2018年2月に日本プライマリ・ケア連合学会　若手医師のための冬季セミナーで行ったワークショップのスライド

1. 2018 2 10 ( )
13
( )
http://www.irasutoya.com/2017/09/blog-post_552.html
http://www.irasutoya.com/2017/01/blog-post_780.html
1

2. 1.
• (ICER)
• (QALY)
2.
3.
4.
2

3. 13:00-13:05
13:05-13:15
13:15-13:30
• (ICER)
13:30-14:00
14:00-14:10
14:10-14:20
• (QALY)
14:20-14:30
3

4. 1.
2.
3.
1 30
4

5. 5
( 29 4 )

6. 6
https://www.nbcnews.com/health/cancer/heres-look-keytruda-drug-jimmy-carter-says-made-his-
tumors-n475561
https://www.fiercepharma.com/pharma/ke
ytruda-trounces-chemo-big-first-line-lung-
cancer-victory

7. 2016
(Health Technology Assessment; HTA)
7
［鎌江：厚生労働省新 HTA 制度−第 1 回「費用対効果」評価の試行的導入］
30
Fig. 1 新 HTA 制度の流れ

8. 5
1.
2.
3.
4.
5.
8
2010 2 Vol.11 No.11

9. …
20
9
3
3
http://www.irasutoya.com/2017/03/blog-post_613.html

10. 10
http://dl.med.or.jp/dl-med/wma/mem/wma_mem_e.pdf
1
(justice)
1
− ( 3 )

11. 11
(efficacy)
(effectiveness)
2
Drummond et al. (2015), Method for the Economic Evaluation of Health Care Programmes

12. • (cost minimization analysis; CMA)
•
•
• (cost effectiveness analysis; CEA)
• QALY/DALY
•
• (cost utility analysis; CUA)
• QALY/DALY
• (cost benefit analysis; CBA)
•
12

13. ICER( )
!"#$ =
"&'() − "&'(+
,-(.&/0) − ,-(.&/0+
(Incremental Cost-effectiveness Ratio; ICER)
A:
B:
13

14. 14
1,000 90
200 85
ICER
!"#$ =
1,000 − 200
90 − 85
= 160 /

15. ICER →
15
(2014)

16. (willingnessto
pay;W
TP)
CA > CB
OA < OB
CA < CB
OA > OB
(OA-OB)
(CA-CB)
16
B
A
0

17. ICER
CUA CEA
17
1 $50,000 $175,000
2 £20,000 £30,000
3 600-700 ?
WHO-CHOICE4 GDP GDP 3
1) https://icer-review.org/final-vaf-2017-2019/
2) https://www.nice.org.uk/news/blog/carrying-nice-over-the-threshold
3) https://www.jstage.jst.go.jp/article/iken/16/2/16_2_157/_pdf/-char/ja
4) http://www.who.int/choice/cost-effectiveness/en/

18. 18
ISSN: 1524-4563
Copyright © 1981 American Heart Association. All rights reserved. Print ISSN: 0194-911X. Online
72514
Hypertension is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX
1981;3;211-218Hypertension
AG Logan, BJ Milne, C Achber, WP Campbell and RB Haynes
Cost-effectiveness of a worksite hypertension treatment program
http://hyper.ahajournals.org
located on the World Wide Web at:
The online version of this article, along with updated information and services, is

19. PICO1
• Patient
•
• Intervention
•
• Comparison
•
• Outcome2
• ICER
1) PICO EBM
2) outcome
19

20. 20
CER ICER
(B)
(A)
( )
#$%& =
$()*+ − $()*-
./*0(12+ − ./*0(12-

21. PICO (1/2)
• Patient
• 41
18-69 457
• Intervention
• (Worksite Care; WS)
• (2 )
•
• Comparison
• (Regular Care; RC)
•
21

22. PICO (2/2)
• Outcome
•
•
• (≈ )
• ( )
•
•
• ICER
• CA$5.63/mmHg
•
•
22

23. 23
216 HYPERTENSION VOL 3, No 2, MARCH-APRIL 198
TABLE 4. Cost-Effectiveness Analysis of Worksite (WS) and Regular Care (RC) Programs
Cost-effectiveness WS RC WS-RC
Cost ($)
Treatment costs
Treatment & screening costs
Effect (mm Hg)
Reduction in diastolic BP
Cost-effectiveness ratio ($/mm Hg)
With treatment costs only
With treatment & screening costs
242.86
465.86
12.1
20.07
38.50
211.34
434.34
6.5
32.51
66.82
31.52
31.52
5.6
5.63
5.63
Patients with incomplete data did not differ from
patients with complete data in terms of entry BP,
year-end BP, change in BP over the study year, or
medication compliance.
Sensitivity Analysis
The health system, patient and total costs were
recalculated using maximum cost for missing in
dividual items for the WS group and minimum cos
for the RC group (table 5). The incremental C/E ratio
was still less than the C/E ratio for RC.
216 HYPERTENSION VOL 3, No 2, MARCH-APRIL 1981
TABLE 4. Cost-Effectiveness Analysis of Worksite (WS) and Regular Care (RC) Programs
Cost-effectiveness WS RC WS-RC
Cost ($)
Treatment costs
Treatment & screening costs
Effect (mm Hg)
Reduction in diastolic BP
Cost-effectiveness ratio ($/mm Hg)
With treatment costs only
With treatment & screening costs
242.86
465.86
12.1
20.07
38.50
211.34
434.34
6.5
32.51
66.82
31.52
31.52
5.6
5.63
5.63
Patients with incomplete data did not differ from
patients with complete data in terms of entry BP,
year-end BP, change in BP over the study year, or
medication compliance.
Sensitivity Analysis
The health system, patient and total costs were
recalculated using maximum cost for missing in-
dividual items for the WS group and minimum cost
for the RC group (table 5). The incremental C/E ratio
was still less than the C/E ratio for RC.

24. Table 4 …
24
(CA$) (CA$) (mmHg) (mmHg)
CER
(CA$/mmHg)
ICER
(CA$/mmHg)
RC 211.34 6.5 32.51
WS 242.86 31.52 12.1 5.6 20.07 5.63

25. 25
medication compliance.
300 r
200
CO
O
o
100
0
WS
RC
0 4 6 8
EFFECT
10 12 14
(reduction in diastolic blood pressure
in mmhtg)
FIGURE 2. Cost-effectiveness graph The points represent
the treatment cost and effect of each program. If it is
assumed that each group's average blood pressure (BP)
would be unchanged in the absence of identification, the
slopes of the solid lines represent the cost-effectiveness
(C/E) of each program. The intervention for which the slope
is steepest is the most costly for the effect. Under the
assumption that diastolic BP would fall by 5 mm Hg in I
year without any expenditure, the slopes of the small-dashed
lines represent the C/E ratio of each program The incre-
mental C/E ratio is given by the slope of the large-dashed
line connecting the RC and WS points. (WS indicates
worksite; RC, regular care).
dividual items for the WS group and minimum c
for the RC group (table 5). The incremental C/E r
was still less than the C/E ratio for RC.
Discussion
We have shown that treatment of emplo
hypertensives at their place of work is both more ef
tive and more cost-effective than usual care in
community.
The C/E ratios for the WS and RC groups w
calculated in each case under the assumption that
effect was entirely caused by the treatment progr
This supposes that if the two patient groups had
been identified and treated, the group's average
would be unchanged after 1 year. In the absence
third "no treatment" control group, this assump
cannot be tested. In the report of the Med
Research Council Working Party on mild
moderate hypertension, however, control subjects
ing inert tablets or only under observation had
proximately a 5 mm Hg fall in their diastolic B
year after entry, which was attributed to familia
with the measurement procedure and regres
toward the mean of the BP in the general populatio
To test the effect of such a change, we recalculated
C/E ratios after subtracting 5 mm Hg from the ef
and found that patients receiving RC had little
reduction (table 6 and fig. 2). The WS group, on
other hand, continued to experience a substan
effect beyond the estimated natural reduction in
The health system cost of the WS program
significantly higher than RC. This was rel
primarily to the use of more medication by the
care team to control hypertension and the cos
parallel care from community physicians. The la
expense appeared to reflect some initial ambivale
of WS patients to participate in a work-ba
program without some collaboration from their ph
cian. However, the infrequency of physician visits
the low dropout rate in the WS group suggested g
patient acceptance of the medical care provided a
work place.

26. 1 50
Accounting cost
•
• 15
• 35
50
Economic cost
•
• 15
• 35
• (= )
• 2,500 40
60
50
60

27. ( )
27
http://www.irasutoya.com/2016/04/blog-post_23.html
…

28. •
•
• (purchasing power)
•
•
•
•
28

29. QALY (1/2)
!"#$ = &'×#$
(quality adjusted life-year; QALY)
qa: quality adjuster (0-1 )
• QoL
LY: life-year (0 or 1 2 )
• 1 1
• 1 0
29

30. QALY (2/2)
30
http://www.irasutoya.com/
LY
QALY
1 1 1 0
0.81 0.3 0
QoL
• 5 QALY
• 0.3 5 = 1.5 QALYs

31. Quality adjuster
•
• Rating scale (VAS )
• Standard gambling (SG)
• Time trade-off (TTO)
• ( )
• EQ-5D
• SF-6D
31

32. 32
! ! Methods for the Economic Evaluation
of Health Care Programmes
Drummond