論文 - 後藤　励

From fragmentation toward integration: A preliminary study of a new long-term care policy in a fast-aging country

Chiu T.Y., Yu H.W., Goto R., Lai W.L., Li H.C., Tsai E.T., Chen Y.M.

BMC Geriatrics （BMC Geriatrics）  19 （ 1 ）  2019年06月

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Background: Taiwan, one of the fastest-aging countries in the world, started implementing version 1.0 of its long-term care (LTC) plan in 2008. In 2017, LTC Plan 2.0 began a new era with its goal to integrate Taiwan's fragmented LTC service system. LTC Plan 2.0 also aims to establish an integrated community-based LTC system incorporating both health care and disability prevention. This three-tier model consists of the following: two LTC services with a day-care center as their base and case management (Tier A), a day-care center and a single LTC service (Tier B), and LTC stations that provide primary prevention services and respite services for frail community-dwelling older adults to prevent further disabilities (Tier C). A defined cluster of agencies in a local area works together as a Tier ABC team. LTC Plan 2.0 is a new policy for Taiwan, and hence it is important to understand the agencies' initial difficulties with implementation and identify future challenges to help further policy development. Methods: This preliminary study explored the challenges to implementing LTC 2.0 through in-depth interviews based on Evashwick's integration mechanisms with representatives from three service teams. We interviewed three chief executive officers and three case managers. Results: We found that the LTC Plan 2.0 mechanisms for service integration have been insufficiently implemented. Recommendations include (1) Build up the trust between agencies and government, avoid duplication of LTC services within Tier ABC team, and encourage agencies within a team to create a shared administrative system with the same mission and vision. (2) Clarify the roles and responsibilities of government care managers and agency case managers. (3) Provide an integrated information system and create an official platform for sharing client records across different agencies and caregivers. (4) Establish a tool and platform to track the budget and payment across different levels of service as soon as possible. Conclusion: There is an increased demand for LTC services in Taiwan because of its rapidly aging population. Our findings shed some light on the challenges to developing integrated LTC services and thus may help both policymakers and service providers find ways to overcome these challenges.

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Comparison of Equity Preferences for Life Expectancy Gains: A Discrete Choice Experiment among the Japanese and Korean General Public

Goto R., Mori T.

Value in Health Regional Issues （Value in Health Regional Issues）  18   8 - 13 2019年05月

ISSN  22121099

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Background: Setting priorities for limited public resources has become a topic of heated discussion the world over. Assigning different weights for the health gains of different population groups allows for equity considerations in cost-effectiveness analysis. However, only a few empirical works have elicited the preferences of the general public. Objective: To compare the equity preferemce assigned by Japanese and Koreans. Methods: We conducted a Web-based survey in March 2013, including a discrete choice experiment, to elicit the equity preferences of the general public for the life expectancy gains of different population groups. We selected attributes and designed the experiment following Norman et al.'s study (Norman R, Hall J, Street D, Viney R. Efficiency and equity: a stated preference approach. Health Econ 2013;22:568–81). Accordingly, we analyzed preference for sex, smoking status, lifestyle, caring status, income, and age. Results: The Japanese assigned a higher preference for males (P < 0.001), nonsmokers (P < 0.001), those with lower income (P < 0.001), and carers (P < 0.001), and they assigned a lower preference for those with a life expectancy of 60 years (P = 0.002) and 75-year-olds (P < 0.001). Koreans have the same patterns of preference for lower income (P < 0.001), caring (P < 0.001), and smoking status (P = 0.026). However, they prefer both sexes (P = 0.331) and different age groups equally. In both countries, respondents tend to prefer groups with characteristics similar to their own. Conclusions: People from the two Asian developed countries, with universal health insurance, show different equity preferences. These may reflect the variations in cultural background and coverage of health care services.

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Estimating the Net Utility Gains Among Donors and Recipients of Adult Living Donor Kidney Transplant

Hiragi S., Goto R., Tanaka Y., Matsuyama Y., Sawada A., SakaI K., Miyata H., Tamura H., Yanagita M., Kuroda T., Ogawa O., Kobayashi T.

Transplantation Proceedings （Transplantation Proceedings）  51 （ 3 ） 676 - 683 2019年04月

ISSN  00411345

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Objectives: Living donor kidney transplant relieves the disease burden of patients with end-stage renal disease but may shorten donor life expectancy; however, their quality of life (QOL) is preserved. Nevertheless, the magnitude of the net gain of this procedure is unknown. We evaluated the QOL of both donors and recipients concurrently and calculated the net utility gain. Methods: We recruited 210 subjects who visited the kidney transplantation clinic of a university hospital. Subjects were asked to complete the 5-level EQ-5D-based questionnaire, and patient characteristics were extracted from their medical records. We performed multivariate tobit models analysis to evaluate the QOL change caused by transplant surgery and subsequently ran computational simulations to determine the net utility gains of donors and recipients. We also performed sensitivity analyses. Results: After excluding 16 answers with missing data, we analyzed 203 answers in total. After the transplant surgery, recipients gained 0.07 in utility value while donors lost 0.04. In the net utility analysis, we found that the quality-adjusted life years gained ranged from 7.2 to 7.8 in the most favorable case observed in the combination of middle-aged recipients and elderly donors. Assuming no utility discount, the most favorable combination was that with older donors and younger recipients. Conclusions: These findings indicated that the QOL improvement in recipients was larger than the loss among donors. When calculating the net utilities, a combination of middle-aged recipients and elderly donors yielded the largest net utility, but this was likely derived from assumption in the discount of QOL.

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The impact of anti-vascular endothelial growth factor agents on visual impairment/blindness prevention in patients with diabetic macular edema and on associated patient and caregiver burden in Japan

Kitano S., Sakamoto T., Goto R., Fukushima A., Vataire A.L., Hikichi Y.

Journal of Medical Economics （Journal of Medical Economics）  22 （ 3 ） 254 - 265 2019年03月

ISSN  13696998

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Aims: To estimate the impact of anti-vascular endothelial growth factor (VEGF) agents on visual impairment and blindness avoided in patients with diabetic macular edema (DME) and on associated patient and caregiver productivity loss in Japan. Methods: This study compared the impact of current care (estimated at 53.8% utilization of anti-VEGF agents using current data) with that of hypothetical care (characterized by a higher utilization of anti-VEGF agents [80.0%], as estimated by an expert panel) of DME patients. A population-based Markov model (two-eye approach) simulated visual acuity (Early Treatment Diabetic Retinopathy Study [ETDRS] letters) transitions over 5 years with DME treatments (intravitreal aflibercept, ranibizumab, and triamcinolone acetonide, and grid/focal laser) in patients with DME. Patient and caregiver productivity loss was determined using the human capital method. Results: In total, 570,000 DME patients were included in the model over 5 years. Increased utilization of anti-VEGF agents resulted in 6,659 fewer cases of severe visual impairment (SVI; 26–35 ETDRS letters) or blindness (0–25 ETDRS letters) compared with the current care approach (26,023 vs 32,682 cases; 20.38% reduction) over this period. Increased utilization of anti-VEGF agents also contributed to productivity loss savings of ¥12.58 billion (US $115.64 million) (i.e., 17.01%) at the end of year 5. The total overall saving over 5 years was ¥45.83 billion (US $421.27 million) (13.45%). Limitations: Few Japanese data were available, and assumptions were made for some inputs. Vision changes dependent on the function of both eyes were not studied. Only intravitreal (not sub-Tenon’s) injections of triamcinolone were considered in this model. Direct costs were not considered. Conclusions: Increased utilization of anti-VEGF agents can reduce SVI and legal blindness in patients with DME in Japan. This would also be associated with substantial savings in patient and caregiver productivity loss.

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The effect of model selection on cost-effectiveness research: A comparison of kidney function-based microsimulation and disease grade-based microsimulation in chronic kidney disease modeling

Hiragi S., Tamura H., Goto R., Kuroda T.

BMC Medical Informatics and Decision Making （BMC Medical Informatics and Decision Making）  18 （ 1 ）  2018年11月

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Background: Cost effectiveness research is emerging in the chronic kidney disease (CKD) research field. Especially, an individual-level state transition model (microsimulation) is widely used for these researches. Some researchers set CKD grades as discrete health states, and the transition probabilities between these states were dependent on the CKD grades (disease grade-based microsimulation, MSM-dg), while others set estimated glomerular filtration rate value which determines the severity of CKD as a main variable describing patients' continuous status (kidney function-based microsimulation, MSM-kf). MSM-kf seems to reflect the real world more precisely but is more difficult to implement. We compared the calculation results of these two microsimulation models to evaluate the effect of model selection on CKD cost-effectiveness analysis. Methods: We implemented simplified MSM-dg and MSM-kf emulating natural course of CKD in general, and compared models using parameters derived from an IgA nephropathy cohort. After checking these models' overall behavior, life-years, utilities, and thresholds regarding intervention costs below which the intervention is thought as dominant (V0) or cost-effective (V1) were calculated. In addition, one-way and probabilistic sensitivity analyses were performed. Results: With base-case parameters, the calculated life-years was shorter in MSM-dg (73.89 vs. 75.80 years) while the thresholds were almost equal (86.87 vs. 90.43 (V0), 132.29 vs. 146.25 [V1 in 1000 USD]) compared to MSM-kf. Sensitivity analyses showed a tendency of the MSM-dg to show shorter results in life-years. V0 and V1 were distributed by approximately ±100,000 USD (V0) and ± 150,000 USD (V1) between models. Conclusions: Estimated cost-effectiveness thresholds by both models were not the same and its difference distributed too wide to be ignored. This result indicated that model selection in CKD cost-effectiveness research has large effect on their conclusions.

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Influence of Japan's 2004 postgraduate training on ophthalmologist location choice, supply and distribution

Sakai-Bizmark R., Goto R., Hiragi S., Tamura H.

BMC Medical Education （BMC Medical Education）  18 （ 1 ）  2018年03月

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Background: Highly-competent patient care is paramount to medicine. Quality training and patient accessibility to physicians with a wide range of specializations is essential. Yet, poor quality of life for physicians cannot be ignored, being detrimental to patient care and leading to personnel leaving the medical profession. In 2004, the Japanese government reformed postgraduate training for medical graduates, adding a 2-year, hands-on rotation through different specialties before the specialization residency was begun. Residents could now choose practice location, but it sparked concerns that physician distribution disparities had been created. Japanese media reported that residents were choosing specialties deemed to offer a higher quality of life, like Ophthalmology or Dermatology, over underserved areas like Obstetrics or Cardiology. To explore the consequences of Japan's policy efforts, through the residency reform in 2004, to improve physician training, analyzing ophthalmologist supply and distribution in the context of providing the best possible patient care and access while maintaining physician quality of life. Methods: Using secondary data, we analyzed changes in ophthalmologist supply at the secondary tier of medical care (STM). We applied ordinary least-squares regression models to ophthalmologist density to reflect community factors such as residential quality and access to further professional development, to serve as predictors of ophthalmologist supply. Coefficient equality tests examined predictor differences before and after 2004. Similar analyses were conducted for all physicians excluding ophthalmologists (other physicians). Ophthalmologist coverage in top and bottom 10% of STMs revealed supply inequalities. Results: Change in ophthalmologist supply was inversely associated with baseline ophthalmologist density before (P <.01) and after (P =.01) 2004. Changes in other physician supply were not associated with baseline other physician density before 2004 (P = 0.5), but positively associated after 2004 (P <.01). Inequalities between top and bottom 10% of ophthalmologist supply in STMs were large, with best-served areas maintaining roughly five times greater coverage than least-served areas. However, inequalities gradually declined between 1998 and 2012. Conclusions: Ophthalmologist supply increased both before and after the 2004 reform, yet contrary to media reports, proceeded at a lesser rate than supply increases for other physicians. After 2004, geographical disparities decreased for ophthalmologists, while increasing for other physicians.

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Geographical accessibility to gambling venues and pathological gambling: an econometric analysis of pachinko parlours in Japan

Kato H., Goto R.

International Gambling Studies （International Gambling Studies）  18 （ 1 ） 111 - 123 2018年01月

ISSN  14459795

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The relationship between geographical accessibility to gambling venues and the prevalence of pathological gambling is still unknown. This study aimed to reveal this relationship in Japan as well as its variation by subpopulation. A cross-sectional study was conducted, based on an original web-based survey to understand the level of pathological gambling depending on accessibility to pachinko parlours. Pathological gamblers were measured using the Japanese version of the South Oaks Gambling Screen. Accessibility to gambling venues was defined as the number of pachinko parlours within a 1.5 km radius from home. Moreover, the study adopted the instrumental variable approach to solve the potential endogeneity problem. The results showed that the accessibility was not significantly associated with pathological gambling in general, but that the effects of accessibility varied by subpopulation. Accessibility was significantly and positively correlated with pathological gambling for men and people in low-income areas, but this was not so for women and people in high-income areas. The study’s findings show the importance of the neighbourhood environment and could help in implementing more effective interventions for pathological gamblers.

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Examining the impact of smoking on work productivity and associated costs in Japan

後藤 励

Journal of Medical Economics 2017年

共著, 査読有り

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Does lack of resources impair access to breast and cervical cancer screening in Japan?

後藤 励

PLoS 2017年

共著, 査読有り

Analysis of the evidence-practice gap to facilitate proper medical care for the elderly: investigation, using databases, of utilization measures for National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB)

後藤 励

Environmental Health and Preventive Medicine 22 （ 51 ）  2017年

共著, 査読有り

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Fukushima after the Great East Japan Earthquake: lessons for developing responsive and resilient health system

GOTO Rei,Shingo Fukuma, Shahira Ahmad, Inui S Thomas, Rifat Atun and Shunichi Fukuhara

Journal of Global Health 7 （ 1 ）  2017年

共著, 査読有り

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Potential capacity of endoscopic screening for gastric cancer in Japan

GOTO Rei, Chisato Hamashima

Cancer Science 108 （ 1 ） 101 - 107 2017年

共著, 査読有り

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へき地の勤務条件に対する大都市の内科系勤務医の選好

後藤 励,　佐野洋史, 村上正泰, 柿原浩明

日本労働研究雑誌  （ 680 ） 86 - 101 2017年

共著, 査読有り

医療における費用対効果とは？

後藤 励

Cancer Board Square 3 （ 2 ） 50 - 55 2017年

A discrete choice experiment studying students' preferences for scholarships to private medical schools in Japan

後藤 励

HUMAN RESOURCES IN HEALTH 14 （ 4 ）  2016年02月

研究論文（学術雑誌）, 査読有り,  ISSN  1478-4491

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Cost-effectiveness analysis of smoking cessation interventions in Japan using a discrete event simulation

後藤 励

Applied Health Economics and Health Policy 14   77 - 87 2016年

研究論文（学術雑誌）, 査読有り

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A socioeconomic and behavioral survey of patients with difficult-to-control type 2 diabetes reveals an association between diabetic retinopathy and educational attainment.

後藤 励

Patient Preference and Adherence 10   2151 - 2162 2016年

共著, 査読有り

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生活習慣病・行動変容と医療経済

後藤 励

治療 98 （ 4 ） 551 - 555 2016年

単著

患者満足度と従業員満足度の影響要因

新井康平福嶋誠宣前平秀志後藤 励

久留米大学ビジネス研究 1 （ 1 ）  2016年

研究論文（大学，研究機関等紀要）, 単著

Study protocol of the TRICOLORE trial: a randomized phase III study of oxaliplatin-based chemotherapy versus combination chemotherapy with S-1, irinotecan, and bevacizumab as first-line therapy for metastatic colorectal cancer

後藤 励

BMC CANCER 15 2015年09月

研究論文（学術雑誌）, 査読有り,  ISSN  1471-2407

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