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JKM > Volume 40(3); 2019 > Article
Cho, Jung, and Lim: Association between Korean Medicine Hospital Utilization and Cardiovascular Risks in Patients with Hypertension: a National Korean Cohort Study

Abstract

Objectives

This study aims to investigate the effects of Korean Medicine Hospital Utilization (KMHU) on major adverse cardiovascular events (MACE), myocardial infarction (MI), stroke, and death in hypertensive patients taking antihypertensives.

Methods

Using the Korean National Health Insurance Service-National Sample Cohort database, this study identified and diagnosed 68,457 hypertensive patients taking antihypertensives between 2003 and 2006. They were divided into KMHU and non-KMHU groups. The follow-up period ended with the diagnosis of myocardial infarction, stroke, or death. After propensity score matching (PSM), there were 18,242 patients each in the non-KMHU and KMHU groups. We calculated the incidence rate, hazard ratio (HR), and 95% confidence interval (CI) for MACE, myocardial infarction, stroke, and death in patients with hypertension using a stratified Cox proportional hazard model. In addition, secondary outcome analyses for stroke and cardiovascular mortality were performed.

Results

After PSM, the HRs for MACE (HR: 0.84, 95% CI: 0.81–0.87), all-cause mortality (HR: 0.75, 95% CI: 0.72–0.79), and myocardial infarction (HR: 0.90, 95% CI: 0.83–0.97) were significantly lower in the KMHU group than in the non-KMHU group. Moreover, the HRs for stroke-related mortality, haemorrhage and ischaemic stroke-related mortality, and ischaemic heart disease-related and circulatory system disease-related mortality were significantly lower in the KMHU group than in the non-KMHU group.

Conclusions

On long-term follow-up observation, this study supported the effect of KMHU for managing hypertension and reducing the burden of cardiovascular diseases.

Fig. 1
Flowchart of sample selection process. From 1 million sampled data, patients who were newly diagnosed with hypertension, between 2003 and 2006, were included in this study. Except for subjects that did not meet the criteria, the korean medicine hospital utilization group and the non-korean medicine hospital utilization group group matched with propensity score at a 1:1 ratio.
jkm-40-3-1f1.gif
Fig. 2
Kaplan-Meier Curves on MACE, all-cause mortality, myocardial infarction, and stroke in Korean medicine hospital utilization group and non-Korean medicine hospital utilization group before PSM, after PSM and after stabilized IPTW. MACE indicates Major Adverse Cardiovascular Events; PSM, Propensity Score Matching; and s IPTW, Stabilized Inverse Probability of Treatment Weighting.
jkm-40-3-1f2.gif
Fig. 3
Kaplan-Meier curves on cerebro-cardio vascular mortality in Korean medicine hospital utilization group and non-Korean medicine hospital utilization group before PSM, after PSM and after stabilized IPTW. CSD indicates Circulatory System Disease ; IHD, Ischemic Heart Disease; PSM, Propensity Score Matching; and s IPTW, stabilized Inverse Probability of Treatment Weighting.
jkm-40-3-1f3.gif
Table 1
Baseline characteristics of subjects
Before PSM After PSM After stabilized IPTW

Demographics non-korean medicine hospital utilization korean medicine hospital utilization absolute standardized difference non-korean medicine hospital utilization korean medicine hospital utilization absolute standardized difference non-korean medicine hospital utilization korean medicine hospital utilization absolute standardized difference
N 40798 18328 18242 18242 40832 18311

Age (y) 57.5±10.3 59.2±10.2 0.1729 59.1±10.2 59.2±10.2 0.0116 58.0±10.4 58.0±10.2 0.0055
 40–49 11007 (27.0) 3842 (21.0) 0.1413 3927 (21.5) 3838 (21.0) 0.0119 10321 (25.3) 4637 (25.3) 0.0011
 50–59 11914 (29.2) 5223 (28.5) 0.0156 5173 (28.4) 5207 (28.5) 0.0041 11653 (28.5) 5454 (29.8) 0.0274
 60–69 11755 (28.8) 5816 (31.7) 0.0636 5753 (31.5) 5786 (31.7) 0.0039 12114 (29.7) 5386 (29.4) 0.0056
 70–79 6122 (15.0) 3447 (18.8) 0.1016 3389 (18.6) 3411 (18.7) 0.0031 6744 (16.5) 2835 (15.5) 0.0282

Female sex 18829 (46.2) 11754 (64.1) 0.3676 11631 (63.8) 11674 (64.0) 0.0049 21099 (51.7) 9426 (51.5) 0.0039

Male sex 21969 (53.8) 6574 (35.9) 0.3676 6611 (36.2) 6568 (36.0) 0.0049 19733 (48.3) 8885 (48.5) 0.0039

Household income
 Low 11696 (28.7) 4981 (27.2) 0.0332 4899 (26.9) 4967 (27.2) 0.0084 11501 (28.2) 5139 (28.1) 0.0023
 Middle 13857 (34.0) 6181 (33.7) 0.0051 6199 (34.0) 6160 (33.8) 0.0045 13857 (33.9) 6234 (34.0) 0.0023
 High 15245 (37.4) 7166 (39.1) 0.0356 7144 (39.2) 7115 (39.0) 0.0033 15475 (37.9) 6938 (37.9) 0.0002

Residence Urban 34021 (83.4) 15300 (83.5) 0.0024 15283 (83.8) 15230 (83.5) 0.0079 34065 (83.4) 15284(83.5) 0.0010

Residence Rural 6777 (16.6) 3028 (16.5) 0.0024 2959 (16.2) 3012 (16.5) 0.0079 6767 (16.6) 3028 (16.5) 0.0010

CCI 2.5±1.9 3.1±2.1 0.3074 3.0±2.1 3.0±2.1 0.0007 2.7±2.1 2.7±1.9 0.0008
 0 5494 (13.5) 1454 (7.9) 0.1797 14362 (8.0) 1454 (8.2) 0.0016 4936 (12.1) 2016 (11.0) 0.0337
 1 8383 (20.5) 2805 (15.3) 0.1370 2820 (15.5) 2805 (15.4) 0.0023 7787(19.1) 3404 (18.6) 0.0123
 2 9456 (23.2) 3779 (20.6) 0.0619 3813 (20.9) 3779 (20.7) 0.0046 9103 (22.3) 4125 (22.5) 0.0056
 3 7768 (19.0) 3747 (20.4) 0.0353 3772 (20.7) 3747 (20.5) 0.0034 7864 (19.3) 3652 (19.9) 0.0172
 4 4600 (11.3) 2692 (14.7) 0.1017 2690 (14.7) 2692 (14.8) 0.0003 4898 (12.0) 2332 (12.7) 0.0224
 5 2455 (6.0) 1694 (9.2) 0.1217 1654 (9.1) 1689 (9.3) 0.0067 2767 (6.8) 1331 (7.3) 0.0192
 6 1279 (3.1) 1009 (5.5) 0.1168 928 (5.1) 980 (5.4) 0.0128 1531 (3.7) 735 (4.0) 0.0137
 7 616 (1.5) 530 (2.9) 0.0943 459 (2.5) 499 (2.7) 0.0137 794 (1.9) 357 (1.9) 0.0004
 8 341 (0.8) 298 (1.6) 0.0717 260 (1.4) 293 (1.6) 0.0148 469 (1.1) 185 (1.0) 0.0134
 9 186 (0.5) 157 (0.9) 0.0496 168 (0.9) 156 (0.9) 0.0070 286 (0.7) 91 (0.5) 0.0264
 ≥10 220 (0.5) 160 (0.9) 0.0416 216 (1.2) 148 (0.8) 0.0375 397 (1.0) 83 (0.5) 0.0617

IPTW indicates Inverse Probability of Treatment Weighting; and PSM, Propensity Score Matching.

* Data are expressed as the mean ± standard deviation, or number (%).

Table 2
Incidence rate of MACE, all-cause mortality, myocardial infarction, and stroke by acupuncture
Before PSM After PSM After stabilized IPTW

Events (n) Follow-up duration (person years) Incidence rate (per 1000 person years) Events (n) Follow-up duration (person years) Incidence rate (per 1000 person years) Events (n) Follow-up duration (person years) Incidence rate (per 1000 person years)
MACE
 non-korean medicine hospital utilization 8921 408,268 21.85 4225 181,387 23.29 9153 407,385 22.47
 korean medicine hospital utilization 3542 180,099 19.67 3521 179,301 19.64 3401 180,666 18.83

All-cause mortality
 non-korean medicine hospital utilization 6145 426,213 14.42 2938 189,896 15.47 6372 425,551 14.97
 korean medicine hospital utilization 2209 188,369 11.73 2197 187,527 11.72 2104 188,577 11.16

Myocardial infarction
 non-korean medicine hospital utilization 1561 419,244 3.72 744 186,559 3.99 1585 418,522 3.79
 korean medicine hospital utilization 695 185,274 3.75 690 184,450 3.74 671 185,580 3.62

Stroke
 non-korean medicine hospital utilization 3098 414,448 7.48 1457 184,355 7.90 3159 413,605 7.64
 korean medicine hospital utilization 1402 182,871 7.67 1395 182,055 7.66 1328 183,364 7.24

IPTW indicates Inverse Probability of Treatment Weighting; MACE, Major Adverse Cardiovascular Events; and PSM, Propensity Score Matching.

Table 3
Hazard ratios of MACE, all-cause mortality, myocardial infarction and stroke treated with acupuncture
Crude analysis Multivariable analysis PSM stabilized IPTW

HR (95% CI) P-value HR* (95% CI) P-value HR (95% CI) P-value HR (95% CI) P-value
MACE 0.91 (0.87–0.94) <.0001 0.84 (0.81–0.88) <.0001 0.84 (0.81–0.87) <.0001 0.84 (0.81–0.88) <.0001
All-cause mortality 0.82 (0.78–0.86) <.0001 0.75 (0.71–0.78) <.0001 0.75 (0.72–0.79) <.0001 0.75 (0.72–0.79) <.0001
Myocardial infarction 1.00 (0.92–1.10) 0.9676 0.96 (0.87–1.05) 0.3380 0.90 (0.83–0.97) 0.0076 0.95 (0.87–1.05) 0.3180
Stroke 1.03 (0.97–1.10) 0.3766 0.96 (0.90–1.02) 0.1825 0.98 (0.92–1.03) 0.3860 0.95 (0.89–1.02) 0.1471

CI indicates Confidence Interval; HR, Hazard Ratio; IPTW, Stabilized Inverse Probability of Treatment Weighting; MACE, Major Adverse Cardiovascular Events; and PSM, Propensity Score Matching.

* Adjusted for variables listed in the table 1.

† Cox proportional hazards model stratifying on matched pairs.

‡ Weighted Cox proportional hazards model with robust standard errors.

Table 4
Incidence rate of cerebro-cardiovascular mortality by acupuncture
Before PSM After PSM stabilized IPTW

Events (n) Follow-up duration (person years) Incidence rate (per1000 person years) Events (n) Follow-up duration (person years) Incidence rate (per 1000 person years) Events (n) Follow-up duration (person years) Incidence rate (per 1000 person years)
Stroke-related mortality
 non-korean medicine hospital utilization 670 426,213 1.57 333 189,896 1.75 704 425,551 1.65
korean medicine hospital  utilization 263 188,369 1.40 263 187,527 1.40 241 188,577 1.28

Hemorrhage stroke-related mortality
 non-korean medicine hospital utilization 163 426,213 0.38 90 189,896 0.47 170 425,551 0.40
 korean medicine hospital utilization 59 188,369 0.31 59 187,527 0.31 52 188,577 0.28

Ischemic stroke-related mortality
 non-korean medicine hospital utilization 193 426,213 0.45 93 189,896 0.49 204 425,551 0.48
 korean medicine hospital utilization 78 188,369 0.41 78 187,527 0.42 72 188,577 0.38

IHD-related mortality
 non-korean medicine hospital utilization 366 426,213 0.86 167 189,896 0.88 379 425,551 0.89
 korean medicine hospital utilization 139 188,369 0.74 139 187,527 0.74 135 188,577 0.72

CSD-related mortality
 non-korean medicine hospital utilization 1465 426,213 3.44 730 189,896 3.84 1541 425,551 3.62
 korean medicine hospital utilization 580 188,369 3.08 578 187,527 3.08 539 188,577 2.86

CSD indicates Circulatory System Disease ; IHD, Ischemic Heart Disease; IPTW, Inverse Probability of Treatment Weighting; and PSM, Propensity Score Match

Table 5
Hazard ratios of cerebro-cardiovascular mortality by acupuncture
Crude analysis Multivariable analysis PSM stabilized IPTW
HR (95% CI) P-value HR* (95% CI) P-value HR(95% CI) P-value HR(95% CI) P-value
Stroke-related mortality 0.90 (0.78–1.04) 0.1400 0.78 (0.67–0.90) 0.0009 0.80 (0.71–0.91) 0.0008 0.78 (0.67–0.90) 0.0010
Hemorrhage stroke-related mortality 0.83 (0.62–1.12) 0.2195 0.72 (0.53–0.97) 0.0325 0.72 (0.56–0.92) 0.0097 0.70 (0.52–0.95) 0.0236
Ischemic stroke-related mortality 0.93 (0.71–1.20) 0.5629 0.80 (0.61–1.04) 0.0988 0.79 (0.61–1.01) 0.0622 0.80 (0.61–1.05) 0.1146
IHD-related mortality 0.87 (0.72–1.06) 0.1655 0.79 (0.65–0.97) 0.0225 0.79 (0.66–0.94) 0.0097 0.81 (0.66–1.00) 0.0474
IHD-related mortality 0.87 (0.72–1.06) 0.1655 0.79 (0.65–0.97) 0.0225 0.79 (0.66–0.94) 0.0097 0.81 (0.66–1.00) 0.0474
CSD-related mortality 0.91 (0.83–1.00) 0.0508 0.79 (0.71–0.87) <.0001 0.79 (0.72–0.86) <.0001 0.80 (0.72–0.88) <.0001

CI indicates Confidence interval; CSD, Circulatory System Disease, HR, Hazard Ratio; IHD, Ischemic Heart Disease; IPTW, Inverse Probability of Treatment Weighting; and PSM, Propensity Score Matching.

* Adjusted for variables listed in the table 1.

† Cox proportional hazards model stratifying on matched pairs.

‡ Weighted Cox proportional hazards model with robust standard errors.

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