2. Outlines The NHI The NHIRD 抽樣歸人檔 Statistical analysis Odds ratio Hazard ratio Utilization of NHIRD Example paper 1 Example paper 2 Current tendency: application of data mining techniques
3. The NHI In Taiwan, the National Health Insurance (NHI) program was initiated in 1995 It currently covered over 99% of the entire population (23,010,604 beneficiaries at July of 2010) [1] 24,712 medical institutions at July of 2010 in Taiwan are contracted to provide the service [1]
4. The NHIRD In 2000, the Bureau of NHI began to construct the National Health Insurance Research Database (NHIRD) and to release claims data for academic research 九十六年度申請之研究計畫: 202 九十七年度申請之研究計畫: 230 九十八年度申請之研究計畫: 344 九十九年度申請之研究計畫: 201 (截至目前) [2]
5. The NHIRD (cont’d) 利用Pub Med (U.S. National Library of Medicine)資料庫搜尋使用健保資料庫之文獻 搜尋條件：national health insurance database Taiwan 258 搜尋條件：national health insurance database Taiwan Herng-Ching Lin 66 類似資料庫 The Partners Healthcare Research Patient Data Registry (RPDR) in Boston which covers over three million patients contains electronic medical records from academic medical centers [3] The French national health insurance system insures 99.8% of the French population and covers 75-80% of the nation’s health care expenditures [4, 5]
9. Statistical analysis: hazard ratio 風險比 (HR) ，時間線上發生事件的風險強度 Survival analysis from study start Study end or lost to follow-up Event occurs Cox regression
10. Utilization of NHIRD Lin et al concluded that herpes zoster ophthalmicus (HZO) patients have a 4.52-fold higher risk of follow-up one-year stroke incidence than comparison samples without HZO [6] Neurology; impact factor 8.172; clinical neurology 4/167 Chai et al concluded that patients who underwent coronary artery bypass graft (CABG) by surgeons whose age <40 have higher in-hospital mortality than those operated on by surgeons whose age 40-45 (OR=1.47) and surgeons whose age >45 (OR=1.82) [7] World J Surg; impact factor 2.696; surgery 28/167
11. Utilization of NHIRD: example paper 1 [8] Thiazolidinediones (TZDs) use could alter bone metabolism, resulting in reduced osteoblastic(成骨細胞) bone formation and accelerated bone loss TZDs are prescribed in patients with type 2 diabetes; type 2 diabetes patients have a higher risk of fractures
12. Example paper 1-study population Collect from HIRD all individuals who had their first ambulatory visit with a diagnosis of diabetes (ICD-9 codes: 205.xx) and received at least one prescription for an oral hypoglycaemic agent between 2001 and 2005 Patients having type 1 diabetes (ICD-9 codes: 250.x1) were excluded Patients receiving insulin were excluded except who received insulin after the initial oral hypoglycaemic agent treatment The cohort entry date for each patient was defined as the date that an oral hypoglycaemic agent was first prescribed
13. Example paper 1-cases and comparison controls Both were from the study population of type 2 diabetic patients Case patients were identified who hospitalized with a primary diagnosis of fracture (ICD-9 codes: ?) between 2001 and 2005; only the first hospitalization for fracture was included Identified five control participants per case patient Controls were matched to cases for age, sex, and past medical history For cases, index date was the date of hospitalization for fracture For controls, index date was a random date within the range of the case index dates
14. Example paper 1-exposure to TZDs It assessed whether patients received TZDs during the year prior to the index date Duration of TZDs use was defined according to the number of days TZDs was taken 3 cohorts of TZDs cumulative exposure: < 30 days 30~180 days > 180 days Risk factors were adjusted during statistical analysis
15. Example paper 1-results The use of TZDs was associated with hospitalization for fracture, after adjustments for risk factors; the association was stronger with longer term exposure to TZDs The association between TZDs use and hospitalization for fracture differed by sex TZDs-associated fractures are restricted to the upper limb (forearm, hand, and wrist) or distal lower limb (foot, ankle, fibula 腓骨, and tibia 脛骨) This study found associated fractures related to osteoporosis (骨質疏鬆), such as hip or femur 股骨 fractures
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17. Example paper 1-discussion This population-based case-control study provided further evidence of an increased association between fractures and use of TZDs in type 2 diabetic patients; the dose-response association with exposure was significantly evident in women but not in men The use of NHIRD provides the first major report of odds of fracture among an Asian population of TZDs users; it’s known the common use of TZDs and relatively lower bone mass in Asian groups This study supported warnings by FDA
18. Utilization of NHIRD: example paper 2 [9] In Taiwan, there have been case reports of renal failure associated with use of Chinese herbal products and herbs that contain aristolochic acid (馬兜鈴酸) Consumption of Chinese herbs that contain aristolochic acid has been associated with an increased risk of urinary tract cancer
19. Example paper 2-study population Collect the NHI catastrophic illness registry files for all patients with urinary tract cancer or end-stage renal disease from January 1, 1997 to December 31, 2002. It allows at least 4 years between January 1, 1997, and the date of diagnosis to give time to accumulate sufficient doses of herbal products to induce urinary tract cancer Comparison controls came from the insured population in Taiwan from January 1, 1997 to December 31,2002, who were matched in terms of sex and age. It excluded samples with any diagnosis related to urinary tract cancer Exclude subjects who were ever prescribed acetaminophen and/or nonsteroidal anti-inflammatory drugs. 4594 cases & 174701 controls
20. Example paper 2-exposure assessment Chinese herbal products containing aristolochic acid:馬兜玲、天仙藤、關木通、细辛、廣防己、青木香 Calculate cumulative dose for each herb prescribed to an individual up to 1 year before the diagnosis of urinary tract cancer Use average doses of aristolochic acid per 1 g of 關木通、廣防己、细辛 Control the surrogate for arsenic exposure: 布袋鎮、義竹鄉、學甲鎮、北門鄉
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23. Example paper 2-discussion Having been prescribed more than 60 g of 木通 or more than 150 mg aristolochic acid from Chinese herbal products was associated with an increased risk of developing urinary tract cancer This association is in a dose-dependent manner that was independent of arsenic exposure Continuous surveillance of herbs or Chinese herbal products that might be adulterated with aristolochic acid-containing herbs is recommended
24. Current tendency: application of data mining techniques (1/3) A Bayesian network model composed of age, sex, race, smoking history, and 8 comorbidity variables is able to predict chronic obstructive pulmonary disease (COPD) in asthma patients with an accuracy of 83.3% [10] Journal of American Medical Informatics Association; impact factor 3.974; CS information systems 3/116 & medical informatics 1/23
25. Current tendency: application of data mining techniques (2/3) Strong association rules are found between prescriptions for antacids and nonsteroidal anti-inflammatory drugs, drugs for treating upper respiratory infections, vitamin B complex, and anti-vertigo preparations [11] Clinical Therapeutics; impact factor 3.25; pharmacology & pharmacy 65/237
26. Current tendency: application of data mining techniques (3/3) Attention deficit/hyperactivity disorder (ADHD) is the most prevalent psychiatric condition among children, especially among boys. Tai et al concluded by association rule mining that development delay appears as an important node between ADHD and anxiety disorder, mild mental retardation, and autism [12] International Journal of Medical Informatics; impact factor 3.126; CS information systems 7/116 & medical informatics 3/23
27. References The NHI web site[http://www.nhi.gov.tw] The NHIRD web site [http://w3.nhri.org.tw/nhird/] Partners Healthcare [http://www.partners.org] Duriez, Marc. The French Health Care System: Organization and Functioning. Paris: CREDES, 1994 Lugardon S, Roussel H, Sciortino V, Montastruc JL, Lapeyre-Mestre M: Triptan use and risk of cardiovascular events: a nested-case-control study from the French health system database. European journal of clinical pharmacology 2007, 63(8):801-807 Lin HC, Chien CW, Ho JD: Herpes zoster ophthalmicus and the risk of stroke: a population-based follow-up study. Neurology, 74(10):792-797 Chai CY, Chen CH, Lin HW, Lin HC: Association of increasing surgeon age with decreasing in-hospital mortality after coronary artery bypass graft surgery. World journal of surgery, 34(1):3-9
28. References (cont’d) Hsiao FY, Mullins CD: The association between thiazolidinediones and hospitalisation for fracture in type 2 diabetic patients: a Taiwanese population-based nested case-control study. Diabetologia, 53(3):489-496 Lai MN, Wang SM, Chen PC, Chen YY, Wang JD: Population-based case-control study of Chinese herbal products containing aristolochic acid and urinary tract cancer risk. Journal of the National Cancer Institute, 102(3):179-186 Himes BE, Dai Y, Kohane IS, Weiss ST, Ramoni MF: Prediction of chronic obstructive pulmonary disease (COPD) in asthma patients using electronic medical records. J Am Med Inform Assoc 2009, 16(3):371-379 Chen TJ, Chou LF, Hwang SJ: Application of a data-mining technique to analyze coprescription patterns for antacids in Taiwan. Clinical therapeutics 2003, 25(9):2453-2463 Tai YM, Chiu HW: Comorbidity study of ADHD: applying association rule mining (ARM) to National Health Insurance Database of Taiwan. International journal of medical informatics 2009, 78(12):e75-83
