Kakiuchi et al. Environmental Health and Preventive Medicine (2019) 24:76 Environmental Health and https://doi.org/10.1186/s12199-019-0838-0 Preventive Medicine SHORT COMMUNICATION Open Access The importance of the rate of pure “attended deaths at home” for objective outcome indicator for assessing the prevalence of home care in Japan Yasuhiro Kakiuchi* , Ryoko Nagao, Eriko Ochiai, Yu Kakimoto and Motoki Osawa Abstract Background: No study has yet been performed on the importance of the rate of pure “attended deaths at home,” excluding examined deaths subjected to a postmortem examination. Therefore, in the present study, we investigated actual state of pure “attended deaths at home,” in order to provide reference data for the future development of end- of-life care at home. Methods: We performed a detailed survey in Yokohama City according to the type of death, age, and underlying cause of death in cases of home deaths, based on the detailed version of the Vital Statistics Survey Death Forms. Then, we divided deaths occurring in each municipality in Kanagawa Prefecture into two categories: “examined deaths” or “attended deaths,” which were also stratified by the place of death, based on the Vital Statistics, and data on number of death cases subjected to postmortem examination from the Kanagawa Prefectural Police Headquarters. Results: In 2013, the survey in Yokohama City showed large differences in age distribution and cause of death between examined and attended deaths. In 2014, home deaths accounted for 15.7% of all deaths in the prefecture, whereas the overall proportion of attended deaths at home was 6.9%. Conclusions: We should utilize the rate of pure “attended deaths at home” for objective outcome indicator. Keywords: End-of-life care at home, Super-aging society, Vital Statistics, Regional death investigation system, Police department data Background Currently, there are an insufficient number of hospital Spending the last stage of life in a desired location is an beds to accommodate the hundreds of thousands of dying important element of achieving a desirable death for most people that will require them in the future. This has people [1]. According to a previous study, approximately caused a concern that “end-of-life care refugees” will 50% of Japanese citizens hoped to die at home [2]. Despite emerge as a social problem. To cope with this problem, this, the proportion of home deaths in Japan was only the Japanese healthcare delivery system must conceive a 13.0% in 2016 [3], which indicates a considerable great system whereby people can spend the last stage of their discrepancy between what Japanese citizens desire and lives where they wish, without fear—not only in hospitals, their actual place of death. In line with the current rate of but also at home. aging of the Japanese population, the number of deaths in Several reports on the factors associated with home Japan is estimated to reach 1.6 million in 2030. Mean- death have already been published, not only in Japan but while, the number of hospital beds is being increasingly also overseas [5–11]. One of them showed that these limited to reduce medical care costs in Japan [4]. factors can be broadly classified as disease-associated, personal, and environmental [5]. * Correspondence: [email protected] However, the target of previous studies—that is, the Department of Forensic Medicine, Tokai University School of Medicine, number of people achieving a “home death”—included Shimokasuya 143, Isehara, Kanagawa 259-1193, Japan © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kakiuchi et al. Environmental Health and Preventive Medicine (2019) 24:76 Page 2 of 6 those who chose to die at home and were receiving that occurred in each municipality except for Yokohama home care and other medical services, as well as those of Kanagawa Prefecture according to the place of death who unexpectedly die at home (e.g., solitary deaths) and from the Vital Statistics Survey, which are publicly avail- are subjected to postmortem examination by medical ex- able at the portal site of the Census and Statistics De- aminers. For example, a survey conducted by the Tokyo partment of the Japanese government (E-STAT). In Medical Examiner’s Office revealed that 40.7% of home addition, we retrieved data on the number of death cases deaths occurring in the wards of Tokyo were solitary subjected to postmortem examination according to place deaths [12]. Thus, it would be more appropriate to ex- of death from the police stations in each region of Kana- clude unexpected deaths, when conducting ecological gawa Prefecture except for Yokohama, with the cooper- correlation analysis on the medical factors associated ation of the Coroner Office at the Kanagawa Prefectural with home death. However, in Japan, data on cases of Police Headquarters. unexpected deaths subjected to medical examination by medical examiners at home are possessed only by the Types of death police and are not disclosed to the public. In addition, Deaths in Japan are generally divided into “attended” these data are not generally shared with other adminis- and “examined” (i.e., un-attended) deaths, based on the trative departments (e.g., healthcare and welfare depart- type of postmortem examiner. When the cause of death ments). Therefore, in the present study, we investigated is found to be an obvious disease, it is regarded as the actual state of pure “attended deaths at home,” in “attended,” and the death certificates are prepared by order to provide reference data for the future develop- general physicians. On the other hand, when the cause ment of healthcare policies. of death is not immediately found to be a disease, it is not regarded as an attended death but an “examined” Materials and methods one, and the death certificates are prepared by medical Study area examiners, and there is also a police investigation. In The study area was Kanagawa Prefecture, which is adjacent other words, cases in which medical examiners prepared to Tokyo Metropolis and is located in the southern part of death certificates are regarded as “examined” deaths, Kanto region in Japan. The prefecture has a total population whereas cases in which general physicians prepared the of over 9 million and includes three big cities, Yokohama, certificates are regarded as “attended” deaths (i.e., pure Kawasaki,andSagamihara.YokohamaCityhasthesecond natural death). We further sub-divided examined deaths largest population in Japan, following Tokyo. into “pure unnatural deaths” (i.e., homicide, suicide, accidental deaths [e.g., falling and drowning], and deaths Data sources from unknown causes) and “suspected unnatural deaths” Yokohama City (i.e., deaths subjected to postmortem examination be- In 2013, we formally requested use of the detailed ver- cause it is either a solitary one or because of another sion of the Vital Statistics Survey Death Forms of Yoko- reason; the cause of these deaths is ultimately deter- hama citizens from the Ministry of Health, Labour and mined to have been a disease). Welfare (MHLW), in accordance with Article 33 of the Statistics Act. The personal information of the included Statistical analysis cases was anonymized, de-identified, and delivered to The detailed version of the Vital Statistics Survey Death the Medical Care Bureau of Yokohama City, with details Forms of Yokohama citizens in 2013 were divided into regarding type of death, age, and underlying cause of examined (subdivided into pure and suspected unnat- death. This special survey was conducted only in Yoko- ural) and attended deaths as stated above. The type of hama City, which funded the survey independently and death, age, and underlying cause of death were cross- held sole responsibility. In other words, no other muni- tabulated in cases of home deaths. Pearson’s χ2 test was cipality in Kanagawa Prefecture apart from Yokohama used to evaluate differences in the proportion of deaths has conducted a special survey such as this, mainly from “cardiac disease” or “malignant neoplasm” between owing to the budgetary and manpower restrictions of the attended and suspected unnatural death groups each municipality. among the elderly aged 75 and above. The significance level was defined at 5%. SPSS Statistics 19 (IBM, Tokyo, Kanagawa Prefecture Japan) was used for all the analyses. For the reason stated above, we were unable to obtain We divided deaths occurring in each municipality in detailed information about type of death, age, and Kanagawa Prefecture in 2014 into two categories: “exam- underlying cause of death from any other municipality ined deaths” and “attended deaths,” according to the def- in Kanagawa Prefecture except for Yokohama. There- inition as stated above. Death cases were also stratified fore, in 2014, we obtained data on the number of deaths by the place of death. The “proportion of home deaths” Kakiuchi et al. Environmental Health and Preventive Medicine (2019) 24:76 Page 3 of 6 was defined as the ratio of the number of home deaths shows the detailed underlying causes of death by age to the total number of deaths, while the “proportion of group among two of the three groups (because all deaths attended deaths at home” was defined as the ratio of the in the unnatural death group would naturally include ex- number of attended deaths at home to the total number ogenous deaths and deaths from unknown causes, we do of deaths.