カテゴリー: 地域包括ケア

―文献名―
平林優子ら．保育園児の家族が子供の健康に関して利用する社会資源と要望－首都圏1地区の調査より－．2009

―この文献を選んだ背景―
ここ最近、ケアcaféや地域包括ケアシステムなど、地域・コミュニティケアについて重要視され活動も活発になってきているが、対象が高齢者であることが多い。小児に対してはどうなのか、どのようなことが必要とされているのかなど、今後の活動に参考にしたかったため調べてみた。

―要約―
目的
・首都圏の1地区の公立保育園に通院する家族を対象に、子供の健康に関する社会資源の利用状況や要望を明らかにし、地域の支援のあり方を検討する

方法
・対象：首都圏の1地区の公立保育園に通院する1,217家族のうち回答された652件（回収率53.6%）のうち、有効回答649件を分析対象

・調査：調査用紙は2部構成。第1部は全員に回答を依頼し、子供の健康状態、地区の社会資源の利用の実態と要望などを内容とした。第2部は、特に継続支援を必要とする慢性疾患を持つ保護者に回答を依頼し、子供の健康状態、保育園での健康管理と支援の状況、社会資源の利用と利用の困難や要望を内容とした。

・分析：数値や名義尺度に関しては記述統計、記述項目については質問の目的に沿って回答を分類する内容分析を行った。子供の健康問題、社会資源の利用についてはχ2乗検定により慢性疾患の有無で回答の違いを確認した。

結果
・調査対象：回答は母親がほとんど。第2部まで回答した割合は94件（14.4%）。子供の月齢は42.1ヶ月で、2-5歳が77%。男女はほぼ半数ずつ。3-4名の核家族がほとんどを占めた。

・子供の健康問題（表２）：全体では「風邪をひきやすい（32.6%）」が最も多く、次に「アレルギー（27.4%）」が多く、慢性疾患を持つ子供については「気管支ぜんそく（42.6%）」、「食物アレルギー（41.5%）」、「アトピー性皮膚炎（36.2%）」とアレルギー疾患が多かった。

・慢性疾患を持つ子供に必要なケアと保育園での支援の現状（表３）：必要なケアについては「毎日の服薬（52.1%）」が最も必要とされていたが、保育園において保育士の支援は行われておらず、毎日服薬が必要な子供の86%が1日2回の服用方法になっていた。外用薬は30%が必要とされていたが、保育士の支援が行われていた。また、支援の現状に関しては「子供の体の状態を観察する（80.0%）」と保育士・看護師からの支援があるとの回答が高かったが、「体の状態に合わせ活動し必要時休息をとらせていない（33.0%）」、「子供のコミュニケーションを助けていない（56%）」という結果であった。

・子供の健康に関連して利用している社会資源と要望
①利用している社会資源（表４）：対象の特性から「保育園（80.9%）」は高く、「親族（56.9%）」、「近隣者・友人（52.5%）」、「近所の開業医（53.8%）」、「病院（43.3%）」であり、「インターネット（26.9%）」、「保健センター（19.4%）」と少なかった。また、慢性疾患を持つ子供については「近隣者・友人」の項目のみ有意な差を認め、慢性疾患を持つ子供は「近隣者・友人」を利用する割合が少なかった。また、慢性疾患のみの質問紙の回答では半数近くが「保健師」「保育園看護師」を利用していたが医療者の回答はなく、「医師」についても25%、「病棟や外来看護師」はほとんど回答がなかった。「栄養士（19%）」は比較的高かったが、アレルギー疾患の子供が多いことが関与していると考えられた。

②利用するのに困難がある、あるいはもっと支援を期待したい社会資源：全体的に回答が少なかったが、「保健センター（13.7%）」、「病院（7.7%）」、「近所の開業医（5.4%）」であった。

③子供の健康を守るうえで支援の改善への要望（表５）：全334件のうち、種々の社会資源への要望としては「病院・診療所（121件）」が最も多く、診療時間の拡大・小児に対応可能な診療施設の増加が多かった。診療体制に関しては診療内容や対応の改善、待ち時間改善を望んでいた。次に多かったのは「病児・病後児保育や病児がいる際のサポート（80件）」であり、病児保育などを望む声が多かった。「保育園（28件）」については、健康管理機能の充実・健康教育の場・服薬管理という声があり、「保健センター」では対応時間の柔軟性が求められていた。また、「相談システム」については子供の急な病気への相談・気軽に相談できる窓口が求められていた。「予防接種」に関しては予防接種の情報や健診の充実・時間や日程の拡大などが挙げられた。慢性疾患の子供の家族では特に「病児保育の充実」「病院の対応の改善や小児診療の向上」「療養方法の情報提供」などが挙げられた。

―考察とディスカッション―
今回、小児に対する地域・コミュニティケアのきっかけとして上記を調べてみたが、キーとしては「アレルギー疾患」、「慢性疾患の子供を持つ家族」ではないかと感じた。慢性疾患の子供を持つ家族は慢性疾患のない子供を持つ家族に比べ「隣人・友人」を利用する機会が少なくなっているが、「近所の開業医」を利用する人は同等であるということもあり、医療機関としてアプローチできる印象がある。また、その家族を対象としたアプローチや保育園だけではなく、栄養士との連携などもさらにアプローチが広がるのではないかと感じた。皆さんの地域では小児に対する地域・コミュニティケアはどのようにしているでしょうか？

【開催日】
2014年5月14日(水)

―　文献名　―
　Giulio Formoso et al: Feasibility and effectiveness of a low cost campaign on antibiotic prescribing in Italy: community level, controlled, non-randomised trial.BMJ 2013;347:f5391

　―　要約　―
【Objectives】 
To test the hypothesis that a multifaceted, local public campaign could be feasible and influence antibiotic prescribing for outpatients.

【Design】 
Community level, controlled, non-randomised trial.

【Setting】 
Provinces of Modena and Parma in Emilia-Romagna, northern Italy, November 2011 to February 2012.

【Population】 
1 150 000 residents of Modena and Parma (intervention group) and 3 250 000 residents in provinces in the same region but where no campaign had been implemented (control group).

【Interventions】 
Campaign materials (mainly posters, brochures, and advertisements on local media, plus a newsletter on local antibiotic resistance targeted at doctors and pharmacists). General practitioners and paediatricians in the intervention area participated in designing the campaign messages.

【Main outcomes measures】
Primary outcome was the average change in prescribing rates of antibiotics for outpatient in five months, measured as defined daily doses per 1000 inhabitants/day, using health districts as the unit of analysis.

【Results】
Antibiotic prescribing was reduced in the intervention area compared with control area (−4.3%, 95% confidence interval −7.1% to −1.5%). This result was robust to “sensitivity analysis” modifying the baseline period from two months (main analysis) to one month. A higher decrease was observed for penicillins resistant to β lactamase and a lower decrease for penicillins susceptible to β lactamase, consistent with the content of the newsletter on antibiotic resistance directed at health professionals. The decrease in expenditure on antibiotics was not statistically significant in a district level analysis with a two month baseline period (main analysis), but was statistically significant in sensitivity analyses using either a one month baseline period or a more powered doctor level analysis. Knowledge and attitudes of the target population about the correct use of antibiotics did not differ between the intervention and control areas.

【Conclusions】
A local low cost information campaign targeted at citizens, combined with a newsletter on local antibiotic resistance targeted at doctors and pharmacists, was associated with significantly decreased total rates of antibiotic prescribing but did not affect the population’s knowledge and attitudes about antibiotic resistance.

開催日：平成25年10月23日

【文献名】
著者名：Anthony Jerant et al.
文献タイトル：Primary Care Attributes and Mortality: A National Person-Level Study. 
雑誌名・書籍名：Ann Fam Med.
発行年：January/February 2012 vol. 10 no. 1 34-41

【要約】
＜PURPOSE＞
Research demonstrates an association between the geographic concentration of primary care clinicians and mortality in the area, but there is limited evidence of a mortality benefit of primary care at the individual patient level. We examined whether patient-reported access to selected primary care attributes, including some emphasized in the medical home literature, is associated with lower individual mortality risk.

＜METHODS＞
We analyzed data from 2000?2005 Medical Expenditure Panel Survey respondents aged 18 to 90 years (N = 52,241), linked to the National Death Index through 2006. A score was constructed from 5 yes/no items assessing whether the respondent’s usual source of care had 3 attributes: comprehensiveness, patient-centeredness, and enhanced access. Scores ranged from 0 to 1 (higher scores = more attributes). We examined the association between the primary care attributes score and mortality during up to 6 years of follow-up using Cox survival analysis, adjusted for social, demographic, and health-related characteristics.

＜RESULTS＞
Racial/ethnic minorities, poorer and less educated persons, individuals without private insurance, healthier persons, and residents of regions other than the Northeast reported less access to primary care attributes than others. The primary care attributes score was inversely associated with mortality (adjusted hazard ratio = 0.79; 95% confidence interval, 0.64?0.98; P = .03); supplementary analyses showed mortality decreased linearly with increasing score.

＜CONCLUSIONS＞
Greater reported patient access to selected primary care attributes was associated with lower mortality. The findings support the current interest in ensuring that patients have access to a medical home encompassing these attributes.

【開催日】
2012年6月27日

【文献】

著者名：Alison Dobbie,MD.et al.
文献タイトル：Evaluating Family Medicine Residency COPC programs Meeting the challenge.
雑誌名・書籍名：Fam Med 2006
発行年：38(6):399-407.

【要約】

＜Background and Objectives＞
We conducted a review of the evaluation literature and outcomes from community-oriented primary care (COPC) programs in US family medicine residencies since 1969.

＜Methods＞
We used a Medline and ERIC search for “community-oriented primary care” in English from 1969-2005. 

＜Results＞
Twenty-two articles were found that concerned US family medicine residency COPC. Selection process describes in table1.Finnaly, Eight descriptive and eight evaluative papers described 14 residency COPC programs. Teaching and learning methods included block and longitudinal rotations and COPC projects. Evaluation methodologies included one quasi-experimental control group study, pretests and posttests of knowledge and attitudes, focus groups, and semi-structured interviews. Reported outcomes included changes in residents’ knowledge, attitudes, and behaviors; effect on graduates’ career choice and future practice; and impact on patient care and community health. 

＜Conclusions＞
 Few studies have evaluated residency COPC programs. Evaluation has been less than rigorous, with variable results, but at least one study indicates positive outcomes at each evaluation level. More residency programs must evaluate and disseminate outcomes from their COPC projects to determine the value of COPC to residents, colleagues, community partners, and funding agencies.

＜Recommendations–Designing a COPC Evaluation Plan＞
We recommend that faculty design their evaluation plan before implementing any residency COPC project, because data are more difficult to gather after the event, and the opportunity to gather baseline data is lost. We recommend that faculty design a plan addressing all four of Kirkpatrick’s levels of evaluation, as demonstrated in Table 2.

Level 1 data (reaction) measure course process outcomes, such as whether residents enjoy the learning experience, believe the content and teaching methods to be appropriate and well taught, report the program to be well organized and efficient, and consider it a useful contribution to their training. 

Level 2 data (learning) describe changes in residents’ COPC knowledge and attitudes. In 1999, Oandesan validated a 20-item survey that can serve as a pretest and posttest of residents’ attitudes to COPC. Donsky published a COPC questionnaire in 1998 that can be used as a pretest and posttest of knowledge and attitudes, although this instrument has not yet been validated. Qualitative methods for evaluating learning include focus groups, semi-structured interviews, written case exercises, and reflective essays and journals.

Level 3 data (transfer) concern changes in residents’ behavior and/or clinical practice. Behavior change can be measured through direct observational studies, chart reviews, electronic health record searches, and/or selfreports in written or electronic surveys. Self-reported changes in behavior represent much weaker types of Level 3 data than objective measures such as direct observation or chart review. 

Examples of Level 4 data (results and outcomes) include changes in graduates’ clinical practice resulting from the COPC projects, permanent adoption of the COPC program into the residency curriculum, and measurable effects on community agencies or practice populations. The effect of the COPC program on graduates’ practice behavior can be measured by telephone, electronic, or mailed surveys 1 to 2 years
after residency. Effects on community agencies can be measured by semi-structured interviews or focused group.

【開催日】
2012年4月26日

【文献名】
Robert Howard, M.D.　 Donepezil and Memantine for Moderate-to-Severe Alzheimer’s Disease : NEJM 2012 ;366:10 893-903

【要約】

＜Background＞
Clinical trials have shown the benefits of cholinesterase inhibitors for the treatment of mild-to-moderate Alzheimer’s disease. It is not known whether treatment benefits continue after the progression to moderate(MMSE5~9)-to-severe(MMSE10~13) disease.

＜Methods＞
Design was multicenter, double-blind, placebo-controlled, clinical trial with two-by-two factorial design. The researchers assigned 295 community-dwelling patients who had been treated with donepezil for at least 3 months and who had moderate or severe Alzheimer’s disease (a score of 5 to 13 on the Standardized Mini?Mental State Examination [SMMSE, on which scores range from 0 to 30, with higher scores indicating better cognitive function]) to continue donepezil, discontinue donepezil, discontinue donepezil and start memantine, or continue donepezil and start memantine. Patients received the study treatment for 52 weeks. The coprimary outcomes were scores on the SMMSE and on the Bristol Activities of Daily Living Scale (BADLS, on which scores range from 0 to 60, with higher scores indicating greater impairment). The minimum clinically important differences were 1.4 points on the SMMSE and 3.5 points on the BADLS.

実際
①D○　M×　 = D10mg                               +  placebo M
②D×  M×　 = D5mg(week1?4) → placebo D(week5?) +  placebo M
③D×　M○　 = D5mg(week1?4) → placebo D(week5?) +  M5mg→5mg up/wk →20mg max
④D○　M○　 = D10 mg　　　　　　　　　　　　　　　+　 M5mg→5mg up/wk →20mg max

＜Results＞
The baseline characteristics of the participants in four treatment groups were broadly similar.
Patients assigned to continue donepezil, as compared with those assigned to discontinue donepezil, had a score on the SMMSE that was higher by an average of 1.9 points (95% confidence interval [CI], 1.3 to 2.5) and a score on the BADLS that was lower (indicating less impairment) by 3.0 points (95% CI, 1.8 to 4.3) (P<0.001 for both comparisons). Patients assigned to receive memantine, as compared with those assigned to receive memantine placebo, had a score on the SMMSE that was an average of 1.2 points higher (95% CI, 0.6 to 1.8; P<0.001) and a score on the BADLS that was 1.5 points lower (95% CI, 0.3 to 2.8; P=0.02). The efficacy of donepezil and of memantine did not differ significantly in the presence or absence of the other. There were no significant benefits of the combination of donepezil and memantine over donepezil alone. 　※The minimum clinically important difference in scores on the SMMSE was 1.4 points, on the BADLS was 3.5 points. ＜Conclusions＞ In patients with moderate or severe Alzheimer's disease, continued treatment with donepezil was associated with cognitive benefits that exceeded the minimum clinically important difference and with significant functional benefits over the course of 12 months. 【開催日】 2012年3月14日

【文献名】

FOLASHADE S. OMOLE, MD; CHARLES M. SOW, MD, MSCR; EDITH FRESH, PhD; DOLAPO BABALOLA, MD; and HARRY STROTHERS III, MD. Interacting with Patients’ Family Members During the Office Visit. Am Fam Physician. 2011;84(7):780-784.



【要約】
医師患者関係は患者のより大きな社会システムの一部分であり、患者家族によって影響を受ける。患者家族メンバーは外来での貴重な情報源であり、正確な診断と治療戦略を立てるのに協力してくれる存在になりうる。しかしながら、医師、患者、家族メンバー間で形成される同盟関係を維持するために、関係を呼び掛ける時に医師は適切なバランスを保つ事が重要である。患者中心の医療現場では、患者をケアするコンセプトが医師、患者、患者家族メンバー間の力動に対処するのを助け、そして医師、患者、患者家族メンバー間の強いパートナーシップに影響を与える。外来では、このパートナーシップは民族性、文化的な価値観、病に関する信念、患者や家族の宗教によって影響を受ける。医師は外来で異常な家族力動を認識し、三角関係の位置を避け、中立関係を保つようふるまうべきである。虐待や無視を疑った場合は中立性を保つべきではない。外来で患者が医師とプライベートにコミュニケーションをとる時間が必要になる時もあるという事が重要な事である。



【開催日】

2011年10月12日

【文献名】

Slowing Global Warming: Benefits for Patients and the Planet
CINDY L. PARKER, MD, MPH, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
American Family Physician  Volume 84, Number 3 ◆ August 1, 2011



【要約】

Global warming will cause significant harm to the health of persons and their communities by compromising food and water supplies; increasing risks of morbidity and mortality from infectious diseases and heat stress; changing social determinants of health resulting from extreme weather events, rising sea levels, and expanding flood plains; and worsening air quality, resulting in additional morbidity and mortality from respiratory and cardiovascular diseases. Vulnerable populations such as children, older persons, persons living at or below the poverty level, and minorities will be affected earliest and greatest, but everyone likely will be affected at some point. Family physicians can help reduce greenhouse gas emissions, stabilize the climate, and reduce the risks of climate change while also directly improving the health of their patients. Health interventions that have a beneficial effect on climate change include encouraging patients to reduce the amount of red meat in their diets and to replace some vehicular transportation with walking or bicycling. Patients are more likely to make such lifestyle changes if their physician asks them to and leads by example. Medical offices and hospitals can become more energy efficient by recycling, purchasing wind-generated electricity, and turning off appliances, computers, and lights when not in use. Moreover, physicians can play an important role in improving air quality and reducing greenhouse gas emissions by advocating for enforcement of existing air quality regulations and working with local and national policy makers to further improve air quality standards, thereby improving the health of their patients and slowing global climate change.



【開催日】

2011年9月21日

【文献名】

David T. Liss, Jessica Chubak, Melissa L. Anderson, Kathleen W. Saunders, Leah Tuzzio, and Robert J. Reid 
Patient-Reported Care Coordination: Associations With Primary Care Continuity and Specialty Care Use 
Ann Fam Med 2011 9: 323-329.



【要約】

＜Purpose＞

Care coordination is increasingly recognized as a necessary element of high-quality, patient-centered care. This study investigated following. 
1. The association between care coordination and continuity of primary care.
2. Differences in this association by level of specialty care use



＜Methods＞

Design　:  Cross-sectional study

Setting :  Group Health, an integrated health care delivery system in Washington State and Idaho

Data collection :  During March through September 2008, data were collected from questionnaires mailed to Group Health members who were eligible to enroll.

Participants:  Eligible patients were aged 65 years or older, received care at a Group Health clinic in King County or Pierce County in western Washington State, and had at least 1 of the following chronic conditions: diabetes, coronary artery disease (CAD), or congestive heart failure (CHF).
Coordination measure:  The short form of the Ambulatory Care Experiences Survey (Figure1.)

Continuity measure:  Primary care visit concentration.

Analysis:  Linear regression was used to estimate the association between coordination and continuity, controlling for potential confounders and clustering within clinicians.

To determine whether the association between care coordination and continuity was modified by level of specialty use, an indicator for high specialty care use (10 or more specialist visits during the 1-year study period) and an interaction between high specialty care use and care continuity were included in the model.



＜Results＞

Among low specialty care users, an increase of 1 standard deviation in continuity of care was associated with an increase of 2.71 in coordination (P <.001, Table 3). Among respondents with 
high specialty care use, however, the model showed no association between continuity and reported coordination(P = .77). 



＜Conclusion＞
　High use of specialty care may strain the ability of primary care clinicians to coordinate care effectively. Future studies should investigate care coordination interventions that allow for appropriate specialty care referrals without diminishing the ability of primary care physicians to manage overall patient care.



【開催日】

2011年8月31日

【文献】
Ceille Costelloe, et.al.: Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ: volume340, pp2096, 2010.
この文献へのリンクはこちら

【要約】
《目的》
プライマリ・ケアセッティングにおいて抗菌薬を投与された患者に引き続いて起こる抗菌薬耐性に関する研究のsystematic review。可能ならmeta-analysisも実施する。
《デザイン》
Meta-analysisも実施したsystematic review
《Reviewの方法》
MEDLINEやEMBASE、Cochrane data baseを検索して得た４３７３の文献が対象。
２名の独立した評価者が文献を評価し、データを抽出した。
同様のアウトカムを使用している研究に関してmeta-analysisを実施した。
《結果》
２４の研究がレビューに採用された。
２２の研究が感染症患者を対象としたもの、２つの研究は健康なボランティアを対象としていた。
１９の研究が観察研究（うち２つはprospective）で５つの研究がランダム化試験であった。
尿路感染症を対象とした８つの研究のうち、５つがmeta-analysisに足る研究であった。
抗菌薬による治療後２か月以内の耐性菌検出のオッズ比は2.5（95%CI 2.1 – 2.9）
１２か月以内では1.33（95%CI 1.2 – 1.5）であった。
呼吸器感染症を対象とした９つの研究のうち、７つがmeta-analysisに含まれた。
抗菌薬による治療後２か月以内の耐性菌検出のオッズ比は2.4（95%CI1.4 – 3.9）
１２か月以内では2.4（95%CI1.3-4.5）であった。
投与した抗菌薬の量についてレポートしている研究では抗菌薬投与期間が長いほど、また複数の抗菌薬を使用したときほど耐性菌検出の頻度が高かった。
抗菌薬による耐性菌検出の違いは今回のレビューでは傾向はつかめなかった。
期間による耐性菌検出の変化を追った研究が１例のみ認められた。
抗菌薬治療後１週間ではオッズ比が12.2（95%CI 6.8-22.1），１か月では6.1（同2.8-13.4），２か月では3.6（同2.2-6.0），６か月では2.2（同1.3-3.6）。
《結論》
呼吸器または尿路感染症にたいして抗菌薬の投与を受けた個人はその抗菌薬に対する耐性を獲得する。
その影響は抗菌薬による治療後の１か月以内がもっとも大きいが、１２か月持続する可能性がある。
この影響はfirst lineの抗菌薬に対する耐性菌を地域内にまん延させるばかりでなく、second lineの抗菌薬使用をも増やしてしまう結果を生む。

【開催日】
２０１０年９月１日（水）