Points of View Health Status of the Elderly from the Perspective of Nursing Care System Data -Analysis Using Complementary Indicators of Healthy Life Expectancy

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Minoru Ito, Senior Researcher, Pharmaceutical and Industrial Policy Research Institute

1. Introduction

One of the important goals of next-generation health care is "extension of healthy life expectancy. In order to realize this goal, the center of gravity of health care should expand from "diagnosis and treatment," which focuses on curing diseases, to "pre-disease/prevention," or "prognosis and coexistence," in which people live with as few restrictions as possible after contracting a disease. ¹⁾ The author intends to shift the focus of his research to "pre-disease/prevention, In shifting the focus of his research to "Prevention and Prevalence," the author intended to understand the current situation of aging and the elderly, and conducted research in the previous issue of the Policy Research Institute News (No.64) ²⁾, showing that there are various patterns in the degree of independence (≒health status) of the elderly, and that it is not desirable to consider them all together. In this issue, we conducted research to understand the health status of the elderly (including some aged 40-64) over time and by age group, based on long-term care data, and to examine the main causative diseases that impair health, while also considering the contribution of drugs to causative diseases.

2. relationship between health status and healthy life expectancy through long-term care system data

Understanding the health status of the elderly based on long-term care system data is closely related to understanding the status of healthy life expectancy among the elderly. Healthy life expectancy is an indicator that expresses "the average period during which a person is expected to live in a certain healthy state. There are several types of healthy life ^expectancy3). The issues in calculating healthy life expectancy are the conceptual definition of "healthy" and "unhealthy" and the method of calculating healthy life expectancy. In Japan, "healthy" and "unhealthy" are defined as "having no limitations in daily life" and calculated by ^the Sullivan ^method4)5) based on data obtained from the National Survey of Living Standards conducted every three years by the Ministry of Health, Labor and Welfare. More specifically, to the question, "Do you currently have any health problems that affect your daily life?", a response of "no" is defined as "healthy" and a response of "yes" is defined as "unhealthy". In other words, the "average duration of unrestricted daily living" is the main indicator of healthy life expectancy ^.5)

Health" is a very broad concept. It is inappropriate to judge merely by the presence or absence of injury or disease. Even if a person is physically well, if he or she is not mentally and socially well, it is difficult to say that he or she is "healthy. In this respect, the current indicator, "average duration of unrestricted daily life," is considered to be the most appropriate among currently available indicators of healthy life expectancy, as it is considered to represent not merely physical factors but also mental and social factors to a certain extent in a broad and comprehensive manner. However, due to issues such as the fact that the National Life Expectancy Survey is conducted every three years, a complementary indicator is being considered, and the "average duration of independence in activities of daily living" using long-term care insurance data is considered most appropriate as a complementary indicator. More specifically, "care requirement 1 or less" is defined as "healthy" and "care requirement 2 or more" is defined as "unhealthy" in terms of care requirement certification. ⁶⁾

Based on these findings, this issue of the Journal proceeded to examine the health status of the elderly and others by utilizing relatively easily accessible long-term care-related data. In other words, in another sense, it is a part of understanding the status of healthy life expectancy of the elderly, etc. It should be noted, however, that unlike the current indicators, the complementary indicators utilizing long-term care insurance data reflect mainly physical factors. It should also be noted that compared to the current indicators, the complementary indicators tend to shorten the difference between average life expectancy and healthy life expectancy (Figure 1).

3. overview of long-term care insurance

As shown in Figure 2, those insured by long-term care insurance are divided into two groups: those aged 65 or older (Category 1 insured persons) and those aged 40 to 64 (Category 2 insured persons) who are covered by medical insurance. Category 1 insured persons can receive long-term care services when they are certified as requiring long-term care (support) regardless of the cause, while Category 2 insured persons can receive long-term care services when they are certified as requiring long-term care (support) due to age-related diseases (specified diseases). ⁷⁾

The certification for long-term care (support required) is made by a computerized primary judgment based on a physical and mental condition survey (certification survey) conducted by a municipal certification examiner and an attending physician's written opinion, followed by a secondary judgment by the Long-Term Care Certification Board and certification by the municipality. ⁸⁾ (Figure 3)

The level of care (classification of care required, etc.) is classified as shown in Figure 4. The Complementary Index defines care requirement 2 and above as "unhealthy." Care requirement 2 is a state in which daily assistance is required for some daily activities of daily living (shopping, money management, internal medication management, telephone use) and some daily activities (eating, toileting, bathing, cleaning). ⁹⁾ In 2005, the Care Insurance Law was revised, and there are six levels of care (support required, care requirement 1 to care requirement 2). 9) In addition, due to the 2005 revision of the Long-Term Care Insurance Law, the nursing care level was changed from six levels ⁽ support required, nursing care required ^1-5) to seven levels (support required 1-2, nursing care required 1-5), but there was no change in nursing care required 2 and above, suggesting that the complementary indicators are valid even for pre-2005 nursing care data.

4. Trends in the number of people certified as requiring long-term care (support)

Prior to the examination based on the complementary index, the number of persons certified as requiring long-term care (support) was reviewed. The data used for the long-term care system was the Annual Report on the State of Long-Term Care Insurance ^Business10). This report is conducted annually for municipalities (including wide-area federations and partial administrative associations), and data from FY2000 to FY2020 are accessible. (As of January 2022).

Figure 5 shows the annual changes in the number of persons certified as requiring long-term care (support). a is the total number (total of those insured under Category 1 and Category 2), b is the number of Category 1 insured persons, and c is the number of Category 2 insured persons certified.

As a result, the total number and the number of people certified as requiring long-term care (support) for those insured under Category 1 have increased almost with each year, reaching their highest numbers (approximately 6,686,000 and 6,558,000, respectively) in FY 2019. On the other hand, the number of Category 2 insured persons aged 40-64, who are certified for specified diseases, showed a gradual downward trend after reaching the highest number in FY2011 (approximately 156,000), and reached approximately 128,000 in FY2019, a decrease of 18.0% from FY2011.

Since a different trend was observed for nonelderly persons aged 64 or younger, we felt it necessary to examine the situation by age group even for Category 1 insured persons aged 65 or older, and looked at the situation by dividing Category 1 insured persons into the elderly in the first term (aged 65-74) and the elderly in the second term (aged 75 or older). (Figure 6)

As a result, the number of certified first-term elderly aged 65 to 74 years old remained flat or declined gradually after reaching its highest number (approximately 756,000) in FY2015, reaching approximately 727,000 in FY2019, a decrease of approximately 3.9% from FY2015. On the other hand, the number of people certified as requiring long-term care (support) among the late-stage elderly aged 75 and over expanded almost along with each year, reaching the highest number (approximately 5,831,000) in FY2019.

In the previous issue of Policy Research Institute News (No. 64) ²⁾, the author introduced that the Japan Geriatrics Society and the Japan Geriatrics Society proposed a new definition of the elderly in March 2017. The new definition defines the elderly as those aged 75 or older and the associate elderly as those aged 65 to 74, since the appearance of age-related changes in physical and psychological functions is delayed by 5 to 10 years compared to 10 to 20 years ago, and the majority of the elderly, especially those aged 65 to 74, maintain their physical and mental health and are capable of active social activities. ⁽¹¹⁾ The results of this study also support this new definition, and it seemed necessary to at least treat the Category 1 insured persons separately by age group. Therefore, from this point onward, we proceeded with our examination by dividing them into three groups: (1) the 40-64 age group (Category 2 insured persons), (2) the 65-74 age group (Category 1 insured persons who fall under the elderly in the first term), and (3) the 75 and over age group (Category 1 insured persons who fall under the elderly in the latter term). It should be noted that the Category 1 insured in (2) and (3) applies to all citizens aged 65 and over, while the Category 2 insured in (1) refers only to medical insurance enrollees suffering from specified diseases and does not mean all citizens aged 40 to 64. (Figure 2)

5. status of the elderly as viewed by complementary index of healthy life expectancy

While the previous chapter reviewed the number of people certified as requiring long-term care (or support), this chapter examines the situation of the elderly based on the number of people certified as "requiring long-term care 2 or more," which is defined as "unhealthy" in the complementary index of healthy life expectancy. First, Figure 7 shows the annual changes in the "number of persons certified as requiring nursing care 2 or more," divided into three groups.

Among Category 2 insured persons (medical insurance subscribers aged 40 to 64 with specified diseases), the "number of persons certified as requiring long-term care 2 or more" was the highest in FY2007 (about 99,400) and then gradually declined, reaching 74,900 in FY2019, a decrease of about 24.7% from FY2007. In addition, the number of people certified as requiring long-term care (support) was down approximately 23.4% from the number certified as requiring long-term care 2 or more (approximately 97,700) in FY2011, which was the largest number of people certified as requiring long-term care (support).

Among the Category 1 insured persons (the elderly in the first term: citizens aged 65-74), the "number of persons certified as requiring long-term care 2 or more" was the highest in FY2014 (approximately 367,000), and then leveled off or declined gradually to approximately 357,400 in FY2019, a decrease of 3.4% from FY2014. In addition, the number of people certified as requiring nursing care (support) was down about 3.2% from the number certified as requiring nursing care 2 or more (about 369,100) in FY2015, which was the largest number ever certified.

Among Category 1 insured persons (late-stage elderly: citizens aged 75 and over), the "number of persons certified as requiring long-term care 2 or more" increased almost year by year, reaching the highest number (approximately 3,023,600) in FY 2019.

The "number of persons certified as requiring long-term care 2 or more" showed different trends in each of the three groups, but the population numbers fluctuated from year to year. Therefore, in order to adjust for the fluctuation in the population, the "ratio of the number of persons certified as requiring long-term care 2 or more" was calculated by dividing the number of persons certified as requiring long-term care 2 or more by the estimated annual population corresponding to the age of each of the three groups. The results for the three groups are shown in Figure 8.

As a result, it is clear that the trend of the "ratio of persons requiring long-term care 2 or more to the population certified" is different from that of the "number of persons requiring long-term care 2 or more.

For the No. 2 insured, adjustment was made based on the estimated population aged 40-64. The "ratio of "persons requiring long-term care 2 or more certified vs. the population" was the highest in 2007 (about 0.232%) and then gradually decreased, reaching about 0.177% in 2019, a decrease of about 23.6% from the 2007 level. This group showed a similar trend to that of the "number of persons certified as requiring nursing care 2 or more".

Adjustment was conducted for the first group of insured persons (the elderly in the first term) based on the estimated population aged 65-74. The "ratio of "persons requiring long-term care 2 or more to the population certified" was the highest in 2007 (about 2.415%) and then gradually decreased, reaching about 2.054% in 2019, a decrease of about 14.9% from the 2007 level. In this group, compared to the change in the "number of persons certified as requiring long-term care 2 or more," the highest number of years fluctuated from FY 2014 to FY 2007, and the rate of decrease from the highest number of years to FY 2019 also expanded, making the downward trend more clear.

Adjustments were made for the estimated population aged 75 and over for the No. 1 insured population (late-stage elderly). The "Percentage of population certified as needing long-term care 2 or more vs. the population" showed the highest number (about 17.115%) in FY 2014 and then leveled off or declined slowly to about 16.352% in FY 2019, a decrease of about 4.5% from FY 2014. In this group, the "number of people certified as needing care 2 or more" expanded with each year, but the "ratio of people certified as needing care 2 or more to the population" showed a different trend after FY2014, showing a flat or gradual decrease.

In recent years, the aging rate (the percentage of the population aged 65 and over) has continued to rise, and it seems necessary to consider the "number of persons certified as requiring long-term care 2 or more" (i.e., the status of healthy life expectancy as seen in the complementary index) by distinguishing between those attributable to the number of people in need of care and those attributable to their health status. The recent study focusing on the "ratio of people certified as requiring long-term care 2 or more to the population" suggests that the health status of the 40-74 age group is moving in the right direction, and that the health status of the 75 and older age group may also be maintaining or improving. At the very least, the results support the importance of examining the elderly separately by age group, rather than taking a one-size-fits-all approach.

6. main causes of the need for long-term care

In this chapter, the main causes of the need for long-term care are examined based on data from the National Survey of Basic ^Living13)14). The National Survey is conducted every three years by the Ministry of Health, Labour and Welfare (MHLW) for the purpose of surveying basic matters of national life such as health, medical care, welfare, pensions, and income, etc. The most recent survey results are available for the fiscal year 2028. The most recent results of the survey are available in the year 2022. The data of the Nursing-Care Survey shows the number of representative ^diseases16) per 100,000 persons in need of nursing care by age group as the "main causes of the need for nursing ^care15). Therefore, it should be noted that the extraction rate per population changes every year, making strict comparison of the number of causes of long-term care between years difficult.

In the following sections, annual changes in the number of major causes of the need for nursing care (representative diseases, etc.) are shown for each age group, divided into three groups. In addition, the composition ratios for each year were examined in order to better grasp the weight of each cause.

6-1. main cause of need for long-term care among Category 2 insured persons (aged 40-64)

Figure 9 shows the status of the main causes of the need for nursing care among those aged 40-64 who fall under the category 2 insured.

The number of major causes (including other diseases) that resulted in the need for long-term care (hereinafter referred to as "number of causes") among those aged 40-64 years who fall under the category 2 insured persons showed a downward trend after reaching the highest number (5,215 persons) in 2004, and reached 3,424 persons in 2019. (Figure 9-a)

Cerebrovascular diseases (stroke), joint diseases (rheumatism, etc.), and Parkinson's disease accounted for a high percentage of the total, indicating the importance of these three diseases in the certification of long-term care for those aged 40-64. (Figure 9-b) In particular, cerebrovascular diseases (stroke) accounted for a large proportion at around 60%, and although the number of causes tended to decrease, the composition ratio showed a gradual increasing trend. In addition to cerebrovascular diseases (stroke), which still account for a high proportion of the total, measures against joint diseases (rheumatism, etc.) and Parkinson's disease are important for those aged 40-64 years. The results of the survey also indicated the importance of measures against other diseases (other diseases, etc.). In addition, the number of causes of diseases other than the representative diseases (other diseases) has been increasing, and close examination of these diseases was also considered important.

6-2. main causes of the need for long-term care among the Category 1 insured (elderly in the first term: 65-74 years old)

Figure 10 shows the main causes of the need for nursing care among those aged 65-74 years who fall into the category of Category 1 insured persons (elderly in the first term).

The number of major causes (including other diseases) per 100,000 persons requiring nursing care among those aged 65-74 who fall under the category 1 insured persons (elderly in the first term) showed a decreasing trend after reaching the highest number (17,545) in 2004, and reached 10,383 in 2019. (Figure 10-a)

In terms of composition, cerebrovascular diseases (stroke) and joint diseases (rheumatism, etc.) accounted for 40% and 10% of the total, respectively, followed by diabetes, fractures and falls, malignant neoplasms (cancer), dementia, and Parkinson's disease, which were almost parallel in 2019 at around 7% to 6%. (Figure 10-b)

In particular, the number of causes of cerebrovascular disease (stroke) showed a decreasing trend over the years, but in recent years, there were scattered signs of a bottoming out. The composition ratio remained flat at around 40%, indicating the importance of cerebrovascular disease (stroke) countermeasures. The results also suggest that a wide range of disease countermeasures are required for the 65-74 age group. A certain number of people were certified for long-term care due to causes other than the typical diseases (other diseases), and close examination of these cases was also considered important.

6-3: Main causes of the need for long-term care among Category 1 insured persons (aged 75 and over)

Figure 11 shows the main causes of the need for long-term care for those aged 75 and over who are Category 1 insured persons (late-stage elderly).

The number of major causes (including other diseases) per 100,000 persons requiring long-term care among those aged 75 and older who fall under the category 1 insured persons (late-stage elderly) has shown a consistent upward trend since FY2001, reaching 82,709 in 2019. (Figure 11-a)

In terms of composition, there were considerable differences from the other two groups. Dementia showed an increasing trend over time, with the largest share of over 20% in recent years. Frailty due to old age and fractures/falls followed at around 10% and 50%, respectively. Cerebrovascular disease (stroke) accounted for almost all of the decline over time, falling to the low 10% range in recent years, and these four diseases appeared to be important in the certification of care for those aged 75 and older.

In particular, the proportion of dementia showed a consistent upward trend, suggesting that measures against dementia are of paramount importance in the certification of long-term care for persons aged 75 and older. The proportion of fractures and falls also showed a gradual but increasing trend, suggesting that countermeasures against these diseases are also important. The proportion of debility due to old age showed a flat to slightly decreasing trend, while the proportion of cerebrovascular disease (stroke) showed a clear decreasing trend.

In the above, we have examined the main causes (representative diseases, etc.) of the need for long-term care by dividing the long-term care insured into three groups according to age group. It should be noted that the number of major causes of the need for long-term care (including other diseases) is the number per 100,000 persons requiring long-term care, and thus reflects the effect of population changes in each age group. However, the number of respondents who were insured in the second category (aged 40-64) and the first category (aged 65-74) showed a relatively decreasing trend, while the number of those who were insured in the first category (aged 75 and older) showed an increasing trend. Although the condition is different from that of "those who need nursing care 2 or more," in the previous chapter, we noted that the health status of the 40-74 year olds was improving and that the health status of the 75+ year olds may also be maintaining or improving. The main causes of the need for long-term care were

Examination of the main causes of the need for long-term care in terms of composition showed distinctive results for each of the three groups. Parkinson's disease among the No. 2 insured (aged 40-64) and dementia among the No. 1 insured (late-stage elderly: aged 75 and over) were particularly distinctive. Cerebrovascular disease (stroke) accounted for a higher percentage in the younger age groups, indicating the importance of countermeasures. The importance of examining the elderly not in a uniform manner, but by age group, was thought to continue to be supported in the major causes of the need for long-term care.

7. consideration of drug contribution to the main causative diseases requiring long-term care

In the National Survey of Family Life, there are references to the main causes (representative diseases, etc.) of the need for long-term care (hereafter referred to as "main causative diseases"), but there are no data that examine the main causative diseases in depth, and the impact of drugs is unknown. Therefore, we decided to infer the impact of drugs on the main causative diseases by comparing and referencing the results of the "Medical Needs Survey on 60 Diseases (6th) [Analysis] ¹⁷⁾ " ("Medical Needs Survey") of the Human Science Foundation ("HS Foundation"), which examined drug contribution and treatment satisfaction for the diseases. The Medical Needs Assessment has been conducted since FY1994.

The Medical Needs Assessment is a fixed-point survey conducted approximately every five years from FY1994 to FY 2019, in which physicians and others were surveyed regarding their satisfaction with the contribution of drugs and treatment for 60 socially important diseases. Figure 12 shows the status of the main causes of the need for nursing care for those aged 40 years and older. In addition to the number of major causes of the need for long-term care, we also present the trends of the most important causes. The composition ratios of the main causes of the need for long-term care are also presented.

As a result, the total number of major causes of the need for nursing care (including other diseases) is almost 100,000, although it fluctuates slightly due to the exclusion of responses such as "don't know" and "unspecified. Cerebrovascular disease (stroke) was the leading cause in 2001 with 27,960 cases, but declined over time to 16,095 cases in 2019, a 41.9% decrease from 2001. On the other hand, dementia showed an increasing trend from 10,742 in 2001 to 17,578 in 2019, becoming the leading cause since 2016, with an increase of 63.6% since 2001 (Figure 12-a). accounted for 28.8% in 2001, but declined over the years to 18.4% in 2019. The rate of decline was 36.0%. On the other hand, dementia increased from 11.2% in 2001 to 20.1% in 2019. The rate of increase was 80.1%. (Figure 12-b) The individual trends for the two particularly important causes of the disease are as described above. (Figure 12-c)

The trends in the results of the HS Foundation Medical Needs Assessment for these two particularly important causes are shown in Figure 13.

Cerebrovascular disease (stroke) was determined to correspond to cerebral hemorrhage (including subarachnoid hemorrhage) ¹⁸⁾ ("cerebral hemorrhage") and cerebral infarction in the HS Foundation Medical Needs Assessment. For these two diseases, drug contribution and treatment satisfaction showed almost steady trends. In FY2000, the drug contribution was 36.9% for cerebral hemorrhage and 34.0% for cerebral infarction, rising to 63.5% and 76.5%, respectively, in FY 2014. However, they dropped to 47.4% and 63.1% in FY 2019.

Satisfaction with treatment increased from 24.1% for cerebral hemorrhage and 20.2% for cerebral infarction in FY2000 to 63.6% and 66.1%, respectively, in FY2019. (Figure 13-a) Cerebrovascular disease (stroke) as the main cause of the need for long-term care is on a downward trend, as mentioned earlier. (Figure 12-c) Of course, the improvement in prognosis due to therapeutic intervention such as surgery and rehabilitation is thought to be largely responsible, but it was inferred that the improved drug contribution for cerebral hemorrhage (including subarachnoid hemorrhage) and cerebral infarction, which was observed in the HS Foundation Medical Needs Survey around the same period, may have contributed to the decline in the certification of long-term care. In other words, it was inferred that the improvement in the contribution of drugs for cerebral hemorrhage (including subarachnoid hemorrhage) and cerebral infarction may contribute to healthy life expectancy as measured by the complementary index.

For dementia, we determined that Alzheimer's disease and vascular dementia from the HS Foundation Medical Needs Assessment would be addressed. For these two diseases, the drug contribution and treatment satisfaction were steadily increasing, but the extent of the increase was low. Drug contribution was as low as 9.9% for Alzheimer's disease and 10.0% for vascular dementia in FY2000 and 43.8% and 42.9%, respectively, in 2014, but dropped to 25.5% and 27.5% in FY 2019. Treatment satisfaction was extremely low at 3.9% for both diseases in FY2000 and increased over time, but remained at low levels of 21.1% and 30.2% in FY2019. (Figure 13-b) Dementia as the primary cause of the need for long-term care is on the rise, as noted above. (Figure 12-c) It was inferred that the stagnation in the drug contribution of Alzheimer's disease and vascular dementia observed in the HS Foundation Medical Needs Survey at about the same time may not have contributed to the certification of long-term care. In other words, it was inferred that the stagnation of drug contribution in Alzheimer's disease and vascular dementia may not have a positive impact on healthy life expectancy as measured by the complementary index.

8. summary

The health status of the elderly and those aged 40-64 was examined over time and by age group, based on long-term care data, which is considered to be the most valid complementary indicator of healthy life expectancy. In examining the "number of persons certified as requiring long-term care 2 or more," we found a trend of flat or gradual decline in the number of certifications among the elderly aged 65-74. The "ratio of the number of persons requiring long-term care 2 or more certified to the population" was examined in order to adjust for changes in the number of persons in the population. The results suggest that the health status of those aged 65-74 is trending in a positive direction, and that the health status of those aged 75 and older may also be maintaining or improving. At the very least, the study seemed to have presented the importance of examining the elderly by age group, rather than taking a uniform view of the elderly.

In addition, using data from the National Survey of Living Conditions, we examined the main causes of the need for long-term care (e.g., typical diseases). The number of major causes of the need for nursing care (including other diseases) showed a relative downward trend for those aged 40-74 and an upward trend for those aged 75 and over, although it should be noted that the number per 100,000 persons in need of nursing care reflects the effect of population changes in each age group. The results of the composition of the main causes of the need for nursing care were distinctive for each of the three age groups: cerebrovascular disease (stroke) accounted for a large proportion of those aged 40-64, at around 60%, followed by joint diseases (rheumatism, etc.) and Parkinson's disease, which accounted for less than 10%. Among those aged 75 and over, dementia accounted for the largest proportion at more than 20%, followed by debility due to old age and fractures/falls at around 15%, and cerebrovascular disease (stroke) at the low end of the 10% range. The proportion of cerebrovascular disease (stroke) dropped to the first half of 10%. The present study also demonstrated the importance of examining the elderly by age group.

In the study to infer the effect of drugs on the annual changes in the major causes (representative diseases, etc.) of the need for long-term care in the National Survey of Health Care Needs, the results of both surveys were relatively similar for cerebrovascular disease (stroke) and dementia, but the results of the two surveys were different in terms of the number of people who needed long-term care. The study was limited to a simple comparison of results by age group, and it was difficult to examine the relationship between the health status of the elderly and the contribution of drugs through caregiver data, which is considered to be the most appropriate complementary indicator of healthy life expectancy. As a previous study focusing on the relationship between specific injuries and illnesses and healthy life expectancy, the findings of Myojin et al. are introduced in the "Report of the Study Group of Experts on Healthy Life ^Expectancy6). The study used data from the National Survey of Living Conditions (2007, 75,986 subjects aged 12 years or older) and conducted a logistic regression analysis with "limitation of daily life," the main indicator of healthy life expectancy, as the explained variable and 38 types of injuries and diseases as the explanatory variables. Odds ratios and population contribution ratios were calculated for each injury. （Although the data are for 2007 only (Table 1), the impact of each injury and disease on the main indicator of healthy life expectancy is examined, and it is very interesting to see what the trends would be if we looked at annual trends. The author's study looked at annual trends in three age groups for complementary indicators, and although the perspectives are different, they are similar in that they both indicate the need to examine the impact of each injury and disease on healthy life expectancy. Furthermore, if the impact of drugs on each injury or disease is clarified for each age group, it may provide more useful information on the contribution of the pharmaceutical industry to healthy life expectancy.

Recently, in addition to disease receipt data from the National Database of Diseases (NDB) and information on nursing care requirements and nursing care receipts from the Long-Term Care Database, a consolidated analysis of the DPC database is in the works. ¹⁹⁾ Information obtained from these databases, including injury and disease names, medications, tests, etc., information on nursing care requirements, nursing care expenses, etc., can be analyzed by year and by age group. (19) By examining data by year and age group obtained from these databases, the health status of the elderly can be analyzed more scientifically, and in addition to the impact on medical costs, the impact on nursing care costs and the contribution of drugs can also be examined more precisely. We hope that this will be realized at an early stage and lead to more effective measures and drug development that will contribute to extending healthy life expectancy.

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