臺灣博碩士論文加值系統

背景
中醫是臺灣醫療體系中重要的一部份。全民健康保險自1995年開辦，於1996年將中醫門診納入全民健康保險給付範圍，中醫醫療利用之研究雖曾被研究過，但是中醫醫療利用的趨勢則較少被研究，目前並無橫跨三個世代的全民中醫醫療利用被探討，全民中醫療利用之探討可以提供更多中醫醫療利用之詳細情形。
許多疾病的中醫處方形態已被學者探討過，然而上呼吸道感染的中醫處方的季節性則尚未被探討，掌握上呼吸道感染的中醫處方的季節性，有助於準備適宜的上呼吸道感染的中醫治療策略和建構中醫對上呼吸感染的公共衛生照護模式。此篇論文的研究目的有二：一是探討2000年至2010年的中醫醫療利用之趨勢。二是從中醫理論的觀點，探討上治療呼吸道感染的三種中醫常見證型及三類常見症狀的中醫處方的季節性。

方法
此篇研究是一個分析中醫醫療利用的橫斷面研究，此研究首先比較2000年、2005年以及2010年三個世代的平均中醫醫療利用，自全民健康保險研究資料庫分別取得2000年、2005年以及2010年各近百萬人的樣本，以多元邏輯斯回歸來評估中醫使用者在各類自變項間之勝算值。以百分比改變量來評估在不同世代間平均中醫利用次數之差異。
其次分析來自全民健康保險資料庫的2005年百萬人抽樣人口及其就醫資料，國際疾病分類第九版的診斷碼為：460-465以及486者視為因上呼吸感染就診，共計有160357筆中醫處方可以用來分析，運用多元邏輯斯回歸來估計最常見的三種中醫外感證型及三類症狀的中醫成方在各季節之勝算比。

結果
中醫利用者之比率從2000年、2005年至2010年逐漸增加，在2000年、2005年以及2010年三個世代，中醫利用者之比率在校正後之勝算比 (adjusted odds ratio, AOR)，都是女性多於男性（AOR=1.47、1.52、1.62）。中醫平均利用次數也從2000年至2010年逐漸增加。其中女性的平均中醫利用次數的增加百分比高於男性，小於20歲者的平均中醫利用次數增加最少；介於20-34歲者增加最多。在2000年至2010年，高社經地位者平均中醫利用次數增加最多；其他社經地位者的平均中醫利用次數增加最少。從2000年至2010年，臺北地區的平均中醫利用次數增加最多，中區的平均中醫利用次數增加最少。腫瘤是平均中醫利用次數增加最多的疾病類別；呼吸道疾病是平均中醫利用次數減少最多的疾病類別。
辛涼解表中醫處成方之處方頻率在校正後之勝算比在夏天最高 (AOR=1.07)、在冬天最低是 (AOR=0.92)，辛溫解表中醫處方之處方頻率在校正後之勝算比在冬天最高 (AOR=1.14)、在夏天最低 (AOR-0.95)，清暑袪濕解表中醫處方之處方頻率在校正後之勝算比在夏天最高 (AOR=1.34)。止咳化痰類中醫處方之處方頻率在校正後勝算比在春天最高 (AOR=1.00)、在秋天最低 (AOR=0.86)，治療鼻塞鼻涕的中醫處方之處方頻率在校正後勝算比在冬天最高 (AOR=1.19)、在夏天最低 (AOR=0.97)，減緩頭痛頭暈的中醫處方之處方頻率在校正後勝算比在秋、冬兩季最高 (AOR=1.15)、在春天最低 (AOR=1.00)

結論
平均中醫利用次數和中醫使用者比率從2000年經2005年再到2010年逐漸增加，中醫利用增加的趨勢在2005年至2010年間相較2000年至2005年間趨緩。從2000年至2010年，女性的中醫醫利用在研究期間超過男性並且預期在未來也會超過男性。高社經地位者比起過去對中醫的利用增加。中區一直是平均中醫利用次數最多的地區，然而中醫的平均中醫利用之增加百分比最少，臺北地區的平均中醫利用次數增加百分比最多。雖然呼吸系統疾病的平均中醫利用次數在2000年最高，卻是平均中醫利用次數減少百分比最多的疾病類別；腫瘤則是中醫平均利用次數增加百分比最多的疾病類別
風熱型及暑濕型上呼吸道感染的中醫處方在夏季最多，風寒型上呼吸道感染的中醫處方在冬季最多，意味著治療此三種最常見上呼吸道感染證型的中醫處方有季節性和且中醫理論一致。此外，用以止咳化痰的中醫處方最常在春季，減緩鼻涕和鼻塞的中醫處方最常在冬季，減輕頭痛和頭暈的中醫處方最常在秋、冬二季，意味著減緩常見三類上呼吸道感染症狀的中醫處方可能也有季節性。

臨床或政策意涵
此篇論文中有關2000年至2010年中醫醫療利用趨勢的探討結果，可以作為改善醫療準備及政府政策擬定的參考。由於癌症病人的中醫醫利用大幅增加，意味者未來癌症病人的中醫醫療需要更深一層的探討。
　　此篇論文中有關上呼吸道感染的中醫處方季節性探討的結果不僅驗證引起上呼吸道感染的中醫理論中的六氣，同時提供中醫在臨床上預防和治療上呼吸道感染的參考。掌握上呼吸道感染的中醫處方的季節性可提供治療上呼吸道感染的中醫處方參考，也有助於增中醫在臺灣醫療照護體系中的重要性。

Background:
Traditional Chinese Medicine (TCM) is an important part of the medical system in Taiwan. The National Health Insurance (NHI) program, which was established in 1995, has covered ambulatory visits of TCM since 1996. All the registration files and claims data are collected in the National Health Insurance Research Database (NHIRD) by the National Health Research Institute (NHRI).
TCM utilization has been discussed in several articles, but the trends of TCM utilization have seldom been explored. In particular, no study has investigated the trend of TCM utilization among the whole population over three cohorts. TCM utilization by the whole population can provide a much more extensive picture of TCM utilization.
The patterns of TCM prescriptions for several diseases have been explored by many scholars, but the seasonality of prescriptions for upper respiratory tract infections (URIs) in TCM has not been researched so far. Understanding of the association between the seasonality of and prescriptions for URIs is important in planning optimal treatment strategies in TCM and constructing predictive models to guide public health care for URIs.
The objectives of this dissertation are to investigate the trends of TCM utilization from 2000 to 2010, and to explore the seasonal variation of prescriptions for the three most common types of URIs and the three categories of common URI symptoms from the viewpoint of TCM theories.

Method:
This study was a cross-sectional analysis of TCM utilization over time. First, the mean TCM visits were compared among three cohorts of 2000, 2005, and 2010. The nearly one million randomly sampled representative beneficiaries in each cohort of 2000, 2005, and 2010 were derived from NHIRD for this research. Multivariate logistic regression was performed to evaluate the relative relationship in categorical variables correlating to TCM users. The percentage change (% change) in mean TCM visits between 2000 and 2005 (2010) was used to evaluate the trends of TCM utilization during the period. Second, 1,000,000 randomly sampled beneficiaries were derived from the NHIRD in 2005. Primary diagnoses including International Classification of Diseases, Ninth Revision, Clinical Modification codes 460–465 and 487 were regarded as URIs, for which 160,357 TCM prescriptions were analyzed. The adjusted odds ratios (AOR) of prescription frequency in three categories of Chinese herbal formulae (CHF) used to treat the three most common types of URIs and three categories of CHF used to alleviate three major URI symptoms throughout the four seasons were estimated by multivariate logistic regression analysis. Prescription frequencies were defined as numbers of CHF for a certain syndrome type of URI or number of CHF for certain URI symptoms divided by the number of total prescriptions in one season.

Result:
The ratio of TCM users increased throughout the three cohorts of 2000, 2005, and 2010. The ratio of TCM users among women was more than that among men in all three cohorts of 2000, 2005, and 2010 (AOR=1.47; 1.52; 1.62). The mean TCM visits increased gradually from 2000 to 2010. The % change in mean TCM visits among women was also more than that among men. The group aged < 20 years had the least % change in mean TCM visits; the group aged 20-34 years had the largest % change, and the high SES group had the least % change in mean TCM visits. The high SES group had the largest % change in mean visits to TCM from 2000 to 2010, while the other SES had the least % change. The Taipei region had the largest % change of mean TCM visits from 2000 to 2010; therefore, the central region had the least % change of mean TCM visits. Neoplasms had the greatest increase in % change in mean TCM visits among all disease categories; in contrast, diseases of the respiratory system had the greatest decreased % change in mean TCM visits.
The AOR of prescription frequency for pungent–cool CHF used to relieve external syndromes was highest in the summer (AOR = 1.07) and lowest in winter (AOR=0.92). The AOR of prescription frequency for pungent–warm CHF used to relieve external syndromes was highest in the winter (AOR = 1.14) and lowest in summer (AOR=0.95). The AOR of prescription frequency for CHF eliminating summer-heat and dampness was highest in summer (AOR=1.34). The AOR of prescription frequency for CHF used to alleviate coughing and reduce sputum production was highest in the spring (AOR = 1.00). The AOR of prescription frequency for CHF used to alleviate nasal discharge and congestion was highest in the winter (AOR = 1.19). The AOR of prescription frequency for CHF used to alleviate headaches and dizziness was highest in the autumn and spring (AOR = 1.00).

Conclusion:
Both mean TCM visits and ratio of TCM users increased gradually from 2000 to 2005 and further to 2010. The increased trend of TCM utilization slowed from 2005 to 2010 compared to 2000 to 2005. From 2000 to 2010, women had higher TCM utilization than men during the study period. This disparity between gender in TCM utilization is likely to continue in the future. The group with high SES had more TCM utilization than before. The Taipei region had the greatest increase of % change in mean TCM visits; while the Central region had the least increase of % change in mean visits but the largest mean TCM visits. Among all disease categories explored in this study, the diseases of the respiratory system had the highest mean TCM visits in 2000 and the highest decreased % change from 2000 to 2010. In contrast, neoplasms had the highest increased % change in mean TCM visits from 2000 to 2010.
CHF for wind-heat URIs and summer-heat and dampness URIs were prescribed most frequently in the summer, and CHF for wind-cold URIs were prescribed most frequently in the winter. This result might indicate that these were seasonal variations of CHF for the three most common syndrome types of URIs, and those are consistent with basic TCM theories. Besides, CHF used to alleviate cough and sputum production were prescribed most frequently in the spring, CHF to alleviate nasal discharge and congestion prevail in the winter, and CHF to alleviate headaches and dizziness were prescribed most frequently in the autumn and winter, which indicated that the occurrence of prescriptions for the three categories of major URI symptoms also exhibited seasonal variations.

Clinical or policy Implications:
The results of trends of medical utilization in TCM from 2000 to 2010 in this study may serve as a reference for improving the preparedness of medical service by medical providers and formulation of health policies by government. Finally, the picture of TCM utilization needed by different kinds of cancer patients deserves investigation in future research because of the high % change of trends in TCM utilization from 2000 to 2010.

The findings of seasonal variations of prescriptions for URIs in this study not only verified the basic TCM theories pertaining to the six natural climatic factors that cause URIs throughout the four seasons, but also can serve as a reference for the preparation of preventive strategies against URIs and the treatment for URIs in clinical practice of TCM. Furthermore, comprehension of seasonality of prescriptions for URIs will provide clinicians of TCM the reference prescription for URIs and possibly give TCM a more important role in the whole health care system in Taiwan.
　
Keywords: traditional Chinese medicine, seasonal variation, upper respiratory tract infection, Chinese herbal formula, National Health Insurance, utilization of traditional Chinese medicine, disease category

TABLE OF CONTENTS
ACHKNOWLEDGMENT------------------------------------------------------------------------------i
CHINESE ABSTRACT-------------------------------------------------------------------------------------iv
ENGLISH ABSTRACT-------------------------------------------------------------------------------------ix
TABLE OF CONTENTS----------------------------------------------------------------------------------x
LIST OF FIGURES -------------------------------------------------------------------------------------------xiii
LIST OF TABLES ------------------------------------------------------------------------------------------xiv
Chapter 1 INTRODUCTION-----------------------------------------------------------------------------1
1.1 Background-----------------------------------------------------------------------------------------1
1.2 Specific aims----------------------------------------------------------------------------------------3
1.2.1 Aim 1: Trend of TCM utilization from 2000 to 2010--------------------------------------3
1.2.2 Aim 2: Seasonality of TCM prescriptions for URIs-----------------------------------------3
1.3 Outline of the dissertation------------------------------------------------------------------------3
Chapter 2 LITERATURE REVIEW---------------------------------------------------------------------5
2.1 Complementary and alternative medicine and traditional Chinese medicine------------5
2.1.1 Complementary and alternative medicine----------------------------------------------------5
2.1.2 Traditional Chinese medicine------------------------------------------------------------------5
2.2 Upper respiratory tract infection-----------------------------------------------------------------6
2.2.1 Introduction to (upper) respiratory tract infection-------------------------------------------6
2.2.2 Common cold-------------------------------------------------------------------------------------7
2.2.3 Influenza-------------------------------------------------------------------------------------------8
2.2.4 The epidemiology of URI in Taiwan-----------------------------------------------------------8
2.2.5 Comparison between common cold and influenza-------------------------------------------8
2.3 Introduction to TCM------------------------------------------------------------------9
2.3.1 General introduction to TCM--------------------------------------------------------------------9
2.3.2 Syndrome types and manifestations of URIs in TCM------------------------------------10
2.3.3 Importance of accurate diagnosis of URI in TCM--------------------------------------10
2.3.4 Chinese herbal formulae for treatment of different syndrome types of URI in TCM---10
2.3.5 Chinese herbal formulae for reduction of different manifestations of URI in TCM---11
2.4 Introduction to National Health Insurance (NHI) in Taiwan--------------------11
2.4.1 National Health Insurance---------------------------------------------------------------------11
2.4.2 National Health Insurance Research Database-----------------------------------------12
2.5 Summary of the gaps in literature----------------------------------------------------12
CHAPTER 3 METHODS-----------------------------------------------------------------------------------14
3.1 Data source-----------------------------------------------------------------------------------------14
3.2 Study samples--------------------------------------------------------------------------------------14
3.2.1 Study sample for exploration of trends in TCM utilization from 2000 to
2010--------------------------------------------------------------------------------------15
3.2.2 Study sample for exploration of seasonal variations in prescriptions for URIs in
TCM----------------------------------------------------------------------------15
3.3 Study variable--------------------------------------------------------------------------------------15
3.3.1 Study variables for exploration of trends in TCM utilization from 2000 to 2010---------16
3.3.2 Study variables for exploration of seasonal variations in prescriptions for URIs in TCM------------------------------------------------------------------------------------------------16
3.4 Statistical analysis------------------------------------------------------------------------------------17
3.5 Ethical considerations--------------------------------------------------------------------------------18
3.6 Linkage of reimbursement data---------------------------------------------------------------------18
CHAPTER 4 RESULTS -------------------------------------------------------------------------------------19
4.1 Trend of TCM utilization from 2000 to 2010----------------------------------------------------19
4.1.1 Ratios of TCM Users among Different Cohorts of 2000, 2005 and 2010----------19
4.1.1.1 Number of TCM users-------------------------------------------------------------------19
4.1.1.2 Ratios of TCM users by gender--------------------------------------------------------20
4.1.1.3 Ratios of TCM users by age group--------------------------------------------------20
4.1.1.4 Ratios of TCM users by SES group---------------------------------------------------21
4.1.1.5 Ratios of TCM users by region------------------------------------------------------------21
4.1.2 Trends of Mean TCM Visits from 2000 to 2010-------------------------------------------22
4.1.2.1 Mean TCM visits of TCM users and the whole population------------------------22
4.1.2.2 Mean TCM visits by gender--------------------------------------------------------22
4.1.2.3 Mean TCM visits by age group------------------------------------------------------22
4.1.2.4 Mean TCM visits by SES group-----------------------------------------------------23
4.1.2.5 Mean TCM visits of TCM users by region------------------------------------24
4.1.2.6 Trends of TCM utilization---------------------------------------------------------------24
4.1.2.7 Trends of TCM utilization by gender---------------------------------------------25
4.1.2.8 Trends of TCM utilization by age group-------------------------------------------25
4.1.2.9 Trends of TCM utilization by SES group------------------------------------------26
4.1.2.10 Trends of TCM utilization by region----------------------------------------------26
4.1.3 The Comparison of Mean TCM Visits among Different Disease Categories--------------27
4.1.3.1 The mean TCM visits per thousand enrollees in different disease categories-----------27
4.1.3.2 The trend of mean TCM visits per thousand enrollees--------------------------------------29
4.1.3.3 The top and least five mean TCM visits by disease category-----------------------------30
4.2 Seasonality of TCM prescriptions for URIs----------------------------------------------------30
4.2.1 The flowchart of TCM prescriptions obtained for analysis-----------------------------------30
4.2.2 The number of TCM prescriptions for URIs throughout four seasons----------------------31
4.2.3 The prescription frequencies of the three most common categories of CHF used to treat three major types of URIs throughout four seasons-----------------------------------------------32
4.2.4 The prescription frequencies of the three most common categories of CHF used to alleviate the three categories of major URI symptoms throughout four seasons--------------35
4.2.5 Comparisons of the three categories of CHF used to treat three common syndrome types of URIs--------------------------------------------------------------------------------------------------39
4.2.6 Comparisons of the three categories of CHF used to alleviate the three categories of major URI symptoms----------------------------------------------------------------------41
CHAPTER 5 DISCUSSION ------------------------------------------------------------------------------54
5.1 Trend of TCM utilization from 2000 to 2010-----------------------------------------54
5.2 Seasonal variations of TCM prescriptions for URIs--------------------------------------------59
CHAPTER 6 CONCLUSION -----------------------------------------------------------------------------67
6.1 Trends of TCM utilization from 2000 to 2010-------------------------------------------67
6.2 Seasonal variations of TCM prescriptions for URIs-------------------------------67
References-----------------------------------------------------------------------------------------------------69
Appendices------------------------------------------------------------------------------------------------------77
Original article


LIST OF FIGURE
Figure 1 The flowchart of TCM prescriptions for URIs obtained for analysis -------45



LIST OF TABLE
Table 1 Ratios of TCM users of selected enrollees under NHI in three cohorts of 2000, 2005, and 2010---------------------------------------------------------------------46
Table 2 Mean TCM visits and percentage change (% change) in mean TCM visits from 2000 to 2010---------------------------------------------------------------------------------------47
Table 3 Mean TCM and WM visits per thousand enrollees and percentage change (% change) in different disease categories from 2000 to 2010-------------------------------------48
Table 4 Total prescriptions of CHMs to treat URIs throughout the four seasons------------49
Table 5 Prescription frequencies of the three most common categories of CHF used to treat the three major types of URIs throughout four seasons-----------------50
Table 6 Prescription frequencies of the three categories of CHF used to alleviate the three categories of major URI symptoms throughout four seasons-------------------------51
Table 7 Comparison of the three categories of CHF used to treat the three most common syndrome types of URIs by multivariate logistic regression--------------------------52
Table 8 Comparison of the three categories of CHF used to alleviate the three categories of major URI symptoms by multivariate logistic regression-----------------------------53

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