小池 創一

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.

OBJECTIVES: Appropriate health policies for the supply of dentists have been an ongoing issue in many developed countries. The purpose of this study was to estimate the future distribution of dentists with different working statuses in Japan and to discuss policy implications about the supply of dentists in any country. METHODS: This was a retrospective cohort study using data from the National Survey of Physicians, Dentists and Pharmacists for 1972-2012. Based on data from the 2010 and 2012 surveys, we calculated by means of a Markov model the future number of dentists with different working statuses until 2042 according to sex. RESULTS: We estimated that the total number of active dentists will decrease from 2012 to 2042. The number of active dentists per 1,000 population was predicted to reach a peak in 2018, decrease by 4.2% from 2012 to 2038, and thereafter slightly increase. With regard to working status, the number of dentists with their own practices per 1,000 people was predicted to have reached a peak in 2014 and decrease by 22.0% until 2042. We estimated that the number of dentists used in dental clinics per 1,000 population will increase continuously between 2012 and 2042 by 20.0%. CONCLUSIONS: Our study suggests that maintaining this supply of dentists may lead to maldistribution of their working status in the future.

INTRODUCTION: Conventional monophasic defibrillators for out-of-hospital cardiac-arrest patients have been replaced with biphasic defibrillators. However, the advantage of biphasic over monophasic defibrillation for pediatric out-of-hospital cardiac-arrest patients remains unknown. This study aimed to compare the survival outcomes of pediatric out-of-hospital cardiac-arrest patients who underwent monophasic defibrillation with those who underwent biphasic defibrillation. METHODS: This prospective, nationwide, population-based observational study included pediatric out-of-hospital cardiac-arrest patients from January 1, 2005, to December 31, 2009. The primary outcome measure was survival at 1 month with minimal neurologic impairment. The secondary outcome measures were survival at 1 month and the return of spontaneous circulation before hospital arrival. Multivariable logistic regression analysis was performed to identify the independent association between defibrillator type (monophasic or biphasic) and outcomes. RESULTS: Among 5,628 pediatric out-of-hospital cardiac-arrest patients (1 through 17 years old), 430 who received defibrillation shock with monophasic or biphasic defibrillator were analyzed. The number of patients who received defibrillation shock with monophasic defibrillator was 127 (30%), and 303 (70%) received defibrillation shock with biphasic defibrillator. The survival rates at 1 month with minimal neurologic impairment were 17.5% and 24.4%, the survival rates at 1 month were 32.3% and 35.6%, and the rates of return of spontaneous circulation before hospital arrival were 24.4% and 27.4% in the monophasic and biphasic defibrillator groups, respectively. Hierarchic logistic regression analyses by using generalized estimation equations found no significant difference between the two groups in terms of 1-month survival with minimal neurologic impairment (odds ratio (OR), 1.57; 95% confidence interval (CI), 0.87 to 2.83; P = 0.14) and 1-month survival (OR, 1.38; 95% CI, 0.87 to 2.18; P = 0.17). CONCLUSIONS: The present nationwide population-based observational study could not confirm an advantage of biphasic over monophasic defibrillators for pediatric OHCA patients.

UNLABELLED: BACKGROUND: A growing elderly population along with advances in equipment and approaches for pre-hospital resuscitation necessitates up-to-date information when developing policies to improve elderly out-of-hospital cardiac arrest (OHCA) outcomes. We examined the effects of bystander type (family or non-family) intervention on 1-month outcomes of witnessed elderly OHCA patients. METHODS: Data from a total of 85,588 witnessed OHCA events in patients aged ≥65 years, which occurred from 2005 to 2008, were obtained from a nationwide population-based database. Patients were stratified into three age categories (65-74, 75-84, ≥85 years), and the effects of bystander type (family or non-family) on initial cardiac rhythm, rate of bystander cardiopulmonary resuscitation (CPR), and 1-month outcomes were assessed. RESULTS: The overall survival rate was 6.9% (65-74 years: 9.8%, 75-84 years: 6.9%, ≥85 years: 4.6%). Initial VF/VT was recorded in 11.1% of cases with a family bystander and 12.9% of cases with a non-family bystander. The rate of bystander CPR was constant across the age categories in patients with a family bystander and increased with advancing age categories in patients with a non-family bystander. Patients having a non-family bystander were associated with significantly higher 1-month rates of survival (OR: 1.26; 95% CI: 1.19-1.33) and favorable neurological status (OR: 1.47; 95% CI: 1.34-1.60). CONCLUSIONS: Elderly patient OHCA events witnessed by a family bystander were associated with worse 1-month outcomes than those witnessed by a non-family bystander. Healthcare providers should consider targeting potential family bystanders for CPR education to increase the rate and quality of bystander CPR.