Regional Variance of the Early Use of Tolvaptan for Autosomal Dominant Polycystic Kidney Disease

BackgroundThe development and prompt dissemination of the first drug against a particular disease can contribute to improvements in national health status and medical economy end points and are assumedly affected by socioeconomic factors that have yet to be analyzed. Tolvaptan, a vasopressin receptor 2 antagonist, was developed to treat hyponatremia, congestive heart failure, and cirrhosis ascites, although the approved indications may differ among countries. In Japan, high-dose tolvaptan tablets were approved as the first drug for autosomal dominant polycystic kidney disease (ADPKD) in 2014. This study aimed to better understand the factors that influence the total number of regional prescriptions of tolvaptan for ADPKD since its launch.MethodsThe National Database of Health Insurance Claims and Specific Health Checkups of Japan Open Data was used as a national claim-based database. In each of the 47 prefectures in Japan, the total prescribed number of 30 mg tolvaptan tablets between 2015 and 2017 was examined. The parameters explaining the prescription variation among regions were then examined by correlation analysis.ResultsPrescriptions for high-dose tolvaptan increased substantially 2 years after the drug’s approval; however, the increase differed by approximately 21-fold between regions. Population density was positively associated with prescribed 30 mg tolvaptan tablets per 1000 population in 2015 (r=0.47, P<0.001). In addition, the increase in prescribed number of tablets per 1000 population was correlated with population density in 2016–2017 (r=0.30, P=0.04).ConclusionsThis macro perspective analysis revealed an urban-rural inequity in prescriptions for the newly approved drug for ADPKD. Further studies are needed to elucidate the factors affecting the geographic variation.

Submucosal Myoma Treatment for Women Who Wish to have Children in the Future Nodule Dissection Centripetal Cutting Method of TCR (Transcervical Resection)

Due to the recent trend to marry later, patients with uterine myoma, and who wish to preserve their uterus have increased, are leading to greater demand for minimally invasive myomectomies. For intramural myomas and submucosal myomas, which are located near the uterine cavity, which are high risk for sterility or infertility, incision of the myometrium, and suture to the uterine cavity during laparoscopic myomectomy is required, and Caesarean section is frequently selected as the child delivery method. Hysteroscopic myomectomy is advantageous for persons wishing for pregnancy. The abdominal wall is not damaged, and there is less pain and a shorter hospital stay. Hysteroscopic myomectomy does not cause postoperative intraperitoneal adhesion, contraceptive period is shorter, and vaginal delivery is also possible. Since expensive disposal surgical instrument, surgery assistants are not needed, it also contributes to medical economy, and its widespread is desired. On the other hand, learning the technique is difficult, since unique complications may occur and only an endoscope in the specific field of vision, the uterine cavity is used for this procedure. If only cases with small submucosal myoma are indicated for hysteroscopic myomectomy, technical improvement and wider adoption will not occur. However, if the indication can be correctly recognized and a safe and accurate technique be acquired, adoption of hysteroscopic myomectomy could actually be widened. It is an excellent technique which can become mainstream for fibroid treatment.

The medical economy of makeshifts

This chapter tries to situate parochial medical welfare within the wider medical economy of makeshifts. It argues that paupers engaged in a three strand set of responses to illness in addition to their negotiation of parochial relief. Sometimes they explored medical avenues (for instance charitable treatment by doctors) which shadowed the response of parishes; sometimes they explored avenues which complemented parochial activity; and sometimes (for instance through self-dosing and self-help clubs) they explored avenues which substituted for parochial spending. The chapter concludes that the medical welfare traceable in Old Poor Law records was a small subset of that garnered by the poor.

The Metamorphosis of Managed Care: Implications for Health Reform Internationally

Many writers suggest that managed care had a brief life and that we are now in a post-managed care era. Yet managed care has had a long history and continues to thrive. Writers also often assume that managed care is a fixed entity, or focus on its tools, rather than the context in which it operates and the functions it performs. They overlook that managed care has evolved and neglect to examine the role that it plays in the health system.This article argues that private actors and the state have used managed care tools to promote diverse goals. These include the following: increasing access to medical care; restricting physician entrepreneurialism; challenging professional control over the medical economy; curbing medical spending; managing medical practice and markets; furthering the growth of medical markets and private insurance; promoting for-profit medical facilities and insurers; earning bounties for reducing medical expenditures; and reducing governmental responsibility for, and oversight of, medical care. Struggles over these competing goals spurred the metamorphosis of managed care internationally.