【コラム】Choosing Wisely—過剰医療の抑制と適正化をめざす

Choosing Wisely

過剰な医療費を抑制し質の高い医療ケアを目的とした呼吸器・集中治療領域のChoosing Wiselyとして，①診断検査は考えてオーダーする，②不必要な輸血を制限する，③早期経静脈栄養を控える，④重症患者の深鎮静を避ける，⑤患者・家族の意向に従った生命維持治療の回避，の5つが推奨された。しかしこれら5項目が医療の質改善，コスト削減に有用かについては問題点が指摘されており，また現時点で臨床現場の行動変容へ与える影響も不十分である。今後，エビデンスに基づきChoosing Wiselyをさらに効果的に普及させるためにさまざまな方策を考える必要がある。

To combat the high costs of health care and improve the quality of care, the American Board of Internal Medicine Foundation developed the Choosing Wisely Campaign. The Critical Care Societies Collaboratives made the Top 5 “Choosing Wisely” lists in Critical Care Medicine. The five recommendations are：（1） do not order diagnostic tests at regular intervals （such as every day）, but rather in response to specific clinical questions；（2） do not transfuse red blood cells in hemodynamically stable, nonbleeding ICU patients with a hemoglobin concentration greater than 7g/dl；（3） do not use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of an ICU stay；（4） do not deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation；and （5） do not continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort. Further efforts are needed to promote adherence to these recommendations and to develop additional ways for intensive care clinicians to take leadership in limiting health-care costs.