Article Text

Regional health expenditure and health outcomes after out-of-hospital cardiac arrest in Japan: an observational study
  1. Yusuke Tsugawa1,
  2. Kohei Hasegawa2,
  3. Atsushi Hiraide3,
  4. Ashish K Jha1,4,5
  1. 1Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
  2. 2Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
  3. 3Department of Acute Medicine, Kinki University Faculty of Medicine, Osaka, Japan
  4. 4Harvard Global Health Institute, 42 Church Street, Cambridge, MA 02138
  5. 5Department of General Internal Medicine, Brigham and Women's Hospital and the Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
  1. Correspondence to Dr Yusuke Tsugawa; tsugawa{at}


Objectives Japan is considering policies to set the target health expenditure level for each region, a policy approach that has been considered in many other countries. The objective of this study was to examine the relationship between regional health expenditure and health outcomes after out-of-hospital cardiac arrest (OHCA), which incorporates the qualities of prehospital, in-hospital and posthospital care systems.

Design We examined the association between prefecture-level per capita health expenditure and patients’ health outcomes after OHCA.

Setting We used a nationwide, population-based registry system of OHCAs that captured all cases with OHCA resuscitated by emergency responders in Japan from 2005 to 2011.

Participants All patients with OHCA aged 1–100 years were analysed.

Outcome measures The patients’ 1-month survival rate, and favourable neurological outcome (defined as cerebral performance category 1–2) at 1-month.

Results Among 618 154 cases with OHCA, the risk-adjusted 1-month survival rate varied from 3.3% (95% CI 2.9% to 3.7%) to 8.4% (95% CI 7.7% to 9.1%) across prefectures. The risk-adjusted probabilities of favourable neurological outcome ranged from 1.6% (95% CI 1.4% to 1.9%) to 3.7% (95% CI 3.4% to 3.9%). Compared with prefectures with lowest tertile health expenditure, 1-month survival rate was significantly higher in medium-spending (adjusted OR 1.31, 95% CI 1.03 to 1.66, p=0.03) and high-spending prefectures (adjusted OR 1.30, 95% CI 1.03 to 1.64, p=0.02), after adjusting for patient characteristics. There was no difference in the survival between medium-spending and high-spending regions. We observed similar patterns for favourable neurological outcome. Additional adjustment for regional per capita income did not affect our overall findings.

Conclusions We observed a wide variation in the health outcomes after OHCA across regions. Low-spending regions had significantly worse health outcomes compared with medium-spending or high-spending regions, but no difference was observed between medium-spending and high-spending regions. Our findings suggest that focusing on the median spending may be the optimum that allows for saving money without compromising patient outcomes.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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