The Impact of Job Conditions on Health-Related Quality of Life among Working Japanese Older Adults: A Five-Year Longitudinal Study Using J-MICC Okazaki Study Data

ObjectivesThe number of older adults who continue working after retirement is increasing in Japan. Little is known about how job conditions affect older adults’ health. We examined the association between job conditions and health-related quality of life (HRQOL) during a five-year follow-up study.MethodsThis study included participants aged 65 years or older from the Japan Multi-Institutional Collaborative Cohort Study in the Okazaki area recruited at baseline between 2007 and 2011 and followed up five years later. Participants completed a self-reported questionnaire on the physical and mental health aspects of HRQOL (SF-8™), employment status, and job conditions (job satisfaction, skill use, and job suitability).ResultsData of 1,146 men and 522 women were analyzed (mean age: 69.1 and 68.6 years, respectively). Generalized mixed linear regression analysis revealed that, compared to the not-working group, skill use was positively associated with mental health aspects among men (skill use × time: β = 0.16, SE = 0.08, p < 0.05), while poor job satisfaction and job suitability were negatively associated with mental health aspects among women (job satisfaction, not satisfied × time: β = -0.93, SE = 0.47, p < 0.05; job suitability, not suitable × time: β = -1.06, SE = 0.50, p < 0.05).ConclusionsRegarding job conditions among older adults, skill use in men was marginally associated with mental health, and poor job satisfaction and suitability in women were negatively associated with mental health. Considering the job conditions of older workers is necessary to protect their mental health.     

Factors Associated with Denture Non-use in Older Adults Requiring Long-Term Care

BackgroundEvidence suggests that denture non-use is significantly associated with activities of daily living, oral function, and cognitive decline. Few studies have focused on the possibility that the indications for denture use may differ depending on the cognitive and physical functions in older adults requiring long-term care.ObjectivesThe aim of this study was to elucidate the factors associated with denture non-use in older adults requiring long-term care.MethodsThis cross-sectional study comprised 201 older adults (45 men and 156 women; average age = 86.2 ± 7.1 years) requiring long-term care in Japan. Those who did not require denture treatment were classified by dentists into denture-use and denture non-use groups. The severity of dementia was assessed using the Clinical Dementia Rating scale. Multiple logistic regression analyses were conducted to detect the factors significantly associated with denture non-use.ResultsThe proportion of participants without dentures was 58.2%. Multiple logistic regression analyses revealed that a moderate dementia (odds ratio [OR], 4.44; 95% confidence interval [CI] 1.18–16.71, p=0.027) and rinsing ability (OR 3.00; 95% CI 1.12–8.06; p=0.030) were significant factors related to the non-use of dentures.ConclusionSeverity of dementia and rinsing ability were significantly associated with non-use of dentures. These findings indicate the necessity of evaluating oral and cognitive functions while planning denture treatment in older adults requiring long-term care.     

Electronic tracking devices in dementia care: A systematic review of argument-based ethics literature

Background: Wandering is a behavioral symptom of dementia that often results in patients eloping from home or care facilities, leading to high-risk situations for injury or death. To mitigate this serious problem, caregivers use electronic tracking devices (ETDs) to manage wandering. As these devices can track, record, and monitor wearers, profound ethical questions are raised related to their use in this vulnerable population. The objective of this review was to identify the ethical frames, concepts, and arguments used in the normative literature that focused on ETDs in dementia care.Methods: We conducted a systematic literature review of normative literature that focused on ETDs in dementia care.Results: Twenty-two articles met the inclusion requirements. The majority of articles utilized a principlist approach, with arguments concerning ETDs largely falling under the four principles of biomedical ethics: respect for autonomy, non-maleficence, beneficence, and justice. Privacy and informed consent were specifically emphasized. The normative literature recognizes that ETDs may have a dual effect, potentially bolstering or eroding the values connected to each principle.Conclusions: The prevailing use of principlism in the normative literature on ETDs indicates that there is a need to pursue new ethical approaches and expand upon the few non-principlist approaches already in use. In addition, many of the ethical issues around ETD use involve value-laden questions present during their design. Therefore, future ethical orientations or frameworks should account for ethical questions that exist along the design continuum on the use of ETDs.     

Healthy but unhappy? Cross-national comparative analysis of depressive symptoms in Japanese vs. Korean elders

BackgroundJapan and South Korea, two neighbouring countries in East Asia, enjoy the highest life expectancies in the world, yet suffer paradoxically from high suicide rates.AimWe sought to conduct a cross-national comparative analysis of depressive symptoms among older adults in Japan vs. Korea, focusing particularly on poverty and physical health status.MethodsWe used nationally representative samples aged 65 and over from the Comprehensive Survey of Living Conditions in Japan and the Korean Community Health Survey in South Korea. Multivariate logistic regression models were conducted to examine if equivalized household income, poor self-rated health, disability and comorbidity (number of diseases) were associated with depressive symptoms, adjusting for age, education, marital status, alcohol use, smoking and living alone.ResultsOlder Japanese adults with poor self-rated health and disability were more likely to report depressive symptoms, but income level was not significantly associated with mental distress. By contrast, among older Korean people, depressive symptoms were strongly patterned by household income level, as well as poor self-rated health, disability, and comorbidity.ConclusionPoor physical health status was correlated with depressive symptoms among both Japanese and Korean seniors. However, income level was associated with depressive symptoms among only Korean elders, but not Japanese. Thus, the current generation of older Japanese adults appears to enjoy (relative) financial security, longevity, and mental wellbeing. By contrast, older Koreans experience high levels of mental distress, especially if they are financially insecure.     

Longitudinal associations between cancer history and cognitive functioning among older adults

ObjectivesThis study aimed to examine (1) whether cancer history accelerates older adults’ rates of cognitive decline over time and (2) whether chemotherapy increases older cancer patients’/ survivors’ rates of cognitive decline over time.MethodsThis longitudinal study drew a subsample of 8811 adults aged 65 or older from Wave 6 of the Health and Retirement Study in 2002 and followed biennually until Wave 13 in 2016. Linear mixed-effects models were performed to test whether cancer history and chemotherapy were associated with accelerated rates of cognitive decline over time among older adults in different age groups.ResultsMiddle-old adults (aged 75–84) with a cancer history had significantly reduced rates of cognitive decline over time, including the global measure of cognitive functioning (B = 0.16, p< .01), mental status (B = 0.08, p< .01), and episodic memory (B = 0.09, p< .05) compared to their counterparts without a cancer history. This effect was not significant for the youngest-old (aged 65–74) or oldest-old adults (aged 85 or older). Also, chemotherapy was not significantly associated with older cancer patients’/survivors’ cognitive functioning at baseline or over time in different age groups.ConclusionsThis study finds that cancer history and chemotherapy do not further exacerbate older adults’ cognitive functioning over time. On the contrary, cancer history shows a “protective” effect on middle-old adults’ cognitive functioning. This encouraging finding indicates that older adults can be more actively engaged in the decision-making of treatments and following care plans. Future mediation studies are needed to further investigate underlying mechanisms.     

Experience with outcomes research into the real-world effectiveness of novel therapies in Dutch daily practice from the context of conditional reimbursement

Policymakers more often request outcomes research for expensive therapies to help resolve uncertainty of their health benefits and budget impact at reimbursement. Given the limitations of observational data, we assessed its usefulness in evaluating clinical outcomes for bortezomib in advanced multiple myeloma patients. Data were retrospectively collected from patients included in the pivotal Assessment of Proteasome Inhibition for Extending Remissions trial (APEX; n = 333) and two groups of daily practice patients treated with bortezomib following progression from upfront therapy (n = 201): real-world patients treated as of May 2009 (RW-1; n = 72) and June 2012 (RW-2; n = 129). Prognosis, treatment, and effectiveness were compared. Outcomes research was useful for policymakers for addressing to whom and how bortezomib was administered in daily practice. It was limited however in generating robust evidence on real-world safety and effectiveness. The quality of real-world evidence on effectiveness was low due to missing data in patient charts, existing treatment variation and the dynamics in care during the novel drug's initial market uptake period. Policymakers requesting real-world evidence on clinical outcomes for reimbursement decisions should be aware of these limitations and advised to carefully consider beforehand the type of evidence that best addresses their needs for the re-assessment phase.     

Variations in the Hospital Standardized Mortality Ratios in Korea

Objectives:

The hospital standardized mortality ratio (HSMR) has been widely used because it allows for robust risk adjustment using administrative data and is important for improving the quality of patient care.

Methods:

All inpatients discharged from hospitals with more than 700 beds (66 hospitals) in 2008 were eligible for inclusion. Using the claims data, 29 most responsible diagnosis (MRDx), accounting for 80% of all inpatient deaths among these hospitals, were identified, and inpatients with those MRDx were selected. The final study population included 703 571 inpatients including 27 718 (3.9% of all inpatients) in-hospital deaths. Using logistic regression, risk-adjusted models for predicting in-hospital mortality were created for each MRDx. The HSMR of individual hospitals was calculated for each MRDx using the model coefficients. The models included age, gender, income level, urgency of admission, diagnosis codes, disease-specific risk factors, and comorbidities. The Elixhauser comorbidity index was used to adjust for comorbidities.

Results:

For 26 out of 29 MRDx, the c-statistics of these mortality prediction models were higher than 0.8 indicating excellent discriminative power. The HSMR greatly varied across hospitals and disease groups. The academic status of the hospital was the only factor significantly associated with the HSMR.

Conclusions:

We found a large variation in HSMR among hospitals; therefore, efforts to reduce these variations including continuous monitoring and regular disclosure of the HSMR are required.     

Guidelines should not recommend the type of decision-making for the medical encounter

Clinical practice guidelines (CPGs) often include a recommendation regarding how to approach a clinical encounter and which decision-making model should be used. The GRADE framework, a popular method for developing CPGs, suggests a paternalistic model when recommendations are “strong” and shared decision making (SDM) when recommendations are “weak”. Tying the model of decision making and patient participation to the strength of a recommendation is not justified theoretically and/or empirically in the GRADE literature. Thus, why a CPG should offer any advice on which model to use in the clinical encounter is not clear. We argue that including such instruction is not justified and potentially violates the bioethical norms of autonomy and respect for individual choice and may even violate the clinician’s legal obligation. Rather, the model to be used is better determined by the participants in the individual encounter during the encounter and not the panel developing the CPG.     

费用补偿方式对医疗服务需求和利用的影响

文章采用按服务项目付费和按人头付费2种补偿方式,比较2种方式样本人群的门诊医疗服务需求和利用的情况,探讨不同费用补偿方式对医疗服务需求和利用的影响程度.结果显示2种费用补偿方式在服务需求利用及医疗费用方面存在显著差异(P＜0.01).在医疗服务的费用补偿中引入供方风险分担机制,这是控制医疗费用快速增长的一个重要举措:同时应积极探索多种费用补偿方式的联合使用,相对客观地反映医疗服务的真实成本,对协调医疗费用和服务质量的平衡意义重大.     

失地农民医疗保险制度建设的实践与思考——以杭州经济开发区为例

失地农民是一个国家在城市化的过程中必然出现的一种正常的社会现象,失地农民的医疗保险制度建设是涉及城乡统筹和社会稳定的重大问题。以杭州经济开发区失地农民医疗保险制度实践为例,提出了失地农民医疗保障制度设计思路。