Relation Between Outpatient Medical Expenses and Self-Rated Health in Patients With Hypertension, Dyslipidemia, and Diabetes Mellitus Covered by National Health Insurance

Relation Between Outpatient Medical Expenses and Self-Rated Health in Patients With Hypertension, Dyslipidemia, and Diabetes Mellitus Covered by National Health Insurance | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Relation Between Outpatient Medical Expenses and Self-Rated Health in Patients With Hypertension, Dyslipidemia, and Diabetes Mellitus Covered by National Health Insurance Sanai Kawasaki, Mayumi Ohnishi, Rieko Nakao, Satoko Kosaka, Ryoko Kawasaki This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4471292/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: This study was performed to clarify the relations between subjective self-rated health and outpatient medical expenses as an objective measure in patients with hypertension, dyslipidemia, and/or diabetes mellitus. Methods: We analyzed self-rated health of individuals aged 40–74 years in Unzen and Shimabara cities based on responses to the anonymous self-administered Nagasaki Prefectural Citizen’s Health Survey in 2021 along with data from the national health insurance database for both cities from fiscal year 2020. Results: Data for 1395 respondents to the Nagasaki Prefectural Citizen’s Health Survey covered by national health insurance who incurred outpatient medical expenses in relation to hypertension, dyslipidemia, and/or diabetes mellitus were included in the study. In univariate analysis, outpatient medical expenses were significantly associated with self-rated health in the groups with one or two of the above diseases (χ test, both P < 0.01). Logistic regression analysis adjusted for measures of socioeconomic status, including age, sex, cohabitation/family structure, number of years of education, employment status, and subjective economic status, showed that poor self-rated health was significantly associated with high annual outpatient medical expenses of JPY 100,000 (~US $650). or more in groups with one or two of the above diseases (adjusted odds ratio [AOR], 2.41, 95% confidence interval [CI], 1.60–3.61, AOR, 2.20, 95% CI, 1.41–3.43, respectively). In the one-disease cohort, having diabetes mellitus alone was significantly associated with higher outpatient medical expenses (AOR, 2.63, 95% CI, 1.50–4.63). In contrast, none of the conditions showed a significant association with higher outpatient medical expenses in the two-disease cohort. Conclusions: Poor self-rated health was significantly associated with high outpatient medical expenses in the population covered by national health insurance with one or two of hypertension, dyslipidemia, and/or diabetes mellitus. These associations may have been influenced by the prevalence of diabetes mellitus in the population. outpatient medical expense self-rated health national health insurance Figures Figure 1 Introduction Hypertension, dyslipidemia, and diabetes mellitus are risk factors for cardiovascular diseases, such as ischemic heart disease and stroke [1–5]. As these diseases are associated with the accumulation of excess visceral fat, they can be prevented or ameliorated by changes in lifestyle [6]. The prevalence of lifestyle-related diseases—defined as diseases in which onset and progression are related to lifestyle factors, such as eating habits, exercise, sleep, smoking, and alcohol consumption—increases with age, especially around the age of 40 years [7]. Specific health checkups (SHCs) and specific health guidance (SHG) for individuals in the population aged 40–74 years have been covered by health insurance since 2008 in Japan as part of a health policy aimed toward the early detection and prevention of severe lifestyle-related diseases. The target population of SHG for lifestyle improvement has been stratified and selected according to the results of SHCs to provide individualized SHG. The criteria for stratification of SHG include hypertension, dyslipidemia, and diabetes mellitus, and those at risk of visceral fat accumulation and who have at least one of these diseases are eligible for SHG by public health nurses (PHNs) [8]. Hypertension, dyslipidemia, and diabetes mellitus are associated with increased risk of cardiovascular diseases, such as ischemic heart disease and stroke [9]. Furthermore, diabetes mellitus is associated with vascular complications of persistent poor glycemic control due to hyperglycemia, resulting in irreversible lesions, such as fundus hemorrhage, uremia, neuropathy, and diabetic nephropathy, which can lead to limb amputation as a result of peripheral neuropathy and the requirement for artificial dialysis due to diabetic nephropathy [10]. Therefore, it is important to implement suitable interventions for these diseases at the stage of reversible lesions to improve lifestyle and prevent serious complications with serious adverse effects on quality of life (QoL). The stratification criteria for SHG were selected for subjects with prediabetes (i.e., with fasting blood glucose level 100–109 mg/dL or HbA1c 5.6%–5.9%) to allow intervention before the onset of diabetes mellitus or during the period when lesions are still reversible. Those already receiving treatment for diabetes mellitus are also included in the stratification criteria and require support at early stages of changes in the disease status. Therefore, national and local governments, which implement National Health Insurance (NHI) in Japan, should not only identify individuals in the population who require treatment in the SHC and provide referrals for appropriate medical care but also collaborate with medical institutions for those with at least one of the three diseases outlined above to achieve lifestyle improvements in terms of appropriate control of blood pressure, lipid, and blood glucose levels. Patients require support to prevent progression to ischemic heart disease, stroke, diabetic nephropathy, and dialysis, as well as to reduce the severity of these diseases [11]. Lifestyle-related diseases accounted for approximately 60% of deaths and 30% of medical expenses from all causes in Japan in 2014 [12]. A survey on medical expenses for lifestyle-related diseases conducted by the Federation of Health Insurance Associations in fiscal year (FY) 2019 indicated that cerebrovascular disorders, ischemic heart disease, and dialysis accounted for 37.1%, 28.4%, and 9.2% of medical expenses associated with hospitalizations for 10 lifestyle-related diseases, respectively, together corresponding tomore than 70% of the total inpatient medical expenses [13]. Diabetes mellitus, hypertension, dyslipidemia, and dialysis represented 31.8%, 25.3%, 18.2%, and 16.4% of total outpatient medical expenses, respectively, together accounting for more than 90% of the total. As the data outlined above indicate that lifestyle-related diseases, such as hypertension, dyslipidemia, diabetes mellitus, ischemic heart disease, cerebrovascular disease, and dialysis, account for a large proportion of medical expenses, it is important to adopt measures for preventing their onset and progression from the viewpoint of optimizing medical costs. Under the Act on Securing Medical Care for Older Persons , optimization of medical expenses is an important issue, and early prevention of ischemic heart disease, stroke, diabetic nephropathy, etc., through the promotion of SHC and SHG is the objective of the third phase (FY 2018–2023) of the Medical Cost Optimization Plan [14]. Preventing these diseases and optimizing future medical costs represent ongoing challenges for municipal governments in Japan. Based on receipts for patients aged 65 years or older in two prefectures, Sasaki et al. reported that higher annual medical costs were associated with individuals with more comorbid diseases [15]. A study on medical expenses and lifestyle-related diseases reported that hypertension and diabetes mellitus are associated with high total medical expenses [16], and that outpatient medical expenses for these two diseases are positively correlated with aging of the population [17]. Furthermore, higher outpatient medical expenses were shown to be associated with a history of heart disease and stroke [18]. Due to the severity of hypertension, dyslipidemia, and diabetes mellitus, the development of cardiovascular diseases and diabetic nephropathy, such as ischemic heart disease and stroke, are factors in reduced activities of daily living and the requirement for nursing care [19]. Therefore, it is important for municipal governments to implement measures to prevent the onset of hypertension, dyslipidemia, and diabetes mellitus and thus optimize medical costs as these affect the maintenance of residents’ QoL and long-term care insurance premiums. Furthermore, it has been suggested that municipal PHNs should actively intervene and work to not only support lifestyle improvement and thus prevent the onset of lifestyle-related diseases but also to prevent progression to serious conditions after such diseases have developed [11]. The extension of healthy life expectancy in the Japanese population is a major theme of the Strategic Market Creation Plan as part of the Revitalization Strategy for Japan announced by the government of Japan in 2013. As part of the creation of a new framework for the promotion of health management and disease prevention, “all health insurance associations are required to analyze data, including receipts, prepare and publish data health plans as business plans for the maintenance and promotion of health of their members based on such data, implement and evaluate such plans, and promote the implementation of similar initiatives by municipal NHI associations” [20]. Municipal governments are required to use health and medical-related databases, including the NHI Kokuho Database (KDB), and implement effective and efficient health projects. As KDB supports the preparation and implementation of health project plans by NHI [21], this study utilized data from this database to evaluate municipal governmental health promotion programs. Self-rated health (SRH) has been reported to be a useful predictor of life expectancy [22, 23] and is also considered a predictive indicator of the degree of care required in Japan [24]. As it is a subjective rather than an objective measure of health status, SRH is commonly used to evaluate an individual’s overall health status. Although SRH has been suggested to be independent of the presence or absence of disease, a previous study suggested an association with a history of heart disease [25]. In addition, higher SRH has been shown to be associated with younger age and higher socioeconomic status [26]. SRH has been reported to be lower among people with diseases undergoing treatment or in hospital compared to those free from disease [26], and Yamada et al. reported that hypertension, dyslipidemia, and diabetes mellitus were associated with significantly reduced SRH [27]. Therefore, while it has been reported that disease is associated with poor SRH, the World Health Organization (WHO) defines “health” as “A state of complete physical, social, and mental well-being, and not merely the absence of disease or infirmity” [28]. High SRH has been shown to be important for QoL [29]. It is important for individuals to feel fulfilled even when they are ill, but given the high prevalence of lifestyle-related diseases (hypertension, dyslipidemia, diabetes mellitus, etc.), it is often difficult to evaluate the health of an individual based on medical indicators alone. This study was therefore performed to clarify the relation between subjective SRH and objective outpatient medical expenses in the population with hypertension, dyslipidemia, and diabetes mellitus. Methods This cross-sectional study was conducted from June to August 2021 using the responses to the anonymous self-administered Nagasaki Prefectural Citizen’s Health Survey administered by mail in Unzen and Shimabara cities among those aged 40–74 years covered by NHI as well as data from the KDB for both cities from FY 2020. Study variables The variables examined in this study included annual outpatient medical expenses, SRH, age, sex, cohabitation/family structure, number of years of education, employment status, and current medical history. Data regarding SRH, cohabitation/family structure, number of years of education, employment status, and subjective socioeconomic status were obtained from the Nagasaki Prefectural Citizen’s Health Survey . SRH was divided into four categories ( very healthy , healthy , not so healthy , or not healthy ) in response to the question, “How do you feel about your health in general?” Respondents indicated the presence or absence of a cohabitant by selecting from multiple responses: single , spouse , children , parents , grandchildren , or other . Number of years of education was classified as follows: less than 6 years , 6 – 9 years , 10 – 12 years , 13 years or more , or other . Employment status was selected from the following options: fishing , agriculture , manufacturing , service worker , homemaker , unemployed , or other . Respondents selected from five options ( difficult , somewhat difficult , fair , somewhat comfortable , and comfortable ) in response to the question, “What is your economic condition?” Data regarding annual outpatient medical expenses, current medical history, age, and sex were obtained from the KDB. Outpatient medical expenses referred to the total cost of visits to medical institutions for treatment of injuries and illnesses. Current medical history included data on 19 diseases: diabetes mellitus, hypertension, dyslipidemia, gout and hyperuricemia, fatty liver, musculoskeletal diseases, other cardiovascular diseases, diabetic nephropathy, chronic renal failure, nondiabetic renal diseases, chronic obstructive pulmonary disease, pneumonia, other functional decline-related diseases, cancer, dementia, depression, schizophrenia, dialysis, and peritoneal perfusion. Study areas Unzen City and Shimabara City are located on the Shimabara Peninsula in southeastern Nagasaki Prefecture, Japan. Unzen City faces the Ariake Sea in the north and Tachibana Bay in the west, and is situated around Mt. Unzen. Shimabara City has gently sloping terrain from the mountains of Heiseishinzan and Mayuyama in the central part of the city to the coastal area facing the Ariake Sea with an active tourism industry. According to the census conducted in 2015, the population of both cities is approximately 45,000. Both cities have an aging population of approximately 32%, which is higher than the average of approximately 29.6% in Nagasaki Prefecture [30, 31]. Nagasaki Prefectural Citizen’s Health Survey respondents (Figure 1) In the Nagasaki Prefectural Citizen’s Health Survey , questionnaires were sent to a randomly selected sample (4943 in Unzen City and 4857 in Shimabara City) of NHI subscribers (aged 40–74 years) as of June 2021, of which 50% were stratified according to sex and age group. A total of 3509 people responded to the questionnaire, consisting of 1625 in Unzen City (35.5% response rate) and 1884 in Shimabara City (39.2% response rate). The collected questionnaire responses and KDB data were matched by ID numbers provided by the National Health Insurance and Health Promotion Division of Nagasaki Prefecture. The data were managed by ID number after removal of confidential information, such as name and birth date. Responses with missing values for the variables used in this study were excluded. This study was based on data from respondents with one or more of hypertension, dyslipidemia, and/or diabetes mellitus. Finally, to focus on those who incurred outpatient medical expenses for the three diseases examined in this study, we excluded patients with cancer, mental disorders (depression and schizophrenia), diabetic nephropathy, and dialysis, all of which are already considered to be severe and to be associated with high medical expenditure, such as annual outpatient medical expenses of JPY 1 million (~US $6500) or more. A total of 1395 participants from the two cities were included in the analysis. Statistical analysis As the overlap of hypertension, dyslipidemia, and diabetes mellitus is considered to be associated with a high risk of serious illness, the study population was divided into three groups: the one-disease cohort consisting of participants with only one of the three diseases; the two-disease cohort comprised of those with two of the three diseases; and the three-disease cohort consisting of those with all three diseases. The relation between SRH and annual outpatient medical expenses was analyzed for each of these three groups. The study population was divided into two groups according to SRH for statistical analysis: the good health group consisting of participants who reported being very healthy or healthy ; and the poor health group comprised of those with SRH of not so healthy or not healthy . Subjective economic status was classified into three categories: comfortable consisting of comfortable and somewhat comfortable ; fair; and difficult comprised of difficult and somewhat difficult . With regard to the presence or absence of a cohabitant, no cohabitant was defined as living alone , and other responses were defined as living with someone . The study population was divided according to the number of years of education as follows: less than 9 years, consisting of those with “ less than 6 years ” or “ 6 – 9 years ” of education; 10–12 years; and 13 years or more. With regard to employment status, those who answered fishing , agriculture , manufacturing , and service worker were classified as working, while all other responses were classified as not working. The summary of outpatient medical expenses and distribution of diseases was subjected to descriptive statistical analysis. One-way analysis of variance (ANOVA) and the chi-square test were conducted for analysis of sociodemographic variables and SRH. Annual outpatient medical expenses were divided into two groups: the high-expense group with a median of JPY 100,000 or more; and the low-expense group with a median of less than JPY 100,000. Univariate analysis was conducted using the t test and chi-square test, with outpatient medical expenses as the dependent variable in each group according to sociodemographic variables and SRH. Logistic regression analysis with outpatient medical expenses was also performed using independent variables, including age, sex, cohabitation/family structure, number of years of education, employment status, subjective economic status, and SRH. Logistic regression analyses to evaluate the association between high outpatient medical expenses and presence of diseases, including hypertension, dyslipidemia, and diabetes mellitus, were conducted according to disease cohort. Statistical analyses were performed using IBM SPSS Statistics ver. 28 (IBM, Armonk, NY, USA), and P < 0.05 was taken to indicate statistical significance. Results Background information of study participants Table 1 presents background information of the study participants. The study population was divided into the one-disease cohort consisting of 590 participants, the two-disease cohort consisting of 555 participants, and the three-disease cohort consisting of 250 participants. These groups had median outpatient medical expenses of JPY 89,685 (~US $580), JPY 102,220 (~US $660), and JPY 130,960 (~US $850), respectively. The first quartiles for the one-, two-, and three-disease cohorts were JPY 56,827 (~US $370), JPY 68,340 (~US 440), and JPY 84,865 (~US $550), respectively. The third quartiles were JPY 144,605 (~US $935), JPY 157,590 (~US $1000), and JPY 210,837 (~US $1365), respectively. In the one-disease cohort, 319 participants (54.1%) had hypertension, 205 (34.7%) had dyslipidemia, and 66 (11.2%) had diabetes mellitus. In the two-disease cohort, 355 participants (64.0%) had hypertension and dyslipidemia, 85 (15.3%) had hypertension and diabetes mellitus, and 115 (20.7%) had dyslipidemia and diabetes mellitus. There were no significant relations in socioeconomic status of the study participants in terms of age, cohabitation status, number of years of education, employment status, or subjective economic status between one-, two, and three-disease cohorts, but there were significant differences in sex and SRH according to number of diseases (both P < 0.01) (Table 2). Associations between outpatient medical expenses, socioeconomic status, and self-rated health Outpatient medical expenses were low in 325 participants and high in 265 participants in the one-disease cohort, 268 and 287 participants, respectively, in the two-disease cohort, and 81 and 169 participants, respectively, in the three-disease cohort. participants tended to be older in the high-expense group than in the low-expense group in all disease groups, and the difference in age between the low- and high-expense groups was statistically significant in the two-disease cohort ( P = 0.03). There was also a statistically significant difference in number of years of education between the low- and high-expense groups for the two-disease cohort ( P = 0.02), with a greater proportion of participants in the low-expense group having 10–12 years of education. SRH showed a significant difference between the low- and high-income groups in the one- and two-disease cohorts (both P < 0.01), with a higher proportion of those in the high-income group reporting poor SRH. There were no significant differences between the high- and low-expense groups for all disease cohorts in terms of sex, presence of a cohabitant, employment status, and subjective economic status (Table 3). Factors associated with high outpatient medical expenses group Logistic regression analysis with high medical expenses as the dependent variable and adjustment for socioeconomic status (age, sex, presence of cohabitant, number of years of education, employment status, and subjective economic status) showed that the probability of being in the self-rated poor health group was significantly higher for those with high medical expenses in the one- and two-disease cohorts (one-disease, AOR, 2.41, 95% CI, 1.60–3.61; two-disease, AOR, 2.20, 95% CI, 1.41–3.43). However, there was no significant association of subjective poor health with high medical expenses in the three-disease cohort (Table 4). Association between presence of each disease and high outpatient medical expenses Logistic regression analyses were performed in the one- and two-disease cohorts by adjusting for the presence or absence of hypertension, dyslipidemia, and/or diabetes mellitus (Tables 5 and 6). In the one-disease cohort, adjustment for hypertension was added to Model 1-1, for dyslipidemia to Model 1-2, and for diabetes mellitus to Model 1-3. In the one-disease cohort, only diabetes mellitus (Model 1-3) was significantly associated with higher outpatient medical expenses (AOR, 2.63, 95% CI, 1.50–4.63). In the two-disease cohort, neither condition was significantly associated with higher outpatient medical expenses. Discussion The study population consisted of local residents aged 40–74 years who responded to the Nagasaki Prefectural Citizen’s Health Survey questionnaire and incurred outpatient medical expenses for at least one of three diseases, i.e., hypertension, dyslipidemia, and/or diabetes mellitus. In univariate analysis, outpatient medical expenses were significantly associated with SRH in the one- or two-disease cohorts. Logistic regression analysis adjusted for variables of socioeconomic status, including age, sex, cohabitation/family structure, number of years of education, employment status, and subjective economic status, showed that SRH was significantly associated with high annual outpatient medical expenses of JPY 100,000 or more in the one- or two-disease cohorts. Distribution of outpatient medical expenses and hypertension, dyslipidemia, and diabetes mellitus The difference in the first quartile of outpatient medical expenses between the one- and two-disease cohorts was approximately JPY 12,000, whereas the difference between the two- and three-disease cohorts was approximately JPY 17,000. The difference in the third quartile was approximately JPY 13,000 between the one- and two-disease cohorts and approximately JPY 53,000 between the two- and three-disease cohorts, indicating that greater number of diseases was associated with higher outpatient medical expenses in the three-disease cohort. The ratio of increase in outpatient medical expenses for the three-disease cohort was greater than for the one- and two-disease cohorts. As mentioned in the Introduction, hypertension, dyslipidemia, and diabetes mellitus interact with each other and increase the risk of severe cerebrovascular disease. Therefore, the overlap of the three diseases is expected to increase not only the severity of each disease but also the risk of developing irreversible vascular damage, which may have an impact on outpatient medical expenses. In addition, the presence of more than one disease may result in visits to multiple medical departments, which may influence the outpatient medical expenses. According to a patient survey report in 2020 by the Ministry of Health, Labour and Welfare, the total numbers of outpatients by disease category per 100,000 population were 471 for hypertension, 122 for dyslipidemia, and 170 for diabetes mellitus [ 32 ]. Hypertension is the most common disease among outpatients, followed by diabetes mellitus and dyslipidemia. The distribution of diseases in this study was approximately 50% hypertension, 40% dyslipidemia, and 10% diabetes mellitus. The proportions of participants with dyslipidemia and diabetes mellitus were reversed compared with the patient survey report in 2020. The high rate of dyslipidemia in the present study may have been influenced by the fact that the most common combination of diseases was hypertension and dyslipidemia, accounting for approximately 60% of cases, even in the two-disease cohort with overlapping diseases. The rates of diabetes mellitus were approximately 10% in the one-disease cohort and approximately 40% in the two-disease cohort. Distribution of self-rated health In this study, the proportion of participants who responded that they were very healthy or healthy was high in all disease cohorts, with about 80% of those in the one- and two-disease cohorts and about 70% of those in the three-disease cohort having good SRH. In a previous study of healthy older people (mean age: men, 73.3 ± 4.5 years, women, 72.2 ± 5.1 years) living in the community, 81.1% had good SRH and 18.9% had poor SRH [ 25 ], which was similar to the distribution of SRH in the one- and two-disease cohorts in the present study. The mean age of the study participants with up to two diseases in this study was the late 60s, which was younger than in the previous study, but the distribution of SRH was similar to that of healthy older study participants. However, the three-disease cohort showed a significant increase in the proportion of respondents with poor SRH in comparison to the one- and two-disease cohorts, suggesting that the need for medical examinations for hypertension, dyslipidemia, and diabetes mellitus, all of which are risk factors for ischemic heart disease and stroke, may be a factor in the perception of subjective poor health. Association between outpatient medical expenses and self-rated health Characteristics of the one-, two-, and three-disease cohorts In this study, the variables that were significantly associated with outpatient medical expenses of JPY 100,000 or more were age and number of years of education in the two-disease cohort and SRH in the one- and two-disease cohort. The results adjusted for age, sex, cohabitation/family structure, number of years of education, employment status and subjective economic status were also significantly associated with outpatient medical expenses of JPY 100,000 or more in the two-disease cohort, and those with outpatient medical expenses of JPY 100,000 or more in the one-disease and two-disease cohorts showed a significant increase in SRH in comparison to those with outpatient medical expenses less than JPY 100,000 in the one- and two-disease cohorts. The probability of having poor SRH was significantly higher for those with outpatient medical costs of JPY 100,000 or more compared to those with medical expenditure below this level. On the other hand, in the three-disease cohort, there was no significant association between SRH and outpatient medical expenses of JPY 100,000 or more even after adjusting for age, sex, presence of a cohabitant, number of years of education, employment status, and subjective economic status. The results indicated that participants with medical costs of JPY 100,000 or more in the two-disease cohort included a higher percentage of those with poor SRH, older age, and more than 13 years of education. Older age has been reported to be associated with higher medical expenses [ 15 ], and age was also considered to be associated with outpatient medical expenses of JPY 100,000 or more in the present study. Participants with a greater number of years of education (13 years or more) were more likely to actively seek medical care when an abnormality was identified on a medical checkup, and we speculated that this was likely related to outpatient medical expenses of JPY 100,000 or more in the present study. Here, we assumed that there was a boundary between the two- and three-disease cohorts that had some effect on good or poor SRH because the significant factors related to high medical expenses in the respondents with two diseases disappeared in the three-disease cohort. Yamada et al. reported that low SRH was associated with higher prevalence and worse laboratory values for hypertension, dyslipidemia, and diabetes mellitus [ 27 ]. The increase from two to three diseases in this study was an increase in one disease associated with low SRH, that is, the overlap of these diseases. Therefore, it is possible that the number of respondents with good SRH decreased or the number of those with poor SRH increased by increasing the number of respondents with three diseases from two diseases and the association between outpatient medical expenses of JPY 100,000 or more and SRH was no longer significant. On the other hand, in the groups with one and two diseases, the proportion of respondents with good SRH was high in the low-expense group with annual outpatient medical expenses less than JPY 100,000, indicating that even in those with one or two of hypertension, dyslipidemia, and/or diabetes mellitus, SRH was good if annual outpatient medical expenses remained below JPY 100,000. A previous longitudinal study using a combined database of medical checkup and receipts (i.e., medical fee statements billed to the health insurance association by medical institutions) data for approximately 220,000 people showed that 65% of those with hyperglycemia and 90% of those with hypertension who were found to have abnormalities during medical checkups did not receive subsequent medical examinations. In addition to low levels of hyperglycemia and hypertension and young age, the absence of comorbidities was a predictor of not seeking further medical advice [ 33 , 34 ]. Furthermore, the health belief model suggested that a low threat perception—a sense of crisis where things will not go well unless changes are made—may lead to a lack of medical consultation [ 35 ]. Threat perception requires recognition of both the sense that one is likely to develop a disease or complication (likelihood perception) and a sense that the consequences of developing a disease or complication will be serious (severity perception) [ 36 ]. Health guidance designed to help those who are already aware of their illness and have received medical care to understand the possibility of future illnesses and their severity along with providing methods to avoid these consequences is effective to increase the rate of medical consultation [ 35 ]. In the present study, it is possible that threat perception in the health belief model may have been low when medical expenses were within a certain level and when there were either no or only up to two comorbid lifestyle-related diseases, but this hypothesis requires further verification. In contrast, Ozasa reported that many of the adults receiving health checkups visited a medical institution [ 37 ], which is consistent with the view that having a chronic disease increases health consciousness and attention, while in this study it is possible that respondents with two diseases were also in relatively good health. In our study, it is possible that many respondents with two of the three diseases but outpatient medical expenses less than JPY 100,000 per year may have had good SRH, because living with the disease leads to a sense of health consciousness. However, those with hypertension, dyslipidemia, and/or diabetes mellitus, two of which are considered to risk factors for the development of ischemic heart disease and stroke, are at increased risk of developing complications and serious diseases as their condition progresses in the absence of lifestyle modifications in addition to managing blood pressure, lipid, and blood glucose levels. As the ratio of increase in outpatient medical expenses in this study was higher between the two- and three-disease cohorts than the one- and two-disease cohorts, from the perspective of optimizing outpatient medical expenses, it is recommended to provide disease management support to those with low outpatient medical expenses and one or two diseases in addition to support with lifestyle improvement. Effects of diabetes mellitus In the one-disease cohort, diabetes mellitus was significantly associated with outpatient medical expenses of JPY 100,000 or more. According to a survey on medical expenses for lifestyle-related diseases conducted by the Federation of Health Insurance Associations of Japan in 2000, diabetes mellitus accounted for 31.8% of medical outpatient medical expenses for 10 lifestyle-related diseases, with hypertension and dyslipidemia accounting for 25.3% and 18.2%, respectively [ 13 ]. According to the patient survey report in 2020, the outpatient visit rate by disease category was highest in the order hypertension, diabetes mellitus, and dyslipidemia among the three diseases examined in this study [ 30 ]. These data indicated that diabetes mellitus accounted for the second highest outpatient visit rate among the three diseases but the highest outpatient medical expenses. Consistent with the results of the present study, these data indicated that diabetes mellitus is likely to be associated with high outpatient medical expenditure. Diabetes mellitus requires stricter medication to control the disease and a number of restrictions on daily life, such as dietary restrictions, than hypertension and dyslipidemia. Furthermore, similar to the other two diseases, diabetes mellitus is a risk factor for ischemic heart disease and stroke, as well as for complications and serious illnesses, such as diabetic nephropathy and dialysis. In addition, a study on the outpatient consultation behavior of patients with lifestyle-related diseases, the proportion of those with diabetes who wish to see a specialist is high [ 38 ]. Therefore, we considered that having diabetes mellitus may lead to visits to multiple medical institutions, which may have an impact on outpatient medical expenses. In contrast, in the two-disease cohort, there was no significant relation between the presence or absence of diseases and outpatient medical expenses. That is, SRH, age, and number of years of education were more closely related to outpatient medical expenditure of JPY 100,000 or more than the type of disease, suggesting that an increase in the number of diseases may reduce the impact of diabetes mellitus on outpatient medical expenses. A study in a population of 180 men and women aged 65 years or older reported that a history of diabetes mellitus was associated with poor SRH [ 25 ]. The number of participants with three diseases was higher than the numbers with one or two diseases, which may have increased the rate of poor SRH in the present study. The three-disease cohort was considered to have an increased rate of poor SRH because they all had diabetes mellitus in contrast to the one- and two-disease cohorts. Therefore, diabetes mellitus may explain why there was no statistically significant association between outpatient medical expenses and SRH in the three-disease cohort in this study. Possible implications Participants with annual outpatient medical expenses less than JPY 100,000 (~ US $ 650) were more likely to have good SRH, even if they had one or two of hypertension, dyslipidemia, and/or diabetes mellitus. These observations indicated that poor SRH was associated with outpatient medical expenses of JPY 100,000 or more per year regardless of socioeconomic status. However, a group of respondents still reported good SRH despite having one or two of hypertension, dyslipidemia, and/or diabetes mellitus if their annual outpatient medical expenses were less than JPY 100,000. Therefore, it is possible that threat perception, an important factor facilitating healthy behaviors in the health belief model, was low in the group one- or two-disease cohorts with annual outpatient medical expenses less than JPY 100,000. Hypertension, dyslipidemia, and/or diabetes mellitus are associated with increased risk of serious illness, suggesting that they may be indicators of poor SRH. Our observations suggested that there may be a boundary between the two- and three-disease cohorts affecting whether SRH is favorable or unfavorable. SHCs identify individuals with hypertension, dyslipidemia, and diabetes mellitus who are premenopausal or at risk of developing these diseases and recommend that they visit a medical institution for follow-up. This may be a barrier to the prevention of serious illnesses. It appears necessary to actively motivate such individuals to maintain self-management and make lifestyle improvements even while receiving medical treatment. It is necessary to continue health guidance that includes prediction of potential disadvantages of living with hypertension, dyslipidemia, and/or diabetes mellitus, which are likely to overlap and lead to serious irreversible vascular diseases. Such continuous health guidance should be provided at outpatient clinics for those currently receiving medical care, with support at medical institutions being particularly important. Some municipalities are making pioneering efforts to increase the rate of SHCs in cooperation with medical institutions, and to link those who have interrupted treatment for lifestyle-related diseases with appropriate medical institutions to prevent the development of serious illness among those insured by the NHI system [ 39 ]. As insurers of the NHI system, municipalities should provide health guidance to support disease management and prevent progression to serious illness as well as share information with medical institutions even for patients currently receiving treatment for lifestyle-related diseases. In addition, the increase in outpatient medical expenses for the cohort with all the three diseases was greater than for the one- and two-disease cohorts. To optimize medical costs, it is necessary to focus on groups with one or two diseases and provide health guidance aimed at improving lifestyle and supporting disease management to prevent serious illnesses. This approach will extend the period during which people can live with a sense of health in the presymptomatic stage and will decrease the need for long-term care and outpatient medical expenses in the future. In the population with one disease in this study, diabetes mellitus was significantly associated with outpatient medical expenses of JPY 100,000 or more. As outpatients with type 2 diabetes mellitus require a medication adherence rate of 95% or higher to maintain good glycemic control [ 40 ], disease management—including adherence to medication—is particularly important for individuals with diabetes mellitus. Compared to hypertension and dyslipidemia, focused disease management support is particularly important for diabetes mellitus to prevent the development of severe disease. This study suggested that intensive support is needed for individuals with one or two of the three diseases, hypertension, dyslipidemia, and diabetes mellitus, and for those with diabetes mellitus. The application of the methods outlined here in clinical practice will lead to the optimization of NHI outpatient medical expenses. Limitations As the participants in this study were NHI subscribers aged 40–74 years, the results may to be generalizable to other populations with different characteristics or age distributions. In this study, we selected study participants who incurred outpatient medical expenses for any of three diseases, i.e., hypertension, dyslipidemia, and diabetes mellitus, so the effects of other diseases on our findings cannot be excluded. Therefore, differences in outpatient medical expenses cannot be attributed solely to the effects of these three diseases. The results were based on a self-administered survey using the KDB and questionnaires for a specific municipality, and regional characteristics must be taken into consideration for generalization of our observations. However, this study was significant in that it examined the relation between outpatient medical expenses and SRH by extracting those who actually incurred outpatient medical expenses for hypertension, dyslipidemia, and diabetes mellitus from the KDB and analyzing them in relation to the subjective questionnaire survey data. Conclusion A significant association was observed between high outpatient medical expenses and poor SRH in respondents with one or two of hypertension, dyslipidemia, and/or diabetes mellitus in the population covered by NHI. The number of diseases and the prevalence of diabetes mellitus may have influenced the observed associations. With regard to optimization of outpatient medical expenses, the results suggested that it is important to prevent diabetes mellitus, especially in patients with all three diseases, and to implement lifestyle improvement measures and support disease management to prevent serious illnesses in the population with one or two diseases including diabetes mellitus. Declarations Ethics approval and consent to participate The questionnaire was sent to the target population through the National Health Insurance and Health Promotion Division of Nagasaki Prefecture with a letter requesting research collaboration, and the return of the completed questionnaire was considered consent for participation. The matching list of ID numbers and KDB information was maintained by the National Health Insurance and Health Promotion Division of Nagasaki Prefecture and is inaccessible to researchers. This study was approved by the Ethics Committee of Nagasaki University Graduate School of Biomedical Sciences (approval number: 21061003). Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due protecting the privacy of participants but are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This work was supported by the Bureau of Public Health and Welfare of Nagasaki Prefecture and Grants-in-Aid for Scientific Research from the Japan Society for the Promotion of Science (grant number: 21K19655). Authors' contributions SK contributed to the conception, design and statistical analyses and drafted the manuscript for publication. OM, RN, SK and RK contributed to conceptualizing, designing, and revising the manuscript. All authors provided feedback and approved the final manuscript. Acknowledgements We appreciate all the study participants and the municipal offices of Shimabara City and Unzen City. We are also grateful to the Bureau of Public Health and Welfare Office of Nagasaki Prefecture and the Nagasaki National Health Insurance Organizations. The founders played no role in the analysis of the research and publication. References Kokubo Y, Kamide K, Okamura T, Watanabe M, Higashiyama A, Kawanishi K, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease in a Japanese urban cohort: the Suita Study. Hypertension. 2008;52:652–9. Kitamura A, Noda H, Nakamura M, Kiyama M, Okada T, Imano H, et al. Association between non-high-density lipoprotein cholesterol levels and the incidence of coronary heart disease among Japanese. J Atheroscler Thromb. 2011;18:454–63. Kadowaki S, Okamura T, Hozawa A, Kadowaki T, Kadota A, Murakami Y, et al. 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Goto J, Hosoya T, Kobayashi J, Kanoya Y. Factors associated with self-assessed health status of the elderly who participated in a health program. J Japan Acad Community Health Nurs. 2011;14:30–9. (in Japanese). Akatsuka E, Arimoto A, Tadaka E, Yuka D, Itoh E, Shiratani K, et al. Comparison with factors related to perceived health by sex among community-dwelling elderly in urban area. J Japan Acad Community Health Nurs. 2016;19:12–21. (in Japanese). Yamada C, Moriyama K, Takahashi E. Self-rated health as a comprehensive indicator of lifestyle-related health status. Environ Health Prev Med. 2012;17:457–62. World Health Organization. Health Promotion Glossary of Terms 2021. https://iris.who.int/bitstream/handle/10665/350161/9789240038349-eng.pdf?sequence=1 (accessed April 13, 2024). Taniguchi N, Katsura T, Hoshino A, Usui K. Comparison of QOL factors between so-called younger old and older old community residents. J Rural Med. 2013;62:91–105. (in Japanese). Unzen City. Unzen City National Health Insurance Second Term Insurance Project Implementation Plan and Third Term Specific Health Examination Implementation Plan 2018–2023. (in Japanese). Shimabara City. Shimabara City National Health Insurance Health Service Implementation Plan 2018–2023. (in Japanese). Ministry of Health, Labour and Welfare. Patient Survey 2020. (in Japanese) https://www.mhlw.go.jp/toukei/saikin/hw/kanja/20/index.html (accessed April 13, 2024). Tsujimura Y, Takahashi Y, Ishizaki T, Kuriyama A, Miyazaki K, Satoh T, et al. Predictors of hyperglycaemic individuals who do not follow up with physicians after screening in Japan: A cohort study. Diabetes Res Clin Pract. 2014;105:176–84. Fukuma S, Ikenoue T, Saito Y, Yamada Y, Saigusa Y, Misumi T, et al. Lack of a bridge between screening and medical management for hypertension: health screening cohort in Japan. BMC Public Health. 2020;20:1419–1419. Iso H. A study on verification of the effectiveness of health guidance programs based on a model for promoting medical treatment behavior for the prevention of severe lifestyle-related diseases in local governments. 2015. (in Japanese). Rosenstock IM. Historical origins of the health belief model. Health Educ Monogr. 1974;2:328–35. Ozasa K. Characteristics of participants in multiphasic health examination II. Japanese J Public Health. 1988;43:1004–12. (in Japanese). Takeda M, Hamano T, Kimura Y, Yamasaki M, Shiwaku K. Factors relating utilization of health care facilities in rural mountainous region. J Rural Med. 2014;62:929–40. (in Japanese). Oita Prefecture Council for Promotion of Appropriate Medical Expenses. Promotion of prevention of the onset and severity of lifestyle-related diseases FY2021. (in Japanese) https://www.pref.oita.jp/uploaded/life/2171801_3554784_misc.pdf (accessed April 13, 2024). Kuroda N, Eguchi J, Ashida M, Nakajima M, Wada J, Nakajima H. Medication adherence in patients with type 2 disease: investigations for association of medication adherence and glycemic control. J Japan Diab Soc. 2020;63:609–17. (in Japanese). Tables Tables 1-6 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files NagasakiPrefTables290424.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4471292","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308520900,"identity":"e5741923-841a-4167-b2f3-ee6982413df9","order_by":0,"name":"Sanai Kawasaki","email":"","orcid":"","institution":"Kamakura Public Health Office of Kanagawa Prefecture","correspondingAuthor":false,"prefix":"","firstName":"Sanai","middleName":"","lastName":"Kawasaki","suffix":""},{"id":308520901,"identity":"de63c00c-d441-460f-80fc-d242b498c4fd","order_by":1,"name":"Mayumi Ohnishi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIiWNgGAWjYFACHgaGBIYDPPxQrgEblMFMUItkA0laGBgOMBgcgGoh6Czd9t5jDx78uSNjfLv58Ysff+yM+Rh4DBh+1DCwm+PQYnbmXLpBYtszHrM7x8wse9uSzdiAWhh7jjEwWzbg0HIjx0wiseEwj9mNBDMD3gZmGzb5NwYMvA0MzDCnYtWS8Ocwj/GM9G+Gf/7U24Bt+UtQC9thHgOJHOPHPGyHwQ5jxmvLmTNAh7Ud5pG4kVPGLNt23JiNga3gsMwxCdx+Od5jJvnjz2F7/hnpmz+++VNtOL+BeePDNzU2ybhCDBmwScBYQCdJJBOOIWB8f0Dm2RGjZRSMglEwCkYEAAAPpVW+x1CeWwAAAABJRU5ErkJggg==","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Mayumi","middleName":"","lastName":"Ohnishi","suffix":""},{"id":308520902,"identity":"2e3bfaa7-67d4-4ece-a49d-7b739c34c0a6","order_by":2,"name":"Rieko Nakao","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Rieko","middleName":"","lastName":"Nakao","suffix":""},{"id":308520904,"identity":"25333c26-b48f-447c-adf1-1e63ae7d133d","order_by":3,"name":"Satoko Kosaka","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Satoko","middleName":"","lastName":"Kosaka","suffix":""},{"id":308520907,"identity":"953b17ea-675d-4f63-8445-efecfb347504","order_by":4,"name":"Ryoko Kawasaki","email":"","orcid":"","institution":"Nagasaki University Graduate School of Biomedical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ryoko","middleName":"","lastName":"Kawasaki","suffix":""}],"badges":[],"createdAt":"2024-05-24 09:00:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4471292/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4471292/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58146112,"identity":"4dcb9859-42d8-47cc-a4f0-30308e919270","added_by":"auto","created_at":"2024-06-11 18:34:53","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":772592,"visible":true,"origin":"","legend":"\u003cp\u003eExtraction of Study Participants for Analysis\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4471292/v1/ac3177fca997db726dd2020e.jpeg"},{"id":60827967,"identity":"e580e7ac-20c1-4669-a323-ae2764ca2813","added_by":"auto","created_at":"2024-07-22 14:25:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1402251,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4471292/v1/8fa58276-b605-4230-ac38-315c6569b3fc.pdf"},{"id":58147462,"identity":"802540e2-fd62-48be-aef0-c22a3f41c6fc","added_by":"auto","created_at":"2024-06-11 18:42:53","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":51341,"visible":true,"origin":"","legend":"","description":"","filename":"NagasakiPrefTables290424.docx","url":"https://assets-eu.researchsquare.com/files/rs-4471292/v1/ae526d8c5c5cfbf744bc6832.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Relation Between Outpatient Medical Expenses and Self-Rated Health in Patients With Hypertension, Dyslipidemia, and Diabetes Mellitus Covered by National Health Insurance","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHypertension, dyslipidemia, and diabetes mellitus are risk factors for cardiovascular diseases, such as ischemic heart disease and stroke [1\u0026ndash;5]. As these diseases are associated with the accumulation of excess visceral fat, they can be prevented or ameliorated by changes in lifestyle [6]. The prevalence of lifestyle-related diseases\u0026mdash;defined as diseases in which onset and progression are related to lifestyle factors, such as eating habits, exercise, sleep, smoking, and alcohol consumption\u0026mdash;increases with age, especially around the age of 40 years [7].\u003c/p\u003e\n\u003cp\u003eSpecific health checkups (SHCs) and specific health guidance (SHG) for individuals in the population aged 40\u0026ndash;74 years have been covered by health insurance since 2008 in Japan as part of a health policy aimed toward the early detection and prevention of severe lifestyle-related diseases. The target population of SHG for lifestyle improvement has been stratified and selected according to the results of SHCs to provide individualized SHG. The criteria for stratification of SHG include hypertension, dyslipidemia, and diabetes mellitus, and those at risk of visceral fat accumulation and who have at least one of these diseases are eligible for SHG by public health nurses (PHNs) [8]. Hypertension, dyslipidemia, and diabetes mellitus are associated with increased risk of cardiovascular diseases, such as ischemic heart disease and stroke [9]. Furthermore, diabetes mellitus is associated with vascular complications of persistent poor glycemic control due to hyperglycemia, resulting in irreversible lesions, such as fundus hemorrhage, uremia, neuropathy, and diabetic nephropathy, which can lead to limb amputation as a result of peripheral neuropathy and the requirement for artificial dialysis due to diabetic nephropathy [10]. Therefore, it is important to implement suitable interventions for these diseases at the stage of reversible lesions to improve lifestyle and prevent serious complications with serious adverse effects on quality of life (QoL).\u003c/p\u003e\n\u003cp\u003eThe stratification criteria for SHG were selected for subjects with prediabetes (i.e., with fasting blood glucose level 100\u0026ndash;109 mg/dL or HbA1c 5.6%\u0026ndash;5.9%) to allow intervention before the onset of diabetes mellitus or during the period when lesions are still reversible. Those already receiving treatment for diabetes mellitus are also included in the stratification criteria and require support at early stages of changes in the disease status. Therefore, national and local governments, which implement National Health Insurance (NHI) in Japan, should not only identify individuals in the population who require treatment in the SHC and provide referrals for appropriate medical care but also collaborate with medical institutions for those with at least one of the three diseases outlined above to achieve lifestyle improvements in terms of appropriate control of blood pressure, lipid, and blood glucose levels. Patients require support to prevent progression to ischemic heart disease, stroke, diabetic nephropathy, and dialysis, as well as to reduce the severity of these diseases [11].\u003c/p\u003e\n\u003cp\u003eLifestyle-related diseases accounted for approximately 60% of deaths and 30% of medical expenses from all causes in Japan in 2014 [12]. A survey on medical expenses for lifestyle-related diseases conducted by the Federation of Health Insurance Associations in fiscal year (FY) 2019 indicated that cerebrovascular disorders, ischemic heart disease, and dialysis accounted for 37.1%, 28.4%, and 9.2% of medical expenses associated with hospitalizations for 10 lifestyle-related diseases, respectively, together corresponding tomore than 70% of the total inpatient medical expenses [13]. Diabetes mellitus, hypertension, dyslipidemia, and dialysis represented 31.8%, 25.3%, 18.2%, and 16.4% of total outpatient medical expenses, respectively, together accounting for more than 90% of the total.\u003c/p\u003e\n\u003cp\u003eAs the data outlined above indicate that lifestyle-related diseases, such as hypertension, dyslipidemia, diabetes mellitus, ischemic heart disease, cerebrovascular disease, and dialysis, account for a large proportion of medical expenses, it is important to adopt measures for preventing their onset and progression from the viewpoint of optimizing medical costs. Under the \u003cem\u003eAct on Securing Medical Care for Older Persons\u003c/em\u003e, optimization of medical expenses is an important issue, and early prevention of ischemic heart disease, stroke, diabetic nephropathy, etc., through the promotion of SHC and SHG is the objective of the third phase (FY 2018\u0026ndash;2023) of the Medical Cost Optimization Plan [14]. Preventing these diseases and optimizing future medical costs represent ongoing challenges for municipal governments in Japan. Based on receipts for patients aged 65 years or older in two prefectures, Sasaki\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e reported that higher annual medical costs were associated with individuals with more comorbid diseases [15]. A study on medical expenses and lifestyle-related diseases reported that hypertension and diabetes mellitus are associated with high total medical expenses [16], and that outpatient medical expenses for these two diseases are positively correlated with aging of the population [17]. Furthermore, higher outpatient medical expenses were shown to be associated with a history of heart disease and stroke [18].\u003c/p\u003e\n\u003cp\u003eDue to the severity of hypertension, dyslipidemia, and diabetes mellitus, the development of cardiovascular diseases and diabetic nephropathy, such as ischemic heart disease and stroke, are factors in reduced activities of daily living and the requirement for nursing care [19]. Therefore, it is important for municipal governments to implement measures to prevent the onset of hypertension, dyslipidemia, and diabetes mellitus and thus optimize medical costs as these affect the maintenance of residents\u0026rsquo; QoL and long-term care insurance premiums. Furthermore, it has been suggested that municipal PHNs should actively intervene and work to not only support lifestyle improvement and thus prevent the onset of lifestyle-related diseases but also to prevent progression to serious conditions after such diseases have developed [11].\u003c/p\u003e\n\u003cp\u003eThe extension of healthy life expectancy in the Japanese population is a major theme of the Strategic Market Creation Plan as part of the Revitalization Strategy for Japan announced by the government of Japan in 2013. As part of the creation of a new framework for the promotion of health management and disease prevention, \u0026ldquo;all health insurance associations are required to analyze data, including receipts, prepare and publish data health plans as business plans for the maintenance and promotion of health of their members based on such data, implement and evaluate such plans, and promote the implementation of similar initiatives by municipal NHI associations\u0026rdquo; [20]. Municipal governments are required to use health and medical-related databases, including the NHI\u0026nbsp;Kokuho Database (KDB), and implement effective and efficient health projects. As\u0026nbsp;KDB\u0026nbsp;supports the preparation and implementation of health project plans by NHI [21], this study utilized data from this database to evaluate municipal governmental health promotion programs.\u003c/p\u003e\n\u003cp\u003eSelf-rated health (SRH) has been reported to be a useful predictor of life expectancy [22, 23] and is also considered a predictive indicator of the degree of care required in Japan [24]. As it is a subjective rather than an objective measure of health status, SRH is commonly used to evaluate an individual\u0026rsquo;s overall health status. Although SRH has been suggested to be independent of the presence or absence of disease, a previous study suggested an association with a history of heart disease [25]. In addition, higher SRH has been shown to be associated with younger age and higher socioeconomic status [26].\u003c/p\u003e\n\u003cp\u003eSRH has been reported to be lower among people with diseases undergoing treatment or in hospital compared to those free from disease [26], and Yamada\u003cem\u003e\u0026nbsp;et al.\u003c/em\u003e reported that hypertension, dyslipidemia, and diabetes mellitus were associated with significantly reduced SRH [27]. Therefore, while it has been reported that disease is associated with poor SRH, the World Health Organization (WHO) defines \u0026ldquo;health\u0026rdquo; as \u0026ldquo;A state of complete physical, social, and mental well-being, and not merely the absence of disease or infirmity\u0026rdquo; [28]. High SRH has been shown to be important for QoL [29]. It is important for individuals to feel fulfilled even when they are ill, but given the high prevalence of lifestyle-related diseases (hypertension, dyslipidemia, diabetes mellitus, etc.), it is often difficult to evaluate the health of an individual based on medical indicators alone.\u003c/p\u003e\n\u003cp\u003eThis study was therefore performed to clarify the relation between subjective SRH and objective outpatient medical expenses in the population with hypertension, dyslipidemia, and diabetes mellitus.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis cross-sectional study was conducted from June to August 2021 using the responses to the\u0026nbsp;anonymous self-administered\u003cem\u003e\u0026nbsp;Nagasaki Prefectural Citizen\u0026rsquo;s Health Survey\u003c/em\u003e administered\u0026nbsp;by mail in Unzen and Shimabara cities among those aged 40\u0026ndash;74 years\u0026nbsp;covered by\u0026nbsp;NHI as well as data from the KDB for both cities from FY 2020.\u003c/p\u003e\n\u003ch2\u003eStudy variables\u003c/h2\u003e\n\u003cp\u003eThe\u0026nbsp;variables\u0026nbsp;examined in this study included annual outpatient medical expenses, SRH, age, sex, cohabitation/family structure, number of years of education, employment status, and current medical history. Data regarding SRH, cohabitation/family structure, number of years of education, employment status, and subjective socioeconomic status were obtained from the \u003cem\u003eNagasaki Prefectural Citizen\u0026rsquo;s Health Survey\u003c/em\u003e. SRH was divided into four categories (\u003cem\u003every healthy\u003c/em\u003e, \u003cem\u003ehealthy\u003c/em\u003e, \u003cem\u003enot so healthy\u003c/em\u003e, or \u003cem\u003enot healthy\u003c/em\u003e) in response to the question, \u0026ldquo;How do you feel about your health in general?\u0026rdquo; Respondents indicated the presence or absence of a cohabitant by selecting from multiple responses: \u003cem\u003esingle\u003c/em\u003e, \u003cem\u003espouse\u003c/em\u003e, \u003cem\u003echildren\u003c/em\u003e, \u003cem\u003eparents\u003c/em\u003e, \u003cem\u003egrandchildren\u003c/em\u003e, or \u003cem\u003eother\u003c/em\u003e. Number of years of education was classified as follows: \u003cem\u003eless than 6 years\u003c/em\u003e, \u003cem\u003e6\u003c/em\u003e\u0026ndash;\u003cem\u003e9 years\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e\u0026ndash;\u003cem\u003e12 years\u003c/em\u003e, \u003cem\u003e13 years or more\u003c/em\u003e, or \u003cem\u003eother\u003c/em\u003e. Employment status was selected from the following options: \u003cem\u003efishing\u003c/em\u003e, \u003cem\u003eagriculture\u003c/em\u003e, \u003cem\u003emanufacturing\u003c/em\u003e, \u003cem\u003eservice worker\u003c/em\u003e, \u003cem\u003ehomemaker\u003c/em\u003e, \u003cem\u003eunemployed\u003c/em\u003e, or \u003cem\u003eother\u003c/em\u003e. Respondents selected from five options (\u003cem\u003edifficult\u003c/em\u003e, \u003cem\u003esomewhat\u003c/em\u003e \u003cem\u003edifficult\u003c/em\u003e, \u003cem\u003efair\u003c/em\u003e, \u003cem\u003esomewhat comfortable\u003c/em\u003e, and \u003cem\u003ecomfortable\u003c/em\u003e) in response to the question, \u0026ldquo;What is your economic condition?\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData regarding annual outpatient medical expenses, current medical history, age, and sex were obtained from the KDB. Outpatient medical expenses referred to the total cost of visits to medical institutions for treatment of injuries and illnesses. Current medical history included data on 19 diseases: diabetes mellitus, hypertension, dyslipidemia, gout and hyperuricemia, fatty liver, musculoskeletal diseases, other cardiovascular diseases, diabetic nephropathy, chronic renal failure, nondiabetic renal diseases, chronic obstructive pulmonary disease, pneumonia, other functional decline-related diseases, cancer, dementia, depression, schizophrenia, dialysis, and peritoneal perfusion.\u003c/p\u003e\n\u003ch2\u003eStudy areas\u003c/h2\u003e\n\u003cp\u003eUnzen City and Shimabara City are located on the Shimabara Peninsula in southeastern Nagasaki Prefecture, Japan. Unzen City faces the Ariake Sea in the north and Tachibana Bay in the west, and is situated around Mt. Unzen. Shimabara City has gently sloping terrain from the mountains of Heiseishinzan and Mayuyama in the central part of the city to the coastal area facing the Ariake Sea with an active tourism industry. According to the census conducted in 2015, the population of both cities is approximately 45,000. Both cities have an aging population of approximately 32%, which is higher than the average of approximately 29.6% in Nagasaki Prefecture [30, 31].\u003c/p\u003e\n\u003ch2\u003eNagasaki Prefectural Citizen\u0026rsquo;s Health Survey respondents (Figure 1)\u003c/h2\u003e\n\u003cp\u003eIn the \u003cem\u003eNagasaki\u003c/em\u003e \u003cem\u003ePrefectural Citizen\u0026rsquo;s Health Survey\u003c/em\u003e, questionnaires were sent to a randomly selected sample (4943 in Unzen City and 4857 in Shimabara City) of NHI subscribers (aged 40\u0026ndash;74 years) as of June 2021, of which 50% were stratified according to sex and age group. A total of 3509 people responded to the questionnaire, consisting of 1625 in Unzen City (35.5% response rate) and 1884 in Shimabara City (39.2% response rate). The collected questionnaire responses and KDB data were matched by ID numbers provided by the National Health Insurance and Health Promotion Division of Nagasaki Prefecture. The data were managed by ID number after removal of confidential information, such as name and birth date. Responses with missing values for the variables used in this study were excluded. This study was based on data from respondents with one or more of hypertension, dyslipidemia, and/or diabetes mellitus. Finally, to focus on those who incurred outpatient medical expenses for the three diseases examined in this study, we excluded patients with cancer, mental disorders (depression and schizophrenia), diabetic nephropathy, and dialysis, all of which are already considered to be severe and to be associated with high medical expenditure, such as annual outpatient medical expenses of JPY 1 million (~US $6500) or more. A total of 1395 participants from the two cities were included in the analysis.\u003c/p\u003e\n\u003ch2\u003eStatistical analysis\u003c/h2\u003e\n\u003cp\u003eAs the overlap of hypertension, dyslipidemia, and diabetes mellitus is considered to be associated with a high risk of serious illness, the study population was divided into three groups: the one-disease cohort consisting of participants with only one of the three diseases; the two-disease cohort comprised of those with two of the three diseases; and the three-disease cohort consisting of those with all three diseases. The relation between SRH and annual outpatient medical expenses was analyzed for each of these three groups.\u003c/p\u003e\n\u003cp\u003eThe study population was divided into two groups according to SRH for statistical analysis: the good health group consisting of participants who reported being \u003cem\u003every healthy\u003c/em\u003e or \u003cem\u003ehealthy\u003c/em\u003e; and the poor health group comprised of those with SRH of \u003cem\u003enot so\u003c/em\u003e \u003cem\u003ehealthy\u003c/em\u003e or \u003cem\u003enot healthy\u003c/em\u003e. Subjective economic status was classified into three categories: comfortable consisting of \u003cem\u003ecomfortable\u003c/em\u003e and \u003cem\u003esomewhat comfortable\u003c/em\u003e; fair; and difficult comprised of \u003cem\u003edifficult\u003c/em\u003e and \u003cem\u003esomewhat difficult\u003c/em\u003e. With regard to the presence or absence of a cohabitant, no cohabitant was defined as \u003cem\u003eliving alone\u003c/em\u003e, and other responses were defined as \u003cem\u003eliving with someone\u003c/em\u003e. The study population was divided according to the number of years of education as follows: less than 9 years, consisting of those with \u0026ldquo;\u003cem\u003eless than 6 years\u003c/em\u003e\u0026rdquo; or \u0026ldquo;\u003cem\u003e6\u003c/em\u003e\u0026ndash;\u003cem\u003e9 years\u003c/em\u003e\u0026rdquo; of education; 10\u0026ndash;12 years; and 13 years or more. With regard to employment status, those who answered \u003cem\u003efishing\u003c/em\u003e, \u003cem\u003eagriculture\u003c/em\u003e, \u003cem\u003emanufacturing\u003c/em\u003e, and \u003cem\u003eservice worker\u003c/em\u003e were classified as working, while all other responses were classified as not working.\u003c/p\u003e\n\u003cp\u003eThe summary of outpatient medical expenses and distribution of diseases was subjected to descriptive statistical analysis. One-way analysis of variance (ANOVA) and the chi-square test were conducted for analysis of sociodemographic variables and SRH. Annual outpatient medical expenses were divided into two groups: the high-expense group with a median of JPY 100,000 or more; and the low-expense group with a median of less than JPY 100,000. Univariate analysis was conducted using the \u003cem\u003et\u003c/em\u003e test and chi-square test, with outpatient medical expenses as the dependent variable in each group according to sociodemographic variables and SRH. Logistic regression analysis with outpatient medical expenses was also performed using independent variables, including age, sex, cohabitation/family structure, number of years of education, employment status, subjective economic status, and SRH. Logistic regression analyses to evaluate the\u0026nbsp;association between high outpatient medical expenses and\u0026nbsp;presence of\u0026nbsp;diseases, including hypertension, dyslipidemia, and diabetes mellitus, were conducted according to disease cohort. Statistical analyses were performed using IBM SPSS Statistics ver. 28 (IBM, Armonk, NY, USA), and \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05 was taken to indicate statistical significance.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eBackground information of study participants\u003c/h2\u003e\n\u003cp\u003eTable\u0026nbsp;1\u0026nbsp;presents background information of the study\u0026nbsp;participants.\u0026nbsp;The study\u0026nbsp;population\u0026nbsp;was divided into the one-disease cohort consisting of 590 participants, the two-disease cohort consisting of 555 participants, and the three-disease cohort consisting of 250 participants. These groups had median outpatient medical expenses of JPY 89,685 (~US $580), JPY 102,220 (~US $660), and JPY 130,960 (~US $850), respectively. The first quartiles for the one-, two-, and three-disease cohorts were JPY 56,827 (~US $370), JPY 68,340 (~US 440), and JPY 84,865 (~US $550), respectively. The third quartiles were JPY 144,605 (~US $935), JPY 157,590 (~US $1000), and JPY 210,837 (~US $1365), respectively.\u003c/p\u003e\n\u003cp\u003eIn the one-disease cohort, 319 participants (54.1%) had hypertension, 205 (34.7%) had dyslipidemia, and 66 (11.2%) had diabetes mellitus. In the two-disease cohort, 355 participants (64.0%) had hypertension and dyslipidemia, 85 (15.3%) had hypertension and diabetes mellitus, and 115 (20.7%) had dyslipidemia and diabetes mellitus.\u003c/p\u003e\n\u003cp\u003eThere were no significant relations in socioeconomic status of the study participants in terms of age, cohabitation status, number of years of education, employment status, or subjective economic status between one-, two, and three-disease cohorts, but there were significant differences in sex and SRH according to number of diseases (both \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01) (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAssociations between outpatient medical expenses, socioeconomic status, and self-rated health\u003c/h2\u003e\n\u003cp\u003eOutpatient medical expenses\u0026nbsp;were low in 325 participants and high in 265 participants in the one-disease cohort, 268 and 287 participants, respectively, in the two-disease cohort, and 81 and 169 participants, respectively, in the three-disease cohort. participants tended to be older in the high-expense group than in the low-expense group in all disease groups, and the difference in age between the low- and high-expense groups was statistically significant in the two-disease cohort (\u003cem\u003eP\u003c/em\u003e = 0.03). There was also a statistically significant difference in number of years of education between the low- and high-expense groups for the two-disease cohort (\u003cem\u003eP\u003c/em\u003e = 0.02), with a greater proportion of participants in the low-expense group having 10\u0026ndash;12 years of education. SRH showed a significant difference between the low- and high-income groups in the one- and two-disease cohorts (both \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01), with a higher proportion of those in the high-income group reporting poor SRH. There were no significant differences between the high- and low-expense groups for all disease cohorts in terms of sex, presence of a cohabitant, employment status, and subjective economic status\u0026nbsp;(Table 3).\u003c/p\u003e\n\u003ch2\u003eFactors associated with high outpatient medical expenses group\u003c/h2\u003e\n\u003cp\u003eLogistic regression analysis with high medical expenses as the dependent variable and adjustment for socioeconomic status (age, sex, presence of cohabitant, number of years of education, employment status, and subjective economic status) showed that the probability of being in the self-rated poor health group was significantly higher for those with high medical expenses in the one- and two-disease cohorts (one-disease, AOR, 2.41, 95% CI, 1.60\u0026ndash;3.61; two-disease, AOR, 2.20, 95% CI, 1.41\u0026ndash;3.43). However, there was no significant association of subjective poor health with high medical expenses in the three-disease cohort (Table 4).\u003c/p\u003e\n\u003ch2\u003eAssociation between presence of each disease and high outpatient medical expenses\u003c/h2\u003e\n\u003cp\u003eLogistic regression analyses were performed in the one- and two-disease cohorts by adjusting for the presence or absence of hypertension, dyslipidemia, and/or diabetes mellitus (Tables 5 and 6). In the one-disease cohort, adjustment for hypertension was added to Model 1-1, for dyslipidemia to Model 1-2, and for diabetes mellitus to Model 1-3. In the one-disease cohort, only diabetes mellitus (Model 1-3) was significantly associated with higher outpatient medical expenses (AOR, 2.63, 95% CI, 1.50\u0026ndash;4.63). In the two-disease cohort, neither condition was significantly associated with higher outpatient medical expenses.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study population consisted of local residents aged 40\u0026ndash;74 years who responded to the \u003cem\u003eNagasaki Prefectural Citizen\u0026rsquo;s Health Survey\u003c/em\u003e questionnaire and incurred outpatient medical expenses for at least one of three diseases, i.e., hypertension, dyslipidemia, and/or diabetes mellitus. In univariate analysis, outpatient medical expenses were significantly associated with SRH in the one- or two-disease cohorts. Logistic regression analysis adjusted for variables of socioeconomic status, including age, sex, cohabitation/family structure, number of years of education, employment status, and subjective economic status, showed that SRH was significantly associated with high annual outpatient medical expenses of JPY 100,000 or more in the one- or two-disease cohorts.\u003c/p\u003e\n\u003ch3\u003eDistribution of outpatient medical expenses and hypertension, dyslipidemia, and diabetes mellitus\u003c/h3\u003e\n\u003cp\u003eThe difference in the first quartile of outpatient medical expenses between the one- and two-disease cohorts was approximately JPY 12,000, whereas the difference between the two- and three-disease cohorts was approximately JPY 17,000. The difference in the third quartile was approximately JPY 13,000 between the one- and two-disease cohorts and approximately JPY 53,000 between the two- and three-disease cohorts, indicating that greater number of diseases was associated with higher outpatient medical expenses in the three-disease cohort. The ratio of increase in outpatient medical expenses for the three-disease cohort was greater than for the one- and two-disease cohorts. As mentioned in the Introduction, hypertension, dyslipidemia, and diabetes mellitus interact with each other and increase the risk of severe cerebrovascular disease. Therefore, the overlap of the three diseases is expected to increase not only the severity of each disease but also the risk of developing irreversible vascular damage, which may have an impact on outpatient medical expenses. In addition, the presence of more than one disease may result in visits to multiple medical departments, which may influence the outpatient medical expenses.\u003c/p\u003e \u003cp\u003eAccording to a patient survey report in 2020 by the Ministry of Health, Labour and Welfare, the total numbers of outpatients by disease category per 100,000 population were 471 for hypertension, 122 for dyslipidemia, and 170 for diabetes mellitus [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Hypertension is the most common disease among outpatients, followed by diabetes mellitus and dyslipidemia. The distribution of diseases in this study was approximately 50% hypertension, 40% dyslipidemia, and 10% diabetes mellitus. The proportions of participants with dyslipidemia and diabetes mellitus were reversed compared with the patient survey report in 2020. The high rate of dyslipidemia in the present study may have been influenced by the fact that the most common combination of diseases was hypertension and dyslipidemia, accounting for approximately 60% of cases, even in the two-disease cohort with overlapping diseases. The rates of diabetes mellitus were approximately 10% in the one-disease cohort and approximately 40% in the two-disease cohort.\u003c/p\u003e\n\u003ch3\u003eDistribution of self-rated health\u003c/h3\u003e\n\u003cp\u003eIn this study, the proportion of participants who responded that they were \u003cem\u003every healthy\u003c/em\u003e or \u003cem\u003ehealthy\u003c/em\u003e was high in all disease cohorts, with about 80% of those in the one- and two-disease cohorts and about 70% of those in the three-disease cohort having good SRH. In a previous study of healthy older people (mean age: men, 73.3 \u0026plusmn; 4.5 years, women, 72.2 \u0026plusmn; 5.1 years) living in the community, 81.1% had good SRH and 18.9% had poor SRH [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], which was similar to the distribution of SRH in the one- and two-disease cohorts in the present study. The mean age of the study participants with up to two diseases in this study was the late 60s, which was younger than in the previous study, but the distribution of SRH was similar to that of healthy older study participants. However, the three-disease cohort showed a significant increase in the proportion of respondents with poor SRH in comparison to the one- and two-disease cohorts, suggesting that the need for medical examinations for hypertension, dyslipidemia, and diabetes mellitus, all of which are risk factors for ischemic heart disease and stroke, may be a factor in the perception of subjective poor health.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAssociation between outpatient medical expenses and self-rated health\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eCharacteristics of the one-, two-, and three-disease cohorts\u003c/h2\u003e \u003cp\u003eIn this study, the variables that were significantly associated with outpatient medical expenses of JPY 100,000 or more were age and number of years of education in the two-disease cohort and SRH in the one- and two-disease cohort. The results adjusted for age, sex, cohabitation/family structure, number of years of education, employment status and subjective economic status were also significantly associated with outpatient medical expenses of JPY 100,000 or more in the two-disease cohort, and those with outpatient medical expenses of JPY 100,000 or more in the one-disease and two-disease cohorts showed a significant increase in SRH in comparison to those with outpatient medical expenses less than JPY 100,000 in the one- and two-disease cohorts. The probability of having poor SRH was significantly higher for those with outpatient medical costs of JPY 100,000 or more compared to those with medical expenditure below this level. On the other hand, in the three-disease cohort, there was no significant association between SRH and outpatient medical expenses of JPY 100,000 or more even after adjusting for age, sex, presence of a cohabitant, number of years of education, employment status, and subjective economic status. The results indicated that participants with medical costs of JPY 100,000 or more in the two-disease cohort included a higher percentage of those with poor SRH, older age, and more than 13 years of education. Older age has been reported to be associated with higher medical expenses [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and age was also considered to be associated with outpatient medical expenses of JPY 100,000 or more in the present study. Participants with a greater number of years of education (13 years or more) were more likely to actively seek medical care when an abnormality was identified on a medical checkup, and we speculated that this was likely related to outpatient medical expenses of JPY 100,000 or more in the present study.\u003c/p\u003e \u003cp\u003eHere, we assumed that there was a boundary between the two- and three-disease cohorts that had some effect on good or poor SRH because the significant factors related to high medical expenses in the respondents with two diseases disappeared in the three-disease cohort. Yamada \u003cem\u003eet al.\u003c/em\u003e reported that low SRH was associated with higher prevalence and worse laboratory values for hypertension, dyslipidemia, and diabetes mellitus [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The increase from two to three diseases in this study was an increase in one disease associated with low SRH, that is, the overlap of these diseases. Therefore, it is possible that the number of respondents with good SRH decreased or the number of those with poor SRH increased by increasing the number of respondents with three diseases from two diseases and the association between outpatient medical expenses of JPY 100,000 or more and SRH was no longer significant.\u003c/p\u003e \u003cp\u003eOn the other hand, in the groups with one and two diseases, the proportion of respondents with good SRH was high in the low-expense group with annual outpatient medical expenses less than JPY 100,000, indicating that even in those with one or two of hypertension, dyslipidemia, and/or diabetes mellitus, SRH was good if annual outpatient medical expenses remained below JPY 100,000. A previous longitudinal study using a combined database of medical checkup and receipts (i.e., medical fee statements billed to the health insurance association by medical institutions) data for approximately 220,000 people showed that 65% of those with hyperglycemia and 90% of those with hypertension who were found to have abnormalities during medical checkups did not receive subsequent medical examinations. In addition to low levels of hyperglycemia and hypertension and young age, the absence of comorbidities was a predictor of not seeking further medical advice [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Furthermore, the health belief model suggested that a low threat perception\u0026mdash;a sense of crisis where things will not go well unless changes are made\u0026mdash;may lead to a lack of medical consultation [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Threat perception requires recognition of both the sense that one is likely to develop a disease or complication (likelihood perception) and a sense that the consequences of developing a disease or complication will be serious (severity perception) [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Health guidance designed to help those who are already aware of their illness and have received medical care to understand the possibility of future illnesses and their severity along with providing methods to avoid these consequences is effective to increase the rate of medical consultation [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In the present study, it is possible that threat perception in the health belief model may have been low when medical expenses were within a certain level and when there were either no or only up to two comorbid lifestyle-related diseases, but this hypothesis requires further verification.\u003c/p\u003e \u003cp\u003eIn contrast, Ozasa reported that many of the adults receiving health checkups visited a medical institution [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], which is consistent with the view that having a chronic disease increases health consciousness and attention, while in this study it is possible that respondents with two diseases were also in relatively good health. In our study, it is possible that many respondents with two of the three diseases but outpatient medical expenses less than JPY 100,000 per year may have had good SRH, because living with the disease leads to a sense of health consciousness. However, those with hypertension, dyslipidemia, and/or diabetes mellitus, two of which are considered to risk factors for the development of ischemic heart disease and stroke, are at increased risk of developing complications and serious diseases as their condition progresses in the absence of lifestyle modifications in addition to managing blood pressure, lipid, and blood glucose levels. As the ratio of increase in outpatient medical expenses in this study was higher between the two- and three-disease cohorts than the one- and two-disease cohorts, from the perspective of optimizing outpatient medical expenses, it is recommended to provide disease management support to those with low outpatient medical expenses and one or two diseases in addition to support with lifestyle improvement.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEffects of diabetes mellitus\u003c/h2\u003e \u003cp\u003eIn the one-disease cohort, diabetes mellitus was significantly associated with outpatient medical expenses of JPY 100,000 or more. According to a survey on medical expenses for lifestyle-related diseases conducted by the Federation of Health Insurance Associations of Japan in 2000, diabetes mellitus accounted for 31.8% of medical outpatient medical expenses for 10 lifestyle-related diseases, with hypertension and dyslipidemia accounting for 25.3% and 18.2%, respectively [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. According to the patient survey report in 2020, the outpatient visit rate by disease category was highest in the order hypertension, diabetes mellitus, and dyslipidemia among the three diseases examined in this study [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These data indicated that diabetes mellitus accounted for the second highest outpatient visit rate among the three diseases but the highest outpatient medical expenses. Consistent with the results of the present study, these data indicated that diabetes mellitus is likely to be associated with high outpatient medical expenditure. Diabetes mellitus requires stricter medication to control the disease and a number of restrictions on daily life, such as dietary restrictions, than hypertension and dyslipidemia. Furthermore, similar to the other two diseases, diabetes mellitus is a risk factor for ischemic heart disease and stroke, as well as for complications and serious illnesses, such as diabetic nephropathy and dialysis. In addition, a study on the outpatient consultation behavior of patients with lifestyle-related diseases, the proportion of those with diabetes who wish to see a specialist is high [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Therefore, we considered that having diabetes mellitus may lead to visits to multiple medical institutions, which may have an impact on outpatient medical expenses. In contrast, in the two-disease cohort, there was no significant relation between the presence or absence of diseases and outpatient medical expenses. That is, SRH, age, and number of years of education were more closely related to outpatient medical expenditure of JPY 100,000 or more than the type of disease, suggesting that an increase in the number of diseases may reduce the impact of diabetes mellitus on outpatient medical expenses. A study in a population of 180 men and women aged 65 years or older reported that a history of diabetes mellitus was associated with poor SRH [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The number of participants with three diseases was higher than the numbers with one or two diseases, which may have increased the rate of poor SRH in the present study. The three-disease cohort was considered to have an increased rate of poor SRH because they all had diabetes mellitus in contrast to the one- and two-disease cohorts. Therefore, diabetes mellitus may explain why there was no statistically significant association between outpatient medical expenses and SRH in the three-disease cohort in this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePossible implications\u003c/h2\u003e \u003cp\u003eParticipants with annual outpatient medical expenses less than JPY 100,000 (~\u0026thinsp;US \u003cspan\u003e$\u003c/span\u003e650) were more likely to have good SRH, even if they had one or two of hypertension, dyslipidemia, and/or diabetes mellitus. These observations indicated that poor SRH was associated with outpatient medical expenses of JPY 100,000 or more per year regardless of socioeconomic status. However, a group of respondents still reported good SRH despite having one or two of hypertension, dyslipidemia, and/or diabetes mellitus if their annual outpatient medical expenses were less than JPY 100,000. Therefore, it is possible that threat perception, an important factor facilitating healthy behaviors in the health belief model, was low in the group one- or two-disease cohorts with annual outpatient medical expenses less than JPY 100,000. Hypertension, dyslipidemia, and/or diabetes mellitus are associated with increased risk of serious illness, suggesting that they may be indicators of poor SRH. Our observations suggested that there may be a boundary between the two- and three-disease cohorts affecting whether SRH is favorable or unfavorable. SHCs identify individuals with hypertension, dyslipidemia, and diabetes mellitus who are premenopausal or at risk of developing these diseases and recommend that they visit a medical institution for follow-up. This may be a barrier to the prevention of serious illnesses. It appears necessary to actively motivate such individuals to maintain self-management and make lifestyle improvements even while receiving medical treatment. It is necessary to continue health guidance that includes prediction of potential disadvantages of living with hypertension, dyslipidemia, and/or diabetes mellitus, which are likely to overlap and lead to serious irreversible vascular diseases. Such continuous health guidance should be provided at outpatient clinics for those currently receiving medical care, with support at medical institutions being particularly important. Some municipalities are making pioneering efforts to increase the rate of SHCs in cooperation with medical institutions, and to link those who have interrupted treatment for lifestyle-related diseases with appropriate medical institutions to prevent the development of serious illness among those insured by the NHI system [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. As insurers of the NHI system, municipalities should provide health guidance to support disease management and prevent progression to serious illness as well as share information with medical institutions even for patients currently receiving treatment for lifestyle-related diseases.\u003c/p\u003e \u003cp\u003eIn addition, the increase in outpatient medical expenses for the cohort with all the three diseases was greater than for the one- and two-disease cohorts. To optimize medical costs, it is necessary to focus on groups with one or two diseases and provide health guidance aimed at improving lifestyle and supporting disease management to prevent serious illnesses. This approach will extend the period during which people can live with a sense of health in the presymptomatic stage and will decrease the need for long-term care and outpatient medical expenses in the future.\u003c/p\u003e \u003cp\u003eIn the population with one disease in this study, diabetes mellitus was significantly associated with outpatient medical expenses of JPY 100,000 or more. As outpatients with type 2 diabetes mellitus require a medication adherence rate of 95% or higher to maintain good glycemic control [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], disease management\u0026mdash;including adherence to medication\u0026mdash;is particularly important for individuals with diabetes mellitus. Compared to hypertension and dyslipidemia, focused disease management support is particularly important for diabetes mellitus to prevent the development of severe disease.\u003c/p\u003e \u003cp\u003eThis study suggested that intensive support is needed for individuals with one or two of the three diseases, hypertension, dyslipidemia, and diabetes mellitus, and for those with diabetes mellitus. The application of the methods outlined here in clinical practice will lead to the optimization of NHI outpatient medical expenses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eAs the participants in this study were NHI subscribers aged 40\u0026ndash;74 years, the results may to be generalizable to other populations with different characteristics or age distributions. In this study, we selected study participants who incurred outpatient medical expenses for any of three diseases, i.e., hypertension, dyslipidemia, and diabetes mellitus, so the effects of other diseases on our findings cannot be excluded. Therefore, differences in outpatient medical expenses cannot be attributed solely to the effects of these three diseases. The results were based on a self-administered survey using the KDB and questionnaires for a specific municipality, and regional characteristics must be taken into consideration for generalization of our observations.\u003c/p\u003e \u003cp\u003eHowever, this study was significant in that it examined the relation between outpatient medical expenses and SRH by extracting those who actually incurred outpatient medical expenses for hypertension, dyslipidemia, and diabetes mellitus from the KDB and analyzing them in relation to the subjective questionnaire survey data.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA significant association was observed between high outpatient medical expenses and poor SRH in respondents with one or two of hypertension, dyslipidemia, and/or diabetes mellitus in the population covered by NHI. The number of diseases and the prevalence of diabetes mellitus may have influenced the observed associations. With regard to optimization of outpatient medical expenses, the results suggested that it is important to prevent diabetes mellitus, especially in patients with all three diseases, and to implement lifestyle improvement measures and support disease management to prevent serious illnesses in the population with one or two diseases including diabetes mellitus.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u0026nbsp;Ethics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe questionnaire was sent to the target population through the National Health Insurance and Health Promotion Division of Nagasaki Prefecture with a letter requesting research collaboration, and the return of the completed questionnaire was considered consent for participation. The matching list of ID numbers and KDB information was maintained by the National Health Insurance and Health Promotion Division of Nagasaki Prefecture and is inaccessible to researchers. This study was approved by the Ethics Committee of Nagasaki University Graduate School of Biomedical Sciences (approval number: 21061003).\u003c/p\u003e\n\u003ch2\u003e\u0026nbsp;Consent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003e\u0026nbsp;Availability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due protecting the privacy of participants but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003e\u0026nbsp;Competing interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003e\u0026nbsp;Funding\u003c/h2\u003e\n\u003cp\u003eThis work was supported by the Bureau of Public Health and Welfare of Nagasaki Prefecture and Grants-in-Aid for Scientific Research from the Japan Society for the Promotion of Science (grant number: 21K19655).\u003c/p\u003e\n\u003ch2\u003e\u0026nbsp;Authors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eSK contributed to the conception, design and statistical analyses and drafted the manuscript for publication. OM, RN, SK and RK contributed to conceptualizing, designing, and revising the manuscript. All authors provided feedback and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003e\u0026nbsp;Acknowledgements\u003c/h2\u003e\n\u003cp\u003eWe appreciate all the study participants and the municipal offices of Shimabara City and Unzen City. We are also grateful to the Bureau of Public Health and Welfare Office of Nagasaki Prefecture and the Nagasaki National Health Insurance Organizations. The founders played no role in the analysis of the research and publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKokubo Y, Kamide K, Okamura T, Watanabe M, Higashiyama A, Kawanishi K, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease in a Japanese urban cohort: the Suita Study. 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(in Japanese).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1-6 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"outpatient medical expense, self-rated health, national health insurance","lastPublishedDoi":"10.21203/rs.3.rs-4471292/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4471292/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e This study was performed to clarify the relations between subjective self-rated health and outpatient medical expenses as an objective measure in patients with hypertension, dyslipidemia, and/or diabetes mellitus.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We analyzed self-rated health of individuals aged 40–74 years in Unzen and Shimabara cities based on responses to the anonymous self-administered\u003cem\u003e Nagasaki Prefectural Citizen’s Health Survey\u003c/em\u003e in 2021 along with data from the national health insurance database for both cities from fiscal year 2020.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Data for 1395 respondents to the \u003cem\u003eNagasaki Prefectural Citizen’s Health Survey\u003c/em\u003e covered by national health insurance who incurred outpatient medical expenses in relation to hypertension, dyslipidemia, and/or diabetes mellitus were included in the study. In univariate analysis, outpatient medical expenses were significantly associated with self-rated health in the groups with one or two of the above diseases (χ test, both \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01). Logistic regression analysis adjusted for measures of socioeconomic status, including age, sex, cohabitation/family structure, number of years of education, employment status, and subjective economic status, showed that poor self-rated health was significantly associated with high annual outpatient medical expenses of JPY 100,000 (~US $650).\u003c/p\u003e\n\u003cp\u003eor more in groups with one or two of the above diseases (adjusted odds ratio [AOR], 2.41, 95% confidence interval [CI], 1.60–3.61, AOR, 2.20, 95% CI, 1.41–3.43, respectively). In the one-disease cohort, having diabetes mellitus alone was significantly associated with higher outpatient medical expenses (AOR, 2.63, 95% CI, 1.50–4.63). In contrast, none of the conditions showed a significant association with higher outpatient medical expenses in the two-disease cohort.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Poor self-rated health was significantly associated with high outpatient medical expenses in the population covered by national health insurance with one or two of hypertension, dyslipidemia, and/or diabetes mellitus. These associations may have been influenced by the prevalence of diabetes mellitus in the population.\u003c/p\u003e","manuscriptTitle":"Relation Between Outpatient Medical Expenses and Self-Rated Health in Patients With Hypertension, Dyslipidemia, and Diabetes Mellitus Covered by National Health Insurance","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-11 18:34:49","doi":"10.21203/rs.3.rs-4471292/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ba800feb-4ed3-44bd-94d2-6391b1ee6573","owner":[],"postedDate":"June 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-22T14:16:57+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-11 18:34:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4471292","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4471292","identity":"rs-4471292","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}