吕迁洲-临床药学和临床药师的价值与作用课件.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,*,目录,2,临床药学的定义,为什么需要临床药学,临床药师的价值与作用,总结,ACCP,对临床药学的定义,2,ACCP,美国临床药学协会,American College of Clinical Pharmacy,定义：关于合理用药方面的科学研究与实践的药学领域,Pharmacy,）,3,是药师利用药学专业的知识、理论、技术、方法及仪器和药师特有的专业思维、判断能力，在药物治疗的各个环节为医师、护师及病人提供帮助的综合性应用学科。,目的：病人用药,更加,安全、有效、经济、合理。,ACCP,对临床药学的定义,6,临床药师应该关注病人卫生保健的各个方面。他们不仅具有全面而深厚的药物学知识，而且应该具有能够将生物医学、药学、社会行为学及临床医学科学与药物学知识结合起来为病人服务的能力。,ACCP,对临床药学的定义,7,为了达到预期的治疗目标，临床药师应该将循证医学、新兴的医药科学理论、新型的技术以及相关法规、伦理、社会、文化、经济的原则应用到工作实践中去。,为什么需要临床药学？,8,医疗需求,提高药物治疗效果,缩短药物疗程,减少药物治疗差错和事故,经济需求,降低病人经济支出,医改需求,节约卫生资源,医疗保险需求,减轻国家经济负担,为什么需要临床药学？,9,药学学科发展变化的需求,信息化、工业化、自动化、集约化,社会需求,药物警戒、人文进步、科技进步,生命质量需求,药物治疗和生活质量的平衡,人才培养、出路需求,药学专业结构合理化需求,临床药师的价值与作用,10,发现潜在的或实际存在的用药问题,解决实际发生的用药问题,防止潜在的用药问题发生,临床药师的价值与作用,11,有研究表明，临床药师能：,缩短平均住院日；,降低死亡率；,减少患者医疗费用，,提高患者生命质量；,降低药品不良反应及不良药物相互作用发生比率；,减少药物差错、事故。,C.A.Bond.Interrelationships among Mortality Rates,Drug Costs,Total Cost of Care,and Length of Stay in United States Hospitals:Summary and Recommendations for Clinical Pharmacy Services and StaffingJ.Pharmacotherapy.2001;21(2):129-41,检索方法,12,临床治疗结果,主题,=(controlled trials)AND,主题,=(pharmacist)AND,主题,=(patient),；精炼依据,:Web of Science Categories=(PHARMACOLOGY PHARMACY),用药差错,主题,=(medic*error)AND,主题,=(pharmacist)AND,主题,=(patient),；精炼依据,:Document Type=(ARTICLE OR REVIEW),不良反应,主题,=(adverse drug event or adverse drug reation or adr)AND,主题,=(pharmacist)AND,主题,=(patient),；精炼依据,:Document Type=(ARTICLE OR REVIEW),检索工具,web of knowledge,检索年限,2001-2012,检索方法,13,医疗费用,主题,=(cost)AND,主题,=(pharmacist)AND,主题,=(patient),；精炼依据,:Document Type=(ARTICLE OR REVIEW)AND Web of Science Categories=(HEALTH CARE SCIENCES SERVICES),平均,住院日,主题,=(length of stay)AND 主题=(pharmacist)；精炼依据:Document Type=(ARTICLE OR REVIEW),依从性,主题,=(complian*or adherence)AND,主题,=(pharmacist)AND,主题,=(patient),；精炼依据,:Web of Science Categories=(HEALTH CARE SCIENCES SERVICES),检索工具,web of knowledge,检索年限,2001-2012,检索结果,类别统计,15,类 别,数量,临床治疗结果,（,Clinical Outcome,）,49,用药差错,（,Medication Error,）,115,不良反应,（,ADR,）,109,医疗费用,（,Cost,）,127,平均住院日,（,Length of Stay,Los,）,72,依从性,（,Compliance,）,84,汇总（去重复）,490,序号,国家,数量,百分比,1,USA,250,51.020%,2,Canada,41,8.367%,3,England,37,7.551%,4,Australia,31,6.327%,5,Netherlands,29,5.918%,6,France,15,3.051%,7,Spain,15,2.857%,8,Germany,9,1.837%,9,Japan,9,1.837%,10,Scotland,9,1.837%,11,China,7,1.429%,16,检索结果,国家统计,检索结果,国家统计,17,检索结果,出版物统计,18,序号,出版杂志,影响因子,数量,百分比,1,Journal of Managed Care Pharmacy,2.250,49,10.000%,2,American Journal of Health System Pharmacy,1.962,27,5.510%,3,Annals of Pharmacotherapy,2.126,26,5.306%,4,Pharmacotherapy,2.900,24,4.898%,5,Pharmacy World Science,1.215,23,4.694%,6,American Journal of Managed Care,2.458,20,4.082%,7,Drug Safety,3.634,17,3.469%,8,Quality Safety in Health Care,1.683,16,3.265%,9,BMC Health Services Research,1.660,15,3.061%,10,Disease Management Health Outcomes,14,2.857%,11,British Journal of Clinical Pharmacology,2.958,13,2.653%,加权平均影响因子,2.352,检索结果,机构统计,19,检索结果,发表年份统计,20,检索结果,文献类型统计,21,改善临床治疗结果（,Clinical Outcome,）,22,TI,SO,RP,Medication review and reconciliation with cooperation between pharmacist and general practitioner and the benefit for the patient:a systematic review,BRITISH JOURNAL OF CLINICAL PHARMACOLOGY,Netherlands,2012,Effectiveness of Dader Method for Pharmaceutical Care on Control of Blood Pressure and Total Cholesterol in Outpatients with,Cardiovascular Disease or Cardiovascular Risk,:EMDADER-CV Randomized Controlled Trial,JOURNAL OF MANAGED CARE PHARMACY,Colombia,2012,Impact of pharmaceutical care on health outcomes in patients with,COPD,INTERNATIONAL JOURNAL OF CLINICAL PHARMACY,Jordan,2012,减少用药差错（,Medication Error,）,23,TI,SO,RP,Tenfold Medication Errors:5 Years Experience at a University-Affiliated Pediatric Hospital,PEDIATRICS,Canada,2012,Factors Associated with Reported Preventable Adverse Drug Events:A Retrospective,Case-Control Study,ANNALS OF PHARMACOTHERAPY,IN USA,2012,A Prospective,Multicenter Study of Pharmacist Activities Resulting in Medication Error Interception in the Emergency Department,ANNALS OF EMERGENCY MEDICINE,USA,2012,降低不良反应（,ADR,）,24,TI,SO,RP,Risk factors associated with adverse drug reactions in hospitalized children:international multicentre study,EUROPEAN JOURNAL OF CLINICAL PHARMACOLOGY,Germany,2012,Analysis of risk factors for adverse drug events in critically ill patients,CRITICAL CARE MEDICINE,USA,2012,Adverse Drug Reactions in Older People Detection and Prevention,DRUGS&AGING,Belgium,2012,减少医疗费用（,Cost,）,25,TI,SO,RP,Approaches to the Management of Agents Used for the Treatment of Multiple Sclerosis:Consensus Statements from a Panel of US Managed Care Pharmacists and Physicians,JOURNAL OF MANAGED CARE PHARMACY,USA,2012,An Integrated Pharmacy-Based Program Improved Medication Prescription And Adherence Rates In Diabetes Patients,HEALTH AFFAIRS,RI USA,2012,Narcotic analgesic utilization amongst injured workers:using concept mapping to understand current issues from the perspectives of physicians and pharmacists,BMC HEALTH SERVICES RESEARCH,Canada,2011,缩短平均住院日（,Length of Stay,）,26,TI,SO,RP,Clinical Pharmacists on Medical Care of Pediatric Inpatients:A Single-Center Randomized Controlled Trial,PLOS ONE,China,2012,Efficacy and safety of a pharmacist-managed inpatient anticoagulation service for warfarin initiation and titration,JOURNAL OF CLINICAL PHARMACY AND THERAPEUTICS,Singapore,2011,Cost and Resource Allocation Issues in Managing Hyponatremia.The Pharmacists Role,PHARMACOTHERAPY,USA,2011,提高依从性（,Compliance,）,27,TI,SO,RP,An Integrated Pharmacy-Based Program Improved Medication Prescription And Adherence Rates In Diabetes Patients,HEALTH AFFAIRS,RI USA,2012,The Impact of 90-Day Prescriptions on Adherence at Workplace Pharmacies Compared to Traditional Mail Order,POPULATION HEALTH MANAGEMENT,USA,2011,Effects of a clinical pharmacist service on health-related quality of life and prescribing of drugs:a randomised controlled trial,BMJ QUALITY&SAFETY,Sweden,2011,国内相关研究,28,1,2,3,4,web of knowledge,检索网络,Pharmacist;,Pharmaceutical care;,Pharmaceutical service,关键词,中国,限定区域,2001-2012,检索时间,共,41,篇文章，通过筛选获得,9,篇关于药师临床干预的研究,国内相关研究,29,文献,试验方案,人数,时间,干预方式,研究切入点,结果,1,随机对照研究：,干预组和对照组,105,：,I=51,C=54,9mo,药师提供咨询服务,2,型糖尿病患者的冠心病风险水平及患者依从性,干预组较对照冠心病风险下降,1.64%,*,，中风率下降,1.37%,*,（控制组风险升高），血红素,A1c,水平下降,1.17%,*,，,LDL,水平下降,0.33,mmolL,*,，依从性从,2%,提高至,22.5%,*,2,随机对照研究：,干预组和对照组,160:,I=80,C=80,药师提供治疗意见，检验处方向出院病人提供咨询服务,多种儿科疾病治疗情况：用药差错，平均住院日，依从性，医疗费用,干预组较对照组平均住院日缩短,4.43,天,*,，依从性提高,11.14%,*,，以及较少的不良反应发生率与用药差错,3,随机对照研究：,干预组和对照组,278,：,I=139,C=139,6mo,药师向干预组提供,192,项用药意见：,42.7%,为增添一种抗高血压药，,39.8%,于首次访问时给出,高血压病人的血压控制水平及用药依从性,干预组较对照组血压控制率提高,25.8%,*,，,SBP,下降,8.5mmHg,*,，,DBP,下降,4.7mmHg,*,；依从性提高,16.9%,*,*表示数据有显著性差异；,I,代表干预组，,C,代表对照组,国内相关研究,30,文献,试验方案,人数,时间,干预方式,研究切入点,结果,4,随机对照研究：,干预组和对照组,354,：,I=178,C=176,14mo,药师纠正抗生素不合理运用，从五方面提供治疗意见：适用症、剂量、给药时间，持续时间、剂型更换,呼吸道感染患者医疗费用，住院日，五项抗生素不合理用药评分,干预组较对照组住院费用及抗生素用药费用分别减少,$287.6,*,与,$111.9,*,，住院日缩短,1.6,天,*,；五项抗生素不合理用药得分均较低。,5,前瞻性对照研究：,干预组和对照组,300,：,I=150,C=150,24mo,增强对健康生活方式的教育，每月定期电话随访,降脂治疗中,LDL-C,水平及其他相关指标；依从性及合理用药水平,干预组较对照组,LDL-C,治疗目标达成率上升,13.4%,，,LDL-C,，,TC,，,TG,平均下降幅度分别增大,13.8%,，,10.8%,，,18.5%,；所提供的服务每月仅增加每位高血脂患者,$385/600,6,前瞻性随机对照研究：,干预组和对照组,118:,I=58,C=60,9mo,药师与病人进行,15-30min,的交流，并对药物与生活方式的改善提供意见，之后进行,4,周的电话随访,降脂治疗中,LDL-C,水平及,TC,水平,干预组较对照组有更低的,LDL-C,（,2.,80,0.89mmol,L vs.3.,240,.,78mmolL,）,*,以及更低的,TC,水平（,4.,75 1,.,08mmolL vs.,5.,180,.,93mmolL,）,*,国内相关研究,31,文献,试验方案,人数,时间,干预方式,研究切入点,结果,7,前瞻性随机对照研究：,干预组和对照组,137,：,I=68,C=69,药师对病人进行药物教育，监测华法林与药物、与食物，与草药的相互作用；并进行电话随访,华法林使用者的,PSQ-18,评分以及病人每日花费,干预组较对照组病人平均每月花费较少（,US$76,95 vs.US$98,158,）,*,，,PSQ-18,评分相对较高（,3.8,0.2 vs.3.6,0.3,）,*,8,随机对照研究：,电话咨询组和对照组,502,：,I=219,C=223,60,人违约,2y,药师与电话咨询组病人进行面对面随访，同时多次电话随访；对照组不进行电话随访,低依从性病人的死亡率以及依从性的改善情况,电话咨询组较对照组降低死亡风险,41%,（,RR 0.59 95%CI 0.35-0.97,）,*,9,前瞻性对照研究：,个体化咨询组和对照组,50,：,I=26,C=24,3mo,药师向病人个体提供咨询服务；并监测胆固醇浓度,降脂治疗中,LDL-C,水平及其他相关指标；依从性,个体化咨询组较对照组有更高的依从水平（高依从者占,76.9%vs.41.7%,）,*,；更大幅度的降低,LDL-C,（,27.7%vs.16.3%,）,*,，,TC,（,28.3%vs.,15.3%,）,*,，,TG,（,26.1%vs.10.6%,）,*,临床药师的价值与作用,31,在目前我国医院运行机制仍是项目收费、自负盈亏的情况下，临床药学的学术价值仅仅可通过社会的、伦理的、道德的、医疗的价值来实现。这样学科发展是没有动力的。,只有当我国医院运行机制采取病种收费或预付费方式的时候，临床药学的经济价值才能显现出来。只有这个时候学科发展才有了真正的动力。,Thank you!,Lv.qianzhouzs-,复旦大学附属中山医院,