吉村 健佑

Onychomycosis, a fungal nail infection, is a common dermatological condition in Japan, with a prevalence of approximately 5%-10%. Despite the introduction of new antifungal medications and updated treatment guidelines published in 2019, data on real-world prescription trends and the associated medical costs are limited. This study aimed to investigate the prescription patterns and medical costs of topical and oral antifungal medications for onychomycosis in Japan from fiscal years 2014 to 2021 using the National Database of Health Insurance Claims and Specific Health Checkups of Japan Open Data. We analyzed the annual prescription volumes and medical costs of four antifungal medications: efinaconazole, luliconazole, fosravuconazole, and terbinafine. The prescription volume of efinaconazole, a topical medication launched in 2014, rapidly increased and dominated the market share. Fosravuconazole, an oral medication introduced in 2018, showed an increasing trend, coinciding with a decline in efinaconazole prescriptions. Terbinafine, a well-established oral medication, experienced a substantial decrease in prescription volume. The sex- and age-adjusted prescription volume per 100 000 population was higher among older adults, particularly for efinaconazole. The total medical costs for onychomycosis treatment more than doubled in fiscal year 2015 compared with that for 2014, mainly driven by efinaconazole prescriptions, and exceeded 30 billion Japanese yen in fiscal years 2019-2021. The costs slightly decreased in fiscal years 2020 and 2021, possibly due to the introduction of fosravuconazole. The predominance of topical prescriptions, especially in older adults, raises concerns regarding adherence to the Japanese guidelines that recommend oral antifungals as the first-line treatment for onychomycosis. The substantial increase in medical costs also highlights the economic burden of onychomycosis and the need for cost-effective treatment strategies. This study provides valuable insights into the real-world prescription trends and medical costs of onychomycosis treatment in Japan, suggesting an opportunity to assess potential gaps between guideline recommendations and clinical practice.

BACKGROUND: Osteoporosis is a global issue with a worldwide prevalence of 18.3%, and the presence of coexisting fragility fractures can reduce the survival rate by approximately 20%. In Japan, the prevalence of osteoporosis is estimated to be 12.8 million, and the annual occurrence of hip fractures is approximately 193,400. Remarkably, coexisting hip or spinal fragility fractures caused by slight external force meet the Japanese diagnostic criterion for osteoporosis regardless of bone mineral density. However, only 191 deaths due to osteoporosis were published in 2021 in Japan. With the concern that some cases of hip and spinal fragility fractures were assigned an underlying cause of death of traumatic fracture instead of osteoporosis, this study aimed to elucidate the actual number of deaths due to osteoporosis in Japan. METHODS: We used the data from Japan in 2018. First, the number of deaths due to osteoporosis and hip or spinal fractures was reviewed using published vital statistics. Second, we calculated the number of elderly deaths (age ≥80 years) resulting from hip or spinal fractures caused by falls on the same level using data from approximately 1.4 million annual individual death certificates. Combining the above data, the actual number of deaths due to osteoporosis was estimated. RESULTS: Only 190 deaths due to osteoporosis were reported in the published data. The individual certificate data revealed 3437 elderly deaths due to hip or spinal fractures caused by falls on the same level, which could meet the criteria of osteoporotic fragility fractures. Accordingly, the estimated number of deaths caused by osteoporosis was calculated as 3,627, approximately 19 times the published value. CONCLUSIONS: After researching the individual death certificate data focusing on the coexisting hip or spinal fragility fracture, it was implied that osteoporosis may have a higher mortality rate in Japan than what is published.

Abstract Aim The spread of the novel coronavirus infection (coronavirus disease 2019 [COVID‐19]) has caused behavioral changes and mental illness in patients and their attendants during its early phase. The present study aimed to examine the association between precautionary behaviors against COVID‐19 and psychosocial factors in outpatients with pre‐existing disease and their attendants. Methods We conducted a cross‐sectional paper‐based questionnaire survey in Chiba University Hospital on 1019 patients and 513 attendants, and a web‐based questionnaire survey in Japan on 3981 individuals from the general population. We evaluated the participants' anxiety about COVID‐19, depression, health anxiety, and precautionary behaviors. Results Regarding knowledge and anxiety about COVID‐19, the protective factors for the high precautionary behaviors group were knowledge of COVID‐19 (odds ratio [OR] = 1.178, 95% confidence interval [CI]: 1.099–1.263), anxiety about the spread of COVID‐19 (OR = 1.348, 95% CI: 1.243–1.461), and anxiety about infecting someone with COVID‐19 (OR = 1.135, 95% CI: 1.039–0.239). Regarding psychosocial factors, the protective factors for the high precautionary behaviors group were patients (OR = 1.759, 95% CI: 1.056–2.929), their attendants (OR = 3.892, 95% CI: 1.416–10.700), health anxiety (OR = 2.005, 95% CI: 1.451–2.772), and nondepression states (OR = 1.368, 95% CI: 1.004–1.864). Conclusion Our findings suggest that patients and their attendants may perform high precautionary behaviors. Health anxiety and nondepression states may be associated with high precautionary behaviors.

日本は急激な人口減少や疾病構造の変化により,従来の医療提供とは異なる体制に変化する必要がある。そのために厚生労働省は三位一体改革,すなわち「医師の偏在対策」「医師の働き方改革」「地域医療構想の実現」を進めている。これは,2040年の医療提供体制を見据え,医療提供のあり方を変えてゆくもので,それに従って予算や制度が作られている。精神科医療を含め,保険医療は強烈な規制産業であり,各医療機関は三位一体改革を重要な経営課題と位置づけざるを得ない。現在の精神科医療が最適化していないことは,臨床現場の感覚やデータにより論を俟たない所であろう。改善の余地は大きいが,自発的な変化の前に制度や外部環境の変化により,変わらざるを得ない点が大きい。特に2024年4月に適用される「医師の働き方改革」関連法の影響は大きい。精神科領域で特に影響を受けるのは,入院病棟を持つ総合病院精神科や精神科救急に対応している急性期病院である。詳細は本稿に記載するが,精神科医療に対しても外部環境の変化は大きく,各医療機関は対応にあたって困難は大きいだろう。もはや「無傷」でいられる医療機関は存在しないが,われわれ精神科医はこの状況を乗り切らねばならない。そのためには,自院の利益「のみ」にこだわる考えを捨て,地域全体の精神科医療をいかに維持するか,真剣に相談するしかない。この時代の「曲がり角」をうまくクリアするため,その方法を考える必要がある。(著者抄録)

本稿ではCOVID-19対策への取り組み,及びヘルスコミュニケーションの事例として,新型コロナワクチン啓発活動「こびナビ」プロジェクトが行った活動とそれを通じた考察を記す。2021年1月の時点では周囲の医療従事者の中にも,同ワクチンの安全性・有効性が十分には認識されておらず,ワクチンに対する慎重な意見が多くみられた。筆者はこのままでは新型コロナワクチンの正確な知識が伝わらず,結果的にワクチン忌避感が高まってしまうのではないか,という危機感を感じた。そこで,「こびナビ」を立ち上げ,仲間の医師らとともに科学的事実をわかりやすく説明する活動を実施した。手始めに,医療従事者向けにmRNAワクチンの有効性と安全性について解説する動画を作成し,ホームページに次々掲載した。特に重要な概念は「有害事象」と「副反応」を混同しないように説明することであった。続いて,SNSや大手既成メディアを使った発信,紙媒体のガイドブックなど作成し,一般の方にもわかりやすい情報発信を行った。「こびナビ」は各分野の専門家が,民間の立場,かつ無償で行った啓発活動である。これは,持続可能性に問題がある。今後は諸外国のような公的な組織が中心となり,プロジェクトベースで実施するのが望ましいのではないかと考えた。本学会は社会医学の一領域として,社会への発信と対話は必須の態度であると考え,筆者らの取り組みが何らかの参考となれば幸いである。(著者抄録)

高度医療提供・技術開発等の役割・機能を有する特定機能病院精神科部門は,日本の精神科臨床実践の牽引役として新たな知見やモデルケースの提示などが期待される。本研究は有床の同部門の特性の明確化を目的として,業務報告書より病床規模,精神科専門医数,地理的分布などを,臨床実践の範囲として当該病院のwebサイトのテキストマイニングにより診療の対象・内容などについて抽出・記述した。該当した75病院の精神病床数は日本の全精神病床の約1%であり,公的機関による開設が多く,人口あたりの分布では関東地方が有意に少ない状況であった。臨床実践の範囲として,身体合併症を有する患者も含めた多様かつ広範な診療対象ならびに治療法,多部署・機関連携などの様相が明らかとなった。(著者抄録)

2020年から始まった新型コロナウイルス感染症の拡大のなかで,感染予防策の1つとして,遠隔医療が注目されることとなり,世界各国で規制緩和が行われ利用が促進された.わが国でも,種々の規制緩和により,従来利用が少なかった精神科領域でもオンライン診療が活用されることが増えた.日本精神神経学会オンライン精神科医療検討作業班では,オンライン診療の現状把握と課題分析を目的として,臨床現場でオンライン診療の実践に取り組む医療機関にヒアリング調査を行った.17の医療機関から調査の協力を得られた.回答した医療機関のうち6施設(35.3%)が2020年から新たにオンライン診療を導入しており,15施設(88.2%)で新型コロナウイルス感染症の拡大における時限的・特例的な措置に基づく診療を行っており,今般の規制緩和によって利用が拡大していることが示唆された.また,導入に際しての困難については,7施設(41.2%)が診療報酬の価格の低さや対象範囲の狭さを挙げており,精神科診療でオンライン診療を普及させるうえでの課題についての質問でも,診療報酬の価格を対面診療に近づけることと回答した医療機関が9施設(52.9%)であり,診療報酬が普及の障害となっていると考える医療機関が多かった.厚生労働省に対する要望についての質問でも,診療報酬の点数や施設基準の改善を求めるという回答が12施設(70.6%)と圧倒的に多かった.オンライン診療は患者のニーズに合わせた普及がなされるべきであり,普及の障害となっている規制で合理性に欠けるものについては,見直しがされていくことが望ましいといえる.一方で,オンライン診療の安易な多用は,医療の質の観点から問題となる場合もあると考えられるため,適切な規制のあり方についての議論も継続していくべきである.(著者抄録)

【目的】全国の保険請求の95%以上を網羅する「レセプト情報・特定健診等情報データベース(NDB)」のオープンデータを用い,クロザピン(CLZ)の使用実態を明らかにする.【方法】2014年度から2018年度のCLZの入院処方数と治療抵抗性統合失調症治療指導管理料の算定回数(外来+入院)を分析した.また管理料算定回数から患者数を推定し,さらに入院患者の平均投与量を調べた.【結果】CLZ 100mg錠の総入院処方数は2015年度の82万錠から2018年度は171万錠に増えていた.25mg錠を含めて100mg錠に換算すると2018年度は196万錠で,人口千人あたり15.5錠であった.管理料の算定回数は2014年度が16,000回(外来50.3%),2018年度が39,000回(外来55.3%)に増え,CLZ使用患者数は1,330人から3,254人に増えた.2018年度の人口千人あたりの100mg換算入院処方数は最多が沖縄62.9錠,最少が島根3.5錠であった.2018年度の人口千人あたり管理料の算定回数は全国で0.31回,最多は宮崎1.6回,最少は埼玉0.077回,人口10万人あたりのCLZ使用患者数は,最多の宮崎13.4人,最少の埼玉0.64人であった.2019年のクロザリル患者モニタリングサービス患者登録済み医療機関あたりの2018年度の管理料の算定回数は84.3回(1施設7.0人)で,最多は岡山で170回,最少は島根9回であった.2018年度の人口10万人あたりのCLZ使用患者数は男性2.8人,女性2.4人であり,男女とも35～39歳が多く,男性7.2人,女性6.6人であった.CLZ使用入院患者の1日あたり平均投与量は男性387mg,女性348mgであった.【考察】NDBオープンデータの性質上の限界はあるものの,CLZの使用患者数や都道府県別,性・年齢階級別の実態を明らかにできた.歴史的・制度的背景から海外と比べると使用患者数は少ないものの増加傾向であり,また地域差も縮小傾向ではあった.(著者抄録)

BACKGROUND: Cognitive behavioral therapy is known to improve the management of chronic pain. However, the components of this therapy are still being investigated and debated. OBJECTIVE: This study aimed to examine the effectiveness of an integrated cognitive behavioral therapy program with new components (attention-shift, memory work, video feedback, and image training) delivered via videoconferencing. METHODS: This study was unblinded and participants were recruited and assessed face-to-face in the outpatient department. We conducted a randomized controlled trial for chronic pain to compare 16 weekly videoconference-based cognitive behavioral therapy (vCBT) sessions provided by a therapist with treatment as usual (TAU). Thirty patients (age range, 22-75 years) with chronic pain were randomly assigned to either vCBT (n=15) or TAU (n=15). Patients were evaluated at week 1 (baseline), week 8 (midintervention), and week 16 (postintervention). The primary outcome was the change in pain intensity, which was recorded using the numerical rating scale at 16 weeks from the baseline. Secondary outcomes were pain severity and pain interference, which were assessed using the Brief Pain Inventory. Additionally, we evaluated disability, pain catastrophizing cognition, depression, anxiety, quality of life, and cost utility. RESULTS: In the eligibility assessment, 30 patients were eventually randomized and enrolled; finally, 15 patients in the vCBT and 14 patients in the TAU group were analyzed. Although no significant difference was found between the 2 groups in terms of changes in pain intensity by the numerical rating scale scores at week 16 from baseline (P=.36), there was a significant improvement in the comprehensive evaluation of pain by total score of Brief Pain Inventory (-1.43, 95% CI -2.49 to -0.37, df=24; P=.01). Further, significant improvement was seen in pain interference by using the Brief Pain Inventory (-9.42, 95% CI -14.47 to -4.36, df=25; P=.001) and in disability by using the Pain Disability Assessment Scale (-1.95, 95% CI -3.33 to -0.56, df=24; P=.008) compared with TAU. As for the Medical Economic Evaluation, the incremental cost-effectiveness ratio for 1 year was estimated at 2.9 million yen (about US $25,000) per quality-adjusted life year gained. CONCLUSIONS: The findings of our study suggest that integrated cognitive behavioral therapy delivered by videoconferencing in regular medical care may reduce pain interference but not pain intensity. Further, this treatment method may be cost-effective, although this needs to be further verified using a larger sample size. TRIAL REGISTRATION: University Hospital Medical Information Network UMIN000031124; https://tinyurl.com/2pr3xszb.

AIM: To investigate whether the addition of a nurse-led cognitive behavioral group therapy for recovery of self-esteem (CBGTRS) program to usual care for individuals with mental disorders can improve clinical outcomes and reduce direct medical costs. METHODS: This study employed single-group pre-post design, and recruited 51 community-dwelling individuals with mental disorders. Participants received 12 weekly CBGTRS sessions by a nurse in addition to usual care. The primary outcome measure was the level of self-esteem, with other clinical outcomes and direct medical costs. The clinical outcomes were measured at pre-intervention (T0), intervention midpoint (T1), immediate post-intervention (T2), and 3 months post-intervention (T3). Direct medical costs were calculated for 3 months pre-intervention (A0), 3 months post-intervention (A1), between 4-6 months post-intervention (A2), and between 7-9 months post-intervention (A3). RESULTS: Self-esteem scores were significantly improved from T0 to T2 and T3 (p = .009 and .006, respectively); within-group effect sizes were .49 (small) for T0-T2, and .51 (medium) for T0-T3. Other secondary clinical outcomes for mood, cognitive bias, global functioning, and quality of life were also improved by T3 (all p < .05). The mean total direct medical costs were significantly reduced from A0 (49,569.51 JPY) to A2 and A3 (21,845.76 JPY and 25,981.69 JPY, respectively) (p = .003 and .017, respectively). CONCLUSIONS: The results suggest that nurse-led CBGTRS for mental disorders is a potentially effective approach in improving self-esteem and other clinical outcomes, and in reducing direct medical costs. Further controlled studies that address the limitations of this study are required.

OBJECTIVES: To clarify the dissemination status of cognitive behavioural therapy (CBT) in Japan under the national health insurance scheme. DESIGN: Retrospective observational study. SETTING: National Database of Health Insurance Claims and Specific Health Checkups of Japan. PARTICIPANTS: Patients who received CBT under the national health insurance scheme from fiscal years (FY) 2010 to 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: We estimated the change rate and the standardised claim ratio (SCR) for the number of patients receiving CBT and analysed the association between the CBT status and several regional factors. RESULTS: We found that (a) a total of 60 304 patients received CBT during the study period; (b) the number of patients receiving CBT was highest in the first year (-1.8% from FY2010 to FY2015); (c) the number of patients who received CBT per 100 000 population decreased (or remained at zero) in most prefectures (32 out of 47); (d) there was a maximum 424.7-fold difference between prefectures in the standardised claim ratio for CBT and (e) the number of registered CBT institutions was significantly associated with the number of patients who received CBT. CONCLUSIONS: The provision of CBT did not increase in the first 6 years (FY2010-2015) after its coverage in Japan's national health insurance scheme. Further studies including a questionnaire survey of registered CBT institutions are required to get more detailed information on the dissemination of CBT in Japan.

BACKGROUND: Cognitive behavioral therapy (CBT) is the first-line treatment for adults with obsessive-compulsive disorder (OCD), panic disorder (PD), and social anxiety disorder (SAD). Patients in rural areas can access CBT via the internet. The effectiveness of internet-delivered cognitive behavioral therapy (ICBT) has been consistently shown, but no clinical studies have demonstrated the feasibility of ICBT with real-time therapist support via videoconference for OCD, PD, and SAD at the same time. OBJECTIVES: This study aimed to evaluate the feasibility of videoconference-delivered CBT for patients with OCD, PD, or SAD. METHODS: A total of 30 Japanese participants (mean age 35.4 years, SD 9.2) with OCD, SAD, or PD received 16 sessions of individualized videoconference-delivered CBT with real-time support of a therapist, using tablet personal computer (Apple iPad Mini 2). Treatment involved individualized CBT formulations specific to the presenting diagnosis; all sessions were provided by the same therapist. The primary outcomes were reduction in symptomatology, using the Yale-Brown obsessive-compulsive scale (Y-BOCS) for OCD, Panic Disorder Severity Scale (PDSS) for PD, and Liebowitz Social Anxiety Scale (LSAS) for SAD. The secondary outcomes included the EuroQol-5 Dimension (EQ-5D) for Quality of Life, the Patient Health Questionnaire (PHQ-9) for depression, the Generalized Anxiety Disorder (GAD-7) questionnaire for anxiety, and Working Alliance Inventory-Short Form (WAI-SF). All primary outcomes were assessed at baseline and at weeks 1 (baseline), 8 (midintervention), and 16 (postintervention) face-to-face during therapy. The occurrence of adverse events was observed after each session. For the primary analysis comparing between pre- and posttreatments, the participants' points and 95% CIs were estimated by the paired t tests with the change between pre- and posttreatment. RESULTS: A significant reduction in symptom of obsession-compulsion (Y-BOCS=-6.2; Cohen d=0.74; 95% CI -9.4 to -3.0, P=.002), panic (PDSS=-5.6; Cohen d=0.89; 95% CI -9.83 to -1.37; P=.02), social anxiety (LSAS=-33.6; Cohen d=1.10; 95% CI -59.62 to -7.49, P=.02) were observed. In addition, depression (PHQ-9=-1.72; Cohen d=0.27; 95% CI -3.26 to -0.19; P=.03) and general anxiety (GAD-7=-3.03; Cohen d=0.61; 95% CI -4.57 to -1.49, P<.001) were significantly improved. Although there were no significant changes at 16 weeks from baseline in EQ-5D (0.0336; Cohen d=-0.202; 95% CI -0.0198 to 0.00869; P=.21), there were high therapeutic alliance (ie, WAI-SF) scores (from 68.0 to 73.7) throughout treatment, which significantly increased (4.14; 95% CI 1.24 to 7.04; P=.007). Of the participants, 86% (25/29) were satisfied with videoconference-delivered CBT, and 83% (24/29) preferred videoconference-delivered CBT to face-to-face CBT. An adverse event occurred to a patient with SAD; the incidence was 3% (1/30). CONCLUSIONS: Videoconference-delivered CBT for patients with OCD, SAD, and SAD may be feasible and acceptable.