Perspectives on low-value care and barriers to de-implementation among primary care physicians: a multinational survey.

BACKGROUND: Healthcare costs are rising worldwide. At the same time, a considerable proportion of care does not benefit or may even be harmful to patients. We aimed to explore attitudes towards low-value care and identify the most important barriers to the de-implementation of low-value care use in primary care in high-income countries. METHODS: Between May and June 2022, we email surveyed primary care physicians in six high-income countries (Austria, Finland, Greece, Italy, Japan, and Sweden). Physician respondents were eligible if they had worked in primary care during the previous 24 months. The survey included four sections with categorized questions on (1) background information, (2) familiarity with Choosing Wisely recommendations, (3) attitudes towards overdiagnosis and overtreatment, and (4) barriers to de-implementation, as well as a section with open-ended questions on interventions and possible facilitators for de-implementation. We used descriptive statistics to present the results. RESULTS: Of the 16,935 primary care physicians, 1,731 answered (response rate 10.2%), 1,505 had worked in primary care practice in the last 24 months and were included in the analysis. Of the respondents, 53% had read Choosing Wisely recommendations. Of the respondents, 52% perceived overdiagnosis and 50% overtreatment as at least a problem to some extent in their own practice. Corresponding figures were 85% and 81% when they were asked regarding their country's healthcare. Respondents considered patient expectations (85% answered either moderate or major importance), patient's requests for treatments and tests (83%), fear of medical error (81%), workload/lack of time (81%), and fear of underdiagnosis or undertreatment (79%) as the most important barriers for de-implementation. Attitudes and perceptions of barriers differed significantly between countries. CONCLUSIONS: More than 80% of primary care physicians consider overtreatment and overdiagnosis as a problem in their country's healthcare but fewer (around 50%) in their own practice. Lack of time, fear of error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. Due to the wide variety of barriers to de-implementation and differences in their importance in different contexts, understanding local barriers is crucial when planning de-implementation strategies.

Smoking cessation interventions and implementations across multiple settings in Japan: a scoping review and supplemental survey.

BACKGROUND: Smoking is the leading risk factor for death worldwide. In Japan, although several evidence-based interventions (EBIs) for smoking cessation have been disseminated or adopted, there is a gap between scientific evidence and the actual implementation. This scoping review aimed to describe the knowledge gaps in local-level smoking cessation interventions in Japan, their implementation outcomes, implementation barriers and facilitators, and the use of implementation strategies. METHODS: This study comprised two approaches: (1) a comprehensive scoping review of primary and grey literature, and (2) a supplemental survey of organizations in the grey literature. For the scoping review, we included original studies or reports on smoking cessation interventions targeting adults aged 18 years and older, or providers of cessation support at various settings (community, workplace, school, and clinical settings) in Japan. The extracted data included basic characteristics, intervention categories, implementation outcomes, factors influencing implementation, and implementation strategies for each intervention. Responses to the supplemental survey were extracted same used for the scoping review. To gain a deeper understanding, semi-structured interviews were conducted with some of the organizations in the survey. RESULTS: A total of 600 interventions with 691 intervention components, based on EBIs in the 2020 US Surgeon General Report, from 498 articles were included in the data extraction; 32 of the 88 organizations responded to the survey. Regarding the overall knowledge about smoking cessation intervention components, behavioral counseling, and cessation medication in clinical settings were mostly reported (34.7%). Implementation outcomes were measured in 18 articles (3.0%) and penetration was mostly reported. Regarding influential factors, "available resources," and "knowledge and beliefs about the intervention" for barriers, and "relative priority" for facilitators were mostly reported. Implementation strategies were measured in 29 articles (4.8%), and "Train and educate stakeholders" was mostly reported. CONCLUSIONS: Most EBIs reported in the Japanese literature included smoking cessation treatments in clinical settings. While a few articles focused on the implementation indicators in Japan, significant knowledge and experience were extracted from the grey literature, especially in the workplace and community settings. Future research should focus more on implementation to reduce the knowledge gap regarding smoking cessation interventions.

ChatGPT-Generated Differential Diagnosis Lists for Complex Case-Derived Clinical Vignettes: Diagnostic Accuracy Evaluation.

BACKGROUND: The diagnostic accuracy of differential diagnoses generated by artificial intelligence chatbots, including ChatGPT models, for complex clinical vignettes derived from general internal medicine (GIM) department case reports is unknown. OBJECTIVE: This study aims to evaluate the accuracy of the differential diagnosis lists generated by both third-generation ChatGPT (ChatGPT-3.5) and fourth-generation ChatGPT (ChatGPT-4) by using case vignettes from case reports published by the Department of GIM of Dokkyo Medical University Hospital, Japan. METHODS: We searched PubMed for case reports. Upon identification, physicians selected diagnostic cases, determined the final diagnosis, and displayed them into clinical vignettes. Physicians typed the determined text with the clinical vignettes in the ChatGPT-3.5 and ChatGPT-4 prompts to generate the top 10 differential diagnoses. The ChatGPT models were not specially trained or further reinforced for this task. Three GIM physicians from other medical institutions created differential diagnosis lists by reading the same clinical vignettes. We measured the rate of correct diagnosis within the top 10 differential diagnosis lists, top 5 differential diagnosis lists, and the top diagnosis. RESULTS: In total, 52 case reports were analyzed. The rates of correct diagnosis by ChatGPT-4 within the top 10 differential diagnosis lists, top 5 differential diagnosis lists, and top diagnosis were 83% (43/52), 81% (42/52), and 60% (31/52), respectively. The rates of correct diagnosis by ChatGPT-3.5 within the top 10 differential diagnosis lists, top 5 differential diagnosis lists, and top diagnosis were 73% (38/52), 65% (34/52), and 42% (22/52), respectively. The rates of correct diagnosis by ChatGPT-4 were comparable to those by physicians within the top 10 (43/52, 83% vs 39/52, 75%, respectively; P=.47) and within the top 5 (42/52, 81% vs 35/52, 67%, respectively; P=.18) differential diagnosis lists and top diagnosis (31/52, 60% vs 26/52, 50%, respectively; P=.43) although the difference was not significant. The ChatGPT models' diagnostic accuracy did not significantly vary based on open access status or the publication date (before 2011 vs 2022). CONCLUSIONS: This study demonstrates the potential diagnostic accuracy of differential diagnosis lists generated using ChatGPT-3.5 and ChatGPT-4 for complex clinical vignettes from case reports published by the GIM department. The rate of correct diagnoses within the top 10 and top 5 differential diagnosis lists generated by ChatGPT-4 exceeds 80%. Although derived from a limited data set of case reports from a single department, our findings highlight the potential utility of ChatGPT-4 as a supplementary tool for physicians, particularly for those affiliated with the GIM department. Further investigations should explore the diagnostic accuracy of ChatGPT by using distinct case materials beyond its training data. Such efforts will provide a comprehensive insight into the role of artificial intelligence in enhancing clinical decision-making.

Barriers and facilitators to implementing geriatric assessment in daily oncology practice in Japan: A qualitative study using an implementation framework.

INTRODUCTION: Various guidelines recommend geriatric assessment (GA) for older adults with cancer, but it is not widely implemented in daily practice. This study uses an implementation framework to comprehensively and systematically identify multi-level barriers and facilitators to implementing GA in daily oncology practice. MATERIALS AND METHODS: We conducted 16 semi-structured interviews with healthcare providers in 10 designated cancer hospitals in Japan, using purposive and convenience sampling. The Consolidated Framework for Implementation Research (CFIR) was used to guide collection and analysis of interview data following a deductive content analysis approach with consensual qualitative research methods. After coding the interview data, ratings were assigned to each CFIR construct for each case, reflecting the valence and strength of each construct relative to implementation success. Then, those constructs that appeared to distinguish between high-implementation hospitals (HI) where GA is routinely performed in daily practice and low-implementation hospitals (LI) where GA is performed only for research purposes or not at all were explored. RESULTS: Of the 24 CFIR constructs assessed in the interviews, 15 strongly distinguished between HI and LI. In HI, GA was self-administered (Adaptability), or administered via a mobile app with interpretation (Design Quality and Packaging). In HI, healthcare providers were strongly aware of the urgent need to change practice for older adults (Tension for Change) and recognized that GA was compatible with existing workflow as part of their jobs (Compatibility), whereas in LI, they did not realize the need to change practice, and dismissed GA as an extra burden on their heavy workload. In HI, usefulness of GA was widely recognized by healthcare providers (Knowledge & Beliefs about the Intervention), GA had a high priority (Relative Priority) and had strong support from hospital directors, managers, and nursing chiefs (Leadership Engagement), and multiple stakeholders were successfully engaged, including nurses (Key Stakeholders), peer doctors (Opinion Leaders), and those who drive implementation of GA (Champions). DISCUSSION: These findings suggest that successful implementation of GA should focus on not only individual beliefs about the usefulness of GA and the complexity of GA itself, but also organizational factors related to hospitals and the engagement of multiple stakeholders.

The environmental impact of inhaler replacement: A carbon footprint and economic calculation of the National Database of Health Insurance Claims in Japan.

Background: Drugs are a major source of greenhouse gas (GHG) emissions from healthcare systems. Pressurized metered-dose inhalers (pMDIs) have raised concerns over their environmental impact due to GHG emissions. Evaluations and reduction strategies for GHGs have been primarily studied in Europe, but not in other regions, including Japan. Therefore, our objective was to calculate the carbon footprint of inhalers in Japan and evaluate their reduction scenarios. Methods: Using the National Database of Health Insurance Claims, our analysis was conducted on inhaler prescriptions in Japan for the fiscal year of 2019. We calculated the number of inhalers used, GHG emissions, and total costs. Next, we simulated the environmental and economic impacts of three reduction scenarios: the first scenario replaced pMDI with dry power inhalers, followed by age-based replacements. In the last scenario, we replaced pMDI with a propellant with a lower global warming potential. Results: All inhaler-related GHG emissions were 202 ktCO2e, of which 90.9% were attributed to pMDI use. Scenario analysis demonstrated that replacing 10% pMDI with DPI would reduce emissions by 6.7%, with a relatively modest increase in cost; substituting 10% of pMDI used by adults (excluding children and older adults) with alternative inhalers would reduce emissions by 6.1%, with a 0.7% increase in cost; and, replacing 10% of pMDI propellants with lower global warming potential would reduce emissions by 9.3%. Conclusions: Selecting appropriate inhalers can mitigate GHG emissions in Japan, but its impact will be less than in other countries. Nevertheless, collaborative efforts between physicians, patients, and pharmaceutical companies are necessary to reduce GHG emissions.

Screening practices of cancer survivors and individuals whose family or friends had a cancer diagnoses-a nationally representative cross-sectional survey in Japan (INFORM Study 2020).

PURPOSE: We examined cancer screening practices and related beliefs in cancer survivors and individuals with family or close friends with a cancer diagnosis compared to individuals without the above cancer history for 5 population-based (gastric, colorectal, lung, breast, cervical) and 1 opportunistic (prostate) cancer screenings using nationally representative cross-sectional survey in Japan. METHODS: We analyzed 3269 data from 3605 respondents (response rate, 37.1%) and compared the screening beliefs and practices of cancer survivors (n = 391), individuals with family members (n = 1674), and close friends with a cancer diagnosis (n = 685) to those without any cancer history (n = 519). RESULTS: Being a cancer survivor was associated with screening for gastric (OR, 1.75; 95% CI, 1.04-2.95), colorectal (OR, 1.56; 95% CI, 1.03-2.36), and lung cancer (OR, 1.71; 95% CI, 1.10-2.66) but not breast, cervical cancer or PSA test. Having a family cancer diagnosis was associated with colorectal and lung cancer screening. Having friends with a cancer diagnosis was associated with PSA test. Cancer survivors and family members perceived themselves as being more susceptible and worried about getting cancer than individuals without any cancer history. Cancer survivors strongly believed screening can detect cancer and were more likely to undergo screening. Subgroup analysis indicated an interrelation between gastric and colorectal cancer screening among survivors. CONCLUSIONS: A cancer diagnosis in oneself or family or friend influences an individual's health-related belief and risk perception, which can increase the likelihood of cancer screening. IMPLICATIONS FOR CANCER SURVIVORS: Targeted and tailored communication strategies can increase awareness of cancer screening.

Temporal Arteritis Caused by Tertiary Syphilis.

A 77-year-old man arrived at our hospital with bilateral shoulder pain persisting for several months and headache for 1 month. Giant cell arteritis with polymyalgia rheumatica was suspected. However, considering his medical history of testing positive for syphilis, we submitted a sample for a syphilis serology test, which yielded positive results. The Treponema pallidum hemagglutination assay of cerebrospinal fluid was positive, and a temporal artery biopsy revealed vasculitis, confirming the diagnosis of tertiary syphilis. He was successfully treated for two weeks with penicillin G infusions. Symptoms reminiscent of giant cell arteritis and polymyalgia rheumatica may reveal syphilis, which is called the "great imitator."

Factors affecting the implementation of guideline-based prophylactic antiemetic therapy for chemotherapy-induced nausea and vomiting in Japan: a protocol for a hospital-based qualitative study.

INTRODUCTION: Chemotherapy-induced nausea and vomiting (CINV) decrease patients' quality of life and negatively impact treatment outcomes. Although standard prophylactic antiemetic therapy for acute CINV recommended by guidelines is effective, poor guideline implementation is a worldwide problem. In Japan, prophylactic antiemetic therapy is relatively well implemented for chemotherapy associated with high emetogenic risk, while implementation gaps are observed for that with low emetogenic risk.Although most reports on factors influencing appropriate antiemetic prescription focus on physicians' attitudes and behaviours, a more comprehensive exploration is needed since chemotherapy is expected to involve pharmacists, nurses and eventually hospital directors. The purpose of this qualitative study is to comprehensively explore the factors that influence the implementation of appropriate prophylactic antiemetic procedures at cancer care hospitals in Japan. METHODS AND ANALYSIS: This study is a hospital-based qualitative study using semistructured individual interviews. The target population will be hospital directors, and chiefs (including proxies) of departments of oncology and/or chemotherapy, pharmacy and nursing, working in the hospitals, selected by purposive sampling. We will obtain information on antiemetics in chemotherapy regimens, antiemetic routine use and awareness of guidelines using prequestionnaires. Interviews will then be conducted online using an interview guide. The Consolidated Framework for Implementation Research will be used to collect and analyse the interview data. We will also create new codes inductively, as required. In addition, we will refer to the aggregate results of the Quality Indicator survey to determine the implementation of recommended antiemetic prescriptions for each hospital and discuss the relationship with influencing factors. ETHICS AND DISSEMINATION: This study has been approved by the National Cancer Centre Ethics Approval Committee (approval number: 2020-305). The study findings will be disseminated via peer-reviewed journal publications and presentations to academics, policy-makers, and clinicians at scientific conferences.

Smoking cessation interventions and implementations in Japan: a study protocol for a scoping review and supplemental survey.

INTRODUCTION: Despite various tobacco control measures in Japan, smoking remains a leading cause of mortality. This manuscript outlines proposed methodology for scoping review that aims to describe the knowledge gaps for local-level smoking cessation interventions in Japan, their implementation barriers and facilitators, and the use of implementation strategies. METHODS AND ANALYSIS: A scoping review will be conducted using the updated guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for Scoping Reviews to systematically search peer-reviewed journal articles and grey literature to identify studies on smoking cessation interventions in Japan. The six-stage scoping review model will involve (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting data; (5) collating, summarising and reporting the results; and (6) consultation exercise. Since there is little information available on the implementation context in the literature, we will use grey literature to identify organisations implementing smoking cessation interventions and conduct a cross-sectional survey among them to supplement the information gap. Based on a literature review, findings will be organised on smoking cessation interventions in local settings (ie, communities, workplaces, schools and hospitals) at the population, provider and individual levels in Japan to understand knowledge gaps. We will adopt the consolidated framework for implementation research to identify implementation barriers and facilitators, and the expert recommendations for implementing change to identify implementation strategies. ETHICS AND DISSEMINATION: This study does not require ethical committee approval. The scoping review method will be robust in searching available smoking cessation interventions in Japan. The findings of this study will be compiled as case studies of best practices on smoking cessation interventions and disseminated to relevant stakeholders at the public and private levels through publications, presentations in conferences and stakeholder meetings.

Peripheral Ulcerative Keratitis Associated With Large Vessel Vasculitis.

Peripheral ulcerative keratitis (PUK) is a non-infectious ulcer at the peripheral corneal stroma. Autoimmune diseases can cause PUK, but PUK caused by large vessel vasculitis (LVV) has rarely been reported. We report the case of a 71-year-old woman with complaints of low-grade fever and left eye pain. Ophthalmologic examination revealed PUK in the left eye, and we diagnosed LVV by 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) findings. The patient was treated with topical betamethasone eye drops for PUK and oral prednisolone for LVV. This case suggests that LVV can cause PUK.

A Perspective from a Case Conference on Comparing the Diagnostic Process: Human Diagnostic Thinking vs. Artificial Intelligence (AI) Decision Support Tools.

Artificial intelligence (AI) has made great contributions to the healthcare industry. However, its effect on medical diagnosis has not been well explored. Here, we examined a trial comparing the thinking process between a computer and a master in diagnosis at a clinical conference in Japan, with a focus on general diagnosis. Consequently, not only was AI unable to exhibit its thinking process, it also failed to include the final diagnosis. The following issues were highlighted: (1) input information to AI could not be weighted in order of importance for diagnosis; (2) AI could not deal with comorbidities (see Hickam's dictum); (3) AI was unable to consider the timeline of the illness (depending on the tool); (4) AI was unable to consider patient context; (5) AI could not obtain input information by themselves. This comparison of the thinking process uncovered a future perspective on the use of diagnostic support tools.

[Toward a "Choosing Wisely" Future in Medicine].

The "Choosing Wisely" campaign is an activity to promote conversations between patients and doctors about unnecessary examinations, treatments, or procedures. A "Top five list" published by a number of specialty societies consists of five evidence-based recommendations in their own fields. Choosing Wisely Japan was launched in 2016; the campaign soon became widespread among primary care physicians. To make wiser choices in prescriptions of any medicine, it is necessary to consider the balance between its efficacies, risks, and costs. The purpose of this campaign is not only to publish recommendations to reduce waste in health care resources but also to disseminate and implement the recommendations contents. To put them into practice, it is necessary to think about interprofessional and interdisciplinary approaches.

Meningeal carcinomatosis presenting with leukoencephalopathy-like imaging findings.

Meningeal carcinomatosis is a unique and rare form of metastasis observed in patients with malignant tumours. Diagnosis is simple when the primary lesion of the malignant tumour is clear, and when multiple miliary lesions are confirmed via cranial contrast MRI; however, many patients exhibit atypical imaging findings. In the present report, we discuss the case of a 72-year-old man who presented with subacute consciousness impairment and MRI findings suggestive of progressive, bilateral leukoencephalopathy-like lesions around the ventricles. Idiopathic hydrocephalus was initially suspected due to increased cerebrospinal fluid (CSF) pressure accompanied by normal cell counts. Although the patient underwent a ventriculoperitoneal shunt operation, his symptoms did not improve. Whole-body CT revealed findings suggestive of adenocarcinoma in the left lung. Paraneoplastic syndrome was suspected, and he was treated with three courses of high-dose intravenous methylprednisolone. However, his neurological symptoms did not improve, and he died 2 months after admission. The patient was ultimately diagnosed with meningeal carcinomatosis due to lung adenocarcinoma upon autopsy. In this case, we suspected that the white matter lesions observed on MRI resulted from secondary hydrocephalus due to obstruction of the CSF circulation. This is the first reported case of progressive leukoencephalopathy-like imaging findings in a patient with meningeal carcinomatosis.

Asymmetric Synthesis of an Amino Acid Derivative from Achiral Aroyl Acrylamide by Reversible Michael Addition and Preferential Crystallization.

Single-handed α-amino acid derivatives were generated from achiral precursors without an external chiral source. Conjugate addition of phenethylamine to an achiral aroyl acrylamide under homogeneous conditions gave the α-amino amides in quantitative yields, which crystallized as a conglomerate of a P21 crystal system. Dynamic preferential crystallization or attrition-enhanced deracemization resulted in the formation of enantiomorphic crystals of 99 % ee.