藥師詢問病患用藥史對發掘藥品相關問題之貢獻：以腎臟科病房為例

Drug History Taking and Identification of Drug-Related Problems by Pharmacists: Experience in A Nephrology Ward

李怡婷(Yi-Ting Lee)

指導教授 ： 林慧玲

國立臺灣大學/醫學院/臨床藥學研究所/碩士(2007年)

https://doi.org/10.6342/NTU.2007.02918

摘要

研究背景：
在臺灣，許多病患不清楚自己的用藥，用藥安全的政策顯得更加重要。目前，臺灣末期腎臟病患人口盛行率高居世界第二，這些族群乃為發生藥品相關問題的高危險群。因此評估他們藥品相關問題是目前迫切需要的研究之ㄧ。然而因為臺灣醫院內藥師人力往往不足，使得藥師不易有時間取得住院病患的用藥史，以協助評估藥品相關問題。
研究目的：
評估藥師擷取住院病患用藥史所需人力資源，以及對入院時藥品相關問題之貢獻。
研究方法：
研究中納入非隔離病房之所有住院病患，排除因原發性皮質醛酮症入院病患、其他科借住的病患、前次住院已受訪之病患與無法提供用藥史之病患。將病患資料紀錄於事先設計之問卷，以此做為訪談病患後評估其藥品相關問題，同時紀錄藥師花費時間。比較藥師紀錄與病歷紀錄的差異，連續變項採用魏可遜符號等級檢定或成對樣本T檢定方式分析，一致性檢定則以Kappa檢定分析。以多元邏輯斯迴歸分析藥品相關問題預測因子。
研究結果：
研究期間共計207位病患符合納入條件，而藥師訪談了其中108人。受訪與未受訪病患的基本資料，除住院天數、腎臟疾病與心血管疾病有顯著差異外，其餘皆無顯著差異。藥師記錄的病患用藥史在病患的過敏/藥品不良反應史、住院前使用西醫院所處方藥品項目數量、註明其成份名/劑量頻率/單位含量，以及使用自我醫療/替代療法藥品紀錄上，與病歷紀錄皆有顯著差異。108位病患中，共66位病患完成藥品相關問題評估。完成與未完成藥品相關問題評估病患之基本資料、用藥史、藥師花費時間上，只有住院天數以無母數分析時有顯著差異。藥師共發現149項藥品相關問題，而病歷紀錄僅有22項，其中的差異也具顯著意義。藥師從準備工作到完成訪談平均花費36分鐘，完成藥品相關問題評估與藥事照顧紀錄平均需耗時62分鐘。
本研究結果顯示，最常發生之藥品相關問題為不適當藥品選擇（30.9%）、藥品不良反應（18.1%）、病人未依醫囑用藥（13.4%）與藥物交互作用（13.4%）。最常引起藥品相關問題之藥品為精神抑制劑（7.4%）、利尿劑（6.9%）、礦物質補充劑（6.3%）以及作用在renin-angiotensin系統藥物（5.3%）。對於肝臟疾病患者，藥師皆發現有藥品相關問題，但醫師卻無。藥師發現有較多住院前西醫院所處方藥品的病患，較易有藥品相關問題。藥師也發現肝臟疾病與癌症患者、非代謝/內分泌疾病患者以及女性病患較容易有藥品相關問題。
結論：
本研究結果顯示，藥師確實能依此研究方法取得較完整病患用藥史，並發掘當中藥品相關的問題，但因時間因素而無法施行於所有病患。藉由實習藥師取得病患用藥史以及改善電子化資訊的可得性，或許能讓藥師擷取用藥史更為可行。為了有效運用有限的時間來評估我們的建議是藥師針對那些使用常發生藥品相關問題之藥品的病患，或是有較多西醫院所處方藥品的病患，以及患有肝臟疾病、癌症與非代謝/內分泌疾病患者或是女性病患來評估藥品相關問題。

關鍵字

藥品相關問題 ； 藥師 ； 用藥史 ； 住院病患 ； 腎臟科病房 ； 腎臟病

並列摘要

Background:
In Taiwan, most patients are not aware about what drugs they are taking and medication safety policies are important. Currently, the prevalence of end-stage renal disease in Taiwan is ranked as the second highest in the world. These patients are at high risk of having drug-related problems (DRPs). Thus, to identify DRPs is an important issue. However, with insufficient human resources, inpatient pharmacists in Taiwan can hardly have time to take drug history and assess the DRPs.
Objective:
To estimate the human resources of pharmacist required for drug history taking, and to evaluate the contribution of identifying DRPs on admission
Method:
All patients in the nephrology ward were included in the study except those who were quarantined. Those who were admitted for primary aldosteronism, belonged to other specialties, had been interviewed by the study pharmacist during last admission, or could not provide drug history were excluded. The patients’ basic and clinical information were recorded on a questionnaire, and used as a guide to interview the patients. After interview, each patient’s DRPs were identified, and the time spent on all the above activities was also recorded. To compare pharmacy records and medical records, the continuous variables were analyzed by Wilcoxon signed rank test or paired t test, and the test of agreement was Kappa test. Predictive factors of DRPs were analyzed with multiple logistic regression.
Results:
During the study period, 207 patients met the inclusive criteria. Among them, 108 were interviewed by pharmacist. There were no significant difference in the demographic data of the patients who were interview and those who were not, except in length of stay, and incidence of renal and cardiovascular disease. We also found that drug histories taken by the pharmacist vary from which taken by physicians, which included histories of allergy/adverse drug reaction, the number of medications prescribed before admission, and their ingredients/dosage/strengths noted, records of self-medications and alternative medications. Sixty-six of 108 patients interviewed, DRPs were assessed. Among these patients and those who DRPs were not assessed, only length of stay was significantly different. The number of DRPs documented by pharmacists and by physicians was 149 and 22 respectively, which were significantly different. The average time spent on recording and interview was 36 minutes, while it took the pharmacist 62 minutes to complete the DRPs assessment and wrote a pharmacy note on the medical record.
In this study, the most common DRPs were improper drug selection (30.9%), adverse drug reactions (18.1%), failure to receive drugs (13.4%), and drug interactions (13.4%). The most common drugs that involved DRPs were psycholeptics (7.4%), diuretics (6.9%), mineral supplement (6.3%), and agents acting on the renin-angiotensin system (5.3%). Pharmacists identified at least 1 DRP in each patient with liver disease, which was overseen by physicians. Pharmacists observed that patients with more medications prescribed before admissions tend to have DRPs. It was also found that patients with liver disease, malignancy, non-metabolic/endocrine disease, and females were more vulnerable to DRPs.
Conclusion:
In this study, pharmacists were able to get more comprehensive drug history from patients in the nephrology ward and to identify DRPs. However, because of time-strait, pharmacist may not be able to take drug history of all inpatients. Drug history may render taken by intern pharmacists and availability of good computerized information. To identify the most DRPs in limited time, we suggest that pharmacists identify DRPs of patients on drugs commonly associated with DRPs, those who receive many drugs before admission, those with liver disease/malignancy, those with non-metabolic/endocrine disease, or female gender.

並列關鍵字

drug-related problems ； pharmacist ； drug history ； inpatient ； nephrology ward ； renal disease

參考文獻

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