Background: Community-acquired pneumonia (CAP) is a common illness that can lead to mortality. Chest radiographs are the gold standard method of confirmation of pneumonia but could unnecessarily expose patients to radiation. Heckerling’s criteria (HC) scoring is a useful substitute for chest radiographs and can be used to rule out CAP. HC score ≥ 4 is strongly indicative of pneumonia, while ≤ 1 indicates the patient is pneumonia-free. HC scoring is well validated in Western populations, but has not been validated in an Asian population. Racial differences in symptoms and differences in the method of measuring body temperature might affect the validity of HC scoring in this population. We evaluate the use of HC scoring in a Japanese primary care setting. Methods: We conducted a prospective observational study of patients aged ≥ 16 years who had fever and respiratory symptoms in one of two community hospitals between December 2016 and October 2018. We evaluated the accuracy of HC in discrimination of patients with and without CAP. Pneumonia was defined as when patients suffered from respiratory symptoms and had new infiltration recognized on chest X-ray or chest computed tomography. Results: Analyzable data from 296 of 341 patients was available (37.2% were female, mean age: 41.1 years). CAP was diagnosed in 58 patients (19.6%). HC discriminated CAP with ROC area of 0.69 (95% CI 0.62-0.76). Sensitivity was 0.66 (95% CI 0.52-0.78) (HC score ≤ 1) and specificity was 0.68 (95% CI 0.61-0.74) (HC score >1). Conclusions: HC failed to detect CAP in approximately 30% of our Japanese cases presenting acute respiratory illness. HC scoring should be used cautiously in non-Western populations.

Background: Despite recognition of the importance of primary health care, the opportunities for medical students to participate in family medicine clerkships (FMCs) are still inadequate around the world. In order for FMCs to be accepted in the undergraduate curriculum, it is necessary to clarify whether FMCs complement clerkships at teaching hospitals.Methods: Throughout the academic year 2018–2019, a total of 125 fifth-year students in Fukushima Medical University participated in an FMC. The students evaluated themselves at the beginning and end of their FMC whilst the family doctors evaluated students at the end of the FMC. The evaluations were a 5-point scale on 31 items in the following seven areas; objectives in general practice, practical skills and patient care, communication skills, patient-physician relationship, practice of team-based health care, medical practice in society and medical knowledge and problem-solving ability. A multiple regression analysis was conducted to assess whether self-evaluation was increased by clerkships at teaching hospitals where students rotated before the start of FMC. A Wilcoxon signed-rank sum test was used to assess self-evaluation changes before and after the FMC.Results: All 125 students completed the study. Pre-FMC self-evaluation scores for 19 items tended to be higher depending on when the FMC was conducted; the later the semester, the higher the score (e.g. diagnostic reasoning: first semester, 2.23; second semester, 2.48 [p = 0.11]; third semester, 2.61 [p = 0.02]). However, this tendency was not observed in the remaining 12 items: psychological and social background, home medical care, interprofessional work, healthcare system, team-based health care, participate as a member of the team, role of the physician in team collaboration, current medical situation in the community, community-based integrated care system, necessity of primary care, discover necessary tasks, and rank the tasks. In post-FMC evaluation, six of the 12 items were higher than four point in both the self-evaluations and family doctor evaluations. A significant increase was observed between the pre-and post-FMC self-evaluation scores in all 31 items (e.g. diagnostic reasoning: pre 2.2 and post 3.9 [p <0.0001]).Conclusion: The results of the present study suggest that FMCs complement clerkships at teaching hospitals.

BackgroundPatients with diabetes on insulin therapy use sharps (e.g., needles) on a regular basis and a considerable proportion of them, within their home environments. These sharps and other bloodstained materials, if not disposed of appropriately has the potential to be a public health hazard.ObjectiveOur objective was to explore the practices related to sharps disposal among patients with diabetes from North Colombo Teaching Hospital (CNTH), Ragama, Sri Lanka.MethodsWe conducted a cross-sectional study on 158 patients with diabetes from the CNTH. Patients had to use sharps for the daily management of their disease for inclusion into the study group. Data were collected on sharps disposal practices using an interviewer-administered questionnaire. Clinic records were also used as a secondary data source.ResultsMost patients, 153/158 (96.8%) used syringes to inject insulin. Forty-three patients (27%) involved others (e.g., family) when disposing of sharps. Used sharps were commonly disposed to the household garbage bin by 66 participants (41.7%). Other methods used for sharps disposal were: sharps container, toilet pit, household garbage dump and indiscriminate measures. Importantly most patients, 147 (93%) had received no information on how to dispose of sharps after usage.ConclusionPatients commonly used unsafe practices in home-based sharps disposal. These included disposing of in the household garbage bin, burning sharps in the household garbage dump and disposing of into the common garbage dump of the community. Being male and being > 60 years of age was associated with a higher dependence on family members for sharps disposal. Patient education and public resources for sharps handling can help improve this situation.

BackgroundAs research in family medicine covers varied topics, multiple methodologies such as qualitative research (QR) and mixed methods research (MMR) are crucial. However, we do not know about the difference in the proportion of QR or MMR between Japan, the UK and the US. This knowledge is needed to shape future research within countries with developing primary care such as Japan and other Asian countries. This study aims to describe the use of QR and MMR in Japanese primary care and compare this to the UK and US; then to make informed recommendations for primary care research.MethodsA repeated cross-sectional study (2012–2016) based on the abstracts submitted to the annual conferences of the Japanese Primary Care Association in Japan, the Royal College of General Practitioners in the UK, and the North American Primary Care Research Group in the US and other North American countries. The proportions of QR/MMR among all the posters and paper presentations for each of these three conferences were assessed. Also examined were trends and types of qualitative techniques for all three countries and participants/settings for Japan.ResultsThere were 1080 abstracts for Japan, 575 for UK and 3614 for US conferences. QR/MMR proportions were 7.5%, 15.1% and 28.1%, respectively. Japan’s proportion was lower than that of UK and US (p < 0.001). The proportion was increasing over time for the UK (p = 0.02). Steps for coding and analyses was most popular for Japan, thematic analysis for the UK and grounded theory for the US. Primary care doctors and hospitals were the commonest contexts for Japan.ConclusionsQR and MMR were not as popular in primary care in Japan compared to the UK and the US, whereas their use was increasing in the UK. Approaches, participants and settings may differ among these countries. Education and promotion of QR/MMR and multi-disciplinary collaborations need to be recommended in Japan with developing primary care.

BackgroundTo be recognized as a primary care physician (PCP), an Indonesian general practitioner (GP) has to follow a formal postgraduate training in primary care. However, 4 years since the regulation was published, the progress of the training is slow. There is a need to deeply investigate the doctors’ perspectives, particularly to explore factors associated with their willingness to follow this training.AimThis study aims to explore the GPs’ views and perspectives related to the formal postgraduate training in primary care that may influence their enrolment in PCP program.MethodsWe conducted semi-structured interviews with a topic guide. The study took place in Yogyakarta from January to December 2016. The participants were GPs practicing in Yogyakarta primary care clinics who were recruited using purposive-maximum variation sample design. The interviews were audio-recorded and transcribed. The data were analysed using interpretative phenomenological analysis approach.ResultsNineteen GPs participants were involved in this study. Three major themes were identified, namely unfamiliarity, resistance, and positivism. Almost all the GP participants were unfamiliar with the primary care training program. They were also pessimistic if the training could change the health service in the country while it lacked resources and infrastructures. However, exposure to the training brought positive insights that it could improve the doctors’ knowledge and skills in primary care practice.DiscussionThe government intention to establish PCP training is currently on the right tract. However, information dissemination and more supports in primary care are also essential.

BackgroundA universal health coverage policy was implemented in Thailand in 2002 and led to an increase in accessibility to, and equity of, healthcare services. The Thai government and academics have focused on the large-scale aspects, including effectiveness and impacts, of universal health coverage over one decade. Here, we aimed to identify patients’ perspectives on hospital visits under universal health coverage.MethodsA qualitative study was carried out in four public hospitals in rural Thailand. We collected data through focus group discussions (FGDs) and in-depth interviews (IDIs). The semi-structured interview guide was designed to elicit perspectives on hospital visits among participants covered by the Universal Coverage Scheme, Social Security Scheme or Civil Servant Medical Benefit Scheme. Data were transcribed and analysed using a thematic approach.ResultsTwenty-nine participants (mean age, 56.76 ± 16.65 years) participated in five FGDs and one IDI. The emerging themes and sub-themes were identified. Factors influencing decisions to visit hospitals were free healthcare services, perception of serious illness, the need for special tests, and continuity of care. Long waiting times were barriers to hospital visits. Employees, who could not leave their work during office hours, could not access some services such as health check-ups. From the viewpoint of participants, public hospitals provided quality and equitable healthcare services. Nevertheless, shared decision making for treatment plans was not common.ConclusionsThe factors and barriers to utilisation of healthcare services provide exploratory data to understand the healthcare-seeking behaviours of patients. Perceptions towards free services under universal health coverage are positive, but participation in decision making is rare. Future studies should focus on finding ways to balance the needs and barriers to hospital visits and to introduce the concept of shared decision making to both doctors and patients.

BackgroundConducting university-based research is important for informing primary care, especially in lower- and middle- income countries (LMICs) such as Indonesia. Syiah Kuala University (SKU), the largest educational institution in Aceh province, Indonesia, is actively establishing itself as a leader in research innovation; however, this effort has not yet demonstrated optimum results. Understanding faculty members’ perceptions of how research is conducted in this setting is crucial for the design and implementation of successful and sustainable research strategies to increase the quantity and quality of primary care research conducted at LMIC universities. The objective of this study was to identify current attitudes, barriers and enablers/facilitators towards primary care research participation and implementation in this higher education institution.MethodsA descriptive-interpretive qualitative study was conducted. 29 participants, representing 90% of all faculty members providing primary care, were included. A mixed-methods approach was used, combining the use of a participant survey with 10 focus group discussions. Participants were encouraged to complete the survey in either English or Bahasa Indonesia. All of the focus group discussions were recorded, transcribed and translated into English. Thematic content analysis of these transcripts was carried out.ResultsThe majority of participants agreed that SKU has set research as a priority, as it is one of the three pillars of higher education, mandatory in all Indonesian higher education institutions. This research identified many barriers in conducting research, i.e. weak research policy, lack of research funding and infrastructure, complicated research bureaucracy and administrative process, as well as time constraints for conducting research relative to other duties. Participants expressed that personal motivation was a very important enabler/facilitator for increasing research activities. In order to improve research productivity, the majority of participants suggested that having local awards and formal recognition, having the opportunity to partner with local business and communities, provision of incentives, and having access to a research help-desk would be beneficial.ConclusionsGenerally, participants showed a supportive and positive attitude towards research, and provided examples of how to improve research productivity in the Asian university context.

BackgroundIn 2015 in Japan 12.7% of people die at home. Since the government has no policy to increase the number of hospital beds, at-home deaths should inevitably increase in the near future. Previous researches regarding expected place of death have focused on end-of-life patients. The aim of this study is to clarify the percentage and factors of senior people who expect at-home deaths whether they are end-of-life or not.MethodsUsing cross-sectional questionnaire survey data which had been taken by a research group with the support from Tama City Medical Association (Tokyo) in 2014, univariable and multivariable logistic regression analyses were conducted to identify associations among factors. The dependent variable was the expected site of death and other factors were set as independent variables.ResultsOf 1781 respondents, 46.5% expected at-home deaths. Data from 1133 people were analyzed and 46.5% of those wanted at-home deaths. Factors significantly associated with expectation of at-home death were men, stand-alone houses for dwelling, expectation to continue life in Tama city, twosome life with the spouse, healthiness, and economic challenge.ConclusionPercentage of those who expected at-home deaths was much higher than the latest percentage of at-home deaths. Some factors associated with expectation of at-home deaths in this study have never been discussed.

BackgroundDetecting and treating dementia at an early stage are important. Although the Revised Hasegawa Dementia Scale (HDS-R) is commonly used to detect dementia, it takes about 10 min to complete. In contrast, the 1-min animal test (OMAT) takes only 1 min to complete and may be a helpful screening test for general practitioners in deciding whether to proceed with administering further diagnostic tests such as the HDS-R. We sought to examine the relationship between the OMAT and HDS-R scores, and determine the cut-off OMAT score that balanced the sensitivity and specificity in identifying HDS-R-positive patients.MethodsA total of 122 consecutive patients with diabetes who visited the outpatient clinic at the Fujiidera Municipal Hospital were enrolled. The patients underwent the OMAT and HDS-R on the same day. Tests were conducted in a single-blinded manner. The relationship between the OMAT and HDS-R scores was examined using Spearman’s rank correlation. Receiver operating characteristic curve analysis was performed to identify the optimal cut-off score of OMAT that will determine whether to proceed with further diagnostic tests.ResultsA strong positive correlation between the OMAT and HDS-R scores was observed (r = 0.70). The sensitivity and specificity of OMAT using cut-off scores of 12/13, 13/14, and 14/15 for HDS-R-positive patients were 0.87 and 0.66, 1.00 and 0.51, and 1.00 and 0.40, respectively among all the subjects. Similar results were obtained in a subgroup of subjects aged ≥ 65 years.ConclusionsA cut-off score of 13/14 on the OMAT balanced the sensitivity closest to 1.00 and allowed for the highest specificity for the HDS-R not only among all the patients, but also among just the patients aged ≥ 65 years. The OMAT may be an optimal screening test to determine whether to proceed with further diagnosis using HDS-R.Trial registration UMIN UMIN000025260. This study is retrospectively registered on December 13th, 2016

BackgroundThe efficacy of implementing practices based on the best evidence is determined by the limitations and preparedness of the structure and processes of the healthcare system as well as healthcare professionals’ (HCP) levels of knowledge and acceptance. Facilitating implementation of such practices also partly depends on HCPs’ attitudes.MethodWe investigate the attitudes and beliefs of four groups of physicians in the United Arab Emirates on clinical practice guidelines (CPGs), with a focus on applying revisions to these CPGs in a different setting than the one in which they were developed, and where no locally developed guidelines exist.ResultsCPGs were the main source of information for revisions. We identified a rising concern in the applicability of the recommendations, which persists due to a lack of locally developed revisions. Other concerns include the pressures of practice management changes and of coping with the rapid development in resources and the growing demand on its use. Some international and government-endorsed CPGs were still accepted as being the best candidates for adoption.ConclusionsThis group welcomes evidence-based practice and is supported by electronic medical records, structured care programmes, and ongoing quality monitoring. Barriers and facilitators of clinical practice guidelines are discussed and thoughts on effective implementation strategies are considered.