中醫利用對中風病人預後之影響

Abstract

研究背景與目的 在世界各國與台灣，腦中風都是對大眾健康的一個重要威脅。之前的研究顯示，中風住院病人接受住院時中醫輔助治療對其健康預後有極大的幫助，包括降低泌尿道感染、肺炎、癲癇、消化道出血與死亡的風險。本研究之目的在探討中風病人一年內不同的中醫門診利用程度差異對預後事件的影響。 研究材料與方法 本研究利用2003-2010年全國健保研究資料庫串聯死因檔，篩選出2003-2010年18歲以上之中風新發病人，同時排除中風初發三個月內即再中風之病人(n=23,800)、中風初次住院即死亡(n=32,616)、中風後無中風相關醫療利用之病人(n=66,673)、中風前有癲癇病史(n=1,500)與研究期間無西醫利用者(n=278)。中風相關中醫利用之定義主要計算病人中風後至預後事件發生為止的中醫相關門診利用。同時控制年齡、性別、中風發生年、中風型態、Elixhauser共病、前一年中醫門診利用、中風住院天數及加護病房住院天數、低收入、重大傷病、使用藥物、居住地區都市化程度與當地中西醫療資源。利用Cox proportional hazard model來校正基本特性之差異，探討中風病人不同的中醫門診利用差異對其一年預後的影響。 研究結果 一共篩選出230,477位新發中風病人，其中58.66%是男性，70-79歲的人最多佔29.74%；其中78.10%是缺血性中風。癲癇、肺炎、再中風與一年內死亡的發生率分別為4.45%、7.41%、5.23%與8.09%。中風後的中風相關西醫利用與中醫利用具有交互作用的情形，相對於無中醫利用和低度西醫利用組，高度中醫利用 (不管是高西醫利用與低西醫利用)對癲癇、肺炎、再中風與一年內的死亡均可降低之發生風險。此外，高度中醫利用配合西醫利用對肺炎和一年內的死亡有降低發生風險的輔助效果。 結論與建議 在中風急性照護期後，不同中醫門診的利用程度差異會對中風病人一年內的預後事件產生影響。建議政府衛生主管機關應儘速建構一個含有中醫治療的完整中風急性期後之中西醫合作照護模式，以輔助西醫對中風的治療，使中風患者能接受最佳的醫療照護。

Background and Objectives: Stroke poses a great threat to public health internationally and in Taiwan. Previous studies indicated that hospitalized stroke patients receiving in-hospital adjuvant Traditional Chinese Medicine (TCM) therapy could have health benefits, including lower risk of urinary tract infection, pneumonia, epilepsy, gastrointestinal bleeding and death. This study aims to examine the effects of different level of stroke-related TCM utilization and acupuncture on health outcomes of hospitalized stroke patients one year after their admission. Materials and Methods: Retrospective analyses were conducted by linking National Health Insurance (NHI) claims data to Death Registry data. Incident stroke patients aged 18 years old and above during 2003-2010 were identified. Patients who had re-stroke in the first 3 months after initial stroke (n=23,800), died at initial stroke admission (n=32,616) , had no stroke-related medical utilization after stroke (n=66,673), epilepsy medical history before stroke (n=1,500), and without western medical (WM) utilization in the study period (n=278) were excluded. The level of TCM outpatient visits was identified by the utilization of stroke-related TCM outpatient visit between initial stroke and the occurrence of any event. Patient’s age, gender, year of having stroke diagnosis, type of stroke, Elixhauser comorbidity scores, TCM outpatient visit in the last year, length of stay of initial stoke, length of stay of Intensive care unit, whether or not being low-income, catastrophic disease, concomitant drugs, urbanization of residence, local number of TCM and western medicine doctor were also gathered. Cox proportional hazard models were used to adjust for the baseline characteristics. Results: Among the 230,477 incident stroke patients who were identified during the study period, 58.66% of them were male and patients aged 70-79 years old has the highest percentage (29.74%). Most of them (78.10%) were ischemic stroke. The incidence of epilepsy, pneumonia, re-stroke and 1-year mortality were 4.45%, 7.41%, 5.23% and 8.09%, respectively. We found that there are interactions between stroke-related WM utilization and TCM utilization. Compared to the group of non-TCM and low WM utilization, the group of high TCM utilization had lower risk of epilepsy, pneumonia, re-stroke and 1-year mortality after stroke. Furthermore, high TCM utilization combined with WM has complementary effect on reducing risk of pneumonia and 1-year mortality. Conclusions and Recommendations: After post-acute care, different level of TCM outpatient visit had a significant influence on one-year health outcomes of stroke patients. The competent health authority is recommended to establish a complete post-acute care cooperative model containing both TCM and WM treatment for stroke patients to ensure the best medical care.