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The relationship between geographical accessibility to gambling venues and the prevalence of pathological gambling is still unknown. This study aimed to reveal this relationship in Japan as well as...

Background/Aims: Strategies for an effective intervention after chronic kidney disease (CKD) screening have not been well examined. We describe the rationale and design of a protocol of a pragmatic randomized controlled trial (RCT) to test the effect of a behavioral intervention using the nudge approach in behavioral economics on CKD patients’ visiting behaviors to physicians and change in their kidney function after CKD screening. Methods: The RCT will include CKD patients (N = 4500) detected at screening (estimated glomerular filtration rate [eGFR]

Aims: Various drugs have recently been launched for the treatment of multiple myeloma (MM). This increase in the number of treatment options has potentially changed treatment patterns and medical c...

In this paper, a modelling and suppression method of the guided mode in high performance temperature compensated surface acoustic wave (TC-SAW) devices is introduced. First, we analyzed the polarizations, acoustic velocity and dispersion characteristics of guided mode, Then, instead of the traditional single-mode COM model, an extended COM model is introduced for analysis of the coupling between the Rayleigh mode and guided mode. This multi-mode COM model can predict the interaction between Rayleigh and guided modes in TC-SAW devices. Last, we verified the effectiveness of this method by a one-port synchronous SAW resonator. This method was very effective in improving the prediction accuracy of the spurious response.

In this study, modeling and suppression method of the spurious response that are indispensable for the design of Temperature Compensated Surface Acoustic Wave filter (TC-SAW) of SiO2/LiNbO3 structure are introduced. First, we propose an extended COM model that considers multiple mode mutual coupling. This multi-mode COM model can predict the interaction between Rayleigh and SH modes in the TC-SAW structure. It was then applied to the analysis of a dual-mode SAW filter (DMS), and this method was very effective in improving the prediction accuracy of the spurious response. Next, the modeling method of the transverse mode in TC-SAW and suppression method are introduced. We have developed the spurious free LTE Band 8 TC-SAW Duplexer that is mass-produced and commercialized.

Reports on the expenditure of cancer treatments per patient using comprehensive data remain unavailable in Japan. This study aimed to use Japan’s cancer registry data and health service utilization data for evaluating the disease-specific, per-patient costs of five major cancers—stomach, lung, colorectal, liver, and breast cancers. We used a database linking the 2017 data from a hospital-based cancer registry and the health service utilization data from the Diagnosis Procedure Combination survey. All patients who started their first treatment course at each hospital were included. The costs were calculated using the total volume of the health services provided and the unit fee information included in the data. We analyzed 304,698 patients. Lung cancer had the highest healthcare cost per-patient for the first year of diagnosis and the longest median hospitalization duration. Conversely, breast cancer showed the lowest cost and the shortest median hospitalization duration. However, in the first month after diagnosis, colorectal cancer showed the highest cost. Subsequently, the gaps between the costs of the five common cancers drastically diminished. The cancer type having the longest hospitalization duration had the highest overall healthcare resource utilization costs. This information is essential for care planning and research studies.

In 2016, the Japanese government decided to introduce endoscopic screening for gastric cancer as a national program. To provide endoscopic screening nationwide, we estimated the proportion of increase in the number of endoscopic examinations with the introduction of endoscopic screening, based on a national survey. The total number of endoscopic examinations has increased, particularly in clinics. Based on the national survey, the total number of participants in gastric cancer screening was 3 784 967. If 30% of the participants are switched from radiographic screening to endoscopic screening, approximately 1 million additional endoscopic examinations are needed. In Japan, the participation rates in gastric cancer screening and the number of hospitals and clinics offering upper gastrointestinal endoscopy vary among the 47 prefectures. If the participation rates are high and the numbers of hospitals and clinics are small, the proportion of increase becomes larger. Based on the same assumption, 50% of big cities can provide endoscopic screening with a 5% increase in the total number of endoscopic examinations. However, 16.7% of the medical districts are available for endoscopic screening within a 5% increase in the total number of endoscopic examinations. Despite the Japanese government's decision to introduce endoscopic screening for gastric cancer nationwide, its immediate introduction remains difficult because of insufficient medical resources in rural areas. This implies that endoscopic screening will be initially introduced to big cities. To promote endoscopic screening for gastric cancer nationwide, the disparity of medical resources must first be resolved.

Naoya Emoto,1,2 Fumitaka Okajima,1,2 Hitoshi Sugihara,2 Rei Goto3 1Department of Endocrinology, Nippon Medical School Chiba-Hokusoh Hospital, Chiba, 2Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, Tokyo, 3Graduate School of Business Administration, Keio University, Kanagawa, Japan Background: We have recently reported that the attitude of patients toward risk could be a factor in the progression of diabetic complications. In general, risk preference is closely related to socioeconomic status (SES), which includes factors such as age, sex, income, and educational attainment.Objective: We aimed to determine the effect of SES and behavioral propensity on the progress of diabetic complications in patients with type 2 diabetes mellitus (T2DM).Methods: We conducted a survey of 238 patients with difficult-to-control T2DM treated at a hospital in Japan using a modified behavioral economics questionnaire that included questions related to SES. The patients had been referred by general practitioners or other departments in the hospital because of poor metabolic control or unstable complications.Results: Educational attainment was significantly associated with progression of retinopathy in patients

Objectives: Theoretically, willingness-to-pay (WTP) for quality-adjusted life years (QALY) can vary depending on social and personal preferences and on ex-ante and ex-post settings. However, empirical investigations into the theoretical differences are lacking. In Japan, setting the threshold has been controversial since a pilot project to implement health technology assessments (HTA) launched in 2016. The study aim is to estimate WTP values for one additional QALY from different perspectives, health statuses, and contexts to confirm the difficulty in setting a uniform price threshold using WTP. Methods: More than 1,000 respondents representing a cross-section of the Japanese population answered each of nine questionnaire decks in an online panel. WTP values were estimated on three different perspectives (personal, social, and socially inclusive) and on two contexts (ex-ante and ex-post). This study primarily used the non-parametric spike model based on double-bounded dichotomous choice (DBDC) settings to obtain the conditional WTP values. Results: WTP per QALY was higher in the severe health status than in the moderate health status from all perspectives. Respondents from the socially inclusive perspective estimated the highest WTP value for a new drug. Respondents were also asked about life-threatening diseases in ex-post and ex-ante. The WTP value in ex-ante was higher than in ex-post, and demographic factors affecting the WTP were different in both situations. The various WTP values were obtained from these surveys. Limitations: The analysis was based on data collected from an internet panel, which could be biased. There is also a risk that respondents answered the questionnaire differently if asked in everyday situations. Conclusion: Use of a uniform price threshold may not be appropriate in policy settings, because it may not reflect diverse preferences based on different situations, such as disease type and severity. Setting a price threshold as Japan institutes an HTA system requires further research.

Objectives Living donor kidney transplant relieves the disease burden of patients with end-stage renal disease but may shorten donor life expectancy; however, their quality of life (QOL) is preserved. Nevertheless, the magnitude of the net gain of this procedure is unknown. We evaluated the QOL of both donors and recipients concurrently and calculated the net utility gain. Methods We recruited 210 subjects who visited the kidney transplantation clinic of a university hospital. Subjects were asked to complete the 5-level EQ-5D-based questionnaire, and patient characteristics were extracted from their medical records. We performed multivariate tobit models analysis to evaluate the QOL change caused by transplant surgery and subsequently ran computational simulations to determine the net utility gains of donors and recipients. We also performed sensitivity analyses. Results After excluding 16 answers with missing data, we analyzed 203 answers in total. After the transplant surgery, recipients gained 0.07 in utility value while donors lost 0.04. In the net utility analysis, we found that the quality-adjusted life years gained ranged from 7.2 to 7.8 in the most favorable case observed in the combination of middle-aged recipients and elderly donors. Assuming no utility discount, the most favorable combination was that with older donors and younger recipients. Conclusions These findings indicated that the QOL improvement in recipients was larger than the loss among donors. When calculating the net utilities, a combination of middle-aged recipients and elderly donors yielded the largest net utility, but this was likely derived from assumption in the discount of QOL.

Background Taiwan, one of the fastest-aging countries in the world, started implementing version 1.0 of its long-term care (LTC) plan in 2008. In 2017, LTC Plan 2.0 began a new era with its goal to integrate Taiwan’s fragmented LTC service system. LTC Plan 2.0 also aims to establish an integrated community-based LTC system incorporating both health care and disability prevention. This three-tier model consists of the following: two LTC services with a day-care center as their base and case management (Tier A), a day-care center and a single LTC service (Tier B), and LTC stations that provide primary prevention services and respite services for frail community-dwelling older adults to prevent further disabilities (Tier C). A defined cluster of agencies in a local area works together as a Tier ABC team. LTC Plan 2.0 is a new policy for Taiwan, and hence it is important to understand the agencies’ initial difficulties with implementation and identify future challenges to help further policy development. Methods This preliminary study explored the challenges to implementing LTC 2.0 through in-depth interviews based on Evashwick’s integration mechanisms with representatives from three service teams. We interviewed three chief executive officers and three case managers. Results We found that the LTC Plan 2.0 mechanisms for service integration have been insufficiently implemented. Recommendations include (1) Build up the trust between agencies and government, avoid duplication of LTC services within Tier ABC team, and encourage agencies within a team to create a shared administrative system with the same mission and vision. (2) Clarify the roles and responsibilities of government care managers and agency case managers. (3) Provide an integrated information system and create an official platform for sharing client records across different agencies and caregivers. (4) Establish a tool and platform to track the budget and payment across different levels of service as soon as possible. Conclusion There is an increased demand for LTC services in Taiwan because of its rapidly aging population. Our findings shed some light on the challenges to developing integrated LTC services and thus may help both policymakers and service providers find ways to overcome these challenges.

Background Highly-competent patient care is paramount to medicine. Quality training and patient accessibility to physicians with a wide range of specializations is essential. Yet, poor quality of life for physicians cannot be ignored, being detrimental to patient care and leading to personnel leaving the medical profession. In 2004, the Japanese government reformed postgraduate training for medical graduates, adding a 2-year, hands-on rotation through different specialties before the specialization residency was begun. Residents could now choose practice location, but it sparked concerns that physician distribution disparities had been created. Japanese media reported that residents were choosing specialties deemed to offer a higher quality of life, like Ophthalmology or Dermatology, over underserved areas like Obstetrics or Cardiology. To explore the consequences of Japan’s policy efforts, through the residency reform in 2004, to improve physician training, analyzing ophthalmologist supply and distribution in the context of providing the best possible patient care and access while maintaining physician quality of life. Methods Using secondary data, we analyzed changes in ophthalmologist supply at the secondary tier of medical care (STM). We applied ordinary least-squares regression models to ophthalmologist density to reflect community factors such as residential quality and access to further professional development, to serve as predictors of ophthalmologist supply. Coefficient equality tests examined predictor differences before and after 2004. Similar analyses were conducted for all physicians excluding ophthalmologists (other physicians). Ophthalmologist coverage in top and bottom 10% of STMs revealed supply inequalities. Results Change in ophthalmologist supply was inversely associated with baseline ophthalmologist density before (P

Both Japan and Korea provide population-based screening programs. However, screening rates are much higher in Korea than in Japan. To clarify the possible factors explaining the differences between these two countries, we analyzed the current status of the cancer screening and background healthcare systems. Population- based cancer screening in Korea is coordinated well with social health insurance under a unified insurer system. In Japan, there are over 3,000 insurers and coordinating a comprehensive strategy for cancer screening promotion has been very difficult. The public healthcare system also has influence over cancer screening. In Korea, public healthcare does not cover a wide range of services. Almost free cancer screening and subsidization for medical cost for cancers detected in population-screening provides high incentive to participation. In Japan, on the other hand, a larger coverage of medical services, low co-payment, and a lenient medical audit enables people to have cancer screening under public health insurance as well as the broad range of cancer screening. The implementation of evidence-based cancer screening programs may be largely dependent on the background healthcare system. It is important to understand the impacts of each healthcare system as a whole and to match the characteristics of a particular health system when designing an efficient cancer screening system.

Objectives Our objectives were to conduct a web-based survey using adult participants to investigate 1) differences in attitudes towards smoking in the presence of non-smokers between smokers and non-smokers and 2) the potential impact of knowledge regarding the harmful effects of smoking and secondhand smoke (SHS) on smoker behavior in a restaurant.Method Japanese smokers and non-smokers aged 20 to 69 were separately sampled and both groups were randomly allocated to either a knowledge group or a control group. The participants were asked to complete an online questionnaire to capture their attitudes and how they think they would behave in a restaurant where it was not clear whether smoking is prohibited or not. Data were analyzed using a t-test for numerical variables and a χ

The aim in this study is to evaluate economic value for leuprorelin acetate 6-month depot compared with leuprorelin acetate 3-month depot in Japanese pre-menopausal breast cancer patients from a societal perspective.The cost analysis was conducted by estimating direct and indirect cost, and intangible costs associated with one 6-month injection compared with two 3-month injections. Claims data were used for the analyses of direct and indirect cost and Medical Fee Schedule Table for direct cost. Discrete choice experiments were conducted by web-based survey to determine the intangible costs. Another web-based survey was also conducted on premenopausal breast cancer patients with injections of leuprorelin acetate, to calibrate the results of discrete choice experiments.The medical costs saved for having one less injection in pre-menopausal breast cancer patients with leuprorelin acetate injection were JPY 6,183. The productivity loss saving was JPY 1,419. An estimation of intangible costs saved for having one less injection of leuprorelin acetate was JPY 58,430, which included the disbenefit due to pain (JPY 8,535), injection site reactions (JPY 44,051), waiting time (JPY 9,595), and subtracting value in medical consultation (JPY 3,751). The total cost saved for having one less injection was JPY 66,032.The respondents from the internet panel provided by a survey company do not necessarily reflect a population of Japanese society.Leuprorelin acetate 6-month depot demonstrates a higher value than leuprorelin acetate 3-month depot through saving medical costs and loss of productivity, as well as intangible costs saved for having one less injection when treating pre-menopausal breast cancer patients. In the costs for treating with leuprorelin acetate, the percentage of intangible costs might not be negligible. The intangible costs will probably be actively evaluated to proceed to patient-centered healthcare in society.

This study aimed to evaluate the economic value for leuprorelin acetate 6-month depot compared with leuprorelin acetate 3-month depot from a societal perspective in Japanese prostate cancer patients.The cost analysis estimated the reduction in direct and indirect costs as well as intangible costs saved by having one less injection. Claims data were used for the analyses of direct and indirect costs reduction. A discrete choice experiment based on a web-based survey estimated the monetary value of the intangible costs for one injection. Another web-based survey of prostate cancer patients, who had received treatment with leuprorelin acetate injections, was carried out to calibrate the results of the discrete choice experiment.Reductions in medical costs and loss of productivity for having one less injection in prostate cancer patients receiving leuprorelin acetate were JPY 5,670 and JPY 1,723, respectively. Intangible costs saved by using a 6-month depot formulation instead of a 3-month depot formulation for the injection of leuprorelin acetate were estimated to be JPY 19,872, including the values for a reduction in pain (JPY 3,131), injection site reactions (JPY 11,545), waiting time (JPY 9,479), and subtracting the value of medical consultation (JPY 4,283). The total cost reduction for having one less injection was JPY 27,265.The respondents from the internet panel provided by a survey company are not necessarily a representative population of Japanese society.Leuprorelin acetate 6-month depot has an advantage in monetary value in the reduction in medical costs, loss of productivity, and intangible costs for having one less injection in prostate cancer patients compared with leuprorelin acetate 3-month depot. In the costs for treating with leuprorelin acetate, the percentage of intangible costs might not be negligible. The intangible costs will probably be actively evaluated to proceed to patient-centered healthcare in society.

Smoking is associated with significant health and economic burden globally, including an increased risk of many leading causes of mortality and significant impairments in work productivity. This burden is attenuated by successful tobacco cessation, including reduced risk of disease and improved productivity. The current study aimed to show the benefits of smoking cessation for workplace productivity and decreased costs associated with loss of work impairment.The data source was the 2011 Japan National Health and Wellness Survey (n = 30,000). Respondents aged 20-64 were used in the analyses (n = 23,738) and were categorized into: current smokers, former smokers, and never smokers. Generalized linear models controlling for demographics and health characteristics examined the relationship of smoking status with the Work Productivity and Activity Impairment questionnaire (WPAI-GH) endpoints, as well as estimated indirect costs.Current smokers reported the greatest overall work impairment, including absenteeism (i.e. work time missed) and presenteeism (i.e. impairment while at work); however, after controlling for covariates, there were no significant differences between former smokers and never smokers on overall work impairment. Current smokers and former smokers had greater activity impairment (i.e. impairment in daily activities) than never smokers. Current smokers reported the highest indirect costs (i.e. costs associated with work impairment); however, after controlling for covariates, there were no significant differences between former smokers and never smokers on indirect costs.Smoking exerts a large health and economic burden; however, smoking cessation attenuates this burden. The current study provides important further evidence of this association, with former smokers appearing statistically indistinguishable from never smokers in terms of work productivity loss and associated indirect costs among a large representative sample of Japanese workers. This report highlights the workplace benefits of smoking cessation across productivity markers and cost-savings.

Evidence is limited and mixed as to how improved price transparency affects patients' demand for healthcare. Price transparency usually affects both the supply and the demand side of healthcare. However, in Japan—where healthcare providers cannot compete on prices—we can examine an independent impact of price transparency on patients' demand for healthcare. The aim of this study is to investigate the impact of improved price transparency on patients' demand for healthcare. We conducted an experiment by presenting patients with the “price list” of individual healthcare services. We provided the price list for a limited time and compared the healthcare spending and utilization of care between these patients who were provided the price list (patients who visited between the first and third week of January in 2016) versus those who were not (patients who visited during the same period in 2015 or 2017), adjusting for potential confounders. A total of 1053 patients were analyzed (27.5% were provided the price list). We found that improved price transparency was associated with a higher total cost per patient (adjusted difference, +16.1%; 95%CI, +0.6% to +34.0%; p = 0.04). We also found that improved price transparency was associated with higher costs related to laboratory tests and imaging studies, and a larger total number of items of blood tests and urine tests. By conducting an experiment in a real-world setting, we found that improved price transparency paradoxically increased the utilization of healthcare services in Japan. These findings suggest that when prices are relatively low, as is the case in Japan, reduced uncertainty about the prices of healthcare service may make patients comfortable requesting more healthcare services.

The temperature-compensated surface acoustic waves (TC-SAW) have been developed to fulfill tight roll-off requirements for recent mobile communication systems. Use of the Rayleigh SAW on SiO2-overlay/LiNbO3 substrate structure is one of the most promising techniques for the purpose. Currently, SAW device designs are done entirely through computer simulation, and their accuracy significantly impacts achievable device performance. The coupling of modes (COM) model is widely used for the acoustic simulation and its applicability is well recognized. This paper proposes a simple simulation model based on COM model for the transverse mode behaviors in the TC-SAW devices and applied to the device design. Double mode saw filter and ladder type filter are optimized with the proposed model. Optimized structure is applied to the development of the 1.6 × 1.2 mm2 sized duplexer for LTE Band 8. Smooth passband characteristics with less transverse modes responses are achieved by using the proposed method.

As Japan becomes a super-aging society, presentation of the best ways to provide medical care for the elderly, and the direction of that care, are important national issues. Elderly people have multi-morbidity with numerous medical conditions and use many medical resources for complex treatment patterns. This increases the likelihood of inappropriate medical practices and an evidence-practice gap. The present study aimed to: derive findings that are applicable to policy from an elucidation of the actual state of medical care for the elderly; establish a foundation for the utilization of National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB), and present measures for the utilization of existing databases in parallel with NDB validation. Cross-sectional and retrospective cohort studies were conducted using the NDB built by the Ministry of Health, Labor and Welfare of Japan, private health insurance claims databases, and the Kyoto University Hospital database (including related hospitals). Medical practices (drug prescription, interventional procedures, testing) related to four issues—potential inappropriate medication, cancer therapy, chronic kidney disease treatment, and end-of-life care—will be described. The relationships between these issues and clinical outcomes (death, initiation of dialysis and other adverse events) will be evaluated, if possible.

This paper conducts a five-month follow-up survey of 608 Japanese adults who just started smoking cessation within the previous month, and measures economic-psychological parameters such as the time preference rate and risk aversion coefficient using a conjoint analysis. We reach two main conclusions. First, cessation successes are more risk-averse than cessation failures, both at the starting and finishing points of the survey. Furthermore, between the two points, the time preference rates decrease for cessation successes, while the values increase for cessation failures. Second, we find that along with individual characteristics, economic-psychological parameters are important predictors of successful cessation.

The temperature-compensated surface acoustic wave (TC-SAW) is widely studied to achieve the tight roll-off characteristics required for mobile communication systems. LiNbO3 covered with a SiO2 film structure is proposed for one of the temperature compensation methods. One of the issues with applying the SiO2/LiNbO3 substrate for filter devices is the prediction of spurious responses. These spurious responses are caused by the interaction of the different propagation Rayleigh mode and shear horizontal (SH) mode. In this paper, the extended coupling of modes (COM) model can be expressed and the mutual coupling between SH and Rayleigh modes is proposed. To verify the proposed multimode COM model, the transmission characteristics were simulated and compared with the measurement results.

Measuring time and risk preferences and relating them to economic behaviors are important topics in behavioral economics. We developed a new method to simultaneously measure the rate of time preference and the coefficient of risk aversion. Analyzing the individual-level relationships between preference parameters and cigarette smoking, we conclude that current smokers are more impatient and risk-prone than non-smokers. Heavy smokers are the most impatient and risk-prone, while ex-smokers are the most patient and risk-averse. Among non-smokers, neither age-related nor gender-related differences were found. On the other hand, risk and time preferences are significantly different according to age and gender for smokers.

Aim To identify whether time and risk preference predicts relapse among smokers trying to quit. Design A cohort study of smokers who had recently started to quit. Time and risk preference parameters were estimated using a discrete choice experiment (DCE). Participants A total of 689 smokers who began quitting smoking within the previous month. Measurements Time discount rate, coefficient of risk-aversion measured at study entry and duration of smoking cessation measured for 6 months. Findings In the unadjusted model, Cox's proportional hazard regression showed that those with a high time discount rate were more likely to relapse [hazard ratio: 1.18, 95% confidence interval (CI): 1.11–1.25]. A high coefficient of risk-aversion reduced the hazard of relapse (0.96, 0.96–0.97). When adjusted for other predictors of relapse (age, gender, self-efficacy of quitting, health status, mood variation, past quitting experience, the use of nicotine replacement therapy, nicotine dependence), the hazard ratios of time discount rate and the coefficient of risk-aversion is 1.17 (95% CI: 1.10–1.24) and 0.98 (95% CI: 0.97–0.99), respectively. Conclusions Those who emphasize future rewards (time–patient preference) and those who give more importance to rewards that are certain (higher risk-aversion) were significantly more likely to continue to abstain from smoking.

This chapter simultaneously measures the rate of time preference and the coefficient of risk aversion, as well as investigates the interdependencies of four addictive behaviours: smoking, drinking, pachinko (a popular Japanese form of pinball gambling), and horse betting among a sample of the Japanese population. We reach two main conclusions. First, there are significant interdependencies among the four addictive behaviours, in particular between smoking and drinking and between gambling on pachinko and the horses. Second, we conclude that the higher the time preference rate and the lower the risk aversion coefficient becomes, the more likely individuals smoke, drink frequently, and gamble on pachinko and the horses.

Background: In spite of gradual increases in tobacco price and the introduction of laws supporting various anti-tobacco measures, the proportion of smokers in Japan’s population is still higher than in other developed nations. Objective: To understand what information and individual characteristics drive smokers to attempt to quit smoking. These determinants will help to realise effective tobacco control policy as a base for understanding of cessation behaviour. Method: Discrete choice experiments on a total of 616 respondents registered at a consumer monitoring investigative company. Results: The effect of price is greater on smokers with lower nicotine dependence. For smokers of moderate and low dependency, short term health risks and health risks caused by passive smoking have a strong impact, though the existence of penalties and long term health risks have little influence on smokers’ decisions to quit. For highly dependent smokers, non-price attributes have little impact. Furthermore, the effects of age, sex and knowledge are also not uniform in accounting for smoking cessation. Conclusion: Determinants of smoking cessation vary among levels of nicotine dependency. Therefore, how and what information is provided needs to be carefully considered when counselling smokers to help them to quit.

Objectives: Improvement in the specificity of primary screening tests, without significant cost elevation of the assay, provides cost savings in prostate cancer screening programs by reducing unnecessary secondary screening procedures. The purpose of this study was to evaluate the economic impact of improvement in the specificity of primary screening tests and to estimate the socially acceptable cost elevation for improved specificity. Methods: A decision-analytic model was designed to evaluate the total costs of prostate cancer mass screening according to the changes in the specificity and the cost of the primary screening test. All assumed factors were tested by three-way sensitivity analyses incorporating cost and specificity. Results: The base case analysis showed that a 1% improvement in the specificity of the primary screening test provides a $1.19 cost reduction per participant. Sensitivity analyses showed that an acceptable cost elevation for a 1% improvement in the specificity ranged from 0.68 to 2.90 $/% with respect to changes in several factors in the screening program. Conclusions: The specificity and cost of the primary screening test has a significant economical impact on prostate cancer mass screening. For each screening program, it should be taken into consideration whether the cost of the new test deserves the specificity.

Background Metastatic colorectal cancer carries a poor prognosis and cannot be cured by currently available therapy. Chemotherapy designed to prolong survival and improve the quality of life (QOL) of patients is the mainstay of treatment. Standard regimens of FOLFOX/bevacizumab and CapeOX/bevacizumab can cause neurotoxicity, potentially disrupting treatment. The results of 3 phase II studies of combination therapy with S-1, irinotecan, and bevacizumab showed comparable efficacy to mFOLFOX6/bevacizumab and CapeOX/bevacizumab, without severe neurotoxicity. Therefore, the establishment and evaluation of S-1-containing irinotecan-based regimens for first-line treatment are expected to become more important. Methods The TRICOLORE trial is a multicenter, randomized, open-label, controlled phase III study which aims to evaluate the non-inferiority of combination therapy with S-1/irinotecan/bevacizumab (a 3-week regimen [SIRB] or 4-week regimen [IRIS/bevacizumab]) to oxaliplatin-based standard treatment (mFOLFOX6/bevacizumab or CapeOX/bevacizumab) in patients with metastatic colorectal cancer who had not previously received chemotherapy. Patients will be randomly assigned to either the control group (mFOLFOX6/bevacizumab or CapeOX/bevacizumab) or study group (SIRB or IRIS/bevacizumab). The target sample size is 450 patients. The primary endpoint is progression-free survival (PFS), and the secondary endpoints are overall survival (OS), response rate (RR), time to treatment failure (TTF), relative dose intensity (RDI), the incidence and severity of adverse events, quality of life (QOL), quality-adjusted life years (QALY), health care costs, and relations between biomarkers and treatment response (translational research, TR). Discussion The results of this study will provide important information that will help to improve the therapeutic strategy for metastatic colorectal cancer, and we believe that this study is very meaningful from the perspective of comparative effectiveness research. Trial registration UMIN000007834 Electronic supplementary material The online version of this article (doi:10.1186/s12885-015-1630-1) contains supplementary material, which is available to authorized users.

Naoya Emoto,1 Fumitaka Okajima,1 Hitoshi Sugihara,2 Rei Goto3,4 1Division of Endocrinology, Department of Medicine, Nippon Medical School Chiba Hokusoh Hospital, Chiba, 2Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, Tokyo, 3Hakubi Center of Advanced Research, Kyoto University, Kyoto, 4Graduate School of Economics, Kyoto University, Kyoto, Japan Background: Adherence to treatment and the metabolic control of diabetes are challenging in many patients with diabetes. The theory of neuroeconomics can provide important clues for understanding unreasonable human behavior concerning decisions between outcomes occurring at different time points. Objective: We investigated patients with type 1 and type 2 diabetes to determine whether patients who are at a risk of developing complications are less risk averse. We also examined whether patients with type 1 and type 2 diabetes have different behavioral traits in decision making under risk. Methods: We conducted a behavioral economics survey of 219 outpatients, 66 with type 1 diabetes and 153 with type 2 diabetes. All patients had been referred by general practitioners or other departments in the hospital. At the time of the survey, levels of hemoglobin A1c were not significantly different between patients with type 1 and type 2 diabetes. Results: Patients with type 2 diabetes showed a lower response rate to the survey compared with patients with type 1 diabetes (71.9% vs 87.9%, P

Health Technology Assessment (HTA) is the systematic evaluation to measure the value of new health technologies. It improves the quality of choices on hand for cost-effective health technologies that are considered valuable. Japan has built a society of longevity consisted of the institution of the universal health care system, which is financially unsustainable. In Japan, no independent HTA organization has been publicly established but the government is contemplating implementation of such system. To advance the usage of HTA into surgery, we need to establish methods for evaluating new surgical technologies with steep learning curves. The promotion of clinical researches is also essential, especially by taking advantage of observational studies from medical big data such as the Japanese nationwide database which has more than four million surgical cases registered. In addition, we need more clinical information regarding each surgical patient's quality of life and socioeconomic status. The countries already introduced HTA into their health care system have measures to solve the problems that arose and have developed necessary evaluating methods. To introduce and promote HTA in Japan without taking away the benefit of our current healthcare, it is required that surgeons collaborate with other specialists such as methodologists and health economists.

In the vulvar region, epithelioid sarcoma (ES) is the most frequent SMARCB1-deficient neoplasm, followed by myoepithelial carcinoma (MC). Previous studies have demonstrated that some SMARCB1-deficient vulvar neoplasms cannot be classified as either ES or MC. Herein, we report of a 42-year-old woman with a SMARCB1-deficient neoplasm with prominent myxoid stroma in the vulva. It contained both epithelioid and spindled tumor cells, both of which showed vimentin and EMA expression. Although other markers useful for the differential diagnosis among SMARCB1-deficient tumors were negative, this tumor displayed characteristic expression of ERG and FLI1. As there are no reliable data regarding expression of ERG and FLI1 in MC, which are demonstrated to be often expressed in ES, further classification of cases such as the one reported here requires reliable data regarding their expression status in MC.

[Background] In 2004, the Japanese government permitted medical graduates for the first time to choose their training location directly through a national matching system. While the reform has had a major impact on physicians’ placement, research on the impact of the new system on physician distribution in Japan has been limited. In this study, we sought to examine the determinants of physicians’ practice location choice, as well as factors influencing their geographic distribution before and after the launch of Japan’s 2004 postgraduate medical training programme. [Methods] We analyzed secondary data. The dependent variable was the change in physician supply at the secondary tier of medical care in Japan, a level which is roughly comparable to a Hospital Service Area in the US. Physicians were categorized into two groups according to the institutions where they practiced; specifically, hospitals and clinics. We considered the following predictors of physician supply: ratio of physicians per 1, 000 population (physician density), age-adjusted mortality, as well as measures of residential quality. Ordinary least-squares regression models were used to estimate the associations. A coefficient equality test was performed to examine differences in predictors before and after 2004. [Results] Baseline physician density showed a positive association with the change in physician supply after the launch of the 2004 programme (P-value < .001), whereas no such effect was found before 2004. Urban locations were inversely associated with the change in physician supply before 2004 (P-value = .026), whereas a positive association was found after 2004 (P-value < .001). Urban location and area-level socioeconomic status were positively correlated with the change in hospital physician supply after 2004 (P-values < .001 for urban centre, and .025 for area-level socioeconomic status), even though in the period prior to the 2004 training scheme, urban location was inversely associated with the change in physician supply (P-value = .015) and area-level socioeconomic status was not correlated. [Conclusion] Following the introduction of the 2004 postgraduate training programme, physicians in Japan were more likely to move to areas with already high physician density and urban locations. These changes worsened regional inequality in physician supply, particularly hospital doctors.

Background: Cancer screening rates in Japan are much lower than those in Western countries. This study evaluated the relationship between cancer screening rates and strategies used to improve screening rates, and determined which strategy is the most effective. Materials and Methods: All municipalities are responsible for conducting gastric, lung, colorectal, cervical, and breast cancer screenings in Japan. Of the 1,746 municipalities in total, 92-99% were included in the analyses for each cancer screening. Using national data in 2009, the correlations between cancer screening rates and strategies for improving screening rates of all municipalities, both large (populations of over 30,000) and small (populations of under 30,000), were determined. The strategies used were as follows: sending personal invitation letters, personal visits by community health workers, use of a clinical setting for screening, and free screening. Results: Of all four strategies used to improve cancer screening rates, sending personal invitation letters had the highest correlations with all screening rates, with the exception of breast cancer screening. The partial correlation coefficients linking this strategy with the screening rates in all municipalities were 0.28, 0.32, 0.30, and 0.26 for gastric, lung, colorectal, and cervical cancer screening, respectively. In large municipalities, the correlations between the number of examinees in a clinical setting and the screening rates were also relatively high, particularly for cervical cancer screening (r=0.41). Conclusions: Sending personal invitation letters appears to be particularly effective in improving cancer screening rates in all municipalities. All municipalities should implement a system that sends personal invitation letters for cancer screening. In large municipalities, increasing the availability of screening in a clinical setting is also effective in improving cancer screening rates.

In prostate specific antigen (PSA) -based prostate cancer mass screening, the optimal re-screening interval is still in question, although guidelines suggest that a prolonged interval would be safe and cost-saving. We examined the socioeconomic feasibility of prolonged re-screening interval based on individual baseline PSA values. Markov decision-analytic models of prostate cancer screening were established for cost-effectiveness comparison of prolonged re-screening in men with low (≦1 ng/ml) PSA level (meta-interval strategy) and annual re-screening in every participant (control strategy). Effectiveness and socioeconomic feasibility were evaluated according to quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER ; Δcost per ΔQALY), respectively. As a result, outcomes including cancer detection rates and stage shift suggested that these models well recapitulated actual prostate cancer mass screening. The meta-interval strategy was more cost-effective than the control strategy. The ICER for the control strategy with respect to the meta-interval strategy exceeded US$62, 000/QALY through the sensitivity analyses for every assumption. The meta-interval strategy was more effective and less expensive if the trade-off of impaired clinical outcomes caused by delayed detection was small. In conclusion, our models suggest that the meta-interval strategy is more cost-effective than annual screening. It can be even more effective if the interval is determined appropriately such that cancer can be detected within the therapeutic window.

The incidence of oral alpha-streptococci with inhibitory activity against pathogens as a defense mechanism in the oral cavity was investigated in healthy individuals. Inhibitory strains were isolated from tonsil, tongue, cheek, saliva and dental plaque, and the detection rate of these strains isolated from tonsil was the highest. These results suggested that tonsillar flora is most important as a defense mechanism of the oral cavity. With respect to the effects of antibiotics against inhibitory alpha-streptococci, minimal inhibitory concentration of 90% of cells (MIC90) of PCG, ABPC, CCL, CFIX and EM against inhibitory alpha-streptococci, and relative detection rates of inhibitory alpha-streptococci before and after antimicrobial therapy were investigated. MIC90s of all antibiotics against these strains were low and sensitive to antibiotics tested. However, in vivo, detection rates of these strains before and after therapy did not differ significantly. Therefore, inhibitory strains were not affected by antibiotics as their MIC90 were low during short term medication.