Comparison of Primary Care Experience in Hospital-Based Practices and Community-Based Office Practices in Japan

We wish to express our appreciation to Dr. Kaneko for their insightful comments on our paper entitled 'Comparison of Primary Care Experience in Hospital-Based Practices and Community-Based Office Practices in Japan' published in Annals of Family Medicine.

As noted by Dr. Kaneko, in Japan, there is no national data on the proportions of patients who visited hospitals and community-based offices which is limited to primary care. Therefore, we have simply compared our data with the national profile of overall outpatients.

Although in Japan, there is general consensus that the majority of community-based offices are solo practices, we agree that this point requires clarification. In our study, the proportion of community-based offices with solo practice (single full-time physician) was 84%. Participants of the previous report mentioned by Dr. Kaneko were only certified family physicians which are a small part of primary care physicians in Japan.

Reference 1. Aoki T, Yamamoto Y, Fukuhara S. Comparison of primary care patient experience in hospital-based and community-based office practices in Japan. Ann Fam Med. 2020;18(1):24-9. 2. Ikegami N. Japanese health care: Low cost through regulated fees. Health Aff. 1991;10(3):87-109. 3. Powell M, Anesaki M. Health care in Japan. Routledge. 2010.

Competing interests: None declared

We appreciate the thoughtful comments by Drs. Okada and Takahashi on our study entitled 'Comparison of Primary Care Experience in Hospital- Based Practices and Community-Based Office Practices in Japan' published in Annals of Family Medicine.

In the current study, community orientation score was lower for primary care in hospitals vs community-based offices. We made a hypothesis about the mechanisms of this result. We considered that a broader scope of practice of hospital primary care physicians might affect the poorer patient experience of community orientation in hospitals. Because primary care physicians in hospitals are engaged in inpatient care in addition to outpatient and home care in Japan.

It is a hypothesis and we can not verify it in the current study. Primary care physicians' scope of practice includes inpatient care, however, comprehensiveness domain of the JPCAT, which is a tool for outpatients in primary care, assess only the scope of practice in outpatient care.

We support the hypothesis of Drs. Okada and Takahashi that the higher distribution shift of work tasks toward inpatient care is competing with community-oriented work. Association between primary care physicians' scope of practice and shift of work tasks is naturally expected.

Further studies are needed to investigate the mechanism underlying the difference in community orientation scores between hospitals and community-based offices.

Reference 1. Aoki T, Yamamoto Y, Fukuhara S. Comparison of primary care patient experience in hospital-based and community-based office practices in Japan. Ann Fam Med. 2020;18(1):24-9. 2. Ie K, Ichikawa S, Takemura YC. Development of a questionnaire to measure primary care physicians' scope of practice. BMC Fam Pract. 2015;16(1).

Competing interests: None declared

We read the article by Takuya Aoki with great interest and appreciate the author's efforts to analyze the quality of primary care in Japan from a patient-centered perspective, comparing community-based office practices with hospital-based practices. However, we have a concern about patients' views on the first point of contact in hospital-based practices.

We would like to know whether the six hospitals included in this study have emergency departments that provide emergency after-hours care, as this would affect the meaning of the first point of contact in hospital -based practice. In Japan, around 45 % of all hospitals are designated as secondary or tertiary emergency medical hospitals by the municipal government and are supposed to provide 24-hour emergency care services and acute inpatient care.[1,2] The study showed that hospital-based practice was associated with improved patient experiences at first point of contact relative to community-based office practice. However, if the six hospitals had emergency departments and provided such emergency care services after hours, better patient experiences at first point of contact might simply result from better access to the emergency department. This would be opposite to the reduction in emergency department visits that the author expected. Therefore, it should be clarified whether the six hospitals had emergency departments and provided emergency care after hours. If hospitals with and without after-hours care were included in the study, providing the result of each group separately would help us to understand and appreciate the precise meaning of the point of first contact in hospital-based practice.

In conclusion, we should be aware that patient experiences at first point of contact may reflect access to emergency departments, in the context of hospitals that have emergency departments that provide emergency care services after hours. Identifying whether the study hospitals provide after-hours care would help us to identify if this is a factor in shaping patients' perceptions of "primary care".

References

1. Ministry of Health, Labour and Welfare. [Survey of Medical Institutions of Japan 2019]. Tokyo; 2019. Japanese. Available from: https://www.mhlw.go.jp/toukei/saikin/hw/iryosd/m19/dl/is1911_01.pdf

2. Ministry of Health, Labour and Welfare. [Current situations about emergency medicine in Japan]. Tokyo; 2018 [cited 2020 Feb 14]. Japanese. Available from: https://www.mhlw.go.jp/content/10802000/000505783.pdf

Competing interests: None declared

This study is well-designed and distills an important aspect of primary care in Japan. Also, the difference between hospitals and clinics is useful information for other countries. However, there are some points of uncertainty about the participants and settings. First, were the participants really representative of the national profile? The authors stated: "The proportions of patients who visited hospitals and community-based offices in our study population were generally reflective of the national profile in Japan." Although reference 17 which the authors cited provided national data of the estimated number of patients by sex and age, the data included not only patients in a primary care department but also all departments. In Japan, it is difficult to grasp a national profile of patients in primary care departments due to lack of a database. Therefore, "generally reflective of national profile in Japan" seems an overstatement. Second, is group practice not popular in Japan? Although the authors described the number of physicians as "usually 1" in community-based offices, the previous report described a median number of physicians working at office-based clinic as 2, and 44.6% of physicians worked with three or more colleagues among Japan Primary Care Association certified family physicians. (Toi T, Murata A, Ota H et al. Research on actual condition of family physician in Japan. Off J Jpn Prim Care Assoc 2016; 39: 243-9. in Japanese) In the Discussion section, however, the authors stated that the "majority of Japanese offices are solo practices, wherein a single full-time physician runs the office, making it difficult to provide out-of-hours care." I think it is not always true. Therefore, describing the number of physicians included in facilities may be useful to discuss the reason for poorer patient experince of accessibility in community-based offices. I really enjoyed reading the article and believe the questions will be helpful to hold a constructive discussion.

Competing interests: None declared