建立與評估腎臟移植藥師門診及雲端藥歷整合門診以發揮藥師專業效能

背景:妥善的藥事照護及有效的照護模式可以提昇病人用藥安全、預防藥物相關問題於未然。國內目前門診藥事照護模式多為被動的經由醫師轉介或病人藥物諮詢需求，屬於問題解決模式；而主動的藥事照護是由藥師主動面談病人、發現藥物相關問題、提出用藥建議、施行用藥指導以強化用藥整合，是一種改善被動藥物諮詢之不足、預防藥物相關問題的模式。若再加強藥事照護記錄工具之運用，建立通用的藥物相關問題檔案，將能使藥師專業發揮更大的效能。目的:本研究以腎臟移植門診與雲端藥歷整合門診為例建立主動的藥事照護模式。研究分為二部分，第一部分探討移植門診病人腹瀉造成移植後腎功能惡化之危險因子。第二部分為建立雲端藥歷藥事整合照護模式，探討無雲端藥歷、雲端藥歷線上查詢及批次下載雲端藥歷之照護模式，對辨識病人藥物相關問題之效能，以及藥物問題、問題導因分佈之差異。方法: 本研究以南部某醫學中心之門診病人為對象。第一部分為以Hyperin進行資料庫回溯之觀察性研究，搜尋移植後一年而有腹瀉診斷、腹瀉持續三天以上、使用或未使用抗生素治療腹瀉者；腎臟移植接受者腹瀉前後血清肌酸酐值的變化與腹瀉原因、腹瀉持續時間之相關性以student t-test或ANOVA進行檢定。第二部分以橫斷面對照研究方式比較有或無雲端藥歷協助，與即時線上查詢或批次下載雲端藥歷藥事照護，藥師對藥物相關問題的辨識度。比較不同照護方式辨識之問題與導因的勝算比（Odds ratio）；藥物相關問題以判斷性服務AABBCC編碼與PCNE-DRP 6.2版進行分類。類別變相以Pearson’s Chi-squared test 或Fisher’s exact test檢定，連續變相以Wilcoxon signed-rank test分析之。結果與討論：第一部分研究發現腎臟移植後因感染CMV或C.difficile引起腹瀉者其血清肌酸酐值(Scr)的上升大於非感染性腹瀉(0.31±0.52 vs.0.1±0.27)，且當腹瀉持續10天時其Scr 變化又較持續<10天者顯著(0.53±0.55 vs. 0.05±0.22; p=0.0018)，可知感染性腹瀉與腹瀉持續時間是造成移植後腎功能惡化之危險因子；使用TAC-MMF組合之免疫抑制劑可能是引起非感染性腹瀉的主因。第二部分研究發現，雲端藥歷線上查詢組以發現醫師處方問題為主(藥物使用不符合適應症佔50.0%)，而非雲端藥歷組則以發現病人用藥過程的問題為主(病人配合度差佔55.0%)；雲端藥歷批次下載較線上查詢辨識藥物相關問題的效能較高(55.2%、50.2%；p < 0.05; OR 2.7 )。在藥物相關問題分類的問題面向中，線上查詢組以Treatment effectiveness發生率最高(41.3%)，批次下載組則以Treatment cost發生率最高(48.3%)，次分類則皆以Unnecessary drug treatment 的分佈最高；問題導因方面，線上查詢及批次下載皆以Drug selection為主。可知雲端藥歷可協助發現醫師潛在的處方問題，尤其是非必要的藥物治療及其所衍生的治療花費。結論：移植後腹瀉造成移植後腎功能惡化之危險因子，以感染性腹瀉及腹瀉持續大於10天以上者為主因。雲端藥歷可協助發現醫師處方問題為主的藥物相關問題，而批次下載的雲端藥歷因能讓藥師事先查看，因此辨識藥物相關問題的效能較線上查詢方式高。總結以上研究結果可知，主動照護之藥師門診模式因能有效發現病人的用藥問題而研究問題導因，進而解決甚至預防病人問題再發生，是比過去被動諮詢服務更能發揮藥師專業效能的模式。

關鍵字

腎臟移植；藥師門診；藥事照護；雲端藥歷系統；整合照護；藥物相關問題

並列摘要

Background: To prevent drug-related problems in advance and thus ensure patient safety is closely related to proper pharmaceutical care and effective model for pharmaceutical care. At the moment, OPD pharmaceutical consultation is provided according to physicians’ orders and patients’ need. However, proactive pharmaceutical care is to be initiated and offered by pharmacists to interview face-to-face the patients, discover drug-related problems, provide with therapy recommendations, and instruct the patients how to take the medicines properly. Together with well records of pharmaceutical care and documents for drug-related problems, greater professionalism of pharmacists would be demonstrated. Objective: The study aims to establish a model of proactive pharmaceutical care based on data on the NHI PharmaCloud and has two objectives. First, to evaluate if persistent infectious diarrhea is a risk factor for deterioration of renal function in kidney transplant recipients. Secondly, to analyze the data regarding the prevalence and types of drug-related problems (DRPs) and the recommendations for optimizing medication provided by clinical pharmacists after two stages (First stage (FS): pharmacists reviewed the data real-time and recorded the DRPs; Second stage (SS): pharmacists reviewed and evaluated the pre-downloaded patient prescription data and recorded all the DRPs) of implementation of NHI PharmaCloud System. Methods: A cross-sectional prospective study was conducted at a medical center in Southern Taiwan. In the first part of the study, a retrospective and observational study was conducted using Hyperin Database of the hospital. Patients were collected according to diagnoses of diarrhea, diarrhea period ≥ 3 days, use (or not) of antibiotic agents. Student t-tests or ANOVA were used to verify the correlation among the serum creatinine changes and diarrhea causes, diarrhea periods (continuous variables). In the second part of the study, data are presented as means with standard deviations for continuous variables and numbers with for categorical variables. Drug-related problems were probed and encoded with AABBCC and recorded according to PCNE DRP v6.2 guideline (Pharmaceutical Care Network Europe Working group on DRPs). Wilcoxon signed-rank test for continuous variables and Pearson's Chi-square test or Fisher's exact test for categorical variables was used to compare the differences between two groups. The logistic regression was used to estimate the association between each drug-related problems and stages. The multivariable logistic regression calculated the odds ratios (ORs) and 95% confidence intervals (CIs) after adjusting potential confounding factors. Significance was set at p< 0.05. All analyses were presented using Statistical Analysis System (SAS) statistical software (version 9.4; SAS Institute, Inc, Cary, NC). Results and discussion: The preliminary results of the first part of the study revealed that in kidney transplant recipients, patients with infectious diarrhea demonstrated a larger mean serum creatinine (Scr) change than those with non-infectious diarrhea (0.31±0.52 vs.0.1±0.27), and when their diarrhea persisted for more than 10 days, a significant larger mean serum creatinine change would be observed (0.53±0.55 vs. 0.05±0.22; compared with those with diarrhea period of < 10 days, p=0.0018), showing that the irreversible kidney allograft function change was associated with both persisted diarrhea and infectious diarrhea. Besides, the immunosuppressive combination of tacrolimus (TAC) and mycophenolate mofitil (MMF) might be associated with an increased risk of noninfectious diarrhea. The results of the second part of the study revealed that “Treatment effectiveness” (Untreated indication; 50.0%) was the main problem in the FS group and “Patient” (Patient forgets to use/take drug; 55.0%) in the SS group. Further analyses of logistic regressions revealed that patients in the SS group had a 2.7 times of risk to receive “Unnecessary drug-treatment (P 3.2)” than they did in FS group (OR 2.7; p<0.0001) indicating that the prescription data downloaded in batches from the PharmaCloud System could be helpful for clinical pharmacists to identify DRPs more efficiently with significant clinical benefits. On classification of the drug-related problems, “Treatment effectiveness” (41.3%) was the most frequently seen problem in the FS group and “Treatment cost” (48.3%) in the SS group, and further analyses demonstrated that “Unnecessary drug treatment” was the main problem for all patients. On the cause of the problems, “Drug selection” became the main cause for all the problems. This study demonstrated that the PharmaCloud System allowed prescription information of patients to be shared across hospitals and enabled pharmacists and physicians to review and evaluate medications in advance. The potential problems of “Unnecessary drug treatment” and the treatment cost derived from that would be resolved efficiently. Conclusion: Our study brings new data in the direction showing that infectious diarrhea does more damages to renal function than non-infectious ones in kidney transplant recipients, especially when the diarrhea persists for more than 10 days. Our study also demonstrated that higher efficiency of the use of the proactive model of pharmaceutical care was easily achieved to prevent and/or solve drug-related problems in advance with PharmaCloud system.

並列關鍵字

Kidney transplantation ； pharmacists for OPD ； pharmaceutical care ； PharmaCloud system ； integrated care ； drug-related problem

參考文獻

1.Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. American Journal of Hospital Pharmacy. 1990;47: 533-543.

Google Scholar

2.譚延輝. 藥事照護在台灣. 藥學雜誌. 2011;27:42-45.

Google Scholar

3.Institute of Medicine (US) Committee on the Roles of Academic Health Centers in the 21st Century; Kohn LT, editor. Academic Health Centers: Leading Change in the 21st Century. Washington (DC): National Academies Press (US); 2004. EXECUTIVE SUMMARY. 2004; http://www.ncbi.nlm.nih.gov/books/NBK221671/. Accessed Nov 11, 2015

Google Scholar

4.Luisetto M, Carini F, Bologna G, Nili-Ahmadabadi B. Pharmacist Cognitive Service and Pharmaceutical Care:Today and Tomorrow Outlook. UK Journal of Pharmaceutical and Biosciences. 2015;3:67-72.

Google Scholar

5.Medication Therapy Management in Pharmacy Practice: Core elements of an MTM Service Model. 2008 ver.2; http://www.pharmacist.com/sites/default/files/files/core_elements_of_an_mtm_practice.pdf. Accessed Nov 11, 2015

Google Scholar

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建立與評估腎臟移植藥師門診及雲端藥歷整合門診以發揮藥師專業效能

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