MacLaren Robert, Bond C A
Department of Clinical Pharmacy, School of Pharmacy, University of Colorado Denver, Aurora, Colorado 80045, USA.
Pharmacotherapy. 2009 Jul;29(7):761-8. doi: 10.1592/phco.29.7.761.
To assess the effects of clinical pharmacist participation in the care of critically ill Medicare patients with thromboembolic or infarction-related events (TIE) on clinical and economic outcomes.
In this retrospective database review (September 1, 2004-August 31, 2005), patient data were retrieved from the 2004 Expanded Modified Medicare Provider Analysis and Review database. Outcomes data evaluated included mortality rates, length of intensive care unit (ICU) stay, total Medicare charges, drug and laboratory charges, and rates of bleeding complications. In addition, outcomes related to the bleeding complications (transfusions, mortality rate) were assessed. Patient outcomes in ICUs with clinical pharmacy services were compared with patient outcomes in ICUs without these services. Clinical pharmacy services were defined as direct patient care services provided by a pharmacist specifically devoted to the ICU; other services such as order processing or drug distribution were not part of these services. A description of ICU pharmacy services was obtained from a 2004 national survey.
We identified 141,079 patients with TIE, of whom 7987 also had bleeding complications. In hospitals with ICU clinical pharmacy services, mortality rates in patients with TIE only and TIE with bleeding complications were higher by 37% (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.36-1.46) and 31% (OR 1.35, 95% CI 1.13-1.61), respectively, than in ICUs with clinical pharmacy services. Lengths of ICU stay were longer by 14.8% (mean +/- SD 7.28 +/- 8.17 vs 6.34 +/- 7.80 days, p<0.0001) and 15.8% (12.4 +/- 13.28 vs 10.71 +/- 9.53 days, p=0.008), respectively. The lack of clinical pharmacist participation in a patient's care was associated with extra Medicare charges of $215,397,354 (p<0.001) and $63,175,725 (p<0.0001) and extra drug charges of $26,363,674 (p<0.0001) and $2,610,750 (p<0.001) for TIE only and TIE with bleeding complications, respectively. Without clinical pharmacy services, bleeding complications increased by 49% (OR 1.53, 95% CI 1.46-1.60), resulting in 39% more patients requiring transfusions (OR 1.47, 95% CI 1.28-1.69); these patients also received more blood products (mean +/- SD 6.8 +/- 10.4 vs 3.1 +/- 2.6 units/patient, p=0.006).
Involving clinical pharmacists in the direct care of intensive care patients with TIE was associated with reduced mortality, improved clinical and charge outcomes, and fewer bleeding complications. Hospitals should promote direct involvement of pharmacists in the care of patients in the ICU.
评估临床药师参与患有血栓栓塞或梗死相关事件（TIE）的重症医疗保险患者护理对临床和经济结局的影响。
在这项回顾性数据库审查（2004年9月1日至2005年8月31日）中，从2004年扩展的修正医疗保险提供者分析与审查数据库中检索患者数据。评估的结局数据包括死亡率、重症监护病房（ICU）住院时间、医疗保险总费用、药物和实验室检查费用以及出血并发症发生率。此外，还评估了与出血并发症相关的结局（输血、死亡率）。将提供临床药学服务的ICU中的患者结局与未提供这些服务的ICU中的患者结局进行比较。临床药学服务定义为由专门负责ICU的药师提供的直接患者护理服务；诸如医嘱处理或药品分发等其他服务不属于这些服务。ICU药学服务的描述来自2004年的一项全国性调查。
我们识别出141,079例患有TIE的患者，其中7987例还伴有出血并发症。在设有ICU临床药学服务的医院中，仅患有TIE的患者和伴有出血并发症的TIE患者的死亡率分别比设有临床药学服务的ICU中的患者高37%（优势比[OR]1.41，95%置信区间[CI]1.36 - 1.46）和31%（OR 1.35，95%CI 1.13 - 1.61）。ICU住院时间分别延长了14.8%（平均值±标准差7.28±8.17天对6.34±7.80天，p<0.0001）和15.8%（12.4±13.28天对10.71±9.53天，p = 0.008）。临床药师未参与患者护理与仅患有TIE的患者和伴有出血并发症的TIE患者分别额外产生215,397,354美元（p<0.001）和63,175,725美元（p<0.0001）的医疗保险费用以及额外产生26,363,674美元（p<0.0001）和2,610,750美元（p<0.001）的药物费用相关。在没有临床药学服务的情况下，出血并发症增加了49%（OR 1.53，95%CI 1.46 - 1.60），导致需要输血的患者增加了39%（OR 1.47，95%CI 1.28 - 1.69）；这些患者还接受了更多的血液制品（平均值±标准差6.8±10.4单位/患者对3.1±2.6单位/患者，p = 0.006）。
让临床药师直接参与患有TIE的重症监护患者的护理与降低死亡率、改善临床和费用结局以及减少出血并发症相关。医院应促进药师直接参与ICU患者的护理。
