資料４ ➨51ᅇ ESRI䠉⤒῭ᨻ⟇䝣䜷䞊䝷䝮 䝭䜽䝻䝕䞊䝍䜢ά⏝䛧䛯ᨻ⟇◊✲䛻䛴䛔䛶 ་⒪ศ㔝䛻䛚䛡䜛䝕䞊䝍⏝䛾ᣑ 䠉National Data Base䠄䝺䝉䝥䝖䝕䞊䝍䠅䛾ά⏝ྍ⬟ᛶ䛸⌧≧䠉 2015ᖺ2᭶27᪥ ᪩✄⏣Ꮫ䞉ᨻ⤒῭Ꮫ⾡㝔 㔝ཱྀᬕᏊ 1 ᮏ᪥䛾ヰ䛾ὶ䜜 ¾ ་⒪䝃䞊䝡䝇ᕷሙ䛾㏱᫂ᛶ䠄”㉁”䛾ィ 䛾㞴䛧䛥䠅 ¾ 䛂ほᐹ䛃䠄㠀ᐇ㦂䠅䝕䞊䝍䛻䜘䜛᳨ド䛾ၥ㢟Ⅼ䠄ෆ⏕ᛶ䠅 ¾ 䛂ほᐹ䛃䠄㠀ᐇ㦂䠅䝕䞊䝍䛾ྍ⬟ᛶ䜢䛥䛠䜛 ¾ 䛂ᐇ㦂ⓗ䛃䛺ᡭἲ䛿᭱Ⰻ䛾᪉ἲ䛛䠛 ¾ ⤖ㄒ䠖ᚋ䛾་⒪ᨻ⟇ศ㔝䛻䛚䛡䜛ᐇドศᯒ䛾Ⓨᒎ䜈ྥ䛡䛶 9 National Data Base(NDB)䛾⌧≧䛸ㄢ㢟 9 㧗㱋⪅⮬㌟䚸ᐙ᪘䚸⌧ሙᢸᙜ⪅䚸ᨻ⟇ᢸᙜ⪅䛸◊✲⪅䛸䛾dialog 2 ་⒪䝃䞊䝡䝇ᕷሙ䛾 ㏱᫂ᛶ 䠄”㉁”䛾ィ 䛾㞴䛧䛥䠅 3 ఱ䛷 䜛䛛䠛䠖་⒪ホ౯䛾3䛴䛾ᣦᶆ Donabedian (1969) (1) ᵓ㐀ᣦᶆ(structure): 㝔䜔デ⒪ᡤ➼་⒪䝃䞊䝡䝇䛾౪⤥⪅䛻㛵䜟䜛ᣦᶆ e.g. ≀ⓗ㈨ᮏ ᅵᆅ䞉ᘓ≀䛾㠃✚䚸ᐊ䞉ᗋᩘ䚸་⒪ᶵჾ䞉ᶵᮦ䛾᭷↓䚸 ICU䜔CCU➼䛾᭷↓䚸㈨ᮏ㔠䜔㈈ົἣ➼ ேⓗ㈨ᮏ ᝈ⪅1ேᙜ䛯䜚䛾ᑓ㛛ⓗ㈨᱁䜢᭷䛩䜛⪅䠄་ᖌ䚸┳ㆤᖌ䚸䝋䞊䝅䝱䝹䝽䞊䜹䞊➼䠅䛾 ᩘ䚸タ䛾⟶⌮䝅䝇䝔䝮䜔⤌⧊ᵓ㐀➼ (2) ⤒㐣ᣦᶆ(process): ౪⤥⪅䛻䜘䛳䛶ᥦ౪䛥䜜䜛་⒪䝃䞊䝡䝇䛾䝁䞁䝔䞁䝒 e.g. high-tech treatments 㛤Ⓨ㈝⏝ཬ䜃ᢏ⾡ᬑཬ䛾㝿䛾ᅛᐃ㈝⏝䛸㝈⏺㈝⏝䛜ᕧ㢠䛻䛾䜌䜛⒪ low-tech treatments ẚ㍑ⓗప䝁䝇䝖䛷䛹䛾་⒪タ䛻䛚䛔䛶䜒ᑟධ䛜ྍ⬟䛷䛒䜛་⒪ᢏ⾡ (3) ຠᯝᣦᶆ(outcome): ⒪ᚋ䛾ᝈ⪅ᡂ⦼䜔䜘䜚ໟᣓⓗ䛺QOL䜒ྵ䜐ㅖኚᩘ e.g. Ṛஸ䚸ྜే䛾ేⓎ䜔ᚩೃ䚸ධ㝔䞉እ᮶䛾᭷↓䚸⢭⚄⾨⏕䜔⫗యⓗᶵ⬟䛸䛔䛳䛯 ᝈ⪅䛾ᗣ≧ែ䚸QALY(quality adjusted life years: ㉁ㄪᩚ⏕Ꮡᖺ)➼ 4 ඞ᭹䛥䜜䛴䛴䛒䜛 ་⒪ሗ䛾㞟✚㐣⛬䛸ศᯒ䛻క䛖ᅔ㞴 (1) ་⒪䛾䛂㉁䛃䛾ィ 䛻㛵䛩䜛ᑓ㛛ᐙ㛫䛷䛾䝁䞁䝉䞁䝃䝇䛸⌮ゎ a. ་⒪ᢏ⾡䛾ᛴ⃭䛺㧗ᗘ䞉」㞧䜢⫼ᬒ䛸䛧䛯་⒪䛾䛂㉁䛃䛾ホ౯ b. ≉ᐃ䛤䛸䛾ಶ⚊䝧䞊䝇䛷䛾ヲ⣽䛺་⒪ሗ䛾㞟䛸ศᯒ䛾ᚲせᛶ䛾㧗䜎䜚 c. ་⛉Ꮫศ㔝䛻䛚䛡䜛㈝⏝ຠᯝศᯒ䛸་⒪⤒῭Ꮫཬ䜃ಖ㝤䞉ཌ⏕ᨻ⟇䛸䛾᥋Ⅼ (2) ་⒪䛾䛂㉁䛃䛾⤌⧊ⓗ䞉⥅⥆ⓗ᳨ド䛾䛯䜑䛾䝕䞊䝍䛾㞟䞉⟶⌮䞉㐠Ⴀ a. ᵝ䚻䛺་⒪ሗ㈨※䠄䜹䝹䝔䚸䝺䝉䝥䝖䚸DPC䚸ᡞ⡠䚸ఫẸྎᖒ➼䠅䛾ά⏝䛾ᚲせᛶ b. ་⒪ሗ䛾㞟䛻క䛖ᕧ㢠䛾㈝⏝ c. ་⒪ሗ䛾ᶆ‽䛸㟁⟬ d. ಶேሗಖㆤ䜢☜ಖ䛩䜛䛯䜑䛾⟶⌮䞉㐠Ⴀ䝅䝇䝔䝮䛾☜❧䛸ἲⓗ䞉ไᗘⓗᇶ‽䛾᫂☜ e. ᳨ド⤖ᯝ䜢ᐇ㝿䛾ᨻ⟇⟇ᐃ䜔⒪⌧ሙ䛷䛾ពᛮỴᐃ䛻ᫎ䛥䛫䜛䝅䝇䝔䝮䛾☜❧ (3) ་⒪䛾䛂㉁䛃䜢බṇ䛻ィ 䛩䜛䛯䜑䛾⤫ィᏛᡭἲ䛾☜❧ a. ་⒪䛾䛂㉁䛃䜢ィ 䛩䜛䛯䜑䛾䝂䞊䝹䝗䞉䝇䝍䞁䝎䞊䝗䠉↓సⅭᢳฟヨ㦂 b. ↓సⅭᢳฟヨ㦂䜢⿵䛩䜛ほᐹ䠄㠀ᐇ㦂䠅䝕䞊䝍䛻䜘䜛᳨ド䛾ᚲせᛶ d. බṇ䛺ຠᯝ䜢᥎ᐃ䛩䜛䛯䜑䛾⤫ィᏛⓗ䛺䝸䝇䜽ㄪᩚ䛾ᚲせᛶ 5 䛂ほᐹ䛃䠄䛂㠀ᐇ㦂䛃䠅䝕䞊䝍䛻䜘䜛᳨ド䛾ၥ ၥ㢟Ⅼ 䠄ෆ⏕ᛶ䠖ENDOGENEITY䠅 6 ◊✲1䠖ᛴᛶᚰ➽᱾ሰ䠄Acute Myocardial Infarctions (AMIs) or heart attacks䠅䛾⒪ຠᯝ ᛴᛶᚰ➽᱾ሰ(AMI)䠖 ୍⯡ⓗ䛻䛿䚸⬡⫫ᛶỿ╔≀䛺䛹䛻䜘䜛ື⬦◳䛜ཎᅉ䛸䛺䛳䛶䚸ᚰ⮚ෆ䛾ෙ≧ື ⬦䛜⊃✽䜢䛚䛣䛧䚸⾑ὶ㔞䛜ῶᑡ䛧䚸䛭䜜䛻䜘䜚ᚰ➽䛻㓟⣲䛜༑ศ䛻౪⤥䛥䜜䛪 ⾑≧ែ䛻㝗䜚ቯṚ䛧䛶䛧䜎䛖䚸་Ꮫⓗ䛻⥭ᛴ䜢せ䛩䜛≧ែ 7 US䛻䛚䛡䜛AMIⓎᚋ䛾ᝈ⪅䠄65+䠅䜰䜴䝖䜹䝮 • ᚰ⮚䛿䚸㐣ཤᩘ༑ᖺ㛫䛻䜟䛯䜚䚸䜰䝯䝸䜹䛻䛚䛡䜛Ṛᅉ䛾➨1䜢 ༨䜑䛶䛚䜚䚸䛖䛱䚸䜋䛸䜣䛹䛾䜿䞊䝇䛜ᛴᛶᚰ➽᱾ሰ䠄䛒䜛䛔䛿䚸ᚰ ⮚Ⓨస䠅䛻䜘䜛䜒䛾䛷䛒䜛䚹 (1994ᖺ䛻䛚䛡䜛65ṓ௨ୖேཱྀᑐ10 ேᙜ䛯䜚䛾Ṛஸ⋡䠖⏨ᛶ600䠗ዪᛶ490) • AMIⓎᚋ1ᖺ௨ෆṚஸ⋡ Source: McClellan, Mark and Haruko Noguchi (1998), “Does High-Tech Mean Low Value? Technological Change in Heart Attack Care,” American Economic Review. 8 AMI䛻ᑐ䛩䜛せ䛺⒪ἲ • High-tech treatments䠖 䠖 㛤Ⓨ㈝⏝ཬ䜃ᢏ⾡ᬑཬ䛾 㝿䛾ᅛᐃ㈝⏝䛸㝈⏺㈝⏝䛜 ᕧ㢠䛻䛾䜌䜛⒪ e.g., CATH(Cardiac catheterization) CABG(bypass surgery) PTCA(angioplasty) • Low-tech treatments䠖 ẚ㍑ⓗప䝁䝇䝖䛷䛹䛾་⒪タ䛻䛚䛔䛶䜒ᑟධ䛜ྍ⬟䛷䛒䜛 ་⒪ᢏ⾡ e.g, drug treatments such as aspirin, ace inhibitor, beta blocker,IV NTG 9 US䛻䛚䛡䜛AMIⓎᚋ䛾㝔་⒪㈝䠄65+䠅 Source: McClellan, Mark and Haruko Noguchi (1998), “Does High-Tech Mean Low Value? Technological Change in Heart Attack Care,” American Economic Review. 10 ᐇ㦂䝕䞊䝍䛸ほᐹ䠄㠀ᐇ㦂䠅䝕䞊䝍䛸䛾ẚ㍑ • ↓సⅭᢳฟヨ㦂䛾 VANQWISH (Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital) by Boden WE, O’Rourke RA, Crawford MH, et al., New England Journal of Medicine 1998; 338(25):pp.1785-1792. ᑐ㇟⪅: patients who had milder heart attack with non-Q-wave, but who had higher risk of future attacks • グ㘓䛻ᇶ䛵䛟ほᐹ䠄㠀ᐇ㦂䠅䝕䞊䝍䛾 1994-1995 CCP(Cooperative Cardiovascular Project) 䛻䜘䜛᳨ド by Geppert J, McClellan M.B. , Noguchi H, Stanford University mimeo 1999 ᑐ㇟⪅: VANQWISH䛸ྠᵝ䛾ᐃ⩏䜢⏝䛔௨ୗ䛾ᝈ⪅䜢ศᯒᑐ㇟䛛䜙㝖እ Patients who did not have a confirmed AMI; who had been transferred from another acute care hospital; who had new abnormal Q waves on serial electrocaridograms; who do not have evolving AMI, a level of kinase MB(CK-MB) isoenzymes that was more than 1.5 times the upper limit of normal for the hospital; who had serious coexisting conditions • ┠ⓗ ධ㝔ᚋ7᪥௨ෆ䛾cardiac catheterization䜢䛂✚ᴟⓗ⒪䛃䛸ᐃ⩏䛧䛶䚸ୖグᑐ㇟ ⪅䜈䛾⒪ᡂ⦼䛻ᑐ䛩䜛ຠᯝ䜢᳨ド 11 䝉䝺䜽䝅䝵䞁䞉䝞䜲䜰䝇䛾ᐇែ䠄⥆䛝䠅 ᐇ㦂䝕䞊䝍䠄VANQWISH䠅 VS 㠀ᐇ㦂䝕䞊䝍(CCP) 12 䜎䛸䜑䠖ᐇ㦂䝕䞊䝍䠄VANQWISH䠅 VS 㠀ᐇ㦂䝕䞊䝍(CCP) ¾ ධ㝔ᚋ7᪥௨ෆ䛾CATH䛾ᐇ vs 㠀ᐇྜ䠖 9 9 VANQWISH(462ே vs 458ே) CCP䠄5,866ே(66%) vs 11,607ே䠄34%䠅䠅 ¾ ኚᩘ⩌A(䝁䝇䝖Ᏻ)䠉ᖺ㱋䛸ᛶู: 9 9 VANQWISH䠄⤫ィⓗ䛺᭷ពᕪ䛺䛧䠅 CCP䠄ᖺ㱋䛜ⱝ䛟䠈⏨ᛶ䛾᪉䛜✚ᴟⓗ⒪䜢ཷ䛡䜛☜⋡䛜㧗䛔䠅 ¾ ኚᩘ⩌B䠄䝁䝇䝖㧗䠅䠉䝸䝇䜽せᅉ䠖 9 VANQWISH䠄⤫ィⓗ䛺᭷ពᕪ䛺䛧䠅 9 CCP䠄୍㒊䜢㝖䛝䚸≧ែ䛾Ⰻ䛔ᝈ⪅䛾᪉䛜✚ᴟⓗ⒪䜢ཷ䛡䜛☜⋡䛜㧗䛔䠅 ¾ ⸆≀ᢞ䠖 9 VANQWISH䠄⤫ィⓗ䛺᭷ពᕪ䛺䛧䠅 9 CCP䠄䜹䝹䝅䜴䝮ᣕᢠ⸆䜢㝖䛝䠈✚ᴟⓗ䛻⸆≀ᢞ䜢䛥䜜䛶䛔䜛ᝈ⪅䛾᪉䛜7᪥௨ ෆ䛻CATH 䜢ཷ䛡䜛☜⋡䛜㧗䛔䠅 эほᐹ䝕䞊䝍䛷䛿䠈✚ᴟⓗ⒪䛾ᐇ䛻䠈᫂䜙䛛䛻䠈೫䜚䠄䝉䝺䜽䝅䝵䞁 䞉䝞䜲䜰䝇䠅䛜䛒䜛䛣䛸䜢♧䛧䛶䛔䜛䚹 13 䝉䝺䜽䝅䝵䞁䞉䝞䜲䜰䝇䛾ᐇែ䠄⥆䛝䠅 ༢⣧ᅇᖐ䛾⤖ᯝ 14 䛂ほᐹ䛃䠄㠀ᐇ㦂䠅䝕䞊䝍䛾ྍ⬟ᛶ䜢䛥䛠䜛 15 ⤫ィⓗ䛺ᡭἲ䛻䜘䜛ㄪᩚ 䠉䝃䞁䝥䝹䜢ఝⓗ䛻randamize䛩䜛᧯సኚᩘἲ䠄Instrumental variable:IV䠅䠉 16 㑅ᢥ䝞䜲䜰䝇ㄪᩚ๓ VS ㄪᩚᚋ 17 IV䛾⤖ᯝ 䝉䝺䜽䝅䝵䞁䞉䝞䜲䜰䝇䛾ᐇែ䠄⥆䛝䠅 RCT䛸䜋䜌ྠ ᵝ䛾⤖ᯝ䚹㧗 ౯䛺ሗ䜢⏝ 䛔䛺䛔ሙྜ䜒 4.8(7.4) 㧗౯䛺ሗ䛾 ᭷↓䛻⤖ᯝ䛜 ᕥྑ䛥䜜䛺䛔 18 ཧ⪃䠖IVἲ䜢⏝䛔䜛㝿䛾᳨ᐃᡭἲ 㐣㆑ูไ⣙᳨ᐃ䠄Sargan(1958)䚸Basmann (1960)䠅䠖 䛶䛾᧯సኚᩘ䛜ㄗᕪ㡯䛸↓┦㛵䛷䛒䜛䛸䛔䛖ᖐ↓௬ㄝ䛾Რ༷䛾᭷ ↓䜢☜ㄆ ᙅ┦㛵䛾䛯䜑䛾᳨ᐃ䠄 Andreson(1984) 䠅䠖 ෆ⏕ኚ ᩘX 䛸᧯సኚᩘZ䛾⾜ิ㛫䛾┦㛵䜢ィ⟬䛧䚸᧯సኚᩘ䛜᭷ព䛷䛒䜛 䛸䛔䛖䛣䛸䛿䚸䛩䜉䛶䛾┦㛵䛜᭷ព䛻䝊䝻䛸䛿␗䛺䜛䛿䛪䛷䛒䜛䛣 䛸䜢᳨ᐃ䚹Anderson 䛿᭱ᑠ䛾┦㛵䛿䝊䝻䛷䛒䜛䛸䛔䛖ᖐ↓௬ㄝ䜢 ᑬᗘẚ䜢⏝䛔䛶᳨ᐃ ศᩓᆒ୍ᛶ䛾᳨ᐃ䠄Pagan and Hall (1983) 䚸White (1982)䠅䠖 ㄗᕪ㡯䛿ᆒ୍ศᩓ䛷䛒䜚䚸⣔ิ┦㛵䛜䛺䛔䛣䛸䜢☜ㄆ ෆ⏕ᛶ᳨ᐃ䠄 Hausman (1978) 䠅䠖 ⌮ㄽୖ䛿䛸䜒䛛䛟䚸ᐇドୖ䛿ෆ⏕ኚᩘ䛷䛒䜛䛛䛹䛖䛛䜢᳨ᐃ 19 䛂ᐇ㦂ⓗ䛃䛺ᡭἲ䛿᭱Ⰻ䛾᪉ἲ䛛䠛 20 ◊✲2䠖䜸䝺䝂䞁ᕞ䛻䛚䛡䜛Medicaid䛻ᑐ䛩䜛♫ᐇ㦂 Oregon Health Insurance Experiment䠄OHIE䠅 • Katherine B et al (2013/May)“The Oregon Experiment — Effects of Medicaid on Clinical Outcomes.” New England Journal of Medicine: 368;18, pp1713-1722. • 2008ᖺ䛻䚸⡿ᅜ䜸䝺䝂䞁ᕞ䛻䛚䛔䛶Medicaid(పᡤᚓ⪅ྥ䛡䛾་⒪ಖ㝤)䜢ᣑ 䛩䜛䛻ᙜ䛯䛳䛶㈈※䛜㝈䜙䜜䛶䛔䛯䛣䛸䛛䜙䚸9ே䛾ᚅᶵ䝸䝇䝖䛾୰䛛䜙䛟 䛨ᘬ䛝䛷⣙3ே䛜ᢳฟ䛥䜜䛯 • ㈨᱁せ௳䠖19-64ṓ䚸⡿ᅜᕷẸ䜎䛯䛿ྜἲⓗ䛺⛣Ẹ䛷䚸䜸䝺䝂䞁ᕞ䛾ఫẸ䛷䛒 䜛䛣䛸䚸ᙜヱⅬ䛛䜙㐣ཤ6䛛᭶௨ෆ䛻Medicaid௨እ䛾බⓗಖ㝤䛾ᑐ㇟እ䜎 䛯䛿ಖ㝤ຍධ䛜䛺䛔䛣䛸䚸㐃㑥ᨻᗓ䛜タᐃ䛩䜛㈋ᅔỈ‽䛾100%ᮍ‶(2008ᖺ ⌧ᅾ䚸4ேᐙ᪘䛷ᡤᚓ䛜21,200௨ୗ䠅䛷䛒䜛䛣䛸䚸㈨⏘䛜2,000䝗䝹ᮍ‶䛷䛒䜛 䛣䛸 • Portland metropolitanᆅᇦ䛾䝕䞊䝍䛻⤠䜚䚸20,745ே䜢◊✲ᑐ㇟䛸䛧䛯 䠄䛖䛱䚸10,405ே䛜ᢳ㑅䛷Medicare䛻ຍධ䠗10,340ே䛜㠀ຍධ䠅 • 2009/9-2010/12䛻䛛䛡䛶ᑐ㠃ㄪᰝ䠄ฎ⨨⩌䠄6387䠅䠗ᑐ↷⩌䠄5,842䠅䠅 21 䝉䝺䜽䝅䝵䞁䞉䝞䜲䜰䝇䛾ᐇែ䠄⥆䛝䠅 ฎ⨨⩌䠄Meicaidຍධ䠅VS ᑐ↷⩌(㠀ຍධ) 22 ᗣᣦᶆ䛻ᑐ䛩䜛Medicaid䛾ຍධຠᯝ ¾ ⢭⚄ⓗ䛺ᗣᣦᶆ䛻䛴䛔䛶䛿᭷ព䛺ᨵၿ䛜ぢ䜙䜜䜛䛜䚸㌟ యⓗ䛺ᗣᣦᶆ䜔ほⓗ䛺ᖾ⚟ᗘ䛻䛴䛔䛶䛿䚸᭷ព䛺ᨵၿ 䛜ぢ䜙䜜䛺䛔 23 ⤒῭ᣦᶆ䞉་⒪㟂せ䛻ᑐ䛩䜛Medicaid䛾ຍධຠᯝ 24 OHIE䛾ᨻ⟇䜈䛾Ἴ⣠ March 2013, “The Economic Report of President” , Chapter 5, Reducing Costs and Improving the Quality of Health OHIE䛾ᐇド⤖ᯝ䛿䚸⤫㡿䜈䛾ሗ࿌᭩䛻ᥖ㍕䛥 䜜䚸䜸䝞䝬⤫㡿䛾་⒪ᨻ⟇䜢䜑䛠䜛㆟ㄽ䠄㈶ྰ䠅 䛾䜶䝡䝕䞁䝇䛸䛺䛳䛶䛔䜛䚹 ᑐὴ䠙䠚㌟య㠃䛷䛾ᗣቑ㐍ຠᯝ䛜ㄆ䜑䜙䜜 䛺䛛䛳䛯䛣䛸䚸Medicaid䜢ᣑ䛩䜛䛛䛹䛖䛛䛾ุ᩿ 䛜ᕞᨻᗓ䛻௵䛥䜜䛶䛔䜛䛣䛸 ㈶ᡂὴ䠙䠚ᐙィ㈇ᢸ䜈䛾㍍ῶ䛜ㄆ䜑䜙䜜䛯䛣䛸䚸 పᡤᚓᒙ䛾་⒪㟂せቑ䚸䛧䛯䛜䛳䛶䚸་⒪䝃䞊 䝡䝇䜈䛾䜰䜽䝉䝇ྥୖ䜢ホ౯䛩䜉䛝 ฟᡤ䠖Ᏻ䠄2013/5/15䠅䛂䜰䝯䝸䜹NOW ➨102ྕ ⡿་⒪ᨵ㠉䛻Ἴ⣠䜢ᢞ䛢䛛䛡䛯䜸䝺䝂䞁ᕞ䛾䛂ᐇ 㦂䛃䛃ᮾி㈈ᅋHP䚸http://www.tkfd.or.jp/research/project/news.php?id=1140 25 䛂ᐇ㦂ⓗ䛃䛺ᡭἲ䛿᭱Ⰻ䛾᪉ἲ䛛䠛 ¾ ⌮㠃䛷䛾ၥ㢟: ே䚻䛾⏕䜔ᖾ⚟䛻┤᥋ᙳ㡪䛾䛒䜛ධ䜢”lottery”䛷ᐇ䛩䜛䛣䛸䜢 䛹䛖⪃䛘䜛䛛䠛↓ㄽ䚸་⒪ሗ䛻䛴䛔䛶䛿䚸㧗㱋⪅䜔㔜⠜䛺≧ែ䛾ᝈ ⪅➼䚸㧗䝸䝇䜽⩌䛿䝃䞁䝥䝹䛛䜙㝖እ䛥䜜䜛 ¾ ㈝⏝㠃䛷䛾ၥ㢟 “It was a 15-year, multimillion-dollar effort that to this day remains the largest health policy study in U.S. history” (source: RAND, http://www.rand.org/health/projects/hie.html) ¾ ᐇ㦂⤖ᯝ䛾 ᐃ䛾ᐜ᫆䛥 䛯䛸䛘䜀䚸♫ಖ㞀䜔ᩍ⫱㛵㐃䛾ᨻ⟇䛻䛴䛔䛶䛿䚸ᨻ⟇䝍䞊䝀䝑䝖䛸䛺 䜛䜰䜴䝖䜹䝮䛾 ᐃ䛜ẚ㍑ⓗᐜ᫆䛷䛒䜛䛜䠄↓ㄽ䚸䇾 ᐃㄗᕪ䇿➼䛾ၥ 㢟䛿䛒䜛䛸䛧䛶䠅䚸䜰䜴䝖䜹䝮䛾 ᐃ䛜ᅔ㞴䛺ᨻ⟇䛻䛴䛔䛶䛿䛹䛖䛩䜛䛛 䠛эฟ∧䝞䜲䜰䝇䛾ၥ㢟 26 ⤖ㄒ䠖ᚋ䛾་⒪ᨻ⟇◊✲䛻䛚䛡䜛 ᐇドศᯒ䛾Ⓨᒎ䜈ྥ䛡䛶 27 ฟᡤ䠖⃝₶䠄2011ᖺ11᭶23᪥䠅䛂䝺䝉䝥䝖㟁Ꮚ䛾≧ἣ䛸 䝘䝅䝵䝘䝹䝕䞊䝍䝧䞊䝇䛾ά⏝᪉ྥ䛃 ➨31ᅇ་⒪ሗᏛ㐃ྜ䚸http://yuhan.jp/04japmedinsurance/600;20111121kitazawa.pdf 䠄2015ᖺ2᭶19᪥䜰䜽䝉䝇䠅 28 NDB䛾ㄢ㢟䠖ᆅᇦ䛻䜘䜛᱁ᕪ䠄་⛉䠅䐟 ฟᡤ䠖♫ಖ㝤デ⒪ሗ㓘ᨭᡶᇶ㔠䛂䝺䝉䝥䝖㟁⟬ฎ⌮䝅䝇䝔䝮䠖ᬑཬ≧ἣ䛃http://www.ssk.or.jp/rezept/rezept_01.html 䠄2015ᖺ2᭶ 19᪥䜰䜽䝉䝇䠅䜢ᇶ䛻䚸➹⪅సᡂ䚹 29 NDB䛾ㄢ㢟䠖ᆅᇦ䛻䜘䜛᱁ᕪ䠄ṑ⛉䠅䐠 ฟᡤ䠖♫ಖ㝤デ⒪ሗ㓘ᨭᡶᇶ㔠䛂䝺䝉䝥䝖㟁⟬ฎ⌮䝅䝇䝔䝮䠖ᬑཬ≧ἣ䛃http://www.ssk.or.jp/rezept/rezept_01.html 䠄2015ᖺ2᭶ 19᪥䜰䜽䝉䝇䠅䜢ᇶ䛻䚸➹⪅సᡂ䚹 30 NDB䛾ㄢ㢟䠖ᆅᇦ䛻䜘䜛᱁ᕪ䐡 ฟᡤ䠖♫ಖ㝤デ⒪ሗ㓘ᨭᡶᇶ㔠䛂䝺䝉䝥䝖㟁⟬ฎ⌮䝅䝇䝔䝮䠖ᬑཬ≧ἣ䛃http://www.ssk.or.jp/rezept/rezept_01.html 䠄2015ᖺ2 ᭶19᪥䜰䜽䝉䝇䠅䚸ཬ䜃䚸ཌ⏕ປാ┬䠄2011ᖺ䠅䛂་⒪㈝䛾ᆅᇦᕪศᯒ䛃䜢ᇶ䛻䚸➹⪅᥎ィ䚹 31 NDB䛾ㄢ㢟䠖ᆅᇦ䛻䜘䜛᱁ᕪ䐢 ฟᡤ䠖♫ಖ㝤デ⒪ሗ㓘ᨭᡶᇶ㔠䛂䝺䝉䝥䝖㟁⟬ฎ⌮䝅䝇䝔䝮䠖ᬑཬ≧ἣ䛃http://www.ssk.or.jp/rezept/rezept_01.html 䠄2015ᖺ 2᭶19᪥䜰䜽䝉䝇䠅䚸ཬ䜃䚸ཌ⏕ປാ┬䠄2011ᖺ䠅䛂་⒪㈝䛾ᆅᇦᕪศᯒ䛃䜢ᇶ䛻䚸➹⪅᥎ィ䚹 32 ᥦ౪䛥䜜䛶䛔䜛䝕䞊䝍䛾✀㢮 ཎКਁЈ ؕஜႎƳǤȡȸǸ ဎᛪᎍƷᙲஓƷࣖ ơŴȇȸǿșȸǹƴ ƋǔμȇȸǿƷƳƔ ƔǒŴᛆ࢘Ƣǔ̾ᅚ ƷऴإǛਁЈƠŴ੩ ̓Ƣǔ ੩̓ȇȸǿ ̾ᅚ ǵȳȗȪȳǰȇȸǿ ǻȃȈ ኧႎᄂᆮǁƷȋȸ ǺƴࣖݣƠŴਁЈŴ ҕӸ҄ƳƲǛƠƯ ܤμࣱƴҗЎᣐॾƠ ƨŴҥஉЎƷȇȸǿ ǻȃȈ ɟᢿҕӸ҄ሁǛ ᘍƬƨ̾ᅚ ؕஜȇȸǿǻȃȈ λᨈŴٳஹŴ၌धК ƳƲႸႎƴӳǘƤƯ ࠰ࡇƝƱƴኜ˄ƚƕ ӧᏡưŴቇତƴЎௌ ƢǔƜƱƕӧᏡƳ ȇȸǿǻȃȈ ࠢٻƴьƠƨ̾ᅚ ᨼᚘᘙऴإ ဎᛪᎍƷᙲஓƴࣖ ơŴȇȸǿǛьƠ Ư˺ƠƨᨼᚘᘙǛ ੩̓Ƣǔ ᨼᚘᘙ ȬǻȗȈऴإŴཎܭ धᎍƷؕஜࣱޓऴإ ࠎݲƳऴإƕƋǒƔ ͤᚮሁऴإƴԃLJǕ ˌٳƸŴɼͻ၏ӸŴ ᨼᚘᘙ ơNJҕӸ҄ȷЪถƞ ƯƍǔŴDŽDžƢǂƯ ᚮၲᜤКऴإŴᙲஓ ǕƨȬǻȗȈȇȸǿ ƷႸ ƴࣖơƨdzȸȉƳƲ ȇȸǿМဇƴŴऴ إǻǭȥȪȆǣȞȍ ཎКਁЈư൭NJǒǕǔǻǭȥȪȆǣ൦แƱൔ᠋ƠƯ МဇƴƋƨǓφͳ ǸȡȳȈǷǹȆȠǛ ƋǔᆉࡇφͳƠǍƢƍǻǭȥȪȆǣ൦แưƷМဇƕӧᏡ ƢǂƖǻǭȥȪȆǣ ᄩܱƴᢃဇưƖǔМ ဇؾǛૢƑǔ ȬǻȗȈᄂᆮƴɟܭ ȬǻȗȈᄂᆮƴ᧙࣎ ȬǻȗȈƷನᡯǛ៊ ƷჷᙸƕƋǓŴဎЈ ƸƋǔƕኺ᬴ƕLJƩ LJƑƳƕǒᄂᆮƢǔ ᨼᚘƞǕƨኽௐǛ࣏ ϋܾǍਁЈவˑǛӿ җЎưƳƘŴȇȸǿ ǑǓNjŴؕஜႎႸ ᙲƱƠŴȇȸǿϼྸ ԛƠŴٻƷȇȸǿ ेܭƞǕǔМဇᎍ ƷཎࣉǍӲႸƷಒ ƴƭƍƯቇҥƴЎௌ ǛᘍƏƜƱǛेܭƠ Ǜ᭗ᡮƴϼྸƢǔƜ ᙲǛ৭੮ƠƨƍƱᎋ ǛᚾLjƨƍƱᎋƑƯ ƯƍƳƍМဇᎍ ƱǛेܭƠƯƍǔМ ƑƯƍǔМဇᎍ ƍǔМဇᎍ ဇᎍ ЈᲴҽဃіႾ̬ᨖޅዮѦᛢȷ̬ᨖǷǹȆȠ᭗ࡇ҄ਖ਼ᡶܴ ࠰உଐžȬǻȗȈऴإሁƷᇹɤᎍ੩̓Ʒ ዓƖሁƴƭƍƯſJVVRYYYOJNYIQLRHKNG5JKPIKMCK*QMGPM[QMW 5QWOWMCRFHᲢ࠰உଐǢǯǻǹᲣ ԃLJǕƯƍǔ ȇȸǿႸ̊ ௦⾲ᛶ䞉ಙ㢗ᛶ䠄䠇䠅 ௦⾲ᛶ䞉ಙ㢗ᛶ䠄䠉䠅 ↹㞧ᛶ䞉᥈⣴ᛶ䠄䠉䠅 ↹㞧ᛶ䞉᥈⣴ᛶ䠄䠇䠅 33 NDB䛾ᥦ౪≧ἣ 34 Center for Medicare and Medicaid Services (CMS) 䛻䜘䜛ᨭ䜢ཷ䛡䛯ᐇయ䛾ෆヂ䠄2011ᖺ⌧ᅾ䠅 ฟᡤ䠖Center for Medicare and Medicaid Services (2011) “Active Report List”. http://cms.hhs.gov/Research-Statistics-Data-and-Systems/StatisticsTrends-and-Reports/ActiveProjectReports/Active-Projects-Report-List.html#䠄2015ᖺ2᭶19᪥䜰䜽䝉䝇䠅䜢ᇶ䛻➹⪅సᡂ䚹 35 ⤖ㄒ䠖ಖ㝤་⒪⾜ᨻ䛜EBM䛻ᑐ䛧䛶 ᯝ䛯䛩䜉䛝ᙺ(1) • ་⒪ሗ䛾ᶆ‽䜢ಁ䛩䛯䜑䛾♫య䛾⌮ゎ䛸༠ ຊ䛜ᚓ䜙䜜䜛䜘䛖䛺⥅⥆ⓗ䛺ാ䛝䛛䛡 • ಖ㝤་⒪ᨻ⟇䛻䛚䛡䜛♫ⓗ䜲䞁䝣䝷䛸䛧䛶䛾NDB⮬య 䛾་⒪䛾ຠ⋡➼䛻ᑐ䛩䜛ᐤᗘ䛾᳨ド • ་⒪ሗ䛾ᶆ‽䛾䛸䛧䛶䚸⡿ᅜ䛾་⒪ᨻ⟇䛷䛒 䜛HCQIP䜢㏻䛧䛶Ꮫ䜆䜉䛝᭱䜒㔜せ䛺Ⅼ䛿䚸ᑓ㛛ᐙ䛾㛫 䛷䛾་⒪ホ౯ᣦᶆ䛻ᑐ䛩䜛ྜព䠙䠚ᑠつᶍㄪᰝ䛾ᐇ 䠙䠚ᣦᶆ䛾᳨ウ䠙䠚ᅜつᶍ䛷䛾ᨻ⟇䛾ᐇ䠙 䠚ᨻ⟇䛾⤖ᯝ䛸ᨻ⟇㐣⛬⮬య䛾ぢ┤䛧䠙䠚䝥䝻䝆䜵䜽 䝖䛾ᒎ㛤䛸䛔䛖䚸ᨻ⟇⾜䛾䝥䝻䝉䝇 36 ⤖ㄒ䠖ಖ㝤་⒪⾜ᨻ䛜EBM䛻ᑐ䛧䛶 ᯝ䛯䛩䜉䛝ᙺ(2) • ⡿ᅜ䛾Research Data Assistance Center (ResDac)䛻௦ ⾲䛥䜜䜛䜘䛖䛺䚸䝺䝉䝥䝖ሗ䛾ά⏝䛻ᑐ䛩䜛ᩍ⫱ ◊✲䛾䛯䜑䛾ᨭάື䛾ᚲせᛶ • ⡿ᅜCMS➼䛾⤒㦂䛛䜙䚸Ẹ㛫ά⏝䜈ྥ䛡䛶䛾⤒⦋䛾 ᳨ド • ་⒪ሗ䛾ᩚഛ䛾㐣⛬䛷䛾Quality Check䚸ᝈ⪅䛸 ་ᖌ䛸䛾⌮ゎ䛸ྠព䛻ᇶ䛵䛟䝁䝭䝳䝙䜿䞊䝅䝵䞁䛾 ✚䚸䜎䛯䚸་⒪ሗ䛾ຠᯝⓗ䛺⟶⌮䛸㐠⏝䜢㐙⾜䛩 䜛䛣䛸䛾䛷䛝䜛◊✲⪅䜔ᢏ⾡⪅䛾⫱ᡂ䛜䚸ᚋ䛾 EBMⓎᒎ䛾♏䛸䛺䜛䚹 䠙䠚ᝈ⪅䠄ᐙ᪘䠅䞉ಖ㝤⪅䞉་⒪ᥦ౪⪅䞉⾜ᨻ䠄ᨻ⟇ᢸᙜ ⪅䠅䞉◊✲⪅䛸䛾ᑐヰ䛸༠ാ䛜㔜せ䟿 37 ᑐヰ䛾ᅵྎ ¾ ௦⾲ᛶ䛾䛒䜛䝕䞊䝍䛾ᵓ⠏䠖 ᨻ⟇䞉◊✲䛾୧㠃䛷䛾♫ⓗ䜲䞁䝣䝷䛷䛒䜚䚸ඹ᭷㈨※䛷䛒䜛䛸 䛔䛖⪃䛘᪉ ¾ ᨻ⟇䛻㛵䜟䜛㆟ㄽ䛾᫂☜䠖 ពぢ䛾୍⮴䛜䚸ᐇドⓗ䛺㒊ศ䛻ᑐ䛩䜛䜒䛾䛺䛾䛛䚸つ⠊ⓗ㒊ศ 䛻䜘䜛䜒䛾䛺䛾䛛䠛䠄䝆䝵䠉䝊䝣䞉䠡䠊䝇䝔䜱䜾䝸䝑䝒䠄⸭ୗྐ㑻ヂ䠅 䠄2003䠅䛄බඹ⤒῭Ꮫ䠄ୖ䠅䛅ᮾὒ⤒῭᪂ሗ♫䠅 ¾ ♫䠄ᅜẸ䠅䛛䜙䛾ಙ㢗䛾⋓ᚓ䠖 ᨻ⟇⟇ᐃ䞉ホ౯䛻䛸䛳䛶ᚲせ䛺䝕䞊䝍㞟䛻ᑐ䛩䜛♫య䛾⌮ ゎ䛸༠ຊ䛜ᚓ䜙䜜䜛䜘䛖䛻ാ䛝䛛䛡䜛䛣䛸䚸䜎䛯䚸㞟䛥䜜䛯䝕䞊 䝍䛾䝁䞁䝔䞁䝒ཬ䜃⟶⌮యไ䜢ᖖぢ┤䛩䛣䛸䛾䛷䛝䜛䜘䛖䛺≀⌮ ⓗ䝅䝇䝔䝮䛸ேⓗ༠ຊయไ䜢䛴䛟䜚䛒䛢䜛䛣䛸 ¾ ேὶ䛾㔜せᛶ䠖 ᨻ⟇ᢸᙜ⪅䛸◊✲⪅䛸䛾䝁䝭䝳䝙䜿䞊䝅䝵䞁䜢䛩䜛䛯䜑䛾 ⨨䜢ᩚഛ䛩䜛 38
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