Patient-centered care, advance care planning, and treatment preferences among home medical care patients in Japan: The ZEVIOUS study

BackgroundIt remains unclear how both the quality of patient-centered care and the patient’s illness affect advance care planning (ACP) in primary care settings. Identifying the facilitators and barriers to ACP in primary care settings has become a growing scientific and clinical challenge.ObjectiveTo examine the association between the quality of primary care and ACP preparedness among patients. Additionally, to investigate whether ACP preparedness and the patient’s illness are associated with the expression of future treatment preferences.DesignMulticenter cross-sectional study.ParticipantsAdult Japanese patients receiving home medical care.Main MeasuresA survey was run to assess consideration of ACP by patients and expression of future treatment preferences. The quality of primary care, which reflects patient centeredness, was assessed with the Japanese version of the Primary Care Assessment Tool– Short Form. Information on the clinical conditions that required home medical care was collected from physicians.Key ResultsOf 194 patients using 29 home medical services, 62 patients (32%) showed signs of ACP preparedness, and 153 patients (78%) expressed their treatment preferences. In a multivariable-adjusted generalized estimating equation, primary care quality was associated with ACP preparedness (per 10-point increase, adjusted OR: 1.96, 95% CI: 1.51–2.56). However, we found insufficient evidence to support that ACP preparedness was associated with a lower incidence of non-expression of treatment preferences (adjusted OR: 1.02, 95% CI 0.49–2.12). In contrast, having cancer was associated with a lower incidence of non-expression of treatment preferences (adjusted OR: 0.12, 95% CI: 0.01–0.995).ConclusionsAt a minimum, patient centeredness in home medical care facilitates must ensure the initiation of ACP preparedness. To understand the association between ACP preparedness and expression of treatment preferences, further efforts are warranted to clarify the quality and content of ACP preparedness simultaneously with the patient’s illness.

Real-World Data on Home End-Of-Life Care for Elderly Cancer Patients: A Yokohama Original Medical Database-Based Retrospective Analysis

Background Cancer incidence is expected to increase with population aging, making the availability of places for treating terminal cancer patients a pressing issue. Thus, home medical care is expected to play a crucial role. However, real-world big data on the actual state of home end-of-life care in Japan are limited. We aimed to clarify the real-world state of home end-of-life care for elderly cancer patients using data from an administrative database. Methods We analyzed the Yokohama Original Medical Database, which included 2,486,834 people and 29,411,895 medical invoices in 2014 and 2015. Data of target patients were extracted based on three criteria: age ≥ 65 years, malignant neoplasm diagnosis, and having a billing code of home end-of-life care. Medical fee points, including data related to home medical care, emergent admission, and survival time at home, were also analyzed. Results Overall, 1,323 people (554 and 769 aged < 80 and ≥ 80 years, respectively; males, 59.2%) had planned to receive home end-of-life care. The < 80-year group had more frequent emergent home visits than the ≥ 80-year group (p < 0.001), but the number of monthly home visits was similar between the two groups (p = 0.267). The average overall survival time at home was 3.9 ± 4.4 months, with the < 80-year group having a shorter survival time than the ≥ 80-year group (p < 0.001). Conclusions Terminal cancer patients aged ≥ 80 years were less dependent on home medical care and had better prognosis at home than terminal cancer patients aged < 80 years did. Our results can provide the basis for providing home medical care through a community-based integrated care system and for evidence-based policymaking.

Wernicke encephalopathy in a lung cancer patient receiving home medical care

Objective Cancer patients often want to spend their final days at home, and it is essential that general practitioners have knowledge of and technical skills related to cancer medicine and symptom relief. Recent clinical studies have revealed that Wernicke encephalopathy (WE) is quite common in cancer patients. However, there have been no reports to date on WE in cancer patients undergoing home medical care. Methods From a series of cancer patient undergoing home medical care, we reported a patient with lung cancer who developed WE. Results An 84-year-old female with lung cancer undergoing home medical care developed an impaired mental state and an attention deficit. Her symptoms fulfilled the diagnostic criteria for delirium. WE was suspected as the patient's food intake had fallen from normal a month previously to somewhere between 50% or just a few mouthfuls. This diagnosis was supported by abnormal serum thiamine and the disappearance of delirium after thiamine administration. Significance of the results When delirium occurs in cancer patients undergoing home treatment, it is necessary to suspect thiamine deficiency as a potential cause, as appropriate diagnosis and treatment can prevent irreversible brain-related sequelae.

Evaluation of a New Home Patient Services Practicum for Community Pharmacy Students in Japan

This study aimed to evaluate the usefulness of the practicum as well as assess the knowledge, skills, and various specific realizations that the students gained from it. A total of 244 students role-played a scenario in which a pharmacist visited a patient at home and provided pharmaceutical management services. After completing the practicum, the students completed (i) a questionnaire survey consisting of six questions that assessed their level of understanding of the role of pharmacists in home medical care and (ii) a rubric survey that evaluated their learning achievement. In addition, they submitted practicum portfolios describing the patients’ living conditions, physical conditions, and background as well as the services that required consideration of said variables. Their responses to the portfolio item “What were noticed through the practicum” were analyzed using the grounded theory approach. After the practicum, 45% and 53% of the students reported having a full and partial understanding of a pharmacists’ role in home medical care. The students’ mean ± standard deviation rubric score was 3.0 ± 0.4. They classified monitoring drug use, support for improving medication adherence, and observation to identify side effects early as major service categories in home medical care. The practicum led the students to perceive the need for communication with patients and various healthcare professionals to improve their readiness for practical training.

Safely replacing a percutaneous endoscopic gastrostomy tube using a portable X-ray system at a patient’s home

An 81-year-old woman who underwent percutaneous endoscopic gastrostomy (PEG) a year before, after cerebral infarction was receiving home medical care. The first accidental PEG tube removal occurred after clinic hours, and the home-care doctor visited her home to quickly reinsert the tube. After the narrowed fistula was dilated, the tube was reinserted with a guide wire. An X-ray taken with a CALNEO Xair, which is an easily portable X-ray system launched in 2018, confirmed that the tip of the PEG tube was successfully placed in the stomach. A similar accidental removal occurred 2 months later, and we managed it in the same way. Both events were resolved with a single radiograph without significant difficulty. With in-home medical care, PEG tube replacement can be performed easily and safely with a handy portable X-ray system.