A study on the contribution of medical expense disclosure to patient satisfaction

わが国での医療の質の向上に対する取り組みは,病院機能評価や様々な満足度調査,医療の情報開示をはじめとして盛んに行われてきているが,診療情報の開示と病院の満足度の関連についての研究はない.本研究では,診療録開示の中でも特に診療費に焦点を当て,診療報酬明細書開示や診療費の情報提供に対する患者の意識と患者満足度の関連を明らかにし,今後の患者への情報提供について検討するものである.本研究は,調査対象施設に来院した外来患者とその付き添いの者に対し,診療費に関する意識・医療費の情報提供・患者満足度に関する自記式質問紙調査を行った.得られた回答より,559名を有効回答とし,診療費に関する情報提供の意識と満足度の関連を分析した.その結果,下記のような結果が得られた.1)病院全体への満足度に最も寄与したのは,「医師の説明」と「看護師の技術と能力」と「院内の待ち時間」であった.2)65%の患者が詳細な明細書を必要とし,その理由は診療内容を知る目的であった.3)詳細な明細書の要望は病院全体への満足度に関連していた.今後,明細書に記載される内容として,レセプト開示が患者の求めている情報になるかを明らかにする必要がある.Approaches to improve the quality of medical service have been studied in Japan by investigating patient satisfaction, the disclosure of their medical records and others. On the other hand, there have been no research studies on the relationship between patient satisfaction and the disclosure of the details of payment for medical services. In this study, we focused especially on medical expenses and investigated whether the disclosure of the details of payment contributed to patient satisfaction. We carried out a questionnaire to be filled out of out-patients and their attendants on patient satisfaction and the disclosure of the details of payment, and obtained 559 valid replies. The results of the statistical analysis were as follows: 1)The factors that contributed most to patient satisfaction were physicians' explanations, the skill and the competency of nurses, and waiting time. 2)65% of patients requested a detailed receipt, the main reason being to know the details of medical treatment. 3)The request for a detailed receipt (a break-down of payment for medical services) was also associated with satisfaction with the hospital as a whole. These results revealed the possibility that disclosing the details of payment for medical services could contribute to patient satisfaction. They also suggested the necessity of further studies on medical record disclosure and the actual informational needs of patients.広島保健学学会 特別講

The Association of Percent Body Fat using Multi- frequency Bioelectrical Impedance Method and Various Indices from a Medical Examination in Japanese Adults

本研究は, 多周波数インピーダンス法による身体組成値と健康診断成績による生活習慣病危険因子との関連を検討した。対象は, 健康診断時に調査に同意の得られた18～84歳の男性383名, 女性454名であった。身体組成値は, 2.5～350kHzの周波数のインピーダンス値を140点で測定できる多周波数インピーダンス機器(MLT-100)により測定した。健康診断成績は, aspartate aminotransferase(AST), alanine aminotransferase(ALT), 血清総コレステロール(TC), HDLコレステロール(HDL), 中性脂肪(TG), 空腹時血糖(FBS), 収縮期および拡張期血圧(SBP, DBP)を用いた。体脂肪率高値群での除脂肪組織量の値は18～29歳の男性を除いて体脂肪率正常値群での値との差を認めないが, 脂肪組織量, body mass indexの値は体脂肪率正常値群での値に比べ高くなった。また, 体脂肪率と健康診断成績との関係では, 性別や年齢によりどの項目と相関するかは異なるが, 体脂肪率高値群では正常値群に比べ, 男性ではAST値, ALT値, TG値, 女性ではSBP値, DBP値が有意に高く, 男女ともHDL値が有意に低くなった。したがって, 体脂肪の高値は糖尿病や高血圧症, 脂質代謝異常などの疾患と共存する可能性が示唆され, 体脂肪率を測定することは医療や健康管理において有用な指標となると考えられた。We investigated percent body fat (%fat) using multi-frequency impedance method and discussed the correlation with medical examination values. The subjects were 379 males (39±15 years) and 398 females (45±18 years), aged 18 to 84 years. Each person was previously informed about the purpose of this study. Body composition was measured by multi-frequency impedance instrument using 140 points frequency 2.5 to 350 kHz (MLT-100,Sekisui). Medical examination was assessed by values of aspartate aminotransferase (AST), alanine aminotransferase (ALT), total cholesterol (TC), high density lipoprotein cholesterol (HDL), triglyceride (TG), fasting blood sugar (FBS), systolic blood pressure (SBP) and diastolic blood pressure (DBP). The relation between the %fat value and medical examination values were interlaced with various factors such as age and sex. In high %fat groups except for males aged 18 to 29 years, the median values of fat mass and body mass index were higher than those in normal %fat groups, and there was no difference in the median value of fat free mass between the two groups. In high 0.000000AT groups, the median values of AST, ALT, TG for males and SBP, DBP for females were higher than those in normal %fat groups. In high %fat groups, the median values of AST, ALT, TG for males and SBP, DBP for females were higher than those in normal %fat groups. In high %fat groups, the median values of HDL for males and females were lower than those in normal %fat groups. These results suggest that higher body fat individuals are related to life style, dependeing on the diseases. It was concluded that measuring %fat will be useful to screan for medical and health checks

The subjective experience of the recovery process for stroke patients : From acute to recovery period

本研究の目的は,脳卒中患者の回復過程における主観的体験を明らかにすることである.Grounded Theory法を参考にした質的帰納的研究を行った.74歳以下の脳卒中発作(初発)で緊急入院した患者のうち,入院直後におけるFIM79点以下,言語コミュニケーション可能で痴呆のない12名を分析対象とした.発症1週間以内から約6ヶ月後まで関わり,継続してインタビューを行った.分析の結果,回復過程に沿って《了解不能》《実感》《喜び》《アンビバレンス》《新たな価値》という意味の変化の局面と,それぞれの局面に一時的に落ち込む《落胆体験》があり,その発生時期と頻度の相違により合計5つの回復のパターンが認められた.従来,《落胆体験》は,リハビリテーションを妨げるマイナス要因とされてきたが,本研究においては《落胆体験》から立ち直った後に元の局面に戻るのでなく新たな局面に移行することが認められた.よって《落胆体験》は,回復を促進する契機と捉え,それを支える看護援助の重要性が示唆された.The purpose of this research is to clarify recovery subjective experiences of stroke patients.Qualitative inductive research was performed using Grounded Theory as a reference. The subjects of the study were twelve patients who were urgently admitted to the hospital for seizures associated with stroke (first incidence) at 74 years of age or younger, who had a score less than FIM79 immediately after being admitted to the hospital, and who were able to verbally communicate without dementia. Interviews were consistently performed from within 1 week of the occurrence of the stroke for approximately 6 months. The results of the study showed that there were a total of 5 patterns of recovery based on changes in the aspects of "lack of comprehension", "actually feeling", "happiness", "ambivalence", and "new values", as well as the timing and frequency of periods of temporary despondency during each of these aspects. Conventionally, bouts of despondency have been considered a negative factor that hinders rehabilitation, but in this study, it was seen that after overcoming a bout of despondency, the patient not only recovered to the original level, but was able to proceed to a new level. Therefore, bouts of despondency can be perceived as an opportunity to promote recovery and suggest the need to support that opportunity with nursing care

Multi-frequency Bioelectrical Impedance Method for the Assessment of Body Composition in Japanese Adults

多周波数生体電気インピーダンス(BI)法による日本成人の身体組成の標準値を設定する目的で, 体脂肪率(0.000000AT)および体水分量(TBW), 細胞外液量(ECW), 細胞内液量(ICW)の年代間の比較検討を行った。調査に同意の得られた18～84歳の日本成人2,034名(男性1,022名, 女性1,012名)を対象に, 多周波数インピーダンス機器(積水化学工業社MLT-100)により身体組成を測定した。%FATとBMI(body mass index)の相関はすべての年代群で有意に高くなった。BMI=22kg/m^2(22×体重/身長^2)に相当する%FAT値は, 男性21.2%, 女性32.4%となった。男性の%FAT判定の標準範囲は, 10および20歳代で13.8～22.4%, 30～70歳代以上で22.7～30.1%であり, 肥満値は, 10および20歳代で25.1%以上, 30～70歳代以上で32.2%以上であった。女性の標準範囲は, 10～40歳代で23.1～31.6%, 50～70歳代以上で31.1～39.6%であり, 肥満値は, 10～40歳代で33.9%以上, 50～70歳代以上で41.4%以上であった。%TBW平均値およびICW/TBW平均値は, 男女とも加齢に伴い減少し, ECW/TBW平均値は男女とも加齢に伴い増加した。本研究では, 多周波数BI法による%FATの年齢別の標準値を示した。また, 体脂肪および体水分は, 加齢に伴い変化することが示唆された。We determined body composition of Japanese adults using multi-frequency bioelectrical impedance measurements (MBI) in order to clarify age-related changes in percent body fat (%FAT) and body water distribution (TBW, ECW, ICW). The subjects were 1,022 males and 1,012 females 18~84 years of age. Each person was informed as to the purpose of the study. Body composition was measured by a multi-frequency impedance apparatus (2.5 to 350 kHz, 100 μA). Analysis of variance was used to test for differences between age groups in each gender. Percent body fat showed high correlation with body mass index in all age groups. The average %FAT increased with age in both genders. Percent body fat in the 25~75 percentiles was 13.8~22.4% in males 18~29 years of age, and 22.7~30.l % in males 30~81 years of age. Among the females, the corresponding values were 23.1 ~31.6% for 18~49 years of age and 31.1 ~39.6% for 50~84 years. In both genders, significant decreases in %TBW and ICW/TBW, and a significant increase in ECW/TBW were observed with age. These data suggest that there is a definite gender difference in age-related changes in %FAT and body water distribution

Regulation of Mitochondrial Dynamics and Neurodegenerative Diseases

Mitochondria are important cellular organelles in most metabolic processes and have a highly dynamic nature, undergoing frequent fission and fusion. The dynamic balance between fission and fusion plays critical roles in mitochondrial functions. In recent studies, several large GTPases have been identified as key molecular factors in mitochondrial fission and fusion. Moreover, the posttranslational modifications of these large GTPases, including phosphorylation, ubiquitination and SUMOylation, have been shown to be involved in the regulation of mitochondrial dynamics. Neurons are particularly sensitive and vulnerable to any abnormalities in mitochondrial dynamics, due to their large energy demand and long extended processes. Emerging evidences have thus indicated a strong linkage between mitochondria and neurodegenerative diseases, including Alzheimer's disease, Parkinson's disease and Huntington's disease. In this review, we will describe the regulation of mitochondrial dynamics and its role in neurodegenerative diseases

Bacteremia Derived from Clinical Materials on Blood Culture and Catheter Tip after Intravenous Infusion Therapy in a University Hospital

中心静脈内にカテーテル(以下CVCとする)を挿入して行う輸液管理は重症患者への医療には欠くことの出来ないものとなっている一方, カテーテル留置に伴う血流感染の危険性は高い。大学病院におけるCVC由来血流感染症の実態を明らかにするため, 1996年1月から1998年12月までの3年間に広島大学医学部附属病院での各診療科別にみた微生物検査室へのCVCおよび血液の培養依頼状況およびその結果を明らかにした。本調査ではCVCおよび血液の培養の原因菌が一致し, それらの症例について, 薬剤感受性やカルテの内容からCVC挿入が血流感染の直接的な原因になっていたか否かを検討することによりCVC由来菌血症と定義した。血液およびCVCの検査依頼総数は2,233件, 菌検出検体は283件, 検出率は12.7%であった。3年間に検出された菌種の過半数は, 血液およびCVC共にグラム陽性球菌であった。診療科により検出される菌の種類, またその数の違いが見られており, 外科系においてはグラム陽性菌の検出数が多く, 内科系ではグラム陰性菌の検出数が多い傾向が見られたが, 統計的な有意差は認められなかった。血液とCVCから同種の菌検出が認められた症例は13件であり, 1996年に6件, 1997年に5件, 1998年に2件であった。これらの症例を検討した結果, 明らかにCVC由来感染と考えられたものは各年毎2例であり, 原因菌以外の操作中の汚染として見過ごされがちなCoagulase negative-staphylococciが多く見られた。これらのことから, CVC由来血流感染を防止し, 患者の生命予後を改善していくため, CVCを用いた輸液管理に関する正しい理解と正確な技術に基づいたルート管理の必要性が考えられた。To clarify the contamination pattern of samples from central venous catheter tip and blood, all submitted materials by each clinical department from Jan. 1996 to Dec. 1998 were summarized the contaminated cases were determined whether to be catheter-related bacteremia or not. Positive samples were counted as well as those in which bacteria were matched between the catheter tip and the blood. We further checked the later cases from the viewpoint of antibiotic sensitivity and other information in the clinical chart to decide whether the patient had catheter-related bacteremia or not. The total sample materials were 2,233,including 283 (12.7%) bacteria-positive samples. More than halves of the bacteria specimens were gram positive cocci. Detected bacteria differed according to the clinical department. More of the bacteria were gram positive cocci than gram-negative bacilli, the former dominant in the surgical departments than the latter in the non-surgical departments. But these difference were not significant statistically. In thirteen cases, the same bacteria were detected in both the central venous catheter tip and the blood, including six cases in 1996,5 cases in 1997,and 2 cases in 1998,and definitive catheter-related bacteremia was found in 2 cases each year. The other 11 cases were coagulase negative-staphylococci and thought to be contaminated during the sampling maneuver. The medical staff always should keep in mind to improve the patient outcomes by reducing catether-related infections. We must thus have appropriate knowledge and technical skills for catheter administration

Differencial Diagnosis of an Abdominal Tumors of Uncertain Origin Using Fine Needle Aspiration Biopsy (FNAB)

FNAB under ultrasonic guidance was performed on 14 cases with abdomical tumors of uncertain origin. All of them could not be clarified their relationship with the liver, the biliary tract, the pancreas or the alimentary tract by routine clinical exams including diagnostic imaging such as CT and Ultrasonography. Preoperating histological diagnosis has been obtained for 12 of these by FNAB, thus diagnostic rate being 85.7%. The details of tumors identified by autopsy and operations were: 3 cases of lymphoma; 3 cases of leiomyosarcoma; 4 cases of adenocarcinoma; 2 cases of hematoma; and 1 case of inflammatory mass. Non-epithelial tumor was most frequently observed. FNAB is a simple diagnostic method with high cost-effectiveness for determining the therapeutical plan for an abdominal tumor of uncertain origin which is encounted in the daily treatment

Gastric Mucosal Lesions in Cases of Nonshunting Procedures for Esophageal Varices

Gastric mucosal lesions in 74 patients with esophageal varices for whom the nonshunting procedure was given in our institute from 1973 to 1983 were studied. Out of 9 patients of operative death, the direct cause of death in 2 patients was acute gastric mucosal lesion (AGML), and both patients belonged to Child C according to Child's Classification. The rate of complication of gastric mucosal lesion before operation was 42%, while it was 64% after operation, and all cases were complicated with liver cirrhosis. Among 31 cases in whom the condition before and after operation in the same case was compared, and found that gastric mucosal lesions were aggravated after operation in 12 patients (39%). The rate of post-operative aggravation of gastric mucosal lesions classified by the surgical formula was 18.8% of esophageal transection, and in comparison Hassab's operation was a high as 61.1%. In patients with liver cirrhosis, the defensive factors of the gastric mucosa had been reduced. Hassab's operation which changes the gastric mucosal blood flow by periesophago-gastric devascularization has a high possibility of aggravating gastric mucosal lesions

Surgical Treatment for Insulinoma: a Study of 6 Cases

The authors treated six patients with insulinoma in our department during a period up to 1984, and performed seven operations including one re-operation. In this paper, the results of our study of the clinical symptoms, diagnosis and surgical formula in these cases are presented. Selective angiography and percutaneous transhepatic portal venous sampling (PTPVS) proved useful for pre-operative tumor localization diagnosis. Blood glucose monitoring during operation became a good index for the selection of the surgical formula. In the cases of surfacial and single tumors, enucleation alone was able to obtain satisfactory surgical results. In the cases, however, when re-operative, deep or multiple tumors were suspected, staged distal pancreatectomy under blood glucose monitoring was considered to be indicated. It was therefore thought that the preservation of the pancreas should be made as far as possible

A Case Report of Carcinoma Originating from Aberrant Breast Tissue

A case of breast cancer originating from accessory breast gland tissue is to be presented. Treatment included the subcutaneous removal of the upper half of the mammary gland and the dissection of axillary lymphnodes. As the incidence of aberrant breast carcinoma is rare, a definite prognostic conclusion can not be made at this point. But follow up (5 years) in our case without recurrence will prove that it is enough when the masses were not palpable within the breast