請用此 Handle URI 來引用此文件：
http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/91895完整後設資料紀錄
| DC 欄位 | 值 | 語言 |
|---|---|---|
| dc.contributor.advisor | 郭年真 | zh_TW |
| dc.contributor.advisor | Raymond N. Kuo | en |
| dc.contributor.author | 楊如燁 | zh_TW |
| dc.contributor.author | Ju-Yeh Yang | en |
| dc.date.accessioned | 2024-02-26T16:20:15Z | - |
| dc.date.available | 2024-02-27 | - |
| dc.date.copyright | 2024-02-26 | - |
| dc.date.issued | 2024 | - |
| dc.date.submitted | 2024-01-22 | - |
| dc.identifier.citation | Administration, F. a. D. (2019). Clinical Decision Support Software-Draft Guidance for Industry and Food and Drug Administration Staff. https://www.fda.gov/media/109618/download
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Development and exploitation of a clinical decision support system for the management of renal anaemia. Nephrol Dial Transplant, 22 Suppl 4, iv31-iv36. https://doi.org/10.1093/ndt/gfm163 Winkelmayer, W. C. (2011). Potential effects of the new Medicare Prospective Payment System on drug prescription in end-stage renal disease care. Blood Purif, 31(1-3), 66-69. https://doi.org/10.1159/000321856 Yusof, M. M., Kuljis, J., Papazafeiropoulou, A., & Stergioulas, L. K. (2008). An evaluation framework for Health Information Systems: human, organization and technology-fit factors (HOT-fit). Int J Med Inform, 77(6), 386-398. https://doi.org/10.1016/j.ijmedinf.2007.08.011 Zhu, X., & Perazella, M. A. (2006). Nonhematologic complications of erythropoietin therapy. Semin Dial, 19(4), 279-284. https://doi.org/10.1111/j.1525-139X.2006.00173.x | - |
| dc.identifier.uri | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/91895 | - |
| dc.description.abstract | 研究背景： 臨床決策支援系統(Clinical Decision Support System, CDSS)是基於專家經驗或數據研發的電腦演算流程，用在臨床情境以改善照護流程或病人預後，但約一半的CDSS無法達到預期的效果，最重要的因素是臨床人員對CDSS的接受度不足。亞東紀念醫院針對血液透析病患的貧血處置，於2019年設置了個人化貧血處置的CDSS，希望能協助改善血液透析病患血色素(Hb)達標率過低的現象。過去文獻報告透析患者貧血處置CDSS介入後的效果評估，大多直接比較介入前後的差異，沒有考慮臨床醫師對CDSS的接受度。
研究目的：本研究利用量性與質性分析，評估腎臟科醫師對透析患者貧血處置CDSS的接受度，探討影響臨床醫師對CDSS接受度的因素。 研究方法： 量性研究部分，分析2016~2020年間亞東醫院血液透析資料，按年代分為CDSS介入前期(2016~2018)、過度期(2019)及介入後期(2020)三個時期，比較三個時期貧血治療相關指標的變化趨勢，並探討此變化是否受CDSS接受度的影響。質性部分，邀請17位長期在亞東醫院血液透析室工作的腎臟科醫師，進行半結構式(semi-structured)的深度訪談(in-depth interview)，探討臨床醫師對CDSS的看法與顧慮。 研究結果: 量性分析納入717名患者共36,091次Hb量測。在多變數模型中，CDSS介入後的Hb升高（0.17 g/dL；95%信賴區間[CI]：CI 0.14–0.21 g/dL），造血激素(ESA)的使用量增加(264U/week； 95CI: 158-371U/week)，達標率下降(勝算比為0.71倍，95% CI：0.66–0.75），超標率增加(勝算比為1.81倍，95% CI：3.1–3.6），而失敗率在校正後沒有顯著改變(勝算比為0.92倍，95% CI：0.84–1.01）。醫囑更改跟醫矚與建議的一致性的比例都增加(更改勝算比為2.55倍，95% CI：2.39–2.73；一致勝算比為3.37倍，95% CI：3.15–3.60）。路徑分析顯示，介入後血色素增加、ESA使用量增加、達標率下降、超標率增加、醫囑更改率增加，都有部分效果是經由醫囑與CDSS建議的一致性所中介。質性研究共訪談了十七名腎臟科醫師，所有腎臟科醫師一致認為CDSS對臨床工作有助益的。其中十四名醫師認為CDSS可以加速工作，節省了數據評估的時間；八名醫師稱讚了CDSS的提醒功能。十六名醫師提到了CDSS的各種限制，例如無法根據患者情況進行個性化、無法處理罕見或突發情況、參考時間過短等。沒有醫師認為CDSS會影響專業判斷或專業自主性。相反，有十一名醫師提到CDSS可以為臨床判斷提供有益的參考。值得注意的是，多達十二名醫師表達了對醫師依賴CDSS的擔憂。 結論: CDSS的介入確實會影響醫師處方行為，影響貧血控制，且醫師處方與CDSS建議的一致性，為CDSS介入效果的中介因素。臨床醫師一致認為CDSS能減輕工作負擔，且不認為會威脅醫師的專業，但擔憂有能會有依賴CDSS的風險。我們的研究強調了在設計和介入CDSS時，優化醫師對CDSS的接受度，減少醫師對CDSS的顧慮，才能達到CDSS的效果。 | zh_TW |
| dc.description.abstract | Background: Clinical decision support systems (CDSS) are developed based on algorithms in attempts to improve healthcare implementation or patient outcomes. The most important factor that hinders the successful implementation of CDSS is the acceptance of physicians. There remain gaps in the optimal ways to evaluate the performance of CDSS. One practical example resides in the CDSS-guided clinical management of anemia in patients on hemodialysis (HD).
Objective: This study evaluated the CDSS performance in anemia management in HD patients, the impact of physician compliance on CDSS efficacy and the relevant factors associated with physician acceptance. Methods: We conducted a mixed method study. We extracted the electronic health records of HD patients in Far Eastern Memorial Hospital (FEMH) between 2016 to 2020. The CDSS program was implemented in 2019, thus we divided data into two phases: Pre-CDSS phase (2016-2018) and Post-CDSS phase (2020). We compared the managements of anemia between the two phases using random intercept models. Physician compliance was defined as the concordance of erythropoietin-stimulating agent (ESA) doses between the CDSS recommendations and the actual prescriptions. For qualitative part, we invited nephrologists with more than 3 months experience of caring HD patients at FEMH to participate in a semi-structured in-depth interview. We particularly explored nephrologists’ concerns on CDSS. Results: We included 717 patients with a total of 36,091 hemoglobin (Hb) measurements. In the adjusted random intercept model, the post-CDSS phase showed an increased hemoglobin level (by 0.17 g/dL; 95% confidence interval [CI]: CI 0.14–0.21 g/dL), an increased ESA dosage (264U/week, 95CI: 158-371), a reduced on-target rate (OR 0.71, 95% CI:0.66-0.75), an increased over-target rate (OR 1.81, 95% CI:1.68-1.95), an increased prescription rate (OR 2.55, 95% CI:2.39-2.73) and an increased concordance rate (OR 3.37, 95% CI: 3.15–3.60). Path analysis revealed that the concordance rate significantly mediated the effects of CDSS. For qualitative part, a total of seventeen nephrologists were interviewed. All interveiwees concurred that CDSS was beneficial to clinical care. Fourteen (4/17) nephrologists believed CDSS could expedite the work and saved the time in interpretation of data. Eight physicians praised reminder functions of CDSS. Sixteen physicians mentioned about limitations of CDSS. No physician thought CDSS would influence professional autonomy. In contrast, eleven physicians mentioned that CDSS could provide beneficial inputs for clinical judgement. Of note, up to twelve physicians expressed concerns of physicians’ dependence on CDSS. Conclusions: Our findings confirmed that CDSS had effects on anemia management of HD patients and physician compliance was a significant intermediate factor for the CDSS efficacy. Nephrologists concurred that CDSS could lessen workload, but expressed concerns about over-dependency on CDSS. Our study highlights the importance of optimizing physician compliance while designing and implementing CDSSs to improve the healthcare outcomes. | en |
| dc.description.provenance | Submitted by admin ntu (admin@lib.ntu.edu.tw) on 2024-02-26T16:20:15Z No. of bitstreams: 0 | en |
| dc.description.provenance | Made available in DSpace on 2024-02-26T16:20:15Z (GMT). No. of bitstreams: 0 | en |
| dc.description.tableofcontents | 口試委員會審定書 I
誌謝 II 中文摘要 III ABSTRACT V 第 壹 章 緒論 1 第一節 研究背景與動機 1 第二節 研究目的 4 第三節 研究重要性 4 第 貳 章 文獻探討 6 第一節 透析患者的貧血 6 第二節 臨床決策支援系統 10 第三節 運用臨床決策支援系統協助透析患者貧血治療 19 第四節 文獻總結與知識缺口 24 第 參 章 研究方法 33 第一節 研究設計與架構 33 第二節 研究假說 34 第三節 研究對象 34 第四節 資料來源與處理流程 35 第五節 研究變項與操作型定義 38 第六節 統計分析方法 41 第七節 質性訪談 42 第 肆 章 研究結果 47 第一節 量性分析 47 第二節 質性訪談 69 第 伍 章 討論 83 第一節 量性分析 83 第二節 質性訪談 85 第三節 綜合討論 87 第四節 研究限制 89 第五節 未來研究方向 92 參考文獻 94 附 表 105 附 件 107 | - |
| dc.language.iso | zh_TW | - |
| dc.subject | 臨床決策支援系統 | zh_TW |
| dc.subject | 血液透析 | zh_TW |
| dc.subject | 貧血 | zh_TW |
| dc.subject | 一致性 | zh_TW |
| dc.subject | 接受度 | zh_TW |
| dc.subject | 顧慮 | zh_TW |
| dc.subject | 專業自主性 | zh_TW |
| dc.subject | 倚賴 | zh_TW |
| dc.subject | Professional autonomy | en |
| dc.subject | Clinical decision support systems | en |
| dc.subject | Dependence | en |
| dc.subject | Hemodialysis | en |
| dc.subject | Anemia | en |
| dc.subject | Consistency | en |
| dc.subject | Acceptance | en |
| dc.subject | Concern | en |
| dc.title | 探討醫師對臨床決策支援系統的接受度--以透析患者貧血治療為例 | zh_TW |
| dc.title | Assessing Physicians' Acceptance of a Clinical Decision Support System: A Focus on Anemia Management for Hemodialysis Patients | en |
| dc.type | Thesis | - |
| dc.date.schoolyear | 112-1 | - |
| dc.description.degree | 博士 | - |
| dc.contributor.coadvisor | 鄭守夏 | zh_TW |
| dc.contributor.coadvisor | Shou-Hsia Cheng | en |
| dc.contributor.oralexamcommittee | 楊銘欽;官晨怡;劉德明;林寬佳 | zh_TW |
| dc.contributor.oralexamcommittee | Ming-Chin Yang;Chen-I Kuan;Der-Ming Liou;Kuan-Chia Lin | en |
| dc.subject.keyword | 臨床決策支援系統,血液透析,貧血,一致性,接受度,顧慮,專業自主性,倚賴, | zh_TW |
| dc.subject.keyword | Clinical decision support systems,Hemodialysis,Anemia,Consistency,Acceptance,Concern,Professional autonomy,Dependence, | en |
| dc.relation.page | 108 | - |
| dc.identifier.doi | 10.6342/NTU202400153 | - |
| dc.rights.note | 同意授權(限校園內公開) | - |
| dc.date.accepted | 2024-01-22 | - |
| dc.contributor.author-college | 公共衛生學院 | - |
| dc.contributor.author-dept | 健康政策與管理研究所 | - |
| dc.date.embargo-lift | 2024-11-20 | - |
| 顯示於系所單位： | 健康政策與管理研究所 | |
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