Death at home versus other locations in older people receiving physician-led home visits: A multicenter prospective study in Japan.

BACKGROUND: The Japanese government is promoting physician-led home visits as well as end-of-life care at home. However, the proportion of deaths occurring at home has remained unchanged for the past 20 years. OBJECTIVES: To report the cumulative incidence of deaths at home and to explore the factors associated with deaths at home versus other places, mainly hospitals. METHODS: This was a multicenter prospective cohort study in a primary care setting. We enrolled patients aged ≥65 years who had started to receive regular visits by family physicians from 13 facilities in and around Tokyo between February 1, 2013 and January 31, 2016. Patients were followed-up until January 31, 2017. The primary outcome measures were mortality rate and cumulative incidence of deaths at home. RESULTS: We enrolled 762 patients. Of 368 deaths, 133 occurred in the patient's home. The mortality rates at home were 137.6/1000 person-years (95% confidence interval 116.1-163.1). In cumulative incidence function, the longer duration of care at home lowers the likelihood of death at home. Multivariable multinomial logistic models showed that younger age and higher Barthel Index score reduced the likelihood of deaths at home, while receiving oxygen therapy and the presence of a full-time caregiver increased the likelihood of deaths at home relative to deaths at other locations. CONCLUSIONS: Of deceased patients, only one-third died in patients' homes. We found several factors associated with deaths at home, which appeared to reflect the readiness of patients and their families for death. Geriatr Gerontol Int 2022; 22: 1005-1012.

Use of a 2-year continuing professional development programme to change Japanese physicians' attitudes to learning primary care: a qualitative study.

OBJECTIVE: To evaluate changes in the learning attitudes of primary care physicians. DESIGN: Qualitative study through one focus group interview with the programme's participants. Analysis of the focus group content using the Steps for Coding and Theorization method. SETTING: Japan. PARTICIPANTS: Eight primary care physicians who completed a 2-year continuing professional development (CPD) programme using a problem-based learning (PBL) approach, focused on acquiring the skills needed to practise as primary care physicians in the community. RESULTS: Participants described positive changes in their attitudes and behaviours as a result of the training programme. These changes were grouped into three main themes: 'changes in learning methods regarding medical practice', 'encounters with diverse perspectives and values, and confidence gained from those encounters', and 'showing one's attitude towards learning and its influence on others'. The experienced practitioners participating in this study reported that the programme helped them apply their skills more broadly; for example, searching the literature for psychosocial aspects of practice and engaging more comfortably with diverse perspectives. They reported the positive impact of their learning on their coworkers. CONCLUSION: A 2-year CPD programme using PBL can influence primary care physicians' attitudes and learning-related behaviours. Further research is needed to determine which specific aspects of the programme are the most effective and whether the changes in attitudes and behaviours described affect patient care.

Patient experience of residents with restricted primary care access during the COVID-19 pandemic.

OBJECTIVES: To evaluate primary care access for COVID-19 consultation among residents who have a usual source of care (USC) and to examine their associations with patient experience during the pandemic in Japan. DESIGN: Nationwide cross-sectional study. SETTING: Japanese general adult population. PARTICIPANTS: 1004 adult residents who have a USC. MAIN OUTCOME MEASURES: Patient experience assessed by the Japanese version of Primary Care Assessment Tool Short Form (JPCAT-SF). RESULTS: A total of 198 (19.7%) reported restricted primary care access for COVID-19 consultation despite having a USC. After adjustment for possible confounders, restricted primary care access for COVID-19 consultation was negatively associated with the JPCAT-SF total score (adjusted mean difference = -8.61, 95% CI -11.11 to -6.10). In addition, restricted primary care access was significantly associated with a decrease in all JPCAT-SF domain scores. CONCLUSIONS: Approximately one-fifth of adult residents who had a USC reported restricted primary care access for COVID-19 consultation during the pandemic in Japan. Our study also found that restricted primary care access for COVID-19 consultation was negatively associated with a wide range of patient experience including first contact. Material, financial and educational support to primary care facilities, the spread of telemedicine and the application of a patient registration system might be necessary to improve access to primary care during a pandemic.

Usual source of primary care and preventive care measures in the COVID-19 pandemic: a nationwide cross-sectional study in Japan.

OBJECTIVES: To assess multiple preventive care measures and to examine their associations with having a usual source of primary care and primary care performance during the COVID-19 pandemic in Japan. DESIGN: Nationwide cross-sectional study. SETTING: Japanese general adult population. PARTICIPANTS: 1757 adult residents. PRIMARY OUTCOME MEASURES: Fourteen preventive care measures aggregated the overall screening, immunisation and counselling composites. RESULTS: Depression screening, zoster vaccination and tetanus vaccination had low implementation rates even among participants with a usual source of primary care. After adjustment for possible confounders, having a usual source of primary care was positively associated with all preventive care composites. Primary care performance assessed by the Japanese version of Primary Care Assessment Tool Short Form was also dose dependently associated with an increase in all composites. Results of the sensitivity analyses using a different calculation of preventive care composite were similar to those of the primary analyses. CONCLUSIONS: Receipt of primary care, particularly high-quality primary care, contributed to increased preventive care utilisation even during the COVID-19 pandemic. However, the rate of mental health screening in primary care was at a very low level. Therefore, addressing mental health issues should be a major challenge for primary care providers during and after the pandemic.

Associations of primary care structures with polypharmacy and patient-reported indicators in patients with complex multimorbidity: a multicentre cross-sectional study in Japan.

OBJECTIVES: Evidence supporting the effects of primary care structures on the quality of care for patients with complex multimorbidity, which is one of the most important challenges facing primary care, is scarce internationally. This study aimed to examine the associations of the types of primary care facilities with polypharmacy and patient-reported indicators in patients with complex multimorbidity, with a focus on differences between community clinics and hospitals. DESIGN: Multicentre cross-sectional study. SETTING: A total of 25 primary care facilities (19 community clinics and 6 small- and medium-sized hospitals). PARTICIPANTS: Adult outpatients with complex multimorbidity, which was defined as the co-occurrence of three or more chronic conditions affecting three or more different body systems within one person. PRIMARY OUTCOME MEASURE: Polypharmacy, the Patient-Reported Experience Measure using the Japanese version of Primary Care Assessment Tool Short Form (JPCAT-SF) and the Patient-Reported Outcome Measure using self-rated health status (SRH). RESULTS: Data were analysed for 492 patients with complex multimorbidity. After adjustment for possible confounders and clustering within facilities, clinic-based primary care practices were significantly associated with a lower prevalence of polypharmacy, higher JPCAT-SF scores in coordination and community orientation, and a lower prevalence of poor or fair SRH compared with hospital-based primary care practices. In contrast, the JPCAT-SF score in first contact was significantly lower in clinic-based practices. The associations between the types of primary care facilities and JPCAT-SF scores in longitudinality and comprehensiveness were not statistically significant. CONCLUSIONS: Clinic-based primary care practices were associated with a lower prevalence of polypharmacy, better patient experience of coordination and community orientation, and better SRH in patients with complex multimorbidity compared with hospital-based primary care practices. In the primary care setting, small and tight teams may improve the quality of care for patients with complex multimorbidity.

Effect of multimorbidity patterns on the decline in health-related quality of life: a nationwide prospective cohort study in Japan.

OBJECTIVES: Longitudinal studies, which consider multimorbidity patterns, are useful for better clarifying the effect of multimorbidity on health-related quality of life (HRQoL) and for identifying the target population with poorer clinical outcomes among patients with multimorbidity. This study aimed to examine the effects of different multimorbidity patterns on the decline in HRQoL. DESIGN: Nationwide prospective cohort study. SETTING: Japanese adult residents. PARTICIPANTS: Residents aged ≥50 years selected by the quota sampling method. PRIMARY OUTCOME MEASURE: Clinically relevant decline in HRQoL was defined as a 0.50 SD (5-point) decrease in the 36-Item Short Form Health Survey (SF-36) component summary scores for 1 year. RESULTS: In total, 1211 participants completed the follow-up survey. Among the multimorbidity patterns identified using confirmatory factor analysis, multivariable logistic regression analyses revealed that high cardiovascular/renal/metabolic and malignant/digestive/urologic pattern scores were significantly associated with the clinically relevant decline in SF-36 physical component summary score (adjusted OR (aOR)=1.25, 95% CI: 1.08 to 1.44 and aOR=1.28, 95% CI: 1.04 to 1.58, respectively). High cardiovascular/renal/metabolic pattern score was also significantly associated with the clinically relevant decline in SF-36 role/social component summary score (aOR=1.23, 95% CI: 1.06 to 1.42). CONCLUSIONS: Our study revealed that multimorbidity patterns have different effects on the clinically relevant decline in HRQoL for 1 year. These findings can be useful in identifying populations at high risk and with poor clinical outcomes among patients with chronic diseases and multimorbidity for efficient resource allocation.

Perspectives on expert generalist practice among Japanese family doctor educators: a qualitative study.

BACKGROUND: Expert generalist practice (EGP) is increasingly being viewed as the defining expertise of generalist care. In Japan, several prominent family doctors consider it important and relevant in the Japanese context. However, no study has examined Japanese family doctor educators' perceptions of EGP. AIM: To explore Japanese family doctor educators' perceptions of EGP. DESIGN & SETTING: A qualitative study among family doctor educators in Japan. METHOD: Focus group interviews were conducted using a semi-structured interview guide following a short lecture on EGP. A qualitative description method was adopted and the framework method was used to conduct thematic analysis. RESULTS: Participants were 18 family medicine doctor educators, including 11 directors and six associate directors of family medicine training programmes. The results suggested that the concept of EGP was important and applicable to primary care in Japan. Participants' perceptions on EGP pertained to the following four areas: impact of EGP, triggers for EGP, enablers for EGP, and educational strategies for EGP. CONCLUSION: The concept of EGP may be useful in clinical practice in Japan, especially in complex patient care. A clearer framework for or description of EGP, and of non-traditional methods, such as ascetic practice and awareness of the self, were proposed as possible educational strategies.

Overall mortality in older people receiving physician-led home visits: a multicentre prospective study in Japan.

BACKGROUND: Japan has the most rapidly ageing population in the world. The Japanese government has, therefore, promoted physician-led home health care for frail and disabled people. OBJECTIVES: To describe mortality among older people receiving physician-led health care at home or at a nursing home in Japan and to identify risk factors. METHODS: This was a multicentre prospective cohort study. Participants were aged ≥65 years and had started to receive regular physician-led health care at home or at nursing homes from 13 facilities between 1 February 2013 and 31 January 2016. The observation period ended on 31 January 2017. We used a biopsychosocial approach for exploratory analysis of 13 variables to identify mortality risk factors. RESULTS: The median (25th to 75th percentile) observation time was 417 (121-744) days. Of 825 participants, 380 died. The total cumulative survival for 180, 360, 720 and 1440 days was 73.4% (95% confidence interval: 70.2-76.3), 64.2% (60.8-67.5), 52.6% (48.8-56.3) and 34.6% (23.5-46.0). The Kaplan-Meier cumulative survival curve showed a steep drop during the first 6 months of observation. A multivariate Cox proportional hazard model showed that sex (male), high Charlson Comorbidity Index score, low serum albumin level, low Barthel Index score, receipt of oxygen therapy, high Cornell Scale for Depression in Dementia score and non-receipt of public assistance were associated with mortality. CONCLUSIONS: Overall mortality in physician-led home visits in Japan was described and mortality risk factors identified. Public assistance receipt was associated with lower mortality.

The need for home care physicians in Japan - 2020 to 2060.

BACKGROUND: Japan faces the most elderly society in the world, and the Japanese government has launched an unprecedented health plan to reinforce home care medicine and increase the number of home care physicians, which means that an understanding of future needs for geriatric home care is vital. However, little is known about the future need for home care physicians. We attempted to estimate the basic need for home care physicians from 2020 to 2060. METHODS: Our estimation is based on modification of major health work force analysis methods using previously reported official data. Two models were developed to estimate the necessary number of full-time equivalent (FTE) home care physicians: one based on home care patient mortality, the other using physician-to-patient ratio, working with estimated numbers of home and nursing home deaths from 2020 to 2060. Moreover, the final process considered and adjusted for future changes in the proportion of patients dying at home. Lastly, we converted estimated FTE physicians to an estimated head count. RESULTS: Results were concordant between our two models. In every instance, there was overlap of high- and low-estimations between the mortality method and the physician-to-patient method, and the estimates show highly similar patterns. Furthermore, our estimation is supported by the current number of physicians, which was calculated using a different method. Approximately 1.7 times (1.6 by head count) the current number of FTE home care physicians will be needed in Japan in the late 2030's, peaking at 33,500 FTE (71,500 head count). However, the need for home care physicians is anticipated to begin decreasing by 2040. CONCLUSION: The results indicate that the importance of home care physicians will rise with the growing elderly population, and that improvements in home care could partially suppress future need for physicians. After the late 2030's, the supply can be reduced gradually, accounting for the decreasing total number of deaths after 2040. In order to provide sufficient home care and terminal care at home, increasing the number of home care physicians is indispensable. However, the unregulated supply of home care physicians will require careful attention in the future.

How a problem-based learning approach could help Japanese primary care physicians: a qualitative study.

OBJECTIVES: This study aimed to identify training needs among primary care physicians in Japan who had no formal primary care training. METHODS:  We conducted a focus group interview with seven Japanese primary care physicians who had not previously undergone specialist training in primary care and had been recruited to a family medicine training program that used a problem-based learning approach. At the start of the program, the physicians attended the interview. The discussion was recorded, and the transcribed interview was analyzed using the Steps for Coding and Theorization method. RESULTS:  Three main themes emerged. First, there is a lack of standard re-education programs for physicians who move away from their specializations into primary care. Second, there is insufficient training on primary care in undergraduate and postgraduate medical education in Japan. Third, continuing professional development programs should cover the communication skills, attitudes, and behaviors necessary for primary care practice. CONCLUSIONS:  This study clarified the needs to be addressed in our training program for primary care physicians involved in retraining in primary care. It is important to consider how to best include the communication skills, attitudes, and behaviors necessary for primary care among the topics covered in the program. As the program undergoes further iteration, it will be important to check whether it meets the needs of primary care practitioners. It will be necessary to investigate the needs of re-education programs for more physicians in many areas, and to emphasize the importance of primary care re-education in these abilities in undergraduate and postgraduate medical education.

Correlation of patient complexity with the burden for health-related professions, and differences in the burden between the professions at a Japanese regional hospital: a prospective cohort study.

OBJECTIVES: An ageing society includes high patient complexity. Various biopsychosocial problems result in a high burden for health-related professionals. The direct relationship between the burden and patient complexity, however, has not been reported. We aimed to examine correlations between the burden for the attending physicians and nurses, and Patient Centred Assessment Method (PCAM) scores of patient complexity. DESIGN: Prospective cohort study. SETTING: A regional secondary care hospital in Japan. PARTICIPANTS: We included all inpatients admitted to our acute care unit between 1 July 2014 and 30 September 2014. Exclusion criteria were age <20 years, refusal to participate in the study and length of stay fixed at the time of admission. MAIN PREDICTOR: PCAM total score in the initial phase of hospital admission. MAIN OUTCOME: The burden for each profession (measured on a Visual Analogue Scale). RESULTS: In total, 201 inpatients participated [female/male=98/103, mean (SD) age of 77.4±11.9 years]. Spearman's rank correlation coefficients between the burden and the PCAM score ranged from 0.23 to 0.32. All p values were <0.05. Multivariate analysis was conducted using multilevel mixed-effects linear regression to determine the association between the burden and the PCAM score in two models. Model 1 used the total PCAM score as the predictive variable. Model 2 used the PCAM factors, patient-oriented complexity and medicine-oriented complexity, as predictive variables. In Model 2, with the burden of physicians, medicine-oriented complexity was statistically significant, whereas with the burden of nurses, both age and patient-oriented complexity were statistically significant. CONCLUSIONS: PCAM scores correlated with the burden for physicians and nurses. Individual PCAM factors affected the burden for each profession differently.

Combining Scores Based on Compensatory and Noncompensatory Scoring Rules to Assess Resident Readiness for Unsupervised Practice: Implications From a National Primary Care Certification Examination in Japan.

PURPOSE: Competence decisions in health professions education require combining scores from multiple sources and identifying pass-fail decisions based on noncompensatory (required to pass all subcomponents) and compensatory scoring decisions. This study investigates consequences of combining scores, reliability, and implications for validity using a national examination with subcomponent assessments. METHOD: National data were used from three years (2015, 2016, and 2017) of the Japan Primary Care Association Board Certification Examination, with four subcomponent assessments: Clinical Skills Assessment-Integrated Clinical Encounter (CSA-ICE), CSA-Communication and Interpersonal Skills (CSA-CIS), Multiple-Choice Questions (MCQ), and Portfolio. Generalizability theory was used to estimate variance components and reliability. Kane's composite reliability and kappa decision consistency were used to examine the impact of using compensatory and noncompensatory scoring. RESULTS: Mean performance (n = 251) on the CSA-ICE, CSA-CIS, MCQ, and Portfolio subcomponent assessments were, respectively, 61% (SD = 11%), 67% (SD = 13%), 74% (SD = 8%), and 65% (SD = 9%); component-specific Φ-coefficient reliability ranged between, respectively, 0.57 and 0.67; 0.50 and 0.60; 0.65 and 0.76; and 0.87 and 0.89. Using a completely noncompensatory scoring approach on all four subcomponents, decision-consistency reliability was 0.33. Fully compensatory scoring yielded reliability of 0.86. CONCLUSIONS: Assessing a range of abilities in making entrustment decisions requires considering the balance of assessment tools measuring distinct but related competencies. These results indicate that noncompensatory pass-fail decision making, which seems more congruent with competency-based education, may lead to much lower reliability than compensatory decision making when several assessment subcomponents are used.

Social Isolation and Patient Experience in Older Adults.

PURPOSE: Social isolation has been identified as a major health problem, particularly in the elderly. In the present study, we examine the association between social isolation and patient experience in elderly primary care patients. METHODS: This cross-sectional study was conducted in a primary care practice-based research network (28 clinics) in Japan. We assessed social isolation using an abbreviated Lubben Social Network Scale and patient experience of primary care using a 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. We used a linear mixed effects model to adjust clustering within clinics and individual covariates. RESULTS: Data were analyzed for 465 elderly primary care patients aged ≥65 years. After adjustment for possible confounders and clustering within clinics, social isolation was negatively associated with the JPCAT total score, (mean difference = -3.67; 95% CI, -7.00 to -0.38). Among the JPCAT domain scores, social isolation was significantly associated with longitudinality, comprehensiveness (service provided), and community orientation scores. CONCLUSIONS: Social isolation was associated with negative patient experience in elderly primary care patients. Raising awareness regarding patient social networks among primary care providers and targeted interventions for socially isolated elderly patients aimed at improving the experience of primary care, especially regarding longitudinality, comprehensiveness, and community orientation, may be warranted.

Effect of Patient Experience on Bypassing a Primary Care Gatekeeper: a Multicenter Prospective Cohort Study in Japan.

BACKGROUND: To discuss how best to implement the gatekeeping functionality of primary care; identifying the factors that cause patients to bypass their primary care gatekeepers when seeking care should be beneficial. OBJECTIVE: To examine the association between patient experience with their primary care physicians and bypassing them to directly obtain care from higher-level healthcare facilities. DESIGN AND METHODS: This prospective cohort study was conducted in 13 primary care clinics in Japan. We assessed patient experience of primary care using the Japanese version of Primary Care Assessment Tool (JPCAT), which comprises six domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. The primary outcome was the patient bypassing their usual primary care physician to seek care at a hospital, with this occurring at least once in a year. We used a Bayesian hierarchical model to adjust clustering within clinics and individual covariates. KEY RESULTS: Data were analyzed from 205 patients for whom a physician at a clinic served as their usual primary care physician. The patient follow-up rate was 80.1%. After adjustment for patients' sociodemographic and health status characteristics, the JPCAT total score was found to be inversely associated with patient bypass behavior (odds ratio per 1 SD increase, 0.44; 95% credible interval, 0.21-0.88). The results of various sensitivity analyses were consistent with those of the primary analysis. CONCLUSIONS: We found that patient experience of primary care in Japan was inversely associated with bypassing a primary care gatekeeper to seek care at higher-level healthcare facilities, such as hospitals. Our findings suggest that primary care providers' efforts to improve patient experience should help to ensure appropriate use of healthcare services under loosely regulated gatekeeping systems; further studies are warranted.

Validity and reliability of the Patient Centred Assessment Method for patient complexity and relationship with hospital length of stay: a prospective cohort study.

OBJECTIVES: Several instruments for evaluating patient complexity have been developed from a biopsychosocial perspective. Although relationships between the results obtained by these instruments and the length of stay in hospital have been examined, many instruments are complicated and not easy to use. The Patient Centred Assessment Method (PCAM) is a candidate for practical use. This study aimed to test the validity and reliability of the PCAM and examine the correlations between length of hospital stay and PCAM scores in a regional secondary care hospital in Japan. DESIGN: Prospective cohort study. PARTICIPANTS AND SETTING: Two hundred and one patients admitted to Ouji Coop Hospital between July 2014 and September 2014. MAIN PREDICTOR: PCAM total score in initial phase of hospital admission. MAIN OUTCOME: Length of stay in hospital. RESULTS: Among 201 patients (Female/Male=98/103) with mean (SD) age of 77.4±11.9 years, the mean PCAM score was 25±7.3 and mean (SD) length of stay in hospital (LOS) 34.1±40.9 days. Using exploratory factor analysis to examine construct validity, PCAM evidently has a two-factor structure, comprising medicine-oriented and patient-oriented complexity. The Spearman rank correlation coefficient for evaluating criterion-based validity between PCAM and INTERMED was 0.90. For reliability, Cronbach's alpha was 0.85. According to negative binomial regression analyses, PCAM scores are a statistically significant predictor (p<0.001) of LOS after adjusting for age, gender, Mini Nutritional Assessment Short-Form, Charlson Comorbidity Index, serum sodium concentration, total number of medications and whether public assistance was required. In another model, each factor in PCAM was independently correlated with length of stay in hospital after adjustment (medicine-oriented complexity: p=0.001, patient-oriented complexity: p=0.014). CONCLUSION: PCAM is a reliable and valid measurement of patient complexity and PCAM scores have a significant correlation with hospital length of stay.

Attributes of primary care in relation to polypharmacy: a multicenter cross-sectional study in Japan.

OBJECTIVE: To investigate the association between attributes of primary care and polypharmacy. DESIGN: Cross-sectional study. SETTING: A primary care practice-based research network in Japan (28 primary care clinics). PARTICIPANTS: Adult outpatients filled out a standardized questionnaire. MAIN OUTCOME MEASURE: Polypharmacy defined as the use of five or more concurrent prescription or over-the-counter medications. METHODS: Attributes of primary care were assessed via patient experience using the Japanese version of Primary Care Assessment Tool (JPCAT). Poisson mixed effects model was used to adjust for clustering within clinics and covariates. RESULTS: Data were analyzed for 544 primary care outpatients. After adjusting for patients' sociodemographic and health characteristics, the JPCAT community orientation score was found to be inversely associated with polypharmacy at the clinic level [risk ratio per 1 standard deviation increase = 0.83; 95% confidence interval (CI), 0.73-0.96; P = 0.008]. Sensitivity analyses using a different definition of polypharmacy showed results similar to those of the primary analyses. CONCLUSIONS: We found that a higher level of community-oriented primary care is associated with a lower prevalence of polypharmacy in outpatients at the clinic level. These findings may be useful in developing community-based interventions to minimize polypharmacy.

Patient experience of primary care and advance care planning: a multicentre cross-sectional study in Japan.

Background: Advance care planning (ACP) is becoming increasingly important in the primary care setting because of its positive impact on the end-of-life care. Objective: We aimed to investigate the relationship between patient experience of primary care and ACP. Methods: This cross-sectional study was conducted in 28 primary care clinics in Japan. We assessed patient experience of primary care using a Japanese version of Primary Care Assessment Tool (JPCAT), which comprises six domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided) and community orientation. The primary outcome measures were ACP discussion between patients and primary care providers and completion of advance directives (AD). We used a generalized linear mixed model to adjust clustering within clinics and individual covariates. Results: Data were analysed for 535 primary care patients. After adjustment for patients' sociodemographic and health characteristics, the JPCAT total score was found to be significantly associated with ACP discussion [odds ratio (OR) per 1 SD increase = 4.33; 95% confidence interval (CI), 2.53-7.47] but not with completion of AD (OR per 1 SD increase = 1.42; 95% CI, 0.94-2.12). All domains of JPCAT, which represent attributes of primary care, had positive associations with ACP discussion. First contact and comprehensiveness (services provided) domain scores were significantly associated with completion of AD. Conclusions: We found that better patient experience of primary care was strongly associated with ACP discussion. Our findings reinforce the significance of patient experience in primary care as part of quality end-of-life care.

Psychological impact of lifestyle-related disease disclosure at general checkup: a prospective cohort study.

BACKGROUND: Little is known about psychological impact of disclosing lifestyle-related diseases. Previous studies discussed the long-term psychological impact of disease disclosure, and a significant psychological impact was not observed. This study clarified the psychological impact on anxiety state of patients when lifestyle-related diseases are disclosed at general checkups for local residents. In particular, this study evaluated the short-term impact on patients, and how the notification of abnormal values and the disclosure of disease at general checkups affect patients' subsequent behavioral changes. METHODS: The study design was a prospective cohort study. We compared the anxiety state of participants using a self-administered anxiety assessment scale, State-Trait Anxiety Inventory (STAI), before and after Physician's explanation of abnormal values in markers of lifestyle-related diseases. The participants were those between the age of 40 and 75 years who underwent general checkups at two primary care facilities. In addition, we assessed the effects on lifestyle habits and the psychological impact caused by general checkup using STAI and a survey on behavioral changes one month after the checkup. RESULTS: The valid response rate at the survey of the general checkup was 92% (534/578). Of those who showed abnormal levels in markers of lifestyle-related diseases, anxiety was augmented significantly among those who responded that the physician had told them of their diagnosis compared to those who responded that the physician had not told them of their diagnosis (Wilcoxon rank-sum test, P < 0.007). The percentage of patients whose state anxiety scale of STAI increased ≥5 points was 30% in the disease disclosed group (33/111) and 17% in the disease undisclosed group (27/159), respectively. The risk ratio was 1.5 (95% CI: 1.1-2.0). One month after the general checkup, overall anxiety diminished regardless of whether diagnosis of lifestyle-related diseases was disclosed to patients notified of abnormal values. In addition, improvements in daily life behaviors as a result of notification of abnormalities or disclosure of diagnosis at general checkup were not observed. CONCLUSION: Even in a general checkup for the general population, disclosing non-critical diseases such as lifestyle-related diseases exacerbated anxiety as a short-term psychological impact.

Prospective cohort study of fever incidence and risk in elderly persons living at home.

OBJECTIVE: To determine the incidence of fever among elderly persons under home medical management, diagnosis at fever onset and outcomes from a practical standpoint. DESIGN: Prospective cohort study. SETTING: 5 clinics in residential areas of Tokyo that process an average of 50-200 outpatients/day. PARTICIPANTS: Patients (n=419) aged ≥65 years who received home medical management from the five clinics between 1 October 2009 and 30 September 2010. MAIN OUTCOME MEASURES: Fever (≥37.5°C or ≥1.5°C above usual body temperature), diagnosis at onset and outcomes (cure at home, hospitalisation and death). RESULTS: The incidence of fever was 2.5/1000 patient-days (95% CI 2.2 to 2.8). Fever occurred at least once (229 fever events) among one-third of the participants during the study period. Fever was more likely to arise in the wheelchair users or bedridden than in ambulatory individuals (HR 1.9 (95% CI 1.3 to 2.8; p<0.01); in patients with moderate-to-severe rather than those with none-to-mild cognitive impairment (HR, 1.7 (95% CI 1.1 to 2.6, p=0.01); and in those whose care-need levels were ≥3 rather than ≤2 (HR, 4.5 (95% CI 2.9 to 7.0; p<0.01). The causes of fever were pneumonia/bronchitis (n=103), skin and soft tissue infection (n=26), urinary tract infection (n=22) and the common cold (n=13). Fever was cured in 67% and 23% of patients at home and in hospital, respectively, and 5% of patients each died at home and in hospital. Antimicrobial agents treated 153 (67%) events in the home medical care setting. CONCLUSIONS: Fever was more likely to occur in those requiring higher care levels and the main cause of fever was pneumonia/bronchitis. Healthcare providers should consider the conditions of elderly residents with lower objective functional status.