2017/9/21

:
: 2017/09/22

10

dr.kenta.sato@gmail.com

(GPMEC)

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http://todo-ran.com/t/tdfk/gunma

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 2017/9/21

1053050 HP http://www.min-iren.gr.jp/ikei-gakusei/igakusei/zi5_medi/2011/049/mw-ken-49.html
HP http://www.chidoribashi-hp.or.jp/chidoribashi-hph/index.html

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ICTACLS

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 2017/9/21

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QOL

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 2017/9/21

2



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!!

Before
After

5
 2017/9/21

ICU

PT









JPCA

SNS

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 2017/9/21

?


: :

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CommonDisease

Common disease
Common health issue

Common disease
?
2016711
http://www.igaku-shoin.co.jp/paperDetail.do?id=PA03182_01

7
 2017/9/21

EBM or

or


or

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HP http://www.min-iren.gr.jp/ikei-gakusei/igakusei/zi5_medi/2011/049/mw-ken-49.html
HP http://www.chidoribashi-hp.or.jp/chidoribashi-hph/index.html

8
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WebSNS
NPO

ICU

30%

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4.
5.
6.

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Community-oriented medical education MNA-SF





Common problem



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Common Disease


Common disease

Common disease
TOP50

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Multimorbidity



,. 2000

Common Disease?
2.0
COPD 1.4
1.3

ACS COPD

35.7 28.5% 45 45
19.5 15.5% 7 7
12.5 9.9%
5% 22%
5%
12.4 9.9% VTE/PTE 4%
COPD 4%
5.9 4.8% 4%
5.2 4.2% DKA 5% 12%
2.9 2.3% 4%
AIHA/ITP 3%
2.5 2.0% 5% 5%
COPD 1.7 1.4% 2% 4%
: 1%
1.6 1.3%
1%
25.3 20.2% 307/151147/263/

11
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1 11
2 12
3 13
4 14
5 15
6 16
7 17
8 18
9 19
10 20
20
11.1%

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Common Disease
Chronic Organ Dysfunction

CHD:Chronic Heart Disease

!
CPD:Chronic Pulmonary Disease
COPD
CLD:Chronic Liver Disease
DPC! NAFLD/NASH
CKD:Chronic Kidney Disease
DMHT
CBD:Chronic Brain Disease

At risk Basal Clinical Discomfort / End

change symptom decompensated stage
stageA Stage B Stage C Stage D ?
CHD AHA)

Stage Stage Stage~

Stage
CPD
Stage
Child A Child B Child C

PLT
CLD

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3A
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CKD HD

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COD

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Clinical symptom
Basal Change

a
a


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Discomfort/Discompensated
Endstage






RAS

ACP
DPC

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ACP

SPSSICF

:Multimorbidity



QOL, etc.

:Managing patients with multimorbidity in primary care. BMJ. 2015

2015127 http://cmj.publishers.fm/

https://www.igaku-shoin.co.jp/paperDetail.do?id=PA03153_01

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Illness Trajectory

(:Stage1~2)

:Stage3

:Stage4
:Stage5
Patterns of Functional Decline at the End of Life. JAMA. 2003;289(18):2387-2392

:Multimorbidity


QOL

STARTSTOPP/BEERS
:Managing patients with multimorbidity in primary care. BMJ. 2015
Generalist masters. http://cmj.publishers.fm/

Coordination Coordination
Kurt C. Stange. A science of Connectedness. Ann Fam Med 2009 7 387-394

Refer!! System holarchy

(Hierarchy of holons
Collateral referral

Interval referral

Cross referral

Sprit referral

GERD

???

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QOL
!


ABCDE+III+QRST

:Infection : :

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Insulin & nutrition: :

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Common disease

Difficult PatientDifficult Encounter

Cannarella Lorenzetti, R. , et, al. (2013). Managing difficult encounters:
understanding physician, patient, and situational factors. American family physician, 87(6), 41925.

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Simple Complicated
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MaintenanceCrisis

by Wikipedia

17
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Design by WPThemeDesigner.com.

4


Simple

Complicated

Compex

Chaotic

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Risk Ignorance






RCT

Uncertainty

NEJM( )
()

Ambiguity

Informed concent

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1
DMUrosepsis
DNAR




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MultimorbidityPolydoctor

20
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...

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Social detarminants of healthSDH)

1



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Interprofessional work()

()

22
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Rural medicine

(ACS/StroketPA

Community care
RuralUrban



Urban medicine


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COPC

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1.69
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BMI 18.5
28
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CL

FC

2550%

24
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SDHIKEN.ORG

PDCA

NPO

25
 2017/9/21

10
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Coordination



Coordination

Cooperation

Collaboration

Cooperation Collaboration

26
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Interprofessional WorkIPW



IPE

3

Uni - professional Stage




Inter - professional Stage !Common health issues

Trans - professional Stage

27