Subsidy and parental attitudes toward pediatric health care in the Tokyo metropolitan area

Short-term effects of reduced cost sharing on childhood dental care utilization and dental caries prevention in Japan

OBJECTIVES

Generous dental insurance coverage can improve oral health among children. However, most previous studies were from the United States, and the results may not be applicable to countries with universal healthcare systems. The purpose of the present study was to examine the effect of dental subsidy on dental service utilization and oral health among school-aged children.

METHODS

An administrative claims database in Kumamoto Prefecture, Japan, between 2014 and 2015 was used for the study. Municipalities in which the upper age limit of qualification for the dental subsidy was either 9 years of age or older were selected. The difference-in-differences approach was used to investigate the impact of subsidy discontinuation on dental care utilization and dental caries prevention. Dental care utilization was measured by number of first visits, number of total visits, and dental care cost per visit. Failure in dental caries prevention was determined by identifying treatment for acute severe dental conditions.

RESULTS

During the study period, 1108 eligible children made a total of 6276 visits to the 455 selected dental clinics. Among the dental clinics, 230 (50.5%) were located in municipalities in which the dental subsidy was discontinued when children reached age 10. After adjusting for area income and minimal user charges, there were no significant differences in subsequent dental care utilization (mean ratio 1.01, 95% confidence interval [CI] 0.97-1.04 for first visits; mean ratio 1.01, 95% CI 0.98-1.05 for total visits), acute severe dental conditions (mean ratio 1.06, 95% CI 0.90-1.24) or cost (coefficient 0.7 US dollars; 95%CI -0.2-1.6) during the 12-month period following the policy change.

CONCLUSION

The current dental subsidy policy may have limited value for promoting dental care utilization and improving oral health among school-aged children in Japan.

Universal school lunch programme closes a socioeconomic gap in fruit and vegetable intakes among school children in Japan

Background

Universal school lunch programmes are expected to cover all children equally, compared with selective programmes that may stigmatize socially vulnerable children. However, the effectiveness of universal programmes in closing dietary disparity has not been empirically proven. We evaluated whether Japan's universal school lunch programmes contribute to a reduction in the socioeconomic status (SES)-related gradient in fruit and vegetable intakes.

Methods

We analyzed data for 719 school children aged 6-12 years in a population-based survey conducted in the greater Tokyo metropolitan area. We measured dietary intakes using a validated self-administered brief diet history questionnaire for young children (BDHQ-10 y). We assessed parental education, annual household income and maternal employment status as SES indicators of children. We used multiple regression to estimate mean fruit and vegetable intakes by parental education and household income, and the contribution of school lunch to reducing the SES-related gradient in fruit and vegetable intakes.

Results

Compared with children with high maternal education (>15 years), those with low maternal education (<13 years) had less vegetable intake by 22.3 g/1000 kcal (95% confidence interval = 12.5, 32.2) and less fruit intake by 7.5 g/1000 kcal (95% confidence interval = -2.4, 17.3). However, fruit and vegetable intakes from school lunch did not vary by SES, indicating that school lunch intake alleviated the SES-related gradient of total vegetable intake by 9.9% and that of fruit intake by 3.4%.

Conclusions

Universal school lunch programmes can partially contribute to a reduction in the SES-related gradient in dietary intakes.

Impact of medical subsidy disqualification on children's healthcare utilization: A difference-in-differences analysis from Japan

Financial support for children's medical expenses has been introduced in many countries. Limited work has been done on price elasticity in children's healthcare demand, especially in countries other than the United States. Moreover, it remains unclear how the effects of a change in the cost sharing rate on healthcare demand would differ by medical condition. We investigated the impact of an increase in the cost sharing rate on medical service utilization among school children as a whole and for each of nine common conditions, applying a difference-in-differences approach. The study period ranged from April 1, 2012, to March 30, 2014. Participants were elementary school children in an urban area who were eligible for National Health Insurance (a community-based public insurance) during the study period and who were enrolled in the 2nd, 3rd, or 4th grade in April 2013. We collected observations from 2896 persons and 69,504 (2896 × 24 months) person-months. When elementary school children were promoted to the 4th grade, they became disqualified for a municipal medical subsidy. The control group was the children promoted to the 2nd or the 3rd grade, who remained eligible for the subsidy. All data were obtained from health insurance claims. We identified the nine most common medical conditions among the subject children, and stratified the analyses by the condition diagnosed. We found that an increase in the cost sharing rate reduced outpatient service utilization as a whole. Also, we observed an increase in inpatient service utilization, not because of worsened health conditions, but rather due to substitution of inpatient service for outpatient service. The reductions in outpatient service were heterogeneous across medical conditions; declines were sharper for mild or chronic conditions. These findings may help to characterize how a change in cost sharing rate affects health outcomes in children.

Labor factor barriers to seeking medical services among metropolitan workers: a cross-sectional analysis by sex using the J-SHINE study

OBJECTIVES

There is limited evidence on the relationship between labor factors and the decision to refrain from seeking medical services. This study aimed to examine how labor factors are related to medical service access among male and female workers in Tokyo and surrounding areas.

METHODS

We used data from 4,385 respondents to the survey in the Japanese Study on Stratification, Health, Income, and Neighborhood (J-SHINE), an ongoing epidemiologic household panel study. Surveys from 2010 to 2011 were analyzed. The outcome variable was whether or not an individual refrained from seeking medical services. Labor factors included employment type (permanent, temporary, or self-employed), company size (<100, 100-1,000, or >1,000 employees) and occupation type (white-collar, blue-collar).

RESULTS

We included a total of 2,013 people after excluding those with missing data (analysis utilization: 45.9%). After adjusting covariates, we found that men working in small companies were more likely to refrain from seeking medical services than were those in medium or large companies (adjusted prevalence ratio [PR]: 1.19, 95% confidence interval [CI]: 1.04-1.37). Among women, however, those in self-employment (PR: 1.38, 95% CI: 1.08-1.77) and blue-collar employment (PR: 1.24, 95% CI: 1.04-1.47) were more likely to refrain than were those classified as permanent or white-collar workers.

CONCLUSIONS

The relationship between labor factors and refraining from seeking medical services differed among men by company size, and among women by employment type and occupation type.

Effects of financial support on treatment of adolescents with growth hormone deficiency: a retrospective study in Japan

BACKGROUND

Treatment costs for children with growth hormone (GH) deficiency are subsidized by the government in Japan if the children meet clinical criteria, including height limits (boys: 156.4 cm; girls: 145.4 cm). However, several funding programs, such as a subsidy provided by local governments, can be used by those who exceed the height limits. In this study, we explored the impacts of financial support on GH treatment using this natural allocation.

METHODS

A retrospective analysis of 696 adolescent patients (451 boys and 245 girls) who reached the height limits was conducted. Associations between financial support and continuing treatment were assessed using multiple logistic regression analyses adjusting for age, sex, height, growth velocity, bone age, and adverse effects.

RESULTS

Of the 696 children in the analysis, 108 (15.5 %) were still eligible for financial support. The proportion of children who continued GH treatment was higher among those who were eligible for support than among those who were not (75.9 % vs. 52.0 %, P < 0.001). The odds ratios of financial support to continuing treatment were 4.04 (95 % confidence interval [CI]: 1.86-8.78) in boys and 1.72 (95 % CI: 0.80-3.70) in girls, after adjusting for demographic characteristics and clinical factors.

CONCLUSIONS

Financial support affected decisions on treatment continuation for children with GH deficiency. Geographic variations in eligibility for financial support pose an ethical problem that needs policy attention. An appropriate balance between public spending on continuation of therapy and improved quality of life derived from it should be explored.