Research Article| Volume 158, P47-54, April 2022

Adjuvant therapy with traditional Chinese medicine and long-term mortality in patients with stroke: A nationwide population-based cohort study in Taiwan

  • Chung-Yen Lu
    Department of Chinese Medicine, Taitung Hospital, Ministry of Health and Welfare, Taitung, Taiwan

    The School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung, Taiwan

    Department of Sport and Health Management, Da-Yeh University, Changhua, Taiwan
    Search for articles by this author
  • Shu-Ru Lee
    Research Services Center for Health Information, Chang Gung University, Taoyuan, Taiwan
    Search for articles by this author
  • Author Footnotes
    1 These authors contributed equally to this work.
    Chee-Jen Chang
    1 These authors contributed equally to this work.
    Research Services Center for Health Information, Chang Gung University, Taoyuan, Taiwan

    Graduate Institute of Clinical Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan

    Clinical Informatics and Medical Statistics Research Center, Chang Gung University College of Medicine, Taoyuan, Taiwan

    Department of Cardiovascular Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
    Search for articles by this author
  • Author Footnotes
    1 These authors contributed equally to this work.
    Pei-Chun Chen
    Corresponding author.
    1 These authors contributed equally to this work.
    Department of Public Health, China Medical University, No. 100, Sec. 1, Jingmao Rd., Beitun Dist., Taichung 406040, Taiwan
    Search for articles by this author
  • Author Footnotes
    1 These authors contributed equally to this work.


      • The use of adjuvant therapy with different forms of traditional Chinese medicine after stroke was associated with reduced mortality.
      • The most commonly used form of traditional Chinese medicine in this cohort was acupuncture.
      • The use of acupuncture alone was associated with reduced mortality.



      We investigated whether the use of adjuvant traditional Chinese medicine (TCM) therapy, a form of complementary and alternative medicine, is associated with long-term mortality after stroke.

      Study design

      We conducted a retrospective cohort study and used claims data from Taiwan's National Health Insurance program linked to the National Registry of Death. The cohort included patients aged ≥18 years who were hospitalized for their first stroke event between January 1, 2006, and December 31, 2013. Adjuvant TCM therapy was defined as additional treatments with TCM, which included acupuncture, Chinese herbal medicine, and Tuina, during hospitalization for up to six months.

      Main outcome measure

      The mortality rate was measured through to December 31, 2014.


      Of 321,157 patients with stroke, 14,579 received adjuvant TCM therapy. Propensity score matching resulted in 13,918 matched pairs of patients who did and did not receive adjuvant TCM care. Both multivariable-adjusted Cox proportional hazards models (hazard ratio [HR] 0.67, 95% confidence interval [CI] 0.64–0.69) and propensity score-matching analysis (HR, 0.65; 95% CI, 0.60–0.66) revealed a reduced mortality risk associated with the use of adjuvant TCM therapy, as compared with routine inpatient care only. Acupuncture was the most commonly used TCM therapy. Patients treated with acupuncture only, which accounted for 41.3% of TCM users, had a reduced risk of mortality compared with those treated with routine inpatient care.


      The use of TCM therapy adjuvant to Western inpatient care in the acute and subacute stages of stroke recovery is associated with a reduced risk of long-term mortality.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Maturitas
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.
        Lancet. 2017; 390: 1260-1344
        • Feigin V.L.
        • Krishnamurthi R.V.
        • Parmar P.
        • Norrving B.
        • Mensah G.A.
        • Bennett D.A.
        • Barker-Collo S.
        • Moran A.E.
        • Sacco R.L.
        • Truelsen T.
        • Davis S.
        • Pandian J.D.
        • Naghavi M.
        • Forouzanfar M.H.
        • Nguyen G.
        • Johnson C.O.
        • Vos T.
        • Meretoja A.
        • Murray C.J.
        • Roth G.A.
        Update on the global burden of ischemic and hemorrhagic stroke in 1990-2013: the GBD 2013 study.
        Neuroepidemiology. 2015; 45: 161-176
        • Balami J.S.
        • Chen R.L.
        • Grunwald I.Q.
        • Buchan A.M.
        Neurological complications of acute ischaemic stroke.
        Lancet Neurol. 2011; 10: 357-371
        • World Health Organization
        WHO Traditional Medicine Strategy: 2014–2023.
        World Health Organization, 2021 (Accessed 20 September)
      2. C.C. Liao, J.G. Lin, C.C. Tsai, H.L. Lane, T.C. Su, H.H. Wang, F.C. Sung, T.L. Chen, C.C. Shih, An investigation of the use of traditional chinese medicine in stroke patients in taiwan, Evidence-based complementary and alternative medicine: eCAM 2012 (2012) 387164.

        • Chang C.C.
        • Chen T.L.
        • Chiu H.E.
        • Hu C.J.
        • Yeh C.C.
        • Tsai C.C.
        • Lane H.L.
        • Sun M.F.
        • Sung F.C.
        • Liao C.C.
        • Lin J.G.
        • Shih C.C.
        Outcomes after stroke in patients receiving adjuvant therapy with traditional Chinese medicine: a nationwide matched interventional cohort study.
        J. Ethnopharmacol. 2016; 177: 46-52
      3. Y.C. Wei, M.F. Sun, K.C. Chang, C.J. Chang, Y.C. Hung, Y.J. Lin, H.H. Chiu, Pilot scheme of health policy in stroke adjuvant acupuncture therapy for acute and subacute ischemic stroke in taiwan, Evidence-based complementary and alternative medicine: eCAM 2011 (2011) 689813.

      4. National Health Insurance Administration, Ministry of Health and Welfare, Taiwan. Universal Health Coverage in Taiwan. Accessed 2 November 2019.

      5. National Health Insurance Administration, Ministry of Health and Welfare, Taiwan. 2017-2018 National Health Insurance in Taiwan Annual Report (bilingual). Accessed 21 September 2021.

        • Austin P.C.
        An introduction to propensity score methods for reducing the effects of confounding in observational studies.
        Multivar. Behav. Res. 2011; 46: 399-424
        • Austin P.C.
        A comparison of 12 algorithms for matching on the propensity score.
        Stat. Med. 2014; 33: 1057-1069
        • Mamdani M.
        • Sykora K.
        • Li P.
        • Normand S.L.
        • Streiner D.L.
        • Austin P.C.
        • Rochon P.A.
        • Anderson G.M.
        Reader's guide to critical appraisal of cohort studies: 2. Assessing potential for confounding.
        BMJ. 2005; 330: 960-962
        • Austin P.C.
        The performance of different propensity score methods for estimating marginal hazard ratios.
        Stat. Med. 2013; 32: 2837-2849
        • Lau B.
        • Cole S.R.
        • Gange S.J.
        Competing risk regression models for epidemiologic data.
        Am. J. Epidemiol. 2009; 170: 244-256
        • Xu M.
        • Li D.
        • Zhang S.
        Acupuncture for acute stroke.
        Cochrane Database Syst. Rev. 2018; 3Cd003317
        • Zhang J.H.
        • Wang D.
        • Liu M.
        Overview of systematic reviews and meta-analyses of acupuncture for stroke.
        Neuroepidemiology. 2014; 42: 50-58
        • Zhang S.
        • Wu B.
        • Liu M.
        • Li N.
        • Zeng X.
        • Liu H.
        • Yang Q.
        • Han Z.
        • Rao P.
        • Wang D.
        Acupuncture efficacy on ischemic stroke recovery: multicenter randomized controlled trial in China.
        Stroke. 2015; 46: 1301-1306
        • Chang C.C.
        • Lee Y.C.
        • Lin C.C.
        • Chang C.H.
        • Chiu C.D.
        • Chou L.W.
        • Sun M.F.
        • Yen H.R.
        Characteristics of traditional Chinese medicine usage in patients with stroke in Taiwan: a nationwide population-based study.
        J. Ethnopharmacol. 2016; 186: 311-321
        • Lee Y.S.
        • Kwon S.
        • Chae Y.
        • Jang B.H.
        • Ko S.G.
        A retrospective cohort study on the outcomes of ischemic stroke patients with adjuvant Korean Medicine treatment.
        Sci. Rep. 2018; 8: 1656
        • Xu J.
        • Pei J.
        • Fu Q.H.
        • Wang L.Y.
        • Zhan Y.J.
        • Tao L.
        Earlier acupuncture enhancing long-term effects on motor dysfunction in acute ischemic stroke: retrospective cohort study.
        Am. J. Chin. Med. 2020; 48 (Gard City N Y): 1787-1802
        • Markaki I.
        • Franzén I.
        • Talani C.
        • Loizou L.
        • Kostulas N.
        Long-term survival of ischemic cerebrovascular disease in the acute inflammatory stroke study, a hospital-based cohort described by TOAST and ASCO.
        Cerebrovasc. Dis. 2013; 35: 213-219
        • Chavez L.M.
        • Huang S.S.
        • MacDonald I.
        • Lin J.G.
        • Lee Y.C.
        • Chen Y.H.
        Mechanisms of acupuncture therapy in ischemic stroke rehabilitation: a literature review of basic studies.
        Int. J. Mol. Sci. 2017; 18 (2270)
        • Zhang J.
        • Lu C.
        • Wu X.
        • Nie D.
        • Yu H.
        Neuroplasticity of acupuncture for stroke: an evidence-based review of MRI.
        Neural Plast. 2021; (2021)2662585
        • Han X.
        • Jin H.
        • Li K.
        • Ning Y.
        • Jiang L.
        • Chen P.
        • Liu H.
        • Zhang Y.
        • Zhang H.
        • Tan Z.
        • Cui F.
        • Ren Y.
        • Bai L.
        • Zou Y.
        Acupuncture modulates disrupted whole-brain network after ischemic stroke: evidence based on graph theory analysis.
        Neural Plast. 2020; 20208838498
      6. Z. Xie, F. Cui, Y. Zou, L. Bai, Acupuncture enhances effective connectivity between cerebellum and primary sensorimotor cortex in patients with stable recovery stroke, evidence-based complementary and alternative medicine: eCAM 2014 (2014) 603909.

        • Jiang M.
        • Lu C.
        • Zhang C.
        • Yang J.
        • Tan Y.
        • Lu A.
        • Chan K.
        Syndrome differentiation in modern research of traditional Chinese medicine.
        J. Ethnopharmacol. 2012; 140: 634-642
        • Cheng F.
        • Wang X.
        • Song W.
        • Lu Y.
        • Li X.
        • Zhang H.
        • Wang Q.
        Biologic basis of TCM syndromes and the standardization of syndrome classification.
        J. Tradit. Chin. Med. Sci. 2014; 1: 92-97
        • Sung S.F.
        • Hsieh C.Y.
        • Kao Yang Y.H.
        • Lin H.J.
        • Chen C.H.
        • Chen Y.W.
        • Hu Y.H.
        Developing a stroke severity index based on administrative data was feasible using data mining techniques.
        J. Clin. Epidemiol. 2015; 68: 1292-1300
        • Lu C.Y.
        • Huang H.C.
        • Chang H.H.
        • Yang T.H.
        • Chang C.J.
        • Chang S.W.
        • Chen P.C.
        Acupuncture therapy and incidence of depression after stroke.
        Stroke. 2017; 48: 1682-1684