Importance of explanation before and after forensic autopsy to the bereaved family: lessons from a questionnaire study.

To investigate how bereaved families felt about the explanation received before and after forensic autopsies, the authors conducted a cross-sectional survey of the bereaved families whose next of kin underwent a forensic autopsy at the two Departments of Forensic Medicine and a few bereaved families of crime victims. Of 403 questionnaires sent, 126 families responded. Among 81.5% of the respondents who received an explanation from policemen before the autopsy, 78.8% felt that the quality of the explanation was poor or improper. In Japan, the law has restricted disclosure of information from a forensic autopsy. Despite legal restrictions, 82% wanted to hear from the person who conducted the autopsy. However, police explained the results of autopsy to 65.2% of respondents. Among the families whose frustration and anger increased after autopsy, 86.4% had not been satisfied with the explanation before the autopsy. Additionally, 57.7% had not been informed on the autopsy findings at the time of the questionnaire when more than 2 years had passed after the autopsy. These results reminded us of the importance of an explanation before and shortly after a forensic autopsy for a better understanding and acceptance by bereaved families.

Sleep patterns and impulse control among Japanese junior high school students.

Adolescents with decreased impulse control exhibit behavioral problems. Lifestyles are related to impulse control. However, the relations of sleep patterns and impulse control among adolescents are unknown. Thus we examined how sleep patterns were associated with impulse control among Japanese junior high school students. Surveys were completed by a nationwide sample of 1934 students. A significant association between decreased impulse control and bedtimes after midnight was revealed. Specific lifestyle factors related to bedtimes after midnight were older age, greater numbers of hours spent watching television, lack of participation in an extracurricular activity, greater use of convenience stores, and increased attendance at cram schools. This study revealed that going to sleep after midnight was significantly related to decreased impulse control among adolescents. Data about specific lifestyle factors related to going to sleep after midnight should be useful in preventing those behaviors demonstrated by school children that derive from decreased impulse control.

The health impact of remarriage behavior on chronic obstructive pulmonary disease: findings from the US longitudinal survey.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major disease among adults, and its deterioration was reported to be associated with psychological imbalance. Meanwhile, bereavement and divorce have proven harmful to the health status of a surviving spouse. But few studies have been conducted to evaluate the remedial effect on survivors' health outcome by remarriage after bereavement. The present study thus examined the associations between remarriage and the onset of COPD. METHODS: Our cohort was drawn from Health and Retirement Study participants in the United States, and consisted of 2676 subjects who were divorced or bereaved from 1992 to 2002. We then followed them for up to 11 years and assessed the incidence rate of COPD using a Cox proportional hazard model after adjusting for marital status, age, gender, education and the number of cigarettes smoked. RESULTS: Among all subjects, 224 who remarried after bereavement or divorce tended to be younger and more male dominated. Remarriage after bereavement/divorce was associated with significantly decreased risk of COPD onset for overall subjects [hazard ratio (HR): 0.51, 95% confidence interval (95% CI): 0.28-0.94], female subjects [HR: 0.36, 95% CI: 0.13-0.98], and for those under 70 years old [HR: 0.36, 95% CI: 0.17-0.79]. CONCLUSION: This study investigates the impact of remarriage on health outcome based on a large-scale population survey and indicates that remarriage significantly correlates with reduced risk of COPD incidence, even after adjusting smoking habit.

Family caregivers and care manager support under long-term care insurance in rural Japan.

Care managers are expected to coordinate care services for the elderly and to function as a source of social support under the Long-term Care Insurance programme in Japan. Thus far, however, little attention has been paid to the social support function of the care manager. To clarify the role of care manager support, we evaluated how care manager support ('social talk,' 'information giving' and 'reassurance') affects the burden of family caregivers categorised by caregiver gender and living arrangement. The interaction between 'information giving' and 'memory and behaviour problems' had a negative effect on 'social activity' among females living with elderly relatives (p < 0.05). 'Information giving' had a direct negative effect on caregiver burden among males living with elderly relatives (p < 0.05). Although 'social talk' had a moderating effect on caregiver burden (p < 0.05), the interaction between 'social talk' and 'memory and behaviour problems' had a negative impact on caregiver burden among females living with elderly relatives (p < 0.05). These results indicate that care manager support is only effective for female caregivers living with elderly relatives, and is ineffective or works poorly for female caregivers living separately and male caregivers living with elderly relatives. We concluded that the social support function of care managers would be improved by ensuring that they have adequate time for each case, and the skills to assess psychosocial needs. To achieve these goals, it is necessary to improve the work environment and introduce systematic training for psychosocial needs assessment.

Predicting the discharge destination of rehabilitation patients using a signal detection approach.

OBJECTIVE: To predict the discharge destination of rehabilitation patients using signal detection analysis. DESIGN: Cross-sectional and follow-up studies. SUBJECT: The subjects were 324 patients discharged from a hospital in Fukuoka, Japan, between April 2005 and March 2006 and 313 patients discharged from the same hospital between 1 April and 31 October 2006. METHODS: The discharge destinations of the 324 patients were predicted using signal detection analysis. As a validation study, 7 variables identified in the first analysis were used to categorize 313 patients, organized retrospectively into 8 groups, and to calculate the home discharge rate in each group. RESULTS: A patient's activities with respect to daily living, key person preference, dementia, age, route taken to hospitalization, residence before hospitalization, and gender were significant predictors of his or her discharge destination. Signal detection analysis established 8 subgroups, with 17.9-99.1% of the patients returning home after discharge. As a validation study, the actual and expected rates in the 8 subgroups were compared, and no significant difference was observed between the rates in any subgroup. CONCLUSION: Signal detection analysis is a useful technique for predicting the discharge destination of rehabilitation patients.

Physician and patient perceptions of the physician explanations in medical encounters.

Although, in actual practice, physicians have to subjectively judge the level of the explanation that they provide, little is known about this judgment. Therefore, making use of 630 physician-patient pairs in Japan, we investigated the association between patient and physician evaluations of physician explanations of medical test results and diagnoses. We found that the physician's judgment does not always agree with that of the patient, with regard to the level of explanation necessary. In addition, we first identified factors relating to the accuracy of physician judgments with regard to their explanations to patients. More studies will be necessary to verify the present findings.

[Interpretation and related factors of healthy eating among young people in Japan].

OBJECTIVE: The purpose of this study is to interpret and determine factors related to "healthy eating" among young people in Japan. The findings would be useful in improving the consciousness among young people regarding healthy food, eventually leading to the prevention of lifestyle-related diseases. METHOD: We conducted a questionnaire survey among young people in Saga and Fukuoka prefecture (n = 482) from October through November, 2004. The data were analyzed using chi-square test, one-way ANOVA, factor analysis and multiple regression analysis. RESULTS: (1) As for the interpretation of "healthy food", 2 factors ("eating style and habits" and "food and nutrition") were extracted in the factor analysis. This was in line with the interpretation among adults. (2) The scores of "eating style and habits" and "food and nutrition" increased with the age of the subjects, and a significant difference in grade was observed (p = 0.00). (3) Sex and physical exercise were related to "eating style and habits" score (p = 0.00), whereas age and sex were related to "food and nutrition" score (p = 0.00). CONCLUSION: The interpretation of "healthy food" among young people was consistent with that among adults. However, it is implied that the traditional view of "healthy food" has begun to change among young people. The necessity of proper eating habits at home and food education out side is implied.

[Factors related to the length of rehabilitation unit stay among elderly patients].

AIM: In order to suppress increases in medical costs in Japan, with regard to rehabilitation, it is extremely important to shorten the length of stay at rehabilitation units. Thus, factors related to the length of stay were analyzed in the study. METHODS: The subjects of the study were patients who stayed and left the rehabilitation unit at H hospital in Fukuoka, Japan during the period of May 1, 2003 and December 31, 2004. Of the 236 patients, 167 patients had no missing values with respect to 15 study variables. Thus, these 167 patients were used for analyses. In order to isolate factors related to the length of unit stay, a multiple regression analysis was performed with the length of stay as a dependent variable and other factors as independent variables. RESULTS: Of the 3 types of rehabilitation interventions (i.e., physical, occupational and speech therapies), the quantity of physical therapy was a significant predictor (p< 0.05). CONCLUSION: The findings imply the following. (1) The level of physical activity, which is a target of physical therapy, is used as a criterion for leaving the unit. (2) The three types of rehabilitation interventions highly correlated with one another, and the quantity of physical therapy is greatest. Thus, it is possible that only physical therapy could be isolated as a significant predictor. Since the present finding is based upon patients in a single rehabilitation unit, further studies using patients from multiple facilities is necessary.

A signal detection approach to patient-doctor communication and doctor-shopping behaviour among Japanese patients.

OBJECTIVES: As one of the factors related to doctor-shopping behaviour (i.e. consulting multiple doctors with regard to the same illness episode), very little has been revealed about the role of doctor explanation. We examined therefore the association between doctor explanation and doctor-shopping behaviour. METHODS: The subjects were internist-patient pairs in Japan. Signal detection analysis (SDA) was used for the data analysis. RESULTS: Of the 303 patients, 84 patients engaged in doctor shopping (27.7%). The following results were obtained: (1) of the 19 relevant variables, the 'level of doctor explanation: treatment' was the most significant predictor of doctor-shopping behaviour (P < 0.01), and (2) with regard to their subjective evaluations of the sufficiency of their explanations about treatment or testing, the evaluations of the doctors, rather than those of the patient, were significant predictors of doctor-shopping behaviour. CONCLUSIONS: These results imply the following: (1) a patient's inability to understand a doctor's explanation about treatment, which results from a large gap between the perceptions of the patient and those of the doctor, is the most significant predictor of doctor-shopping behaviour, and (2) in the context of favourable patient-doctor interactions, when doctors feel their explanations are insufficient, they may be able to prevent doctor-shopping behaviour by providing relatively thorough explanations about treatment.

Positive and negative effects of social support on the relationship between work stress and alcohol consumption.

OBJECTIVE: This study was performed to evaluate both positive and negative influences of social support on the relationship between work stress and alcohol consumption in male white-collar workers. METHOD: This study was performed in a population of male white-collar workers in Osaka, Japan. The subjects (N = 661) were categorized into nine subgroups based on the moderated mediation model of Frone and on the results of signal detection analysis using chi-square parameters calculated from work stressors and depression (mediators). Hierarchical linear regression analyses were performed among the nine subgroups to test the effects of interactions between four types of social support (i.e., two types of belonging support and two types of appraisal support) and work stress on alcohol consumption. RESULTS: Our results verified that social support has both positive and negative effects on the relationship between work stress and alcohol consumption: (1) interactions between "belonging support (1)" and depressive symptoms were related to decreased alcohol consumption in two subgroups (p < .01 in Group 1 and p < .05 in Group 6), whereas the interaction was related to increased alcohol consumption in one subgroup (p < .01 in Group 7); (2) interaction between "belonging support (2)" and depressive symptoms was related to decreased alcohol consumption in two groups (p < .05 in Group 5 andp < .01 in Group 7), whereas the interaction was related to increased alcohol consumption in one group (p < .01 in Group 1). CONCLUSIONS: Social support was suggested to have various types of influences (i.e., positive, negative or no effect) on the relationship between work stress and alcohol consumption, depending on the type of social support and environmental factors defining the groups.

Standard of care and liability in medical malpractice litigation in Japan.

Although the incidence of medical malpractice litigation is increasing in Japan, it remains unclear whether medical malpractice litigation gives doctors and hospitals, an economic incentive to provide high-quality medical care by requiring that they compensate patients for harm caused by negligence. Therefore, to evaluate whether the medical malpractice litigation system contributes to the delivery of high-quality medical care, we first analyzed the decisions made in medical malpractice cases between 1986 and 1998 in ten district courts (n=421). We found the following results: (1) the probability that patients received compensation and the amount of compensation received, increased with the level of negligence, for all injury severity levels; (2) the significant predictors that a case would be decided in favor of the patient were the patient's legal basis (P=0.00) and the severity of injury (P=0.02). Although, it seems that Japanese medical malpractice litigation gives doctors an economic incentive to avoid delivering substandard medical care, since both the severity of injury and negligence were significant predictors, medical litigation in Japan might in fact corrupt the compensation process by creating an adversarial atmosphere.

Analysis of hospital charges for cerebral infarction stroke inpatients in Beijing, People's Republic of China.

OBJECTIVE: Stroke is a heavy economic burden on the individuals, society and health services in China, where health expenditure is rising rapidly. The purpose of the present study is to examine health services and demographic factors associated with inpatient charges for cerebral infarction in China, focusing on hospital charges of insured and uninsured patients. METHODS: The study subjects were 545 patients with a principal diagnosis of cerebral infarction stroke who were discharged from the China-Japan Friendship Hospital from January 1, 1997 through December 31, 1998. Demographic, clinical and administrative data were retrospectively collected from the medical record and financial database. The influence of social and medical factors on total charges was analyzed with stepwise multiple regression model. RESULTS: Of 545 subjects, 429 (79%) were the insured patients and 116 (21%) were the uninsured patients. Length of hospital stay (LOHS) for the insured patients (median, 32 days) was significantly longer (P<0.001) than that for the uninsured (median, 23 days). The hospital charges per discharge for the insured was significantly higher (geometric mean, 10407 yuan) (P<0.0001) than that for the uninsured patients (geometric mean, 5857 yuan). With stepwise multiple regression, factors associated independently with the hospital charge were: longer hospital stay, insurance status, increased number of head magnetic resonance imaging (MRI) and computerized tomography (CT), infection in hospital stay, and more severe condition of stroke. CONCLUSIONS: Inpatient charge for cerebral infarction stroke was positively associated with being the insured. The findings suggest an overuse of health care resources in insured patients and limited use of resources by those who are not.

Analysis of hospital charges for ischemic stroke in Fukuoka, Japan.

OBJECTIVES: Stroke is a heavy economic burden on individuals, society, and health services in Japan, where health expenditures are rising rapidly. The objective of the present study was to examine medical services and demographic factors associated with increased inpatient charges for ischemic stroke in Japan. SUBJECTS AND METHODS: The study subjects were 316 patients with a principal diagnosis of acute ischemic stroke who were discharged from the National Kyushu Medical Center Hospital from 1 July 1995 through 31 June 1999. Demographic, clinical, and administrative data were retrospectively collected from medical records and the hospital Clinical Financial Information System (CFIS). The influence of social and medical factors on total charges was analyzed using the stepwise multiple regression model. RESULTS: Among the total subjects, the mean (median) length of hospital stay (LOHS) was 33 (30) days (range, 2-155 days). The mean (median) hospital charge per patient was US dollars 9020 (dollars 7974) with a range of dollars 336-54,509. The distribution of charges was 42% for fundamental, 17% for injection therapies, 13% for radiological test, 11% for other laboratory examinations, 3% for drugs, and 3% for operations. Stepwise multiple regression analysis revealed that LOHS was the key determinant of the hospital charge (partial R2=0.5993, P=0.0001). Operations (P=0.0001) and angiography (P=0.03) were also independent but less contributory determinants of the hospital charge. CONCLUSIONS: LOHS was strongly, positively associated with inpatient charges for ischemic stroke in Japan. This implies that significant charge reductions are more likely to rely on shortening LOHS, which probably can be achieved by altering reimbursement policies.

The use of experts in medical malpractice litigation in Japan.

In medical malpractice litigation, the cooperation of medical experts is important. However, the appointment of experts has become problematic in Japan, apparently because many medical experts refuse to act in this capacity. However, this supposition has not until now been supported by quantitative evidence, since the fact that so few judgments in Japan are published made it impossible to investigate the situation. Therefore, we aim to show the state of the use of experts in medical malpractice litigation using objective data. Over the last ten years, the rate of the use of experts has averaged only 22.5%, varying according to region. Experts were used in 24.5% of cases involving an attorney on the patient's side, and in only 3.4% of cases where no attorney was used. The success rate of patients was higher when experts were adopted (39.1%) than when they were not (29.9%). The length of litigation involving experts was 4.0 years, and 2.7 years when no expert was involved. This research suggested the necessity of establishing a formal cooperation system as soon as possible in Japan with no regional maldistribution.

The structure of medical malpractice decision-making in Japan.

The article summarises the problems in the medical malpractice litigation systems in the United Kingdom and Japan, demonstrating the similarities and identifying the length of time between initiating an action and its decision and other factors responsible for lengthy litigation. Based on analysis of decisions of medical malpractice cases between 1986 and 1998 in Japan, the functioning of the Japanese medical malpractice litigation system is discussed. Lengthy litigation is shown to be correlated with outcome and implies that the Japanese medical dispute resolution mechanism favours those who can endure lengthy litigation, namely the defendants, who are physicians or hospitals. In view of the similarities between the two systems, it is likely that the same bias--that the wealthier party in the litigation is more likely to win the case--also occurs in medical malpractice litigation in the United Kingdom and Australia.

Association between civil procedure and medical malpractice litigation in Japan.

The effect of shortcomings in the system of civil procedure in Japan, such as excessive delay and possible mistaken judgment on the existence of negligence, on medical malpractice litigation and legal outcomes has not been examined. Using data on judgments and the decisions in medical malpractice litigation by the Tokyo and Osaka District Courts, we examined the association between civil procedure and medical malpractice litigation, and predictors of the decisions of medical malpractice litigation. The basis of the civil procedure to secure quick decisions was related to the amount of medical malpractice litigation, but not to the decisions in medical malpractice litigation. Negligence and a factor other than negligence were related to the rate of decisions in favor of the plaintiff. Although the study implies that shortcomings in civil procedure negatively influence medical malpractice litigation, it was not determined whether decisions were made based on mistaken judgment concerning the existence of negligence. Since there are methodological limitations to this study, further studies are necessary to verify these findings.

Applicability of press needles to a double-blind trial: a randomized, double-blind, placebo-controlled trial.

OBJECTIVES: Owing to a lack of a suitable needle procedure, it has been impossible to evaluate the efficacy of acupuncture in clinical studies using double-blind testing. We evaluated the applicability of a new kind of press needle (Pyonex) to a double-blind trial by comparing the press needle with a placebo (lacking the needle element). METHODS: The purpose of the study consisted of 2 phases. In the phase 1, to evaluate the applicability and efficacy of the press needles, 90 participants who had never been treated using acupuncture were randomly assigned to receive either the press needle (n=45) or a placebo (n=45). The applicability was measured using a questionnaire regarding the perception of penetration, and efficacy was measured using a visual analog scale of low back pain (LBP). When the applicability and efficacy of the press needles were confirmed in phase 1, the mechanism of LBP relief by the press needles was examined in phase 2. RESULTS: In phase 1, intergroup comparisons showed no significant differences concerning the perception of penetration. In addition, for patients with LBP, the press needles reduced the subjective evaluation of LBP compared with the placebo (P<0.05). In phase 2, visual analog scale results indicated that LBP was reduced significantly more in the press needle group than in the local anesthesia group (P<0.05). DISCUSSION: The participants could not distinguish between the press needle and a placebo, and the data from the press needle group suggested a specific influence on patients with LBP. These findings imply that the press needle and a placebo provide an effective means of realizing a double-blind setting for clinical studies of acupuncture.

Development of a patient safety climate scale in Japan.

BACKGROUND: Although patient safety climate is an important factor in preventing adverse events in health care organizations, there is no usable Japanese scale. OBJECTIVE: To develop a Japanese scale to measure patient safety climate and to evaluate its psychometric properties. METHODS: Cross-sectional questionnaire survey was conducted with respect to 9 non-academic general hospitals in Japan. A total of 1878 health care professionals (nurses, therapists, technicians, pharmacists and physicians) were included in a study. RESULTS: The eight dimensions measuring worker attitudes (free communication flow, continuous improvement, reporting/rules compliance and patient/family involvement) and organizational factors (supervisors' safety leadership, allied professionals' safety leadership, patient safety committee leadership and rules/equipment availability) were extracted by factor analysis. The internal consistency (measured by Cronbach's alpha) and repeatability (measured by intraclass correlation) were more than 0.70 for all subscales. In addition, the mean score, the within-group interrater reliability statistic (r(wg)) and the correlation coefficients of the mean score were confirmed at the workplace level. CONCLUSIONS: The scale showed acceptable dimensionality, reliability and validity. It also provided workplace team-evaluation and a tool for assessing the patient safety climate at the level of the workplace.