論文

目的:医療資源の限られた地域で働く多職種は、どのような関係性の認識の中で在宅医療の問題をどのように認識しているか、そしてそれがどのように変容するかを明らかにする。方法:茨城県K市で働く多職種が在宅医療について主体的に話し合う場を提供し、その会議内容を逐語録化しテーマ分析を行った。結果:多職種は互いの関係性を階層構造の中で捉えるフェーズから、対話を通じて相互理解が深化する関係、ホラクラシーを理想とする考えが共有できる関係と変容する中で、在宅医療の問題を他人事の問題から自分事、地域全体の問題へと考えるようになった。結論:在宅医療推進に関わる問題は複雑であり、課題の共有や解決策を模索するだけでなく、問題に関わる多職種の関係性の変容が必要である。対話を通じて各専門職の関係性が変わることで、在宅医療不足の問題を自らの地域の問題として捉え、主体的に解決策を模索するようになることが明らかになった。(著者抄録)

© 2017 Japan Geriatrics Society Aim: We investigated factors that predict the prognosis of activities of daily living (ADL) in elderly patients who had undergone rehabilitation during hospitalization for acute infectious disease. Methods: The present prospective cohort study included 131 patients who were hospitalized due to acute infectious disease and who had undergone rehabilitation during hospitalization. Patient characteristics collected from medical records included age, sex and comorbidity score. The level of ADL 2 weeks before admission was assessed by interview at the start of rehabilitation. Grip strength testing, Short Physical Performance Battery as an assessment of lower limb function and the Mini-Mental State Examination as an assessment of cognitive status were carried out at the time of hospital discharge. The level of ADL at 6 months after discharge was assessed by telephone interview. Multivariate logistic regression analysis was used to identify factors that independently predict ADL dependence (defined as being dependent in one or more ADL items at 6 months after discharge). Results: The average age of participants was 81.5 years, and 52.7% were women. A total of 22.1% of patients showed dependence in an ADL at 6-month follow-up. Factors that predicted an ADL dependence were comorbidity score (OR 4.19, 95% CI 1.19–14.69) and lower limb function (OR 0.51, 95% CI 0.36–0.72) at discharge. Conclusions: The present findings have implications for the healthcare planning and well-being of elderly patients during hospitalization and after discharge. Geriatr Gerontol Int 2018; 18: 615–622.

Background: With the rapid aging of the population, collaboration among the various medical professions throughout the country is becoming increasingly indispensable in Japan. To promote collaboration in medical care, it is necessary to introduce the concept of collaboration to students at an early stage of their professional education. Despite this need, there are no core medical, healthcare and welfare education curricula in Japan that include interprofessional education (IPE). Therefore, the status of IPE in Japanese schools of medicine and other healthcare-related services is unclear. Methods: We sent 3,430 questionnaires to 13 schools of medicine and related healthcare providers: doctors, nurses, physical therapists, registered dieticians, dentists, dental hygienists, social workers, pharmacists, occupational therapists, clinical psychologists, medical administrators, certified care workers, and speech therapists. The items addressed implementation rate of IPE, teaching methods and grading methods. Results: Of the 3,430 surveys distributed, 572 completed surveys were returned (response rate 17%). Of the completed surveys, 493 qualified as valid, resulting in a final response rate of 14%. Only 19% (n = 93) of the analysed medical educational institutions included IPE instruction in their curricula. Conclusion: While many educational institutions were conducting IPE, there were important inter-institutional differences with respect to attitudes towards IPE, teaching methods, and evaluation methods. This study was unprecedented in scale, and provides important basic information for the future development of IPE in Japan.

© Author(s) (or their employer(s)) 2019. Objective Interprofessional collaboration is considered an important strategy in overcoming the complex issues associated with healthcare outcomes. A nationwide, community-based integrated care system developed for the care of older people in individual communities in Japan requires community hospitals to deliver integrated care to coordinate efforts for creating effective environments for health. This study aimed to explore the factors associated with the self-assessment score of interprofessional collaboration in community hospitals. Design Cross-sectional study using the Assessment of Interprofessional Team Collaboration Scale (AITCS). Setting This study was conducted in three small community hospitals in Japan. Participants All healthcare staff in the hospitals via research collaborators were asked to complete the anonymous self-administered questionnaire of the AITCS comprising questions related to individual factors (age, gender, profession), hospital to which they belonged, relationships with neighbouring facilities, job burden and job satisfaction from July to October 2018. The association between the questionnaire items as explanatory variables and AITCS score as an objective variable was determined using univariate followed by multiple regression analyses. Results The data from 325 of 630 participants were analysed, of whom 252 were female (77.5%) and 240 were nurses (73.8%). The mean of the total AITCS score was 117.6 (range 37-185), and the Visual Analogue Scale for relationships with neighbouring facilities, job satisfaction and job burden was 53.0 mm (0-100), 46.1 mm (0-100) and 64.3 mm (0-100), respectively. In univariate analyses of the association with AITCS score, explanatory variables with a significance level of <0.05 were relationships with neighbouring facilities, job satisfaction and job burden. On multiple regression analysis, the total AITCS score was independently associated with age, profession (nurse/non-nurse), relationships with neighbouring facilities and job satisfaction. Conclusions Better self-assessment score of interprofessional collaboration is more strongly associated with younger age, a nursing profession, better relationships with neighbouring facilities and greater job satisfaction than with the hospital to which the participant belonged. These findings may help community hospitals enhance the integration of service delivery and benefit to the community through interprofessional collaboration.

© 2019 Maeno et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Interprofessional education (IPE) for medical students is becoming increasingly important, as reflected in the increasing number of medical schools adopting IPE. However, the current status of and barriers to pre-registration IPE implementation in Japanese medical schools remain unknown. The purpose of this study was to clarify the status and barriers of IPE implementation in medical schools in Japan. We conducted a curriculum survey from September to December 2016 of all 81 medical schools in Japan. We mailed the questionnaire and asked the schools’ undergraduate education staff to respond. The survey items were the IPE implementation status and barriers to program implementation. Sixty-four of the 81 schools responded (response rate 79.0%), of which 46 (71.9%) had implemented IPE, 42 (89.1%) as compulsory programs. Half of IPE programs were implemented in the first 2 years, while less than 10% were implemented in the latter years of medical programs. As part of the IPE programs, medical students collaborated with a wide range of professional student groups. The most common learning strategy was lectures. However, one-third of IPE programs used didactic lectures without interaction between multi-professional students. The most common perceived major barrier to implementing IPE was adjustment of the academic calendar and schedule (82.8%), followed by insufficient staff numbers (73.4%). Our findings indicate that IPE is being promoted in undergraduate education at medical schools in Japan. IPE programs differed according to the circumstances of each school. Barriers to IPE may be resolved by improving learning methods, introducing group discussions between multi-professional students in lectures or introducing IPE programs using team-based learning. In summary, we demonstrated the current status and barriers of IPE implementation in Japanese medical schools. Our findings will likely lead to the promotion of IPE programs in Japan.

© 2019, © 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis. Introduction: We examined the interrelationships between context, mechanism, and outcome using a realist approach following the introduction of interprofessional education (IPE) to clinical practice for medical students in the community. Methods: Through participant observation and interviews, a working hypothesis was developed. To evaluate IPE in clinical practice, medical students’ reports were thematically analyzed, and configuration on contexts, mechanisms, and outcomes were identified using a realist approach. Results: Influential contexts were medical students’ experience of clinical practice and learning characteristics, the capacity of other professionals, interprofessional relationships, and characteristics of the community hospital. One key mechanism was observational learning. Others were self-regulated learning, legitimate peripheral participation, experiential learning, contact hypotheses, awareness of social structure, and cognitive empathy. As faculties supported these key mechanisms, medical students became aware of the legitimacy of community-oriented primary care, noting the roles of physicians who support patients’ and/or their family’s life in collaboration with other professionals, and reflecting the necessity of shifting from physician-centered perspectives. As a result, medical students deepened their empathic understanding for other professionals. Conclusion: Faculties should develop IPE programs in clinical practice based on the ‘mechanism’, ‘context’, ‘outcome’ pattern and ‘context-mechanism-outcome’ configuration in primary care settings.

【目的】急性感染症で入院した高齢患者を対象に退院後のADL予後予測要因を明らかにすることを目的とした。【方法】急性感染症で入院した65歳以上の患者のうち、入院2週間前と比較して退院時にADL低下を認めた者を解析対象とした。データ収集は、リハビリテーション開始時(基本情報・入院前ADL等の収集)・退院時(身体機能等の評価)・退院後6ヵ月時(生活状況等の収集)の3時点で行った。対象者のうち、退院後6ヵ月時点のADLが、入院2週間前と同等まで回復した場合を「ADL回復群」、そうでない場合を「ADL低下群」と定義し、ADL回復を予測する要因を検討した。【結果】対象者(74例)の平均年齢は83.4±6.0歳、女性が43例(58.1%)であった。また、74例のうち40例(54.1%)が「ADL回復群」であり、その予測要因は、「退院時の下肢機能が高い」であった。【結論】退院時の下肢機能が高く保たれていることは、退院後のADL自立度に影響する可能性が考えられた。(著者抄録)

© 2020, Society of General Internal Medicine. Background: Older adults’ uptake of influenza and pneumococcus vaccines is insufficient worldwide. Although patient experience of primary care is associated with vaccine uptake in children, this relationship remains unclear for older adults. Objective: This study examined the association between patient experience of primary care and influenza/pneumococcal vaccine uptake in older adults. Design and Methods: We conducted a multicentered cross-sectional survey involving 25 primary care institutions in urban and rural areas in Japan. Participants were outpatients aged ≥ 65 years who visited one of the participating institutions within the 1-week study period. We assessed patient experience of primary care using the Japanese version of the Primary Care Assessment Tool (JPCAT), which includes six domains: first contact (accessibility), longitudinality (continuity of care), coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. We used a generalized linear mixed-effects model to adjust for clustering within institutions and individual covariates. Key Results: One thousand participants were included in the analysis. After adjusting for clustering within institutions and other possible confounders, influenza and pneumococcal vaccine uptake was positively associated with JPCAT total scores (odds ratio per 1 standard deviation increase: 1.19, 95% confidence interval: 1.01–1.40 and odds ratio: 1.26, 95% confidence interval: 1.08–1.46, respectively). Of the JPCAT domains, coordination and community orientation were associated with influenza vaccine uptake and longitudinality, coordination, and comprehensiveness were associated with pneumococcal vaccine uptake. Conclusions: Influenza and pneumococcal vaccine uptake were positively associated with patient experience of primary care in older adults. Consideration of patient experience, particularly longitudinality, coordination, comprehensiveness, and community orientation, could improve vaccine uptake.

© 2019 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association. Background: Advance directives (ADs) are seldom discussed between primary care physicians (PCPs) and their patients, especially those with noncancer diseases. The aim was to identify the factors associated with discussing AD by noncancer patients with their physicians. Methods: This cross-sectional study was conducted in a hospital or clinic from October to December 2017. Physicians chose eligible noncancer patients aged 20 years or older to respond to an anonymous self-completed questionnaire inquiring about the objective variable “I want to discuss AD with my doctor,” as well as basic characteristics, and facilitators and barriers to discussing AD identified in previous studies. The physicians responded to a survey comprising the Palliative Performance Scale (PPS) and inquiring about the disease category for each patient. Data were analyzed using binomial logistic regression analysis. Results: A total of 270 patients (valid response rate, 79.6%) were included. Multivariate analysis identified a period of visit to the study site ≥ 3 years (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.05-4.10), physicians who are very good at taking care of patients’ disease (OR, 12.68; 95% CI, 1.12-143.22), and patients’ worry about their quality of life (QOL) in the future (OR, 2.69; 95% CI, 1.30-5.57) as facilitators for discussing AD with physicians, and PPS ≤ 90 (OR, 0.51; 95% CI, 0.26-0.98) as a barrier. Conclusions: Our study indicates that patients’ future QOL concerns, a long period of visit to a hospital, and the presence of physical symptoms were associated with the willingness of noncancer patients to discuss AD with PCPs.

Background The progress in aging and the shortage of physicians is a significant problem in Japan. Hence, healthcare professionals including pharmacists should cooperate to provide medical services with limited resources. However, pharmacists might have inadequate skills in taking medical histories. Therefore, we developed an interview tool to collect accurate medical history. In this study, we aimed to validate the contents of medical histories taken by a pharmacist using the interview tool and investigate physician consultation length. Methods Setting intervention days alternately, adult outpatients of the Kitaibaraki Center for Family Medicine who had new symptoms had their medical histories taken by one of two pharmacists before their physician visit during the study period. The contents of the medical history taken by a pharmacist using text analysis were validated on other four days. All sentences collected by a pharmacist or five physicians were divided into segments, and six other physicians assessed each segment. Differences in length of the physician consultation between those with and without (intervention and control groups, respectively) medical history taken by a pharmacist were investigated. Results Of 23 patients’ medical histories taken by a pharmacist using the interview tool, 84.4% of segments were related to the clinical diagnosis. The mean consultation length was 10.1±8.4 minutes in the intervention group (n=104) and 13.0±10.4 minutes in the control group (n=96) (p=0.048). Conclusions Medical histories taken by a pharmacist using the interview tool had high content validity and might reduce physician consultation length.

Lay people without a body of specialty knowledge, like the professionals, have not been able to partake in interprofessional education (IPE). Transprofessional education (TPE), which was defined as IPE with non-professionals /lay people, is an important extension of (IPE). A TPE programme was developed to explore how health professionals and lay people learn with, from and about each other in a Japanese community. The present study was conducted in a hospital and the surrounding community in Japan. An ethnographic study design was adopted, and the study participants were six lay individuals from the community and five professionals working in the community-based hospital. During the health education classes, the first author acted as a facilitator and an observer. On reviewing interview data and field notes using a thematic analysis approach, findings showed that healthcare professionals and lay participants progressed through uniprofessional and interprofessional before achieving transprofessional learning. Both type of participants became to transcend boundaries after sharing their viewpoints in a series of classes and recognized that they were important partners in their local community step by step, which increased their sense of belonging to the community. The transformation was driven by dynamic interaction of the following four factors: reflection, dialogue, reinforcement of ties, and expanding roles. We believe this process led both groups to come to feel collective efficacy and inspire healthcare professionals to reflect on their transprofessional learning. We clarified how healthcare professionals and lay people achieved transprofessional learning in a TPE programme where participants advanced through uniprofessional, interprofessional stage before achieving transprofessional learning.