臺灣博碩士論文加值系統

研究目的：比較中醫師與一般民眾罹患第二型糖尿病、腎臟透析、癌症與死亡之風險，以及第二型糖尿病之醫療利用情形，並分析其相關影響因素。
研究方法：罹患第二型糖尿病、腎臟透析、癌症與死亡之風險部分，資料來自 1998–2012 年台灣全民健康保險研究資料庫 (National Health Insurance Research Database, NHIRD)。擷取 1998–2005 年 25–90 歲之中醫師與一般民眾，以性別、年齡、投保金額、投保地區都市化程度、共病嚴重度 (Charlson comorbidity index, CCI) 為配對變項，利用傾向分數分配法 (Propensity Score Matching, PSM) 進行 1：4 配對，配對後之中醫師與一般民眾為研究對象。
以 χ2 test 分析兩組（中醫師、一般民眾）包含基本特性（性別、年齡）、經濟因素（投保金額）、環境因素（投保地區都市化程度）、健康因素（共病嚴重度 (CCI)、糖尿病併發症嚴重度 (Diabetes Complications Severity Index, DCSI)）與罹患第二型糖尿病、腎臟透析、癌症、死亡之差異。以單因素卜瓦松迴歸分析檢驗中醫師與一般民眾罹患第二型糖尿病、腎臟透析、癌症的發生率是否顯著差異（每千人年）。以 Cox 比例風險模式探討中醫師與一般民眾罹患第二型糖尿病、腎臟透析、癌症、死亡之風險，並找出影響其罹患第二型糖尿病、腎臟透析、癌症、死亡之相關因素。觀察時間由 1998 年 1 月 1 日至 2012 年 12 月 31 日止。
第二型糖尿病之醫療利用部分，取 2000–2007 年 25–90 歲之糖尿病中醫師與一般糖尿病民眾，以基本特性（性別、年齡）、健康情形（共病嚴重度 (CCI)、糖尿病併發症嚴重度 (DCSI)）為配對變項，利用傾向分數分配法進行 1：10 配對，配對後之糖尿病中醫師與一般糖尿病民眾為研究對象。以 t-test 檢驗糖尿病中醫師與一般糖尿病民眾人年平均就醫次數（中、西醫門診、急診、住院）及醫療費用（中、西醫門診、急診、住院）是否顯著差異。觀察時間由 2000 年 1 月 1 日至 2010 年 12 月 31 日止。
研究結果：中醫師第二型糖尿病之發生率（5.39 vs. 8.51/每千人年）及風險 (HR = 0.64) 皆比一般民眾低。中醫師與一般民眾罹患第二型糖尿病的影響因素包括性別、年齡、投保金額、投保地區都市化程度和共病嚴重度 (CCI)。中醫師不論男、女，第二型糖尿病風險 (HR = 0.43–0.67)皆低於一般民眾 (p < 0.05)。中醫師不論共病嚴重度 (CCI) 分數為何，第二型糖尿病風險 (HR = 0.39–0.71) 皆低於一般民眾 (p < 0.05)。若只探討中醫師族群，影響中醫師罹患第二型糖尿病之相關因素包含性別、年齡及共病嚴重度 (CCI)。罹患第二型糖尿病的風險，男中醫師高於女中醫師 2.42 倍 (95％ CI = 1.61–3.63) (p < 0.05)。中醫師年齡越大第二型糖尿病風險越高 (p < 0.05)。共病嚴重度 (CCI) ≥ 2 組相較共病嚴重度 (CCI) 0–1 組，罹患第二型糖尿病風險高 1.27 倍 (95％ CI = 1.02–1.57)。
中醫師腎臟透析之發生率（1.28 vs. 0.47/每千人年）及風險 (HR = 2.90) 皆比一般民眾高。中醫師與一般民眾腎臟透析的影響因素包括性別、年齡、投保金額、投保地區都市化程度、共病嚴重度 (CCI) 及糖尿病併發症嚴重度 (DCSI)。中醫師不論男、女，其腎臟透析風險 (HR = 2.71–4.36) 皆高於一般民眾。中醫師不論居住地區，其腎臟透析風險 (HR = 2.41–3.64) 皆高於一般民眾 (p < 0.05)。中醫師不論共病嚴重度 (CCI) 分數，其腎臟透析風險 (HR = 1.90–4.59) 皆高於一般民眾 (p < 0.05)。若只探討中醫師族群，影響中醫師腎臟透析之相關因素包含年齡、共病嚴重度 (CCI) 及糖尿病併發症嚴重度 (DCSI)。
中醫師罹患癌症與死亡風險較一般民眾稍高，但無統計顯著差異 (p  0.05)。大於 65 歲的中醫師癌症發生率高於同年齡的一般民眾 (p  0.05)。住在第 6 級（農業市鎮）及第 7 級（偏遠地區）都市化程度地區的中醫師罹患癌症風險，為相同都市化程度地區民眾的 1.99 倍 (95% CI = 1.03–3.86)。在各種癌症類別中，中醫師以膀胱癌 (HR = 3.04) 與腎及泌尿器官癌 (HR = 4.77) 的罹患風險為一般民眾的 3–4.8 倍，最為突顯。男中醫師 (HR = 0.6) 罹患癌症機率較女中醫師低。中醫師罹患癌症的影響因素包括性別、年齡、共病嚴重度 (CCI)。影響中醫師與一般民眾死亡風險之相關因素包括性別、年齡、投保金額、共病嚴重度 (CCI) 和有無罹患癌症。
第二型糖尿病之中醫師 (22.78%) 中醫門診就醫比例，為一般糖尿病民眾 (6.37%) 的 3.6 倍。人年平均中醫門診利用次數，糖尿病中醫師（0.95 ± 3.11 次）為一般糖尿病民眾 （0.19 ± 1.34 次）的5 倍 (p < 0.05)。人年平均中醫門診費用，糖尿病中醫師（528.48 ± 1,642.32 元）為一般糖尿病民眾（122.98 ± 892.08 元）的 4.3 倍 (p < 0.05)。
西醫門診之就醫比例，一般糖尿病民眾 (89.89%) 為糖尿病中醫師 (78.65%)的1.1 倍。人年平均西醫門診利用次數，一般糖尿病民眾（8.11 ± 6.76 次）為糖尿病中醫師（6.37 ± 6.80 次）的1.3 倍 (p < 0.05)。人年平均西醫門診費用，一般糖尿病民眾（11,623.50 ± 14,655.62 元）為糖尿病中醫師（9,509.17 ± 13,617.69 元）的1.2倍 (p < 0.05)。
急診之就醫比例，一般糖尿病民眾 (12.53%) 為糖尿病中醫師 (11.03%)的1.1 倍。住院之就醫比例，一般糖尿病民眾 (31.35%) 為糖尿病中醫師 (28.11%) 的1.1 倍。
研究結論：本研究結果顯示，第二型糖尿病之發生率及風險，中醫師比一般民眾低。不論性別、共病嚴重度 (CCI) 分數，中醫師第二型糖尿病風險皆低於一般民眾。不論性別、居住地、共病嚴重度 (CCI) 分數，中醫師腎臟透析風險皆高於一般民眾。本研究結果證實中醫師有腎臟透析的職業風險。罹患癌症與死亡之風險，中醫師較一般民眾稍高，但未達統計差異。中醫師比一般民眾易罹患泌尿系統癌症。第二型糖尿病確診後的中醫師比一般糖尿病民眾，有較多的人年平均中醫門診利用次數及費用，較少的人年平均西醫門診利用次數及費用，較少的急診就醫比例及住院就醫比例。

Background: This study compared the incidence risks of diabetes, dialysis, cancer, and death, as well as diabetic health care utilizations among Chinese medicine physicians (CMPs) and general people.
Methods: The data were retrieved from the National Health Insurance Research Database, Taiwan, 1998-2012. The observation time period for the risks of diabetes, dialysis, cancer and mortality was from 1998 January 1 to 2012 December 31. The study subjects included CMPs aged 25 to 90 during 1998 to 2005 as the CMP cohort. Then we selected non-CMP people under a 1:4 propensity score match by age, gender, income (surrogated by monthly premium), urbanization levels in the residence, and severity of comorbitity surrogated by Charlson Comorbidity Index (CCI), as the control cohort.
Using χ2 test, we compared the differences in demographic characteristics (age, gender), economic factors (monthly premium), environmental factors (urbanization levels in the residence), health factors (severity of comorbitity, severity of diabetic complications, surrogated by Diabetes Complications Severity Index, DCSI), and the risks for Type II diabetes (T2DM), dialysis, cancers and mortality among these two cohorts. We used Univariate Poisson regression analysis to investigate the differences of incidence (per thousand person-years) of T2DM, dialysis and cancers among these 2 cohorts. Further, we used Cox proportional hazard model to compare the hazards of T2DM, dialysis, cancers and mortality among these 2 cohorts; and explore the related factors for these 4 outcomes.
For the part of diabetic health care utilizations, the observation time was from 2000 January 1 to 2010 December 31. The study subjects included CMPs aged 25 to 90 during 2000-2007 as the CMP group. Then we selected non-CMP people under a 1:10 propensity score match by age, gender, and health factors (Charlson comorbidity index (CCI) and Diabetes Complications Severity Index (DCSI)). We used t-test to evaluate the differences, among these 2 groups, of mean annual health care seeking times (including outpatient visits in western medicine, traditional Chinese medicine, emergency and hospitalization) and health care cost.
Results: CMPs had lower incidence (5.39 vs. 8.51 per thousand person-year) and risk (HR = 0.64) of T2DM than general people. The associated factors for T2DM included gender, age, monthly premium, urbanization levels in the residence and Charlson comorbidity index (CCI). CMPs had lower risks of T2DM regardless of gender (HR = 0.43-0.67, p < 0.05) or CCI (HR = 0.39-0.71, p < 0.05). Among CMPs, the associated factors for incident T2DM included age, gender, and CCI. Increasing age has higher risk (p < 0.05). Male CMPs had 2.42 folds higher risk for T2DM than female CMPs (95％ CI = 1.61–3.63, p < 0.05). CMPs with CCI >= 2 had 1.27 folds higher risk for T2DM than CMPs with CCI 0-1 (95％ CI = 1.02–1.57).
CMPs had higher incidence (1.28 vs. 0.47 per thousand person-year) and risk (HR = 2.90) of incident dialysis than general people. CMPs had higher risks of incident dialysis regardless of gender (HR = 2.71-4.36, p < 0.05), urbanization levels in the residence (HR = 2.41–3.64, p < 0.05) or CCI (HR = 1.90–4.59, p < 0.05). The associated factors among CMPs and general people for incident dialysi included age, gender, monthly premium, urbanization levels in the residence, CCI and DCSI. The associated factors for incident dialysis for CMPs included age, CCI, and DCSI.
Overall speaking, the risks of cancer and mortality in CMPs are not different with those in general people (p  0.05). Elderly CMPs (age at or over 65) had higher cancer risks than general people of the same age level (p  0.05). CMPs dwelling in areas with lower urbanization levels (level 6 and level 7) had higher cancer risks for general people living in the same areas (HR = 1.99, 95% CI = 1.03–3.86). CMPs had higher risks of cancer risks in urinary bladder and genitor-urinary tract (HR = 3.04 for urinary bladder, HR = 4.77 for other genitor-urinary tract. Male CMPs had lower cancer risk than female CMPs (HR = 0.6). The associated factors with cancers in CMPs included age, gender and CCI. The associated factors with mortality in CMPs and general people included age, gender, monthly premium, CCI and presence of cancer.
After definitive diagnosis of T2DM, in terms of health care utilization, the proportion of receiving Chinese traditional medical treatments (CTMT) in CMPs with diabetes was 3.6 folds higher than the proportion in general people with diabetes (22.78 % vs. 6.37%). As to the annual frequency of CTMT outpatient visits, the data of CMPs with diabetes was 5-folds higher than the data of general people with diabetes (0.95 ± 3.11 vs. 0.19 ± 1.34 , p < 0.05). The annual CTMT outpatient visits cost of CMPs with diabetes was 4.3-folds higher than that of general people with diabetes (NT$ 528.48 ± 1642.32 vs. 122.98 ± 892.08, p < 0.05).The proportion of receiving Western medicine in general people with diabetes was 1.1-fold higher than the proportion in CMPs with diabetes (89.89 % vs. 78.65%). As to the annual frequency of Western medicine outpatient visits, the data of general people with diabetes was 1.3-folds higher than the data of CMPs with diabetes (8.11 ± 6.76 vs. 6.37 ± 6.80, p < 0.05). The annual Western medicine outpatient visits cost of general people with diabetes was 1.2-folds higher than that of CMPs with diabetes (NT$ 11,623.50 ± 14,655.62 vs. 9,509.17 ± 13,617.69, p < 0.05).
The proportion of having emergency visits in general people with diabetes was 1.1-fold higher than the proportion in CMPs with diabetes (12.53 % vs. 11.03%). The proportion of receiving hospitalization treatment in general people with diabetes was 1.1-fold higher than the proportion in CMPs with diabetes (31.35 % vs. 28.11%). The proportion of overall health care utilization (outpatient services and hospitalization care) in general people with diabetes were higher than the proportion in CMPs with diabetes (94.63 % vs. 90.75%).
Conclusion: Our data reveal that the incidence and risk of T2DM in CMPs is lower. Regardless of gender and CCI, the risk of T2DM is lower in CMPs. The incidence and risk of receiving dialysis in CMPs is higher than general people regardless of gender, urbanization levels in the residence, or CCI. Our data confirm that CMPs have higher occupation risk of receiving dialysis. CMPs have slightly higher risk of cancer and mortality, but the difference is non-significant. CMPs have significantly higher risk for cancers of genitourinary system. Upon definitive diagnosis of T2DM, CMPs have higher frequency and cost of utilizing CTMT, lower frequency and cost of utilizing Western medicine, lower proportion of emergency visits, hospitalization care and overall health care utilization.

第一章 緒論 1
第一節 研究背景與研究動機 1
第二節 研究的重要性 3
第三節 研究目的 5
第四節 名詞界定 7
第二章 文獻探討 9
第一節 糖尿病 9
第二節 慢性腎臟病 15
第三節 癌症的流行病學 18
第四節 醫師的疾病類別與死亡率 20
第五節 醫師的健康態度和行為 23
第六節 中醫師與中草藥使用 25
第七節 頻繁接觸中草藥者易罹患之疾病 26
第八節 社經地位與醫療利用 27
第九節 文獻總結 28
第三章 研究方法 29
第一節 研究資料來源 29
第二節 研究對象 30
第三節 研究架構 35
第四節 資料收集與變項定義說明 39
第五節 資料統計與分析 44
第四章 研究結果 48
第一節 罹患第二型糖尿病風險及其相關因素 48
第二節 腎臟透析之風險及其相關因素 53
第三節 罹患癌症之風險及存活分析 57
第四節 第二型糖尿病確診後之醫療利用情形 62
第五章 討論 67
第一節 罹患第二型糖尿病風險及其相關因素之討論 67
第二節 腎臟透析風險及其相關因素之討論 69
第三節 罹患癌症風險及存活分析之討論 71
第四節 第二型糖尿病確診後醫療利用之討論 74
第六章 結論與建議 78
第一節 結論 78
第二節 研究限制 80
第三節 建議 81
參考文獻 127
附錄 138

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