Collaboration between university hospitals and local medical communities in Japan evaluated by a questionnaire among doctors

AIM AND METHODS: To provide quality medical service in a society with many elderly, university hospitals should clearly define their roles and contribute to the establishment of an integrated, comprehensive medical system. In this study, we conducted a questionnaire survey of doctors working at Kyoto University Hospital and at private practices in Kyoto about their attitude toward collaboration between the university hospital and private practices and asked their opinions on the role of university hospitals in the local medical community. RESULTS: The survey showed that doctors both at the university hospital and in private practice regarded close collaboration as important, but also highlighted obstacles and problems that block collaboration. CONCLUSION: Overcoming these problems and constructing collaboration models will be a key for university hospitals to fully contribute to the establishment of a quality medical system.     

The role of task shifting in reforming the working styles of pediatricians in Japan: A questionnaire survey

We aimed to shorten the working hours of pediatricians who are regularly experiencing overwork in Japan, recommended tasks for task shifting must be identified, and the impact of promoting task shifting on both the quality of medical care and working hours must be examined. Characteristics of the pediatric department must also be considered. A questionnaire survey was conducted with pediatricians working in hospitals across Japan. A multiple logistic regression analysis was performed with pediatricians who did not recommend task shifting in the workplace as the explained variable and the attributes of the responding pediatricians (gender, age, primary workplace, number of pediatricians, pediatric medical management fee) as the explanatory variables. Details about the tasks recommended for task shifting and the impact of recommending task shifting on the quality of medical care and working hours were described. Questionnaires were sent nationwide to 848 hospitals that calculated pediatric inpatient medical management fees and received responses from 1539 pediatricians in 416 hospitals (response rate: 49%). As a characteristic of 231 (15%) doctors who thought that the task shift had not progressed at all at their place of employment, significant positive associations were found in men, working at national and public university hospitals, private university hospitals, and private hospitals and pediatric inpatient medical care management fee 1 hospitals. Task shifting was not recommended overall, as the task items that a majority of pediatricians marked as “transferred” were limited to “medication instructions” and “intravenous injection of antibiotics, etc” More than half of the respondents (60%, a total of 921 doctors) reported that the quality of medical care improved slightly or significantly when task shifting was promoted. The most frequent response to survey items querying the number of work hours that could be shortened through task shifting was “1 to 2 hours.” The tasks suitable for task shifting were identified based on the characteristics of participants’ pediatric departments. Results suggest that task shifting was not recommended in university hospitals and that promotion of task shifting could improve the quality of medical care and reduce the working hours of pediatricians.     

Incidence of adverse drug reactions in geriatric units of university hospitals

Background:   Adverse drug reactions (ADR) in elderly people are often attributed to functional decline and polypharmacy.
Methods:   In this study, a multi-institutional retrospective survey was undertaken to investigate the current status of ADR in geriatric units of university hospitals. The inpatient databases from 2000 to 2002 for five university hospitals were studied, and a total of 1289 patients were analyzed.
Results:   The incidence of ADR, as determined by attending physicians, was 9.2% on average, but varied from 6.3 to 15.8% among the institutions. Factors significantly related to ADR were the number of diagnoses, the number of geriatric syndromes, the number of prescribed drugs, an increase of two or more drugs during hospitalization, longer hospital stay, emergency admission, depression and apathy.
Conclusion:   These results are mostly consistent with previous reports and provide important information on drug treatment in elderly people.     

Factors enabling home death of the elderly in an institution specializing in home medical care: Analysis of apprehension of the bereaved family

Aim:   To determine the factors enabling home death despite caregiver apprehension about home medical care.
Methods:   This study was an anonymous mailed survey of bereaved family members (the caregiver) of patients who died in a home medical care setting provided by an institution specializing in home medical care in Japan (home death rate, ∼80%). We analyzed the relationships between caregiver apprehension about home medical care, overall satisfaction with home medical care and the place of death.
Results:   Higher caregiver apprehension about home medical care and lower overall satisfaction with home medical care were significantly associated with dying in a hospital. In addition, the home death group with apprehension about home medical care significantly rated higher overall satisfaction with home medical care than the hospital death group. Meanwhile, there was no difference in the overall satisfaction with home medical care between those with or without apprehension about home medical care in the home death group. Factors influencing overall satisfaction with home medical care in the home death group with apprehension about home medical care were: (i) being free from pain or symptoms (partial regression coefficient: 0.83); and (ii) fulfilled medical care service system (partial regression coefficient: 0.40).
Conclusion:   These results suggest that caregiver satisfaction with home medical care is an essential factor to enable home death of the patient despite the caregiver apprehension about home medical care.     

Are specialist physicians missing out on the e‐Health boat?

Background:  Nationally health systems are making increasing investments in the use of clinical information systems. Little is known about current computer use by specialist physicians, particularly outside the hospital setting.
Aims:  To identify the extent and reasons physician Fellows of the Royal Australasian College of Physicians (RACP) use computers in their work.
Methods:  A self-administered survey was emailed from the RACP to all practising physicians in 2007 that were living in Australia and New Zealand who had consented to email contact with the College.
Results:  The survey was sent to a total of 7445 eligible physicians, 2328 physicians responded (31.3% response rate), but only 1266 responses (21.0%) were able to be analysed. Most 97.5% had access to computers at work and 96.5% used home computers for work purposes. Physicians in public hospitals (72.6%) were more likely to use computers for work (65.6%) than those in private hospitals (12.6%) or consulting rooms (27.3%). Overall physicians working in public hospitals used a wider range of applications with 70.5% using their computers for searching the internet, 53.7% for receiving results and 52.7% used their computers to engage in specific educational activities. Physicians working from their consulting rooms (33.6%) were more likely to use electronic prescribing (11%) compared with physicians working in public hospitals (5.7%).
Conclusions:  Fellows have not incorporated computers into their consulting rooms over which they have control. This is in contrast to general practitioners who have embraced computers after the provision of various incentives. The rate of use of computers by physicians for electronic prescribing in consulting rooms (11%) is very low in comparison with general practitioners (98%). One reason may be that physicians work in multiple locations whereas general practitioners are more likely to work from one location.     

How well do doctors know their patients with severe asthma?

Abstract
Background:  Rates of asthma mortality have fallen in Australia since the commencement of the National Asthma Campaign and promotion of the Australian asthma management plan. New strategies are now needed to further reduce mortality.
Aim:  To examine agreement about key features between asthma patients and their general practitioners (GPs).
Methods:  We interviewed: (i) the next of kin of 56 asthma deaths, (ii) 91 asthma patients presenting to emergency departments with acute severe asthma and (iii) 147 of their GPs.
Results:  Agreement was substantial for usage of oral symptomatic medication, but poor for inhaled symp­tomatic and preventive medications. There was moderate agreement regarding hospital admissions within the last 12 months among the cases, but little about other markers of severity. There was moderate agreement where the presenting or fatal attack was triggered by an upper respiratory-tract infection or aspirin. The next of kin and GPs agreed about family problems, but not about other psychosocial issues. They also agreed about which cases had been given action plans or verbal instructions, but few other aspects of asthma management. There was also moderate agreement regarding the use of peak flow meters by the controls.
Conclusions:  Doctors often have relatively poor insights into self-management practices, social background or trigger factors, even in high-risk patients. This should be considered when planning future campaigns to improve asthma management and further reduce mortality. (Intern Med J 2003; 33: 557−565)     

Paradigmenwechsel in der universitären Medizin?

1. The intended fusion of the university hospitals Marburg and Giessen in the state of Hessia is "a marriage under pressure with uncalculated risk" (Spiegel 2005). In the present political and financial situation it hardly appears to be avoidable. From the point of the view of the faculty of medicine in Marburg it is difficult to understand, that the profits of this well guided university hospital with a positive yearly budget should go to the neighboring university hospital which still had a fair amount of deficit spending in the last years.2. Both medical faculties suffer from a very low budget from the state of Hessia for research and teaching. Giessen much more than Marburg, have a substantial need for investments in buildings and infrastructure. Both institutions have a similar need for investments in costly medical apparatuses. This is a problem, which many university hospitals face nowadays.3. The intended privatisation of one or both university hospitals will need sound answers to several fundamental questions and problems:a) A privatisation potentially endangers the freedom of research and teaching garanteed by the German constitution. A private company will undoubtedly influence by active or missing additional support the direction of research in the respective academic institution. An example is the priorisation of clinical in contrast to basic research.b) With the privatisation practical absurdities in the separation of research and teaching on one side and hospital care on the other will become obvious with respect to the status of the academic employees, the obligatory taxation (16%) when a transfer of labor from one institution to the other is taken into account. The use of rooms for seminars, lectures and bedside with a double function for both teaching, research and hospital care has to be clarified with a convincing solution in everyday practice.c) The potential additional acquisition of patients, which has been advocated by the Hessian state government, may be unrealistic, when the 4th biggest university hospital in Germany will be created by the merger. University hospitals recrute the patients for high end medicine beyond their region because of the specialized academic competence and advanced technical possibilities. Additional recruitment of patients for routine hospital can hardly be expected.d) A private management will have to consider primarily the "shareholder value", even when investing in infrastructure and buildings, as it can be expected for one partner. On the longterm this will not be possible without a substantial reduction of employees in both institutions. There are, however, also substantial efforts of some private hospital chains in clinical research, e. g. by Helios in Berlin and Rh?n Gmbh at the Leipzig Heart Center.e) There is a yet underestimated but very substantial risk because of the taxation for the private owner when academic staff is transferred from the university to hospital care in their dual function as academic teachers and doctors. This risk also applies for the university if the transfer should come from hospital to the university. These costs would add to the financial burden, which has to be carried in addition to the DRGs.     

Medical activity of the French internal medicine departments in 2000-2001 from the DRG system

PURPOSE: Medical activity of the French Internal Medicine Departments has been described until now only by limited declarative surveys. The aim of this study was to describe this activity using the French DRG system. METHODS: A postal survey was conducted using the list of the French Society of Internal Medicine. The same questionnaire was posted to 212 departments (university, public and private hospitals) to collect the 2000 or 2001 data from the DRG system. RESULTS: 192,197 reports were analysed. One hundred and eighty four groups were listed on a theoretical number of 313 medical groups. The first 10 groups concerned common general diseases (pneumonia, anaemia, heart failure, diabetes, stroke.). The main difference between university and non-university hospitals concerned the management of systemic diseases, which was more frequently quoted in university hospitals. Benign and malignant haematological diseases and oncology were frequently quoted in both types of hospitals. CONCLUSION: This study allows for the first time in France to have an objective survey of the medical activity of Internal Medicine Departments. It confirms that these departments have a central role in the hospital management of current diseases but also of haematological diseases and cancer. University departments are more specifically implicated in the management of systemic diseases.     

Schnittstelle universitäre Medizin und Patientenversorgung

The working profile of university hospitals includes medical education, research and implementation of medical innovations as well as large volume patient care. University hospitals offer inpatient, day care and outpatient care which are of essential value for many patients. Besides their primary role in treating rare and orphan diseases and complex cases, they increasingly support general patient care. There are different kinds of outpatient access and treatment options available. The funding of university hospitals and clinics is based on general university funding, income from third party funds for research, income from patient care and funding from the federal states for investments. In recent years these institutions have suffered more and more from economic deficits, a lack of investment and inadequate funding whereby high performance medicine cannot be sufficiently supported. Professors are developing into scientific managers and are frequently assessed by economic outcome and competitiveness. At the same time they are embedded in the structures of the university and are not in the position to make decisions on their own, in contrast to doctors in private practices. Therefore, processes, necessary investments and restructuring are significantly delayed. There is a need to develop strategies for long-term funding and providing university hospitals and clinics with the means to deliver the necessary services.     

They just don't get enough! Variable intern experience in bedside procedural skills

Background: Medical school and resident training programmes offer different learning opportunities and outcomes. The aim of the study was to assess medical student and intern experience in common clinical procedures.
Methods: Interns employed in a metropolitan teaching hospital from 2000 to 2004 completed a survey of experience and confidence in clinical procedures at the beginning and end of their intern year. Attendance at and the contribution to procedural confidence of a voluntary procedural skill-training programme were examined.
Results: For the 314 interns, clinical experience before and during internship varied for each procedure and between year cohorts as did training programme attendance (44–84%). Student procedural confidence was predicted by pre-intern experience either on patients or by simulation ( β  = 0.17, 95% confidence interval (CI) 0.02–0.21, P  = 0.03) and age >30 years on commencing internship ( β  = 8.44, 95%CI 3.03–14.06, P  = 0.003. Adjusted R ² = 0.08, P  = 0.002). Intern procedural confidence by year's end was predicted by attendance at the training programme ( β  = 0.48, 95%CI 0.34–0.62, P  < 0.001), intern experience with patient procedures ( β  = 0.34, 95%CI 0.21–0.47, P  < 0.001) and a clear decision to enter a postgraduate training programme ( β  = 0.13, 95%CI 0.04–0.22, P  = 0.007, Adjusted R ² = 0.50, P  < 0.001).
Conclusion: Interns and students receive variable experience to carry out procedural skills on patients. This makes designing training programmes difficult as training needs vary each year. Both mandatory supervision of key skills and opportunities to supplement limited experience are needed during the intern year to ensure a uniform experience.     

Internet in der Rheumatologie

OBJECTIVE: On behalf of the "Systemic Inflammatory Rheumatic Diseases Network" comprehensive, nationwide horizontal and vertical cross-linking of research and care is to be developed for the first time. The quality of scientific work and patient care is to be increased in the medium term through this improved communication and co-operation. Our objective was to determine what hardware and software are avail- able to the physicians involved, with a view to the Internet being used as a basis for communication and documentation within the network. METHODS: A survey was carried out among 723 active members of the German Rheumatology Society (DGRh). Data on the hardware and software used and on Internet access were collected using a unilateral questionnaire. RESULTS: The response rate among the addressed rheumatologists was 55.3%, with 64.1% of members in private practice replying. Of those responding 85% have Internet access, with rheumatologists in private practice using the Internet significantly less frequently at work than those working at a hospital (42% vs 80%). The latter accordingly reported a higher proportion of medical Internet usage (69% vs 52%, p<0.001). The survey demonstrated that software for private practices and hospitals shows a very variable picture with a multiplicity of systems being used. CONCLUSION: Use of the Internet for communication in the "Systemic Inflammatory Rheumatic Diseases Network" is practicable in hospitals but clearly restricted in the private practice sector. The widely varying software used in hospitals and private practices underlines the need for standardized, comprehensive documentation systems to be developed. To ensure acceptance and broadly based application, they need to be integrated into the existing computer infrastructure. In this context, Internetbased applications offer new opportunities through the use of system-independent file formats.     

Medical aspects of fitness to drive. What do public hospital doctors know and think?

Background: In Australia medical practitioners are often required to assume the responsibility for assessing fitness to drive. However the clinical practice, knowledge and attitudes of doctors with regards to this responsibility are unknown. The aim of this study was to determine the clinical practice, knowledge and attitudes of public hospital doctors in the area of fitness‐to‐drive decision‐making. Methods: A survey of public hospital doctors in Adelaide, South Australia was undertaken in 2003, shortly after the promulgation nationwide of guidelines to assist in the assessment of patients’ fitness to drive. The survey sought details on medical practitioners’ clinical practice in this regard, as well as their knowledge of the guidelines. In addition, it sought their attitudes to undertake this responsibility. Results: Eighty‐four per cent of respondents had at some time in their working career at least discussed the issue of fitness to drive with their patients. Seventy per cent acknowledged that they had received the recently published guidelines on fitness to drive. Despite this, knowledge of the contents of the guidelines was poor. Attitudes to the responsibility were equivocal with several significant reservations expressed. Conclusion: Public hospital doctors in Australia have poor knowledge of the content of published guidelines in the area of fitness to drive. If this situation is to be improved, alternative approaches to the education of this group with respect to this significant public health problem should be considered. Many doctors are uncomfortable with their responsibilities in this area and alternative models of decision‐making should be considered.     

Access, sources and value of new medical information: views of final year medical students at the University of Nairobi

Objectives  To evaluate final year medical students' access to new medical information.
Method  Cross-sectional survey of final year medical students at the University of Nairobi using anonymous, self-administered questionnaires.
Results  Questionnaires were distributed to 85% of a possible 343 students and returned by 44% (152). Half reported having accessed some form of new medical information within the previous 12 months, most commonly from books and the internet. Few students reported regular access; and specific, new journal articles were rarely accessed. Absence of internet facilities, slow internet speed and cost impeded access to literature; and current training seems rarely to encourage students to seek new information.
Conclusion  Almost half the students had not accessed any new medical information in their final year in medical school. This means they are ill prepared for a career that may increasingly demand life-long, self-learning.     

Comprehensive geriatric assessment for community-dwelling elderly in Asia compared with those in Japan: IV. Savannakhet in Laos

Background:   The objective of the present study is to compare the findings of comprehensive geriatric assessments (CGA) of community-dwelling elderly people living in Lao People's Democratic Republic (Laos) with those in Japan.
Methods:   A cross-sectional, interview- and examination-based study was undertaken. The subjects consisted of community-dwelling elderly people in Songkhon, a rural district in Laos and in Sonobe, a rural town in Kyoto, Japan. Two hundred and ninety-four people aged 60 years and over in Laos and 411 aged 65 years and over in Japan were examined using a common CGA tool. Interviews pertaining to activities of daily living (ADL), medical and social history, quality of life (QOL) and Geriatric Depression Scale as well as anthropometric, and blood chemical examinations were included in the assessment.
Results:   All scores for basic and instrumental ADL, intellectual activity and social roles, body mass index, prevalence of hypertension, mean total and HDL cholesterol levels were lower in Laos than in Japan, while prevalence of depression, impaired glucose tolerance and anemia were higher in Laos than in Japan.
Conclusion:   Differences in lifestyle and medical status were found between economically developing Laos and highly developed Japan. Almost all comprehensive geriatric functions such as ADL, QOL, mood and nutritional condition in blood chemistry were lower in the elderly in Songkhon than in Kyoto. Of particular note were the higher prevalence of diabetes mellitus and anemia and lower prevalence of hypertension in the elderly population in Songkhon district, which should be examined in future studies.     

Person and environment predictors of blood alcohol concentrations: a multi-level study of college parties

Aims:  This study builds upon previous research by assessing the relationship of breath blood alcohol concentrations (BrAC) to environmental and individual characteristics.
Design:  We conducted a multi-level study of college parties. Our design included observational measures of party environments, a brief self-administered questionnaire, and the collection of breath samples from partygoers.
Setting:  Data were collected in private residences of students living in a neighborhood adjacent to a large public university located in the Southwestern United States.
Participants:  A total of 1,304 individuals attending 66 parties participated in the study.
Measures:  Observational measures of party characteristics were made by 2 trained research assistants at each party. Four to 5 trained interviewers administered a brief field survey to partygoers at each party. In addition, the trained interviewers collected breath samples using handheld breathalyzer devices.
Findings:  Hierarchical linear modeling analyses revealed significant variation at the party and individual levels. At the individual level, motivations to socialize were significantly associated with lower BrAC, while drinking games and providing the sample after 11:00  pm were associated with higher BrACs. At the party level, large parties were significantly associated with lower BrACs while reports of many intoxicated partygoers were associated with higher BrACs. Finally, we identified a significant gender by theme party interaction, indicating women had higher BrACs at theme parties relative to nontheme parties; however, BrACs for men were similar regardless of the type of party attended.
Conclusions:  Alcohol consumption among young adults in natural settings is a function of both person and environmental factors.     

Barriers to the implementation of evidence in osteoporosis treatment in hip fracture

An audit at a private tertiary hospital showed low rates of assessment and treatment of osteoporosis in minimal trauma patients of hip fracture. A survey sent to all doctors involved in hip fracture care to establish medical beliefs about effective management of osteoporosis in minimal trauma hip fracture patients showed a lack of ownership for investigation and beliefs influencing treatment choices. Understanding the barriers to the translation of evidence into practice is vital to improve patient care.     

Decline of outpatient asthma management in Argentina

Background and objectives:   To assess management of adult patients admitted with acute asthma and compare the results obtained with a similar study 5 years earlier.
Methods:   A cross-sectional survey of 211 consecutive patients admitted to hospital during a 12-month period was conducted. Patients were surveyed using a validated management questionnaire and the results compared with those of the previous survey.
Results:   There were 211 patients in the present survey and patient demographics were similar in both populations studied. Comparison of the previous to the current survey showed significant differences in predicted FEV₁% at admission (30.2 ± 10.7 vs 23.9 ± 8.9, respectively, P  < 0.001), and the average number of hospital admissions in the year prior to the survey (0.7 ± 1.2 vs 1.3 ± 0.7, P  < 0.0001). In the present survey, more patients changed their medication after acute exacerbation and more received an action plan. Compared with the previous survey, there were no significant differences between the mean number of emergency department visits, need for mechanical ventilation, number of patients prescribed inhaled corticosteroids and other related variables.
Conclusion:   Compared with the previous study the severity of asthma at the time of admission was worse. Some of the recommended international asthma management programmes appear to have been followed.     

Who is willing to participate in and provide Family Doctor Contract Service?: A cross-sectional study based on the medical staff's perspective in China

China encourages medical staff from non-primary hospitals (higher-level hospitals) to participate in and provide Family Doctor Contract Service (FDCS) due to a lack of primary medical resources in community health service centers. This study aims to explore the factors affecting the willingness of family doctor contracting from the tertiary hospital medical staff''s perspective.An anonymous self-administered survey was conducted among the medical staff from tertiary hospitals in Hangzhou, Zhejiang Province. Information of the socio-demographic characteristics, the willingness of participating in FDCS and its related reasons, and factors that might affect willingness were investigated. A multivariate logistic regression was used to identify the statistically significant variables associated with willingness.A total of 346 medical staff were recruited in the survey, and 37.86% of them were willing to participate in and provide FDCS. Medical staff with the following characteristics had stronger will:

• (1)with higher education level;
• (2)having better knowledge with family doctor;
• (3)being more attracted by the national policy of FDCS;
• (4)thinking it help for income increase.

The majority of willing doctors (25.95%) believed that participating in FDCS could help them achieve their personal value, and the reason chosen most for unwilling reason was “low income and unrealized personal value (32.21%).”It is necessary for the government to establish the essential matching mechanisms to guarantee the development of the family doctor, including increasing the final financial support for primary health facilities, and developing the national incentive mechanism for family doctors.