Assistive products for long-term care among older people with chronic obstructive pulmonary disease in Japan: A retrospective cohort study

doi:10.21203/rs.3.rs-4315334/v1

Background: Assistive products support energy conservation in older adults with chronic obstructive pulmonary disease (COPD) that exhibits some disease-specific symptoms, such as dyspnea. This study aimed to determine the utilization of assistive products and evaluate its association with COPD.

Methods:We conducted a retrospective cohort study using anonymized medical and long-term care insurance claims data obtained from a Japanese city. The participants were ≥65 years old and first certified as requiring long-term care between April 2015 and March 2020. We selected seven types of assistive products that could support the daily activities of older adults with COPD: handrails/grab bars, ramps, canes, walkers, wheelchairs, electronic beds, and bathing aids. After stratifying care needs levels into care needs level 2 or lower, indicating partial care, and care needs level 3 or higher, indicating total care, we conducted multivariable logistic regression analyses to evaluate the association between the presence or absence of COPD and the use of each assistive product during the six months following certification, adjusting for sociodemographic and physical characteristics.

Results:Among 18,597 participants, 769 (4.1%) had COPD. The assistive productsfrequently used by participants with COPD included handrails/grab bars (12.6%), electronic beds (7.3%), and bathing aids (5.4%) among those who required partial care, and electronic beds (37.8%), handrails/grab bars (25.2%), and wheelchairs (15.6%) among those who required total care. Among participants who required partial care (n=15,460), those with COPD were less likely to use handrails/grab bars (adjusted odds ratio [AOR], 0.74; 95% confidence interval [CI], 0.58–0.95) and more likely to use bathing aids (AOR, 1.55; 95% CI, 1.07–2.27)compared with those without COPD. Among participants requiring total care (n=3,137), those with COPD were more likely to use electronic beds (AOR, 1.47; 95% CI, 1.01–2.15) than those without COPD.

Conclusions:Older adults with COPD were more likely to use assistive products for bathing and beds than those without, which may help in self-care activities, but the use of handrails/grab bars might be suboptimal in those with COPD. Healthcare providers and policymakers should draw more attention to assistive product use for managing respiratory symptoms in older people with COPD.

assistive device

claims data

home care

housing adaptation

long-term care

respiratory disease

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and death worldwide [1, 2]. The prevalence of COPD in those aged ≥ 70 years is higher than that in younger people [3]. Furthermore, the number of older people with COPD who require long-term care (LTC) is predicted to increase in super-aged societies such as Japan [4], in which more than half of the deaths among patients with COPD occur in their 80s [5]. A previous study found that 23% of community-dwelling older adults with COPD required LTC [6]. Therefore, it is essential to develop a strategy to improve the quality of care for older people with COPD by considering disease-specific symptoms, such as dyspnea [7].

Assistive products, which are defined as products that maintain or improve an individual's functioning and independence [8, 9], are crucial tools for LTC in older adults, including those with COPD. Assistive products can enhance the performance in various key functional domains, such as cognition, communication, hearing, mobility, self-care, and vision [8]. They include many types of products: mobility devices, such as wheelchairs; assistive products for self-care activities, such as bathing aids; and digital software that supports communication. They may also be used as assistive products for environmental modifications, such as handrails [9]. Previous studies have reported the effects of assistive products on improving physical function [8]; for example, mobility devices have been associated with preventing functional decline [10], and handrails/grab bars prevent falls and functional decline [11, 12]. For patients with COPD who experience dyspnea during their daily activities [7], some assistive products, such as mobility devices and bathing aids, could support them not only in improving physical function but also in preventing energy consumption and reducing dyspnea [13, 14]. However, little is known about the patterns of utilization of these assistive products in older adults with COPD.

Understanding the utilization of assistive products according to patient characteristics is important for healthcare providers involved in COPD care. Pilegaard et al. [15] investigated assistive products used by people with advanced cancer and found that they were primarily used for positioning and resting, such as small aids for dressing, pillows for positioning, and electronic beds. Just as there are characteristics to the use of assistive products for patients with cancer, the type of assistive products used by patients with COPD are different from those used by patients with other diseases because of disease-specific symptoms, such as dyspnea. However, the assistive products used by patients with COPD are unspecified in comparison to those used in patients without COPD. To determine the appropriate living environment for older adults with COPD, it is necessary to clarify the usage of assistive products.

In Japan, older people requiring LTC can use assistive products by receiving housing adaptation services, such as the installation of handrails; rental services of assistive products, such as wheelchairs; and purchasing services, such as bathing aids, through the LTC insurance system, which all people ≥ 65 years of age can use if the insurers accept its necessity [16–18]. By combining LTC claims data with medical claims data, it is possible to examine the use of assistive products in consideration of a user's disease, such as COPD.

Given the aforementioned context, this study aimed to determine the utilization of assistive products and evaluate its association with COPD..

Study design and data sources

We conducted a retrospective cohort study using an anonymized data from April 2015 to September 2020 in Hachioji City, Tokyo, Japan. The city is located on the western side of Tokyo and its population was approximately 578,000 in 2015, of whom 25.0% were aged ≥ 65 years [19]. We received the data following an agreement from a collaborative research project between the municipality and the affiliation of the first author. All data were anonymized, and unique numbers were assigned to each insured person to connect the medical and LTC insurance claims data.

This study used medical insurance claims, LTC insurance claims, LTC insurance premium, and care needs certification data obtained from the city. Medical insurance claims data include beneficiaries of the national health insurance system or the medical care system for older people in later stages of life. In Japan's medical care insurance system, 70% of people aged 65–74 years were beneficiaries of the national health insurance system in 2015 [20], and all those aged ≥ 75 years were enrolled in the medical care system for older people in the later stages of life [21]. Therefore, the data covered most community-dwelling older adults in the city.

Participants

The eligibility criteria were as follows: (1) beneficiaries of the national health insurance or medical care system for older people in the later stages of life who were first certified as having LTC needs between April 2015 and March 2020 and (2) aged ≥ 65 years at the first certification. We selected people who were first certified because some assistive products used by home adaptation or purchase services are often used only once after being certified for LTC needs [22]. The exclusion criteria were as follows: (1) lack of LTC insurance premium data; (2) those who were not insured by the national health insurance or medical care system for older people in the later stages of life within one year before the first certification, which means those who did not have one-year baseline data; and (3) those who used LTC facility services for six consecutive months within the six months after the first certification, because those who use LTC facility services may use the assistive products possessed by the facility and do not generally rent or purchase assistive products.

Measurements

The presence or absence of COPD was determined within one year before the first certification (i.e., baseline period). We defined participants with COPD as having both a COPD diagnosis and COPD-related prescriptions for daily dyspnea. First, COPD diagnosis was defined by the International Classification of Diseases and Related Health Problems, 10th revision, codes J41–J44 (not including suspected diagnosis) for two or more months within the first certification [6, 23–25]. Second, we also identified long-acting muscarinic antagonist, long-acting β2 agonist prescriptions, or both (including combination products) for two or more months as treatments for daily dyspnea of COPD [7].

Assistive product utilization delivered as Japanese LTC insurance services were evaluated during the six months following the first certification because the validity period for newly certified care needs is usually six months [26]. The assistive products included those for environmental modifications (handrails/grab bars and ramps), mobility (canes, walkers, and wheelchairs), and self-care activities in daily life (electronic beds and bathing aids). Three medical professionals (an occupational therapist, physical therapist, and nurse) familiar with assistive products selected only assistive products that were expected to help reduce energy consumption for older people with COPD and excluded those that compensate for memory functions, such as motion sensors to prevent falls or wandering. We did not include assistive products such as portable toilets and bathtubs with a low utilization rate at less than 1%.

We also identified the following sociodemographic and physical factors that were expected to be associated with assistive product utilization [22, 27, 28]: age, sex (male or female), household income (low or middle to high), care needs level, use of home oxygen therapy (used or not), and diseases other than COPD (present or absent). We examined LTC insurance premiums to classify the participants’ household income as economic status. If the participant and all family members were exempt from residential taxation based on their income, the household income was classified as low income, and the rest were classified as middle-to-high income [29]. The LTC need levels were selected from the certification data for LTC needs levels. LTC needs levels were categorized as care supports level 1 (least dependent) and 2, or care needs level 1 to 5 (most dependent) [16]. We also selected the use of oxygen therapy using certification data for LTC needs levels through a question asking whether the patient had received oxygen therapy in the past 14 days. We examined comorbidities expected to be associated with LTC needs certification based on medical claims one year before the first certification, including cancer, cerebrovascular disease, dementia, diabetes, fractures, heart failure, ischemic heart disease, Parkinson’s disease, and pneumonia, according to a previous study [30].

Statistical analysis

First, we compared the basic characteristics and the assistive product utilization between the participants with or without COPD, using the Mann–Whitney U or χ² test. We then conducted multivariable logistic regression analyses to examine the associations between the utilization of each assistive product and COPD using all covariates with stratifying those who required partial care in daily life (care supports level 1 to care needs level 2) and those who required total care in daily life (care needs level 3 to 5), because it was expected that assistive product utilization would differ according to their care needs levels. Previous studies that examined care management or changes in the care needs level also distinguished care needs level 2 or less from care needs level 3 or more in the analysis [31, 32]. Furthermore, as the standard for admission to LTC welfare facilities is set at care needs level 3 to 5 [18], we judged that it was appropriate to stratify by care needs level 2 or lower and care needs level 3 or higher. In multivariable logistic regression analyses, age was treated as a continuous variable, while other variables were treated as categorical variables. Care supports level 1 and care needs level 2 were set as reference for the analyses in participants who required partial care and in those who required total care, respectively. All statistical analyses were performed using Stata/MP 16.0 for Windows (Stata Corporation, College Station, TX, USA). Statistical significance was defined as a p-value < 0.05.

Participants’ characteristics

The study included 18,597 participants (Figure 1) with a median age of 81 years; 45.8% male (Table 1). There were 769 (4.1%) participants with COPD. Compared to those without COPD, those with COPD were more likely to be male, receive oxygen therapy, have comorbidities (such as cancer, heart failure, ischemic heart disease, and pneumonia), and not have dementia.

Table 1. Characteristics of participants according to the presence of COPD
	All (n = 18,597)		Participants who require partial care ^a)					Participants who require total care ^b)
	All (n = 18,597)		Participants with COPD (n = 634)		Participants without COPD (n = 14,826)			Participants with COPD (n = 135)		Participants without COPD (n = 3,002)
	median (IQR) or n (%)		median (IQR) or n (%)		median (IQR) or n (%)		p-value	median (IQR) or n (%)		median (IQR) or n (%)		p-value
Age	81	(77-85)	80	(77-85)	81	(77-85)	0.078	80	(76-83)	81	(76-86)	0.089
Sex							<0.001					<0.001
Male	8,517	(45.8)	438	(69.1)	6,330	(42.7)		106	(78.5)	1,643	(54.7)
Female	10,080	(54.2)	196	(30.9)	8,496	(57.3)		29	(21.5)	1,359	(45.3)
Household income ^c)
Low	6,275	(33.7)	193	(30.4)	5,058	(34.1)	0.056	41	(30.4)	983	(32.7)	0.57
Middle-to-high	12,322	(66.3)	441	(69.6)	9,768	(65.9)		94	(69.6)	2,019	(67.3)
Long-term care needs levels							0.052					0.24
Care supports level 1	6,111	(32.9)	239	(37.7)	5,872	(39.6)
Care supports level 2	1,923	(10.3)	100	(15.8)	1,823	(12.3)
Care needs level 1	5,739	(30.9)	221	(34.9)	5,518	(37.2)
Care needs level 2	1,687	(9.1)	74	(11.7)	1,613	(10.9)
Care needs level 3	971	(5.2)						33	(24.4)	938	(31.3)
Care needs level 4	1,174	(6.3)						56	(41.5)	1,118	(37.2)
Care needs level 5	992	(5.3)						46	(34.1)	946	(31.5)
Oxygen therapy	626	(3.4)	94	(14.8)	179	(1.2)	<0.001	50	(37.0)	303	(10.1)	<0.001
Comorbidities
Cancer	4,446	(23.9)	204	(32.2)	3,096	(20.9)	<0.001	68	(50.4)	1,078	(35.9)	0.001
Cerebrovascular disease	5,919	(31.8)	186	(29.3)	4,462	(30.1)	0.68	50	(37.0)	1,221	(40.7)	0.40
Dementia	3,145	(16.9)	64	(10.1)	2,568	(17.3)	<0.001	7	(5.2)	506	(18.9)	<0.001
Diabetes	7,759	(41.7)	301	(47.5)	6,033	(40.7)	0.001	62	(45.9)	1,363	(45.4)	0.91
Fractures	3,241	(17.4)	91	(14.4)	2,449	(16.5)	0.15	23	(17.0)	678	(22.6)	0.13
Heart failure	5,224	(28.1)	286	(45.1)	3,781	(25.5)	<0.001	76	(53.3)	1,081	(36.0)	<0.001
Ischemic heart disease	4,931	(26.5)	215	(33.9)	3,818	(25.8)	<0.001	50	(37.0)	848	(28.3)	0.027
Parkinson's disease	584	(3.1)	13	(2.1)	463	(3.1)	0.13	2	(1.5)	106	(3.5)	0.20
Pneumonia	1,570	(8.4)	193	(30.4)	844	(5.7)	<0.001	49	(36.3)	484	(16.1)	<0.001
COPD: chronic obstructive pulmonary disease; IQR: interquartile range
We conducted Mann–Whitney U or χ²tests.
a) Participants who require partial care are those with long-term care supports level 1 to care needs level 2.
b) Participants who require total care are those with long-term care needs level 3 to care needs level 5.
c) Household income: low (long-term care insurance premium levels 1 to 3, which means exemption from residential tax); middle-to-high (long-term care insurance premium levels 4 to 20, which means no exemption from residential tax)

[Insert Table 1 here]

The utilization of assistive products among participants with COPD

Among participants with COPD, 634 (82.4%) required partial care and 135 (17.6%) required total care. Regarding assistive products for environmental modifications, 12.6% of those who required partial care and 25.6% of those who required total care used handrails/grab bars (Table 2). The proportion of mobility device utilization was 2–3% of those who required partial care. However, those who required total care used wheelchairs (15.6%), walkers (10.0%), and canes (3.5%) in that order, and there were differences in the proportions. Regarding assistive products for specific self-care, the proportion of electronic beds and bathing aids was 5–7% among those who required partial care. Among those requiring total care, 37.8% used electronic beds.

In the unadjusted analyses, among those who required partial care (n=15,460), those with COPD were less likely to use handrails/grab bars (p=0.017) and wheelchairs (p=0.044) and more likely to use electronic beds (p=0.013) and bathing aids (p = 0.016) than those without COPD.

Table 2. Utilization of assistive products according to the presence of COPD
	Participants who require partial care ^a)							Participants who require total care ^b)
	All (n = 15,460)		Participants with COPD (n = 634)		Participants without COPD (n = 14,826)			All (n = 3,137)		Participants with COPD (n = 135)		Participants without COPD (n = 3,002)
	n (%)		n (%)		n (%)		p-value	n (%)		n (%)		n (%)		p-value
Environmental modifications
Handrails/grab bars	2,479	(16.0)	80	(12.6)	2,399	(16.2)	0.017	804	(25.6)	34	(25.2)	770	(25.7)	0.90
Ramps	198	(1.3)	8	(1.3)	190	(1.3)	0.97	191	(6.1)	7	(5.2)	184	(6.1)	0.65
Mobility
Canes	392	(2.5)	16	(2.5)	376	(2.5)	0.98	110	(3.5)	4	(3.0)	106	(3.5)	0.73
Walkers	748	(4.8)	20	(3.2)	728	(4.9)	0.044	314	(10.0)	9	(6.7)	305	(10.2)	0.19
Wheelchairs	324	(2.1)	19	(3.0)	305	(2.1)	0.11	488	(15.6)	21	(15.6)	467	(15.6)	1.0
Self-care activities in daily life
Electronic beds	793	(5.1)	46	(7.3)	747	(5.0)	0.013	994	(31.7)	51	(37.8)	943	(31.4)	0.12
Bathing aids	559	(3.6)	34	(5.4)	525	(3.5)	0.016	143	(4.6)	3	(2.2)	140	(4.7)	0.18
COPD: chronic obstructive pulmonary disease
We conducted χ² tests.
a) Participants who require partial care are those with long-term care supports level 1 to care needs level 2.
b) Participants who require total care are those with long-term care needs level 3 to care needs level 5.

[Insert Table 2 here]

Associations of COPD with each assistive product utilization

Among those who required partial care (n=15,460), those with COPD were less likely to use handrails/grab bars (adjusted odds ratio [AOR], 0.74; 95% confidence interval [CI], 0.58–0.95) and more likely to use bathing aids (AOR, 1.55; 95% CI, 1.07–2.27) than those without COPD (Table 3). Among those requiring total care (n=3,137), those with COPD were more likely to use electronic beds (AOR, 1.47; 95% CI, 1.01–2.15) than those without COPD.

Regarding other factors associated with assistive product use, higher care needs levels and the absence of dementia were associated with increased use of all assistive products among those who required partial care (Additional File 1). However, among those requiring total care, individuals with care needs level 5, compared to those with care needs level 3, were less likely to use all assistive products (Additional File 2).

Table 3. Associations of COPD with each assistive product use
	Participants who required care partially (n=15,460) ^a)			Participants who required care totally (n= 3,137)^b)
	AOR	95%CI	p-value	AOR	95%CI	p-value
Environmental modifications
Handrails/grab bars	0.74	(0.58－0.95)	0.02	1.22	(0.80－1.88)	0.36
Ramps	0.95	(0.45－2.01)	0.90	0.98	(0.44－2.18)	0.96
Mobility
Canes	1.11	(0.66－1.89)	0.69	1.03	(0.36－2.92)	0.96
Walkers	0.68	(0.43－1.09)	0.11	0.81	(0.40－1.66)	0.56
Wheelchairs	1.16	(0.69－1.93)	0.58	1.24	(0.75－2.04)	0.40
Self-care activities in daily life
Electronic beds	1.10	(0.75－1.61)	0.63	1.47	(1.01－2.15)	0.046
Bathing aids	1.55	(1.07－2.27)	0.022	0.46	(0.14－1.51)	0.20
AOR: adjusted odds ratio; CI: confidence interval; COPD: chronic obstructive pulmonary disease
Multivariable logistic regression analyses were conducted, adjusting for age, sex, household income, long-term care needs levels, oxygen therapy, and each comorbidity.
a) Participants who required care partially were those with long-term care supports level 1 to care needs level 2.
b) Participants who required care totally were those with long-term care needs level 3 to care needs level 5.

This study characterized the utilization of assistive products for environmental modifications, mobility, and self-care activities provided by the Japanese LTC insurance services among older people with COPD who have LTC needs. Specifically, older people with COPD were more likely to use assistive products for bathing and beds than those without COPD, which might help with self-care activities. Although the use of handrails/grab bars was higher than that of other products in older people with COPD, their utilization was lower than that of those without COPD.

Regarding environmental modifications, approximately 13% of those who required partial care and 26% of those who required total care used handrails/grab bars, with higher proportions of utilization among all the assistive products. Handrails and grab bars are common in Japan and other countries as assistive products that improve the housing environment in terms of accessibility [33]. Especially in Japan, owing to the high population density in urban areas, many houses are small and older people have to live with steps in their home environments [33]. According to a previous study, assistive products for environmental modifications might also be helpful for older people with COPD who require LTC. However, the results showed that those with COPD were less likely to use handrails/grab bars, compared with those without COPD, even after adjusting for covariates. As many patients with COPD are in an unstable condition with a risk of exacerbations [7], they may prefer to use other medical and LTC services rather than assistive products. However, the necessity of installing handrails/grab bars that take the specificity of the respiratory pathological condition into consideration, distinguished from the characteristics of other diseases, such as disuse syndrome, has been pointed out [34]. Our study suggest the necessity for education on environmental modifications, with consideration for respiratory symptoms, for professionals who consider LTC plans.

Regarding mobility, 2–3% of those who required partial care used canes, walkers, and wheelchairs, and 7–16% of those who required total care used walkers and wheelchairs. A previous study in Canada reported that 15–20% of older people used mobility devices [27]. Another study in the United States reported that 65% of older adults with chronic disability used canes or walkers and 22% used wheelchairs [35]. Our study showed lower utilization among patients with and without COPD than those in previous studies [27, 35]. This may have been affected by the fact that those who purchased equipment without LTC insurance were excluded in our study. Our study also clarified that there was no difference in mobility device utilization between participants with and without COPD. The factors associated with mobility device utilization in this study were physical functions, such as LTC need levels, which is consistent with a previous study [28]. Although mobility devices can prevent energy consumption and reduce dyspnea [13], they may be used based on comprehensive decisions regarding care needs arising from the limitations of physical or cognitive functions.

Regarding assistive products for self-care activities in daily life, 5–7% of those who required partial care used electronic beds and bathing aids. The use of electronic beds was particularly high among those who required total care (38%). As older people without severe disabilities have little need for electronic beds and electronic beds are expensive, rental services through LTC insurance services might be useful for older people with declining physical function. Moreover, among those who required total care, those with COPD had more electronic beds than those without COPD. In addition to difficulty in getting up among those who required total care, those with COPD had dyspnea during movements in their beds, such as getting up [7, 14]. The Semi-Fowler position has the effect of relaxation and reducing dyspnea among COPD patients as it increases diaphragmatic excursion [37, 38]. For participants who required total care and had difficulty getting up, electric beds might have been used not only to help them get up but also to alleviate dyspnea. We also showed that those with COPD were more likely to use bathing aids, compared to those without COPD, among those who required partial care. Bathing is one of the most affected activities of daily living tasks among patients with COPD [36]. Bathing aids, such as bathing chairs and grab bars in the bathroom, may be used to relieve dyspnea. Although those who require total care may use daycare or visiting bathing services, those who require partial care may often take baths at home. Therefore, bathing aids might help patients with COPD with dyspnea to take baths continuously at home after being certified as requiring LTC. These results suggest that even if physical function is at the same level, improving the beds and bathing environment among those with COPD using assistive products might support living with less dyspnea. Further research is required to investigate the long-term effects of assistive product utilization. It would also be important to consider other factors related to utilization, such as cost and professional recognition, and to consider methods that can be used effectively by as many people who need assistive products as possible.

This study had several limitations. First, we could not clarify the gap between the need for assistive products and their actual utilization or determine the effects of assistive products. Previous studies have pointed out the gaps between the needs and actual utilization of assistive products [15, 28]. To explore the effective use of assistive products, it is necessary to investigate these aspects in the future. Second, although oxygen therapy was used as a covariate in this study, we could not examine the severity of COPD in more detail based on the claims data alone. Further studies are required to determine the differences in use according to the severity of COPD. Third, the claims data did not include some potentially important covariates, such as family caregivers or home environments. In a previous study, widowed older adults used mobility-assistive devices more frequently than married older adults [27]. Finally, because we used data from a single city, our findings may differ across Japan and other countries. The city in this study has a considerable population and a well-established supply of home medical care; therefore, the results may not apply to rural, underpopulated areas.

Older people with COPD used assistive products for self-care activities in daily life, such as bathing and getting up from bed, more often than those without COPD. The use of handrails/grab bars might be suboptimal in older people with COPD. Healthcare providers and policymakers should draw more attention to assistive product use for respiratory symptoms in older people with COPD.

AOR: Adjusted odds ratio

CI: Confidence interval

COPD: Chronic obstructive pulmonary disease

LTC: Long-term care

Ethics approval and consent to participant

This study was conducted in accordance with the tenets of the Declaration of Helsinki and approved by the review board of the Institute for Health Economics and Policy (R2-001). The requirement for informed consent was waived due to the anonymous nature of the database.

Consent for publication

Not applicable.

Availability of data and materials

The datasets analyzed in the current study, which include long-term care insurance claims data and medical insurance claims data, are not publicly available because Hachioji City owns the original data and only approved the secondary use of the data for the current study. If readers are interested in the data, please contact the corresponding author.

Competing interests

SH is an endowed chair, funded by donations from Hakue Technology, PROUMED, Japan BioProducts, Towa Pharmaceutical, Yellow Eight, and Sugi Holdings. SH received research funding from SOMPO Care, Inc. outside of this work. Although SH is an editorial board member of BMC Geriatrics, SH had no relationship with this paper’s peer-review process. The authors declare that they have no competing interests.

Funding

This study was supported by JSPS KAKENHI (grant number 21K21209). This funding source was not involved in the study design, methods, analysis, or preparation.

Authors’ contributions

Study concept and design: SK and RTI; analysis and interpretation of data: SK, RTI, RT, TI, TO and SH; drafting of the manuscript: SK; critical revision of the manuscript for important intellectual content: SK, RTI, RT, TI, TO and SH

Acknowledgments

We sincerely thank the Hachioji City officials who provided the data for this study.

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Competing interest reported. SH is an endowed chair, funded by donations from Hakue Technology, PROUMED, Japan BioProducts, Towa Pharmaceutical, Yellow Eight, and Sugi Holdings. SH received research funding from SOMPO Care, Inc. outside of this work. Although SH is an editorial board member of BMC Geriatrics, SH had no relationship with this paper’s peer-review process. The authors declare that they have no competing interests.

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Assistive products for long-term care among older people with chronic obstructive pulmonary disease in Japan: A retrospective cohort study

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Abstract

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Background

Methods

Study design and data sources

Participants

Measurements

Statistical analysis

Results

Discussion

Conclusions

Abbreviations

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References

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Supplementary Files

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Version 1