居家照護之老年管灌病人不適合磨碎藥物的處方分析

A Study Shows that Medications Should Not Be Crushed in Elderly Home Care Patients with Nasogastric Tubes

目的：六成居家照護的病患長期使用鼻胃管作為攝食營養與給藥的途徑，給予管灌病人違反磨藥禁忌之藥物或可視為處方藥物劑型不適當。本研究旨在探討居家老年管灌病患接受不適合磨碎藥物處方（以下簡稱不適磨碎處方）的狀況與其相關之影響因子。方法：本研究以二次資料分析方式，由2004年全民健康保險門診申報資料中取得研究對象在申報鼻胃管置放後30日內的西醫門急診處方之口服藥物、天數、處方醫師科別、處方醫院層級等資料，以t檢定、單因子變異數分析檢定、及卡方檢定分析病患特性、處方特性、以及醫師及醫院特性與不適磨碎處方間的關係，並且以羅吉斯迴歸分析探討上述變項對於不適磨碎處方之影響。結果：共有20,239位使用居家照護的老年管灌病患，於鼻胃管置入後30日內共接受處方295,954次，共使用口服藥物1,475,689項；曾經接受不適磨碎處方的病患佔64.3%。處方箋中含有至少一種以上不適合磨碎藥物之處方佔28.9%，而此不適磨碎處方中僅含1種不適合磨碎藥物者佔67%，含2種不適合磨碎藥物者佔26%。在處方特性中，藥物品項總數及給藥日數與處方適當性皆有顯著相關。醫院層級與醫師類別也都與處方適當性有顯著之相關性。單變項羅吉斯迴歸分析顯示，藥物品項總數愈多、給藥天數愈長，發生不適當處方的勝算比則愈高；與醫學中心相比，區域醫院的風險比較高，而地區醫院及基層診所的風險比較低；與家醫科醫師相比，內科系醫師的勝算比較高，而外科系、一般科及其他科的勝算比較低。多變項羅吉斯迴歸分析顯示，增加不適當處方發生風險的影響因子為：藥物品項總數多於3項以上、給藥天數超過7天、非醫學中心之醫院層級，其中以藥物品項總數及給藥天數為主要的預測因子。結論：許多居家照護老年管灌病患曾經接受含有不適合磨碎藥物的處方，但是其中絕大部分僅含有1至2種不適合磨碎藥物；而且多重用藥及長期處方含有不適合磨碎藥物的危險性較高。因此醫師在處方藥物同時，必須要瞭解藥物的特性以及投藥的禁忌，而且定期審視用藥，以避免不適當用藥的情形發生。

Objective: Sixty percent of elderly home care patients in Taiwan use nasogastric tubes for nutritional support. Crushing certain medications may be inappropriate for these patients. The objective of this study was to estimate the prevalence of improper prescriptions and identify the factors associated with inappropriate crushing of certain medications for this home care population. Methods: This was a secondary analysis of data drawn from the Taiwan National Health Insurance Database between January and December of 2004. Records of prescriptions for elderly outpatients within 30 days of nasogastric intubation were retrieved. Variables in the analysis included the number of medications, number of days for each prescription, the specialty of the prescribing physician, and the rank of the hospital that dispensed the medications. Inappropriate prescription use was defined as dispensing medications that should not be crushed for nasogastric tube use. Results: This study involved 20,239 patients, and during the course of this study, 64.3% of them received at least one medication that should not be crushed. Of the total 295,954 prescriptions (1,475,689 medications), 28.9% were inappropriate prescriptions (67% and 26% containing one and two medications, respectively). Factors significantly associated with inappropriate prescribing included number of medications, duration of prescription, rank of hospital, and the specialty of prescribing physician. The univariate logistic regression showed that more prescribed medication, longer duration of prescription, not a medical center, family doctor, and internist physician were potentially associated with inappropriateness of prescription. The multivariate logistic regression model showed that the most significant factors were the number of medications and the duration of the prescription. In this study, the most common inappropriate prescriptions were for biascodyl, felodipine, and extended released aminophylline. Conclusion: Patients with nasogastric tubes are at high risk for receiving inappropriate prescriptions. Most inappropriate prescriptions contain only 1 or 2 medications. Prescriptions of multiple drugs and of longer duration increase the rate of inappropriate prescribing. To lower this rate, knowledge of the drug characteristics and periodic reviews of the appropriate use or of the need to discontinue medications are necessary.