Shiga Cooperative Conference for Cancer Treatment, Regional Cooperation Unit, developed regional medical care cooperation system for malignancies using critical pathways (CPs) in 2010. CPs in Shiga had several characteristics such as comprehensive constitution, escalation of adapted stage of cancers, and proper secretariat function, for smooth introduction among prefecture. CPs were proposed by bottom-up and widespread by top-down manner, referring existing social systems. The initial CPs for five major malignancies in an early stage were equipped with manifested outcomes, variance-sheet, which evolved therapeutic utilities for advanced gastrointestinal, prostatic carcinoma and furthermore, palliative medicine. Secretariat office independently established collective notification of cooperating medical institution, contributing the promotion of CPs and development of medical cooperation for malignancies. The strategic development of CPs played a leading and promoting role in medical care cooperation system for patients of carcinomas.

Unlike local cities, the access to medical intervention is easy in urban cities due to the numbers of rheumatologists. However, its treatment methods vary. Particularly after the treatment with biological products is spread, it often makes difficult to refer those patients with adverse events or complications. We set up a core hospital, which accepts patients' refferral at 24 hours a day, 365 days a year, and established a medical network that can safely treat patients with rheumatoid arthritis and collagen diseases in Tokyo Johoku-area. To enhance the medical collaboration in this network, the scientific lectures and the case study meetings were organized three times a year. In the results of these activities, the number of registrants and registered facilities are increased year by year, and so are the co-medical participants. The number of the patient referred to core hospitals due to severe side effects such as fulminant hepatitis and interstitial pneumonia have been decreasing year by year. Currently, the life-saving rate of referred patients is 100%, and this medical cooperation model seemed to be a suitable treatment model for urban rheumatoid arthritis and collagen diseases.

In the medical fee revision in FY 2014, the use of “brought-in medications" to treat the disease which led to scheduled hospitalization was prohibited under DPC/PDPS. With the revision in FY 2016, it is requisite to describe names and amount of “brought-in medications” on the DPC EF file after October, 2016.

Since our medication reconciliation system was not linked to the electronic medical record system, it seemed difficult to describe how we used “brought-in medications” on the DPC EF file or to evaluate how we managed “brought-in medications”. However, a multidisciplinary management of “brought-in medications” to our hospital in accordance with DPC/PDPS led to continuous usage of “brought-in medications” even after October 2016.

Few medications were found to be used by mistake to treat the disease which led to hospitalization. Proper use of “brought-in medications” resulted in cost reduction and contributed to hospital management.

In several hospitals, double-checking is a common practice when mixing injectable drugs to ensure safety and is practiced when mixing all drugs；however, the efficacy of this method remains debatable. In two internal medicine wards in an advanced treatment hospital, double-checking was switched to single-checking for mixing injectable drugs, except for high-risk drugs. This study aims to compare the safety and time taken for mixing after introducing single-checking.

We investigated the number of injectable drugs mixing-related incidents reported, along with the details and levels of incidences in the 8 months before and after the single-checking introduction to assess safety. Cameras were set up in two wards to investigate the time required. Checking was recorded for 24 hours, and the time for checking was calculated by video analysis. Five days each from the double-checking period, and 2 and 4 weeks after introducing single-checking, were compared.

During the double- and single-checking periods, 0.09 incidents/1000 drugs and 0.12 incidents/1000 drugs were reported, respectively, which was not statistically significant (p=0.654). Moreover, no significant differences were noted between double- and single-checking regarding the details and levels of incidents. The mean time taken for checking was 32.8 s per drug during the double-checking period, and 14.0 s and 15.1 s after 2 and 4 weeks of introducing single-checking. Hence, checking required a markedly greater amount of time during the double-checking period (p<0.01).

This study found no difference in safety between the double- and single-checking method, excluding high-risk drugs；however, checking time halved after introducing single-checking.

Preparing reports on clinical specialization began in October 2016. Although medical institutions selected their functions from advanced acute, acute, recovery, and chronic phases, there were no defined criteria. Thus, using a case mix index, the classification method for “advanced acute phase” and “acute phase” was investigated. The case mix index of 16 wards (general beds, excluding ICU, NICU, HCU, PCI) for patients discharged from one university hospital from July 1, 2016 to June 30, 2017 was calculated using the Comorbidity Complication Procedure Matrix payment classification. The case mix index and correlation coefficient for each ward were calculated based on the medical cost (COST method) and the length of stay (LOS method).

The results of the analysis were as follows：No correlation was found between COST method and LOS method (r=0.50, p=0.51). The respective COST and LOS method indexes were as follows：1.28 and 1.07, for the entire hospital；1.34 and 1.04, for the surgical wards；and 1.10 and 1.23 for the internal medicine wards. For each ward, the indexes were almost similar. However, for two wards, the indexes were found to be divergent (1.69 for COST method and 1.74 for LOS method vs 2.41 for COST method and 0.91 for LOS method). For five wards, the indexes of both COST and LOS methods were less than 1.0.

The case mix index reflects the severity of the patient. Thus, we consider that the index may be used as a reference value for the functional division of advanced acute phase/acute phase.

In patients scheduled for surgery and taking antithrombotics, incidents such as surgery postponement due to misdirected medication occurred. In this study, with consents from patients on antithrombotic medication who underwent surgery, we evaluated the incident occurrence rate related to interruption and resumption of antithrombotic medication by investigating the influence or effects of the advises and interventions provided by the hospital pharmacists to the patients' family physicians or family pharmacy.

When surgery was scheduled, the hospital pharmacist confirmed the medicines to be taken, and other related matters on the scheduled surgery day, and the hospital pharmacist intervened in order to appropriately perform surgery, adjusting the drug withdrawal measures and coordinating with the doctor and family pharmacy. The intervention group consisted of 85 patients out of 1466 surgical patients during the period from December 24, 2014 to April 30, 2017, for whom the doctor explained the discontinuation of antithrombotic drugs, and advice and intervention were given by the hospital pharmacist. The control group was 195 patients out of 1844 surgical patients from January 1st, 2012 to December 23rd, 2014, who received only explanations about discontinuation of antithrombotic drugs by doctors. The incidents were “operation postponement due to wrong medication”, “misdirection among medical personnel” and “bleeding/blood clot”. The intervention group and the control group were adjusted by tendency score matching. Based on 11 variables, it matched 1 to 1, and matched 81 pairs. Incidents were noted in 1 case in the intervention group and in 12 cases in the control group (P=0.139). In the analysis by tendency score matching, a significant difference was found in one intervention group (1%) compared to eight control groups (10%) (P=0.040). This revealed that hospital pharmacists' interventions could contribute in preventing interruption and resumption incidents for patients scheduled for surgery and taking antithrombotic drugs.

Today, medical institutions can be said to be an equipment-industry. They are often required to be equipped with many large-scale medical and general machines such as CT, MRI, generators, boilers, etc. Although they are known to be a labor-intensive industry depending on doctors, nurses and other medical technicians, modern medical care definitely needs these expensive equipment. It is also true that these equipment will bring considerable maintenance cost every year as well as the initial investment cost. Our research and achievement have revealed that cost cut can be realized if we pay attention to the maintenance charges. Through considered negotiations with the contractors, maintenance charges could be reduced without changing maintenance contents.

In order to provide better medical care and to keep securing necessary profits, it is essential for a medical institution to invest valuable equipment under the appropriate medium-and long-term investment plans, and to control the costs with proper reductions.