Implementation of two novel schemes for patients on dialysis as a response to the COVID-19 surge in Tokyo.

The Japanese government recommended hospitalization of patients on dialysis once they tested positive because of their high COVID-19 mortality rate and definite need for periodic dialysis. However, after experiencing the Delta variant surge, strategic changes towards outpatient care for mild or asymptomatic cases, along with strengthening emergency preparedness were needed. Facing the Omicron surge, the Tokyo Metropolitan Government introduced two novel schemes: i) a temporary medical facility with a dialysis center for infected patients on hemodialysis, which started admitting patients on dialysis on January 20, 2022, to provide additional bed capacity and access to hemodialysis and ii) a transportation scheme for patients who need travel to maintenance dialysis facilities from their homes, which was introduced on February 5. The Tokyo Metropolitan Government, cooperating with some nephrology experts, announced these schemes and urged local dialysis facilities to change strategies, providing information regarding infection prevention measures and treatments in online seminars on February 3 and 7. Consequently, promoting outpatient care did not lead to an increase in the case fatality ratio (CFR) in patients on dialysis with COVID-19 in Tokyo during the first Omicron surge (January 7 to February 10, 8.2%; February 11 to March 31, 5.5%). Furthermore, after an additional online seminar on July 20, the CFR dramatically declined in the second Omicron surge (July 8 to September 8, 1.2%). Implementation of public health intervention and careful communication with local dialysis facilities were both crucial to the strategic changes. To maintain essential health services, emergency preparedness should be cultivated during regular times.

Risk factors associated with hospital transfer among mild or asymptomatic COVID-19 patients in isolation facilities in Tokyo: a case-control study.

Objectives: The Tokyo Metropolitan Government has been implementing facility-based isolation of asymptomatic/mild coronavirus disease (COVID-19) patients to facilitate timely hospital referral. However, there are only a few published studies in prehospital settings, and the factors associated with hospital transfer are unclear. Our study identified the factors associated with COVID-19 deterioration in a prehospital setting. Methods: This case-control study assessed the risk factors for hospital transfer from isolation facilities and the need for ambulance transport due to deterioration among COVID-19 patients, using multivariate logistic regression analysis. Results: In total, 10 590 patients (median age 34 years), with male predominance (61.1%), were included. 367 (3.5%) were transferred to hospital, of whom 44 (12.0%) required ambulance transport. Hypertension, diabetes, and bronchial asthma were prevalent in 704 (6.6%), 195 (1.8%), and 305 (2.9%) patients, respectively. After adjustment, older age, male sex, higher body mass index (BMI), and comorbidities (including diabetes, inflammatory bowel disease, and bronchial asthma) were associated with hospital transfer. Older age, male sex, and higher BMI significantly increased the risk of transfer by ambulance. Conclusions: Our results may be beneficial for the development of intervention measures for probable future COVID-19 waves.

Reporting on the implementation to set up a "care and isolation facility" for mild COVID-19 cases in Tokyo.

The increasing number of COVID-19 cases has placed pressure on medical facilities. Against this backdrop, the Tokyo Metropolitan Government established a facility for mild and asymptomatic COVID-19 cases by using existing hotels. These kinds of facilities were established in several countries, and represented a spectrum from hotel-like to hospital-like care. In this article, we focused on implementation and related strategies for establishing such a facility in Tokyo as implementation research, while ensuring patient and staff safety. This facility had three functions: care, isolation, and buffering. For the implementation strategy, we used several strategies from the Expert Recommendations for Implementing Change (ERIC) to implement functions similar to an ordinary hospital, but using fewer inputs. This experience can be applied to other resource-limited settings such as that in less developed countries.

[Patient-centered medicine for tuberculosis medical services].

The 2011 edition of Specific Guiding Principles for Tuberculosis Prevention calls for a streamlined medical services system capable of providing medical care that is customized to the patient's needs. The new 21st Century Japanese version of the Directly Observed Treatment Short Course (DOTS) expands the indication of DOTS to all tuberculosis (TB) patients in need of treatment. Hospital DOTS consists of comprehensive, patient-centered support provided by a DOTS care team. For DOTS in the field, health care providers should select optimal administration support based on patient profiles and local circumstances. In accordance with medical fee revisions for 2012, basic inpatient fees have been raised and new standards for TB hospitals have been established, the result of efforts made by the Japanese Society for Tuberculosis and other associated groups. It is important that the medical care system be improved so that patients can actively engage themselves as a member of the team, for the ultimate goal of practicing patient-centered medicine. We have organized this symposium to explore the best ways for practicing patient-centered medicine in treating TB. It is our sincere hope that this symposium will lead to improved medical treatment for TB patients. 1. Providing patient-centered TB service via utilization of collaborative care pathway: Akiko MATSUOKA (Hiroshima Prefectural Tobu Public Health Center) We have been using two types of collaborative care pathway as one of the means of providing patient-centered TB services since 2008. The first is the clinical pathway, which is mainly used by TB specialist doctors to communicate with local practitioners on future treatment plan (e.g. medication and treatment duration) of patients. The clinical pathway was first piloted in Onomichi district and its use was later expanded to the whole of Hiroshima prefecture. The second is the regional care pathway, which is used to share treatment progress, test results and other necessary patient information among the relevant parties. The regional care pathway was developed by the Tobu Public Health Center. It is currently being used by several other public health centers in Hiroshima. Utilization of these two pathways has resulted in improved adherence, treatment being offered at local clinics, shorter hospitalization and better treatment outcomes. 2. Patient-centered DOTS in Funabashi-city: Akiko UOZUMI (Funabashi-city Public Health Center) In Funabashi-city, all TB patients, including those with LTBI, are treated under DOTS which recognizes and tries to accommodate the various different needs of each individual patient. For example, various types of DOTS are offered, such as pharmacy-based DOTS and DOTS supported by caregivers of nursing homes. This enables public health nurses to take into consideration both the results of risk assessment and convenience for the patient, and choose DOTS which most effectively support the patient. Furthermore, DOTS in principle is offered face-to-face, so that DOTS providers may not only build relationship of trust with the patient, but also to collect and analyze the necessary information regarding the patient and respond timely when problems arise. Such effort has directly contributed to improved default and treatment rate. 3. Hospital DOTS and clinical path for the treatment of tuberculosis: Kentaro SAKASHITA, Akira FUJITA (Tokyo Metropolitan Tama Medical Center) We introduced a version of hospital DOTS at Tama Medical Center (formerly Fuchu Hospital) in 2004. As part of this three-stage version, patients are allowed to progress to the next stage if they meet the step-up criteria. Following the introduction of this hospital DOTS, the occurrence of drug administration-related incidents decreased and support for patient adherence became easier for health care workers than before. In 2006, we developed a clinical path based on this hospital DOTS with consistent eligibility criteria for patients. This clinical path helped increase the efficiency of medical services in the TB ward. In conclusion, a patient's initiative for tuberculosis treatment can be supported through our hospital's TB treatment system. 4. Survey of TB patients' understanding and satisfaction of hospital DOTS: Yoko NAGATA, Minako URAKAWA, Noriko KOBAYASHI, Seiya KATO (Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association) We surveyed the satisfaction and understanding of recently discharged TB patients regarding DOTS to analyze how to better implement DOTS. The questionnaire consisted of nine items covering knowledge of TB, comfort in talking to and asking questions of the medical staff, explanations given to family members, and motivation for continuing medication. Two hundred and eight of the 228 patients who accepted the questionnaire responded (response rate: 91.2%). The level of understanding and satisfaction tended to be higher among patients in hospitals that employed a primary nursing system, more coverage and duration of DOT, and audiovisual materials for patient education. The level of understanding and satisfaction also tended to be slightly higher among institutions that conducted in-hospital conferences and collaborated with public health centers more frequently. 5. Medical cooperative system against tuberculosis elimination: Dai YOSHIZAWA (Tuberculosis and Infectious disease control division, Ministry of Health, Labour and Welfare) There are 3 points we should consider. First, despite one of the intermediate burden countries, emphasis for infectious incidence is insufficient. Besides new incidence decreases gradually, increased ratio of the elderly causes necessity of implementation against each complications. The second is how find infectious one, especially from high burden countries, before they spread it. Final, unspecific symptoms suffer the patients and medical staff. It's the key of implementation that spread of tuberculosis must be caused by delayed diagnosis.

[Implementation status of community Directly Observed Therapy Short-course (dots) practice in medical facilities designated for tuberculosis treatment in the Tama area].

OBJECTIVES: We conducted a survey of tuberculosis (TB) treatment and community Directly Observed Therapy, Short-course (DOTS) practice of doctors at the medical facilities designated for TB treatment in the Tama area, Tokyo, to determine the current status and issues of community DOTS and to enhance cooperation between public health centers and medical institutions. METHODS: A self-administered questionnaire was sent by postal mail to 500 medical institutions selected through stratified random sampling in each public health center region. RESULTS: We received 287 (57.4%) replies. Of these, 169 (58.9%) had not treated TB patients in the previous 2 years. A total of 48.8% of the doctors were aware of DOTS, and 2.8% were currently conducting DOTS, while 18.7% wanted to conduct DOTS. In contrast, 51.2% had barriers to conducting DOTS, and 27.2% had no plans to conduct DOTS. Knowledge of DOTS was correlated with the future possibility of conducting DOTS and with the use of medication diaries. Doctors in private clinics had lower participation rates in seminars compared to those doctors in hospitals. CONCLUSION: In order to expand DOTS it is necessary to provide private doctors with educational tools with which doctors can update their knowledge of TB treatment.

[Development and perspectives of community DOTS].

The Japanese version of DOTS seems to have established itself. However, there is criticism that the primary purpose of DOTS expansion has often been supplanted by pressure to meet a quota. In this symposium, we returned to the starting point of DOTS, i.e., seeking a total cure of TB patients, and rededicated ourselves to our ultimate goal--TB elimination. In order to promote community DOTS more effectively, we should endeavor to build a community DOTS network with unified related information systems backed by government commitments. In so doing, we must continue to provide patients with support while respecting their rights and emphasizing their improved quality of life. 1. Achievements and challenges of DOTS conference: Yukiko SAITO (Fukujuji Hospital, JATA). We conduct face-to-face DOTS for all patients from the time of their admission until the time they are discharged. The DOTS conference is a place where hospitals and public health centers can share patient information, linking hospital DOTS with community DOTS. This meeting is an indispensable process in order to prevent patients' defaulting and irregular treatment. The ultimate goal of DOTS is treatment completion of tuberculosis patients, and in order to achieve that goal, a partnership among clinical, public health, and social services is crucial. The DOTS conference provides an opportunity for several public health centers to come together and share information. Conducting hospital DOTS and the DOTS conference in parallel facilitates providing comprehensive patient support. Continuing to hold regular DOTS conferences is both a sign of achievement of DOTS and a challenge for the future. 2. Achievements and challenges of cohort meeting in the TB control program in Kobe: Noriko TANAKA (Kobe City Public Health Office) The TB control program of Kobe City is based on the Second Five-Year TB strategy targeting the reduction of the TB incidence rate. It has five policy pillars, prevention and IEC, early case-finding, standardized treatment, quality patient support, and research, which are implemented in twenty-four related activities including the cohort meeting. This meeting is held regularly and contributes greatly to the comprehensive patient care and support for their completion of regular treatment. 3. Development of TB clinical path in hospital-community health partnership--from public health centers' viewpoint: Yui ASO (Nishi Tama Public Health Center), Tomoyo NARITA (Bureau of Social Welfare and Public Health Tokyo Metropolitan Government) In order to lead all TB patients to treatment success, public health centers of the Tokyo Metropolitan Government and Tokyo Metropolitan Fuchu Hospital developed a TB clinical path (TBCP) hospital-community health partnership with the cooperation of the local medical association, the pharmacists' association, and organizations for home recuperation of elderly people. In a questionnaire, all the patients who used TBCP answered that they could take medicine themselves. It was also found that over 50% of hospital doctors and nurses, pharmacists, and public health nurses who were involved in TBCP were satisfied with good cooperation with other partners and patients' positive attitude toward their treatment. These trials revealed that the important keys to the effectiveness of TBCP include a) the shared informed consent by all the partners of the TBCP, b) timely sharing of information about patients, c) standardization of treatment and care for patients, and d) promotion of cooperation with other related players. 4. Development of TB clinical path in hospital-community health partnership--from a hospital's viewpoint: Akira FUJITA (Department of Pulmonary Medicine Tokyo Metropolitan Fuchu Hospital). Health Centers of the Tokyo Metropolitan Government, Tokyo Metropolitan Fuchu Hospital, and other organizations developed a tuberculosis clinical path in a hospital-community health partnership (TBCP). Preliminarily, we applied TBCP for 23 patients with smear-positive tuberculosis. Information-sharing by TBCP booklets between patients and health care providers will improve patients'satisfaction. The instruction for phone- and/or fax-based communication enabled healthcare providers to respond quickly in the event of variance. TBCP promoted the standardization of examinations and the actions to be taken in response to variances, as listed in the clinical path. The variance of controllable adverse effects due to anti-tuberculosis drugs was most common, having occurred 12 times. 5. Attempts of DOTS conference in the outpatient department: Yoko NAGATA (Research Institute of Tuberculosis, JATA), Kayoko MIZUKAMI, Satomi OKAWA (Daiichi Dispensary, JATA). The outpatient DOTS conference is a place where public health centers and clinics can share information on treatment and adherence support. Patient support under community DOTS targeting outpatients who do not need hospitalization requires closer cooperation between public health centers and related organizations now more than ever before. From the point of view of continuing treatment, it is thought necessary to focus on young Japanese patients, not just foreign-born patients.