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Article in Press: Journal of Infection and Public Health
Article in Press: Journal of Infection and Public Health
a r t i c l e i n f o a b s t r a c t
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/).
http://dx.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/).
Please cite this article in press as: Lin C-L, et al. Risk of pneumonia in patients with insomnia: A nationwide population-based retro-
spective cohort study. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2017.08.002
G Model
JIPH-792; No. of Pages 5 ARTICLE IN PRESS
2 C.-L. Lin et al. / Journal of Infection and Public Health xxx (2017) xxx–xxx
Fig. 1. The flowchart of study sample selection from National Health Insurance Research Database in Taiwan.
Materials and methods sion (ICD-9-CM codes 296.2, 296.3, 300.4, and 311), HT (ICD-9-CM
codes 401–405), and stroke (ICD-9-CM codes 430–438). Individu-
Participants als with any of the aforementioned comorbidities were classified
as having a comorbidity.
Taiwan’s National Health Insurance (NHI) program was
launched as a single-payer system on March 1, 1995. As of 2014, Statistical analysis
the NHI program provides insurance for 99.9% of Taiwan’s popula-
tion. In the present study, data were collected from the Longitudinal Descriptive statistics were used for basic information, including
Health Insurance Database 2005 (LHID2005), a subset of the NHIRD. the percentage, mean, and standard deviation. Chi-squared and t
The LHID2005 comprises 1 million people randomly selected from tests were used to evaluate the distributions of categorical and con-
the NHIRD. To protect patient privacy, the National Health Research tinuous variables between the insomnia and control cohorts. The
Institutes encrypted all personal identification numbers before incidence densities of pneumonia were calculated according to age,
releasing the LHID2005. In the LHID2005 dossier, the disease diag- sex, urbanization level, season of diagnosis outcome, and comor-
nosis codes are based on the International Classification of Diseases, bidity. Cox proportional hazards regression models were used to
Ninth Revision, Clinical Modification (ICD-9-CM). This study was determine the risk of pneumonia, and the results are presented as
approved by the Ethics Review Board of National Taiwan University hazard ratios (HRs) with a 95% confidence interval (CI). The same
(IRB No. 201412130W). variables were used in a multivariable analysis. All analyses were
The present study applied a retrospective cohort study design. performed using SPSS version 21 (SPSS, Inc., Chicago, IL, USA).
The study cohort comprised patients aged ≥20 years who had
received a diagnosis of insomnia between 2000 and 2005. They
Results
were identified according to the corresponding ICD-9 code (780.52;
insomnia, unspecified). For the control cohort, we randomly
Demographic data
selected patients without a history of insomnia. The insomnia and
control cohorts were frequency-matched by age (5-year spans), sex,
Demographic data of the study participants are presented in
and year of diagnosis (Fig. 1).
Table 1. The insomnia and control cohorts comprised 8061 and
16,112 patients, respectively. Most patients were older than 65
Outcome measures years (46.8% and 48.5% in the insomnia and control cohorts, respec-
tively) and male. The main comorbidity in the insomnia cohort was
All study individuals were followed up from the index date until COPD (23.2%) and that in the control cohort was HT (17.5%). In both
the onset of pneumonia (ICD-9-CM 480–486) in the subset file from cohorts, most patients were classified as living in a medium urban-
the LHID2005, withdrawal from the NHI program, or the end of ization level (41.5% vs. 44.5%). The average follow-up duration was
2010, whichever occurred first. 3.5 (SD 2.9) years for the insomnia cohort and 3.7 (SD 3.6) years for
the control cohort.
Variable definitions
Incidence rates and adjusted HR of pneumonia by age, sex,
The individuals were grouped by sex, urbanization level (low, urbanization level, and comorbidities
medium, and high; according to their registered address with the
NHI) [15], and season of diagnosis outcome (spring, March–May; The incidence rates and adjusted HRs of pneumonia by age,
summer, June–August; autumn, September–November; and win- sex, urbanization level, and comorbidities are presented in Table 2.
ter, December–February). The comorbidities considered in this During the follow-up period, the pneumonia incidence rate in the
study were asthma (ICD-9-CM code 493), chronic kidney disease insomnia cohort was significantly higher than that in the control
(CKD; ICD-9-CM codes 585.3, 585.4, 585.5, and 585.9), chronic cohort (50.6 vs. 30.9 per 1000 person-years), and the risk of pneu-
obstructive pulmonary disease (COPD; ICD-9-CM codes 490–496), monia was 2.43 times higher in the insomnia cohort than in the
cardiovascular disease (CVD; ICD-9-CM codes 410–414), depres- control cohort (adjusted HR, 2.43 [95% CI, 2.24–2.62]).
Please cite this article in press as: Lin C-L, et al. Risk of pneumonia in patients with insomnia: A nationwide population-based retro-
spective cohort study. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2017.08.002
G Model
JIPH-792; No. of Pages 5 ARTICLE IN PRESS
C.-L. Lin et al. / Journal of Infection and Public Health xxx (2017) xxx–xxx 3
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
Please cite this article in press as: Lin C-L, et al. Risk of pneumonia in patients with insomnia: A nationwide population-based retro-
spective cohort study. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2017.08.002
G Model
JIPH-792; No. of Pages 5 ARTICLE IN PRESS
4 C.-L. Lin et al. / Journal of Infection and Public Health xxx (2017) xxx–xxx
Please cite this article in press as: Lin C-L, et al. Risk of pneumonia in patients with insomnia: A nationwide population-based retro-
spective cohort study. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2017.08.002
G Model
JIPH-792; No. of Pages 5 ARTICLE IN PRESS
C.-L. Lin et al. / Journal of Infection and Public Health xxx (2017) xxx–xxx 5
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Please cite this article in press as: Lin C-L, et al. Risk of pneumonia in patients with insomnia: A nationwide population-based retro-
spective cohort study. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2017.08.002