臺灣博碩士論文加值系統

本研究評估投入臨床藥師參與加護病房醫療團隊進行藥事照顧，是否能降低用藥成本及是否會影響病人結果。以某財團法人私立醫學中心外科加護病房為研究地點，自2001年10月起，至2002年5月，將住進外科加護病房之病人，以簡單隨機方式分入實驗組或對照組，由一位臨床藥師對實驗組的病人提供臨床藥事服務。臨床藥師並記錄所有介入的詳細內容，由研究者以醫院成本與健保給付價計算所有介入導致的藥物治療成本節省（cost saving），並請二位評估醫師針對藥師的介入評估所可能達成的成本避免（cost avoidance）。
研究結果共有169位病人納入對照組，185位病人納入實驗組。藥師平均每日在加護病房工作時數為3.15小時。研究期間臨床藥師共介入106件，提供醫護人員藥物資訊服務有86件。「介入行為種類」最多的前三項為「遺漏應有的藥物治療」（16.0％）、「藥物動力學諮詢」（13.2％）、「檢驗報告異常」（12.3％）。「建議」最多的前三項為「停用藥物」（23.6％）、「改變藥物」（22.6％）、「開出新的處方」（17.9％）。「建議結果，根據藥師建議所做的處方改變」最多的項目為「藥物停用」（21.7％）、「藥物改變」（16.0％）。「建議不被接受」有15.1％，所以根據藥師建議而導致處方改變的比率佔84.9％。臨床藥師介入最多的藥物使用種類為抗感染製劑（anti-infective agents）（35.6％）、心血管藥物（cardiovascular drugs）（18.3％）及胃腸道藥物（gastrointestinal drugs）（12.5％）。
以健保給付價而言，總共節省新台幣375,333元，藥費節省最多的藥物種類是抗感染製劑，第二位的是心血管製劑。以醫院成本價來計算，節省的費用達新台幣258,135元。該藥師當時年薪約新台幣750,000元，平均時薪為260.42元。根據所達成的成本節省對藥師薪水計算，利益對成本比率（benefit-to-cost ratio）為2.20。
二位評估醫師分別認為有69個（65.1％）與55個（51.9％）建議是無藥師介入時，可能會造成病人傷害的。至於無藥師介入可能造成的結果，都是以「可能造成藥物不良反應」最多，分別是34個（49.3％）與30個（56.6％）。對藥師建議所做的重要性評估則分別是以第二個等級「很有意義」，百分比為41.5％；與第三個等級「有意義」，百分比為34.9％為最多。
成本避免方面，依據二位醫師的評估結果所計算的可能成本避免平均為新台幣1,074,288元（708,712元到1,462,008元），平均每個月可能的成本避免為新台幣134,286元（88,589元到182,751元）。
就病人的結果來看，兩組病人在「轉至一般病房」、「轉至其他加護病房」、「死亡或自動出院」三項指標上並未見到有統計上的差異。而對照組與實驗組病人的平均住院天數亦無統計上顯著意義的差異（7.60  1.05天對7.43  0.92天，平均值  標準誤；p = 0.904）。
根據此研究的結果，臨床藥師參與外科加護病房醫療團隊進行藥事照顧，可達到藥費節省與成本避免的目的。

The purpose of this study was to determine the effect of interventions by a clinical pharmacist on the cost of drug therapy and possible health cost avoidance in a 13-bed surgical intensive care unit (SICU) in a private medical center.
All patients admitted to the SICU from October 2001, to May 2002 were consecutive random to receive either pharmacist’s pharmaceutical care (care group) or not (control group). Costs that were avoided or added as a result of pharmacist’s interventions were calculated according to the drug price determined by the Bureau of National Health Insurance and the drug acquisition costs of the hospital. All pharmacist’s interventions were subjected to physicians’ reviews and to cost avoidance evaluation.
There were 169 patients in control group and 185 patients in care group. The average time spent was 3.15 hours per day. A total of 106 interventions and 86 drug information services were documented during the study period.
The majority of pharmacist’s interventions involved “drug therapy omission (16.0%),” “pharmacokinetic consult (13.2%),” “abnormal laboratory test result (12.3%);” pharmacist’s recommendations included “discontinue drug (23.6%),” “change drug (22.6%)” and “initiate drug order (17.9%);” as far as physicians’ order changed based upon pharmacist’s recommendations were “drug discontinuation (21.7%),” “drug changed (16.0%).”
Except for the 15.1% of recommendations were not accepted by physicians, there were 84.9% recommendations resulted in order changed. The major classes of drug involved were anti-infective agents (35.6%), cardiovascular drugs (18.3%) and gastrointestinal drugs (12.5%).
These interventions during the study period accounted for NT$375,333 and NT$258,135 in cost saving（based on reimbursed price from health insurance and drug acquisition costs, respectively）. Since the annual salary of the pharmacist was about NT$750,000 (NT$260.42 per hour), the benefit-to-cost ratio was 2.20（calculated by drug acquisition costs）.
As far as evaluators’ responses to the question, “Could this event have resulted in adverse health consequences to the patient if no pharmacist’s intervention?” the responded “yes” that patients could be harmed were 69 (65.1%) and 55 (51.9%) interventions by two evaluators, respectively. The most responded health adverse consequences were that “the risk of adverse effects would be increased” in both evaluators, the frequency were 49.3% and 56.6%, respectively. The majority of interventions were given a rank of “very significant” (41.5%) and “significant” (34.9%) by two evaluators, respectively.
The average of potential cost avoidance totaled NT$1,074,288 (from NT$708,712 to NT$1,462,008) for the eight-month period. The mean cost avoidance per month was NT$134,286 (from NT$88,589 to NT$182,751).
There was no statistical difference between the care group and the control group in 3 indicators of the patients’ outcome: transferred to ordinary ward, transferred to other intensive care unit, and death or AAD (Against Advice Discharge). There was no statistical difference in length of stay (LOS) between these two groups (the care group was 7.43 ± 0.92 days (mean ± SEM) and the control group was 7.60 ± 1.05 days (mean ± SEM), respectively).
Based on the results of this study, the clinical pharmacist providing pharmaceutical care in SICU had a positive impact on the cost saving of drug therapy and cost avoidance of health care cost.

內容目錄
表目錄IV
圖目錄V
附錄目錄VI
中文摘要VII
Abstract IX
第一章 前言1
第一節 研究緣起4
第二節 研究目的6
第三節 研究假說7
第二章 文獻回顧8
第一節 臨床藥師在重症加護病房的角色8
第二節 加護病房藥師的貢獻17
第三節 研究方法文獻回顧22
壹、 藥師建議分類22
貳、 成本避免計算方法23
參、 敏感度分析26
第三章 研究方法27
第一節 研究地點27
第二節 研究過程28
壹、 藥師建議分類方法28
貳、 成本節省的計算29
參、 成本避免的計算31
肆、 病人結果與住院天數之分析35
第三節 資料處理與分析35
第四章 研究結果37
第一節 研究對象的基本資料及特性37
第二節 藥師建議分類37
第三節 臨床藥師介入所導致的費用節省39
第四節 藥師介入的結果評估41
第五節 臨床藥師介入所導致的費用避免44
第六節 病人結果46
壹、 病人住院結果分析46
貳、 病人住院天數分析46
第五章 研究討論48
第一節 研究方法限制48
壹、 藥師本身的因素影響48
貳、 執業場所不同的影響50
參、 醫療機構的成本50
肆、 成本避免的估算51
伍、 健保給付藥價的影響52
陸、 隨機分配病人的方法53
第二節 研究結果之討論53
壹、 未估計的附加價值53
貳、 研究結果對目前執業環境型態的應用55
參、 與其他研究的比較與差異56
第三節 加護病房藥師執業模式的建立60
第四節 建議與展望61
壹、 經濟分析型研究容易發生的缺點61
貳、 評估臨床藥事服務經濟成效時需考慮之重點62
參、 對未來研究方向的建議63
第六章 結論65
參考文獻88
表目錄
表4-1 病人基本資料67
表4-2 兩組病人之主診斷分類比較表68
表4-3 臨床藥師在外科加護病房進行臨床介入之時數69
表4-4 臨床介入行為種類對健保費用與醫院成本影響70
表4-5 藥物分類對健保費用與醫院成本影響71
表4-6 評估「若無藥師介入是否會造成傷害」結果整理72
表4-7 評估醫師之間對介入重要性的意見一致性73
表4-8 病人結果74
表4-9 研究期間兩組病人住院天數比較75
表5-1 外科加護病房藥師在不同時間的臨床服務結果比較76
表5-2 執行一般藥物治療監測各研究之利益對成本比率77
表5-3 文獻中對藥師建議的接受度78
圖目錄
圖2-1 研究流程圖79
圖4-1 介入行為種類80
圖4-2 建議81
圖4-3 根據藥師建議所做的處方改變82
圖4-4 介入之藥物分類83
圖4-5 藥物諮詢內容分類84
圖4-6 評估醫師評估若無藥師介入可能造成的結果85
圖4-7 評估醫師對藥師介入重要性之評估86
圖4-8 兩組病人住院天數87
附錄目錄
附錄一、 藥師介入分類表95
附錄二、 Pharmacist Intervention Report Evaluation 96
附錄三、 藥師介入評估表97
附錄四、 藥師建議重要性說明98

1. Billi RJ, Spevetz A, Branson RD, Campbell GM, Cohen H, Dasta JF, Harvey MA, Kelley MA, Kelly KM, Rudis MI, St Andre AC, Stone JR, Teres D, Weled BJ. The American College of Critical Care Medicine Task Force on Models of Critical Care Delivery. The American College of Critical Care Medicine Guidelines for the Definition of an Intensivist and the Practice of Critical Care Medicine. Critical care delivery in the intensive care unit: defining clinical roles and the best practice model. Crit Care Med 2001; 29(10): 2007-19.
2. Papadopoulos J, Rebuck JA, Lober C, Pass SE, Seidl EC, Shah RA, Sherman DS. The critical care pharmacist: an essential intensive care practitioner. Pharmacotherapy 2002; 22(11): 1484-8.
3. Haupt MT ( prinicipal author ), American College of Critical Care Medicine of the Society of Critical Care Medicine. Critical care services and personnel: recommendations based on a system of categorization into two levels of care. Crit Care Med 1999; 27: 422-6.
4. Dasta JF, Jacobi J. The critical care pharmacist: what you get is more than what you see. Crit Care Med 1994; 22: 906-9.
5. Anonymous. ASHP supplemental standard and learning objectives for residency training in critical care pharmacy practice. Am J Hosp Pharm 1990; 47: 609-12.
6. Rudis MI, Brandl KM, SCCM & ACCM Task Force on Critical Care Pharmacy Services. Position paper on critical care pharmacy services. Pharmacotherapy 2000; 20(11): 1400-6.
7. Anonymous. American College of Clinical Pharmacy Practice Affairs Committee. Practice guidelines for pharmacotherapy specialists. Pharmacotherapy 1990; 10: 308—11.
8. Schumock GT, Meek PD, Ploetz PA, Vermeulen LC. Economic evaluations of clinical pharmacy services - 1988 - 1995. The Publications Committee of the American College of Clinical Pharmacy. Pharmacotherapy 1996; 16: 1188-208.
9. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, Bates DW. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999; 282: 267-70.
10. 詹前彥：現行醫療體制下醫療人員對重症加護藥師認知與滿意度之研究。碩士論文，2002。
11. 譚延輝：藥事經濟學入門，第一版，台北，九州圖書文物有限公司，2000，21,145頁。
12. 張鴻仁：全民健保政策實施重點及未來發展方向。2001年9月。
許茜甯：實施"單純性闌尾切除術"之臨床路徑的藥物使用評估及初分析。碩士論文，1996。
13. 許茜甯：實施"單純性闌尾切除術"之臨床路徑的藥物使用評估及初分析。碩士論文，1996。
14. 郭錦璋：藥師對一般外科病房提供藥事照顧之探討。碩士論文，1997。
15. 陳本源：臨床藥學服務與全民健保。中華民國八十五年藥師節慶祝大會既藥事聯合學術研討會。1996年1月14日。
16. 譚延輝：藥事經濟學入門，第一版，台北，九州圖書文物有限公司，2000，132頁。
17. Bootman LJ, Wertheimer AI, Zaske D, Rowland C. Individualizing gentamicin dosage in burn patients with gram-negative septicemia: a cost-benefit analysis. J Pharm Sci 1979; 168: 267-72.
18. Baldinger SL, Chow MS, Gannon RH, Kelly ET 3rd. Cost savings from having a clinical pharmacist work part-time in a medical intensive care unit. Am J Health-Syst Pharm 1997; 54(24): 2811-4.
19. Miyagawa CI, Rivera JO. Effect of pharmacist interventions on drug therapy costs in a surgical intensive-care unit. Am J Hosp Pharm 1986; 43(12): 3008-13.
20. Bearce WC ,Willey GA ,Fox RL, Coleman LT. Documentation of clinical interactions: quality of care issues and economic considerations in critical care pharmacy. Hosp Pharm 1988; 23(10): 883-90.
21. Rosenbaum CL, Fant WK, Miyagawa CI, Armitstead JA. Inability to justify a part-time clinical pharmacist in a community hospital intensive-care unit. Am J Hosp Pharm 1991; 48(10): 2154-7.
22. Chuang LC, Sutton JD, Henderson GT. Impact of a clinical pharmacist on cost saving and cost avoidance in drug therapy in an intensive care unit. Hosp Pharm 1994; 29(3): 215-8,221.
23. Montazeri M, Cook DJ. Impact of a clinical pharmacist in a multidisciplinary intensive care unit. Crit Care Med 1994; 22(6): 1044-8.
24. White CM, Chow MS.S. Cost impact and clinical benefits of focused rounding in the cardiovascular intensive care unit. Hosp Pharm 1998; 34(4): 419-23.
25. Gandhi PJ, Smith BS, Tataronis GR, Maas B. Impact of a pharmacist on drug costs in a coronary care unit. Am J Health-Syst Pharm 2001; 58(6): 497-53.
26. Hatoum HT, Hutchinson RA, Witte KW, Newby GP. Evaluation of the contribution of clinical pharmacists: inpatient care and cost reduction. Drug Intell Clin Pharm 1988; 22 (3): 252-9.
27. Chisholm MA, Pittman DG, Longley JM, Mullis SR. Implementation of pharmaceutical care in acute medical cardiovascular patients. Hosp Pharm 1995; 30(7): 572-4,577-8.
28. Mutnick AH, Sterba KJ, Peroutka JA, Sloan NE, Beltz EA, Sorenson MK. Cost savings and avoidance from clinical interventions. Am J Health-Syst Pharm 1997; 54(4): 392-6.
29. Rupp MT. Value of community pharmacists'' interventions to correct prescribing errors. Ann Pharmacother 1992; 26(12): 1580-4.
30. Nesbit TW, Shermock KM, Bobek MB, Capozzi DL, Flores PA, Leonard MC, Long JK, Militello MA, White DA, Barone LD, Goldman MP, Kvancz DA. Implementation and pharmacoeconomic analysis of a clinical staff pharmacist practice model. Am J Health-Syst Pharm 2001;58(9): 784-90.
31. Lee AJ, Boro MS, Knapp KK, Meier JL, Korman NE. Clinical and economic outcomes of pharmacist recommendations in a Veterans Affairs medical center. Am J Health-Syst Pharm 2002; 59(21): 2070-7.
32. Overhage JM, Lukes A. Practical, reliable, comprehensive method for characterizing pharmacists'' clinical activities. Am J Health-Syst Pharm 1999; 56(23): 2444-50.
33. Classen DC, Pestotnik SL, Evans RS, Lioyd JF, Purke JP. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA 1997; 277: 301-6.
34. Bates DW, Spell N, Cullen DJ, Brudick E, Laird N, Petersen LA, Small SD, Sweitzer BJ, Leape LL. The costs of adverse drug events in hospitalized patients. JAMA 1997; 277: 307-11.
35. Rosner B. Fundamentals of biostatistics 4th ed. Wadsworth publishing company; 1995: p. 427.
36. 王婷瑩：前導性探討藥師進行判斷性服務之價值。碩士論文， 2001。
37. Warrian K, Irvine Meek J. Cost-benefit of a clinical services integrated with a decentralized unit dose system. Can J Hosp Pharm 1992; 27:1052-3, 1056-8, 1060.
38. Bjornson DC, Hiner WO Jr, Potyk RP, Nelson BA, Lombardo FA, Morton TA, Larson LV, Martin BP, Sikora RG, Cammarata FA. Effect of pharmacists on health care outcomes in hospitalized patients. Am J Hosp Pharm 1993; 50: 1875-84.
39. Baciewicz AM, Cowan RI, Michaels PE, Kyllonen KS. Quality and productivity assessment of clinical pharmacy interventions. Hosp Formul 1994; 29: 773, 777-9.
40. Yee DK, Veal JH, Trinh B, Bauer S, Freeman CH. Involvement of HMO-based pharmacists in clinical rounds at contract hospitals. Am J Health-Syst Pharm 1997; 54: 670-3.
41. Baldinger SL, Chow MS, Gannon RH, Kelly ET. Cost savings from having a clinical pharmacist work part-time in a medical intensive care unit. Am J Health-Syst Pharm 1997; 54: 2811-4.
42. Suseno M, Tedeski L, Kent S, Rough S. Impact of documented pharmacists'' interventions on patient care and costs. Hosp Pharm 1998; 33: 676-81.
43. Schumock GT, Michaud J, Guenette AJ. Re-engineering: an opportunity to advance clinical practice in a community hospital. Am J Health-Syst Pharm 1999; 56: 1945-9.
44. Bond CA, Raehl CL, Framke T. Interrelationships among mortality rates, drug costs, total cost of care, and length of stay in Unites States hospitals: summary and recommendations for clinical pharmacy services and staffing. Pharmacotherapy 2001; 21(2): 129-41.
45. McMullin TS, Hennenfent JA, Ritchie DJ, Huey WY, Lonergan TP, Schaiff RA, Tonn ME, Bailey TC. A prospective, randomized trial to assess the cost impact of pharmacist-initiated interventions. Arch Intern Med 1999; 159(19): 2306-9.
46. Bayliff DC, Einarson TR. Physician assessment of pharmacists'' interventions- a method of estimate cost avoidance and determining quality assurance. Can J Hosp Pharm 1990; 43: 167-71.
47. 鄭鴻基、陳本源，台中榮總臨床藥學服務之評估，台灣臨床藥學雜誌，第一卷(二期), p31-43,(1992).
48. Willett MS, Bertch KE, Rich DS, Ereshefsky L. Prospectus on the economic value of clinical pharmacy services. A position statement of the American College of Clinical Pharmacy. Pharmacotherapy 1989; 9(1): 45-56.
49. Anonymous. American College of Clinical Pharmacy. Template for the evaluation of a clinical pharmacist. Pharmacotherapy 1993; 13(6): 661-7.
50. Schumock GT, Leister KA, Edwards D, Wareham PS, Burkhart VP. Method for evaluating performance of clinical pharmacists. Am J Hosp Pharm 1990; 47: 127-31.
51. 譚延輝：藥事經濟學入門，第一版，台北，九州圖書文物有限公司，2000，127頁。