This study used data obtained from anonymized medical records and internet-based questionnaires which were completed by patients who used AHHC medical services between January 1 and December 31, 2019. The study was reviewed and approved by the Research Ethics Committee of the University of Tsukuba (approval number, 1527).
Data Sources
In this study, the anonymized clinical records of all patients who had used the AHHC services during the study period were reviewed, along with the questionnaires completed by them. Information regarding patient sex, age, and illness severity were extracted from the medical records. The questionnaire consisted of two questions: what action would the patient have taken in the absence of AHHC services (stay home, wait for consultation until a hospital opens, visit ED, or call an ambulance) and what action was taken within three days following the use of the AHHC services (no hospital visit, visited an outpatient clinic, visited an ED, received another house call, or called an ambulance) (Supplemental File).
Japan’s Health Care System
Emergency hospitals in Japan are categorized as primary, secondary, or tertiary [13]. Generally, for primary care, holiday and night-time EDs are available for non-severe conditions. Secondary hospitals provide emergency first aid for patients and, if necessary, inpatient care. Tertiary hospitals provide tertiary emergency medical and advanced critical care [14, 15].
Under Japan’s universal health care system, ambulatory patients have free access to any hospital facility, regardless of their symptoms [16]. This is because Japan has not established a general practitioner system, like in Europe. Furthermore, anyone can call an ambulance service, without any expenditure [17]. If an ambulance is called, patients are transported to a secondary or tertiary hospital, depending on the severity of their condition.
AHHC Medical Services in Japan
A private AHHC medical service (Fast Doctors, Shinjuku, Tokyo, Japan), covered by Japan’s universal health care system, has been operating in Tokyo since 2016. Patients can access the service via direct phone call, or can request a consultation online. The company operates seven days/week outside of regular hospital visiting hours (i.e., 19:00-06:00 on weekdays, 18:00-06:00 on Saturdays, and 24 hours/day on Sundays and holidays). The AHHC services have about 4-12 doctors/shift.
Following a telephone triage, instead of sending an ambulance, the service sends a doctor directly to the patient's residence. The telephone triage involves a patient calling an emergency telephone consultation service and being classified into one of five categories (red, orange, yellow, green, or white), based on symptom acuity. The red category implies the presence of a life-threatening condition or one that is likely to worsen or change rapidly; orange reflects a condition requiring immediate hospital attendance, as the symptom(s) may worsen over time; yellow requires a hospital visit as the symptom(s) may worsen over time; green does not have symptoms listed in the previous categories but requires a hospital visit; and white reflects symptoms that do not require a hospital visit [9].
After the telephone triage, the AHHC service doctors perform home visits for patients classified as orange and yellow. Following the consultation, the doctor assesses the illness severity (mild, moderate, or severe); mild illnesses are those that can be treated using over-the-counter medications, moderate illnesses require the patient to visit a hospital or clinic, and severe illnesses require ambulance transportation.
Statistical Analysis
We compared the patient characteristics (age, sex, and illness severity) between questionnaire responders and non-responders. As appropriate, Pearson's chi-square test or Fisher's exact test were used to compare categorical variables, and Student's t-test or the Wilcoxon-Mann-Whitney test were used to compare continuous variables. Analyses were performed using JMP 14.3 statistical software (SAS Institute, Cary, NC, USA) and a value of p < 0.05 was considered statistically significant.