[Follow-up discussion on restructuring the medical-service system].Kekkaku 2012; 87(12):809-19K
The Japan Tuberculosis Society organized symposia on restructuring the medical-service system at the 84th and 86th annual meetings. These symposia clarified the following issues and concerns. It is becoming difficult to maintain tuberculosis beds in wards in many areas, since beds required for tuberculosis are declining due to the decreasing incidence of tuberculosis and shortened hospitalization periods. The extremely poor profitability of medical practices has caused closure of tuberculosis wards. A highly urbanized area may have a shortage of tuberculosis beds, while some rural areas have the problem of poor access to hospitalization. Aging of tuberculosis patients causes an increase in the number of patients with serious complications that are sometimes difficult to treat within a prefectural jurisdiction. Infection control for multi-drug resistant tuberculosis needs to be solid. To address these issues and challenges, it will be necessary to restructure the medical-service system for tuberculosis. The Prevention Guideline addressed in May 2011 by the Ministry of Health, Labour, and Welfare mentions that the medical-service system should seek to ensure enough tuberculosis beds and to realize patient-centered medical service. The future directions should be 1) ensuring a core hospital for tuberculosis treatment at the prefectural level, 2) ensuring a principal hospital for treating tuberculosis patients with serious complications in an area, 3) ensuring the treatment environment is suitable to individual patient conditions, 4) formulating a regional coordination mechanism with a core hospital at the center in each area, and 5) achieving complete infection control. This symposium was organized based on discussions in the previous symposia to present points necessary to realize the future medical-service system described in the Prevention Guideline. When constructing a new hospital or renovating a ward, attention must be paid to infection control and amenities for tuberculosis patients whose hospitalization is often longer than patients of other diseases. There is no official standard for a facility with tuberculosis beds at this moment. Professor Atsuo Kakehi, a hospital architectural expert, discussed the points in a draft of the standard he proposed in his report. Aging of tuberculosis patients increases the number of patients with serious complications. Ensuring medical service for such patients is a major challenge. The new National Hospital Organization Hokkaido Medical Center was built in March 2010 with tuberculosis wards. Dr. Arisu Kamada reported on infection control and medical practice for patients with serious complications in a general hospital. Psychiatric diseases including senile dementia are among the largest problems among tuberculosis complications. The National Hospital Organization Kamo Psychiatric Center, which has model beds for tuberculosis, produced successful outcomes by collaborating with the National Hospital Organization Higashihiroshima Medical Center tuberculosis hospital. Dr. Masahiro Nomura reported on the implementation of DOT and regional collaboration as well as medical practice in his hospital. An important point in the National Guideline is regional collaboration. Dr. Tadatoshi Suruda from the National Hospital Organization Wakayama National Hospital discussed the status and outcomes from their regional collaboration system in Wakayama Prefecture, the top runner in this area. Thanks to solid presentation from the speakers and thoughtful comments from the floor, the symposium was very useful for promoting patient-centered medical service, a keyword in the National Guideline. 1. Environment of hospital beds for treating TB patients: Atsuo KAKEHI (Department of Architectural Design, School of Architecture, Kogakuin University) It is becoming more difficult to configure wards since the number of tuberculosis beds is decreasing. It is therefore necessary to mix general beds and tuberculosis beds in one ward, making it necessary to develop criteria for designing facilities as part of a general ward for isolated space. This paper describes the current care environment of tuberculosis patients and the draft guidelines for a more appropriate hospital environment. 2. Treatment to complications in the patients in the tuberculosis hospital: Arisu KAMADA (National Hospital Organization Hokkaido Medical Center) Recently, many patients with tuberculosis, especially the elderly, have been exhibiting various complications. It is often difficult to treat complications at a tuberculosis hospital, especially at the old sanatorium hospital. Our hospital is both a tuberculosis hospital and a general hospital in which various complications can be treated. However, such general hospitals are very rare in Japan. Many patients passed away immediately after transferring to a tuberculosis hospital due to inadequate treatment of complications. To avoid repeating such tragedies, continuing treatment of complications without transferring to a tuberculosis hospital should be considered. Kamo Psychiatric Center has eight model beds for tuberculosis patients with psychiatric diseases. We retrospectively studied 71 cases of hospital DOTS from 2006 to 2011. There were 33 dementia cases and 30 schizophrenia cases. The standard regimens (A or B) were performed for 68 of the 71 cases. The median duration of hospitalization was six months. Some schizophrenia cases taking antipsychotic medications experienced worse mental symptoms when they started tuberculosis treatment. 4. Medical collaboration for tuberculosis patients' care in region: Tadatoshi SURUDA (National Hospital Organization Wakayama National Hospital) Complete medical collaboration for tuberculosis patients' care is possible by close cooperation utilizing coordination tools such as the regional critical path among TB hospitals, other medical facilities, welfare organizations, and health centers that function as a coordinator in an area. TB hospitals and health centers, both major role players in the collaboration scheme, should maintain good ties and share responsibilities. Through establishing close collaboration, medical service for TB patients will be a part of primary practice. It is expected to raise TB awareness among general medical staff and result in early case detection in the area.