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研究生:邱春吉
研究生(外文):Chun-Chi Chiu
論文名稱:醫院藥師介入腦中風門診病人危險因子改善之研究
論文名稱(外文):Study of Improvements in Risk Factors of Stroke Outpatients by Hospital Pharmacist Intervention
指導教授:張谷州張谷州引用關係吳信昇吳信昇引用關係
指導教授(外文):Ku-Chou ChangShihn-Sheng Wu
學位類別:碩士
校院名稱:高雄醫學大學
系所名稱:藥學研究所碩士在職專班
學門:醫藥衛生學門
學類:藥學學類
論文種類:學術論文
論文出版年:2004
畢業學年度:92
語文別:中文
論文頁數:95
中文關鍵詞:藥師介入藥事照護可治療危險因子腦中風
外文關鍵詞:pharmacist interventionstrokemordifiable risk factors
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研究背景:腦中風在全世界是造成死亡率與罹病率增加的最主要因素之一,在許多工業國家它是第三常見的死亡原因,而在國內根據行政院衛生署的統計它是第二常見的死亡原因。高血壓、糖尿病和高血脂是引起腦中風之重要且確立的可治療危險因子與預測因子。雖然許多研究顯示治療這些重要的危險因子可減少腦中風病人的罹病率與死亡率,而在治療上也有詳盡的建議準則當參考,但目前仍有許多腦中風門診病人的上述危險因子未能有效控制,適當的藥事照護對於這些危險因子還有明顯的改善空間。
研究目的:測定藥師介入神經科門診腦中風病患藥事照護,評估改善腦中風危險因子的成效。
研究方法:本研究為一項前瞻性、等量分層隨機取樣之臨床試驗,經隨機取樣160位病患分配為實驗組80人和對照組80人,實驗組接受藥師積極介入之藥事照護研究計畫,對照組則如醫院一般程序。主要指標是(1)兩組內與兩組間收縮壓、舒張壓、糖化血色素、空腹血糖、飯後血糖、總膽固醇、三酸甘油酯、低密度脂蛋白膽固醇和高密度脂蛋白膽固醇等,相較於基準點之變化差異;(2)高血壓、糖尿病和高血脂相較於基準點之足夠治療比例,以及評估研究後改善的比例。次要指標是兩組內與兩組間麩酸草醋酸丙酮轉胺酶、麩酸丙酮酸轉胺酶、血尿素氮和肌酸酐等,相較於基準點之變化差異。
研究結果:實驗組在收縮壓、舒張壓、總膽固醇和低密度脂蛋白膽固醇有明顯意義的改善;對照組在這些可治療的危險因子則無改善。實驗組符合高血壓控制情形的人數比例改善了37 % ( p=0.000),符合高血脂控制情形的人數比例改善了29 % ( p=0.002);對照組符合高血壓、糖尿病和高血脂等控制情形的人數比例並未有明顯意義改善。麩酸草醋酸丙酮轉胺酶、麩酸丙酮酸轉胺酶、血尿素氮等,無論在實驗組或對照組研究前後皆無變化差異。
結論:我們的研究顯示,醫院藥師提供藥事照護,對於腦中風門診病人的血壓與血脂等危險因子之改善有顯著的統計意義。因此,藥師介入初級門診醫療照護體系,對腦中風門診病人的危險因子之改善有明顯助益。
Background : Stroke is one of the leading factors of morbidity and mortality worldwide. It represents the third most common cause of death in many industrialized countries and the second most common cause of mortality in Taiwan. Hypertension, diabetes mellitus and hyperlipidemia are important and established modifiable risk factors and predictors for stroke. Although many studies had demonstrated treatment of these important risk factors can reduce morbidity and mortality of stroke patients. But still had many stroke patients inadequate management of these risk factors despite explicit management recommendations. There are marked room for improvement in the management of these risk factors.
Objective : To determine the efficacy of pharmacist intervention in the management of modifiable risk factors in the neurologic clinic in Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
Methods : This was a prospective and equal allocation stratified random sampling clinical trial. One-hundred sixty patients were randomly assigned to experimental (n=80) or control (n=80) group. The experimental group received pharmacist intervention while the control group did as routine. Primary endpoints were (1) the differences of within groups and between groups of systolic blood pressure, diastolic blood pressure, glycosylated hemoglobin, fasting blood glucose, postprandial blood glucose, total cholesterol, triglyceride, low-density lipoprotein and high-density lipoprotein levels from baseline to the end of study. (2) the proportion of adequate management or assessed improvement of hypertension, diabetes, hyperlipidemia from baseline to the end of study. Secondary endpoints were the differences of within groups and between groups of glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, blood urea nitrogen and creatinine levels from baseline to the end of study.
Results : In the experimental group had significant improvement in systolic blood pressure, diastolic blood pressure, total cholesterol and low-density lipoprotein. In the control group did not improved in these modifiable risk factors. Hypertension adequate management improved 37 % (p = 0.000) and hyperlipidemia adequate management improved 29 % (p = 0.002) in the experimental group. There was no significant improvement in hypertension, hyperlipidemia and diabetes adequate management in the control group. Glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, blood urea nitrogen were no difference in the experimental and control group.
Conclusion : Our study was indicated that pharmacist-managed modifiable risk factors program integrated into a primary care medical clinic can effectively improve blood pressure and lipid control in stroke outpatients.
目 錄
中文摘要………………………………………………………… Ⅰ
英文摘要………………………………………………………… Ⅲ
表目錄…………………………………………………………… Ⅸ
圖目錄…………………………………………………………… Ⅹ

本 文
第一章、 前言與研究背景……………………………………… 1
第二章、 文獻探討……………………………………………… 3
一、腦中風與高血壓之相關性…………………… 3
二、腦中風與糖尿病之相關性…………………… 7
三、腦中風與高血脂之相關性…………………… 9
第三章、 研究目的……………………………………………… 13
一、主要指標 (primary endpoints)……………… 14
二、次要指標 (secondary endpoints)…………… 14
第四章、 研究方法與材料……………………………………… 15
一、研究設計……………………………………… 15
二、研究單位……………………………………… 15
三、研究期間……………………………………… 15
四、研究對象與個案收集………………………… 15
五、研究方法……………………………………… 16
六、病患基本資料來源與記錄…………………… 19
七、研究工具……………………………………… 19
八、研究之名詞定義……………………………… 20
九、研究資料統計分析方法……………………… 21
十、研究架構與流程步驟………………………… 22
第五章、 結果描述與分析……………………………………… 23
一、研究對象基本資料與基準點藥物相關資料
與檢驗參數值…………………………………
23
1、研究對象基本資料………………………… 23
2、研究對象基準點之藥物相關資料………… 26
3、研究對象基準點之檢驗參數值…………… 30
二、主要指標變化值分析………………………… 32
1、血壓………………………………………… 32
2、飯前(空腹)血糖、飯後血糖與糖化
血色素………………………………………
33
3、血脂………………………………………… 34
三、次要指標變化值分析………………………… 41
1、評估病人肝功能……………………………… 41
2、評估病人腎功能……………………………… 42
四、研究前後,可治療危險因子之控制結果
分析……………………………………………
43
第六章、 討論與評估…………………………………………… 45
一、對於腦中風有相關性之危險因子
之改善情形與影響……………………………
45
第一部份、血壓方面…………………………… 46
1、藥師積極提供藥事服務對血壓控制
之影響………………………………………
46
2、藥師積極提供藥事服務在續發性中風預防
的角色………………………………………
48
3、神經內科一科醫師處方不同類降血壓
藥之型態分析………………………………
50
4、神經內科一科醫師處方合併降血壓藥
之型態分析…………………………………
53
第二部份、血糖方面…………………………… 55
1、藥師積極提供藥事服務對血糖控制之影響… 55
2、神經內科一科醫師處方降血糖藥之型態
分析…………………………………………
58
第三部份、血脂方面…………………………… 59
1、藥師積極提供藥事服務對血脂控制之
影響…………………………………………
59
2、神經內科一科醫師處方降血脂藥之型態
分析…………………………………………
61
第四部份、次要指標方面……………………… 63
1、藥師積極提供藥事服務對病人肝功能指數
之影響………………………………………
63
2、藥師積極提供藥事服務對病人腎功能指數
之影響………………………………………
63
第五部份、其它方面討論…………………… 64
二、 研究之限制…………………………………… 65
第七章、 結論與建議…………………………………………… 67
一、結論……………………………………………… 67
二、建議……………………………………………… 68
第八章、 參考文獻……………………………………………… 69
第九章、 附錄…………………………………………………… 79
表目錄
表 一 研究對象之基本資料…………………………………… 25
表 二 研究對象基準點之藥物相關資料……………………… 30
表 三 研究對象基準點之檢驗參數值………………………… 33
表 四 實驗組研究前、後之檢驗參數值變化情形…………… 38
表 五 對照組研究前、後之檢驗參數值變化情形…………… 39
表 六 研究前、後,實驗組與對照組之檢驗參數值變化情形… 40
表 七 兩組研究前後收縮壓變化情形及統計檢定結果……… 41
表 八 兩組研究前後舒張壓變化情形及統計檢定結果……… 41
表 九 兩組研究前後血糖、糖化血色素變化情形及統計檢定
結果………………………………………………………
42
表 十 兩組研究前後血脂變化情形及統計檢定結果………… 42
表 十一實驗組(n=80)在基準點與研究後,可治療危險因子之控制情形……………………………………………………
47
表 十二對照組(n=80)在基準點與研究後,可治療危險因子之控制情形……………………………………………………
47
圖目錄
圖 一 研究架構與流程步驟……………………………………… 22
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