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系統識別號 U0026-1908201415544300
論文名稱(中文) 急性心肌梗塞後藥物治療順從性與死亡率之相關性
論文名稱(英文) Association between Adherence to Secondary Prevention Therapies and Mortality in Acute Myocardial Infarction
校院名稱 成功大學
系所名稱(中) 臨床藥學與藥物科技研究所
系所名稱(英) Institute of Clinical Pharmacy and Pharmaceutical sciences
學年度 102
學期 2
出版年 103
研究生(中文) 劉姿祺
研究生(英文) Tzu-Chi Liu
學號 s66014039
學位類別 碩士
語文別 中文
論文頁數 145頁
口試委員 指導教授-高雅慧
口試委員-鄭靜蘭
口試委員-李貽恆
口試委員-李政翰
口試委員-許美英
中文關鍵字 心肌梗塞  次級預防治療  藥物順從性 
英文關鍵字 myocardial infarction  secondary prevention therapies  medication adherence 
學科別分類
中文摘要 研究背景
目前治療指引建議心肌梗塞病患出院時應處方次級預防藥物,並且長期使用,包含抗血小板劑、乙型受體阻斷劑、血管張力素轉換酶抑制劑/血管張力素受體阻斷劑及降血脂劑。許多研究也已證實這四類藥物的療效,能夠有效降低心血管事件的發生與死亡率。
另一方面,也有越來越多的研究發現,藥物順從性與心肌梗塞病患之預後具有高度相關性,例如心肌梗塞再復發率與死亡率,發現低順從性產生不良預後的危險性顯著較高。然而,臨床上藥物順從性仍有所不足,而台灣目前缺乏相關研究。期望透過此研究分析台灣心肌梗塞後之病患對次級預防藥物之順從性,以及探討順從性與死亡率的關係,提供台灣目前心肌梗塞病患藥物使用狀況及其預防成效之相關資訊。

研究方法
以1999年至2009年全民健康保險資料庫作為資料來源,建立一個回溯性世代研究,納入18至100歲、於2002年1月1日至2007年9月30日期間首次診斷為急性心肌梗塞、出院後至少存活1年又3個月之病患。並根據當次住院之診斷碼分為STEMI與NSTEMI兩大研究族群,再根據病患出院後3個月內所使用之次級預防藥物進行分組:anti-platelet組、beta-blocker組、ACEI/ARB組、statin組,以藥品日數覆蓋比例(proportion of days covered, PDC)計算一年順從性,並定義PDC 80%為高順從性,40% PDC <80%為中順從性,PDC <40%為低順從性。
以全因性死亡做為主要成效評估指標,並利用Kaplan-Meier曲線圖及Cox proportional hazard model進行分析。

研究結果
本研究共納入20,978位STEMI病患與16,174位NSTEMI病患作為研究對象,結果顯示STEMI病患之四組研究藥物中達高順從性比例分別為72.8% (anti-platelets)、62.5% (beta-blockers)、61.6% (ACEIs/ARBs)、55.0% (statins);NSTEMI病患之四組研究藥物中達高順從性之比例分別為70.7% (anti-platelets)、60.8% (beta-blockers)、60.4% (ACEIs/ARBs)、53.7% (statins)。
多變項分析結果顯示相對於高順從性,各組研究藥物之低順從性之全因性死亡風險皆顯著較高,除了NSTEMI病患之ACEI/ARB組之低順從性組未達統計上顯著意義。STEMI病患於anti-platelet組之低順從性風險比為1.64 (95% CI, 1.47-1.83);beta-blocker組為1.26 (95% CI, 1.12-1.43);ACEI/ARB組為1.36 (95% CI, 1.22-1.51);statin組為1.62 (95% CI, 1.38-1.90)。NSTEMI病患於anti-platelet組之低順從性風險比為1.29 (95% CI, 1.16-1.44);beta-blocker組為1.34 (95% CI, 1.19-1.51);ACEI/ARB組為1.11 (95% CI, 0.99-1.24);statin組為1.45 (95% CI, 1.25-1.69)。

研究結論
整體而言,台灣心肌梗塞病人之次級預防藥物順從性仍有不足,另外,相對於高順從性,低順從性之全因性死亡風險較高。心肌梗塞病患次級預防藥物的使用仍有改善的空間,建議擬定相關策略以提高藥物治療順從性。
英文摘要 Practice guidelines recommend that post-MI patients receive preventive therapies including anti-platelets, beta-blockers, ACEIs/ARBs, and statins, unless contraindicated. Despite the evidence supporting their use, the poor adherence has been documented. The purposes of this study were to assess adherence to secondary prevention therapies and to evaluate the association between medication adherence and mortality following AMI in Taiwan using data from National Health Insurance Research Database (NHIRD). We measured medication adherence by determining the proportion of days covered (PDC) for each therapeutic group in 1 year following hospital discharge. Adherence was classified into three categories—high (PDC 80%), intermediate (40% PDC <80%), and low (PDC <40%). After calculating the one year PDC, the proportion of highly adherent patients was suboptimal in both STEMI and NSTEMI groups. The association of adherence with mortality estimated by Cox proportional hazards models showed the risk of mortality was higher for low adherers compared with high adherers among the study drugs. Overall, adherence rates for post-MI secondary medications were suboptimal in Taiwan. Patients with lower adherence were at increased mortality risk. Our results indicate that there remains room to improve the use of secondary prevention therapies to AMI patients.
論文目次 中文摘要 I
Abstract III
誌謝 VI
目錄 VIII
表目錄 XI
圖目錄 XIV
縮寫與全名對照表 XVI

第一篇、 急性心肌梗塞後藥物治療順從性與死亡率之相關性1
第一章、 研究背景1
第二章、 文獻回顧2
第一節、 急性心肌梗塞2
第二節、 急性心肌梗塞後次級預防藥物7
第三節、 次級預防藥物治療之順從性13
第四節、 總結22
第三章、 研究目的及重要性23
第四章、 研究方法24
第一節、 研究設計24
第二節、 研究名詞與變項之操作定義30
第三節、 研究變項校正及排除條件之操作定義36
第四節、 研究結果變項之操作定義38
第五節、 資料處理流程39
第六節、 統計方法40
第七節、 其他分析41
第五章、 研究結果42
第一節、 研究對象之納入與排除42
第二節、 研究對象之一年藥物順從性與分組46
第三節、 STEMI病患於各組研究藥物之人口學特性48
第四節、 NSTEMI病患於各組研究藥物之人口學特性56
第五節、 次級預防藥物之一年順從性與死亡率相關性64
第六節、 敏感性分析 85
第七節、 次族群分析 92
第六章、 研究討論95
第一節、 研究對象之納入、排除情況分析95
第二節、 次級預防藥物治療之順從性98
第三節、 次級預防藥物治療順從性之成效評估109
第四節、 研究限制113
第七章、 結論與建議 115
第八章、 未來研究方向116

第二篇、 臨床藥事服務117
第一章、 冠狀動脈疾病住院患者衛教117
第一節、 前言117
第二節、 臨床藥事服務目的118
第三節、 臨床藥事服務方法118
第四節、 臨床藥事服務結果120
第五節、 心得與建議 123
第二章、 「冠狀動脈疾病指導手冊」修訂 125
第一節、 前言125
第二節、 臨床藥事服務目的125
第三節、 臨床藥事服務流程125
第四節、 冠狀動脈疾病指導手冊修訂內容126

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