東京日和＠元勤務医の日々

メイヨークリニック・最高責任者　米ＤＲＧ、患者ごとの包括化も

日刊薬業2007/07/31

　米メイヨークリニック経営管理部門のロバート・スモルト最高責任者は27日、東京都内で開かれたセミナー（新社会システム総合研究所主催）で、米国のＤＲＧ制度について講演し、今後、支払い単位が現行の「１入院」から、外来を含む「１患者」に拡大されるとの見通しを示した。

　米国ＤＲＧ制度では入院患者に対し、579の診断群分類に基づき入院期間にかかわらず一定の診療報酬が病院に支払われている。2004年の急性期病院数は5759病院で、ＤＲＧ導入前の1980年から17％減少した。スモルト氏は「ＤＲＧの最大教訓は病床ニーズの低下だった」と指摘した。

　また、ＤＲＧ下での病院経営では、目標を「満床」から「費用を下げる」に、成功を「病床増加」から「病床削減」に、焦点を「投入資源のコントロール」から「アウトカムマネジメント」にそれぞれ変換することが求められると訴えた。

　メイヨークリニック（ミネソタ州、947床）の試算では、ＤＲＧ導入前の診療パターンを続けた場合、医師数や患者数が倍増した06年は、１日当たり平均病床利用数が2911床と推定されたが、実際には診療の効率化や外来シフトなどにより889床に抑えられ、20億ドルものコスト削減効果があったという。

　スモルト氏は、米国ではＤＲＧが医療提供体制と病院側のマネジメントアプローチを変えたとし、病床数を削減することで財務資本のニーズを削減し、医療の質改善も促したと述べた。今後については、すでに診断群分類を745に増やす法案があるなど分類数の増加や、疾病重症度のさらなる調整が行われると予測。現在、別途支払われている医師の医療行為も、包括化の対象になる可能性があるとした。
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　アメリカの突っ走り具合はすごいですね。別に悪くはないのですが、「早く追い出せばたくさん儲かる」という経済的なメリットは、患者さんの健康を害さないか心配です。

　また、数字で出る以上に、コスト削減にかかる圧力が現場の医師や看護師にかかっていかないか心配です。日帰り入院が僕はベストじゃないと思います。必要があれば入院して経過を見たほうがいいですし、濃密な患者のみを受け入れる病棟などのスタッフの疲労を考えると、病院の経営陣とはまた違った話になりそうな気がしますが、さらにアメリカは包括化、医療費削減の道を進むようですね(検査などしなければ儲かるという仕組みは支払い側の保険会社が考えたに決まっていますが)。 

 

薬物で患者死亡早める＝臓器移植担当医を訴追－米検察

時事通信　2007/07/31-16:04

 

【シリコンバレー３０日時事】米カリフォルニア州サンルイスオビスポ郡地検は３０日、臓器移植に使う臓器摘出を急ぐため、昏睡（こんすい）状態の２５歳の男性患者に薬物を過剰投与して死亡を早めた罪で、外科医フータン・ローズロク容疑者（３３）を訴追した。地元紙によると、臓器移植担当医の摘発は全米で初めて。

Transplant surgeon charged with trying to hasten patient's death

 

A San Francisco transplant surgeon was criminally charged Monday with excessively prescribing drugs to a 25-year-old disabled man last year in order to hasten his death and harvest his organs sooner.

The felony charges are believed to be the first in the nation against a physician for his role in a transplant.

Experts said the case is likely to raise uneasiness among potential organ donors and could prompt doctors to shy away from a somewhat controversial practice of retrieving organs before a patient is brain dead.

The San Luis Obispo County district attorney's office accused Dr. Hootan Roozrokh, 33, of dependent adult abuse, administering a harmful substance and prescribing controlled substances without a legitimate medical purpose.

The surgeon allegedly ordered massive amounts of narcotic painkillers and sedatives for Ruben Navarro, a physically and mentally disabled man, on Feb. 3, 2006. In addition, Roozrokh is accused of administering the antiseptic Betadine through a feeding tube into Navarro's stomach, a sterilization procedure typically done after a donor is dead.

"The law and the facts indicated that Dr. Roozrokh … tried to accelerate [Navarro's] death to facilitate the harvesting of his organs," said Chief Deputy Dist. Atty. Stephen Brown.

Navarro survived for more than seven hours after he was removed from life support and given the drugs. By that time, his organs were no longer viable and could not be recovered.

Roozrokh's lawyer, M. Gerald Schwartzbach, called his client an "extremely dedicated and accomplished organ transplant surgeon" and said the charges filed against him were "unfounded and ill-advised."

"Dr. Roozrokh did not commit any crime," Schwartzbach said in a written statement.

If convicted of the three counts, Roozrokh could receive up to eight years in state prison and a $20,000 fine, the district attorney's office said. A warrant has been issued for Roozrokh's arrest, and he is expected to turn himself in this week. He will be required to post a $10,000 bond.

Roozrokh was a surgeon with Kaiser Permanente's now-defunct kidney transplant program in San Francisco when he and a Kaiser colleague went to Sierra Vista Regional Medical Center in San Luis Obispo to retrieve Navarro's organs. However, the two surgeons were not working on behalf of Kaiser when they went to Sierra Vista but for the group that procures and distributes organs in much of Northern and Central California.

Navarro had been on life support after being found unresponsive Jan. 29, 2006, at a nearby long-term care facility. His family agreed to donate his organs.

Late in the evening of Feb. 3, he was taken to the operating room and removed from life support. As at least six people stood by, including Navarro's treating physician, Roozrokh ordered a total of 200 milligrams of the narcotic morphine and 80 milligrams of the sedative Ativan for him, according to a report by federal inspectors. Those were many times the normal doses of the drugs, experts have told The Times.

After Navarro had been off life support for about 30 minutes — the time limit set to ensure the viability of organs — the process was ended. Navarro was returned to the intensive care unit, where he died early the next morning, five days before his 26th birthday. (Authorities and The Times have sometimes said incorrectly that Navarro was 26 at the time of his death.)

The case came under scrutiny by medical and law enforcement authorities after the operating room staff expressed concerns about the actions of the doctor and of the nurse who was administering the drugs. Under state law, transplant doctors cannot direct the care of organ donors before they are declared dead.

The San Luis Obispo County coroner's office ruled this March that Navarro died of natural causes. But "the central issue of the case was the mistreatment of a severely disabled adult," said Brown of the district attorney's office.

Brown said it would have been difficult to pursue a more serious charge of murder or attempted murder because Navarro survived for hours after being given the drugs. No one besides Roozrokh has been criminally charged.

Schwartzbach said Monday that Roozrokh is blameless.

"Nothing that Dr. Roozrokh did or said at the hospital that night adversely affected the quality of Mr. Navarro's life or contributed to Mr. Navarro's eventual death," he said.

Roozrokh was placed on administrative leave by Kaiser in May 2006 after HMO officials became aware of the allegations against him. He was reinstated in January but the next month voluntarily agreed not to see patients, Kaiser spokesman Matthew Schiffgens said. With the filing of criminal charges Monday, the surgeon once again has been placed on leave.

"The case did not involve a Kaiser Permanente patient, or a Kaiser Permanente hospital," Schiffgens said in a written statement, adding that Kaiser was cooperating fully with the investigation.

Similarly, Sierra Vista officials said in a statement that Roozrokh was not a member of its staff and that the hospital continues to cooperate with authorities.

Although prosecution of doctors for medical performance is rare and generally opposed by physician groups, some ethicists and doctors said Monday that strong action was warranted in this case.

If his intention was "to kill the person, have the person die sooner, but the person didn't actually die, that's attempted murder," said Michael Shapiro, an ethicist and law professor at USC.

But some transplant professionals worried that the charges might prompt surgeons to be overly cautious in how and when they recover organs — especially in the type of organ retrieval attempted in Navarro's case, known as "donation after cardiac death."

Surgeons "will pull back. They will be more careful," said Dr. Goran Klintmalm, head of the Baylor Regional Transplant Institute in Dallas and president of the American Society of Transplant Surgeons. "They will turn situations down because they don't want to have any exposure."

Donation after cardiac death involves patients who have suffered a devastating brain injury and require ventilators to breathe but who still have minimal brain function.

In such cases, patients are removed from life support with their families' consent. Generally, their hearts stop within minutes and they are declared dead. Their organs are then harvested.

Such procedures have become more common in recent years as doctors have sought to expand the donor pool. But some hospitals question the ethics of removing life support from a patient for the purpose of retrieving organs.

As of Monday, nearly 97,000 people were on the national waiting list for organs.

Some transplant experts and medical ethicists said the charges against Roozrokh tap into a primal fear about transplants and concerns that organs might be taken too soon.

"You get one case like this and people get worried," said Dr. Michael Grodin, director of medical ethics at Boston University's School of Public Health.

"This could be a major, major setback for actually appropriate donation. This is an example of something that could be really, really scary for the public at large."

Navarro's mother said that her son, 80 pounds and cognitively impaired, was exploited.

"They mistreated him and they abused him and they took advantage of him and me," said Rosa Navarro, who is suing Roozrokh, the regional transplant procurement group, Sierra Vista and others.

"He didn't die with dignity, and I didn't have the chance to really say goodbye to him. I don't think it's right. These people need to pay for what they did to him."

charles.ornstein@latimes.com
tracy.weber@latimes.com

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　これも行過ぎた問題ですね。いくら全米で臓器が不足しているからといっても、モルヒネ過量投与による臓器の確保は、安楽死とはまた違う次元です。

　日本ではここまでは至らないと思いたいですし、倫理的な問題以前に常識という歯止めがあるのを信じたいです。しかし、こういう積極的な医師はまさに現代版Dr.キリコですね。

 　流動化といえば、キレイに聞こえますが、引き抜き合戦などで、人材派遣会社が跋扈して地方自治体の病院経営が危うくなったりしているのを見ると、こういう動きはどうなんでしょうかね？もちろん職場の労働条件に難があったり、魅力がなければ、看護師さんも離れていきますが、現在の大規模病院の生き残りのための「無理やり転職ブーム」は7:1の看護水準が、ゴールでない限り、この動きは続くように思いました。ちなみに看護協会は５：１の導入を厚生労働省などに提言しています。急性期には確かにマンパワーが必要なのは間違いありませんが、そういう病院以外まで今回の場合、経営上の理由で人を集めてしまったという…転職業者さんが悪いともいえませんし、流動化によって、いいことがないわけではりません。ただ、新人ナースだらけの大学病院など、怖くて入院なんかしたくありませんけどね。

人材サービス各社、看護師の転職支援を拡大

2007/08/01日本経済新聞

　人材サービス会社が看護師の転職を支援する事業に力を入れている。昨春の診療報酬改定で看護体制が手厚い病院ほど報酬が多くなったのを機に、看護師の争奪戦が激化。労働条件の良い病院を求めて転職する動きも広がっている。少子化に伴い人材不足が一段と深刻になるとみて、出産で離職した女性など「潜在戦力」の取り込みを急ぐ。

　ジェイエイシージャパンは年末までに看護師資格を持つ転職コンサルタントを現在の２倍に増やす。出産などでいったん離職した看護師の悩み相談にきめ細かく応じることで、人材確保につなげる。病院からの求人依頼は前年比約６割増で推移。今年の看護師の紹介人数は前年比３割増の320人程度を目指す。

　リンクスタッフ（東京・港）は看護師の人材紹介を担当する転職コンサルタントを向こう1年で現在の三倍の30人程度に増やし、2007年10月期の紹介人数(常勤ベース)を前期の二倍強の1500人前後に引き上げる。中小規模の民間病院に加え、規模が大きな大学病院からの依頼も伸びていると言う。

　メディカル・コンシェルジュ（東京・渋谷）は営業拠点を現在の10拠点から今秋までに12拠点に増やす。高松や仁方など看護師不足が深刻な地方都市に進出、顧客開拓を進める。

　キャリアブレイン（東京・港）は今夏をメドに大手ポータル（玄関）サイトに医療ニュースを提供。自社サイトの閲覧者を増やし、看護師の登録拡大につなげる。

　三十代以上の層を中心に夜勤が多い病院での勤務を嫌う看護師が増えていることに着目。看護師資格が生かせる異業種の職場への転職を支援する動きも広がっている。

　人材派遣大手のピープルスタッフは看護師を訪問介護会社や介護施設向けに派遣する事業を拡大する。メンタルヘルスなど看護師の関心が高い分野のセミナーを前年比3倍の年6回ペースで開催、看護師資格をも登録スタッフ数を増やす。

診療報酬改定で拍車

　看護師は夜勤の多さなど労働条件の厳しさから慢性的に不足しがちなうえ、景気拡大で雇用を増やした他業種に人材が流れたことで、人手不足が深刻化していた。

　昨年４月の診療報酬改定をきっかけに大規模病院が相次ぎ採用枠を拡大、看護師の引き抜きも目立つようになった。看護師の雇用流動化を受け、人材サービス会社への引き合いが急増している。売り手市場のため「転職で給与は５-１０％程上がる」（リンクスタッフ）という。

　病院側が診療報酬を増やそうと安易に看護師を増員動きを抑制するため、厚生労働省が新たな数値基準を導入する動きもみられる。一本調子での流動化には不透明な要素も残っている。