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系統識別號 U0026-0812200910243003
論文名稱(中文) 建立藥師在門診第2型糖尿病患的藥事照護模式
論文名稱(英文) Developing An Ambulatory Pharmaceutical Care Model Operated by Pharmacists in Type 2 Diabetic Patients
校院名稱 成功大學
系所名稱(中) 臨床藥學研究所
系所名稱(英) Institute of Clinical Pharmacy
學年度 90
學期 2
出版年 91
研究生(中文) 邵愛玫
研究生(英文) Ai-Mei Shao
學號 s6689104
學位類別 碩士
語文別 中文
論文頁數 203頁
口試委員 口試委員-林慧玲
指導教授-高雅慧
指導教授-張智仁
中文關鍵字 糖尿病患照護  衛生教育  第2 型糖尿病患  藥師 
英文關鍵字 diabetes care  pharmacists  type 2 diabetes mellitus  patient education 
學科別分類
中文摘要 研究背景:糖尿病為台灣常見的慢性病之一,其盛行率逐年攀升。相較於過去十年,因血糖控制不佳所產生併發症而導致死亡的人數,足足增加了二倍之多,且台灣自一九八七年起一直高居第五大死亡原因,造成個人及國家龐大的醫療經濟負擔。故近年來,行政院衛生署計畫推動由醫師、營養師、護理師為主導的糖尿病共同照護系統(Diabetes Shared Care System),預期建立一個有效率的糖尿病照護模式,但藥師並未能積極參與其中。藥物在糖尿病治療上扮演了舉足輕重的角色,且病患多伴隨有其他合併症,故在藥物選擇及併用可能產生的交互作用及藥物相關的問題,並未能有效的解決,而使得團隊的功用無法發揮良好的成效。

研究目的:瞭解藥師在糖尿病照護上的角色及建立藥師在門診糖尿病患照護模式。
研究方法:本研究為前瞻性、隨機分配之臨床試驗。共納入56位病患第2型糖尿病患,隨機分配為兩組,一為對照組,僅接受基本的糖尿病衛教內容;另一為實驗組,接受進階的糖尿病衛教內容(包含藥物衛教),前後追蹤四個月。其主要指標為研究前後病患的血糖變化,包括糖化血色素及空腹血糖值。而次要指標為觀察其他相關代謝參數變化(包括空腹血脂值、腎臟及肝臟功能)及病患對藥物及藥師認知程度的改變,並記錄觀察到的藥物相關問題。
研究結果:在糖化血色素方面,實驗組於二個月後即呈現明顯下降趨勢(變化量為0.67±0.14 %,p<0.001),四個月後亦然(變化量為0.76±0.19 %, p=0.0006);而對照組於研究四個月後變化量才具統計學明顯下降(0.39±0.18 %,p=0.0411);若兩組相比,實驗組於二個月及四個月後之變化明顯優於對照組(p=0.01, 0.03)。在空腹血糖值方面,實驗組於二個月及四個月後均達明顯下降(p=0.0051, 0.0005),對照組亦然(p=0.0219, 0.0191)。兩組相比,三個月後其變化量呈現明顯差異(p=0.02)。研究前後,在其他相關代謝參數變化方面,不管實驗組或對照組,於體重、身體質量指數變化均達明顯差異。實驗組於研究後,對藥師及藥物的認知程度明顯提升,而對照組對藥師及藥物認知程度前後差異不大。
研究結論:藥師參與糖尿病患照護,教導病患正確之用藥觀念及方式,可以增加糖尿病患對藥物的認知及避免許多藥物相關問題發生,進而改善病患血糖控制,因此,藥師對於門診第2型糖尿病患的角色得以確立。
英文摘要 Background: Diabetes is one of the chronic disease commonly found among the general population in Taiwan. Its prevalence has been increasing over the years. The death due to the complications caused by poor glycemic control had doubled over the last ten years. Diabetes remains to be the fifth leading cause of death since 1987, which had placed heavy burden on individual and health care system. Therefore, the Department of Health recently introduced an initiative ”Diabetes Shared Care System” which is a patient-centered program operated with a team consisted of physicians, dieticians and nurses. It is hoped that this initiative can improve the quality of diabetes care. However, pharmacists involvement is not mandatory in the program. Since medications are the major intervention in diabetes management, the absence of pharmacists involvement can result in inappropriate medication use or drug-related problems and reduce the effectiveness of the team.
Objective: To assess the effectiveness of a pharmaceutical care model on the management of type 2 diabetes mellitus in the diabetic clinic in National Cheng Kung University Hospital (NCKUH).
Methods: Sixty eligible patients were entered into a four-month prospective study and were randomized to either the experimental or control group. A pharmacist solely provided all diabetes-related consultation. The experimental group received advanced pharmaceutical care while the controll group did not. Primary endpoints were the difference of glycosylated hemoglobin and fasting plasma glucose from baseline. Secondary endpoints were the change of the other metabolic parameters, such as body weight, systolic blood pressure, diastolic blood pressure, total cholesterol, triglyceride, high-density lipoprotein, low-density lipoprotein, creatinine, BUN, GOT and GPT from baseline, the patients’ comprehension on medication use and the role of pharmacists by structured questionnaires.
Results: A total of 60 subjects were recuited and fifth-six people completed
the study. We found that the significant improvement in glycosylated
hemoglobin and fasting plasma glucose and the patients’ comprehension on
medication use and pharmacists in the experimental group. In the control
group, improvement was also found in glycosylated hemoglobin and fasting
plasma glucose. However, the changes in the experimental group were more
pronounced. Moreover, significant change in the comprehension on
medication use and pharmacists in the experimental group and no difference
in the control group.
Conclusion: Patient education operated by pharmacists can improve diabetic patients in their understanding of their medications, identify found drug-related problems from them, and improve glycemic control. Our study established the effectiveness of pharmacist-provided diabetes care in the type 2 diabetes mellitus.
論文目次 中文摘要 i
英文摘要 iii
誌謝 v
表目錄 xii
圖目錄 xiv
第一章、研究背景與現況 1
第二章、文獻探討 4
第一節、糖尿病之簡介 4
第一項、從流行病學角度看糖尿病 6
第二項、從經濟學角度看糖尿病 11
第二節、第2型糖尿病之臨床處置 13
第一項、生活型態之調整 13
一、適當的飲食控制 13
二、規律的運動 14
三、減低危險因子的暴露 14
第二項、糖尿病的衛生教育 17
第三項、糖尿病之藥物治療 18
一、糖尿病藥物治療之重要性 18
二、糖尿病之藥物治療 18
第三節、糖尿病患潛在用藥危機 23
第一項、潛在用藥問題之定義 23
第二項、糖尿病患潛在用藥問題探討 26
第三項、糖尿病患糖尿病患特殊用藥考量 31
第四節、糖尿病之照護制度 55
第一項、糖尿病照護之現況 55
一、國外糖尿病照護現況 55
二、國內糖尿病照護現況 61
第二項、糖尿病共同照護概念 63
第三項、目前國內之糖尿病共同照護制度 66
第五節、藥師於糖尿病共同照護之角色 72
第一項、藥師參與糖尿病共同照護之簡介 72
第二項、美國疾病管理藥師國家標準機構成立 75
第三項、藥事照護於糖尿病照護之重要性 78
第三章、研究目的 80
第四章、研究方法與材料 81
第一節、研究設計 81
第二節、研究單位 81
第三節、研究期間 81
第四節、研究對象 81
第五節、研究方法 83
第六節、研究工具 84
第一項、糖尿病衛教內容 84
第二項、問卷內容 86
第三項、病患基本資料之紀錄 87
第七節、本研究之操作型定義 88
第一項、相關名詞之操作意義 88
第八節、研究架構及流程步驟 92
第一項、研究架構 92
第二項、研究流程表 93
第九節、統計方法 94
第一項、統計模式設定 94
第二項、資料分析方法 94
第三項、統計軟體 94
第五章、研究結果 95
第一節、研究資料及完成結果描述 95
第二節、研究對象的基本資料及臨床特徵分布 97
第一項、研究對象的基本資料及臨床特徵分佈 97
第二項、主要指標 106
一、糖化血色素(HbA1C)106
二、空腹血糖值的變化量 108
第三項、次要指標 110
一、其他相關代謝參數變化 110
二、評估研究對象對「藥師的認知程度」的改變 114
三、評估研究對象對藥物的認知程度的改變 127
四、藥品相關問題之紀錄 147
第六章、討論 150
第一節、評估藥事照護對於糖尿病患之影響 150
第一項、藥師所提供之藥事照護對「血糖控制」之影響 150
第二項、藥師所提供之藥事照護對「其他相關代謝參數」之影響 152
第三項、藥師所提供之藥事照護對「藥物認知程度」之影響 153
第四項、藥師所提供之藥事照護對「藥師認知程度」之影響 157
第二節、研究之限制 159
第七章、結論及建議 160
第一節、結論 160
第一項、改善糖尿病患之血糖控制及減少藥品相關問題 160
第二節、建議 161
參考文獻 164
附錄 176
附錄一、糖尿病衛教內容設計 176
附錄二、糖尿病藥物衛教單張 182
附錄三、成大醫院三大慢性病(高血壓、高血脂、糖尿病)藥物 188
附錄四、糖尿病飲食衛教單 193
附錄五、對藥物認知問卷 195
附錄六、對藥師的認知問卷 197
附錄七、病患基本資料紀錄表 199
附錄八、臨床藥事服務 201
自述 203
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