Clinical and investigative critical care medicine in Japan
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The structure, delivery of care, and outcomes of intensive care services vary widely, even among developed countries. While the services rendered by North American and Western European intensive care units (ICUs) have been described and compared , far less is known about these services provided in Asian countries. We briefly review the history and the national and regional organizations of ICU in Japan, with a view to describe the current state of critical care medicine, including research in the field, and discuss opportunities for improvements.
Overall organization of intensive care
Currently, the 29 existing paediatric ICUs contain 200 beds (a median of 8 beds per unit), representing approximately 42 % of the supply offered by other developed countries, calculated by the number of inhabitants younger than 15 years old [JSICM data]. In paediatric ICUs, 68 % of physicians are board-certified intensivists, and 38 % of the units are staffed by intensivists around the clock, 365 days/year [JSICM data]. There is no board certification for paediatric intensivists.
The low prevalence of ICU services in Japan may be due to a weak historical tradition, insufficient public and social awareness, and scarce governmental funding. Furthermore, the low number of trained intensivists might, in part, be due to an underdeveloped educational system. The medical specialty of “intensivist” is not officially acknowledged by MHLW, and intensive care services are reimbursed despite the absence of contributions by certified intensivists.
Critical care research
The Japanese contributions to research in the field of critical care medicine are considered insufficient. Although the mean impact factor of articles originating from Japan ranked second, behind Canada, the “total product” of research in a 1995–2003 worldwide survey, calculated by the number of articles published, multiplied by their impact factor, compared with the gross national products per capita, was strikingly low . Moreover, in 2011, only 12 articles from Japan were published in 10 major critical care journals , occupying third place among the Asian countries. Remarkably, the number of articles published decreased from 48 in 2000, a 75 % decrease . Furthermore, between 2006 and 2010, the three major core clinical journals (New England Journal of Medicine, Lancet and Journal of the American Medical Association) published only two articles in the field of critical care medicine from Japan . This negative evolution is in contrast with the increase in the number of publications originating from China, Taiwan and Korea, a trend observed similarly in other medical specialties . A recent review reported that among 248 randomized trials published in the field of paediatric ICU medicine from inception to 16 April 2013, a single article originated from Japan, suggesting an even more troublesome weakness in that area of research . Besides the language barrier, insufficient public or private scientific funding due to a stagnating economy in the last decade, combined with a scarcity of researchers in the field of intensive care medicine might be the cause of a low scientific research productivity.
Conclusions and future perspectives
The Japanese ICU services are in need of improvement. Sociopolitical movements must be promoted to raise the resources and funds needed to support the delivery of intensive care, drawing on the movements of globalization supported by government. Then, with an ultimate goal of leadership by intensivists, larger ICUs might be created to improve the outcomes of critically ill patients .
The JSICM has just begun offering (1) a board certification for intensivists within a new governmental program of medical doctor certifications, emulating the European CoBaTrICE program , (2) an educational program using parts of multiprofessional critical care review courses, and (3) a clinical trial group to promote multicentre, multinational studies . The modernization of Japanese ICU services is absolutely necessary to (a) satisfy the needs of an aging society over the next few decades , (b) adapt the delivery of care to the constant progress of medicine , and (c) promote “evidence-based medicine” adapted to local clinical settings.
Intensive Care Medicine plays a clear role in highlighting the culture of critical care in Japan and is perceived as a most desirable target for the publication of Japanese research including issues discussed in this article .
Compliance with ethical standards
Conflicts of interest
Dr. Shime has no potential conflict of interest to disclose.
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