| 摘要: | 國人十大死因癌症連續36年居首。癌症藥物治療包括化學治療、標靶藥物、免疫治療等，眾所周知會造成許多副作用，對於首次接受化療的病人，預防和處理副作用是重要的，以減輕副作用的程度與焦慮，改善生活品質。隨機分派研究顯示，藥師持續提供化學治療病人諮詢可有效提升癌症病人化學治療及副作用處理的知識，改善生活品質及減輕焦慮。然而何種類型的衛教策略較為理想，仍不清楚。
本研究之目的為比較藥師提供兩種策略之用藥指導 (互動式照護與傳統式照護)，對於首次化學治療病人，在連續性的成效如化學治療及副作用處理的知識、人文成效 (生活品質與焦慮)、病人滿意度、醫療利用 (非預期性門診與急診次數)等方面的差異。本研究亦描述化學治療後發生副作用的種類與嚴重度，和分析藥師所提出之支持性藥物建議。
首次化學治療藥師訪視時，病人需先填寫知識、生活品質、焦慮的前測問卷，而後隨機分派成兩組並給予不同策略之首次化療用藥指導，接著需填寫知識後測及病人滿意度調查；第二次和第三次化學治療藥師訪視時，病人需回報化學治療副作用發生種類與嚴重度，，並填寫知識、生活品質、焦慮後測。互動式照護組會依據病人知識測驗的結果，進一步加強衛教。醫療利用、化學治療副作用、支持性藥物使用等，一併於訪視過程中調查，或以查閱病歷方式收集。
研究期間為2019年1月1日至6月14日，共收錄32位乳癌及大腸直腸癌病人。知識方面，接受第三次衛教後，互動式照護組平均分數由研究開始的6.06分(滿分為10分)成長到9.18分，傳統式照護組則由研究開始的7.50分成長到8.46分。以概化估計方程式進行分析，結果顯示在第二次及第三次藥師訪視後，互動式照護組知識顯著優於傳統式照護組(p = 0.013及p = 0.005)，生活品質方面，互動式照護組在整體生活品質、社交功能、疼痛、疲倦、呼吸困難等項目，顯著劣於傳統式照護組。焦慮方面兩組則無顯著差異，滿意度兩組皆高於90%。醫療利用方面，互動式照護組急診就醫比例，較傳統式照護組稍多(13.8% vs. 0%, p= 0.112)。
本研究為第一個比較藥師提供互動式照護與傳統式照護兩種衛教模式，對於首次接受化學治療的病人在知識、生活品質、焦慮、滿意度、醫療利用之影響的隨機分派研究。初步結果顯示藥師提供互動式照護有助於增進病人化學治療及副作用處理的知識，但可能是由於互動式照護組發生較多嚴重副作用的緣故，並未改善生活品質、焦慮及醫療利用。未來可進行評估藥師提供癌症病人互動式衛教模式與成本效益分析的相關研究，以增進病人的治療效果。
Cancer has become the most lethal disease in Taiwan since 36 years ago. Pharmacological treatments for cancer such as chemotherapy, targeted therapy and immunotherapy are known to cause many side effects. Prevention and management of side effects are important for patients who undergo first-time chemotherapy in order to reduce the severity of chemotherapy side effects and anxiety, and improve quality of life. Randomized controlled trials revealed that pharmacist-provided, repeated chemotherapy patient counseling is effective in improving knowledge of chemotherapy and side effects, improving quality of life and decreasing anxiety of cancer patients. However, the form of the ideal education strategies is unclear.
The objectives of this study were to compare longitudinal outcomes of knowledge, humanistic outcomes (quality of life and anxiety), patient satisfaction, and health care utilization (unexpected outpatient clinic visit and emergency department visit) between two pharmacist-provided education strategies (interactive education vs. traditional education) for patients undergoing first-time chemotherapy. This study also described the types and severity of chemotherapy side effects occurred, and analyzed pharmacist recommendations on supportive care agents for chemotherapy side effects management.
During the first pharmacist visit, patients were asked to respond to the pre-test for knowledge, quality of life and anxiety before randomization. Pharmacist provided first-time chemotherapy education with two different strategies for each group, and then asked the patients to respond to the post-tests of knowledge and patient satisfaction. During the second and third pharmacist visits, patients were asked to report their types and severity of chemotherapy side effects occurred and respond to the post-tests of follow-up. Patients in the interactive education group were re-educated according to their answers of knowledge questionnaire. Health care utilization, chemotherapy side effects and supportive care recommendations were collected during pharmacist visits and through medical records review.
The study period was from January 1, 2019 to June 14, 2019 with a total of 32 patients of breast or colorectal cancer. The average knowledge score from baseline to the third visit increased from 6.06 to 9.18 of 10 in the pharmacist-provided interactive education group, and increased from 7.50 to 8.46 of 10 in the traditional education group. The results of generalized estimating equation showed that knowledge in the interactive education group was significantly better after the second and third pharmacist visits compared to traditional education group (p = 0.013 and p = 0.005). The outcome of quality of life showed that overall quality of life, social function, symptoms of pain, fatigue and dyspnea in the interactive education group were significantly worse than those in the traditional education group. No significant difference in anxiety between groups was found. Patients were highly satisfied (more than 90%) in both education groups. Health care utilization of emergency department visits in the interactive education group was slightly more than the traditional education group (13.8% vs. 0%, p= 0.112).
This is the first randomized controlled study comparing the outcomes of knowledge, quality of life, anxiety, patient satisfaction, and health care utilization between pharmacist-provided interaction education and traditional education for patients undergoing first-time chemotherapy. Preliminary results showed that pharmacist-provided interactive education was beneficial in improving patients’ knowledge of chemotherapy and side effects management, but did not improve quality of life, anxiety and health care utilization, potentially due to more severe side effects in the interactive education group. Future studies evaluating pharmacist-provided interactive education model for cancer patients and cost-effectiveness analysis could be conducted to better improve patient outcomes. |
