Regional Disparities in Rehabilitation Resources and Service Provision for Older Adults in Secondary Healthcare Regions: Analysis of a Large Health Insurance Claim Database in Japan

Abstract

Background

Regional health disparities have been reported in many countries, including Japan. As rehabilitation needs increase worldwide owing to population aging and the epidemiological shift from communicable to non-communicable diseases, addressing unmet rehabilitation needs is crucial.

Objective

To analyze and compare rehabilitation resources and service provision for older adults across secondary healthcare regions in Japan.

Design

A quantitative, analytical cross-sectional design was used in this study.

Methods

Nara Prefecture, a representative region in Japan comprising five secondary healthcare regions, was selected as the study setting. Data relevant to rehabilitation were obtained from routine national surveys and the Kokuho local government database for the period April 2019 to March 2020, and retrospectively analyzed as secondary data. The Kokuho database includes medical insurance claims for 213,933 residents aged ≥ 75 years, covering the entire prefectural population in this age group. A descriptive regional comparison was conducted using aggregated administrative data, including age-standardized claims ratios for rehabilitation sessions, to compare secondary healthcare regions.

Results

The southern secondary healthcare region, characterized by the smallest population and lowest population density, showed distinctive features. It had the lowest per capita number of rehabilitation beds and professionals across all medical institutions within the region among the secondary healthcare regions. Although the proportion of individuals receiving rehabilitation services was the highest, the overall volume of services provided was the lowest, even after adjusting for age and population size. Notably, the provision of outpatient rehabilitation services across all providers within the region was particularly low compared with that in other regions.

Conclusions

This study revealed regional disparities in rehabilitation resources and service provision in secondary healthcare regions, highlighting the need for more equitable access. These findings underscore the value of routinely collected administrative and claims data for regional need assessment, particularly for informing evidence-based planning and resource allocation.

Keywords

rehabilitation access to healthcare health services utilization health information systems healthcare policy health insurance healthcare equity resource allocation

Introduction

Regional health disparities have been reported in various countries, including Japan,^1-7 and differences in healthcare resources have been identified as one of the contributing factors.^8,9 For example, Hosokawa et al⁸ found a positive correlation between life expectancy, including healthy life expectancy, and the number of medical workers and clinics that provide home healthcare services. Hosseini et al⁹ reported an association between regions with fewer physicians and lower immunization and higher mortality rates. Regional disparities in health and access to healthcare facilities have also been reported in Japan.^6,10 Addressing these disparities by developing and implementing appropriate policies is important.^11,12

Rehabilitation needs have increased globally owing to demographic aging and the epidemiological transition from communicable to non-communicable diseases.¹³ In response, the World Health Organization (WHO) launched the Rehabilitation 2030 initiative to address current and future unmet rehabilitation needs, particularly in low- and middle-income countries.¹⁴ Rehabilitation leads to positive health outcomes,^15-18 and rehabilitation across the phases of care is particularly important for certain diseases, such as stroke.^19,20 Disparities in rehabilitation care, however, have been reported across regions in terms of the number of facilities providing services and the volume of service provision.^21,22 Implementing policies that can prevent or reduce disparities in rehabilitation is crucial.

Japan has the world’s most aged society, and the provision of rehabilitation services has expanded as the population ages.²³ Particularly, the provision of rehabilitation services and number of rehabilitation professionals have increased significantly since 2000, when the Japanese long-term care insurance system was established, and the system for recovery rehabilitation wards was introduced. Rehabilitation services under the medical and long-term care insurance are mainly provided by rehabilitation professionals, such as physical therapists (PT), occupational therapists (OT), and speech-language therapists (ST).²⁴ Although medical insurance covers rehabilitation for all age groups, most recipients are older adults, particularly those aged ≥ 75 years.²⁴

In Japan, regional medical care areas are defined under the Medical Care Plan to ensure equitable access to healthcare resources. Secondary healthcare regions are sub-prefectural units, typically comprising multiple municipalities, defined by each prefecture in accordance with national regulations issued by Japan's Ministry of Health, Labour and Welfare (MHLW). These units are designated for the planning and delivery of inpatient and outpatient care and serve as the basic units for healthcare resource allocation and planning. Tertiary healthcare regions are broader units, often encompassing an entire prefecture, and are intended for the provision of highly specialized services, such as those offered by university hospitals and major tertiary care centers. Each prefecture formulates and implements medical plans every 6 years in accordance with the Medical Care Plan established by MHLW. These medical plans are required to include specific measures for designated diseases, such as cancer, cerebrovascular disease, and diabetes, which encompass plans for rehabilitation, and key issues such as emergency medicine and pandemic preparedness. Furthermore, these measures must be developed at the level of secondary healthcare regions, considering the specific characteristics of each region.²⁵

In Japan, one of the most progressive countries in providing rehabilitation for older adults, there are still regional disparities. Although disparities between prefectures have been reported,^26,27 the actual situation in each secondary healthcare region, which is important for policy planning, has not been sufficiently examined.

This study aimed to analyze the disparities in rehabilitation between secondary healthcare regions, focusing on a single prefecture in Japan as a model, and to further discuss countermeasures to the current situation. Analysis of the situation based on objective quantitative data should be useful for formulating and monitoring appropriate health plans. These findings may provide insights into future policies for other regions and countries with aging populations.

Methods

Setting and Participants

Nara Prefecture, a representative prefecture for Japan, was selected as the model. It has a population of 1.3 million (national population: 123 million), an area of 3,691 km² (national area: 377,975 km²), and a proportion of 32% of older adults aged ≥ 65 years (national proportion: 29%).^28,29 It is located in the center of Japan’s main island and has both urban and rural mountainous areas.³⁰ With these characteristics, Nara can be regarded as a miniature version of Japan, with approximately 1/100th of the country’s population and land area. It comprises five secondary healthcare regions: the Capital City, Eastern, Central, Western, and Southern regions, all of which are organized under a single tertiary healthcare region covering the entire prefecture. The data were compared among regions, and the overall situation in the prefecture was analyzed. The data included medical insurance claims for 213,933 residents aged ≥ 75 years who were insured under the medical insurance system for late-stage older adults, which, under Japan’s universal health insurance, encompasses the entire prefectural population in this age group; this age group was selected as it represents most rehabilitation service users in Japan and allows for complete population-based analysis within the prefecture. All eligible individuals were included in the analysis.

Data Collection

Data for the period April 2019 to March 2020 were obtained from two main sources: publicly available information systems and a governmental administrative database from Nara Prefecture. The former included demographic information and data on medical resources and was downloaded from the respective websites. The latter contained data on the provision of rehabilitation services and was securely transferred, stored, and analyzed on a standalone personal computer within a password-protected folder in a designated secure room, in accordance with established data protection regulations, as it contained confidential information.

Two WHO tools were referred to align with standard indicators for rehabilitation workforce and service delivery: the Template for Rehabilitation Information Collection and the Routine Health Information Systems - Rehabilitation Module guidance document (see Annexure for details).^31-33 To populate the indicators, variables were selected from the available resources. To avoid potential confounding effects of the COVID-19 pandemic, data from fiscal year 2019 were used.

Demographic Information and Data Regarding Medical Resources

For each secondary healthcare region, information on demographic characteristics were obtained, including total population, the region’s proportion of the prefectural population, population density, aging rate (defined as the percentage of individuals aged ≥ 65 years), and the proportion of older adults requiring long-term care. Population data were obtained from the 2019 Basic Resident Ledger (national monthly data), and data on the number of older adults requiring long-term care were obtained from the 2019 Long-Term Care Insurance Business Status Report (national annual data). Both datasets are national governmental statistics administered by the relevant ministries and are publicly available online. Data on medical resources were obtained from the National Medical Facilities Survey, a nationwide survey conducted every 3 years in Japan, including the numbers of hospitals and clinics; the numbers of beds in hospitals, clinics, and hospitals with rehabilitation wards; and the numbers of medical doctors, nurses, and rehabilitation professionals (PT, OT, and ST) for each secondary healthcare region. Figures per 100,000 population were also calculated for these items. These data on demographic characteristics and medical resources were downloaded from official governmental websites and stored in the author’s office.

Provision of Rehabilitation Services

The prefectural medical insurance claims database was used to examine the provision of acute and recovery (i.e., convalescent) rehabilitation services across secondary healthcare regions. Claims data are widely used in health and medical research, including studies on rehabilitation.^34-36 This study specifically employed the Kokuho local government database (KDB) maintained by Nara Prefecture to identify the number of rehabilitation services provided under the medical insurance system for late-stage older adults. These data were originally collected for insurance reimbursement and are systematically reviewed during the claim submission process. The database is subsequently managed under strict administrative control by Nara Prefecture.

Medical insurance in Japan covers acute and recovery rehabilitation under a fee-for-service payment system, with services generally billed on a per-session basis (one session = 20 minutes) and individually provided by PTs, OTs, and STs. For this study, rehabilitation was defined as “rehabilitation care provided individually by PTs, OTs, or STs,” and only fees corresponding to this definition were included in the analysis. This definition encompasses intensive, disease-specific rehabilitation during the acute and recovery phases for cardiovascular, cerebrovascular, musculoskeletal, and respiratory conditions, as well as disuse syndromes, rehabilitation for patients with cancer, and rehabilitation for patients with dementia. For disease-specific rehabilitation, the maximum permissible duration of service provision is set at 150 days for cardiovascular, 180 days for cerebrovascular, 150 days for musculoskeletal, 90 days for respiratory conditions, and 120 days for disuse syndromes. Additionally, disease-specific rehabilitation fees are applicable for a maximum of six or nine sessions per patient per day, depending on the patient’s condition. Most hospitals provide rehabilitation services daily, including on weekends.²³

The KDB contains two types of claims related to rehabilitation: the number of monthly claims submitted per patient (maximum one claim per month) and the actual number of rehabilitation sessions provided per patient. In this study, we used the total number of sessions, as it more accurately reflects the volume of services delivered. Data on the number of patients and sessions were extracted by gender, age group, and municipality (city or town) for the defined rehabilitation services between April 2019 and March 2020. We analyzed the aggregated data by secondary healthcare region, separately for inpatients and outpatients. Data validity was confirmed through comparison with publicly available national claims data.

Data Analysis

A descriptive regional comparison was conducted using aggregated administrative data to investigate differences across secondary healthcare regions. Regional variation was assessed using two measures: the maximum-to-minimum ratio for each variable and age- and population-standardized values for rehabilitation service provision (number of sessions).

To compare the provision of rehabilitation services across secondary healthcare regions, the standardized claims ratio (SCR) for rehabilitation sessions was calculated, accounting for population size and age distribution, based on methods used in previous studies.^37,38 The SCR score was calculated separately for inpatient services, outpatient services, and overall services (inpatient and outpatient combined), with the prefectural average set to one. Age groups were defined in 5-year increments. The SCR was calculated using the following formula:

SCR = [Σ (number of claims received by age group) / Σ (expected number of claims by age group)] = [Σ (number of claims received by age group) / Σ (population by age group) \times (prefectural claims rate by age group)] .

Results

Tables 1 and 2 present the demographic characteristics, medical resources, and rehabilitation service provision for each secondary healthcare region.

Table 1.

Demographic Characteristics and Medical Resources by Secondary Healthcare Regions

	Capital	Eastern	Central	Western	Southern
Demographic^*,†
Population	354,630	198,650	367,425	338,775	64,993
- Females, n	187,710	108,267	196,001	181,656	37,135
- Females, %	52.9	54.5	53.3	53.6	57.1
Percentage of total prefecture population (%)	26.8	15.0	27.7	25.6	4.9
Density of population (people/km²)	1,281	302	1,526	2,011	28
Urbanity (rural, semi-urban, urban)^**	Semi-urban	Rural	Semi-urban	Semi-urban	Rural
Aging rate (people ≥ 65 years) (%)	31.1	32.4	29.0	31.7	40.4
Rate of older adults requiring long-term care (%)	33.8	33.0	30.4	30.1	35.3
Resources: Number of facilities and beds^‡
Hospitals	22	19	18	12	4
General clinics	348	279	245	128	50
Beds in hospitals	4,264	4,798	3,933	2,488	538
Beds in clinics	88	124	92	132	50
Beds in hospitals with rehabilitation wards	251	276	129	315	36
Hospitals/total population × 100,000	6	6	5	5	6
General clinics/total population × 100,000	98	64	76	72	77
Beds in hospitals/total population × 100,000	1,202	1,253	1,306	1,161	828
Beds in clinics/total population × 100,000	25	67	34	27	77
Beds in hospitals with rehabilitation wards/total population × 100,000	71	139	35	93	55
Resources: Number of workforce^‡
Medical doctors	1,009	671	1,438	762	176
Nurses	2,802	2,051	3,347	2,594	498
Physical therapists	312	202	329	253	32
Occupational therapists	95	112	141	111	7
Speech-language therapists	65	50	60	43	7
Medical doctors/total population × 100,000	285	338	391	225	271
Nurses/total population × 100,000	790	1,032	911	766	765
Physical therapists/total population × 100,000	88	102	90	75	49
Occupational therapists/total population × 100,000	27	56	38	33	11
Speech-language therapists/total population × 100,000	18	25	16	13	10

^*Data from basic resident register data as of 2019.

^**Urbanity: Regions were classified as urban, semi-urban, or rural according to an established categorization widely used in Japan.

^†Data from the Long-Term Care Insurance Business Status Annual Report as of 2019.

^‡Data from the Medical Facilities Annual Survey as of 2020. The gray box indicates the minimum among regions.

Table 2.

Provision of Rehabilitation for Older Adults by Age Group Across Secondary Healthcare Regions

Age group (years)	Capital	Eastern	Central	Western	Southern
Number of patients
75–79	2,220	1,371	2,335	2,416	515
80–84	2,185	1,282	2,047	2,072	614
85–89	1,983	1,180	1,800	1,744	681
≥ 90	1,771	1,030	1,445	1,571	656
Total	8,159	4,863	7,627	7,803	2,466
Patient rates^*
75–79	0.10	0.10	0.10	0.10	0.10
80–84	0.13	0.13	0.13	0.14	0.14
85–89	0.19	0.18	0.19	0.19	0.20
≥ 90	0.26	0.23	0.25	0.27	0.28
Total	0.14	0.14	0.14	0.14	0.16
Rehabilitation sessions^†
75–79	220,533	125,265	222,829	200,990	34,441
80–84	249,854	129,759	244,281	195,854	50,029
85–89	246,114	127,474	226,639	174,905	50,884
≥ 90	199,468	106,258	153,097	154,008	43,211
Total	915,969	488,756	846,846	725,757	178,565
Rehabilitation sessions (inpatients)^†
75–79	197,304	111,901	204,586	178,832	32,219
80–84	233,835	118,787	233,746	183,293	48,811
85–89	237,885	122,269	222,452	170,466	49,876
≥ 90	196,060	104,959	152,316	152,588	42,988
Total	865,084	457,916	813,100	685,179	173,894
Rehabilitation sessions (outpatients)^†
75–79	23,229	13,364	18,243	22,158	2,222
80–84	16,019	10,972	10,535	12,561	1,218
85–89	8,229	5,205	4,187	4,439	1,008
≥ 90	3,408	1,299	781	1,420	223
Total	50,885	30,840	33,746	40,578	4,671

All data are calculated from the Nara Kokuho local government database. The gray box indicates the minimum among regions.

^*Calculated as the percentage of people who received rehabilitation in each region.

^†Number of total rehabilitation sessions; duration of one session is 20 min.

Regarding demographic characteristics, the Southern secondary healthcare region has the smallest population size and the lowest population density, with the highest aging rate and the highest proportion of older adults requiring long-term care.

The Southern region also had the lowest number of hospital beds and hospital beds in rehabilitation wards per 100,000 population, with ratios of 0.63 and 0.40, respectively, compared to the region with the highest values. Conversely, it had the highest number of clinic beds per 100,000 population, with a ratio of 3.10 compared to the region with the lowest values. Furthermore, it had the lowest density of rehabilitation professionals, including PT, OT, and ST, with ratios of 0.48, 0.19, and 0.40, respectively, compared to the region with the highest values.

The ratio of patients receiving rehabilitation was highest in the Southern region compared to other regions and across all age groups (Table 2). However, their amount of rehabilitation services received was the lowest, even in age-standardized scores, particularly in outpatient settings (Figure 1). Figure 1 shows the SCR for each region, which is the ratio of the calculated standardized rehabilitation sessions that have been provided. As shown in the graphs, the SCR of the Southern region is the lowest compared to other regions for inpatient and outpatient services, and in total.

Figure 1.

The age-standardized claims ratio for rehabilitation sessions by secondary healthcare regions

Discussion

The results show health disparities with respect to rehabilitation (April 2019 to March 2020) among the secondary healthcare regions. In particular, the Southern region, which has the smallest population and lowest population density, had the lowest number of beds in the rehabilitation wards and rehabilitation professionals per population. Despite having the highest proportion of people receiving rehabilitation services, the volume of rehabilitation sessions provided was the lowest, even after age-standardization.

Such disparities in rehabilitation resources and service provision between geographical and administrative areas have been reported by previous studies in different countries.^21,22 Armstrong et al analyzed data from a single Canadian province and suggested that residential location is a determinant of rehabilitation service provision and may lead to inequities in access to services. Mitch et al conducted interviews with service providers and patients in rural and remote areas in Australia regarding equity in the provision of rehabilitation services for brain injuries. Their results showed that access to services was limited compared to other regions, and the number of workers and the quality of services were insufficient. Our results from the Southern region show that, compared to other regions, rehabilitation utilization was high (a high percentage of patients received rehabilitation services), but rehabilitation uptake was low (those receiving rehabilitation underwent fewer sessions). According to WHO Routine Health Information Systems – Rehabilitation guidance, this most probably means that many people have access to services but are not able to complete a required rehabilitation episode.³³ This may be particularly relevant for patients with neurological conditions, prevalent among older adults. For example, it has been demonstrated that a higher exposure to rehabilitation care in patients with stroke is associated with improved outcomes, such as greater independence in activities of daily living.^39,40

The Southern region is characterized by a mountainous terrain with scattered residential settlements. In such geographic settings, ensuring healthcare access for all residents is inherently challenging. Statistics on medical institution resources indicate that clinics are more prevalent than hospitals in this region. However, in Japan, rehabilitation services are predominantly provided in hospital settings rather than clinics, which may partly account for the relatively low level of rehabilitation service provision in the Southern region. As a result, the regional health system may be less adequately structured to support rehabilitation service delivery. Our findings highlight the importance of developing both highly specialized rehabilitation services at higher levels of care and basic services at the primary care level to reduce regional disparities.⁴¹

The limited availability of rehabilitation-related medical resources, such as hospital beds within rehabilitation wards and rehabilitation professionals per capita, contributes to the overall low capacity for rehabilitation service provision. From a policy and system perspective, the healthcare system in Japan is publicly financed through social health insurance covering both public and private providers, while service delivery operates under market-based principles. Within this framework, private institutions, constituting the majority of medical care providers, tend to locate in areas with larger populations of potential patients to ensure financial sustainability. This dynamic might result in an uneven distribution of medical resources, with resources being more concentrated in urban areas. Future service planning should consider expanding rehabilitation services at existing hospitals and clinics within the region. Furthermore, reallocating prefectural (public) rehabilitation professionals to underserved areas and implementing scholarships or incentives to encourage professionals to work in the region may help address resource imbalances.^42,43

The low SCR for outpatients is likely owing to residents in the area experiencing difficulties in accessing hospitals. One possible mitigation strategy could be to maximize the length of hospital stays, particularly when it is shorter than the maximum permissible period, thereby enabling rehabilitation to be provided during hospitalization. Although previous studies have highlighted the potential benefits of home-based rehabilitation in rural and remote areas,⁴⁴ expanding such services is challenging owing to the limited number of rehabilitation professionals working in local medical facilities. However, home-based rehabilitation covered by long-term care insurance could be made available for individuals certified as requiring long-term care. Furthermore, emerging rehabilitation modalities, such as telerehabilitation and task-sharing approaches, are being explored for their potential utility and may be worth considering.^45-47

The Eastern secondary healthcare region, which has the second-lowest population density, did not exhibit fewer rehabilitation resources or a lower SCR compared with other regions. However, this region may share certain characteristics with the Southern region, as it also includes remote areas. Further analyses should be conducted, such as examining the relationship between patients’ residential locations and the hospitals they attend.

Although this study focused solely on Nara Prefecture as a model, the region may be regarded as a microcosm of Japan. Therefore, our methodology can be applied nationwide, using the national claims data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB). Furthermore, this approach could be adapted to analyze current conditions and regional disparities in other countries with similar health information systems. Our findings also highlight how routine health information systems and real-world databases, such as the NDB and KDB, can support policymaking. As population aging is a growing global public health concern, insights from Japan, a country experiencing rapid demographic aging, may contribute to informing rehabilitation strategies in other nations facing similar challenges.

Study Strengths and Limitations

This study exhibits several strengths. First, it used routine health information and administrative claims databases to assess the actual volume of rehabilitation service provision for older adults across secondary healthcare regions. In addition, policies and systems unique to Japan - such as universal health insurance and nationally standardized regulations governing hospital functions - enabled the comprehensive collection of population-level data, thereby enhancing the reliability and comparability of regional analyses.

This study also has some limitations. First, the analysis did not include claims for fully publicly funded medical services or services provided to welfare-payment recipients. In addition, rehabilitation services delivered in Community Comprehensive Care Wards were excluded because rehabilitation in these settings is bundled into overall hospitalization charges and not billed separately as rehabilitation fees. Furthermore, this study focused on rehabilitation services provided under the medical insurance system and did not include those delivered under the long-term care insurance system, which potentially also provides rehabilitation to older adults. Analyzing rehabilitation services delivered under both the medical and long-term care insurance systems would provide more comprehensive insights into rehabilitation service provision for older adults. Second, although the analysis was conducted at the level of secondary healthcare regions, patient-level analyses could provide further insights, such as examining the associations between rehabilitation service provision and individual health outcomes. Third, while this study assessed rehabilitation service provision across all health conditions, a stratified analysis by specific conditions, such as neurological, musculoskeletal, and respiratory conditions, as recommended by the WHO,³³ would allow for more targeted policy development and more detailed rehabilitation service planning.

Conclusions

This study identified regional disparities in rehabilitation resources, accessibility, and utilization under the medical insurance system in Nara Prefecture, Japan. Potential countermeasures to address these disparities, particularly in rural and remote areas, include allocating an appropriate number of rehabilitation professionals, maximizing the length of hospital stays for rehabilitation, and expanding home-based rehabilitation services under the long-term care insurance system. Further analyses examining the duration of rehabilitation care, the settings of service provision (hospital, clinic, or community-based), and the volume of rehabilitation services delivered under long-term care insurance will be valuable for identifying data-driven solutions. In addition, this study highlights the importance of using routinely collected administrative and claims data for regional needs assessment, particularly through the combined analysis of rehabilitation resources and service provision, to inform evidence-based planning and policy development at the regional level.

Footnotes

ORCID iDs

Kaori Yamaguchi

Yasuhiro Nakanishi

Yuichi Nishioka

Tomoaki Imamura

Wouter De Groote

Manabu Akahane

Ethical Considerations

The study was approved by the Ethics Committee of the National Institute of Public Health (NIPH-IBRA#12324-2) on June 2, 2023 and followed the principles of the Declaration of Helsinki. KDB data obtained from Nara Prefecture were handled and disclosed in compliance with relevant prefectural policies.

Consent to Participate

The claims dataset was anonymized and did not contain identifiable personal information (individual-level information); therefore, it was exempt from informed consent requirements, in accordance with the principles of confidentiality and data protection.

Author Contributions

KY contributed to the conception and design of the work, analysis and interpretation of data, drafting and revising the manuscript, and preparing figures and tables as the first author. YNa contributed to the conception and design of the work and the interpretation of data. YNi and TI contributed to data acquisition and interpretation. WDG contributed to the design of the work and revised the manuscript. MA contributed to the conception and design of the work, drafting it from various perspectives based on his expertise in health policy, rehabilitation, data analysis, and providing financial support as the final author. All the authors approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was partially supported by a Grant-in-Aid for Scientific Research from the Ministry of Health, Labour, and Welfare, Japan.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All datasets from KDB were generated and published in compliance with the relevant policies of Nara Prefecture, Japan. The data used in this study, other than the data extracted from KDB, are publicly available and can be obtained from the 2019 Basic Resident Ledger, the 2019 Long-Term Care Insurance Business Status Report, and the National Medical Facilities Survey.*

Appendix

References

Zhou

Wang

Zhu

, et al. Cause-specific mortality for 240 causes in China during 1990–2013: a systematic subnational analysis for the Global Burden of Disease Study 2013. Lancet. 2016;387:251-272.

Gómez-Dantés

Fullman

Lamadrid-Figueroa

, et al. Dissonant health transition in the states of Mexico, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2016;388:2386-2402.

Steel

Ford

Newton

, et al. Changes in health in the countries of the UK and 150 English Local Authority areas 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2018;392:1647-1661.

GBD 2016 Brazil Collaborators . Burden of disease in Brazil, 1990–2016: a systematic subnational analysis for the Global Burden of Disease Study 2016. Lancet. 2018;392:760-775.

Achoki

Miller-Petrie

Glenn

, et al. Health disparities across the counties of Kenya and implications for policy makers, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Glob Health. 2019;7:e81-e95.

Nomura

Sakamoto

Glenn

, et al. Population health and regional variations of disease burden in Japan, 1990–2015: a systematic subnational analysis for the Global Burden of Disease Study 2015. Lancet. 2017;390:1521-1538.

Fukuda

Nakao

Yahata

Imai

. Are health inequalities increasing in Japan? The trends of 1955 to 2000. BioSci Trends. 2007;1:38-42.

Hosokawa

Ojima

Myojin

Aida

Kondo

. Associations between healthcare resources and healthy life expectancy: a descriptive study across secondary medical areas in Japan. Int J Environ Res Public Health. 2020;17:6301.

Hosseini Jebeli

Hadian

Souresrafil

. Study of health resource and health outcomes: organization of economic corporation and development panel data analysis. J Educ Health Promot. 2019;8:70.

10.

Fujiwara

Osanai

Kobayashi

, et al. Accessibility to tertiary stroke centers in Hokkaido, Japan: use of novel metrics to assess acute stroke care quality. J Stroke Cerebrovasc Dis. 2018;27:177-184.

11.

Cookson

Asaria

Ali

, et al. Health Equity Indicators for the English NHS: a longitudinal whole-population study at the small-area level. Health Services Delivery Res. 2016;4(26):1-224.

12.

Doran

Fullwood

Kontopantelis

Reeves

. Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the quality and outcomes framework. Lancet. 2008;372:728-736.

13.

Cieza

Causey

Kamenov

Hanson

Chatterji

Vos

. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2021;396:2006-2017.

14.

World Health Organization . Rehabilitation 2030 call for action. 2017. https://www.who.int/publications/m/item/rehabilitation-2030-a-call-for-action. Accessed January 6, 2024.

15.

Ward

Drahota

Gal

Severs

Dean

. Care home versus hospital and own home environments for rehabilitation of older people. Cochrane Database Syst Rev. 2008;2008:CD003164.

16.

Crotty

Unroe

Cameron

Miller

Ramirez

Couzner

. Rehabilitation interventions for improving physical and psychosocial functioning after hip fracture in older people. Cochrane Database Syst Rev. 2010;1:CD007624.

17.

Connolly

Salisbury

O'Neill

, et al. Exercise rehabilitation following intensive care unit discharge for recovery from critical illness. Cochrane Database Syst Rev. 2015;2015:CD008632.

18.

Dibben

Faulkner

Oldridge

, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2021;11:CD001800.

19.

Pollock

Baer

Campbell

, et al. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database Syst Rev. 2014;2014:CD001920.

20.

Imura

Nagasawa

Fukuyama

Imada

Oki

Araki

. Effect of early and intensive rehabilitation in acute stroke patients: retrospective pre-/post-comparison in Japanese hospital. Disabil Rehabil. 2018;40:1452-1455.

21.

Mitsch

Curtin

Badge

. The provision of brain injury rehabilitation services for people living in rural and remote New South Wales, Australia. Brain Inj. 2014;28:1504-1513.

22.

Armstrong

Zhu

Hirdes

Stolee

. Rehabilitation therapies for older clients of the Ontario home care system: regional variation and client-level predictors of service provision. Disabil Rehabil. 2015;37:625-631.

23.

Yamaguchi

Nakanishi

Tangcharoensathien

, et al. Rehabilitation services and related health databases, Japan. Bull World Health Organ. 2022;100:699-708.

24.

Yamaguchi

Makihara

Kono

. Rehabilitation professionals for the aging society in Japan: their scopes of work and related health policies and systems. Hoken Iryou Kagaku. 2022;71:35-44.

25.

Ministry of Health, Labor and Welfare . Iryokeikaku (medical service management plan). https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kenkou_iryou/iryou/iryou_keikaku/index.html. Accessed July 7, 2025.

26.

Kato

Shimizu

Hori

, et al. Association between the number of board-certified physiatrists and volume of rehabilitation provided in Japan: an ecological study. J Rural Med. 2022;17:73-78.

27.

Morii

Abiko

Ishikawa

Fujiwara

Konomura

Ogasawara

. Regional disparity in the provision of rehabilitation services using the open data from the Japanese national claims database: an ecological study. BMJ Open. 2023;13:e071670.

28.

Technical Report of the Geospatial Information Authority of Japan. Koremadenikouhyositamensekicho (Area Survey Published to Date). https://www.gsi.go.jp/KOKUJYOHO/OLD-MENCHO-title.html. Published 2024. Accessed May 30, 2024.

29.

Cabinet Office . R5Koreishahakusyo. White Paper on Aging Society). 2023. https://www8.cao.go.jp/kourei/whitepaper/w-2023/zenbun/05pdf_index.html. Published 2024. Accessed May 30, 2024.

30.

Nara Prefecture . TokeikarashiruNara (What statistics tell us about Nara). https://www.pref.nara.jp/33754.html. Published 2013. Accessed May 30, 2024.

31.

Kleinitz

Sabariego

Cieza

. Development of the WHO STARS: a tool for the systematic assessment of rehabilitation situation. Arch Phys Med Rehabil. 2022;103:29-43.

32.

World Health Organization . Template for rehabilitation information collection. https://iris.who.int/bitstream/handle/10665/330956/9789241516013-eng.pdf?sequence=1. Published 2019. Accessed January 10, 2024.

33.

World Health Organization . Guidance on the analysis and use of routine health information systems: rehabilitation module. https://iris.who.int/bitstream/handle/10665/354390/9789240050242-eng.pdf?sequence=1. Published 2022. Accessed January 10, 2024.

34.

Hayashi

Noda

Kubo

, et al. Data regarding fracture incidence according to fracture site, month, and age group obtained from the large public health insurance claim database in Japan. Data Brief. 2019;23:103780.

35.

Ohtera

Kato

Ueshima

, et al. A nationwide survey on participation in cardiac rehabilitation among patients with coronary heart disease using health claims data in Japan. Sci Rep. 2021;11:20096.

36.

Nakanishi

Tsugihashi

Akahane

, et al. Comparison of Japanese centenarians' and noncentenarians' medical expenditures in the last year of life. JAMA Netw Open. 2021;4:e2131884.

37.

Fujimori

. [Practical use of E-claim data for regional healthcare planning]. Nihon Eiseigaku Zasshi. 2012;67:56-61.

38.

Tamaki

Fujimori

Ikehara

, et al. Estimates of hip fracture incidence in Japan using the National Health Insurance Claim Database in 2012-2015. Osteoporos Int. 2019;30:975-983.

39.

Tani

Imai

Inoue

Kanazawa

Fushimi

. Association between volume of patients undergoing stroke rehabilitation at acute care hospitals and improvement in activities of daily living. J Stroke Cerebrovasc Dis. 2023;32:106872.

40.

Clark

Whitall

Kwakkel

Mehrholz

Ewings

Burridge

. The effect of time spent in rehabilitation on activity limitation and impairment after stroke. Cochrane Database Syst Rev. 2021;10:CD012612.

41.

World Health Organization . Rehabilitation in health systems: guide for action. https://www.who.int/publications/i/item/9789241515986. Published 2019. Accessed January 6, 2024.

42.

Gumede

Ross

Campbell

MacGregor

. Rural-origin health professional students' perceptions of a support programme offered by Umthombo Youth Development Foundation. Afr J Prim Health Care Fam Med. 2017;9:e1-e6.

43.

Russell

Mathew

Fitts

, et al. Interventions for health workforce retention in rural and remote areas: a systematic review. Hum Resour Health. 2021;19:103.

44.

Dollard

Smith

R Thompson

Stewart

. Broadening the reach of cardiac rehabilitation to rural and remote Australia. Eur J Cardiovasc Nurs. 2004;3:27-42.

45.

Laver

Adey-Wakeling

Crotty

Lannin

George

Sherrington

. Telerehabilitation services for stroke. Cochrane Database Syst Rev. 2020;1:CD010255.

46.

Lee

AYL

Wong

AKC

Hung

TTM

Yan

Yang

. Nurse-led telehealth intervention for rehabilitation (telerehabilitation) among community-dwelling patients with chronic diseases: systematic review and meta-analysis. J Med Internet Res. 2022;24:e40364.

47.

Vielvoye

Nanninga

Achterberg

Caljouw

MAA

. Informal caregiver stroke program in geriatric rehabilitation of stroke patients: a qualitative study. J Clin Med. 2023;12:3085.