[Patient-centered medicine for tuberculosis medical services].Kekkaku 2012; 87(12):795-808K
The 2011 edition of Specific Guiding Principles for Tuberculosis Prevention calls for a streamlined medical services system capable of providing medical care that is customized to the patient's needs. The new 21st Century Japanese version of the Directly Observed Treatment Short Course (DOTS) expands the indication of DOTS to all tuberculosis (TB) patients in need of treatment. Hospital DOTS consists of comprehensive, patient-centered support provided by a DOTS care team. For DOTS in the field, health care providers should select optimal administration support based on patient profiles and local circumstances. In accordance with medical fee revisions for 2012, basic inpatient fees have been raised and new standards for TB hospitals have been established, the result of efforts made by the Japanese Society for Tuberculosis and other associated groups. It is important that the medical care system be improved so that patients can actively engage themselves as a member of the team, for the ultimate goal of practicing patient-centered medicine. We have organized this symposium to explore the best ways for practicing patient-centered medicine in treating TB. It is our sincere hope that this symposium will lead to improved medical treatment for TB patients. 1. Providing patient-centered TB service via utilization of collaborative care pathway: Akiko MATSUOKA (Hiroshima Prefectural Tobu Public Health Center) We have been using two types of collaborative care pathway as one of the means of providing patient-centered TB services since 2008. The first is the clinical pathway, which is mainly used by TB specialist doctors to communicate with local practitioners on future treatment plan (e.g. medication and treatment duration) of patients. The clinical pathway was first piloted in Onomichi district and its use was later expanded to the whole of Hiroshima prefecture. The second is the regional care pathway, which is used to share treatment progress, test results and other necessary patient information among the relevant parties. The regional care pathway was developed by the Tobu Public Health Center. It is currently being used by several other public health centers in Hiroshima. Utilization of these two pathways has resulted in improved adherence, treatment being offered at local clinics, shorter hospitalization and better treatment outcomes. 2. Patient-centered DOTS in Funabashi-city: Akiko UOZUMI (Funabashi-city Public Health Center) In Funabashi-city, all TB patients, including those with LTBI, are treated under DOTS which recognizes and tries to accommodate the various different needs of each individual patient. For example, various types of DOTS are offered, such as pharmacy-based DOTS and DOTS supported by caregivers of nursing homes. This enables public health nurses to take into consideration both the results of risk assessment and convenience for the patient, and choose DOTS which most effectively support the patient. Furthermore, DOTS in principle is offered face-to-face, so that DOTS providers may not only build relationship of trust with the patient, but also to collect and analyze the necessary information regarding the patient and respond timely when problems arise. Such effort has directly contributed to improved default and treatment rate. 3. Hospital DOTS and clinical path for the treatment of tuberculosis: Kentaro SAKASHITA, Akira FUJITA (Tokyo Metropolitan Tama Medical Center) We introduced a version of hospital DOTS at Tama Medical Center (formerly Fuchu Hospital) in 2004. As part of this three-stage version, patients are allowed to progress to the next stage if they meet the step-up criteria. Following the introduction of this hospital DOTS, the occurrence of drug administration-related incidents decreased and support for patient adherence became easier for health care workers than before. In 2006, we developed a clinical path based on this hospital DOTS with consistent eligibility criteria for patients. This clinical path helped increase the efficiency of medical services in the TB ward. In conclusion, a patient's initiative for tuberculosis treatment can be supported through our hospital's TB treatment system. 4. Survey of TB patients' understanding and satisfaction of hospital DOTS: Yoko NAGATA, Minako URAKAWA, Noriko KOBAYASHI, Seiya KATO (Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association) We surveyed the satisfaction and understanding of recently discharged TB patients regarding DOTS to analyze how to better implement DOTS. The questionnaire consisted of nine items covering knowledge of TB, comfort in talking to and asking questions of the medical staff, explanations given to family members, and motivation for continuing medication. Two hundred and eight of the 228 patients who accepted the questionnaire responded (response rate: 91.2%). The level of understanding and satisfaction tended to be higher among patients in hospitals that employed a primary nursing system, more coverage and duration of DOT, and audiovisual materials for patient education. The level of understanding and satisfaction also tended to be slightly higher among institutions that conducted in-hospital conferences and collaborated with public health centers more frequently. 5. Medical cooperative system against tuberculosis elimination: Dai YOSHIZAWA (Tuberculosis and Infectious disease control division, Ministry of Health, Labour and Welfare) There are 3 points we should consider. First, despite one of the intermediate burden countries, emphasis for infectious incidence is insufficient. Besides new incidence decreases gradually, increased ratio of the elderly causes necessity of implementation against each complications. The second is how find infectious one, especially from high burden countries, before they spread it. Final, unspecific symptoms suffer the patients and medical staff. It's the key of implementation that spread of tuberculosis must be caused by delayed diagnosis.