著者名:Alison Dobbie, al.
文献タイトル:Evaluating Family Medicine Residency COPC programs Meeting the challenge.
雑誌名・書籍名:Fam Med 2006


<Background and Objectives>
We conducted a review of the evaluation literature and outcomes from community-oriented primary care (COPC) programs in US family medicine residencies since 1969.

We used a Medline and ERIC search for “community-oriented primary care” in English from 1969-2005. 

Twenty-two articles were found that concerned US family medicine residency COPC. Selection process describes in table1.Finnaly, Eight descriptive and eight evaluative papers described 14 residency COPC programs. Teaching and learning methods included block and longitudinal rotations and COPC projects. Evaluation methodologies included one quasi-experimental control group study, pretests and posttests of knowledge and attitudes, focus groups, and semi-structured interviews. Reported outcomes included changes in residents’ knowledge, attitudes, and behaviors; effect on graduates’ career choice and future practice; and impact on patient care and community health. 

 Few studies have evaluated residency COPC programs. Evaluation has been less than rigorous, with variable results, but at least one study indicates positive outcomes at each evaluation level. More residency programs must evaluate and disseminate outcomes from their COPC projects to determine the value of COPC to residents, colleagues, community partners, and funding agencies.

<Recommendations–Designing a COPC Evaluation Plan>
We recommend that faculty design their evaluation plan before implementing any residency COPC project, because data are more difficult to gather after the event, and the opportunity to gather baseline data is lost. We recommend that faculty design a plan addressing all four of Kirkpatrick’s levels of evaluation, as demonstrated in Table 2.

Level 1 data (reaction) measure course process outcomes, such as whether residents enjoy the learning experience, believe the content and teaching methods to be appropriate and well taught, report the program to be well organized and efficient, and consider it a useful contribution to their training. 

Level 2 data (learning) describe changes in residents’ COPC knowledge and attitudes. In 1999, Oandesan validated a 20-item survey that can serve as a pretest and posttest of residents’ attitudes to COPC. Donsky published a COPC questionnaire in 1998 that can be used as a pretest and posttest of knowledge and attitudes, although this instrument has not yet been validated. Qualitative methods for evaluating learning include focus groups, semi-structured interviews, written case exercises, and reflective essays and journals.

Level 3 data (transfer) concern changes in residents’ behavior and/or clinical practice. Behavior change can be measured through direct observational studies, chart reviews, electronic health record searches, and/or selfreports in written or electronic surveys. Self-reported changes in behavior represent much weaker types of Level 3 data than objective measures such as direct observation or chart review. 

Examples of Level 4 data (results and outcomes) include changes in graduates’ clinical practice resulting from the COPC projects, permanent adoption of the COPC program into the residency curriculum, and measurable effects on community agencies or practice populations. The effect of the COPC program on graduates’ practice behavior can be measured by telephone, electronic, or mailed surveys 1 to 2 years
after residency. Effects on community agencies can be measured by semi-structured interviews or focused group.





Quint Studer著、エクセレント・ホスピタル、ディスカバー社、2011年


5つの柱とは「医療の質」、「サービス」、「人材」、「成長」、「財務」の柱である(※Balanced Score Cardの考え方に「人材」が加えられた形)。以下、一つ一つの原則について触れる。

5つの柱それぞれについて測定可能な指標を設定することから始まる。それぞれの目標を定め、行動計画を作成し、評価制度を設定すれば、職員は目標達成に主体的に関わるチャンスが生まれる。そのためにはa) 職員の意識を高めるため全ての会議の議題を「5つの柱」に合わせる、b) 責任感をもたせるためにリーダーの評価を「5つの柱」に合わせる、c) 指標の進捗状況を知らせるために「5つの柱」で表した部門間のコミュニケーションボードを作成する。サンプル指標を揚げる(図1)。




この原則に重点を置くことは全ての柱の改善につながる(※参考:Service-Profit Chain)。リーダーへのフィードバックはリーダーのトレーニングにもなる(図2)。改善すべき課題は「90日間行動計画」に落とし込む。














著者名:O’Flynn N, Staniszewska S et al. 
文献タイトル:Improving the experience of care for people using NHSserveices; summary of NICE guidance. 


The emphasis in healthcare has often been on clinical efficacy and outcomes, which can come at the expense of the patient’s experience. Developments in healthcare delivery can make giving attention to the individual more difficult, especially as healthcare has become more technological and specialised, increasing the number of people and services that a patient has contact with. Changes in the working practices of healthcare staff (such as more part time working) and the rise in the number of large institutions delivering care can mean that patients have less opportunity to develop relationships with professionals who treat them and are more likely to be treated by a team.
The NHS “next stage” review, a review commissioned to develop a vision of an NHS fit for the 21st century, recognised the experience of patients as one of three dimensions of quality.1 The other two dimensions were clinical effectiveness and safety.

<Essential requirements of care>
・Do not discuss the patient in their presence without involving them in the discussion.
・Be prepared to raise sensitive issues (such as sexual activity, continence care, and end of life) as these will not be raised by some patients.
・Ensure that the patient’s nutrition and hydration are adequate at all times (when they are unable to manage this themselves) by:

Providing regular food and fluid of adequate quantity and quality in an environment conducive to eatingPlacing food and drink where the patient can reach them easily
Encouraging and helping the patient to eat and drink if needed
Providing appropriate support, such as modified eating aids and/or drinking aids.
・Ensure that the patient’s pain relief is adequate at all times when they are unable to manage their own analgesia by: Not assuming that the patient’s pain relief is adequate
Asking the patient regularly about pain

Assessing pain using a pain scale if necessary 
Providing pain relief regularly and adjusting as needed.
・When the patient is unable to manage their own personal needs (for example, relating to continence, personal hygiene, and comfort), inquire regularly and try to meet such needs at the time of asking. Ensure maximum privacy.

<Shared decision making>
・When trying to reach a shared decision on investigations and treatment, discuss the matter in a style and manner that enables the patient to express their personal needs and preferences. 
・Give the patient the opportunity to discuss their diagnosis, prognosis, and treatment. 
・Before starting any investigations or treatment: Explain the medical aims of the proposed care 
Openly discuss and provide information about the risks, benefits, and consequences of the investigation or treatment (taking into account factors such as coexisting conditions and the patient’s preferences) 

Set aside adequate time to allow any questions to be answered, and ask the patient if they would like a further consultation. 
・Clarify what the patient hopes the treatment will achieve and discuss any misconceptions.
・Give the patient, and their family members and/or carers if appropriate, adequate time to decide whether they wish to have investigations and/or treatment. 
・Accept and acknowledge that patients may vary in their views about the balance of risks, benefits, and side effects of treatments. 
・Use the following principles when discussing risks and benefits with a patient:
Personalise risks and benefits as far as possible.. 

Use absolute risk rather than relative risk–for example, the risk of an event increases from 1 in 1000 to 2 in 1000, rather than the risk of the event doubles. 

Use natural frequency rather than a percentage–for example, 10 in 100 (better still, 1 in 10) rather than 10%. 

Be consistent in the use of data–for example, use the same denominator when comparing risk: 7 in 100 for one risk and 20 in 100 for another, rather than 1 in 14 and 1 in 5 
Present a risk over a defined period of time (months or years) if appropriate–for example, if 100 people are treated for 1 year, 10 will experience a given side effect. 

Include both positive and negative framing–for example, treatment will be successful for 97 out of 100 patients and unsuccessful for 3 out of 100 patients. 

People differ in the way they interpret terms such as rare, unusual, and common, so use numerical data if available. 

Consider using a mixture of numerical and pictorial formats–for example, numerical rates and pictograms (such as figures 1 and 2). 
・Offer support to the patient when they are considering options. Use the principles of shared decision making: Ensure that the patient is aware of the options available, and explain the risks, benefits, and consequences of these.
Check that the patient understands the information.
Encourage the patient to clarify what is important to them, and check that their choice is consistent with this.
・Be aware of the value and availability of patient based decision aids. If suitable high quality decision aids are available, offer the most appropriate one to the patient.

<Tailoring healthcare services to the patient>
・At intervals agreed with the patient, review their knowledge, understanding, and concerns about their condition and treatments, and their view of their need for treatment, as these may change over time. Offer the patient repeat information and review, especially when treating a long term condition. 
・Tailor healthcare services to the patient’s needs and circumstances, taking into account locality, access, personal preferences, and coexisting conditions. Review the patient’s needs and circumstances regularly. 
・Give the patient information about relevant and available treatment options even if these are not provided locally. 
・Tell the patient about available health and social services (such as smoking cessation services) and encourage them to access these according to their individual needs. 
・Ensure that discussions are held in a way that allows the patient to express their personal needs and preferences for care. Allow adequate time so that discussions do not feel rushed. 
・Clarify with the patient at the outset whether and how they would like their spouse, partner, family members, and/or carers to be involved in key decisions about the management of their condition. 
・Accept that the patient may have different views from healthcare professionals about the balance of risks, benefits, and consequences of treatments. 
・Accept that the patient has the right to decide not to have a treatment (even if you do not agree with the decision) as long as he or she has the capacity to make an informed decision and has been given the information needed to do this. 
・Inform the patient that they have a right to a second opinion.
・Respect and support the patient in their choice of treatment or decision to decline treatment. 
・When patients in hospital are taking medicines for long term conditions, consider and discuss with them whether they are able to, and would prefer to, manage these medicines themselves. 

<Continuity of care>
・Consider each patient’s requirement for continuity of care and how that requirement will be met. This may involve the patient seeing the same healthcare professional throughout a single episode of care or ensuring continuity within a healthcare team. 
・Inform the patient about:
Who is responsible for their care and treatment 
The roles and responsibilities of the different members of the healthcare team 
The communication that takes place between members of the healthcare team. 
・Give the patient (and their family members and/or carers if appropriate) information about what to do and whom to contact in different situations, such as “out of hours” or in an emergency. 
・For patients who need several different services, ensure effective coordination and prioritisation of care to minimise the impact on the patient. 
・Ensure clear and timely exchange of patient information between healthcare professional teams and other agencies–for example, transitions of care including discharge. 


Fig 1 Personalised pictogram and bar chart based on high quality predictive models showing that of 100 patients with particular clinical characteristics 49 will experience a cardiovascular event (such as a heart attack or stroke) over the next 10 years. Adapted with permission from the Institute of Health and Society, Newcastle University


Fig 2 Personalised pictogram and bar chart showing the likely reduction in risk of cardiovascular events after stopping smoking, reduced from 49 in 100 to 31 in 100. Adapted with permission from the Institute of Health and Society, Newcastle University




著者名:Klabunde CN, Marcus PM, et al.
文献タイトル:Lung Cancer Screening Practice of Primary Care Physicians: Results From a National Survey. 
雑誌名・書籍名:Ann Fam Med.









山田隆司、吉村学、名郷直樹ら:日常病・日常的健康問題とは–ICPC(プライマリ・ケア国際分類)を用いた診療統計から(第1報)–.プライマリ・ケア:P80−89, Vol.23 No.1 2000












著者名:Huybrechts K F, Gerhard T, et al.
文献タイトル: Differential risk of death in older residents in nursing homes prescribed specific antipsychoticdrugs: population based cohort study. 
発行年:2012 Feb 23;344.


To assess risks of mortality associated with use of individual antipsychotic drugs in elderly residents in nursing homes.

Population based cohort study with linked data from Medicaid, Medicare, the Minimum Data Set, the National Death Index, and a national assessment of nursing home quality.

Nursing homes in the United States.

75 445 new users of antipsychotic drugs (haloperidol, aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone). All participants were aged ≥65, were eligible for Medicaid, and lived in a nursing home in 2001-5.

Cox proportional hazards models were used to compare 180 day risks of all cause and cause specific mortality by individual drug, with propensity score adjustment to control for potential confounders.

Compared with risperidone, users of haloperidol had an increased risk of mortality (hazard ratio 2.07, 95% confidence interval 1.89 to 2.26) and users of quetiapine a decreased risk (0.81, 0.75 to 0.88). The effects were strongest shortly after the start of treatment, remained after adjustment for dose, and were seen for all causes of death examined. No clinically meaningful differences were observed for the other drugs. There was no evidence that the effect measure modification in those with dementia or behavioural disturbances. There was a dose-response relation for all drugs except quetiapine.

Though these findings cannot prove causality, and we cannot rule out the possibility of residual confounding, they provide more evidence of the risk of using these drugs in older patients, reinforcing the concept that they should not be used in the absence of clear need. The data suggest that the risk of mortality with these drugs is generally increased with higher doses and seems to be highest for haloperidol and least for quetiapine.