➨7ᅇ㻌 CSP-HORᖺ఍䛿䛨䜑䛻➨䠎㒊㻌 䜰䜴䝖䜹䝮䛻㛵䛩䜛ಶே䛸♫఍䛾㑅ᢥ་⒪䛻䛚䛡䜛ຠ⋡ᛶ䛸බᖹᛶn ᮏ᪥䛾⚾䛾ᙺ┠䛿䚸ඣ⋢ඛ⏕䛾ᇶㄪㅮ₇䛸䚸䛭䛾ᚋ䛾䝅䝵䞊䝖䝥䝺䝊䞁䝔䞊䝅䝵䞁䛾㟢ᡶ䛔䚹n ㄽⅬ䚸どⅬ䛾┠ḟⓗ䛺䜒䛾䜢♧䛧䛯䛔䚹ୗጔ ᫭஧㑻
Kojiro Shimozuma, MD, PhDk.shimozuma@gmail.com❧࿨㤋኱Ꮫ ⏕࿨⛉Ꮫ㒊 ⏕࿨་⛉Ꮫ⛉㻌 䠄་⒪ᨻ⟇䞉⟶⌮Ꮫ䠅Div of Health Services Res, Dpt of Biomed Sciences, College of Life Sciences,Ritsumeikan University
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1

July, 13, 2013@Tokyo Univ.

䛂Ᏻᚰ䛸⣡ᚓ䛾་⒪䝅䝇䝔䝮䛃䜢ᐇ⌧䛩䜛䛯䜑䛻ᚲせ䛺་⒪㈨※䛸䛭䛾㓄ศ䛿䛨䜑䛻䠄䛴䛵䛝䠅㆟ㄽ䛾どⅬ䠉ಶே䛛♫఍䛛ே䠄་ᖌ䚸┳ㆤᖌ䚸⸆๣ᖌ䚸䜒䛾䠄⑓㝔䚸デ⒪ᡤ䚸䛺䛹་⒪䜔⚟♴䛾ᑓ㛛ᐙ䠅デ᩿䞉἞⒪ჾᶵ䚸䛺䛹䠅n ୚䛘䜙䜜䛯䝔䞊䝬䚸䛂་⒪䛾ຠ⋡ᛶ䛸බᖹᛶ䛃䛿䚸ᇶᮏⓗ䛻䛂་⒪㈨※㓄ศ䛃䛾ヰ䚹Ᏻᚰ䛸⣡ᚓ䛾་⒪䝅䝇䝔䝮ᐇ⌧
䛚㔠䠄㈈※䠅᝟ሗ䠄㇏ᐩ䛺᝟ሗ䚸┦ㄯ❆ཱྀ䛺䛹䠅ᅜẸ䚸ᝈ⪅䚸ᐙ᪘䛾
3೺ᗣ䞉ᖾ⚟䛿䛨䜑䛻䠄䛴䛵䛝䠅䛿䛨䜑䛻㆟ㄽ䛾どⅬ䠉ಶே䛛♫఍䛛䠄䛴䛵䛝䠅㆟ㄽ䛾どⅬ䠉䜰䜴䝖䜹䝮䛛䝥䝻䝉䝇䛛

4n ㈨※㓄ศ䛾ᣦᶆ䛸䛧䛶䚸་⒪䛾㉁䛾ホ౯䛾䛂䝗䝘䝧䝕䜱n ㈨※㓄ศ䛿䚸♫఍䛾どⅬ䛷⪃䛘䛜䛱䚹䜰䞁䛾䝰䝕䝹䛃䛾䠏せ⣲䛾䛖䛱䚸䜰䜴䝖䜹䝮䜢㔜ど䛩䜛䛛䚸䝥䝻䝉䝇䜢㔜ど䛩䜛䛛䚹n 䛧䛛䛧་⒪䛿ಶูᛶ䛜ᴟ䜑䛶㔜せ䛺ศ㔝䚹¨ ᝈ⪅䜔୍⯡ே䛿䜒䛸䜘䜚䚸་⒪ᑓ㛛ᐙ䛷䛩䜙♫఍䛾どⅬ䛾¨ ་⒪䛻䛚䛔䛶䛿䚸䝥䝻䝉䝇䜒኱ኚ㔜せ䚹ヰ䛻㐪࿴ឤ䜢ឤ䛨䞉䞉䞉೔⌮ⓗ䛻᢬ᢠ䜢ぬ䛘䛜䛱䚹n ➨䠎㒊䛾䝍䜲䝖䝹䛜䚸䛂䜰䜴䝖䜹䝮䛻㛵䛩䜛ಶே䛸♫఍䛾㑅ᢥ䛃䛸䛺䛳䛶䛔䜛䛜䞉䞉䞉n ಶே䛾฼┈䛸♫఍䛾฼┈䛿┦཯䛩䜛䛣䛸䜒䛒䜛䚸䛣䛸¨䜎䛯䚸་⒪䛾ຠᯝ䛿baseline䛾೺ᗣ≧ែ䛻䛛䛺䜚ᕥྑ䛥䜜䜛䛣䛸䜒⪃៖䛩䜛ᚲせ䛒䜚䠄ᚋ㏙䠅䚹䜢ᛕ㢌䛻⨨䛝䛴䛴㆟ㄽ䜢ᒎ㛤䛩䜛䛸⌮ゎ䛜῝䜎䜛䚹n ᖐ⤖୺⩏䛛䚸㠀ᖐ⤖୺⩏䛛䚸䛾㆟ㄽ䛻⧅䛜䜛䚹
56

་⒪䛾㉁䜢ホ౯䛩䜛㝿䛻㔜ど䛥䜜䜛せ⣲䠄Donabedian䛾䝰䝕䝹䠅ᵓ㐀
structure㐣⛬process⤖ᯝ䞉ᡂᯝ䠄䜰䜴䝖䜹䝮䠅outcomeØ་ᖌ䚸┳ㆤᖌ䚸⸆๣ᖌ䚸ᚰ⌮ኈ䚸་⒪䡻䡬䡸䡨䢕䢘䡬䡲䡬䛺䛹ᑓ㛛ᐙ䛾㉁䜔
ேᩘØデ᩿䞉᳨ᰝ䛾ᢏ⾡Ø⏕Ꮡᮇ㛫䞉⏕Ꮡ⋡Ø἞⒪䛾ᢏ⾡Ø἞⒵⋡Øデ⒪䜺䜲䝗䝷䜲䞁䛾㑂Ᏺ⋡Ø೺ᗣ䜰䜴䝖䜹䝮Ø་⒪ᶵჾ䚸᳨ᰝᶵჾ䚸⑓㝔タഛ䚸䜰䝯䝙䝔䜱䛾඘ᐇØ䜲䞁䝣䜷䞊䝮䝗䞉䝁䞁䝉䞁䝖Ø೺ᗣᗘ䚸QOLØ䝇䝍䝑䝣䛾ែᗘØ䝇䝍䝑䝣䛾ែᗘØ‶㊊ᗘ་⒪䛾ຠ⋡ᛶØ⑕≧78୺せඛ㐍ᅜ䛾ᖹᆒᑑ࿨䛾᥎⛣᪥ᮏ䠄ዪ䠅䛣䛾50ᖺ㛫䛷㦫␗ⓗ䛺ఙ䜃

᪥ᮏ䠄⏨䠅䠉᭱ୗ఩䛛䜙᭱ୖ఩䜈䠉䜟䛜ᅜ䛾་⒪䛿ຠ⋡ⓗ䛛䠛910OECD*ㅖᅜ䛾་⒪㈝ᑐGDPẚ⋡䠄2006ᖺ䠅ୡ⏺ಖ೺ᶵ㛵(WHO)䛾೺ᗣ㐩ᡂᗘ⥲ྜホ౯
n 1఩ 㻌 㻌 ᪥ᮏn ホ౯䛾ᇶ‽n 2఩ 㻌 㻌 䝇䜲䝇¨ 䠄䠍䠅೺ᗣᑑ࿨䠄1఩䠅

n 3఩ 㻌 㻌 䝜䝹䜴䜵䞊¨ 䠄䠎䠅೺ᗣᑑ࿨䛾ᆅᇦ᱁ᕪn 4఩ 㻌 㻌 䝇䜴䜶䞊䝕䞁¨ 䠄䠏䠅ᝈ⪅䛾⮬୺Ỵᐃᶒ䜔䚸἞⒪䜈䛾‶㊊ᗘ䛺䛹䛾㐩ᡂලྜn 5఩ 㻌 㻌 䝹䜽䝉䞁䝤䝹䜽䞉¨ 䠄䠐䠅ᆅᇦ䜔ே✀䛺䛹䛻䜘䜛ᝈ⪅ᑐᛂ䛾ᕪู䛾⛬ᗘඛ㐍ᅜ䛾୰䛷᪥ᮏ䛿≉䛻་⒪䛻䛚㔠䜢䛛䛡䛶
䛔䛺䛔ᅜ䛾୍䛴䞉䞉䞉¨ 䠄䠑䠅་⒪㈝㈇ᢸ䛾බᖹ䠄3఩䠅䞉䞉n 15఩㻌 㻌 ⡿ᅜ11OECD*ㅖᅜ䛾་⒪㈝ᑐGDPẚ⋡䠄2011ᖺ䠅12䠆 ⤒῭༠ຊ㛤Ⓨᶵᵓ་⒪㈝䛸ᖹᆒᑑ࿨㻌 ᅜ㝿ẚ㍑
᪥ᮏ䛾་⒪䛿䚸䛒䜛ព࿡䚸㈝⏝ᑐຠᯝ䛜ᴟ䜑䛶㧗䛔䞉䞉䞉䛰䛳䛯䛜䚸GDP䛜ୗ䛜䛳䛯䛯䜑䚸䛔䛴䛾㛫䛻䛛ⱥᅜ䛸䜲䝍䝸䜰䜢ᢤ䛛䛧䛯䚹⡿ᅜ䛾་⒪䛿㈝⏝ᑐຠᯝ䛜ప䛔

13䠆 ⤒῭༠ຊ㛤Ⓨᶵᵓ

14䛔䛪䜜䛻䛫䜘䚸ᅜẸ་⒪㈝䛿
ẖᖺ䠍඙෇䛪䛴ቑຍ15ᅜ❧ಖ೺་⒪⛉Ꮫ㝔㻌 ⓑᒾ೺ඛ⏕㻌 ᭷㆑⪅఍㆟䛷䛾㈨ᩱ
16䜟䛜ᅜ䛾་⒪䛾ຠ⋡ⓗ㐠⏝䛻㛵䛩䜛ᨻ⟇ᛂ⏝䛾ື䛝䜟䛜ᅜ䛾་⒪䛿ຠ⋡ⓗ䛛䠛䠄⤖ㄽ䠅n ᑡ䛺䛔㈨※䛷㧗䛔ຠᯝ䜢ୖ䛢䛶䛝䛯䛸䛔䛖ព࿡䛷䛿ຠ⋡ⓗ䠄䛷䛒䛳䛯䠅䛸ゝ䛘䜛䛜䞉䞉䞉n ཌປ┬䛻䛚䛔䛶䚸◊✲⌜䠄⚟⏣⌜䠅䛸୰་༠䠄㈝⏝ᑐຠᯝホ౯㒊఍䠅䛷䛿䚸་⒪ᢏ⾡ホ౯䛻ᇶ䛵䛔䛯౯᱁タᐃ䜔ൾ㑏䛾⠊ᅖ䠛䛻䛴䛔䛶㆟ㄽ䛜㛤ጞ䛥䜜䛯䚹¨ 䛂་⒪ᔂቯ䛃䛸䛔䛖ᙧ䛷㝈⏺䛜ぢ䛘䛴䛴䛒䜛䚹n ௒ᚋ䛾་⒪ᢏ⾡䛾㐍Ṍ䛸ᑡᏊ㧗㱋໬䚸䛭䛧䛶⤒῭䛾ప㏞䛜⥆䛟䛸ண᝿䛥䜜䜛䛣䛸䜢⪃៖䛩䜛䛸䚸䛥䜙䛻ຠ⋡ᛶ䜢ୖ䛢䜛ᚲせ䛜䛒䜛䚹

1718䛂ຠ⋡䛃䛾ศ㢮n 䠍䠊ᢏ⾡ຠ⋡䚸⏘ᴗຠ⋡¨ 䛂ᢞධ input䛃䛻ᑐ䛩䜛䛂⏘ฟ output䛃䛾ẚ䛂ຠ⋡䛃䛾ศ㢮䛸㈨※㓄ศ䛾ᣦᶆ䜔⌮ㄽ

1920㓄ศຠ⋡䛂ຠ⋡䛃䛾ศ㢮䠄䛴䛵䛝䠅n ౛䠖㻌 ⫵⒴ᑐ⟇ண⟬䛜୍ᐃ䛾ሙྜn 䠍䠊ᢏ⾡ຠ⋡䚸⏘ᴗຠ⋡¨ ⚗↮䛾ၨⵚ¨ 䛂ᢞධ input䛃䛻ᑐ䛩䜛䛂⏘ฟ output䛃䛾ẚ¨ ⫵⒴᳨デ¨ እ⛉἞⒪¨ ෆ⛉ⓗ἞⒪n 䠎䠊㓄ศຠ⋡¨ ㈨※䛜㝈䜙䜜䛶䛔䜛᫬¨ ୖグ䛾䛹䜜䛻ண⟬䜢ከ䛟㓄ศ䛩䜛䛛䛻䜘䛳䛶䚸Ṛஸ¨ ㈨※䛾᣺䜚ศ䛡᪉䛻䜘䜚᭱⤊䛾⤖ᯝ䛻㐪䛔䛜ฟ䜛ሙྜn⋡䠄⏘ฟ䠅䛜㐪䛳䛶䛟䜛䚹๓⪅䛜⌮᝿ⓗ䛷䛒䜛䛜䚸་⒪䛿௚䛾⏘ᴗ䛸ẚ䜉䛶᣺䜚ศ䛡䜙䜜䜛㈨※䛜㝈䜙䜜䛶䛔䜛䠄බඹ㈈䠅䛣䛸䛜ከ䛔䛾䛷䚸㓄ศຠ⋡䛾㆟ㄽ䛜୺䛸䛺䜛䚹¨ ඃඛ㡰఩䜢䛴䛡䜛ᚲせᛶ䛒䜚䚹¨priority rating, rationing

2122

་⒪㈨※㓄ศ䛾ᣦᶆ䠄஺᥮ྍ⬟䛺㈈䜒䛒䜛䠅n ᅜ㝿ⓗ䛻Ⰻ䛟౑䜟䜜䛶䛔䜛་⒪⤒῭ᣦᶆn ୺䛻㓄ศຠ⋡䛷⪃䛘䜛䚸䛸䛿ゝ䛳䛯䛜䞉䞉䞉n

᪂἞⒪䛾㈝⏝ᑐຠᯝ䜢䚸᪤Ꮡ䠄ᶆ‽䠅἞⒪䛾㈝⏝ᑐຠᯝ䛸ẚ䜉䜛n

ቑศ㈝⏝ຠᯝẚ incremental cost-effectiveness ratio:
ቑศ㈝⏝ຠᯝẚ㻌ICERn ⤒῭඲య䛾䝟䜲䜢ቑ䜔䛥䛺䛟䛶䜒䚸་⒪㛵㐃ศ㔝௨እ䛾㈨※䜢౑䛖䛣䛸䛷೺ᗣ䜰䜴䝖䜹䝮䜢ᨵၿ䛩䜛䛣䛸䜒ྍ⬟¨ ౛䠖㻌 ⥲ົ┬䛾ண⟬ቑ㢠n 䠄᪂἞⒪䛾㈝⏝䠉᪤Ꮡ἞⒪䛾㈝⏝䠅䠋䠄᪂἞⒪䛾ຠᯝ䠉n ⚗↮䛾ၨⵚ䛻䝬䝇䝯䝕䜱䜰䜢኱䚻ⓗ䛻౑䛖䛣䛸䠄㟁Ἴ஦ᴗ䜈䛾᪤Ꮡ἞⒪䛾ຠᯝ䠅ᨭ᥼䠅䛷⫵⒴䛜ῶ䜛䚹¨ ౛䠖㻌 ⎔ቃ┬䛾ண⟬ቑ㢠n ኱Ẽởᰁ䜢ῶ䜙䛩䛣䛸䛷࿧྾ჾ⑌ᝈ䛜ῶ䜛䚹
2324ᮇᚅຠ⏝⌮ㄽ

་⒪㈨※㓄ศ䛾ᣦᶆ䠄䛴䛵䛝䠅

John von Neumannn 䛷䛿䚸⑌ᝈᶓ᩿ⓗ䛻ẚ㍑ྍ⬟䛷䚸ᅜ㝿ⓗ䛻䜘䛟Oskar Morgensternn౑䜟䜜䜛䛂ຠᯝ䛃䛾ᣦᶆ䛿䠛䝣䜷䞁䞉䝜䜲䝬䞁(1903-57)䛸䝰䝹䝀䞁䝅䝳䝔䝹䞁(1902-77)
n 䝀䞊䝮⌮ㄽ䛾䛯䜑䛾ᇶ♏ᴫᛕ䛸䛧䛶ᥦ♧䛥䜜䛯୙☜ᐇᛶୗ䛾ពᛮỴᐃ⌮ㄽ䚹¨ ㉁ㄪᩚ⏕Ꮡᖺ㉁ㄪᩚ⏕Ꮡᖺ㻌 Quality-adjusted life year: QALYn¨ QALYҸຠ⏝䚸䛸ぢ䛺䛧䛶䚸ᮇᚅຠ⏝⌮ㄽ䠄ḟ䝇䝷䜲䝗䠅䛻ᇶᇶᮏⓗ䛺⪃䛘᪉¨ ⾜Ⅽ䛾⤖ᯝ䛜୙☜ᐃ䛺≧ἣୗ䛷䛿䠈⤒῭୺య䛿ຠ⏝䜢☜⋡䛷ຍ㔜ᖹᆒ䛧䛯ᮇᚅຠ⏝䜢᭱኱໬䛩䜛䜘䛖䛻㑅ᢥ䛩䜛䛸䛔䛖䛣䛸䛷䛒䜛䚹䛵䛟㈨※㓄ศ䛜⾜䜟䜜䜛䚹n ຌ฼୺⩏¨ 䛂᭱኱ከᩘ䛾᭱኱ᖾ⚟䛃䛜ᚓ䜙䜜䜛䜘䛖䛺㈨※㓄ศ䚹
25

QALY䛾⟬ฟ

26

QALY䛾 ᐃ䝰䝕䝹

QALYs = å QH ´ LH
HH 㸸೺ᗣ≧ែQH㸸೺ᗣ≧ែH࡛ࡢQuality Weight㸦Full health=1,Dead=0㸧
LH㸸೺ᗣ≧ែH࡛ࡢ⏕Ꮡᖺᩘ1QALY㸸᏶඲࡞೺ᗣ≧ែ࡛⏕Ꮡࡍࡿ1ᖺᅜ❧ಖ೺་⒪⛉Ꮫ㝔㻌 ⚟⏣ᩗඛ⏕㻌 䝇䝷䜲䝗2728ᮾ኱㻌 ⚟⏣ᩗඛ⏕䜘䜚೉⏝ICER䛾♫఍ⓗᐜㄆ⠊ᅖຠ⋡ⓗ䛛䛹䛖䛛䛾ุ᩿n 㜈್ thresholdcost
trade-off–ⱥᅜࡢNICE*㸸᪂἞⒪㻌 BICER–⡿ᅜ㸸QALYᶆ‽἞⒪㻌 A

㺿20,000-㺿30,000 / QALY㸦⣙500-700୓෇㸧
$50,000-$100,000 /dominant㸦⣙600-1,200୓෇㸧⣙500-600୓෇㸦Shiroiwa T, et al㸧 –᪥ᮏ㸸0lᑐゅ⥺䜘䜚ୗ䛻䛒䜛䛸䚸ᇶᮏⓗ䛻䛿cost-effectiveୡ⏺ⓗ䛻䛿⣙500୓෇䛜㜈್䛸䛧䛶ཧ↷䛥䜜䜛䛣䛸䛜ከ䛔effectiveness29l䛯䛰䛧䚸ICER䛜♫఍ⓗᐜㄆ䛾⠊ᅖ䛷䛒䜛䛛䛹䛖䛛䛾☜ㄆ䛜ᚲせCost/QALY League Table – ἞⒪㛫ẚ㍑
220㢌㒊እയ䛻ᑐ䛩䜛⬻⚄⤒እ⛉ⓗ἞⒪240㻳㻼䛻䜘䜛⚗↮ᣦᑟ

270䜽 䝰⭷ୗฟ⾑䛻ᑐ䛩䜛⬻⚄⤒እ⛉ⓗ἞⒪490⬻༞୰ண㜵䛾䛯䜑䛾㧗⾑ᅽ἞⒪䠄 㻠㻡㻙 㻢㻠ᡯ䠅940䝨䞊䝇䝯 䞊䜹 䞊⿦╔

1,100⫤㛵⠇ேᕤ㦵㢌⨨᥮ᡭ⾡

1,180኱ື⬦⊃✽⑕䛻ᑐ䛩䜛ᘚ⨨᥮ᡭ⾡

1,140

䝁 䝺䝇䝔䝻䞊䝹᳨ᰝ䛸 ἞⒪1,480ෙື⬦䝞䜲 䝟䝇ᡭ⾡䠄 ᕥ୺ᖿ㒊⑓ኚ䚸 㔜ᗘ䛾⊃ᚰ⑕䠅

2,090

⭈⮚⛣᳜

4,710

ங䛜䜣䝇䜽 䝸 䞊䝙䞁䜾

5,780

ᚰ⮚⛣᳜

14,150ᐙᗞ䛷䛾⾑ᾮ㏱ᯒ

17,260ෙື⬦䝞䜲 䝟䝇ᡭ⾡䠄 䠍 ᯞ⑓ኚ䚸 ㍍ᗘ䛾⊃ᚰ⑕䠅

18,830⭡⭷㏱ᯒ

19,870⑓㝔䛷䛾⾑ᾮ㏱ᯒ

21,970ᝏᛶ⬻⭘⒆䛻ᑐ䛩䜛⬻⚄⤒እ⛉ⓗ἞⒪㏱ᯒᝈ⪅䛾㈋⾑䛻ᑐ䛩䜛䜶䝸 䝇䝻䝫䜶䝏䞁⒪ἲ䠄 Ṛஸ⋡ῶᑡ䛺䛧 䛸 ௬ᐃ䠅
Maynard(1991)n 䠍䠊ຠ⏝䜔QOL䛿䛭䜒䛭䜒䜜䜛䛾䛛䠄ྍ
ಶே㛫䛾ẚ㍑䛿ྍ⬟䛛䠄ẚ㍑ྍ⬟ᛶ䠅䠛ᛶ䠅䠛㻌¨ ᇶᩘⓗຠ⏝䛸ᗎᩘⓗຠ⏝¨ ィ㔞ᚰ⌮Ꮫ䛷䛿ᙜ䛯䜚๓䛾䛣䛸䛜䚸㏆௦⤒῭Ꮫ䛷䛿ᙜ䛯䜚๓䛷䛿䛺䛔䚹7,840

䝁 䝺䝇䝔䝻䞊䝹᳨ᰝ䛸 ẁ㝵ⓗ἞⒪䠄 㻞㻡㻙 㻟㻥ᡯ䠅㏱ᯒᝈ⪅䛾㈋⾑䛻ᑐ䛩䜛䜶䝸 䝇䝻䝫䜶䝏䞁⒪ἲ䠄 Ṛஸ⋡㻝㻜㻑 ῶᑡ䛸 ௬ᐃ䠅30බᖹᛶ䛾㆟ㄽ䛻ධ䜛๓䛻䠉ຠ⏝⌮ㄽ䛾ᢏ⾡ⓗㄢ㢟

Cost/QALY( £ Aug 1990)䝁 䝺䝇䝔䝻䞊䝹᳨ᰝ䛸 㣗஦⒪ἲ䠄 㻠㻜㻙 㻢㻥ᡯ䠅* National Institute for Health and Clinical Excellenceൾ㑏䛷䛝䜛㜈್?㻌
(threshold)n 䠎䠊䛂QALY䛃䛿೺ᗣ㔞䛷䛿䛒䜛䛜䚸䛂ຠ⏝䛃䛸ぢ䛺䛧䛶ᮇᚅຠ⏝⌮ㄽ䜢⏝䛔䛶㈨※㓄ศ䛾ᣦᶆ䛸䛧䛶䛔䛔䛛䠛

54,380107,780
126,2903132

බᖹᛶ䜢㔜ど䛧䛯་⒪㈨※㓄ศ䛸䛿䠛n ከ䛟䛾ே䛜୙බᖹឤ䜢ឤ䛨䛪䚸ᛌ㐺䛻ཷ䛡䜛䛣䛸䛜䛷䛝䜛་⒪䛜ྍ⬟䛸䛺䜛㈨※㓄ศ䜢⾜䛖䛣䛸䛜ᮃ䜎䛧䛔䚹¨ ே䚻䛿౯್䛒䜛䜒䛾䜢ᖹ➼䞉බᖹ䛻ཷ䛡䜛ᶒ฼䛜䛒䜛䚹་⒪䛾බᖹᛶ䠄⾮ᖹᛶ䠅
䡆ustice, equality, equityn Cost/QALY䜢ᣦᶆ䛸䛧䛯་⒪㈨※㓄ศ䜢ᨻ⟇ᛂ⏝䛩䜛ሙྜ䛾೔⌮ⓗㄢ㢟䚸㆟ㄽ䛩䜉䛝Ⅼ䜢ḟ䛻ᣲ䛢䜛䚹¨ ᚋ༙䛾୍㒊䛿䚸ᐇ㝿䛻ⱥᅜ䛺䛹」ᩘ䛾ᅜ䚻䛜䚸㈝⏝ᑐຠᯝ䛻ᇶ䛵䛟㈨※㓄ศ䜢⾜䛳䛶䛝䛯୰䛷䛾ゎỴ䛩䜉䛝ㄢ㢟䛸䛧䛶ᣲ䛢䛶䛔䜛䜒䛾䛷䛒䜛䚹3334䠌䠊␒እ䠛㻌 ┦ᑐⓗᡤᚓ௬ㄝ䠍䠊ຌ฼୺⩏䛭䛾䜒䛾䛾೔⌮ⓗጇᙜᛶn ᡤᚓ᱁ᕪ䛜኱䛝䛔♫఍䛷䛿ே䚻䛾೺ᗣ≧ែ䛜ᝏ໬䛩䜛䛣䛸䛜▱䜙䜜䛶䛔䜛䚹n ᮇᚅຠ⏝⌮ㄽ䛾ᇶ┙䛷䛒䜛ཌ⏕⤒῭Ꮫ䜔ຌ฼୺⩏䛭䛾䜒䛾䛾೔⌮ⓗጇᙜᛶ䛿䠛n་⒪䜔ಖ㝤ไᗘ䛾ᕤኵ䜔ᨵ㠉䛾䜏䛻㢗䜙䛪䚸䜘䜚ୖὶ䛻䛚䛡䜛᪋⟇䚸䛩䛺䜟䛱♫఍⤒῭ⓗ᱁ᕪ䜢᫝ṇ䛩䜛ᚲせ䛜䛒䜛䠄䝎䝙䜶䝹䝈䜙䠅䚹n ຌ฼୺⩏䛷䛿䚸ಶே㛫䛾୙ᖹ➼䛿⪃៖䛥䜜䛺䛔䠛n ಶே㛫䛾ᖹ➼䜘䜚䜒ඃඛ䛩䜛ጇᙜᛶ䛿䛒䜛䛛䠛nᡤᚓ䛾෌㓄ศ䛻䜘䜛೺ᗣ᱁ᕪᨵၿ䜢ඃඛ䛩䜉䛝䛷䛿䛺䛔䛛䠛

3635䠏䠊㔜⑕ᗘ䛾㧗䛔⑌⑓䜢ඃඛ䠛
㻌 Severity-of-illness approach䠎䠊ᖐ⤖୺⩏䛾೔⌮ⓗጇᙜᛶn ຌ฼୺⩏䛻䛫䜘䚸ᖹ➼䛺㈨※㓄ศ䛻䛫䜘䚸⤖ᯝ䠄䜰䜴䝖n Baseline䛾㔜⑕ᗘ(severity/burden of illness)䛜㧗䛔

䜹䝮䠅䛻ᇶ䛵䛟㓄ศ䜢⪃䛘䛶䛔䜛䚹ே䛻ඃඛⓗ䛻㈨※㓄ศ䛩䜉䛝䛛䠛(Nord E)䠛

¨ ᖐ⤖୺⩏n 䛧䛛䛧䚸≉䛻㞀☀⪅䛺䛹♫఍ⓗ䛻䝝䞁䝕䜱䜻䝱䝑䝥䜢᭷䛩䜛ே䚻䛿䚸⤖ᯝ䛾䜏䛻ᇶ䛵䛛䛺䛔䚸౛䛘䜀ᇶᮏⓗ₯ᅾ⬟ຊ(basic capability)䛻ᇶ䛵䛔䛯㓄ศ䠄䜰䝬䝹䝔䜱䜰䞉䝉䞁䚸ᚋ⸨⋹Ꮚ䜙䠅䜢⾜䜟䛺䛔䛸䚸ᩆ䜟䜜䛺䛔䚸䛸䛔䛖⪃䛘䛜䛒䜛䚹n ከ䛟䛾Ḣ⡿ㅖᅜ䛷㔜ど䛥䜜䛶䛔䜛ཎ๎¨ ௒ᚋ᪥ᮏ䛷䜒DPC䜔DRG䛜ᬑཬ䛩䜛䛸ᛂ⏝䛥䜜䜛ྍ⬟ᛶ䛜㧗䛔䛜䚸ᚑ᮶䛿䛒䜎䜚⪃៖䛥䜜䛶䛣䛺䛛䛳䛯䠄ᝏᖹ➼䠛䠅䠛¨ 㠀ᖐ⤖୺⩏37䠐䠊ᕼᑡ⑌ᝈ䜢ඃඛ38䠑䠊ஸ䛟䛺䜛┤๓䛾ே䚻䜢ඃඛ䠛n ஸ䛟䛺䜛┤๓䛾ே䚻䛿ຠ⏝್䛜ప䛟䠄༶䛱ICER䛜㧗䛟n ᕼᑡ⑌ᝈ䜢᭷䛩䜛ᝈ⪅䛿䚸୍⯡䛻♫఍ⓗᙅ⪅䛜䛺䜚䛜䛱䠅䚸≉ู䛺㓄៖䜢⾜䜟䛺䛔䛸஧㔜ⱞ(Doublejeopardy)䛾≧ែ䛻䛺䜚䛛䛽䛺䛔䚹ከ䛟䚸ኌ䛜ᑠ䛥䛔䜀䛛䜚䛷䛺䛟䚸་⸆ရ䛺䛹἞⒪ἲ
㛤Ⓨ䜲䞁䝉䞁䝔䜱䝤䛜䛛䛛䜚䛻䛟䛔䚹¨ ౛䠖㻌 ⱥᅜNICE䛻䛚䛡䜛End-of-life䛾ྲྀᢅ䛔䛾䜺䜲䝗䝷䜲䞁(1)వ࿨䛜24䞄᭶௨ෆ䛷䛒䜛䛣䛸(2)᪤Ꮡ἞⒪䛸ẚ䜉䛶᫂☜䛺ᘏ࿨ຠᯝ䚸㏻ᖖ䛿3䞄᭶௨ୖ䛾ᘏ࿨ຠᯝ䛜ㄆ䜑䜙䜜䜛䛣䛸(3)௦᭰䛸䛺䜛἞⒪䛜Ꮡᅾ䛧䛺䛔䛣䛸(4)㐺ᛂ䛸䛺䜛ᝈ⪅ᩘ䛜ᑡ䛺䛔䛣䛸

3940䠒䠊ⱝᖺ⪅䜢ඃඛ䠛㻌 Fair-innings rule䠓䠊ᩆຓ䠄ᩆ῭䠅ཎ๎㻌 Rule of rescuen ᖺ㱋䛜ⱝ䛔ே䜔ᑠඣ䛻ඃඛⓗ䛻㓄ศ䚹n ୙≉ᐃ䛒䜛䛔䛿༏ྡ䛾ಶே䜘䜚䜒䚸≉ᐃ䛾ಶே䜢n ୍ᐃ䛾ᖺ㱋䛻㐩䛧䛯㧗㱋⪅䛻ᑐ䛩䜛㈨※㓄ศ䛾㔜䜏ຓ䛡䜘䛖䛸䛩䜛ᙉ䛔♫఍ⓗഴྥ䠄䜰䝹䝞䞊䝖䞉䝆䝵䞁䝉䞁䠅 䠄ඣ⋢⪽䠅䜢䚸䛭䜜௨๓䛾ᖺ㱋ᒙ䜘䜚㍍䛟䛩䜛(Williams A䜙䠅䚹¨ 䡞⋓ᚓ䛧䛯QALY䛃䛾ᖹ➼ᛶ䜢㔜䜣䛨䜛❧ሙ䚹n ┠䛾๓䛾Ṛ䛻䛭䛖䛺ே䛾ᩆຓ䜢䚸▱䜙䛺䛔ከ䛟䛾n ୍⯡䛻䚸ᑠඣ䜢ඃඛ䛩䜛䛣䛸䛿䛹䛾ᅜ䛷䜒ྜព䛥䜜䛶ே䛾ᩆຓ䜘䜚䜒ඃඛ䛩䜛䚹䛔䜛䛜䞉䞉䞉n 㧗㱋⪅ᕪู䛻⧅䛜䜛䠛¨ 䛹䛱䜙䛛䛸䛔䛖䛸䚸⮫ᗋ⌧ሙ䛾どⅬ䛾ㄽⅬ䛛䠛

41nn42㈝⏝ᑐຠᯝ䛾ᨻ⟇ᛂ⏝䛻䛚䛔䛶䚸䛂䛹䛾ẁ㝵䛷䛃೔⌮ⓗ㓄៖䜢┒䜚㎸䜐䛛䠛

Equity-adjusted procedure- Proportional shortfall୍⯡ⓗ䛻䛿’appraisal䠄ホ౯䠅’䛾ẁ㝵䛷䚸䝁䞁䝉䞁䝃䝇䝟䝛䝹䛷᳨ウ䚹n (⑓Ẽ䛷ኻ䛖QALY)/(ᮇᚅవ࿨䛾QALY)䛷㔜䜏䛵䛡䜢䛩䜛䚹n䛧䛛䛧䚸’assessment䠄ศᯒ䠅’䛾ẁ㝵䛻┒㎸䜐ヨ䜏䜒⾜䜟䜜䛶䛔䜛䠄ḟ䝇䝷䜲䝗䠅䚹“severity-of-illness approach”䛸“fair-innings rule”䛾୰㛫ⓗ䛺఩⨨䛵䛡¨ ᮇᚅవ࿨䛜40 QALY䛾ⱝ䛔ே䛜⑓Ẽ䛷10 QALYኻ䛖ሙྜ䛸䚸ᮇᚅవ࿨䛜4 QALY䛾㧗㱋⪅䛜⑓Ẽ䛷1 QALYኻ䛖ሙྜ䛾౯್䛜➼䛧䛟䛺䜛䠄䛔䛪䜜䜒䚸ᮇᚅవ࿨䛾25%䜢ኻ䛖䠅䚸䛸䛔䛖⪃䛘᪉䚹୰་༠㻌 ㈝⏝ᑐຠᯝホ౯㒊఍㈨ᩱ
䠄ᅜ❧ಖ೺་⒪⛉Ꮫ㝔㻌 ⚟⏣ᩗඛ⏕䠅
nStolk EA, et al. Pharmacoeconomics. 2004;22(17):1097-107.
ᅜ❧ಖ೺་⒪⛉Ꮫ㝔㻌 ⓑᒾ㻌 ೺㻌 ඛ⏕䛾䝇䝷䜲䝗䜢୍㒊ᨵኚ
4443Equity-adjusted CE threshold䛭䛾௚䛾೔⌮ⓗㄢ㢟n ་⒪㈨※䜢ⷧ䛟ᗈ䛟㓄ศ䛩䜛䛛䚸⊃䛟ཌ䛟㓄ศ䛩䜛䛛䠛n 㠀་Ꮫⓗせ⣲䜢䛹䛣䜎䛷⪃៖䛩䜉䛝䛛䠛䠄ຠᯝ䛾ᣦᶆ䚸䝁䝇䝖䛾ィ⟬⠊ᅖ୧᪉䛻㛵㐃䠅n බᖹᛶ䛾䛯䜑䛻ຠ⋡ᛶ䜢≛≅䛻䛩䜛䛛䠛n ⌧ᅾ䛾ᝈ⪅䛸ᑗ᮶䛾ᝈ⪅䛾㛫䛾බᖹᛶ䜢䛹䛖䛩䜛䛛䠛䠄ୡ௦㛫බᖹᛶ䠅n බᖹ䠙ᖹ➼䚸䛸⪃䛘䜛䛛䚸බᖹ䠙⮬⏤䚸䛸⪃䛘䜛䛛䠛(⑓Ẽ䛷ኻ䛖QALY)/(ᮇᚅవ࿨䛾QALY)䛷㔜䜏䛵䛡䜢䛩䜛
45

46