利用健保資料庫分析常見自體免疫疾病合併精神疾病患者之存活分析

Survival Analysis for Patients with Common Autoimmune Disorder Comorbid with Psychiatric Disorder: A Population-Based Retrospective Cohort Study

林秀縵(Hsiu-Man, Lin)

指導教授 ： 邱政元副教授

中山醫學大學/健康管理學院/醫療產業科技管理學系碩士班/碩士(2018年)

摘要

研究背景與動機：
自體免疫疾病及精神疾病多是慢性病程需終身治療的。根據過去研究，兩種疾病間常有共病情形，對於病患個人及醫療支出都是相當大的負擔。本研究及針對此現象，由過去健保資料庫的資料試圖探討此類共病患者在醫療利用及存活率上，進行分析，以供臨床的參考與重視。
研究方法：
本研究使用全民健保學術資料庫2000年承保之100萬隨機抽樣歸人資料，統計1997-2012年間，依照ICD-9經過三次門診或一次住院確診的患者進行分析。研究變項分別為常見的自體免疫疾病、精神疾病、兩者共病者、社會人口學特質，依變相為門診、住診的醫療利用，及其他生理合併症和死亡率，並且使用SPSS 20.0套裝軟體與SAS 9.4進行統計分析。收集符合自體免疫的個案，追蹤到精神疾病發生或病人死亡為止。並以1比4的比例找出對照組。總收案數為6,868人，納入27,474人為對照組。本研究通過倫理審查，案號為 CS15134 (the Institutional Review Board of Chung Shan Medical University in Taiwan)。
研究結果：
資料顯示1997-2013自體免疫疾病盛行率為1.10%，精神科相關疾病盛行率為8.13%。經回溯性世代研究分析，自體免疫疾病患者有較高的精神相關疾病發生率，發生率為1.08(95%信賴區間=0.99-1.18)，校正風險比值（ aHR）=1.42(95% 信賴區間=1.27-1.59)，其中以SLE的aHR=1.66(95%信賴區間1.21-2.27)最高。自體免疫疾病患者也有較高的死亡率1.31(95%信賴區間1.20-1.42)，校正後的風險比值（為1.52(95%信賴區間=1.38-1.67)，其中以紅斑性狼瘡的aHR=3.17(95%信賴區間2.52-3.97)最高。
透過此回溯性世代研究，我們產生一項巢式病歷對照研究(nested case control)分成有精神疾病者與無精神疾病者 ，我們發現精神科合併自體免疫疾病患者有最高的門診就醫次數、醫療申報點數以及後續的死亡風險(勝算比為2.037)。
結論與建議：
與國外現有資料相似，自體免疫患者合併生理共病時的死亡率較控制組高。與精神疾病共病者，其門、住院的醫療利用率以及死亡的風險增加。建議使病人早期診斷，發現共病，整合治療，可以減少病人的死亡率及醫療支出，此研究可供臨床醫療人員的重視，作為未來擬定治療策略的參考。

關鍵字

自體免疫疾病 ； 精神疾病 ； 共病 ； 醫療利用率 ； 健保資料庫

並列摘要

Background:
Autoimmune diseases and psychiatric diseases are chronic diseases. Both of diseases have multiple comorbidity and more medical utilization. The complexity of the diseases made a challenge for the clinicians and health provider to manage it. The diseases makes burden to treatment and management. . We used a population-based retrospective cohort study to explore the questions on clarifying the correlation when the two diseases coexist; including the comorbidity, the medical utilization and the survival rate. The results may help the cli-nician to notice the special need for these patients and the health provider to design the better treatment strategy.
Method:
We identified subjects who were diagnosed with common autoimmune disease including rheumatoid arthritis, systemic lupus erythematous, Sjogren’s syndrome, ankylosing spon-dylitis and psoriasis between January 1, 2000, and December 31, 2012, in the Taiwan Na-tional Health Insurance (NHI) Research Database. A cross-sectional cohort study was con-ducted for patients with the diagnosis as mentioned above. Independent variation including common autoimmune diseases, psychiatric diseases, coomorbidity, and demographic characteristics; the independent variation were other comorbidity and medical utilization and mortality. There were patients 6,868 were included and 27,472 matched controls observed until diagnosed with psychiatric disorders or until death. This study was approved by the Institutional Review Board of Chung Shan Medical University in Taiwan (CS15134).

Results:
The collected data showed the prevalence of the selected autoimmune disease and psychi-atric diseases were 1.1% and 8.13%from 1997 to 2013. Under analysis of this retrospective cohort study, there was higher incidence of psychiatric disease for patients with autoim-mune disesase; the incident rate was 1.08 (95% confidential interval =0.99-1.18) and ad-justed hazard ratio was 1.42 (95% confidential interval=1.27-1.59). Systemic lupus ery-thematosus showed highest adjusted hazard ratio (aHR=1.66, 95% confidential ratio is 1.31(95% confidential incidence= 1.20-1.42). The mortality rate in patient with autoim-mune disease, the aHR=1.52(95% confidential incidence=1.38-1.67). Patients with system-ic lupus erythematosus showed the highest, aHR=3.17(95% confidential incidence=2.527-3.979).
Through this study, we conducted a nested cases (cases with or psychiatric disease) and control (without psychotic diesease). Patients with autoimmune disease had more physical comorbidity and more psychiatric comorbidity, especially comorbid with depression and anxiety. Autoimmune disease combined with psychiatric disorders had highest mortality risk (OR= 2.037). The medical utilization marked increased in hospitalization and outpa-tient followed-up.
Conclusion:
Patients with autoimmune disease comorbid with psychiatric disease have more comor-bidity, more medical utilization and more mortality rate. The results remind clinicians to pay more attention on identify the psychiatric disease while treating patients with autoim-mune disease. To determine if the combined care with psychiatrists leading to better out-come and better cost efficiency would need further investigation.

並列關鍵字

autoimmune disorder ； psychiatric disorder ； comorbidity ； medical utilization

參考文獻

英文文獻

1. https://www.statista.com/statistics/418328/diagnosed-autoimmune-conditions-prevalence-in-selected-countries/

2. Al-Jefri, K., Newbury-Birch, D., Muirhead, C. R., Gilvarry, E., Araujo-Soares, V., Reynolds, N. J., . . . Hampton, P. J. (2017). High prevalence of alcohol use disorders in patients with inflam-matory skin diseases. Br J Dermatol, 177(3), 837-844. doi:10.1111/bjd.15497

3. Alunno, A., Studenic, P., Wiek, D., Balazova, P., & Aletaha, D. (2018). Missing pebble in the mosaic of rheumatic diseases and mental health: younger does not always mean happier. Ann Rheum Dis. doi:10.1136/annrheumdis-2018-213611

4. Amanat, M., Salehi, M., & Rezaei, N. (2018). Neurological and psychiatric disorders in psoriasis. Rev Neurosci. doi:10.1515/revneuro-2017-0108