Taiwan J Fam Med Vol.26 No.1 台灣糖尿病相關死亡率的趨勢分析從民國50年開始上升一直到民國90年位有提及糖尿病者推算出直接及非直終於趨緩此後緩慢下降到103年回降接導因於糖尿病的死亡率有鑒於疾病 [4,5] 糖尿病死亡率下型態改變人口

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质栋樊
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1 [ ] 35-1,2 3,4 目的 : - 方法 : 95% 結果 : 結論 : 2016; 26: DOI: / [1,2] 21 [3]

2 Taiwan J Fam Med Vol.26 No.1 台灣糖尿病相關死亡率的趨勢分析從民國50年開始上升一直到民國90年位有提及糖尿病者推算出直接及非直終於趨緩此後緩慢下降到103年回降接導因於糖尿病的死亡率有鑒於疾病 [4,5] 糖尿病死亡率下型態改變人口的死亡原因由傳染性疾降是否代表死亡負擔已經下降了呢病漸漸轉變為慢性疾病許多國家如過去國家的疾病別死亡率都是以原死美國瑞典加拿大芬蘭及台灣等已因為統計基礎然而越來越多國家在建置多重死因資料庫到民國80年的水準 [9] 原死因之外同時參考多重死因死亡率來推估疾病死亡負擔 [6,7] 本研究目的是以原死因及多重死因死亡率推估台灣-年糖尿病死亡率的變化並比較兩種死亡率趨勢型態的異同進一步以多重死因死亡率輔助何謂多重死因死亡率 [8] 依WHO 原死因統計規則每分析原死因死亡率趨勢變化的原因一張死亡證明書只有一個原死因如圖 1 原死因是啟始一連串病症導致文獻回顧最後死亡的原因它通常位在第一部有許多文獻建議推估慢性疾病的死份直接引起死亡之疾病或傷害的最亡負擔應提供兩種死亡率資料以避下面一行開立證明書的臨床醫師或法免單看原死因死亡率而低估疾病死亡負醫師會依病患死亡當時情況整理出單擔一死因因果鏈將每個死亡原因填入死助分析原死因死亡率趨勢改變的原因因欄的適當位置填在第一部份最下面 16] 一行的就是原死因傳統生命統計資分析年牛津健康照護地區糖尿料庫中只保留原死因而多重死因資料病死亡率趨勢庫則保留死因欄的每一個死亡原因並中期( )突然上升而多重死因依所填報位置給予編號及歸檔多重死亡率20年間趨勢平穩作者進一步比死因死亡率就是採計死亡原因任一欄對死亡率波動期間洽與原死因選取規則 [9-13] 此外多重死因死亡率可用來輔以糖尿病為例 [10] [10,17-20] [14- Goldacre等人發現原死因死亡率在變動時間吻合故推斷原死因死亡率的十一死亡原因儘量不要填寫症狀或死亡當時之身體狀況如心臟衰竭身體衰弱 1.直接引起死亡之疾病或傷害甲先行原因若有引起上述死因之疾病或傷害乙甲之原因變化是人為因素造成 Park與Peter比較加拿大年糖尿病原死因與多重死因死亡率趨勢 [17] 原死因死亡率在觀察期間改變不大但多重死因死亡率上升了14% 顯示雖然糖尿病原死因死亡率沒有增加但因為糖尿病併發症或共病症而死亡的比率則上升許多男女性丙乙之原因都呈現相似的現象 Cho等人分析美國丁丙之原因年原住民糖尿病死亡率[18] 並 2.其他對於死亡有影響之疾病或身體狀況但與引起死亡之疾病或傷害無直接關係者圖1 死亡證明書上死亡原因欄與白人做比較結果原住民及白人的原死因及多重死因死亡率都是先上升後下降顯示因糖尿病而死亡的人口真的在下降不是僅僅因為糖尿病從原死因欄

3 Lin Lu - [19] 資料前置處理及轉換 (National Center of Health Statistics, NCHS) Automated Classification of Medical Entities ACME [20] ACME ICD-10 ICD-9 multiple-causeof-death automated data entry system MADE ACME ICD-10 變項定義 ICD-10 code E10-E14 資料來源統計分析 Excel SAS %

4 Taiwan J Fam Med 38 台灣糖尿病相關死亡率的趨勢分析區再依性別年齡別分層分析同 2016 Vol.26 No.1 時以卜瓦松迴歸進行糖尿病死亡率之年原死因死亡率無顯著趨勢變化而多重死因死亡率則顯著上升代線性趨勢檢定當p值小於0.05視為有台灣-年間糖尿病原死意義因與多重死因死亡率趨勢有所不同圖 2A 原死因死亡率從年的每十萬結果人口33.2人上升到年的39.1人表 1 之後逐漸降到年的28.7人及年回升到29.8人以卜瓦松迴歸模年以糖尿病為原死因人數分別為型推估整體趨勢無顯著差異(p=0.099) 4,131 5,870 6,260 7,120 7,772及多重死因死亡率則是呈現上升的趨勢 9,281人占當年度死亡人數的4.3% (p=0.13) 年每十萬人口43.8人 5.4% 5.2% 5.6% 5.6%及6.0% 提及年54.2人年56.6人年糖尿病死亡人數分別為5,342 6, 人年58.4人年63.0人 6,795 7,953及8,797人占當年度死亡人數的5.7% 7.5% 8.8% 10.4% 1%及12.8% 圖2 原死因與多重死因死亡率趨勢有性別差異台灣糖尿病原死因與多重死因死亡率趨勢 -年

5 台灣家醫誌民國105年26卷1期林玉珮 39 呂宗學男性多重死因死亡率呈現較明顯的 2B 表1 而女性則不同圖2C 表男性以四個年齡層分析原死因死亡率大多持平而多重死因死亡率皆上升 1 多重死因死亡率在觀察期間無顯著將男性依四個年齡層分層分析表的趨勢變化而原死因死亡率則呈現顯 2 原死因死亡率僅0-44歲者有顯著上著下降趨勢綜合以上不同性別在原升趨勢其餘年齡層在觀察期間變化不死因與多重死因這兩種死亡率趨勢有差大而多重死因死亡率除45-64歲組以異外其餘皆有顯著上升其中以0-44歲上升趨勢原死因死亡率變化不大圖族群上升幅度最大死亡率從年的 -年台灣糖尿病*原死因與多重死因死亡率趨勢表1 原死因死亡率 RR p值死亡率 RR 年 95%CI 多重死因 95%CI 男女總合男性 < 女性 *糖尿病 ICD-10 code E10-E14 原死因以美國國立衛生統計中心電腦軟體自動選取以台灣年為標準人口死亡率單位為十萬分之一死亡率趨勢分析 p<0.05 RR: Relative Risk p值

6 Taiwan J Fam Med 40 表 Vol.26 No.1 台灣糖尿病相關死亡率的趨勢分析 -年台灣男性糖尿病*原死因與多重死因年齡別死亡率趨勢年死亡率男性歲歲歲歲原死因 RR 95%CI p值死亡率多重死因 RR 95%CI *糖尿病 ICD-10 code E10-E14 原死因以美國國立衛生統計中心電腦軟體自動選取以台灣年為標準人口死亡率單位為十萬分之一死亡率趨勢分析 p<0.05 RR: Relative Risk p值 <

7 女性依年齡分層分析, 原死因在中間區段年齡組呈下降趨勢, 多重死因在歲組下降而 75 歲組呈上升趨勢 (trend of p<0.05) Chang [21] % 23.4% 16% % 67.9% 28.2% % % , % 7% 27% [22] , % 7% 32.4% [23] [24-26] % % WHO % [27] Park [17] Cho [18] [19] 1989 [28] 0-44

8 Taiwan J Fam Med 42 表 Vol.26 No.1 台灣糖尿病相關死亡率的趨勢分析 -年台灣女性糖尿病*原死因與多重死因年齡別死亡率趨勢年死亡率女性歲歲歲歲原死因 RR 95%CI 0.9 p值死亡率多重死因 RR 95%CI < *糖尿病 ICD-10 code E10-E14 原死因以美國國立衛生統計中心電腦軟體自動選取以台灣年為標準人口死亡率單位為十萬分之一死亡率趨勢分析 p<0.05 RR: Relative Risk p值

9 [29] [30] [18,31,32] [31] Allegheny county study [32] [33] Emerging Risk Factors Collaboration: Diabetes mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med 2011; 364: Franco OH, Steyerberg EW, Hu FB, Mackenbach J, Nusselder W: Associations of diabetes mellitus with total life expectancy and life expectancy with and without cardiovascular disease. Arch Intern Med ; 157: World Health Organization: GLOBAL STATUS REPORT on noncommunicable diseases Attaining the nine global noncommunicable diseases targets; a shared responsibility. Geneva, Switzerland: World Health Organization, 2014: Lin RS, Lee WC: Trends in mortality from diabetes mellitus in Taiwan, Diabetologia ; 35: DOS/Statistic. aspx?f_list_no=312&fod_list_ no= Manderbacka K, Peltonen R, Koskinen S, Martikainen P: The burden of diabetes mortality in Finland a brief report. BMC Public Health 2011; 11: Centers for Disease Control and Prevention.

10 Taiwan J Fam Med Vol.26 No.1 National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, Atlanta, GA: U.S. Department of Health and Human Services, 2014: World Health Organization. Manual of the International Classification of Diseases, Injuries, and Causes of Death, Ninth Revision, Volume 1. Geneva: World Health Organization, 1977: Israel RA, Rosenberg HM, Curtin L: Analytical potential for multiple cause-ofdeath data. Am J Epidemiol 1986; 124: Goldacre MJ, Duncan ME, Cook-Mozaffari P, Neil HA: Trends in mortality rates for death-certificate-coded diabetes mellitus in an English population Diabet Med 2004; 21: Wier LM, Gjelsvik A: Diabetes Mortality in Rhode Island: Comparing underlying cause of death versus any listed cause of death. Med Health R I 2008; 91: Romon I, Jougla E, Balkau B, Fagot- Campagna A: The burden of diabetes-related mortality in France in : an analysis using both underlying and multiple causes of death. Eur J Epidemiol 2008; 23: Wall MM, Huang J, Oswald J, McCullen D: Factors associated with reporting multiple causes of death. BMC Med Res Methodol 2005; 5: Krueger DE: Hypertensive and chronic respiratory disease mortality: confirmation of trends by multiple cause of death data. Public Health Rep 1966; 81: Speizer FE, Trey C, Parker P: The uses of multiple causes of death data to clarify changing patterns of cirrhosis mortality in Massachusetts. Am J Public Health 1977; 67: Lu TH, Lin JJ: Using multiple-cause-of-death data as a complement of underlying-cause-ofdeath data in examining mortality differences in psychiatric disorders between countries. Soc Psychiatry Psychiatr Epidemiol 2010; 45: Park J, Peter PA: Mortality from diabetes mellitus, 2004 to 2008: A multiple-cause ofdeath analysis. Health Rep 2014; 25: Cho P, Geiss LS, Burrows NR, Roberts DL, Bullock AK, Toedt ME: Diabetes-Related Mortality Among American Indians and Alaska Natives, Am J Public Health 2014; 104: S Lin YP, Lu TH: Trends in death rate from diabetes according to multiple-cause-of-death differed from that according to underlyingcause-of-death in Taiwan but not in the United States, -. J Clin Epidemiol ; 65: Lu TH, Tsau SM, Wu TC: The Automated Classification of Medical Entities (ACME) system objectively assessed the appropriateness of underlying cause-of-death certification and assignment. J Clin Epidemiol 2005; 58: Chang TJ, Jiang YD, Chang CH, Chung CH, Yu NC, Chuang LM: Accountability, utilization and providers for diabetes management in Taiwan, : An analysis of the National Health Insurance database. J Formos Med Assoc ; 111: Chuang LM, Tsai ST, Huang BY, Tai TY, Diabcare-Asia 1998 Study Group: The status of diabetes control in Asia-a cross-sectional

11 survey of 24,317 patients with diabetes mellitus in Diabet Med ; 19: Yu NC, Su HY, Tsai ST, et al: ABC control of diabetes: survey data from National Diabetes Health Promotion Centers in Taiwan. Diabetes Res Clin Pract 2009; 84: Chou P, Chen HH, Hsiao KJ: Communitybased epidemiological study on diabetes in Pu-Li, Taiwan. Diabetes Care ; 15: Chou P, Liao MJ, Kuo HS, Hsiao KJ, Tsai ST: A population survey on the prevalence of diabetes in Kin-Hu, Kinmen. Diabetes Care 1994; 17: Lu FH, Yang YC, Wu JS, Wu CH, Chang CJ: A population-based study of the prevalence and associated factors of diabetes mellitus in southern Taiwan. Diabet Med 1998; 15: tw/bhpnet/portal/file/themedocfi le/ /. Accessed 28. Tolson GC, Barnes JM, Gay GA, Kowaleski JL: The 1989 Revision of the U.S. Standard Certificates and Reports. Vital and Health Statistics, Series 4, No. 28. Hyattsville, MD: National Center for Health Statistics Edge JA, Ford-Adams ME, Dunger DB: Causes of death in children with insulin dependent diabetes Arch Dis Child 1999; 81: Office for National Statistics: Definition of avoidable mortality. London: Office for National Statistics;. 31. Centers for Disease Control and Prevention: Diabetes death rates among youths aged 19 years--united States, MMWR Morb Mortal Wkly Rep ; 61: Chang YF, LaPorte RE: Calendar time trends of the insulin-dependent diabetes mellitus mortality in Allegheny county, Pennsylvania. Diabetes Res Clin Pract 1996; 34: S Songer TJ, Laorte RE, Dorman IS, Orchard TJ, Becker DJ, Drash AL: Health, life and automobile insurance characteristics in adults with IDDM. Diabetes Care 1991; 14: June 10, 2015.

12 46 [Original Article] Diabetes-related Mortality Trends in Taiwan, - Yu-Pei Lin 1,2 and Tsung-Hsueh Lu 3,4 Objectives: Multiple cause-of-death (MCOD) data can be used to supplement underlying causeof-death (UCOD) data to provide more information in demonstrating diabetes mortality burden. The study aims to analyze the mortality trends of diabetes using compiled UCOD data and MCOD data. Methods: Multiple cause mortality files for,,,, and were used to calculate the age-adjusted death rates from diabetes based on the MCOD and UCOD data in Taiwan. Relative risks of mortality rate between and subsequent years were estimated by Poisson regression model to examine the temporal trends in diabetes mortality. Results: During the period from to, diabetes mortality emerged to be on the wane according to the UCOD data but appeared to rise persistently in line with the MCOD data. For men, both the UCOD- and MCOD-based diabetest mortality rates reported a steady increase amont all the four age groups examined. For women, on the other hand, a trend of decline was observed in the UCOD- and MCOD-based death rates of those aged 0-44 years and 75 years or above, while a significant increase was detected in the MCOD- and UCOD-based mortality rates of those in the other two age groups (45-64 and years) Conclusion: It should be noted that analysis based exclusively on underlying cause-of-death data can be misleading when it comes to tracing the mortality trends in patients with diabetes in Taiwan. Both UCOD and MCOD data should be taken into consideration to help develop a more effective public health program. (Taiwan J Fam Med 2016; 26: 35-46) DOI: / Key words: mortality trends, multiple cause-of-death, underlying cause-of-death 1 Department of Family Medicine, Kaohsiung Municipal Min-Shen Hospital, Kaohsiung; 2 Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan; 3 Research Center for Health Data and 4 Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan. Received: October 21, 2015; Revised: December 14, 2015; Accepted: January 4, 2016.

國民健康狀況是分配醫療資源及訂定全國健康目標之主要依據，更是衡量一個國家發展概況的重要指標之一

國民健康狀況是分配醫療資源及訂定全國健康目標之主要依據，更是衡量一個國家發展概況的重要指標之一 89 5 1 212 312 412~19 520~65 1 30 CDC, 1998 1957 1994 89 1 2 3 1994 3,814 15,000 1995 1989 4,049 60 1997 2 1980 1998 1956 2000 2000 3 (computer-assisted telephone interviewing, CATI) (computer-assisted