Gatekeeping function of primary care physicians under Japan's free-access system: a prospective open cohort study involving 14 isolated islands.

BACKGROUND: Gatekeeping is important for strong primary care and cost containment. Under Japan's free-access system, patients can access any medical institution without referral, which makes it difficult to evaluate the gatekeeping function of primary care physicians (PCPs). OBJECTIVES: To examine the gatekeeping function of PCPs in Japan, we compared the frequencies of visits to primary care clinics, referrals to advanced care and hospitalizations between 14 remote islands and a nationwide survey. METHODS: This study was a prospective, open cohort study involving 14 isolated islands (12 238 inhabitants) in Okinawa, Japan. Participants were all patients who visited the clinics on these islands in 1 year. Main outcome measures were the incidence of on-island clinic visits and referrals to off-island advanced care. RESULTS: There were 54 741 visits to the islands' clinics with 2045 referrals to off-island medical facilities, including 549 visits to emergency departments and 705 hospitalizations. The age- and sex-standardized incidences of healthcare use per 1000 inhabitants per month were: 360.0 (95% confidence interval: 359.9 to 360.1) visits to primary care clinics, 11.6 (11.0 to 12.2) referrals to off-island hospital-based outpatient clinics, 3.3 (2.8 to 5.2) visits to emergency departments and 4.2 (3.1 to 5.2) hospitalizations. Comparison with the nationwide survey revealed a lower incidence of visits to hospital-based outpatient clinics in this study, while more patients had visited PCPs. CONCLUSIONS: The lower incidence of visits to secondary care facilities in this study might suggest that introduction of a gatekeeping system to Japan would reduce the incidence of referral to advanced care.

Associations of Patient Experience in Primary Care With Hospitalizations and Emergency Department Visits on Isolated Islands: A Prospective Cohort Study.

PURPOSE: In rural areas, the management of hospitalizations and emergency department (ED) visits is an important issue, and it is compounded by factors such as the long distance to secondary care facilities, funding difficulties in many rural medical institutions, and shortage of medical staff. While better patient experience (PX) has been shown to reduce hospitalizations and ED visits, previous studies have not considered the differences between urban and rural areas. In addressing this gap, this study examines the association between PX and hospitalizations/ED visits on isolated islands. METHODS: This prospective cohort study was conducted on 5 isolated islands in Okinawa, Japan. We assessed the PX of primary care using the 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. The primary outcome was hospitalizations and ED visits in a year. We used a mixed effect model to adjust clustering within islands and individual covariates. FINDINGS: Of 1,258 residents, 740 responded to a questionnaire for PX measurement. There were 73 hospitalizations and 62 ED visits. Adjusting for confounding and geographical clustering, hospitalizations had significant positive association with the PX score of each patient. ED visits were not associated with the total score of the JPCAT. CONCLUSION: On the isolated islands, PX in primary care had positive correlation with hospitalizations. The contrast of our findings to those of previous studies may be due to the close patient-doctor relationship on isolated islands.

Septic abortion presenting as a right lower trapezius abscess secondary to Bacteroides fragilis bacteraemia.

A 43-year-old Japanese woman was evaluated in the outpatient department for right shoulder pain and fever, which began 5 days earlier. MRI of the right shoulder revealed a high-intensity area deep in the right trapezius muscle. Aspiration revealed purulent fluid, and Gram staining of the fluid showed Gram-negative bacilli. The patient was also found to be profoundly anaemic and to have a positive urine pregnancy test. On admission, we initiated intravenous ampicillin-sulbactam and aztreonam. She underwent dilatation and curettage for septic abortion and surgical drainage of the right shoulder abscess. Bacteroides fragilis was isolated from the blood, uterine aspiration and abscess samples. On hospital day 4, a whole-body CT scan revealed no other abscesses, and ampicillin-sulbactam was continued for 28 days. The patient was discharged on hospital day 29. Gram staining is an important tool for evaluating infectious aetiologies.

Rural physicians' scope of practice on remote islands: A case report of severe pneumonia that required overnight artificial airway management.

Objective: To clarify the scope of practice on rural islands of Okinawa. Patient: A 59-year-old man presented to our clinic with shortness of breath. He was intubated due to acute respiratory failure caused by severe pneumonia. We could not transfer him owing to bad weather, and had to continue patient care in the clinic for more than 24 hours. Discussion: In remote regions, rural physicians may require a broad scope of practice from primary to tertiary care, in addition to preventive and end-of-life care. Conclusion: This case illustrates the current state of emergency care and unique scope of practice on rural islands of Okinawa.

Parsonage-Turner syndrome in a patient with bilateral shoulder pain: A case report.

Objective: Parsonage-Turner syndrome is a peripheral neuropathy characterized by acute onset shoulder pain, myalgia, and sensory disturbances. The present report discusses a rare case of Parsonage-Turner syndrome and highlights the importance of accurate history recording and thorough physical examination for the diagnosis of the disease in rural areas. Patient: A 28-year-old woman presented to our clinic with acute bilateral shoulder pain and difficulty moving her right arm. A diagnosis of Parsonage-Turner syndrome was suspected based on the progression of symptoms, severity of pain, and lack of musculoskeletal inflammation. The diagnosis was confirmed by neurological specialists, and the patient was treated with methylprednisolone, after which her symptoms gradually improved. Discussion: The differential diagnosis of shoulder pain is complicated due to the wide variety of conditions sharing similar symptoms. Accurate history recording and thorough physical examination are required to differentiate among conditions involving the central nerves, peripheral nerves, and nerve plexuses. Conclusion: Although the symptoms of Parsonage-Turner syndrome vary based on disease progression and the location of impairment, proper diagnosis of acute shoulder pain without central neurological symptoms can be achieved in rural areas via thorough examination.

Rheumatoid arthritis following ciguatera poisoning: A case report.

Objective: To report the first case of ciguatera-associated rheumatoid arthritis in Japan. Patient: A 53-year-old man presented to our clinic with morning stiffness and pain in the fingers and wrists. Results: For six months, he had suffered from chronic pain in both hands and shoulders caused by ciguatera poisoning. He was referred to a local general hospital and diagnosed with RA. Conclusion: When synovitis becomes evident in chronic ciguatera poisoning, reevaluation is necessary, including investigation of chronic arthritis, which might be associated with the onset of RA.

Primary Effusion Lymphoma in an Elderly HIV-Negative Patient with Hemodialysis: Importance of Evaluation for Pleural Effusion in Patients Receiving Hemodialysis.

Pleural effusion is a ubiquitous complication in hemodialysis (HD) patients. Common etiologies of pleural effusion in this patient group are heart failure, volume overload, parapneumonic effusion, tuberculotic pleuritis, and uremic pleuritis. Although thoracentesis is a useful diagnostic method of pleural effusion, empirical reduction of the dry weight is often attempted without thoracentesis because pleural effusion is commonly caused by volume overload and responds to the dry-weight reduction. However, this empiricism has a risk of overlooking or delaying the diagnosis of potentially fatal etiologies that need specific treatments. We report an 86-year-old human immunodeficiency virus (HIV)-negative male on HD with primary effusion lymphoma (PEL), a large-cell non-Hodgkin lymphoma presenting with characteristic lymphomatous effusions in the absence of solid tumor masses, which is in association with human herpes virus 8 (HHV8) infection in immunocompromised individuals. The patient presented with left-sided pleural effusion. This is the first case report of PEL developing in a patient receiving HD. Thoracentesis and cytological analysis of the effusion was key to the diagnosis. We also review the literature regarding pleural effusion in HD patients. Further, we examine Kaposi's sarcoma herpes virus/HHV8-negative effusion-based lymphoma, a newly proposed distinct lymphoma that clinically and cytomorphologically resembles PEL, because it can be cured without chemotherapy. This report may arouse clinicians' attention regarding the importance of evaluation for pleural effusion in HD patients, especially when the effusion or symptoms associated with pleural effusion are refractory to volume control.

Renal vein thrombosis associated with oral contraception and smoking: a case report from Japan, with literature review.

Renal vein thrombosis, one of the common thrombotic complications of nephrotic syndrome or renal cell carcinoma, is reportedly a rare complication of hormonal contraception. Solitary renal vein thrombosis in the Japanese population is thought to be very rare because the incidence of venous thromboembolism is comparatively very low in Asian populations. We report a 38-year-old Japanese female with left renal vein thrombosis associated with oral contraception and concurrent smoking as the first Japanese case of solitary renal vein thrombosis associated with oral contraceptives, with a review of the literature. Seven cases were previously reported. The results revealed that all patients complained of acute onset of pain around the involved kidney without urinary symptoms or fever, and were effectively treated with anticoagulants. Other remarkable facts include that nausea and vomiting were frequently seen, and that the renal outcome was benign, despite various initial urine abnormalities. This report may alert clinicians to the importance of these risk factors as an etiology of renal vein thrombosis even in Asian populations. Clinicians should regard renal vein thrombosis as one of the differential diagnoses for acute flank pain in patients using oral contraceptives. A detailed history taking that reveals oral contraception, smoking, and other thrombophilic predispositions as well as timely computed tomographic scans would be the keys to diagnosis. Smoking cessation should be strongly recommended to oral contraceptive users, especially women over 35 years of age, regardless of dosage.