Effect of Patient Experience on Bypassing a Primary Care Gatekeeper: a Multicenter Prospective Cohort Study in Japan.

BACKGROUND: To discuss how best to implement the gatekeeping functionality of primary care; identifying the factors that cause patients to bypass their primary care gatekeepers when seeking care should be beneficial. OBJECTIVE: To examine the association between patient experience with their primary care physicians and bypassing them to directly obtain care from higher-level healthcare facilities. DESIGN AND METHODS: This prospective cohort study was conducted in 13 primary care clinics in Japan. We assessed patient experience of primary care using the Japanese version of Primary Care Assessment Tool (JPCAT), which comprises six domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. The primary outcome was the patient bypassing their usual primary care physician to seek care at a hospital, with this occurring at least once in a year. We used a Bayesian hierarchical model to adjust clustering within clinics and individual covariates. KEY RESULTS: Data were analyzed from 205 patients for whom a physician at a clinic served as their usual primary care physician. The patient follow-up rate was 80.1%. After adjustment for patients' sociodemographic and health status characteristics, the JPCAT total score was found to be inversely associated with patient bypass behavior (odds ratio per 1 SD increase, 0.44; 95% credible interval, 0.21-0.88). The results of various sensitivity analyses were consistent with those of the primary analysis. CONCLUSIONS: We found that patient experience of primary care in Japan was inversely associated with bypassing a primary care gatekeeper to seek care at higher-level healthcare facilities, such as hospitals. Our findings suggest that primary care providers' efforts to improve patient experience should help to ensure appropriate use of healthcare services under loosely regulated gatekeeping systems; further studies are warranted.

Social Isolation and Patient Experience in Older Adults.

PURPOSE: Social isolation has been identified as a major health problem, particularly in the elderly. In the present study, we examine the association between social isolation and patient experience in elderly primary care patients. METHODS: This cross-sectional study was conducted in a primary care practice-based research network (28 clinics) in Japan. We assessed social isolation using an abbreviated Lubben Social Network Scale and patient experience of primary care using a Japanese version of the Primary Care Assessment Tool (JPCAT), which comprises 6 domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. We used a linear mixed effects model to adjust clustering within clinics and individual covariates. RESULTS: Data were analyzed for 465 elderly primary care patients aged ≥65 years. After adjustment for possible confounders and clustering within clinics, social isolation was negatively associated with the JPCAT total score, (mean difference = -3.67; 95% CI, -7.00 to -0.38). Among the JPCAT domain scores, social isolation was significantly associated with longitudinality, comprehensiveness (service provided), and community orientation scores. CONCLUSIONS: Social isolation was associated with negative patient experience in elderly primary care patients. Raising awareness regarding patient social networks among primary care providers and targeted interventions for socially isolated elderly patients aimed at improving the experience of primary care, especially regarding longitudinality, comprehensiveness, and community orientation, may be warranted.

Patient experience of primary care and advance care planning: a multicentre cross-sectional study in Japan.

Background: Advance care planning (ACP) is becoming increasingly important in the primary care setting because of its positive impact on the end-of-life care. Objective: We aimed to investigate the relationship between patient experience of primary care and ACP. Methods: This cross-sectional study was conducted in 28 primary care clinics in Japan. We assessed patient experience of primary care using a Japanese version of Primary Care Assessment Tool (JPCAT), which comprises six domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided) and community orientation. The primary outcome measures were ACP discussion between patients and primary care providers and completion of advance directives (AD). We used a generalized linear mixed model to adjust clustering within clinics and individual covariates. Results: Data were analysed for 535 primary care patients. After adjustment for patients' sociodemographic and health characteristics, the JPCAT total score was found to be significantly associated with ACP discussion [odds ratio (OR) per 1 SD increase = 4.33; 95% confidence interval (CI), 2.53-7.47] but not with completion of AD (OR per 1 SD increase = 1.42; 95% CI, 0.94-2.12). All domains of JPCAT, which represent attributes of primary care, had positive associations with ACP discussion. First contact and comprehensiveness (services provided) domain scores were significantly associated with completion of AD. Conclusions: We found that better patient experience of primary care was strongly associated with ACP discussion. Our findings reinforce the significance of patient experience in primary care as part of quality end-of-life care.

Attributes of primary care in relation to polypharmacy: a multicenter cross-sectional study in Japan.

OBJECTIVE: To investigate the association between attributes of primary care and polypharmacy. DESIGN: Cross-sectional study. SETTING: A primary care practice-based research network in Japan (28 primary care clinics). PARTICIPANTS: Adult outpatients filled out a standardized questionnaire. MAIN OUTCOME MEASURE: Polypharmacy defined as the use of five or more concurrent prescription or over-the-counter medications. METHODS: Attributes of primary care were assessed via patient experience using the Japanese version of Primary Care Assessment Tool (JPCAT). Poisson mixed effects model was used to adjust for clustering within clinics and covariates. RESULTS: Data were analyzed for 544 primary care outpatients. After adjusting for patients' sociodemographic and health characteristics, the JPCAT community orientation score was found to be inversely associated with polypharmacy at the clinic level [risk ratio per 1 standard deviation increase = 0.83; 95% confidence interval (CI), 0.73-0.96; P = 0.008]. Sensitivity analyses using a different definition of polypharmacy showed results similar to those of the primary analyses. CONCLUSIONS: We found that a higher level of community-oriented primary care is associated with a lower prevalence of polypharmacy in outpatients at the clinic level. These findings may be useful in developing community-based interventions to minimize polypharmacy.

Treatment strategies for insomnia in Japanese primary care physicians' practice: A Web-based questionnaire survey.

BACKGROUND: It is unclear how primary care physicians manage insomnia after the introduction of novel hypnotics such as orexin receptor antagonists and melatonin receptor agonists. This Web-based questionnaire survey aimed to examine treatment strategies for insomnia in Japanese primary care practice. METHODS: One-hundred-and-seventeen primary care physicians were surveyed on the familiarity of each management option for insomnia on a binary response scale (0 = "unfamiliar"; 1 = "familiar") and how they managed insomnia using a nine-point Likert scale (1 = "I never prescribe/perform it"; 9 = "I often prescribe/perform it"). Physicians who were unfamiliar with a management option were deemed to have never prescribed or performed it. RESULTS: Regarding medication, most physicians were familiar with novel hypnotics. Suvorexant was the most used hypnotic, followed by lemborexant and ramelteon. These novel hypnotics averaged 4.8-5.4 points and 4.0-4.7 points for sleep onset and sleep maintenance insomnia, respectively. By contrast, most benzodiazepines were seldom used below two points. Regarding psychotherapy, only approximately 40% of the physicians were familiar with cognitive behavioral therapy for insomnia (CBT-I) and they rarely implemented it, at an average of 1.5-1.6 points. More physicians were familiar with single-component psychotherapies (i.e., relaxation, sleep restriction therapy, and stimulus control) compared to CBT-I, and 48-74% of them implemented it slightly more often, with scores ranging from 2.6 to 3.4 points. CONCLUSION: This study suggests that Japanese primary care physicians seldom use CBT-I to treat insomnia. In addition, they use novel sleep medications more frequently than benzodiazepines in terms of pharmacotherapy. The use and availability of CBT-I in Japanese primary care might be facilitated by: educating primary care physicians, implementing brief or digital CBT-I, and/or developing collaborations between primary care physicians and CBT-I specialists.

Exploring the experiences and learning of young primary care physicians in disaster-affected areas: A qualitative study on the Great East Japan Earthquake.

Background: Primary care physicians (PCPs) play a critical role in disaster medicine. However, it is unclear how PCPs who provide chronic support to disaster-affected areas learn from their experiences. Methods: This qualitative study investigates the learnings of young PCPs who provided medical care during the chronic phase of the Great East Japan Earthquake disaster. Results: Thematic analysis of interviews with five physicians revealed the challenges faced by them and their learnings in providing medical support to disaster-affected areas. Conclusions: They not only learned medical skills but also humanistic aspects such as empathizing with the survivors' loss.

Mental health training in family medicine residencies: International curriculum overview.

Integration of mental health into primary care has become a global trend, and many countries have developed mental health training in primary care. However, systematic mental health training for family physicians is insufficient in Japan. The newly established Japan Primary Care Association Mental Health Committee surveyed the current status of mental health training curricula in family medicine residency internationally. Participants were individuals involved in family medicine residency programs who were from Australia, Brazil, Hong Kong, the Philippines, Taiwan, the United Kingdom, and the United States. The results revealed that many academic societies have created competency lists and curriculum guidelines for mental health training; however, the implementation varied. This study is novel as it examined and compared different countries' curriculum; the findings of which can be used as a reference to develop future mental health training curriculum in Japan.

Physicians' attitudes toward hypnotics for insomnia: A questionnaire-based study.

Introduction: Benzodiazepines and non-benzodiazepines are still widely prescribed despite safety concerns and the introduction of novel hypnotics (orexin receptor antagonists [ORA] and melatonin receptor agonists [MRA]), which may be influenced by physicians' attitudes toward hypnotics. Methods: A questionnaire survey was administered to 962 physicians between October 2021 and February 2022, investigating frequently prescribed hypnotics and the reasons for their selection. Results: ORA were the most frequently prescribed at 84.3%, followed by non-benzodiazepines (75.4%), MRA (57.1%), and benzodiazepines (54.3%). Compared to non-frequent prescribers of hypnotics, a logistic regression analysis showed that frequent ORA prescribers were more concerned with efficacy (odds ratio [OR]: 1.60, 95% confidence interval [CI]: 1.01-2.54, p = 0.044) and safety (OR: 4.52, 95% CI: 2.99-6.84, p < 0.001), frequent MRA prescribers were more concerned with safety (OR: 2.48, 95% CI: 1.77-3.46, p < 0.001), frequent non-benzodiazepine prescribers were more concerned with efficacy (OR: 4.19, 95% CI: 2.91-6.04, p < 0.001), and frequent benzodiazepine prescribers were more concerned with efficacy (OR: 4.19, 95% CI: 2.91-6.04, p < 0.001) but less concerned with safety (OR: 0.25, 95% CI: 0.16-0.39, p < 0.001). Discussion: This study suggested that physicians believed ORA to be an effective and safe hypnotic and were compelled to prescribe benzodiazepine and non-benzodiazepine frequently, choosing efficacy over safety.

Management of unspecified anxiety disorder: Expert consensus.

AIMS: Treatment guidelines with respect to unspecified anxiety disorder have not been published. The aim of this study was to develop a consensus among field experts on the management of unspecified anxiety disorder. METHODS: Experts were asked to evaluate treatment choices based on eight clinical questions concerning unspecified anxiety disorder using a nine-point Likert scale (1 = "disagree" to 9 = "agree"). According to the responses from 119 experts, the choices were categorized into first-, second-, and third-line recommendations. RESULTS: Benzodiazepine anxiolytic use was not categorized as a first-line recommendation for the primary treatment of unspecified anxiety disorder, whereas multiple nonpharmacological treatment strategies, including coping strategies (7.9 ± 1.4), psychoeducation for anxiety (7.9 ± 1.4), lifestyle changes (7.8 ± 1.5), and relaxation techniques (7.4 ± 1.8), were categorized as first-line recommendations. Various treatment strategies were categorized as first-line recommendations when a benzodiazepine anxiolytic drug did not improve anxiety symptoms, that is, differential diagnosis (8.2 ± 1.4), psychoeducation for anxiety (8.0 ± 1.5), coping strategies (7.8 ± 1.5), lifestyle changes (7.8 ± 1.5), relaxation techniques (7.2 ± 1.9), and switching to selective serotonin reuptake inhibitors (SSRIs) (7.0 ± 1.8). These strategies were also highly endorsed when tapering the dosage of or discontinuing benzodiazepine anxiolytic drugs. There was no first-line recommendation regarding excusable reasons for continuing benzodiazepine anxiolytics. CONCLUSIONS: The field experts recommend that benzodiazepine anxiolytics should not be used as a first-line option for patients with unspecified anxiety disorder. Instead, several nonpharmacological interventions and switching to SSRIs were endorsed for the primary treatment of unspecified anxiety disorder and as alternatives to benzodiazepine anxiolytics.

Clinical practice for unspecified anxiety disorder in primary care.

Aim: Clinicians face difficulties in making treatment decisions for unspecified anxiety disorder due to the absence of any treatment guidelines. The objective of this study was to investigate how familiar and how often primary care physicians use pharmacological and nonpharmacological approaches to manage the disorder. Methods: A survey was conducted among 117 primary care physicians in Japan who were asked to assess the familiarity of using each treatment option for unspecified anxiety disorder on a binary response scale (0 = "unfamiliar," 1 = "familiar") and the frequency on a nine-point Likert scale (1 = "never used," 9 = "frequently used"). Results: While several benzodiazepine anxiolytics were familiar to primary care physicians, the frequencies of prescribing them, including alprazolam (4.6 ± 2.6), ethyl loflazepate (3.6 ± 2.4), and clotiazepam (3.5 ± 2.3), were low. In contrast, certain nonpharmacological options, including lifestyle changes (5.4 ± 2.3), coping strategies (5.1 ± 2.7), and psychoeducation for anxiety (5.1 ± 2.7), were more commonly utilized, but to a modest extent. When a benzodiazepine anxiolytic drug failed to be effective, primary care physicians selected the following management strategies to a relatively high degree: differential diagnosis (6.4 ± 2.4), referral to a specialist hospital (5.9 ± 2.5), lifestyle changes (5.2 ± 2.5), and switching to selective serotonin reuptake inhibitor (5.1 ± 2.4). Conclusion: Primary care physicians exercise caution when prescribing benzodiazepine anxiolytics for unspecified anxiety disorder. Nonpharmacological interventions and switching to SSRI are modestly employed as primary treatment options and alternatives to benzodiazepine anxiolytics. To ensure the safe and effective treatment of unspecified anxiety disorder in primary care, more information should be provided from field experts.

Attitudes and Difficulties Associated with Benzodiazepine Discontinuation.

Long-term use of benzodiazepine receptor agonists (BZDs) may depend on clinicians' BZD discontinuation strategies. We aimed to explore differences in strategies and difficulties with BZD discontinuation between psychiatrists and non-psychiatrists and to identify factors related to difficulties with BZD discontinuation. Japanese physicians affiliated with the Japan Primary Care Association, All Japan Hospital Association, and Japanese Association of Neuro-Psychiatric Clinics were surveyed on the following items: age group, specialty (psychiatric or otherwise), preferred time to start BZD reduction after improvement in symptoms, methods used to discontinue, difficulties regarding BZD discontinuation, and reasons for the difficulties. We obtained 962 responses from physicians (390 from non-psychiatrists and 572 from psychiatrists), of which 94.0% reported difficulty discontinuing BZDs. Non-psychiatrists had more difficulty with BZD discontinuation strategies, while psychiatrists had more difficulty with symptom recurrence/relapse and withdrawal symptoms. Psychiatrists used more candidate strategies in BZD reduction than non-psychiatrists but initiated BZD discontinuation after symptom improvement. Logistic regression analysis showed that psychosocial therapy was associated with less difficulty in BZD discontinuation (odds ratio, 0.438; 95% confidence interval, 0.204-0.942; p = 0.035). Educating physicians about psychosocial therapy may alleviate physicians' difficulty in discontinuing BZDs and reduce long-term BZD prescriptions.

Influence of overstated abstract conclusions on clinicians: a web-based randomised controlled trial.

OBJECTIVES: To investigate whether overstatements in abstract conclusions influence primary care physicians' evaluations when they read reports of randomised controlled trials (RCTs) DESIGN: RCT setting: This study was a parallel-group randomised controlled survey, conducted online while masking the study hypothesis. PARTICIPANTS: Volunteers were recruited from members of the Japan Primary Care Association in January 2017. We sent email invitations to 7040 primary care physicians. Among the 787 individuals who accessed the website, 622 were eligible and automatically randomised into 'without overstatement' (n=307) and 'with overstatement' (n=315) groups. INTERVENTIONS: We selected five abstracts from published RCTs with at least one non-significant primary outcome and overstatement in the abstract conclusion. To construct a version without overstatement, we rewrote the conclusion sections. The methods and results sections were standardised to provide the necessary information of primary outcome information when it was missing in the original abstract. Participants were randomly assigned to read an abstract either with or without overstatements and asked to evaluate the benefit of the intervention. OUTCOME MEASURES: The primary outcome was the participants' evaluation of the benefit of the intervention discussed in the abstract, on a scale from 0 to 10. A secondary outcome was the validity of the conclusion. RESULTS: There was no significant difference between the groups with respect to their evaluation of the benefit of the intervention (mean difference: 0.07, 95% CI -0.28 to 0.42, p=0.69). Participants in the 'without' group considered the study conclusion to be more valid than those in the 'with' group (mean difference: 0.97, 95% CI 0.59 to 1.36, P<0.001). CONCLUSION: The overstatements in abstract conclusions did not significantly influence the primary care physicians' evaluations of the intervention effect when necessary information about the primary outcomes was distinctly reported. TRIAL REGISTRATION NUMBER: UMIN000025317; Pre-results.