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Shimakami T, Setoyama H, Oza N, Itakura J, Kaneko S, Korenaga M, Toyama T, Tanaka J, Kanto T. Development of performance indicators for hepatitis countermeasures as a tool for the assessment and promotion of liver cancer prevention in Japan. J Gastroenterol 2023; 58:257-267. [PMID: 36645470 PMCID: PMC9841952 DOI: 10.1007/s00535-023-01956-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 01/04/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND Hepatitis countermeasures are being promoted by governments in Japan. We aimed to develop performance indicators (PIs) to assess the process and outcome of such countermeasures implemented for the prevention of viral hepatitis-related liver cancer at the national and prefectural government levels. METHODS We developed 19 PIs for hepatitis countermeasures implemented by local governments, covering the morbidity and mortality of liver cancer, hepatitis testing, subsidy programs for examinations and antiviral treatment, and education on hepatitis patient care to healthcare workers. We analyzed the PIs for each prefecture from Fiscal Year (FY) 2018-2020. RESULTS The morbidity and mortality of liver cancer significantly decreased in the study period. The percentage of municipalities conducting hepatitis screening was already high at 95% in FY2017. The usage rate of government-subsidized screenings did not change. The subsidy usage rate for periodic viral hepatitis examination significantly increased. Meanwhile, the subsidy usage rate for antiviral treatment of hepatitis B increased, whereas that for hepatitis C decreased. The number of certified healthcare workers providing care for hepatitis patients increased significantly, and these workers were efficiently placed at regional core centers, institutions specialized in liver diseases, health care centers, and municipal governments. Liver cancer mortality was positively correlated with hepatitis screening, subsidies for periodic examinations, and the number of hepatitis medical care coordinators but was negatively correlated with subsidies for anti-HCV therapy, suggesting that rigorous countermeasures were implemented in prefectures with high liver cancer mortality. CONCLUSIONS The developed PIs could be a useful tool for monitoring government efforts and achievements, thereby providing basic data for setting practical goals in liver cancer prevention.
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Affiliation(s)
- Tetsuro Shimakami
- Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Hiroko Setoyama
- Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
| | - Noriko Oza
- Department of Hepatology, Sagaken Medical Centre Koseikan, Saga City, Saga, Japan
| | - Jun Itakura
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Musashino, Tokyo, Japan
- Department of Gastroenterology, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Shun Kaneko
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Musashino, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masaaki Korenaga
- The Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Ichikawa, Chiba, Japan
| | - Tadashi Toyama
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
- Innovative Clinical Research Center (iCREK), Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Junko Tanaka
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan
| | - Tatsuya Kanto
- The Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Ichikawa, Chiba, Japan.
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Setoyama H, Tanaka Y, Kanto T. Seamless support from screening to anti-HCV treatment and HCC/ decompensated cirrhosis: Subsidy programs for HCV elimination. Glob Health Med 2021; 3:335-342. [PMID: 34782877 DOI: 10.35772/ghm.2021.01079] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 11/08/2022]
Abstract
Viral hepatitis poses a major public health problem in Japan. Chronic viral hepatitis is a progressive liver disease that eventually develops into liver cirrhosis and liver cancer. Since nucleic acid analog therapy for hepatitis B and interferon-free therapy for hepatitis C have made it possible to control the disease status or eliminate the viruses, it is very important that more people receive hepatitis virus tests to confirm the presence of infection at an early stage, and that patients with hepatitis detected by the tests receive appropriate medical care. Currently, the government of Japan is implementing comprehensive measures for hepatitis control based on five key strategies. Moreover, the goal listed in the Basic Guidelines on Hepatitis Measures is to reduce the frequency of progression of hepatitis to cirrhosis or liver cancer through a scheme consisting of testing people for hepatitis, getting those who test positive to visit a medical institution and receive treatment, and providing appropriate and high-quality hepatitis care through specialized medical institutions and regional core centers for the management of liver disease. To achieve the goal, various subsidy programs including an expense subsidy system for hepatitis treatment have been implemented in Japan. It is important for healthcare professionals to have sufficient knowledge of public support for efficient hepatitis C virus (HCV)-related liver disease detection and care.
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Affiliation(s)
- Hiroko Setoyama
- Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan.,Hepatitis Information Center, The Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Ichikawa, Japan
| | - Yasuhito Tanaka
- Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Tatsuya Kanto
- Hepatitis Information Center, The Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Ichikawa, Japan
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3
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Korenaga M, Kanto T. Testing, diagnosis of viral hepatitis, and the follow-up policy in Japan. Glob Health Med 2021; 3:308-313. [PMID: 34782874 DOI: 10.35772/ghm.2021.01072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/19/2021] [Accepted: 07/26/2021] [Indexed: 12/21/2022]
Abstract
Viral hepatitis is one of the major infectious diseases in Japan and causes liver cirrhosis and liver cancer. Therefore, screening for hepatitis viruses was started in 2002, based on the geriatric health care program. The screening plan has now been transferred to the Health Promotion Project and it is estimated that more than half of the population has been tested for hepatitis viruses. The Basic Act on Hepatitis Measures was enacted in 2009 and the Basic Guidelines for Promotion of Control Measures for hepatitis was issued in 2011. It reported that there were about 770,000 positive people who were unaware that they were infected, and about 0.5 to 1.2 million positive people who knew they were infected but did not continue to receive medical examinations. Ten years have passed since that report and it is estimated that the number of hepatitis virus-positive individuals who need medical examination/treatment is decreasing. Therefore, in order to eradicate viral hepatitis, it is essential to identify areas and age groups in which hepatitis virus testing is inadequate, to encourage people to undergo testing and to promptly send positive patients to hepatologists for continued medical care. This review describes the current status and challenges of hepatitis virus testing measures in Japan, led by the Ministry of Health, Labour and Welfare, and the promotion of visits to medical institutions by positive patients.
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Affiliation(s)
- Masaaki Korenaga
- Hepatitis Information Center, The Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Ichikawa, Chiba, Japan
| | - Tatsuya Kanto
- Hepatitis Information Center, The Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Ichikawa, Chiba, Japan
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Kanto T. Messages from Japan policy for viral hepatitis. Glob Health Med 2021; 3:249-252. [PMID: 34782865 PMCID: PMC8562090 DOI: 10.35772/ghm.2021.01078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/21/2021] [Accepted: 10/04/2021] [Indexed: 11/08/2022]
Abstract
In Japan, the estimated number of chronic HBV infections was 1.1-1.2 million and that of chronic HCV was 0.9-1.3 million in 2015. The mortality of hepatocellular carcinoma (HCC) had been increasing and hit a peak at around 2002, which subsequently started to decrease. Japan has a national action plan for addressing viral hepatitis called, "Basic Act on Hepatitis Measures", established in 2009. "Basic Guidelines for Promotion of Control Measures for Hepatitis" was issued in 2011 and was updated in 2016, comprising 9 principles in order to promote measures to prevent hepatitis B and C. According to these guidelines, national and local government share screening costs for testing HBV and HCV for those residents who are over 40 years old. Thus, out-of-pocket expenses from examinees are free of charge or reduced to a minimum. In addition, for patients with chronic hepatitis B or C being treated: drug prices of nucleotide analogues, interferon treatment or direct antiviral agents, and examination expenses should be covered by a special program for viral hepatitis. From December 2018, the special coverage program of medical expenses, shared by central and local government, has started for patients with HBV- or HCV-induced liver cancer and decompensated cirrhosis. However, in the cascade-of-care of viral hepatitis in Japan, significant gaps still remain in the diagnosis, treatment and transition to patients in need. Several advantages have prevailed in Japanese health care systems for patients with viral liver disease compared to those in other countries in the Western Pacific Region. Therefore, Japan should take a lead in helping the implementation of a practical hepatitis action plan for each country in need.
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Affiliation(s)
- Tatsuya Kanto
- The Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Ichikawa, Japan
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Takeuchi Y, Ohara M, Kanto T. Nationwide awareness-raising program for viral hepatitis in Japan: the " Shitte kan-en" project. Glob Health Med 2021; 3:301-307. [PMID: 34782873 DOI: 10.35772/ghm.2021.01063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/01/2021] [Accepted: 08/06/2021] [Indexed: 11/08/2022]
Abstract
Chronic viral hepatitis is one of the most widespread infectious diseases in Japan. In the 2009 financial year, the Japanese government enacted the Basic Act on Hepatitis Measures, followed by the Basic Guidelines for Promotion of Control Measures for Hepatitis 2 years later. The guidelines emphasize the importance of provision and dissemination of accurate information on viral hepatitis and public awareness-raising. A subsidy program on hepatitis was therefore launched by the Ministry of Health, Labour and Welfare in 2011, called "Shitte kan-en" (in English, "Let's learn about hepatitis"), and involves popular Japanese actors and singers. The project started awareness-raising activities in the 2013 financial year, as the "National Campaign Project for Hepatitis Measures". It aims to communicate concise and accurate information about hepatitis and the necessity of testing for viral hepatitis. It also encourages citizens to take a positive approach to early detection and treatment. To date, the main initiatives of the project are as follows: i) celebrity visits to prefectural governors to draw attention to the condition, ii) educational events in cooperation with hepatologists in regional core hospitals, iii) support for partner companies' hepatitis awareness activities in workplaces, and iv) support for the activities of program promoters. Targeting approaches to particular groups is likely to be key to success for general awareness-raising. Evaluation of the effectiveness of this multifaceted approach is warranted to reduce the undiagnosed population and improve the link between testing and care for viral hepatitis in Japan.
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Affiliation(s)
- Yasue Takeuchi
- Office for Promotion of Hepatitis Measures, Cancer and Disease Control Division, Health Service Bureau, Ministry of Health, Labour and Welfare, Tokyo, Japan.,Department of Gastroenterology and Metabolism, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masatsugu Ohara
- Office for Promotion of Hepatitis Measures, Cancer and Disease Control Division, Health Service Bureau, Ministry of Health, Labour and Welfare, Tokyo, Japan.,Department of Gastroenterology and Hepatology, National Hospital Organization Hokkaido Medical Center, Hokkaido, Japan.,Department of Gastroenterology and Hepatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Hokkaido, Japan
| | - Tatsuya Kanto
- Hepatitis Information Center, The Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Chiba, Japan
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Isoda H, Eguchi Y, Takahashi H. Hepatitis medical care coordinators: Comprehensive and seamless support for patients with hepatitis. Glob Health Med 2021; 3:343-350. [PMID: 34782878 DOI: 10.35772/ghm.2021.01073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/23/2021] [Accepted: 09/01/2021] [Indexed: 12/22/2022]
Abstract
Chronic liver disease, especially viral hepatitis, is an urgent issue in Japan. Human resource management is important to promote appropriate care for patients with chronic liver disease in medical institutions and in the community. In 2011 the Ministry of Health, Labour and Welfare in Japan started training hepatitis medical care coordinators (HMCCs). Various medical professionals (such as public health nurses, general nurses, and clinical technicians), patients, and ordinary citizens are certified as HMCCs by the prefectural government after learning about liver diseases in a training program. The training program can be optimized in accordance with the regional circumstances and basic knowledge and skills of the applicants. HMCCs encourage residents and patients to undergo a hepatitis screening test, after which positive patients undergo detailed examination, treatment, and follow-up. HMCCs contribute to the expansion of knowledge about hepatitis in their workplace and community. By 2018, there were HMCCs in all 47 prefectures of Japan. There were 20,049 HMCCs in 2019. The most common professions of HMCCs were public health nurses, followed by general nurses, hospital pharmacists, laboratory technicians, and medical social workers. After certification, the activities of HMCCs vary; to ensure that HMCCs are adequately used in medical institutions, the supervisor and physicians must recognize the importance of HMCCs and generate opportunities for HMCC activity. The training and effective utilization of HMCCs is a promising way to decrease the prevalence and mortality of chronic liver diseases in Japan.
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Affiliation(s)
| | - Yuichiro Eguchi
- Liver Center, Saga University Hospital, Saga, Japan.,Loco Medical General Institute, Ogi, Saga, Japan
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Masaki N, Kawasaki Y, Nozaki Y, Yanase M. Characteristics of patients aged over 75 years with hepatitis C virus infection treated with direct-acting antivirals in Japan: Evidence based on the nationwide, real-world database in Japan. Hepatol Res 2021; 51:417-425. [PMID: 33217105 DOI: 10.1111/hepr.13596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/16/2020] [Accepted: 11/09/2020] [Indexed: 01/01/2023]
Abstract
AIM Direct-acting antivirals (DAAs) have dramatically changed the treatment of chronic hepatitis C. Their high efficacy helps in eradicating hepatitis C virus with few adverse events. Information on real-world use of DAAs therapy in patients aged 75 years and older is inadequate. METHODS The Japanese DAAs database was constructed in 2014 as a cooperative system between 18 prefectures. The medical reports filled in by doctors and anonymized at the local government office were collected. The patients' demographic features, viral factors, and treatment characteristics were compared among three groups stratified by age when therapy was initiated: Group A (<60 years old), Group B (60-74 years old), and Group C (≥75 years old). RESULTS Out of the 22,454 patients whose age upon starting therapy could be identified, 24.8% (n = 5597) belonged to Group C, which was ten times the number in the Japanese Interferon Database. Female patients, advanced stages of liver fibrosis, and past history of hepatocellular carcinoma treatment were significantly higher in the older age groups (Group A < B < C), whereas sustained virologic response (SVR) rates were not different (91%-93%). In Group C, multivariate logistic regression analysis revealed that predicting factors for virologic response varied among DAAs regimens. However, the completion of DAAs therapy commonly contributed to SVR, regardless of DAAs regimen. CONCLUSIONS DAAs therapy is associated with high SVR rates, even in the oldest age group, and therapy should not be withheld on the basis of old age.
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Affiliation(s)
- Naohiko Masaki
- Laboratory Testing Department, National Center for Global Health and Medicine, Tokyo, Japan
| | - Youhei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan.,Faculty of Nursing, Japanese Red Cross College of Nursing, Tokyo, Japan
| | - Yuichi Nozaki
- Department of Gastroenterology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mikio Yanase
- Department of Gastroenterology, National Center for Global Health and Medicine, Tokyo, Japan
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Takahashi H, Eguchi Y. What Can Be Done to Address the Exhaustive Referral of Patients with Viral Hepatitis to Specialists? Intern Med 2021; 60:323-324. [PMID: 32963173 PMCID: PMC7925262 DOI: 10.2169/internalmedicine.5967-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Hirokazu Takahashi
- Liver Center, Saga University Hospital, Faculty of Medicine, Saga University, Japan
| | - Yuichiro Eguchi
- Liver Center, Saga University Hospital, Faculty of Medicine, Saga University, Japan
- Loco Medical General Institute, Japan
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Tojima H, Kakizaki S, Takakusagi S, Hoshino T, Naganuma A, Nagashima T, Namikawa M, Ueno T, Shimada Y, Hatanaka T, Takizawa D, Arai H, Sato K, Takagi H, Uraoka T. Follow-up after Direct-acting Antiviral Treatment for Chronic Hepatitis C Virus Infection: Most Patients Are Followed Appropriately. Intern Med 2021; 60:3061-3070. [PMID: 34602520 PMCID: PMC8545640 DOI: 10.2169/internalmedicine.6591-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective Chronic hepatitis C virus (HCV) infection carries a residual risk of hepatocarcinogenesis even after viral elimination, so appropriate follow-up is necessary. The present study investigated the current hospital visits and hepatocarcinogenesis status of patients who received daclatasvir plus asunaprevir treatment (DCV+ASV) to determine whether or not appropriate follow-up was being performed. Methods We retrospectively analyzed hepatocarcinogenesis, the overall survival, and the length of hospital visits in 442 patients who applied for the medical expense subsidy system for viral hepatitis and received DCV+ASV treatment in Gunma Prefecture between October 2014 and December 2015. This also included 61 patients who had a history of hepatocellular carcinoma (HCC). Results Among 442 patients, 388 achieved a sustained viral response (SVR) by DCV+ASV therapy (87.8%), and 95.9% achieved an SVR if additional treatment was included. HCC was found in 75 cases (17.0%). A history of HCC, the FIB-4 index and the treatment effect SVR were determined to be factors affecting the incidence of HCC. Regarding the follow-up rate, 89.9% of patients continued to regularly visit the hospital after 5 years of treatment. However, patients ≤60 years old had significantly lower persistence rates than older patients. The persistence rate of hospital visits to the same institution was 67.7% over a 5-year period, which was significantly better in small and medium-sized institutions than in large, specialized institutions (71.7% vs. 63.9%, p=0.039). Conclusion Patients with direct-acting antiviral treatment generally received adequate follow-up, but younger patients had a slightly higher rate of follow-up interruption and were considered to need support.
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Affiliation(s)
- Hiroki Tojima
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Japan
| | - Satoru Kakizaki
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Japan
- Department of Clinical Research, National Hospital Organization Takasaki General Medical Center, Japan
| | | | - Takashi Hoshino
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, Japan
| | - Atsushi Naganuma
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, Japan
| | - Tamon Nagashima
- Department of Gastroenterology, National Hospital Organization Shibukawa Medical Center, Japan
| | - Masashi Namikawa
- Department of Internal Medicine, Kiryu Kosei General Hospital, Japan
| | - Takashi Ueno
- Department of Internal Medicine, Isesaki Municipal Hospital, Japan
| | - Yasushi Shimada
- Department of Internal Medicine, Isesaki Municipal Hospital, Japan
| | - Takeshi Hatanaka
- Department of Gastroenterology, Gunma Saiseikai Maebashi Hospital, Japan
| | - Daichi Takizawa
- Department of Gastroenterology, Maebashi Red Cross Hospital, Japan
| | - Hirotaka Arai
- Department of Gastroenterology, Maebashi Red Cross Hospital, Japan
| | - Ken Sato
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Japan
| | - Hitoshi Takagi
- Department of Gastroenterology, Kusunoki Hospital, Japan
| | - Toshio Uraoka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Japan
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Setoyama H, Korenaga M, Kitayama Y, Oza N, Masaki N, Kanto T. Nationwide survey on activities of regional core centers for the management of liver disease in Japan: Cumulative analyses by the Hepatitis Information Center 2009-2017. Hepatol Res 2020; 50:165-173. [PMID: 31747717 PMCID: PMC7027808 DOI: 10.1111/hepr.13458] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 10/31/2019] [Accepted: 11/05/2019] [Indexed: 01/17/2023]
Abstract
AIM Regional core centers for the management of liver disease, which are located in every prefecture in Japan, not only take the lead in hepatitis care in their respective regions, but also serve a wide range of other functions, such as education, promotion of hepatitis testing, treatment, and research. METHOD Since fiscal year 2010, the Hepatitis Information Center has conducted surveys of regional core centers throughout Japan regarding information about their facilities, programs for patient support, training, and education of medical personnel. RESULTS By compiling and analyzing the results of these surveys, we have elucidated the status of regional core centers and the issues they currently have. We found that regional core centers have come to play widely varied roles in hepatitis treatment and have expanded their programs. These surveys also suggest that uniform accessibility of hepatitis treatment has been implemented throughout Japan. CONCLUSION To continue serving their diverse roles, regional core centers require further development of hepatitis care networks that include specialized institutions, primary care physicians, and local and central governments; as well as collaboration with other professions and groups.
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Affiliation(s)
- Hiroko Setoyama
- Hepatitis Information Center, Research Center for Hepatitis and ImmunologyNational Center for Global Health and MedicineIchikawaJapan,Department of Gastroenterology and HepatologyKumamoto Rosai HospitalYatsushiroJapan,Department of Gastroenterology and Hepatology, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Masaaki Korenaga
- Hepatitis Information Center, Research Center for Hepatitis and ImmunologyNational Center for Global Health and MedicineIchikawaJapan
| | - Yuko Kitayama
- Hepatitis Information Center, Research Center for Hepatitis and ImmunologyNational Center for Global Health and MedicineIchikawaJapan
| | - Noriko Oza
- Hepatitis Information Center, Research Center for Hepatitis and ImmunologyNational Center for Global Health and MedicineIchikawaJapan,Department of Hepatobiliary and PancreatologySaga‐Ken Medical Center KoseikanSagaJapan
| | - Naohiko Masaki
- Department of Clinical LaboratoryNational Center for Global Health and MedicineShinjyukuJapan
| | - Tatsuya Kanto
- Hepatitis Information Center, Research Center for Hepatitis and ImmunologyNational Center for Global Health and MedicineIchikawaJapan
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