Gender Inequality Improvement in Medical School Admissions in Japan.

Purpose: To investigate the effects of gender discrimination in Japan's medical school admission process and to assess whether the situation has improved since the disclosure of such discrimination in 2018. Materials and Methods: A cross-sectional study was conducted using secondary data from the Ministry of Education, Culture, Sports, Science, and Technology. The proportions of male and female applicants vis-à-vis all successful candidates admitted from 2016 to 2021 were analyzed; four medical schools were found to be systematically guilty of discriminatory admission practices. Acceptance rate ratios (ARRs) were estimated, and difference-in-differences (DID) analysis was used to examine the differences in ARRs between the two groups-the 4 and 75 medical schools that were and were not reported, respectively-in the predisclosure (2016-2018) and postdisclosure (2019-2021) periods. Results: Female applicants were subjected to discriminatory admission practices at the four reported medical schools in the predisclosure period. However, postdisclosure, those four medical schools had higher female than male acceptance rates in all 3 years. DID analysis revealed a statistically significant estimated average treatment effect on the treated of 0.25148 (95% confidence interval [0.00455-0.49840]), indicating a 0.25-point increase in ARRs relative to the other 75 medical schools. Conclusions: Discriminatory practices against female applicants have decreased since the disclosure in 2018, with the acceptance rate of female students exceeding that of male students for the first time in 2021. In response to these findings, we propose recommendations to further promote gender equality in medicine.

Nationwide survey on Japanese residents' experience with and barriers to incident reporting.

The ability of any incident reporting system to improve patient care is dependent upon robust reporting practices. However, under-reporting is still a problem worldwide. We aimed to reveal the barriers experienced while reporting an incident through a nationwide survey in Japan. We conducted a cross-sectional survey. All first- and second-year residents who took the General Medicine In-Training Examination (GM-ITE) from February to March 2021 in Japan were selected for the study. The voluntary questionnaire asked participants regarding the number of safety incidents encountered and reported within the previous year and the barriers to reporting incidents. Demographics were obtained from the GM-ITE. The answers of respondents who indicated they had never previously reported an incident (non-reporting group) were compared to those of respondents who had reported at least one incident in the previous year (reporting group). Of 5810 respondents, the vast majority indicated they had encountered at least one safety incident in the past year (n = 4449, 76.5%). However, only 2724 (46.9%) had submitted an incident report. Under-reporting (more safety incidents compared to the number of reports) was evident in 1523 (26.2%) respondents. The most frequently mentioned barrier to reporting an incident was the time required to file the report (n = 2622, 45.1%). The barriers to incident reporting were significantly different between resident physicians who had previously reported and those who had never previously reported an incident. Our study revealed that resident physicians in Japan commonly encounter patient safety incidents but under-report them. Numerous perceived and experienced barriers to reporting remain, which should be addressed if incident reporting systems are to have an optimal impact on improving patient safety. Incident reporting is essential for improving patient safety in an institution, and this study recommends establishing appropriate interventions according to each learner's barriers for reporting.

Prevalence and changes of low-value care at acute care hospitals: a multicentre observational study in Japan.

OBJECTIVES: We aimed to examine the use and factors associated with the provision of low-value care in Japan. DESIGN: A multicentre observational study. SETTING: Routinely collected claims data that include all inpatient and outpatient visits in 242 large acute care hospitals (accounting for approximately 11% of all acute hospitalisations in Japan). PARTICIPANTS: 345 564 patients (median age (IQR): 62 (40-75) years; 182 938 (52.9%) women) seeking care at least once in the hospitals in the fiscal year 2019. PRIMARY AND SECONDARY OUTCOME MEASURES: We identified 33 low-value services, as defined by clinical evidence, and developed two versions of claims-based measures of low-value services with different sensitivity and specificity (broader and narrower definitions). We examined the number of low-value services, the proportion of patients receiving these services and the proportion of total healthcare spending incurred by these services in 2019. We also evaluated the 2015-2019 trends in the number of low-value services. RESULTS: Services identified by broader low-value care definition occurred in 7.5% of patients and accounted for 0.5% of overall annual healthcare spending. Services identified by narrower low-value care definition occurred in 4.9% of patients and constituted 0.2% of overall annual healthcare spending. Overall, there was no clear trend in the prevalence of low-value services between 2015 and 2019. When focusing on each of the 17 services accounting for more than 99% of all low-value services identified (narrower definition), 6 showed decreasing trends from 2015 to 2019, while 4 showed increasing trends. Hospital size and patients' age, sex and comorbidities were associated with the probability of receiving low-value service. CONCLUSIONS: A substantial number of patients received low-value care in Japan. Several low-value services with high frequency, especially with increasing trends, require further investigation and policy interventions for better resource allocation.

Allocation of Mechanical Ventilators During a Pandemic: A Mixed-Methods Study of Perceptions Among Japanese Health Care Workers and the General Public.

BACKGROUND: In Japan, public dialogue on allocation of life-saving medical resources remains taboo, and discussion largely has been avoided. RESEARCH QUESTION: Do Japanese health care workers and the general public agree with principles of ventilator allocation developed internationally? STUDY DESIGN AND METHODS: A four-point Likert scale questionnaire was used to assess the extent of agreement or disagreement with internationally developed triage principles for rationing mechanical ventilators during pandemics. Questionnaires were distributed in person or online, and generalized linear models were used to analyze quantitative data. Free-text descriptions were analyzed qualitatively, both deductively and inductively, to compare respondent opinions with those described in previous US studies. RESULTS: Of 3,191 surveys distributed, 1,520 were returned. Allocation of resources to maximize survival from current illness ("save the most lives") was the most popular triage principle, with 95.8% of respondents in agreement. Allocation to ensure a minimum duration of benefit, as determined by predicted prognosis after illness ("ensure minimum duration of benefit"), and allocation to persons who have experienced fewer life stages ("life cycle") obtained agreement of 82.2% and 80.1%, respectively. Withdrawal and reallocation of mechanical ventilators to more appropriate patients was supported by 64.4% of respondents. Only 28.4% of respondents supported the principle of first-come, first-served access to ventilators. INTERPRETATION: Most respondents supported allocation principles developed internationally and disagreed with the idea of first-come, first-served allocation during resource shortages. The Japanese public seems largely to be prepared to discuss the ethical dilemmas and possible solutions regarding fair and transparent allocation of critical care resources as a necessary step in confronting present and future pandemics and disasters.

Physicians' prediction for the assessment of atypical pathogens in respiratory tract infections.

BACKGROUND: Patients with acute respiratory tract infections are frequently prescribed antimicrobials despite high rates of virus detection. Physicians may overprescribe antimicrobials owing to the concern of bacterial infections, including those because of atypical pathogens. We investigated the accuracy of clinical predictions concerning atypical pathogen infections. METHODS: We prospectively enrolled adult patients who presented with a fever and cough in outpatient clinics between December 2016 and August 2018. After taking a history and performing physical examinations, physicians predicted the possibility of respiratory infections because of atypical pathogens. Disease probabilities were categorized into 3 grades (high: ≥50%, intermediate: 20% ≥ and <50%, and low: <20%) and were judged by physicians who were taking care of the patients. Confirmation of atypical pathogens was performed by comprehensive molecular analyses of respiratory samples. RESULTS: Atypical pathogens were detected in 21 of 210 patients. A close contact history (odds ratio [OR]: 11.4, 95% confidence interval [CI]: 2.4-53.5) and the presence of pneumonia (OR: 12.9, CI: 4.3-39.2) were associated with the detections. Atypical pathogens were detected in 32.3% of high-probability cases (10/31), while atypical pathogens were only detected in 8.8% of intermediate-probability cases (8/91) and 3.4% of low-probability cases (3/88) (P < .001). CONCLUSIONS: The current study indicates that physicians' predictions were associated with the detection of atypical pathogens; however, overestimation was observed.

Factors and impact of physicians' diagnostic errors in malpractice claims in Japan.

BACKGROUND: Diagnostic errors are prevalent and associated with increased economic burden; however, little is known about their characteristics at the national level in Japan. This study aimed to investigate clinical outcomes and indemnity payment in cases of diagnostic errors using Japan's largest database of national claims. METHODS: We analyzed characteristics of diagnostic error cases closed between 1961 and 2017, accessed through the national Japanese malpractice claims database. We compared diagnostic error-related claims (DERC) with non-diagnostic error-related claims (non-DERC) in terms of indemnity, clinical outcomes, and factors underlying physicians' diagnostic errors. RESULTS: All 1,802 malpractice claims were included in the analysis. The median patient age was 33 years (interquartile range = 10-54), and 54.2% were men. Deaths were the most common outcome of claims (939/1747; 53.8%). In total, 709 (39.3%, 95% CI: 37.0%-41.6%) DERC cases were observed. The adjusted total billing amount, acceptance rate, adjusted median claims payments, and proportion of deaths were significantly higher in DERC than non-DERC cases. Departments of internal medicine and surgery were 1.42 and 1.55 times more likely, respectively, to have DERC cases than others. Claims involving the emergency room (adjusted odds ratio [OR] = 5.88) and outpatient office (adjusted OR = 2.87) were more likely to be DERC than other cases. The initial diagnoses most likely to lead to diagnostic error were upper respiratory tract infection, non-bleeding digestive tract disease, and "no abnormality." CONCLUSIONS: Cases of diagnostic errors produced severe patient outcomes and were associated with high indemnity. These cases were frequently noted in general exam and emergency rooms as well as internal medicine and surgery departments and were initially considered to be common, mild diseases.

Ultrasonographic Assessment of Passive Cephalic Excursion of Diaphragm During Cough Expiration Predicts Cough Peak Flow in Healthy Adults.

BACKGROUND: Evaluation of cough strength is clinically important, especially for patients with neuromuscular disorders and before extubation of mechanically ventilated patients. The pressure gradient between the airway and thoracoabdominal cavities during the cough expiratory phase generates cough flow and passive cephalic movement of the diaphragm. We hypothesized that passive diaphragmatic cephalic excursion, peak velocity, or both during cough expiration might predict cough peak flow (CPF). This physiologic study investigated associations of CPF with simultaneously measured ultrasonographic indices in healthy adults during the cough expiratory phase. METHODS: 56 healthy adults participated in this study. Right hemidiaphragm excursion and peak velocity were measured with ultrasonography during voluntary cough expiration with maximum effort. CPF was simultaneously measured for all coughs along with the ultrasonographic measurements. A linear regression model was used to determine whether ultrasonographic indices predicted CPF. RESULTS: Simple regression analysis showed significant associations between excursion and CPF in men and women (P < .001, beta coefficient 37.8, 95% CI 10.9-64.7, adjusted R2 = 0.195 for men; P < .001, beta coefficient 46.1, 95% CI 22.3-69.9, adjusted R2 = 0.386 for women). A multiple regression model adjusted for age, height, and sex showed a significant association between CPF and excursion (P < .001, adjusted beta coefficient 38.32, 95% CI 21.20-55.44, adjusted R2 = 0.643). Simple regression analysis showed a significant association between diaphragmatic peak velocity and CPF only in women (P = .004, beta coefficient 5.07, 95% CI 1.81-8.33, adjusted R2 = 0.280 for women). CONCLUSIONS: Passive cephalic excursion of the diaphragm during the cough expiratory phase significantly predicted CPF with maximum cough effort in healthy adults. Future studies should investigate the relationship between CPF and excursion in persons with respiratory and neuromuscular disorders.

Antimicrobial Stewardship in Inpatient Settings in the Asia Pacific Region: A Systematic Review and Meta-analysis.

BACKGROUND: An antimicrobial stewardship program (ASP) is one of the core elements needed to optimize antimicrobial use. Although collaboration at the national level to address the importance of ASPs and antimicrobial resistance has occurred in the Asia Pacific region, hospital-level ASP implementation in this region has not been comprehensively evaluated. METHODS: We conducted a systematic review and meta-analysis to assess the efficacy of ASPs in inpatient settings in the Asia Pacific region from January 2005 through March 2016. The impact of ASPs on various outcomes, including patient clinical outcomes, antimicrobial prescription outcomes, microbiological outcomes, and expenditure were assessed. RESULTS: Forty-six studies were included for a systematic review and meta-analysis. The pooled risk ratio for mortality from ASP before-after trials and 2-group comparative studies were 1.03 (95% confidence interval [CI], .88-1.19) and 0.69 (95% CI, .56-.86), respectively. The pooled effect size for change in overall antimicrobial and carbapenem consumption (% difference) was -9.74% (95% CI, -18.93% to -.99%) and -10.56% (95% CI, -19.99% to -3.03%), respectively. Trends toward decreases in the incidence of multidrug-resistant organisms and antimicrobial expenditure (range, 9.7%-58.1% reduction in cost in the intervention period/arm) were also observed. CONCLUSIONS: ASPs in inpatient settings in the Asia Pacific region appear to be safe and effective to reduce antimicrobial consumption and improve outcomes. However, given the significant variations in assessing the efficacy of ASPs, high-quality studies using standardized surveillance methodology for antimicrobial consumption and similar metrics for outcome measurement are needed to further promote antimicrobial stewardship in this region.

Prevalence and Appropriateness of Urinary Catheters in Japanese Intensive Care Units: Results From a Multicenter Point Prevalence Study.

BACKGROUND: Catheter-associated urinary tract infection is a common and costly problem throughout the world. As limited data from Asia exist regarding the prevalence and appropriateness of urinary catheters in critically ill patients, we sought to assess both prevalence and appropriateness of urinary catheters in Japan. METHODS: Using independent observers, we evaluated the prevalence and clinical necessity of indwelling urinary catheters in 7 Japanese intensive care units. RESULTS: Data were collected on 1289 catheter-days and 1706 patient days in the 7 participating intensive care units between August 2015 and May 2016. Urinary catheter prevalence was 76% (range, 49%-94%). The observers deemed that only 54% of the catheters met an appropriate indication for use (range, 40%-74%). The most common appropriate indications for urinary catheter use were (1) the need for accurate input and output monitoring in critically ill patients; (2) perioperative use; and (3) prolonged immobilization. The use of monitoring accurate input and output in critically ill patients, however, may be overused as bedside nurses used this indication in 27% more patients than the objective observer deemed necessary. CONCLUSIONS: Urinary catheters were frequently used in the 7 participating Japanese intensive care units and almost half did not meet an appropriate indication for use. Overusing catheters for monitoring accurate input and output was especially notable. Multimodal interventions may be needed to limit inappropriate urinary catheter use.

The impact of carperitide usage on the cost of hospitalization and outcome in patients with acute heart failure: High value care vs. low value care campaign in Japan.

BACKGROUND: The usefulness of carperitide in patients with acute heart failure (AHF) has not been confirmed; carperitide is expensive, and thus, its routine use has not been shown to add much value in clinical settings. We analyzed the impact of carperitide usage on the outcome and cost of hospitalization in AHF patients. METHODS: Data obtained from the Diagnosis Procedure Combination (DPC) database from July 2014 until June 2015 from 371 hospitals were analyzed. Emergent patients with acute heart failure (ICD code I50* and DPC code 050130) who did not undergo any surgical procedures were enrolled. We compared the outcomes and cost between the carperitide group and non-carperitide group using propensity score matched analysis. RESULTS: In 37,891 heart failure patients (52.2% male; 79.2±11.9years), 13,421 pairs were selected according to the propensity score matching. In-hospital death occurred more frequently in the carperitide group (n=997; 7.4%) than in the non-carperitide group (n=844; 6.3%; p<0.01). Carperitide use was also related with higher costs of hospitalizations, and total dose of carperitide administered during hospitalization decreased with the increasing case volume (p<0.01). On the other hand, carperitide usage was frequently recognized in hospitals with larger annual case volumes (32.1%, Q1; 37.3%, Q2; 40.7%, Q3, p-value<0.01). CONCLUSIONS: Carperitide usage negatively affected patient outcomes and cost of hospitalization. In hospitals with lower annual case volume, clinicians should pay attention to the total dose and duration of carperitide. On the other hand, in hospitals with larger annual case volumes, clinicians should pay attention to the thresholds/indications to prescribe carperitide in AHF patients.

Assessment of Self-Efficacy and its Relationship with Frailty in the Elderly.

Objective It has been increasingly recognized in various clinical areas that self-efficacy promotes the level of competence in patients. The validity, applicability and potential usefulness of a new, simple model for assessing self-efficacy in the elderly with special reference to frailty were investigated for improving elderly patients' accomplishments. Methods The subjects of the present study comprised 257 elderly people who were members of the New Elder Citizen Movement in Japan and their mean age was 82.3±3.8 years. Interview materials including self-efficacy questionnaires were sent to all participants in advance and all other physical examinations were performed at the Life Planning Center Clinic. Results The internal consistency and close relation among a set of items used as a measure of self-efficacy were evaluated by Cronbach's alpha index, which was 0.79. Although no age-dependent difference was identified in either sex, gender-related differences in some factors were noted. Regarding several parametric parameters, Beck's inventory alone revealed a significant relationship to self-efficacy in both sexes. Additionally, non-parametric items such as stamina, power and memory were strongly correlated with self-efficacy in both sexes. Frailty showed a significant independent relationship with self-efficacy in a multiple linear regression model analysis and using Beck's inventory, stamina, power and memory were identified to be independent factors for self-efficacy. Conclusion The simple assessment of self-efficacy described in this study may be a useful tool for successful aging of elderly people.

A comparison of estimated drug costs of potentially inappropriate medications between older patients receiving nurse home visit services and patients receiving pharmacist home visit services: a cross-sectional and propensity score analysis.

BACKGROUND: There have been no multicenter studies that estimated the relations of either nurse or pharmacist home visit program to drug costs of potentially inappropriate medications (PIMs). This study aimed to establish whether patients who used nurse or pharmacist home visit programs (nurse or pharmacist program) had lower drug costs of PIMs than those who did not use nurse or pharmacist programs for older patients living at home. METHODS: This cross-sectional study was conducted in home care settings in Japan, involving 430 patients aged 65 or older, of whom 276 were female. All received regular home visits from five clinics between May and December 2013. After the PIMs were identified with the Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria, we estimated the drug costs based on actual pharmaceutical prices and measured against who using nurse or pharmacist programs after a propensity score weighted adjustment. RESULTS: Patients who used nurse programs had lower drug cost of PIMs than those who did not use, but it was not significantly different (5.9 ± 13.1 vs 7.1 ± 13.9 USD per month, P = 0.199). The cost of PIMs for patients who used pharmacist programs also had no difference. (7.2 ± 14.5 vs 5.5 ± 11.5 USD per month, P = 0.06). In the patient groups who used nurse programs, patients who also used pharmacist programs had significantly higher costs of PIMs than those who used only nurse programs (5.5 ± 13.9 vs 2.5 ± 6.0 USD per month, P = 0.006). In patients group who did not use pharmacist programs, patients who only used nurse programs had significantly lower costs of PIMs than those who did not use nurse programs (3.6 ± 7.7 vs 5.8 ± 12.7 USD per month, P = 0.022). CONCLUSIONS: Patients who used nurse program have a trend towards lower drug costs of PIMs than those who used nurse and pharmacist program or pharmacist program alone. Although this study tried to adjust the potential confounders as possible as we could by using propensity score analysis, further studies are needed to confirm our results.

The measurement of axillary moisture for the assessment of dehydration among older patients: a pilot study.

PURPOSE: Dry axilla can sometimes be found among dehydrated older patients. In this study, we measured the axillary moisture and assessed it as possible marker for dehydration. METHODS: Twenty-nine older patients admitted with acute medical conditions participated in this study. Dehydration was diagnosed by the calculated serum osmolality of greater than 295 mOsm/L. The moisture of axilla was measured by a skin moisture impedance meter which was applied at the center of axilla of patients. RESULTS: 11 patients (7 males and 4 females) were diagnosed as dehydrated and 18 patients (10 males and 8 females) were diagnosed as non-dehydrated. The mean axillary moisture (33%) in the dehydrated group was significantly lower than that (42%) in the non-dehydrated group (p<0.05). The axillary moisture ≥50% showed the sensitivity of 88%. The axillary moisture <30% showed the specificity of 91%. Use of a single cutoff value of 40% moisture produced the sensitivity of 59% and the specificity of 9%. As for the physical signs, dry axilla had also moderate sensitivity and excellent specificity to detect dehydration. CONCLUSIONS: The measurement of the axillary moisture could help assess dehydration. Dehydration could be ruled out when the axillary moisture ≥50%, while it could be ruled-in when the axillary moisture is <30%.

Associations between hours worked, symptoms and health resource utilization among full-time male Japanese workers.

OBJECTIVES: To investigate the association between hours worked, symptoms experienced, and health resource utilization. METHODS: Data were collected from a nationally representative sample of households in Japan. We studied full-time male workers aged 18-65 yr who worked 100 h or more per month. First, we examined the association between hours worked and symptoms experienced. Second, we examined the association between hours worked and the type of health resource utilized, such as physician visits, over-the-counter (OTC) medication use, dietary supplement use, and complementary and alternative medicine (CAM) provider visits. We used a multivariable negative binominal model in each analysis. RESULTS: Of the 762 male workers, 598 reported experiencing symptoms at least once a month. We categorized participants based on the number of hours worked per month (h/mo): 100-200 h/mo, 201-250 h/mo, and over 250 h/mo. Compared with those working 201-250 h/mo, those working 100-200 h/mo had more frequent physician visits (rate ratio:1.67, 95% CI: 1.17 to 2.38) and those working over 250 h/mo had significantly lower rates of CAM provider visits and tended to use dietary supplements for symptoms. Participants who worked 201-250 h/mo used OTC medication most frequently. No significant association was observed between the number of hours worked and number of symptoms experienced. CONCLUSIONS: The more hours worked by full-time male workers, the more likely they were to use health resources that had a lower time requirement. Greater attention should be paid to patterns of health resource utilization among workers and their consequent influence on long-term health status.

Cognitive error as the most frequent contributory factor in cases of medical injury: a study on verdict's judgment among closed claims in Japan.

BACKGROUND: Cognitive errors in the course of clinical decision-making are prevalent in many cases of medical injury. We used information on verdict's judgment from closed claims files to determine the important cognitive factors associated with cases of medical injury. METHODS: Data were collected from claims closed between 2001 to 2005 at district courts in Tokyo and Osaka, Japan. In each case, we recorded all the contributory cognitive, systemic, and patient-related factors judged in the verdicts to be causally related to the medical injury. We also analyzed the association between cognitive factors and cases involving paid compensation using a multivariable logistic regression model. RESULTS: Among 274 cases (mean age 49 years old; 45% women), there were 122 (45%) deaths and 67 (24%) major injuries (incomplete recovery within a year). In 103 cases (38%), the verdicts ordered hospitals to pay compensation (median; 8,000,000 Japanese Yen). An error in judgment (199/274, 73%) and failure of vigilance (177/274, 65%) were the most prevalent causative cognitive factors, and error in judgment was also significantly associated with paid compensation (odds ratio, 1.9; 95% confidence interval [CI], 1.0-3.4). Systemic causative factors including poor teamwork (11/274, 4%) and technology failure (5/274, 2%) were less common. CONCLUSIONS: The closed claims analysis based on verdict's judgment showed that cognitive errors were common in cases of medical injury, with an error in judgment being most prevalent and closely associated with compensation payment. Reduction of this type of error is required to produce safer healthcare.

Development and validation of a 15-item Japanese Health Knowledge Test.

BACKGROUND: Health literacy affects the acquisition of health knowledge and is thus linked to health outcomes. However, few scales have been developed to assess the level of health knowledge among the general public. METHODS: The 15-item Japanese Health Knowledge Test (J-HKT) was developed by using item response theory to score an item pool. We examined the construct validity of the J-HKT in relation to health literacy items, and analyzed the sociodemographic and behavioral factors associated with poor health knowledge. RESULTS: We enrolled 1040 adult participants (mean age, 57 years; women, 52%). The 15 items that best identified people with poor health knowledge were selected. For all items on the J-HKT, the information function curves had a peak in the negative spectrum of the latent trait. As compared with participants reporting high levels of income, educational attainment, and literacy, those with low levels of income, education, and literacy had a lower total score on the J-HKT. As compared with non/light drinkers, moderate and heavy drinkers had lower total scores on the J-HKT. CONCLUSIONS: The J-HKT may prove useful in measuring health knowledge among the general public, and in identifying and characterizing those with poor health knowledge.

Population-level preferences for primary care physicians' characteristics in Japan: a structural equation modeling.

OBJECTIVE: Primary care has potential to play a role for improving the patient care in Japanese health care system; however, little information is available about how patients perceive the roles of primary care physicians (PCPs) within the Japanese health care system. We aimed to assess population-level preferences for PCPs and investigated the extent to which preferences vary in relation to different population groups in Japan. METHODS: Data were extracted from a cross-sectional questionnaire survey in October 2003. An 18-item questionnaire was used to measure the preferences for PCPs. Exploratory factor analysis was performed to identify latent factors, while confirmatory factor analysis was used to evaluate the fit of the structure using structural equation modeling (SEM). PATIENTS: Nationally representative sample of the adult Japanese general population was chosen by controlling for age, sex, and the size of cities. RESULTS: A total of 2,453 adults>or=18-years-old were analyzed. SEM provided a 4-factor structural model of the population-level preference for PCPs, such as clinical competence (path coefficient (pc)=0.72), gate-keeping (pc=0.64), communication with patients or specialists (pc=0.49) and high education (pc=0.25) and demonstrated the best goodness-of-fit. Those who were middle aged, have a high family income, and a high level of education, placed more importance on gate-keeping characteristics, and the rural residents emphasized communication rather than clinical competence. CONCLUSION: Our results indicate that the preferences for PCPs are divided into four main factors and underscore the variation among preferences according to different population groups, such as age, socioeconomic and educational status, and places of living. These variations should be considered to improve the primary care system in Japan.