ORIGINAL ARTICLE J Neurocrit Care 2018;11(2):110-118 eissn 2508-1349 뇌신경계중환자실전담약사의활동에따른약물조정효과및회피비용분석 조의상 1 송영주 1 정영미 1 최경숙 1 이은숙 1 김은경 2 한문구 3 1 분당서울대학교병원약제부, 2 서울대학교약학대학, 3 분당서울대학교병원신경과 Effects of Medication Reconciliation and Cost Avoidance Analysis by Clinical Pharmacists in a Neurocritical Care Unit Ui Sang Cho 1, Young Joo Song 1, Young Mi Jung 1, Kyung Suk Choi 1, Eunsook Lee 1, Euni Lee 2, Moon-Ku Han, MD 3 1 Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam; 2 College of Pharmacy, Seoul National University, Seoul; 3 Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea Background: The role of clinical pharmacists in medication therapy to improve clinical and economic outcomes has been reported in the literature. This study was conducted to analyze the changes in details of medication interventions before and after the introduction of clinical pharmacists into the care of neurocritical care unit (NCU) patients, and to evaluate the economic effects of clinical pharmacists by calculating the avoidance cost. Methods: A retrospective study was conducted reviewing the electronic medical records from June 2013 to May 2014 (before), and from June 2016 to May 2017 (after). We calculated the number and rates of intervention, the acceptance rates of it, and also reviewed the list of interventions. We calculated avoidance cost if there was no intervention. Results: The monthly mean number of interventions increased from 8.0 (±5.7) to 31.7 (±12.8) (P<0.001) and the frequency of intervention also increased from 0.8% to 1.6% (P =0.003). The most frequently provided pharmacist intervention was nutritional support before introduction of clinical pharmacists and discussions on the medication plan after. The number of classified interventions was 14 before introduction of clinical pharmacist services and 33 after. The calculated cost avoidance associated with a clinical pharmacists integration was 77,990,615 won per year. Conclusion: Introduction of clinicals pharmacist into the NCU was associated with increased intervention rates and expanded types of clinical interventions. The cost avoidance achieved by the pharmacists interventions can be further explored to evaluate if similar expansions of pharmacists services achieve similar results in other settings. J Neurocrit Care 2018;11(2):110-118 Received October 30, 2018 Revised December 6, 2018 Accepted December 6, 2018 Corresponding Author: Moon-Ku Han, MD Department of Neurology, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Tel: +82-31-787-7469 Fax: +82-31-719-7985 E-mail: mkhan@snu.ac.kr Copyright 2018 The Korean Neurocritical Care Society Key words: Intensive care units; Pharmacist; Medication reconciliation; Costs and cost analysis cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 110 www.e-jnc.org
Ui Sang Cho, et al. Effects of Medication Reconciliation by Pharmacist 서론 중환자는질병의심각성, 다약제사용, 신체기능의저하로 처방오류발생시에약물이상반응에대한위험과빈도수 가높다. 1-3 중환자실에서팀의료의일원으로써약사가참여 하는것은적절한약물정보제공및조정에기여할수있으며 약물이상반응예방, 재원기간감소및경제적이득을가져 온다고보고되었다. 4-7 2008 년시행된연구에서국제적으로 74.4% 의중환자전담약사가중환자약물치료에기여하고있 으며, 8 국내의경우 2014 년건강보험심사평가원에서 중환자 실적정성평가 실시를결정하면서중환자약물치료를위하 여약사의참여는필수적인요소가되었다. 9 중환자실전담약사의조정활동이처방관련오류및약물 이상반응감소를통하여환자안전및경제적인측면에긍정 적인효과를나타낸다고보고되었으나뇌신경계중환자실 (neurocritical care unit, NCU) 환경에서연구된바는없다. 뇌신 경계중환자의주된입원사유는뇌동맥류, 뇌출혈, 뇌경색, 뇌종양, 발작등이며적절한초기치료가예후에큰영향을미 치는질환들이다. 이러한신경과적응급상황에서뇌신경계 질환에대한이해를바탕으로적절한약물치료학적접근을 위해서는 NCU 전담약사가필요할것으로사료된다. NCU 전 담약사는약물처방감사를통하여약물용량, 부작용, 상호 작용등을확인하여올바른약물사용및대체약물에대한 추천을하며, NCU 환자의집중적인모니터링을통하여시시 각각변하는상황에필요한약물요법추천및임상업무등 을할수있다. 이에본연구는 NCU 전담약사의활동전과후 의약물조정변화를분석하고, 전담약사활동후약물조정 에대한회피비용을산출함으로써 NCU 전담약사의약물조 정효과를평가하고자하였다. 대상및방법 1. 연구대상중환자실에서약사의역할에대한인식과함께분당서울대 학교병원에서는 2013 년 3 월 NCU 가신설된이후, 2014 년 11 월 1 일부터 NCU 전담약사가배정되어회진참여, 환자투약이력 관리, 약물검토및조정등의업무를시작하였다. 본연구는 분당서울대학교병원 NCU 입원환자중뇌신경센터, 신경과, 신 경외과의진료를받은 20 세이상의환자를대상으로연구를 진행하였다. 10 2013 년 6 월 1 일부터 2014 년 5 월 31 일까지를전 담약사활동전분석기간으로, 2016년 6월 1일부터 2017년 5월 31일까지를전담약사활동후분석기간으로하였다. 그러나 NCU의재실기간이 1일미만인환자는제외하였다. 2. 자료수집및연구방법 1) 조정활동분석전담약사활동전과후의약물조정에대한분석은분당서울대학교병원약제부약사에의하여이루어진약물조정활동을분석하였다. 약물조정방법은원내메신저, 전화, 문자등에의하여이루어졌으며, 전담약사활동전에는 NCU 환자에게처방된약을조제하는과정에서비전담약사에의하여이루어지는처방감사를바탕으로조정활동을분석하였다. 또한처방단위오류, 제형오류등의약물조정이외에 NCU 환자의영양자문, clinical pharmacokinetic consultation service (CPCS) 자문이있을때회신을하는 NCU 비전담약사의임상업무활동을분석하였다. 전담약사활동후에는전담약사의처방감사에의한약물조정활동, 영양자문및 CPCS 자문등의임상업무, 회진참여, 주치의문의사항에대한답변및약물추천등의활동과전담약사근무외시간에있었던비전담약사의처방감사를바탕으로약물조정활동을분석하였다. 연구대상의전자의무기록을후향적으로검토하였으며, 조정활동은조정약물을기준으로분석하였다. 평가지표로약물조정건수, 처방대비약물조정률, 수용률, 약물조정유형, 조정약물군에대한자료를수집하였다. 약물조정건수는분당서울대학교병원전산시스템에기록된약물조정내역을조회하여분석하였다. 처방대비약물조정률은전체약물처방건수에대한전체조정건수의비율로계산하였다. 수용률은약물조정이후 3일이내처방이변경된경우로정의하였다. 11 약물조정유형은약사가작성한문의내역내용을기준으로총 8개의카테고리로분류하였으며, 영양지원, 용량변경, 제형변경, 약물치료계획상의, 투여계획변경, 적응증해당하지않음, 약물유해반응가능성, CPCS 자문관련문의가해당하였다. 예를들어, 약물치료계획상의 항목에는균동정결과에따른항생제사용기간및 step up, step down 여부, 약물상호작용가능성에의한대체약품추천등의내용이포함되었으며, 투여계획변경 항목에는동일효능의경구제형, 주사제형중복처방시단일약물사용추천, 식전, 식후, 공복복용등약효및약물상호작용을고려한투여스케줄변경추천, 약물투여의보험인정기준안내를통한투여일정변경등의내용이포함되었다. 111
조정약물군분류는세계보건기구 Anatomical Therapeutic Chemical (ATC) code 분류체계를기준으로하였다. 2) 회피비용분석연구기간중전담약사활동후 1년동안의약물조정에대한회피비용을계산하였다. 회피비용은전담약사의조정활동이실제수용되어환자의치료결과에긍정적인영향을미쳤다고판단할수있는경우계산하였으며회피비용계산방법은다음과같다. 12,13 회피비용 = 약물조정의심각성 약물조정없었을경우연장되었을입원일수 평균 1일입원비용. 약물조정의심각성은세계보건기구지침에근거한분당서울대학교병원의환자안전보고체계를기준으로 1명의전공약사가 1차분류하였다. 4,14,15 잠재적으로치명적결과초래, 잠재적으로심각한결과초래, 잠재적으로중요한결과초래, 잠재적으로미미한결과초래, 중요하지않음으로분류하였으며, 각각 1, 0.6, 0.4, 0.1, 0의환산지수를반영하여약물조정의심각성에따라차등계산하였다. 예를들어, 약물조정이없었을경우수술, 사망등생명에치명적인상태가유발될가능성이높은경우에 잠재적으로치명적결과초래 로분류, 심각한독성을유발할수있는경우는 잠재적으로심각한결과초래 로분류, 약물용량오류, 처방누락, 영양자문및 CPCS 자문과같이즉각적인해가발생하지않으나관찰이필요한경우 잠재적으로중요한결과초래 로분류, 약품정보제공등환자에게해가발생하지않는경우는 잠재적으로미미한결과초래 로분류, 약사의약물조정활동이환자의임상결과에영향을미치지않는경우는 중요하지않음 으로분류하여각각의환산지수를대입하여계산하였다. 조정이없었을경우연장되었을입원일수의경우약사의약물조정활동을경제적가치로환산하는방법의일환으로회피비용을분석한선행연구의계산방법을차용하였으며, 국내객관적기준이없는실정으로본연구에서도 1일로가정하여계산하였다. 11-13 입원비용은분당서울대학교병원 NCU 평균 1일입원비용을사용하여계산하였으며, 여기에는약제비용, 검사비용등환자처치에대하여발생한모든수가가포함되었다. 연구기간휴일및법정공휴일을제외한전담약사의평균근무일수는약 250일이었다. 1일 8시간근로시간중병원약사로써의기본적인조제업무, 부서내업무등을제외하고전담약사로써의일일평균활동시간은약 3시간이었으며, 이를통하여전담약사활동시간에대한회피비용을분석하였다. 3. 통계분석방법통계적분석방법으로전체처방대비중재율은 t-test, 약물조정건수, 수용률, 환자군특성분석은 chi-square test 를통하여분석되었으며, IBM SPSS statistic ver. 21.0 (IBM Corp., Armonk, NY, USA) 프로그램을이용하였다. 모든자료는 P<0.05일때통계적으로유의한것으로간주하였다. 4. 피험자보호본연구는분당서울대학교병원임상시험윤리위원회의승인하에시행되었다. 의무기록검토를통한후향적연구로써연구대상자의동의거부를추정할만한사유가없고, 동의를면제하여도연구대상자에게미치는위험이극히낮아동의서가면제되었다 (IRB No. B-1709/420-105). 결과 1. 연구대상의특성분당서울대학교병원 NCU 입원환자중본연구의기준에적합한환자수는 2013 년 6월 1일부터 2014년 5월 31일까지 59명, 2016년 6월 1일부터 2017년 5월 31일까지 143명이었으며, 총 202명을연구대상으로하였다. 대상환자의기본특성은 Table 1과같다. 전담약사활동전 NCU 입원환자의평균연령은 61.7세 (±16.0) 이고, 남자는 55.9% (n=33) 였다. 전담약사활동후 NCU 입원환자의평균연령은 65.2세 (±16.7) 이고, 남자는 62.2% (n=89) 였다. 입실시중환자의질병중증도와사망률예측을할수있는 acute physiology and chronic health evaluation II Score의평균은활동전군에서 24.9점 (±10.0), 활동후군에서 25.5점 (±6.0) 이었다. 16 NCU 재실기간의중간값은활동전군에서 13일 (2-351), 활동후군에서 12일 (2-365) 이었다. 입원당시주진단명은두군모두뇌경색, 뇌동맥류, 뇌종양, 뇌출혈등이었다. 활동전군과후군의특성은통계적으로유의한차이가없었다 (Table 1). 2. 전담약사의조정활동 1) 약물조정건수및수용률변화전담약사활동후약물조정건수와수용률변화는다음과같다 (Table 2). 월평균약물조정건수는전담약사활동전 8.0건 (±5.7) 에서전담약사활동후 31.7건 (±12.8) 으로증가 112
Ui Sang Cho, et al. Effects of Medication Reconciliation by Pharmacist Table 1. Basic characteristics of the study population Before group (n=59) After group (n=143) P value Male 33 (55.9) 89 (62.2) 0.405 Age (years) 61.7 (16.0) 65.2 (16.7) 0.175 Weight (kg) 62.8 (11.4) 68.1 (39.6) 0.312 Height (cm) 163.9 (9.7) 163.8 (9.0) 0.906 Admission causes Infarction 12 (20.3) 39 (27.3) 0.302 Aneurysm 8 (13.6) 17 (11.9) 0.743 Brain tumor 7 (11.9) 11 (7.7) 0.344 Intracerebral hemorrhage 6 (10.2) 13 (9.1) 0.811 Subdural hemorrhage 4 (6.8) 11 (7.7) 0.822 Status epilepticus 3 (5.1) 5 (3.5) 0.599 Encephalitis 3 (5.1) 5 (3.5) 0.599 Subarachnoid hemorrhage 2 (3.4) 7 (4.9) 0.637 Hydrocephalus 2 (3.4) 2 (1.4) 0.356 Moyamoya disease 2 (3.4) 3 (2.1) 0.591 Other 10 (16.9) 30 (21.0) 0.513 APACHE II Score 24.9 (10.0) 25.5 (6.0) 0.695 Length of NCU stay in days 13 (2-351) 12 (2-365) 0.454 APACHE, acute physiology and chronic health evaluation; NCU, neurocritical care unit. Values are presented as number (%), the mean (standard deviation) for normally distributed variables, or as the median (25th-75th percentile, interquartile range) for non-normally distributed variables. Table 2. Changes in medication reconciliation Before group After group P value Total number of medication reconciliations, N mr 96 380 - The monthly mean number of medication reconciliations 8.0 (5.7) 31.7 (12.8) <0.001 The rates of medication reconciliation (%) 0.8 1.6 0.003 Acceptance rate (%) 78.1 85.0 0.104 mr, medication reconciliation. Table 3. Types of medication intervention Types of medication intervention Before group (N mr =96) After group (N mr =380) Nutritional support 40 (41.7) 30 (7.9) Change of dose 20 (20.8) 54 (14.2) Change of dosage form 14 (14.6) 16 (4.2) Discussion of medication plan 9 (9.4) 105 (27.6) Change of medication plan 4 (4.2) 58 (15.3) Indication error 4 (4.2) 32 (8.4) Probability of adverse drug reaction 3 (3.1) 66 (17.4) Clinical pharmacokinetic consultation 2 (2.1) 19 (5.0) mr, medication reconciliation. Values are presented as number (%). 113
Table 4. Changes in drug categories due to medication reconciliation Drug categories* Before group (N mr =96) After group (N mr =380) Agents acting on the renin-angiotensin system - 3 (0.8) All other therapeutic products - 2 (0.5) Analgesics 2 (2.1) 7 (1.8) Anesthetics - 3 (0.8) Antianemic preparations - 2 (0.5) Antibacterials 13 (13.5) 137 (36.1) Antidiarrheals, intestinal anti-inflammatory/antiinfective agents 1 (1.0) 3 (0.8) Antiemetics and antinauseants - 1 (0.3) Antiepileptics 8 (8.3) 24 (6.3) Antihistamines for systemic use - 1 (0.3) Anti-inflammatory and antirheumatic products - 5 (1.3) Antimycobacterials 1 (1.0) 5 (1.3) Antimycotics for systemic use - 8 (2.1) Antithrombotic agents 1 (1.0) 19 (5.0) Anxiolytics 5 (5.2) - Beta blocking agents - 1 (0.3) Bile and liver therapy - 5 (1.3) Calcium channel blockers 1 (1.0) 4 (1.1) Cardiac therapy 5 (5.2) 2 (0.5) Corticosteroids for systemic use - 9 (2.4) Cough and cold preparations - 4 (1.1) Digestives, including enzymes - 2 (0.5) Drugs for acid related disorders 4 (4.2) 45 (11.8) Drugs for constipation - 5 (1.3) Drugs for functional gastrointestinal disorders 1 (1.0) 6 (1.6) Drugs for obstructive airway diseases 1 (1.0) - Drugs used in diabetes 1 (1.0) 3 (0.8) Immunosuppressants - 2 (0.5) Lipid modifying agents - 1 (0.3) Muscle relaxants - 7 (1.8) Ophthlamologicals - 8 (2.1) Pituitary and hypothalamic hormones and analogues 1 (1.0) 1 (0.3) Psychoanaleptics - 1 (0.3) Psycholeptics - 5 (1.3) Thyroid therapy - 1 (0.3) Solutions and solution additives 51 (53.1) 48 (12.6) mr, medication reconciliation. *Based on the World Health Organization Anatomical Therapeutic Chemical code system s level 2 pharmacological effects. 하였다 (P<0.001). 처방대비약물조정률은전담약사활동전 0.8% 에서전담약사활동후 1.6% 로증가하였다 (P =0.003). 약물조정에대한수용률은전담약사활동전 78.1%, 전담약 사활동후 85.0% 로통계적으로유의하지않았지만증가한 경향을보였다 (P=0.104). 114
Ui Sang Cho, et al. Effects of Medication Reconciliation by Pharmacist Table 5. Classification of severity of the clinical consequences without pharmacist intervention Patient outcome Conversion index Definition Death 1 On balance of probabilities, death was caused or hastened by the incident Severe 0.6 Patient outcome is symptomatic, requiring life-saving intervention or major surgical/ medical intervention, shortening life expectancy or causing major permanent or long term harm or loss of function Moderate 0.4 Patient outcome is symptomatic, requiring intervention (e.g., additional operative procedure, additional therapeutic treatment), an increased length of stay, or causing permanent, or long term harm or loss of function Mild 0.1 Patient outcome is symptomatic, symptoms are mild, loss of function or harm is minimal; or intermediate, but short term, and no or minimal intervention (e.g., extra observation, investigation, review or minor treatment) is required None 0 Patient outcome is asymptomatic or no symptoms detected, and no treatment is required Table 6. Cost avoidance by the medication reconciliation program Severity of the clinical consequences Conversion index Value Cost avoidance* Death 1 0 (0.0) - Severe 0.6 12 (4.3) 6,143,681 won Moderate 0.4 193 (68.9) 65,873,911 won Mild 0.1 70 (25.0) 5,973,023 won None 0 5 (1.8) - Total 280 (100.0) 77,990,615 won/year 103,987 won/hour NCU, neurocritical care unit; WHO, World Health Organization. Values are presented as number (%). *The mean hospitalization cost per 1 day in NCU is 853,289 won. Among 380 cases, 280 cases reconciliated by clinical pharmacist in NCU were accepted and could be judged by WHO guideline. 750 hour/year, the average of working time for NCU patient medication profile was about 3 hours a day during study period. 2) 약물조정유형변화전담약사활동후약물조정유형변화는다음과같다 (Table 3). 전담약사활동전총 96건의약물조정이있었으며, 상위세가지항목은영양지원 40건, 용량변경 20건, 제형변경 14건으로전체약물조정의 77.1% 를차지하였다. 전담약사활동후총 380건의약물조정이있었으며, 상위세가지항목은약물치료계획상의 105건, 약물유해반응가능성 66건, 투여계획변경 58건으로전체약물조정의 60.3% 를차지하였다. 전담약사활동전과후약물조정유형이차지하는비율의변화와함께약물조정유형의분포도가변화하였으며, 활동후더다양한분포를나타냈다. 3) 조정약물군변화전담약사활동후조정약물군의변화는다음과같다 (Table 4). 약물군분류는세계보건기구 ATC code 체계 2단 계약효에따른세부분류군을기준으로하였다. 조정내용을기반으로약물효능과상관성이부족하다고판단되는 total parenteral nutrition 제제, 수액제제, 단백질제제, 지질제제, 전해질은약물군분석대상에서제외하였으며, 용액 (solution) 과용액첨가제 (solution additives) 로개별분류하였다. 조정약물군은전담약사활동전 14군, 전담약사활동후 33군이었다. 변화율이가장큰약물군은항생제였으며, 항생제관련약물조정건수가전담약사활동전 13건 (13.5%) 에서전담약사활동후 137건 (36.1%) 으로증가하였다. 세부적으로전담약사활동전조정항생제는 8종, 활동후 21종이었다. CPCS에의하여약물농도확인후적절한용량 / 용법추천, 균동정결과에따른항생제 step up과 step down에대한약물추천등의활동이포함되었다. 115
3. 전담약사의조정활동에따른회피비용전담약사활동후기간의조정활동에대하여회피비용을 계산하였다. 2016 년 6 월 1 일부터 2017 년 5 월 31 일까지 1 년 동안약물조정건수는총 380 건이었고, 실제수용되어심각 성판단이가능한건수는 323 건이었다. 이중전담약사에의 한 280 건에대하여세계보건기구지침에근거하여심각성을 분류하였다 (Table 5). 15 연구기간분당서울대학교병원 NCU 입원환자의평균 1 일 입원비용은약제비용을포함하여환자처치에발생한모 든수가를포함하였을때 853,289 원이었다. 약물조정의심 각성에따른회피비용은잠재적으로심각한결과초래단계 6,143,681 원, 중요한결과초래단계 65,873,911 원, 미미한결 과초래단계 5,973,023 원으로총 77,990,615 원이었다. 연구 기간전담약사의근무일수 ( 약 250 일 ) 와일평균근무시간 ( 약 3 시간 ) 을통하여전담약사의활동시간은약 750 시간으 로계산되었으며, 시간에대하여발생한회피비용은 103,987 원 / 시간으로계산되었다 (Table 6). 고찰 본연구는 NCU 에입실하여뇌신경센터, 신경과, 신경외과의 진료를받은환자를대상으로하였으며, 전담약사활동전과 후약물조정에변화가있었음을분석한국내첫번째연구인 것에의의가있다. 중환자에게최적의약물치료를위하여다 학제진료팀의일원으로약사가참여하는것은임상및경제 적측면에서긍정적인효과가있다는논문들이보고되었다. 4-7 1970 년대부터중환자약료가시작된미국에서는 2000 년에 중환자의학회와임상약화회에서중환자약사의업무를기술 한보고서를발표하였으며, 17 국내의경우 2003 년부터한국 병원약사회주최로중환자약물치료에대한교육을하고있 다. 18 또한, 한국병원약사회에서는의약품에대한기본지식 외에도심층적약물요법및약제서비스를제공할수있는능 력을갖춘약사를양성하기위하여중환자약료를포함한각 분야에전문화된병원약사를배출하고있다. 중환자실약사가중점적으로관심을가져야할업무는신 기능및간기능장애환자에서의약물용량조절, 복합적인 약물요법에서발생할수있는약물상호작용과약물부작용 의감시및예방, 경구섭취가어렵거나영양요구량을변경해 야하는환자에서의영양평가, 환자에게투여되는다수의정 맥투여약물간배합금기및안정성확인, 병원감염의예방 과치료가있다. 17 이를바탕으로약물조정유형을분류하여분석하였으며, 연구결과에서나타난약물조정건수의절대적증가및처방대비약물조정률의증가를통하여전담약사활동후중환자실약사의업무가적극적으로수행되었음을유추해볼수있었다. 본연구의결과에의하면 NCU 전담약사활동후약물조정의양적인증가가있었다. NCU 병상수변화에의한단순한양적증가가아님을보완하기위하여병상수차이가가장적었던연구기간각 1년을계획하였고, 전담약사활동전연구기간에는 15병상, 전담약사활동후연구기간에는 14병상이었다. 1병상이줄었지만, 실제본연구의기준에적합하였던환자는전담약사활동전 59명, 전담약사활동후 143명이었다. 제외환자수또는재원일수에따른병상회전율차이를배제할수없지만, 전담약사활동에의하여 NCU 환자의약물요법이좀더적극적으로모니터링되었음을확인하였다. 이는환자의전자의무기록을바탕으로환자의투약이력을관리하고, 중환자의임상상황변화에따른긴급처방에대한모니터링이지속적으로이루어지는것과연관이있는것으로판단된다. 약물조정에대한의료진의수용률은통계적으로유의하지않았지만 78.1% 에서 85.0% 로증가하였으며, 국내참고문헌에서발표한수용률과비교하였을때상대적으로높은편이었다. 18,19 전담약사활동후특징적으로약물조정유형및약물분류군의변화가있었다. 전담약사활동전에는기존에영양집중지원팀업무가이루어지고있었던것을고려하여전체약물조정에서영양지원관련비율이 41.7% 로가장높게나타났고, 용량변경, 제형변경순으로약물조정이있었다. 원내처방전을통하여약을조제하고감사하는병원약사의일반적인약물조정활동이다수를차지하였다. 전담약사활동후에는약물치료계획상의, 투여계획변경이 42.9% 로높은비율을나타냈고, 약물처방과투약이되는과정에서적극적인약물조정활동이있었다. 조정세부내용에는균동정결과에따른항생제의선택과용량및용법추천, 신기능변화에따른용량및용법변경, 대체약물추천, NCU 프로토콜및중환자실약물치료지침에근거한약물투여추천등이있었다. 이외에도치료적저체온요법을고려한적절한영양지원자문, 예방적항경련제약물사용에대한약품정보제공등 NCU 환자에대한이해와지식을바탕으로한약물조정활동이있었다. 중환자들에게발생하는다양한긴급상황에대한약물조정활동은앞서약물조정유형의변화와함께분포의변화에도영향을미쳤으며, 전담약사활동전일부약 116
Ui Sang Cho, et al. Effects of Medication Reconciliation by Pharmacist 물조정활동에편중되어있었던것과비교하여약물조정내용이더다양화된것을확인하였다. 이와연관하여전담약사활동후조정약물군이 14군에서 33군으로확대되었으며, 특히항생제사용에대한조정비율이 13.5% 에서 36.1%, 소화성궤양용제는 4.2% 에서 11.8% 로크게증가하였다. 조정세부내용에는적응증에해당하지않는용량및용법에대한조정, 신기능저하에따른약물조정, 제형변경및투여경로변경에따른대체약물추천등이있었다. 중환자의경우감염의증상및균동정의결과에따라항생제긴급처방이발행되는경우가많다. 또한호흡보조를위하여기계적환기를하는경우가많아스트레스궤양예방약제의처방이빈번한상황이다. 연구결과는이러한중환자의특성을이해하고, 실시간으로의무기록을검토함으로써시의적절하게약물조정을하는전담약사의역할이반영된것으로사료된다. 전담약사활동후회피비용분석결과전담약사활동시간에대하여 103,987원 / 시간의회피비용이발생하였다. 회피비용계산수식에포함되어있는항목들의객관적지표가부재한상황에서분석에어려운점이있었으나, 선행연구에서의회피비용분석방법을차용하여본연구에맞는기준을세워계산하였다. 18,20 선행연구에서는약물조정한건에대하여회피비용을분석하였으나, 본연구에서는전담약사의활동시간에대한회피비용을계산하였다. 본연구의회피비용분석만으로전담약사의약물조정활동에대한종합적인경제성을평가하는것은한계가있겠으나, 전담약사의활동과경제적이득의상관성을분석해볼수있을것으로사료된다. 본연구에서전담약사활동시간에대하여발생한회피비용이외에도선행연구와의비교를위하여전담약사에의한약물조정한건에대한회피비용을계산하였을때 278,538원 / 건의회피비용이발생하였다. 국내참고문헌에서외과계중환자실환자 90명을대상으로 5개월간약물조정 159 건에대하여회피비용을분석한결과 162,686원 / 건의회피비용이발생하였음이보고되었다. 18 노인의료센터 89명을대상으로 6개월간약물조정 336건에대한분석결과 155,407 원 / 건의회피비용이발생하였다는연구결과가있다. 20 국내참고문헌과의회피비용차이는심각성판단에대한약사의판단기준과회피비용계산식에포함되어있는평균 1일입원비용의차이등에기인한것으로판단되며, 비교에참고가필요할것으로사료된다. 약물조정활동이없었을경우연장되었을입원일수에대한객관적인기준을마련하고, 비용계산시급여, 비급여등항목세부화와기타비용관련지표를추가한다면추후경제적효과에대한포괄적인분석이이루어질것으로사료된 다. 13 본연구는전담약사의활동전후비교를통하여약물조정활동의변화를관찰하였다는한계점이있다. 2001년발표된 Bond 등의연구 21 에서전담약사의활동이사망률감소에기여한다는결과가있었으며, 2003년 Kane 등의연구 22 에서중환자실약사의조정활동이약물부작용감소, 처방오류감소등환자치료에긍정적인결과를가져왔다는결과가있었다. 본연구에서도전담약사의약물조정활동이임상결과의개선에기여하였다는객관적평가자료로활용되기위하여사망률및재원일수감소등에대한후속연구가필요할것으로사료된다. 수용률분석에서도한계점을나타냈다. 전담약사활동후약물치료계획상의에대한조정내용이많았으며, 환자의신체기능변화, 주치의의임상적판단에따라수용여부가결정되었다. 본연구에서는수용여부에대한이분법적인분석을하였지만, 추후약물조정내용과임상적상황변화를반영한새로운수용률판단기준마련이필요할것으로보여진다. 결론 본연구를통하여 NCU 전담약사활동후약물조정건수및처방대비조정률증가, 수용률변화, 약물조정유형의다양화, 약물조정군확대와회피비용발생을확인하였다. 전담약사활동은중환자에게최적의약물치료를제공하는데긍정적인영향을가져옴을확인하였으며, 또한회피비용산출을통하여경제적효과를간접적으로예상할수있었다. 향후본연구를바탕으로약사의임상업무영역확대를위한평가자료가될수있을것으로기대한다. REFERENCE 1. Klopotowska JE, Kuiper R, van Kan HJ, de Pont AC, Dijkgraaf MG, Lie-A-Huen L, et al. On-ward participation of a hospital pharmacist in a Dutch intensive care unit reduces prescribing errors and related patient harm: an intervention study. Crit Care 2010;14:R174. 2. Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med 1997;25:1289-97. 117
3. Kane-Gill S, Rea RS, Verrico MM, Weber RJ. Adverse-drugevent rates for high-cost and high-use drugs in the intensive care unit. Am J Health Syst Pharm 2006;63:1876-81. 4. Kopp BJ, Mrsan M, Erstad BL, Duby JJ. Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist. Am J Health Syst Pharm 2007;64:2483-7. 5. MacLaren R, Bond CA, Martin SJ, Fike D. Clinical and economic outcomes of involving pharmacists in the direct care of critically ill patients with infections. Crit Care Med 2008;36:3184-9. 6. Mutnick AH, Sterba KJ, Peroutka JA, Sloan NE, Beltz EA, Sorenson MK. Cost savings and avoidance from clinical interventions. Am J Health Syst Pharm 1997;54:392-6. 7. Zaidi ST, Hassan Y, Postma MJ, Ng SH. Impact of pharmacist recommendations on the cost of drug therapy in ICU patients at a Malaysian hospital. Pharm World Sci 2003;25:299-302. 8. LeBlanc JM, Seoane-Vazquez EC, Arbo TC, Dasta JF. International critical care hospital pharmacist activities. Intensive Care Med 2008;34:538-42. 9. Choi JH, Choi KS, Lee KS, Rhie SJ. Initiation of pharmaceutical care service in medical intensive care unit with drug interaction monitoring program. Korean J Clin Pharm 2015;25:138-44. 10. Jeong JH, Bang JS, Jeong WJ, Yum KS, Chang JY, Hong JH, et al. A dedicated neurological intensive care unit offers improved outcomes for patients with brain and spine injuries. J Intensive Care Med 2017;20:1-5. 11. Shin S, Heo E, Kim Y, Choi K, Lee J, Lee E, et al. The effects of designated pharmacist on intervention and cost avoidance in the surgical intensive care unit. J Kor Soc Health Syst Pharm 2017;34:401-9. 12. Lee AJ, Boro MS, Knapp KK, Meier JL, Korman NE. Clinical and economic outcomes of pharmacist recommendations in a Veterans Affairs medical center. Am J Health Syst Pharm 2002;59:2070-7. 13. Chung J, Kang YJ, Moon MY, Moon SY, Park HM, Yang SM, et al. Preliminary study for economic evaluation of clinical pharmacist intervention. J Kor Soc Health Syst Pharm 2011;28:327-36. 14. Nesbit TW, Shermock KM, Bobek MB, Capozzi DL, Flores PA, Leonard MC, et al. Implementation and pharmacoeconomic analysis of a clinical staff pharmacist practice model. Am J Health Syst Pharm 2001;58:784-90. 15. World Health Organization. Conceptual framework for the international classification for patient safety, version 1.1: final technical report. Geneva: WHO 2009;1-149. 16. Kang CH, Kim YI, Lee EJ, Park K, Lee JS, Kim Y. The variation in risk adjusted mortality of intensive care units. Korean J Anesthesiol 2009;57:698-703. 17. Kim YS, Go YS. Role of the intensive care unit pharmacist. J Kor Soc Health Syst Pharm 2011;28:105-10. 18. Kang M, Kim A, Cho Y, Kim H, Lee H, Yu YJ, et al. Effect of clinical pharmacist interventions on prevention of adverse drug events in surgical intensive care unit. Korean J Crit Care Med 2013;28:17-24. 19. Park T, Kim Y, Jung Y, Lee J, Lee E. The comparison analysis of the prevention of adverse drug events through order interventions by designated-pharmacists. J Kor Soc Health Syst Pharm 2014;31:638-43. 20. Lee J, Roh J, Suh Y, Lee J, Lee E, Lee B, et al. Assessment of medications for geriatric inpatients based on revised inappropriate medication criteria and cost avoidance by intervention of pharmacists. J Kor Soc Health Syst Pharm 2014;31:629-37. 21. Bond CA, Raehl CL, Franke T. 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 staffing. Pharmacotherapy 2001;21:129-41. 22. Kane SL, Weber RJ, Dasta JF. The impact of critical care pharmacists on enhancing patient outcomes. Intensive Care Med 2003;29:691-8. 118