Tzeng-Ji Chen

Use frequency of traditional Chinese medicine in Taiwan

BackgroundUse of Traditional Chinese medicine (TCM), an important category of complementary and alternative medicine (CAM), has increased substantially in Western countries during the past decade. Use of TCM is also widespread in the Chinese population. However, few informative data have been obtained to date by large-scale investigations of TCM use in the Chinese population. This study was aimed at elucidating the demographics and patterns of TCM use in Taiwan.MethodsWe employed the complete datasets of TCM outpatient reimbursement claims from 1996 to 2001, including the use of Chinese herbal remedies, acupuncture and traumatology manipulative therapy, to analyse use frequencies, the characteristics of TCM users, and the disease categories that were treated by TCM in Taiwan.ResultsAt the end of 2001, 6,142,829 (28.4%) among the 21,653,555 valid beneficiaries of the National Health Insurance in Taiwan had used TCM during the year. However, 13,536,266 subjects (62.5%) had used TCM at least once during the whole 6-year period from 1996 to 2001, with a total of 156,224,266 visits (mean 11.5 visits per user). The mean number of TCM users per annum was 5,733,602, with a mean increment of 1,671,476 (29.2%) of new users yearly. Among TCM users, female was higher than male (female:male = 1.13:1), and the age distribution displayed a peak at around the 30s, followed by the 20s and 40s. Chinese herbal remedies (85.9%) were the most common TCM modality used by this population, followed by acupuncture (11.0%) and traumatology manipulative therapies (3.1%). Private TCM clinics provided most of the TCM care (82.6%), followed by private TCM hospitals (12.0%). The top ten major disease categories for TCM visits were diseases of the respiratory system, musculoskeletal system and connective tissue; symptoms, signs and ill-defined conditions; injury and poisoning; diseases of the digestive system, genitourinary system, skin and subcutaneous tissue, nervous system and sense organs, circulatory and endocrine system; nutritional and metabolic diseases; and immunological disorders.ConclusionTCM was popular among the Chinese population in Taiwan during the period studied. More than 60% of all subjects had used TCM during the 6-year interval. TCM was widely used by the Chinese population to treat problems and diseases of major human organ systems recognised by western medicine. This study provides information about the use frequencies of TCM and the disease categories treated by TCM, which should be useful for health policy makers and for those considering the integration of TCM and Western medicine.

Taiwan's National Health Insurance Research Database: administrative health care database as study object in bibliometrics

The trend to use administrative health care databases as research material is increasing but not well explored. Taiwan’s National Health Insurance Research Database (NHIRD), one of the largest administrative health care databases around the world, has been used widely in academic studies. This study analyzed 383 NHIRD studies published between 2000 and 2009 to quantify the effects on overall growth, scholar response, and spread of the study fields. The NHIRD studies expanded rapidly in both quantity and quality since the first study was published in 2000. Researchers usually collaborated to share knowledge, which was crucial to process the NHIRD data. However, once the fundamental problem had been overcome, success to get published became more reproducible. NHIRD studies were also published diversely in a growing number of journals. Both general health and clinical science studies benefited from NHIRD. In conclusion, this new research material widely promotes scientific production in a greater magnitude. The experience of Taiwan’s NHIRD should encourage national- or institutional-level data holders to consider re-using their administrative databases for academic purposes.

Prevalence of atopic dermatitis, allergic rhinitis and asthma in Taiwan: a national study 2000 to 2007.

To study the prevalence of atopic dermatitis, allergic rhinitis, and asthma in Taiwan, we analysed the claims data of a nationally representative cohort of 997,729 enrolees from the National Health Insurance register from 2000 to 2007. Overall, 66,446 patients were diagnosed with atopic dermatitis, and 49.8% of them had concomitant allergic rhinitis and/or asthma. The overall 8-year prevalences of atopic dermatitis, allergic rhinitis, and asthma were 6.7%, 26.3% and 11.9%, respectively. Children and adolescents had significantly higher prevalences of these atopic diseases. The prevalence of atopic dermatitis in females was lower than that in males before the age of 8 years, but became higher after that. Patients with atopic dermatitis were more likely to have allergic rhinitis and asthma. Those having both atopic dermatitis and allergic rhinitis possessed an even higher risk for asthma (odds ratio 9.04). The numbers of visits for atopic dermatitis were highest in late spring to mid-summer. These data suggest that atopic diseases are common in Taiwan.

Statins, risk of diabetes, and implications on outcomes in the general population.

OBJECTIVES This study aimed to evaluate the association of statin exposure and incident diabetes, and subsequent outcomes in the general population. BACKGROUND Cardiovascular events as consequences of atherosclerosis and diabetes are reduced by statins. However, statins are associated with excessive risk of diabetes occurrence according to clinical trial analyses. From daily-practice perspectives, it remains unclear whether statin use increases risk; prognoses of diabetes after exposure require further clarification. METHODS From Taiwan National Health Insurance beneficiaries age ≥45 years (men) and ≥55 years (women) before 2004, subjects continuously treated with statins ≥30 days during 2000 to 2003 and nonusers before 2004 were identified. Among nondiabetic individuals at the cohort entry, controls were matched to statin users on a 4:1 ratio by age, sex, atherosclerotic comorbidities, and year of their entry. Outcomes as diabetes, major adverse cardiovascular events (MACE, the composite of myocardial infarction and ischemic stroke), and in-hospital deaths were assessed. RESULTS Over a median of 7.2 years, annual rates of diabetes were significantly higher in statin users (2.4% vs. 2.1%, p < 0.001), whereas MACE (hazard ratio [HR]: 0.82; 95% confidence interval [CI]: 0.68 to 0.98 for myocardial infarction; HR: 0.94; 95% CI: 0.86 to 1.03 for ischemic stroke; HR: 0.91; 95% CI: 0.84 to 0.99 for MACE]) and in-hospital mortality (HR: 0.61; 95% CI: 0.55 to 0.67]) were less. The risk-benefit analyses suggested that statin treatment was favorable in high-risk (HR: 0.89; 95% CI: 0.83 to 0.95) and secondary prevention (HR: 0.89; 95% CI: 0.83 to 0.96) populations. Among diabetic patients, prior statin use was associated with fewer MACE (HR: 0.75; 95% CI: 0.59 to 0.97). In-hospital deaths were similar in statin-related diabetes among high-risk (HR: 1.11; 95% CI: 0.83 to 1.49) and secondary prevention (HR: 1.08; 95% CI: 0.79 to 1.47) subjects compared with nondiabetic controls. CONCLUSIONS Risk of diabetes was increased after statins, but outcomes were favorable.

Association between antidepressant resistance in unipolar depression and subsequent bipolar disorder: cohort study

BACKGROUND People with major depressive disorder who fail to respond to adequate trials of antidepressant treatment may harbour hidden bipolar disorder. AIMS We aimed to compare the rates of a change in diagnosis to bipolar disorder among people with major depressive disorder with stratified responses to antidepressants during an 8-year follow-up period. METHOD Information on individuals with major depressive disorder identified during 2000 (cohort 2000, n = 1485) and 2003 (cohort 2003, n = 2459) were collected from a nationally representative cohort of 1,000,000 health service users in Taiwan. Participants responding well to antidepressants were compared with those showing poor responses to adequate trials of antidepressants. RESULTS In 7.6-12.1% of those with a diagnosis of unipolar major depressive disorder this diagnosis was subsequently changed to bipolar disorder, with a mean time to change of 1.89-2.98 years. Difficult-to-treat participants presented higher rates of change to a bipolar diagnosis (25.6% in cohort 2000; 26.6% in cohort 2003) than easy-to-treat participants (8.8-8.9% in cohort 2000; 6.8-8.6% in cohort 2003; P<0.0001). Regression analysis showed that the variable most strongly associated with the change in diagnosis was antidepressant use history. The difficult-to-treat participants were associated most with diagnostic changing (cohort 2000: odds ratio (OR) = 1.88 (95% CI 1.12-3.16); cohort 2003: OR = 4.94 (95% CI 2.81-8.68)). CONCLUSIONS This is the first large-scale study to report an association between antidepressant response history and subsequent change in diagnosis from major depressive disorder to bipolar disorder. Our findings support the view that a history of poor response to antidepressants in unipolar depression could be a useful predictor for bipolar diathesis.

Diabetes Mellitus and the Risk of Alzheimer’s Disease: A Nationwide Population-Based Study

Objectives Possible association between diabetes mellitus (DM) and Alzheimer’s disease (AD) has been controversial. This study used a nationwide population-based dataset to investigate the relationship between DM and subsequent AD incidence. Methods Data were collected from Taiwan’s National Health Insurance Research Database, which released a cohort dataset of 1,000,000 randomly sampled people and confirmed it to be representative of the Taiwanese population. We identified 71,433 patients newly diagnosed with diabetes (age 58.74±14.02 years) since January 1997. Using propensity score, we matched them with 71,311 non-diabetic subjects by time of enrollment, age, gender, hypertension, hyperlipidemia, and previous stroke history. All the patients were followed up to December 31, 2007. The endpoint of the study was occurrence of AD. Results Over a maximum 11 years of follow-up, diabetic patients experienced a higher incidence of AD than non-diabetic subjects (0.48% vs. 0.37%, p<0.001). After Cox proportional hazard regression model analysis, DM (hazard ratio [HR], 1.76; 95% confidence interval [CI], 1.50–2.07, p<0.001), age (HR, 1.11; 95% CI, 1.10–1.12, p<0.001), female gender (HR, 1.24; 95% CI, 1.06–1.46, p = 0.008), hypertension (HR, 1.30; 95% CI, 1.07–1.59, p = 0.01), previous stroke history (HR, 1.79; 95% CI, 1.28–2.50, p<0.001), and urbanization status (metropolis, HR, 1.32; 95% CI, 1.07–1.63, p = 0.009) were independently associated with the increased risk of AD. Neither monotherapy nor combination therapy with oral antidiabetic medications were associated with the risk of AD after adjusting for underlying risk factors and the duration of DM since diagnosis. However, combination therapy with insulin was found to be associated with greater risk of AD (HR, 2.17; 95% CI, 1.04–4.52, p = 0.039). Conclusion Newly diagnosed DM was associated with increased risk of AD. Use of hypoglycemic agents did not ameliorate the risk.

Patterns of ambulatory care utilization in Taiwan

BackgroundWe used the insurance claims of a representative cohort to quantify the patterns of ambulatory care visits, especially the doctor-shopping phenomenon, in Taiwan.MethodsThe ambulatory visit files of the 200,000-person cohort datasets from the National Health Insurance Research Database in 2002 were analyzed. Only a visit with physician consultation would be considered. We computed the visit patterns both by visit count and by patient count.ResultsIn 2002, there were 182,474 eligible people with 2,443,003 physician consultations. During the year, 87.4% of the cohort had visited physician clinics and 57.5% had visited hospital-based outpatient or emergency departments. On average, a person had 13.4 physician consultations and consulted 3.4 specialties, 5.2 physicians, and 3.9 healthcare facilities in a year. In 2002, 17.3% of the cohort had ever visited different healthcare facilities on the same day; 23.5% had ever visited physicians of the same specialty at different healthcare facilities within 7 days and the percentage of second visits was 3.8% of all visits. Besides, 7.6% of the cohort had visited two or more specialties at the same facility on the same day, and such visits make up 2.5% of all visits.ConclusionThe people in Taiwan did visit the physicians and outpatient departments frequently. Many patients not only consulted several physicians of different specialties and at different healthcare facilities during the year, but also switched the physicians and facilities quickly. An effective referral system with efficient data exchange between facilities might be the solution.

Epidemiological study of psoriasis in the national health insurance database in Taiwan.

The aim of this study was to determine the prevalence, treatment modalities and comorbidity of psoriasis in Taiwan. A nationally representative cohort of 1,000,000 individuals from the National Health Insurance database was followed up for the years 2000 to 2006. Their claims data was used for an epidemiological study. The mean one-year prevalence of psoriasis was 0.23% for men and 0.16% for women, respectively. The prevalence of psoriasis increased more rapidly in male patients aged 30 years and over and reached its peak in patients aged 70 years and over, regardless of sex. Overall, 98.4% of patients received treatment with topical corticosteroids, while 13.1% used Chinese herbal medicines and 13.6% received systemic treatment. Patients with psoriasis had a higher comorbidity of diabetes, hyperlipidaemia, and hypertension. In conclusion, in contrast to Caucasians, the prevalence of psoriasis in Taiwanese people is high er in men than in women and the prevalence increases significantly in patients over 70 years of age.

A nation-wide analysis of venous thromboembolism in 497,180 cancer patients with the development and validation of a risk-stratification scoring system

The Asian population is thought to have a low risk of venous thromboembolism (VTE), but the epidemiology of VTE in cancer patients remains unclear. The National Health Insurance Research Database of Taiwan was used to find hospitalised patients newly-diagnosed with cancer to determine the incidence of VTE in cancer patients and to identify the risk factors for VTE. Between 1997 and 2005, 497,180 cancer patients were identified. During a median follow-up of 21.3 months (range 0-119.9 months), 5,296 patients developed VTE. The estimated incidence was 185 events per 100,000 person-years. Patients with a prior history of VTE and female patients between the ages of 40 and 80 carried high risk of VTE. The rate of VTE was relatively high in patients with myeloma, prostate cancer, lung cancer, gynaecologic cancers, sarcoma, and metastasis of unknown origin. We developed a risk-stratification scoring system to divide the cancer patients into four discrete risk groups (very low risk, low risk, intermediate, and high risk). The incidence of VTE in each group was 0.5%, 0.9%, 1.5%, and 8.7%, respectively (p < 0.001). This scoring system was validated in a separate patient cohort. In conclusion, VTE is a distinct burden for cancer patients in Taiwan. The risk scoring system could prove helpful in decision-making concerning thromboprophylaxis in cancer patients.

Prevalence of the prescribing of potentially inappropriate medications at ambulatory care visits by elderly patients covered by the Taiwanese National Health Insurance program

BACKGROUND The use of potentially inappropriate medications can have profound medical consequences for elderly patients and place a substantial burden on the health care system. OBJECTIVES This study was conducted to determine the prevalence of potentially inappropriate medication prescribing at ambulatory care visits by patients aged > or =65 years covered by the Taiwanese National Health Insurance program, to examine the characteristics of and risk factors for such prescribing, and to investigate its influence on health care resource utilization. METHODS Ambulatory care visits by patients aged > or =65 years in 2001-2004 were identified from the National Health Insurance claims database. The 2003 Beers criteria for drugs to be avoided in the elderly were used to identify potentially inappropriate medications prescribed at these visits. Only drugs with the potential to lead to higher-severity adverse events were included. Multivariate logistic regression was used to determine predictors of the prescribing of potentially inappropriate medications at ambulatory care visits. Independent variables in the regression model included patient characteristics (eg, sex, age), physician characteristics (sex, age, and specialty), and visit characteristics (site and prescribed drug number). The dependent variable was visits that included a prescription for a potentially inappropriate medication. RESULTS Overall, 176,661,994 ambulatory care visits by patients aged > or =65 years were identified in 2001-2004. Of these, 19.1% involved a prescription for a potentially inappropriate medication. Although the frequency of potentially inappropriate medication prescribing declined over the study period, 62.5% of elderly patients were exposed to such medications in 2004. The only patient characteristic associated with an increased likelihood of the prescribing of potentially inappropriate medications was female sex (male sex: odds ratio [OR] = 0.982 [95% CI, 0.980-0.983], P < 0.001). Physician characteristics associated with a greater likelihood of the prescribing of potentially inappropriate medications was male sex (OR = 1.206 [95% CI, 1.202-1.210], P < 0.001); older age (43-50 years: OR = 1.021 [95% CI, 1.018-1.025], P < 0.001; >/=51 years: OR = 1.238 [95% CI, 1.235-1.242], P < 0.001); and family medicine/general practice (OR = 1.267 [95% CI, 1.265-1.269], P < 0.001). For visit characteristics, significant associations were found with visits to a primary care clinic (OR = 1.887 [95% CI, 1.881-1.892], P < 0.001) and the number of drugs prescribed (4-6 drugs: OR = 2.701 [95% CI, 2.696-2.706], P < 0.001; > or =7 drugs: OR = 4.528 [95% CI, 4.517-4.538], P < 0.001). The most commonly prescribed types of potentially inappropriate medications were antihistamines (4.8% of all prescriptions in 48.3% of elderly patients), muscle relaxants/antispasmodics (4.0% and 40.3%, respectively), and long-acting benzodiazepines (2.4% and 21.4%). In 2004, the mean number of ambulatory care visits per patient was significantly higher among those who received potentially inappropriate medications compared with those who did not (30.78 vs 16.57, respectively; P < 0.001). Patients who received potentially inappropriate medications also had significantly more emergency department visits (0.27 vs 0.15; P < 0.001) and hospital admissions (0.46 vs 0.27; P < 0.001). CONCLUSION There was a high prevalence of the prescribing of potentially inappropriate medications at ambulatory care visits by elderly patients in Taiwan in 2001-2004.