Gender differences in traditional Chinese medicine use among adults in Taiwan

Epidemiology and Risk Determinants of Drug-Induced Liver Injury: Current Knowledge and Future Research Needs

AIMS

Drug-induced liver injury (DILI) is a major global health concern resulting from adverse reactions to medications, supplements or herbal medicines. The relevance of DILI has grown with an aging population, the rising prevalence of chronic diseases and the increased use of biologics, including checkpoint inhibitors. This article aims to summarise current knowledge on DILI epidemiology and risk factors.

METHODS

This review critically appraises available evidence on DILI frequency, outcomes and risk determinants, focusing on drug properties and non-genetic host factors that may influence susceptibility.

RESULTS

DILI incidence varies across populations, with hospitalised patients experiencing notably higher rates than outpatients or the general population. Increased medication use, particularly among older adults and women, may partly explain age- and sex-based disparities in DILI incidence and reporting. Physiological changes associated with aging likely increase susceptibility to DILI in older adults, though further exposure-based studies are needed for definitive conclusions. Current evidence does not strongly support that women are inherently more susceptible to DILI than men; rather, susceptibility appears to depend on specific drugs. However, once DILI occurs, older age and female sex are associated with greater severity and poorer outcomes. Other less-studied host-related risk factors are also discussed based on available evidence.

CONCLUSIONS

This article summarises existing data on DILI frequency, outcomes, drug properties affecting hepatotoxicity and non-genetic host risk factors while identifying critical knowledge gaps. Addressing these gaps through future research could enhance understanding and support preventive measures.

Adjunctive Therapy with Chinese Herbal Medicine Lowers Risk of Hearing Loss in Type 2 Diabetes Patients: Results from a Cohort-Based Case-Control Study

Hearing loss is a frequently observed complication of type 2 diabetes (T2D). Emerging evidence has found that Chinese herbal medicine (CHM) can effectively treat chronic disease; nevertheless, it is unclear if adding CHM to the routine management of T2D would modify sequent risk of hearing loss. This cohort-based case-control study was conducted to address this issue. First, a total of 64,418 subjects aged 20-70 years, diagnosed with T2D between 2002 and 2011, were extracted from a nationwide health claims database. Among them, we identified 4516 cases of hearing loss after T2D by the end of 2013. They were then randomly matched to 9032 controls without hearing loss at a 1:2 ratio. Following conditional logistic regression, we found the addition of CHM to conventional care reduced the risk of developing hearing loss, with an adjusted odds ratio of 0.75 (95% confidence interval: 0.70-0.83). Specifically, taking CHM products for at least two years benefits T2D patients in lowering sequent risk of hearing loss. The findings herein implicated that integrating CHM into conventional care substantially correlated to lower risk of hearing loss for T2D patients, but further basic research is needed to secure the application of finished herbal products.

New potential selective estrogen receptor modulators in traditional Chinese medicine for treating menopausal syndrome

Women go through several predictable conditions and symptoms during menopause that are caused by age, changes in sex hormone levels, and other factors. Conventional menopause hormone therapy has raised serious concerns about the increased risks of cancers, blood clots, depression, etc. Selective estrogen receptor modulators (SERMs) that can be both agonists and antagonists of estrogen receptors in a tissue-specific manner are being developed to reduce the health concerns associated with menopause hormone therapy. Here, we have searched the Chinese national traditional Chinese medicine (TCM) patent database to identify potential SERM-like compounds with reduced health risks. TCM has been widely used for treating complex symptoms associated with menopause syndrome and thus can be a particularly rich source for pharmaceutical alternatives with SERM properties. After extensive literature review and molecular simulation, we conclude that protopanaxatriol, paeoniflorin, astragalin, catalpol, and hyperoside among others may be particularly promising as SERM-like compounds in treating the menopausal syndrome. Compounds in TCM hold promise in yielding comparable outcomes to hormone therapy but with reduced associated risks, thus presenting promising avenues for their clinical applications.

Complementary Chinese Herbal Medicine Treatment is Associated with a Reduction of Surgical Rate in Patients with Dysfunctional Uterine Bleeding: A Propensity-Score Matched Cohort Study

Background

Many patients with dysfunctional uterine bleeding (DUB) seek traditional medicine consultations. This study intended to investigate the association of complementary Chinese herbal medicine (CHM) with the surgery rate in patients with DUB in Taiwan.

Methods

We enrolled 43,027 patients with newly diagnosed DUB (ICD-9-CM codes 626.8) from the National Health Insurance Research Database in Taiwan during the period of 1997 to 2010. Among them, 38,324 were CHM users, and 4703 did not receive CHM treatment. After performing a 1:1 propensity-score match based on patients' age (per 5 years), comorbidities, conventional drugs, childbirth status, duration from the diagnosis year of DUB and index year, there were an equal number (n=4642) of patients in the CHM cohort and non-CHM cohort. The outcome measurement was the comparison of incidences of surgical events, including hysterectomy and endometrial ablation, in the two cohorts before the end of 2013.

Results

CHM users had a lower incidence of surgery than non-CHM users (adjusted HR 0.27, 95% CI: 0.22-0.33). The cumulative incidence of surgery was significantly lower in the CHM cohort during the follow-up period (Log rank test, p < 0.001). A total of 146 patients in the CHM cohort (4.99 per 1000 person-years) and 485 patients in the non-CHM cohort (20.19 per 1000 person-years) received surgery (adjusted HR 0.27, 95% CI: 0.22-0.33). CHM also reduced the risk of surgery in DUB patients with or without comorbidities. Regardless of childbirth status or whether patients took NSAIDs, tranexamic acid or progesterone, fewer patients in the CHM cohort underwent surgery than in the non-CHM cohort. The most commonly prescribed single herb and formula were Yi-Mu-Cao (Herba Leonuri) and Jia-Wei-Xiao-Yao-San, respectively.

Conclusion

The real-world data revealed that CHM is associated with a reduced surgery rate in DUB patients. This information may be provided for further clinical investigations and policy-making.

Consumer characteristics and preferences for mobulid gill plates in China

Mobulid species are endangered globally, and the market trade for gill plates is believed to be a major threat. Successful conservation and the sustainable use of mobulids therefore require an objective understanding of consumer characteristics and preferences for gill plates. Previous studies focused on qualitative descriptions, and reliable quantitative analyses are currently lacking. We used a latent class choice experiment method and a semistructured questionnaire to provide important new quantitative information about gill plate consumer characteristics and the heterogeneous nature of demand for gill plates. From May to July 2019, we conducted a field study in Guangzhou, the primary consumption hub for mobulid gill plates in mainland China. Utilizing a simple random sampling method, we engaged in face-to-face interviews with 428 consumers of gill plates in the major trading markets in Guangzhou. Our results showed that 59.8% of consumers of gill plates were over 40 years old, 62.6% were female, 80.7% had annual household incomes of <200,000 yuan, and 84.5% recognized the medical and health value of gill plates and purchased them. About seventy-two percent of consumers preferred to purchase imported and less expensive gill plates from unprotected species, but they had a strong preference for large gill plates from protected species, such as Mobula birostris. This contradiction arose from consumers' lack of knowledge of mobulids and their conservation status. We found, for example, female consumers over 40 years old had the least understanding of conservation status of mobulid species and the link between size of gill plates and rarity of mobulids. This suggests there may be opportunities to promote mobulid conservation through education and marketing targeted at this demographic. Consumers who had a positive preference for gill plates from protected species (regardless of price) (10%) may be harder to influence. Overall, we believe education alone is not enough and that the conservation of mobulids would benefit from an integrated approach that involves conservation education and strengthened trade regulations, such as the introduction of traceability systems and a stiffer legal framework for consumption of protected species.

Decreased Risk of Osteoporosis Incident in Subjects Receiving Chinese Herbal Medicine for Sjögren syndrome Treatment: A Retrospective Cohort Study with a Nested Case-Control Analysis

Sjögren syndrome (SS) is a long-lasting inflammatory autoimmune disease that may cause diverse manifestations, particularly osteoporosis. Though usage of Chinese herbal medicine (CHM) can safely manage autoimmune disease and treatment-related symptoms, the relation between CHM use and osteoporosis risk in SS persons is not yet recognized. With that in mind, this population-level nested case-control study aimed to compare the risk of osteoporosis with and without CHM use. Potential subjects aged 20-70 years, diagnosed with SS between 2001 and 2010, were retrieved from a national health claims database. Those diagnosed with osteoporosis after SS were identified and randomly matched to those without osteoporosis. We capitalize on the conditional logistic regression to estimate osteoporosis risk following CHM use. A total of 1240 osteoporosis cases were detected and randomly matched to 1240 controls at a ratio of 1:1. Those receiving conventional care plus CHM had a substantially lower chance of osteoporosis than those without CHM. Prolonged use of CHM, especially for one year or more, markedly dwindled sequent osteoporosis risk by 71%. Integrating CHM into standard care may favor the improvement of bone function, but further well-designed randomized controlled trials to investigate the possible mechanism are needed.

Complementary acupuncture treatment and reduced risk of sudden sensorineural hearing loss in nasopharyngeal carcinoma patients: a retrospective, nested case-control study

PURPOSE

Hearing loss is a frequently observed comorbidity in patients with nasopharyngeal carcinoma (NPC). Accumulating evidence demonstrated that acupuncture can safely manage cancer and its treatment-related symptoms, but its effect in minimizing the likelihood of experiencing sudden sensorineural hearing loss (SSHL) has not been established. So this work aimed to determine the risk of SSHL among NPC persons with or without acupuncture use.

METHODS

One population-level, nested case-control design within a cohort study is employed. Relevant information on persons aged 20-80 years who were afflicted with NPC between 2000 and 2010 was extracted from a nationwide health claims database. From them, we identified the cases who had the first SSHL diagnosis occurring after NPC, and all of them were randomly matched to two controls without SSHL. Conditional logistic regression was employed to calculate odds ratios (OR) and its respective 95% confidence intervals (CI) for incident SSHL in relation to acupuncture treatment.

RESULTS

Eight hundred eleven SSHL cases were randomly matched to 1452 controls. Those receiving conventional care plus acupuncture use had a reduced adjusted OR of 0.39 (95% CI, 0.25-0.60) for SSHL. We further discovered that the longer usage of acupuncture remarkably correlated with reduction of SSHL risk in a dose-dependent manner.

CONCLUSIONS

Delineation of the benefit from integration of acupuncture into conventional care may be a reference in instituting more appropriate care for NPC subjects.

IMPLICATIONS FOR CANCER SURVIVORS

Patients living with NPC may benefit from a timely integration of acupuncture into routine care to lessen SSHL risk.

The long-term trend in utilization of traditional Chinese medicine and associated factors among older people in Taiwan

BACKGROUND

Both the size of the older population and the use of complementary and alternative medicine are increasing worldwide. This study evaluated the long-term trend in utilization of traditional Chinese medicine (TCM) and associated factors among older people in Taiwan.

METHODS

Using the database of population-based interview surveys, we evaluated the one-month prevalence of TCM use among 13,945 older people aged over 65 years from 2001-2017. The sociodemographic status and medical comorbidities of older people who did and did not use TCM were compared by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs) in the multiple logistic regressions.

RESULTS

The one-month prevalence of TCM use increased from 5.5% in 2001 to 9.1% in 2017 among older people in Taiwan. Overall, 7.3% of older people had used TCM within the previous month. People with a history of heart disease (OR 1.62, 95% CI 1.24-2.12), use of folk therapy (OR 3.16, 95% CI 2.00-4.99), and purchase of non-prescribed Chinese herbal medicine (OR 2.08, 95% CI 1.48-2.91) were more likely to use TCM than the comparison group. However, age ≥80 years (OR 0.48, 95% CI 0.31-0.72) and previous hospitalization (OR 0.59, 95% CI 0.41-0.85) were associated with the reduced use of TCM.

CONCLUSION

From 2001-2017, the use of TCM increased in the older population in Taiwan. The use of folk medicine and purchase of non-prescribed Chinese herbal medicine were significant predictors for the use of TCM.

Integrating Chinese Herbal Medicine into Conventional Care Was Related to Lower Risk of Sarcopenia Among Rheumatid Arthritis Patients: A Retrospective, Population-Based Study

Objective

Sarcopenia is a frequently observed comorbidity of rheumatoid arthritis (RA) due to the chronic activation of the innate immune system. Accumulating evidence has indicated that Chinese herbal medicine (CHM) safely suppresses proinflammatory pathways and controls inflammation-associated disease, but its effect in reducing the risk of developing sarcopenia among RA subjects has not been established. We conducted a population-level cohort study to compare the sarcopenia risk in patients with RA who use or do not use CHM.

Methods

Using claims from a nationwide insurance database, we recruited patients with newly diagnosed RA and without sarcopenia between 2002 and 2010. Propensity score matching was applied to randomly select sets of CHM users and non-CHM users to compare the sarcopenia risk until the end of 2013. The risk of new-onset sarcopenia was assessed using the Cox proportional hazards model.

Results

As compared to non-CHM users, those receiving CHM treatment had a lower incidence of sarcopenia (7.69 vs 9.83 per 1000 person-years). CHM was correlated with a decreased chance of sarcopenia after controlling for potential covariates. Notably, use of CHM for more than two years may diminish the risk of getting sarcopenia by about 47% when taken as prescribed. Prescriptions of several herbal formulae may benefit the reduction of sarcopenia risk, such as Yan-Hu-Suo, Bei-Mu, Da-Huang, Huang Qin, Ping-Wei-San (PWS), Shu-Jing-Huo-Xue-Tang (SJHXT) and Chuan-Xiong-Cha-Tiao-San (CXCTS).

Conclusion

This study produced new evidence as it is the first to show that the longer duration of CHM use was correlated to reduced risk of sarcopenia in a dose-dependent manner, implying that CHM treatment could be embraced as a routine care strategy for preventing sarcopenia.

Use of Chinese Herbal Medicine Was Related to Lower Risk of Osteoporotic Fracture in Sarcopenia Patients: Evidence from Population-Based Health Claims

Introduction

With population aging, sarcopenia and its accompanying risk of osteoporotic fracture has drawn increased attention. Nowadays, while Chinese herbal medicine (CHM) is often used as complementary therapy for many medical conditions, its effect against likelihood of osteoporotic fracture among sarcopenia subjects was not fully elucidated yet. We therefore conducted a population-level study to compare osteoporotic fracture risk for sarcopenia persons with or without CHM use.

Methods

Using the patient record from a nationwide insurance database, we recruited persons with newly diagnosed sarcopenia and simultaneously free of osteoporotic fracture between 2000 and 2010. Propensity score matching was then applied to randomly select sets of CHM users and non-CHM users. All of them were tracked until end of 2013 to measure the incidence and adjusted hazard ratios (HRs) for new new-onset fracture in multivariable Cox proportional hazards model.

Results

Compared to non-CHM users, the CHM users indeed had a lower incidence of osteoporotic fracture (121.22 vs 156.61 per 1000 person-years). Use of CHM correlated significantly with a lower fracture likelihood after adjusting for potential covariates, and those receiving CHM treatment for more than two years experienced a remarkably lower risk by 73%. Uses of several herbal formulae were correlated to reduced risk of osteoporotic fracture, such as Caulis Spatholobi, Xuduan, Duzhong, Danshen, Shu-Jing-Huo-Xue-Tang, Du-Huo-Ji-Sheng-Tang, Shao-Yao-Gan-Cao-Tang, and Shen-Tong-Zhu-Yu -Tang.

Conclusion

Our study depicted that cumulative CHM exposure was inversely associated with osteoporotic fracture risk in a duration-dependent manner, implying that CHM treatment may be embraced as routine care in preventing incident osteoporotic fracture.

Utilization patterns and prescription characteristics of traditional Chinese medicine among patients with irritable bowel syndrome in Taiwan

Background: Few studies have investigated traditional Chinese medicine (TCM) utilization patterns for irritable bowel syndrome (IBS), despite the potential benefits of exploring TCM utilization patterns in optimizing TCM management. This study aimed to evaluate TCM utilization patterns and clinical features for IBS patterns in Taiwan. Methods: This was a population-based cross-sectional study using claim data from the National Health Insurance Research Database between 2012 and 2018. Patients newly diagnosed with IBS and aged over 20 years were included. The TCM utilization patterns and characteristics, including Chinese herbal medicine (CHM) treatment types and prescription patterns, were evaluated. Results: A total of 73,306 patients newly diagnosed with IBS used TCM for IBS at least once. Females used TCM for IBS more than males (female-to-male ratio = 1.89: 1). The age distribution showed a peak at 30-39 years (27.29%), followed by 40-49 years (20.74%) and 20-29 years (20.71%). Patients who received Western medications for IBS had a lower tendency to seek TCM. CHM was the most commonly used TCM modality (98.22%), with Jia-wei-xiao-yao-san being the most commonly prescribed Chinese herbal formula and Bai-zhu being the most frequently prescribed single Chinese herb. Conclusion: This study enhances our understanding of TCM usage patterns for IBS, particularly CHM prescriptions. Further research is needed to investigate commonly used TCM formulas and individual herbs.

Who consumes curative care expenditure of medical institutions in Beijing: a case study based on System of Health Accounts 2011

BACKGROUND

China's health system is challenged by complex health problems experienced by different population groups and caused by multiple diseases. This study examined the distribution of curative care expenditure (CCE) of medical institutions in Beijing using beneficiary characteristics such as residency, gender, age, and disease. Suggestions are presented for the development of health policies.

METHODS

A total of 81 medical institutions with approximately 80 million patients in Beijing, China, were selected via a multistage stratified cluster random sampling approach. Based on this sample, the System of Health Accounts 2011 was used to estimate the CCE of medical institutions.

RESULTS

The CCE of medical institutions in Beijing was ¥246.93 billion in 2019. The consumption of patients from other provinces was ¥60.04 billion, accounting for 24.13% of the total CCE. The CCE of female consumption (52.01%/¥128.42 billion) exceeded that of male consumption (47.99%/¥118.51 billion). Almost half of the CCE (45.62%/¥112.64 billion) was consumed by patients aged 60 or above. Adolescent patients up to an age of 14 (including those aged 14) mainly chose secondary or tertiary hospitals for treatment. Chronic non-communicable diseases accounted for the largest share of CCE consumption, with circulatory diseases accounting for the highest proportion.

CONCLUSIONS

This study identified significant differences in CCE consumption in Beijing according to region, gender, age, and disease. Currently, the utilization of resources in medical institutions is not reasonable, and the hierarchical medical system is not sufficiently effective. Therefore, the government needs to optimize the allocation of resources according to the needs of different groups and rationalize the institutional process and functions.

Relationship between Chinese Herbal Medicine Use and Risk of Sjögren’s Syndrome in Patients with Rheumatoid Arthritis: A Retrospective, Population-Based, Nested Case-Control Study

Background and Objectives: Sjögren’s Syndrome (SS) is a common extra-articular feature among subjects with rheumatoid arthritis (RA). While Chinese herbal medicine (CHM) has been used to treat symptoms of RA for many years, few studies have examined its efficacy in guarding against the SS onset. This study aimed to compare risk of SS for RA patients with and without use of CHM. Materials and Methods: Data obtained for this nested case-control study were retrieved from Taiwanese nationwide insurance database from 2000–2013. Cases with SS claims were defined and matched to two randomly selected controls without SS from the recruited RA cohorts. Risk of SS in relation to CHM use was estimated by fitting multiple conditional logistic regression. Results: Patients aged between 20 and 80 years were included and 916 patients with incident SS were matched to 1832 non-SS controls by age, sex and index year. Among them, 28.1% and 48.4% cases ever received CHM therapy, respectively. After adjusting for baseline characteristics, CHM use was found to be related to a lower risk of SS among them (adjusted odds ratio = 0.40, 95% confidence interval: 0.34–0.47). A dose-dependent, reverse association, was further detected between the cumulative duration of CHM use and SS risk. Those receiving CHM therapy for more than 730 days showed a significantly reduced risk of SS by 83%. Conclusions: Findings of this study indicated that the add-on CHM formula, as part of RA care, may be a beneficial treatment for prevention against the incident SS.

Adding Chinese Herbal Medicine to Routine Care is Associated With a Lower Risk of Rheumatoid Arthritis Among Patients With Asthma: A Population-Based Retrospective Cohort Study

Objective: Due to the shared pathogenesis of asthma and rheumatoid arthritis (RA), patients with asthma were found to have a higher risk of RA. While the benefits and safety of Chinese herbal medicine (CHM) for asthma have been reported, the scientific evidence regarding its effect on RA is limited. This longitudinal cohort study aimed to determine the relation between CHM use and RA risk in patients with asthma.

Methods: Using the nationwide claims data, we enrolled 33,963 patients 20–80 years of age who were newly diagnosed with asthma and simultaneously free of RA between 2000 and 2007. From this sample, we utilized propensity score matching to create sets of participants as treatment and control groups, which comprised 13,440 CHM users and 13,440 non-CHM users. The incidence rate and hazard ratio (HR) for RA between the two groups were estimated at the end of 2013. A Cox proportional hazards model was constructed to examine the impact of the CHM use on the risk of RA.

Results: The cumulative incidence of RA was substantially lower in the CHM user group. In the follow-up period, 214 patients in the CHM user group (1.92 per 1,000 person-years) and 359 patients in the non-CHM user group (2.92 per 1,000 person-years) developed RA (adjusted HR = 0.63, 95% confidence interval: 0.54–0.75). Of the commonly-prescribed formulae, nine CHM products were associated with a lower RA risk: Xiao-Qing-Long-Tang, Ma-Xing-Gan-Shi-Tang, Ding-Chuan-Tang, Xin-Yi-Qing-Fei-Tang, Bei Mu, Jie Geng, Xing Ren, Da Huang, and San Chi.

Conclusion: This study found that patients with asthma who received CHM treatment, in addition to the conventional therapy, had a lower risk of RA. Use of CHM treatment may be integrated into conventional therapy to reduce subsequent RA risk among asthma patients.

Traditional and complementary medicine (TCM) usage and its association with Patient Assessment of Chronic Illness Care (PACIC) among individuals with metabolic syndrome in primary care

Background

Traditional and Complementary Medicine (TCM) is widely used particularly among patients with chronic diseases in primary care. However, evidence is lacking regarding TCM use among patients with Metabolic Syndrome (MetS) and its association with patients’ experience on chronic disease conventional care that they receive. Therefore, this study aims to determine the prevalence and pattern of TCM use, compare the patients’ experience of chronic disease care using the Patient Assessment of Chronic Illness Care - Malay version (PACIC-M) questionnaire between TCM users and non-users and determine the factors associated with TCM use among patients with MetS in primary care.

Methodology

A cross-sectional study was conducted at a university primary care clinic. Patients aged 18 to 80 years old with MetS were recruited. Socio-demographic characteristic, clinical characteristics and information on TCM use and its pattern were recorded in a proforma. Patient’s experience of chronic disease conventional care was measured using PACIC-M questionnaire. The comparison of PACIC-M mean score between TCM users and non-users was measured using independent t-test. The factors associated with TCM use were determined by simple logistic regression (SLogR), followed by multiple logistic regression (MLogR).

Results

Out of 394 participants, 381 (96.7%) were included in the final analysis. Of the 381 participants, 255 (66.9%) were TCM users (95% CI 62.7, 71.7). Only 36.9% of users disclosed about TCM use to their health care providers (HCP). The overall mean PACIC-M score was 2.91 (SD ± 0.04). TCM users had significantly higher mean PACIC-M score compared to non-users (2.98 ± 0.74 vs 2.75 ± 0.72, p = 0.01). The independent factors associated with TCM use were being female (Adj. OR 2.50, 95% CI 1.55, 4.06), having high education level (Adj. OR 2.16, 95% CI 1.37, 3.41) and having high overall PACIC-M mean score (Adj. OR 1.49, 95% CI 1.10, 2.03).

Conclusion

TCM use was highly prevalent in this primary care clinic. However, the disclosure rate of TCM use to HCP was low. Females, those with high education and high PACIC-M mean score were more likely to use TCM. Further research should explore the reasons for their TCM use, despite having good experience in conventional chronic disease care.

A Comparison of the Risk of Fracture in Rheumatoid Arthritis Patients with and without Receiving Chinese Herbal Medicine

Objective

Patients with rheumatoid arthritis (RA) often suffer from bone complications due to persistent joint inflammation, especially incident fracture. Nowadays, Chinese herbal medicines (CHMs) have provided safe and effective therapy for treating skeletal conditions, but it is unclear whether CHMs can prevent fracture onset among RA individuals. This study aimed to determine the association between the use of CHMs and the risk of fracture among them.

Methods

This retrospective, population-based study retrieved administrative health data from the Taiwan National Health Insurance (NHI) database to identify patients with newly diagnosed RA between 2000 and 2009. Of the 6178 incident RA patients, 2495 matched pairs of CHMs users and non-CHMs users were identified by propensity score matching. Enrollees with hip fractures prior to RA onset were excluded. Included subjects were followed until the end of 2013. Incidence and adjusted hazard ratios (HR) of new-onset bone fracture in the multivariable Cox proportional hazard model were measured with 95% confidence interval (CI).

Results

Fracture incidence was lower in CHMs users than in the comparison cohort (26.91 vs 32.94 per 1000 person-years, respectively), with an adjusted HR of 0.82 (95% CI: 0.73-0.92). Subjects receiving CHMs for more than 2 years had a much lower risk of fracture onset by more than 50%. Some CHMs prescriptions (Yan Hu Suo, Bei Mu, Da Huang, Dang Shen, Fu-Zi, Shu-Jing-Huo-Xue-Tang, Dang-Gui-Nian-Tong-Tang, Jia-Wei-Xiao-Yao-San, Gan-Lu-Yin, and Gui-Zhi-Shao-Yao-Zhi-Mu-Tang) were associated with reduced fracture risk.

Conclusion

Adding CHMs to routine treatment was found to be related to lower fracture risk in RA patients.

A system for reporting and evaluating adverse drug reactions of herbal medicine in Taiwan from 1998 to 2016

The Taiwan Adverse Drug Reaction Reporting System for Herbal Medicine (TADRRS-HM) has systematically documented suspected adverse events from adverse drug reaction (ADR) reports from 1998 (prior to its formal establishment in 2001) and evaluates safety profiles of herbal medicines. This article describes findings from 2079 ADR reports filed between 1998 and 2016: 941 reports involved single herbs and 87 involved folk herbals; 842 were generated from clinical trials, while 209 ADR reports involving foods, health foods, dietary supplement foods and herbal cuisine were grouped as Other. Severity assessments using the Modified Hartwig and Siegel scale classified 72.4% of ADRs as mild, 17.4% as moderate and 6.5% as severe. System Organ Class classification of the ADRs identified gastrointestinal system disorders as the most common (33.4%), followed by skin and subcutaneous tissue disorders (21.2%). The TADRRS-HM records indicate that herbal medicines may cause a wide range of ADRs. Aconiti Radix, Xiao-Qing-Long-Tang, and Datura suaveolens were the most commonly reported single herb, herbal formula, and folk herbal, respectively. The data indicate that herbal medicines may cause a wide range of ADRs. This system will confer long-term benefits for the development of Taiwan’s herbal medicines adverse reaction database and facilitate epidemiological analysis.

Adding Pay-for-Performance Program to Routine Care Was Related to a Lower Risk of Depression Among Type 2 Diabetes Patients in Taiwan

Background: Patients with type 2 diabetes (T2DM) often experience depression during treatment, negatively influencing their treatment compliance and clinical outcomes. Recently, the pay-for-performance (P4P) program for chronic diseases, with high-cost and high-risk feature, such as T2DM, has been implemented and has been operational for several years. Nevertheless, its effect on the risk of developing depression among T2DM cases is unknown. This study aims to explore the association of P4P use with the subsequent risk of developing depression among these patients. Methods: This cohort study used a nationwide health insurance database to identify patients 20-70 years of age newly diagnosed with T2DM who enrolled in the P4P program between 2001 and 2010. From this group, we enrolled 17,022 P4P users and then 17,022 non-P4P users who were randomly selected using propensity-score-matching. Enrolled patients were followed until the end of 2012 to record the occurrence of depression. The Cox proportional hazards regression was utilized to obtain the adjusted hazard ratio (aHR) for P4P use. Results: During the study period, a total of 588 P4P users and 1,075 non-P4P users developed depression at incidence rates of 5.89 and 8.41 per 1,000 person-years, respectively. P4P users had a lower depression risk than did non-P4P users (aHR, 0.73; 95% Confidence Interval, 0.65-0.80). This positive effect was particularly prominent in those receiving high-intensity use of the P4P program. Conclusion: Integrating P4P into routine care for patients with T2DM may have beneficial effects on curtailing the subsequent risk of depression.

Chinese Herbal Medicine to Reduce Radiation-Induced Oral Mucositis in Head and Neck Cancer Patients: Evidence From Population-Based Health Claims

BACKGROUND

Subjects with head and neck cancer (HNC) often experience post-treatment side effects, particularly radiation-induced oral mucositis (RIOM). This study aimed to explore the association of Chinese herbal medicine use with the sequent risk of RIOM among them.

METHODS

This cohort study used a nationwide health insurance database to identify subjects newly diagnosed with HNC, aged 20 to 60 years, who received treatment between 2000 and 2007. Among them, a total of 561 cases received CHM after HNC onset (CHM users); the remaining 2395 cases were non-CHM users. All patients were followed to the end of 2012 to identify any treatment for RIOM as the end point. Cox proportional hazards regression was used to compute the adjusted hazard ratio (aHR) of RIOM by CHM use.

RESULTS

During the follow-up period, 183 CHM users and 989 non-CHM users developed RIOM at incidence rates of 40.98 and 57.91 per 1000 person-years, respectively. CHM users had a lower RIOM risk than the non-CHM users (aHR: 0.68; 95% Confidence Interval: 0.58-0.80). The most potent effect was observed in those taking CHM for more than 1 year. Use of Baizhi, Danshen, Shao-Yao-Gan-Cao-Tang, Gan-Lu-Yin, Huangqin, Shu-Jing-Huo-Xue-Tang, and Xin-Yi-Qing-Fei-Tang, was significantly related to a lower risk of RIOM.

CONCLUSION

Findings of this study indicated that adding CHM to conventional clinical care could be helpful in protecting those with HNC against the onset of RIOM. Further clinical and mechanistic studies are warranted.

Effect of Chinese Herbal Medicines on Hearing Loss Risk in Rheumatoid Arthritis Patients: Retrospective Claims Analysis

Objectives: Patients with rheumatoid arthritis (RA) are at a higher risk of extra-articular manifestations, especially hearing loss (HL). Although Chinese herbal medicines (CHM) are proven safe and effective treatments for inflammatory conditions, the effect of CHM use on HL in RA patients is unknown. This cohort study aims to determine the relationship between CHM use and the subsequent risk of HL among RA patients. Methods: From health insurance claims data in Taiwan, a total of 6,905 persons aged 20-80 years with newly-diagnosed RA in 2000-2009 were identified. Of these, we recruited 2,765 CHM users and randomly selected 2,765 non-CHM users who matched with the users by the propensity score. Both cohorts were followed up until the end of 2012 to estimate the incidence of HL. Cox proportional hazards regression was used to estimate the adjusted hazard ratio (HR) for HL. Results: The incidence of HL was lower in the CHM users than in the comparison cohort (8.06 vs. 10.54 per 1,000 person-years) (adjusted HR, 0.77; 95% CI, 0.63-0.94). Those who received CHM for more than 2 years had the greatest benefit against the onset of HL, with over 50% risk reduction. Prescriptions of Hai Piao Xiao, Yan Hu Suo, San-Qi, Huang Qin, Dang Shen, Jia-Wei-Xiao-Yao-San, Shu-Jing-Huo-Xue-Tang, and Dang-Gui-Nian-Tong-Tang were found to be associated with a reduced risk of HL. Conclusions: Our findings suggest that adding CHM to conventional therapy may reduce the subsequent risk of HL in RA patients. Prospective randomized trials are recommended to further clarify whether the association revealed in this study supports such a causal relationship.

The Chang Gung Research Database: Multi-institutional real-world data source for traditional Chinese medicine in Taiwan

BACKGROUND

The Chang Gung Research Database (CGRD), the largest multi-institutional electronic medical records collection in Taiwan, has been used to establish real-world evidence related to traditional Chinese medicine (TCM). We aimed to evaluate patient characteristics and representativeness of TCM patients in CGRD.

METHODS

We identified a cohort of patients who had TCM records both from CGRD and from Taiwan's National Health Insurance Database (NHIRD) during 2010-2015 to investigate the representativeness of CGRD for TCM uses. The NHIRD was considered as reference because it covers all medical claims from 99.9% of the entire Taiwanese population. We investigated the coverage rates of TCM patients within CGRD compared to NHIRD, and compared the characteristics of patients between CGRD and NHIRD including age, sex, and 15 health conditions.

RESULTS

We identified 71 002 average annual patients within the CGRD, which accounted for 1.1% of the patients from the NHIRD. The patients from CGRD were older than those from NHIRD (≥65: 16.6% vs. 9.9% for CGRD vs. NHIRD). The ratios of female over male patients were 1.7 vs. 1.5 for CGRD vs. NHIRD. We found higher patient coverage rates for patients with major comorbidities in CGRD, specifically for neoplasm (9.2%) and mental disorders (6.0%). The most frequently prescribed Chinese herbal medicines in CGRD included Jia-Wei-Xiao-Yao-San, Xiang-Sha-Liu-Jun-Zi-Tang and Gui-Lu-Er-Xian-Jiao.

CONCLUSION

Higher patient coverage rates were found in CGRD for TCM patients with major comorbidities. Investigators should note possible selection bias since TCM patient disorders may be more severe in CGRD than in the NHIRD.

Risk of diabetes in stroke patients who used Bu Yang Huan Wu Tang: A nationwide propensity-score matched study

BACKGROUND

The utilization of traditional Chinese medicine is a common therapeutic approach for stroke patients in Chinese population, but little is known about the effect of Bu Yang Huan Wu Tang (BYHWT) on post-stroke diabetes.

PURPOSE

We aimed to evaluate the risk of diabetes in stroke patients who used BYHWT.

STUDY DESIGN

A retrospective cohort study based on a real-world database was conducted.

METHODS

Newly diagnosed stroke patients receiving inpatient care from 2000 to 2004 were identified using a large-scale insurance database in Taiwan. Propensity score matching was used to select eligible stroke patients who did (n = 9849) and did not (n = 9849) receive BYHWT. These two groups were followed up until the end of 2009 to track incident diabetes. Cox proportional hazard models were used to calculate the adjusted hazard rations (HRs) and 95% confidence intervals (CIs) for post-stroke diabetes associated with BYHWT during the follow-up period.

RESULTS

Stroke patients who used BYHWT had a reduced incidence of diabetes (14.1% vs. 19.0%, p < 0.0001) and reduced risk of diabetes (HR 0.77; 95% CI 0.72 to 0.83) compared with the control group. The association between BYHWT and reduced risk of post-stroke diabetes was significant across sexe, age group, and stroke subtype. Additionally, the use of BYHWT was associated with a reduced risk of post-stroke diabetes even after excluding the initial three months of diabetes cases in the sensitivity analysis.

CONCLUSIONS

Stroke patients who received BYHWT therapy had a reduced risk of diabetes, and a positive effect was observed in various subgroups. However, future clinical trials will be necessary to validate the present findings and identify the biochemical mechanism involved.

Decreased Risk of Dementia Among Patients With Traumatic Brain Injury Receiving Acupuncture Treatment: A Population-Based Retrospective Cohort Study

OBJECTIVE

We conducted a longitudinal cohort study comparing the effect of acupuncture on the risk of dementia in Taiwanese individuals with traumatic brain injury (TBI).

DESIGN AND PARTICIPANTS

A national health insurance database was used to identify 15 440 newly diagnosed TBI patients 20 to 70 years old between 1998 and 2007. Of the identified patients, 6308 received acupuncture following the onset of TBI (acupuncture users) and 9132 patients did not receive acupuncture (nonacupuncture users).

MEASURES

All enrollees were followed until the end of 2012 to record incident cases of dementia. A Cox proportional hazards regression model was used to compute adjusted hazard ratios for the relationship of acupuncture use with dementia.

RESULTS

During the follow-up period, 249 acupuncture users and 810 nonacupuncture users developed dementia, corresponding to incidence rates of 6.11 and 9.64 per 1000 person-years, respectively. Use of acupuncture was significantly associated with a lower risk of dementia. Those who received more than 5 sessions of acupuncture benefited most from it.

CONCLUSIONS

Adding acupuncture to the clinical management of patients with TBI may benefit these patients by decreasing their risk of developing dementia.

HIV Vaccine Preparedness among Men Who Have Sex with Men in Taiwan: Sociocultural and Behavioral Factors

In Taiwan, men who have sex with men (MSM) are at disproportionate risk of HIV infection. We examined awareness and acceptability of future HIV vaccines. From July to August 2014, we conducted a cross-sectional survey with MSM recruited through community-based organizations (CBOs) in 2 cities. Among 200 participants (mean age, 27.6 years), half reported multiple partners and one-third condomless anal sex (past 3 months); 12% were HIV-positive. Traditional Chinese medicine (TCM) use was reported by 42.7%. Over two-thirds (69.0%) were aware of HIV vaccine research, but less than half (43.8%) would accept an HIV vaccine if available. In multivariable analysis, higher educational attainment, >5 sex partners, and TCM use were positively associated with HIV vaccine awareness. Culturally informed HIV vaccine preparedness in Taiwan may be supported by a complementary approach to TCM and HIV prevention technologies, tailoring information for MSM with lower education and targeting those at high risk through gay-identified CBOs.

Belief in and use of traditional Chinese medicine in Shanghai older adults: a cross-sectional study

Background

Traditional medicine is broadly used across Asian societies for various medical conditions and health concerns. However, there remains a wide disparity between users and non-use, which makes it imperative to understand the factors affecting the lay perception and utilization of traditional medicine. This study systematically examined the demographic, medical, and socioeconomic factors affecting belief in and use of traditional medicine among older adults of Shanghai, China.

Methods

We used the data from Survey of Life and Opinion on Shanghai Older Adults in 2013 with a sample of 3418 older adults aged 50 years or older. The multilevel logistic models were applied to examine the associations between faith and utilization of traditional medicine and a set of factors of the respondents, including demographics (gender, age, rural/urban residence), socioeconomic status (educational attainment, income, primary occupation), social support (marital status, social network), and disease/conditions. The associations between individual use of traditional medicine and the profile of socioeconomic development and the medical services conditions of local communities were also modelled.

Results

We found that cardiovascular diseases, lung diseases, cancer, prostatitis, arthritis, and nervous system diseases were positive correlates for using traditional medicine. Older adults who had a cancer, a prostatitis, or a fracture had more faith in traditional treatment. Rural living, higher educational attainment, and white-collar occupation promoted the use of traditional medicine. A higher number of strong social ties and a tie connected with medical staff were positive factors of use as well.

Conclusion

The belief in and use of traditional medicine were prevalent among older adults in Shanghai, China. Though not conclusive, our study suggested that traditional medicine in China appears to serve two distinct functions, namely complementary medicine for those socioeconomically advantaged whereas alternative medicine for those socioeconomically disadvantaged.

The risk of coronary artery disease in patients with rheumatoid arthritis using Chinese herbal products and conventional medicine in parallel: a population-based cohort study

Background

Few studies have evaluated the association between the risk of coronary artery disease (CAD) and the use of Chinese herbal products (CHP) in patients with rheumatoid arthritis (RA). This study investigated the risk of CAD among patients with RA using CHP in combination with conventional medicine.

Methods

A retrospective cohort study was conducted using the Taiwan National Insurance Research Database to assess 22,353 patients who had been newly diagnosed with RA between 1997 and 2010. Patients were assigned to the CHP group or non-CHP group according to their use or nonuse of CHP after being diagnosed with RA. The Cox proportional hazards model was used to estimate the hazard ratio (HR) of CAD for a 1:1 matched sample.

Results

Both the CHP and non-CHP groups comprised 4889 patients after 1:1 matching. The risk of CAD was significantly reduced in the CHP group [adjusted HR (aHR): 0.59, 95% confidence interval (CI): 0.50–0.71] compard with the non-CHP group. Those who used CHP for > 180 days had an even lower risk of CAD than users with CHP usage less than 30 days (aHR: 0.64, 95% CI: 0.43–0.95). Additionally, frequently prescribed formulae, such as Kuei-Chih-Shao-Yao-Chih-Mu-Tang, Tang-Kuei-Nien-Tung-Tang, and Shu-Ching-Huo-Hsieh-Tang, were associated with a reduced risk of CAD.

Conclusion

The use of CHP was associated with a lower risk of CAD in patients with RA. Additional randomized controlled trials are required to assess any causal relationship between the effect of CHP usage and the risk of CAD.

Association of Chinese Herbal Medicines Use with Development of Chronic Obstructive Pulmonary Disease Among Patients with Rheumatoid Arthritis: A Population-Based Cohort Study

Purpose

Rheumatoid arthritis (RA) patients appear to report a higher risk of chronic obstructive pulmonary disease (COPD). While Chinese herbal medicine (CHMs) is proven to lower COPD risk, the scientific evidence regarding its effect in relation to COPD onset among them is limited. This longitudinal cohort study aimed to determine the relationship between CHMs use and the COPD risk in RA patients.

Methods

Using the nationwide claim data, 8349 patients newly diagnosed with RA and simultaneously free of COPD between 1998 and 2010 were eligible for enrollment. From this sample, we enrolled 3360 CHMs users and 3360 non-CHMs users, randomly selected using propensity scores matching from the remaining cases. They were followed until the end of 2012 to record COPD incidence. The hazard ratio (HR) of COPD with regard to CHMs use was estimated by the Cox proportional hazards regression model.

Results

In the follow-up period, 136 CHMs users and 202 non-CHMs users developed COPD, representing incidence rates of 5.16 and 7.66, respectively, per 1000 person-years. CHMs use was associated with a 32% lower subsequent risk of COPD (adjusted HR: 0.68, 95% Confidence Interval: 0.54–0.84). Eight commonly prescribed CHMs were discovered to be associated with lower COPD risk: Yan Hu Suo, Sānɡ Zhī, Dang Shen, Huang Qin, Jia-Wei-Xiao-Yao-San, Shu-Jing-Huo-Xue-Tang, Du-Huo-Ji-Sheng-Tang and Ge-Gen-Tang.

Conclusion

A significant association of CHMs use with a lower risk of COPD onset in RA patients was found, suggesting that CHMs could be integrated into conventional therapy to reduce COPD risk.

Regulation effect and mechanism of Sheng-Hua-Tang on female reproductive system: From experimental transcriptomic analysis to clinical applications

ETHNOPHARMACOLOGICAL RELEVANCE

Sheng-Hua-Tang (SHT) is commonly used to treat female illnesses, especially postpartum conditioning. However, its effects and mechanisms on female reproductive system remain unclear. The aim of the present study was to investigate the effect of SHT on female brain-ovary-uterus axis from bench to clinic.

MATERIALS AND METHODS

Mice were administrated SHT (200 mg/kg) orally for seven consecutive days. Brain, ovary, and uterus tissues were then collected for microarray analysis. A nationwide database analysis and a pilot randomized, open-label clinical trial were further applied to evaluate the clinical application and effects of SHT on postpartum women.

RESULTS

Microarray analysis showed that oral administration of SHT induced a cascade reaction of gene expression, with 17, 883, and 1592 genes were significantly regulated by SHT in brain, ovary, and uterus, respectively. Population-based analysis of one million subjects in Taiwan's National Health Insurance Research Database between 1997 and 2013 showed that SHT was commonly used in menstrual disorders in female population, especially dysmenorrhea, abnormal uterine bleeding, and variation of menstrual cycle. Clinical trial on postpartum women showed that oral administration SHT for one week alleviated uterine contraction pain and breast swelling pain. Furthermore, Mmp2, Mmp3, Mmp9, Mmp11, Mmp15, Oxtr, Plrl, and Tph2 gene expression affected by SHT in mice were correlated with clinical effects of SHT in human subjects.

CONCLUSION

This report provided the scientific evidences of mechanisms and clinical efficacies of SHT. Moreover, our findings might afford insights for clinical doctors in terms of SHT prescription.

Herbal medicine from the perspective of type II diabetic patients and physicians: what is the relationship?

Background

Diabetes mellitus (DM) is a major public health problem and one of the most challenging diseases worldwide. According to the World Health Organization (WHO), the Kingdom of Saudi Arabia (KSA) has the second highest rate of diabetes in the Middle East and seventh highest globally. Some diabetic patients may prefer to use alternative approaches such as herbal remedies to control their blood glucose level and this study aims to assess the prevalence of herbal usage and to evaluate users’ and doctors’ knowledge, attitudes and beliefs about herbal medicine as well as the patient/doctor relationship in this regard.

Method

A cross-sectional survey was conducted in several hospitals and medical centres in Makkah, KSA, between January and March 2019. Around 289 type II diabetic patients and 105 doctors were interviewed.

Results

We found that 68% of the participants were frequent consumers of herbal remedies, especially cinnamon, ginger and fenugreek. Patients’ knowledge of herbal usage was mainly gleaned from family and friends as well as social media, and we found that many (71.4%) did not bother to consult or inform their doctors about their choice to self-medicate with herbs. Patients had no concerns regarding the efficacy and safety of herbal usage use in diabetes, as around half of the participants believe that herbal medicine is effective (54%) and safe (46%) for treating symptoms of diabetes. Two-thirds of the doctors (66%) routinely ask patients whether they use herbs for their condition. Although 25% of the doctors took a positive view of herbal medicine in relation to diabetes, others expressed concerns with the rise in herb use and want to see more attention paid to safety aspects.

Conclusion

The study concludes that herbal remedies are commonly used by diabetic patients and that a gap exists in the relationship between patients and doctors concerning the disclosure of herbal remedy use and views on its safety.

Trends in the utilization of acupuncture among children in Taiwan from 2002 to 2011: a nationwide population-based study

BACKGROUND

In recent years, acupuncture has been increasingly integrated into pediatric care worldwide. However, recent epidemiological studies about pediatric users of acupuncture are lacking. The current study aimed to fill the gap and carry out the large-scale investigation on the basis of the pediatric population in Taiwan.

METHODS

We conducted a nationwide population-based study to investigate the utilization of acupuncture in Taiwan. We analyzed data from the Longitudinal Health Insurance Database 2000 (LHID 2000). The datasets contained all original claims data for 1 million beneficiaries who were randomly sampled from the registry of all beneficiaries enrolled in the Taiwan's National Health Insurance Program from January 1, 2000 to December 31, 2011. Children younger than 18 years old were enrolled into our study for analysis. The demographic data, treatment modalities and distributions by disease categories of the pediatric acupuncture users were analyzed by descriptive statistics. Logistic regression analysis was used to investigate the trends in acupuncture use over time.

RESULTS

The one-year prevalence of pediatric acupuncture users increased from 1.78% in 2002 to 5.34% in 2011. Acupuncture use significantly increased each year (p-value< 0.0001). Patients who were male, of greater age, resided in highly urbanized areas and suffered from injury or disorders of the musculoskeletal system were more likely to accept acupuncture treatment. Infantile cerebral palsy and psychoses were the top two health issues among those receiving complex acupuncture treatment. Older (> 9 years old) children tended to receive acupuncture treatment due to injury and musculoskeletal system disorders more than younger (≤9 years old) children.

CONCLUSIONS

Our study revealed that the utilization of acupuncture in pediatrics became increasingly popular year by year in Taiwan from 2002 to 2011. The results of this study may provide some valuable information for further clinical practice and acupuncture research, as well as to the government and societies concerning pediatric health care.

The impact of uncertainty in society on the use of traditional, complementary and alternative medicine: a comparative study on visits to alternative/traditional/folk health care practitioners

Background

While traditional, complementary and alternative medicine (TCAM) is gaining increased interest worldwide, the structural factors associated with the usage of TCAM at the social level have not been sufficiently explored. We aim to understand the social structure of uncertainty in society that affects the TCAM usage for men and women.

Methods

We studied 32 countries using data from the International Social Survey Programme and the World Bank. In this study, we defined TCAM usage as visits to an alternative/traditional/folk health care practitioner during the past 12 months. We performed a correlation analysis and used a generalized linear model .

Results

The prevalence of TCAM usage in terms of visits to practitioners was 26.1% globally, while usage varied across the 32 countries. Generalized linear models showed that unemployment rate was associated with the prevalence of TCAM usage in terms of visits to practitioners.

Conclusions

At the social-structural level TCAM usage involving visits to practitioners was related to job insecurity. Job insecurity led to a decrease in TCAM usage regarding visits to practitioners. These findings suggest that it is necessary to consider the social-structural factors of uncertainty in society when designing health policies related to TCAM.

Electronic supplementary material

The online version of this article (10.1186/s12906-019-2662-x) contains supplementary material, which is available to authorized users.

Utilization of Traditional Chinese Medicine Practitioners in Later Life in Mainland China

Mainland China is one of the world's most rapidly aging countries, and yet there is very limited literature on traditional Chinese medicine (TCM) use in older individuals. This study aimed to determine the national and provincial prevalence of TCM practitioner utilization in later life and associated factors. We used World Health Organization China Study on Global Aging and Adult Health Wave 1 data to determine descriptive statistics of the study population of participants aged 50 years and over. Multivariate logistic regression was conducted controlling for sociodemographic and health factors. A total of 14% of participants utilized a TCM practitioner, and the prevalence of utilization varied significantly by locality. Utilization was more likely in participants living in rural areas [adjusted odds ratio (OR) = 12.96; p < 0.001], Hubei (OR = 7.17; p < 0.001), or Shandong provinces (OR = 4.21; p < 0.001) and being diagnosed with chronic lung disease (OR = 1.97; p = 0.005). Hence, rurality, provincial influence, and chronic lung diseases are significant factors associated with TCM practitioner utilization among older individuals in China. These findings may inform policy for preservation and development of TCM nationally as well as its sustainability in an increasingly aging society.

The Influence of Standardized Residency Training on Trainees' Willingness to Become a Doctor: A Comparison between Traditional Chinese Medicine and Western Medicine

A standardized residency training program (SRT) was launched in Shanghai in 2010, for both Western Medicine (WM) and Traditional Chinese Medicine (TCM). This study aimed to assess whether the program impacted trainees' willingness to become a doctor and whether the program had different effects among WM and TCM trainees. A structured questionnaire was distributed to 2114 trainees to assess their perceptions and satisfaction with the program and their willingness to become a doctor after the exposure to the program. The trainees' characteristics were compared between WM and TCM specialties using X² tests. The potential factors associated with trainees' perception of the program and willingness to become a doctor after the exposure to the SRT program were assessed by multiple linear and logistic regression models. Compared to WM trainees (n = 1853), TCM trainees (n = 261) would be more likely to become doctors if there were no SRT program (p = 0.003). Both individual and program-wide (different specialties) factors contributed to trainees' perception, overall satisfaction, and willingness. Only specialty played an independent role in the associations with all three outcome variables. Inequality of characteristics between TCM and WM trainees reduced TCM trainees' willingness to become a doctor after the exposure to the SRT program.

Use of Chinese herbal medicines by rheumatoid arthritis patients was associated with lower risk of stroke: A retrospective cohort study

BACKGROUND AND PURPOSE

Rheumatoid arthritis (RA) patients have increased risk of developing stroke. The use Chinese herbal medicines (CHMs) is increasing, but whether they can reduce the risk of developing stroke remains unclear. We conducted a longitudinal cohort study to compare the effect of CHMs use on the subsequent stroke risk in RA individuals.

MATERIALS AND METHODS

Using claims data from the National Health Insurance of Taiwan, we identified 7925 newly-diagnosed RA patients with no history of previous stroke who were 20 years of age or older between 1998 and 2010. From this sample, we enrolled 3134 CHMs users and 3134 non-CHMs users, randomly selected using propensity scores matching from the remaining cases. They were followed until the end of 2012 to record stroke incidence. A Cox proportional hazards regression model was used to compute the hazard ratio of stroke with regard to CHMs use.

RESULTS

During the follow-up, 299 CHMs users and 395 non-CHMs users developed stroke, representing incidence rates of 10.94 and 16.69, respectively, per 1000 person-years. CHMs use was associated with 38% (adjusted HR: 0.62; 95% confidence interval: 0.54-0.73) lower subsequent risk of stroke. The most prominent effect was observed in those receiving CHMs for over two years. The following seven commonly-prescribed CHMs were found to lessen the stroke risk: Dan-Shen, Tian-Hua-Feng, Fu-Zi, Shao-Yao-Gan-Cao-Tang, Jia-Wei-Xiao-Yao-San, Ge-Gen-Tang, and Gui-Zhi-Shao-Yao-Zhi-Mu-Tang.

CONCLUSION

The CHMs use was associated with lower risk of stroke for RA patients, suggesting that it could be integrated into conventional therapy to prevent subsequent stroke incident.

Association between use of Chinese herbal medicine and depression risk in patients with rheumatoid arthritis: A nationwide retrospective cohort study

AIM

Depression is a common mental disorder in rheumatoid arthritis (RA) patients and may provoke the onset of poor clinical prognoses. In view of this, whether or not the use of Chinese herbal medicines (CHMs) can alleviate the risk of depression still remains unclear. We conducted a longitudinal cohort study to evaluate the association between CHMs us and depression risk among RA patients.

METHOD

Using claims data from the National Health Insurance of Taiwan, we identified 6609 newly diagnosed RA patients aged 20 years or older between 1998 and 2010. From this sample, we recruited 3386 CHM users and randomly selected 3223 controls using propensity scores matching from the remaining cases as the non-CHMs users. They were followed until the end of 2012 to record depression incidence. A Cox proportional hazards regression model was used to compute the hazard ratio (HR) of depression with regard to the use of CHMs.

RESULTS

During the 15-year follow-up, 249 CHM users and 314 non-CHM users developed depression, representing an incidence rate of 9.33 and 14.98, respectively, per 1000 person-years. We found that use of CHMs was associated with lower risk of depression by 38% (95% confidence interval 0.54-0.76). The most predominant effect was observed in those receiving CHMs for over 2 years (adjusted HR 0.34). Seven commonly prescribed CHMs could lessen the risk of depression: Chuan-niu-xi, Jie-geng, San-qi, Jia-wei-xia-yao-san, Dang-gui-nian-tong-tang, Zhi-gan-cao-tang, and Suan-zao-ren-tang.

CONCLUSION

This study supports that adding CHMs into conventional therapy may prevent subsequent depression risk for RA patients.

Association of use of Chinese herbal medicines and the risk of fracture in patients with osteoporosis: a population-based cohort study

After utilizing a large population-based claims database and the application of propensity score match approach to reduce the confounding effects, we found that the use of Chinese herbal medicines (CHMs) was related to the lower risk of sequent osteoporotic fracture by 27% among the individuals with osteoporosis. The predominant effect was observed in those receiving CHMs for more than two years.

INTRODUCTION

Osteoporosis (OS) is a highly disabling condition that can lead to fragility fracture, thus posing greater burdens of functional limitations for the affected individuals. It is unclear if the use of Chinese herbal medicines (CHMs) could reduce the risk of fracture due to OS. This study aimed to investigate the association of CHMs and the subsequent osteoporotic fracture risk among OS patients.

METHODS

This longitudinal cohort study used the Taiwanese National Health Insurance Research Database to identify 250,699 newly diagnosed OS patients aged 20 years or older between 1998 and 2010. We recruited 103,325 CHM users following the onset of OS (CHM users) and randomly selected 103,325 subjects without CHM usage as controls (non-CHM users) by propensity score matching according to the demographic characteristics and comorbidities at enrollment. All enrollees were followed until the end of 2012 to record the incidence of osteoporotic fracture. We applied the Cox proportional hazard regression model to compute the hazard ratio (HR) of the risk of osteoporotic fracture.

RESULTS

During the 15-year follow-up period, 7208 CHM users and 11,453 non-CHM users sustained osteoporotic fracture, with an incidence rate of 9.26 and 12.96, respectively, per 1000 person-years. We found that CHM users had a significantly reduced risk of osteoporotic fracture compared to non-CHM users (adjusted HR 0.73; 95% confidence interval [CI] = 0.70-0.75). Those treated with CHMs for longer than 730 days had a lower fracture risk by 54%. Some commonly used CHMs, such as Yan hu suo (Rhizoma Corydalis), Huang Qin (Scutellaria Baicale), Jie Geng (Platycodon grandifloras), Xiang Fu (Cyperus rotundus), Hai Piao Xiao (Cuttlebone Sepium), Jia-Wei-Xiao-Yao-San, Ge-Gen-Tang, Shao-Yao-Gan-Cao-Tang, and Du-Huo-Ji-Sheng-Tang, are related to the lower risk of fracture.

CONCLUSIONS

The use of CHMs was associated with lower risk of osteoporotic fracture for OS patients, suggesting that it could be integrated into conventional therapy to prevent subsequent bone fracture.

The characteristics and prescription patterns of Chinese herbal medicine in clinical practice for the treatment of anemia

OBJECTIVE

Chinese herbal medicine (CHM) is frequently applied to patients to improve the symptoms and signs associated with anemia. The aim of this study is to use the claims data from the National Health Insurance Research Database (NHIRD) in Taiwan to analyze CHM prescription patterns and to identify the frequency and combinations of CHM commonly used to treat anemia.

MATERIALS AND METHODS

A total of 41,028 patients were diagnosed with anemia in Taiwan within the defined study period. After randomly equal matching for age and sex, data from 7682 patients characterized as CHM users and non-users were analyzed. Network analyses of the 30 most frequently applied herbs and formulas were used to indicate CHM combinations in patients with anemia.

RESULTS

Those patients with anemia who were older, office workers, and lived in central areas of Taiwan had higher tendencies toward CHM usage. Based on considerations of comorbidities, anemia patients associated with chronic kidney diseases, diabetes mellitus, and hypertensive diseases preferred Western medical management and demonstrated a lesser likelihood of combining treatment with CHM; by contrast, those with coronary artery disease demonstrated a higher tendency for CHM use. Notably, Astragalus membranaceus (AM) and Gui-Pi-Tang (GPT) were the most commonly prescribed CHM single herb and formula, respectively. The core prescription pattern consisted of AM, Salvia miltiorrhiza (SM), Angelica sinensis (AS), GPT, and Si-Wu-Tang (SWT), as indicated by the associations and frequency of CHM utilization by traditional Chinese medicine (TCM) physicians.

CONCLUSION

This study demonstrates that CHM may be applied as an integral element of treatment for patients with anemia. It also provides insight regarding individual therapy and common clinical practices of TCM physicians in the treatment of anemia. Further research is required to explore potential interactions and possible mechanisms at play with CHM management of anemia.

Prevalence and Factors Associated with the Use of Acupuncture and Chinese Medicine: Results of a Nationally Representative Survey of 17161 Australian Women

Background

Traditional Chinese Medicine has considerable public support in Australia and elsewhere around the world; the literature suggests Chinese medicine (CM) and acupuncture are particularly popular.

Aim

To examine factors associated with CM/acupuncture use among young/middle-aged Australian women.

Methods

This research formed part of the Australian Longitudinal Study on Women's Health (ALSWH), a population-based cohort study. Data were obtained from the ‘young’ (34–39 years; n=8010) and ‘middle-aged’ (62–67 years; n=9151) ALSWH cohorts, who completed survey 6 (in 2012) and survey 7 (in 2013), respectively. Outcome measures included use of CM and visits to an acupuncturist in the previous 12 months. Predictive factors included demographic characteristics, and measures of health status (diagnosed chronic medical conditions) and health service utilisation. Statistical analyses included bivariate χ2 tests, two proportions Z-tests and backward stepwise multiple logistic regression modelling.

Results

In total, 9.5% and 6.2% of women in the young and middle-aged cohorts, respectively, had consulted an acupuncturist, and 5.7% and 4.0%, respectively, had used CM. Young women with low iron levels and/or endometriosis were more likely to use CM and/or acupuncture. Middle-aged women with low iron levels and/or chronic fatigue syndrome (CFS) were more likely to use CM, while middle-aged women with arthritis and/or CFS were more likely to use acupuncture.

Conclusions

Women with chronic conditions (including arthritis, low iron, CFS and endometriosis) were associated with higher odds of CM/acupuncture use. There is a need for further research to examine the potential benefits of CM/acupuncture for these chronic illnesses.

Utilization of Chinese medicine for respiratory discomforts by patients with a medical history of tuberculosis in Taiwan

Background

Tuberculosis (TB) is one of the world’s major communicable infectious diseases, and it still imposes a great health burden in developing countries. The development of drug-resistant TB during the treatment increases the treatment complexity, and the long-term pulmonary complications after completing treatment raise the epidemic health burden. This study intended to investigate the utilization of Chinese medicine (CM) for respiratory symptoms by patients with a medical history of TB in Taiwan.

Methods

We analyzed a cohort of one million individuals who were randomly selected from the National Health Insurance Research Database in Taiwan. The inclusion criteria of patients (n = 7905) with history of TB (ICD-9-CM codes 010–018 and A02) were: (1) TB diagnosed between January 1, 1997 and December 31, 2010 (2) 18 years old or over (3) Clinical records for at least 2 months with complete demographic information (4) Record of treatment with first-line TB medication prescriptions. CM users for conditions other than respiratory discomforts (n = 3980) were excluded. Finally, a total of 3925 TB patients were categorized as: CM users for respiratory discomforts (n = 2051) and non-CM users (n = 1874).

Results

Among the 3925 subjects, 2051 (52.25%) were CM users, and 1874 (44.753%) were non-CM users. Female patients and those who were younger (18–39 y/o) and who lived in urbanized areas relatively tended to be CM users (p < .0001). Most of the CM users (1944, 94.78%) received Chinese medicines. The most commonly prescribed herbal formulas and single herbs were Xiao-Qing-Long-Tang and Radix Platycodonis (Jie-Geng), respectively. The core pattern of Chinese medicines for TB patients consisted of Ma-Xing-Gan-Shi-Tang, Bulbus Fritillariae Thunbergii (Bei-Mu), Radix Platycodonis (Jie-Geng) and Semen Armeniacae (Xing-Ren).

Conclusions

The use of CM is popular among patients with a medical history of TB complicated with long-term respiratory discomforts in Taiwan. Further pharmacological investigations and clinical trials are required.

The Evaluation of Professional Divisions of Traditional Chinese Medicine in Taiwan through Patient Visit Records of 2012

For decades, professional divisions have been represented as the main structural divisions in Western medicine throughout the world. In Taiwan, medical policymakers are also interested in designing professional divisions of traditional Chinese medicine (TCM). Therefore, this study evaluated the current status and potentiality of professional divisions of TCM in Taiwan using data from the year 2012 obtained from the National Health Insurance Research Database; the database provides information regarding age and gender of TCM physicians (TCMPs); total visit counts; contracted medical institution codes; groupings of diseases classified under International Classification of Diseases, Ninth Revision, Clinical Modification codes; numbers of children and female patients seeking treatment; and claim disposition codes used by each TCMP. The results indicated that there were 5522 TCMPs in 2012, and 4876 (90.3%) TCMPs practiced in primary clinics. The proportions of pediatric visits to these TCMPs were mostly below 0.2, and acupuncture or traumatology-related visit proportions were below 0.5. Only a few of the studied Taiwan-based TCMPs practiced gynecology and pediatrics, but most of them performed “internal medicine”, or “acupuncture” or “traumatology” treatments. Thus, the number of TCM specialists practicing gynecology or pediatrics is insufficient, indicating that a policy that forms professional divisions of TCM practitioners in Taiwan should be reconsidered.

Traditional Chinese Medical Care and Incidence of Stroke in Elderly Patients Treated with Antidiabetic Medications

Objectives: Experimental research has shown that herbal and traditional Chinese medicines (TCM) may serve as complements to Western medicine treatments in the control of blood glucose and cardiovascular complications, but population-based studies are limited. We investigated the association between TCM use and subsequent risk of stroke in older patients with diabetes. Study design: The database used in this cohort study contained longitudinal medical claims for one million subjects randomly selected among beneficiaries of a universal health care program in Taiwan. We identified a cohort of patients with diabetes aged 65 years and older who initiated anti-diabetic medications from 2000 to 2012. Patients who had at least two TCM outpatient visits after their initiation of anti-diabetic medications were considered TCM users. Main outcome measures: The incidence of stroke was measured until 2013. Cox regression models with TCM use as a time-dependent variable were used to calculate the adjusted hazard ratios (HRs) comparing TCM use with no use. Results: Over the 13-year period, 17,015 patients were identified; 4912 (28.9%) of them were TCM users. The incidence of stroke during the follow-up (per 1000 person-years) was 22.8 in TCM users and 25.7 in non-users. TCM users had an adjusted HR of 0.93 for the incidence of ischemic stroke (95% confidence interval [CI] 0.83, 1.04) and of 0.89 for developing hemorrhagic stroke (95% CI 0.66, 1.19), compared with non-users. Conclusions: In this study, in older patients receiving Western medicine treatments for diabetes, TCM use was not associated with an increased risk of developing ischemic stroke and hemorrhagic stroke.

Use of Complementary Traditional Chinese Medicines by Adult Cancer Patients in Taiwan: A Nationwide Population-Based Study

BACKGROUND

Many patients with cancer seek complementary and alternative medicine treatments. We investigated the use of traditional Chinese medicine (TCM) by adult cancer patients in Taiwan.

METHODS

We reviewed the Registry for Catastrophic Illness Patients Database of Taiwan, and included all adult patients diagnosed cancer, based on the International Classification of Diseases (ninth revision), from 2001 to 2009 and followed until 2011. This database allowed categorization of patients as TCM users (n = 74 620) or non-TCM users (n = 508 179). All demographic and clinical claims data were analyzed.

RESULTS

Compared with non-TCM users, TCM users were younger and more likely to be female, white-collar workers, and reside in highly urbanized areas. The average interval between cancer diagnosis and TCM consultation was 15.3 months. The most common cancer type was breast cancer in TCM users (19.4%), and intrahepatic bile duct cancer in non-TCM users (13.6%). The major condition for which TCM users visited clinics were endocrine, nutritional and metabolic diseases, and immunity disorders (23.2%). A total of 33.1% of TCM users visited TCM clinics more than 9 times per year and their time from diagnosis to first TCM consultation was 5.14 months. The most common TCM treatment was Chinese herbal medicine. The common diseases for which cancer patients sought TCM treatment were insomnia, malaise and fatigue, dizziness and headache, gastrointestinal disorders, myalgia and fasciitis, anxiety, and depression. Overall, TCM users had a lower adjusted hazard ratio (aHR) for mortality (aHR = 0.69, 95% CI = 0.68-0.70) after adjustment for age, sex, urbanization of residence, occupation, annual medical center visits, and annual non-medical center visits.

CONCLUSIONS

This study provides an overview of TCM usage among adult cancer patients in Taiwan. TCM use varied among patients with different types of cancer. Physicians caring for cancer patients should pay more attention to their patients' use of complementary TCM.

Trends in use of acupuncture among adults in Taiwan from 2002 to 2011: A nationwide population-based study

In recent years, acupuncture has gained in popularity worldwide. However, recent epidemiological studies are lacking. We conducted this study to investigate the trends in acupuncture utilization among adults in Taiwan from 2002 to 2011. We analyzed data from the Longitudinal Health Insurance Database 2000 (LHID 2000), which contains all original claims data for 1 million beneficiaries randomly sampled from the registry of all beneficiaries enrolled in the National Health Insurance (NHI) program in 2000. The one-year prevalence of acupuncture use among adults increased from 7.98% in 2002 to 10.9% in 2011. Acupuncture use significantly increased yearly (incidence rate ratio = 1.04, 95% CI = 1.03-1.05, p<0.001). Patients who were female, were middle-aged, resided in highly urbanized areas and suffered from injury or disorders of the musculoskeletal system were prone to more frequent acupuncture use. Our study revealed that the utilization of acupuncture became increasingly popular in Taiwan from 2002 to 2011. Our findings may provide useful information for clinical practice and research as well as for health policy decision making.

Exploring saiga horn consumption in Singapore

The Critically Endangered saiga antelope Saiga tatarica faces an uncertain future, with populations dwindling from epidemics in its range countries, and ongoing demand for its horns in the traditional Chinese medicine trade. Singapore is a major hub for the global trade in saiga horn and an important consumer country, with saiga horn products widely available in the domestic market. Despite this, little is known about the consumers that drive domestic demand. Before interventions are carried out, it is important to understand who the consumers are, and their motivations. We conducted an investigation into consumption prevalence and consumer demographics, knowledge and motivations. We surveyed 230 Chinese Singaporeans, through a combination of face-to-face interviews and self-administered questionnaires. Recent consumption incidence (in the previous 12 months) was relatively high, at 13%. Younger respondents (18–35 years) had the highest prevalence of recent consumption (25%), often as a result of influence from an older family member or friend. Bottled saiga horn cooling water was the most popular product among recent users (50%), followed by horn shavings (31%) and tablets (13%). Awareness of conservation issues and regulations was uniformly low. Awareness raising may have an effect in reducing consumer demand in Singapore. However, given the exploratory nature of this study, it is best used to guide and inform future research underlying behavioural change interventions in a relatively understudied but important consumer group, Chinese Singaporeans.

Prescription of Chinese herbal products is associated with a decreased risk of invasive breast cancer

The finding of a decrease in endometrial cancer incidence among breast cancer survivors following the use of Chinese herbal products (CHPs) has led to speculation that CHPs might play a role in breast cancer prevention.This study provides an overview of breast cancer incidence, comparing CHP users with those who do not use traditional Chinese medicine (TCM), referred to as non-TCM users. The results can provide information to clinicians for counseling women about the preventive use of TCM.A total of 184,386 women (20-79 years of age) were recruited from a nationwide 1-million-person representative sample of those covered by National Health Insurance in Taiwan and were followed from 1999 to 2012. A total of 1853 incidents of invasive breast cancer were diagnosed. The person-year approach with the Poisson assumption was used to estimate the incidence density rate. The age-specific hazard ratios of breast cancer in relation to either CHP or siwutang (SWT) use were calculated with multivariate Cox proportional hazard regression.More than 78% of patients had used a CHP at some point previously. The overall incidence density rate of breast cancer for non-TCM users was estimated at 1.73 per 10,000 patient-years. The corresponding values for CHP and SWT users were lower than those of the non-TCM group (CHP group = 0.85; SWT group = 0.63 per 10,000 patient-years). The covariate adjusted HRs for breast cancer were 0.57 (95% confidence interval [CI] 0.50-0.65) and 0.36 (95% CI 0.28-0.46) in women using CHPs and SWT, respectively. The findings were confirmed using propensity score matching.Consumption of CHPs reduces the incidence of invasive breast cancer. Although the mechanism of action of these products is unclear, their use as a preventive agent for breast cancer is appropriate for many women at an increased risk of breast cancer.

The utilization of traditional Chinese medicine in patients with dysfunctional uterine bleeding in Taiwan: a nationwide population-based study

BACKGROUND

Many patients with gynecological disorders seek traditional medicine consultations in Asian countries. This study intended to investigate the utilization of traditional Chinese medicine (TCM) in patients with dysfunctional uterine bleeding (DUB) in Taiwan.

METHODS

We analyzed a cohort of one million individuals randomly selected from the National Health Insurance Research Database in Taiwan. We included 46,337 subjects with newly diagnosed DUB (ICD-9-CM codes 626.8) from January 1, 1997 to December 31, 2010. The patients were categorized into TCM seekers and non-TCM seekers according to their use of TCM.

RESULTS

Among the subjects, 41,558 (89.69%) were TCM seekers and 4,779 (10.31%) were non-TCM seekers. Patients who were younger tended to be TCM seekers. Most of the patients had also taken Western medicine, especially tranexamic acid and non-steroidal anti-inflammatory drugs (NSAIDs). More than half of TCM seekers (55.41%) received combined treatment with both Chinese herbal remedies and acupuncture. The most commonly used TCM formula and single herb were Jia-Wei-Xiao-Yao-San (Bupleurum and Peony Formula) and Yi-Mu-Cao (Herba Leonuri), respectively. The core pattern of Chinese herbal medicine for DUB patients consisted of Jia-Wei-Xiao-Yao-San, Xiang-Fu (Rhizoma Cyperi), and Yi-Mu-Cao (Herba Leonuri).

CONCLUSIONS

TCM use is popular among patients with DUB in Taiwan. Further pharmacological investigations and clinical trials are required to validate the efficacy and safety of these items.