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.



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


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.


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). 

 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.





Memantine Treatment in Patients With Moderate to Severe Alzheimer Disease Already Receiving Donepezil  A Randomized Controlled Trial JAMA 2004 Jan 21;Vol291,No.3:317-324



Memantine is a low- to moderate-affinity, uncompetitive N-methyl-Daspartate receptor antagonist. Controlled trials have demonstrated the safety and efficacy of memantine monotherapy for patients with moderate to severe Alzheimer disease(AD) but no controlled trials of memantine in patients receiving a cholinesterase inhibitor have been performed.

Objective  To compare the efficacy and safety of memantine vs placebo in patients with moderate to severe AD already receiving stable treatment with donepezil.

<Design, Setting, and Participants>

A randomized, double-blind, placebo controlled clinical trial of 404 patients with moderate to severe AD and Mini-Mental State Examination scores of 5 to 14, who received stable doses of donepezil, conducted at 37 US sites between June 11, 2001, and June 3, 2002. A total of 322 patients (80%) completed the trial.


Participants were randomized to receive memantine (starting dose 5 mg/d, increased to 20 mg/d, n=203) or placebo (n=201) for 24 weeks.

<Main Outcome Measures>

Change from baseline on the Severe Impairment Battery (SIB), a measure of cognition, and on a modified 19-item AD Cooperative Study? Activities of Daily Living Inventory (ADCS-ADL19). Secondary outcomes included a Clinician’s Interview-Based Impression of Change Plus Caregiver Input (CIBIC-Plus), the Neuropsychiatric Inventory, and the Behavioral Rating Scale for Geriatric Patients (BGP Care Dependency Subscale).


The change in total mean (SE) scores favored memantine vs placebo treatment for SIB (possible score range, 0-100), 0.9 (0.67) vs ?2.5 (0.69), respectively (P_.001); ADCS-ADL19 (possible score range, 0-54), ?2.0 (0.50) vs ?3.4 (0.51), respectively (P=.03); and the CIBIC-Plus (possible score range, 1-7), 4.41 (0.074) vs 4.66 (0.075), respectively (P=.03). All other secondary measures showed significant benefits of memantine treatment. Treatment discontinuations because of adverse events for memantine vs placebo were 15 (7.4%) vs 25 (12.4%), respectively.


In patients with moderate to severe AD receiving stable doses of donepezil, memantine resulted in significantly better outcomes than placebo on measures of cognition, activities of daily living, global outcome, and behavior and was well tolerated. These results, together with previous studies, suggest that memantine represents a new approach for the treatment of patients with moderate to severe AD.





Leslee L. Subak, M.D.,  Weight Loss to Treat Urinary Incontinence in Overweight and Obese Women N Engl J Med 2009 360;5 jan 29, 481-490



Obesity is an established and modifiable risk factor for urinary incontinence, but conclusive evidence for a beneficial effect of weight loss on urinary incontinence is lacking.


Researchers randomly assigned 338 overweight and obese women with at least 10 urinary incontinence episodes per week to an intensive 6-month weight-loss program that included diet, exercise, and behavior modification (226 patients) or to a structured education program (112 patients).


The mean (±SD) age of the participants was 53±11 years. The body-mass index (BMI) (the weight in kilograms divided by the square of the height in meters) and the weekly number of incontinence episodes as recorded in a 7-day diary of voiding were similar in the intervention group and the control group at baseline (BMI, 36±6and 36±5, respectively; incontinence episodes, 24±18 and 24±16, respectively). The women in the intervention group had a mean weight loss of 8.0% (7.8 kg), as compared with 1.6% (1.5 kg) in the control group (P<0.001). After 6 months, the mean weekly number of incontinence episodes decreased by 47% in the intervention group, as compared with 28% in the control group (P = 0.01). As compared with the control group, the intervention group had a greater decrease in the frequency of stress incontinence episodes (P = 0.02), but not of urge-incontinence episodes (P = 0.14).A higher proportion of the intervention group than of the control group had a clinically relevant reduction of 70% or more in the frequency of all incontinence episodes (P<0.001), stress-incontinence episodes (P = 0.009), and urge-incontinence episodes(P = 0.04).

 A 6-month behavioral intervention targeting weight loss reduced the frequency of self-reported urinary-incontinence episodes among overweight and obese women as compared with a control group. A decrease in urinary incontinence may be another benefit among the extensive health improvements associated with moderate weight reduction. 


患者中心のケアを患者の視点で測定するためのツール(Systematic Review)


Hudon C. Fortin M, et al. Measuring Patients’Perception of Patient-Centered Care: A Systematic Review of Tools for Family Medicine. Ann Fam Med 2011; 9:155-164.



このSystematic Reviewは家庭医療学における患者中心のケアを患者の視点で評価するための測定法、スケール、アイテムを見いだし、比較することを目的とした。


MEDLINE、Embase、Cochrane database3つのデータベースを1980年から2009年4月までの期間で検索し、Systematic Reviewを行った。ハンドサーチと専門家からのアドバイスによりこれらの検索結果を補足した。以下の条件をすべて満たす文献を採択した。

(1)    患者中心の視点で患者中心のケアを測定する自記式のツールを使用

(2)    開発と妥当性の検証は量的またはpsychometric(精神測定)な結果で報告していること

(3)    家庭医療の外来診療というセッティングに応用可能であること
採択された文献はStandards for Reporting of Diagnostic Accuracyの修正版を用いて解析した。





検索された3045の文献のうち90の文献が詳細に検討され、26の文献が取り扱っていた13の測定方法がinclusion criteriaに合致していた。5つの文献で取り扱われている2つの測定法が患者中心のケア測定のために開発されていた(「the Patient Perception of Patient-Centeredness」と「the Consultation Care Measure」)。21の文献で取り扱われている11の測定法が利用可能な下位尺度、アイテムとして見いだされた。




今回採用された文献の一覧はTable 1.

PPPCは直近の家庭医療外来を患者の視点で評価する方法。4段階のリッカートスケールを用いた14の質問項目で構成されている(Cronbach’s α reliability = 0.71)。不快や不安からの回復・軽減、初回外来から2か月後の感覚的な健康観、不要な検査や専門医へのコンサルトの少なさとよく相関した。
CCMもPPPCと同様、直近の家庭医療外来を患者の視点で評価する方法。4段階のリッカートスケールを用いた21の質問項目(コミュニケーションとパートナーシップ、人間関係、ヘルスプロモーション、ポジティブで明快な問題へのアプローチ、人生・背活への影響に対する関心、の5つにグループ分けされている)で構成されている(Cronbach’s α reliability = 0.84-0.96)。患者満足度、Enablement、症状の軽減、不要な専門医へのコンサルトの減少と相関する。





Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. The Lancet, Volume 378, Issue 9789, Pages 403 – 411, 30 July 2011.

うつ症状を示すアルツハイマー病患者に、選択的セロトニン再取り込み阻害薬(SSRI)のセルトラリン、ノルアドレナリン作動性・特異的セロトニン作動性抗うつ薬(NaSSA)のミルタザピン、偽薬のいずれかを投与した無作為化試験の結果が、Lancet誌2011年7月18日号に掲載された。英London King’s CollegeのSube Banerjee氏らによると、13週後と39週後のうつ症状の変化において、どちらの抗うつ薬にも偽薬を上回る利益は見られず、有害事象発生率は高かった。


現状では、主要学会は抗うつ薬の認知症患者への適用を支持しており、セルトラリンなどが第1選択として処方されている。高齢化が進む先進国では、認知症患者のうつは臨床的に重要な領域であると考えた英National Institute of Health Research (NIHR)は、著者らに臨床試験の実施を依頼した。















大浦武彦,見て・考える褥瘡ケア 創面をみればすべてがわかる ここで差がつくテクニック,














スタチンを実際に使用して、副作用はどの程度起こるか? UKでのProspective コホート研究より


Julia Hippisley-Cox : Unintended effects of statins in men and women in England and Wales: population based cohort study using the QResearch database(¶1)  BMJ 2010;340:c2197



To quantify the unintended effects of statins according to type, dose, and duration of use.


Prospective open cohort study using routinely collected data. 

368 general practices in England and Wales supplying data to the QResearch database. 【Participants】 2 004 692 patients aged 30-84 years of whom 225 922 (10.7%) were new users of statins: 159 790 (70.7%) were prescribed simvastatin(訳注;リポバスR), 50 328 (22.3%) atorvastatin(訳注;リピトールR), 8103 (3.6%) pravastatin(訳注;メバロチンR), 4497 (1.9%) rosuvastatin(訳注;クレストールR), and 3204 (1.4%) fluvastatin(訳注;ローコール).


Cox proportional hazards models were used to estimate effects of statin type, dose, and duration of use. The number needed to treat (NNT) or number needed to harm (NNH) were calculated and numbers of additional or fewer cases estimated for 10 000 treated patients.

<Main outcome measure>

First recorded occurrence of cardiovascular disease, moderate or serious myopathic events, moderate or serious liver dysfunction, acute renal failure, venous thromboembolism, Parkinson’s disease,dementia, rheumatoid arthritis, cataract, osteoporotic fracture, gastric cancer, oesophageal cancer, colon cancer, lung cancer, melanoma, renal cancer, breast cancer, or prostate cancer.


(To help reading, I added the number to the original article. See Table6 in original article.)

1.Individual statins were not significantly associated with risk of Parkinson’s disease, rheumatoid arthritis, venous thromboembolism, dementia, osteoporotic fracture, gastric cancer, colon cancer, lung cancer, melanoma, renal cancer, breast cancer, or prostate cancer. 

2.Statin use was associated with decreased risks of oesophageal cancer but increased risks of moderate or serious liver dysfunction, acute renal failure, moderate or serious myopathy, and cataract. 

3. Adverse effects were similar across statin types for each outcome except liver dysfunction where risks were highest for fluvastatin. A dose-response effect was apparent for acute renal failure and liver dysfunction. All increased risks persisted during treatment and were highest in the first year. After stopping treatment the risk of cataract returned to normal within a year in men and women. Risk of oesophageal cancer returned to normal within a year in women and within 1-3 years in men. Risk of acute renal failure returned to normal within 1-3 years in men and women, and liver dysfunction within 1-3 years in women and from three years in men.

4. Based on the 20% threshold for cardiovascular risk, for women the NNT with any statin to prevent one case of cardiovascular disease over five years was 37 (95% confidence interval 27 to 64) and for oesophageal cancer was 1266 (850 to 3460) and for men the respective values were 33 (24 to 57) and 1082 (711 to 2807).

5. In women the NNH for an additional case of acute renal failure over five years was 434 (284 to 783), of moderate or severe myopathy was 259 (186 to 375), of moderate or severe liver dysfunction was 136 (109 to 175), and of cataract was 33 (28 to 38). Overall, the NNHs and NNTs for men were similar to those for women, except for myopathy where the NNH was 91 (74 to 112).


Claims of unintended benefits of statins, except for oesophageal cancer, remain unsubstantiated, although potential adverse effects at population level were confirmed and quantified. Further studies are needed to develop utilities to individualise the risks so that patients at highest risk of adverse events can be monitored closely.





Shimoli V. Shah and Brian F. Gage. Cost-Effectiveness of Dabigatran for Stroke Prophylaxis in Atrial Fibrillation. (Circulation. 2011;123:2562-2570.)



Recent studies have investigated alternatives to warfarin for stroke prophylaxis in patients with atrial fibrillation (AF), but whether these alternatives are cost-effective is unknown.

<Methods and Results>

On the basis of the results from Randomized Evaluation of Long Term Anticoagulation Therapy
(RE-LY) and other trials, we developed a decision-analysis model to compare the cost and quality-adjusted survival of various antithrombotic therapies. We ran our Markov model in a hypothetical cohort of 70-year-old patients with AF using a cost-effectiveness threshold of $50 000/quality-adjusted life-year. We estimated the cost of dabigatran as US $9 a day. For a patient with an average risk of major hemorrhage (3%/y), the most cost-effective therapy depended on stroke risk. For patients with the lowest stroke rate (CHADS 2 stroke score of 0), only aspirin was cost-effective. For patients with a moderate stroke rate (CHADS 2 score of 1 or 2), warfarin was cost-effective unless the risk of hemorrhage was high or quality of international normalized ratio control was poor (time in the therapeutic range 57.1%). For patients with a high stroke risk (CHADS 2 stroke score 3), dabigatran 150 mg (twice daily) was cost-effective unless international normalized ratio control was excellent (time in the therapeutic range  72.6%). Neither dabigatran 110 mg nor dual therapy (aspirin and clopidogrel) was cost-effective.


Dabigatran 150 mg (twice daily) was cost-effective in AF populations at high risk of hemorrhage or high risk of stroke unless international normalized ratio control with warfarin was excellent. Warfarin was cost-effective in moderate-risk AF populations unless international normalized ratio control was poor.





木を見る西洋人 森を見る東洋人~思考の違いはいかにして生まれるか
リチャード・E・ニスベット著 ダイヤモンド社2004年











Common groundの立ち方であるケンブリッジモデル(トレードしていくようなイメージ)などは、西洋的であり、東洋ではまた違ったプロセスが医師患者関係の間に働いているような気がする。





Moubarak G, Guiot A, Benhamou Y, et al. Facebook activitiy of residents and fellows and its impact on the doctor-patients relationship. J Med Ethics 2011;37: 101-104











上記以外にもBMAの指針のKey pointとして