臺灣博碩士論文加值系統

本研究之目的在於探究門診藥師執行處方審核時(1)所進行的判斷性服務的主要內容；(2)估算各項判斷性服務能夠節省的藥費，作為未來申請給付時的參考。所使用的研究材料為臺北市立聯合醫院8個院區提供94年3月至12月的判斷性服務記錄表。在研究期間共收集1,676份有效的判斷性服務表，分析其服務內容與健保藥費的變化。
藥師在判斷性服務中發現的最主要用藥治療問題為給藥間隔太短(17.8%)，其次為重複用藥(15.1%)及不符合適應症(13.0%)。而藥師介入的主要活動為建議改變劑量(20.8%)、建議改變用要間隔(19.5%)及建議換另一種藥物(16.3%)。前兩者與用藥量有關的建議就佔了所有建議的40%。而建議換另一種要多是醫師在醫令系統上選錯了藥。以上劑量與選錯藥的問題，其實可以透過功能強大的電腦資訊系統在醫師處方的當時就篩選出異常並對醫師提出警告。藥師介入的結果有94%處方進行修改，而最主要處方變動為換藥(21.2%)及更改用藥間隔(18.4%)，這些處方若沒有修正有可能造成藥物治療無效或產生副作用。
分析藥師的介入活動對藥費影響方面，63%的案件會使藥費降低，只有18%的案件是使藥費增加。平均而言，藥師每進行一次判斷性服務所節省的健保藥費為189元。藥師於門診執行判斷性服務確實能減少藥費，在健保財源日益緊縮的趨勢下，若能給予藥師足夠的時間，並鼓勵藥師多進行判斷性服務，並有足夠的相關資訊(例如腎功能異常值、藥物過敏史、病患完整藥歷檔等資訊)，則藥師更能夠發現藥物交互作用、重複用藥、劑量需調整等治療問題。除了節省健保藥費外，還能保障病人的用藥安全，促進用藥的效果，及避免用藥的危害，這些無法估算的好處，所減少總醫療花費金額，可能遠比節省的藥費更加可觀。
本研究藉由個案的分析，探討藥師各項介入活動對於藥費的差異變化，做為未來向健保局申請該項服務納入給付之參考。建議健保局可對選擇不同類型的醫院進行試辦，利用記錄表網路上傳的方式來收集資料，將能夠全面的探查門診藥師所進行的判斷性服務。也期望有更多醫院的資料呈現，做為未來向健保局申請判斷性服務給付的依據。

The purposes of this study were (1) to determine the major contents of cognitive services while pharmacists review prescriptions; and (2) its impact on drug expenditures (fee) via cognitive service, as a references of future health insurance reimbursement. The research materials were the records of cognitive services collected in the eight branches of Taipei City Hospital from March to December, 2005. Total 1,676 valid records of cognitive services were collected during the study period to analyze contents of services and changes of drug fees.
The cognitive service records reveal that the major medication problem that pharmacists found was shorter interval between two doses (17.8%), followed by repetition medication (15.1%) and unlabeled use (13.0%). Changing doses, changing intervals of doses, and changing other medicines were the main pharmacists’ interventions. Of all suggestions, forty percent were related to doses. However, the most situations of changing other drugs were resulted from doctors selecting wrong medicines on computers when they prescribed. Above problems could be solved by a well-designed computer program. When a physician prescribed, the program could screen unusual situations and inform or warn the doctor. Ninety-four percent of prescriptions were revised because of pharmacists’ interventions. The major changes were changing another medicine and changing the interval of doses. If those prescriptions were not revised, it has probably caused invalid therapy or result in side effects.
For cost perspective, this study showed that pharmacists’ interventions have successfully decreased drug expenditure in 63% of cases and only increased drug expenditure in 18% of cases. In average, each time a pharmacist offered cognitive services could help National Health Insurance to save drug fees of $ 189 NTD. Pharmacists executing cognitive services in outpatient pharmacy department can indeed reduce drug expenditure. With the decreasing financial availability of National Health Insurance, if giving enough time to pharmacists, encouraging them to execute cognitive services, and offering enough information (eg. abnormal level of renal function, history of drug allergy, complete drug files, and etc.) to them, pharmacists can find out more problems associated with drug interactions, repetition medication, and dose adjustments. It not only can save drug expenditures, but also can assure patients’ safety of drug use, can improve effectiveness of drugs, and can avoid damage of drug use. All these inestimable benefits – total medical expenses eliminated – could be even higher than drugs fees saved.
According to analysis of case report, this study was to determine the drug fees’ fluctuation that caused by pharmacists’ interventions. The results of study can be references for applying the subsidy of cognitive services that may be included in reimbursements from the Bureau of National Health Insurance (BNHI) in the future. BNHI authorities can select different types of hospitals to execute the services. The data can be collected from uploading the records of cognitive services via the Internet, in order to investigate entirely cognitive services offered by pharmacists in outpatient pharmacy department. It hopes that more and more hospitals can contribute more information to help claiming reimbursements from BNHI in the future.

中文摘要…………………………………………………………… i
英文摘要…………………………………………………………… iii
目錄………………………………………………………………… v
表目錄……………………………………………………………… vii
第一章、 前言…………………………………………………… 1
第一節、 研究背景與動機……………………………………… 1
第二節、 研究目的……………………………………………… 2
第二章、 文獻探討……………………………………………… 3
第一節、 藥事服務……………………………………………… 3
第二節、 我國門診藥師執業的規範…………………………… 4
第三節、 美國OBRA ‘90法案…………………………………… 5
第四節、 判斷性服務…………………………………………… 7
第五節、 國外判斷性服務的給付……………………………… 8
第六節、 我國藥事服務費的給付……………………………… 11
第三章、 研究方法……………………………………………… 12
第一節、 研究材料與收集方法………………………………… 12
第二節、 判斷性服務記錄表格………………………………… 13
第三節、 研究過程……………………………………………… 14
第四章、 研究結果……………………………………………… 15
第一節、 研究案例件數及來源………………………………… 15
第二節、 藥物治療問題的種類………………………………… 17
第三節、 藥師介入活動的統計………………………………… 20
第四節、 藥師介入後的結果…………………………………… 21
第五節、 藥師介入對處方藥費的影響………………………… 22
第六節、 各項藥師介入活動與藥費的差異…………………… 23
第七節、 各項藥師介入結果與藥費的差異…………………… 25
第五章、 討……………………………………………………… 27
第一節、 判斷性服務過程的記錄……………………………… 27
第二節、 判斷性服務佔總處方數的比例……………………… 29
第三節、 藥師進行判斷性服務的價值………………………… 31
第四節、 藥師發現藥物治療問題……………………………… 31
第五節、 藥師介入對處方藥費的影響………………………… 33
第六節、 研究結果推論上的限制……………………………… 34
第六章、 結論與建議…………………………………………… 36
參考文獻…………………………………………………………… 38
附錄一、優良藥品調劑作業規範………………………………… 39
附錄二、優良藥品調劑作業準則………………………………… 44
附錄三、判斷性服務記錄表及填表說明………………………… 46

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