背景：老年病患用藥不當會對醫療結果和醫療保健利用產生負面影響。美國老年醫學協會在2013年和2014年推出了明智選擇(CW)運動，該運動建議避免將抗精神病藥作為治療失智症行為和心理症狀的第一線治療方法，因為它可能存在不良反應。此外，應避免將苯二氮卓類藥物和其他鎮靜催眠藥物作為老年人失眠、躁動或譫妄的第一線治療方法。這就提出了一個關鍵的研究問題，即不適當用藥對台灣老年病患的情況和影響。
方法：本研究利用國際疾病分類第9和第10版來識別患有失智、失眠、躁動和譫妄的個體。解剖學治療學即化學分類(ATC)代碼用於識別處方抗精神病藥物、苯二氮卓類藥物和Z類藥物的病患。根據CW運動反對將特定藥物作為老年人的第一線用藥的建議，根據新病例作為是否特定藥物新使用者以其歸類為病例組或對照組。該研究於2014年1月1日至2021年12月31日期間從台灣南部一家醫學中心收集的回顧性數據使用傾向得分匹配(PSM)和各種統計分析，包括多元邏輯迴歸、負二項迴歸和多元線性迴歸模型。該研究獲得了台灣高雄榮民總醫院(KSVGH22-CT8-14)的IRB批准。
結果：與患有失智症的對照組相比，病例組的門診就診率(p<0.001)和急診室使用率 (p<0.001)顯著更高，但住院率(p<0.001)和住院天數(p<0.001)顯著降低。病例組的藥物支出(p<0.001)和醫療總支出(p<0.001)也顯著增加，同時住院的可能性(p<0.001, OR=0.420, 95% CI=0.372, 0.475)、急診室使用的可能性(p<0.001, OR=0.513, 95% CI=0.435, 0.605)、14天內再入院的可能性(p<0.001, OR=0.652, 95% CI=0.562, 0.755)、30天內再入院的可能性(p<0.01, OR=0.812 , 95% CI=0.715, 0.922)和死亡的可能性(p<0.001, OR=0.694, 95% CI=0.642, 0.750)顯著降低。然而，病例組的髖部骨折的可能性(p<0.001, OR=2.582, 95% CI=1.551, 4.297)和中風的可能性(p<0.001, OR=1.242, 95% CI=1.137, 1.358)顯著升高。與失眠、躁動和譫妄的對照組相比，病例組的門診就診率(p<0.001)、急診室使用率(p<0.001)、住院率(p<0.001)和住院天數(p<0.001）顯著降低。病例組的藥物支出(p<0.001)和總醫療支出(p<0.001)也顯著增加，同時住院的可能性(p<0.001, OR=1.700, 95% CI=1.534, 1.883)和髖部骨折的可能性顯著增加 (p<0.001, OR=1.794, 95% CI=1.329, 2.423)。然而，病例組的急診室使用的可能性(p<0.001, OR=0.770, 95% CI=0.718, 0.825)、14天內再入院的可能性(p<0.05, OR=0.855, 95% CI=0.748, 0.976)、30天內在入院的可能性（p<0.01，OR=0.865，95% CI=0.777，0.963）以及死亡（p<0.001，OR=0.796，95% CI=0.743，0.853）顯著降低。
結論：通過改善老年病患的臨床用藥實踐，本研究的醫療機構可能會觀察到改善的照護結果和減輕的照護負擔。明智選擇運動提出了一個可接受的實踐指南，以加強照護並最大限度地降低與治療老年病患相關的風險，從而顯著提高病患的安全性。

Introduction: Inappropriate medication use among older patients negatively impacts medical outcomes and healthcare utilization. The American Geriatrics Society introduced the Choosing Wisely (CW) campaign in 2013 and 2014, which recommended avoiding antipsychotics as the first-line treatment for behavioral and psychological symptoms of dementia due to potentially adverse effects. Additionally, benzodiazepines and other sedative-hypnotic medications should be avoided as the primary treatment for insomnia, agitation, or delirium in the elderly. This raises the crucial research question of the circumstances and impact of inappropriate medication use on older patients in Taiwan.
Methods: This study utilized the International Classification of Disease, 9th and 10th Revisions, Clinical Modification to identify individuals with dementia, insomnia, agitation, and delirium. The Anatomical Therapeutic Chemical Classification (ATC) codes were employed to identify patients prescribed antipsychotics, benzodiazepines, and Z-drugs. Following the CW campaign's recommendations against specific medications as first-line options for older individuals, new cases were categorized as either the case or control group based on their status as new users of particular medications. Retrospective data collected from a medical center in southern Taiwan between January 1, 2014, and December 31, 2021, were analyzed using propensity score matching (PSM) and various statistical analyses, including multivariate logistic regression, negative binomial regression, and multiple linear regression models. The study received IRB approval from the Kaohsiung Veterans General Hospital, Taiwan (KSVGH22-CT8-14).
Results: Compared to the control group with dementia, the case group exhibited significantly higher rates of outpatient visits (p<0.001) and emergency room (ER) utilization (p<0.001) but significantly lower rates of hospitalization (p<0.001) and length of stay (LOS) (p<0.001). The case group also incurred significantly higher medication expenditures (p<0.001) and total expenditures (p<0.001) while demonstrating a significantly lower probability of hospitalization (p<0.001, OR=0.420, 95% CI=0.372, 0.475), ER use (p<0.001, OR=0.513, 95% CI=0.435, 0.605), readmission within 14 days (p<0.001, OR=0.652, 95% CI=0.562, 0.755) and 30 days (p<0.01, OR=0.812, 95% CI=0.715, 0.922), and death (p<0.001, OR=0.694, 95% CI=0.642, 0.750). However, the case group exhibited a significantly higher probability of hip fracture (p<0.001, OR=2.582, 95% CI=1.551, 4.297) and stroke (p<0.001, OR=1.242, 95% CI=1.137, 1.358). When compared to the control group with insomnia, agitation, and delirium, the case group had significantly lower rates of outpatient visits (p<0.001), ER utilization (p<0.001), hospitalization (p<0.001), and LOS (p<0.001). The case group also incurred significantly higher medication expenditures (p<0.001) and total expenditures (p<0.001) while exhibiting a significantly higher probability of hospitalization (p<0.001, OR=1.700, 95% CI=1.534, 1.883) and hip fracture (p<0.001, OR=1.794, 95% CI=1.329, 2.423). However, the case group had a significantly lower probability of ER utilization (p<0.001, OR=0.770, 95% CI=0.718, 0.825), readmission within 14 days (p<0.05, OR=0.855, 95% CI=0.748, 0.976) and 30 days (p<0.01, OR=0.865, 95% CI=0.777, 0.963), and death (p<0.001, OR=0.796, 95% CI=0.743, 0.853).
Conclusion: By improving the clinical medication practices for elderly patients, the studied medical facility may observe improved care outcomes and a reduction in the burden of care. The CW campaign presents an acceptable practice guideline to enhance care and minimize risks associated with treating elderly patients, significantly improving patient safety.

論文審定書 i
論文公開授權書 ii
摘要 iii
Abstract v
1. Introduction 1
2. Literature review 3
2-1 Choosing Wisely campaign 3
2-2 The impact of using antipsychotics for older dementia patients 6
2-3 The impact of using benzodiazepines or other sedative-hypnotics for older patients with insomnia, agitation, or delirium 8
3. Method 9
3-1 Conceptual framework 9
3-2 The flow chart of selecting samples 11
3-3 Study data 12
3-4 Study sample characteristics 12
3-5 Measurements 15
a. Outcome variables 15
b. Control variables 16
3-6 Statistical analysis 16
4. Result 17
5. Discussion 36
6. Conclusion 42
7. Reference 43

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