COPC、地域コミュニティケアの研修プログラムをしっかり評価していきましょう!

【文献】

著者名:Alison Dobbie,MD.et 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
発行年:38(6):399-407.

【要約】

<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.

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

<Results>
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. 

<Conclusions>
 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.

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【開催日】
2012年4月26日

中等症?重症の認知症に対するドネペジルとメマンチンの効果

【文献名】
Robert Howard, M.D.  Donepezil and Memantine for Moderate-to-Severe Alzheimer’s Disease : NEJM 2012 ;366:10 893-903

【要約】

<Background>
Clinical trials have shown the benefits of cholinesterase inhibitors for the treatment of mild-to-moderate Alzheimer’s disease. It is not known whether treatment benefits continue after the progression to moderate(MMSE5~9)-to-severe(MMSE10~13) disease.

<Methods>
Design was multicenter, double-blind, placebo-controlled, clinical trial with two-by-two factorial design. The researchers assigned 295 community-dwelling patients who had been treated with donepezil for at least 3 months and who had moderate or severe Alzheimer’s disease (a score of 5 to 13 on the Standardized Mini?Mental State Examination [SMMSE, on which scores range from 0 to 30, with higher scores indicating better cognitive function]) to continue donepezil, discontinue donepezil, discontinue donepezil and start memantine, or continue donepezil and start memantine. Patients received the study treatment for 52 weeks. The coprimary outcomes were scores on the SMMSE and on the Bristol Activities of Daily Living Scale (BADLS, on which scores range from 0 to 60, with higher scores indicating greater impairment). The minimum clinically important differences were 1.4 points on the SMMSE and 3.5 points on the BADLS.

実際
①D○ M×  = D10mg                               +  placebo M
②D×  M×  = D5mg(week1?4) → placebo D(week5?) +  placebo M
③D× M○  = D5mg(week1?4) → placebo D(week5?) +  M5mg→5mg up/wk →20mg max
④D○ M○  = D10 mg               +  M5mg→5mg up/wk →20mg max

<Results>
The baseline characteristics of the participants in four treatment groups were broadly similar.
Patients assigned to continue donepezil, as compared with those assigned to discontinue donepezil, had a score on the SMMSE that was higher by an average of 1.9 points (95% confidence interval [CI], 1.3 to 2.5) and a score on the BADLS that was lower (indicating less impairment) by 3.0 points (95% CI, 1.8 to 4.3) (P<0.001 for both comparisons). Patients assigned to receive memantine, as compared with those assigned to receive memantine placebo, had a score on the SMMSE that was an average of 1.2 points higher (95% CI, 0.6 to 1.8; P<0.001) and a score on the BADLS that was 1.5 points lower (95% CI, 0.3 to 2.8; P=0.02). The efficacy of donepezil and of memantine did not differ significantly in the presence or absence of the other. There were no significant benefits of the combination of donepezil and memantine over donepezil alone.  ※The minimum clinically important difference in scores on the SMMSE was 1.4 points, on the BADLS was 3.5 points. <Conclusions> In patients with moderate or severe Alzheimer's disease, continued treatment with donepezil was associated with cognitive benefits that exceeded the minimum clinically important difference and with significant functional benefits over the course of 12 months. 【開催日】 2012年3月14日

外来中の患者家族メンバーとの相互作用について

【文献名】

FOLASHADE S. OMOLE, MD; CHARLES M. SOW, MD, MSCR; EDITH FRESH, PhD; DOLAPO BABALOLA, MD; and HARRY STROTHERS III, MD. Interacting with Patients’ Family Members During the Office Visit. Am Fam Physician. 2011;84(7):780-784.



【要約】
医師患者関係は患者のより大きな社会システムの一部分であり、患者家族によって影響を受ける。患者家族メンバーは外来での貴重な情報源であり、正確な診断と治療戦略を立てるのに協力してくれる存在になりうる。しかしながら、医師、患者、家族メンバー間で形成される同盟関係を維持するために、関係を呼び掛ける時に医師は適切なバランスを保つ事が重要である。患者中心の医療現場では、患者をケアするコンセプトが医師、患者、患者家族メンバー間の力動に対処するのを助け、そして医師、患者、患者家族メンバー間の強いパートナーシップに影響を与える。外来では、このパートナーシップは民族性、文化的な価値観、病に関する信念、患者や家族の宗教によって影響を受ける。医師は外来で異常な家族力動を認識し、三角関係の位置を避け、中立関係を保つようふるまうべきである。虐待や無視を疑った場合は中立性を保つべきではない。外来で患者が医師とプライベートにコミュニケーションをとる時間が必要になる時もあるという事が重要な事である。



【開催日】

2011年10月12日

地球の温暖化に対して家庭医は何ができるのか?

【文献名】

Slowing Global Warming: Benefits for Patients and the Planet
CINDY L. PARKER, MD, MPH, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
American Family Physician  Volume 84, Number 3 ◆ August 1, 2011



【要約】

Global warming will cause significant harm to the health of persons and their communities by compromising food and water supplies; increasing risks of morbidity and mortality from infectious diseases and heat stress; changing social determinants of health resulting from extreme weather events, rising sea levels, and expanding flood plains; and worsening air quality, resulting in additional morbidity and mortality from respiratory and cardiovascular diseases. Vulnerable populations such as children, older persons, persons living at or below the poverty level, and minorities will be affected earliest and greatest, but everyone likely will be affected at some point. Family physicians can help reduce greenhouse gas emissions, stabilize the climate, and reduce the risks of climate change while also directly improving the health of their patients. Health interventions that have a beneficial effect on climate change include encouraging patients to reduce the amount of red meat in their diets and to replace some vehicular transportation with walking or bicycling. Patients are more likely to make such lifestyle changes if their physician asks them to and leads by example. Medical offices and hospitals can become more energy efficient by recycling, purchasing wind-generated electricity, and turning off appliances, computers, and lights when not in use. Moreover, physicians can play an important role in improving air quality and reducing greenhouse gas emissions by advocating for enforcement of existing air quality regulations and working with local and national policy makers to further improve air quality standards, thereby improving the health of their patients and slowing global climate change.



【開催日】

2011年9月21日

「継続性」が連携に及ぼす影響

【文献名】

David T. Liss, Jessica Chubak, Melissa L. Anderson, Kathleen W. Saunders, Leah Tuzzio, and Robert J. Reid 
Patient-Reported Care Coordination: Associations With Primary Care Continuity and Specialty Care Use 
Ann Fam Med 2011 9: 323-329.



【要約】

<Purpose>

Care coordination is increasingly recognized as a necessary element of high-quality, patient-centered care. This study investigated following. 
1. The association between care coordination and continuity of primary care.
2. Differences in this association by level of specialty care use



<Methods>

Design :  Cross-sectional study

Setting :  Group Health, an integrated health care delivery system in Washington State and Idaho

Data collection :  During March through September 2008, data were collected from questionnaires mailed to Group Health members who were eligible to enroll.

Participants:  Eligible patients were aged 65 years or older, received care at a Group Health clinic in King County or Pierce County in western Washington State, and had at least 1 of the following chronic conditions: diabetes, coronary artery disease (CAD), or congestive heart failure (CHF).
Coordination measure:  The short form of the Ambulatory Care Experiences Survey (Figure1.)

Continuity measure:  Primary care visit concentration.

Analysis:  Linear regression was used to estimate the association between coordination and continuity, controlling for potential confounders and clustering within clinicians.

To determine whether the association between care coordination and continuity was modified by level of specialty use, an indicator for high specialty care use (10 or more specialist visits during the 1-year study period) and an interaction between high specialty care use and care continuity were included in the model.



<Results>

Among low specialty care users, an increase of 1 standard deviation in continuity of care was associated with an increase of 2.71 in coordination (P <.001, Table 3). Among respondents with 
high specialty care use, however, the model showed no association between continuity and reported coordination(P = .77). 
 111003


<Conclusion>
 High use of specialty care may strain the ability of primary care clinicians to coordinate care effectively. Future studies should investigate care coordination interventions that allow for appropriate specialty care referrals without diminishing the ability of primary care physicians to manage overall patient care.



【開催日】

2011年8月31日

~プライマリ・ケアの外来における抗菌薬投与が与える抗菌薬耐性への影響~

【文献】
Ceille Costelloe, et.al.: Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ: volume340, pp2096, 2010.
この文献へのリンクはこちら

【要約】
《目的》
プライマリ・ケアセッティングにおいて抗菌薬を投与された患者に引き続いて起こる抗菌薬耐性に関する研究のsystematic review。可能ならmeta-analysisも実施する。
《デザイン》
Meta-analysisも実施したsystematic review
《Reviewの方法》
MEDLINEやEMBASE、Cochrane data baseを検索して得た4373の文献が対象。
2名の独立した評価者が文献を評価し、データを抽出した。
同様のアウトカムを使用している研究に関してmeta-analysisを実施した。
《結果》
24の研究がレビューに採用された。
22の研究が感染症患者を対象としたもの、2つの研究は健康なボランティアを対象としていた。
19の研究が観察研究(うち2つはprospective)で5つの研究がランダム化試験であった。
尿路感染症を対象とした8つの研究のうち、5つがmeta-analysisに足る研究であった。
抗菌薬による治療後2か月以内の耐性菌検出のオッズ比は2.5(95%CI 2.1 – 2.9)
12か月以内では1.33(95%CI 1.2 – 1.5)であった。
呼吸器感染症を対象とした9つの研究のうち、7つがmeta-analysisに含まれた。
抗菌薬による治療後2か月以内の耐性菌検出のオッズ比は2.4(95%CI1.4 – 3.9)
12か月以内では2.4(95%CI1.3-4.5)であった。
投与した抗菌薬の量についてレポートしている研究では抗菌薬投与期間が長いほど、また複数の抗菌薬を使用したときほど耐性菌検出の頻度が高かった。
抗菌薬による耐性菌検出の違いは今回のレビューでは傾向はつかめなかった。
期間による耐性菌検出の変化を追った研究が1例のみ認められた。
抗菌薬治療後1週間ではオッズ比が12.2(95%CI 6.8-22.1),1か月では6.1(同2.8-13.4),2か月では3.6(同2.2-6.0),6か月では2.2(同1.3-3.6)。
《結論》
呼吸器または尿路感染症にたいして抗菌薬の投与を受けた個人はその抗菌薬に対する耐性を獲得する。
その影響は抗菌薬による治療後の1か月以内がもっとも大きいが、12か月持続する可能性がある。
この影響はfirst lineの抗菌薬に対する耐性菌を地域内にまん延させるばかりでなく、second lineの抗菌薬使用をも増やしてしまう結果を生む。

【開催日】
2010年9月1日(水)