Real world patterns of dyslipidemia care before and after a national fee revision in Japan: A nationwide study using a 30 million patient claims database.
Yamasaki S, Tokunou T, Horiuchi T • PloS one • 2026
Low-density lipoprotein cholesterol goals were attained at 58.3% of outpatient visits under the previous fee and 58.5% under the new fee, with broadly similar lipid levels and cardiovascular event rates across fee periods, though post-revision follow-up was limited to approximately 6 months.
Key Findings
Results
LDL cholesterol goal attainment rates were nearly identical under the previous and new fee structures.
LDL-C goals were attained at 58.3% of outpatient visits under the previous disease-specific management fee.
LDL-C goals were attained at 58.5% of outpatient visits under the new lifestyle disease management fee.
Goal attainment was less frequent in secondary prevention than in primary prevention patients.
High statin use and frequent combination therapy with ezetimibe or fibrate were observed despite suboptimal goal attainment.
Results
Lipid levels were broadly similar across the two fee periods.
The study compared lipid parameters between the previous disease-specific management fee period and the new lifestyle disease management fee period.
No meaningful differences in lipid levels were detected between the two fee categories.
The analysis was conducted at the outpatient visit level across 23,600,010 outpatient visits from 590,000 patients.
Results
Cardiovascular event rates were similar across fee periods, but the post-revision follow-up period was highly limited.
Post-revision patient-years were limited to approximately 6 months.
Pre-revision patient-years totaled 1,542,800 compared to only 58,500 post-revision patient-years.
The authors characterized the cardiovascular comparison as 'exploratory' and stated it 'cannot exclude an effect of the new fee structure.'
Both major adverse cardiovascular events and all-cause mortality were analyzed as secondary outcomes at the patient level.
Results
Secondary prevention patients achieved LDL-C goals less often than primary prevention patients despite high rates of statin use and combination therapy.
The disparity between primary and secondary prevention goal attainment was observed despite frequent use of statins.
Combination therapy with ezetimibe or fibrate was also frequently used, particularly in higher-risk patients.
This pattern suggests that secondary prevention patients represent a group that may benefit from additional lifestyle-based interventions.
The overall goal attainment rate of approximately 58% across both fee periods indicates a substantial proportion of patients not meeting LDL-C targets.
Methods
The study used a nationwide claims database encompassing 590,000 patients with dyslipidemia contributing over 23.6 million outpatient visits.
The study was a retrospective cohort study among adults aged ≥18 years with dyslipidemia (ICD-10 code E78) and at least one lipid measurement.
A 30 million patient claims database was used as the data source.
Outpatient visits were the unit of observation for lipid and fee-category analyses.
Cardiovascular outcomes and patient-years were analyzed at the patient level.
The 2024 fee revision in Japan's insurance system, which replaced the disease-specific management fee with a lifestyle disease management fee, served as the natural policy experiment.
Background
Japan's 2024 fee revision aimed to encourage a more holistic approach and better patient involvement in treatment planning, but its real-world impact on patient outcomes remains unclear.
The fee change replaced the previous disease-specific management fee with a new lifestyle disease management fee.
The stated goal of the policy change was to encourage a more holistic approach and better patient involvement in developing treatment plans.
The authors concluded that 'longer follow-up and complementary designs are needed to evaluate the causal impact of the new fee on outcomes.'
Dyslipidemia prevalence continues to rise with population aging in Japan, making this a high-priority public health concern.
What This Means
This research used a massive database of 30 million patient records in Japan to examine how well patients with high cholesterol (dyslipidemia) are being managed, and whether a 2024 change to Japan's health insurance payment system made any difference. The new payment system was designed to encourage doctors to take a broader, more lifestyle-focused approach and involve patients more in their own care plans. The study tracked 590,000 patients across more than 23 million clinic visits and found that about 58% of visits showed patients meeting their LDL ('bad') cholesterol targets — and this rate was virtually unchanged before and after the new payment rules took effect.
The research also found that patients who already had cardiovascular disease (secondary prevention) were less likely to meet their cholesterol targets than those trying to prevent a first event (primary prevention), even though these higher-risk patients were already using statins at high rates and were often on combination drug therapies. Cholesterol levels overall and rates of serious cardiovascular events were similar between the two time periods, suggesting the payment change had not yet produced a measurable improvement — though the authors caution that only about six months of data existed after the new rules started, compared to years of data before, making any definitive conclusion impossible.
This research suggests that while Japan's new insurance payment approach has the right intentions, it is too early to tell whether it actually improves patient health outcomes. The roughly 42% of patients not meeting cholesterol goals — especially those at highest cardiovascular risk — represent an important group where better lifestyle support and treatment optimization may be needed. The authors call for longer follow-up studies before drawing firm conclusions about whether the policy change is working.
Yamasaki S, Tokunou T, Horiuchi T. (2026). Real world patterns of dyslipidemia care before and after a national fee revision in Japan: A nationwide study using a 30 million patient claims database.. PloS one. https://doi.org/10.1371/journal.pone.0358270