【摘要】 目的 探讨驻科药师主导的药物治疗管理（MTM）模式在老年医学中心心血管内科的应用效果，为优化驻科药学服务提供参考。方法 采用回顾性队列研究，纳入2023年3-8月（传统组，n=903）与2024年3-8月（MTM组，n=963）我院老年医学中心心血管内科住院患者的数据。传统组患者仅接受常规药学服务（处方前置审核、事后医嘱点评），MTM组患者在常规服务基础上，接受驻科药师主导的药物重整、治疗药物监测（TDM）、静脉输液规范化管理的MTM服务。通过比较两组患者的主要结局指标（如静脉输液率、TDM达标率等）和次要结局指标[如药物相互作用（DDIs）发生率、3级及以上急性肾损伤发生率、人均住院时长及人均总药费等]评估MTM模式实施效果。结果 与传统组相比，在主要结局指标方面，MTM组患者的总静脉输液使用率、抑酸类药物注射剂使用率均显著降低（P<0.05），地高辛、万古霉素TDM达标率均显著升高（P<0.05）；在次要结局指标方面，MTM组患者3级及以上急性肾损伤发生率、DDIs发生率、非医嘱离院率、丙氨酸氨基转移酶、天冬氨酸氨基转移酶、胆固醇及人均总药费均显著降低（P<0.05），肌酐、估算的肾小球滤过率均显著升高（P<0.05），人均住院时长显著缩短（P<0.05）。结论 驻科药师主导的MTM模式能有效优化药物治疗流程，提升用药安全性与经济性，对促进合理用药、改善患者结局具有积极作用。更多还原

【Abstract】 OBJECTIVE To investigate the effectiveness of resident clinical pharmacist-led medication therapy management(MTM) model in geriatric cardiology departments, and provide reference for optimizing resident pharmaceutical services. METHODS A retrospective cohort study was conducted, incorporating data from inpatients admitted to the Department of Cardiovascular Medicine in the Geriatric Medical Center of our hospital during March to August 2023(conventional group, n=903) and the same period in 2024(MTM group, n=963). The conventional group received only standard pharmaceutical services(including prospective prescription review and retrospective order evaluation), while the MTM group received additional resident clinical pharmacist-led interventions-such as medication reconciliation, personalized therapeutic drug monitoring(TDM), standardized intravenous infusion management, and a four-stage closed-loop monitoring process-based on conventional care. The effectiveness of the MTM model was evaluated by comparing the primary outcome measures(e.g., intravenous infusion rate, TDM target attainment rate) and secondary outcome measures [e.g., incidence of drug-drug interactions(DDIs), incidence of grade 3 or higher acute kidney injury, average length of hospital stay, cholesterol, and medication cost per capita] between the two groups. RESULTS Compared with the conventional group, in terms of primary outcome indexes: both the overall intravenous infusion rate and the use rate of acid-suppressive injection were significantly lowered in the MTM group(P<0.05); serum concentration target attainment rates for digoxin and vancomycin were increased significantly(P<0.05). For secondary outcome indexes, the MTM group exhibited significant decreases in the incidence of grade 3 or higher acute kidney injury, the incidence of DDIs, the rate of patients leaving the hospital against medical advice, alanine amino-transferase, aspartate transferase and the per capita total medication cost(P<0.05). Additionally, there was a notable increase in the creatinine, estimated glomerular filtration rate and a significant shortening of the per capita length of hospital stay(P<0.05). CONCLUSIONS The resident clinical pharmacist-led MTM model can significantly optimize medication therapy processes, enhance medication safety and cost-effectiveness, thus playing a positive role in promoting rational drug use and improving patient outcomes.更多还原