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目的：多重用藥(polypharmacy)、高齡及藥品處方複雜都是影響病人用藥安全的風險因子，文獻結果顯示用藥整合提供病人生理層面的用藥安全維護，減少多重用藥和處方複雜造成的風險，本研究以某醫院的用藥整合服務紀錄，分析藥師提供的用藥整合服務成效，並探討病人在用藥整合過程中表示的全人照護需求與藥師提供的服務。 方法：本研究的資料為某醫院2019年度的用藥整合服務紀錄，分析項目包括服務對象資料、用藥品項數目與頻次、醫療資源使用型態與用藥指導項目，並統計用藥整合服務後用藥品項與頻次的變化以及訪談諮詢櫃台藥師，調查病人接受用藥服務後回饋的意見，用藥複雜度以medication regimen complexity index (MRCI)評量。 結果：本研究共分析219位病人接受用藥整合服務的紀錄，病人年齡中位數為71.5歲，每人正在用藥科別中位數為2科，MRCI中位數為29分。經過藥師進行整合服務後，有28位病人的用藥數量及用藥複雜度降低，整合服務前每人用藥數目的中位數為15項，整合後用藥數目的中位數降為11.5項，減少的用藥顆數的中位數為30顆；整合前MRCI中位數為35.8分，整合後下降至30.3分。在17件服務紀錄中有紀錄到心理與社會層面的全人照護，其中藥師提供的心理層面照護共9項，社會層面的照護共8項。 結論：在本研究中MRCI與醫療資源使用程度有關，高醫療資源使用的病人，MRCI中位數顯著較高，代表用藥較為複雜度，發生遵醫囑性不佳的風險較高。對於高醫療資源使用、使用特殊劑型且同時有多種疾病的病人，需要醫療專業人員的合作，進行用藥的全面評估與整合，減少用藥複雜度，降低重覆用藥與遵醫囑性不佳等情形。 Background: Polypharmacy, aging, and complex medication regimen are risk factors for adverse drug effect. Literature indicates that medication reconciliation helps increase medication safety and reduce the risk of polypharmacy and complex medication. We analyzed medication reconciliation records of our hospital to evaluate the efficacy of the medication reconciliation service offered by our pharmacists based on the holistic needs of the patients and the responses of our pharmacists to the needs. Methods: Medication reconciliation record in 2019 in one hospital was analyzed, including patient profile, number of medication, dosage and frequency of medication, health resource demand and patient education. Changes in medication dosage and frequency were analyzed, and pharmacists were interviewed to obtain patient’s feedback about medication reconciliation service. Medication regimen complexity index (MRCI) was used to measure the complexity of the regimen. Results: A total of 219 medication reconciliation records were analyzed, and the median of age of patients was 71.5 years. Patient’s medication was prescribed from one or multiple clinics; the median of clinics was 2. The median of MRCI score was 29. Pharmacists had reduced 28 patients’ medication number and MRCI score after reconciliation service. For the 28 patients, the median of medication before and after the reconciliation service were 15 and 11.5. With the service, the median of reduced tablets was 30, leading to a drop from 35.8 to 30.3 in the median of MRCI score. Seventeen records showed patients with psychological and social needs, and pharmacists responded by providing 9 patients with psychological support and health care resources and 8 patients with social support and services. Conclusion: MRCI is correlated with the degree of health resource utilization. Patients with a higher demand for health resource tend to report a higher MRCI score and more complex medication regimen. The risk of medication nonadherence is increased with higher medication complexity. For patients consuming greater health resource, using special formulation of medicine, and with multiple comorbidities, health care professionals should perform comprehensive assessment for medication reconciliation to help decrease the risk of polypharmacy and medication nonadherence. |
