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講演資料 - 東京大学医学教育基礎コース
⮬ᕫ⤂ ᆅᇦ䛾デ⒪ᡤ䛻䛚䛡䜛 䝥䝷䜲䝬䝸䞉䜿䜰䛾ホ౯䛾ヨ䜏 -䝥䝷䜲䝬䝸䞉䜿䜰デ⒪䛾ྥୖᨭ䜢┠ᣦ䛧䛶- 2015ᖺ9᭶2᪥ ᮾிᏛ་Ꮫᩍ⫱䝉䝭䝘䞊 ᯇᮧ་㝔㻌 ᯇᮧ┿ྖ • 1967ᖺ㻌 ᮾி㒔ୡ⏣㇂༊ୖ㔝ẟ⏕䜎䜜 • 1991ᖺ㻌 ᾏ㐨Ꮫ་Ꮫ㒊༞ • ឿᜨ་◊ಟ་䚸ᅜ❧ᮾி➨㝔⥲ྜデ ⒪⛉䚸ᮾிᏛᏛ㝔 • 䠱䠟䠨䠝⥲ྜෆ⛉/බ⾗⾨⏕Ꮫ㝔䝦䝹䝇 䝃䞊䝡䝇Ꮫ⛉ • ᮾிᏛ་Ꮫᩍ⫱ᅜ㝿༠ຊ◊✲䝉䞁䝍䞊 • 2001ᖺ㻌 ᯇᮧ་㝔㻌 㝔㛗 ᯇᮧ་㝔 • ᮾி㒔ୡ⏣㇂༊ • 1969ᖺ㛤ᴗ • 2000ᖺ⥅ᢎ • 㒔ᕷᆺデ⒪ᡤ – ᶆᴶ䠖ෆ⛉䞉ᑠඣ⛉ – ↓ᗋデ⒪ᡤ 䛔䜟䜖䜛⏫䛾䜅䛴䛖 䛾䛚་⪅䛥䜣㻌 㻌 㻌 㻌 እ㒊⎔ቃ䛾ኚ 䑷 Ⲉᮌಖ ᮏ᪥䛾ෆᐜ • 㛤Ⓨ䛾⤒⦋ • ྥୖᨭ䛾䛯䜑䛾ヨ䜏 – ᐙᗞ་⒪䛾㉁䝒䞊䝹䝤䝑䜽 – 䝥䝷䜲䝬䝸䜿䜰ໟᣓホ౯䝟䜲䝻䝑䝖ᴗ • ㄢ㢟䛸ᒎᮃ 䛭䜜䛰䛡䛷䛔䛔䛾䠛 䛹䛳䛱䛜Ⰻ䛔㌴䠛 ་⒪䛾㉁ • “Quality of care is the degree to which health services toward individual and population increase the likelihood of desired health outcomes and are consistent with current professional knowledge” 㻌 䝧䞁䝒SL 䝎䜲䝝䝒䝁䝨䞁 㻌 Institute of Medicine 䠄1990䠅 • ་⒪䛾㉁䛸䛿ಶே䛚䜘䜃㞟ᅋ䛻ᑐ䛩䜛་⒪ ⾜Ⅽ䛜ᮃ䜎䜜䛯ᗣ≧ែ䜢䜒䛯䜙䛩☜⋡䜢 䛒䛢䚸᭱᪂䛾ᑓ㛛▱㆑䛸ྜ⮴䛩䜛ᗘྜ䛔䜢 䛔䛖 • 䛴䜎䜚㐩ᡂྍ⬟䛺┠ᶆ䛻䚸デ⒪䜢䛹䛾⛬ᗘ ㏆䛵䛡䜛䛣䛸䛜䛷䛝䜛䛛䚸䛸䛔䛖䛣䛸 㻌 ᆅᇦ䛾་ᖌ䛸䛧䛶䛾㢪䛔 • 䝥䝷䜲䝬䝸䞉䜿䜰་䛸䛧䛶䚸᪥䚻䛾⮬䜙䛾デ⒪ 䜢ྥୖ䛥䛫䜛䚸ᑡ䛺䛟䛸䜒ᚋ㏥䛥䛫䛺䛔䛯䜑䛾 ດຊ䜢䛧䛶䛔䜛་⒪ᶵ㛵䛿䛒䜛䛿䛪 ホ౯䛻㛵䛩䜛䠎䛴䛾どⅬ ᨵၿⅬ䜢䜏䛴䛡䜛 䛡䜛 ุ᩿ᮦᩱ䛻䛩䜛 • 䛭䛾䜘䛖䛺ດຊ䜢䛧䛶䛔䜛タ䜢ᨭ䛧䛯䛔 • ⤖ᯝ䛸䛧䛶䚸ᝈ⪅䛥䜣/ᆅᇦఫẸ䛾ᗣ≧ែ 䛜Ⰻ䛟䛺䜜䜀䛔䛔 ලయⓗ᪉ἲㄽ䛾᳨ウస ᴗ䜢㛤ጞ㻌 䠄2011ᖺ䠅 ホ౯䛾┠ⓗ䛸≉ᚩ ホ౯ㄗᕪ䚸 ㄗศ㢮 ᨵၿ䛾䛯䜑䛾ホ౯ ุ᩿䛾䛯䜑䛾ホ౯ チᐜྍ⬟ ᅔ䜛 ᣦᶆ䛾 ᨵゞ䞉ኚ᭦ ᰂ㌾䛻ᑐᛂ ཧຍタ䛾 ᢠ 䛒䜎䜚䛺䛔 ᙉ䛔 ⮬ᛶ䛻ᕥྑ ᙉ䛔 ᨵၿ䜈䛾 ືᶵ䛵䛡 㣕⾜㊥㞳 㣕ᙧⅬ 䛭䛾… 䠄ᯟ⤌䜏䠅㉁ホ౯䛾䠏どⅬ 䠄䝗䝘䝧䝕䜱䜰䞁䝰䝕䝹䠅 ನᡯᴾ ᢅᆉᴾ ኽௐᴾ ἋἚἻἁἓἵὊᴾ ἩἿἍἋᴾ ỴỸἚỽἲᴾ ་⒪䛾ᥦ౪యไ㻌 㻌 •デ⒪ᶵჾ䛾᭷↓䞉ᩘ㻌 •ᣦᑟ་䛾ᩘ㻌 •䝇䝍䝑䝣䛾ᩘ㻌 •ཷデཷ㛫㻌 ఱ䛜⾜䜟䜜䛯䛛㻌 㻌 •デ᩿䛿ⓗ☜䛛㻌 •⒪䛿㐺ษ䛛㻌 •䝣䜷䝻䞊䛿㐺ษ䛛㻌 •グ㘓䛾㐣㊊㻌 㻌 㻌 Ᏻᐃ䛜㔜せ ᝈ⪅䛻ఱ䛜㉳䛣䛳䛯䛛㻌 㻌 •⏕Ꮡ⋡㻌 •ධ㝔⋡㻌 •ྜేⓎ⏕⋡㻌 •㠀ணᐃධ㝔⋡㻌 ᅜ❧䛜䜣◊✲䝉䞁䝍䞊㻌 ᮾᑦᘯඛ⏕㻌 ㅮ⩏䝇䝷䜲䝗䜘䜚 ᅜ❧䛜䜣◊✲䝉䞁䝍䞊㻌 ᮾᑦᘯඛ⏕㻌 ㅮ⩏䝇䝷䜲䝗䜘䜚୍㒊ᨵኚ 12 䝥䝻䝆䜵䜽䝖㛤ጞ䠄2012䠅 • 䜟䛜ᅜ䛾デ⒪ᡤ䛻䛚䛡䜛ྥୖ䛾䛯䜑䛾ᣦᶆ/᪉ ἲㄽ䛾㛤Ⓨ – – – – – 䜟䛜ᅜ䛾⌧≧䛻㐺䛧䛯䜒䛾 䝥䝻䝉䝇/䜰䜴䝖䜹䝮ホ౯䜢య䛸䛩䜛 ᐈほᛶ䛜㧗䛔䜒䛾 ᐇ⾜ྍ⬟/⌧ᐇⓗ䛺䜒䛾 ⌧Ⅼ䛷䛿බ㛤䜢๓ᥦ䛸䛫䛪䚸ෆ㒊䛻䛚䛡䜛ᨵၿ䛾 䛯䜑䛻⏝䛔䜛 • ᖹᡂ24ᖺ-26ᖺᗘᩥ㒊⛉Ꮫ◊✲㈝ຓᡂ㔠䠄ᇶ┙ ◊✲䠟䠅䜿䜰Ꮫ 䝥䝷䜲䝬䝸䞉䜿䜰䛾䠑せ⣲ 䠝䠖Accessibility䠄㏆᥋ᛶ䠅 䠟䠖Comprehensiveness䠄ໟᣓᛶ䠅 䝥䝷䜲䝬䝸䜿䜰 • Institute of medicine 䠄1997䠅 – 䝥䝷䜲䝬䝸䞉䜿䜰䛸䛿䚸ᝈ⪅䛾ᢪ䛘䜛ၥ㢟䛾㒊ศ䛻 ㈐௵䜢䜒䛳䛶ᑐฎ䛷䛝䜛ᖜᗈ䛔⮫ᗋ⬟ຊ䜢᭷䛩䜛⮫ ᗋᐙ䛻䜘䛳䛶ᥦ౪䛥䜜䜛䝦䝹䝇䜿䜰䞉䝃䞊䝡䝇䛷䛒䜛䚹 䛭䛾䝦䝹䝇䜿䜰䞉䝃䞊䝡䝇䛿ཷデ䛜䛧䜔䛩䛟䚸⥲ྜⓗ 䛷䛛䛴⥅⥆ⓗ䛷䛒䜚䚸䜎䛯ᐙ᪘䛚䜘䜃ᆅᇦ䜢ど㔝䛻 䛔䜜䛯䜒䛾䛷䛺䛡䜜䜀䛺䜙䛺䛔䚹 • ᪥ᮏ䝥䝷䜲䝬䝸䞉䜿䜰㐃ྜᏛHP – 䛂ᅜẸ䛾䛒䜙䜖䜛ᗣୖ䛾ၥ㢟䚸䛻ᑐ䛧䚸⥲ྜ ⓗ䞉⥅⥆ⓗ䚸䛭䛧䛶ேⓗ䛻ᑐᛂ䛩䜛ᆅᇦ䛾ಖ་ ⒪⚟♴ᶵ⬟䛸⪃䛘䜙䜜䜎䛩䚹䛃 䜟䛜ᅜ䛾デ⒪ᡤ䛜ᯝ䛯䛩䜉䛝ᆅᇦ䛾 デ⒪ᡤ䛾ᙺ䞉ᶵ⬟䛿䠛 • ෆእ䛾ᣦᶆ/ඛ⾜ᩥ⊩䛾ㄪᰝ • ᴫᛕ䜹䝔䝂䝸䞊䛾ᩚ⌮ • 䝣䜷䞊䜹䝇䜾䝹䞊䝥䜲䞁䝍䝡䝳䞊䠄2013䠅 䠟䠖Coordination䠄༠ㄪᛶ䠅 – 䝥䝷䜲䝬䝸䜿䜰デ⒪䛻ᚑ䛩䜛་ᖌ䞉䞉䞉ᇶᖿ㝔䚸୰ᑠ 㝔䚸ᅜಖデ⒪ᡤ䚸㛤ᴗ་䚸䝸䝝䝡䝸䚸ᑠඣ⛉ 䠟䠖Continuity䠄⥅⥆ᛶ䠅 – 䝥䝷䜲䝬䝸䜿䜰デ⒪䛻ᚑ䛩䜛་⒪䞉ㆤ䞉⚟♴ 㛵ಀ⫋䠄㠀་ᖌ䠅䞉䞉䞉ᰤ㣴ኈ䚸⸆ᖌ䚸ゼၥ┳ㆤ ᖌ䚸⌮Ꮫ⒪ἲኈ䚸ᆅ᪉་⒪⾜ᨻᐁ䚸ᆅᇦ་⒪㐃 ᦠᐊ䚸䜿䜰䝬䝛䞊䝆䝱䞊 A䠖Accountability䠄㈐௵ᛶ䠅 䠄Institute of Medicine, 1976) 䛣䜜䜙䛾⌮ᛕ䛻ᇶ䛵䛟ᙺ䛜ᯝ䛯䛫䛶䛔䜛䛛䠛 ⤖ᯝ 㐃ᦠ ከ⫋✀䛸䛾㐃ᦠ デ㐃ᦠ䞉デデ㐃ᦠ ⸆ᒁ䛸䛾㐃ᦠ 䝏䞊䝮䝸䞊䝎䞊 ᶆ‽ⓗデ⒪ EBM䞉䜺䜲䝗䝷䜲䞁㑂Ᏺ ಖ㝤デ⒪䛾㑂Ᏺ ⥅⥆ⓗ䛺▱㆑/ᢏ⾡䛾᭦᪂ ឤᰁண㜵 Quality Primary Care ᝈ⪅⫼ᬒ䛾ᑛ㔜 ᆅᇦ䜈䛾㈉⊩ ⏕ά㠃䛾䜰䜴䝖䜹䝮㔜ど 㣗⏕ά䛺䛹䜈䛾㛵 ㈝⏝䞉⤒῭㠃䜈䛾㓄៖ ⮬ᕫ⟶⌮䛾ᨭ ་ᖌάື ᩆᛴ䞉ఇ᪥ᙜ␒ ᕷẸᩍ⫱ ♫ᨭ ᖜᗈ䛔デ⒪ 䝁䝰䞁䞉䝕䜱䝆䞊䝈 䛒䜙䜖䜛ᗣၥ㢟 ୍ḟᩆᛴ ண㜵་⒪䞉ᑠእ⛉ 㧗㱋⪅䜿䜰 䜰䜽䝉䝇 㛫እᑐᛂ 㟁ヰᑐᛂ ཷデඛ䛾☜ಖ ḟ䜰䜽䝉䝇 䝁䝭䝳䝙䜿䞊䝅䝵䞁 ぶ㏆ឤ䞉ே㛫ᛶ 䜲䞁䝣䜷䞊䝮䝗䝁䞁䝉䞁䝖 䝥䝷䜲䝞䝅䞊䜈䛾㓄៖ ᝈ⪅㑅ዲ䜈䛾㓄៖ ⪃ᐹ • ᖜᗈ䛔デ⒪䞉ᝈ⪅⫼ᬒ䛾⪃៖䞉䜰䜽䝉䝇䞉㐃 ᦠ䞉䝁䝭䝳䝙䜿䞊䝅䝵䞁䛺䛹䛿䚸ඛ⾜◊✲䜔ෆ እ䛾䜹䝔䝂䝸䞊䛸ඹ㏻䛾䜒䛾䛷䛒䛳䛯䚹 • ᖜᗈ䛔デ⒪䛾䛖䛱䚸㧗㱋⪅䜿䜰䛻㛵䛩䜛䜒䛾 䛜䛝䛺㒊ศ䜢༨䜑䛯䚹 • ᆅᇦ䜈䛾㈉⊩䛜䚸䜘䜚᫂☜䛺䜹䝔䝂䝸䞊䛸䛧䛶 ᙧᡂ䛥䜜䛯䚹බඹᛶ䞉බṇᛶ䛸䛧䛶⾲⌧䛥䜜䜛 䜒䛾䛜䚸ᮏ㑥䛷䛿䛂ᆅᇦ䜈䛾㈉⊩䛃䛸䛧䛶ศ㢮 䛥䜜䛶䛔䜛䛛䚹 ᐙᗞ་⒪䛾㉁ デ⒪ᡤ䛷䛖䝒䞊䝹䝤䝑䜽 Quality in family practice Book of Tools • 䜹䝘䝎䞉䜸䞁䝍䝸䜸ᕞ䛾 ᐙᗞ་⒪デ⒪ᡤ䛾䛯 䜑䛾⥙⨶ⓗ䛺䝒䞊䝹 䝤䝑䜽 • ⮬Ⓨⓗ䛺⥅⥆ⓗ㉁ᨵ ၿάື䛾䛯䜑䛻⏝䛔䜙 䜜䜛 • ᪥ᮏ䝥䝷䜲䝬䝸䞉䜿䜰㐃 ྜᏛ⩻ヂ䝏䞊䝮䛻䜘 䜚㑥ヂ䛜2015ᖺ䛻ฟ∧ 䞉䝬䜽䝬䝇䝍䞊Ꮫᐙᗞ་⒪⛉䛻 䜘䜚㛤Ⓨ 䞉8䜹䝔䝂䝸䞊䚸70䛾ᣦᶆ 䞉43䛜デ⒪ᡤ⟶⌮䚸27䛜⮫ᗋ 䞉2009ᖺ䛻ฟ∧ Cheryl Levitt Linda Hilts http://qualitybookoftools.ca/ 䜹䜲᭩ᯘ㻌 2015ᖺ 䜹䝔䝂䝸䞊㡯┠ 3WCNKV[$QQMQH6QQNU +PUVKVWVGQH/GFKEKPG ᝈ⪅୰ᚰᛶ㻌 ᝈ⪅୰ᚰᛶ㻌 බᖹ䞉බṇᛶ㻌 බᖹ䞉බṇᛶ㻌 㐺ᛶ䛸㏆᥋ᛶ㻌 㐺ᛶ㻌 Ᏻᛶ㻌 Ᏻᛶ㻌 ຠᯝⓗ䛺デ⒪㻌 ຠᯝⓗ䛺デ⒪㻌 ຠ⋡ᛶ㻌 ຠ⋡ᛶ㻌 ᣦᶆ䛾 C㻌 㐺ᛶ䛸㏆᥋ᛶ C.1㻌 ㏿䜔䛛䛥䞉䜰䜽䝉䝇䛾Ⰻ䛥 C.2㻌 㛫እデ⒪䠈ᩆᛴデ⒪ ⤫ྜ䜿䜰䛸⥅⥆ᛶ㻌 㐺ษ䛺デ⒪ᡤ䝸䝋䞊䝇㻌 C.1.1.1㻌 㡯┠䛸ゎ㔘 䠟.1㻌 㐺ᛶ䛸㏆᥋ᛶ • 䠟.1.1 㻌 㻌 ᝈ⪅䛿㟁ヰ䠈䠡䝯䞊䝹䚸䛭䛾䛾㟁Ꮚ፹య䛻䜘䛳䛶デ ⒪ᡤ䛻䜰䜽䝉䝇䛷䛝䜛 䞉㻌 䠟.1.2 ᝈ⪅䛿ᚲせ䛻ண⣙䛜䛷䛝䜛 䞉㻌 䠟.1.3 ᪂ᝈⓏ㘓䛸䜹䝹䝔䛜㐺䛻⏝䛷䛝䜰䜽䝉䝇䜒䜘䛔 䞉㻌 C.1.4 ᳨ᰝ䝉䞁䝍䞊䜔ᑓ㛛་䜈䛾⤂䛜ᚲせ䛻⾜䜟䜜䛶 䛔䜛㻌 㻌 㻌 ண⣙䜔㐺ษ䛺ຓゝ䚸䝯䝑䝉䞊䝆䜢ṧ䛩䛣䛸䛾䛷䛝䜛ຠ⋡ⓗ䛺㟁 ヰ䝅䝇䝔䝮䚸㟁Ꮚ䝯䞊䝹䛚䜘䜃/䜒䛧䛟䛿䛾㟁Ꮚ፹య䛜䛒䜛䚹 㻌 ゎ㔘䠖デ⒪ᡤ⟶⌮⪅䛿௨ୗ䜢グ㏙䛷䛝䜛 • 㟁ヰ䛾䝅䝇䝔䝮䠄ཷ䛡䜛ሙྜ䛸䛛䛡䜛ሙྜ䠅䚸䝪䜲䝇䝯䞊䝹䝯䝑䝉䞊䝆䝅䝇䝔 䝮䛸䛭䛾ᑐᛂ᪉ἲ䚹 • ᝈ⪅䛸䝁䝭䝳䝙䜿䞊䝅䝵䞁䜢䛸䜛䛯䜑䛾㟁Ꮚ䝯䞊䝹䛚䜘䜃/䜒䛧䛟䛿䛾㟁Ꮚ ፹య䚹 • ᝈ⪅䛜ண⣙䛺䛧䛷䜒䜿䜰䛻㛵䛩䜛ຓゝ䜔ሗ䜢ᚓ䜛䛣䛸䛜䛷䛝䜛᪉ἲ䚹 䠄䠖㟁ヰ䛒䜛䛔䛿㟁Ꮚ፹య䠅 • 㟁ヰ䛒䜛䛔䛿䝯䝑䝉䞊䝆䝅䝇䝔䝮䛾ᨵၿ䛻ᙺ❧䛶䜛䛯䜑䛻䛹䛾䜘䛖䛻ᝈ⪅ 䛛䜙䝣䜱䞊䝗䝞䝑䜽䜢ᚓ䚸ά⏝䛩䜛䛛䚹䠄䠖ᖺ୍ᅇ䛾ᝈ⪅‶㊊ᗘㄪᰝ䠅 • 䛛䛛䛳䛶䛟䜛㟁ヰ䛻㛵䛧䛶ᐃᮇⓗ䛺䜸䞊䝕䜱䝑䝖䛜⾜䜟䜜䛶䛔䜛䛛䠛䠄ཷヰ ჾ䜢䛸䜛䜎䛷䛾䝧䝹䛾ᅇᩘ䚸ᛂ⟅䜢ᚅ䛯䛫䛶䛔䛯㛫䚸䛛䛡┤䛧䚸䝯䝑䝉䞊 䝆䛾グ㘓䞉᳨⣴䞉䝣䜷䝻䞊䜰䝑䝥䛾᪉ἲ䠅 䛯䛸䛘䜀ᙜ㝔䛾≧ἣ ண⣙䜔㐺ษ䛺ຓゝ䚸䝯䝑䝉䞊䝆䜢ṧ䛩䛣䛸䛾䛷䛝䜛ຠ⋡ⓗ䛺㟁 ヰ䝅䝇䝔䝮䚸㟁Ꮚ䝯䞊䝹䛚䜘䜃/䜒䛧䛟䛿䛾㟁Ꮚ፹య䛜䛒䜛䚹 㻌 㻌 ᐙᗞ་⒪䛾㉁ デ⒪ᡤ䛷䛖䝒䞊䝹䝤䝑䜽 • 䜸䞁䝍䝸䜸་ᖌ/䝬䜽 䝬䝇䝍䞊Ꮫ䛜㐠Ⴀ䛩 䜛䝥䝻䜾䝷䝮䛷⏝ • ໟᣓⓗ/⮬ⓗ䝥䝻䜾 䝷䝮 ゎ㔘䠖デ⒪ᡤ⟶⌮⪅䛿௨ୗ䜢グ㏙䛷䛝䜛 • 㟁ヰ䛾䝅䝇䝔䝮䠄ཷ䛡䜛ሙྜ䛸䛛䛡䜛ሙྜ䠅䚸䝪䜲䝇䝯䞊䝹䝯䝑䝉䞊䝆䝅䝇 䝔䝮䛸䛭䛾ᑐᛂ᪉ἲ㻌 ї㻌 䕿 • ᝈ⪅䛸䝁䝭䝳䝙䜿䞊䝅䝵䞁䜢䛸䜛䛯䜑䛾㟁Ꮚ䝯䞊䝹䛚䜘䜃/䜒䛧䛟䛿䛾㟁 Ꮚ፹య䚹㻌 ї䕿 • ᝈ⪅䛜ண⣙䛺䛧䛷䜒䜿䜰䛻㛵䛩䜛ຓゝ䜔ሗ䜢ᚓ䜛䛣䛸䛜䛷䛝䜛᪉ἲ 䠄䠖㟁ヰ䛒䜛䛔䛿㟁Ꮚ፹య䠅㻌 ї㻌 䕿 • 䜟䛜ᅜ䛷䜒㐠⏝㠃䛷ᕤ ኵ䛧ヨ㦂ⓗ䛻᥇⏝/ヨ ⏝䛧䛶䛔䜛デ⒪ᡤ䜒 • 㟁ヰ䛒䜛䛔䛿䝯䝑䝉䞊䝆䝅䝇䝔䝮䛾ᨵၿ䛻ᙺ❧䛶䜛䛯䜑䛻䛹䛾䜘䛖䛻ᝈ ⪅䛛䜙䝣䜱䞊䝗䝞䝑䜽䜢ᚓ䚸ά⏝䛩䜛䛛䚹䠄䠖ᖺ୍ᅇ䛾ᝈ⪅‶㊊ᗘㄪᰝ䠅㻌 ї㻌 㽢 • 䛛䛛䛳䛶䛟䜛㟁ヰ䛻㛵䛧䛶ᐃᮇⓗ䛺䜸䞊䝕䜱䝑䝖䛜⾜䜟䜜䛶䛔䜛䛛䠛䠄ཷ ヰჾ䜢䛸䜛䜎䛷䛾䝧䝹䛾ᅇᩘ䚸ᛂ⟅䜢ᚅ䛯䛫䛶䛔䛯㛫䚸䛛䛡┤䛧䚸䝯䝑 䝉䞊䝆䛾グ㘓䞉᳨⣴䞉䝣䜷䝻䞊䜰䝑䝥䛾᪉ἲ䠅㻌 ї㻌 㽢 㛤Ⓨ䝥䝻䝉䝇 㡯┠᳨ウ ͻ 㡯┠᳨ウ/ᣦᶆೃ⿵㞟 ͻ 䝣䜷䞊䜹䝇䜾䝹䞊䝥䠄་⒪⪅䞉ಖ⚟♴㛵ಀ⪅䠅 ᣦᶆ㑅ᢥ ͻ Delphiἲ䜢㏻䛨ྜពᙧᡂ ͻ ᐇ⾜ྍ⬟ᛶ䞉ጇᙜᛶ䜢᳨ウ䛧㑅ᢥ 䝰䝕䝹ᴗ ͻ 䝺䝉䝥䝖䞉デ⒪㘓䞉ᝈ⪅ㄪᰝ ͻ ᐇ⾜ྍ⬟ᛶ/⌧ሙ䛾ពぢ䜢㋃䜎䛘ಟṇ 䝕䝹䝣䜯䜲ἲ䛾ὶ䜜 2013ᖺ䠓᭶ ᑓ㛛ᐙ䝯䞁䝞䞊䛾Ỵᐃ 2013ᖺ䠔᭶୰᪪ ᣦᶆ㻌 ㏦ 2013ᖺ9᭶ึ᪪ ➨୍ᅇホⅬ䠇㞟ィ 2013ᖺ9᭶22᪥ 䝁䞁䝉䞁䝃䝇㆟ 2013ᖺ10᭶୰᪪ ➨ᅇホⅬ䠇㞟ィ 2013ᖺ11᭶୰᪪ ពぢ㞟⣙ 2013ᖺ12᭶ ᣦᶆ㡯┠㻌 Ỵᐃ ໟᣓⓗ㉁ᣦᶆ䛾సᡂ • 㡯┠ೃ⿵䛾సᡂ – ඛ䛻సᡂ䛥䜜䛯䜹䝔䝂䝸䞊䛤䛸䚸ඛ⾜ᩥ⊩䛸⌧ሙ䛾▱ぢ䜢 䜒䛸䛻㡯┠ೃ⿵䜢సᡂ䚹 – 䝕䞊䝍※䜢䐟䝺䝉䝥䝖㻌 䐠デ⒪㘓㻌 䐡ᝈ⪅䝃䞊䝧䜲㻌 䐢ᐇ ᆅㄪᰝ/⮬ᕫホ౯䛻ᩚ⌮䚹 • 㡯┠㑅ᐃ䠖䠱䠟䠨䠝/䠮䠝䠪䠠䛾Delphiኚἲ – ๓䛾༏ྡㄪᰝ䛚䜘䜃1ᅇ䛾ᑐ㠃ᘧ᳨ウ䠄䝁䞁䝉䞁䝃䝇 ㆟䠅䛚䜘䜃ᚋホ౯ • ୰ኸ್䠓䚸䛒䜛䛔䛿ពぢ䛻೫䜚䛜䜏䜙䜜䜛䜒䛾䛿୰ኸ್8௨ୖ䜢㑅 ᐃᇶ‽䛸タᐃ䚹 • ᐇ⾜ྍ⬟ᛶ䜢୰ᚰ䛸䛧䛯ḟ㑅ᐃ – ጇᙜᛶホ౯䜢⤒䛯㡯┠䛛䜙ᐇ⾜ྍ⬟ᛶ䜢᳨ウ䛧䚸᭱⤊㡯 ┠䜢⟇ᐃ䚹 䝟䝛䝹ᑓ㛛ᐙ • ᪥ᖖ䛾䝥䝷䜲䝬䝸䜿䜰デ⒪䛾ᐇ㝿䜢⇍▱ • ᛶู䚸デ⒪ᙧែ䚸デ⒪ᆅᇦ䚸⮫ᗋ⤒㦂䛾Ⅼ 䛷೫䜚䛜䛺䛔䜘䛖ᣍ⪸ • ་ᖌ10ྡ䛷ᵓᡂ • ୍㒊㡯┠䛻䛴䛔䛶䛿㛵㐃⫋✀䠄ゼၥ┳ㆤ䞉 ㆤ䞉⸆ᖌ䠅䛜ྛ1ྡ䛪䛴ཧຍ ᭱⤊䜹䝔䝂䝸䞊 ⤖ᯝ • ๓タᐃᇶ‽䛻฿㐩䠖㻌 70㡯┠/159㡯┠ – 䐟ᖜᗈ䛔デ⒪㻌 32/58䚸䐠䜰䜽䝉䝇㻌 3/13㻌 䐡䝁䝭䝳䝙 䜿䞊䝅䝵䞁㻌 9/15䚸䐢㐃ᦠ-15/29䚸䐣ᆅᇦ㈉⊩㻌 0/17䚸 䐤ᝈ⪅⫼ᬒ䛾⪃៖㻌 4/12䚸䐥ᶆ‽ⓗデ⒪㻌 7/15䛷 䛒䛳䛯䚹 • ୍㒊䜹䝔䝂䝸䞊䛻䛴䛔䛶䛿ᇶ‽䜢⦆䜑䠄୰ኸ್䠓 ௨ୖ䠅㑅ᐃ䚸䛭䛾ୖ䛷ᐇ⾜ྍ⬟ᛶ䜢㋃䜎䛘᳨ ウ䚹 • ᭱⤊ⓗ䛻42㡯┠䜢᥇⏝䚹 • ᥇⏝㡯┠ᩘ䛾ᑡ䛺䛛䛳䛯䛂ᶆ‽ⓗデ⒪䛃䠄2㡯┠䠅 䛿䚸䛂ᖜᗈ䛔デ⒪䛃䛸䜹䝔䝂䝸䞊䜢⤫୍䛧䛯䚹 ᖜᗈ䛔デ⒪/ ᶆ‽ⓗデ⒪ 䠄20㡯┠䠅 䝁䝰䞁䞉䝕䜱䝆䞊䝈 ண㜵་⒪ 㧗㱋⪅䜿䜰 䠡䠞䠩/䜺䜲䝗䝷䜲䞁㑂Ᏺ 㐃ᦠ 䠄5㡯┠䠅 ከ⫋✀䛸䛾㐃ᦠ デ㐃ᦠ䞉デデ㐃ᦠ 䝏䞊䝮䝸䞊䝎䞊 Quality Primary Care ᝈ⪅⫼ᬒ䛾ᑛ㔜 䠄6㡯┠䠅 ⏕ά㠃䛾䜰䜴䝖䜹䝮㔜ど 㣗⏕ά䛺䛹䜈䛾㛵 ㈝⏝䞉⤒῭㠃䜈䛾㓄៖ ⮬ᕫ⟶⌮䛾ᨭ ་ᖌάື ᩆᛴ䞉ఇ᪥ᙜ␒ ᕷẸᩍ⫱ ♫ᨭ ෆᐜ 䝕䞊䝍※ ᖜᗈ䛔デ⒪ 䠋ᶆ‽ⓗデ⒪ 20 ႚ↮Ṕ䞉⚗↮⒪䞉⫵⅖⌫⳦䝽䜽䝏䞁䞉ㄆ ▱䞉㢌③䞉⭡③䞉㧗⾑ᅽ䞉⢾ᒀ䞉Ẽ⟶ᨭ ႍᜥ䞉៏ᛶᝈᝈ⪅䜈䛾ฎ᪉䞉ஙඣண㜵 ᥋✀䞉㝔㏻㝔Ṕ䠋䛚⸆ᡭᖒ䛾☜ㄆ 䝺䝉䝥䝖3 デ⒪㘓15 ᝈ⪅䝃䞊䝧䜲2 䜰䜽䝉䝇 3 㛫እᑐᛂ ⌧ᅾ⒪୰䛾ᝈ௨እ䜈䛾ᑐᛂ ᝈ⪅䝃䞊䝧䜲3 䝁䝭䝳䝙䜿䞊䝅䝵䞁 8 ᝈ⪅ពぢ䛾ᑛ㔜䚸⸆䛾ㄝ᫂䚸䝥䝷䜲䝞 ᝈ⪅䝃䞊䝧䜲8 䝅䞊䜈䛾㓄៖䚸ぶ㏆ឤ䚸ㄔᐇ䛺ᑐᛂ 㐃ᦠ 5 デ⒪ሗᥦ౪᭩䞉䜿䜰䝬䝛䝆䝱䞊䛾ྠ デ⒪㘓2 ᐃ䚸ᑓ㛛་㑅ᢥ䜈䛾ᡭຓ䛡㻌 ᝈ⪅䝃䞊䝧䜲3 ᝈ⪅⫼ᬒ䛾⪃៖ 6 ྠᒃᐙ᪘䛾᭷↓䚸㈝⏝㈇ᢸ䛾⪃៖䚸 ᙺ䛾⌮ゎ䚸ᆅᇦ⎔ቃ䜈䛾㓄៖䛺䛹 デ⒪㘓1 ᝈ⪅䝃䞊䝧䜲5 ᣦ㻌 㻌 ᶆ ႚ↮Ṕ 20ṓ௨ୖ䛾䛩䜉䛶䛾ᝈ⪅䛾㐣ཤ1ᖺ௨ෆ䛾ႚ↮Ṕ 䛜デ⒪㘓䛻グ㍕䛥䜜䛶䛔䜛 ⚗↮⒪ ႚ↮ᝈ⪅䛻ᑐ䛧䛶䚸㐣ཤ24䜹᭶௨ෆ䛻⚗↮⒪䛜 㛤ጞ䛥䜜䛶䛔䜛䚸䛒䜛䛔䛿⚗↮⒪䛜ᥦ♧䛥䜜䛯䛣 䛸䛜デ⒪㘓䛻グ㍕䛥䜜䛶䛔䜛 ⫵⅖⌫⳦䝽䜽䝏䞁 65ṓ௨ୖ䛾䛩䜉䛶䛾ᝈ⪅䛻䛴䛔䛶䚸5ᖺ䛤䛸䛻⫵⅖ ⌫⳦䝽䜽䝏䞁᥋✀䛾グ㍕䛜䛒䜛䛛䚸ཷデṔ䛜5ᖺ䛻 ‶䛯䛺䛔ሙྜ䛻䛿䚸㐣ཤ5ᖺ௨ෆ䛾⫵⅖⌫⳦䝽䜽䝏 䞁᥋✀Ṕ䛾グ㍕䛜䛒䜛 ㄆ▱ᝈ⪅䛾 ㆤ⪅ྠᐃ 䠄8㡯┠䠅 ぶ㏆ឤ䞉ே㛫ᛶ 䜲䞁䝣䜷䞊䝮䝗䝁䞁䝉䞁䝖 䝥䝷䜲䝞䝅䞊䜈䛾㓄៖ ᝈ⪅㑅ዲ䜈䛾㓄៖ 32 75ṓ௨ୖ䛾䚸䝺䝉䝥䝖䛻䛚䛔䛶ㄆ▱䠄䛔ྵ䜐䠅 䛾ྡ䛜䛔䛶䛔䜛ᝈ⪅䛻䛴䛔䛶䚸䛯䜛ㆤ⪅ 䛜ㄡ䛷䛒䜛䛛ྠᐃ䛥䜜䚸㐣ཤ1ᖺ௨ෆ䛾デ⒪㘓䛻 グ㍕䛥䜜䛶䛔䜛 ᣦ㻌 㻌 ᶆ 㝆ᅽᒀᢞᝈ⪅ 䜈䛾స⏝䝏䜵䝑䜽 㝆ᅽᒀᢞ䛜1ᖺ௨ୖ⾜䜟䜜䛶䛔䜛ᝈ⪅ 䛻䛴䛔䛶䚸㐣ཤ1ᖺ㛫䛻䚸䜹䝸䜴䝮䞉䜽䝺䜰䝏䝙䞁䚸 ⬡㉁䝥䝻䝣䜯䜲䝹(Tcho,HDL,LDL,TG 䛾䛔䛪 䜜䛛3䛴) 䛜⾜䜟䜜䛶䛔䜛 ⢾ᒀᝈ⪅䛾 ᒀ䛯䜣䜁䛟 ᐃ ⢾ᒀ䛾㏻㝔ᝈ⪅䛷䚸⢾ᒀ⸆䛜ฎ᪉䛥䜜䛶 䛔䛺䛔ᝈ⪅䛻䛴䛔䛶䚸᭱㏆1ᖺ㛫䛷ᒀ䛯䜣䜁䛟 䠄䜒䛧䛟䛿㝶ᒀ䜰䝹䝤䝭䞁䠅䛜 ᐃ䛥䜜䛶䛔䜛 ႍᜥᝈ⪅䜈䛾 ྾ධ䝇䝔䝻䜲䝗ᑟධ ǃ2่⃭䜢㐃᪥⏝䛔䛶䛔䜛ᡂேẼ⟶ᨭႍᜥᝈ ⪅䛻䛴䛔䛶䚸䝁䞁䝖䝻䞊䝷䞊䛸䛧䛶྾ධ䝇䝔䝻䜲 䝗䛜ᑟධ䛥䜜䛶䛔䜛 ホ౯ᣦᶆ䠖䠄ᝈ⪅䝃䞊䝧䜲䠅㻌 ホ౯ᣦᶆ䠖䠄デ⒪㘓䠅 㡯㻌 ┠ 䝁䝭䝳䝙䜿䞊䝅䝵䞁 デ⒪ᣦᶆ䠖䠄䝺䝉䝥䝖䠅 㡯㻌 ┠ 㡯┠ᩘ 䠄3㡯┠䠅 㛫እᑐᛂ 㟁ヰ䞉FAXᑐᛂ ཷデඛ䛾☜ಖ ᆅᇦ䜈䛾㈉⊩ ᭱⤊㡯┠ 䜹䝔䝂䝸䞊 䜰䜽䝉䝇 ஙඣ䛾ண㜵᥋✀Ṕ䛾 䛣䛾デ⒪ᡤ䛷䛿䚸ẕᏊᡭᖒ䜢⏝䛔䛶ண㜵᥋✀䛾 ☜ㄆ グ㘓䜢䛹䛾⛬ᗘ☜ㄆ䛧䛶䛔䜎䛩䛛 䛣䛾デ⒪ᡤ䛾་⒪䝇䝍䝑䝣䛿䚸䛒䛺䛯䛾㝔䜈䛾 㝔䜈䛾㏻㝔Ṕ䛚䜘 ㏻㝔Ṕ䛚䜘䜃䛚⸆ᡭᖒ䛾ෆᐜ䛻䛴䛔䛶☜ㄆ䛧䛶 䜃䛚⸆ᡭᖒ䛾☜ㄆ 䛔䜎䛩䛛 㛫እᑐᛂ デ⒪㛫እ䛻ලྜ䛜ᝏ䛟䛺䛳䛯ሙྜ䚸䛹䛾䜘䛖䛻 ᑐᛂ䛩䜜䜀䜘䛔䛛䛻䛴䛔䛶䚸䛒䛺䛯䛿䛹䛾⛬ᗘ ▱䛳䛶䛔䜎䛩䛛 ⌧ᅾ⒪୰௨እ䛾 ᝈ䛾┦ㄯ 㐣ཤ୍ᖺ㛫䛻䚸⌧ᅾ⒪୰䛾Ẽ௨እ䛷䛒䛺䛯 䛻ఱ䛛ᗣୖ䛾ၥ㢟䛜⏕䛨䛯䛸䛝䚸䛣䛾デ⒪ᡤ䛻 ┦ㄯ䛧䜎䛧䛯䛛 㛫እ䛾ᝈ⪅グ㘓 䜈䛾䜰䜽䝉䝇 䛒䛺䛯䛿䚸䛒䛺䛯䛜⌧ᅾ㣧䜣䛷䛔䜛⸆䚸స⏝䞉䜰 䝺䝹䜼䞊䛾グ㘓䚸䛣䜜䜎䛷䛛䛛䛳䛯Ẽ䜔䛡䛜䛾 グ㘓䜢䛚ᣢ䛱䛷䛩䛛 ⪃ᐹ 䝰䝕䝹ᴗ • 䛂ᆅᇦ䜈䛾㈉⊩䛃䜹䝔䝂䝸䞊䛿䚸᥇⏝䛥䜜䛯㡯 ┠䠄4㡯┠䠅䛿ᐇᆅㄪᰝ/⮬ᕫホ౯䛜ከ䛟䚸᭱ ⤊㡯┠䛸䛧䛶䛿㑅ᐃ䛥䜜䛺䛛䛳䛯䚹 • ᖜᗈ䛔デ⒪/ᶆ‽ⓗデ⒪䛿䝺䝉䝥䝖䞉デ⒪㘓 ㄪᰝ䛜䛺䝕䞊䝍※䛷䛒䜛䚹 • ᾏ㐨ᆅᇦ䛾ྠ୍ἲே䛻䛚䛡䜛䠒デ⒪ᡤ䠄㒔 ᕷ㒊䞉୰ᑠ㒔ᕷ䞉䜈䛝ᆅ䠅䛻䛶ᐇ • 2014ᖺ8᭶10᭶ • 䝺䝉䝥䝖䞉デ⒪㘓䞉ᝈ⪅ㄪᰝ䜢ྠᐇ • 䝁䝭䝳䝙䜿䞊䝅䝵䞁䚸䜰䜽䝉䝇䛻㛵䛩䜛ᣦᶆ䛿 䛩䜉䛶䛜ᝈ⪅䝃䞊䝧䜲䛜䝕䞊䝍※䛷䛒䜛䚹 – 䝺䝉䝥䝖䠖㐣ཤ1ᖺ䠄ᅾᏯᝈ⪅䜢㝖䛟䠅 – デ⒪㘓䠖デ⒪ᡤෆ䛷⫋ဨ䛜ᑐ㇟ᝈ⪅䜢ᥦ♧䞉㜀 ぴ䚸⤖ᯝ䜢ㄪᰝ⪅䠄┳ㆤᖌ䠅䛜㌿グ – ᝈ⪅ㄪᰝ䠖ㄪᰝᮇ㛫䠄1㐌㛫䠅䛻᮶㝔䛧䛯ᝈ⪅䛻 㓄ᕸ䞉ᅇ䜢౫㢗 ⤖ᯝ ⤖ᯝ䠄䠅ႚ↮Ṕ • 䝺䝉䝥䝖ㄪᰝ䠖㝔እฎ᪉䛾䛯䜑⸆ྡ䛜᫂䛷 䛒䜚䛩䜉䛶䛜デ⒪㘓ㄪᰝ䛸䛺䜛 • デ⒪㘓ㄪᰝ – ་ពぢ᭩䛾ಖ⟶䞉ᵝᘧ䛜ᆅᇦ䛤䛸䛻␗䛺䜛䛯䜑 1タ䛾䜏䛷᩿ᛕ – 䠍タ䛒䛯䜚45᪥䛾ㄪᰝᮇ㛫 – 2タ䛷䛿2㡯┠䛾ㄪᰝ䜢᩿ᛕ – 2タ䛿ୖ㝈10ྡ䛸䛩䜛 㡯┠䢢 ႚ↮Ṕ㻌 • ᝈ⪅ㄪᰝ ᢳฟㄪ ධຊ䢢 デ⒪ᡤ䢢 ᰝᑐ㇟ 傽僅䢢 ศẕ䢢 ศᏊ䢢 ᝈ⪅䢢 ᝈ⪅䢢 ᣦᶆ䢢 㻞㻜ṓ௨ୖ䛾䛩 䜉䛶䛾ᝈ⪅䛾 㐣ཤ㻝ᖺ௨ෆ 䛾ႚ↮Ṕ䛜デ ⒪㘓䛻グ㍕䛥 䜜䛶䛔䜛㻌 䢧䢢 䣕䣇䢢 䢻䢷䢧䣅䣋䢢 A 㻝㻜㻜㻌 㻢㻢㻌 㻢㻜㻌 㻝㻟㻌 㻞㻝㻚㻣㻌㻌 㻜㻚㻜㻡㻌 㻜㻚㻝㻞㻌 㻜㻚㻟㻠㻌 B 㻝㻜㻜㻌 㻝㻜㻜㻌 㻝㻜㻜㻌 㻞㻣㻌 㻞㻣㻚㻜㻌㻌 㻜㻚㻜㻠㻌 㻜㻚㻝㻥㻌 㻜㻚㻟㻣㻌 C 㻤㻞㻌 㻤㻞㻌 㻤㻞㻌 㻝㻟㻌 㻝㻡㻚㻥㻌㻌 㻜㻚㻜㻠㻌 㻜㻚㻜㻥㻌 㻜㻚㻞㻢㻌 D 㻝㻜㻜㻌 㻝㻜㻜㻌 㻝㻜㻜㻌 㻞㻢㻌 㻞㻢㻚㻜㻌㻌 㻜㻚㻜㻠㻌 㻜㻚㻝㻤㻌 㻜㻚㻟㻢㻌 E 䞊㻌 㻣㻌 㻣㻌 㻡㻌 㻣㻝㻚㻠㻌㻌 㻜㻚㻝㻣㻌 㻜㻚㻞㻥㻌 㻜㻚㻥㻢㻌 F 䞊㻌 㻡㻌 㻡㻌 㻟㻌 㻢㻜㻚㻜㻌㻌 㻜㻚㻞㻞㻌 㻜㻚㻝㻡㻌 㻜㻚㻥㻡㻌 – ᅇ⟅⪅䛿18ྡ䡚131ྡ䛸䛝䛺䜀䜙䛴䛝 ⤖ᯝ䠄䠅ႚ↮Ṕ 㡯┠䢢 ᣦᶆ䢢 㻢㻡ṓ௨ୖ䛾䛩 䜉䛶䛾ᝈ⪅䛻 䛴䛔䛶䚸㻡ᖺ䛤 䛸䛻⫵⅖⌫⳦ 䝽䜽䝏䞁᥋✀ 䛾グ㍕䛜䛒䜛 ⫵⅖⌫⳦ 䛛䚸ཷデṔ䛜 䝽䜽䝏䞁㻌 㻡ᖺ䛻‶䛯䛺 䛔ሙྜ䛻䛿䚸 㐣ཤ㻡ᖺ௨ෆ 䛾⫵⅖⌫⳦䝽 䜽䝏䞁᥋✀Ṕ 䛾グ㍕䛜䛒䜛㻌 ᢳฟㄪ ධຊ䢢 デ⒪ᡤ䢢 ᰝᑐ㇟ 傽僅䢢 ศẕ䢢 ศᏊ䢢 ᝈ⪅䢢 ᝈ⪅䢢 A 㻝㻜㻜㻌 㻝㻜㻜㻌 㻝㻜㻜㻌 㻠㻌 ⤖ᯝ䠄䠅ႚ↮Ṕ 䢧䢢 䣕䣇䢢 㻠㻚㻜㻌㻌 㻜㻚㻜㻞㻌 䢻䢷䢧䣅䣋䢢 㻜㻚㻜㻝㻌 㡯┠䢢 ᣦᶆ䢢 㻜㻚㻝㻜㻌 B 㻝㻜㻜㻌 㻝㻜㻜㻌 㻥㻝㻌 㻥㻌 㻥㻚㻥㻌㻌 㻜㻚㻜㻟㻌 㻜㻚㻜㻡㻌 㻜㻚㻝㻤㻌 C 㻝㻜㻜㻌 㻝㻜㻜㻌 㻝㻜㻜㻌 㻝㻌 㻝㻚㻜㻌㻌 㻜㻚㻜㻝㻌 㻜㻚㻜㻜㻌 㻜㻚㻜㻡㻌 D 㻝㻜㻜㻌 㻝㻜㻜㻌 㻥㻤㻌 㻠㻌 㻠㻚㻝㻌㻌 㻜㻚㻜㻞㻌 㻜㻚㻜㻝㻌 㻜㻚㻝㻜㻌 E 㻝㻜㻜㻌 㻝㻜㻌 㻝㻜㻌 㻜㻌 㻜㻚㻜㻌㻌 㻜㻚㻜㻜㻌 㻜㻚㻜㻜㻌 㻜㻚㻟㻝㻌 F 㻝㻜㻜㻌 㻝㻜㻌 㻝㻜㻌 㻜㻌 㻜㻚㻜㻌㻌 㻜㻚㻜㻜㻌 㻜㻚㻜㻜㻌 㻜㻚㻟㻝㻌 㻣㻡ṓ௨ୖ䛾䚸 䝺䝉䝥䝖䛻䛚䛔 䛶ㄆ▱䠄䛔 ྵ䜐䠅䛾ྡ 䛜䛔䛶䛔䜛 ㄆ▱ᝈ ᝈ⪅䛻䛴䛔䛶䚸 ⪅䛾ㆤ 䛯䜛ㆤ⪅ ⪅ྠᐃ㻌 䛜ㄡ䛷䛒䜛䛛 ྠᐃ䛥䜜䚸㐣ཤ 㻝ᖺ௨ෆ䛾デ ⒪㘓䛻グ㍕䛥 䜜䛶䛔䜛㻌 ᢳฟㄪ ධຊ䢢 デ⒪ᡤ䢢 ᰝᑐ㇟ 傽僅䢢 ศẕ䢢 ศᏊ䢢 ᝈ⪅䢢 ᝈ⪅䢢 䢧䢢 䣕䣇䢢 䢻䢷䢧䣅䣋䢢 A 㻠㻠㻌 㻝㻜㻌 㻝㻜㻌 㻤㻌 㻤㻜㻚㻜㻌㻌 㻜㻚㻝㻟㻌 㻜㻚㻠㻠㻌 㻜㻚㻥㻣㻌 B 㻞㻜㻌 㻞㻜㻌 㻝㻣㻌 㻝㻟㻌 㻣㻢㻚㻡㻌㻌 㻜㻚㻝㻜㻌 㻜㻚㻡㻜㻌 㻜㻚㻥㻟㻌 C 㻡㻡㻌 㻡㻡㻌 㻟㻞㻌 㻠㻌 㻝㻞㻚㻡㻌㻌 㻜㻚㻜㻢㻌 㻜㻚㻜㻠㻌 㻜㻚㻞㻥㻌 D 㻞㻝㻌 㻞㻝㻌 㻞㻜㻌 㻞㻌 㻝㻜㻚㻜㻌㻌 㻜㻚㻜㻣㻌 㻜㻚㻜㻝㻌 㻜㻚㻟㻞㻌 E 㻠㻤㻌 㻝㻞㻌 㻝㻜㻌 㻝㻌 㻝㻜㻚㻜㻌㻌 㻜㻚㻜㻥㻌 㻜㻚㻜㻜㻌 㻜㻚㻠㻡㻌 F 㻠㻠㻌 㻝㻜㻌 㻝㻜㻌 㻤㻌 㻤㻜㻚㻜㻌㻌 㻜㻚㻝㻟㻌 㻜㻚㻠㻠㻌 㻜㻚㻥㻣㻌 ⤖ᯝ䠄䠅䠖ᝈ⪅ㄪᰝ ⤖ᯝ䠖デ⒪ᡤ⟶⌮⪅䜲䞁䝍䝡䝳䞊 䛣䛾デ⒪ᡤ䛷䛿䚸ᗣ䛻䛴䛔䛶䛺䜣䛷䜒┦ㄯ䛩䜛䛣䛸䛜䛷 䛝䜛䛸ᛮ䛔䜎䛩䛛䚹䠄䠂䠅 A 11.1 B 6.3 C D 12.9 E 9.9 F (n=124) 26.6 58.9 34.6 53.1 (n=81) 29.8 63.2 5.3 (n=18) 38.9 55.6 5.6 (n=63) 25.4 66.7 䛭䛖ᛮ䜟䛺䛔 䛒䜎䜚䛭䛖ᛮ䜟䛺䛔 䛭䛖ᛮ䛖 ኚ䛭䛖ᛮ䛖 䛂ົ䛾䚸ཷ䛻䛔䜛䝇䝍䝑䝣䛜䛱䜗䛳䛸ᡭ㛫䛜䛛 䛛䛳䛯䛛䛺䚸䛸ᛮ䛖䜣䛷䛩䛡䛹䚸䜙䛿䜋䛸䜣䛹㈇ ᢸ䛺䛧䛷䛷䛝䛯䛾䛷䚸ኚ䛒䜚䛜䛯䛛䛳䛯䛷䛩䚹䛃 (n=18) 22.2 66.7 • デ⒪㠃䜈䛾ᙳ㡪䛿ᑡ䛺䛔 (n=57) • ⤖ᯝ䛿ཷ䛡Ṇ䜑䜙䜜䜛 㻌 䛂య䛸䛧䛶䛿䚸䛣䛖䛔䛖䜅䛖䛻ホ౯䛧䛶䛔䛯䛰 䛡䛶䜛䛾䛛䛺䛳䛶䛔䛖䜅䛖䛻䛿ᛮ䛔䜎䛩䚹䛃 • ୍㒊㡯┠䜈䛾ពぢ – 䝃䝬䝸䞊䝅䞊䝖䠄ู⥛䛨ሗ䠅 䛹䛱䜙䛸䜒䛔䛘䛺䛔 ⤖ᯝ䠄䠅䠖ᝈ⪅ㄪᰝ ⪃ᐹ ᙜデ⒪ᡤ䛜䚸䛣䛾䜘䛖䛺 䜰䞁䜿䞊䝖䜢ᐃᮇⓗ䛻䛩 䜛䛣䛸䛿ዲ䜎䛧䛔䛣䛸䛰䛸 ᛮ䛔䜎䛩䛛䚹 ᙜデ⒪ᡤ䛜䚸デ⒪ෆᐜ䛻 䛴䛔䛶ᐃᮇⓗ䛻እ㒊䛛䜙 ホ౯䜢ཷ䛡䜛䛣䛸䛿ዲ䜎 䛧䛔䛣䛸䛰䛸ᛮ䛔䜎䛩䛛䚹 4.7 27.3 23.1 49 59.3 䛭䛖ᛮ䜟䛺䛔 䛒䜎䜚䛭䛖ᛮ䜟䛺䛔 䛭䛖ᛮ䛖 䛸䛶䜒䛭䛖ᛮ䛖 16.4 (n=341) 12.6 (n=334) 䛹䛱䜙䛸䜒䛔䛘䛺䛔 • デ⒪ᡤ䛜ᥦ౪䛩䜛䝥䝷䜲䝬䝸䞉䜿䜰䛻䛴䛔䛶 ᅇ䛾᪉ἲ䛷䛾ホ౯䛸䝣䜱䞊䝗䝞䝑䜽䛿ᐇ⾜ ྍ⬟䛷䛒䜛 • 䛣䜜䜙䛾άື䛾ጇᙜᛶ䛻䛴䛔䛶䛿䚸ᴫ䛽デ ⒪ᡤ⟶⌮⪅䛻䛿ྠព䜢ᚓ䜙䜜䛯 • ᝈ⪅䛿䛣䜜䜙䛾άື䜢ዲពⓗ䛻䛸䜙䛘䛶䛔䛯 • 䛣䜜䜙䛾సᴗ䛻䛿୍ᐃ䛾㛫䛸ປຊ䛜ᚲせ 䛷䛒䜛 ㄢ㢟 ᝈ⪅‶㊊䛸ᢏ⾡ⓗ䛺㉁ ᧙̞ƳƠ • 䛂ᆅᇦ㈉⊩䛃䛾䜹䝔䝂䝸䞊䛻䛴䛔䛶䛿䛥䜙䛺䜛 ᳨ウ䛜ᚲせ • ຠ⋡ᛶ䛻ၥ㢟䛒䜚䚸䛸䜚䜟䛡デ⒪㘓ㄪᰝ䛻䛚 䛡䜛㛫ⓗ/ᢏ⾡ⓗᅔ㞴 • ᝈ⪅ㄪᰝ䛾䜏䛷䛿䛭䛾᭷ຠᛶ䛻㝈⏺ धᎍƷᚸ̖ • ホ౯㡯┠䛻䛴䛔䛶䛿䛥䜙䛺䜛ᨵኚ䞉㏣ຍ䛜ᚲ せ ǘƣƔƴ᧙̞ƋǓ 100 ᢏ⾡ⓗ䛺㉁䠄䝇䝁䜰䠅 ホ౯άື䛻䛴䛔䛶 90 80 70 60 50 ২ᘐႎƳᚮၲƷឋ ᭱ప 1/4 㻌㻌㻌 1/4 㻌㻌 1/4 ᭱㧗 1/4 धᎍឱࡇᲢ၏ᨈᲣ Acute Myocardial Infarction Congestive Heart Failure Pneumonia Chang et al. Annals of Int Med 2006:665-672 Jha et al. NEJM 2008:1921-31. ᅜ❧䛜䜣◊✲䝉䞁䝍䞊㻌 ᮾᑦᘯඛ⏕㻌 ㅮ⩏䝇䝷䜲䝗䜘䜚 ᚋ䛾ᒎᮃ • 㐠⏝㠃䛷䛾ᨵၿ – ホ౯సᴗ䚸䛸䛟䛻デ⒪㘓ホ౯䛻䛚䛡䜛ᨵၿ – 䛣䛸䛺䜛䝥䝷䝑䝖䝣䜷䞊䝮䛷䛾సᴗ • ⥅⥆䛧䛶ᐇ䛻䛴䛺䛢䜛䛯䜑䛾᪉⟇ • ᆅᇦ㈉⊩䚸ᅾᏯデ⒪䚸㐃ᦠ䛻㛵䛩䜛ホ ౯᪉ἲ䛾㛤Ⓨ • ྥୖᨭ䜢䛹䛖䛩䜛䛛䠋⏕ᾭᏛ⩦䛸䛾䝸䞁䜽 䛤Ύ⫈䛒䜚䛜䛸䛖䛤䛦䛔䜎䛧䛯