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

Kaneko, Makoto; Motomura, Kazuhisa; Mori, Hideki; Ohta, Ryuichi; Matsuzawa, Hiroki; Shimabukuro, Akira; Matsushima, Masato

doi:10.1093/fampra/cmy084

Cited by 19 publications

(19 citation statements)

References 16 publications

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“…Generally, elderly people use EDs and are admitted to hospitals at a higher rate compared to younger people, 17 and we assumed outcomes such as ED visits/hospitalizations frequently occurred among elderly people based on our previous study conducted on isolated islands in Okinawa, Japan. 18 The participants were residents of the 5 islands whose local governments cooperated in our survey. The characteristics of these islands are provided in Appendix 1 (available online only).…”

Section: Participantsmentioning

confidence: 99%

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

Kaneko

Aoki

Mori

et al. 2018

The Journal of Rural Health

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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.

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Section: Participantsmentioning

confidence: 99%

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

Kaneko

Aoki

Mori

et al. 2018

The Journal of Rural Health

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“…Most initiatives did not lead to imposition of gatekeeping regulations, but resulted in introduction of stronger incentives for patients to use primary care, with negligible effects [15]. Other countries that traditionally provide unrestricted access to specialists, such as China [16] and Japan [17], only piloted the gatekeeping function of PCPs in small areas, without extending it to the entire nation. Considering these challenges, understanding bypass behavior is critical to devise effective policies for establishing a tiered delivery system.…”

Section: Introductionmentioning

confidence: 99%

Do patients bypass primary care for common health problems under a free-access system? Experience of Taiwan

Liang

Huang

Shen

et al. 2020

BMC Health Serv Res

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Background A common challenge for free-access systems is that people may bypass primary care and seek secondary care through self-referral. Taiwan’s government has undertaken various initiatives to mitigate bypass; however, little is known about whether the bypass trend has decreased over time. This study examined the extent to which patients bypass primary care for treatment of common diseases and factors associated with bypass under Taiwan’s free-access system. Methods This repeated cross-sectional study analyzed data from Taiwan’s National Health Insurance Research Database. A random sample of 1 million enrollees was drawn repeatedly from the insured population during 2000–2017. To capture visits beyond the community level, the bypass rate was defined as the proportion of self-referred visits to the top two levels of providers, namely academic medical centers and regional hospitals, among all visits to all providers. Subgroup analyses were conducted for visits with a single diagnosis. Logistic regressions were used to investigate factors associated with bypass. Results The standardized bypass rate for all diseases analyzed exhibited a decreasing trend. In 2017, it was low for common cold (0.7–1.3%), moderate for hypertension (14.0–29.5%), but still high for diabetes (32.0–47.0%). Moreover, the likelihood of bypass was higher for male, patients with higher salaries or comorbidities, and in areas with more physicians practicing in large hospitals or less physicians working in primary care facilities. Conclusions Although the bypass trend has decreased over time, continuing efforts may be required to reduce bypass associated with chronic diseases. Both patient sociodemographic and market characteristics were associated with the likelihood of bypass. These results may help policymakers to develop strategies to mitigate bypass.

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“…This gives patients in urban areas more choices when it comes to their care. They can go to medical institutions that specialize in their health conditions [18]. In contrast, in rural areas, health care providers are required to provide holistic and comprehensive care [19].…”

Section: Discussionmentioning

confidence: 99%

Geographic Distribution of Family Physicians in Japan and the United States: A Cross-sectional International Comparative Study

Okazaki¹,

Yoshida

Kashima

et al. 2020

Preprint

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Background: Family physicians are known to distribute more equally among the population than other physicians. The maturity of family medicine, i.e. the length of its history as a part of healthcare system and the population of qualified family medicine experts, may affect the distribution, but this has not been shown in the literature. This study compares the geographic distribution of family physicians in Japan and the United States (U.S.), both of which are developed countries without a physician allocation system by the public sector, but the two countries differ greatly in the maturity of family medicine as a clinical specialty.Methods: This is a cross-sectional international comparative study using publicly available online database on the number of physicians in Japan (Board-certification Database of Japan Primary Care Association, and Survey of Physicians, Dentists and Pharmacists by Ministry of Health, Labour and Welfare) and the U.S. (Area Resource File by Health Resources and Services Administration). The municipalities in Japan and counties in the U.S. were divided into quintile groups according to population density. The number of family physicians per unit population in each group of areas was calculated. 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 that in the U.S (11.8%).Results: The distribution of family physicians in Japan noticeably shifted to the areas with the lowest population density. In contrast, family physicians in the U.S. distributed equally across areas. The distribution of physicians with other specialties (general internists, pediatricians, surgeons and obstetricians/gynecologists) shifted heavily to the areas with highest population density in both countries. The simulation analysis showed the geographic maldistribution of all physicians improved substantially if the proportion of family physicians in Japan increases to that in the U.S. Conclusion: The distribution of family physicians is more equal than other medical specialists, and the immaturity of family medicine can even lead to a rural-biased distribution. In a country with emerging family medicine such as Japan, increasing the number of family physicians may effectively mitigate the urban-rural imbalance of physician supply.

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

Abstract: 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.

Cited by 19 publications

References 16 publications

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

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

Do patients bypass primary care for common health problems under a free-access system? Experience of Taiwan

Geographic Distribution of Family Physicians in Japan and the United States: A Cross-sectional International Comparative Study

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