Gatekeeping function of primary care physicians under Japan's free-access system: a prospective open cohort study involving 14 isolated islands

Factors associated with adherence to recommendations for medical visits following annual health checkups among Japanese employees: A prospective cohort study

There are growing concerns in Japanese workplaces that many employees do not follow recommendations to visit medical institutions for further examinations following annual health checkups. Although previous studies have shown that job- and health-related factors affect adherence to such recommendations, these longitudinal associations are unknown. We examined the longitudinal associations between job- and health-related factors and visiting medical institutions after annual health checkups among Japanese employees. We conducted a prospective cohort study in a food-related company in fiscal year 2019. Participants completed a self-administered questionnaire to assess job- and health-related factors. Of 2914 employees who completed the questionnaire, 615 received recommendations to visit medical institutions following annual health checkups in fiscal year 2020; these employees comprised our sample. We used logistic regression analysis to examine the associations between each factor and medical institution visits. Of participants, 474 (77.1 %) were men, 432 (70.2 %) were aged over 40 years, and 293 (47.6 %) visited a medical institution. Logistic regression analysis showed that participants with a primary doctor and those with obesity were more likely to visit medical institutions. In Japanese workplaces, having a primary doctor may be important in increasing adherence to medical visit recommendations following annual health checkups. However, more focus is also needed on employees without obesity who may be more confident about their health and so less likely to follow recommendations. Further intervention studies focusing on these factors are needed to identify effective interventions to improve adherence to medical recommendations.

Challenges in Help-Seeking Behaviors among Rural Older People Mitigated through Family Physician-Driven Outreach: A Systematic Review

Help-seeking behaviors (HSBs) refer to approaches taken by individuals towards their health and symptoms, and they are supported by healthcare professionals. Outreach interventions aimed at older people in rural communities can mitigate difficulties in implementing HSBs and help them remain healthy. This systematic review investigated evidence regarding family medicine-involved outreach aimed at HSBs among older individuals in rural areas. We searched three databases (PubMed, EMBASE, and Web of Science) for international and original interventional articles regarding family physicians involved in outreach to older people in rural or underserved areas between April 2000 and October 2022. The articles were analyzed and summarized based on the setting, country, health issues, and outreach outcomes. Of the 376 studies identified, four were included in this review. Our findings showed that family physician-involved outreach to rural and underserved areas improved health outcomes, including anxiety, subjective physical function, and diabetic care. The challenges of outreach interventions include the duration and continuity of outreach, the active participation of family physicians and patients in the outreach programs, and the focus of outreach participants. Although the number of studies included was small, family physician-involved outreach to rural and underserved areas was shown to improve various health outcomes.

Ecology of medical care for 90+ individuals: An exhaustive cross-sectional survey in an ageing city

AIM

Urbanization and ageing are worldwide issues for healthcare providers. In particular, older adults aged 90 years and older have increased cognitive impairment and lower daily functioning than younger adults. However, the healthcare use of the oldest old remains unclear. This study aimed to describe the healthcare use of the oldest old compared with younger older adults in a city using the ecology of medical care model.

METHODS

We conducted a cross-sectional study. This study targeted all residents aged 75 years and older registered in a city in Japan for one year. We described healthcare use per 1000 inhabitants over a 1-month period and included: outpatient visits, emergency department visits, hospitalizations, home visits, home care services, and facility services. We also compared healthcare use among older adults aged 75-89 years and 90 years and older.

RESULTS

We described the healthcare use of 454 366 (male/female: 186 177/268 189) older adults. The numbers of persons per 1000 residents who used healthcare resources at least once in 1 month (75-89 years/90 years and older) were: outpatient clinic visits, 622/570; hospital outpatient visits, 300/263; advanced treatment hospital outpatient visits, 16/6; emergency department visits, 10/27; hospitalizations, 45/96; advanced treatment hospital hospitalizations, 2/1; planned home visits, 36/228; urgent home visits, 6/38; home care services, 173/533; and facility services, 32/178.

CONCLUSIONS

The results revealed that older adults over 90 years had more hospitalizations, emergency department visits and home visits, and used facility/home care services more compared with older adults aged 75-89 years. The results provide a useful benchmark for healthcare use estimation. Geriatr Gerontol Int 2022; 22: 483-489.

Improvement in Quality of Life through Self-Management of Mild Symptoms during the COVID-19 Pandemic: A Prospective Cohort Study

The COVID-19 pandemic has inhibited people's help-seeking behaviors (HSBs). In particular, older people in rural communities experienced limited access to medical care, which negatively affected their quality of life (QOL). Within HSB, self-management of mild symptoms may mitigate the difficulties experienced by older people in rural communities. However, few studies have examined the relationship between self-management and QOL. Therefore, we conducted a prospective cohort study to clarify this relationship. Our participants were over 65 years of age and lived in rural communities. QOL was measured with the EuroQol 5-Dimension 5-Level (EQ-5D-5L). Demographic data and QOL were collected from participants via questionnaires in 2021 and 2022. The exposure group showed a significantly greater change in EQ-5D-5L health status index scores than the control group (p = 0.002). In addition, the exposure group scored significantly lower than the control group on the EQ-5D-5L dimension "usual activities" in 2021 and on all dimensions in 2022. Thus, self-management of mild symptoms may improve QOL among older people in rural communities during the COVID-19 pandemic. Educational interventions for this population regarding self-management could improve QOL for entire communities.

Association between Self-Medication for Mild Symptoms and Quality of Life among Older Adults in Rural Japan: A Cross-Sectional Study

Self-medication, a help-seeking behavior to control individual symptoms, can be promoted to prevent the overuse of medical care and improve self-management among older adults. However, evidence regarding the association between self-medication and quality of life (QOL) is lacking. The purpose of this study is to investigate the association between QOL and the usage of self-medication among rural older adults. This cross-sectional study included participants older than 65 years in rural Japanese communities. Data were collected using a questionnaire regarding self-medication trends, the EQ-5D-5L to assess QOL, and a demographics questionnaire. Participants were divided into exposure and control groups based on their tendencies toward self-medication usage. Differences in the demographics between groups were adjusted using propensity score matching. Results: The health status in the exposure group was statistically significantly better than that in the control group in the dimensions of movement, self-care, and usual activities. Conversely, the pain/discomfort and anxiety/depression dimensions were not statistically significantly different. The quality of self-medication behaviors for mild symptoms can be improved with practical knowledge of and access to home remedies and over-the-counter drugs. Educational interventions and system development for better self-medication for mild symptoms and medical care for critical symptoms in rural contexts can be effective in improving QOL among rural older adults.

Event Monitoring and Evaluation by Community Pharmacists in Japan: A Pilot study on Fenofibrate and Pemafibrate

BACKGROUND

The Japan Pharmaceutical Association has conducted drug event monitoring to detect drug-related events related to pemafibrate. A pilot study evaluating the association between drug use and detected events was performed in Japan, as there are few studies on the safety of pemafibrate in clinical settings.

AIM

We investigated the association between detected events and pemafibrate, utilizing pharmacy records maintained by community pharmacists. We identified the new-user cohort comprising a test and active comparison drug and collected baseline information. An active comparison group comprising new users was used to assess the events.

METHOD

A retrospective cohort study using questionnaires on baseline and event data was conducted by community pharmacists belonging to the Japan Pharmaceutical Association. The incidence of event and estimated hazard ratio were calculated using the Cox proportional hazards model that was adjusted for confounding factors, such as age and sex.

RESULTS

A total of 1294 patients using pemafibrate and 508 patients using fenofibrate were identified as new drug users. The most reported events for suspected adverse reactions and add-on drugs were increased blood pressure and lipid-lowering drugs with pemafibrate use, and nasopharyngitis, pruritus, dizziness, and lipid-lowering drug with fenofibrate use. No significant differences were found for common events, except for an add-on of an anti-hypertensive for pemafibrate compared with fenofibrate.

CONCLUSION

Although further study is needed, this study by pharmacists can facilitate the safety assessment of newly marketed drugs, as few drug use investigations with a comparator are carried out by the Japanese authority for pharmaceutical companies.

Predicting the Travel Distance of Patients to Access Healthcare Using Deep Neural Networks

OBJECTIVE

Improving geographical access remains a key issue in determining the sufficiency of regional medical resources during health policy design. However, patient choices can be the result of the complex interactivity of various factors. The aim of this study is to propose a deep neural network approach to model the complex decision of patient choice in travel distance to access care, which is an important indicator for policymaking in allocating resources.

METHOD

We used the 4-year nationwide insurance data of Taiwan and accumulated the possible features discussed in earlier literature. This study proposes the use of a convolutional neural network (CNN)-based framework to make predictions. The model performance was tested against other machine learning methods. The proposed framework was further interpreted using Integrated Gradients (IG) to analyze the feature weights.

RESULTS

We successfully demonstrated the effectiveness of using a CNN-based framework to predict the travel distance of patients, achieving an accuracy of 0.968, AUC of 0.969, sensitivity of 0.960, and specificity of 0.989. The CNN-based framework outperformed all other methods. In this research, the IG weights are potentially explainable; however, the relationship does not correspond to known indicators in public health.

CONCLUSIONS

Our results demonstrate the feasibility of the deep learning-based travel distance prediction model. It has the potential to guide policymaking in resource allocation. Clinical and Translational Impact Statement- Deep learning technology is feasible in investigating the distance that patients would travel while accessing care. It is a tool that integrates complex interactive variables with highly imbalanced data distributions.

The Association between the Self-Management of Mild Symptoms and Quality of Life of Elderly Populations in Rural Communities: A Cross-Sectional Study

Maintaining people’s health based on their help-seeking behavior (HSB) regarding mild symptoms is essential. An effective HSB, especially self-management, can facilitate the attainment of appropriate healthcare resources and affect health outcomes such as quality of life (QOL). However, clear evidence regarding the relationship between self-management, mild symptoms, and QOL is unavailable. Therefore, this cross-sectional study investigated this association in a rural elderly population. The participants, aged over 65 years, were living in rural communities. The primary outcome of QOL was examined using the EuroQol 5-Dimension 5-Level (EQ-5D-5L). After adjusting for propensity score matching, 298 participants in the self-management usage group were matched with 298 in the group not using self-management. The most frequent HSB trend was consulting with primary care physicians, followed by self-care, consulting with families, utilizing home medicines, and buying medicines. The EQ-5D-5L scores were statistically higher in the self-management usage group than in the other group. The HSBs with a trend of using self-management were related to a high QOL. Self-management of symptoms along with other HSBs can improve elderly HSBs in rural contexts. Educational interventions and system development for HSBs in rural contexts could be effective in enhancing the QOL of rural elderly populations.

What resources do elderly people choose for managing their symptoms? Clarification of rural older people's choices of help-seeking behaviors in Japan

Background

Appropriate help-seeking behavior (HSB) that involves lay and professional care may moderate the usage of medical resources and promote good health, especially among the rural elderly. However, there is little evidence regarding the rural elderly’s HSB choices for mild symptoms. Therefore, this study attempts to bridge this gap.

Methods

The participants were patients living in rural areas and over the age of 65, who attended Japanese clinics and general hospitals. In Phase 1, monthly diaries and one-on-one interviews about their mild symptoms and HSB were used to establish HSB items and assess its content validity. Content analysis helped determine the items. In Phase 2, participants were asked to complete the list to measure HSB. The answers to the list and HSB mentioned in the diaries were compared to evaluate concurrent validity. Retests were conducted to examine the content’s reliability and test-retest reliability.

Results

Phase 1 included 267 participants (average age = 75.1 years, standard deviation [SD] = 4.3; 50.1% male). The diary collection rate was 97.6%. Of the participants, 70.4% used lay care and 25.4% used professional care. Content analysis identified eight types of lay care and four types of professional care. Phase 2 included 315 participants (average age = 77.7 years, SD = 8.27; 46.0% male). In terms of validity, the results of the list and the diaries were correlated (Spearman r 0.704; p < 0.001). The most common behavior with mild symptoms was consulting with primary care physicians, followed by self-care and using home medicine. The test-retest reliability for mild symptoms found kappa values of 0.836 for lay care and 0.808 for professional care.

Conclusions

The choices of HSB for mild symptoms clarified identified in this study have high validity and reliability. Therefore, it can be used to assess the relationships between HSB and health conditions and the effectiveness of health promotion on rural older people’s HSB.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06684-x.

Patient Choice and Willingness Toward Gatekeepers as First-Contact Medical Institutions in Chinese Tiered Healthcare Delivery System: A Cross-Sectional Study

Introduction: Gatekeeping mechanism of primary care institutions (PCIs) is essential in promoting tiered healthcare delivery system in China. However, patients seeking for higher-level institutions instead of gatekeepers as their first contact has persisted in the past decade. This study aims to explain patients' choice and willingness and to provide potential solutions. Methods: A survey was conducted among residents who had received medical care within the previous 14 days. Patients' choice and willingness of PCIs for first contact together with influencing factors were analyzed using binary logistic regression. Results: Of 728 sampled patients in Hubei, 55.22% chose PCIs for first contact. Patients who are older, less educated, with lower family income, not living near non-PCIs, with better self-perceived health status, only buying medicines, and living in rural instead of urban area had significantly higher probability of choosing PCIs. As of willingness, over 90% of the patients inclined to have the same choice for their first contact under similar health conditions. Service capability was the primary reason limiting patients' choice of PCIs. Conclusions: The gatekeeper system did not achieve its goal which was 70% of PCIs among all kinds of institutions for first contact. Future measures should aim to improve gate-keepers' capability.

Do patients bypass primary care for common health problems under a free-access system? Experience of Taiwan

Background

A common challenge for free-access systems is that people may bypass primary care and seek secondary care through self-referral. Taiwan’s government has undertaken various initiatives to mitigate bypass; however, little is known about whether the bypass trend has decreased over time. This study examined the extent to which patients bypass primary care for treatment of common diseases and factors associated with bypass under Taiwan’s free-access system.

Methods

This repeated cross-sectional study analyzed data from Taiwan’s National Health Insurance Research Database. A random sample of 1 million enrollees was drawn repeatedly from the insured population during 2000–2017. To capture visits beyond the community level, the bypass rate was defined as the proportion of self-referred visits to the top two levels of providers, namely academic medical centers and regional hospitals, among all visits to all providers. Subgroup analyses were conducted for visits with a single diagnosis. Logistic regressions were used to investigate factors associated with bypass.

Results

The standardized bypass rate for all diseases analyzed exhibited a decreasing trend. In 2017, it was low for common cold (0.7–1.3%), moderate for hypertension (14.0–29.5%), but still high for diabetes (32.0–47.0%). Moreover, the likelihood of bypass was higher for male, patients with higher salaries or comorbidities, and in areas with more physicians practicing in large hospitals or less physicians working in primary care facilities.

Conclusions

Although the bypass trend has decreased over time, continuing efforts may be required to reduce bypass associated with chronic diseases. Both patient sociodemographic and market characteristics were associated with the likelihood of bypass. These results may help policymakers to develop strategies to mitigate bypass.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05908-w.

Association between the size of healthcare facilities and the intensity of hypertension therapy: a cross-sectional comparison of prescription data from insurance claims data

Hypertension is a heterogeneous disease for which role sharing in treatment between specialized facilities and small clinics is needed for efficient healthcare provision. However, the Japanese healthcare system has a “free access” attribute; therefore, nobody can control treatment resource allocation. We aimed to describe the current situation of role sharing by comparing antihypertensive therapies among different types of medical facilities. We analyzed 1% sampled Japanese medical insurance claims data related to outpatient care as of October 2014. We divided the target patients into four groups according to the size of the facilities that issued the insurance claim for them. Among these groups, we compared the number of antihypertensive drugs and proportion of difficult-to-treat hypertensive cases and performed a stratified analysis. The proportion of patients with hypertension and diabetes mellitus receiving renin-angiotensin-aldosterone system inhibitors (RAASis) as the first-choice drug was also compared. We identified 3465, 1797, 2323, and 34,734 claims issued from large, medium-sized, small hospitals, and clinics, respectively. The mean number of hypertensive drugs was 1.96, 1.87, 1.81, and 1.69, respectively, and the proportion of difficult-to-treat hypertensive cases was 18.9, 17.0, 14.3, and 12.0%, respectively, with both showing significant differences. Stratified analysis showed similar results. The proportion of patients with hypertension and diabetes mellitus receiving RAASis as the first-choice drug was higher in large hospitals than in clinics. In conclusion, facility size is positively associated with the number of antihypertensive drugs and proportions of difficult-to-treat hypertensive cases. This finding describes the current role sharing situation of hypertension therapy in the Japanese healthcare system with a “free-access” attribute.

Performance and Sociodemographic Determinants of Excess Outpatient Demand of Rural Residents in China: A Cross-Sectional Study

Excess healthcare utilization is rapidly rising in rural China. This study focused on excess outpatient demand (EOD) and aimed to measure its performance and sociodemographic determinants among China’s rural residents. A total of 1290 residents from four counties in central China were enrolled via multistage cluster random sampling. EOD is the condition in which the level of hospital a patient chooses is higher than the indicated level in the governmental guide. A multilevel logistic regression was used to examine the sociodemographic determinants of EOD. Residents with EOD accounted for 85.83%. The risk of EOD was 51.17% and value was 5.69. The value of EOD in diseases was higher than that in symptoms (t = −21.498, p < 0.001). Age (OR = 0.489), educational level (OR = 1.986) and hospital distance difference (OR = 0.259) were the main sociodemographic determinants of EOD. Excess outpatient demand was evident in rural China, but extreme conditions were rare. Results revealed that age, educational level and hospital distance were the main sociodemographic determinants of EOD. The capacity of primary healthcare institutions, universality of common disease judgement and understanding of institution’s scope of disease curing capabilities of residents should be improved to reduce EOD.

Home care workers' judgments about users' acute conditions: A qualitative study on interprofessional collaboration

Home care workers' (HCWs) approaches to home care users' acute symptoms are critical for users' safety and quality of life. However, the processes of these approaches are unclear. This study investigates how HCWs assess users' conditions. Focus group discussions and semi-structured interviews with HCWs were conducted in a rural Japanese city. HCWs' decisions were affected by interactions and previous relationships with care managers, home care nurses, physicians, and users' families. Rural HCWs act flexibly, changing the professionals and families they consult with. Understanding HCWs' behaviors and improving relationships among medical/care professionals and families can improve management of users' acute conditions.

Associations of Patient Experience in Primary Care With Hospitalizations and Emergency Department Visits on Isolated Islands: A Prospective Cohort Study

PURPOSE

In rural areas, the management of hospitalizations and emergency department (ED) visits is an important issue, and it is compounded by factors such as the long distance to secondary care facilities, funding difficulties in many rural medical institutions, and shortage of medical staff. While better patient experience (PX) has been shown to reduce hospitalizations and ED visits, previous studies have not considered the differences between urban and rural areas. In addressing this gap, this study examines the association between PX and hospitalizations/ED visits on isolated islands.

METHODS

This prospective cohort study was conducted on 5 isolated islands in Okinawa, Japan. We assessed the PX of primary care using the Japanese version of the Primary Care Assessment Tool (JPCAT), which comprises 6 domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. The primary outcome was hospitalizations and ED visits in a year. We used a mixed effect model to adjust clustering within islands and individual covariates.

FINDINGS

Of 1,258 residents, 740 responded to a questionnaire for PX measurement. There were 73 hospitalizations and 62 ED visits. Adjusting for confounding and geographical clustering, hospitalizations had significant positive association with the PX score of each patient. ED visits were not associated with the total score of the JPCAT.

CONCLUSION

On the isolated islands, PX in primary care had positive correlation with hospitalizations. The contrast of our findings to those of previous studies may be due to the close patient-doctor relationship on isolated islands.