- 文献名 -
 John. W Saultz. Chapter 3. Access to Care. In Textbook of Family Medicine. McGraw-Hill. 1999.
- 要約 -
Definition of “Access to care”: “The ability to obtain health services when needed” (Bodenheimer TS etal. Understanding Health Policy. East Norwalk, CT: Appleton & Lange, 1995).
Of the five principles of family medicine, access to care has been associated most strongly with positive health outcomes.
 Access to care is not the same thing as access to health; Access to medical care is a less powerful determinant of population health than sanitation, nutrition, and socioeconomic class.
  Evidence that access to care is an important determinant of health is extensive and can be classified as follows.

1. Access to certain types of preventive services is associated unequivocally with decreased morbidity and mortality(ex. immunizations, prenatal care).
2. Access to care that allows management of certain chronic medical conditions prolongs life and minimizes complications (ex. hypertension, diabetes).
3. Access to primary care has been shown to decrease hospitalization rate and probably decreases overall health care costs(Casanova C, Starfield B. Int J Health Sev 25:283-294,1995. Bindman AB et al. JAMA 274:305-311, 1995.).
4. Substantial data establish that access to care is an important determinant of patient satisfaction with care.

【Access to Acute Care】

The ability of the patient or family to obtain access to the physician or physician’s office staff by telephone has become an important quality-of-care measure in Amerian medicine.

【Access to Preventive Care】

In U.S., the HMO is holding family physicians accountable for preventive services of habitants. The HMO believes that its expectations are reasonable, since it is paying family physicians a monthly capitation fee to assume this responsibility. A system of EHR will make it easier to monitor which patients have and have not received a particular preventive service or set of preventive services.

【Access to Chronic Care】

Family physicians believe that frequent visits with chronically ill patients improve doctor/patient compliance and facilitate a more rich and complex relationship between the patient, physician, and family.

【Access to Specialty and Hospital Care】

Highly technical and specialized care can harm patients as well as help them. Thus, assuring and managing access to specialty care has become a central part of family practice.

【Managing Underaccess to Care】

1.Overcoming Financial Barriers
inancial barriers to access in a given practice can best be overcome by specifically discussing these issues, establishing a written policy for the practice, and communicating and enforcing the policy in a caring and humane manner.
2. Overcoming Geographic Barriers
Telecommunications technology can be used to extend the physician’s service range( ex. Psychiatrist see patients with this technology in Rebun island,)
3. Overcoming Cultural Barriers
Family physician should evaluate the language needs of the practice and should establish a plan to care for patients when language barriers are present. The practice should also evaluate the cultural and religious needs of the community as an important step to assure access to care.
4. Overcoming Family Barriers
Decisions are often made by family health decision makers. Family physicians should include an assessment of this process in all formal family assessments and should also assess family health decision making for patients with chronic illness.
5. Overcoming Health System Barriers
If it is difficult for patients to access care on weekdays during the day, then family physicians should open their offices in the evenings and on weekends.
6. Overcoming Educational Barriers
The protocol for scheduling routine appointments, obtaining prescription refills, or getting health advice by telephone should also be provided to patients in writing when they enroll in the practice and reinforced periodically.

Overaccess to care

Overuse of care happens when there is a mismatch between illness and illness behavior.



SV. Hudson, SM. Miller, J Hemler, JM. Ferrante, J Lyle, KC Oeffinger and RS. DiPaola. Adult Cancer Survivors Discuss Follow-up in Primary Care: ‘Not What I Want, But Maybe What I Need’. Ann Fam Med Sep/Oct 2012, 10(5):418-427.


Nearly one-third of office visits for cancer are handled by primary care physicians. Yet, few studies examine patient perspectives on these physicians’ roles in their cancer follow-up care or their care preferences.

 We explored survivor preferences through qualitative, semistructured, in-depth interviews drawing on patients recruited from 2 National Cancer Institute-designated comprehensive cancer centers and 6 community hospitals. We recruited a purposive sample of early-stage breast and prostate cancer survivors aged 47 to 80 years, stratified by age, race, and length of time from and location of cancer treatment. Survivors were at least 2 years beyond completion of their active cancer treatment

Forty-two survivors participated in the study. Most participants expressed strong preferences to receive follow-up care from their cancer specialists (52%). They described the following barriers to the primary care physician’s engagement in follow-up care: (1) lack of cancer expertise, (2) limited or no involvement with original cancer care, and (3) lack of care continuity. Only one-third of participants (38%) believed there was a role for primary care in cancer follow-up care and suggested the following opportunities: (1) performing routine cancer-screening tests, (2) supplementing cancer and cancer-related specialist care, and (3) providing follow-up medical care when “enough time has passed” or the survivors felt that they could reintegrate into the noncancer population.

Survivors have concerns about seeing their primary care physician for cancer-related follow-up care. Research interventions to address these issues are necessary to enhance the quality of care received by cancer survivors


The ‘ologies ‘ (understanding academic disciplines) of primary health care

著者名:Trisha Greenhalgh
文献タイトル:PRIMARY HEALTH CARE -theory and practice-(BMJ books). 
雑誌名・書籍名:Blackwell Publishing. P23-56

Two medical disciplines are very important to effective practice
1  Biomedical science (anatomy, physiology, pathology, cardiology, pharmacology and so on)
2  Epidemiology (the study of disease patterns in populations and interventions to change these)

However, these medical sciences would give us a narrow and incomplete view of primary care. 
This chapter covers six additional disciplines that underpin an academic perspectives on primary care.

1 Psychology
  The scientific study of mind and behavior. There are broad scope of knowledge…
  Ex: Cognitive – , Social – , Development- , Educational-…

2 Sociology
  The study of human society and the relationship between its members.
  Peter Berger says that Sociology is to discover many layers of meaning. 
    Ex: Sick role, Professional role, Medical Uncertainty …

3 Anthropology(人類学)
  The study of human.
    a Structuralist -:
To discover what universal principles of the human mind underlie each culture.  
Ex. Claude Levi-Strauss (1st researcher about Family Structure)
  Ferdinand de Saussure (Famous Linguist, to discover the unconscious rules and principles embedded within a language 『肩が凝る』)
  b Post- Structuralist- :
    Anthropology developed out of structuralism, that are closely to the work of Pierre Bourdieu.
    Symbolic capital as a crucial source of power. 
  c Symbolic -:
        To analyze symbols (image, courtesy, idol/icon) meaning in culture system. 
        Ex: Mary Douglas (Purity and Danger : What is defined “Dirty” in different societies )
            『こんにゃくゼリー choked risk is lower than rice cake, but more “dirty” in Japan』

4 Literary Theory 
   Theory of literature and literacy criticism. 
     Ex: Patient Story, Voice of Medicine/ Voice of Human World. 

5 Philosophy, including epistemology(認識論)
  a  Epistemology :the study of valid forms of knowledge.
Ex : Scepticism(懐疑論), Rationalism, Empiricism, Objectivism, Relativism…
    b  Moral philosophy : the study of moral value of human behavior.
        Ex: Consequentialism(結果主義), Deontology(義務的倫理学), Virtue ethics, Emotivism
    c  Rhetoric and logic : the study of persuasion.

6 Pedagogy (= Learning Theory)
  a  Experimental learning theory
    b  Social learning theory
    c  Social development theory



文献タイトル:日本の医療 制度と政策
発行年:2011, 東京大学出版会

序章 問題の所在と分析視角

 老年従属人口は2005年30.5%(3.3人で1人を支える)、2030年 54.4%(1.8人で1人を支える)と急激に増加する。団塊の世代が2024年に後期高齢者となるからである。これに伴い多死社会が到来し2005年 108万人から2030年 160万人が死亡する。未婚の1人暮らし高齢者は2005年80万人から2030年 290万人となる。医療費は医療の進歩に伴い自然増があり、年率3%とすると2030年の国民医療費は78兆円(※2009年の国民医療費は36兆)。少子高齢化により経済成長立は引き下がり、年平均経済成長率が1%、医療費伸び率3%とすると、国民医療費のGDP比は2030年 12%程度となる(※2009年 10.6%)。

 ①医療の質、②アクセスの公平性、③コストが評価基準である。何を守り、何を攻めるか。日本の特徴としてa. 職域保険と地域保健の2階建てで国民皆保険を実現、b. ファイナンスは「公」、デリバリーは「私」中心、c. フリーアクセスの尊重、が揚げられる。これにはここに至る歴史がある。






※家庭医医療過疎地域で活躍し地域住民から高い評価を受けている実例として、島崎(2007)『医療等の供給体制の総合化・効率化に関する研究』(厚生労働科学研究補助金/政策科学推進事業 平成16-18年度総合研究方向書)より島崎(2007)「北海道更別村におけるプライマリ・ケアの実践とその効果評価」、及び中川貴史(2007)「公的有床診療所を運営維持していく必要性とその問題点-寿都町立寿都診療所の事例」が引用されている。