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研究生：	簡孟恬 Chien, Meng-Tian
論文名稱：	藥師介入門診多重慢性病患整合式照護模式之成效評估 Pharmacist's Intervention in Patients with Multiple Chronic Diseases in Ambulatory Care
指導教授：	高雅慧 Kao, Yea-Huei 張慧真 Chang, Hui-Jen
學位類別：	碩士 Master
系所名稱：	醫學院 - 臨床藥學研究所 Institute of Clinical Pharmacy
論文出版年：	2011
畢業學年度：	99
語文別：	中文
論文頁數：	86
中文關鍵詞：	藥品相關問題、整合模式、藥師、藥事照護、多重慢性疾病
外文關鍵詞：	Drug-related problems, Care coordination, Pharmacist, Pharmaceutical care, Multiple chronic diseases
相關次數：	點閱：161 下載：13
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研究背景：
我國自開辦全民健康保險後，醫療可近性(Access of care)的提昇使得門診就診次數倍增；而在此醫療照護體系中，有多重慢性狀態(Multiple chronic conditions)的病人為最主要的資源使用者。
許多因素使罹患慢性疾病的人口增加，且影響的層面廣泛。國外文獻指出，慢性狀態數目與每年平均處方量及住院率成正相關，而愈多的處方量也暗示愈多的藥品相關問題(Drug-related problems)產生；此外，多重慢性疾病病人由於需要到各種專科治療不同的疾病，在缺乏整合性的醫療型態下，除了可能造成醫療資源的浪費，更容易使病人暴露在藥品引起相關問題的危險之中，進而影響病人安全。

研究目的：
本研究旨在以藥師的專業，透過病人訪談以及給予其照護醫師建議和回饋，從中達成整合與協調的目的，並評估其成效。評估的項目包含：藥品相關問題、處方數、日藥費、診次、服藥順從性及用藥知識的改變。

研究方法：
本研究為等組事前事後比較研究設計(Pretest-posttest with comparison group design)。藥師為訪談人員，自2011年1月至2011年5月，於國立成功大學醫學院附設醫院之門診藥局諮詢窗口進行。

研究對象：
介入組篩選自主要在成大醫院就診的病人，亦即健保局計畫所定義之忠誠病人。研究期間預約如下科別上午診：包括一般內科、心臟血管科、外科、腎臟科、胃腸肝膽科、家庭醫學科、神經科及泌尿科的忠誠病人，經查閱半年內電子藥歷，若符合下列條件之一則納入介入組，並進行訪談：
1.半年內同時掛號三個或以上科別
2.目前同時使用九種或以上藥品
3.經檢視半年內電子病歷發現有藥品相關問題
訪談未到或不願意接受訪談的研究對象納入控制組(依循尋常照護模式)，不足額部分依上述條件篩選後補齊。

研究結果：
共收錄280位病人，包含有效介入組137人及控制組143人。基期介入組共有藥品相關問題70項，平均每人0.51項，顯著高於控制組，平均每人0.30項。經藥師介入後，介入組減少為23項，兩者間有統計上顯著的差異(p<0.0001)；而控制組在兩次評估中，藥品相關問題都為43項，沒有改變(p=1.000)。兩次評估中，任一組於處方數、日藥費與診次都沒有差別。

結論：
本研究指出藥師的介入的確對於門診多重慢性病患找出及避免藥品相關問題有正向的影響。未來應進行更長期的研究以利觀察更直接的預後，如死亡率、再住院率及生活品質等。

Background:
Since Taiwan launched the national health insurance (NHI) program to cover the entire civilian population on 1995, outpatient visits doubled and access of care improved significantly. People who have multiple chronic conditions are generally high-end users of healthcare resources. Many factors results in developing the high prevalence of multiple chronic diseases, which affect men and women of all ages, ethnicities, and income levels.
Having the higher numbers of chronic illness implies more prescriptions per year and longer hospital stays. Moreover, polypharmacy has been associated to lots of drug-related problems in previous studies. Particularly, people who have multiple chronic diseases may look for medical consultation from various specialties and physicians. Therefore, lack of consolidation can place people in danger.

Objectives:
To evaluate the effect of pharmacist's intervention in patients with multiple chronic diseases in ambulatory care setting.

Methods:
This study was conducted from January to May 2011 at pharmacy consulting counter in National Cheng Kung University Hospital (NCKUH). The study was a pretest-posttest with comparison group design and pharmacists acted as interviewers.
The enrolled subjects were those who had ambulatory care mainly in NCKUH, as defined in the NHI consolidation project. The interview was undertaken in intervention group, which included patients scheduled an appointment in departments of general medicine, cardiology, surgery, nephrology, gastroenterology, family medicine, neurology and urology in the morning and also met one of the following criteria.
1.Visiting more than 3 different specialties concomitantly
2.Using 9 or more drugs concomitantly
3.Identified drug-related problems (DRPs) in electronic medication record
Control group was selected by the same criteria except the last one and did not receive interview.

Results:
A total of 280 patients were analyzed: 137 patients in intervention arm and 143 patients in control arm. At baseline, there are 70 drug-related problems in intervention group significantly higher than control group. After an average 2-month period, we observed a significant reduction in the mean number of DRPs per patient in the intervention group (p<0.0001); the mean number of DRPs per patient was not seen significant reduction in the control group (p=1.000).
The number of medications, daily medication costs and the number of ambulatory visits were not significantly reduced in both groups.

Conclusion:
This study showed a positive impact of pharmacist in medical center in Taiwan on reducing actual or potential DRPs in patients with multiple chronic diseases in ambulatory care. Future study should focus on hard outcomes including mortality, re-hospitalization and quality of life.

目錄:
中文摘要	I
ABSTRACT	III
致謝	V
目錄	VII
表目錄	XI
圖目錄	XII
第一章 緒論	1
第一節、研究背景	1
第二節、建構整合式照護模式並逐步朝促進醫療體系整合計畫	3
第二章 文獻回顧	5
第一節、多重慢性疾病	5
2.1.1 國內外多重慢性疾病的盛行率	5
2.1.2 多重慢性疾病盛行對醫療照護體系之影響	8
第二節、整合性的醫療及支持照護模式	10
2.2.1 醫療導向照護整合模式	12
2.2.2 整合模式─小結	19
第三節、藥品相關問題	21
2.3.1 定義	21
2.3.2 分類系統	23
第三章、研究目的與重要性	32
第四章 研究方法	33
第一節、研究設計	33
4.1.1 研究類型	33
4.1.2 研究單位及期間	33
4.1.3 研究對象	33
4.1.4 排除條件	34
4.1.5 收樣方法	34
4.1.6 訪談暨評估人員	34
第二節、研究架構及流程	35
第三節、研究工具	38
4.3.1 各類型資料庫	38
4.3.2 病人資訊事先備妥、統一規格	38
4.3.3 制式化訪談人員記錄單張	38
4.3.4 藥品相關問題評估準則	39
第四節、研究變項與評估指標定義說明	40
4.4.1 研究變項	40
4.4.2 評估指標	41
第五節、資料彙整與分析	42
4.5.1 資料整合軟體	42
4.5.2 統計分析軟體	42
4.5.3 統計分析方法	42
第五章 研究結果	43
第一節、研究對象納入、排除與分組	43
第二節、研究對象基本資料分析	45
第三節、藥品相關問題之改變	48
5.3.1 藥品相關問題盛行率	48
5.3.2 常見的藥品相關問題	48
5.3.3 藥品相關問題之改變	48
5.3.2 解決藥品相關問題的方法	51
第四節、處方數、日藥費與診次之改變	55
第五節、服藥順從性及用藥知識之改變	56
5.5.1 服藥順從性	56
5.5.2 用藥知識	58
第六章 研究討論	59
第一節、研究對象的納入、排除與分組	59
第二節、研究對象基本資料分析	60
6.2.1 基期時兩組人口學特性及評估指標之比較	60
6.2.2 基期時兩組處方型態之比較	60
6.2.3 基期時介入組的其他特性	61
第三節、藥品相關問題之改變	62
6.3.1 藥品相關問題盛行率	62
6.3.2 常見的藥品相關問題	63
6.3.3 藥品相關問題之改變	64
6.3.4 解決藥品相關問題的方法	65
第四節、處方數、日藥費與診次之改變	66
第五節、服藥順從性與用藥知識的改變	67
6.5.1 服藥順從性	67
6.5.2 用藥知識	68
第六節、研究限制	69
第七章、結論與建議	70
參考文獻	73
附錄	77
附錄一	77
附錄二	78
附錄三	79
附錄四	83
附錄五	84

表目錄:
表 2.2-1 透過個案管理計畫執行的整合照護模式之執行特色	13
表 2.2-2 各篇研究收錄族群、介入方式與觀察結果(精簡版)	18
表 2.3-1 藥品相關問題分類系統梗概	26
表 2.3-2 藥品相關問題分類項目整理	28
表 2.3-3 近年藥品相關問題調查或藥師介入成效評估之實證研究	30
表 5.2-1 基期時兩組人口學特性及評估指標之比較	46
表 5.2-2 基期時兩組處方型態之比較	46
表 5.2-3 基期時介入組的其他特性	47
表 5.3-1 藥品相關問題之改變	49
表 5.3-2 分析藥品相關問題之改變	50
表 5.3-3 藥事建議的項目與編碼	51
表 5.3-4 醫師回覆的項目與編碼	51
表 5.3-5 藥品相關問題、其對應之藥事建議與醫師接受程度一覽	53
表 5.3-6 藥品相關問題、其對應之藥事建議與病人接受程度一覽	54
表 5.4-1 處方數、日藥費與診次之改變	55
表 5.5-1 服藥順從性不理想之比例改善程度	56
表 5.5-2 分層分析服藥順從性不理想之比例改善程度	57
表 5.5-3 用藥知識改善程度	58
表 6.3-1 國外門診藥品相關問題盛行率	62

圖目錄:
圖 1.2-1 執行流程示意圖	4
圖 2.1-1 美國罹患慢性狀態人口與年齡層之關係	7
圖 2.1-2 美國罹患慢性狀態人口(預測)趨勢圖	7
圖 2.1-3 罹患慢性狀態數目與住院天數之關係	9
圖 2.1-4 罹患慢性狀態數目與平均年處方筆數之關係	9
圖 2.3-1 藥品相關問題的結構與關連示意圖	22
圖 4.2-1 研究流程	37
圖 4.3-1 資料庫串連及對應關係	39
圖 5.1-1 研究對象收入、排除與分組情況	44
圖 5.5-1 分層分析服藥順從性不理想之比例改變情形	57

                                    

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