Yonago Acta medica 2014;57:103–107

Original Article

Relationship between Health-Seeking Behavior by Basic Health Examination and
Subsequent Health Expenditure among Remote Island Inhabitants of Japan
Aya Kinjo, Yoshinori Myoga and Yoneatsu Osaki
Division of Environmental and Preventive Medicine, Department of Social Medicine, School of Medicine, Tottori University Faculty of
Medicine, Yonago 683-8503, Japan

ABSTRACTThis examination includes anthropometric measurements, blood pressure, laboratory tests, electrocardiography, fundoscopy and physical examination by a doctor.
Since revision of the law in 2008, disease prevention
and containment of health care costs for the elderly by
early detection of illnesses are emphasized as the rolesof the basic health examination.1 However, there is still
no convincing evidence that undergoing the basic healthexamination in the prime of life reduces the explosionof health care costs in the elderly. Many previous studies performed in Japan have shown that in areas with ahigh percentage of residents undergoing the basic healthexamination, per capita health care costs are lower.2–9
However, other studies that compared health care expenditure between participants and nonparticipants inthe basic health examination have not consistently founda relation with lower costs,10–14 possibly as a result ofdifferences in the age of the subjects and the observation period, calculation of health care costs as mean ormedian values, and differences of access to medical resources among the regions studied. Accordingly, to evaluate the association between undergoing the basic healthexamination and health care expenditure 10 to 12 years,
we compared health care costs between participants andnonparticipants in the basic examination among persons
aged 40 to 64 years old living on a remote Japanese island.

BackgroundConvincing evidence has not been obtained as to whether having a basic health examinationin the prime of life inhibits the surge of health expenditure in old age.
Methods Data sources: Data on participants in thebasic health examination from 1996 to 2000 among residents of a remote island in Japan, and individual healthcare expenditure data from March 2005 to February
2008. Study design: A community-based retrospective
study. Data collection: Japanese residents who weresubscribers to the National Health Insurance Scheme of
Chibu Town from March 1996 to March 2007 and wereaged 40 to 64 years in March 1996 (n = 179) were divided into 3 groups depending on the frequency of participating in the basic health examination over 5 years: 0
times (nontakers), 1 to 3 times (occasional takers), or 4 to
5 times (regular takers). The distribution of total healthexpenditure according to the frequency of having a basic
health examination was determined, and the CochraneArmitage test was used for comparison.
Results Nontakers formed the highest proportion ofsubjects with low expenditure (0–200,000 yen) (nontaker,
occasional, regular: 38.5%, 24.1%, 23.5%; P = 0.002),
and also accounted for the highest proportion of subjects
with high expenditure (> 1,400,000 yen) (33.3%, 16.1%,
9.4%; P = 0.004).
Conclusion Persons not participating in health examinations during middle age include a group with highfuture health care expenditure.

SUBJECTS AND METHODS
Subjects

We performed this study on a remote Japanese island,
Chiburijima (administrative center: Chibu Town, Oki
County, Shimane Prefecture), which is one of the Oki Islands and is located about 40 km from the mainland. In
June 2007, the population was 666 and 44.7% were aged
65 years or older. The medical resources consist of one
municipal clinic without beds and a dental clinic. For
diseases requiring secondary medical care, patients aretransported to a hospital on a neighboring island or tothe mainland. The subjects were 179 local residents who
belonged to the National Health Insurance Scheme of
Chibu Town from March 1996 to March 2007 without
interruption and were age from 40 to 64 years in March
1996. Co-serial numbers were used to combine indi-

Key words

basic health examination; health expenditure; Japan; middle age; rural health
In Japan, a basic health examination (also translated into
English as the “general health examination” or “healthcheckup” in other reports) has been provided for persons
aged 40 years or older since 1963 by local governments.
Currently, this is done under the Act for Assurance ofMedical Care for Elderly People, which was promulgated in 1982 to maintain the health of elderly persons.
Corresponding author: Aya Kinjo, MD, PhD
kinjo_aya@med.tottori-u.ac.jp
Received 2014 May 15
Accepted 2014 June 17103

A. Kinjo et al.

Fig. 1. Distribution of individual
health expenditure according tofrequency of having a basic healthexamination.

vidual data from basic health examinations and healthexpenditure. Researchers used only anonymous data.
The study protocol was reviewed and approved by the
Ethics Committee of Tottori University (approval number: 1226).

erated by each medical institution every month, even if
a patient consults 2 or more doctors in that month. If apatient attends doctors at different medical institutions ina month, multiple invoices are generated. Therefore, theamounts on all invoices were totaled on an individual
basis.

Identifying the frequency of health examination

The frequency of each subject undergoing the basic
health examination during 5 years from 1996 to 2000
was determined from the basic health examinee lists of
Chibu Town and the subjects were divided into 3 groups
depending on the frequency of undergoing the examination: the nontaker group had no examinations over 5
years, the occasional taker group had 1 to 3 examinations and the regular takers had 4 to 5 examinations.

Statistical analysis

We compared the total health expenditure over 3 years
from 2005 to 2007 and the frequency of undergoing
the basic health examination over 5 years from 1996
to 2000. The total health expenditure of each subject
in relation to the frequency of undergoing the healthexamination is shown in Fig. 1. Based on total healthexpenditure, patients were divided into 3 categories: expenditure of ≤ 200,000 yen over 3 years was defined as
low health expenditure, from 200,000 yen to 1,400,000
yen was moderate expenditure, and > 1,400,000 yen
was high expenditure. (For reference, the average annual salary in Japan was about 4,400,000 yen in 2006.)
The Cochrane-Armitage test was used to compare theDetermining individual medical costs

To determine the medical costs, the National Health
Insurance invoices of Chibu Town were used to calculate the total health expenditure from March 2005 to
February 2007 for each subject. A single invoice is genTable 1. Charactristics of participants

NumberAge in 1996 (years old)Male
FemaleFrequency of basic health examination for 5 years
Nontaker group
Occasional taker group

Regular taker group

Total

39		
54.1 ± 6.4
28 (71.8%)
11 (28.2%)

53		
55.1 ± 6.3
16 (30.2%)
37 (69.8%)

179
54.0 ± 6.7
84 (46.9%)
95 (53.1%)

87		
53.2 ± 7.1
40 (46.0%)
47 (54.0%)

Age in 1996 presented mean ± SD. Male and Female showed the number of people.
* Student t-test.
† χ2 test.

104

P value
0.291*< 0.001†

Health-seeking behavior and expenditure
Table 2. The proportions of individuals involved in each frequency groups of taking basic health examination according to sex and 3 health expenditure categories
Health Expenditure category (yen)LowModerate
0–200,000
200,001–1,400,000

High1,400,001–

All

Nontaker group [39]Occasional taker group [87]Regular taker group [53]Total [179]P value15 (38.5%)
21 (24.1%)
6 (11.3%)
42 (23.5%)
0.002

11 (28.2%)
52 (59.8%)
42 (79.2%)
105 (58.7%)< 0.00113 (33.3%)
14 (16.1%)
5 (9.4%)32 (17.9%)
0.004

Male

Nontaker group [28]Occasional taker group [40]Regular taker group [16]Total [84]P value

12 (42.9%)
11 (27.5%)
3 (18.8%)
26 (31.0%)
0.079

8 (28.6%)
23 (57.5%)
12 (75.0%)
43 (51.2%)
0.002

8 (28.6%)
6 (15.0%)
1 (6.2%)15 (17.9%)
0.051

FemaleNontaker group [11]Occasional taker group [47]Regular taker group [37]
Total [95]P value

3 (27.3%)
10 (21.3%)
3 (8.1%)16 (16.8%)
0.067

3 (27.3%)
29 (61.7%)
30 (81.1%)
62 (65.3%)
0.001

5 (45.5%)
8 (17.0%)
4 (10.8%)
17 (17.9%)
0.021

P value with Cochran-Armitage test among 3 group divided by the frequency of basic health examination for 5 years at each medical expenditure categories. Total medical care expenditure for 3 years from 2005 to 2007 was adopted.

number of subjects in each health expenditure category
among the health examination groups. Student’s t-test
was employed to compare age among the health examination groups, while the chi-square test was performed
to compare the proportion of men and women among
these groups. The mean health expenditure was calculated as the total health expenditure over 3 years in eachgroup divided by the number of subjects in that group.
Statistical analysis was performed with Microsoft Excel
and the SPSS 16.0 statistical software package (SPSS,
Chicago, IL), with P < 0.05 being considered significant.

jects who had more examinations were more likely to
be in the moderate expenditure group, while those withfewer examinations formed a high proportion of the highexpenditure group. Both men and women showed similar results.
Among men, the average total health care expenditure over 3 years was 1,022,658 yen for nontakers,
830,793 yen for occasional takers and 848,254 yen forregular takers. Among women, the average total healthcare expenditure over 3 years was 1,164,339 yen for non-

RESULTSThe baseline characteristics of the subjects in 1996 areshown in Table 1. There was no significant differenceof age among the 3 health examination groups. The
proportion of men was significantly higher than that ofwomen in the nontaker group (P < 0.001, Table 1). The
distribution of total health care expenditure is shownaccording to the frequency of basic health examinationin Fig. 1. The nontakers formed the largest proportionof the low expenditure group, regular takers were thelargest proportion of the moderate expenditure group
and nontakers were predominant in the high expendituregroup.
The proportion of subjects in each basic health examination group stratified according to sex and healthexpenditure category is shown in Table 2. Subjects who
had fewer examinations were more likely to be in the
low expenditure group, although not significantly. Sub-

Fig. 2. Total health expenditure for 3 years per capita according to
the frequency of having a basic health examination.

105

A. Kinjo et al.

takers, 1,010,922 yen for occasional takers and 805,002
yen for regular takers (Fig. 2).

ease was detected. The study also showed that inpatient
health care expenditure tended to be higher for nontakers, although the difference was not significant, so nontakers may include a high-risk population that requires
expensive health care. In the present study, the nontakermen with a high health care expenditure had hypertension or diabetes and developed complications such as
cardiovascular disease or stroke requiring hospitalization. For disease prevention, intervention targeting highrisk nontakers is required. If health care expenditure had
been compared on the basis of average or median values,
the difference of distribution according to the frequencyof examination might have been missed. Also, healthcare expenditure was assessed either at the same time as
the basic examination11–13 or up to a few years it in mostother studies,10, 13, 14 and few studies allowed a long period from examination to assessment of expenditure. The
present results suggested that participation of middleaged people in the basic health examination was related
to lower health care expenditure not only just after examination, as reported by previous studies, but also after
10 years.
There were several limitations of this study. First,
the study population was so small that the age of eachhealth care expenditure category did not match. Therefore, the subjects were limited to those 40 to 64 years
old. There was no significant age difference among theexamination frequency groups. Second, the health andconsultation status of the nontakers in 1996 was not assessed. Individuals who visited hospital regularly might
not have needed the basic health examination and so
could have been included among the nontakers. Somestudies of basic health examination participants haveshown that the health status and the presence of lifestylerelated diseases increase future health expenditure.15–19
Third, there was no adjustment for lifestyle and interestin health. Some researchers have reported that smoking, drinking and regular exercise influence an increaseor decrease of health care expenditure.20–22 In anotherstudy, nontakers were divided into 2 groups according
to whether they saw a doctor regularly or not,23 and theresults suggested that bachelors and low-income earners
accounted for a higher proportion of the people who did
not undergo the basic health examination and did not see
a doctor. The nontakers in our study may have contained
both of these groups, suggesting that a social epidemiologic approach with improvement of socioeconomic status may be needed for the high-risk group of nontakers.
To adjust for these factors, a cohort study would be required, but it would be difficult to perform because most
nontakers refuse to cooperate. Despite these limitations,
we confirmed that the highest future expenditure was

DISCUSSION
We examined the relationship between the frequency
of undergoing the basic health examination from 1996
to 2000 and health care expenditure from 2005 to 2007
among the inhabitants aged 40 to 64 years living on aremote Japanese island. We found that nontakers werelikely to be in either the low or high expenditure group,
while occasional or regular takers were likely to be in
the moderate expenditure group. In addition, health expenditure per capita after 10 to 12 years was highest for
the nontakers. In other words, the nontakers included a
subgroup within which they required high health careexpenditure over time. Our results suggested that undergoing the basic health examination regularly increased
contact with medical services and reduced future medical costs per capita despite the high consultation rate
for this small island population with enthusiastic publichealth nurses.
In Japan, several community-based studies have already compared individual health care expenditure withthe frequency of undergoing the basic health examination.10–14 The common result of these studies was thatthe number of consultations was higher for examinees
than non-examinees. This is consistent with the present result that health care expenditure shifted from low
to moderate as the frequency of undergoing the basic
health examination increased. However, the results ofthese 5 studies on the relationship between participationin the basic health examination and health care expenditure did not correspond, and such differences may havebeen related to the distribution of medical expenditureaccording to the frequency of a basic health examinationthat we found in our study. We found 2 peaks (low andhigh) of health care expenditure among nontakers, so the
proportion of individuals with low or high expenditure
decreased and the proportion with moderate expenditure increased as the frequency of participating in thebasic health examination became higher. In some takers,
chronic diseases such as hypertension or diabetes weredetected during the basic health examination and they
subsequently attended a doctor regularly. As a result, theproportion of takers with moderate health care expenditure became higher. It has been reported that frequent
takers of the basic health examination show a significant increase of outpatient health care expenditure for a
5-year period after taking the examination.13 However,such findings regarding health care expenditure during this period after the basic health examination maylargely reflect the cost of new outpatients in whom dis106

Health-seeking behavior and expenditure

required by nontakers. Fourth, health care expenditure
was not examined in relation to the underlying diseases.
In contrast to cancer screening, however, the basic healthexamination is used to check for multiple diseases, so it
seemed appropriate to assess total health care expenditure.
In conclusion, our findings suggested that more frequent participation in basic health examinations reduced
the proportion of subjects with either low or high healthcare expenditure and increased those with moderate expenditure. In a small community, like the setting of thisstudy, the per capita health expenditure decreases as thefrequency of basic health examination increases.

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Acknowledgments: The authors would like to thank Ms Kumiko
Yamamoto, a public health nurse at the Chibu Town office, forperforming data collection.
The authors declare no conflict of interest.
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