Projecting prevalence of frailty and dementia and the economic cost of care in Japan from 2016 to 2043: a microsimulation modelling study

BACKGROUND

Dementia and frailty often accompany one another in older age, requiring complex care and resources. Available projections provide little information on their joint impact on future health-care need from different segments of society and the associated costs. Using a newly developed microsimulation model, we forecast this situation in Japan as its population ages and decreases in size.

METHODS

In this microsimulation modelling study, we built a model that simulates an individual's status transition across 11 chronic diseases (including diabetes, coronary heart disease, and stroke) as well as depression, functional status, and self-reported health, by age, sex, and educational strata (less than high school, high school, and college and higher), on the basis of nationally representative health surveys and existing cohort studies. Using the simulation results, we projected the prevalence of dementia and frailty, life expectancy with these conditions, and the economic cost for formal and informal care over the period 2016-43 in the population of Japan aged 60 years and older.

FINDINGS

Between 2016 and 2043, life expectancy at age 65 years will increase from 23·7 years to 24·9 years in women and from 18·7 years to 19·9 years in men. Years spent with dementia will decrease from 4·7 to 3·9 years in women and 2·2 to 1·4 years in men. By contrast, years spent with frailty will increase from 3·7 to 4·0 years for women and 1·9 to 2·1 for men, and across all educational groups. By 2043, approximately 29% of women aged 75 years and older with a less than high school education are estimated to have both dementia and frailty, and so will require complex care. The expected need for health care and formal long-term care is anticipated to reach costs of US$125 billion for dementia and $97 billion for frailty per annum in 2043 for the country.

INTERPRETATION

Japan's Government and policy makers should consider the potential social challenges in caring for a sizable population of older people with frailty and dementia, and a widening disparity in the burden of those conditions by sex and by educational status. The future burden of dementia and frailty should be countered not only by curative and preventive technology innovation, but also by social policies to mitigate the health gap.

FUNDING

Japan Society for the Promotion of Science, Hitachi - the University of Tokyo Laboratory for a sustainable society, and the National Institute of Ageing.

Future projection of the health and functional status of older people in Japan: A multistate transition microsimulation model with repeated cross-sectional data

Accurate future projections of population health are imperative to plan for the future healthcare needs of a rapidly aging population. Multistate-transition microsimulation models, such as the U.S. Future Elderly Model, address this need but require high-quality panel data for calibration. We develop an alternative method that relaxes this data requirement, using repeated cross-sectional representative surveys to estimate multistate-transition contingency tables applied to Japan's population. We calculate the birth cohort sex-specific prevalence of comorbidities using five waves of the governmental health surveys. Combining estimated comorbidity prevalence with death record information, we determine the transition probabilities of health statuses. We then construct a virtual Japanese population aged 60 and older as of 2013 and perform a microsimulation to project disease distributions to 2046. Our estimates replicate governmental projections of population pyramids and match the actual prevalence trends of comorbidities and the disease incidence rates reported in epidemiological studies in the past decade. Our future projections of cardiovascular diseases indicate lower prevalence than expected from static models, reflecting recent declining trends in disease incidence and fatality.

Social policies and change in education-related disparities in mortality in Japan, 2000-2010

Persistent socioeconomic disparity in mortality is a widely observed phenomenon despite improvements in the economic standard of living and the prevailing universal healthcare coverage policy. In this study, we selected Japan as a case in which public universal coverage has maintained horizontal equity in healthcare access while demographic and economic challenges have affected the life chances of vulnerable subpopulations over the past decade. We assessed the changing trends in the education-related disparity in mortality over a decade across demographic subpopulations for different causes of death, with the goal of generating social policy lessons to contribute to closing the mortality gap. Using a deterministic data merge between nationwide census and death records, we estimated age- and sex-specific mortality rates for 14 causes and their education-related gradients with absolute and relative indices of inequality in 2000 and 2010 via Poisson regression. Estimation parameters were standardized to the age structure of the sub-population of high school graduates in 2000 as the reference. The results demonstrated that the relative gaps in all-cause mortality persisted despite a decrease in the average mortality rate over the study period. The absolute gaps in mortality increased for preventable causes of death associated with lifestyle behavior choices. The average mortality worsened among socioeconomically vulnerable populations such as youth and women, who were left behind in the existing social/economic policy. External causes of death such as suicide and traffic accidents showed decreasing absolute gaps in a subpopulation targeted by universal social and labor policy measures. These change patterns indicate that, compared with a high-risk approach, a universal policy approach to dealing with societal and fundamental causes of health inequality seems more effective in reducing the education-related mortality gap in both absolute and relative terms.

•

Socioeconomic gaps in mortality persist despite extended healthcare coverage.

•

Education-related mortality gaps were confirmed in 2000 and 2010 in Japan.

•

Relative inequality in preventable diseases increased under checkup-for-all policy.

•

Youth and women, left behind in the current social policy, faced worsened gaps.

•

Mortality gaps decreased when a universal policy on societal causes was adopted.

Influenza vaccine supply and racial/ethnic disparities in vaccination among the elderly

BACKGROUND

The impact of vaccine shortages on disparities in influenza vaccination is uncertain.

PURPOSE

The objective of this research was to examine the association between influenza vaccine supply and racial/ethnic disparities in vaccination rates among elderly Medicare beneficiaries.

METHODS

Cross-sectional multivariable logistic regression analyses were performed in 2010 to examine whether racial/ethnic disparities in vaccination rates changed across two consecutive seasons: from (Period 1) 2000-2001 and 2001-2002 seasons through (Period 4) 2003-2004 and 2004-2005 seasons. Self-reported receipt of influenza vaccine across consecutive years was examined among community-dwelling non-Hispanic African-American (AA); non-Hispanic white (W); English-speaking Hispanic (EH); and Spanish-speaking Hispanic (SH) elderly enrolled in the Medicare Current Beneficiary Survey (unweighted n=2306-2504, weighted n=8.23-8.99 million for Periods 1 through 4).

RESULTS

During Periods 1 and 2, when vaccine supply increased nationally, adjusted racial/ethnic disparities in the influenza vaccination rate decreased by 1.8%-7.4% (W-AA disparity); 4.5%-6.6% (W-EH disparity); and 6.6%-11% (W-SH disparity) (all p<0.001). During Period 4, when vaccine supply declined, adjusted disparities in vaccination rates increased by 2.3% (W-AA disparity) and 6.1% (W-EH disparity) but decreased by 6.6% (W-SH disparity) probably due to a "floor effect" (constant low rates among SH; all p<0.001).

CONCLUSIONS

Improved vaccine supply was generally associated with reduced racial/ethnic disparities in influenza vaccination rates, whereas worse supply was associated with increased disparities. To avoid future widening of racial health disparities, policy options include stabilizing the vaccine supply and preferential delivery of vaccines to safety-net providers serving AA and Hispanic populations during a shortage.

Association between Medicaid reimbursement and child influenza vaccination rates

OBJECTIVE

We examined associations between influenza vaccination rates and Medicaid reimbursement rates for vaccine administration among poor children who were eligible for Medicaid (<100% of the federal poverty level in all states).

METHODS

We analyzed 3 consecutive National Immunization Surveys (NISs) to assess influenza vaccination rates among nationally representative children 6 to 23 months of age during the 2005-2006 (unweighted N = 12 885), 2006-2007 (unweighted N = 9238), and 2007-2008 (unweighted N = 11 785) influenza seasons (weighted N = 3.3-4.0 million per season). We categorized children into 3 income levels (poor, near-poor, or nonpoor). We performed analyses with full influenza vaccination as the dependent variable and state Medicaid reimbursement rates (continuous covariate ranging from $2 to $17.86 per vaccination) and terms with income levels as key covariates.

RESULTS

In total, 21.0%, 21.3%, and 28.9% of all US children and 11.7%, 11.6%, and 18.8% of poor children were fully vaccinated in the 2006, 2007, and 2008 NISs, respectively. Multivariate analyses of all 3 seasons found positive significant (all P < .05) associations between state-level Medicaid reimbursement and influenza vaccination rates among poor children. A $10 increase, from $8 per influenza vaccination (the US average) to $18 (the highest state reimbursement), in the Medicaid reimbursement rate was associated with 6.0-, 9.2-, and 6.4-percentage point increases in full vaccination rates among poor children in the 2006, 2007, and 2008 NIS analyses, respectively.

CONCLUSION

Medicaid reimbursement rates are strongly associated with influenza vaccination rates.

Effects of an ongoing epidemic on the annual influenza vaccination rate and vaccination timing among the Medicare elderly: 2000-2005

OBJECTIVES

We assessed short-term responsiveness of influenza vaccine demand to variation in timing and severity of influenza epidemics since 2000. We tested the hypothesis that weekly influenza epidemic activity is associated with annual and daily influenza vaccine receipt.

METHODS

We conducted cross-sectional survival analyses from the 2000-2001 to 2004-2005 influenza seasons among community-dwelling elderly using the Medicare Current Beneficiary Survey (unweighted n = 2280-2822 per season; weighted n = 7.7-9.7 million per season). The outcome variable was daily vaccine receipt. Covariates included the biweekly changes of epidemic and vaccine supply at 9 census-region levels.

RESULTS

In all 5 seasons, biweekly epidemic change was positively associated with overall annual vaccination (e.g., 2.7% increase in 2003-2004 season) as well as earlier vaccination timing (P < .01). For example, unvaccinated individuals were 5%-29% more likely to receive vaccination after a 100% biweekly epidemic increase.

CONCLUSIONS

Accounting for short-term epidemic responsiveness in predicting demand for influenza vaccination may improve vaccine distribution and the annual vaccination rate, and might assist pandemic preparedness planning.

[Problems in combined resection of adjacent organ in lung cancer: significance of preoperative and intraoperative ultrasonic examination]

Aggressive combined resections were carried out, on 24 lung cancer cases which showed invasion into surrounding organs. Those cases with wide infiltration of the ribs, and into surrounding intercostal tissues, and for those with invasion to diaphragm, the outcome of the operations was rather poor but, for those with invasion in pericardium and left atrium, fairly favorable results were obtained. These present results indicated that aggressive resections of adjacent organs is to be recommended for cases without N 2 infiltration. Experiences from these operations have taught us the importance and useful of diagnosis of the status of invasion of the tumor, during the operation by ultrasonogram (IUS), with direct contact of the probe to the thoracic wall or mediastinal organs, to discriminate the areas of chest wall and mediastinal organs that require resections. This method, in combination with esophagus ultrasonic endoscopy (EUS), enabled defining the infiltrated areas with accuracy far exceeding that obtained by tactile examination. Techniques of, and observations obtained by these examination methods are presented.

[A case of primary leiomyosarcoma of the lung]

We reported a case of 66-year-old female with leiomyosarcoma of the right lower lobe of the lung with the complaint of abnormal shadow of the chest roentgenogram. On December 2, 1987, partial resection was performed and the tumor was totally removed. Histological examination revealed primary leiomyosarcoma of the lung. By electron microscopic observation, pinocytotic vesicle was not observed, but myofilaments were observed in the cytoplasm.

Long-term survival of patients with hepatocellular carcinoma combined with liver cirrhosis. Report of two patients

Two patients with hepatocellular carcinoma combined with liver cirrhosis lived more than 5 years after hepatic resection. One patient with liver cirrhosis combined with schistosomiasis japonica survived 5 years and 2.5 months after left lobectomy and died of liver failure. Two recurrent tumors, each 1 cm in diameter, were present in the remaining lobe but were not responsible for death. Another patient is well 9 years and 2 months after extended right lobectomy. The tumor was bulky, and the resected specimen was 2800 g in weight. These facts show that patients with hepatocellular carcinoma combined with liver cirrhosis can survive for a long period even if a large tumor is involved.

Effect of cimetidine on the regeneration of the gastric mucosa around a peptic ulcer

Histological changes in gastric ulcers during the healing process with cimetidine treatment were compared with those seen with conventional treatment. Healing time of the ulcers was clearly shortened, and the regeneration of the marginal mucosa of gastric ulcers was strongly stimulated by cimetidine. Heightening of the marginal mucosa resulted from active regeneration of the mucosal cells and made the endoscopic features mimic those of gastric cancer. These results suggest that it is necessary to differentiate clearly peptic ulcer from gastric cancer before beginning treatment of a gastric ulcer with cimetidine.

Hepatic resection upon patients with jaundice

Fourteen jaundiced patients with carcinoma at the bifurcation of the hepatic ducts, primary carcinoma of the liver and congenital cystic dilation of the intrahepatic bile ducts underwent hepatic resection without an operative mortality after the jaundice was relieved preoperatively. All patients did well, with jaundice and fever being absent postoperatively, although nine patients died of a recurrence of carcinoma in the follow-up period. It is now clear that the jaundiced patient become candidates for hepatic resection.

Hepatoma with obstructive jaundice due to the migration of a tumor mass in the biliary tract: report of a successful resection

A 51-year-old man underwent extended right lobectomy for hepatoma of the right lobe with obstructive jaundice due to migration of the tumor mass in the common and bilateral hepatic ducts. Severe jaundice amounting to 32.6 mg% and suppurative cholangitis were relieved by drainage through the cannulation into the hepatic ducts of the bilateral lobes. Although hepatoma was combined with liver cirrhosis, the patient could tolerate extended right lobectomy. The patient is doing relatively well without jaundice 2 years after operation, but a recurrent tumor appeared on the celiac angiogram taken 1 year and 6 months following operation. This is the fourth report on hepatic resection of such cases, and difficult problems involved with that procedure are presented and discussed.