類別:
http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/150
2024-03-28T09:51:05Z針對診斷為高血脂的病人,醫病共享決策與服藥順從性之間的關係
http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/84517
標題: 針對診斷為高血脂的病人,醫病共享決策與服藥順從性之間的關係; Examining the association between shared decision-making and medication adhesion
作者: Ying-Na Hsiao; 蕭吟娜
摘要: 背景介紹 服藥順從性指的是,病患是否按醫師處方規定次數服用藥物,以及他們是否持續 照醫師處方服用藥物,好的服藥順從性比起新型的治療方法更能增進病人的健 康。影響服藥順從性的因素有很多面項,病人、藥物、看診醫師及一些系統性因 素等皆會影響服藥順從性。增加服藥順從性的策略也有很多,舉凡病人教育、藥 物管理及認知行為療法等等策略。近年來醫病關係變化,醫師不再像過去是主要 的單一決策者,醫病共享決策此種以病人為中心的看診模式更逐漸被提倡,而認 知行為的介入方式也漸被納入探討其和服藥順從性的關聯性。由過去的文獻回顧 可以發現,醫病共享決策對於高血壓的病人可以增加其服藥順從性,但對於糖尿 病的病人卻沒有辦法增加其服藥順從性,且主動式及共享式的醫病決策關係比起 較為被動式的醫病決策關係更能增加病人的服藥順從性。然而過去的文獻較少提 到醫病共享決策對於高血脂病人其服藥順從性是否有影響。過去的研究也顯示, 對於高血脂症或其他慢性疾病的病人而言,高服藥順從性的病人比低服藥順從性 的病人增加了 26%健康狀況的改善。因此可以知道,好的服藥順從性對於高血脂 症的病人來說可以有較好的健康狀況,也因此增加高血脂症病人的服藥順從性是 至關重要的議題。因此,本研究針對高血脂病人去探討醫病共享決策是否會影響 其服藥順從性。 研究方法與材料 本研究的受試者來自於臺大醫院金山分院門診病人。我們收集 182 例於門診具備 高血脂診斷的病人,請病人於看診結束後填答問卷,請病人填寫自覺其看診時和 醫生之間的醫病關係為何種醫病共享決策關係,共分成五個層次的醫病共享決策 關係分別對應不同的醫病共享決策模式(主動式、被動式、共享式),排除一例於 醫病共享決策題目填錯答案者,排除 29 例於宗教信仰、婚姻狀態、醫療保險、 月收入、疾病嚴重度等未填答完整有缺漏者,最終可納入分析之個案為 152 人。年齡分佈從 27 歲到 94 歲,平均年齡 64.1 歲,女性 92 位,男性 60 位。服藥順 從性的部份則是用藥物持有率來計算,藥物持有率越高表示其服藥順從性越好。 本研究以簡單及多重迴歸分析來探討藥物持有率及醫病共享決策之關係,並探討 問卷中各個變項和藥物持有率之關聯性。 結論 本研究之結果顯示,對於高血脂的病人而言,醫病共享決策並無法增加病人的服藥順從性,對於高血脂的病人來說,影響其服藥順從性的因素為月收入差異和不同的門診醫師,月收入高的病人其服藥順從性相對較差,而不同門診醫師之間即便醫病共享決策的方式類似,仍存在不同的服藥順從性差異,故不同門診醫師對病人服藥順從性的影響仍需待後續研究加以深入探討。; Introduction Medication adherence refers to whether patients take the medication as prescribed by the physician. Good medication adherence can improv the patients health more than new treatment methods. There are many factors that affect medication adherence. Patients , drugs, physicians, and some systemic factors can all affect medication adherence. There are also many strategies to increase medication adherence, such as patient education, medication management, and cognitive behavioral therapy. In recent years, the doctor-patient relationship has changed. Physicians are no longer the main decision-makers as in the past. The concept of shared decision making between doctors and patients is gradually being promoted, and this cognitive behavioral intervention had gradually been included to explore its relationship with medication adherence. From the literature review , it can be found that the policy of shared decision making can increase the medication adherence rate among patients with Hypertension, but it cannot increase the medication adherence rate among patients with Diabetes mellitus. Compared with passive shared decision making policy, active and shared decision making policy increased medication adherence rate . However, previous literatures seldom mentioned about whether the policy of shared decision making affects the medication adherence rate among patients with hyperlipidemia. Previous studies have also shown that for patients with hyperlipidemia or other chronic disease, patients with high medication adherence rate increased their health status by 26% compared with those with low medication adherence rate. Therefore, it can be known that good medication adherence can lead to better health status for patients with hyperlipidemia. It is important to increase the medication adherence rate among patients with hyperlipidemia. Therefore, our study aimed at examining the association between shared decision making policy and medication adherence among patients with hyperlipidemia. Material and Method The subjects of this study were enrolled from outpatient clinics from the Jinshan Branch of National Taiwan University Hospital. We collected 182 participants who were diagnosed with hyperlipidemia in the outpatient clinic. The patients were asked to fill in the basic questionnaires after visiting the outpatient clinic, and the patients were asked to fill in what they think about the doctor-patient relationship during this outpatient clinic. The relationship was divided into five levels according to the questionnaires. The decision making relationships correspond to three different decision making modes(active, passive and shared). One case was excluded due to wrong answer about the questionnaires of shared decision making, and 29 cases were excluded due to wrong answer or unanswered about the questions related to religion, marital status, medication insurance, monthly income, and disease severity. There were 152 cases that could be finally included in the analysis. The age of patients ranged from 27 to 94 years old, with an average age of 64.1 years, 92 females and 60 males. The medication adherence rate is calculated by the Medication Possession ratio(MPR). The higher the Medication Possession ratio(MPR) means the better the medication adherence rate. Our study use simple and multiple linear regression analysis to analyze the relationship between Medication Possession ratio(MPR) and shred decision making. Our study also analyze the relationship between each variable in the questionnaire and Medication Possession ratio(MPR). Conclusion The result of this study show that for patients with hyperlipidemia, the policy of shared decision making cannot increase the medication adherence rate. Factors that affect the medication adherence rate are differences in monthly income and different outpatient physicians. Patients with higher monthly income have poor medication adherence rate. Even if similar policy of shared decision making among different outpatients physicians, there are still differences in medication adherence rates. It still need further research about the influence of different outpatients physicians on medication adherence rate .2022-01-01T00:00:00Z運用高擬真模擬假人系統於見習醫學生之兒童初始評估及基本救命術教學
http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/49715
標題: 運用高擬真模擬假人系統於見習醫學生之兒童初始評估及基本救命術教學; Application of high fidelity patient simulator in the teaching of pediatric initial assessment and
basic life support to medical clerks
作者: Yu-Chun Chiu; 邱郁淳
摘要: 研究背景及目的
情境模擬(simulation)訓練在臨床醫學的進階訓練中是很受歡迎的教學方式,並被認為可以減少學習過程中出現的醫療失誤。兒童醫療的初學者往往對於評估和處理兒童患者覺得陌生且缺乏信心,因此,本研究的目的在探討以高擬真情境模擬假人(high-fidelity patient simulator)系統介入的醫學情境模擬訓練在醫學生實習醫學生教學的可行性,及此教學方式是否能幫助實習醫學生學習對病童的初步評估和處置。
研究方法
研究對象為從2014.09至2015.08在台大醫院小兒部實習的台大醫學系五年級實習醫學生共141名。每一梯次的學生被平均分成兩組,對照組為常規教學組S(-)接受以病童影片及急救教學模具輔助的兒童評估三角(Pediatric assessment triangle, PAT)初始評估、初步處置及基本教命術(Basic life support, BLS)教學;研究組為情境模擬教學組S(+)在常規課程後增加30分鐘以高擬真情境模擬假人系統介入的情境模擬練習並加上教師及同儕的討論回饋。一共有三位教師輪流參與課程。學生於課前課後皆填寫評量病童評估、處置之能力與信心的自評問卷,並在課後問卷中調查對課程的滿意度及課程對其學習助益。各問題的答案以李克特量表(Likert scale)1至5分表示,分數愈高表示愈同意,當問卷中所有問題皆為同樣答案時被定義為無效問卷。經卡方檢定(Chi-square test)、學生t檢定(Student t test)、變異數分析(Analysis of variance, ANOVA)及線性回歸分析(Linear regression)等統計方法分析,p值<0.05定義為具有統計上顯著的差異。
研究結果
共有141名學生填寫問卷,其中有108份(76.6%)有效問卷。S(-)組有44位學生而其中的37份為有效問卷;S(+)組有97位學生而其中的71份為有效問卷。在所有的學生中,課前愈同意模擬教學能增加其學習動機者,在課後愈覺得此課程對其學習有助益(p值<0.01)。針對學員課前問卷對「模擬教學能增加學習動機」的看法,課前Likert scale>3分的學生比≦3分的學生課後更同意「此課程對學習有助益」(4.55分 v.s. 4.31分,p值= 0.04)。此外,在課後「整體臨床能力」較課前分數進步≧2分的學生中,課前「整體臨床能力」與課後「此課程對學習有助益」的Likert scale分數有臨界值的相關性(p值= 0.06);但對其中S(+)組的學生來說,則達到統計上顯著的相關性,當學生的課前「整體臨床能力」分數愈高,課後愈覺得「這堂課對學習有助益」(p值= 0.03)。
討論
高擬真情境模擬訓練是一種受歡迎和有趣的學習/教學方法,並可以減少訓練過程中出現的醫療失誤。在本研究中,以高擬真情境模擬假人系統介入教學的S(+)組學生滿意度和S(-)組一樣好,S(+)組其課後學習助益的評價則較S(-)組稍高但尚未達到統計學上顯著的差異。經進一步統計分析證實,愈符合學習者興趣引發學習動機的教學方式愈能提高其課後的課程滿意度和學習成效。此外,課前愈具備先備知識能力的學習者,愈能在課程內獲得良好學習成效。
結論
運用高擬真情境模擬假人系統介入的情境模擬教學做為醫學系實習醫學生的臨床教育,為一具體可行的教學模式,且課後學員滿意度及對學習助益的評價高;此外,此教學方式對於課前學習動機或先備知識能力較高的學生教學成效更高。; Background and Aim
Simulation is popular in advanced clinical training and considered to reduce errors made during learning. Medical beginners feel more unfamiliar in assessing and managing the pediatric patients. This study aims to explore the feasibility of using high-fidelity patient simulator in the teaching of medical clerks , and whether this new course helps them to learn the initial assessment and management for the sick children.
Material and Method
A total of 141 fifth-year medical students rotated pediatric clerkship in National Taiwan University Hospital from Sep.2014 to Aug.2015 were enrolled. Students were separated into two groups. Students in the conventional group S(-) received video and teaching aid-assisted teaching of pediatric initial assessment, initial management and basic life support(BLS). Students in the simulation group S(+) had an additional 30-minutes of practice and debriefing with high-fidelity infant simulator after the conventional course. There were 3 teachers involved in this course. The self-evaluated ability and confidence for pediatric patient assessment and management, the attitude for learning, and the evaluation and satisfaction for this course were evaluated by pre and post-course questionnaires which were not included into the semester score. The answer of each questions were scored with Likert scale 1 to 5. The questionnaire with all the questions have same answers of Likert scale was defined as invalid questionnaire. Data of the questionnaires were analyzed by Chi-square test, Student t test, Analysis of variance(ANOVA) and Linear regression. A p value<0.05 was considered statistically significant.
Result
One hundred and forty-one students were enrolled with 108 (76.6%) questionnaires were valid. Forty-four students were in the S(-) group and 37 valid questionnaires were obtained. Ninety-seven students were in the S(+) group and 71 valid questionnaires were obtained. For all students , the pre-course scale of “simulation increases learning motivation” had positive association with the scale of “this course is helpful for learning” (p value <0.01) after the course. Students who have scale of pre-course “simulation increases motivation” >3 stated significantly higher score for ‘this course is helpful for learning’ (4.55 v.s. 4.31, p value=0.04). In addition, for students with “overall clinical capacity” scale improvement≧2, the pre-course scale of“overall clinical capacity”had borderline association with the agreement of “this course is helpful for learning” (p value=0.06) but had significant association specifically for students in the S(+) group (p value=0.03). Students who stated higher scale of pre course “overall clinical capacity’, scored higher scale of “this course is helpful for learning”(p value=0.03) after the course.
Discussion
High-fidelity simulation is a popular and interesting learning / teaching method which reduces error made in training. In this study, the student satisfaction was high in both group. The rating of “this course is helpful for learning” was higher in the S(+) group but had not reached statistically significance. Supported by further analysis, the learning / teaching method meets the learner’s preference and leads to learning motivation is crucial for the course satisfaction and good learning outcome. Moreover, the learner’s prior knowledge and ability are important for gaining learning effectiveness.
Conclusion
High-fidelity patient simulator-assisted teaching is a feasible teaching method in the training of medical clerks and the student’s satisfaction is high. Besides, simulation is more beneficial in the teaching of students with active motivation or having prior knowledge and ability.2016-01-01T00:00:00Z緩和醫療家庭會議之內容與不施行心肺復甦術決定之關聯性
http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/3729
標題: 緩和醫療家庭會議之內容與不施行心肺復甦術決定之關聯性; The association between the content of palliative family conferences and do-not-resuscitate decisions
作者: Ping-Hsun Chang; 張炳勛
摘要: 民國101年12月起,為鼓勵安寧緩和醫療及末期病人預立醫囑,台灣之全民健康保險增列「緩和醫療家庭諮詢費」。透過此一給付,家庭會議開始有正式之記錄。在末期或重症醫療情境中,醫病溝通時常不足。家庭會議做為溝通之重要手段雖已有共識,但在台灣,有關家庭會議之實證研究仍相當有限。
本研究為一回溯性觀察研究,收集台大醫院腫瘤科病房2014年12月至2015年11月申報緩和醫療家庭諮詢費之病患共248人,分析患者之人口學變項、疾病嚴重度、參與家庭會議之角色及人數、家庭會議內容,以及相關醫療處置等,以迴歸分析家庭會議中可能影響「不施行心肺復甦術」之決定的因子。
研究發現,在家庭會議後一週、二週、一個月及追蹤結束(2016/5/31)時,會顯著提高不施行心肺復甦術之決定的因子有:照會安寧緩和醫療團隊、會議時之ECOG分數較高、病情緩慢惡化中或病危、癌症有遠端轉移、淋巴球百分比較低、醫療團隊出席會議人數較多,和信仰佛、道教或民間信仰。而其中最重要且效果持久的因素是照會安寧緩和醫療團隊,其次則是會議時之ECOG。而年齡、性別、該次住院是否使用抗癌藥物、患者本人是否出席、會議中是否討論DNR相關議題等,與患者在上述四個時間點是否決定DNR沒有顯著的關聯性。會議前仍在使用抗生素、未婚離婚分居或喪偶等婚姻狀態,在家庭會議後的兩天內與DNR之決定有關。家庭會議中有若男性家屬出席可能也對DNR決定的速度有影響。患者本人的出席與否,則與性別、年齡、ECOG、參與會議的人數、男性親友出席會議,和會議中是討論DNR相關議題有關。; Since Dec 2012, Taiwan's National Health Insurance started to cover palliative family conference, and formal meeting records were required for the payment package.
In critical or terminal diseases, the communication between patients, their families and medical teams are often insufficient. Family meetings serve an important role in medical communication. But only few empirical studies exist for the famliy meetings in Taiwan.
This is a retrospective cohort study. All family meeting payment package records in a medical center in northen Taiwan were collected from Dec 2014 to Nov 2015. 248 patients and their medical records, including variables of demographic data, diseae severity, participants and the content of the family meetings, and relevant medical interventions, were included. Multivariate logistic regression was performed to identify the association of these factors and the designation of Do-Not-Resuscitate (DNR) decisions.
The association was tested in 7 days, 14 days, 30 days after the family meeting, and on May 31, 2015. The result showed that consulting a palliative team, high ECOG score during the meeting, disease in progression or imminent dying, distant metastasis, low lymphocyte percentage, more medical personnel attending the meeting, and believing in Buddism, Daoism or Taiwanese Folk Religion, were signinificantly and positively assosicated with DNR dicisions. Age, gender, using anti-cancer medication, the patient's participation of the family meeting, and discussing about DNR during the meeting, showed no significant association. Taking antiiotics during the meeting and marital status were significant only within 2 days after a family meeting. Having male family members in the meeting also potentially influences the DNR decisions.
We also analysed factors influencing a patient's participation of a family meeting. The significantly associated variables were: age, gender, ECOG, number of participants, having male family members in the meeting, and discussing about DNR in the meeting.2016-01-01T00:00:00Z病人所感受的醫師跨文化能力與醫療依從性的關係
http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/70759
標題: 病人所感受的醫師跨文化能力與醫療依從性的關係; The Association between Patient Perceived Cultural Competence of Physicians and Medication Adherence.
作者: Nien-Lin Yang; 楊念霖
摘要: 背景:
因為醫療的全球化及文化的多元性已是現代醫學的趨勢,醫師跨文化的能力(Cultural Competence)成為當前醫師必須具備的重要能力,希望藉由醫師的跨文化溝通能力的培養,以減少不同族群間的健康分歧。
目的:
試圖了解金山地區的慢性病患所感受到醫師跨文化的能力(Cultural Competence)如何,並探討病人所感受的醫師跨文化能力會不會影響病人的醫療從性(Adherence),藉此釐清不同疾病種類下,病人感受的醫師跨文化能力與健康成效間的關係。
研究方法:
研究對象為台大醫院金山分院家醫科門診慢性病患,採立意取樣,使用「消費者對醫療服務提供者評價調查計畫(CAHPS®)文化能力項目集」問卷作為病人感受之醫師跨文化能力評估工具,翻譯為中文後,利用探索性因素分析(Exploratory factor analysis)分析問卷至構面效度,Cronbach's alpha計算內部一致性信度(Internal consistency reliability),並利用雙相變項及多變項分析,了解影響病人感受之醫師跨文化能力各構面的因素。醫療依從性的評估則利用藥物持有率(Medication Possession Ratio, MPR),計算過去一年中,金山家醫科門診慢性病患領取處方的總天數所佔的比例,作為連續變項代表病人的醫療依從性,並利用多變項線性迴歸,在控制各項干擾因子後,不同疾病診斷下,病人所感受之醫師跨文化能力之各構面與醫療依從性的關係。
結果:
收案200例,因填答不完整及門診追蹤不滿一年,僅158例接受分析。「消費者對醫療服務提供者評價調查計畫(CAHPS®)文化能力項目集」原問卷包含八個層面,因本次收案之個案並未包含外籍病患,因此將語言翻譯服務層面排除後,剩下的七個層面做探索式因素分析,最終得到五個有意義之新構面,分別為:1.醫病溝通-良好互信2.共享醫療決策3.醫病溝通-關懷4.平等的醫療5.醫病溝通-健康提升(Kaiser-Meyer-Olkin Measure of Sampling Adequacy:0.729, p-value:<0.001,Total Variance Explained Cumulative percentage:73.67%)。內部一致性信度Cronbach’s alpha分別是0.824、0.962、0.602、0.840、0.842,總內部一致性信度為0.786。影響高血壓病人感受醫師跨文化能力的因素包括:年齡、宗教信仰、教育程度、性別、月收入、出生地、母親國籍、父親民族、病人自覺疾病嚴重度及慣用語言;影響糖尿病病患感受醫師跨文化能力的因素包括:信仰佛教、教育程度、婚姻狀態、保險種類及月收入。多變項線性迴歸分析發現,高血壓病患所感受的醫師跨文化能力與醫療依從性並無顯著相關性,而糖尿病病患所感受之平等的醫療構面,與較好的醫療依從性相關(B=1.413,p=0.026,Adjusted R-square:0.13),在以上兩個多變項分析中,高血壓及糖尿病病患的自覺疾病嚴重度皆與病人之醫療依從性有正向關係(B=50.504,p=0.012及B=103.67,p=0.004)。
結論:
糖尿病病患所感受之平等的醫療跨文化能力構面確實與醫療依從性有正向關係,但其他醫師跨文化構面在兩類疾病中皆未達統計顯著性,日後應就不同疾病及不同跨文化能力之構面分別探討。; Background:
Cultural competence is an essential ability for health providers to reduce health disparities between different cultural groups. Because of globalization of health care and cultural diversity of the modern world, cultural competence become more important.
Aim:
To explore relationships between patient-perceived cultural competence and medication adherence in patients with chronic disease at the family medicine outpatient clinics of National Taiwan University Hospital Jinshan branch. To establish correlations between confounder factors and patient-perceived cultural competence in Jinshan area.
Method:
The data were collected between May 2018 and June 2018 at the family medicine clinics of National Taiwan University Hospital Jinshan branch. Patients with hypertension(HTN), diabetes mellitus(DM), hyperlipidemia and gout were included, and at least one-year follow-up at Jinshan hospital was required. The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Cultural Competence (CC) Item Set was adopted to evaluate patient-perceived health provider cultural competence. Exploratory factor analysis was conducted to examine the construct validity, and internal consistency reliability of Chinese version of CAHPS® CC item set. Medication adherence was measured using Medication Possession Ratio (MPR). Relationships between confounder factors and patient-perceived health provider cultural competence, and relationships between patient-perceived health provider cultural competence and medication adherence were analyzed with multivariate linear regression.
Result:
200 participants were enrolled and 158 participants were analyzed. Five factors were extracted to evaluate patient-perceived health provider cultural competence. These five main factors include: 1) Doctor communication-positive behaviors and trust, 2) Share decision making, 3) Doctor communication-concerned behaviors, 4) Equitable treatment, 5) Doctor communication-health promotion (Kaiser-Meyer-Olkin Measure of Sampling Adequacy: 0.729, p-value:< .001, Total Variance Explained Cumulative percentage: 73.67%). The Cronbach’s alpha of these five factors were 0.824, 0.962, 0.602, 0.840 and 0.842, the total Cronbach’s alpha was 0.786. The factors correlated with patient- perceived health provider cultural competence of HTN patients included age, religion, education, gender, income, birth place, language, mother’s nation, father’s ethnicity and patient-perceived disease severity. The factors correlated with patient-perceived health provider cultural competence of DM patients included religion, education, marital status, insurance type and income. The full model multivariate regression revealed no significant correlation between patient-perceived health provider cultural competence and medication adherence in HTN patients group, but positive effect was found between equitable treatment and medication adherence in DM patients group (B=1.413, p=0.026, Adjusted R-square: 0.13). In addition, patient-perceived disease severity had positive effect on medication adherence in both groups (B=50.504, p=0.012 in HTN group; B=103.67, p=0.004 in DM group).
Conclusion:
The patient equitable treatment of perceived health provider cultural competence had positive effect on medication adherence in DM patient group, but there was no significant correlation between patient-perceived health provider cultural competence in other factors and different diseases. Further study should include closer examination of these issues separately.2018-01-01T00:00:00Z