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標題: | 住院老年病患潛在性不當處方及相關因素探討 Prevalence and Risk Factors of Potentially Inappropriate Medications in Hospitalized Elderly Patients |
作者: | 林筠倩 Yun-Chien Lin |
指導教授: | 鄭守夏 Shou-Hsia Cheng |
關鍵字: | 潛在不適當用藥,住院老年病人,醫療院所層級,主診斷之疾病類別,2019版Beers criteria, Potential inappropriate medication,hospitalized older adults,level of healthcare facility,Disease categories of primary diagnoses,2019 Beers criteria, |
出版年 : | 2023 |
學位: | 碩士 |
摘要: | 研究背景:老年人因體內組成、藥物吸收和代謝功能改變,加上常有多重共病症和多重用藥的情形,使得他們暴露於藥物不良反應和交互作用的風險。潛在不當用藥是導致老年族群藥物相關問題與不良健康結果的原因之一,造成用藥安全的疑慮。為進一步推動改善老年人用藥適當性的策略,需了解老年病患使用潛在不當用藥的情形與相關的風險因子,然而台灣目前仍缺乏含括各級醫療院所及不同疾病狀況的住院老人,並以2019版Beers criteria分析整體PIM風險及分布情形的研究,使得整體住院老人的用藥適當性無從評估與改善。
研究目的:本研究目的為評估台灣住院老年病患的潛在不當用藥的盛行率,了解常見的潛在不當藥物成分和類別,並分析醫療院所的層級和主診斷之疾病類別與老年人住院期間被處方PIM的風險之關聯性。 研究方法:為橫斷式回溯性觀察型研究,以台灣健保資料庫兩百萬抽樣歸人檔為資料來源,研究對象為2017至2018年間年滿65歲以上、有出入院資料且主診斷之疾病類別符合收案條件的老年病患,每位病患僅納入研究期間第一次住院的資料進行分析。以2019年版Beers criteria評估潛在不當用藥,利用卡方檢定進行雙變項分析;以羅吉斯迴歸分析院所層級和疾病類別對住院病患發生PIM風險之影響,接著以負二項式迴歸分析對住院病患被處方的PIM成分種類數之影響。 研究結果:共收案80036人,結果顯示住院老人於住院時被處方至少一種潛在不當用藥的盛行率為55.3%,最常見的PIM藥物依序為 Benzodiazepines類(鎮靜安眠作用)、Metoclopramide(止吐、調整消化道運動作用)、NSAIDs類(消炎及解熱鎮痛作用)、第一代抗組織胺(止吐、抗動暈及抗過敏作用)、Meperidine(麻醉及鎮痛作用)。迴歸分析顯示,院所層級越低,病患發生潛在不當用藥的風險越高,被處方的PIM成分種類數也較多,相較於醫學中心,區域醫院及地區醫院的病患發生PIM的OR值分別為1.53及1.68 ;區域醫院的病患被處方的PIM種類數比醫學中心多24%,地區醫院比醫學中心多28%,皆達顯著差異(p<0.0001)。主診斷之疾病類別中以「精神、行為和神經發育障礙」的病人發生PIM的風險最高(OR值=6.84),接著依序為「傷害中毒與其他外因造成的影響結果」(OR值=1.24)、「肌肉骨骼系統與結締組織疾病」(OR值=1.23)和「神經系統疾病」(OR值=1.14),相較於參考組(消化系統疾病)皆達統計上的顯著差異,此四類疾病類別之病患被處方的PIM成分種類數皆顯著比參考組的病患多超過10%。 研究結論:台灣的住院老年人有超過一半在住院時被處方潛在不當用藥,且院所層級越低及特定疾病類別的病患,發生的風險及被處方的成分種類數較多的風險也越高。為改善用藥適當性,可提供醫療人員有關PIM及處方優化的教育資訊,並將處方審視和藥物風險效益之評估整合進老年病患的臨床照護中。未來應深入探討處方潛在不當用藥的原因及減少潛在不當用藥的介入措施之成效。 Background: The elderly face increased risks of adverse drug reactions and interactions due to age-related changes in body composition, drug absorption, metabolism, and the presence of multiple comorbidities and polypharmacy. Potentially inappropriate medication (PIM) contributes to medication-related issues and adverse health outcomes in the elderly, raising concerns about medication safety. However, there is a lack of large-scale database analysis on hospitalized older adults from various hospital levels and different disease conditions in Taiwan. Additionally, there is a lack of research analyzing the overall PIM risk and distribution using the 2019 Beers criteria.This hinders assessing and improving overall medication appropriateness for hospitalized older adults. Objective: This study aimed to evaluate the prevalence of PIM use among elderly inpatients in Taiwan, identify commonly prescribed PIM drug classes and medications, and analyze the associations between hospital levels, disease category of primary diagnoses, and the risk of PIM use during hospitalization. Methods: This retrospective cross-sectional study utilized the Longitudinal Generation Tracking Database of National Health Insurance Research Database. This study included elderly inpatients aged 65 and above with hospitalization records between January 1, 2017-December 31, 2018 and primary diagnoses meeting the inclusion criteria. Only data from the first hospitalization during the study period were analyzed. PIMs were assessed using the 2019 Beers criteria, and chi-square tests were performed for bivariate analysis. Logistic regression was used to analyze the associations between hospital levels, disease category of primary diagnoses, and the occurrence of PIM use among hospitalized patients. Negative binomial regression was used to analyze the association between the independent variable and the number of prescribed PIMs. Results: Of 80,036 included patients, 44,234 (55.3%) were prescribed at least one PIM during hospitalization. The most commonly prescribed PIM classes were Benzodiazepines (sedative and hypnotic effects), Metoclopramide(antiemetic and gastrointestinal regulatory effects), NSAIDs(anti-inflammatory and antipyretic analgesic effects), first-generation antihistamines(antiemetic, anti-motion sickness, and antiallergic effects), and Meperidine(anesthetic and analgesic effects). Regression analysis showed that lower-level hospitals were associated with a higher risk of PIM use among elderly inpatients, as well as a higher number of PIMs prescribed. Compared to medical centers, the odds ratios for PIM occurrence were 1.53 for regional hospitals and 1.68 for local hospitals. Patients in regional hospitals had 24% more PIMs prescribed number than those in medical centers, while patients in local hospitals had 28% more PIMs prescribed, with both statistically significant (p<0.0001). Among the disease category of primary diagnosis, patients with " Mental, behavioral, and neurodevelopmental disorders " had the highest risk of PIM use (OR=6.84), followed by " Injury, poisoning, and certain other consequences of external causes " (OR=1.24), "Musculoskeletal system and connective tissue diseases" (OR=1.23), and "Nervous system diseases" (OR=1.14). Patients in these categories also had significantly more PIMs prescribed number, exceeding 10% more than the reference group (Digestive system diseases). Conclusion: Over half of the elderly inpatients in Taiwan were prescribed PIMs during their hospital stay. The risk of PIM occurrence and the number of PIMs prescribed were higher in lower-level hospitals and specific disease categories. To improve medication appropriateness for hospitalized older adults, it is crucial to provide healthcare professionals with education on PIMs and deprescribing. Integrating medication review and risk-benefit evaluation of medication into the clinical care of elderly inpatients is recommended. Future research should further investigate the reasons for PIM being prescribed and evaluate the effectiveness of interventions to reduce the use of potentially inappropriate medication in hospitalized older adults. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/89625 |
DOI: | 10.6342/NTU202303267 |
全文授權: | 同意授權(限校園內公開) |
顯示於系所單位: | 健康政策與管理研究所 |
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