- 學位論文
健保特約門診處方適當性(重複用藥)探討
Medication Appropriateness (Therapeutic Duplications) of BNHI Outpatient Prescriptions
摘要
研究背景： 國內於民國84年實施醫藥分業，藉由醫師與藥師的專業分工合作以增進病人健康，藥事專業服務品質是用藥安全中相當重要的一環。民眾就醫時，可選擇是否持交付處方箋至社區藥局調劑領藥，社區藥事人員可為民眾建立個人用藥紀錄並協助長期追蹤病人健康狀況。然而目前國內醫藥分業仍存在「雙軌制」，調劑服務場所除了社區藥局、醫院藥局之外，尚有診所附設調劑服務，藥事人員無論於何處執業，都應審慎評估處方，把關病人用藥安全。 研究目的： 本研究藉由全民健康保險申報資料探勘，期了解國內各調劑處所重複處方之調劑概況及處方適當性藥事評估情形，並探討藥事人員在調劑作業上可能遇到的問題，做為提升服務品質及用藥安全之參考。 研究方法： 利用全民健康保險研究資料庫2000至2007年百萬承保資料抽樣歸人檔，自新開立且有申報藥品調劑之全部處方中，以簡單隨機抽樣自各年抽取分別0.5%處方做為分析主體，研究指標為重複用藥（同藥理機轉、同學名及同品項）；此外，另再從分析主體中篩選出含慢性疾病（糖尿病、高血壓及高脂血症）用藥之處方，以大於（含）4項口服降血糖藥（糖尿病處方）、同一類化學結構且降血糖藥理機轉重複（糖尿病處方）、降血壓藥理機轉重複（高血壓處方）及含有與statins間有潛在不良交互作用之藥品（高脂血症處方）等四項研究指標，分析處方適當性之藥事評估情形。本研究進一步比較健保特約藥局、醫院及診所間處方基本資料及各研究指標發生比例之差異，並以多元迴歸分析探求各研究指標之相關因素。 研究結果： 本研究納入分析的處方共計388,744張，於特約藥局調劑之處方有68,289張（17.6%）、醫院112,043張（28.8%）、診所208,410張（53.6%），八年間之處方釋出率平均為17.6%，以2005年之26.6%為最高。簡表申報處方佔總處方數55.5%，平均每張處方中品項數為3.7 ± 1.9項、給藥日份為7.1 ± 8.8天。在排除處方中的外用藥品後，有347,771張處方納入重複用藥分析，同藥理機轉、同學名、及同品項重複用藥之發生比例分別為17.4%、4.0%、1.7%，且在此八年間有逐年降低之趨勢，然而診所之此三類重複用藥皆顯著高於醫院及特約藥局（p＝< 0.0001、< 0.0001、< 0.0001）。發生重複用藥之相關因子包括：處方中之品項數愈多、急診處方、診所調劑之簡表申報處方、開方醫師年齡愈大及開方到領藥日間距超過1天者，較易有重複用藥的情形；而病人年處方次數愈少、調劑藥事人員年齡愈小，較少發生重複用藥。 含降血糖用藥之處方共10,674張，超過4種口服降血糖藥之處方有101張（1.0%），在特約藥局、醫院、診所調劑者分別為7（佔社區藥局總處方數0.9%）、82（佔醫院總處方數1.0%）、12（佔診所總處方數0.5%）張；藥品屬同一類化學結構且降血糖藥理機轉重複者之發生比例為1.4%（152張），在特約藥局、醫院、診所調劑者分別為10（佔社區藥局總處方數1.3%）、91（佔醫院總處方數1.25%）、51（佔診所總處方數2.0%）張。含降血壓用藥處方共有32,109張，其中441張處方（1.4%）有降血壓藥理機轉重複情形，在特約藥局、醫院、診所調劑者分別為42（佔社區藥局總處方數1.6%）、314（佔醫院總處方數1.6%）、51（佔診所總處方數0.9%）。處方中含statins者計有3,423張，其中有210張（6.1%）處方含有與statins間有潛在不良交互作用之藥品，在特約藥局、醫院、診所調劑者分別為8（佔社區藥局總處方數3.7%）、184（佔醫院總處方數6.9%）、18（佔診所總處方數3.4%）張。此三類慢性疾病處方適當性評估相關因子包括：處方中之品項數愈多、急診處方，含此兩項因子者其處方不適當情形較為常見，而就醫醫療院所為醫學中心者則是較少發生。 結論： 在研究年度間，各類重複用藥發生比例有逐年降低之趨勢，然而各年均以診所調劑之處方發生比例最高；在慢性疾病用藥適當性評估中，醫院調劑之處方，除降血糖藥理機轉重複指標發生比例最低之外，其他三項指標皆高於特約藥局及診所。影響處方適當性評估之因素包括有處方藥品品項數愈多、急診處方、診所調劑之簡表申報處方、開方醫師年齡愈大、處方開立到領藥日期間距愈長，病人之年處方次數愈多，較容易發生處方不適當用藥的情形。為增進病人用藥安全，藥事人員於調劑時應確實依憑專業覆核處方。未來可針對多重慢性疾病及使用較多項藥品之病人適當處方覆核服務及評估研究，進一步了解國內慢性疾病之用藥概況及需求，對病人能有更完善的藥事照護，提升藥事專業服務品質。
並列摘要
Background: The separation of drug prescribing and dispensing has been implemented in Taiwan since 1995. The intimate collaboration between pharmacists and physicians is definitely beneficial to patients’health care. Quality pharmaceutical service is the key to safe medication use. The public should have the right to choose pharmacies of their own preference, either community or hospital pharmacies for prescription dispensing. Community pharmacists can help profiling patients’medication records and performing follow-ups for patients’ medication use and their health status. Currently, patients in Taiwan can have their prescription filled either at community pharmacies, hospital pharmacies, or quite contrast to advanced countries, even at primary-care clinics. Pharmacists, no matter practice settings are they at, are entitled to verifying medication orders to ensure medication safety. Objectives: The aims of the study was to investigate, by using the National Health Insurance Research Database (NHIRD), the incidence of therapeutic duplications and to evaluate medication appropriateness of prescriptions dispensed by various settings, namely community pharmacies, hospital pharmacies, and clinics. Factors associated with therapeutic duplications and medication appropriateness were also determined in the study. Methods: New prescriptions with dispensing records, from a cohort dataset of one-million enrollees of the NHIRD from year 2000 through 2007, were selected yearly by simple random sampling by a ratio of 0.5%. Study endpoints were therapeutic duplications in medication orders prescribed within one ambulatory visit. Three levels of therapeutic duplications were assessed, namely duplicated by therapeutic class, by generic name, or by identical medicine (same generic name, strength, and dosage form). In addition, if one prescription contained at least one oral hypoglycemia agent (OHA), antihypertensive agent, or statin, the prescription would then be selected for appropriateness evaluation and for comparison among practice settings. Respective endpoints were: (1) concomitant use of 4 or more OHAs and duplication of OHAs of the same chemical classes for prescriptions containing OHAs; (2) duplicated pharmacological mechanisms for prescriptions containing antihypertensives; and (3) with potentials for adverse drug-statin interactions for prescriptions containing statins. Multiple logistic regressions were performed to identify factors associated with these four endpoints. Results: In 388,744 sampled prescriptions, prescriptions dispensed by community pharmacies, hospital pharmacies, and clinics were 68,289 (17.6%), 112,043 (28.8%), and 208,410 (53.6%), respectively. The highest prescription release rate was seen in 2005 (26.6%). Prescriptions claimed by simplified processes accounted 55.5% of total prescriptions. The average items per prescription were 3.7 ± 1.9 medications with a supply of 7.1 ± 8.8 days. After excluding topical medications, a total of 347,771 prescriptions were enrolled for therapeutic duplication analyses. The rates for therapeutic class duplications, generic name duplications, and the duplication of identical medicines were 17.4%, 4.0%, and 1.7%, respectively. A trend of decreasing incidence in therapeutic duplications was observed among the eight years studies. However, clinics had higher rates of therapeutic duplications in each year for all three types of duplications (p<0.0001,<0.0001,<0.0001). Factors associated with therapeutic duplications included more medication items per prescription, ER prescriptions, prescriptions from clinics and claimed through simplified processes, elder prescriber, and the interval between prescription prescribing and dispensing>1 day. On the other hand, patients with fewer yearly prescriptions and younger pharmacists were negatively correlated with therapeutic duplications. There were 10,674 prescriptions containing at least one OHA. A hundred and one (1.0%) prescriptions contained 4 or more OHAs. Seven (accounted for 0.9% prescriptions) were dispensed at community pharmacies; 82 (accounted for 1.0% prescriptions) at hospital pharmacies and twelve (accounted for 0.5% prescriptions) at clinics. The incidence of duplicated OHAs of the same chemical classes was 1.4% (152 prescriptions), with the highest incidence occurring at clinics (2.0%; 51 prescriptions). There were 32,109 prescriptions containing at least one anti-hypertension agent. Pharmacological mechanism duplications were seen in 441 prescriptions (1.4%), including 42 (1.6%) at community pharmacies, 314 (1.6%) at hospital pharmacies, and 51 (0.9%) at clinics. Prescriptions containing statins amounted 3,423. There were 210 (6.1%) prescriptions detected for potential drug-statin interactions that were of clinical significance. Those dispensed at community pharmacies, hospital pharmacies, and clinics were 8 (3.7%), 184 (6.9%), and 18 (3.4%) prescriptions, respectively. We found that factors associated with medication inappropriateness included more medication items per prescription and ER prescriptions, whereas medical-center prescriptions was a protective factor. Conclusions: A trend of decreasing incidence in therapeutic duplications was observed among the eight years studies. Clinics had higher rates of therapeutic duplications in each year for all three types of duplications. Hospitals have the higher rates of medication inappropriateness than those of community pharmacies and clinics, except the endpoint that is duplication of OHAs of the same chemical classes for prescriptions containing OHAs. The factors associated with medication inappropriateness included more medication items per prescription, ER prescriptions, prescriptions from clinics and claimed through simplified processes, elder prescriber, the interval between prescription prescribing and dispensing>1 day, and the times of prescribing per patient per year. In order to enchance the medication use safety, pharmacists should be aimed at these characteristics when evaluating prescriptions. Studies of medication appropriateness in patients with multiple chronic diseases and long-term using medicines can be implemented in the future.