspective, medical expenditure attributable to hypertension comes mainly from pre-to-mild hypertension. Therefore, there is also a need to consider a population strategy that aims to shift the entire population to lower levels of blood pressure.

Nicotine dependence and cost-effectiveness of individualized support for smoking cessation: evidence from practice at a worksite in Japan

Given the lack of economic studies evaluating the outcomes of smoking cessation programs from the viewpoint of program sponsors, we conducted a case study to provide relevant information for worksites. The present study was carried out between 2006 and 2008 at a manufacturing factory in the Toyama Prefecture of Japan and included subjects who voluntarily entered a smoking cessation program. The program included face-to-face counselling followed by weekly contact to provide encouragement over six months using e-mail or inter-office mail. Nicotine patches were available if required. All 151 participants stopped smoking immediately. Over the 24-month study period, self-report showed 49.7% abstained continuously from smoking. The rate of 24-month consecutive abstinence was higher in participants with lower Fagerström Test scores for Nicotine Dependence at baseline than in those with higher scores (63.6% for 0–2 points vs. 46.5% for 3–6 points vs. 43.8% for 7–10 points; chi-square test p = 0.19). A logistic regression model showed a significant linear trend for the association between the score and abstinence status after adjustment for possible confounding factors (p = 0.03). The crude incremental cost for one individual to successfully quit smoking due to the support program was ¥46,379 (i.e., ¥100 = $1.28, £0.83, or €1.03 at foreign exchange rates). The corresponding costs for the three categories of the Fagerström Test score for Nicotine Dependence were ¥31,953, ¥47,450 and ¥64,956, respectively. When a sensitivity analysis was conducted based on the 95% confidence interval of the success rate, the variance in the corresponding costs was ¥25,514–45,034 for 0–2 points, ¥38,344–61,824 for 3–6 points, and ¥45,698–108,260 for 7–10 points. The degree of nicotine dependence may therefore be an important determinant of the cost-effectiveness of smoking cessation programs.

Estimating medical expenditures spent on rule-out diagnoses in Japan

BACKGROUND

According to the regulations concerning reimbursement rules for the uniform coverage scheme in Japan's health insurance system, rule-out diagnoses must be included in a health insurance claim (HIC) to ensure reimbursement for clinical procedures whose results show that a suspected disease is not present. However, estimations of disease-specific medical expenditure by conventional methods have not considered the information on rule-out diagnoses.

OBJECTIVES

To estimate disease-specific medical expenditure for rule-out diagnoses.

METHODS

Data were obtained from 169,622 outpatient HICs in May 2006 from corporate health insurance societies. We used the proportional distribution method to estimate medical expenditure for each of the major disease categories defined by the Classification of Diseases for the use of Social Insurance, which is based on the International Statistical Classification of Diseases and Related Health Problems, 10th Revision.

RESULTS

There were 442,010 diagnoses on the HICs, of which 20,330 (4.60%) were rule-out diagnoses. Rule-out diagnoses accounted for 8.5% of total medical expenditure. The proportion of medical expenditure spent on rule-out diagnoses varied across the major diseases categories, and it was estimated that more than one-third (36.9%) of the medical expenditure on neoplasm is spent on rule-out diagnoses.

CONCLUSIONS

The existence of rule-out diagnoses affects the estimation of disease-specific medical expenditure. Therefore, the estimation of disease-specific medical expenditure and evaluation of prevention and treatment programmes should be improved by utilizing information on rule-out diagnoses.

[Effect of cardiovascular risk factors on individual and population medical expenditures: a 10-year cohort study of 4,535 National Health Insurance beneficiaries in Shiga]

A 10-year follow-up cohort study of 4,535 National Health Insurance beneficiaries aged 40 to 69 years in Shiga was performed as part of a research project conducted by the Health Promotion Research Committee of the Shiga National Health Insurance Organizations in 2002. The relationship between cardiovascular risk factors and medical expenditures during the 10-year study period has been examined in this cohort. For example, there was a positively graded correlation between blood pressure and individual total medical expenditures per month. The odds ratio for cumulative hospitalization and hazard ratio for all-cause mortality in severe hypertensives were also higher than those in normotensives. However, from the viewpoint of the entire population, the excess medical expenditures attributable to hypertension within the total medical expenditures were higher for mild-to-moderate hypertensives than for severe hypertensives. On the other hand, although individual medical expenditures per month were 1.7-fold higher for participants with 2 or 3 risk factors and obesity, which was broadly equivalent to metabolic syndrome, than for those without these factors, the excess medical expenditures determined by risk clustering within the total medical expenditures were higher in normal-weight people than in obese people because of the higher prevalence of normal weight. These findings suggest that high-risk individuals are a good target of a high-risk approach, such as intensive health guidance, from the viewpoint of medical expenditures. However, another approach for the majority with a low-to-moderate cardiovascular risk should be considered, because they account for a greater proportion of the excess medical expenditures. Another way to solve this problem may be a population approach with an effective method of providing information to citizens.