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      Influence of Municipality-Level Mean Income on Access to Aortic Valve Surgery: A Cross-Sectional Observational Study under Japan's Universal Health-Care Coverage

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          Abstract

          Background

          Universal health-care coverage has attracted the interest of policy makers as a way of achieving health equity. However, previous reports have shown that despite universal coverage, socioeconomic disparity persists in access to high-tech invasive care, such as cardiac treatment. In this study, we aimed to investigate the association between socioeconomic status and care of aortic stenosis in the context of Japan's health-care system, which is mainly publicly funded.

          Methods

          We chose aortic stenosis in older people as a target because such patients are likely to be affected by socioeconomic disparity. Using a large Japanese claim-based inpatient database, we identified 12,893 isolated aortic stenosis patients aged over 65 years who were hospitalized between July 2010 and March 2012. Municipality socioeconomic status was represented by the mean household income of the patients' residential municipality, categorized into quartiles. The likelihood of undergoing aortic valve surgery and in-hospital mortality was regressed against socioeconomic status level with adjustments for hospital volume, regional number of cardiac surgeons per 1 million population, and patients' clinical status.

          Results

          We found no significant differences between the highest and lowest quartile groups in surgical indication (odds ratio, 0.84; 95% confidence interval, 0.69–1.03) or in-hospital mortality (1.00; 0.68–1.48). Hospital volume was significantly associated with lower postoperative mortality (odds ratio of the highest volume tertile to the lowest, 0.49; 0.34–0.71).

          Conclusions

          Under Japan's current universal health-care coverage, municipality socioeconomic status did not appear to have a systematic relationship with either treatment decision for surgical intervention or postoperative survival following aortic valve surgery among older patients. Our results imply that universal health-care coverage with high publicly funded coverage offers equal access to high-tech cardiovascular care.

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          Most cited references24

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          Effects of socioeconomic status on access to invasive cardiac procedures and on mortality after acute myocardial infarction.

          Universal health care systems seek to ensure access to care on the basis of need rather than income and to improve the health status of all citizens. We examined the performance of the Canadian health system with respect to these goals in the province of Ontario by assessing the effects of neighborhood income on access to invasive cardiac procedures and on mortality one year after acute myocardial infarction. We linked claims for payment for physicians' services, hospital-discharge abstracts, and vital-status data for all patients with acute myocardial infarction who were admitted to hospitals in Ontario between April 1994 and March 1997. Patients' income levels were imputed from the median incomes of their residential neighborhoods as determined in Canada's 1996 census. We determined rates of use and waiting times for coronary angiography and revascularization procedures after the index admission for acute myocardial infarction and determined death rates at one year. In multivariate analyses, we controlled for the patient's age, sex, and severity of disease; the specialty of the attending physician; the volume of cases, teaching status, and on-site facilities for cardiac procedures at the admitting hospital; and the geographic proximity of the admitting hospital to tertiary care centers. The study cohort consisted of 51,591 patients. With respect to coronary angiography, increases in neighborhood income from the lowest to the highest quintile were associated with a 23 percent increase in rates of use and a 45 percent decrease in waiting times. There was a strong inverse relation between income and mortality at one year (P<0.001). Each $10,000 increase in the neighborhood median income was associated with a 10 percent reduction in the risk of death within one year (adjusted hazard ratio, 0.90; 95 percent confidence interval, 0.86 to 0.94). In the province of Ontario, despite Canada's universal health care system, socioeconomic status had pronounced effects on access to specialized cardiac services as well as on mortality one year after acute myocardial infarction.
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            Unmet health needs of uninsured adults in the United States.

            In 1998, 33 million US adults aged 18 to 64 years lacked health insurance. Determining the unmet health needs of this population may aid efforts to improve access to care. To compare nationally representative estimates of the unmet health needs of uninsured and insured adults, particularly among persons with major health risks. Random household telephone survey conducted in all 50 states and the District of Columbia through the Behavioral Risk Factor Surveillance System. A total of 105,764 adults aged 18 to 64 years in 1997 and 117,364 in 1998, classified as long-term (>/=1 year) uninsured (9.7%), short-term (<1 year) uninsured (4.3%), or insured (86.0%). Adjusted proportions of participants who could not see a physician when needed due to cost in the past year, had not had a routine checkup within 2 years, and had not received clinically indicated preventive services, compared by insurance status. Long-term- and short-term-uninsured adults were more likely than insured adults to report that they could not see a physician when needed due to cost (26.8%, 21.7%, and 8.2%, respectively), especially among those in poor health (69.1%, 51.9%, and 21.8%) or fair health (48.8%, 42.4%, and 15.7%) (P<.001). Long-term-uninsured adults in general were much more likely than short-term-uninsured and insured adults not to have had a routine checkup in the last 2 years (42.8%, 22.3%, and 17.8%, respectively) and among smokers, obese individuals, binge drinkers, and people with hypertension, elevated cholesterol, diabetes, or human immunodeficiency virus risk factors (P<.001). Deficits in cancer screening, cardiovascular risk reduction, and diabetes care were most pronounced among long-term-uninsured adults. In our study, long-term-uninsured adults reported much greater unmet health needs than insured adults. Providing insurance to improve access to care for long-term-uninsured adults, particularly those with major health risks, could have substantial clinical benefits. JAMA. 2000;284:2061-2069
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              Socioeconomic status and health in the Japanese population.

              There is growing interest in the influence of socioeconomic status (SES) on health. Individual SES has been shown to be closely related to mortality, morbidity, health-related behavior and access to health care services in Western countries. Whether the same set of social determinants accounts for higher rates of mortality or morbidity in Japan is questionable, because over the past decade the magnitude of the social stratification within the society has increased due to economic and social circumstances. SES must be interpreted within the economic, social, demographic and cultural contexts of a specific country. In this report we discuss the impact of individuals' socioeconomic position on health in Japan with regard to educational attainment, occupational gradient/class, income level, and unemployment. This review is based mainly on papers indexed in Medline/PubMed between 1990 and 2007. We find that socioeconomic differences in mortality, morbidity and risk factors are not uniformly small in Japan. The majority of papers investigate the relationship between education, occupational class and health, but low income and unemployment are not examined sufficiently in Japan. The results also indicate that different socioeconomic contexts and inequality contribute to the mortality, morbidity, and biological and behavioral risk factors in Japan, although the pattern and direction of the relationships may not necessarily be the same in terms of size, pattern, distribution, magnitude and impact as in Western countries. In particular, the association between higher occupational status and lower mortality, as well as higher educational attainment and either mortality or morbidity, is not as strongly expressed among the Japanese. Japan is still one of the healthiest and most egalitarian nations in the world, and social inequalities within the population are less expressed. However, the magnitude of the social stratification has started to increase, and this is an alarming sign.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2014
                31 October 2014
                : 9
                : 10
                : e111071
                Affiliations
                [1 ]Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
                [2 ]Department of Health and Social Behavior, The University of Tokyo, Tokyo, Japan
                [3 ]Clinical Research Support Center, The University of Tokyo, Tokyo, Japan
                [4 ]Department of Clinical Epidemiology and Systems, The University of Tokyo, Tokyo, Japan
                [5 ]Department of Clinical Epidemiology and Health Economics, The University of Tokyo, Tokyo, Japan
                [6 ]Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization Headquarters, Tokyo, Japan
                [7 ]Department of Clinical Informatics, Jichi Medical University, Tochigi, Japan
                [8 ]Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
                Hamamatsu University School of Medicine, Japan
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: SLL H. Hashimoto HY. Analyzed the data: SLL H. Hashimoto HY. Contributed reagents/materials/analysis tools: HY H. Horiguchi KF. Wrote the paper: SLL H. Hashimoto TK. Intellectual input and critical review/comments: DK IK TY HY.

                Article
                PONE-D-14-25024
                10.1371/journal.pone.0111071
                4215927
                25360759
                0d178d7d-1e21-4f44-8145-be7e93b6faca
                Copyright @ 2014

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 4 June 2014
                : 18 September 2014
                Page count
                Pages: 8
                Funding
                This study is supported by a Grant-in-Aid for Research on Policy Planning and Evaluation (H22-Policy-031 and, in part, H22-Policy-033) from the Ministry of Health, Labour and Welfare, Japan; by a Grant-in-Aid for Scientific Research B (No. 22390131) from the Ministry of Education, Culture, Sports, Science and Technology, Japan; and by the Funding Program for World-Leading Innovative R&D on Science and Technology (FIRST program) from the Council for Science and Technology Policy, Japan (No. 0301002001001). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Epidemiology
                Cardiovascular Disease Epidemiology
                Health Care
                Health Services Research
                Socioeconomic Aspects of Health
                Surgical and Invasive Medical Procedures
                Cardiovascular Procedures
                Custom metadata
                The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the paper.

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