Low-Cost, High-Volume Health Services Contribute the Most to Unnecessary Health Spending due to Low-Value Care in Japan

Low-Cost, High-Volume Health Services Contribute the Most to Unnecessary Health Spending due to Low-Value Care in Japan | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (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];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Low-Cost, High-Volume Health Services Contribute the Most to Unnecessary Health Spending due to Low-Value Care in Japan View ORCID Profile Atsushi Miyawaki , John N. Mafi , Tsuguya Fukui , Yuya Kimura , Daiki Kobayashi , Sara Odawara , Kazuhiro Abe , Rei Goto , Yusuke Tsugawa doi: https://doi.org/10.1101/2025.08.21.25334207 Atsushi Miyawaki 1 Public Health Research Group, Institute of Medicine, University of Tsukuba , Tsukuba, Ibaraki, Japan 2 Department of Health Services Research, Graduate School of Medicine, The University of Tokyo , Bunkyo-ku, Tokyo, Japan MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Atsushi Miyawaki For correspondence: amiyawaki{at}md.tsukuba.ac.jp John N. Mafi 3 Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California Los Angeles (UCLA) , Los Angeles, California, USA 4 RAND Corporation , Santa Monica, California, USA MD, MPH Find this author on Google Scholar Find this author on PubMed Search for this author on this site Tsuguya Fukui 5 Nihon Pharmaceutical University , Saitama and Tokyo, Japan MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Yuya Kimura 2 Department of Health Services Research, Graduate School of Medicine, The University of Tokyo , Bunkyo-ku, Tokyo, Japan MD, MPH Find this author on Google Scholar Find this author on PubMed Search for this author on this site Daiki Kobayashi 6 Division of General Internal Medicine, Department of Internal Medicine, Tokyo Medical University Ibaraki Medical Center , Ibaraki, Japan MD, MPH, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Sara Odawara 7 Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo , Bunkyo-ku, Tokyo, Japan MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Kazuhiro Abe 8 Department of Health Care Policy, Faculty of Medicine, Hokkaido University , Sapporo, Hokkaido, Japan MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Rei Goto 9 Graduate School of Business Administration, Keio University , Yokohama, Kanagawa, Japan MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Yusuke Tsugawa 3 Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California Los Angeles (UCLA) , Los Angeles, California, USA 10 Department of Health Policy and Management, UCLA Fielding School of Public Health , Los Angeles, California, USA MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Abstract Full Text Info/History Metrics Supplementary material Data/Code Preview PDF Abstract Importance As healthcare costs continue to rise, high-income countries—including Japan—face the urgent task of reducing healthcare spending incurred by low-value care. However, evidence is limited as to which low-value care services contribute most to unnecessary healthcare spending outside of the United States. Objective To identify which low-value care services contribute the most to unnecessary healthcare spending in Japan. Design, Setting, and Participants The cross-sectional study of all beneficiaries using a population-based claims database from April 1, 2022, to March 31, 2023, encompassing all age groups, reflecting approximately 2% of the total Japanese population. Main Outcomes and Measures We identified 52 low-value care services based on clinical evidence, and examined their contributions to healthcare spending using two versions of claims-based measures with different sensitivities and specificities (broader and narrower definitions). Each service was categorized into four groups based on its average per-service price: very low (<1,000 Japanese yen [JPY] = 8 US dollars [USD] in 2022), low (1,000–9,999 JPY), medium (10,000–99,999 JPY), or high (≥100,000 JPY). Results Among 1,923,484 beneficiaries (mean [SD] age 58.6 [23.5] years; 52.7% female), we identified 3.1 million (narrower definition) to 3.7 million (broader definition) episodes of low-value care services (1.6–1.9 per capita), with 36–40% of patients receiving at least one low-value care service. These services accounted for 0.7–1.0% of total healthcare spending, amounting to 207–331 billion JPY (1.7–2.6 billion USD) when extrapolated nationwide with adjustments for age, sex, and region. When applying narrower definitions, over 99% of low-value care episodes involved very-low-cost or low-cost services, which accounted for 67% of unnecessary healthcare spending—far exceeding the 33% attributed to medium-cost or high-cost services. Conclusion and Relevance Over one in three Japanese individuals received low-value care during 2022-2023, contributing to 0.7–1.0% of total healthcare spending. Among these services, low-cost services contributed to virtually all low-value care utilization and over two-thirds of unnecessary healthcare spending. Compared to focusing solely on high-cost services, targeting the reduction of frequently performed, lower-cost services may be a more effective strategy for reducing wasteful spending. Question Which low-value care services—low-cost or high-cost—contribute most to unnecessary healthcare spending in Japan? Findings In a cross-sectional study of nearly two million beneficiaries examining 52 low-value care services, over one-third received at least one such service during a one-year period, accounting for 0.7–1.0% of total healthcare spending. More than 99% of episodes were very-low- or low-cost services, accounting for over two-thirds of low-value care spending, exceeding spending from medium- and high-cost services. Meaning Focusing on frequently performed, lower-cost services may better reduce wasteful healthcare spending than targeting only high-cost services. INTRODUCTION As healthcare spending growth continues to outpace inflation, many high-income countries are facing the urgent task of curbing unsustainable spending growth. Reducing low-value care (LVC)—healthcare services that provide little or no net clinical benefit in specific scenarios 1 – 3 —is appealing to policymakers because it can eliminate wasteful spending without compromising the quality of care and patients’ health outcomes. Reducing spending on LVC services has the potential to directly curb unnecessary healthcare spending, improve care quality and patient safety by minimizing overdiagnosis and overtreatment, and lead to better population health outcomes by reallocating healthcare resources toward high-value services. 4 Despite the publication of numerous guidelines, a global Choosing Wisely campaign, and decades of attention to this issue, spending on LVC services remains persistent. 5 – 8 Several studies have reported problems due to the use of high-cost LVC services 9 , 10 —such as knee arthroscopy among patients with osteoarthritis—and their associated spending. 11 – 13 However, existing research has also shown that even low-cost LVC can amount to considerable unnecessary healthcare spending when provided at scale. 14 , 15 High- and low-cost services may differ in several respects, including the setting in which care is delivered (hospitals vs. clinics), the specialty of the physician providing the service (specialists vs. generalists), and the characteristics of the patient populations they target (e.g., individuals with severe vs. minor illnesses). Identifying which LVC services contribute more significantly to unnecessary healthcare spending is essential for prioritizing effective strategies to reduce their use. However, evidence is limited regarding the relative contributions of high-cost and low-cost services to unnecessary healthcare spending. While existing research on this topic suggests that spending on low-cost LVC services exceeds that of high-cost LVC services, 16 – 18 these studies are confined to the United States (US), and it is unclear whether this finding can be generalized to countries with different healthcare systems, access to physician services, and payment models. LVC represents a critical public health issue in Japan, as it does in the US Japan faces the dual challenge of maintaining fiscal sustainability while ensuring patient safety in the context of a rapidly aging population. The widespread coverage of numerous LVC services under social insurance plans, 7 , 19 combined with limited perceptions of LVC provision among physicians, 20 can lead to higher healthcare spending and an increased risk of patient exposure to its adverse effects. In this context, using a nationwide health insurance claims database in Japan, we examined how high-cost and low-cost LVC services contribute to unnecessary healthcare spending. METHODS Health Systems in Japan Japan’s health system is characterized by predominantly private clinics and hospitals financed by a combination of social health insurance and cost-sharing from patients. Japanese citizens are required by law to enroll in one of the social health insurance plans (i.e., either employment-based or residence-based insurance), and regardless of the plan, beneficiaries are covered under standardized benefits, such as the uniform fee schedules, the same co-insurance rates (10–30%, varying by age categories), out-of-pocket maximum (covered by the catastrophic health insurance program), and freedom to choose any hospital or clinic (similar to Preferred Provider Organization plans in the US, although some tertiary hospitals charge an additional “first visit fee” for patients without a referral letter from a primary care physician). Insurance benefits are also standardized and include all healthcare services except for preventive services (which are financed using general tax revenues) and long-term care (covered under long-term care insurance). The majority of outpatient services are reimbursed through the fee-for-service model. The majority of inpatient care at large acute care hospitals is paid through a bundled payment called the Diagnosis Procedure Combination, which is a per diem payment system based on diagnosis and procedures (a modified version of the diagnosis-related group in the US). While these features ensure broad access to care, they may also create incentives for clinics or hospitals to increase the volume of physician visits and diagnostic tests. 21 In turn, this may facilitate the widespread provision of LVC especially in outpatient settings and influence the cost distribution of services that may explain unnecessary spending. Data Sources We used data obtained from the DeSC claims database, a nationwide health insurance claims database compiled and maintained by DeSC Healthcare, Inc. (Tokyo, Japan). 22 23 , 24 The dataset, extracted in September 2024, included approximately 2.3 million insured individuals as of April 2023, representing about 2% of the total Japanese population. The database includes all age groups and comprises individuals from diverse socioeconomic backgrounds. It includes beneficiaries in several major social health insurance schemes in Japan: the National Health Insurance program (covering unemployed, self-employed, and retired individuals and their dependents aged <75 years); corporate health insurance societies (covering employed individuals and their dependents aged <75 years); and the Late-Stage Medical Care System (covering all individuals aged ≥75 years). Individuals from households receiving public assistance, who constitute approximately 1.6% of the total Japanese population, were not included in this database because their healthcare costs were covered by public funds rather than health insurance. Although the age distribution in the database is slightly older than that of the total Japanese population, the prevalence of major comorbidities is comparable to estimates from a national survey. 25 The DeSC database includes the beneficiary registry, medical claims, and dispensing claims. The beneficiary registry contains an encrypted personal identifier and beneficiaries’ demographics, insurance type, and region, enabling longitudinal tracking of individuals across multiple health care settings. Medical claims provide detailed information on both outpatient and inpatient care (service dates, diagnosis codes, and corresponding start and end dates). Dispensing claims document prescriptions, specifying drug names, quantities, and prescription/dispensing dates. Diagnosis codes are recorded using the International Classification of Diseases, 10th Revision (ICD-10); drug agents are categorized according to the World Health Organization’s Anatomical Therapeutic Chemical classification system; and tests and procedures are recorded using the Japanese Medical Practice Codes , a collection of standardized codes representing medical procedures, supplies, products, and services used in Japan. Study Population To examine LVC provided in fiscal year 2022 (April 1, 2022, to March 31, 2023), we included all beneficiaries who were continuously enrolled in the DeSC database from April 2022 through March 2023. We required continuous enrollment over a lookback period of one year preceding the fiscal year 2022 and over subsequent cascade periods of one month, as some LVC services required information on medical history from the preceding year and preoperative status within one month. LVC Measurement This study identified 52 LVC services provided in Japan through a review of published clinical literature ( eTable 1 and eTable 2 in Supplement File ). We began with 31 LVC services identified and detected in a previous study conducted in acute care hospital settings in Japan. 7 Next, to conduct a more comprehensive assessment, we updated this list by assembling a panel of physicians from 19 specialties. Each specialist was asked to list services within their specialty that are definitively low-value—defined as having evidence of no clinical benefit, supported by meta-analyses or multiple studies (including randomized controlled trials) showing no efficacy with minimal variability in outcomes—together with the relevant clinical evidence. Two independent physicians on the research team (A.M. and Y.K.), who are experienced in claims-based analysis, reviewed the provided clinical evidence and selected services consistently categorized as “definitely low-value” by both the specialists and the independent reviewers. They then assessed whether each service was measurable using Japanese claims data, excluding those with insufficient information or not covered by the public health insurance system ( eTable 3 in Supplement File ). This process resulted in the identification of 24 measurable LVC services. Finally, we combined these 24 newly validated services with the original 31 services, and after removing three duplicates, we established a final set of 52 LVC services. Details of these processes are provided in eMethod 1 in Supplement File . Each service and its operational definition are presented in eTable 1 in Supplement File , with corresponding codes provided in eTable 2 in Supplement File . To address the inherent uncertainty in quantifying LVC services using administrative claims data, we specified two versions of each LVC measure following previous studies: 1 , 7 a broader (more sensitive) definition and a narrower (more specific) definition. First, we created the broader definition to include all LVC, which runs the risk of misclassifying appropriate care as low-value. By adding some criteria to this broader definition, we next created the narrower definition to minimize the misclassification of appropriate care; conversely, this runs the risk of missing some LVC. For example, the prescription of antibiotics for patients diagnosed with an acute respiratory infection was classified as low-value under the broader definition. Under the narrower definition, antibiotics were considered low-value only if there was no accompanying diagnosis for which antibiotics may be appropriate. We adopted operational definitions from previous research in Japan, 7 using a consensus-based approach, with minor modifications for compatibility with the DeSC claims database. For the newly added services, definitions were established through a consensus method involving three physicians experienced in analyzing healthcare administrative data (A.M., Y.K., and Y.T.). Spending Calculations To quantify spending associated with each LVC service, we calculated the total amount paid to healthcare providers (including patients’ out-of-pocket costs). In doing so, we used government-set prices for each service—which are standardized by law in Japan—across geography, clinical settings, and insurers. For 42 of 52 measures, the spending was defined as costs of the detected LVC service itself to avoid overestimation of the spending on LVC. It should be noted that although inpatient services at large hospitals in Japan are reimbursed under a per diem payment system, we followed a previous study 7 and calculated spending of detected services on a fee-for-service basis, per the Guideline for Healthcare Spending-Effectiveness Evaluation issued by the Japan Central Social Insurance Council. 26 For the remaining 10 measures, which were all procedural/surgical services, it was not possible to comprehensively specify the many codes that could be relevant to the service. Therefore, for three services often performed in the outpatient setting (e.g., spinal injection for low back pain), all costs incurred during the same day of service were included in the healthcare spending estimates to capture all related costs within the same episode of care (e.g., in the case of spinal injections, we included the costs of the physician’s effort [examinations and procedures] as well as infusion of the drug 6 ). For seven services occurring nearly exclusively in the inpatient setting (e.g., carotid endarterectomy), the total cost of the hospitalization was considered as the healthcare spending estimates to capture all related costs within the same episode of care, given that the hospitalization occurred because of the LVC service. Details are provided in eTable 2 in Supplement File . Statistical Analysis First, we described the characteristics of the beneficiaries. Second, we examined the total volume of identified LVC services and the proportion of beneficiaries who received at least one LVC service from April 2022 to March 2023. As was the case with prior research, 16 , 27 we primarily presented the narrower set of LVC measures to minimize the risk of misclassifying high-value care services as LVC services, even at the cost of potentially underestimating the prevalence of LVC. We also reported the associated unnecessary healthcare spending. Furthermore, we analyzed the total LVC volume and associated spending by age group (<18 years, 18–64 years, 65–74 years, and ≥75 years). We also presented estimates of national volume and spending on LVC by extrapolating the age-, sex-, and region-specific per capita volume and spending to the national population (see eMethod 2 in Supplement File for details). Third, we examined how different service price categories (e.g., low-cost vs. high-cost services) contributed to the total volume and spending of LVC. Service price categories were determined based on their average per-service spending as very low (<1,000 Japanese yen [JPY] or 8 US dollars [USD]; 125 JPY=1 USD in 2022), low (1,000–9,999 JPY [8–80 USD]), medium (10,000–99,999 JPY [80–800 USD]), or high (≥100,000 JPY [800 USD]). Average per-service spending was calculated based on the calculated volume and associated spending for each LVC service in the total sample. Furthermore, we identified the top ten LVC services contributing to unnecessary spending in the sample and reported average per-service spending, LVC volume and associated spending, and percentage in grand total LVC spending. Sensitivity Analyses We conducted a few sensitivity analyses. First, to test whether our findings were sensitive to the definition of LVC, we quantified the LVC volume and spending by using the broader set of more sensitive and less specific LVC measures instead of the narrower one and examined the price category distribution of LVC services. Second, we repeated the analyses using alternative price category cutoffs by classifying LVC services into quartiles based on service price, rather than using the cutoffs of 1,000, 10,000, and 100,000 JPY. Finally, as the analytic sample was slightly older than the national population, we reanalyzed the price distribution of LVC based on age-, sex-, and region-adjusted national extrapolations. Stratified Analyses To examine how the price category distribution of LVC services varied by beneficiaries’ age, we examined the proportion of total LVC volume and spending in each of the price categories for different age categories (<18 years, 18–64 years, 65–74 years, and ≥75 years). The Ethics Committee of the University of Tokyo approved this study and waived written informed consent because we retrospectively analyzed deidentified data. This manuscript follows the STROBE reporting guidelines for observational studies. RESULTS Volume of and Spending on LVC Services The analytic sample included 1,923,484 beneficiaries (mean [SD] age, 58.6 [23.5] years; 52.7% female) ( Table 1 ). For these beneficiaries, LVC services defined by 52 LVC measures were provided a total of 3,123,618 times from April 2022 to March 2023, corresponding to 1,623.9 times per 1,000 beneficiaries ( Table 2 ). We found that 36.2% of beneficiaries (696,190 individuals) received at least one LVC services annually. In this cohort, unnecessary spending on LVC services totaled 5.3 billion JPY (42.6 million USD), corresponding to 2.78 million JPY (22.2 thousand USD) per 1,000 beneficiaries. This accounted for 0.65% of the overall healthcare spending of 823.7 billion JPY (6.6 billion USD) in this cohort. Age-stratified analyses revealed that the LVC spending per 1,000 beneficiaries increased with beneficiary age, from 0.49 million JPY (3,920 USD) among those aged <18 years to 5.50 million JPY (44.0 thousand USD) among those aged ≥75 years. After extrapolating to the national population with age-, sex-, and region-adjustments, we calculated that the annual national volume and spending on LVC in Japan were 138.8 million services and 207.2 billion JPY (1.7 billion USD), respectively. View this table: View inline View popup Download powerpoint Table 1. Patient characteristics View this table: View inline View popup Download powerpoint Table 2. Volume and cost of low-value care services during April 2022 to March 2023, overall and by age group Cost Distribution for LVC Volume and Spending Price categories of very-low-cost, low-cost, medium-cost, and high-cost services consisted of 15, 18, 9, and 10 services, respectively. Among the 3,123,618 LVC services, 3,095,563 were very low cost and low cost (99.1%), compared with only 28,055 such services that were medium cost or high cost (0.9%) ( Figure 1 ). The total spending of very-low-cost or low-cost services in our sample (67.3% of unnecessary healthcare spending, or 3.6 billion JPY [28.7 million USD]) exceeded the total spending of medium or high-cost services (32.7% of unnecessary healthcare spending, or 1.7 billion JPY [13.9 million USD]). Download figure Open in new tab Figure 1. Proportion of total low-value care volume and spending by price category Low-value care services were classified into four price categories according to average spending per service: very low (< 1,000 Japanese yen [JPY] or 8 US dollars [USD]; 125 JPY = 1 USD in 2022), low (1,000–9,999 JPY [8–80 USD]), medium (10,000–99,999 JPY [80–800 USD]), or high (≥ 100,000 JPY [800 USD]). Categories of very-low-cost, low-cost, medium-cost, and high-cost consisted of 15, 18, 9, and 10 services, respectively. Five of the top 10 LVC services contributing to unnecessary spending were derived from very-low-cost or low-cost services ( Table 3 ). Especially, three services—including topical salicylates or long-term topical nonsteroidal anti-inflammatory drugs (NSAIDs) for chronic pain (very low cost), early imaging for acute low back pain (low cost), and injection for low back pain (low cost)—accounted for approximately half of the grand total LVC spending. All 52 measures are presented in eTable 4 in Supplement File , along with age-, sex-, and region-adjusted national extrapolations. View this table: View inline View popup Download powerpoint Table 3. The 10 most costly low-value care (LVC) in the total sample Sensitivity Analyses When using the broader set of LVC definitions ( eTable 5 in Supplement File ), a total of 3,714,442 LVC services (1931.1 per 1,000 beneficiaries) were provided in 2022-2023, with 39.5% of patients receiving at least one LVC service. The associated spending in this cohort amounted to 8.4 billion JPY (67.2 million USD), representing 1.02% of total healthcare spending. National spending on LVC in Japan, adjusted for age, sex, and region and based on the broader definition, was estimated at 330.5 billion JPY (2.6 billion USD) ( eTable 6 in Supplement File) . The findings of the price category distribution were qualitatively unchanged when applying the broader definitions of LVC ( eFigure 1 in Supplement File ). The findings of the price category distribution were also qualitatively unchanged by using alternative cutoffs based on the average spending per service ( eFigure 2 in Supplement File ) and when reanalyzed based on national estimates of LVC volume and spending ( eFigure 3 in Supplement File ). Stratified Analyses by Beneficiaries’ Age Very-low-cost or low-cost services accounted for most (> 99%) of the volume of LVC services across beneficiaries’ age categories ( Figure 2 ). Furthermore, total spending on very-low-cost or low-cost services exceeded that on medium- or high-cost services across all age groups. Download figure Open in new tab Figure 2. Proportion of total low-value care volume and spending by price category, by beneficiaries’ age group Low-value care services were classified into four price categories according to an average spending per service: very low (< 1,000 Japanese yen [JPY] or 8 US dollars [USD]; 125 JPY = 1 USD in 2022), low (1,000–9,999 JPY [8–80 USD]), medium (10,000–99,999 JPY [80–800 USD]), or high (≥ 100,000 JPY [800 USD]). DISCUSSION Using a nationwide claims database in Japan, we examined 52 LVC services and found that more than one-third of beneficiaries received at least one LVC service in 2022-2023. The spending for these 52 services alone accounted for 0.7–1.0% of total healthcare spending, corresponding to 207–331 billion JPY (1.7–2.6 billion USD) when extrapolated to the national population with age-, sex-, and region-adjustment. Over 99% of LVC episodes were classified as very-low-cost or low-cost services, and the associated spending on these LVC services exceeded spending for medium-cost or high-cost LVC services. This pattern was consistent across all age groups, including older adults, who often require costly services due to multiple coexisting conditions. These findings suggest that frequently provided low-cost LVC services can cumulatively impose a substantial financial burden on the healthcare system, and represent an important opportunity to identify and reduce wasteful spending. Interventions to reduce LVC may target policy, medical institutional, physician, and patient levels. 28 At macro levels, “top-down” approaches to reduce LVC include redesigning supply-side interventions (e.g., payment reforms through global budgets programs 29 or insurer restrictions 30 ) and demand-side strategies (e.g., increasing patient cost-sharing). As suggested by prior literature, 31 it is important to note that increasing cost-sharing has a higher risk of the unintended consequences of curbing medically necessary care due to patients’ difficulties in choosing care based on value. At micro levels, “bottom-up” approaches, data-driven and non-judgmental dialogue with specialists, 32 and nudging interventions using electronic health records 33 have been reported as effective. Enhancing patient education may also be effective. 34 Ultimately, multi-modal strategies combining these approaches may be most promising. 34 While high-cost services have frequently been discussed as drivers of rising healthcare spending, 9 – 13 our findings suggest that even modest reductions in very-low-cost or low-cost LVC across broad patient populations can cumulatively lead to substantial reduction in unnecessary healthcare spending. Unlike high-cost services, which may have significant financial influence for specific clinical specialties or healthcare sectors, efforts to reduce low-cost LVC are less likely to disrupt provider revenue streams, potentially minimizing policy conflicts. 16 Nevertheless, designing cost-effective interventions for reducing frequently delivered, low-cost LVC services remains a critical challenge. 35 For example, broad interventions, such as claims audits targeting all physicians, may not be efficient as de-implementation costs could exceed the low cost of the services. However, prior studies have shown that a large proportion of low-cost LVC is concentrated among a small portion of physicians, 36 suggesting that targeted interventions focusing on physicians providing high-volume, low-cost services may offer an efficient strategy for maximizing the impact of limited resources. 37 Among the top 10 LVC services contributing the most to unnecessary spending, low-cost LVC services for pain management—such as topical salicylates or long-term topical NSAIDs therapy for chronic pain, early imaging for acute low back pain, injections for low back pain, and pregabalin for low back pain—were particularly prominent. Collectively, these four services accounted for 52.7% of the total unnecessary spending among the studied measures. Given that low back pain is a leading cause of disability worldwide, including in Japan, reducing LVC in this area is an important public health priority. 38 The widespread use of LVC services highlights the need to educate physicians on guidelines-based care and to promote high-value and multi-modal alternatives, like exercise programs, physical therapy, yoga, and cognitive behavioral therapy. 39 Our findings on the price category distribution of unnecessary healthcare spending are consistent with previous studies in the US, where low-cost services contributed more to total LVC spending than high-cost services. 16 – 18 The estimated spending due to LVC accounted for 0.65% of total healthcare spending when applying the narrower LVC definition in our study, which is similar to studies in the US that quantified 28 services for the Medicare or commercially insured population. 1 , 40 The frequency of LVC (approximately 1.6 per beneficiary per year) in our study was higher than in these US studies. This suggests that Japan’s healthcare system is structurally prone to the provision of low-cost, high-volume LVC. In Japan, hospital-based inpatient care is primarily reimbursed through a bundled payment system, while outpatient services are predominantly reimbursed via a fee-for-service model. This system can create incentives for physicians to frequently provide low-cost LVC in outpatient settings. This tendency may be influenced by the characteristics of Japan’s health system, including low patient cost-sharing (particularly for those aged 75 and older, who pay only 10% unless they are high-income earners) and unrestricted access to clinics and hospitals. Our study has limitations. First, as with any study measuring LVC directly, 1 , 7 , 16 , 27 our analysis was subject to the inherent limitations of using administrative claims data. Although claims data reliably indicate whether a given procedure was performed, they often lack the detailed clinical context required to determine the appropriateness of that care—information more commonly available in medical records. To address this limitation, we selected definitions of LVC with higher specificity to better capture instances of overuse. Despite these constraints, claims data represent a cost-efficient alternative to medical record review and are particularly valuable for continuous monitoring and the development of payment policies. 1 Second, although we included 52 LVC services, our measures were limited to those assessable using claims data. For example, because symptoms such as frequent or painful urination cannot be reliably identified in claims data, we could not evaluate bacteriuria screening in asymptomatic patients, which reportedly accounts for about 0.1% (1.2 billion USD) of total Medicare spending in the US. 41 Furthermore, preventive services, like prostate-specific antigen screening for older men, were not covered by public insurance in Japan and thus not captured. However, including these would likely not change our cost distribution findings, as such services are typically low-cost despite frequent use. Third, we did not capture downstream costs associated with LVC, such as healthcare spending on adverse events and complications associated with LVC, 42 – 45 which may have resulted in an underestimation of total unnecessary spending. For example, a recent study demonstrated that when indirect costs from downstream testing and treatments triggered by low-value preoperative electrocardiograms before cataract surgery are included, the associated costs increase by a factor of ten. 43 Despite these limitations, our estimates indicate a substantial burden of LVC services in Japan. Finally, the claims data we used were based on a convenient sample, leading to a slightly older study population compared to the general Japanese population. However, findings were qualitatively unchanged when stratified by beneficiaries’ age or when using age-sex-region national extrapolations, suggesting generalizability to the entire Japanese population. CONCLUSION This nationwide study in Japan found that low-cost, high-volume services contributed substantially to unnecessary healthcare spending across all age groups. Rather than solely targeting high-cost services, curbing the overuse of frequently performed, lower-cost services may offer a more effective approach to reducing LVC. Data Availability The DeSC database is a proprietary database owned by DeSC Healthcare, Inc.; therefore, it cannot be shared. Individuals who are interested in using the DeSC data should contact DeSC Healthcare, Inc. https://desc-hc.co.jp/en Author Contributions Dr. Miyawaki had full access to the study data and takes responsibility for the accuracy and integrity of the data and analyses. Study concept and design: Miyawaki, Tsugawa. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Miyawaki. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Miyawaki. Administrative, technical, or material support: All authors. Conflict of Interest Disclosures Dr. Miyawaki received funding from the Ministry of Health, Labour and Welfare (23AA2004), the Japan Society for the Promotion of Science (24K02701), and the TRiSTAR program (the Strategic Professional Development Program for Young Researchers conducted by the Ministry of Education, Culture, Sports, Science and Technology) for other work not related to this study; and received consulting fees from M3, Inc. and Datack Inc.; and lecture fees from Janssen Pharma (in the last 36 months). Dr. Mafi was supported by a National Institute of Health (NIH)/National Institute on Aging (NIA) award (R01AG070017-01) and an NIH/NIA Beeson Emerging Leaders in Aging Research Career Development Award (K76AG064392-01A1) for other work not related to this study. Dr. Tsugawa received funding from NIH/NIA (R01AG068633 & R01AG082991), NIH/National Institute on Minority Health and Health Disparities (R01MD013913), and GRoW @ Annenberg for other work not related to this study; and serves on the board of directors of M3, Inc. Funding and Support This study was supported by a grant from the General Incorporated Association Evidence Studio (Tokyo, Japan). Role of the Funder or Sponsor None. Data-Sharing Statement The DeSC database is a proprietary database owned by DeSC Healthcare, Inc.; therefore, it cannot be shared. Individuals who are interested in using the DeSC data should contact DeSC Healthcare, Inc. ( https://desc-hc.co.jp/en ). Acknowledgments The authors would like to acknowledge the contribution of the following team of specialist physicians who reviewed clinical evidence and developed a candidate list of low-value care services. The team members are as follows: Dr. Yuichiro Matsuo; Dr. Junya Arai; Dr. Naoko Hidaka; Dr. Hideaki Watanabe; Dr. Yuki Uehara; Dr. Masashi Miyawaki; Dr. Arisa Iba; Dr. Shinichiro Shiomi; Dr. Yu Mizushima; Dr. Teiichiro Aoyagi; Dr. Yoshio Hayashi; Dr. Asahi Fujita; Dr. Risa Ishida; Dr. Takuya Sato; Dr. Ayako Yanagisawa; and Dr. Shinji Sugahara. References 1. ↵ Schwartz AL , Landon BE , Elshaug AG , Chernew ME , McWilliams JM . Measuring low-value care in Medicare . JAMA Intern Med . 2014 ; 174 ( 7 ): 1067 – 1076 . doi: 10.1001/jamainternmed.2014.1541 OpenUrl CrossRef PubMed 2. Shrank WH , Rogstad TL , Parekh N . Waste in the US health care system: estimated costs and potential for savings . JAMA . 2019 ; 322 ( 15 ): 1501 – 1509 . doi: 10.1001/jama.2019.13978 OpenUrl CrossRef PubMed 3. ↵ Brooks DJ , Reyes CE , Chien AT . Time to set aside the term ‘Low-Value Care’—Focus on achieving high-value care for all . Health Affairs Forefront. Published online 2021 . doi: 10.1377/forefront.20210518.804037 OpenUrl CrossRef 4. ↵ Mafi JN , Parchman M . Low-value care: an intractable global problem with no quick fix . BMJ Qual Saf . 2018 ; 27 ( 5 ): 333 – 336 . doi: 10.1136/bmjqs-2017-007477 OpenUrl FREE Full Text 5. ↵ Brownlee S , Chalkidou K , Doust J , et al. Evidence for overuse of medical services around the world . The Lancet . 2017 ; 390 ( 10090 ): 156 – 168 . doi: 10.1016/S0140-6736(16)32585-5 OpenUrl CrossRef PubMed 6. ↵ Mafi JN , Reid RO , Baseman LH , et al. Trends in low-value health service use and spending in the US Medicare fee-for-service program, 2014-2018 . JAMA Netw Open . 2021 ; 4 ( 2 ): e2037328 . doi: 10.1001/jamanetworkopen.2020.37328 OpenUrl CrossRef PubMed 7. ↵ Miyawaki A , Ikesu R , Tokuda Y , et al. Prevalence and changes of low--value care at acute care hospitals: a multicentre observational study in Japan . BMJ Open . 2022 ; 12 ( 9 ): e063171 . doi: 10.1136/bmjopen-2022-063171 OpenUrl Abstract / FREE Full Text 8. ↵ Rockwell MS , Vangala S , Rider J , et al. Increased spending on low-value care during the COVID-19 pandemic in Virginia . Health Affairs Scholar . 2024 ; 2 ( 11 ): qxae133 . doi: 10.1093/haschl/qxae133 OpenUrl CrossRef 9. ↵ Wong SM , Freedman RA , Sagara Y , Aydogan F , Barry WT , Golshan M . Growing use of contralateral prophylactic mastectomy despite no improvement in long-term survival for invasive breast cancer . Annals of Surgery . 2017 ; 265 ( 3 ): 581 . doi: 10.1097/SLA.0000000000001698 OpenUrl CrossRef 10. ↵ Howard G. Association between age and risk of stroke or death from carotid endarterectomy and carotid stenting: a meta-analysis of pooled patient data from four randomised trials . 2016 ; 387 : 7 . OpenUrl 11. ↵ Lan T , Chen L , Hu Y , Wang J , Tan K , Pan J . Measuring low-value care in hospital discharge records: evidence from China . The Lancet Regional Health – Western Pacific . 2023 ; 38 . doi: 10.1016/j.lanwpc.2023.100887 OpenUrl CrossRef 12. Badgery-Parker T , Pearson SA , Chalmers K , et al. Low-value care in Australian public hospitals: prevalence and trends over time . BMJ Qual Saf . 2019 ; 28 ( 3 ): 205 – 214 . doi: 10.1136/bmjqs-2018-008338 OpenUrl Abstract / FREE Full Text 13. ↵ Chalmers K , Pearson SA , Badgery-Parker T , Brett J , Scott IA , Elshaug AG . Measuring 21 low-value hospital procedures: claims analysis of Australian private health insurance data (2010–2014) . BMJ Open . 2019 ; 9 ( 3 ): e024142 . doi: 10.1136/bmjopen-2018-024142 OpenUrl Abstract / FREE Full Text 14. ↵ Kale MS , Bishop TF , Federman AD , Keyhani S . “Top 5” lists top $5 billion . Archives of Internal Medicine . 2011 ; 171 ( 20 ): 1858 – 1859 . doi: 10.1001/archinternmed.2011.501 OpenUrl CrossRef PubMed Web of Science 15. ↵ McAlister FA , Lin M , Bakal J , Dean S . Frequency of low-value care in Alberta, Canada: a retrospective cohort study . BMJ Qual Saf . 2018 ; 27 ( 5 ): 340 – 346 . doi: 10.1136/bmjqs-2017-006778 OpenUrl Abstract / FREE Full Text 16. ↵ Mafi JN , Russell K , Bortz BA , Dachary M , Hazel WA , Fendrick AM . Low-cost, high-volume health services contribute the most to unnecessary health spending . Health Affairs . 2017 ; 36 ( 10 ): 1701 – 1704 . doi: 10.1377/hlthaff.2017.0385 OpenUrl Abstract / FREE Full Text 17. Reid RO , Mafi JN , Baseman LH , Fendrick AM , Damberg CL . Waste in the Medicare program: a aational cross-sectional analysis of 2017 low-value service use and spending . J Gen Intern Med . 2021 ; 36 ( 8 ): 2478 – 2482 . doi: 10.1007/s11606-020-06061-0 OpenUrl CrossRef PubMed 18. ↵ Oronce CIA , Fendrick AM , Ladapo JA , Sarkisian C , Mafi JN . The Utilization and Costs of Grade D USPSTF Services in Medicare, 2007–2016 . J GEN INTERN MED . 2021 ; 36 ( 12 ): 3711 – 3718 . doi: 10.1007/s11606-021-06784-8 OpenUrl CrossRef PubMed 19. ↵ Soshi M , Mizuta T , Tokuda Y. Overtesting in Japan . Journal of General and Family Medicine . 2018 ; 19 ( 2 ): 42 . doi: 10.1002/jgf2.167 OpenUrl CrossRef 20. ↵ Raudasoja A , Tikkinen KAO , Bellini B , et al. Perspectives on low-value care and barriers to de-implementation among primary care physicians: a multinational survey . BMC Primary Care . 2024 ; 25 ( 1 ): 159 . doi: 10.1186/s12875-024-02382-9 OpenUrl CrossRef PubMed 21. ↵ OECD . Health at a Glance 2023: OECD Indicators . OECD Publishing ; 2023 . Accessed July 1, 2025 . doi: 10.1787/7a7afb35-en OpenUrl CrossRef 22. ↵ Yasunaga H . DeSC database . Annals of Clinical Epidemiology . 2025 ; 7 ( 2 ): 46 – 49 . doi: 10.37737/ace.25006 OpenUrl CrossRef PubMed 23. ↵ Arai J , Miyawaki A , Aoki T , et al. Association between Vonoprazan and the risk of gastric cancer after Helicobacter pylori eradication . Clinical Gastroenterology and Hepatology . 2024 ; 0 ( 0 ). doi: 10.1016/j.cgh.2024.01.037 OpenUrl CrossRef PubMed 24. ↵ Masuda S , Fukasawa T , Matsuda S , Kawakami K . Cardiovascular safety and fracture prevention effectiveness of Denosumab versus oral bisphosphonates in patients receiving dialysis: a target trial emulation . Ann Intern Med . 2025 ; 178 ( 2 ): 167 – 176 . doi: 10.7326/ANNALS-24-03237 OpenUrl CrossRef PubMed 25. ↵ Okada A , Yasunaga H . Prevalence of noncommunicable diseases in Japan using a newly developed administrative claims database covering young, middle-aged, and elderly people . JMA J . 2022 ; 5 ( 2 ). doi: 10.31662/jmaj.2021-0189 OpenUrl CrossRef PubMed 26. ↵ Research Team on Cost-Effectiveness Evaluation (Strategic Integrated Scientific Research Project) . Guideline for Preparing Cost-Effectiveness Evaluation to the Central Social Insurance Medical Council . Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health ; 2019 . Accessed November 2, 2021 . https://c2h.niph.go.jp/tools/guideline/guideline_en.pdf 27. ↵ Ganguli I , Morden NE , Yang CWW , Crawford M , Colla CH . Low-value care at the actionable level of individual health systems . JAMA Intern Med . 2021 ; 181 ( 11 ): 1490 – 1500 . doi: 10.1001/jamainternmed.2021.5531 OpenUrl CrossRef PubMed 28. ↵ Patey AM , Soong C . Top-down and bottom-up approaches to low-value care . BMJ Qual Saf . 2023 ; 32 ( 2 ): 65 – 68 . doi: 10.1136/bmjqs-2022-014977 OpenUrl FREE Full Text 29. ↵ Schwartz AL , Chernew ME , Landon BE , McWilliams JM . Changes in low-value services in year 1 of the Medicare Pioneer Accountable Care Organization Program . JAMA Intern Med . 2015 ; 175 ( 11 ): 1815 – 1825 . doi: 10.1001/jamainternmed.2015.4525 OpenUrl CrossRef PubMed 30. ↵ Henderson J , Bouck Z , Holleman R , et al. Comparison of payment changes and Choosing Wisely recommendations for use of low-value laboratory tests in the United States and Canada . JAMA Internal Medicine . 2020 ; 180 ( 4 ): 524 – 531 . doi: 10.1001/jamainternmed.2019.7143 OpenUrl CrossRef PubMed 31. ↵ Baicker K , Levy H . Cost sharing as a tool to drive higher-value care . JAMA Internal Medicine . 2015 ; 175 ( 3 ): 399 – 400 . OpenUrl PubMed 32. ↵ Mafi JN , Godoy-Travieso P , Wei E , et al. Evaluation of an intervention to reduce low-value preoperative care for patients undergoing cataract surgery at a safety-net health system . JAMA Internal Medicine . 2019 ; 179 ( 5 ): 648 – 657 . doi: 10.1001/jamainternmed.2018.8358 OpenUrl CrossRef PubMed 33. ↵ Meeker D , Linder JA , Fox CR , et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial . JAMA . 2016 ; 315 ( 6 ): 562 . doi: 10.1001/jama.2016.0275 OpenUrl CrossRef PubMed 34. ↵ Colla CH , Mainor AJ , Hargreaves C , Sequist T , Morden N . Interventions aimed at reducing use of low-value health services: A systematic review . Med Care Res Rev . 2017 ; 74 ( 5 ): 507 – 550 . doi: 10.1177/1077558716656970 OpenUrl CrossRef PubMed 35. ↵ Kroon D , Dulmen SA van , Westert GP , Jeurissen PPT , Kool RB . Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study . BMJ Open . 2022 ; 12 ( 11 ): e062902 . doi: 10.1136/bmjopen-2022-062902 OpenUrl Abstract / FREE Full Text 36. ↵ Miyawaki A , Mafi JN , Abe K , et al. Primary care physician characteristics and low-value care provision in Japan . JAMA Health Forum . 2025 ; 6 ( 6 ): e251430 . doi: 10.1001/jamahealthforum.2025.1430 OpenUrl CrossRef 37. ↵ Sacarny A , Barnett ML , Le J , Tetkoski F , Yokum D , Agrawal S . Effect of peer comparison letters for high-volume primary care prescribers of quetiapine in older and disabled adults: a randomized clinical trial . JAMA Psychiatry . 2018 ; 75 ( 10 ): 1003 – 1011 . doi: 10.1001/jamapsychiatry.2018.1867 OpenUrl CrossRef PubMed 38. ↵ World Health Organization . Low back pain . 2023 . Accessed August 12, 2025 . https://www.who.int/news-room/fact-sheets/detail/low-back-pain 39. ↵ WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings . Accessed April 9, 2025 . https://www.who.int/publications/i/item/9789240081789 40. ↵ Reid RO , Rabideau B , Sood N . Low-value health care services in a commercially insured population . JAMA Intern Med . 2016 ; 176 ( 10 ): 1567 – 1571 . doi: 10.1001/jamainternmed.2016.5031 OpenUrl CrossRef PubMed 41. ↵ Kim DD , Fendrick AM . Projected savings from reducing low-value services in Medicare . JAMA Health Forum . 2025 ; 6 ( 8 ): e253050 . doi: 10.1001/jamahealthforum.2025.3050 OpenUrl CrossRef PubMed 42. ↵ Jacobs JC , Jarvik JG , Chou R , et al. Observational study of the downstream consequences of inappropriate MRI of the lumbar spine . J Gen Intern Med . 2020 ; 35 ( 12 ): 3605 – 3612 . doi: 10.1007/s11606-020-06181-7 OpenUrl CrossRef PubMed 43. ↵ Ganguli I , Lupo C , Mainor AJ , et al. Prevalence and cost of care cascades after low-value preoperative electrocardiogram for cataract surgery in fee-for-service Medicare beneficiaries . JAMA Intern Med . 2019 ; 179 ( 9 ): 1211 – 1219 . doi: 10.1001/jamainternmed.2019.1739 OpenUrl CrossRef PubMed 44. Ganguli I , Ying W , Shakley T , Colbert JA , Mulligan KL , Friedberg MW . Cascade services and spending following low-value imaging for uncomplicated low back pain among commercially insured adults . J Gen Intern Med . 2022 ; 38 ( 4 ): 1102 . doi: 10.1007/s11606-022-07829-2 OpenUrl CrossRef PubMed 45. ↵ Ganguli I , Simpkin AL , Lupo C , et al. Cascades of care after incidental findings in a US national survey of physicians . JAMA Network Open . 2019 ; 2 ( 10 ): e1913325 . doi: 10.1001/jamanetworkopen.2019.13325 OpenUrl CrossRef View the discussion thread. Back to top Previous Next Posted August 26, 2025. Download PDF Supplementary Material Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. 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Mafi , Tsuguya Fukui , Yuya Kimura , Daiki Kobayashi , Sara Odawara , Kazuhiro Abe , Rei Goto , Yusuke Tsugawa medRxiv 2025.08.21.25334207; doi: https://doi.org/10.1101/2025.08.21.25334207 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Health Policy Subject Areas All Articles Addiction Medicine (567) Allergy and Immunology (863) Anesthesia (297) Cardiovascular Medicine (4412) Dentistry and Oral Medicine (443) Dermatology (380) Emergency Medicine (606) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1505) Epidemiology (15205) Forensic Medicine (30) Gastroenterology (1119) Genetic and Genomic Medicine (6575) Geriatric Medicine (666) Health Economics (994) Health Informatics (4511) Health Policy (1365) Health Systems and Quality Improvement (1608) Hematology (537) HIV/AIDS (1264) Infectious Diseases (except HIV/AIDS) (15904) Intensive Care and Critical Care Medicine (1103) Medical Education (620) Medical Ethics (144) Nephrology (666) Neurology (6573) Nursing (345) Nutrition (998) Obstetrics and Gynecology (1139) Occupational and Environmental Health (954) Oncology (3319) Ophthalmology (968) Orthopedics (369) Otolaryngology (420) Pain Medicine (435) Palliative Medicine (129) Pathology (662) Pediatrics (1689) Pharmacology and Therapeutics (691) Primary Care Research (710) Psychiatry and Clinical Psychology (5423) Public and Global Health (9205) Radiology and Imaging (2191) Rehabilitation Medicine and Physical Therapy (1367) Respiratory Medicine (1191) Rheumatology (593) Sexual and Reproductive Health (709) Sports Medicine (529) Surgery (709) Toxicology (99) Transplantation (288) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9fed1793b919300f',t:'MTc3OTI5ODQ2NQ=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();