The document summarizes research using Taiwan's National Health Insurance Research Database (NHIRD). It describes the database's creation and contents, sample population files, statistical analysis methods like odds ratios and hazard ratios, example studies on fractures in diabetes patients using thiazolidinediones and aristolochic acid exposure and urinary tract cancer, and current use of data mining techniques with the NHIRD.

1. 醫療資訊系統全民健保研究資料庫D95922001 楊孟翰資訊所 博士五10/26/2010

2. OutlinesThe NHIThe NHIRD抽樣歸人檔Statistical analysisOdds ratioHazard ratioUtilization of NHIRDExample paper 1Example paper 2Current tendency: application of data mining techniques

3. The NHIIn Taiwan, the National Health Insurance (NHI) program was initiated in 1995It 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 NHIRDIn 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 Taiwan258搜尋條件：national health insurance database Taiwan Herng-Ching Lin66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]

6. 抽樣歸人檔以承保資料檔(ID)為抽樣母群體，採簡單隨機抽樣後，得到樣本ID(人)，然後擷取每人各年所有就醫申報資料，製成承保抽樣歸人檔 [2]門診處方及治療明細檔(CD)門診處方醫令明細檔(OO)住院醫療費用清單明細檔(DD)住院醫療費用醫令明細檔(DO)特約藥局處方調劑醫令明細檔(GO)基本資料檔 (醫事機構基本資料檔、承保資料檔、 …)

7. 抽樣歸人檔 (cont’d)抽樣歸人檔從2000年開始製作，以每五年為一個世代抽樣一次，2000年共抽20萬人，以五萬人為一組發行；2005年共抽100萬人，以四萬人為一組發行。每年更新2005年抽樣歸人檔100萬人，擷取1996-訖年該100萬人在全民健保研究資料庫中所有就醫資料統計抽樣檔之年齡、性別分布、平均投保金額，與母體、內政部公布人口資料間均無顯著差異 [2]

8. Statistical analysis: odds ratio勝算比 (OR)，用來呈現兩個類別變數相關的強度Logistic regression

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 startStudy end or lost to follow-upEvent occursCox regression

10. Utilization of NHIRDLin 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 4/167Chai 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 lossTZDs are prescribed in patients with type 2 diabetes; type 2 diabetes patients have a higher risk of fractures

12. Example paper 1-study populationCollect 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 2005Patients having type 1 diabetes (ICD-9 codes: 250.x1) were excludedPatients receiving insulin were excluded except who received insulin after the initial oral hypoglycaemic agent treatmentThe 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 controlsBoth were from the study population of type 2 diabetic patientsCase 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 includedIdentified five control participants per case patientControls were matched to cases for age, sex, and past medical historyFor cases, index date was the date of hospitalization for fractureFor controls, index date was a random date within the range of the case index dates

14. Example paper 1-exposure to TZDsIt assessed whether patients received TZDs during the year prior to the index dateDuration of TZDs use was defined according to the number of days TZDs was taken3 cohorts of TZDs cumulative exposure:< 30 days30~180 days> 180 daysRisk factors were adjusted during statistical analysis

15. Example paper 1-resultsThe use of TZDs was associated with hospitalization for fracture, after adjustments for risk factors; the association was stronger with longer term exposure to TZDsThe association between TZDs use and hospitalization for fracture differed by sexTZDs-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

17. Example paper 1-discussionThis 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 menThe 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 groupsThis 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 populationCollect 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 cancerComparison 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 cancerExclude subjects who were ever prescribed acetaminophen and/or nonsteroidal anti-inflammatory drugs. 4594 cases & 174701 controls