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Article history: Evidence is lacking regarding whether insomnia increases the risk of infectious disease. Accordingly, the
Received 13 April 2017 present study examined the risk of pneumonia in patients with insomnia.
Accepted 5 August 2017 This study was a population-based retrospective cohort study on a cohort of 8061 patients with insom-
nia and a control cohort of 16,112 patients (matched by age, sex, and year of diagnosis) from the Taiwan
Keywords: National Health Insurance Research Database for the 2000–2010 period.
Insomnia
Overall incidence of pneumonia was 50.6 per 1000 person-years in the insomnia cohort, which was
Pneumonia
significantly higher than that in the control cohort (30.9 per 1000 person-years). Overall, the insomnia
Retrospective cohort study
Infectious disease cohort exhibited a higher risk of pneumonia (HR = 2.43; CI, 2.24–2.62). By age group, the risk of pneumonia
was significantly higher in the insomnia cohort for those aged ≤40 years (HR = 3.23, CI: 1.38–7.57), 41–65
years (HR = 2.62, CI: 2.07–3.32), and >65 years (CI: 2.21–2.61).
Compared with the controls, the insomnia cohort exhibited a higher risk of pneumonia, particularly in
young adults.
© 2017 The Authors. Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University
for Health Sciences. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.jiph.2017.08.002
1876-0341/© 2017 The Authors. Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
C.-L. Lin et al. / Journal of Infection and Public Health 11 (2018) 270–274 271
Fig. 1. The flowchart of study sample selection from National Health Insurance Research Database in Taiwan.
Materials and methods sex, urbanization level, season of diagnosis outcome, and comor-
bidity. Cox proportional hazards regression models were used to
Participants determine the risk of pneumonia, and the results are presented as
hazard ratios (HRs) with a 95% confidence interval (CI). The same
Taiwan’s National Health Insurance (NHI) program was variables were used in a multivariable analysis. All analyses were
launched as a single-payer system on March 1, 1995. As of 2014, performed using SPSS version 21 (SPSS, Inc., Chicago, IL, USA).
the NHI program provides insurance for 99.9% of Taiwan’s popula-
tion. In the present study, data were collected from the Longitudinal
Health Insurance Database 2005 (LHID2005), a subset of the NHIRD. Results
The LHID2005 comprises 1 million people randomly selected from
the NHIRD. To protect patient privacy, the National Health Research Demographic data
Institutes encrypted all personal identification numbers before
releasing the LHID2005. In the LHID2005 dossier, the disease diag- Demographic data of the study participants are presented in
nosis codes are based on the International Classification of Diseases, Table 1. The insomnia and control cohorts comprised 8061 and
Ninth Revision, Clinical Modification (ICD-9-CM). This study was 16,112 patients, respectively. Most patients were older than 65
approved by the Ethics Review Board of National Taiwan University years (46.8% and 48.5% in the insomnia and control cohorts, respec-
(IRB No. 201412130W). tively) and male. The main comorbidity in the insomnia cohort was
The present study applied a retrospective cohort study design. COPD (23.2%) and that in the control cohort was HT (17.5%). In both
The study cohort comprised patients aged ≥20 years who had cohorts, most patients were classified as living in a medium urban-
received a diagnosis of insomnia between 2000 and 2005. They ization level (41.5% vs. 44.5%). The average follow-up duration was
were identified according to the corresponding ICD-9 code (780.52; 3.5 (SD 2.9) years for the insomnia cohort and 3.7 (SD 3.6) years for
insomnia, unspecified). For the control cohort, we randomly the control cohort.
selected patients without a history of insomnia. The insomnia and
control cohorts were frequency-matched by age (5-year spans), sex,
and year of diagnosis (Fig. 1).
Incidence rates and adjusted HR of pneumonia by age, sex,
urbanization level, and comorbidities
Outcome measures
Table 1
Demographic data for the study participants.
Insomnia
N % N %
Table 2
Incidence rates and adjusted HR of pneumonia by age, gender, urbanization level and comorbidities.
Age (y)
≤40 28 4178.8 6.7 7 6800.7 1.0 3.228** (1.376–7.571)
41–65 206 11,952.6 17.2 110 18,724.8 5.9 2.620*** (2.067–3.321)
>65 1213 12,440.7 97.5 1168 33,547.8 34.8 2.403*** (2.211–2.612)
Gender
Male 1160 15,142.1 76.6 997 33,748.2 29.5 2.602*** (2.382–2.842)
Female 287 13,429.9 21.4 288 25,325.2 11.4 1.863*** (1.574–2.204)
Urbanization level
Low 641 10,561.6 60.7 308 15,067.6 20.4 3.130*** (2.719–3.602)
Middle 626 11,788.4 53.1 630 26,707.4 23.6 2.332*** (2.082–2.612)
High 180 6221.9 28.9 347 17,298.3 20.1 1.755*** (1.460–2.111)
Seasons
Spring 376 5829.1 64.5 345 13,356.5 25.8 2.416*** (2.075–2.813)
Summer 341 7168.4 47.6 285 14,992.6 19.0 2.544*** (2.516–3.002)
Autumn 358 9111.6 39.3 321 17,138.7 18.7 2.361*** (2.020–2.759)
Winter 372 6462.9 57.6 334 13,585.5 24.6 2.442*** (2.094–2.848)
Comorbiditiesb
No 0 15,201.9 0 0 32,752.6 0 –
Yes 1447 13,370.1 108.2 1285 26,320.7 48.8 2.425*** (2.243–2.622)
Abbreviations: PY, person-years; IR, incidence rate; HR, hazard ratio; CI, confidence interval; y, years.
**p < 0.01; ***< 0.001.
a
Indicates the IR per 1000 person-years.
b
Indicates a patient with any of the comorbidities that were classified as the comorbidities group.
c
Indicates adjustment for age, gender, urbanization level, period, and presence of comorbidities.
d
“With insomnia” compared with “Without insomnia (reference)”.
Table 3
Cumulative incidence rate of pneumonia in the follow-up period with and without insomnia.
With n 653 916 1093 1214 1296 1351 1401 1433 1440 1446 1447
% 8.1 11.4 13.6 15.1 16.1 16.8 17.4 17.8 17.9 17.9 18.0
Without n 366 566 709 820 931 1024 1104 1179 1214 1249 1285
% 2.3 3.5 4.4 5.1 5.8 6.4 6.8 7.3 7.5 7.7 8.0
Difference 5.8 7.9 9.2 10.0 10.3 10.4 10.5 10.5 10.3 10.2 10.0
C.-L. Lin et al. / Journal of Infection and Public Health 11 (2018) 270–274 273
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