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系統識別號 U0026-0812200915215263
論文名稱(中文) 透析病患用藥知識及藥師介入角色之研究
論文名稱(英文) To Evaluate the Cognition of Medication Use in Dialysis Patients and the Impact of Pharmacist Intervention
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 97
學期 2
出版年 98
研究生(中文) 陳乃瑜
研究生(英文) Nai-Yu Chen
電子信箱 s6696104@mail.ncku.edu.tw
學號 s6696104
學位類別 碩士
語文別 中文
論文頁數 113頁
口試委員 口試委員-王明誠
口試委員-高淑敏
指導教授-高雅慧
指導教授-曾進忠
口試委員-劉信良
中文關鍵字 透析  藥師  藥物衛教  服藥順從性  用藥知識 
英文關鍵字 education  adherence  dialysis  medication cognition  pharmacists 
學科別分類
中文摘要 研究背景
血液透析,腹膜透析及腎臟移植是末期腎臟病患者的腎臟替代療法。隨著近年來台灣地區末期腎臟疾病發生率與盛行率持續增加,透析病患也逐年增高。除了透析指標要受到良好監控外,預防病患的心臟血管疾病、預防與治療腎性骨病變、紅血球生成素與鐵劑的使用情形、肝炎及傳染疾病管制等,也都需要受到定期的評估。病患對於藥物的認知程度是影響服藥順從性,及疾病控制是否合宜的因素之一。由國外臨床藥事照護的介入,對於透析病患有正面影響,除了提供藥物相關資訊,包含藥名、適應症、服用劑量、服用頻次及不良反應等,也衛教患者相關的交互作用,提升用藥認知程度。

研究目的
由藥師介入,了解及探討透析病患使用藥物之知識程度,提供透析病患用藥衛教與諮詢,提升病患對於使用藥物的了解,改善病患的服藥順從性及臨床治療成效。

研究方法
自2008年12月至2009年5月於國立成功大學附設醫院血液透析室、腹膜透析室及南台灣某地區血液透析中心,針對長期追蹤治療的病患進行研究。第一階段研究為期8週,藥師介入61位衛教組透析病患提供藥物資訊及用藥知識衛教,而59位控制組透析病患則沒有藥師介入;第二階段研究為期8週,藥師持續介入30位衛教組透析病患之衛教,剩餘27位衛教組透析病患則無藥師介入衛教,作為控制組。比較衛教介入前後之用藥知識、知識進步程度、介入前後服藥順從率、順從率改變程度、臨床治療各項指標之改變情形,如:血壓、血磷值、血比容等。
研究結果
兩組研究對象的基本特徵沒有統計學上的差異。第一階段8週介入結束後,兩組病患在用藥知識成績及服藥順服率皆有顯著的進步 (p<0.001),且衛教組相對控制組而言,在用藥知識進步程度及服藥順從率改變程度皆分別明顯高出14.36分 (p<0.001) 及5.84% (p=0.003);在臨床治療成效方面,兩組則沒有顯著的改變。第二階段8週結束後,持續有藥師介入衛教組之用藥知識有持續顯著的進步6.23分 (p=0.003)。

結論
藉由本研究證實,藥師加入腎臟照護醫療團隊,給予透析病患正確之用藥觀念及方式,可以增加用藥知識提升用藥之順從性,因此對於病患的臨床治療成效具有正向影響。
英文摘要 Background
Haemodialysis, peritoneal dialysis, and renal transplantation are renal replacement therapies for renal failure. Along with the progressive increase in the incidence rate and prevalence of end-stage renal disease (ESRD) over the last decades in Taiwan, the number of dialysis patients has increased. In addition to well-established dialysis quality indicator, it is necessary to monitor the prevention and the treatment of multiple comorbid conditions, including cardiovascular disease, anemia, hypercalcemia or hypocalcemia, hyperphosphatemia, and secondary hyperparathyroidism. Patients’ lack of medication cognition is one of the factors influencing adherence and disease control. Therefore, adding pharmaceutical services into a renal dialysis unit can help optimize pharmacotherapy in patients with ESRD.It will also improve patients’ understanding of medication, including names, indications, dosages, frequency and the side effects of the prescription.

Objectives
The objectives are to determine the effects of pharmacists' intervention in the treatment of chronic dialysis patients, including patients’ cognition of their medications, compliance with medication regimens and therapeutic responses.

Methods
This study is conducted from December 2008 to May 2009 in the dialysis center of National Cheng Kung University Hospital and one local dialysis center in Tainan County. In the first phase of the research, within lasted 8 weeks, we compared the following 2 groups, intervention group (n=61) receiving pharmaceutical services and control group (n=59) continuing to receive usual care.In the second phase of the research, within also lasted 8 weeks, intervention group was divided into 2 groups. One group (n=30) continued to receive clinical pharmacist’s intervention while the other group (n=27) was removed from intervention. We carefully investigated the difference of the following outcomes: knowledge score, adherence rate, change in knowledge score and adherence rate, and the clinically therapeutic targets,e.g. blood pressure, serum phosphate,and hematocrit.

Results
At baseline, there was no significant difference in patients’ characteristics, medication knowledge score and adherence rate between the 2 groups. After the phase I knowledge score and adherence rate in the both groups were statistically significantly higher (p<0.001). The elevation in knowledge score and adherence rate of intervention group were 14.36 (p<0.001) and 5.84% (p=0.003), which were significantly higher than control group. However there is no significant improvement in therapeutic responses. In Phase II, the mean score of continued intervention group is significant higher (p=0.003) than that of the removed intervention group.

Conclusions
This study confirms that the participation of pharmacy services in the multidisplinary dialysis team can improve patients’ medication cognition and adherence .Further a pharmacist plays a vital role to provide positive effect on clinical therapeutic responses.
論文目次 中文摘要 I
Abstract III
誌謝 V
目錄 VI
表目錄 IX
圖目錄 X
第一篇 透析病患用藥知識及藥師介入角色之研究 1
第一章 研究背景 1
第二章 文獻回顧 3
第一節 腎臟與透析 3
1.1 前言 3
1.2 初次血液透析及腹膜透析適應症 5
第二節 透析病患之罹病率及治療準則 6
2.1 透析病患的流行病學 6
2.2 心臟血管疾病 7
2.2.1 高血壓 8
2.2.2 血脂異常 11
2.3 鈣離子與磷離子的變化 13
2.4 貧血 16
第三節 透析病患之用藥問題 19
3.1 順從性的影響及重要性 19
3.2 處方型態 20
3.3 服藥順從性 22
第四節 透析病患之長期照護 26
4.1 透析病患的臨床藥事照護 26
4.2 藥師在長期透析病患之責任與角色 28
第三章 研究目的 30
第四章 研究設計 31
第一節 研究類型 31
第二節 研究單位及期間 31
第三節 研究對象 31
第四節 研究材料 32
4.1 病患追蹤紀錄表 32
4.2 病患服藥順從性評估表 32
4.3 病患基本資料表 32
4.4 病患服藥習慣 32
4.5 病患用藥認知評估表 32
4.6 用藥知識衛教單張 33
第五節 研究方法 34
5.1 評估表信效度 34
5.2 用藥知識評估 34
5.3 透析病患服藥順從性評估 35
第六節 統計方法 36
6.1 資料統計模式 36
6.2 資料彙整與分析方法 36
6.2.1 描述性統計 36
6.2.2 推論性統計 36
6.2.3 統計軟體 37
第五章 研究結果 38
第一節 研究對象基本資料特徵分布情形 38
第二節 研究對象用藥特性及習慣 42
第三節 病患用藥知識 47
3.1 處方型態分布差異性 47
3.2 用藥知識前後差異性 50
3.3 用藥知識分布差異性 54
第四節 病患服用藥物順從性差異 60
第五節 病患臨床治療成效 64
5.1 血壓變化之差異性 64
5.2 透析間體重增加量變化之差異性 65
5.3 血磷值變化之差異性 66
5.4 血鈣值變化之差異性 67
5.5 血比容變化之差異性 68
5.6 白蛋白變化之差異性 69
第六節 藥師持續介入對病患用藥知識之成效 70
第六章 研究討論 72
第一節 研究對象基本資料特徵之分布與比較 72
1.1 年齡與性別 72
1.2 透析方式 72
1.3 透析史 72
1.4 進入透析之原發病因 73
1.5 教育程度與病患分佈情形 73
第二節 研究對象用藥特性及習慣之比較 74
2.1 藥袋標示與藥物儲放 74
2.2 透析病患服用中草藥行為 74
2.3 病患諮詢藥物之對象 75
第三節 用藥知識成績之評估與探討 76
3.1 用藥知識改變分析討論 76
3.2 用藥知識影響因素 76
3.3 各類藥物知識程度分佈之探討 77
第四節 透析病患服藥順從率之探討 79
第五節 透析病患臨床治療成效變化之探討 80
5.1 臨床治療成效之改善 80
5.2 白蛋白改善之討論 81
第六節 持續藥師介入衛教對透析病患之評估 82
6.1 持續衛教成效之探討 82
6.2 台灣藥師介入透析病患之現況 82
第七章 研究限制與未來研究方向 83
第八章 結論與建議 84
8.1 結論 84
8.2 建議 84
第二篇 臨床藥事服務 85
參考文獻 93
附錄一:人體試驗委員會證明書 99
附錄二:受試者同意書 100
附錄三:追蹤紀錄表 102
附錄四:服藥順從性紀錄表 103
附錄五:病患基本資料紀錄表 104
附錄六:透析病患服藥習慣調查表 105
附錄七:透析病患用藥知識評估表 106
附錄八:衛教單張 110
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