跳到主要內容

臺灣博碩士論文加值系統

(44.211.31.134) 您好!臺灣時間:2024/07/21 04:59
字體大小: 字級放大   字級縮小   預設字形  
回查詢結果 :::

詳目顯示

我願授權國圖
: 
twitterline
研究生:李國任
研究生(外文):Kuo-Jen Li
論文名稱:老年慢性病門診病患之潛在性不適當處方的相關危險因子探討
論文名稱(外文):Risk Factors of Potentially Inappropriate Prescribing among Ambulatory Older Patients with Chronic Disease
指導教授:陳宣志陳宣志引用關係
指導教授(外文):Shiuan-Chih Chen
學位類別:碩士
校院名稱:中山醫學大學
系所名稱:醫學研究所
學門:醫藥衛生學門
學類:醫學學類
論文種類:學術論文
論文出版年:2013
畢業學年度:101
語文別:中文
論文頁數:50
相關次數:
  • 被引用被引用:0
  • 點閱點閱:181
  • 評分評分:
  • 下載下載:0
  • 收藏至我的研究室書目清單書目收藏:0
前言:臨床上老人用藥問題亦逐漸受到重視。在國內外老人用藥佔總用藥量比例均甚高,且因老化及慢性疾病狀態,服用潛在性不適當處方可使發生藥物不良反應之機會增加,許多研究都顯示潛在性不適當處方之盛行率均偏高,而相關危險因子未有明確定論。故本研究意欲探究門診老年慢性病患之潛在性不適當處方的盛行率以及相關危險因子。
方法:本研究資料取自2009年7月到12月至中部某醫學中心家醫科門診開立慢性處方之65歲含以上558位老年患者,根據病歷紀錄患者之年齡、性別、慢性病狀態以及處方藥物,使用2003年Beers Criteria評估患者潛在性不適當處方。以Student’s t檢定和卡方檢定各變項與潛在性不適當處方之相關性,進而以多變項邏輯斯迴歸模式分析,探究潛在性不適當處方之危險因子。
結果:研究對象平均年齡為74.89 ± 6.65歲;平均疾病診斷數目為5.20 ± 2.58種;平均藥物數目為4.88 ± 2.56個;平均看診科別為1.25 ± 0.56科;平均處方籤數為1.40 ± 0.75張。其中107位(19.17%)有一項以上潛在性不適當處方。558位患者常見之慢性病診斷為循環系統疾病(76.88%)、肌肉骨骼與結締組織疾病(56.09%)以及消化系統疾病(46.59%)。107位患者服用之PIM,常見的包括非類固醇抗發炎藥物(24.29%)、benzodiazepine類藥物(16.82%)、抗膽鹼作用藥物(15.88%)以及解痙劑(11.21%)。經多變項邏輯斯回歸分析顯示,潛在性不適當處方與藥物數目(勝算比= 1.35;95%信賴區間= 1.23-1.48;p < 0.001)、年齡(勝算比= 1.03;95%信賴區間= 1.01-1.07;p = 0.049)、以及精神疾病(勝算比= 1.85;95%信賴區間= 1.14-3.00;p = 0.010)有關。
結論:本研究顯示潛在不適當處方在家醫科門診的慢性處方中並不少見,臨床醫師對於多種藥物處方、高齡以及情感性精神疾病或失智症患者,應考慮其高風險性潛在不適當處方的可能性。


Objective: Problems related to prescriptions for older patients is considered a major public health issue in recent studies. The elderly patients took a great proportion of total drug use according to different statistical analyses in several countries. Potentially inappropriate medications(PIMs) in elderly could lead to an increase in the likelihood of adverse drug events because of aging and multiple chronic comorbidities. The prevalence of PIM use was high in numerous studies. The factors associated with potentially inappropriate medication had been frequently explored but still had some controversies. The aim of our study is to identify the prevalence and risk factors for PIM use in ambulatory older patients with chronic diseases.
Methods: This study included 558 consecutive patients, aged ≥ 65 years with chronic diseases, who received long-term prescriptions during their outpatient visits to family medicine clinics at a university hospital in central Taiwan between July 1 and December 31, 2009. PIM was assessed according to the 2003 updated Beers Criteria. Data regarding demographic characteristics, coexisting diseases, and ambulatory prescriptions were collected and analyzed. The clinical factors related to PIM were determined using logistic regression.
Results: The mean age of the 558 patients was 74.89 ± 6.65 years. The mean number of comorbid conditions was 5.20 ± 2.58; the mean number of drugs prescribed was 4.88 ± 2.56. PIM was identified in 107 patients (19.17%). Most common chronic disease was disease of circulatory system (76.88%), followed by musculoskeletal and connective tissue diseases (56.09%), and diseases of digestive system (46.59%). Most common PIMs were non-steroid anti-inflammatory drugs (24.29%), followed by benzodiazepines (16.82%), anticholinergic agents (15.88%), and antispasmotics (11.21%). Multivariate analysis revealed that PIM was significantly associated with the number of drugs prescribed (p< 0.001), advanced age (p= 0.049), and psychiatric illnesses (p= 0.010).
Conclusions: Clinicians should be alert to the possibility of PIM in ambulatory older patients with chronic diseases, especially in those taking multiple medications and those who have advanced age or psychiatric illnesses.


目錄
誌謝----------------------------------------------------I
中文摘要-----------------------------------------------II
英文摘要-----------------------------------------------IV
第一章 緒論
第一節 研究背景與動機---------------------------------1
第二節 不適當處方之評估工具---------------------------2
第三節 Beers Criteria之發展與應用---------------------3
第四節 研究目的---------------------------------------4
第二章 文獻探討
第一節 潛在性不適當處方之盛行率-----------------------5
第二節 潛在性不適當處方之危險因子---------------------5
第三章 研究設計
第一節 研究對象與資料收集-----------------------------7
第二節 研究工具---------------------------------------7
第三節 研究架構---------------------------------------8
第四節 統計分析---------------------------------------8
第四章 研究結果
第一節 病患基本特性----------------------------------10
第二節 單變項分析------------------------------------12
第三節 多變項邏輯斯迴歸分析--------------------------12
第五章 討論
第一節 潛在性不適當處方之盛行率--------------------13
第二節 常見潛在性不適當處方之藥物------------------14
第三節 潛在性不適當處方之危險因子------------------15
第四節 研究限制------------------------------------17
第六章 結論與建議--------------------------------------19
參考文獻-----------------------------------------------20

表目錄
表1 慢性疾病種類及其相關疾病診斷碼--------------------29
表2 老年慢性病門診病患之臨床特性----------------------32
表3 老年慢性病門診病患之潛在性不適當處方,根據2002年Beers Criteria:不考慮患者診斷,一般即應避免的潛在性不適當處方藥物-----------------------------------------------------33
表4 老年慢性病門診病患之潛在性不適當處方,根據2002年Beers Criteria:考慮患者慢性病或失能狀態下,應避免的潛在性不適當處方藥物-------------------------------------------------34
表5 潛在性不適當處方危險因子之單變項分析--------------36
表6 潛在性不適當處方危險因子之多變項分析--------------38

圖目錄
圖1 研究流程圖----------------------------------------39

附錄1 老年門診患者PIM盛行率與相關因子比較-------------40
附錄2 2003 Beers Criteria:一般狀況應避免之潛在性不適當處方--------------------------------------------------------43
附錄3 2003 Beers Criteria: 特定疾病或狀況應避免之潛在性不適當處方-------------------------------------------------47
附錄4 合併症嚴重度評估Charlson’s comorbidity index---50


1. Chutka DS, Takahashi PY, Hoel RW: Inappropriate medications for elderly patients. Mayo Clin Proc 2004;79:122-39.
2. Lamy PP: New dimensions and opportunities. Drug Intell Clin Pharm 1985;19:399-402.
3. Lin HY, Liao CC, Cheng SH, Wang PC, Hsueh YS: Association of potentially inappropriate medication use with adverse outcomes in ambulatory elderly patients with chronic diseases: experience in a Taiwanese medical setting. Drugs Aging 2008;25:49-59.
4. Chang CM, Liu PY, Yang YH, Yang YC, Wu CF, Lu FH: Potentially inappropriate drug prescribing among first-visit elderly outpatients in Taiwan. Pharmacotherapy 2004;24:848-55.
5. 黃盈翔、盧豐華: 老年人之用藥原則。台灣醫學2003;7:385-95.
6. Gallagher PF, Barry PJ, Ryan C, Hartigan I, O''Mahony D: Inappropriate prescribing in an acutely ill population of elderly patients as determined by Beers'' Criteria. Age Ageing 2008;37:96-101.
7. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH: Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 2003;163:2716-24.
8. Fick DM, Mion LC, Beers MH, L Waller J: Health outcomes associated with potentially inappropriate medication use in older adults. Res Nurs Health 2008;31:42-51.
9. Hanlon JT, Schmader KE, Samsa GP, et al: A method for assessing drug therapy appropriateness. J Clin Epidemiol 1992;45:1045-51.
10. Naugler CT, Brymer C, Stolee P et al: Development and validation of an improved prescribing in the elderly tool. Can J Clin Pharmacol 2000;7:103-7.
11. Zhan C, Sangl J, Bierman AS, Miller MR, Friedman B, Wickizer SW, Meyer GS: Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey. JAMA 2001; 286:2823-9.
12. National Committee on Quality Assurance. Drugs to be avoided in the elderly. Available at: http://www.ncqa.org/portals/0/Newsroom/2007/Drugs_Avoided_Elderly.pdf. Accessed June 15, 2013.
13. Gallagher P, Ryan C, Byrne S et al: a STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment): consensus validation. Int J Clin Pharm Ther 2008;46:72–83.
14. Guaraldo L, Cano FG, Damasceno GS, Rozenfeld S: Inappropriate medication use among the elderly: a systematic review of administrative databases. BMC Geriatr 2011;11:79.
15. American Geriatrics Society 2012 Beers Criteria Update Expert Panel: American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012;60:616-31.
16. Jano E, Aparasu RR: Healthcare outcomes associated with beers'' criteria: a systematic review. Ann Pharmacother 2007;41:438-47.
17. Chang CM, Liu PY, Yang YH, Yang YC, Wu CF, Lu FH: Use of the Beers criteria to predict adverse drug reactions among first-visit elderly outpatients. Pharmacotherapy 2005;25:831-8.
18. Gurwitz JH, Field TS, Harrold LR, et al: Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 2003;289:1107-16.
19. Fialová D, Topinková E, Gambassi G, et al: Potentially inappropriate medication use among elderly home care patients in Europe. JAMA. 2005;293:1348-58.
20. Lai HY, Hwang SJ, Chen YC, Chen TJ, Lin MH, Chen LK: Prevalence of the prescribing of potentially inappropriate medications at ambulatory care visits by elderly patients covered by the Taiwanese National Health Insurance program. Clin Ther 2009;31:1859-70.
21. Steinman MA, Landefeld CS, Rosenthal GE, Berthenthal D, Sen S, Kaboli PJ: Polypharmacy and prescribing quality in older people. J Am Geriatr Soc 2006;54:1516-23.
22. Lang PO, Hasso Y, Dramé M, et al: Potentially inappropriate prescribing including under-use amongst older patients with cognitive or psychiatric co-morbidities. Age Ageing 2010;39:373-81.
23. Gallagher P, Barry P, O’Mahony D: Inappropriate prescribing in the elderly. J Clin Pharm Ther 2007;32:113-21.
24. Chronic Disease Patients (Refill Prescriptions). Definition of Bureau National Health Insurance in Taiwan. http://www.nhi.gov.tw/English/webdata/webdata.aspx?menu=11&menu_id=596&WD_ID=596&webdata_id=3179 [Accessibility verified April.20.2013]
25. Charlson ME, Pompei P, Ales KL, MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373-83.
26. van der Hooft CS, Jong GW, Dieleman JP, et al: Inappropriate drug prescribing in older adults: the updated 2002 Beers criteria – a population based cohort study. Br J Clin Pharmacol 2005;60;137–44.
27. Aparasu RR, Mort JR: Inappropriate prescribing for the elderly: Beers criteria-based review. Ann Pharmacother 2000;34:338-46.
28. Bjerrum L, Rosholm JU, Hallas J, Kragstrup J: Methods for estimating the occurrence of polypharmacy by means of a prescription database. Eur J Clin Pharmacol 1997;53:7-11.
29. Fulton MM, Allen ER: Polypharmacy in the elderly: a literature review. J Am Acad Nurse Pract 2005;17:123-32.
30. Hajjar ER, Cafiero AC, Hanlon JT: Polypharmacy in elderly patients. Am J Geriatr Pharmacother 2007;5:345-51.
31. Frazier SC: Health outcomes and Polypharmacy in elderly individuals: an integrated literature review. J Gerontol Nurs 2005;31:4-11.
32. Pugh MJV., Starner CI, Amuan ME, et al: Exposure to potentially harmful drug-disease interactions in older community-dwelling veterans based on the healthcare effectiveness data and information set quality measure: Who is at risk? J Am Geriatr Soc 2011;59:1673-8.
33. Zhan C, Sangl J, Bierman AS, et al: Potentially inappropriate medication use in the community dwelling elderly. JAMA 2001;286:2823-9.
34. Chang CB, Chen JH, Wen CJ, et al: Potentially inappropriate medications in geriatric outpatients with polypharmacy: application of six sets of published explicit criteria. Br J Clin Pharmacol 2011;72:482-9.
35. Hume AL, Quilliam BJ, Goldman R, Eaton C, Lapane KL: Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms. BMJ Qual Saf 2011;20:875-84.
36. Aparasu RR, Fliginger SE. Inappropriate medication prescribing for the elderly by office-based physicians. Ann Pharmacother 1997;31:823-9.
37. Aparasu RR, Sitzman SJ: Inappropriate prescribing for elderly outpatients. Am J Health Syst Pharm 1999;56:433-9.
38. Piecoro LT, Browning SR, Prince TS, Ranz TT, Scutchfield FD. A database analysis of potentially inappropriate drug use in an elderly medicaid population. Pharmacotherapy 2000;20:221-8.
39. Curtis LH, Ostbye T, Sendersky V, et al: Inappropriate prescribing for elderly Americans in a large outpatient population. Arch Intern Med 2004;164:1621-5.
40. Pugh MJ, Hanlon JT, Zeber JE, Bierman A, Cornell J, Berlowitz DR: Assessing potentially inappropriate prescribing in the elderly Veterans Affairs population using the HEDIS 2006 quality measure. J Manag Care Pharm 2006;12:537-45.
41. Maio V, Hartmann CW, Poston S, Liu-Chen X, Diamond J, Arenson C: Potentially inappropriate prescribing for elderly patients in 2 outpatient settings. Am J Med Qual 2006;21:162-8.
42. de Oliveira Martins S, Soares MA, Foppe van Mil JW, Cabrita J: Inappropriate drug use by Portuguese elderly outpatients--effect of the Beers criteria update. Pharm World Sci 2006;28:296-301.
43. Maio V, Yuen EJ, Novielli K, Smith KD, Louis DZ: Potentially inappropriate medication prescribing for elderly outpatients in Emilia Romagna, Italy: a population-based cohort study. Drugs Aging 2006;23:915-24.
44. De Wilde S, Carey IM, Harris T, et al: Trends in potentially inappropriate prescribing amongst older UK primary care patients. Pharmacoepidemiol Drug Saf 2007;16:658-67.
45. Bierman AS, Pugh MJ, Dhalla I, et al: Sex differences in inappropriate prescribing among elderly veterans. Am J Geriatr Pharmacother 2007;5:147-61.
46. Ryan C, O''Mahony D, Kennedy J, Weedle P, Byrne S: Potentially inappropriate prescribing in an Irish elderly population in primary care. Br J Clin Pharmacol 2009;68:936-47.
47. Zaveri HG, Mansuri SM, Patel VJ: Use of potentially inappropriate medicines in elderly: A prospective study in medicine out-patient department of a tertiary care teaching hospital. Indian J Pharmacol 2010;42:95-8.
48. Maio V, Del Canale S, Abouzaid S, et al: Using explicit criteria to evaluate the quality of prescribing in elderly Italian outpatients: a cohort study. J Clin Pharm Ther 2010;35:219-29.
49. Ghadimi H, Esmaily HM, Wahlstrom R: General practitioners'' prescribing patterns for the elderly in a province of Iran. Pharmacoepidemiol Drug Saf 2011;20:482-7.


QRCODE
 
 
 
 
 
                                                                                                                                                                                                                                                                                                                                                                                                               
第一頁 上一頁 下一頁 最後一頁 top