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研究生:陳合發
研究生(外文):Ho-Fa Chen
論文名稱:藥師執行高診次患者藥事居家照護之成效評估
論文名稱(外文):Outcomes Assessment of Home Pharmaceutical Care on High User of Medical Resources by a Pharmacist
指導教授:王四切王四切引用關係
指導教授(外文):Tzu-Chueh Wang
口試委員:黃耀斌李冠漢譚延輝王四切
口試委員(外文):Yaw-Bin HuangKuan-Han LeeYen-Huei TarnTzu-Chueh Wang
口試日期:2013-07-18
學位類別:碩士
校院名稱:嘉南藥理大學
系所名稱:藥學系
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:2014
畢業學年度:103
語文別:中文
論文頁數:97
中文關鍵詞:藥事照護藥師居家訪視高診次民眾醫療支出
外文關鍵詞:pharmaceutical Carepharmacistshigh user of medical resourceshome visitshealthcare expenditure
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中華民國藥師公會全國聯合會於2010年起承接中央健康保險局的試辦方案,針對一年就醫100次以上的高就診民眾由培訓及格的藥師執行藥事居家照護,提升病人用藥認知以導正高就診的就醫行為,並解決藥物治療問題,降低用藥風險,提高病人生活品質。
本研究主要目的是呈現提供藥事居家照護四年期間,針對減少門診次數、解決藥物治療問題、提升病人生活品質及減少醫療花費的成效。研究成果以三方向呈現:臨床成果、人性成果及經濟上成果。
自2010年3月至2013年12月的三年十個月,共照護51位高診次病患,經個案簽署同意書後納入研究。依據藥師公會全聯會制定的藥事照護流程,採用病情與用藥評估、擬定與執行照顧計畫、並持續追蹤療效的方式照顧個案,同時記錄發現到的藥物治療問題,針對問題建議解決辦法,並依據測量之結果進行統計分析與比較。
依據研究者成功訪視51位個案之資料分析,平均每人服務7.02次,女性(62.4%)稍多於男性。年齡範圍從36歲到88歲不等,而年齡分布在65~88歲之間的個案人數最多,有35位(68.6%)。以在早期個案平均就診次數,去比較晚期個案平均就診次數,採用t檢定,就診次數有顯著下降(4.98±4.74次比3.13±3.10次,p<0.05)。
本計畫在人性上之成果是測量個案滿意度與健康相關生活品質。超過90%的個案都很同意且很滿意藥師的服務與價值,並有高的意願繼續接受藥師的照顧。在健康相關生活品質方面,過半數個案的健康相關生活品質有提升,表現最好的可以由30分提升到80分。
從「門診醫療費用」數據分析51位高診次個案,已明顯看出藥師在居家照護輔導個案平均7.02個月以後,99年平均下降29.01%(目標值-10%),100年平均下降29.48%(目標值-10%),101年平均下降26.04%(目標值-12%),102年平均下降26.52%(目標值-12%)。在節省門診醫療總花費方面的成本利益比為1.00:3.56。這代表研究者四年可協助健保局節省門診醫療花費,高達新台幣 938,915元。
四年的成績,已看到藥事居家照護有顯著之成果,可降低高就診民眾的就診次數和減少總門診醫療花費。在目前健保署的「高診次藥事照護試辦計畫」推展實施之下,藥師到高診次病患家中執行藥事照護是可行的且符合成本效益的推廣模式。專業藥師到病人家中與病人訪談中,可以發現病人多重看診用藥,以及其他許多藥物治療問題,經藥師溝通與解決問題,可保障民眾的用藥安全,並減少健保的醫療支出。

The Taiwan Pharmacists Association implemented a pilot project supported by the National Health Insurance Administration and started in 2010. The project was to, with respect to the patients receiving medical treatment for more than 100 times a year, study the outcomes of home pharmaceutical care provided by pharmacists.
This thesis was to present the author’s performance on decreasing the number of clinical visits, identify and resolve drug therapy problems, enhancing quality of life of the patients, and the overall reduction of healthcare expenditures. Therefore, the outcomes of the study were measured from three dimensions: clinical outcomes, humanistic outcomes, and economic outcomes.
This thesis was undertaken from March 2010 to December 2013, a total of three years and 10 months. Total of 51 high users of medical resources were included with their consent to participate the study. Based on the processes of home pharmaceutical care formulated by the Taiwan Pharmacists Association, all information related to patient diseases and drug usage were assessed, care plans were formulated and implemented, then all the actions and resolutions were followed up and recorded.
Of the total 51 patients under the study period, pharmacist conducted in average 7.02 home visits per patient. Their age ranges from 36 to 88 years old and the female patients accounts for 62.4%. Patients in the range of 65 to 88 years old have the largest number, 35 persons, and accounts for 68.6% of the total. Number of clinical visits at early and late stages showed significant decreased from 4.98±4.74 to 3.13±3.10.
More than 90 % of the patients under this study were highly agreed that pharmacist can indeed help them, and highly satisfied with the home care service offered by the pharmacists, and patients are willing to continue such pharmaceutical care performed by the pharmacists. In addition, more then half of the patients their health related quality of life increased with some increased even from 30 up to 80, on a scale of 0 ~ 100.
The economic outcome using reduction of outpatient healthcare expenditure as indicator also showed that after 7.02 months of the home care individually, healthcare expenditure decreased significantly. The average OPD healthcare expenditure decreased by 29.01 % in the year 2010 (the BNHI target was 10% reduction), 29.48% in 2011 (the target was 10% reduction), 26.04% in 2012 (the target was 12%), and 26.52% in 2013 (the target was 12%), respectively. Using the reimbursement of service fee to pharmacist as the cost and saving of OPD healthcare expenditure as the benefit, the cost-benefit ration for this thesis study was 1.00 : 3.56. The author’s effort in these few years can helped to save the outpatient healthcare expenses from National Health Insurance program up to NT$938,915 dollars.
In conclusion, under the current pilot project sponsored by the National Health Insurance Administration, inviting pharmacists to conduct home visit and pharmaceutical care is quite feasible and cost beneficial. At patient’s home, pharmacist can collect all the drugs patient is taing, identify drug therapy problems that make the patient’s disease not effective and even has adverse reaction, also, adherence issue can be identified and resolved. By doing so, pharmacist can guarantee to protect the safe and appropriate use of medication and increase patient’s quality of life, and finally help to reduce the waste of healthcare resources.

第一章 緒言 1
第一節 研究背景 1
第二節 研究動機 10
第三節 研究目的 14
第四節 研究假說 15
第二章 文獻探討 17
第一節 居家照護文獻之探討 17
第二節 藥事照護的療效結果測量之文獻探討 28
第三節 國內、外照護研究文獻之探討 43
第三章 研究方法 46
第一節 研究流程 46
第二節 研究分析工具 48
第四章 研究結果 52
第一節 研究結果 52
一、臨床結果 52
二、經濟結果 53
三、人性結果 55
第二節 資料分析結果 58
第五章 討論 82
第六章 結論 93
參考文獻 98
附錄一、高診次藥事居家照護藥師選案辦法 104
附錄二、藥事居家照護報告書 108
附錄三、民眾對藥師所提供居家照護之滿意度調查 109
附錄四、2011 EuroQol Group. EQ-5D-5L 111

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