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PURPOSE: The aim of this study was to evaluate the cost-effectiveness of apixaban compared with to warfarin, current standard of care, for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF) in Japan. METHODS: A previously published lifetime Markov model was adapted to evaluate the cost-effectiveness of apixaban compared with warfarin in patients with NVAF in Japan. In the same model, the costs associated with each clinical event and background mortality were replaced with Japanese data. Whenever available, some of the utility parameters were derived from Japanese published literature. Lifetime horizon was selected to evaluate the value of the treatment benefit (stroke prevention) against potential risks (such as major bleedings) among patients with NVAF. Direct medical cost, long-term care cost, and quality-adjusted life years (QALYs) were calculated from the payers' perspective. FINDINGS: Compared with warfarin, treatment with apixaban was estimated to increase life expectancy by 0.231 year or 0.240 QALYs while treatment cost increased by ¥511,692 (US $5117 at an exchange rate of US $1 = ¥100). The incremental cost-effectiveness ratio was ¥2,135,743 per QALY (US $21,357 per QALY). On the basis of the results of the probabilistic sensitivity analysis, when the willingness-to-pay threshold was set at approximately ≥¥2,250,000 (US $22,500) per QALY, the probability of apixaban being cost-effective was ≥50%. Assuming a willingness-to-pay threshold of ¥5,000,000 (US $50,000) and ¥6,700,000 (US $67,000) in Japan, the probability of apixaban being cost-effective was 85% and 91%, respectively. CONCLUSION: Although most participants in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial used for the efficacy data of apixaban in the model were non-Japanese patients, the impact of the limitations on our results was considered small, and our results were deemed robust because of the additional effect in Japanese patients compared with that in the global population according to the subanalysis of Japanese patients in the trial. Therefore, based on an adaptation of a published Markov model, apixaban is a cost-effective alternative to warfarin in Japan for stroke prevention among patients with NVAF.

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INTRODUCTION: In this study, we compared the choice of medical specialty and subspecialty interest among problem-based-learning (PBL) graduates and non-PBL graduates. MATERIALS AND METHODS: Questionnaires were mailed to a total of 1398 female doctors who graduated from Tokyo Women's Medical University (TWMU) between 1989 and 2003. The response rate was over 30%, giving 248 respondents who had undergone a PBL curriculum (PBL+) and 220 subjects who had not (PBL-). Current specialty of the graduates were compared between the PBL+ and PBL-, and also compared with the general Japanese female doctors (Control 1 and 2) of similar age groups. Respondents were analysed in terms of their interests in subspecialty medical care or general medical practise, which includes comprehensive medical care, primary care and basic medicine. Internal medicine doctors working in the university hospitals were compared with those working outside the university hospitals. Internal medicine doctors were also compared with specialists in ophthalmology, otolaryngology, dermatology and psychiatry. Subjects were compared by odds ratio (OR) to examine group difference in the field of interest. OR >2.0 was considered statistically significant. RESULTS: Most doctors in all groups chose internal medicine. More PBL+ internal medicine doctors showed interests in comprehensive medical care and primary care; more PBL+ internal medicine doctors working outside university hospitals showed interest in comprehensive medical care and primary care when compared with those who were working in the university hospitals. The PBL- graduates did not show such a characteristic. CONCLUSIONS: More PBL+ graduates who chose internal medicine showed interest in holistic medical practices such as primary care and community medicine and more PBL+ specialists showed sustained interest in their respective fields.

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BACKGROUND: Adaptation to problem-based learning (PBL) is a difficult process for high school graduates who are not used to self-directed learning, especially in the freshmen year of medical school. The difficulty includes finding problems from a given case. PURPOSE: Evaluate the effect of an intervention to facilitate case-based problem finding among medical school freshmen undergoing a PBL tutorial. METHODS: Medical school freshmen in 2000 (nonintervened group) and 2001 (intervened group) participated in the study. The intervened group received the modified problem-based program by (a) having briefings on the importance of problem finding, (b) encouragement by the tutors in problem finding, and (c) reinforcement using a self-assessment sheet. At the end of the year, the ability of students to extract problems from a short case was evaluated and compared with the nonintervened students. RESULTS: The intervened group extracted a significantly greater number of problems than the nonintervened group. When extracted problems were categorized, the intervened group was able to generate more questions in a greater number of specified categories. CONCLUSIONS: Interventions to foster problem finding significantly facilitated acquisition of problem extraction skills among young medical students.

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