| 摘要: | 研究背景：台灣從1993年起正式邁入高齡化社會，至2010年65歲以上老年人占總人口數10.63%。隨著年齡增長，老化年人身體生理機能逐漸退化，易罹患多種急、慢性疾病，必需同時看多科別醫療，導致服用多種藥品。當併用多種藥物進行治療時，發生藥物交互作用與藥品副作用的機率都會提高。依健保局資料庫分析顯示多重慢性門診病人(排除急重症病患)全年多數固定在一家醫院就診者（忠誠病人），其就醫人數佔全體就醫人數3.5%（約65萬人），使用醫療費用達19.3%（約325億）。目前多重慢性病患是我國醫療照護系統中最重要的資源使用者，多重慢性病的盛行率將因人口老化逐年升高，其醫療照護課題也將愈趨重要。自1995 年全民健保開辦以來，藥品費用由1996 年的622 億元，逐年增加至2007 年的1097 億元，約佔健保醫療費用的24.5％至25.5％之間，相較於美國的11~13％高出許多。因為人口老化、許多新醫療科技獲得給付、慢性與重大疾病治療等原因，造成藥費龐大支出，因此節制藥費成長成為目前健保局的主要目標之一。為使醫療資源合理使用，民國98年12月行政院衛生署針對門診高利用之保險對象中需輔導建立正確服用藥物觀念者，核准進行藥師居家訪視，以避免藥物重複使用，提昇用藥安全，間接減少醫療資源浪費。99年辦理「全民健保高診次民眾就醫行為改善方案—藥事居家照護」計劃、「建構整合式照護模式並逐步朝促進醫療體系整合」計畫，及100年的論人計酬試辦計劃，在在顯示健保局積極降低醫療費用的重要性及迫切性，以及期望透過醫師與藥師合作之藥事居家照護模式來降低醫療費用。
研究目的：建立醫院醫師和醫院藥師合作的藥事居家照護模式，評估藥師介入醫師整合性照護門診之病人，進行居家用藥訪視後，實驗組和對照組兩組之間的成效差異。
研究方法：本研究對象為多重慢性病患者，平均分為兩組，一組為實驗組由醫院藥師進行居家用藥訪視，另一組為對照組依目前作業方式，僅接受藥師於發藥櫃臺進行的用藥指導，前後追蹤三次。觀察兩組之間每日平均用藥顆粒數、每日平均用藥種類以及每月平均藥品費用的變化。
研究結果：本研究共納入並完成87位多重慢性病患者的照顧，時驗組有45位及對照組有42位患者。兩組個案平均年齡為74.2±0.87歲，實驗組平均5.5±0.3種慢性病，對照組平均5.2±0.2種慢性病。實驗組的每日平均用藥顆粒數從介入前的13.4顆在三個月後降低為11.5顆（p=0.001），每日平均用藥種類由8.3種降低為7.5種（p=0.006），每月整體藥品費用由146,611元降低為125,464元（p=0.105）。對照組的每日平均用藥顆粒數從介入前的8.8顆在三個月後增加為9.9顆（p=0.005），每日平均用藥種類由6.7種增加為7.0種（p=0.1999），每月整體藥品費用由90,933元增加為105,224元（p=0.008）。藥師針對實驗組藥物治療問題所提出之建議，84.4％被醫師接受。
結論：本研究認為經過跨專業團隊合作的模式，可以有效降低病人不必要的用藥品項及種類，可以達到病人治療結果的最佳化，即時解決病人用藥問題，協助病人建立正確用藥行為，進而達到疾病治療之成效。
Background：Since 1993, Taiwan formally entered the aging society, to 2010, elderly population reaches 10.63%. With increasing age, the physiological functions of the human body is gradually degrading, easy to suffer from a variety of acute and chronic diseases, needs to go to different medical specialists for help, and leading to have polypharmacy therapy. When patient taking multiple drug therapy, the possibility of getting drug-drug interactions and drug side effects increase. According to the data from Bureau of National Health Insurance (BNHI), the number of patients with multiple chronic diseases (excluding those with acute and severe cases) who seek outpatient medical visits mostly at the same hospital (loyal patients), is about 3.5% of the total population (about 0.65 million people) and used 19.3% of the total healthcare expenditures (about 32.5 billion NT dollars). The patients with multiple chronic diseases is the most important resource users of our current health care system, the prevalence of this population will increase year by year due to the aging process, therefore, their health care issues will become increasingly important. Since the starting of our National Health Insurance program in 1995, the drug expenditure was 62.2 billion NT dollars in 1996, increased to more than 109.7 billion in 2007, accounting for 24.5 to 25.5% of the total healthcare expenditures, which is higher than that of United States which is around 11~13%. Because of the aging population, new technologies got reimbursed and more patients with chronic and severe diseases, the drug expenditure growth rapidly. The containment of drug spending becomes a major goals of the BNHI. To make rational use of medical resources, in December 2009, the Department of Health approved the home pharmaceutical care program for the high users of medical resources because they need assistance on their medical seeking behavior and also drug usage behaviors. By conducting home pharmaceutical care, patients may avoid duplication of drug therapy, improve safety of drug usage, and indirectly reduce the healthcare expenditures. In the year 2010, the BNHI starts "High users medical seeking behavior improvement program –home pharmaceutical care" and "Constructing integrated healthcare model to promote collaboration practice program ", and in 2011 to start the pilot program on capitation scheme, all these indicating the strong wills of BNHI to contain the total medical care expenditures. The collaboration practice between physicians and pharmacists through the hospital system is expected to reduce healthcare costs.
Objective: To establish the collaboration practice model in the hospital setting between physicians and pharmacists by pharmacist providing home care, and give recommendations to the physician regarding patients drug usage behavior at home, any drug therapy problems identified and methods to resolve the problem, so that, physician can change the care plan for that patient. The study wishes to see the difference of the outcomes between the experimental group and control group.
Methods: The study subjects were patients with multiple chronic diseases, they were divided into two groups, the experimental group had hospital pharmacist providing home visits, and the control group had usual practice, as pharmacist provide counseling at the pharmacy counter after dispensing of their prescription three times after they participate the study. The outcome variables were the number of daily medication, the number of daily drug classes, the number of drug therapy problems, and drug expenditures per month.
Results: Ninety patients enrolled and completed the study with evenly distribution in the two groups. The average age of the two groups was 74.2 ± 0.87 years old; the experimental group had 5.5 ± 0.3 chronic diseases and control group had 5.2 ± 0.2 chronic diseases. In experimental group, the average number of daily drugs droped from 13.4 before study to 11.5 at the end of three month intervention (p=0.001); average number of daily drug classes reduced from 8.3 to 7.5 (p=0.006), total monthly drug expenditures reduced from NT$146,611 to NT$125,464 (p=0.105). In the control group, the average number of daily drugs increased from 8.8 before study to 9.9 at the end of three month intervention (p=0.005); average number of daily drug classes increased from 6.7 to 7.0 (p=0.1999), total monthly drug expenditures increased from NT$90,933 to NT$105,224 (p=0.008). In experimental group, the physician accepted 84.4% of the recommendations made by pharmacists to resoled the founded drug therapy problems.
Conclusion: The advancement of healthcare technologies for the treatment of diseases, new drugs and biologics coming out more and more, and patient diseases became more complex, although the required number and types of drug therapy increases and they do bring advantages to the patients, it also increase the possibility of drug interactions and side effects, low adherence to the drug therapy may leads to failure of the drug therapy. The complexity of medical care may need multi-disciplinary team works and collaboration practice is the future trend of our healthcare system. The study confirmed that through pharmacists providing home care, getting more real drug taking behavior information from the patient at home, knowing every drugs patient is taking at home, finding out all the drug therapy problem, pharmacists can help to ensure that all drugs have appropriate indication, more effective, more safe and convenient for patient to use. |
