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1. Gender-based differences in mortality and complementary therapies for patients with stroke in Taiwan. 1

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Dokumen 1 dari 1

Gender-based differences in mortality and

complementary therapies for patients with
stroke in Taiwan
Liu, Chun-Ting; Wu, Bei-Yu; Hu, Wen-Long; Hung, Yu-Chiang . Complementary Therapies in Medicine ;
Kidlington  Vol. 30,  (Feb 01, 2017): 113-117.

Link dokumen ProQuest

ABSTRAK
 
Background
Stroke is a leading cause of death worldwide. In this retrospective study, we investigated the different effects of
gender on medical behavior, medical service, medical cost, and death from stroke in Taiwan.
Methods
We collected data on the stroke-associated mortality rate according to gender and age group for the period
between 2009 and 2013 from the official registry of Ministry of Health and Welfare, Taiwan. We analyzed the data
related to stroke-associated medical care and costs in 2013 from the National Health Insurance Research
Database (NHIRD).
Results
The mortality rate due to stroke was higher in men than in women, despite more inpatient or outpatient medical
treatment and higher medical costs, especially in patients aged <50years. Married women showed a significantly
lower stroke-associated mortality compared to married men. Women were significantly more likely to accept
Western medicine combined with traditional Chinese medicine (TCM) treatment than men (81.51% of women and
74.27% of men). They had lower medical expenditure and lower mortality from stroke than men did. Combined use
of integrative Chinese and Western medicine also was associated with lower mortality from stroke than use of
conventional Western medicine alone.
Conclusions
In Taiwan, stroke-associated mortality is higher in men. Marriage or female sex hormone may have protective
effect against stroke in women. Women also more tended to seek TCM complementary therapies combined with
Western medicine. Integrated Chinese and Western medicine could thus be a potential treatment for stroke.

TEKS LENGKAP
 
Background
Stroke is a cerebrovascular accident that results in brain ischemia due to poor blood flow or hemorrhage. It is a
major cause of mortality and disability worldwide. Two recently published systematic reviews1,2 showed that the
global burden of stroke has increased over the past two decades. Some studies have reported that gender-based
differences exist in the etiology, presentation, treatment, and outcome of stroke.3-6 Epidemiological studies and
analysis of stroke registry data7-11 have indicated that the incidence or prevalence of stroke is higher among men
than among women, although women tend to have poor outcomes. However, some studies have reported no
differences in mortality or disability based on gender;12-15 others have even shown that women have a better
survival rate than men.16,17
Thus, gender-based differences in mortality rate and other parameters related to stroke are controversial. Few

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studies have investigated these differences, which were published over 20 years ago in Taiwan18-20 . They showed
that the mortality rate for women was lower than that for men and increased exponentially with age for cerebral
infarction and hemorrhage. However, gender differences in relation to TCM complementary medicines have not
been previously examined. Therefore, in this study, we used data from the database of the government registry and
the National Health Insurance (NHI) program to investigate the gender-based differences in stroke-related
mortality rate, medical care behavior, and outcomes.
Materials and methods
Data sources
This study was approved by the Human Ethics Committee of our hospital (Chang Gung Medical Foundation
Institutional Review Board No. 104-5420B). Stroke (ICD-9-CM code: 430-438) mortality was retrospectively
collected by gender and age group, for the period between January 2009 and December 2013 from the official
registry of the Ministry of Health and Welfare, Taiwan. The data included the standardized death rate (SDR), which
is the death rate of a population adjusted to the standard age distribution. It is calculated as a weighted average
(based on the age distribution) of the age-specific death rates of a given population. In addition, we downloaded
and analyzed the data on stroke-related medical care and the associated costs in 2013 from the National Health
Insurance Research Database (NHIRD).
Study subjects
In Taiwan, stroke patients may seek treatment with Western medicine or traditional Chinese medicine (TCM), or a
combination of the two. In order to understand the gender-based differences in stroke-related mortality rate,
medical care, and associated costs between patients receiving TCM and those receiving Western medicine, we
conducted a population-based study on stroke patients among one million subjects randomly selected from the
NHI scheme of Taiwan.
Statistical analysis
All statistical analyses were performed using SPSS statistics 17.0. Chi-square test, ANOVA test, hierarchical
loglinear analysis, and odds ratio (OR) were carried out to compare gender-based differences for each factor.
P<0.05 was considered statistically significant.
Results
Gender differences in mortality
For the period from 2009 to 2013, stroke was the third leading cause of death in Taiwan for men; for women it was
the third leading cause of death for the period from 2009 to 2011 and the fourth leading cause of death for the
period from 2011 to 2013. The number of stroke-related deaths and the SDR for stroke during the period from 2009
to 2013 is shown in Table 1 , and the sex ratio is presented in Fig. 1 . The number of stroke patients increased and the
SDR decreased over time during this period. The number of deaths and the SDR for stroke was higher among men
than among women for the period from 2009 to 2013. Gender-based differences were significant in any single year
(P<0.001), but not between years (P=0.424). The sex ratio for stroke-related SDR increased progressively, but the
trend was not significantly different from 2009 to 2013.
We collected data on 121,729 inpatients and 617,606 outpatients with stroke in 2013. The total expenditure on
inpatient and outpatient care in 2013 was 6,900,809,000 New Taiwan Dollar (NTD) and 7,968,647,000 NTD,
respectively. The number, medical costs, and male/female ratio for stroke inpatients and outpatients by age group
are presented in Table 2 and Fig. 2 . The prevalence of stroke patients was 3.16% (739,335/23,373,517) in 2013. The
prevalence in males was 3.5% (408,457/23,373,517), which was higher than the prevalence in females (2.83%;
330,878/23,373,517). Patients with stroke attacks were among the most frequent hospital admissions for inpatient
care in Taiwan. The hospital admission rate was 59.42% (72,337/121,729) for males with stroke, which was higher
than the rate of admissions for stroke in females (40.58%; 49,392/121,729). A significantly greater number of men
received inpatient or outpatient medical care than women. Further, inpatient or outpatient medical expenses were
significantly higher for men than for women. Regardless of sex, patients 50 years of age or older had more medical
care and medical cost. Men also had higher odds of stroke-related medical care and medical cost than women did.

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The OR of men to women increased with age. In spite of this, the mortality rate was higher among men than
among women. Male/female ratio for stroke-related deaths significantly decreased with increasing age, especially
in patients aged >50years. However, the OR of mortality still increased with age.
Gender differences in medical behavior
As shown in Table 2 , among the patients who died of stroke, 61% (4049/6590) of men and 30% (1423/4707) of
women were married. Married women had a significantly lower stroke-related mortality rate compared to that for
married men. In contrast, widowed women showed a higher stroke-related mortality rate compared to that for
widowed males. Married women also had a lower stroke-related mortality rate than widowed women (30.19% vs
61.96%). In addition, if the OR of married status was 1, the OR of widowed status was 6.62. Out of the randomly
sampled one million subjects, a total of 15,896 stroke inpatients were selected for analysis. Of these, 77%
(12288/15896) received Western medicine combined with TCM treatment. When analyzed by gender, this
percentage was 74.27% (6861/9238) for men and 81.51% (5427/6658) for women. The OR of medical behavior was
1.53. Women were significantly more likely to accept Western medicine combined with TCM treatment than men (
Table 2
). In addition, women had lower medical expenditure and lower mortality than men in stroke. Combined
treatment with integrative Chinese and Western medicine had lower mortality than conventional Western medicine
alone (Table 3 ).
Discussion
In this study, we compared the stroke-related mortality rates, the nature, and associated costs of the medical care
received, between men and women in Taiwan for the period between 2009 through 2013. Our results revealed
significant differences in these parameters between men and women. Although the percentage of patients
receiving inpatient or outpatient medical treatment, and the medical costs, were higher among men than among
women, especially in patients aged below 50 years, the overall stroke-related mortality rate was still higher in men
than in women. The number of deaths and the SDR for stroke was higher among men than among women for each
year. SDR is the death rate of a population adjusted to a standard age distribution. It is calculated as a weighted
average of the age-specific death rates of a given population to improve comparability over time and between
countries. If the SDR is higher than 1.0, then there is a higher number of deaths than is expected. From 2009-2013,
the male/female ratio of SDR increased over time. This implies that men are more vulnerable to life-threatening,
and even fatal, illnesses. The decline in male/female ratio among patients who died because of stroke may be due
to the longer life expectancy of women. The male/female ratio declined in patients aged above 50 years and
markedly declined above 75 years of age. This suggested that premenopausal women had a lower stroke-related
mortality than men. This was probably due to the neuroprotective effect of sex hormones, such as estrogen and
progesterone, which promote vascular dilation and blood flow 21 and protect against stroke-related death,4 whereas
testosterone has the opposite effects21 . Similarly, premenopausal women have good cerebrovascular reactivity,
but postmenopausal women have poorer responses21 . Postmenopausal women may have a higher mortality from
stroke than premenopausal women do due to the loss of the neuroprotective effects of sex hormones that protect
against stroke-related death. Also because of their longer life expectancy, women comprise a significant majority
of the older population. Life expectancy in Taiwan rose to an average 80 years in 2013, with an average 83.4 years
for females and 76.9 years for males. In this study, analysis of the death and marital status of stroke patients aged
above 15 years in 2013 revealed that 61% men and 30% women were married when they died from stroke. Married
women had a lower stroke-related mortality rate than married men. In contrast, widowed women had a higher
stroke-related mortality rate than widowed men. Unmarried women are more likely to be living alone or in an
assisted living arrangement or a nursing home. 5 Therefore, being married might have a protective effect against
stroke in women, since it might ensure better care. This may be due to the more marriage-dependent and longer
life expectancy of women. For women, marital breakup has been linked to a greater likelihood of falling into
poverty. Unmarried women are more likely to be living alone or in an assisted living arrangement or a nursing
home. 5 The larger burden of economic vulnerabilities experienced by unmarried women thus appears to be an
important contributor to the protective role of marriage.22 However, this requires further qualitative and

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quantitative study.
Patients treated with integrated Chinese and Western medicine accepted both conventional Western medicine and
adjuvant Chinese medicine simultaneously. Based on the NHI program in Taiwan, more patients with stroke favor
TCM for stroke and its complications. We found that women were more likely to receive TCM treatment combined
with Western medicine than men were. In Taiwan, TCM such as acupuncture or herbs are popular and readily
accepted treatment options for stroke. 23-25 Recent studies26-28 showed that TCM has beneficial effects in stroke
patients. Previous studies5,29,30 have shown that women have poorer outcomes after stroke than men do. Women
experience more post-stroke physical impairments and limitations in activities of daily living after stroke, as
measured by the Barthel index. These sex-specific differences in stroke outcome are mainly explained by the
higher age and lower level of consciousness of women on admission. 21 In contrast, in this study, we found that
women had a lower stroke-related mortality rate, despite receiving lesser inpatient or outpatient medical care and
incurring lower medical costs. Integrated TCM and Western medicine treatment may help improve the post-stroke
survival rate of female patients and reduce the burden of care. A previous study reported favorable circulatory
system outcomes in inpatients receiving adjuvant TCM treatment with fewer re-admissions for circulatory system
events and an approximately 66% reduction in stroke-related re-admission compared to that for patients who
received non-TCM treatments alone. 28
There were some limitations in our study. First, our study showed men had higher percentage of receiving inpatient
or outpatient medical treatment, and higher medical costs; however, the severity, comorbidity, and urban-rural
differences among stroke patients in Taiwan were not presented. Second, we found that women were more likely
to receive TCM treatment combined with Western medicine. However, we were unable to perform a rigorous
assessment of the differences in clinical outcomes between patients receiving Western medicine alone and those
receiving a combination of the two treatments because National Institutes of Health Stroke Scale scores and
Barthel index results were not recorded in the official registry. Thus, we could not compare gender differences in
functional outcome before and after stroke treatment. Third, this study was retrospective and that prospective
studies are needed in the future. Further clinical trials need to be conducted in the future to explore the efficacy of
TCM treatment among stroke patients. Moreover, the government should implement new policies that advocate a
healthier lifestyle for men, and enhance the quality of care for the elderly, especially for women.
Conclusions
In Taiwan, women, especially married women, seemed to be less vulnerable to stroke-related death. Moreover,
female stroke patients tended to seek integrated TCM complementary therapies and Western medicine
conventional treatment more frequently than men, which may have a beneficial effect on post-stroke patients.
Thus, integrated TCM and Western medicine could potentially reduce the care burden and be useful in the
treatment of stroke.
Conflict of interest
No conflict of interest to disclose.
Authors' contributions
Y.-C. Hung and W.-L. Hu conceived and designed the study. C.-T. Liu and B.-Y. Wu performed the study and drafted
the manuscript. Y.-C. Hung analyzed and interpreted the data. Y.-C. Hung and W.-L. Hu critically reviewed and
revised the manuscript. All authors have read and approved the paper.

  2009 2010 2011 2012 2013   N SDR N SDR

N SDR N SDR N SDR Male 6158 40.3 5963 37.6

6395 39.1 6426 38.3 6599 38.0 Female 4225 25.7 4171 24.0

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 M/F
4428 24.1 4635 23.9 4714 23.2 1.46 1.59 1.43 1.57
ratio

Chi-
1.44 1.62 1.39 1.60 1.40 1.64 347.78 316.88 357.49 289.99
square

  Males Females M/F ratio OR P value

Medical care (N) 408,457 330,878 1.23   <0.001

  Inpatient (N) 72,337 49,392 1.46  

  <50 y/o 6952 3199 2.17 1

  50-74 y/o 36,947 20,680 1.79 1.22

  >74 y/o 28,438 25,513 1.11 1.95

    Outpatient (N) 336,120 281,486 1.19

  <0.001 <50 y/o 36,843 24,196 1.52

1   50-74 y/o 184,406 144,506 1.28

1.19   >74 y/o 114,871 112,784 1.02

Medical 8,798,34
1.50     6,071,120
cost(/1000) 2

Inpatient cost 4,071,87

1.45   <0.001 2,828,930
(/1000) 9

1.44     <50 y/o 644,652 319,859

2,251,25
2.02 1   50-74 y/o 1,342,932
2

1,175,97
1.68 1.20   >74 y/o 1,166,139
6

Outpatie
1.01 2.00     nt cost 4,726,460
(/1000)

3,242,187 1.46   <0.001 <50 y/o 511,860

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 50-74
224,423 2.28 1   2,801,096
y/o

1,691,120 1.66 1.38   >74 y/o 1,413,506

Mortality
1,326,647 1.07 2.14    
rate (%)

1.61 1.42 1.13   <0.001 Death (No)

6599 4714 1.40     <50 y/o

484 195 2.48 1   50-74 y/o

2432 1080 2.25 1.10   >74 y/o

3683 3439 1.07 2.32    

Marital status (N)*         <0.001

Unmarried 595(9.01%) 146(3.10%) 4.08 0.70  

Married 4049(61.36%) 1423(30.19%) 2.85 1  

Divorced 516(7.82%) 117(2.48%) 4.41 0.65  

Widowed 1255(19.02%) 2921(61.96%) 0.43 6.62  

Unknown 1842.79% 107(2.27%) 1.72 1.65  

Treatment Gender Medical care (N) Mortality rate Medical cost/1000

Only Western medicine Male 2377 (25.73%) 2.69% 51,201

  Female 1231 (18.49%) 2.45% 25,587

TCM and
  Western Male 6861 (74.27%) 1.23%
medicine

147,789   Female 5427 (81.51%) 1.19%

96,577   OR (Male/Female)   1.53

1.06 1.31 P value   P<0.001

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DETAIL

Subjek: Studies; Womens health; Chinese medicine; Mortality

Lokasi: Taiwan

Pengidentifikasi/kata kunci: Abbreviations NHI National Health Insurance NHIRD National Health Insurance
Research Database NTD New Taiwan Dollar SDR standardized death rate TCM
traditional Chinese medicine

Judul: Gender-based differences in mortality and complementary therapies for patients with
stroke in Taiwan

Pengarang: Liu, Chun-Ting; Wu, Bei-Yu; Hu, Wen-Long; Hung, Yu-Chiang

Judul publikasi: Complementary Therapies in Medicine; Kidlington

Volume: 30

Halaman: 113-117

Tahun publikasi: 2017

Tanggal publikasi: Feb 01, 2017

Penerbit: Elsevier Limited

Tempat publikasi: Kidlington

Negara publikasi: United States, Kidlington

Subjek publikasi: Medical Sciences--Chiropractic, Homeopathy, Osteopathy, Alternative Medicine

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 ISSN: 09652299

Jenis sumber: Scholarly Journals

Bahasa publikasi: English

Jenis dokumen: Journal Article

DOI: http://dx.doi.org/10.1016/j.ctim.2016.12.004

ID dokumen ProQuest: 1863563709

URL Dokumen: https://search.proquest.com/docview/1863563709?accountid=25704

Hak cipta: Copyright Elsevier Limited Feb 01, 2017

Terakhir diperbarui: 2017-02-07

Basis data: Biological Science Database; Family Health Database

Hak cipta basis data  2018 ProQuest LLC. Semua hak cipta dilindungi.

Syarat dan Ketentuan Hubungi ProQuest

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