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quality of primary care in Japan, we need vigorous ... although it has significant importance in the healthcare system. Therefore, it is inevitable for primary care.
Journal of General and Family Medicine

2016, vol. 17, no. 4, p. 267–269.

Editorials

Improving Quality of Care through Primary Care Research Machiko Inoue, MD, MPH, PhD Associate Editor, JGFM

This issue of Journal of General and Family Medicine

behavioral, or socioecological, in practice settings or in

covers a variety of topics in original articles, reviews, case reports, and more, from which readers can learn

a population, would be a pursuable area for primary care researchers. Thinking about the topics and

and apply the knowledge in clinical care. Since the

questions that primary care researchers could pursue

research topics in general and family medicine cover a vast field, residents, primary care physicians, and other

would yield a niche in the field. The second tip is to keep the principles of primary care

health professionals who are starting out in research might consider it hard to find a suitable topic to pursue

in mind and revisit them when you are unsure what could be done to recognize the care gap. These

at first. Infinite opportunities abound, and Japan’s primary care medicine lacks evidence obtained from

principles include accessible, comprehensive, coordinated, continuous, and patient-centered, as well as

practice settings, and thus we are unaware of how wide

family- and community-oriented care. In Japan, how-

an evidence-practice gap may exist. To improve the quality of primary care in Japan, we need vigorous

ever, ways to define, assess, and improve the quality of primary care have not yet been established. This is

research conducted within primary care practices. In this editorial, I suggest some tips to help early-stage

partly due to a long history where general medicine/ family medicine has not been recognized as a specialty.

researchers in primary care to generate research

The value and role of primary care are still ambiguous

questions. The first is to pay attention to the quality of care at your own practice or in other settings, and

for patients, healthcare providers, and the public, although it has significant importance in the healthcare

discern any gap between ideal care based on established evidence or suggested by guidelines as “stand-

system. Therefore, it is inevitable for primary care academics to define the standard for primary care

ard,” and the care actually provided at the practice. Any

according to its principles. By doing so, the existence

gap in care that should be narrowed or eliminated as far as possible implies measures toward a solution should

of “gaps in care” could be assessed and efforts toward quality improvement (QI) could take place.

be sought. Practice-based research questions arise from those gaps, along with any uncertainty physicians and

Looking at the recent primary care reform in the United States would provide Japanese researchers some

staff are experiencing. Such gaps have the potential to

insights to think about a framework to reinforce QI in

offer learning opportunities as well as research questions. Moreover, translational or implementation

primary care. Fifteen years ago, the Institute of Medicine (IOM) in the United States issued a keystone

research for an intervention, whether pharmaceutical,

report, “Crossing the quality chasm: A new health

Corresponding author: Machiko Inoue, MD, MPH, PhD Beth Israel Deaconess Medical Center, Harvard Medical School © 2016 Japan Primary Care Association

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Journal of General and Family Medicine

2016, vol. 17, no. 4

system for the 21st century”.1 Since then, pursuit of higher quality and better safety in health care has been

research. The PCMH practices in the United States employ periodic surveys of their patients’ experiences

recognized as a compelling issue, more than ever, and has been discussed along with the sustainability of

with their practice, as an indicator of patient-centeredness. The survey results are utilized for evaluating and

health. In the report, the IOM defined quality of care as

further improving the quality of care. In addition,

following six aims: care should be safe, effective, patient-centered, timely, efficient, and equitable. Im-

involving patients and their families as advisors in QI activities at PCMH practices is recommended. Some

plementation of various polices, including the Affordable Care Act, in terms of primary care, and redesign of

Japanese primary care practices are collecting patient satisfaction data, but whether patients are experiencing

the delivery model by putting into effect the Patient-

the care that a practice should provide may not be

Centered Medical Home (PCMH), have brought a major paradigm shift for primary care practices,

assessed thoroughly enough to change and improve the quality of care. As a starting point for quality

requiring them to have a systematic focus on QI and safety.2 PCMH attempts to shift the medical paradigm

assessment from the perspective of patient-centeredness, conducting a patient survey is a viable option for

from the care of an individual patient by physicians to

primary care researchers. The PCMH initiative uses

care by a team of providers with coordination and communication for various populations. A number of

“the Consumer Assessment of Healthcare Providers and Systems (CAHPS)” surveys to assess patient

tools and external supports for implementing the PCMH were developed and became available for

experiences and create a database.6 To assess patient experiences in primary care practices or for a

primary care practices’ use. External supports for QI include data feedback and benchmarking, practice

population in Japan, a Japanese version of the Primary Care Assessment Tool (JPCAT), a 29-item survey that

facilitation, expert consultation, and learning collabo-

covers five primary care principles, was developed and

2

ratives. Recognition by the National Committee on Quality Assurance (NCQA) has further pushed forward

made available for use.7 Patient-centeredness is not only an important core concept in primary care, but it

the transformative process taking place at practices, which defines the criteria for PCMH practices from

should be practiced as part of a system-based approach, as a measurable entity, in every practice. A first step to

level 1 to 3, with incentives to actively improve the

assessing the quality of care provided in a practice

quality of care and to meet the criteria to earn the recognition of level 3. The NCQA PCMH 2014

could be made from this aspect. With the three suggestions mentioned above, I would

recognition is based on the following six standards: patient-centered access, team-based care, population

encourage investigators to think outside the box, learning from the primary care movement in various

health management, care management and support,

countries, and pursue research to advance the quality of

care coordination and care transition, and performance measurement and quality improvement. Recent studies

primary care in Japan.

show that the implementation of the PCMH model has had some impact on the quality of primary care; it was

References 1 Crossing the Quality Chasm: A New Health

associated with improved cancer screening rates,3

System for the 21st Century. In. Washington (DC):

increased accessibility and patient-physician communication,4 and modest improvement in healthcare

Institute of Medicine (US) Committee on Quality of Health Care in America. 2001.

utilization.5 These efforts and achievements in U.S. primary care practices provide Japanese primary care

2 Quality Improvement in Primary Care - External supports for practices [http://www.ahrq.gov/research/

researchers some implications for practically imple-

findings/factsheets/quality/qipc/index.html].

menting QI within a healthcare system. Third, assessing the impact on patient-centered out-

3 Markovitz AR, Alexander JA, Lantz PM, Paustian ML: Patient-centered medical home implementation

comes would be an essential approach in primary care

and use of preventive services: the role of practice

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Improving Quality of Care through Primary Care Research

socioeconomic context. JAMA Intern Med. 2015; 175: 598–606.

care quality and utilization: a 5-year cohort study. Ann Intern Med. 2016; 164: 395–405.

4 Shi L, Lock DC, Lee DC, et al: Patient-centered medical home capability and clinical performance in

6 CAHPS Surveys and Tools to Advance PatientCentered Care [http://www.ahrq.gov/cahps/index.

HRSA-supported health centers. Med Care. 2015; 53:

html].

389–395. 5 Kern LM, Edwards A, Kaushal R: The patient-

7 Aoki T, Inoue M, Nakayama T: Development and validation of the Japanese version of Primary Care

centered medical home and associations with health

Assessment Tool. Fam Pract. 2016; 33: 112–117.

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