臺灣博碩士論文加值系統

自從全民健保開辦以來，呼吸道系統疾病一直都是醫療院所門診申報最常見的疾病，在申報前20大疾病中，急性呼吸道感染佔第一位，急性支氣管炎佔第三位，急性扁桃腺炎佔第十位，有見於國內對於不同專科別的兒童急性呼吸道感染其門診處方型態與用藥品質的研究闕如，本研究設計為一回溯性橫斷面研究，針對0-14歲急性呼吸道感染兒童在國軍左營總醫院小兒科、家醫科和耳鼻喉科三個不同專科別進行其門診處方型態與用藥品質之描述性與推論性分析，以作為提升小兒用藥品質與用藥安全的參考。
本研究共分析788個就診人次，其中小兒科270人次，家醫科261人次，耳鼻喉科257人次，一、處方型態：在診斷方面，三個專科的上呼吸道感染都比下呼吸道感染多，其中都以急性鼻咽炎或感冒最常見，其次為急性支氣管炎，前三位的診斷已包含三個科別八成以上的診斷。在用藥筆數方面，以耳鼻喉科每就醫人次處方4.20筆最高，家醫科2.77筆最低。在藥理分類方面，三個科別都是以咳嗽及感冒製劑最常見(大於80%)，其次是抗組織胺(大於60%)，抗氣喘藥劑的被處方以小兒科最高(40.4%)、耳鼻喉科最低(1.9%)，解熱鎮痛劑的被處方以耳鼻喉最高(60.3%)、小兒科最低(28.9%)，抗生素的被處方以耳鼻喉科最高(28.8%)，家醫科最低(5.7%)，在抗氣喘藥、解熱鎮痛劑和抗生素的使用上，三個科別存在顯著性差異。二、用藥品質：小於六歲兒童被處方小兒專用藥劑的比例以家醫科最高(65.8%)、耳鼻喉科最低(46.2%)，藥物磨粉部份以耳鼻喉科最高(51.3%)、家醫科最低(34.2%)。在並用相同藥理分類藥物方面，小兒科、家醫科和耳鼻喉科的比例分別為23%、13.4%及19.8%，其中以咳嗽及感冒製劑最常被並用。在不適當處方方面，三個科別的比例分別為小兒科7.4%、家醫科11.5%及耳鼻喉科10.9%，其中以非核准範疇內使用，如年齡、適應症和劑量不符最常見，各科藥物不良反應的比例分別為小兒科1.5%、家醫科1.1%及耳鼻喉科2.3%
本篇研究結果顯示，不同科別針對兒童急性呼吸道感染的處方型態與用藥品質差異頗大，各科仍然有相當比例的抗生素被處方在感冒、其他非特異性上呼吸道感染和支氣管炎病患身上，如何減少不適當處方、藥物不良反應和加強各專科醫師對於小兒用藥安全的知識，實是當務之急。

Respiratory system disorders are always the most frequently diseases in the ambulatory claim of the hospitals since the implementation of National Health Insurance. Of the top twenty diagnoses, acute respiratory tract infections are the most common diagnoses, third as acute bronchitis, and tenth as acute tonsillitis. Due to the shortage of studies in discussing the prescribing patterns and quality of prescriptions in ambulatory children with acute respiratory tract infections among different specialists in our country, this study is a retrospective cross-section design. All the children who were below 14 years of age , diagnosed to be acute respiratory tract infection and have visited in the pediatric, family medicine, or otolaryngological departments were enrolled in this study. Descriptive and inferential analysis were performed in order to analyze the patterns and quality of prescriptions among different specialists. The result of research may be a useful and important reference for promotion of prescribing quality and medication safety.
There were 788 ambulatory visits recorded in this study. They consisted of 270 pediatric visits, 261 family medicine visits, and 257 otolaryngological visits. The results were devided into two categories:
1. Prescribing patterns: (1) In terms of principal diagnosis, upper respiratory tract infections were more common than lower respiratory tract infections in the three specialists. The majority of diagnoses were acute nasopharyngitis or common cold, followed by acute bronchitis. The top three diseases occupied more than 80% of all diagnoses. (2) In terms of medications prescribed, the highest medications prescribed was 4.20 drugs by the otolaryngological physicians, while the lowest was 2.77 drugs by the family medicine physicians. (3) In terms of pharmacologic classification, the most commonly prescribed medication was cough and cold preparations with more than 80% of prescribing rate in the three specialists, followed by antihistamines with more than 60% of prescribing rate. The highest prescribing rate of anti-asthmatic agents was 40.4% by the pediatricians, while the lowest rate was 1.9% by the otolaryngological physicians. The highest prescribing rate of antipyretic & antalgic agents was 60.3% by the otolaryngological physicians, while the lowest rate was 28.9% by the pediatricians. The highest prescribing rate of antibiotics was 28.8% by the otolaryngological physicians, while the lowest rate was 5.7% by the family medicine physicians. There was significant difference between the prescribing rate about anti-asthmatic, antipyretic & antalgic agents , and antibiotics and different specialists .
2. Quality of prescriptions: (1) In terms of children-specific preparations for less than 6 years of age, the highest prescribing rate was 65.8% by the family medicine physicians, while the lowest rate was 46.2% by the otolaryngological physicians. On the contrary, the highest prescribing rate of powdered medications was 51.3% by the otolaryngological physicians, and the lowest rate was 34.2% by the family medicine physicians. (2) In terms of concurrent use of drug classification, the prescribing rate by the pediatricians, family medicine physicians and otolaryngological physicians was 23%, 13.4% and 19.8%, respectively. Cough and cold preparations were the most commonly prescribed agents.(3) In terms of inappropriate medication use, there was 7.4%, 11.5% and 10.9%, respectively corresponding to the three specialists.Off-label drugs were the most common causes for inappropriate medication use. (4) In terms of adverse drug response or side effects, there was 1.5%, 1.1% and 2.3%, respectively corresponding to the three specialists.
According to the results, significant difference existed among different specialists in terms of prescribing patterns and quality of prescriptions in ambulatory children with acute respiratory tract infections. A substantial proportions of antibiotics were still prescribed to children diagnosed as having common cold, nonspecific upper respiratory tract infection, and bronchitis. It is important to educate the medication safety of children to different specialists and to reduce the prescribing rate of inappropriate medication use and adverse drug response.

論文提要 …………………………………………………i
中文摘要………………………………………………………….ii
英文摘要………………….……………………………..v
誌謝詞……………………………………………………vii
目錄………………………………………………………..ix
表目錄……………………………………………………..xi
圖目錄………………………………………………………….xii
第一章 緒論………...……………………………………..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 小兒呼吸道感染……………………………....3
第二節 小兒處方型態……………………………….10
第三節 小兒用藥安全……………………………….16
第四節 小兒呼吸道疾病的藥物交互作用………….23
第五節 小兒呼吸道感染抗生素的使用……………27
第六節 專科別在照護上的差異................................35
第三章 研究設計與研究方法…………........…………38
第一節 研究範圍........................................................38
第二節 研究流程........................................................38
第三節 研究架構………....…………………………41
第四節 變項的說明…………………………………41
第五節 資料分析……………………………………44
第四章 研究結果分析與探討…………………………46
第一節 處方型態的描述性統計分析………………46
第二節 用藥品質的描述性統計分析………………50
第三節 推論性統計分析……………………............52
第五章 結論與建議……………………………………60
第一節 結論…………………………………………60
第二節 建議…………………………………………62
第三節 研究限制……………………………………63
參考文獻……………………………………………....64
一、中文部份……………………………………....64
二、英文部份……………………………………....66
三、網頁部份……………………………………...73
附錄一 兒童專用藥劑使用情形問卷調查…...……...74
附錄二102種兒童專用藥劑品項表…………....……79
附錄三 ATC藥品分類系統於健保局給付藥品的應用..85

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(三) 網頁部分
中央健康保險局，2001；2005；2006，http://www.nhi.gov.tw/。
行政院衛生署消費者資訊網，2007，「重視小兒用藥安全問題，守護您家的小寶貝」，http:// drug.doh.gov.tw/。
行政院衛生署藥品交互作用資料庫系統，2009，http://dif.doh.gov.tw/。
財團法人台灣醫療改革基金會，2007；2008，http://www.thrf.org.tw/。
財團法人醫院評鑑暨醫療品質策進會，2007，http://www.tjcha.org.tw/。
國軍桃園總醫院藥品資訊查詢公布欄，2008，「兒童用藥安全