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Evaluation by the Basic Checklist and the risk of 3 years incident long‐term care insurance certification

Abstract Background A rapidly aging society needs effective approaches to support frail older people who have a high risk of requiring long‐term care. We investigated the validity of the Basic Checklist (the “Kihon Checklist”) as a tool to select candidates for a program to prevent long‐term care. Method A survey with questions from the Basic Checklist was conducted with functionally independent older residents aged ≥65 years living in Takasaki City, Japan. Subjects who completed the questionnaire were followed over 3 years for the presence or absence of certification for long‐term care requirement. We used multiple logistic regression analysis to calculate the odds ratio (OR) and 95% confidence interval (95%CI) for long‐term care requirement certification. Results A total of 21 325 subjects were analyzed. The odds ratio was the highest when items number one‐20 had a total of ≥10 checked answers (OR, 2.71; 95%CI, 2.22‐3.32). Physical function (OR, 2.29; 95%CI, 2.05‐2.55), nutritional condition (OR, 1.85; 95%CI, 1.38‐2.48), oral function (OR, 1.40; 95%CI, 1.25‐1.57), whether patients were elected as a care prevention program candidate (OR, 1.90; 95%CI, 1.73‐2.08), Homebound state (OR, 1.91; 95%CI, 1.55‐2.37), the presence of dementia (OR, 1.97; 95%CI, 1.75‐2.20), and depression (OR, 1.96; 95%CI, 1.73‐2.22) were associated with a higher odds ratio. Conclusion Individuals who were selected as long‐term care prevention program candidates based on the Basic Checklist had a higher risk of requiring long‐term care. Older residents who corresponded to 10 or more of the 20 Basic Checklist items are at the highest risk of becoming certified as needing long‐term care.

long-term care, and since then municipalities have implemented longterm care prevention programs for frail older people who are at risk of requiring support or long-term care. 2 The Ministry of Health, Labour, and Welfare of Japan developed the Basic Checklist (the "Kihon Checklist") as a screening test to accurately and efficiently identify frail older people who are at risk of requiring support or long-term care, 3 and municipalities throughout Japan use the Basic Checklist to select older people as candidates for long-term care prevention programs. The Basic Checklist comprises seven domains: the instrumental activities of daily living (IADL), physical function, nutritional condition, oral function, homebound state, dementia, and depression. Each negative, care-requiring response equals one point, and persons with higher scores are more likely to be frail. Based on the scores, municipalities invite frail older people to participate in long-term care prevention programs, and adopt appropriate approaches for each candidate.
The Basic Checklist has been used as a tool to determine the effects of exercise intervention in a physical function improvement program, 4,5 to evaluate frail older people's physical functions, 6 and to screen for dementia. 7 The association of the checklist with the ability to perform the IADL 8 and with the homebound state 9 has also been investigated.
However, limited cohort studies have investigated whether the selection of care prevention program candidates based on the checklist can accurately predict which persons will be certified as requiring long-term care.
Although previous studies have suggested that such individuals can be predicted by the checklist, follow-up of study participants was relatively short. 10,11 Long-term care prevention programs are effective whether frail older people participate in these programs early and continue their participation for an extended period of time. Municipalities can efficiently implement such programs through the early selection of older people who are deemed likely to be certified as requiring long-term care. Therefore, to verify the predictive validity of the Basic Checklist, long-term monitoring of the long-term care requirement certification status of older people who have completed the checklist is needed.
The purpose of this study was to investigate how well the selection of care prevention program candidates based on the Basic Checklist can predict those who will be certified as requiring long-term care within 3 years after completing the checklist.

| Subjects
A survey with questions from the Basic Checklist was conducted among older people who had a health checkup provided by the municipality to prevent lifestyle-related diseases between April 2010 and March 2011.
The health checkup targeted 69,755 residents of Takasaki City, Gunma Prefecture, who were aged ≥65 years and did not require long-term care or support. All older people who completed the questionnaire served as the study subjects, and they were followed from the day of questionnaire completion until March 2014 for the presence or absence of certification for long-term care requirement. The presence or absence and timing of long-term care requirement certification were investigated based on the long-term care certification data recorded by Takasaki City government. The date of being certified as requiring long-term care or support by the Review Board for Long-term Care Certification was regarded as the time of requiring long-term care. Older people who died or became exempt from the long-term care insurance system of Takasaki City, for reasons such as moving out of the city, without being certified as requiring long-term care, and people who were certified before March 2011 were excluded from the analyses.
The Medical Ethics Committee of Gunma University approved this study (26-19).

| Summary of the basic checklist
The Basic Checklist comprises seven domains with 25 items ( Table 1) Subjects answer was "yes" or "no" for each item, and each negative, care-requiring response equals one point. Those with higher scores are more likely to be frail. If a subject meets any of the following four criteria; checked more than 10 of the items (Number 1-20), checked ≥3 answers for the domain of physical function, checked answers for both items of the nutritional condition, or checked ≥2 answers for the oral function, they are selected as long-term care prevention program candidates ( Table 2). If a selected candidate meets the criteria for any of the following domains, they are also advised to attend additional programs; physical function improvement and dementia prevention programs: a checked answer for item Number 16 (homebound state), ≥1 checked answer for dementia, or checked ≥2 answers for depression ( Table 2).

| Analyses
We divided subjects into those who were and were not classified as requiring long-term care during study follow-up to compare the variable distribution between the groups. Chi-square tests were used to analyze the categorical variables, and Mann-Whitney's U test was used for the ordinal and nonparametric variables.
We used multiple logistic regression to calculate the odds ratio (OR), 95% confidence interval (CI), chi-square goodness of fit (χ 2 GF), and percentage of correct classifications (%CC) for long-term care requirement certification between care prevention program candidates and noncandidates who were identified based on the Basic Checklist and between individuals who met the criteria for recommended participation in additional care prevention programs, and those who did not. The following factors were used for analyses: age; gender (male:   Table 3 shows the characteristics of the former and latter groups. a If the care prevention program candidate meets any of the criteria mentioned in (6)-(8), he/she will be judged as requiring specialized support covering the domain.

| DISCUSSION
In multiple logistic regression analysis, to calculate the odds ratio (9.3%) in Japan. 12 Furthermore, decreased physical function is closely associated with new long-term care need certification. 12 Therefore, to promote care prevention for community-dwelling older people, it may be useful to improve their physical function. Physical activity interventions for older people have been reported to promote physical function, which prevents falls, 13,14 and improves cognitive function. 15,16 Such approaches have been used by care prevention programs based on the long-term care insurance system in a large number of intervention studies. 17 The Basic Checklist has been used to select participants in some of them, [18][19][20] in addition to being adopted as an index to measure the outcomes of physical activity interventions. 20 It has also been used to select participants by investigators who examine other types of intervention. 21,22 The Basic Checklist is a useful instrument for multiple purposes, such as selecting care prevention program participants and measuring outcomes. selection criteria and risk was observed in previous studies. 10,11 The results of our study confirmed their findings by following a larger number of participants for a longer time.
This study included only the older people who completed the Basic Checklist. The health of persons who do not participate in health surveys of older people has frequently been reported to be poor. 23,24 Persons who did not complete the Basic Checklist were likely to be frail older residents in poor health, with an increased risk of becoming certified as individuals with long-term care needs.
By excluding them from this study, the proportion of persons at risk may have been underestimated. The low coverage rate of study population (32.3%) was a limitation of our study. Furthermore, information on diseases and a decreased functional ability to lead an independent life associated with long-term care need certification was not available, and certified support or care grades were not classified. In consideration of these points, it may be necessary to conduct further research.

| CONCLUSION
Individuals who were selected as long-term care prevention program candidates based on the Basic Checklist had a higher risk of requiring long-term care. Older residents corresponding to 10 or more of the 20 Basic Checklist items are at the highest risk of becoming certified as needing long-term care.