臨床藥師介入對加護病房藥物治療成本的影響
中文摘要
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（ gastrointestin al 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。
Impact of Pharmacist Interventions on Drug Costs in an Intensive Care Unit
英文摘要
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 avoi dance 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 de termined by the Bureau of National Health Insurance and the drug acquisition costs of the hospital. All pharmacist’s interventions were subjected to ph ysicians’ 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 a nd 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 r esult (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 insur ance and drug acquisition costs, respectively ） . Since the annual salary of the pharmacist was about NT$750,000 (NT$260.42 per hour), the benefit-t o-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 interve ntion?” the responded “yes” that patients could be harmed were 69 (65.1%) and 55 (51.9%) interventions by two evaluators, respectively. The most res ponded 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, respectivel y.
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 avoida nce 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) betw een 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).
