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Volume 41 Issue 11
Nov.  2023
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YANG Zhihui, ZHANG Lili, ZHAO Yan, HUANG Jinghui, LIU Yuan, YUAN Hailong. Effect evaluation of the clinical pharmacists participating in the treatment of patients with diabetic foot[J]. Journal of Pharmaceutical Practice and Service, 2023, 41(11): 686-688, 699. doi: 10.12206/j.issn.2097-2024.202209087
Citation: YANG Zhihui, ZHANG Lili, ZHAO Yan, HUANG Jinghui, LIU Yuan, YUAN Hailong. Effect evaluation of the clinical pharmacists participating in the treatment of patients with diabetic foot[J]. Journal of Pharmaceutical Practice and Service, 2023, 41(11): 686-688, 699. doi: 10.12206/j.issn.2097-2024.202209087

Effect evaluation of the clinical pharmacists participating in the treatment of patients with diabetic foot

doi: 10.12206/j.issn.2097-2024.202209087
  • Received Date: 2022-09-30
  • Rev Recd Date: 2023-10-20
  • Available Online: 2023-11-25
  • Publish Date: 2023-11-25
  •   Objective  To evaluate the effect of clinical pharmacists participating in the treatment of hospitalized patients with diabetic foot by antibiotics management index and health economics index.   Methods  40 hospitalized patients with diabetic foot of Wagner Grade 4 in the Endocrine Department of Air Force Medical Center from April to September 2017 were selected as control group, and 40 hospitalized patients with diabetic foot of Wagner Grade 4 in the Endocrine Department from April to September 2019 were selected as interventional group. No clinical pharmacists were involved in drug treatment of patients in the control group, while the clinical pharmacists in the interventional group participated in drug treatment, and implemented antimicrobial stewardship, medication reconciliation, pharmaceutical care and medication education. Antibiotics management indexes (use intensity of antibiotics, use rate of special class antibiotics) and health economics indexes (medicine expenses, hospitalization expenses) of the two groups were compared.   Results  The efficacy of the two groups was similar. The use intensity of antibiotics and use rate of special class antibiotics of the interventional group in which clinical pharmacists participated were significantly lower than the control group (P<0.01), so were the medicine expenses and hospitalization expenses (P<0.01).   Conclusion  Clinical pharmacists participating in the treatment of hospitalized patients with diabetic foot could reduce antibiotics administration index and health economics index, promote rational medicine use and save medical expenses.
  • [1] 谷涌泉. 中国糖尿病足诊治指南[J]. 中国临床医生杂志, 2020, 48(1):19-27.
    [2] RAGHAV A, AHMAD KHAN Z, LABALA R K, et al. Financial burden of diabetic foot ulcers to world: a progressive topic to discuss always[J]. Ther Adv Endocrinol Metab, 2018, 9(1):29-31. doi:  10.1177/2042018817744513
    [3] 王爱红, 武钰翔, 朱平, 等. 2006~2015年糖尿病足病患者住院医疗费用调查[J]. 中华老年多器官疾病杂志, 2018, 17(8):565-568. doi:  10.11915/j.issn.1671-5403.2018.08.129
    [4] 方圆, 董智慧, 符伟国. 糖尿病足多学科分级闭环管理体系的构建[J]. 中国临床医学, 2023, 30(1):1-3. doi:  10.12025/j.issn.1008-6358.2023.20230086
    [5] 许樟荣. 糖尿病足病防治的关键: 解读2019国内外糖尿病足防治指南[J]. 中国临床新医学, 2019, 12(12):1259-1262. doi:  10.3969/j.issn.1674-3806.2019.12.01
    [6] LIPSKY B A, BERENDT A R, CORNIA P B, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections[J]. Clin Infect Dis, 2012, 54(12):e132-e173. doi:  10.1093/cid/cis346
    [7] 关小宏. 糖尿病足病的治疗与预防[J]. 中华损伤与修复杂志(电子版), 2015, 10(2):98-102.
    [8] GERSHATER M A, LÖNDAHL M, NYBERG P, et al. Complexity of factors related to outcome of neuropathic and neuroischaemic/ischaemic diabetic foot ulcers: a cohort study[J]. Diabetologia, 2009, 52(3):398-407. doi:  10.1007/s00125-008-1226-2
    [9] 张一卓, 陈轶坚. 糖尿病足感染的研究进展[J]. 中国临床医学, 2023, 30(1):18-23. doi:  10.12025/j.issn.1008-6358.2023.20230085
    [10] LAVERY L A, ARMSTRONG D G, WUNDERLICH R P, et al. Risk factors for foot infections in individuals with diabetes[J]. Diabetes Care, 2006, 29(6):1288-1293. doi:  10.2337/dc05-2425
    [11] ANDERSEN C A, ROUKIS T S. The diabetic foot[J]. Surg Clin N Am, 2007, 87(5):1149-1177. doi:  10.1016/j.suc.2007.08.001
    [12] 闫向阳, 殷博迪. 356例糖尿病足感染患者的病原菌分布及其耐药情况分析[J]. 抗感染药学, 2023, 20(3):308-312.
    [13] 李燕, 郑玲利, 袁明勇, 等. 临床药师对抗感染治疗方案评价方法的探讨[J]. 药学实践杂志, 2017, 35(1):70-72.
    [14] 林小波, 陈年由, 肖紫婷. 1例糖尿病足骨髓炎患者的药学监护[J]. 中国药师, 2020, 23(5):918-921. doi:  10.3969/j.issn.1008-049X.2020.05.031
    [15] 高庆, 毛敏婕, 金凤鸣等. 糖尿病足感染病原菌分析的研究进展[J]. 中国卫生检验杂志, 2023, 33(14):1789-1792.
    [16] 陈向红, 何红梅, 赵娜等. 糖尿病足感染病原菌分布及多重耐药菌感染相关因素分析[J]. 中国消毒学杂志, 2023, 40(10):757-759, 763.
    [17] LIPSKY B A. Medical treatment of diabetic foot infections[J]. Clin Infect Dis, 2004, 39(Supplement_2):S104-S114. doi:  10.1086/383271
    [18] NICOLAU D, STEIN G. Therapeutic options for diabetic foot infections: a review with an emphasis on tissue penetration characteristics[J]. J Am Podiatr Med Assoc, 2010, 100(1):52-63. doi:  10.7547/1000052
    [19] 贾伟平, 陆菊明. 中国2型糖尿病防治指南(2017年版)编写说明[J]. 中华糖尿病杂志, 2018, 10(1):2-3. doi:  10.3760/cma.j.issn.1674-5809.2018.01.002
    [20] 于旭红, 柳杨, 王光辉, 等. 老年患者药物重整及药学服务研究[J]. 中国临床药理学杂志, 2020, 36(2):203-205. doi:  10.13699/j.cnki.1001-6821.2020.02.028
    [21] 聂晓静, 白荷荷, 张利红, 等. 药物重整对老年2型糖尿病患者慢病管理的效果评价[J]. 药物流行病学杂志, 2020, 29(9):623-628.
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Effect evaluation of the clinical pharmacists participating in the treatment of patients with diabetic foot

doi: 10.12206/j.issn.2097-2024.202209087

Abstract:   Objective  To evaluate the effect of clinical pharmacists participating in the treatment of hospitalized patients with diabetic foot by antibiotics management index and health economics index.   Methods  40 hospitalized patients with diabetic foot of Wagner Grade 4 in the Endocrine Department of Air Force Medical Center from April to September 2017 were selected as control group, and 40 hospitalized patients with diabetic foot of Wagner Grade 4 in the Endocrine Department from April to September 2019 were selected as interventional group. No clinical pharmacists were involved in drug treatment of patients in the control group, while the clinical pharmacists in the interventional group participated in drug treatment, and implemented antimicrobial stewardship, medication reconciliation, pharmaceutical care and medication education. Antibiotics management indexes (use intensity of antibiotics, use rate of special class antibiotics) and health economics indexes (medicine expenses, hospitalization expenses) of the two groups were compared.   Results  The efficacy of the two groups was similar. The use intensity of antibiotics and use rate of special class antibiotics of the interventional group in which clinical pharmacists participated were significantly lower than the control group (P<0.01), so were the medicine expenses and hospitalization expenses (P<0.01).   Conclusion  Clinical pharmacists participating in the treatment of hospitalized patients with diabetic foot could reduce antibiotics administration index and health economics index, promote rational medicine use and save medical expenses.

YANG Zhihui, ZHANG Lili, ZHAO Yan, HUANG Jinghui, LIU Yuan, YUAN Hailong. Effect evaluation of the clinical pharmacists participating in the treatment of patients with diabetic foot[J]. Journal of Pharmaceutical Practice and Service, 2023, 41(11): 686-688, 699. doi: 10.12206/j.issn.2097-2024.202209087
Citation: YANG Zhihui, ZHANG Lili, ZHAO Yan, HUANG Jinghui, LIU Yuan, YUAN Hailong. Effect evaluation of the clinical pharmacists participating in the treatment of patients with diabetic foot[J]. Journal of Pharmaceutical Practice and Service, 2023, 41(11): 686-688, 699. doi: 10.12206/j.issn.2097-2024.202209087
  • 糖尿病足是糖尿病常见的严重慢性并发症之一,主要是由于患者神经病变、下肢血管病变、足部外伤感染等原因导致的足部或下肢组织溃疡破坏,是中晚期糖尿病患者截肢或死亡的主要原因[1]。糖尿病足患者下肢血运不佳,创面愈合慢,住院时间长,医疗费用高[2]。调查数据显示,糖尿病足患者药费、住院费等治疗费用呈逐年增长,患者经济压力大,也增加了国家的经济负担[3]。糖尿病足患者大部分都伴有视网膜病变、血管病变和神经病变等并发症,因此糖尿病足的综合治疗与全身多个器官或系统相关。“以患者为中心”的多学科治疗模式(MDT)目前已应用于糖尿病足患者的诊治中[4-5]。美国感染病学会制订的《糖尿病足感染的诊断和治疗临床实践指南》推荐药师加入糖尿病足治疗团队,在优化药物治疗方案、用药安全、患者教育和降低费用等方面发挥作用[6]。本研究的目的是通过历史性对照研究,比较临床药师参与糖尿病足患者治疗前后,抗菌药物使用强度(AUD)、用药品种数、药费及住院费用等指标变化,评价临床药师参与糖尿病足患者治疗的效果。

    • 选择2017年4月至9月在空军特色医学中心内分泌科住院治疗的wagner4级糖尿病足患者40例为对照组,2019年4月至9月在内分泌科住院治疗的wagner4级糖尿病足患者40例为干预组。入组病例均符合国际糖尿病足工作组和美国感染病学会分类诊断标准[6]中wagner4级糖尿病足诊断标准,患者同意参与本研究;排除放射、动脉炎、恶性肿瘤等其他病因导致的足部溃疡和合并严重心、肝、肾功能不全疾病者,排除存在认知或言语功能障碍、无法有效沟通的患者。对照组男33例,女7例,年龄(59.10±6.78)岁。观察组男35例,女5例,年龄(58.35±7.63)岁。两组患者的性别和年龄等无显著差异,糖尿病的病程、严重程度以及合并症情况比较,差异均无统计学意义(P>0.05),具有可比性。

    • 所有患者入院后,按照空军特色医学中心(原空军总医院)糖尿病足诊疗规范,给予调整血糖、抗感染治疗、改善血液循环、营养神经等对症处理,创面给予窦道切开、坏死组织清创等外科处理。对照组患者临床药师未参与患者的药物治疗监护。干预组患者在患者入院后,临床药师参与药物治疗,提供药学服务,包括开展抗菌药物管理,及时评估抗感染疗效,优化抗感染治疗方案;开展药物重整,优化药物治疗方案,减少重复用药和辅助用药;开展药学监护,监测患者血糖和生化指标,提高血糖控制率;开展患者用药教育,指导患者药物服用方法和注意事项,提高患者用药依从性。

    • 通过医院HIS系统,收集患者入院后的用药名称、用药数量、用药金额、住院天数和出院结算费用,计算药费、住院总费用、AUD和特殊级抗菌药物使用率。

      依据《新编药物学》(第17版)和《抗菌药物临床应用指导原则》(2015版)统计患者用药种类,对抗菌药物的品种进行分类和分级,药费为患者本次住院期间所用药品总金额,住院总费用为患者本次住院的出院结算费用,包括药品、耗材、检验和床位费等。根据WHO推荐的限定日剂量(DDD),结合临床实际应用情况和《新编药物学》(第17版)推荐的成人平均日剂量确定抗菌药物DDD值,计算抗菌药物DDD数和AUD。抗菌药物DDD数=某抗菌药物消耗量/该药的DDD值。AUD是指每100人天中消耗抗菌药物的DDD数,以平均每日每百张床位所消耗抗菌药物的DDD数表示,AUD=(DDD数/同期出院患者人天数)×100。特殊级抗菌药物使用率=(使用特殊级抗菌药物的患者例数/同期出院患者例数)×100%。

    • 应用Excel软件建立数据库,采用SAS 9.2软件进行数据处理,计量资料用均数±标准差($ \bar{x} $±s)表示,采用t检验或Wilcoxon秩和检验进行比较。计数资料用例数、率或构成比表示,采用χ2检验或Fisher精确概率法进行比较。P<0.05为差异有统计学意义。

    • 两组患者在性别、年龄、合并症包括周围血管病变、周围神经病变和糖尿病肾病等方面差异无统计学意义(P>0.05),见表1

      组别 男性[n(%)] 年龄(岁) 合并周围血管病变[n(%)] 合并周围神经病变[n(%)] 合并糖尿病肾病[n(%)]
      干预组 35(87.50) 58.35±7.63 40(100.00) 39(97.50) 15(37.50)
      对照组 33(82.50) 59.10±6.78 38(95.00) 39(97.50) 16(40.00)
    • 与对照组相比,两组疗效相当,干预组抗菌药物消耗DDD数和AUD大幅降低,应用抗菌药物种类和特殊级抗菌药物使用率显著降低(P<0.01),见表2

      组别 好转例数 抗菌药物DDDs AUD 抗菌药物种类 特殊级抗菌药物使用例数[n(%)]
      干预组 40 887.73 82.73 1.93±1.07* 7(17.50)*
      对照组 40 1 454.26 130.78 3.28±1.18 25(62.50)
      *P<0.01,与对照组比较。
    • 与对照组相比,干预组用药种类、药费和住院总费用均显著降低(P<0.01),见表3

      组别 住院天数(t/d) 用药种类 药费(元) 住院总费用(元)
      干预组 26.83±2.11 22.98±8.25 8 794.92±3 739.25* 29 281.47±15 611.29*
      对照组 27.80±1.44 26.93±6.76 18 484.73±5 860.10 41 084.65±10 562.35
      *P<0.01,与对照组比较。
    • 目前,50%以上非创伤性截肢由糖尿病足引起,患者心理压力和经济压力大,严重影响了患者生活质量和生命预后[7-8]。糖尿病足患者并发症多,涉及不同专业,而医师的专业分科越来越细化,单个医师或单一专科已经难以满足糖尿病足患者治疗的需求[5]。近年来,临床药师加强临床实践,深入临床,参与查房和药物治疗,开展药学监护和患者用药教育,已成为治疗团队中重要成员。本研究通过疗效、抗感染管理指标和卫生经济学指标评价临床药师在糖尿病足患者治疗中发挥的作用。

      感染是导致糖尿病足发生和加重的主要原因之一[9],40%~80%的糖尿病足患者的足部溃疡都合并细菌感染。糖尿病足患者出现下肢感染后截肢风险急剧升高,是未合并下肢感染患者的154.5倍[10-11]。糖尿病足感染通常是混合菌感染,进展快,医师为提高疗效,常升级抗感染治疗,可能出现抗菌药物滥用。因此在给予抗感染治疗前必须留取标本,送病原学检査,尽快查明致病菌,根据药敏结果选择抗菌药物,减少抗生素的过度使用[12]。临床药师可以协助医师及时准确留取临床标本送微生物培养,合理选择经验性抗感染治疗药物[13-14]。糖尿病足患者病程长,抗感染治疗时间也较长,随着治疗的进行,致病菌对抗菌药物的药敏结果可能由敏感转为耐药,或筛选出新的致病菌,因此糖尿病足感染患者治疗中还需监测抗感染治疗效果,必要时再次取样送检,及时调整给药方案[15-16]。另外,抗菌药物需到达感染部位,才能有效发挥抗菌作用[17]。糖尿病足患者通常都伴有下肢血管病变,下肢血液循环不好,抗菌药物难以到达感染部位,影响抗感染疗效[18]。临床药师可以协助医师选择组织分布较好的抗菌药物,提高疗效。本研究中,临床药师参与糖尿病足患者的抗感染药物治疗,协助医师优化抗感染方案,包括品种选择、剂量大小和疗程长短,防止细菌耐药,大幅降低了抗菌药物管理指标,包括抗菌药物消耗DDD数、AUD、联合应用抗菌药物种类和特殊级抗菌药物使用率。

      糖尿病足患者常并发糖尿病神经病变、视网膜病变、高血压、糖尿病肾病、心脑血管疾病或下肢动脉病变等疾病[19]。因此糖尿病足患者的治疗可能涉及到全身多个系统,需要多学科、多药物综合治疗。本研究中的wgner4级糖尿病足患者几乎都合并有周围血管病变、周围神经病变或糖尿病肾病,平时长期服用多种药物。患者入院后,医生需要根据患者的病情和入院检查结果,给予调整血糖、抗感染、改善血液循环、营养神经等多种药物对症治疗,部分患者对自己服用的药物表述不清,如果对患者用药史了解不全,可能出现重复用药或者药物相互作用等问题。有研究报道,住院患者中至少发生1次用药史采集差错的比例高达27%~54%[20]。临床药师熟悉药物的商品名、包装外观和剂量等情况,能准确采集患者用药史和过敏史等,可有效防止潜在的医疗事故。临床资料表明,患者药物不良反应发生率随着用药种类的增加急剧上升,慢性病患者用药种类多,疗程长,同时服用6~10种药物的患者不良反应发生率可能高达40%;临床药师通过药物重整和用药教育,可避免80%左右的药物不良事件发生,极大地降低了患者的用药风险[20-21]。在本研究中,临床药师在患者入院后进行药学查房和问诊、开展药物重整、优化药物治疗方案、避免重复用药、减少辅助用药、降低用药品种数,防止潜在的药物不良事件;对重点患者开展药学监护,提高血糖控制率;对患者进行用药教育,提高患者用药依从性和疗效,降低了干预组患者的药费和住院总费用。

      临床药师参与慢性疾病患者的药物治疗管理已成为临床药学工作的主要内容之一。本研究通过抗菌药物管理指标和卫生经济学指标评价临床药师在糖尿病足患者治疗中的作用,临床药师通过开展抗菌药物管理、药物重整、药学监护和患者教育等药学服务,可以促进合理用药,降低AUD和特殊级抗菌药物使用率,节省药费和治疗总费用。

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