研究者詳細 - 後藤　励

論文 - 後藤　励

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Transportation for Patients with Stroke in Need of Mechanical Thrombectomy: A Simulation-Based Study in Hyogo Prefecture, Japan

Yamasaki Bumpei, Goto Rei, Imamura Hirotoshi, Sakai Nobuyuki

脳神経血管内治療（一般社団法人日本脳神経血管内治療学会） 18 （ 12 ） 305 - 312 2024年

ISSN 18824072

Objective: This study aimed to simulate patient transportation to a mechanical thrombectomy (MT)-capable hospital within 60 minutes, taking into account patient volume (demand side of healthcare) and hospital capacity to accept patients (supply side of healthcare).Methods: Simulations were conducted in Hyogo Prefecture, Japan. The estimates of the annual number of patients with stroke eligible for MT in 2020 were based on the incidence of stroke by age group and the percentage of patients with stroke indicated for MT in existing publications. Patients were then randomly placed on a 1 km2 mesh map. The patients were randomly generated 100 times using R software (version 4.1.2; R Foundation for Statistical Computing, Vienna, Austria). Hospitals were selected based on 2 criteria: (1) actual provision patterns (39 hospitals) and (2) consolidated patterns (12 hospitals). Simulations were performed using ArcGIS Pro (version 10.8; Esri, Redlands, CA, USA) and Network Analyst extension (Esri) in 3 cases: (1) number of patients estimated from the population in 2020 transported to hospitals that provided MT, (2) number of patients estimated based on the 2020 population transported to selected hospitals in the case of consolidation, and (3) number of patients estimated based on 2040’s projected population and transportation to the selected hospitals.Results: In Case 1, the estimated annual number of patients undergoing MT in 2020 was 976. The average number of patients undergoing MT and transported was 961, indicating that 98% (961/976) of the total generated patients could be transported within 60 min. In Case 2, the average number of patients undergoing MT and transported was 940, indicating that 96.3% (940/976) of the total patients could be transported within 60 min. In Case 3, the average number of patients undergoing MT and transported was 1184, showing that 95.1% (1184/1244) of the total generated patients could be transported within 60 min. A few patients in rural areas and remote islands required longer transport times.Conclusion: The simulations showed that patient estimates from the incidence of cerebral infarction by age group and the percentage of patients with stroke indicated for MT were similar to the actual values. The simulation was closed to reality when both the supply and demand sides of healthcare were considered. Thus, this simulation study informs future healthcare policy by demonstrating the geographic distribution of human and capital resources and potential cost reduction through consolidation, taking into account demographic changes.

The estimation of healthcare cost of kidney transplantation in Japan using large-scale administrative databases

Hasegawa M., Kato H., Yoshioka T., Goto R.

Clinical and Experimental Nephrology 2024年

ISSN 13421751

Background: The financial burden of kidney replacement therapy (KRT) is considerable, and detailed information on KRT costs is essential for managing these huge healthcare costs. However, cost analyses for kidney transplantation (KTx) are limited in Japan. This study aimed to report the healthcare costs of KTx recipients in Japan based on large medical receipt data. Methods: This cost analysis of KTx recipients using the Japan Medical Data Center Claims Database between January 2005 and August 2020 identified living donor KTx (LDKT) and deceased donor KTx (DKT) recipients. The primary outcome was the total direct healthcare costs of KTx recipients. As an exploratory analysis, we examined the factors that contributed to the increase in the costs of LDKT. Results: In total, 84 LDKT and 17 DKT recipients were included in this study. The total healthcare costs for LDKT and DKT recipients during the first year after KTx were 6,639,982 and 6,840,450 JPY/year, respectively. However, after the second year post-KTx, total healthcare costs decreased to 1,735,931 and 1,348,642 JPY/year for LDKT and DKT recipients, respectively. During the first year, inpatient costs accounted for > 70% of the total healthcare costs, whereas pharmaceutical costs accounted for more than half after the second year post-KTx. The use of everolimus and male sex were associated with higher and lower total healthcare costs in the first and subsequent years after LDKT, respectively. Conclusion: Using large-scale administrative databases, this study revealed the total healthcare costs of KTx in Japan and provided valuable information for the health technology assessment of KTx.

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連載医療システムの質・効率・公正--医療経済学の新たな展開・Vol.18 保健医療の経済学と行動経済学

後藤励

医学のあゆみ（医歯薬出版） 287 （ 10 ） 789 - 794 2023年12月

ISSN 00392359

Healthcare costs for hospitalized COVID-19 patients in a Japanese university hospital: a cross-sectional study

Uno S., Goto R., Honda K., Tokuda M., Kamata H., Chubachi S., Yamamoto R., Sato Y., Homma K., Uchida S., Namkoong H., Uwamino Y., Sasaki J., Fukunaga K., Hasegawa N.

Cost Effectiveness and Resource Allocation （Cost Effectiveness and Resource Allocation） 21 （ 1 ） 2023年12月

Background: A health-economic evaluation related to COVID-19 is urgently needed to allocate healthcare resources efficiently; however, relevant medical cost data in Japan concerning COVID-19 are scarce. Methods: This cross-sectional study investigated the healthcare cost for hospitalized COVID-19 patients in 2021 at Keio University Hospital. We calculated the healthcare costs during hospitalization using hospital claims data and investigated the variables significantly related to the healthcare cost with multivariable analysis. Results: The median healthcare cost per patient for the analyzed 330 patients was Japanese yen (JPY) 1,304,431 (US dollars ~ 11,871) (interquartile range: JPY 968,349–1,954,093), and the median length of stay was 10 days. The median healthcare cost was JPY 798,810 for mild cases; JPY 1,113,680 for moderate I cases; JPY 1,643,909 for moderate II cases; and JPY 6,210,607 for severe cases. Healthcare costs increased by 4.0% for each additional day of hospitalization; 1.26 times for moderate I cases, 1.64 times for moderate II cases, and 1.84 times for severe cases compared to mild cases; and 2.05 times for cases involving ICU stay compared to those not staying in ICU. Conclusions: We clarified the healthcare cost for hospitalized COVID-19 patients by severity in a Japanese university hospital. These costs contribute as inputs for forthcoming health economic evaluations for strategies for preventing and treating COVID-19.

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Comprehensive analysis of long COVID in a Japanese nationwide prospective cohort study

Terai H., Ishii M., Takemura R., Namkoong H., Shimamoto K., Masaki K., Tanosaki T., Chubachi S., Matsuyama E., Hayashi R., Shimada T., Shigematsu L., Ito F., Kaji M., Takaoka H., Kurihara M., Nakagawara K., Tomiyasu S., Sasahara K., Saito A., Otake S., Azekawa S., Okada M., Fukushima T., Morita A., Tanaka H., Sunata K., Asaoka M., Nishie M., Shinozaki T., Ebisudani T., Akiyama Y., Mitsuishi A., Nakayama S., Ogawa T., Sakurai K., Irie M., Yagi K., Ohgino K., Miyata J., Kabata H., Ikemura S., Kamata H., Yasuda H., Kawada I., Kimura R., Kondo M., Iwasaki T., Ishida N., Hiruma G., Miyazaki N., Ishibashi Y., Harada S., Fujita T., Ito D., Bun S., Tabuchi H., Kanzaki S., Shimizu E., Fukuda K., Yamagami J., Kobayashi K., Hirano T., Inoue T., Haraguchi M., Kagyo J., Shiomi T., Lee H., Sugihara K., Omori N., Sayama K., Otsuka K., Miyao N., Odani T., Watase M., Mochimaru T., Satomi R., Oyamada Y., Masuzawa K., Asakura T., Nakayama S., Suzuki Y., Baba R., Okamori S., Arai D., Nakachi I., Kuwahara N., Fujiwara A., Oakada T., Ishiguro T., Isosno T., Makino Y., Mashimo S., Kaido T., Minematsu N., Ueda S., Minami K., Hagiwara R., Manabe T., Fukui T.

Respiratory Investigation （Respiratory Investigation） 61 （ 6 ） 802 - 814 2023年11月

ISSN 22125345

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread rapidly since 2019, and the number of reports regarding long COVID has increased. Although the distribution of long COVID depends on patient characteristics, epidemiological data on Japanese patients are limited. Hence, this study aimed to investigate the distribution of long COVID in Japanese patients. This study is the first nationwide Japanese prospective cohort study on long COVID. Methods: This multicenter, prospective cohort study enrolled hospitalized COVID-19 patients aged ≥18 years at 26 Japanese medical institutions. In total, 1200 patients were enrolled. Clinical information and patient-reported outcomes were collected from medical records, paper questionnaires, and smartphone applications. Results: We collected data from 1066 cases with both medical records and patient-reported outcomes. The proportion of patients with at least one symptom decreased chronologically from 93.9% (947/1009) during hospitalization to 46.3% (433/935), 40.5% (350/865), and 33.0% (239/724) at 3, 6, and 12 months, respectively. Patients with at least one long COVID symptom showed lower quality of life and scored higher on assessments for depression, anxiety, and fear of COVID-19. Female sex, middle age (41–64 years), oxygen requirement, and critical condition during hospitalization were risk factors for long COVID. Conclusions: This study elucidated the symptom distribution and risks of long COVID in the Japanese population. This study provides reference data for future studies of long COVID in Japan.

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Efficacy and safety of a telemedicine system in subjects with gestational diabetes mellitus (TELEGLAM): Study protocol for a randomized controlled trial

Aoyama K., Nakajima Y., Meguro S., Sato Y., Goto R., Hida M., Arimitsu T., Kasuga Y., Tanaka M., Itoh H.

Heliyon （Heliyon） 9 （ 11 ） 2023年11月

ISSN 24058440

Background: Strict glycemic control is important to prevent perinatal complications in patients with gestational diabetes mellitus (GDM). Patients often require insulin injection, and frequent hospital visits are necessary to adjust the dose of insulin, which is considered burdensome for pregnant patients. Telemedicine may reduce the burden of hospital visits, and previous studies have reported its safety in GDM patients. This study aimed to evaluate the efficacy of telemedicine in GDM patients, focusing on patient satisfaction and health economic indicators. Methods: This is a single-center, two-arm, randomized, open-label parallel-group study. Subjects will be selected from the patient population attending the Department of Endocrinology, Metabolism, and Nephrology, Keio University School of Medicine, Japan. Patients diagnosed with GDM by an oral glucose tolerance test (OGTT) by 29 weeks and 6 days of gestation who have undergone self-monitoring of blood glucose (SMBG) and insulin injection are eligible for inclusion. In the intervention group, telemedicine will be administered using the MeDaCa telemedicine system developed by the Medical Data Card, Inc., Tokyo, Japan. Subjects in the control group will be examined face-to-face every 2–3 weeks, as usual. We set health economic indicators and patient satisfaction as the primary endpoints, and will perform a cost-consequence analysis. Glycemic control indicators and perinatal outcomes will be evaluated as secondary endpoints. Conclusions: Eligible patients are currently being recruited. Recruitment will be completed when the expected number of patients are enrolled.

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Effect of influenza vaccine subsidies for older adults on vaccination coverage and mortality before and during the COVID-19 pandemic: an ecological study in Japan

Ando T., Ibuka Y., Goto R., Haruta J., Le D.D., Fujishima S.

Public Health （Public Health） 224 152 - 158 2023年11月

ISSN 00333506

Objective: We aimed to determine how municipal subsidies for seasonal influenza vaccines for the elderly affected vaccination coverage and health outcomes and how responses to vaccine prices changed during the COVID-19 pandemic. Study design and methods: This ecological study includes 1245 municipalities in Japan between 2019 and 2020. Fixed-effects regression analysis was performed to evaluate the effect of influenza vaccine cost subsidy for people aged 65 years or older on vaccination coverage, all-cause mortality, and influenza-related mortality. Results: The vaccination rate increased when patients' copayments decreased, and reducing the copayment by 1000 Japanese Yen (JPY) was estimated to increase the vaccination rate by 6.3% (95% confidence interval [CI] 4.5–8.2%) in the adjusted model. When examining the additional effect of a zero price compared to a nearly zero price, we found that a zero price increased the immunization rate by 6.4% (95% CI 1.4–11.5%). The effect of copayment on the increase in vaccination coverage was significantly lower during the pandemic than in the pre-pandemic period. The municipal and prefectural analyses found no association between influenza vaccine copayments and all-cause, influenza, or pneumonia mortality. Conclusion: Cost subsidies and the zero-price effect were shown to increase vaccination coverage but were not associated with relevant mortality measures. Although the impact was attenuated under pandemic conditions, cost subsidy effectively increases the vaccination rate.

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Effect of aqueous olanexidine versus alcohol-based chlorhexidine for surgical skin antisepsis on incidence of surgical site infections in gastrointestinal surgery: multicentre randomised controlled clinical trial (OEDO trial) protocol

Takeuchi M., Obara H., Furube T., Kawakubo H., Kitago M., Okabayashi K., Aoyama J., Amemiya R., Fujisaki H., Sano J., Goto R., Sato Y., Kitagawa Y.

BMJ Open （BMJ Open） 13 （ 8 ） 2023年08月

Introduction Surgical site infections (SSIs) are among the most common nosocomial infections in surgery patients. Two types of preparations, povidone-iodine and chlorhexidine-alcohol, are commonly used in preoperative antiseptic procedures worldwide. However, there are inconsistencies among international guideline recommendations concerning skin antiseptics. This trial aimed to evaluate the superiority of olanexidine, which reduced SSI rates more than povidone-iodine in our previous randomised trial, over chlorhexidine-alcohol in clean-contaminated surgery. Methods and analysis This multicentre randomised controlled clinical trial will compare two antiseptics (1.5% olanexidine and 1.0% chlorhexidine-alcohol) to prevent SSI in clean-contaminated gastrointestinal surgeries with surgical wounds. On providing consent, patients aged <18 years will be included. The primary outcome will be the postoperative 30-day overall SSI rate, while the secondary outcomes will be the postoperative 30-day superficial incisional SSI rate, deep incisional SSI rate, organ/space SSI rate, positive bacterial wound culture rate, cultured bacterial strains, rates of intervention-related toxicity and allergic events (eg, erythema, pruritus, dermatitis and other symptoms of allergy around the region disinfected by the antiseptic during surgery), rate of reoperations due to SSI, medical economic effect indicators (based on health insurance claims) and hospital duration. The Mantel-Haenszel method will be used to estimate the adjusted risk ratio and its 95% CI for the primary analysis, which will compare the treatment effects. Ethics and dissemination The protocol was approved by the Institutional Review Board of Keio University School of Medicine and subsequently by the board of each participating site. Participant recruitment began in January 2023. The final results will be published in medical journals after international peer review. Trial registration number UMIN000049712.

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【連載】行動変容をそっと促す　ナッジを使ったアプローチ(14) 「記録しないこと」には理由がある?

竹林正樹, 後藤励

コミュニティケア（株式会社日本看護協会出版会） 25 （ 9 ） 42 - 44 2023年07月

ISSN 27580008

Model-based estimation of the health care expenditure and out-of-pocket payment for assisted reproductive technology: A retrospective linkage study using the Japanese national ART registry

Jwa S.C., Goto R., Maeda E., Kajihara T., Ishihara O.

Journal of Obstetrics and Gynaecology Research （Journal of Obstetrics and Gynaecology Research） 49 （ 7 ） 1778 - 1786 2023年07月

ISSN 13418076

Aim: From April 2022, the Japanese government funding system for assisted reproductive technology (ART) has shifted from government subsidies to universal health insurance. To date, studies estimating the health care expenditure for ART are scarce. We estimated health care expenditures for ART cycles and compared the proportion of patients' out-of-pocket payment by ovarian stimulation protocols under the Japanese government subsidy system. Methods: We linked payment information for government subsidies in Saitama Prefecture during 2016 and 2017 with the Japanese ART registry. Health care expenditures for all treatment cycles in Japan during 2017 among women aged <43 years (n = 369 757) were estimated using a generalized linear model. Results: We linked 6269 subsidy applications to the Japanese ART registry. The average treatment fee for a fresh cycle was 376 434 JPY (standard deviation = 159 581). However, significant variation was observed across ovarian stimulation protocols. The estimated health care expenditure for ART during 2017 was 101 278 629 888 JPY (920 714 817 USD), leading to a 0.24% increase in the national health care expenditure for fiscal year 2017. Fresh cycles accounted for 70% of the expenditure. The proportion of the average patient out-of-pocket payment for one treatment cycle was smaller for natural (0%) and mild ovarian stimulation using clomiphene citrate (4.5%–20.7%) than those of conventional stimulation (30.3%–32.4%). Conclusions: Health insurance coverage for ART would increase national health care expenditure by 0.24%. Under the subsidy system, the proportion of the average patient out-of-pocket payment was smaller for natural and mild ovarian stimulation than conventional stimulations.

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医療費負担の公平性について

後藤励

連合総研レポートDIO （公益財団法人連合総合生活開発研究所） 36 （ 3 ） 11 2023年03月

ISSN 27586030

Cost-effectiveness Analysis of Monoclonal Antibodies in the First-line Treatment of RAS Wild-type Metastatic Colorectal Cancer: A Systematic Review

Morimoto T., Fujito K., Yamasaki B., Goto R.

Clinical Therapeutics （Clinical Therapeutics） 45 （ 1 ） 41 - 54 2023年01月

ISSN 01492918

Purpose: First-line treatment with monoclonal antibodies (bevacizumab, cetuximab, and panitumumab) for RAS wild-type metastatic colorectal cancer (mCRC) has advanced. The costs of drugs targeted to mCRC are high. This systematic review aimed to summarize the cost-effectiveness of monoclonal antibodies in the first-line treatment of RAS wild-type mCRC. Methods: We searched 5 databases to find original-research cost-effectiveness analyses of monoclonal antibodies used in the first-line treatment of patients with RAS wild-type mCRC. Three reviewers independently evaluated all of the records to be screened. Findings: A total of 15 articles, 12 cost-effectiveness analyses, and 3 cost-utility analyses were identified. The reporting of identified articles was assessed using the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist. They were assigned to 1 of 6 categories based on the combination of the intervention and control groups, the most common of which was cetuximab + chemotherapy versus bevacizumab + chemotherapy. The results of the cost-effectiveness analyses may have varied because of the differences in settings, such as country, study population, RAS mutation status, efficacy data, and model structure, in which each study was conducted. Implications: Although treatment with monoclonal antibodies has demonstrated efficacy in terms of life-years gained and progression-free survival, the most cost-effective treatment among monoclonal antibodies remains controversial; however, most of the studies that compared a monoclonal antibody + chemotherapy versus chemotherapy alone reported that chemotherapy alone was a cost-effective strategy. Future studies are needed to evaluate the cost-effectiveness of treating patients with mCRC using biomarker-driven precision medicine.

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コロナ対応とワクチン接種に対する医療者と経済学者の相違

後藤励, 大竹文雄, 井深陽子, 野口晴子, 仲田泰祐

現代経済学の潮流（一般社団法人日本経済学会） 2022 （ 0 ） 225 - 270 2023年

The Natural Course of Patients Four Years after Pathological Urinary Sediment Findings at Ningen Dock: The Cost and Benefit of Urine Sediment Examination

Wada Takashi, Goto Rei

Ningen Dock International （公益社団法人日本人間ドック学会） advpub （ 0 ） 2023年

ISSN 21878072

Objective: Urinary sediment is examined in Ningen Dock. We sought to evaluate the costs and diagnostic value associated with abnormal urinary sediment findings, in addition to estimated glomerular filtration rate (eGFR), urinary protein, and occult blood measurement, in Ningen Dock after 4 years.Methods: In the patients who underwent Ningen Dock in 2015, urinalysis was performed using a fully-automated urinalysis system at the central laboratory of each hospital. Urine sediment was microscopically examined by laboratory technicians. Granular casts, epithelial casts, and tubular epithelium were defined as pathological findings. Seventy-six patients who showed these findings in 2015 and were re-examined in 2019. The eGFR, urinary protein, and occult blood were statistically analyzed.Results: Pathological urinary sediment findings detected in 2015 spontaneously disappeared after 4 years in 91% of the patients. No significant change was observed in eGFR, urinary protein or occult blood in the patients who continued to have pathological findings after 4 years. At least \157 was spent per sample in supplies and personnel.Conclusions: Almost the pathological urine sediment was disappeared after four years. The benefit of urine sediment examinations was small for the cost. The eGFR, urine protein and occult blood test are sufficient in the kidney function examinations in Ningen Dock.

Medical care costs according to the stage and subtype of breast cancer in a municipal setting: a case study of Hachioji City, Japan

Nishikawa Y., Agatsuma N., Utsumi T., Funakoshi T., Mori Y., Nakamura Y., Hoshino N., Horimatsu T., Saito T., Kashihara S., Fukuyoshi J., Goto R., Toi M., Takahashi Y., Nakayama T.

Breast Cancer （Breast Cancer） 31 （ 1 ） 105 - 115 2023年

ISSN 13406868

Background: It is important to assess whether the early detection of breast cancer affects medical care costs. However, research remains scant on the actual medical care costs associated with breast cancer treatment in Japan. This study aimed to determine the medical care costs of breast cancer treatment based on its stage using national health insurance claims data. Methods: This was an observational study including patients with breast cancer who had undergone breast cancer treatment, as defined by the disease name and related treatment codes. Between August 2013 and June 2016, patients who underwent surgical treatment without axillary lymph node dissection and other radical treatment were classified as the curable group, while those who underwent palliative treatment were classified as the non-curable group. Patients were further stratified by subtype. The total and treatment-specific medical care costs for the five years were calculated using the national health insurance claims data of Hachioji City between August 2013 and May 2021. Results: The mean total medical care costs for the curable and non-curable groups for the 5 years were JPY 3958 thousand (standard deviation 2664) and JPY 8289 thousand (8482), respectively. The mean medical care costs for specific breast cancer treatment for the curable and non-curable groups were JPY 1142 (728) thousand and JPY 3651 thousand (5337), respectively. Further, human epidermal growth factor receptor 2 + , Hormone + patients had the highest mean cost over the 5 years. Conclusions: The results suggest that the early detection of breast cancer may reduce medical care costs at the patient level.

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糖尿病患者の非合理的選択と慢性合併症

江本直也, 後藤励

日本医科大学医学会雑誌（日本医科大学医学会） 18 （ 4 ） 379 - 388 2022年12月

ISSN 13498975

Diabetes mellitus is a chronic disease in which high blood glucose over long periods leads to diabetic complications including retinopathy, neuropathy, chronic kidney disease, and increased risk for cardiovascular events. Despite the availability of scientifically proven medical treatments, a significant number of patients with diabetes do not attain optimal glycemic control due to failure in self-management and nonadherence to medication. These behaviors appear irrational in terms of conventional economic theory. We applied the theory of behavioral economics, a new concept for clarifying irrational human behaviors, to investigating risk preferences in patients with diabetes. We found specific features in the responses of patients with diabetic complications. Many of these patients had low socioeconomic status, were reluctant to participate in the survey, and had difficulty in making decisions explicitly. Their choices under uncertainty often violated two axioms of the Expected Utility Theory (completeness and transitivity) and were therefore considered irrational, meaning that their choices were difficult to understand and differed from those that would be chosen by the majority of people. Health professionals should be aware of the propensity of such patients to make irrational decisions, which might be an important risk factor for the progression of diabetic complications.

Prevalence and changes of low-value care at acute care hospitals: a multicentre observational study in Japan

Miyawaki A., Ikesu R., Tokuda Y., Goto R., Kobayashi Y., Sano K., Tsugawa Y.

BMJ Open （BMJ Open） 12 （ 9 ） 2022年09月

Objectives We aimed to examine the use and factors associated with the provision of low-value care in Japan. Design A multicentre observational study. Setting Routinely collected claims data that include all inpatient and outpatient visits in 242 large acute care hospitals (accounting for approximately 11% of all acute hospitalisations in Japan). Participants 345 564 patients (median age (IQR): 62 (40-75) years; 182 938 (52.9%) women) seeking care at least once in the hospitals in the fiscal year 2019. Primary and secondary outcome measures We identified 33 low-value services, as defined by clinical evidence, and developed two versions of claims-based measures of low-value services with different sensitivity and specificity (broader and narrower definitions). We examined the number of low-value services, the proportion of patients receiving these services and the proportion of total healthcare spending incurred by these services in 2019. We also evaluated the 2015-2019 trends in the number of low-value services. Results Services identified by broader low-value care definition occurred in 7.5% of patients and accounted for 0.5% of overall annual healthcare spending. Services identified by narrower low-value care definition occurred in 4.9% of patients and constituted 0.2% of overall annual healthcare spending. Overall, there was no clear trend in the prevalence of low-value services between 2015 and 2019. When focusing on each of the 17 services accounting for more than 99% of all low-value services identified (narrower definition), 6 showed decreasing trends from 2015 to 2019, while 4 showed increasing trends. Hospital size and patients' age, sex and comorbidities were associated with the probability of receiving low-value service. Conclusions A substantial number of patients received low-value care in Japan. Several low-value services with high frequency, especially with increasing trends, require further investigation and policy interventions for better resource allocation.

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医療経済評価における小児のQOL値測定法とその課題

本多貴実子, 白岩健, 後藤励, 福田敬

保健医療科学（国立保健医療科学院） 71 （ 3 ） 264 - 275 2022年08月

ISSN 13476459

適正な医療資源の配分のためのエビデンスを提供することを目的として行われる医療経済評価では，異なった領域の介入の比較を容易にするため，アウトカム指標を質調整生存年（Quality-adjusted life year: QALY）とすることが原則とされている．QALYは生存期間にQOL（Quality of life）を 0 から 1 の値に換算したQOL値を重み付けして得られる．QALYにはその国の人々の選好による重みづけが反映されることが望ましいという観点から，QOL値は国内の調査結果を優先的に使用することが推奨されているが，以前から日本人のデータが乏しいことが指摘されていた．近年成人ではその蓄積が進みつつあるが，小児においてはその測定に多くの課題があり，日本ではほぼ行われていないのが現状である．医療経済評価でQOL値測定に用いられる尺度は選好に基づく尺度（Preference-based measure: PBM）である．PBMによってQOL値を得る過程は，評価したい健康状態の「測定」と「価値づけ」に分けられる．これを一度に行うものを直接法，別々に行うものを間接法と呼ぶ．直接法には評点尺度法，時間得失法，基準的賭け法があるが，小児では実施可能性，信頼性，妥当性はまだ十分に検討されていない．成人も含め一般的に現在主流となっている間接法では，multi attribute utility instruments （MAUIs）と呼ばれる尺度を用い，実際にその健康状態にある人（患者）に自らの健康について質問票に記入してもらった後，換算表を用いてQOL値を算出する．一般的に成人を対象に開発されたMAUIsは，小児で使用するにあたって質問の記述の仕方や内容が適していない，さらに換算表が成人の健康についての価値付けになっているなどの問題があり，小児には小児用のMAUIsの使用が望ましいとされる．近年小児用のMAUIsの開発が進んできたが，各国での翻訳や換算表の有無により，どの国でもこれらが使用できるわけではなく，3歳以下の年少児では使用できるものは現在ない．また，どの領域をどのように評価するべきか，誰が記入するべきかなどの「測定」に関する課題，換算表の作成にあたって誰の選好をどの視点を使用して明らかにし，反映するべきなのかという「価値付け」の課題があり，現在あるMAUIsが十分に小児の健康関連QOLをとらえられていない可能性もある．日本ではこれまで小児の使用を想定したMAUIsがなかったが，最近EuroQol 5-dimension Youth version (EQ-5D-Y)日本語版とその換算表が発表され，今後日本人小児のデータの蓄積が期待される．小児のQOL値の測定と解釈にあたっては，その課題や限界を十分に理解しておく必要がある．

Effect of Nudge-Based Intervention on Adherence to Physician Visit Recommendations and Early Health Outcomes among Individuals Identified with Chronic Kidney Disease in Screens

Fukuma S., Sasaki S., Taguri M., Goto R., Misumi T., Saigusa Y., Tsugawa Y.

Journal of the American Society of Nephrology : JASN （Journal of the American Society of Nephrology : JASN） 33 （ 1 ） 175 - 185 2022年01月

ISSN 10466673

BACKGROUND: Although CKD screening programs have been provided in many settings, little is known as to how we can effectively translate those screening programs into improved health. METHODS: We conducted a randomized clinical trial on national health screening for CKD in Japan between April 2018 and March 2019. A total of 4011 participants in CKD screening programs aged 40-63 years were randomly assigned to two interventions or the control, with a ratio of 2:2:1, respectively: (1) the nudge-based letter that contained a message on the basis of behavioral economics, (2) the clinical letter including general information about CKD risks, and (3) the control (informed only of the screening results). The main outcome was adherence to a recommended physician visit within 6 months of the intervention. The secondary outcomes were eGFR, proteinuria, and BP 1 year after the intervention. RESULTS: Compared with the control group, the probability of undergoing a recommended physician visit was higher among participants who received the nudge-based letter (19.7% for the intervention group versus 15.8% for the control; difference, +3.9 percentage points [pp]; 95% CI, +0.8 to +7.0; P=0.02) and the clinical letter (19.7% versus 15.8%; difference, +3.9 pp; 95% CI, +0.8 to +7.0; P=0.02). We found no evidence that interventions were associated with improved early health outcomes. CONCLUSIONS: The behavioral economics intervention tested in this large RCT had limited effect on changing behavior or improving health outcomes. Although the approach has promise, this study demonstrates the challenge of developing behavioral interventions that improve the effectiveness of CKD screening programs.Clinical Trial registry name and registration number: University Hospital Medical Information Network Clinical Trial Registry, UMIN000035230.

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Real-world effectiveness of screening programs for age-related macular degeneration: amended Japanese specific health checkups and augmented screening programs with OCT or AI

Tamura H., Akune Y., Hiratsuka Y., Kawasaki R., Kido A., Miyake M., Goto R., Yamada M.

Japanese Journal of Ophthalmology （Japanese Journal of Ophthalmology） 66 （ 1 ） 19 - 32 2022年01月

ISSN 00215155

Purpose: To investigate the effectiveness of screening and subsequent intervention for age-related macular degeneration (AMD) in Japan. Study design: Best-case-scenario analysis using a Markov model. Methods: The clinical effectiveness and cost-effectiveness of screening for AMD were assessed by calculating the reduction proportion of blindness and the incremental cost-effectiveness ratio (ICER). The Markov model simulation began at screening at the age of 40 years and ended at screening at the age of 90 years. The first-eye and second-eye combined model assumed annual state-transition probabilities in the development and treatment of AMD. Data on prevalence, morbidity, transition probability, utility value, and treatment costs were obtained from previously published reports. Sensitivity analysis was performed to assess the influence of the parameters. Results: In the base-case analysis, screening for AMD every 5 years, beginning at age 40 years and ending at age 74 years (reflecting the screening ages of the current Japanese legal “Specific Health Checkups”) showed a decrease of 40.7% in the total number of blind patients. The screening program reduced the number of blind people more than did the additional AREDS/AREDS2 formula supplement intake. However, the ICER of screening versus no screening was ¥9,846,411/QALY, which was beyond what people were willing to pay (WTP) in Japan. Sensitivity analysis revealed that neither OCT nor AI improved the ICER, but the scenario in which the prevalence of smoking decreased by 30% improved the ICER (¥4,655,601/QALY) to the level under the WTP. Conclusions: Ophthalmologic screening for AMD is highly effective in reducing blindness but is not cost-effective, as demonstrated by a Markov model based on real-world evidence from Japan.

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