Factors associated with regional retention of physicians: a cross-sectional online survey of medical students and graduates in Japan.

BACKGROUND: Physician shortage and maldistribution is an urgent health policy issue requiring resolution. Determination of factors associated with regional retention and development of effective policy interventions will help to solve this issue. The purpose of the present study was to identify factors associated with regional retention and discuss their policy implications. METHODS: We conducted a cross-sectional online survey from February to March of 2022 for graduates from regional quotas (special quotas for medical schools to select students engaged in community medicine) and Jichi Medical University (JMU) and students at 10 medical schools including JMU. Completed surveys were obtained from 375 graduates and 1153 students. Questions included intention to continue to work in their home prefecture in the future, as well as background information and potential factors associated with regional retention. In the analyses, regional quotas and JMU were referred to as community medicine-oriented programs and schools (CMPS). We performed logistic regression analyses to identify factors associated with regional retention. RESULTS: Among the students, scholarship-bonded obligatory service, satisfaction with current life, intention to belong to ikyoku (a traditional physician allocation/training system in Japanese medical schools), and interest in general practice/family medicine were significantly positively associated with regional retention. Among the graduates, satisfaction with training environment, intention to belong to ikyoku, and recommending their program to high school students were significantly positively associated with regional retention. For students of CMPS, satisfaction with the career development program was positively associated with future regional retention. For graduates, this association was observed only in the crude analysis. CONCLUSIONS: In addition to known factors such as interest in general practice/family medicine, intention to belong to ikyoku had a substantial impact on regional retention. The present results suggest that the career support system represented by ikyoku as well as a career development program are of potential importance for increasing regional retention through the mechanisms of a sense of belonging and a life-long education system. These findings provide useful information for the development of further policy interventions that interweave traditional and new systems to maximize their effectiveness.

Ethical issues arising from the government allocation of physicians to rural areas: a case study from Japan.

The geographically inequitable distribution of physicians has long posed a serious social problem in Japan. The government tackled this problem by establishing and managing Jichi Medical University (JMU) and regional quotas (RQs) for medical schools. JMU/RQs recruit local students who hope to work as physicians in rural areas, educate them for 6 years without tuition (JMU) or with scholarship (RQs), and after graduation, assign them to their home prefectures for 9 years, including 4-6 years of rural service. JMU/RQs entrants now occupy 11.6% of all medical school entrants. While JMU/RQs have been shown to be highly effective in securing physicians for rural areas, ethical issues related to these policies have been raised, such as whether the government truly needs to implement these policies using tax money, and whether it is acceptable to limit the personal freedoms of the physicians. In this paper, we discuss these issues from the perspectives of social justice, utilitarianism, luck egalitarianism, liberty, medical professionalism and consistency with national health insurance and the Japanese Constitution. We conclude that JMU/RQs are necessary and ethically valid policies, and also propose some institutional improvements to better secure the integrity and maturity of these systems.

Effects of 2018 Japan floods on healthcare costs and service utilization in Japan: a retrospective cohort study.

BACKGROUND: Floods and torrential rains are natural disasters caused by climate change. Unfortunately, such events are more frequent and are increasingly severe in recent times. The 2018 Japan Floods in western Japan were one of the largest such disasters. This study aimed to evaluate the effect of the 2018 Japan Floods on healthcare costs and service utilization. METHODS: This retrospective cohort study included all patients whose receipts accrued between July 2017 and June 2019 in Hiroshima, Okayama, and Ehime prefectures using the National Database of Health Insurance Claims. We used Generalized Estimating Equations (GEEs) to investigate yearly healthcare costs during the pre-and post-disaster periods, quarterly high-cost patients (top 10%), and service utilization (outpatient care, inpatient care, and dispensing pharmacy) during the post-disaster period. After the GEEs, we estimated the average marginal effects as the attributable disaster effect. RESULTS: The total number of participants was 5,534,276. Victims accounted for 0.65% of the total number of participants (n = 36,032). Although there was no significant difference in pre-disaster healthcare costs (p = 0.63), post-disaster costs were $3,382 (95% CI: 3,254-3,510) for victims and $3,027 (95% CI: 3,015-3,038) for non-victims (p < 0.001). The highest risk difference among high-cost patients was 0.8% (95% CI: 0.6-1.1) in the fourth quarter. In contrast, the highest risk difference of service utilization was in the first quarter (outpatient care: 7.0% (95% CI: 6.7-7.4), inpatient care: 1.3% (95% CI: 1.1-1.5), and dispensing pharmacy: 5.9% (95% CI: 5.5-6.4)). CONCLUSION: Victims of the 2018 Japan Floods had higher medical costs and used more healthcare services than non-victims. In addition, the risk of higher medical costs was highest at the end of the observation period. It is necessary to estimate the increase in healthcare costs according to the disaster scale and plan for appropriate post-disaster healthcare service delivery.

Increased care-need in older long-term care insurance users after the 2018 Japan Floods: a retrospective cohort study based on the Japanese long-term care insurance claims.

BACKGROUND: Level of care-need (LOC) is an indicator of elderly person's disability level and is officially used to determine the care services provided in Japan's long-term care insurance (LTCI) system. The 2018 Japan Floods, which struck western Japan in July 2018, were the country's second largest water disaster. This study determined the extent to which the disaster affected the LOC of victims and compared it with that of non-victims. METHODS: This is a retrospective cohort study, based on the Japanese long-term care insurance claims from two months before (May 2018) to five months after the disaster (December 2018) in Hiroshima, Okayama, and Ehime prefectures, which were the most severely damaged areas in the country. A code indicating victim status, certified by a residential municipality, was used to distinguish between victims and non-victims. Those aged 64 years or younger, those who had the most severe LOC before the disaster, and those whose LOC increased even before the disaster were excluded. The primary endpoint was the augmentation of pre-disaster LOC after the disaster, which was evaluated using the survival time analysis. Age, gender, and type of care service were used as covariates. RESULTS: Of the total 193,723 participants, 1,407 (0.7%) were certified disaster victims. Five months after the disaster, 135 (9.6%) of victims and 14,817 (7.7%) of non-victims experienced the rise of LOC. The victim group was significantly more likely to experience an augmentation of LOC than the non-victim group (adjusted hazard ratio 1.24; 95% confidence interval 1.06-1.45). CONCLUSIONS: Older people who were affected by the disaster needed more care than before and the degree of care-need increase was substantially more than non-victims. The result suggests that natural disasters generate more demand for care services among the older people, and incur more resources and cost for society than before.

Increased prescriptions for irritable bowel syndrome after the 2018 Japan Floods: a longitudinal analysis based on the Japanese National Database of Health Insurance Claims and Specific Health Checkups.

BACKGROUND: The frequency and intensity of natural disasters are increasing worldwide, which makes our understanding of disaster-related diseases more important than ever. Natural disasters cause mental stress and infectious diarrhea, but the causal relationship between disasters and a potential consequence of these conditions, irritable bowel syndrome (IBS), is unreported. The 2018 Japan Floods, which took place in July 2018 was one of the largest water disasters in Japan's recorded history. We investigate the change of drug prescriptions for IBS between disaster-suffers and non-sufferers throughout the disaster period to examine the relationship. METHODS: This is a retrospective cohort study based on the Japanese National Database of Health Insurance Claims and Specific Health Checkups in flood-stricken areas between July 2017 and June 2019. We included subjects older than 15 years of age who had visited a medical institution or been hospitalized in the hardest-hit areas of the disaster. Ramosetron, polycarbophil calcium, and mepenzolate bromide (IBS drugs) approved solely for the treatment of IBS in Japan were analyzed. The monthly rate of prescriptions for IBS drugs was compared between municipality-certified disaster victims and non-victims using a controlled interrupted time series analysis. For those who were not prescribed IBS drugs before the disaster (non-users), the occurrence of an IBS drug prescription after the disaster was evaluated using a multivariable logistic regression analysis adjusted for gender and age. RESULTS: Of 5,287,888 people enrolled, 32,499 (0.61%) were certified victims. The prescription rate for IBS drugs among victims increased significantly by 128% immediately after the disaster, while it was stable among non-victims. The trend for the post-disaster prescription rate among victims moved upward significantly when compared to non-victims (0.01% per month; 95% confidence interval (CI) 0.004-0.015; P = 0.001). Among non-users, the occurrence of an IBS drug prescription for victims was 0.71% and was significantly higher than non-victims (0.35%, adjusted odds ratio 2.05; 95% CI 1.81-2.32). CONCLUSIONS: The 2018 Japan Floods increased the rate of prescriptions for IBS drugs, suggesting that the disaster caused or worsened IBS among victims.

Impact of the 2018 Japan Floods on prescriptions for migraine: A longitudinal analysis using the National Database of Health Insurance Claims.

OBJECTIVE: To determine the impact of the 2018 Japan Floods, one of the largest water disasters in Japan, on the number of prescriptions for triptans and ergotamine (acute treatment). BACKGROUND: Natural disasters frequently occur worldwide and may cause psychological stress-related diseases. Acute migraine attacks can be triggered by psychological stress. Disaster victims are likely to experience tremendous psychological stress; however, the relationship between natural disasters and migraine attacks is not well investigated. METHODS: A retrospective longitudinal cohort study was conducted using the National Database of Health Insurance Claims in the hardest-hit areas of the disaster 1 year before and after the disaster. We included people between the ages of 15 and 64 years. Those who had a victim code that was certificated by a local government were assigned to the victim group, and others to the nonvictim group. For those who were not prescribed acute treatment before the disaster (i.e., group without previous acute treatment), the cumulative incidence of new prescriptions for acute treatment at 12 months of follow-up was calculated and compared between victims and nonvictims with survival analysis. RESULTS: Of 3,475,515 people aged 15 to 64 years enrolled in the study, 16,103 (0.46%) were assigned to the victim group. In the group without previous acute treatment, 111 (0.70%) of 15,933 victims and 14,626 (0.43%) of 3,431,423 nonvictims were newly prescribed acute treatment after the disaster, and new prescriptions for acute treatment were significantly more likely to occur in victims than in nonvictims (adjusted hazard ratio, 1.68; 95% CI, 1.39-2.02). CONCLUSIONS: The 2018 Japan Floods increased the number of prescriptions for acute migraine medications among victims, suggesting that acute migraine attacks occurred more frequently after a natural disaster.

Discontinuation of long-term care among persons affected by the 2018 Japan Floods: a longitudinal study using the Long-term Care Insurance Comprehensive Database.

BACKGROUND: Most older people with disabilities or illnesses continue to use long-term care (LTC) services for the rest of their lives. However, disasters can cause a discontinuation of LTC services, which usually means tragic outcomes of affected persons. In view of the recent progression of population aging and the increase in natural disasters, this study focuses on the impact of disasters on older people's discontinuation of LTC services, and those more risk of such discontinuation than others. However, current evidence is scarce. METHODS: We conducted a retrospective cohort study with 259,081 subjects, 2,762 of whom had been affected by disaster and 256,319 who had not been affected during the 2018 Japan Floods. The sample in the three most disaster-affected prefectures was drawn from the Long-term Care Insurance Comprehensive Database and included older people certified with care-need level. The observation period was two months before the disaster and five months after it. We calculated the hazard ratio (HR) of municipality-certified subjects affected by the disaster versus those who were not. Subgroup analyses were conducted for categories of individual-, facility- and region-associated factors. RESULTS: Affected persons were twice as likely to discontinue LTC services than those who were not affected (adjusted HR, 2.06 95% CI, 1.91-2.23). 34% of affected persons whose facilities were closed discontinued their LTC services at five months after the disaster. A subgroup analysis showed that the risk of discontinuing LTC services for affected persons compared to those who were not affected in the relatively younger subgroup (age < 80: adjusted HR, 2.55; 95% CI, 2.20-2.96 vs. age ≥ 80 : 1.91; 1.75-2.10), and the subgroup requiring a lower level of care (low: 3.16; 2.74-3.66 vs. high: 1.71; 1.50-1.96) were more likely to discontinue than the older and higher care level subgroups. CONCLUSIONS: A natural disaster has a significant effect on the older people's discontinuation of LTC services. The discontinuations are supposedly caused by affected persons' death, hospitalization, forced relocation of individuals, or the service provider's incapacity. Accordingly, it is important to recognize the risk of disasters and take measures to avoid discontinuation to protect older persons' quality of life.

Effects of the 2018 Japan Floods on long-term care insurance costs in Japan: retrospective cohort study.

BACKGROUND: Climate change has increased the frequency and severity of torrential rains and floods around the world. Estimating the costs of these disasters is one of the five global research priorities identified by WHO. The 2018 Japan Floods hit western Japan causing extensive destruction and many deaths, especially among vulnerable elderly. Such affected elderly would need long-term care due to the various health problems caused by the disaster. A Long-Term Care Insurance (LTCI) system provides care services in Japan. The aim of this study was to evaluate the effect of the 2018 Japan Floods on LTCI costs and service utilization. METHODS: The participants of this retrospective cohort study were all verified persons utilizing LTCI services in Hiroshima, Okayama and Ehime prefectures. The observation period was from 2 months before to 6 months after the disaster. We used Generalized Estimating Equations (GEEs) to examine the association between disaster status (victims or non-victims) and the monthly total costs of LTCI service (with gamma-distribution/log-link) by residential environment (home or facility). Among home residents, we also examined each service utilization (home-based service, short-stay service and facility service), using the GEEs. After the GEEs, we estimated Average Marginal Effects (AME) over all observation periods by months as the attributable disaster effect. RESULTS: The total number of participants was 279,578. There were 3024 flood victims. The disaster was associated with significantly higher total costs. The AME for home residents at 2 months after was $214 (Standard Error (SE): 12, p < 0.001), which was the highest through the observation period. Among facility residents, the AME immediately after the disaster increased by up to $850 (SE: 29, p < 0.001). The service utilization among home residents showed a different trend for each service. The AME of home-based services decreased by up to - 15.2% (SE:1.3, p < 0.001). The AME for short-stay service increased by up to 8.2% (SE: 0.9, p < 0.001) and the AME for facility service increased by up to 7.4% (SE: 0.7, p < 0.001), respectively. CONCLUSIONS: The 2018 Japan Floods caused an increase in LTCI costs and the utilization of short-stay and facility services, and a decrease in utilization of home-based services.

Impact of the 2018 Japan Floods on benzodiazepine use: a longitudinal analysis based on the National Database of Health Insurance Claims.

PURPOSE: Natural disaster has an impact on mental health. The 2018 Japan Floods, which took place in July 2018 were one of the largest water disasters in Japan's recorded history. We aimed to evaluate the change in the number of benzodiazepine prescriptions by physicians before and after the disaster. METHODS: A retrospective cohort study based on the National Database of Health Insurance Claims was conducted in the flood-stricken areas between July 2017 and June 2019. The subjects were divided between victims and non-victims according to certification by local governments. Members of both groups were then categorized into three groups based on their pre-flood use of benzodiazepines: non-user, occasional user, and continuous user. Difference-in-differences (DID) analysis with a logistic regression model was conducted to estimate the effect of the disaster among victims by comparing the occurrence of benzodiazepine prescriptions before and after the disaster. RESULTS: Of 5,000,129 people enrolled, 31,235 were victims. Among all participants, the mean prescription rate for benzodiazepines in victims before the disaster (11.3%) increased to 11.8% after the disaster, while that in non-victims (8.3%) decreased to 7.9%. The DID analysis revealed that benzodiazepine prescription among victims significantly increased immediately after the disaster (adjusted ratio of odds ratios (ROR) 1.07: 95% confidence interval 1.05-1.11), and the effect of the disaster persisted even 1 year after the disaster (adjusted ROR 1.2: 95% confidence interval 1.16-1.24). CONCLUSION: The flood increased the number of benzodiazepines prescriptions among victims, and the effect persisted for at least 1 year.

Geographic distribution of family physicians in Japan and the USA: a cross-sectional comparative study.

INTRODUCTION: Solutions for geographic maldistribution of physicians is challenging around the world, but primary care specialists are expected to resolve this issue. This study compares the geographic distribution of family physicians in Japan and the USA, both of which are developed countries without a major system for physician allocation by the public sector; however, the two countries differ greatly in the maturity of family medicine (ie length of its history as part of the healthcare system and the population of qualified family medicine experts). METHODS: This cross-sectional comparative study used publicly available online databases for Japan in 2018 and 2017 in the USA. The municipalities in Japan and counties in the USA were divided into quintile groups according to population density. The number of family physicians per unit population in each group of areas was calculated, and was evaluated with a residual analysis. The geographic distribution of all physicians in Japan was simulated assuming that the proportion of family physicians among all physicians in Japan (0.16%) was increased to match that in the USA (11.8%). RESULTS: Of 320 084 physicians in Japan and 899 244 in the USA, 519 (77.2%) family physicians in Japan and 105 999 (100%) in the USA were included. The distribution of family physicians in Japan was noticeably shifted to areas with the lowest population density. In contrast, family physicians in the USA were distributed equally across areas. The distribution of physicians of other specialties (general internists, pediatricians, surgeons and obstetricians/gynecologists) was shifted heavily to areas with the highest population densities in both countries. The simulation analysis showed the geographic maldistribution of the total number of physicians improved substantially if the proportion of family physicians in Japan is increased to match that in the USA. CONCLUSION: The distribution of family physicians is more equitable than that of other medical specialists; however, an immature family medicine system can lead to an aggregation of family physicians in rural areas. This aggregation supports equity due to the broader scope of practice required by family physicians in rural areas. In countries where family medicine has not yet matured as a specialty, provided that the equitable aggregation of family physicians in rural areas can be maintained, increasing the number of family physicians as a proportion of the total number of physicians may improve the geographic maldistribution of the total number of physicians.

Effect and significance of incorporating access in estimating the number of required physicians: focus on differences in population density in the target area.

BACKGROUND: Geographical imbalances in the health workforce, particularly the shortage of health care workers in rural areas, is an issue of social and political concern in most countries. Estimating the number of required doctors is essential for evidence-based health policy planning. In this study, we propose two methods for estimating the number of required doctors using a simple method. One is counting by unit and the other is incorporating access to medical institutions. The purpose of this study is to verify the need to incorporate access to medical institutions when estimating the number of required physicians in a region by comparing both estimation methods from the viewpoint of regional population density. METHODS: We calculated the ratio of outpatients who can access medical institutions and the number of required physicians using the travel time by car and the number of patients who can be treated per doctor per day (estimation method for the number of physicians based on the access simulation, hereinafter referred to as EAS). We compared the results of this estimation with those of a conventional method, such as the number of doctors per population (estimation method for the number of physicians based on the number of patients, hereinafter referred to as ENP) to show how important it is to incorporate the element of accessibility in such a simulation analysis. Based on the results, we discussed the applicability of the proposed method. RESULTS: ENP estimated that 38,685 outpatient primary care (PC) physicians were required and EAS estimated that 46,378 were required. There was a difference of about 8000. A comparison of the EAS-estimated number of physicians and the ENP-estimated number of physicians showed that the ENP-estimated number was small, particularly in areas with low population density. CONCLUSIONS: The results showed that it is effective to use the proposed EAS method for the estimation of PC physicians, particularly in areas with low population density. We showed that the method of allocating the number of physicians in proportion to the number of patients in a certain unit requires paying attention to the setting of the unit.

Education policies to increase rural physicians in Japan: a nationwide cohort study.

BACKGROUND: Japan has established comprehensive education-scholarship programs to supply physicians in rural areas. Their entrants now comprise 16% of all medical students, and graduates must work in rural areas for a designated number of years. These programs are now being adopted outside Japan, but their medium-term outcomes and inter-program differences are unknown. METHODS: A nationwide prospective cohort study of newly licensed physicians 2014-2018 (n = 2454) of the four major types of the programs-Jichi Medical University (Jichi); regional quota with scholarship; non-quota with scholarship (scholarship alone); and quota without scholarship (quota alone)-and all Japanese physicians in the same postgraduate year (n = 40,293) was conducted with follow-up workplace information from the Physician Census 2018, Ministry of Health, Labour and Welfare. In addition, annual cross-sectional survey for prefectural governments and medical schools 2014-2019 was conducted to obtain information on the results of National Physician License Examination and retention status for contractual workforce. RESULTS: Passing rate of the National Physician License Examination was highest in Jichi, followed in descending order by quota with scholarship, the other two programs, and all medical graduates. The retention rate for contractual rural service of Jichi graduates 5 years after graduation (n = 683; 98%) was higher than that of quota with scholarship (2868; 90%; P < 0.001) and scholarship alone (2220; 81% < 0.001). Relative risks of working in municipalities with the least population density quintile in Jichi, quota with scholarship, scholarship alone, and quota alone in postgraduate year 5 were 4.0 (95% CI 3.7-4.4; P < 0.001), 3.1 (2.6-3.7; < 0.001), 2.5 (2.1-3.0; < 0.001), and 2.5 (1.9-3.3; < 0.001) as compared with all Japanese physicians. There was no significant difference between each program and all physicians in the proportion of those who specialized in internal medicine or general practice in postgraduate years 3 to 5 CONCLUSIONS: Japan's education policies to produce rural physicians are effective but the degree of effectiveness varies among the programs. Policymakers and medical educators should plan their future rural workforce policies with reference to the effectiveness and variations of these programs.

The effect of the 2018 Japan Floods on cognitive decline among long-term care insurance users in Japan: a retrospective cohort study.

BACKGROUND: The July 2018 Japan Floods caused enormous damage to western Japan. Such disasters can especially impact elderly persons. Research has shown that natural disasters exacerbated a decline in cognitive function, but to date, there have been no studies examining the effects of this disaster on the elderly. The object of this study was to reveal the effect of this disaster in terms of cognitive decline among the elderly. METHODS: Study participants were certified users of the long-term care insurance (LTCI) system in Hiroshima, Okayama, and Ehime prefectures from May 2018 to June 2018. The observation period was from July 2018 to December 2018. Our primary outcome was cognitive decline after the disaster using a dementia symptomatology assessment. In addition to a crude model, a multivariate Cox proportional hazards model was used to assess the cognitive decline of victims, adjusting for age classification, gender, the level of dementia scale before the disaster occurred, residential environment, whether a participant used facilities shut down after the disaster, and population density. After we confirmed that the interaction term between victims and residential environment was statistically significant, we stratified them for the analysis. RESULTS: The total number of participants was 264,614. Victims accounted for 1.10% of the total participants (n = 2,908). For the Cox proportional hazards model, the hazard ratio of the victims was 1.18 (95% confidential interval (CI): 1.05-1.32) in the crude model and 1.12 (95% CI: 1.00-1.26) in the adjusted model. After being stratified by residential environment, the hazard ratio of home victims was 1.20 (95% CI: 1.06-1.36) and the hazard ratio of facility victims was 0.89 (95% CI: 0.67-1.17). CONCLUSIONS: This study showed that elderly living at home during the 2018 Japan Floods were at risk for cognitive decline. Medical providers, care providers, and local governments should establish a system to check on the cognitive function of elderly victims and provide necessary care support.

Serum Alanine Transaminase as a Predictor of Type 2 Diabetes Incidence: The Yuport Prospective Cohort Study.

Prior studies have shown an association between the incidence of diabetes with liver enzymes, such as alanine transaminase (ALT). Liver fibrosis scores, such as the Fibrosis-4 index which indicates chronic liver damage, were also associated with diabetes development. However, no literature compared predictive accuracy between ALT and Fibrosis-4 index. Thus, we aimed to determine it, and to assess its association using inverse probability of treatment weighting. This was a non-concurrent prospective cohort study of 9,748 subjects without diabetes receiving Yuport Health Checkup in Japan between 1998 and 2006. ALT was categorized into three groups: the highest ALT group (men ≥ 30 U/L and women ≥ 20 U/L), the middle (men ≥ 20 and < 30 U/L, and women ≥ 14 and < 20 U/L), and the lowest (men < 20 U/L and women < 14 U/L). The primary outcome was the new onset of diabetes. The area under the receiver operating characteristic curves (AUC) of ALT for predicting the diabetes development was higher than that of any other markers of liver damage. The AUC for ALT was 0.71, while that for the Fibrosis-4 index was 0.51 (p < 0.001 for the difference between the AUCs). The highest and middle ALT groups had a significantly higher incidence of diabetes than the lowest group: adjusted relative risk 1.79 [95% confidence interval (CI): 1.29, 2.58], and 1.64 [95% CI: 1.17, 2.38] respectively. Of the various indicators of liver function, ALT is likely to be the most accurate and associated predictor of diabetes development.

Geographical distribution of family physicians in Japan: a nationwide cross-sectional study.

BACKGROUND: Geographical maldistribution of physicians, and their subsequent shortage in rural areas, has been a serious problem in Japan and in other countries. Family Medicine, a new board-certified specialty started 10 years ago in Japan by Japan Primary Care Association (JPCA), may be a solution to this problem. METHODS: We obtained the workplace information of 527 (78.4%) of the 672 JPCA-certified family physicians from an online database. From the national census data, we also obtained the workplace information of board-certified general internists, surgeons, obstetricians/gynaecologists and paediatricians and of all physicians as the same-generation comparison group (ages 30 to 49). Chi-squared test and residual analysis were conducted to compare the distribution between family physicians and other specialists. RESULTS: Five hundred nineteen JPCA-certified family physicians and 137,587 same-generation physicians were analysed. The distribution of family physicians was skewed to municipalities with a lower population density, which shows a sharp contrast to the urban-biased distribution of other specialists. The proportion of family physicians in non-metropolitan municipalities was significantly higher than that expected based on the distribution of all same-generation physicians (p < 0.001). CONCLUSIONS: Family physicians distributed in favour of rural areas much more than any other specialists in Japan. The better balance of family physician distribution reported from countries with a strong primary care orientation seems to hold even in a country where primary care orientation is weak, physician distribution is not regulated, and patients have free access to healthcare. Family physicians comprise only 0.2% of all Japanese physicians. However, if their population grows, they can potentially rectify the imbalance of physician distribution. Government support is mandatory to promote family medicine in Japan.

White Blood Cell Count and C-Reactive Protein Independently Predicted Incident Diabetes: Yuport Medical Checkup Center Study.

Aim: White blood cell (WBC) count or C-reactive protein (CRP) level alone may not fully indicate the chronic inflammation causing type 2 diabetes. We examined both WBC count and CRP level, independently and in combination, as predictive markers for type 2 diabetes and also considered the influence of obesity and other individual characteristics on the relationship. Materials and Methods: In total, 9,706 participants were enrolled with WBC < 10*109/L and CRP < 10 mg/L using data from the Yuport Medical Checkup Center Study. The cumulative incidence of type 2 diabetes [defined either as known diabetes, fasting plasma glucose ≥ 7.0 mmol/L, or HbA1c ≥ 6.5% (47.5 mmol/mol)] was measured. Hazard ratios (HRs) were estimated using a Cox proportional hazards model. Results: During study period, 272 men (5.5%) and 113 women (2.4%) progressed to diabetes. The progression to diabetes was predicted by both increased baseline levels of WBC count [adjusted HR = 1.29 (95% CI: 1.04-1.60)] and CRP level [1.39 (1.10-1.74)], even after adjusting for possible confounders. The combined presence was more predictive of diabetes than either alone in a four-groups analysis [1.75 (1.28-2.40)]. In addition, the elevated HRs of either or both higher WBC and CRP levels were observed across four subgroups of body mass index (BMI), including low BMI, and people who had at least one occurrence of dyslipidemia. Conclusion: Increased WBC counts and CRP levels were predictive for type 2 diabetes and the combination augmented the risk of diabetes, regardless of whether the BMI was high or low.

Factors Associated with Gastric Black Spot, White Flat Elevated Mucosa, and Cobblestone-Like Mucosa: A Cross-Sectional Study.

BACKGROUND/AIMS: Previous studies have reported a possible relevance between proton pump inhibitor (PPI) use and 3 new gastric mucosal changes: black spots (BSs), white flat elevated mucosa (WFEM), and cobblestone-like mucosa (CLM). The aim of this study was to investigate the association between these mucosal changes and multiple factors including PPI use. METHODS: All subjects who underwent a routine esophagogastroduodenoscopy (EGD) were successively enrolled. Endoscopists carried out the EGD after being blinded about -information on patient PPI usage and determined the presence of these mucosal changes. The ratio of each factor was -compared in cases with and without each gastric finding. RESULTS: Out of 1,214 patients, BSs were recognized in 75 (6.2%) cases, WFEM in 59 (4.9%), and CLM in 41 (3.4%). In logistic regression analysis, PPI use was significantly correlated with all of these findings (BSs: OR 2.94; 95% CI 1.66-5.21), (WFEM: OR 3.58; 95% CI 1.94-6.61), and (CLM: OR 4.57; 95% CI 2.34-9.96), and Helicobacter pylori eradication was related to BSs (OR 3.01; 95% CI 1.73-5.24) and WFEM (OR 2.11; 95% CI 1.08-4.11). Decision-tree analyses showed that H. pylori eradication was associated with all findings. CONCLUSIONS: All of the considered findings were correlated with PPI and H. pylori eradication.

Board certification and urban-rural migration of physicians in Japan.

BACKGROUND: The board certification system serves as a quality assurance system for physicians, and its design and operation are important health policy issues. In Japan, board certification was established and operated independently by academic societies and has not been directly linked to reimbursement systems. The phenomenon of younger physicians seeking specialist careers has raised concerns about acceleration of the tendency of fewer physicians working in rural areas and the maldistribution of physicians. Little is known about the associations between physicians' geographical migration patterns and board certification status changes or between the continuation of urban/rural practice and the maintenance of board certification. This study aimed to identify these associations and to discuss their policy implications. METHODS: We analyzed 2012 and 2014 data from the Survey of Physicians, Dentists, and Pharmacists, a national census survey. To analyze geographical migration patterns, transitions in practice location (rural, intermediate, and urban) were analyzed by board certification status change (new, lost, consistently certified, and consistently uncertified). Logistic regression analysis was conducted to assess whether the odds of migrating to more urban/rural municipalities were associated with board certification status changes, adjusting for covariates, and whether practicing in a rural area was associated with maintaining board certification. RESULTS: Among 18,726 newly board-certified physicians, 94.9% (13,435/14,150) of those working in urban areas before certification remained in urban areas, whereas 64.6% (393/608) of those working in rural areas stayed in rural areas. Those who were newly certified had higher odds of moving to more urban areas, adjusting for covariates. Those who stayed in rural areas showed lower odds of maintaining board certification, adjusting for covariates. CONCLUSIONS: Newly board-certified physicians are more likely to migrate to other types of areas, particularly more urban areas, than other physicians. Allocating more training quotas to rural areas could be one option for leveling the distribution of specialists. It also appeared that those practicing in rural areas have difficulty maintaining their certification, so the need to establish a support system for already-certified physicians in rural areas should be emphasized.

Internal medicine board certification and career pathways in Japan.

BACKGROUND: Establishing and managing a board certification system is a common concern for many countries. In Japan, the board certification system is under revision. The purpose of this study was to describe present status of internal medicine specialist board certification, to identify factors associated with maintenance of board certification and to investigate changes in area of practice when physicians move from hospital to clinic practice. METHODS: We analyzed 2010 and 2012 data from the Survey of Physicians, Dentists and Pharmacists. We conducted logistic regression analysis to identify factors associated with the maintenance of board certification between 2010 and 2012. We also analyzed data on career transition from hospitals to clinics for hospital physicians with board certification. RESULTS: It was common for physicians seeking board certification to do so in their early career. The odds of maintaining board certification were lower in women and those working in locations other than academic hospitals, and higher in physicians with subspecialty practice areas. Among hospital physicians with board certification who moved to clinics between 2010 and 2012, 95.8% remained in internal medicine or its subspecialty areas and 87.7% maintained board certification but changed their practice from a subspecialty area to more general internal medicine. CONCLUSION: Revisions of the internal medicine board certification system must consider different physician career pathways including mid-career moves while maintaining certification quality. This will help to secure an adequate number and distribution of specialists. To meet the increasing demand for generalist physicians, it is important to design programs to train specialists in general practice.

The effect of concentrating obstetrics services in fewer hospitals on patient access: a simulation.

BACKGROUND: In Japan, the number of obstetrics facilities has steadily decreased and the selection and concentration of obstetrics facilities is progressing rapidly. Obstetrics services should be concentrated in fewer hospitals to improve quality of care and reduce the workload of obstetricians. However, the impact of this intensification of services on access to obstetrics hospitals is not known. We undertook a simulation to examine how the intensification of obstetrics services would affect access to hospitals based on a variety of scenarios, and the implications for health policy. METHODS: The female population aged between 15 and 49 living within a 30-min drive of an obstetrics hospital was calculated using a Geographic Information System for three possible intensification scenarios: Scenario 1 retained facilities with a higher volume of deliveries without considering the geographic boundaries of Medical Service Areas (MSAs, zones of healthcare administration and management); Scenario 2 prioritized retaining at least one hospital in each MSA and then retained higher delivery volume institutions, while Scenario 3 retained facilities to maximize population coverage using location-allocation modeling. We also assessed the impact of concentrating services in academic hospitals and specialist perinatal medical centers (PMCs) alone. RESULTS: In 2011, 95.0% of women aged 15-49 years lived within a 30-min drive of one of 1075 obstetrics hospitals. This would fall to 82.7% if obstetrics services were intensified into academic hospitals and general and regional PMCs. If 55.0% of institutions provided obstetrics services, the coverage would be 87.6% in Scenario 1, whereas intensification based on access would achieve over 90.5% coverage in Scenario 2 and 93.9% in Scenario 3. CONCLUSIONS: Intensification of obstetrics facilities impairs access, but a greater caseload and better staffing have the potential advantages of better clinical outcomes and reduced costs. It is essential to consult residents of hospital catchment areas when reorganizing clinical services; a simulation is a useful means of informing these important discussions.