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Prevalence of chronic diseases among physicians in Taiwan: a population- based cross-sectional study Li-Ting Kao,1,2,3 Yu-Lung Chiu,1,2,3 Herng-Ching Lin,3 Hsin-Chien Lee,4 Shiu-Dong Chung3,5,6
To cite: Kao cite: Kao L-T, Chiu Y-L, Lin H-C, et al . Prevalence of chronic diseases among physicians in Taiwan: a population-based crosssectional study. study. BMJ Open 6:e009954. 2016;6 2016; doi:10.1136/bmjopen-2015009954 ▸ Prepublication Prepublication history and additional material is available. To view please visit the journal (http://dx.doi.org/ (http://dx.doi.org/ 10.1136/bmjopen-2015009954). 009954 ).
H-CL and S-DC contributed equally. Received 10 September 2015 Revised 24 December 2015 Accepted 28 January 2016
ABSTRACT Objectives: The health of physicians is an important topic which needs to be addressed in order to provide the best quality of patient care. However, there are few studies on the prevalence of chronic diseases among physicians. In this study, we explored the prevalence of chronic diseases among physicians and compared the probability of chronic diseases between physicians and the general population using a population-based data set in Taiwan. Study design: A cross-sectional study. Setting: Taiwan. Participants: Our study consisted of 1426 practising physicians and 5704 general participants. Primary outcome measures: We chose 22 chronic diseases from the Elixhauser Comorbidity index and nine highly prevalent medical conditions in an Asian population for analysis. We used conditional logistic regression analyses to investigate the OR and its corresponding 95% CI of chronic diseases between these two group groups. s. Results: The conditional logistic regression analyses showed that physicians had lower odds of peripheral vascular disorders (OR=0.41, 95% CI=0.19 to 0.90), uncomplicated diabetes (OR=0.76, 95% CI=0.60 to 0.97), complicated diabetes (OR=0.53, 95% CI=0.34 to 0.83), renal failure (OR=0.41, 95% CI=0.19 to 0.90), liver diseases (OR=0.78, 95% CI=0.66 to 0.94), and hepatitis B or C (OR=0.62, 95% CI=0.49 to 0.77) and higher odds of hypert hypertension ension (OR=1.21 (OR=1.21,, 95% CI=1.03 to 1.41), hyperlipidaemia (OR=1.43, 95% CI=1.23 to 1.67) and asthma (OR=1.59, 95% CI=1.16 to 2.18) than the general population. Conclusions: We concluded that although physicians had decreased prevalence of some chronic diseases, they had a significantly increased prevalence of hypertension, hyperlipidaemia and asthma.
For numbered affiliations see end of article. Correspondence to Dr Shiu-Dong Chung; [email protected]
INTRODUCTION Much of the previous literature reported that physicia phy sicians, ns, who have have healthy healthy beha behaviou viours rs or re recei ceive ved d some some prev prevent entiv ivee prac practic tices, es, we were re more likely to counsel their patients to have si simi mila larr heal health th-p -pro romo moti ting ng be beha havi viou ours rs or
Strengths and limitations of this study This study used a population-based population-based data set. sample size to detec detectt ▪ This study had a sufficient sample st stat atis istic tical al si sign gnif ific ican ance ce in th thee pr prev eval alen ence ce of como comorb rbid iditi ities es betw betwee een n ph phys ysic icia ians ns and and th thee general population. ▪ The data set used in this study did not provide inform informat ation ion on edu educa catio tion, n, lif lifest estyle yle or health health behaviour of the participants. ▪ The sampled participants included many different ethnic groups. ▪
preventive measures.1–5 This healthy doctor– healthy patient relationship totally highlights the importance of physicians’ health, including physical and mental health issues. However, to date, most studies on physician hea health lth focu focuse sed d on men enttal heal health th.. For inst instan ance ce,, many many ques questi tion onna nair iree surv survey eyss observed that physicians have a higher prevalence of psychological distress, mental disorders and substance use disor disorders ders than those in the general population.6–9 Another study using records from the USA National Violent Death Deat h Repo Report rtin ing g Syst System em al also so foun found d that that mental illness was an important comorb comorbidity for physicians who were suicide victims.10 On the other hand, one recent study found that ph phys ysic icia ians ns have have low lower od odds ds of ob obse sess ssiv iveecompulsiv compu lsivee disor disorder der,, major depressio depression n and specic phobias compared to their counterparts.11 Therefore, conclusions as to whether phys physic icia ians ns ha havve a high higher er risk risk of me ment ntal al illness illn ess than the general general populat population ion remain remain unclea unc learr. Fu Furth rtherm ermore ore,, no nowa wada days ys,, ve very ry few studi studies es ha have ve concen concentr trat ated ed on the issue issue of physic phy sical al hea health lth among among physic physician ians. s. To the be best st of ou ourr know knowle ledg dge, e, on only ly on onee Finn Finnis ish h study has shown that the self-reported health stat status us of fem female ale physic physician ianss w as better better than that of the general population.9 Nonetheless, they reported that several several chronic diseases diseases including chronic eczema, digestive diseases
Kao L-T, et al . BMJ Open 2016;6 2016;6:e009954. doi:10.1136/bmjopen-2015-009954
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and asthma were more prevalent in physicians than in the general population.9 Additionally,, population-based Additionally population-based data regarding the prevalence of chronic diseases among physicians remain sparse. Conclusions based on data collected in referral cent centre ress may may be li limi mite ted, d, du duee to the the re rela lati tive vely ly small samp sample le si size ze an and d se sele lect ctio ion n bias bias of the the studi tudies es..7–14 Therefore, this study aimed to explore the prevalence of chroni chr onicc dis diseas eases es among among physic physician ianss in Taiwa aiwan n usi using ng a popula pop ulatio tion-b n-base ased d data data set set.. We als also o compar compared ed risks risks of ch chro roni nicc di dise seas ases es amon among g ph phys ysic icia ians ns wi with th thos thosee for for match ma tched ed contr controls ols fr from om the gener general al popula populatio tion. n. We hypothesised that physicians would have a lower prevalence len ce of som somee chroni chronicc dis diseas eases es in the physic physical al aspect aspect because becau se physicia physicians ns have have more medical knowledg knowledgee and betterr health bette health behaviou behaviours rs than the general general populat population. ion. Howeve How everr, phys physicia icians ns may have have increased increased prevale prevalence nce of mental illnesses due to the high levels of work-related stress. MATERIALS AND METHODS Database Thee da Th data ta fo forr thi this stu tudy dy were ere retri etriev eved ed from from the the Lo Long ngit itud udin inaal Heal Health th In Insu surrance nce Databa tabase se 2000 2000 (LHID (LH ID200 2000). 0). The LHID20 LHID2000, 00, deriv derived ed from from Taiwan aiwan’s Bureau of National Health Insurance (NHI) records, is provided to scientists in Taiwan for research purposes by the Taiwan National Health Research Institute (NHRI). The LHID2000 consists of the registration les and original medical claims for 1 000 000 beneciari ciaries es under under the NHI programme. These selected 1 000 000 bene ciar ciarie iess were ere ra rand ndom omly ly sa samp mple led d from from the the ye year ar 2000 2000 Regi gisstry try of Ben eneeci ciar arie iess (n=2 (n=23. 3.72 72 mill millio ion) n).. The The LHID LH ID20 2000 00 pro provi vide dess an excl exclus usiv ivee oppo opport rtun unit ityy for for researchers to follow-up the use of all medical services for these 1 000 000 bene ciaries since initiation of the NHI programm programmee in 1995. Numerous researchers researchers have used the data derived from the Taiw aan n NHI programme 15 16
to perform and publish their studies. The LHID20 LHID2000 00 consis consists ts of de-ide de-identi ntied second secondary ary data data with with scramb scrambled led identi identicatio cation n codes codes of patie patients nts and medical medical fa facil ciliti ities. es. It is re relea leased sed to the public public for rese resear arch ch pu purp rpos oses es,, and and so this this stud studyy wa wass ex exem empt pted ed from from a fu full ll re revi view ew foll follow owin ing g cons consul ulta tati tion on wi with th the the National Nati onal Defense Defense Medical Medical Center Center Institut Institutional ional Review Review Board. Study sample Our crosscross-sec sectio tional nal st study udy includ included ed a physic physician ian group group and a comparison group. The physician group was identied by regis registry try for boardboard-cer certi tied specia speciali lists sts in the LHID20 LHI D2000. 00. These These le less incl includ uded ed da data ta of ph phys ysic icia ian n charact char acteris eristics tics,, such as age, sex, specialt specialtyy (family pracpractic tice, e, intern internal al medici medicine, ne, surger surgeryy, etc), etc), prac practic ticee type type (hospi (ho spital tal-ba -based sed or of ce-bas ce-based) ed),, etc. etc. NHRI NHRI prote protecte cted d patient condenti dentialit alityy in LHID2000 LHID2000 by scrambli scrambling ng the identicati cation on code codes. s. This This stud study y rst rst se sele lect cted ed 1508 1508
physic phy sicia ians ns who we were re prac practis tising ing medici medicine ne betwe between en 1 January 2010 and 31 December 2010. In order to better reect the ac actua tuall sce scenar nario io of phy physic sician ianss prac practis tising ing in Taiwa aiwan, n, ph phys ysic icia ians ns aged aged over over 80 ye year arss (n (n=8 =82) 2) we were re exclu excluded ded from from this this study study.. As a result result,, 1426 1426 physic physicia ians ns were included in the physician group. The compar compariso ison n group group wa wass dened ned as the the gene genera rall population in Taiwan. We likewise selected the comparison son grou group p from from the the re rema main inin ing g be bene neciar ciarie iess of the the LHID2000. We excluded all bene ciaries who had ever been a practising physician. In addition, we excluded all beneciar ciarie iess aged aged over over 80 ye year ars. s. We then then ra rand ndom omly ly sel select ected ed 5704 5704 ben beneecia ciarie riess (four for ev every ery phy physic sicia ian) n) matched with the physician group in terms of sex, age group gro up (25–39, 39, 40–49, 49, 50–59, 59, 60–69, 69, and and >69 >69 ye year ars) s) monthlyy insured monthl insured salary salary,, geographi geographicc location location (north (northern, ern, central, eastern and southern Taiwan) and urbanisation level ( ve levels, with 1 being the most urbanised and 5 being bei ng the least least)) using using the SAS progr program am proc proc surv survey ey sel select ect (SA (SAS S Syst System em for Wi Windo ndows, ws, V.8. .8.2, 2, Cary Cary, North North Carolina Caro lina,, USA). Ultimate Ultimately ly,, there there were were 7130 sampl sampled ed participa part icipants nts including including 1426 physici physicians ans and 5704 comparison participants in this study. Outcome measures This study selected 31 chronic diseases for analysis (see online supplementary supplementary append appendix ix). ). Of these chronic diseases, 22 were selected from the Elixhauser Comorbidity Index, and the other nine were selected due to their high prevalence in Taiwan. The Elixhauser Comorbidity Index includes 30 comorbidity measures. Since there were no clear clinical denitions and a low prevalence in Taiwan, we did not choose the following following eight diseases diseases from the index for analy analysis: sis: valvular disease, other neuro neurological logical disorders, paralysis, weight loss, obesity, coagulopathy, lymphomaa and om and HI HIV V. The The nine nine high highly ly pr prev eval alen entt me medi dica call conditi cond itions ons in Taiw aiwan an include included d strok stroke, e, ischaemi ischaemicc heart heart dis disease ease,, hyperli hyperlipid pidaemi aemia, a, hepatit hepatitis is B or C, mig migrai raines, nes, Parkinson’s dise disease ase (PD), (PD), sy syste stemic mic lupus lupus eryt erythem hemato atosus sus
(SLE), ankylosing spondylitis (AS) and asthma. Since administrative data sets have been criticised for low validity of diagnoses, this study only counted these 31 chroni chronicc diseas diseases es if they they occurr occurred ed in an inpat inpatien ient t set settin ting g or appear appeared ed in two or more more ambul ambulat atory ory care care claims coded between 2010 and 2012. The ICD-9 CM (International Classication of Diseases, Ninth Revision, Clinical Modication) codes of all chronic diseases are presented in the online supplementary online supplementary appendix appendix.. Statistical analysis The SAS sta statis tistica ticall pac package kage (SAS System System for Win Window dows, s, V V.8.2) .8.2) was used to perform all analyses on the data set of this study. The prevalence of individual chronic diseases in this study was the percentage of the study populations which was found to have the relevant diagnosis (as stated in table 1 1)) between 2010 and 2012. We used χ2 tests to explore differences in the prevalence of chronic dis diseas eases, es, partic participa ipants nts’ mont monthl hlyy insu insurred sa sallary, ry,
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Kao L-T, et al . BMJ Open 2016;6 2016;6:e009954. doi:10.1136/bmjopen-2015-009954
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Open Access Table 1 Crude and adjusted ORs of chronic diseases diseases in male physicians compared to female physicians physicians (n=1426) Variable
Cardiovascular diseases Hypertension Ischaemic heart disease Hyperlipidaemia Congestive heart failure Cardiac arrhythmias
Adjusted OR (95% CI)
5.28*** (3.08 to 9.04)
3.37*** (1.93 to 5.91)
–
–
1.56* (1.08 to 2.26)
Blood loss anaemia Peripheral vascular disorders Stroke Neurological diseases Migraines Parkinson’s disease Rheumatologic diseases Rheumatoid arthritis Systemic lupus erythematosus Ankylosing spondylitis Pulmonary diseases Pulmonary circulation disorders Chronic pulmonary disease Asthma Endocrine diseases Diabetes, uncomplicated
–
1.18 (0.81 to 1.74) –
1.70 (0.66 to 4.35)
1.18 (0.45 to 3.12)
0.43 (0.04 to 4.74)
0.51 (0.04 to 6.22)
2.83 (0.67 to 12.01)
1.58 (0.36 to 6.98)
–
0.40* (0.17 to 0.94)
–
–
0.53 (0.22 to 1.30)
0.36* (0.15 to 0.86) –
1.07 (0.13 to 9.23)
–
–
0.47 (0.21 to 1.04)
Diabetes, complicated Hypothyroidism Renal diseases Renal failure Fluid and electrolyte disorders Gastrointestinal diseases Liver diseases Peptic ulcers Viral/infectious diseases Hepatitis B or C Haematological diseases Deficiency anaemias Mental illnesses Depression Psychoses Oncological diseases Metastatic cancer Solid tumour without metastasis Others Alcohol abuse Drug abuse
Male physicians vs female physicians Crude OR (95% CI)
–
1.57 (0.18 to 13.94) –
1.04 (0.60 to 1.78) 1.13 (0.55 to 2.33)
0.87 (0.49 to 1.52) 1.22 (0.58 to 2.57)
1.50 (0.81 to 2.80)
0.76 (0.39 to 1.48)
0.77 (0.28 to 2.09) 0.23*** (0.14 to 0.39)
0.33* (0.11 to 0.98) 0.19*** (0.11 to 0.32)
1.29 (0.16 to 10.75) 0.64 (0.13 to 3.20)
0.66 (0.07 to 5.99) 0.62 (0.12 to 3.32)
2.57*** (1.46 to 4.52) 0.83 (0.53 to 1.28)
2.48** (1.39 to 4.41) 0.74 (0.47 to 1.18)
1.84 (0.94 to 3.60)
2.00* (1.01 to 3.97)
0.16 (0.08 to 0.32)
0.13*** (0.06 to 0.27)
0.91 (0.30 to 2.73) 0.57 (0.15 to 2.16)
0.81 (0.26 to 2.54) 0.49 (0.12 to 1.99)
0.86 (0.10 to 7.71) 0.67 (0.27 to 1.71)
0.68 (0.07 to 6.61) 0.40 (0.15 to 1.08)
–
–
–
–
The adjusted ORs of morbidities for male physicians and female physicians were calculated by logistic regression analyses adjusted for participants’ age group and urbanisation level. *p≤0.05, **p≤0.01, ***p≤0.001.
geograph geogr aphic ic locat location ion,, and urbani urbanisa satio tion n lev level el betwe between en phy physici sician anss an and d the the ge gene nerral popu popula lati tion on.. Su Subj bjec ects ts’ monthly insured salary was categorised by the personal monthl mon thlyy health health insur insuranc ancee salary salary,, and the geogra geographi phicc location loca tion was classi classied into into northe northern, rn, centr central, al, easter eastern n and southern areas. The northern, southern and central areas in Taiwan are much mo more populated and industrialised than the eastern area.17 Moreover, all townships in Taiwan were stratied into ve classications with level 1 be bein ing g the the mos most ur urb bani anise sed d and lev evel el 5 the the le leas ast t
urbanised urbani sed.. Additi Additiona onally lly,, we used used con condit dition ional al log logis istic tic re regr gres essi sion on anal analys yses es cond condit itio ione ned d on se sex, x, age age grou group, p, monthly insured salary, geographic region and urbanisatio tion n level level to fur furthe therr inv inves estig tigat atee the OR and its correcorresponding 95% CI of chronic diseases between these two groups. We also conducted logistic regression analyses to inves inv estig tigat atee the ORs of chr chroni onicc dis diseas eases es in male male phy physisicia cians ns compar compared ed to fem female ale phy physic sician ians. s. A two-si two-sided ded p value of <0.05 was considered statistically statistically signicant for this study.
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RESULTS Tabl ablee 2 shows shows the dis distri tribut bution ion of soc sociod iodemo emogra graphi phicc characteristics between physicians and the general population. Of the 7130 sampled participants, the mean age was 44.4 (SD=11.7) years. Sex, age group, monthly insured salary, geographic region and levels of urbanisation were the matching variables in this study. Table 3 presents presents the prevalen prevalence ce of chronic chronic diseases diseases according to group. It shows that physicians had a signicantly lower prevalence of peripheral vascular disorders (0.5% vs 1.2%; 1.2%; p=0.023), p=0.023), uncomplica uncomplicated ted diabetes diabetes (6.6% (6.6% vs 8.3%; 8.3%; p=0.03 p=0.032), 2), compli complica cated ted diabet diabetes es (1.6% (1.6% vs2.9%; p=0.006), renal failure (0.5% vs 1.2%; p=0.023), liver diseases (11.8% vs 14.6%; p=0.007) and hepatitis B or C (6.5% vs 10.2%; p<0.001) compared to the general population. However, compared to the general population, physicians had a signicantly higher prevalence of hypert hyp ertens ension ion (21.7% (21.7% vs 19.1% 19.1%;; p=0.02 p=0.028), 8), hyperl hyperlipi ipiddaemia (21.0% vs 16.0%; p<0.001), and asthma (3.9% vs 2.5%; 2.5 %; p=0.00 p=0.004). 4). There There were were no sig signi nicant differen differences ces between physicians and the general population in the prevalence of migraines, PD, rheumatoid arthritis, SLE, AS, pulmonary circulation circulation disorders, chronic pulmonary disease, depression or psychoses.
population, physicians had lower odds of peripheral vascular disorders (OR=0.41, 95% CI=0.19 to 0.90), uncomplic plicat ated ed diab diabet etes es (OR= (OR=0. 0.76 76,, 95% 95% CI=0 CI=0.6 .60 0 to 0. 0.97 97), ), complica compl icated ted diabetes diabetes (OR=0.53, (OR=0.53, 95% CI=0.34 to 0.83), 0.83), renal failure (OR=0.41, 95% CI=0.19 to 0.90), liver diseases (OR=0.78, 95% CI=0.66 to 0.94) and hepatitis B or C (OR=0.62, 95% CI=0.49 to 0.77). Additionally, physicians had higher odds of hypertension (OR=1.21, 95% CI=1 CI=1.0 .03 3 to 1. 1.41 41), ), hype hyperl rlip ipid idae aemia mia (OR= (OR=1. 1.43 43,, 95% 95% CI=1.23 to 1.67) and asthma (OR=1.59, 95% CI=1.16 to 2.18) than the general population. Table 1 1 shows shows crude and adjusted OR of chronic diseases in male compared to female physicians. It displays that male physicians had lower adjusted odds of rheumatoid arthritis (OR=0.36, 95% CI=0.15 to 0.86), complica cate ted d diab diabet etes es (OR= (OR=0. 0.33 33,, 95 95% % CI CI=0 =0.1 .11 1 to 0. 0.98 98), ), hypothyro hypot hyroidis idism m (OR=0.19, (OR=0.19, 95% CI=0.11 CI=0.11 to 0.32 0.32), ), and decie ciency ncy ana anaemi emias as (OR (OR=0. =0.13, 13, 95% CI=0.0 CI=0.06 6 to 0.2 0.27) 7) compared compa red to female female physicia physicians ns aft after er adjustin adjusting g for age group grou p and urbanisa urbanisation tion level. level. Addi Additiona tionally lly,, male phy physisici cian anss ha had d high higher er ad adju just sted ed odds odds of hy hype pert rten ensi sion on (OR (O R=3.3 =3.37, 7, 95% 95% CI= I=1 1.9 .93 3 to 5.91) .91),, liv liver dise diseaase sess (OR=2.48, 95% CI=1.39 to 4.41) and hepatitis B or C (OR=2.00, 95% CI=1.01 to 3.97) than female physicians.
4 presents the general ORs of population. various chronic diseases forTable physicians and the Conditional regr regres essi sion on anal analys yses es cond condit itio ione ned d on se sex, x, age age grou group, p, monthly insured salary, geographic region and urbanisation tion lev level revea eveale led d th thaat co comp mpar ared ed to the the ge gene nera rall
DISCUSSION This Th is is the the rst study study to sy system stemati aticall callyy inve investi stigat gatee the prev preval alen ence ce of ch chrronic onic dise diseas ases es amon among g pra pract ctis isin ing g
Table 2 Demographic characteristics characteristics of physicians and the general population in Taiwan (n=713 (n=7130) 0)
Variable
Sex Male Female Age ( years) 25–39 40–49 ≥50 Monthly insured salary ≤NT$15 840 NT$15 841–25 000 ≥NT$25 001 Urbanisation level 1 (most urbanised) 2 3 4 5 (least urbanised) Geographical Region Northern Central Southern Eastern US$1=NT$29.8 in 2010.
Physicians (n=1426) Total no. Column %
General population (n=5704) Total no. Column %
p Value
Matching variables 1174 252
82.3 17.7
4696 1008
82.3 17.7
547 411 468
38.4 28.8 32.8
2188 1644 1872
38.4 28.8 32.8
Matching variables
Matching variables 21 27 1378
1.5 1.9 96.6
84 108 5512
1.5 1.9 96.6 Matching variables
529 484 143 164 106
37.1 33.9 10.0 11.5 7.4
2116 1936 572 656 424
37.1 33.9 10.0 11.5 7.4 Matching variables
667
46.8
2668
46.8
323 406 30
22.7 28.5 2.1
1292 1624 120
22.7 28.5 2.1
4
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Open Access Table 3 Prevalence of chronic diseases in physicians physicians compared to the general general population (n=7130) Variable
n (%) Ph Phy ysi sici cian ans s (n (n=1 =142 426) 6)
Gene Genera rall po popu pula lati tion on (n=5 (n=570 704) 4)
p Value
Cardiovascular diseases Hypertension Ischaemic heart disease Hyperlipidaemia Congestive heart failure Cardiac arrhythmias
309 9 300 10 44
1089 (19.1) 42 (0.7) 911 (16.0) 76 (1.3) 161 (2.8)
0.028 0.673 <0.001 0.051 0.595
(21.7) (0.6) (21.0) (0.7) (3.1)
Blood loss anaemia Peripheral vascular disorders Stroke Neurological diseases Migraines Parkinson’s disease Rheumatological diseases Rheumatoid arthritis Systemic lupus erythematosus Ankylosing spondylitis Pulmonary diseases Pulmonary circulation disorders Chronic pulmonary disease Asthma Endocrine diseases Diabetes, uncomplicated
3 (0.2) 7 (0.5) 28 (2.0)
8 (0.1) 67 (1.2) 135 (2.4)
0.546 0.023 0.362
23 (1.6) 2 (0.1)
106 (1.9) 11 (0.2)
0.534 0.677
29 (2.0) 1 (0.1) 6 (0.4)
145 (2.5) 5 (0.1) 32 (0.6)
0.266 0.838 0.515
1 (0.1) 99 (6.9) 56 (3.9)
3 (0.1) 326 (5.7) 143 (2.5)
0.803 0.080 0.004
94 (6.6)
474 (8.3)
0.032
Diabetes, complicated Hypothyroidism Renal diseases Renal failure Fluid and electrolyte disorders Gastrointestinal diseases Liver diseases Peptic ulcers Viral/infectious diseases Hepatitis B or C Haematological diseases Deficiency anaemias Mental illnesses Depression Psychoses Oncological diseases
23 (1.6) 66 (4.6)
167 (2.9) 217 (3.8)
0.006 0.154
7 (0.5) 8 (0.6)
67 (1.2) 32 (0.6)
0.023 1.000
168 (11.8) 138 (9.7)
830 (14.6) 520 (9.1)
0.007 0.513
93 (6.5)
579 (10.2)
<0.001
34 (2.4)
98 (1.7)
0.095
21 (1.5) 11 (0.8)
119 (2.1) 66 (1.2)
0.135 0.208
5 (0.4) 25 (1.8)
7 (0.1) 133 (2.3)
0.060 0.184
1 (0.1)
15 (0.3) 3 (0.1)
0.169
Metastatic cancer Solid tumour without metastasis Others Alcohol abuse Drug abuse
–
physicians using a population-based database produced by the NHI program in Taiwan and which can provide a large number of physicians for analyses. We found that physicians had signicantly lower odds of peripheral vascular disorders, diabetes, renal failure, liver diseases and hepa hepati titi tiss B or C and and grea greate terr od odds ds of hype hypert rten ensi sion on,, hyperlipi hyper lipidaem daemia ia and asthma asthma than the general general populapopulation. In addition, there was no signicant difference in the prevalence of other chronic diseases between practising physicians and the general population. The ndings regarding the low risks for some chronic diseases in this study were consistent with several studies
–
which investigated investigated differences in health statuses statuses between physic phy sicia ians ns and the gen gener eral al pop popula ulatio tion. n. A Norwegi Norwegian an study study rep reported orted that the self-perc self-perceive eived d healt health h sta status tus of physicians w as as frequently better than that of the general 7 population. A study which included a large physician cohort also found found tha thatt phy physicia sicians ns experien experienced ced signicantly reduced risks of all causes and many major causespecic hospitali hospitalisati sations, ons, including including metabolic metabolic dise diseases, ases, circulatory system diseases, genitourinary system system diseases, Additionallyy, etc compared to the general population.18 Additionall the prior literature showed the prevalence of mental disorders among physicians. According to the results of our
Kao L-T, et al . BMJ Open 2016;6 2016;6:e009954. doi:10.1136/bmjopen-2015-009954
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Open Access physicians hysicians compared compared Table 4 ORs of chronic diseases in p to the general population (n=7130)
Variable
Physicians vs general population OR (95% CI)
Cardiovascular diseases Hypertension Is Isch chae aemi mic c he hea art di dise sea ase Hyperlipidaemia
1.21* (1.03 to 1.41) 0.8 .85 5 (0 (0.4 .41 1 to 1.7 .77) 7) 1.43*** (1.23 to 1.67)
Con onge ges sti tiv ve hea eart rt fail failu ure Cardiac arrhythmias Blood loss anaemia Peri Periph pher eral al va vasc scul ular ar diso disord rder ers s Stroke Neurological diseases Migraines Parkinson’s disease Rheumatological diseases Rheumatoid arthritis System Sys temic ic lup lupus us erythe erythemat matosu osus s Ankylosi sin ng spondylitis Pulmonary diseases Pulmon Pul monary ary circul circulati ation on dis disord orders ers Chro Chroni nic c pulm pulmon onar ary y di dise seas ase e Asthma Endocrine diseases Di Dia abe bete tes, s, unc ncom omp pli lica cate ted d Di Dia abe bete tes, s, comp compli lica cate ted d Hypothyroidism Renal diseases Renal failure Flui Fluid d and and elec electr trol olyte yte diso disord rder ers s Gastrointestinal diseases Liver diseases Peptic ulcers Viral/infectious diseases Hepatitis B or C Haematological diseases Deficiency anaemias Mental illnesses Depression
0.5 .52 2 (0 (0.2 .27 7 1.10 (0.78 1.50 (0.40 0. 0.41 41** (0 (0.1 .19 9 0.82 (0.54
to 1.0 .01) 1) to 1.55) to 5.66) to 0. 0.90 90)) to 1.25)
0.87 (0.55 to 1.37) 0.73 (0.16 to 3.28) 0.79 (0.53 to 1.19) 0.8 0.80 0 (0. (0.09 09 to 6.8 6.85) 5) 0.7 .75 5 (0.31 to 1.8 .80 0) 1.3 1.33 3 (0. (0.14 14 to 12.82) 12.82) 1. 1.24 24 (0 (0.9 .98 8 to 1. 1.57 57)) 1.59** (1.16 to 2.18) 0. 0.76 76** (0 (0.6 .60 0 to 0.9 .97) 7) 0. 0.53 53** ** (0 (0.3 .34 4 to 0.8 .83) 3) 1.23 (0.93 to 1.63) 0.41* (0.19 to 0.90) 1. 1.00 00 (0 (0.4 .46 6 to 2. 2.18 18)) 0.78** (0.66 to 0.94) 1.07 (0.88 to 1.30) 0.62*** (0.49 to 0.77) 1.41 (0.94 to 2.09) 0.70 (0.44 to 1.12)
physicians. physicia ns. A review review reported reported by Brewst Brewster er also showed that the prevalence of substance use and alcohol consumpti sum ption on wa wass simi similar to tha that in phy physici sician anss an and d the the 19 general population. population. How However ever,, some studies studies observed observed that physicians have a higher prevalence of psychological dis distress tress,, mental mental diso disorders rders and substance substance use disorders disorders compared to those in the general population. 8–14 The similar prevalence of psychiatric diseases between physicians and the general population in our study might be expla explaine ined d by phy physic sicia ians ns being being consid considere ered d to be mor moree cautious than the general population in going to a clinic for for diag diagno nose sess and and ther therap apie iess du duee to fear fear of nega negati tive ve impac imp acts ts on their their med medica icall licens licensing ing.. In ad addit dition ion,, som somee physicians might try to self-medicate with exercise, changing lifestyles or toughing it out without seeking treatment me nt.. Acco Accord rdin ingl glyy, the the issu issuee of ph phys ysic icia ians ns’ mental health is still controversial and worth further discussion in the future. Potential reasons for the lower prevalence of peripheral vascular disorders, diabetes and renal failure in physicians compared to the general population in our study might mig ht be due to lifes lifestyl tyles, es, health healthyy habits habits and die dietar tary y factors. fact ors. Several Several studies studies reported reported that a healthy healthy lifestyle lifestyle decreases the the incidence incidence of heart disease, diabetes and 20–22
renal failure. also indicated that physicians have better Some healthstudies and lifestyles than the general population because because of me medical knowledge dical knowledge received from medical training.7 9 15 1 8 2 3–25 Therefore, healthy beha viours might help physicians prevent chronic diseases such suc h as conges congestiv tivee heart heart fai failur lure, e, diabet diabetes es and re renal nal failure. Furthermore, studies have shown that physicians are less lik eely ly to be smokers than the general population.23 26 27 The low prevalence of smokers among physicians may also be one of the major reasons contributing to the low prevalence of renal failure among physicians, becaus bec ausee cigar cigarett ettee smokin smoking g wa wass demons demonstr trat ated ed to be a main ma in risk risk fa fact ctor or for for renal failure failure through through incr increased eased 28–30 renovascular resistance. A prior study also reported that physicians have a tendency to eat eat mo more re fruits and 23
Psychoses Oncological diseases Metastatic cancer Solid Sol id tumour tumour withou withoutt met metas astas tasis is Others Alcohol abuse Drug abuse
0.66 (0.35 to 1.26) 2.86 (0.91 to 9.00) 0.7 0.75 5 (0. (0.48 48 to 1.1 1.15) 5) 0.27 (0.04 to 2.02) –
The ORs of morbidities for physicians and the general population were calculated by conditional logistic regression analyses conditioned on sex, age group, monthly insured salary, urbanisation level and geographical region of the participants. *p≤0.05, **p≤0.01, ***p≤0.001.
study, the prevalence of psychiatric disorders, including depressio depr ession n and psychoses, psychoses, of phys physicia icians ns was similar similar to that of those in the general population. Our nding is consistent with a report by Gagné et al ,12 which found that there was no signicant difference in the prevalence of ps psych ychia iatri tricc dis diseas eases es betwe between en physic physician ianss and nonnon-
vegetables than the general population. The dietary dietary pattern of a higher consumption of fruits and veget aabl bles is associated with a reduced risk for type 2 diabetes.31 32 Nevertheless, most chronic diseases are considered to be resul res ults ts of mul multif tifac actor torial ial condit condition ions. s. Lifes Lifestyl tyle, e, health healthy y habits hab its and dietar dietaryy intak intakee mig might ht not be absolu absolute te risk risk factors which contribute to the occurrence and progression of chronic diseases. Moreover, the socioeconomic status (SES) is another factor which can explain physicians’ better health compared par ed to the gener general al popul populat ation ion.. Some Some stud studies ies found found that that a hig higher her SES wa wass associ associat ated ed with with lowe lowerr mor morbid bid-33 34 ity. A previous study also suggested that a high educationall lev cationa level el may may be a stron trong g pred predic icto torr of go good od 35 health. Although we took the monthly insured salary into consideration in this study, the data set used in this study study did not con contai tain n data data on the educa educatio tional nal level. level. Education is considered to be one of the most signicant items among components of SES. In contrast to the
6
Kao L-T, et al . BMJ Open 2016;6 2016;6:e009954. doi:10.1136/bmjopen-2015-009954
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general population, physicians usually have higher levels of education education.. Therefor Therefore, e, it is plausible plausible that physicia physicians ns are much healthier than the general population. Additionally,, this study also found that physicians had Additionally a lower prevalence of liver diseases and hepatitis B or C than the general population. In Taiwan, hepatitis B virus (HBV) and hepatitis C virus (HCV) are necessary items on physica physicall examina examinations tions for medical medical students students before before they begin clinical training courses in hospitals. Medical students who are negative for antibodies to hepatitis B surface antigen and anti-HB antibodies have to receive hepatiti hepa titiss B vaccina vaccinations tions.. Therefor Therefore, e, medical medical students students would have a reduced chance of being infected with HBV because they have been vaccinated. In regard to HCV, a pr previ evious ous st stud udyy found found that that peop people with higher higher education ran a lower risk of transmission.36 Hence, education may be the reason why physicians had lower risks of liver diseases and hepatitis B or C in our study. Nevertheless, in this study, the prevalence of hypertension and hyperlipidaemia was higher in physicians compared to the general population. The high levels of stress and psycho psycholog logica icall dis distr tress ess experie experienced nced by physici physicians ans might be possible possible reasons reasons contributing contributing to hypertension hypertension and hyperlipida hyperlipidaemia. emia. Many studies studies indicated indicated that physiphysi-
study provided no information on the educational status, cigarette smoking, body mass index or health behaviour of participants, which were considered to affect the ndings in this study. Second, this study used the personal monthl mon thlyy hea health lth insur insuranc ancee salary salary and locat location ion of the administrative of ce as respective surrogate variables for monthlyy inco monthl income me and urbanisa urbanisation tion levels. levels. Evaluat Evaluation ion of the SES in this study might have had some confounding or interm intermedi ediat atee effect effectss on the ndi ndings ngs of this this stud studyy. Third, this study might have overestimated or underestimated ma ted the preva prevalen lence ce of sev sever eral al spe speci cic dise diseas ases es.. In gene genera ral, l, ph phys ysic icia ians ns mi migh ghtt be mo more re al aler ertt to ph phys ysic ical al health problems due to their medical knowledge, so they are more likely to seek health services than the general population. Conversely, physicians might be less likely to exhib exhibit it men mental tal hea health lth issues issues in this this data databas base, e, becaus becausee they may be concerned that such records might impact their licensing or registration. Fourth, the sampled participants included many different ethnic groups in Taiwan, such as Fukien, Hakka, mainlander and Aborigine, and the LHID2000 database provides no records on ethnicity. Therefore, the internal validity of ethnic diversity could not be ascertained in this study. Finally, this study only employed 3 years of data on chronic diseases, and this
cia cians ns fre freque quently ntly have hav e high hig h psychological we weekly ekly workin working g hours hours 37 an38 d usually experience stress and problems. The previous literature further showed that stress might increase bloo blood pressure and blood lipids and affect lipid metabolism.39 40 Althou Although gh the ndings in this study did not show a consistently reduced or increased probability for dif differ ferent ent types types of chronic chronic diseases, diseases, thi thiss might might have have been due to the characteristics of these chronic diseases. Prior studies demonstrated that most chronic chronic diseases are the result of multifactorial conditions.41 42 Many extrinsic and intrinsic factors were indicated to lead to the incidence of these diseases. Each risk factor might play a very dif differ ferent ent role role in the pr progr ogressi ession on of dis dissimi similar lar types types of chronic diseases. Consequently, it is dif cult to dene the main reason for each disease, and it was dif cult to realise potential inuences of various risk factors in this study. A specic str tren engt gth h of ou ourr study udy is the the use of a population-based data set to investigate the prevalence of chroni chronicc dis diseas eases es among among physic physicia ians ns in Taiwan. aiwan. Thi Thiss featur fea turee af affor forded ded suf ci cien entt stat statis isti tica call po powe werr and and an adequa ade quate te sam sample ple siz sizee to detect detect dif differ ferenc ences es in chroni chronicc disease disea se risks between between physicia physicians ns and matched matched controls controls from the general population after adjusting for confounders. We further examined the representativeness of the comparison group to the general population. According to previous studies, the respective prevalences of hypertension, diabetes and hepatitis B were about 25%, 25%, 12% and and 10% 10% in the the gene genera rall po popu pula lati tion on of Taiwa aiwan. n.43–45 These gures are very similar to those reported in the comparison group of our study, although they had differe ferent nt stud studyy de desi sign gns, s, su subj bjec ectt incl inclus usio ion n cr crit iter eria ia and and matching variables.46 Nevertheless, there are several limitations to this study. First, as mentioned above, the LHID2000 used in this
mi migh ghtt not no t full fullyyof the re repr pres esen entt long loparticipants. ng-t -ter erm m pr prev eval alen ence ce of chronic diseases sampled To the best of our knowledge, this is the rst study to systema systematica tically lly inve investig stigate ate the prev prevalen alence ce of chro chronic nic disease easess amon among g pra pract ctis isin ing g phy physici sician anss usin using g a larg largee populat popu lation-ba ion-based sed data data set. Our study study found that physiphysicians have lower risks for peripheral vascular disorders, uncomplic uncom plicated ated diabetes, diabetes, complica complicated ted diab diabetes, etes, renal renal fail failur ure, e, live liverr dise diseas ases es and and hepa hepati titi tiss B or C than than the the general gener al populat population. ion. Further Further,, large-scal large-scalee long-term long-term epidemiological studies are suggested to explore differences in menta mentall hea health lth bet betwe ween en physic physicia ians ns and the genera generall population in other regions and countries. Author affiliations 1
Graduate Institute of Life Science, National Defense Medical Center, Taipei, Taiwan School of Public Health, National Defense Medical Center, Taipei, Taiwan 3 Sleep Research Center, Taipei Medical University Hospital, Taipei, Taiwan 4 Department of Psychiatry and Medical Humanities, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan 5 Graduate Program in Biomedical Informatics, College of Informatics, Yuan-Ze University,, Chungli, Taiwan University 6 Department of Surgery, Far Eastern Memorial Hospital, Banciao, Taipei, Taiwan
2
Acknowledgements The authors thank Chamberlin Daniel Pickren for editing the manuscript manuscript.. Contributors L-TK and Y-LC participated in the design of the study and helped draft the manuscript. H-CL performed the statistical analysis and helped draft the manuscript. H-CL and S-DC conceived of the study, participated in its design and coordination and helped draft the manuscript. All authors reviewed the manuscript. Funding Ministry of Science and Technology, ROC (grant no. NSC102-2632-B-038-001-MY3). Competing interests None declared.
Kao L-T, et al . BMJ Open 2016;6 2016;6:e009954. doi:10.1136/bmjopen-2015-009954
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Data sharing statement No additional data are available. Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work noncommercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http:// creativecommons.org/licenses/by-nc/4.0/
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Prevalence of chronic diseases among physicians in Taiwan: a population-based cross-sectional study Li-Ting Kao, Yu-Lung Chiu, Herng-Ching Lin, Hsin-Chien Lee and Shiu-Dong Chung BMJ Open 2016 6:
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