研究背景：不同老年人間的生理差異性相當大，加上多重疾病與多重藥物問題，無法套用單一照護準則處理所有老年人的需求。國外文獻指出高齡藥事照護能降低老年病患的再住院率、再急診率、死亡率及藥物種類，但國內文獻僅對結果之滿意度有所探討，尚無臨床指標相關研究。周全性高齡藥事照護能增進處方合理性及發現更多老年病患藥物相關問題，但尚須研究證實其對於住院老年病患出院後之後續醫療利用成效。

研究目的：藉由經老年科臨床藥師設計之「周全性高齡藥事照護」介入後，追蹤出院後三個月的調查，分析比較有無接受周全性高齡藥事照護的兩組於藥物種類、死亡率、再住院率及再急診率之差異。並在個案組病患住院期間進行「高齡臨床藥事照護服務調查問卷」，比較入院時及出院前兩次測量之差異。探討周全性高齡藥事照護對於老年病人出院後的後續醫療利用情形與品質指標的影響。

研究方法：類實驗研究設計，收案期間自2014年9月至2015年1月，研究對象為國立成功大學醫學院附設醫院老年科住院病患(個案組)共135名，以性別、年齡(±3歲)、入院時間(±7天)、用藥種類(大於5項)於一般內科病房配對選出對照組135名。個案組於住院期間接受周全性高齡藥事照護，對照組則無。病患出院後三個月由研究者以國立成功大學醫學院附設醫院新住院系統電子病歷紀錄其再住院、再急診、死亡與使用藥物種類等資料進行分析。另外，個案組於周全性高齡藥事照護介入前後分別接受高齡臨床藥照護服務調查。本研究使用Microsoft Office Excel 2013進行建檔及資料編碼，再以SAS for Windows 9.3版統計套裝軟體進行統計分析。描述性統計分析呈現研究樣本之基本人口學變項、共病症、過去病史、住院原因、多重用藥、藥品種類等變項。雙變項分析則使用t test、paired t test及卡方檢定；另外使用線性迴歸研究單一依變項與一個或以上自變項之間的關係。本研究經國立成功大學醫學院附設醫院人體試驗委員會審查通過(A-ER-103-014)。

研究結果：本研究發現住院期間接受周全性高齡藥事照護的個案組住院老年病患，其在出院後一個月的非計畫性再住院及再返急診次數皆明顯較對照組低(0.16±0.37 v.s. 0.28±0.5，p=0.02; 0.21±0.42 v.s. 0.37±0.64，p=0.02)；個案組於出院後三個月的使用藥物種類也較入院前三個月使用藥物種類少(12.35±5.54 v.s. 9.05±3.59，p=0.04)。另外，個案組於介入前後接受高齡臨床藥事照護服務調查，結果發現介入後的高齡臨床藥事照護服務調查分數較介入前顯著提升(p<0.001)。

研究結論：住院老年病患於住院期間若接受周全性高齡藥事照護介入，其於出院後第一個月之非計畫性再住院及非計畫性再返急診次數顯著較低；出院後三個月使用藥物種類也較入院前三個月低；而周全性高齡藥事照護品質指標結果介入後分數也較介入前高。周全性高齡藥事照護可有效改善住院老年病患於出院後之後續醫療利用情形，未來可再進行門診及社區老年族群相關研究，以改善其後續醫療利用及生活品質。

SUMMARY
The aim of this study is to evaluate effect of comprehensive geriatric pharmaceutical care on medical utilization 3 months after discharge among hospitalized elderly patients.
We enrolled 135 hospitalized elderly patients aged ≧65 years in a geriatric ward as the intervention group and 135 in an internal medicine ward as the control group. After 3 months by discharged, we collect data from electronic medical review system to analyze patients’ medical utilization among 3 months after discharged. Results showed that the unplanned readmission rate and unplanned re-emergency rate are lower in the intervention group, lower number of medication, and the quality indicators showed a better outcome after intervention of comprehensive geriatric pharmaceutical care. The result of this prove the effectiveness of comprehensive pharmaceutical care among hospitalized elderly patients.

INTRODUCTION
People aged ≧ 65 years are the most rapidly growing age groups in Taiwan. Older adults suffer from multiple medical conditions, which require multiple medications for proper treatment. Previous studies showed pharmaceutical care among older adults could reduce readmission rate, re-emergency rate, mortality rate and medication numbers. In Taiwan, studies about geriatric pharmaceutical care focused only on satisfaction of pharmaceutical care but not on clinical indicators. Study showed comprehensive geriatric pharmaceutical care can detect more drug-related problems than usual pharmaceutical care. Our study is to investigate the impact on medical utilization among hospitalized elderly patients.

MATERIALS AND METHODS
From September 2014 to January 2015, hospitalized elderly patients in geriatric ward of a medical center in southern Taiwan were enrolled as intervention group, in which a model of comprehensive geriatric pharmaceutical care was initiated by study pharmacists. Information of medical utilization of all patients was reviewed from electronic medical record within 3 months after discharge. In the intervention group, study pharmacists interviewed patients and caregivers to obtain complete information of patients’ medication utilization based on comprehensive geriatric assessment. The drug-related problems would be discussed in geriatric interdisciplinary team. Meanwhile, elderly patients in internal medicine ward were selected as the controlled cases by matched age, gender and admission within ± 1 week of the patients in the intervention group.

RESULTS
A total of 270 patients were enrolled, with 135 each in both groups. Their mean ages were 81.50±8.31 in intervention group and 81.3±7.77 in the control group, 51.85% were female in both groups. The intervention and controlled groups did not differ regarding age, gender or comorbidity. Compared to the controlled group, the intervention group had a lower rate of unplanned readmission and re-emergency rate in the first month after discharged (0.16±0.37 v.s. 0.28±0.50, p=.002; 0.21±0.42 v.s.0.37±0.64, p=0.02). In the intervention group, number of medications after discharged is significant lower than that before admission(12.35±5.54 v.s. 9.05±3.59, p=0.04). Also, the quality indicators of pharmaceutical questionnaire showed improvement by comprehensive pharmaceutical care in the intervention group.

CONCLUSION
Comprehensive geriatric pharmaceutical care might reduce rates of unplanned readmission and unplanned re-emergency of .hospitalized elderly patients in the first month after discharged. A lower number of medications and better quality of pharmaceutical care can be anticipated.

英文部分：
Al‐Rashed, S., Wright, D., Roebuck, N., Sunter, W., & Chrystyn, H. (2002). The value of inpatient pharmaceutical counselling to elderly patients prior to discharge. British Journal of Clinical Pharmacology, 54(6), 657-664.
Bond, C., & Raehl, C. L. (2007). Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 27(4), 481-493.
Boult, C., Green, A. F., Boult, L. B., Pacala, J. T., Snyder, C., & Leff, B. (2009). Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine's “retooling for an aging America” report. Journal of the American Geriatrics Society, 57(12), 2328-2337.
Budnitz, D. S., Shehab, N., Kegler, S. R., & Richards, C. L. (2007). Medication use leading to emergency department visits for adverse drug events in older adults. Annals of Internal Medicine, 147(11), 755-765.
Bultman, D. C., & Svarstad, B. L. (2001). Effects of pharmacist monitoring on patient satisfaction with antidepressant medication therapy. Journal of the American Pharmaceutical Association (Washington, DC: 1996), 42(1), 36-43.
Campanelli, C. M. (2012). American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. Journal of the American Geriatrics Society, 60(4), 616.
Cerreta, F., Eichler, H.-G., & Rasi, G. (2012). Drug policy for an aging population—the European Medicines Agency's geriatric medicines strategy. New England Journal of Medicine, 367(21), 1972-1974.
Chang, C.-B., & Chan, D.-C. (2010). Comparison of published explicit criteria for potentially inappropriate medications in older adults. Drugs & Aging, 27(12), 947-957.
Dimitrow, M. S., Airaksinen, M. S., Kivelä, S. L., Lyles, A., & Leikola, S. N. (2011). Comparison of prescribing criteria to evaluate the appropriateness of drug treatment in individuals aged 65 and older: a systematic review. Journal of the American Geriatrics Society, 59(8), 1521-1530.
Donzé, J., Aujesky, D., Williams, D., & Schnipper, J. L. (2013). Potentially avoidable 30-day hospital readmissions in medical patients: derivation and validation of a prediction model. JAMA Internal Medicine, 173(8), 632-638.
Espino, D. V., Bazaldua, O. V., Palmer, R. F., Mouton, C. P., Parchman, M. L., Miles, T. P., & Markides, K. (2006). Suboptimal medication use and mortality in an older adult community-based cohort: results from the Hispanic EPESE Study. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 61(2), 170-175.
Farley, T. M., Shelsky, C., Powell, S., Farris, K. B., & Carter, B. L. (2014). Effect of clinical pharmacist intervention on medication discrepancies following hospital discharge. International Journal of Clinical Pharmacy, 36(2), 430-437.
Frankenthal, D., Lerman, Y., & Lerman, Y. (2014). The impact of hospitalization on potentially inappropriate prescribing in an acute medical geriatric division. International Journal of Clinical Pharmacy, 1-8.
Fulton, M. M., & Riley Allen, E. (2005). Polypharmacy in the elderly: a literature review. Journal of the American Academy of Nurse Practitioners, 17(4), 123-132.
Gallagher, P., Ryan, C., Byrne, S., Kennedy, J., & O'Mahony, D. (2008). STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. International Journal of Clinical Pharmacology and Therapeutics, 46(2), 72-83.
Gandhi, T. K., Weingart, S. N., Borus, J., Seger, A. C., Peterson, J., Burdick, E., . Bates, D. W. (2003). Adverse drug events in ambulatory care. New England Journal of Medicine, 348(16), 1556-1564. doi: 10.1056/NEJMsa020703
Garfinkel, D., & Mangin, D. (2010). Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Archives of Internal Medicine, 170(18), 1648-1654.
Garfinkel, D., Zur-Gil, S., & Ben-Israel, H. (2007). The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people. The Israel Medical Association Journal , 9(6), 430.
Gillespie, U., Alassaad, A., Hammarlund-Udenaes, M., Mörlin, C., Henrohn, D., Bertilsson, M., & Melhus, H. (2013). Effects of pharmacists' interventions on appropriateness of prescribing and evaluation of the instruments'(MAI, STOPP and STARTs') ability to predict hospitalization–analyses from a randomized controlled trial. PloS One, 8(5), e62401.
Gillespie, U., Alassaad, A., Henrohn, D., Garmo, H., Hammarlund-Udenaes, M., Toss, H., . Mörlin, C. (2009). A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Archives of Internal Medicine, 169(9), 894-900.
Hajjar, E. R., Cafiero, A. C., & Hanlon, J. T. (2007). Polypharmacy in elderly patients. The American Journal of Geriatric Pharmacotherapy, 5(4), 345-351.
Hajjar, E. R., Hanlon, J. T., Sloane, R. J., Lindblad, C. I., Pieper, C. F., Ruby, C. M., . . . Schmader, K. E. (2005). Unnecessary drug use in frail older people at hospital discharge. Journal of the American Geriatrics Society, 53(9), 1518-1523.
Hanlon, J. T., Lindblad, C. I., Hajjar, E. R., & McCarthy, T. C. (2003). Update on drug-related problems in the elderly. The American Journal of Geriatric Pharmacotherapy, 1(1), 38-43.
Hanlon, J. T., & Schmader, K. E. (2013). The Medication Appropriateness Index at 20: where it started, where it has been, and where it may be going. Drugs & Aging, 30(11), 893-900.
Hepler, C. D., & Strand, L. M. (1990). Opportunities and responsibilities in pharmaceutical care. American Journal of Health-System Pharmacy, 47(3), 533-543.
Holt, E. W., Rung, A. L., Leon, K. A., Firestein, C., & Krousel-Wood, M. (2014). Medication adherence in older adults: A qualitative study. Educational Gerontology, 40(3), 198-211.
Hughes, C., & Hughes. (2004). Medication non-adherence in the elderly. Drugs & Aging, 21(12), 793-811.
Inouye, S. K., Studenski, S., Tinetti, M. E., & Kuchel, G. A. (2007). Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. Journal of the American Geriatrics Society, 55(5), 780-791.
Kalisch, L. M., Caughey, G. E., Barratt, J. D., Ramsay, E. N., Killer, G., Gilbert, A. L., & Roughead, E. E. (2012). Prevalence of preventable medication-related hospitalizations in Australia: an opportunity to reduce harm. International Journal for Quality in Health Care, mzs015.
Koehler, B. E., Richter, K. M., Youngblood, L., Cohen, B. A., Prengler, I. D., Cheng, D., & Masica, A. L. (2009). Reduction of 30‐day postdischarge hospital readmission or emergency department (ED) visit rates in high‐risk elderly medical patients through delivery of a targeted care bundle. Journal of Hospital Medicine, 4(4), 211-218.
Larson, E. B., Kukull, Water A, B., David, & Reifler, B. V. (1987). Adverse drug reactions associated with global cognitive impairment in elderly persons. Annals of Internal Medicine, 107(2), 169-173.
Lee C.-T., Chen M.-T., Chen S.-M., Liang C.-K., Chou M.-Y. (2013). Pharmaceutical care in the elderly. The Journal of Taiwan Pharmacy, 29, 148.
Lenaghan, E., Holland, R., & Brooks, A. (2007). Home-based medication review in a high risk elderly population in primary care—the POLYMED randomised controlled trial. Age and Ageing, 36(3), 292-297.
Lenander, C., Elfsson, B., Danielsson, B., Midlöv, P., & Hasselström, J. (2014). Effects of a pharmacist-led structured medication review in primary care on drug-related problems and hospital admission rates: a randomized controlled trial. Scandinavian Journal of Primary Health Care, 32(4), 180-186.
Lipton, H. L., Bero, L. A., Bird, J. A., & McPhee, S. J. (1992). The impact of clinical pharmacists' consultations on physicians' geriatric drug prescribing: A randomized controlled trial. Medical Care, 646-658.
Lynn, M. R. (1986). Determination and quantification of content validity. Nursing research, 35(6), 382-386.
Mangoni, A. A., & Jackson, S. H. (2004). Age‐related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. British Journal of Clinical Pharmacology, 57(1), 6-14.
Matlin, O. S., & Brennan, T. A. (2013). Impact of a patient-centered pharmacy program and intervention in a high-risk group. Journal of Managed Care Pharmacy, 19(3), 228-236.
Milos, V., Rekman, E., Bondesson, Å., Eriksson, T., Jakobsson, U., Westerlund, T., & Midlöv, P. (2013). Improving the quality of pharmacotherapy in elderly primary care patients through medication reviews: a randomised controlled study. Drugs & Aging, 30(4), 235-246.
Mrazek, M. F., & Mossialos, E. (2003). Methods for monitoring and evaluating processes and outcomes. Drugs and Money: Prices, Affordability and Cost Containment, 15, 55.
Pindolia, V. K., Stebelsky, L., Romain, T. M., Luoma, L., Nowak, S. N., & Gillanders, F. (2009). Mitigation of medication mishaps via medication therapy management. Annals of Pharmacotherapy, 43(4), 611-620. doi: 10.1345/aph.1L591
Ryan, A. A. (1999). Medication compliance and older people: a review of the literature. International Journal of Nursing Studies, 36(2), 153-162.
Schmader, K. E., Hanlon, J. T., Landsman, P. B., Samsa, G. P., Lewis, I. K., & Weinberger, M. (1997). Inappropriate prescribing and health outcomes in elderly veteran outpatients. Annals of Pharmacotherapy, 31(5), 529-533.
Schmader, K. E., Hanlon, J. T., Pieper, C. F., Sloane, R., Ruby, C. M., Twersky, J., . . . Artz, M. (2004). Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly. The American Journal of Medicine, 116(6), 394-401.
Scott, I., & Jayathissa, S. (2010). Quality of drug prescribing in older patients: is there a problem and can we improve it? Internal Medicine Journal, 40(1), 7-18.
Somers, A., Robays, H., De Paepe, P., Van Maele, G., Perehudoff, K., & Petrovic, M. (2013). Evaluation of clinical pharmacist recommendations in the geriatric ward of a Belgian university hospital. Clinical Interventions in Aging, 8, 703.
Spinewine, A., Schmader, K. E., Barber, N., Hughes, C., Lapane, K. L., Swine, C., & Hanlon, J. T. (2007). Appropriate prescribing in elderly people: how well can it be measured and optimised? The Lancet, 370(9582), 173-184.
Turnheim, K. (2003). When drug therapy gets old: pharmacokinetics and pharmacodynamics in the elderly. Experimental Gerontology, 38(8), 843-853.
Weiner, D. K., Hanlon, J. T., & Studenski, S. A. (1998). Effects of central nervous system polypharmacy on falls liability in community-dwelling elderly. Gerontology, 44(4), 217-221.
World Health Organization. (2000). Ageing society. Retrieved Jan 4, 2015, from http://www.who.int/ageing/publications/global_health
Zineldin, M. (2006). The quality of health care and patient satisfaction: an exploratory investigation of the 5Qs model at some Egyptian and Jordanian medical clinics. International Journal of Health Care Quality Assurance, 19(1), 60-92.
 
中文部分：
中華民國衛生福利部. (2007). 中華民國衛生福利部法規檢索系統.
內政部統計處. (2014, Sep 4 2014). 內政部統計年報. Retrieved Jan 4, 2015, from http://sowf.moi.gov.tw/stat/year/list.htm
台灣老年學暨老年醫學會. (2012). 老年病症候群. 台灣: 合計圖書出版社.
周玟觀. (2014). 周全性高齡藥事照護用於老年科住院病患之初探. 成功大學老年學研究所學位論文, 1-83.
郭建宏. (2015). 周全性高齡藥事照護使用於內科老年住院病患之探討. 成功大學老年學研究所學位論文, 1-102.
張苙雲. (1998). 「逛醫師」的邏輯：求醫歷程的分析. [The Logic of Care Seeking]. 臺灣社會學刊(21), 59-87.
張家銘, & 蔡智能. (2003). 老年人之周全性評估. 臺灣醫學, 7(3), 364-374.
黃士甄. (2004). 台灣地區 polypharmacy 之流行病學研究. 高雄醫學大學藥學研究所學位論文, 1-79.
鍾慧, 楊凱翔, & 楊瑛碧. (2014). 高齡整合性門診藥師介入之成效. 北市醫學雜誌, 11(2), 129-134.