의사 결정 과정 (Decision Making) 사례 2. 약물요법 vs 행동 요법 사례 6. 제왕절개 vs 제왕절개 후 질식분만(VBAC)

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2 56세여자환자가고지혈증때문에찾아왔다. 기록을보니이미 2년전에도고지혈증이있었는데당시고지혈증처방을했지만이후방문한기록이없었다. 환자는약을먹지않고지냈으며약안먹고조절하는방법을알려달라고했다. 의사는지금이상태를보면몇년째식이요법으로조절이안된것으로보아서식이요법만으로어려울것같으니약을먹는것이좋겠다고말했다. 환자는약을먹으면평생먹는약이라면먹지않고운동이나식이요법과같은방법으로근본적인치료를원한다고말했다.

3 56 세여자 Classical risk factor of CHD (Female, Age>=55) 2 년전에도고지혈증 Chronic disease 방문한기록이없었다., 약을먹지않고지냈으며 Low compliance 대등한동반자관계모형 평생먹는약, 근본적인치료를원한다 환자가약물요법보다행동요법을선호하는이유

4 Total cholesterol concentration & coronary risk It is reasonable to recommend that all patients with high LDL-C undergo lifestyle modifications weight loss in overweight patients, aerobic exercise eating a prudent diet Patients with CHD risks have clearly benefit from treatment with statins Statins can reduce relative cardiovascular risk by 20~30% regardless of baseline LDL-C level WOSCOPS(Pravastatin) AFCAPS/TexCAPS (Lovastatin) ASCOT-LLA (Atorvastatin) JUPITER trial (Rosuvastatin)

5 약물적치료의필요성 Patient s cardiovascular risk 장기적인약물복용에대한부담감 Cost-effectiveness modeling

6 Determining whom to treat with statins The benefits of treatment Burdens of daily statin therapy The cost Potential adverse effects Absolute risk reduction The Framingham Risk Score 10 years risk of general cardiovascular disease

7 The Framingham risk score

The net benefit of lipid-lowering therapy at different levels of risk by assessing both the benefits of therapy as well as its adverse effects and costs Pignone M. et al.

8 The net benefit of lipid-lowering therapy at different levels of risk by assessing both the benefits of therapy as well as its adverse effects and costs Pignone M. et al Middle-aged men without a history of cardiovascular disease 6 levels of 10-year risk for CHD (2.5%, 5%, 7.5%, 10%, 15%, and 25%). The ten-year baseline risk of CHD events was over 10 percent 56,200 dollars per quality-adjusted life-year gained Pletcher MJ. et al noted that the threshold for prescribing a statin is decreasing as statin cost decreases

9 환자의의사결정 환자는의사결정과정에서자율성을존중받을권리가있다. 약물치료없이행동요법만으로고지혈증을조절할경우심각한위험이따른다고하여도환자는치료를거부할권리가있다. 그렇기때문에환자에게미리정확한정보를제공하고환자가그정보를정확하게파악한것을확인한후환자의동의를묻는것이중요하다 (Informed consent) 환자의현재심혈관질환으로의진행의위험도가어느정도인지설명하고, 약물치료를병행하였을경우와하지않았을경우의심혈관질환유병률의어떠한차이가있는지정확하게이해시켜야함. 환자가평생약물을복용하여야하는것에대한부담감에대하여, 정확한연구결과를통해환자의현재상태에서약물을사용하지않을경우이후에더큰소비가생길수있으며, 약물사용에대한비용, 부작용에의한손실보다약물을사용했을때의이익이더클수있음을설명해야한다.

10 의사결정에서의의사의역할 의료서비스의생산자, 또는제공자로서의의사가아닌대등한동반자의관계 환자의자율성존중의측면에치우칠경우의사는의료서비스를제공하는단순한상품판매원이될수있다. 의사는질병과치료에있어전문적지식을갖춘치료자며, 환자치유와박애에대한동기및그가치를지켜야한다. 의사결정과정에서환자의자율성을존중하는행위는환자의치료에대한순응도를높이고치료에대한만족도를높이는것을목표로하여야하며, 결코환자에게모든치료의선택권을떠맡기는행위가되어서는안된다.

11 56 세여환의고지혈증치료에대한의사결정 우선환자가갖는 Risk 를파악하는것이중요하다. 환자가 low risk group 에속한다면 환자가비록저위험군이라할지라도행동요법과함께약물치료를시작하는것이환자의심혈관질환의위험을낮추는데도움이된다. 그러나 risk 가낮은환자의경우약물을사용하는데있어감수해야할손실보다이익이크다고확언할수없다. 따라서의사는약물사용이이후생길수있는심혈관질환을 20~30% 줄일수있다고충분히설명을하고, 그럼에도불구하고환자가약물치료를거부할경우에는환자에게올바른행동요법에대해교육하고, 주기적으로심혈관질환에대한정기검사를받을것을제안하는것이중요하다.

12 56 세여환의고지혈증치료에대한의사결정 환자가 high risk group 에속한다면 환자가의학적근거로미루어보았을때반드시약물치료가필요한상황이므로적극적인설득이필요하다. 환자가갖는심혈관질환의발생에대한위험성을정확하게설명하고약물치료가하나의선택적치료수단이기보다현재꼭필요한치료임을설명하여야하며, 약물치료를하지않았을경우생길수있는위험성에대해 warning 할필요가있다. 그러나만성질환에있어서덜권위적이고환자참여를많이허용하는의사의진료를받는환자들이더나은건강상태를보일뿐아니라만족감, 순응도도높았다는연구가있다. 따라서의사의일방적인지시가아닌환자가갖고있는궁굼한부분, 걱정되는부분을자유롭게말하도록하고, 그에대한충분한설명을하여환자가자발적으로약물치료를받아드릴수있도록하는것이중요하다.

13 첫번째분만에서제왕절개술을받은 32세여성이분만을위해내원하였다. 의사는다시질식분만 (Vaginal Birth After Cesarean, VBAC) 을할경우자궁파열의위험이높기때문에제왕절개술을다시시행하는것이안전하다고하였다. 산모는첫번째분만을제왕절개로한뒤아이에게모유도주지못했기때문에이번에는자연분만을하고싶어했는데의사의이말에망설이게되었다. 자연분만은이런경우에어려운가?

14 The optimum management of the woman who has undergone a previous cesarean delivery has been debated for over 100 years The increasing primary cesarean delivery rate large numbers of women undergoing repeat cesarean deliveries an d multiple cesarean deliveries NIH, ACOG encouraged attempts to increase the rate of VBAC These attempts were highly successful; VBAC increased from 3.4 percent in 1980 to a peak of 28.3 percent in 1996

15 As the VBAC rate increased, however, so did reports of uterine rupture-related maternal and perinatal morbidity ACOG revised the practice bulletin to say that physicians should be immediately available, a position endorsed by the American Society of Anesthesiologists (ASA) Ironically, during this same decade, there were continuing reports describing the success and safety of TOLAC in selected clinical settings

16 TOLAC vs ERCD TOLAC : Trial of labor after cesarean delivery ERCD : Elective repeat cesarean delivery No high-quality trials have been performed comparing the risks and benefits of TOLAC versus ERCD. Women who are potentially at higher risk of uterine rupture and its attendant sequelae Factors known to affect TOLAC success rates

17 Antepartum factors Indication for prior cesarean delivery Success rate: fetal malpresentation (75%), Abnormal fetal heart rate pattern (60%) Failure to progress (54%) History or prior varginal delivary Demographic factors Hispanic, African American, and Asian women (Good) non-hispanic and white women (Bad) Increasing maternal age Single marital status Less than 12 years of education

18 Intrapartum factors Admission labor status(spontaneous labor) Fetal macrosomia (Fetal body weight >4000g) Type of hospital

19 Maternal risks

20 Maternal benefits TOLAC Avoidance of risks associated with repeat cesarean delivery Shorter hospital stay Fewer postpartum complications Quicker return to normal activities Lower maternal morbidity and mortality ERCD Scheduling convenience Ease of sterilization at the time of delivery Avoidance of the risks associated with failed TOLAC

21 Perinatal risks and benefits There is little or no evidence on short- and long-term neonatal outcomes after TOLAC versus ERCD Mortality TOLAC (0.13) > ERCD (0.05) Hypoxic ischemic encephalopathy TOLAC > ERCD Respiratory problems risk of TTNB : ERCD (4.2%) >TOLAC (3.6%) neonatal bag and mask ventilation : TOLAC(5.4%) > ERCD(2.5%) Other complications Five-minute Apgar scores or neonatal intensive care unit admissions : No significant differences Birth trauma from lacerations : ERCD > TOLAC

24 제왕절개후질식분만을원하는환모 출산경로를선택하는것이환모및태아의사망률, 이환율에영향을줄수있다. 질식분만시생길수있는합병증에대해즉각적인개입을할수있는병원시설, 의료진이있을경우에만질식분만을고려할수있다. 의사결정에있어서, 자궁파열의가능성및질식분만, 제왕절개의합병증을일으킬수있는위험인자에대한파악이중요하다. 환모는첫제왕절개시느낀불편함에대한지식만을갖고있기때문에환모에게질식분만, 제왕절개의장점과단점을정확하게설명하여 Informed consent 를형성하여야한다. Level A 의 evidence 를가진환모에게는 TOLAC 을시도할수있지만그이하의 evidence 를가진경우에는시술자의기술, 시설의수준, 환모의의지등을고려하여의사결정을내릴수있다.

한국성인에서초기황반변성질환과 연관된위험요인연구

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