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系統識別號 U0026-1604201215510500
論文名稱(中文) 第二型糖尿病原死因分析暨糖尿病死亡率與致死率之城鄉差異
論文名稱(英文) Underlying Causes of Death and the Urban-Rural Difference in Mortality and Case-Fatality in Patients with Type 2 Diabetes
校院名稱 成功大學
系所名稱(中) 公共衛生研究所
系所名稱(英) Graduate Institute of Public Health
學年度 100
學期 2
出版年 101
研究生(中文) 許智惠
研究生(英文) Chih-Hui Hsu
學號 t86991032
學位類別 碩士
語文別 中文
論文頁數 81頁
口試委員 指導教授-李中一
口試委員-呂宗學
口試委員-楊宜青
中文關鍵字 都市化程度  第二型糖尿病  死亡率  致死率  地區差異  世代研究 
英文關鍵字 Urbanization  Type 2 Diabetes Mellitus  Mortality Rate  Case-fatality Rate  Geographic Variation  Cohort Studies 
學科別分類
中文摘要 背景:第二型糖尿病病人容易有多種合併症,因此死亡的糖尿病病人其所註記的原死因通常會包括糖尿病以外的死因,因此分析糖尿病人的原死因分佈,可以進一步了解糖尿病的死亡負荷。此外,僅管有研究指出,糖尿病的發生率與致死率通常與地區的社會經濟背景有關,但台灣目前有關不同都市化程度地區糖尿病之致死風險差異情況訊息有限,且都市化程度是否會修飾第二型糖尿病之致死相對風險,仍有待進一步探討。
目的:探討我國第二型糖尿病病人之原死因分布,以及全病因與糖尿病死因之累積致死率;此外,也將分析都市化程度與第二型糖尿病病人致死風險的影響,以及都市化程度是否會修飾第二型糖尿病患者死亡之相對風險。
方法:本研究使用由國家衛生研究院所發行健保資料2000年百萬人檔中2000年至2008年有第二型糖尿病診斷之患者(n=65,599)與衛生署死因登記資料進行串連,獲取2000年至2009年研究對象之原死因。本研究首先計算各縣市糖尿病之死亡率與致死率,並估計發生水準;本研究也利用世代研究設計,以多變量比例危害模式分析依照研究對象投保所在地劃分之都市化程度對糖尿病人致死風險的影響;同時以年齡、性別與年代進行匹配選出相同數目的非糖尿病個案(對照組),分析糖尿病個案死亡之相對風險,並檢定都市化程度對於第二型糖尿病死亡相對風險是否有效果修飾作用。
結果:第二型糖尿病病人的原死因分佈主要為癌症(22.6%)、心血管(21.4%)與內分泌疾病(20.7%)。台灣各縣市的第二型糖尿病之死亡狀況具有地理變異,都市化程度較低者,其累積死亡率、累積致死率與發生水準皆較高,複迴歸分析發現,於都市化程度較低地區投保之糖尿病人其致死相對風險較高,其中相對於高度都市化市鎮(都市化程度等級最高)之糖尿病個案,偏遠鄉鎮(都市化程度等級最低)糖尿病個案之全病因與糖尿病病因致死危害對比值分別為1.38(95% CI=1.28-1.49)與1.50(95% CI=1.26-1.79)。此外,相對於對照組,糖尿病個案之全病因致死危害對比值為1.21(95% CI=1.18-1.25),而此危害對比值並不會隨都市化程度不同而有顯著的差異。
結論:第二型糖尿病病人的主要死亡原因中,惡性腫瘤所佔的分率最高約為23%,未來研究需要評估是否需要針對糖尿病病人進行特定的癌症篩檢。投保單位在都市化程度較低地區之糖尿病病人全病因與糖尿病病因之致死相對風險均較高,顯示對糖尿病個案發病後之健康照護的充足性與有效性上存在有都市化程度的差異。
英文摘要 Background: Patients with type 2 diabetes mellitus (DM) frequently suffer from various complications, leading to a number of non-diabetes causes of death may be considered as the underlying-causes-of-death (UCOD) for patients with diabetes. Information on diabetic patients’ UCOD may help assess the disease burden of DM. Despite previous studies suggested an association of socio-economic background with DM incidence and mortality, the information concerning the influence of urbanization on case-fatality rate of patients with DM is rather limited. Moreover, whether urbanization may modify the effect of type 2 DM on case-fatality rate needs further investigation.
Objectives: To investigate the distribution of UCOD in type 2 DM patients, and to estimate the cumulative case-fatality rate from all causes or DM cause-specific. Additionally, the study sought to assess the influence of urbanization on case-fatality rate in type 2 DM, and to explore whether urbanization may modify the effect of type 2 DM on risk of case-fatality.
Methods: This study linked a cohort of patients who sought medical care for type 2 DM from 2000 to 2008 (n=65,599), retrieved from the 1-million random sample of Taiwan’s National Health Insurance Database (LHID2000) released by the NHRIs to the mortality registry to ascertain the patients who died between 2000 and 2009. We first calculated mortality and case-fatality rates from DM in each city/county. With a cohort design and proportional hazard models, we analyzed the effect of urbanization, based on each DM patient’s beneficiary township, on the risk of case-fatality. We also selected an age-sex-calendar year matched non-DM sample (controls) to assess the relative mortality risk in relation to type 2 DM, and to examine whether the relative risk of mortality from type 2 DM can be modified by urbanization.
Results: The leading causes of death in type 2 DM included neoplasm (22.6%), cardiovascular (21.4%), and endocrine disease (20.7%). There was a geographic variation in mortality/case-fatality risk in type 2 DM of Taiwan, where the cumulative mortality, cumulative case-fatality rate, and level of incidence were all higher in less urbanized areas. The multivariate regression analyses indicated that type 2 DM patients with lesser urbanization tended to experience higher risk of case-fatality. Compared to those from highly urbanized areas, type 2 DM patients insured in the remote townships had an increased risk of all-causes and DM cause-specific case-fatality of 1.38 (95% CI=1.28-1.49) and 1.50 (95% CI=1.26-1.79). Additionally, compared to controls, type 2 DM had a significantly increased hazard ratio (HR) of all-causes case-fatality at 1.21 (95% CI=1.18-1.25), and such increased HR was not significantly modified by level of urbanization.
Conclusion: Neoplasm accounts the largest portion (around 23%) of deaths in type 2 DM patients, suggesting careful evaluation of lunching specific-cancer screening programs in type 2 DM. Our study indicated an increased risk of case-fatality in type 2 DM insured in areas with lesser urbanization, which may imply that the adequacy and effectiveness of diabetes care may vary in areas with different levels of urbanization.
論文目次 摘要 i
Abstract iii
致謝 v
表目錄 ix
圖目錄 x
壹、前言 1
1.1研究背景 1
1.2 研究目的 3
1.3 論文結構 3
貳、文獻探討 4
2.1第二型糖尿病定義 4
2.1.1糖尿病分類 4
2.1.2第二型糖尿病之國際疾病分類編碼 4
2.2第二型糖尿病流行病學研究 5
2.2.1第二型糖尿病盛行率 5
2.2.2第二型糖尿病發生率 6
2.2.3第二型糖尿病病人死亡狀況與死亡原因分析 6
2.2.3.1國外研究 7
2.2.3.2國內研究 7
2.2.4小結 8
2.3都市化程度的定義及指標測量 8
2.3.1都市化的定義 8
2.3.2都市化的指標測量 9
2.3.2.1官方提出之定義 9
2.3.2.2學者提出之定義 9
2.3.3小結 10
2.4都市化程度與疾病的相關研究 11
2.4.1都市化程度與慢性疾病 11
2.4.2都市化程度與死亡率 11
2.4.2.1都市化程度與糖尿病死亡率(個人層級研究) 13
2.4.2.2都市化程度與糖尿病死亡率(區位研究) 13
2.4.3小結 14
2.5文獻小結 14
參、研究材料與方法 16
3.1資料來源與研究設計 16
3.1.1資料來源 16
3.1.2研究設計 17
3.2研究個案定義(糖尿病世代與對照世代之選取與追蹤) 17
3.2.1第二型糖尿病世代 17
3.2.2對照組世代 17
3.3資料分析 18
3.3.1糖尿病病人之原死因分布、累積死亡率、累積致死率與累積存活率 18
3.3.2都市化程度指標與第二型糖尿病致死率之相關性分析 19
3.3.3都市化程度指標與第二型糖尿病之交互作用分析 20
肆、研究結果 21
4.1描述性分析 21
4.1.1研究族群之描述性分析 21
4.1.2原死因分布 21
4.1.3累積存活率 22
4.2第二型糖尿病病人累積死亡率、累積致死率之縣市別分析 22
4.2.1累積死亡率之縣市別分析 22
4.2.2累積致死率之縣市別分析 23
4.2.3發生水準之縣市別分析 24
4.3第二型糖尿病病人其致死率與都市化程度之相關性分析 25
4.3.1全病因致死率與都市化程度之單變量分析 25
4.3.2全病因致死率與都市化程度之多變量分析 25
4.3.3糖尿病致死率與都市化程度之單變量分析 26
4.3.4糖尿病致死率與都市化程度之多變量分析 26
4.4第二型糖尿病與都市化程度之交互作用分析 26
4.4.1第二型糖尿病與都市化程度對全病因致死之交互作用 27
4.4.2第二型糖尿病與都市化程度對非糖尿病致死之交互作用 27
伍、討論 28
5.1本研究主要結果 28
5.2與相關研究結果比較 29
5.2.1第二型糖尿病病人之原死因 29
5.2.2縣市別、都市化程度與第二型糖尿病的關係 30
5.3研究優勢與限制 32
5.3.1研究優勢 32
5.3.2研究限制 33
陸、結論與建議 35
參考文獻 36
表 42
圖 57
附錄 71
附錄1:第二型糖尿病ICD-9-CM編碼 71
附錄2:各系統疾病ICD-9-CM編碼 75
附錄3:查爾森疾病指標(Charlson’s score) 76
附錄4:本研究分析350個鄉鎮市區之都市化程度分類 77
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