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  • This population-based study aimed to analyze the demographic and prescribing patterns of CHPs in patients with IHD derived from a random sample of one million beneficiaries in the National Health Insurance (NHI) program in Taiwan. Taiwan’s government launched the NHI program on March 1, 1995, and 22.60 million of the 22.96 million total population was enrolled in this program in 2007. To protect individual’s privacy, the data on patient identities were scrambled cryptographically by the National Health Insurance Research Database (NHIRD). Every individual in Taiwan has a unique personal identification number (PIN). All NHI datasets can be interlinked with each individual’s PIN. This study used the registry datasets for beneficiaries from 2000 to 2010 to examine outpatient care by visits, inpatient care by admissions, and ambulatory care orders. Prescription information was identified from the database for ambulatory care orders, including corresponding prescriptive orders and CHPs. Utilization of TCM outpatient services was defined as at least one TCM use, and all TCM care was provided in ambulatory clinics under NHI coverage. This study was conducted after approval by the Institutional Review Board of China Medical University in Central Taiwan (CMU-REC-101-012). We selected patients with IHD and a diagnosis code of 414, one of three major diagnosis codes according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The patients were selected from the random sample of one million individuals in the NHI dataset; Fig 1 depicts a flowchart of the recruitment process. We identified 75,761 patients diagnosed with IHD (ICD-9-CM code: 414) from the registries of outpatient care by visits and inpatient care by admission. We excluded patients with prevalent IHD (n = 22,207) that had been diagnosed prior to the end of 1999 and those with missing information on age or sex (n = 23). Thus, the final cohort included 53531 patients. These were divided into two groups: 9854 TCM nonusers and 43677 TCM users, and the values of their mean age were 66.75 (SD = 13.5) and 61.82 (13.14) years, respectively. Given the fixed sample size of 53531, the level of absolute precision d, that specifies the width of the 95% confidence interval (CI) would be 0.26% under the assumption that the TCM use in IHD patients was 75%. Because common values for d are usually around ±5% for estimated proportions in the range of 20%-80%, the width of the 95% CI in the present study is small, indicating the size of sample provides high precision for estimating the prevalence of TCM use in patients with IHD. Figure data removed from full text. Figure identifier and caption: 10.1371/journal.pone.0137058.g001 Flowchart of recruitment of subject recruitment from the 1-million random sample of the National Health Insurance Research Database (NHIRD) from 2000 to 2010 in Taiwan.Abbreviation: IHD, ischemic heart disease; TCM, traditional Chinese medicine. To determine the key independent variables for the use of CHPs among IHD patients, we selected the demographic factors of sex, age, occupational status, geographic area, and risk factors for IHD. The baseline sociodemographic characteristics were determined from ID Registry of NHIRD by extracting data that was closest to the first diagnosed date of IHD and comorbidity history was determined for each patient using outpatient or inpatient claims within two years prior to the first diagnosed date. Age was categorized into five groups: ≤29, 30–39, 40–49, 50–59, and ≥60 years. We split occupational status into three levels: white collar, blue collar, and other. Geographic areas of Taiwan were classified into the following four regions: Northern Taiwan, Central Taiwan, Southern Taiwan, and Eastern Taiwan and offshore islands. We considered DM (ICD-9-CM: 250), hyperlipidemia (ICD-9-CM: 272), hypertension (ICD-9-CM: 401 to 405), cardiac dysrhythmias (ICD-9-CM: 427), stroke (ICD-9 CM: 430–438) and MI (ICD-9 CM: 410) as risk factors for IHD. Data analysis included the prevalence of TCM use stratified by the patient’s demographic and risk factors, frequency and proportion of the most frequently prescribed herbal formulas for treating IHD. A multiple logistic regression model was developed to estimate demographic and risk factors that correlated with TCM use. The models produced odds ratios (ORs) and corresponding 95% CIs. An adjusted odds ratio was used to predict patients who may have higher odds to use TCM therapy. The exposure period for counts of CHP or TCM use was defined as the period from the first diagnosed date to the date of withdrawal from the NHI program, death or the end of 2010. Risk ratios (RRs) and 95% confidence intervals (CI) were estimated for yearly counts of CHP by using Poisson regression analysis and sex, age, area, occupational status, DM, hyperlipidemia, hypertension, dysrhythmias, stroke, and MI were adjusted. All statistical analyses were performed using SAS 9.3 (SAS, Cary, NC, USA), with the significance level set to 0.05, two-tailed.
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