Rituximab 복합화학요법에 대한 약사의 환자 교육 개선 및 적용 효과

Abstract

Background: When rituximab, which is a therapeutic agent for non-Hodgkin`s lymphoma, is administered to patients, 50% of the patients have hypersensitivity within 1~2 hours after administration. Thus, a chemotherapy education such as measures to side effects is required before drug administration. In reality, however, the education by pharmacist has been performed in Seoul St. Mary’s Hospital after rituximab administration due to extensive works during the morning. Accordingly, an introduction of an improved chemotherapy education was required to improve educational effects on patients who receive rituximab. Objectives: A survey was conducted to confer between effects of the previous and improves patient education by pharmacist for cancer patients undergoing the chemotherapy with rituximab. The also we evaluated effects of the improved patients education in nurse’s work amd dispensing on a medicine of pharmacy. Methods: A survey was conducted on lymphoma patients aged 19 year or higher who underwent combination chemotherapy including rituximab in Seoul St. Mary’s Hospital from May 2011 to January 2012, and who participated in a chemotherapy education operated by pharmacists. Among the patients who attended the previous education, those who participated in the survey from May 2011 to July 2011 were selected as the control group. Patients who attended the improved education and then participated in the same survey from August 2011 to January 2012 were selected as the study group. On the day of rituximab administration, the chemotherapy education was performed, and the survey was conducted for patient’s subjective side effects and measures to the side effects. The survey was further conducted for hypersensitivity recognition and patient’s understanding, needs, and satisfaction on combination chemotherapy on the day of second administration. A survey was conducted on nurses who were involved in rituximab administration to investigate the effect of the improved education on their work. In addition, waiting time for drug dispensing was compared between the previous education and the improved education. Other data were retrospectively collected via the electronic medical record (EMR). Results: Twenty patients were also assigned to the study and control group, respectively. The improved education was performed on the patients before and during rituximab administration, respectively. The items, method, and total required time of the education were same between before and during rituximab administration. In the control group, six patients (46.2%) immediately reported their subjective side effects without enduring them among 13 patients who experienced subjective side effects. Meanwhile, in the study group, nine patients (81.8%) immediately reported their subjective side effects among 11 patients who experienced subjective side effects (P=0.270). As for the results of the survey conducted on the patients, the hypersensitivity recognition was shown to be 50.0±25.6 and 67.2±22.6 in the control and study groups, respectively, which was significantly higher in the study group (P=0.031). However, the patient’s understanding, needs, and satisfaction on combination chemotherapy were shown to be 68.9±14.0 and 65.0±20.6 (p=0.612), 74.3±14.0 and 75.0±19.4 (P=0.904), and 80.6±14.4 and 81.3±13.1 (P=0.943), respectively, in the control and study groups, respectively, which showed no statistical difference. As for the results of the survey conducted on the nurses to evaluate nurse’s work, the positive reply including no effect and negative reply were shown to be 100% and 0% (P=0.002), respectively. The mean dispensing time per prescription was shown to be approximately 37min and 33min, before and after the improved education was performed (P=0.000), respectively, which showed that dispensing was not delayed due to the improved education. Discussion and Conclusion: When hypersensitivity to rituximab occurred after rituximab administration, the patients had a tendency of enduring it when they did not attend chemotherapy education before rituximab administration, but they had a tendency of immediately reporting it when they attended chemotherapy education before rituximab administration. In addition, the education time partition of the improved chemotherapy education considering hypersensitivity to rituximab improved hypersensitivity recognition, made a positive effect on nursing, and did not delay dispensing. Thus, it can be concluded that the improved chemotherapy education had positive educational effects.;연구 배경: Rituximab은 비호지킨 림프종 치료제로서 주입 후 1~2시간 이내 이상반응이 50%이상 나타나는 특징이 있어서 투여 전에 이상반응 대처방법 등 복합화학요법에 대한 환자교육이 필요하다. 본 연구 대상기관에서는 항암제 투여 전에 의사가 1차로 환자 교육을 하고 약사의 2차 환자 교육은 오전의 과중한 조제업무로 인하여 항암제 투여 후에 시행되고 있었다. 이에 rituximab 투여 환자들의 교육효과를 높여 이상반응에 대한 환자안전관리를 강화하기 위해 약사의 항암교육 개선이 요구되었다. 연구 목적: 현재 rituximab이 포함된 복합화학요법에 대한 약사의 2차 환자교육을 rituximab 투여 후 1회 실시한 환자와 투여 전후 각 1회씩 실시한 환자의 교육효과를 비교하고, 그 밖에 약사와 간호사의 업무에 미치는 영향을 비교함으로써 항암제에 대한 환자교육의 효과와 의료진의 업무 관련성을 분석하고자 하였다. 연구 방법: 서울성모병원에서 2011년 5월부터 2012년 1월까지 rituximab이 포함된 복합화학요법을 외래에서 처음 투여 받은 19세 이상 림프종 환자로서 약사의 항암교육을 받고 설문에 참여한 환자를 대상으로 하였다. 기존 방법으로 항암제 투여 후에 약사의 환자 교육을 실시한 환자를 대조군으로, 2011년 8월을 기준으로 개선된 방법을 사용하여 항암제 투여 전후 2회의 교육을 실시한 환자를 시험군으로 각 20명씩 추출하여 항암제 1차 투여 당일 1차 설문조사를 실시하고 3주 후 2차 항암제 투여 시 2차 설문을 실시하였다. 설문내용은 1차에 주관적 이상반응 호소 유무 및 대처방법을, 2차에 이상반응 인지도, 복합화학요법 이해도, 요구도, 만족도를 설문 조사하였다. Rituximab 투여와 관계된 실무 간호사를 대상으로 개선안 적용이 업무에 미친 영향을 설문조사하였고 항암제 조제시간을 개선안 전후로 비교하였다. 설문조사 외 자료수집은 전자의무기록(electronic medical record, EMR) 검토를 통해 후향적으로 이루어졌다. 연구 결과: 대조군과 시험군 각 20명씩 실시한 환자설문 조사 결과, 대조군에서 주관적인 이상반응을 경험했다고 답변한 13명 중 참지 않고 즉시 의료진에게 보고한 환자는 6명(46.2%)이었으나 시험군에서는 11명 중 9명(81.8%)이었다(P=0.270). 환자설문 결과는 총점 100점 기준으로 이상반응 인지도가 대조군, 시험군 각 50.0±25.6점 vs. 67.2±22.6점으로 시험군에서 유의성 있게 높았다(P=0.031). 하지만 복합화학요법 이해도 68.9±14.0점 vs. 65.0±20.6점(P=0.612), 요구도 74.3±14.0점 vs. 75.0±19.4점 (P=0.904), 만족도 80.6±14.4점 vs. 81.3±13.1점(P=0.943)는 두 군간에 차이가 없었다. 간호사의 업무 평가 설문은 무영향을 포함한 긍정적 영향으로 답변한 비율과 부정적인 영향의 답변 비율이 100% vs. 0% (P=0.002) 이었으며, 개선안 전후 처방전 1매당 평균 조제시간은 약 37분 vs. 약 33분 (P=0.000)으로 개선안 적용이 조제업무 지연에 영향을 미치지 않았다. 고찰 및 결론: Rituximab 투여환자 이상반응 발생 시 약사의 투여 후 교육 시 이상반응에 대하여 참는 비율이 많았으나 투여 전 교육 후에는 즉시 보고하는 대처법을 80%이상 수행하는 경향을 보였다. 또한 개선된 rituximab 환자교육 방법은 환자의 이상반응 인지도 상승을 이끌었고 간호사 업무에 긍정적인 효과를 나타냈으며 약제부 조제업무 지연에는 영향을 미치지 않아 긍정적인 교육 효과를 나타내었다.