Background In 2006, Japan introduced the Revised Medical Care Act aimed to shift end-of-life care from hospitals to communities. For patients and families, dying in hospital can be highly... Show moreBackground In 2006, Japan introduced the Revised Medical Care Act aimed to shift end-of-life care from hospitals to communities. For patients and families, dying in hospital can be highly distressing. Persons with dementia are especially susceptible to negative hospital-related outcomes. This study aims to evaluate whether the Revised Medical Care Act is associated with a decrease in the proportion of hospital deaths for older adults and persons with dementia over a 20-year period covering the reform.Methods and findings This is a population-level, repeated cross-sectional study using mortality data from Vital Statistics Japan. Participants were Japanese older adults 65 years or older with and without dementia who died between 1996 and 2016. The policy intervention was the 2006 Revised Medical Care Act that increased community care infrastructure. The primary outcome was location of death in hospital, nursing home, home, or elsewhere. The trend in the proportion of location of death, before and after the reforms was estimated using an interrupted time-series analysis. All analyses were adjusted for sex and seasonality. Of the 19,307,104 older adult decedents, 216,442 had dementia identified on their death certificate. Death in nursing home (1.10, 95% CI 1.10-1.10), home (1.08, 95% CI 1.08-1.08), and elsewhere (1.07, 95% CI 1.07-1.07) increased over time compared to hospital deaths for the total population after reform implementation. Nursing home (1.04, 95% CI 1.03-1.05) and home death (1.11, 95% CI 1.10-1.12) increased after reform implementation for persons with dementia.Conclusion This study provides evidence that the 2006 Revised Medical Care Act was associated with decreased older adults dying in hospital regardless of dementia status; however, hospital continues as the primary location of death. Show less
