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Hidehiro Sugisawa,1 Yumiko Shimizu,2 Tamaki Kumagai,3 Kanji Shishido,4 Toshio Shinoda5 1International Graduate School for Advanced Studies, J. F. Oberlin University, Machida-city, Tokyo, Japan; 2The Jikei University School of Nursing, Chofu-city, Tokyo, Japan; 3Graduate School of Health Sciences at Odawara, International University of Health and Welfare, Odawara-city, Kanagawa, Japan; 4Kawasaki Clinic, Kawasaki-city, Kanagawa, Japan; 5Faculty of Medical and Health Sciences, Tsukuba International University, Tsuchiura-city, Ibaraki, JapanCorrespondence: Hidehiro Sugisawa, International Graduate School for Advanced Studies, J. F. Oberlin University, 3758, Machida-city, Tokyo, 194-0294, Japan, Tel/Fax +81(0)02-797-9847, Email sugisawa@obirin.ac.jpPurpose: This study analyzed the influence of financial strains over the life course before initiating hemodialysis on the health outcomes of older Japanese patients. This study was limited to financial strains over the life course before initiating hemodialysis to eliminate the influence of financial strains resulting from resignation from paid jobs. We examined which of the four life course models—pathway, latent, social mobility, and accumulation—were appropriate to describe the influences of financial strains over the life course on older patients’ health.Patients and Methods: Data were obtained from a cross-sectional survey of 6,644 outpatients in dialysis facilities across Japan. We selected participants aged 60 years and older at the time of the survey. Numbers of dialysis complications, activities of daily living (ADL) disability, and depressive symptoms were selected as health outcomes. Benchmark periods over the life course were constructed in three parts: less than 18 years (childhood), 18– 35 years (young adults), and 35– 50 years (middle-aged). We retrospectively measured financial strains over the life course.Results: Pathway models best described the influence of financial strains over the life course on the three types of health outcomes. Experiences of financial strains as young adults had a direct influence on ADL disability of older patients. This result supports latent models. Social mobility models (upward and downward mobility) and accumulation models explained the number of dialysis complications, ADL disability, and depressive symptoms in older patients.Conclusion: These results suggest that socioeconomic disadvantages over the life course before initiating hemodialysis were significantly associated with health outcomes in older patients.Keywords: socioeconomic status over the life course, latent models, social mobility models, accumulation models, pathway models

Hidehiro Sugisawa,1 Toshio Shinoda,2 Yumiko Shimizu,3 Tamaki Kumagai,4 Hiroaki Sugisaki,5 Seiji Ohira6,† 1Department of Gerontology, Graduate School of Gerontology, J. F. Oberlin University, Tokyo, 2Department of Medical Care Technology, Faculty of Medical and Health Science, Tsukuba International University, Tsuchiura, 3Department of Community Health Nursing, The Jikei University School of Nursing, Chofu, 4Department of Fundamental Nursing, Graduate School of Nursing, Osaka City University, Osaka, 5Hachioji Azumacho Clinic, Hachioji, Tokyo, 6Sapporo Kita Clinic, Sapporo, Hokkai-do, Japan †Professor Dr. Seiji Ohira passed away on September 5, 2017 Background: This study aimed to investigate the levels of unmet needs for home and ­community-based services (HCBS) evaluated by case managers (CMs) among disabled patients on hemodialysis (DPHD) and to examine factors related to unmet needs. Unmet needs for HCBS were defined as situations in which patients do not use or underuse HCBS despite needing them. Candidates for the factors relating to unmet needs for HCBS included three dimensions: predisposing, enabling, and need factors.Methods: Self-administrated questionnaires were collected from 391 CMs of DPHD certified with long-term care insurance. These were introduced by the dialysis facilities that a member of the Japanese Association of Dialysis Physicians belonged to. CMs were asked questions about their management of each individual case. HCBS included home help, visiting nursing, daycare, and short stay.Results: The prevalence of unmet needs for each HCBS ranged from 32% for home help to 48% for short stay. Barriers to service usage in the patients were associated with unmet needs for all four services. The patients with more severe cognitive malfunction were more likely to have unmet needs for visiting nursing and short stay. Heavier burden with caregiving was associated with more likelihood of unmet needs for home help and short stay.Conclusion: CMs need to monitor unmet needs after coordinating HCBS for DPHD and need to encourage HBCS use among patients with impaired cognitive function and caregivers with heavier caregiving burdens. Keywords: disabled hemodialysis patients, long-term care, home and community-based services, Andersen’s behavioral model, barriers to service usage, Japan

Hidehiro Sugisawa,1 Yumiko Shimizu,2 Tamaki Kumagai,3 Hiroaki Sugisaki,4 Seiji Ohira,5 Toshio Shinoda6 1Graduate School of Gerontology, J.F. Oberlin University, Machida, 2Faculty of Nursing, The Jikei University School of Medicine, Chofu, 3School of Nursing, Osaka City University, Osaka, 4Hachioji Azumacho Clinic, Hachioji, 5Sapporo Kita Clinic, Sapporo, 6Kawakita General Hospital, Suginami, Japan Study purpose: Whether or not socioeconomic status (SES)-related differences in the health of hemodialysis patients differ by age, period, and birth cohort remains unclear. We examined whether SES-related gaps in physical and mental health change with age, period, and birth cohort for hemodialysis patients. Methods: Data were obtained from repeated cross-sectional surveys conducted in 1996, 2001, 2006, and 2011, with members of a national patients’ association as participants. We used raking adjustment to create a database which had similar characteristics to the total sample of dialysis patients in Japan. SES was assessed using family size-adjusted income levels. We divided patients into three groups based on their income levels: below the first quartile, over the second quartile and under the third quartile, and over the fourth quartile. We used the number of dialysis complications as a physical health indicator and depressive symptoms as a mental health indicator. We used a cross-classified random-effects model that estimated fixed effects of age categories and period as level-1 factors, and random effects of birth cohort as level-2 factors. Results: Relative risk of dialysis complications in respondents below the first quartile compared with ones over the fourth quartile was reduced in age categories >60 years. Mean differences in depressive symptoms between respondents below the first quartile and ones over the fourth quartile peaked in the 50- to 59-year-old age group, and were reduced in age groups >60 years. In addition, mean differences varied across periods, widening from 1996 to 2006. There were no significant birth cohort effects on income differences for dialysis complications or ­depressive symptoms. Conclusion: The number of dialysis complications and depressive symptoms in dialysis patients were affected by income differences, and the degree of these differences changed with age category and period. Keywords: complications, depressive symptoms, cross classified random effects model, income status, raking adjustment