Kaifukuki Rehabilitation Ward in Japan

Transcription

1 Jpn J Rehabil Med 2014 ; : Kaifukuki Rehabilitation Ward in Japan Takatsugu OKAMOTO,,, Seiichi ANDO, Shigeru SONODA,, Ichiro MIYAI,, Makoto ISHIKAWA, Introduction In Japan, the ratio of the people aged 65 years or older to the entire population has quadrupled during the past 60 years to reach 23% in As a result, Japan is now one of the world s top countries for longevity. The aging of population is based on low fertility and prolonged life span. The latter has been acquired by good health management under the Japanese universal health insurance system 2 established in 1961, where every person can, in principle, have almost equal and qualified medical services with limited financial burden. The prolonged life span, however, inevitably increases the physically impaired elderly people who must undergo rehabilitation. Aimed chiefly at such people, the system of the Kaifukuki rehabilitation ward KRW was introduced in Japan as a subacute-phase-particularized rehabilitation ward in 2000, 3 when the public long-term care insurance system 4 was at the same time established mainly to support the people who must live their chronic phase lives after discharge from the KRW. For more than 10 years, the KRW system has been operated non-disruptively. In the present paper, we describe the situation that surrounds the rehabilitation in Japan first, outline the KRW system second, and report the KRW Association-conducted annual survey concerning stroke patients third. The Situation that Surrounds Rehabilitation in Japan The present medical care facilities such as so-called hospitals, facilities, home care services or others are, from a different point of view, composed as shown in Fig.. It is emphasized that these facilities must be reorganized and numerically adjusted to the aging of population by 2025, when it is predicted to reach its peak in Japan Fig. 1. Therefore, the reorganization of medical care facilities, with an alteration of the constitutional proportion, is now under promotion as a Japanese fundamental and urgent policy. The efforts are being devoted to carrying out its three major plans, i.e., strict differentiation of the medical care systems, expansion of the home health care and home nursing care services, and upgrading of the community comprehensive care system. The rehabilitation in Japan is briefly reviewed as follows. The functions of rehabilitation belongs to the 3 different stages, i.e. the acute, subacute, and chronic ones Fig.. Kaifukuki is almost comparative to the subacute stage. The main purposes of the KRW, i.e., those of the rehabilitation in the subacute stage, are improvement of activities of daily living ADL, avoidance of prolonged bed rest, and establishment of the independent life, i.e., accomplishment of home discharge. Figure shows the history of the rehabilitation in Ja- Received August 29, This article is based on the lecture of International Symposium Subacute Stroke Rehabilitation System and Outcome at the 50th Annual Meeting of the Japanese Association of Rehabilitation Medicine in Tokyo on June 13, Annual Survey Committee, Kaifukuki Rehabilitation Ward Association, Tokyo, Japan 3 Nishi-Hiroshima Rehabilitation Hospital, Hiroshima, Japan 4 Department of Rehabilitation Medicine, Jikei University School of Medicine, Tokyo, Japan 5 Nanakuri Sanatorium, Mie, Japan 6 Neurorehabilitation Research Institute, Morinomiya Hospital, Osaka, Japan 7 Hatsudai Rehabilitation Hospital, Tokyo, Japan takatsugu@amy.hi-ho.ne.jp Jpn J Rehabil Med VOL. 51 NO

2 Takatsugu OKAMOTO, et al Fig. Reorganization plan of hospitals, facilities and home care services by Fig. Differentiation of the rehabilitation function in Japan. resort. In 1980s, rehabilitation hospitals became concentrated in the urban areas and, as a result, the homebased rehabilitation started. In 1990s, the importance of the acute phase rehabilitation became appreciated more emphatically than before. In 2000, the KRW system was introduced and the public long-term care insurance system began in parallel. In 2010s, we are making efforts to improve the quality of the KRW system and to upgrade the community comprehensive system. Kaifukuki Rehabilitation Ward KRW System in Japan Fig. History of rehabilitation in Japan. pan. In 1970s, rehabilitation was provided at hospitals located in such a countryside as known as a hot spring The KRW system in Japan is outlined. The disabled patients on whom acute phase treatment has finished are, regardless of the patients ages, eligible for admission to KRWs. The revised or present KRW-related law 630 Jpn J Rehabil Med VOL. 51 NO

3 Kaifukuki Rehabilitation Ward in Japan Table Indication for hospitalization in KRW Classification Indication Onset to Length of stay admission LOS interval OAI Neuro rehabilitation Stroke, spinal cord injury, et al 60 days 150 days Orthopedic rehabilitation Femoral neck fracture, et al 60 days 90 days After hip or knee replacement surgery 30 days 90 days Disuse rehabilitation Debility following prolonged bed rest after surgery or pneumonia 60 days 90 days Maximal coverage for inpatient rehabilitation is 3 hours per day. Building Incentive for Improved Quality of Rehabilitation Outcome & Process in the National Insurance Policy for KRW Fig. A constant increase in the number of KRW beds. says that the therapy in KRWs must be started within 60 days from the onset. The diseases concerned are legally limited to stroke, femoral neck fracture, disuse syndrome following prolonged bed rest, or others. By law, the maximal length of the KRW stay LOS is also prescribed in each disease. For example, LOS for a stroke patient is restricted to 150 days, which can be extended to 180 days when the patient s cognitive functions are expected to be improved by rehabilitation for additional 30 days. For comparison, LOS for femoral neck fracture patients is 90 days Table. The maximal coverage for impatient rehabilitation in KRWs is, on the running law, within 3 hours per day. The Ministry of Health, Labor and Welfare regards the KRW system as a main system of the inpatient rehabilitation facilities. The KRW system is covered by the existing national medical system mentioned above. The KRW beds have continuously increased in number Fig.. More than 65,000 beds 51 beds for every 100,000 people are currently available nationwide. The number 65,000 means 5% of total inpatient beds in Japan. Since the KRW system was established in 2000, the national medical insurance fund had reimbursed each KRW hospital based on the achievement level of the hospital routine, the number of doctors, that of nurses, and that of rehabilitation therapists. In 2008, however, the incentive system, which positively evaluated the higher rate of home discharge and the better improvement in the outcomes, was introduced into the national insurance system. This incentive insurance system is thought to be the world s first one that was managed upon the concept of the outcome evaluation. In 2010, furthermore, the incentive payment was added to the more practical doses in daily rehabilitation and the more precise evaluation for the rehabilitation process in each hospital. Annual Survey of Stroke Patients in KRWs Annual Survey Committee, KRW Association ASC- KRW, has investigated the current situation of the KRW system. The investigation is based on the answers to the questionnaires that were sent from KRW Association to KRWs nationwide. The contents are published annually. In 2012 when the collection rate became as high as 66.1%, it was revealed that about a half of inpatients in KRWs were stroke ones. Among those, we analyzed 9,473 adult ones aged 16 years or older 823 wards in 633 hospitals. They were hospitalized in KRWs within 60 days from the onset, stayed for more than 6 days in them from August 2012 to September 2012, and were discharged afterward. The mean standard deviation SD age of the patients was years, and the male-to-female ratio was 56.6 : Cerebral infarc- Jpn J Rehabil Med VOL. 51 NO

4 Takatsugu OKAMOTO, et al Table Clinical Characteristics of Patients With Stroke Admitted to KRWs Number of patients Mean age SD y Mean OAI SD d Mean LOS SD d Discharge disposition Home, % Acute unit, % Other ward, % Chronic hospital, % Intermediate care facility, % Skilled nursing facility, % Died, % Abbreviations: KRW, Kaifukuki rehabilitation ward ; SD, standard deviation; OAI, onsetadmission interval ; LOS, length of stay 71.9(30.9) 70.3(32.1) 68.9(31.6) 49.1(23.3) 47.8(24.3) 46.8(24.2) 86.1(31.4) 101.6(37.2) 66.7(25.6) 22.8(9.8) 22.5(9.6) 22.2(9.5) Fig. Mean scores of FIM on admission. Fig. Mean therapy time per day. 0.24(0.40) 0.27(0.45) 0.24(0.30) min 40min 60min 80min 100min 120min 140min 160min 180min Fig. Mean FIM gain and efficiency. Fig. Total therapy time per day and FIM gain in tions account for 68.2% cerebral hemorrhages 26.5%, and subarachnoid hemorrhages 5.3%. Focusing on the data in 2012, the general tendencies concerning stroke patients in KRWs for the past decade are discussed as follows. The stroke data in KRWs in 2003, 2006 and 2009 are referred from Miyai s paper. 3 ASC-KRW demonstrated that the stroke patients in KRWs have steadily increased in number Table. The increase might be parallel to the continuous rise of KRW beds in number. The mean age has also increased gradually. This gradual increment is supposedly related to the progressing aging in the Japanese population. 632 Jpn J Rehabil Med VOL. 51 NO

5 Kaifukuki Rehabilitation Ward in Japan The onset-to-admission interval OAI dropped down abruptly in 2006, when the KRW-related law curtailed the upper limit of OAI from 90 to 60 days. On the other hand, the length of stay LOS in KRWs has not been shortened for the past 10 years. The unabbreviated LOS in KRWs might be secondary from the gradual increase of the severely disabled inpatients, who have been affirmatively accommodated to KRWs following the Japanese health policies. The rate of home discharge is increasing. Sixty-eight point six percent of stroke patients were discharged home in This high percentage can be thought to be partly related to the above-mentioned incentive system. There are currently 65,000 beds in KRWs in Japan, where 100,000 stroke patients undergo intensive rehabilitation every year and 70,000 of them discharge home. The severity of stroke patients on admission is increasing year by year Fig.. The functional independence measure FIM, used worldwide to assess the functional independence, revealed that the FIM points of the motor function, those of the cognitive function, and the total FIM points were respectively 46.1, 21.5 and 67.7, all of which decreased in 2012 than before Fig. 5. In such patients with severer functions, however, both of the FIM gain and the FIM efficiency could be kept at a reasonable level in 2012 Fig.. The mean time of rehabilitation therapy in KRWs is increasing year by year. One of the main reasons for the prolongation in therapy time is the revision of the KRWrelated law in 2006 under which the maximal coverage for rehabilitation therapy was extended from 120 to 180 minutes a day. In 2012, rehabilitation was provided for more than 2 hours a day on average Fig.. It is generally said that the longer the rehabilitation time is, the better the function improves. Wang et al studied that the patients who received a total therapy time of more than 3 hours per day showed a significantly higher total functional gain when compared to those who were treated for less than 3 hours during inpatient hospital stay in northern California. 5 Figure indicates a similar relationship between the length in a total of rehabilitation time a day and the FIM gain in KRWs. Conclusions and Challenges for the Future Based on the above-shown data, it can be said that the KRW system functions well currently. Despite the increased functional severity of the inpatients in the recent KRWs, neither the scores of FIM gain nor the rate of home discharge decreased. The increase in the rehabilitation time according to the national policy is presumed to contribute to the successful results. It must be kept in mind, however, that the achievement in KRWs might be limited in the literally convalescent period, i.e., Kaifukuki. After discharge of KRWs, there is indeed a system of community-based rehabilitation CBR sustained by the public long-term care insurance, which was introduced in 2000 as mentioned above, but the rehabilitation cannot be necessarily continued smoothly from the KRW system to the CBR one because of the insufficient cooperation between these two systems. KRW Association has to ascertain the cooperation, reinforcing the CBR system. The authors are deeply grateful to President Masazumi Mizuma who gave us the opportunity to present this study at the 50th Annual Meeting of the Japanese Association of Rehabilitation in Tokyo, References 1 Ikeda N, Saito E, Kondo N, Inoue M, Ikeda S, Satoh T, Wada K, Sticklev A, Katanoda K, Mizoue T, Noda M, Iso H, Fujino Y, Sobue T, Tsugane S, Naghavi M, Ezzati M, Shibuya : What has made the population of Japan healty? Lancet 2011 ; : Ikegami N, Yoo B-K, Hashimoto H, Matsumoto M, Ogata H, Babazono A, Watanabe R, Shibuya K, Yang B-M, MR Reich, Kobayashi Y : Japanese universal health coverage : evolution, achievements, and challenges. Lancet 2011 ; : Miyai I, Sonoda S, Nagai S, Takayama, Inoue Y, Kakehi A, Kurihara M, Ishikawa M : Results of new policies for inpatient rehabilitation coverage in Japan. Neurorehabil Neural Repair 2011 ; : Tamiya N, Noguchi H, Nishi A, Reich MR, Ikegami N, Shibuya K, Kawachi I, Campbell JC : Population ageing and wellbeing : lessons from Japan s long-term care insurance policy. Lancet 2011 ; : Wang H, Camicia M, Terdiman J, Mannava M, Sidney S, Sandel E : Daily treatment time and functional gains of stroke patients during inpatient rehabilitation. PM R 2013 ; : Jpn J Rehabil Med VOL. 51 NO