Place of Death and Density of Homecare Resources: A Nationwide Study in Japan

Regional disparities in home health care utilization for older adults and their associated factors at the secondary medical area level: A Nationwide study in Japan

AIM

As aging populations shift health care from hospitals to communities, Japan has implemented policies to promote home health care. This study explored regional differences in home health care recipients among older adults and related factors.

METHODS

We used nationwide data from 2020 to describe the proportion of older adults receiving regular home visits and the medical institutions utilized across secondary medical areas: urban, middle and depopulated areas. We examined factors associated with the proportion of patients receiving regular home visits. Exposures included each secondary medical area's medical and long-term-care (LTC) resources, adjusted for the older adult population; proportion of single-person households; and regional factors. We performed a multivariate negative binomial distribution analysis.

RESULTS

A total of 333 secondary medical areas were included. Urban areas had more patients receiving regular home visits, primarily from enhanced home care support clinics/hospitals (HCSCs). Fewer patients received regular home visits in depopulated areas, and conventional HCSCs were more common. Multivariate analysis revealed that the number of conventional HCSCs (coefficient, 0.17 [95% confidence intervals (CI), 0.08 to 0.26]), enhanced HCSCs (coefficient, 0.21 [95% CI, 0.14 to 0.29]) and population density (coefficient, 0.10 [95% CI, 0.02 to 0.19]) were positively associated with higher home-visit rates. Beds in LTC welfare facilities (coefficient, -0.10 [95% CI, -0.19 to -0.01]) and beds in LTC health facilities (coefficient, -0.09 [95% CI, -0.17 to 0.00]) were negatively associated.

CONCLUSIONS

Policies to promote home health care have led to high home-visit rates in urban areas. Medical and LTC resources and regional factors influence disparities. As Japan's population ages, it is crucial to recognize these disparities and develop medical and LTC systems tailored to each region's characteristics. Geriatr Gerontol Int 2024; 24: 1350-1361.

Impact of home visiting nurses on home death proportion in Japan: A nationwide longitudinal ecological study

OBJECTIVE

Home visiting nurses contribute to end-of-life home care in an aging society. However, few previous studies reported patient outcomes based on nursing practices. This study aimed to examine the correlation between the number of them and the change in home death proportion.

METHODS

We divided the number of home visiting nurses into four categories: absent, shortage, medium, and abundant. This study adopted the interaction term between the nurse categories and year as the major exposure variable, and home death proportion per municipality as the objective variable. We estimated the average marginal effects (AME) as the change in home death proportion from 2015 to 2020.

RESULTS

The total number of home visiting nurses was 36,483 in 2015 and 65,868 in 2020. The coefficients of the interaction term were statistically significant in medium and abundant municipalities (Medium: 1.26 (95% CI: 0.49-2.04), Abundant: 2.15 (95% CI: 0.76-3.55)). Increased home death proportion were estimated as AME: 1.56% (95% CI: 0.99-2.13), 1.35% (95% CI: 0.85-1.84), 2.82% (95% CI: 2.30-3.35), and 3.71% (95% CI: 2.44-4.99) in the absent, shortage, medium, and abundant areas, respectively.

CONCLUSIONS

To increase the proportion of home deaths, municipalities require a certain number of home visiting nurses.

Spatial accessibility of home visiting nursing: An exploratory ecological study

Background and Aims

Japan is one of the oldest societies worldwide and manages a system of care for older adults in the community. In the 2000s, a community-based integrated care system was introduced to enable older adults to live in their neighborhoods. Home visiting nursing (HVN) is a crucial component of this system; however, the current and future shortage of home visiting nurses is a concern. Thus, HVN services may not be available in some areas; however, no indicators of the accessibility of HVN services have been developed. Developing accessibility indicators will serve as a standard for considering the allocation of health care resources and supporting future nursing policies that improve regional disparities.

Methods

We estimated the population-weighted spatial accessibility index (PWSAI) of HVN services in Hokkaido, using the two-step floating catchment area method (2SFCA). The 2SFCA comprised population, location of HVN agencies, number of home visiting nurses, and travel time. A multivariate regression model was run for the number of HVN users in each municipality as the objective variable to test the validity of the PWSAI; the number of home care support clinics, home care support hospitals, HVN agencies, home visiting nurses, home visiting nurses (24/7), total beds in health care facilities for older adults, and nursing homes for older adults were included as other explanatory variables.

Results

The PWSAI was median 9.0 [interquartile range: 6.2-11.8]. The distribution of the PWSAI was mapped to visualize the existence of regional differences. As a result of the conditional autoregressive model, PWSAI and home visiting nurses (24/7) were significant, Exp(β) and 95% credible interval were 1.043 [1.015-1.076] and 1.021 [1.006-1.036], respectively.

Conclusion

The PWSAI was positively correlated with the number of HVN users in each municipality and can serve as an indicator for assessing the accessibility of HVN.

Spatial Analysis of Home and Community-Based Services and Number of Deaths Among Older Adults in Taiwan

This study examined the geographical distribution of home- and community-based services (HCBS) resources in Taiwan's Long-Term Care 2.0 policy and explored its association with the number of deaths among older adults. The main outcome of the study was determination of the number of deaths among older adults in townships (N = 346) in 2021. The results showed that home-based HCBS had a significant positive association with mortality among older adults; moreover, community-based and complementary services, which are highly clustered within a township and among its neighbors, exert a significant protective effect on mortality among older adults. Stratified analyses showed a significantly lower mortality among older adults using adult foster care and transportation services, but a significantly higher mortality among older adults using home-based professional care and respite care services, after considering the sociodemographic characteristics of older adults, urbanization, and the number of long-term care resources in the spatial analysis.

The distribution structure of medical and care resources based on regional characteristics throughout Japan in 2020

BACKGROUND

Given Japan's rapidly aging population, the Ministry of Health, Labour and Welfare's policy of reducing hospital beds and replacing medical care with nursing care requires the establishment of a coordinated system of medical and care services tailored to regional characteristics. To gain useful knowledge for the development of such a system, this study aimed to identify differences in the structure of the relationship between medical and care resources due to differences in regional characteristics.

METHODS

Initially, regional characteristics were used to group all 334 secondary medical areas (SMA) in Japan by principal component analysis. Subsequently, the related structure of the distribution of medical and care resources for each group were compared. For these　comparisons, first, the related structure of the distribution of medical and care resources nationwide was modeled using structural equation modeling. Secondly, multigroup analysis was conducted to investigate differences among the models across groups.

RESULTS

The nationwide SMAs were grouped largely based on urbanicity and middle-density regionality. The groups with high urbanicity and high middle-density regionality consisted of SMAs with a high and medium population density. By contrast, the low middle-density regionality group consisted of SMAs containing large cities with a high population density and depopulated areas with a low population density. The model of the related structure of the distribution of medical and care resources differed among these groups. In the non-urbanicity and middle-density regionality groups, nursing care abundance tended to increase acute care abundance. In addition, in all groups, nursing care abundance tended to increase long-term hospitalization care abundance and clinic care abundance (with beds).

CONCLUSIONS

The key finding of this study was that the government's objective of reducing hospital beds may not be achieved solely by expanding nursing homes. This is because many of the models did not show a tendency that higher nursing care abundance reduces the values of the factors which increase more hospital beds. This finding was particularly relevant in middle-density regionality groups. This finding suggests that the location of nursing homes should be monitored because of concerns about the oversupply of nursing homes and sprawl in those areas.

Implementation of evidence-based heart failure management: Regional variations between Japan and the USA

The implementation of optimal medical therapy is a crucial step in the management of heart failure with reduced ejection fraction (HFrEF). Over the prior three decades, there have been substantial advancements in this field. Early and accurate detection and diagnosis of the disease allow for the appropriate initiation of optimal therapies. The initiation and uptitration of optimal medical therapy including renin-angiotensin system inhibitor, beta-blocker, mineralocorticoid receptor antagonist, and sodium-glucose cotransporter 2 inhibitor in the early stage would prevent the progression and morbidity of HF. Concurrently, individualized surveillance to recognize and treat signs of disease progression is critical given the progressive nature of HF, even among stable patients on optimal therapy. However, there remains a wide variation in regional practice regarding the initiation, titration, and long-term monitoring of this therapy. To cover the differences in approaches toward HFrEF management and the implementation of guideline-based medical therapy, we discuss the current evidence in this arena, differences in present guideline recommendations, and compare practice patterns in Japan and the USA using a case of new-onset HF as an example. We will discuss pros and cons of the way HF is managed in each region, and highlight potential areas for improvement in care.

The Impact of Continuous Use of Home Health Care Resources on End-of-Life Care at Home in Older Patients with Cancer: A Retrospective Cohort Study in Fukuoka, Japan

This study aimed at examining the effect of continued use of home health care resources on end-of-life care at home in older patients with cancer. This retrospective cohort study was conducted using medical and long-term care claims data of 6435 older patients with cancer who died between April 2016 and March 2019 in Fukuoka Prefecture. The main explanatory variables were enhanced home care support clinics and hospitals (HCSCs), enhanced HCSCs with beds, conventional HCSCs, other HCSCs, and home visit nursing care. The covariates were sex, age, required level of care, and the Charlson Comorbidity Index. A logistic regression model was used. The results of the multilevel logistic regression analysis showed that the following were significantly associated with end-of-life care at home: use of enhanced HCSCs with beds (odds ratio, OR: 8.66; 95% confidence interval, CI: [4.31-17.40]), conventional HCSCs (OR: 5.78; 95% CI: [1.86-17.94]), enhanced HCSCs (OR: 4.44; 95% CI: [1.47-13.42]), home-visit nursing care (OR: 1.86; 95% CI: [1.42-2.44]), and a severe need for care (OR: 3.89; 95% CI: [2.92-5.18]). The results suggest that the continued use of home health care resources in older patients with cancer who require out-of-hospital care may lead to increased end-of-life care at home. Particularly, use of enhanced HCSCs with beds is most strongly associated with end-of-life care at home.

Anticipated deaths with physician care (mitori) at home in one town in Japan: A preliminary report

Background

There are few reports on the numbers of anticipated deaths (mitori [り]) at home in Japan.

Method

We used the Japanese death certificate system (shiboukohyou []) for Toyono town citizens who died between 2020 and 2022 and judged a death to constitute mitori when the certificate was not written by a doctor referred from the police.

Results

Among 756 deaths, 109 (14.4%) were mitori at home. Deaths at home were 144 and mitori at home accounted for 75.7%.

Conclusion

Shiboukohyou appear to provide numbers of mitori at home. Death certificate should include a space which shows mitori or not.

The Correlation Between the Attended Deaths at Home and Medical Resources in Osaka City

Introduction Most people would prefer end-of-life care to be provided at home. Although Japan has tried to promote home care and end-of-life care, very few people die at home in Japan. On the other hand, deaths at home are not necessarily attended deaths at home by end-of-life care because they include many deaths, such as deaths from external causes and solitary deaths. We obtained the data on the number of postmortem examinations at home in the main areas of Osaka City and calculated the estimated number of attended deaths at home by subtracting the number of postmortem examinations at home from the number of total deaths at home. We analyzed the contribution of medical resources to end-of-life care from a forensic perspective for a closer analysis of the actual situation. Methods The data about the population, the number of total deaths, deaths at home, and medical resources related to home care in Osaka City was obtained from the website of a public institution in Japan. The data about the number of postmortem examinations in Osaka City was obtained from the Osaka Medical Examiner's Office. The estimated number of attended deaths at home was calculated by subtracting postmortem examinations at home from total deaths at home. We conducted univariate and multivariate analyses between the number of medical resources and the prevalence of attended deaths at home. Results In the univariate analysis of the prevalence of attended deaths at home, a high positive correlation was observed in "doctors," "total clinics," "clinics except HCSC," and "general beds." A high negative correlation was observed in "long-term care beds." In the multivariate analysis, a positive coefficient was observed in "clinics except HCSC," and a negative one was observed in "HCSC or HCSH." Conclusion The policy of shifting general clinics and hospitals to HCSC and HCSH may not be as effective for end-of-life care because the criteria do not include any restrictions on the number or use of beds. However, general clinics may have played an important role in end-of-life care, even if they were not HCSC.

Factors associated with home death in South Korea: Using the exit data from the Korean Longitudinal Study of Aging, 2008-2018

BACKGROUND

Even though home deaths have been reported to improve quality of life, satisfy patients and families, and reduce healthcare expenditures, not enough is known about the factors that influence home deaths in Korea.

OBJECTIVES

This study aimed to examine the factors associated with home deaths among middle-aged and older adults in South Korea.

METHODS

This secondary data analysis used core interview and exit interview data of the Korean Longitudinal Study of Aging conducted between 2008 and 2018. The deceased included adults over the age of 45 years. The exit data were obtained from interviews with family members or other acquaintances known to the deceased every two years since 2008. Complex-sample logistic regression was conducted using 1,565 middle-aged and older deceased adults.

RESULTS

Among 1,565 decedents, the average age at the time of death was 80.67±10.69 in the home death group, and 78.72±9.83 in the non-home death group. The proportion of home-related deaths was 26.4%. Age over 81 years was associated with increased odds of home death, whereas having two or more living children, living in town/small city, paid medical expenses by children/grandchildren and their spouses, expected death, death from disease, and having three or more chronic diseases were associated with decreased odds of home death. An increase in activities of daily living during three months before death was associated with a decrease in home death.

CONCLUSION

The findings could help healthcare professionals develop tailored interventions to help people die at their preferred place of death based on family characteristics and healthcare accessibility. Age, residential area, number of children and children's financial support, and illness-related factors influenced home death by creating differences in access to healthcare resources and support. Policymakers should decrease healthcare disparities and improve health resource allocation and home-based care.

Association between types of home healthcare and emergency house calls, hospitalization, and end-of-life care in Japan

BACKGROUND

To meet the increasing demand for home healthcare in Japan, as part of the national healthcare system, home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in 2006 and 2012 respectively. This study aimed to evaluate whether HCSCs has succeeded in providing 24-h home care services through the end of life.

METHODS

A retrospective cohort study was conducted using the national database in Japan. Participants were ≥ 65 years of age, had newly started regular home visits between July 2014 and September 2015, and used general clinics, conventional HCSCs, or enhanced HCSCs. Each patient was followed up for 6 months after the first visit. The outcome measures were (i) emergency house call(s), (ii) hospitalization(s), and (iii) end-of-life care defined as in-home death. Multivariable logistic regression analyses were performed for statistical analysis.

RESULTS

The analysis included 160,674 patients, including 13,477, 64,616, and 82,581 patients receiving regular home visits by general clinics, conventional HCSCs, and enhanced HCSCs respectively. Compared to general clinics, the use of conventional and enhanced HCSCs was associated with an increased likelihood of emergency house calls (adjusted odds ratio [aOR] and 95% confidence intervals [CIs] of 1.62 [1.56-1.69] and 1.86 [1.79-1.93], respectively) and a decreased likelihood of hospitalizations (aOR [95% CIs] of 0.86 [0.82-0.90] and 0.88 [0.84-0.92] respectively). Among 39,082 patients who died during the follow-up period, conventional and enhanced HCSCs had more in-home deaths (aOR [95% CIs] of 1.46 [1.33-1.59] and 1.60 [1.46-1.74], respectively) compared to general clinics.

CONCLUSIONS

HCSCs (especially enhanced HCSCs) provided more emergency house calls, reduced hospitalization, and enabled expected deaths at home, suggesting that further promotion of HCSCs (especially enhanced HSCSs) would be advantageous.

Evaluation of enhanced home care support clinics regarding emergency home visits, hospitalization, and end-of-life care: a retrospective cohort study in a city of Japan

BACKGROUND

To meet the increasing demand for home healthcare in Japan as the population ages, home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in 2006 and 2012, respectively. This study aimed to evaluate whether enhanced HCSCs fulfilled the expected role in home healthcare.

METHODS

We conducted a retrospective cohort study using linked medical and long-term care claims data from a municipality in Japan. Participants were ≥ 65 years of age, had newly started regular home visits between July 2014 and March 2018, and used either conventional or enhanced HCSCs. Patients were followed up for one year after they started regular home visits or until the month following the end of the regular home visits if they ended within one year. The outcome measures were (i) emergency home visits at all hours and on nights and holidays at least once, respectively, (ii) hospitalization at least once, and (iii) end-of-life care, which was evaluated based on the place of death and whether a physician was present at the time of in-home death. Multivariable logistic regression analyses were conducted for the outcomes of emergency home visits and hospitalizations.

RESULTS

The analysis included 802 patients, including 405 patients in enhanced HCSCs and 397 patients in conventional HCSCs. Enhanced HCSCs had more emergency home visits at all hours than conventional HCSCs (65.7% vs. 49.1%; adjusted odds ratio 1.70, 95% CI [1.26-2.28]), more emergency home visits on nights and holidays (33.6% vs. 16.7%; 2.20 [1.55-3.13]), and fewer hospitalizations (21.5% vs. 32.2%; 0.55 [0.39-0.76]). During the follow-up period, 229 patients (152 patients in enhanced HCSCs and 77 patients in HCSCs) died. Deaths at home were significantly more common in enhanced HCSCs than in conventional HCSCs (80.9% vs. 64.9%; p < .001), and physician-attended deaths among those who died at home were also significantly more common in enhanced HCSCs (99.2% vs. 78.0%; p < .001).

CONCLUSIONS

This study confirms that enhanced HCSCs are more likely to be able to handle emergency home visits and end-of-life care at home, which are important medical functions in home healthcare. Further promotion of enhanced HCSCs would be advantageous.

Factors associated with preferred place of death among older adults: a qualitative interview study in Tama City, Tokyo, Japan

OBJECTIVES

To analyse the cognitive processes involved in the decision-making of older adults who are not in the end-of-life stage regarding the selection of a preferred place of death.

DESIGN

A qualitative cross-sectional study based on semistructured in-depth interviews. The interview scripts were sectioned by context, then summarised, conceptualised and categorised. Post-categorisation, the relationships between the conceptual factors were examined.

SETTING

Tama City, Tokyo, Japan, from November 2015 to March 2016.

PARTICIPANTS

20 long-term care users and their families or care providers were interviewed about their preferred places of death and the factors behind their decisions.

RESULTS

Three categories based on the preferred place of end-of-life care and death were extracted from the interview transcripts: (A) discouraging the decision of a preferred place of death, (B) enhancing the desire for home death and (C) enhancing the desire for a hospital/long-term care facility death. Category A consists of concerns about the caregiver's health, anxiety about solitary death, and constraints of and concerns about the household budget. Both categories B and C consist of subcategories of reinforcing and inhibiting factors of whether to desire a home death or a hospital/long-term care facility death. If their previous experiences with care at home, a hospital or a care facility were positive, they preferred the death in the same setting. If those experiences were negative, they tend to avoid the death in the same setting.

CONCLUSIONS

One's mindset and decision regarding a preferred place of death include the consideration of economic factors, concerns for caregivers, and experiences of care at home or in a hospital/long-term care facility. Furthermore, health professionals need to be aware of the ambivalence of senior citizens to support their end-of-life decisions.

Municipal Characteristics of In-Home Death Among Care-Dependent Older Japanese Adults

IMPORTANCE

The provision of in-home and community end-of-life care has emerged as an important policy issue for aging populations around the world. Despite most patients expressing the wish to die at home (as opposed to in the hospital), substantial geographic variation persists in the prevalence of in-home death at the end of life.

OBJECTIVE

To assess the association of municipal characteristics with variation in the place of death among care-dependent older people in Japan.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study using multilevel logistic regression, analyses were performed using national claims data under Japan's long-term care insurance system. The study population included long-term care insurance beneficiaries 65 years and older who died in 2015, excluding those who died from external causes, such as unintentional injuries. Data analyses were conducted from January 1 to April 31, 2021.

EXPOSURES

Predisposing, enabling, and need factors at the individual and municipal levels according to a behavioral model.

MAIN OUTCOMES AND MEASURES

The outcome was whether individuals died at home or not.

RESULTS

This cross-sectional study analyzed 544 836 decedents (median [IQR] age, 87 [81-91] years; 300 142 [55.1%] female). The proportion of in-home deaths was 10.3%. In the multilevel null model, 7.2% of the variance in the place of death was associated with municipal-level characteristics. Municipal characteristics were associated with more of the variance than were prefectural characteristics (2.7%). The largest proportional change (7.3%) in variance at the municipality level was observed when enabling factors (ie, medical and long-term care resources) were added to the model. Municipalities with a high proportion of in-home death were more likely to have a higher supply of clinics, physicians, and care workers providing in-home services per population, as well as a lower number of hospital beds and long-term care facility workers per population.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, municipal characteristics explained a substantial proportion of the geographic variance in in-home death in Japan. These results suggest that municipal policy makers need to ensure an adequate supply of clinics, physicians, and care workers providing in-home services to meet the preferences of care-dependent older people who wish to spend their final days at home.