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DIGESTIVE DISEASES IN OUTPATIENT SERVICE
Abstract
The article presents the statistical data (morbidity, incidence, mortality and lethality rate) of digestive diseases in the adult working age population of Minsk and older those who are able to work. Increased morbidity and mortality have been noted. A negative effect of alcohol consumption on the morbidity and mortality of the population has been highlighted with an emphasis on alcohol-associated diseases frequency in Minsk. Morbidity and mortality from oncologic diseases are also discussed in the article
Keywords
digestive diseases, morbidity, mortality, lethality, oncologic diseases
AUTHORS
Tatiana Matveichik
PhD, Associate Professor at the chair of Public Health
and Healthcare Belarusian Medical Academy of Post-Graduate Education
Minsk, Belorussia matveichik51 @rambler.ru
Svetlana Antipova
PhD, Associate Professor, Minsk, Belorussia
Irina Bryleva
Senior Teacher of the chair of Public Health and Healthcare, Belarusian Medical Academy of Post-Graduate Education, Minsk, Belorussia
The need for medical care and, therefore, referral to health care institutions is mostly a self-regulating process depending on both the health status of a patient and the condition of the health care system and non-medical factors (influencing the accessibility of medical care).
Since social and individual health is conditioned by political and economic factors, the recorded morbidity rate and disease outcome depend on:
a) the patient (harmful habits, dietary pattern, timely referral for medical aid, attitude to his/her own health, the level of hygienic and general culture, etc.);
b) the health care service (accessibility, timely diagnosis and treatment, diagnostic and medical resources, doctor-nurse-patient interrelations, staffing and qualification of medical personnel, etc.);
c) non-medical factors (low economic status of patients, long distance from health care institutions, transport problems, etc.).
Timely diagnosis, effectiveness of treatment and eventually disability and mortality rates depend on the above-mentioned factors. Though the financial resources are limited nowadays, the health care requirements are growing due to aging of the population and increased cost of up-to-date medical technologies and medications. This burden is laid to a certain extent on health care workers with secondary and higher nursing education [4,5].
Aim of the study: based on medical statistics data, to analyze the morbidity and mortality from digestive diseases in adult population of Minsk over the last years.
Material and methods. Annual collection of official statistical data of the Ministry of Health of the Republic of Belarus "Health care in the Republic of Belarus" during 1992 -2010; the data on the morbidity from digestive diseases in adult population of Minsk from annual statistical report form - 1 "Morbidity rate"; the data on the number of deaths from annual statistical report form - C51 "Distribution of deaths by sex, age and causes of death"; indices from annual collection of statistical data of the Belarusian Cancer Registry "Malignant neoplasms in Belarus"; sex and age-specific data on the number of population from the National Statistical Committee served as a material for the study.
Methods of study: statistical, graphic.
Results and discussion.
The morbidity from digestive diseases in the population of Belarus beginning from 1991 is given in Table 1. The analyzed period was divided in two decades. During the whole 20 years, a certain increase in general morbidity was noted with annual variations. Annual average rate of growth (Arg. %) amounted to 0,4%; during 1991-2000 - 1,1%. In 2001-2010, annual average rate of decrease was 0,3%. Primary morbidity during the 20 years tended to decrease, with annual average rate of decrease being 0,9%, during 1991 -2000 - 1,1% and in 2001-2010 - 0,8%.
TABLE 1. MORBIDITY FROM DIGESTIVE DISEASES IN THE POPULATION OF BELARUS IN DYNAMICS (PER 100.000 POPULATION)
Aver.
ann.
rate of
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 growth , %
General morbi- 8368, 5 8592, 2 8958, 1 9101, 0 9048, 1 9134, 4 9085, 5 8920, 0 9110, 4 9203, 9 1,1
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
dity 9177, 9407, 9276, 9450, 9021, 8965, 8712, 8946, 8827, 8933,
4 5 6 4 7 5 3 4 1 0 -0,3
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Primar 2544, 2574, 2489, 2470, 2404, 2517, 2458, 2354, 2260, 2289,
y 6 9 6 3 1 8 0 3 3 0 -1,1
morbidity 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
2220, 2460, 2382, 2436, 2269, 2191, 2141, 2320, 2074, 2082,
3 5 6 0 8 8 6 4 0 2 -0,8
During the 20 analyzed years, the structure of the population morbidity has changed on the whole. In 1991-1992, the class of digestive diseases made 4% in the structure of primary morbidity and was the fifth after the respiratory, environmental, infectious and skin diseases. In 2010, digestive diseases made 2,5% and were the seventh in the structure of primary morbidity. In the structure of general morbidity in 1991-1992, they were the second after the respiratory diseases; in 2010 - the third after the respiratory and circulatory diseases. In 1991-1992, digestive diseases in adult population made 4,3% in the structure of primary morbidity and were the fifth; in the structure of general morbidity - 6,4% and were the fourth; in 2010, they were the tenth and the sixth in the structure of primary and general morbidity, accordingly. The difference in indices for each class of diseases in the structure of morbidity noted in different years can be accounted for different rate of growth (rarely, decrease) in the morbidity for each class of diseases.
Rather detailed analysis is given in Tables 2, 3, 4 and 5.
A comparative analysis of regional and republican data as a whole is not presented here, because these data could distort the comparison. They include accessibility (first of all, territorial and transport), timely provision of medical care in the capital as compared with other regions; smaller number of people older those who are able to work living in the capital as compared with other regions.
As seen from Table 2, evident growth in digestive diseases in adult population of Minsk is observed during even a small period of 4 years. It was due to increased number of gastritis and duodenitis, as well as the diseases of the liver, gall bladder, bile ducts and the pancreas. General morbidity from gastric and duodenal ulcer did not change in 20072010.
The morbidity among working age people is naturally lower as compared with older population (Table 3).
Table 2 and 3 present the lethality data for digestive diseases as a whole and for separate nosological forms - percentage of deaths from the number of people affected by the disease (general morbidity). As it was true for the morbidity, lethality of patients older those who are able to work is higher than in the working population. It can be accounted for multiorgan pathology and the accumulated burden of diseases in elderly patients, which decreases the effectiveness of treatment of any disease.
TABLE 2. MORBIDITY FROM DIGESTIVE DISEASES IN ADULT POPULATION OF MINSK-CITY IN 2007-2010 (PER 1000) AND LETHALITY (%)
2007 2008 2009 2010
General morb. Primary morb. Lethality % General. morb. Primary morb. Lethality % General morb. Primary morb. Lethality % General morb. Primary morb. Lethality %
Digestive diseases 88,1 14,7 0,67 94,7 17,4 0,67 99,5 16,4 0,65 105,2 18,4 0,66
among them:
oral cavity, salivary glands and jaw diseases 4,1 1,6 4,5 1,7 4,1 1,6 4,6 2,3
gastric and duodenal ulcer 20,9 1,0 0,16 20,7 1,3 0,15 21,2 1,2 0,16 20,9 1,1 0,17
gastritis and duodenitis 27,3 3,2 32,0 4,4 34,1 3,6 0,01 38,3 4,7
hernia 3,6 1,7 0,11 3,8 1,5 0,12 4,2 1,4 0,06 4,7 1,4 0,11
noninfectious
enteritis and
colitis 1,8 0,9 4,00 2,1 1,1 4,02 2,6 1,0 3,28 2,6 0,8 3,59
Liver
diseases 3,7 0,4 9,76 3,8 0,4 10,64 4,3 0,4 9,57 5,0 0,6 8,95
among them:
alcoholic
liver disease
(number of patients) 169 37 60,4 223 36 52,47 211 56 69,67
liver fibrosis
and cirrhosis
(except alcoholic) 1,0 0,1 31,2 1,2 0,1 26,53 1,4 0,2 22,93
Gall bladder
and bile
ducts
diseases 12,9 1,8 0,11 12,9 1,8 0,12 14,0 1,8 0,08 14,8 2,0 0,08
among them:
gallstone disease 4,5 1,1 0,21 4,8 1,1 0,18 5,5 1,1 0,14 6,3 1,3 0,11
Pancreatic
diseases 3,5 0,5 2,03 3,5 0,6 1,94 3,6 0,6 2,18 3,9 0,8 2,04
acute
pancreatitis and other
pancreatic diseases 0,5 14,82 0,6 11,40 0,6 13,4 0,8 10,31
Acute alcohol
intoxication
(number of cases) 0 212 132 170
Mortality from acute
alcohol
intoxication
(number of cases) 351 347 338 336
Total for
acute alcohol
intoxication
(number of cases) 351 100 559 62,1 470 71,9 506 66,4
As seen from Table 3, by the end 2010, 8,3% of adult working age population and 17,7% of retired people in Minsk suffered from this or that digestive disease (mostly from esophageal, gastric and duodenal).
High lethality from non-infectious enteritis and colitis is observed, especially in the retired people (8,67%); every 12th of these patients died in 2010.
Liver diseases are also characterized by high lethality. In 2010, every 11th patient with liver damage among both working age and retired population died. The main nosological form of the liver disease causing death is liver fibrosis and cirrhosis, among them, alcoholic liver disease (adipose hepatosis, alcoholic hepatitis and alcoholic liver cirrhosis). According to the statistical data from outpatient departments in Minsk, alcoholic liver disease makes 8-9% of all cases of liver fibrosis and cirrhosis. Statistics shows that alcoholic liver disease is fatal for every second of these patients of employment age and for almost every retired person (lethality - 78,6%). In 2010, lethality from liver fibrosis and cirrhosis (except alcoholic) was also high: every fifth of these individuals of
employment age and every fourth of the retired people died. It is evident that among patients with liver fibrosis and cirrhosis (except alcoholic), there is a considerable proportion of individuals with alcoholic anamnesis, but due to the lack of precise diagnostic criteria for alcohol-associated diseases, statistical data are not changed.
Acute or chronic alcohol consumption plays a certain role in the pathogenesis of development, manifestation and thanatogenesis of acute and chronic pancreatitis. Pancreatic damage due to alcohol consumption is observed in 25% of alcoholics [1]. The disease is severe with high rate of lethality and mortality, especially in acute pancreatitis.
In general, pancreatic diseases including acute and chronic pancreatitis affect mostly retired people, the morbidity for this part of the population being three times as large as for the working age individuals (Table 3). As for acute pancreatitis, the morbidity is 1,5 times higher for elderly patients as compared with working people. In general, lethality from pancreatitis is higher in working population than in the retired individuals; though in acute pancreatitis, it is 1,6 times higher in elderly patients beginning with 2010. In 2010, every eleventh patient of employment age and every seventh retired individual died from acute pancreatitis, that is, the survival of elderly patients is much lower.
TABLE 3. STRATIFIED GENERAL MORBIDITY PER 1000 POPULATION OF APPROPRIATE AGE AND LETHALITY (%) FROM DIGESTIVE DISEASES IN MINSK-CITY DURING 2008-2010
2008 2009 2010
wor as popul king e ation retired worki popu ng age lation retired working age population retired
general morb. lethality general morb. letha-ity general morb. lethality general morb. lethaity general morb. lethaity general morb. lethality
Digestive diseases 75,8 0,52 160,6 0,93 79,9 0,51 164,7 0,89 82,8 0,55 176,5 0,83
among them:
oral cavity, salivary glands and jaw diseases 4,5 4,3 4,1 4,2 5,0 3,6
esophagus, stomach and duodenum diseases 46,4 85,5 48,2 91,2 53,0 97,2
gastric and duodenal ulcer 18,0 0,09 30,2 0,29 18,2 0,07 31,0 0,33 17,2 0,08 32,8 0,32
gastritis and duodenitis 26,2 52,0 0,01 28,0 54,3 0,02 31,9 58,9
hernia 2,6 0,03 8,2 0,22 2,7 0,03 9,2 0,09 3,0 0,03 10,0 0,19
non-infectious enteritis and colitis 1,9 0,46 3,1 11,47 2,2 0,38 3,8 8,96 2,1 0,52 4,1 8,67
Liver diseases 3,2 9,05 5,8 13,76 3,6 8,63 6,7 11,24 4,0 8,88 8,0 9,06
among them:
alcoholic liver disease 0,1 52,8 0,1 80,4 0,1 46,39 0,2 70,18 0,1 66,45 0,2 78,57
liver fibrosis and cirrhosis 0,8 27,5 1,7 37,5 1,0 23,80 1,9 31,12 1,1 22,14 2,3 24,16
Gall bladder and gall ducts diseases 8,2 0,01 29,3 0,23 8,6 0,03 32,0 0,12 8,6 0,01 34,8 0,14
among them: gallstone disease 3,0 0,03 11,2 0,32 3,1 0,05 13,4 0,21 3,5 0,00 15,2 0,20
Pancreatic diseases 2,4 2,36 7,2 1,45 2,4 2,57 7,6 1,77 2,6 2,33 7,8 1,73
acute pancreatitis 0,5* 11,3 0,9* 11,7 0,5* 11,82 0,8* 16,72 0,7* 8,77 1,0* 13,81
In clinical and pathological practice, there exists a concept of alcoholic disease when long-tem alcohol abuse results in somatic consequences often affecting this or that inner organ (target organs). The form of alcoholic disease is determined by the main target organ. There are hepatic, pancreatic, cardiac, gastric and renal forms of alcoholic disease, as well as bacterial lung destruction resulting from the damage of inner organs due to alcohol consumption. The data of possible direct effect of alcohol on the gastric mucosa and kidneys are also available. It should be noted that somatic effects of alcohol abuse are observed with both the developed alcohol addiction and beyond the frames of alcoholism [1,2]. Mortality from alcoholic damage of the liver and the pancreas prevails in the structure of nosological forms of alcoholic disease.
It is impossible to exclude the peculiarities of making clinical and morphological diagnosis in modern scientific and practical medicine due to lack of clear-cut diagnostic criteria associated with alcohol addiction. Eventually, all this determines a slight difference in the statistical data associated with alcohol addiction in every region.
To focus the attention on the problem of alcohol abuse and its effect on the morbidity and mortality in the adult population of Minsk, Table 2 presents the data of acute and chronic alcohol intoxication during the last years. The comparison of the morbidity and mortality data makes it possible to suppose that not all cases of acute alcohol intoxication were registered by the statistics. More likely it concerns the cases with lethal outcome occurring in hospital resuscitation departments or outside health care establishments, which explains statistical illogic in Table 2 showing that the number of deaths is larger than the number of registered intoxications. So, it is obvious that the morbidity reflects only the cases of those who survived following acute alcohol intoxication. Therefore, we consider it to be correct to analyze the morbidity from acute alcohol intoxication as the total number of those who survived and died.
Among the above-mentioned diseases, the highest lethality is observed in acute alcohol intoxication, with the mean age of people who died from it being 49,5 years in 2010.
Statistical analysis of morbidity and mortality from alcohol-associated diseases in Belarus and its regions was presented earlier in the article [3].
The mortality from digestive diseases in the adult working population of Minsk increased by the year of 2010, but it is lower than the mortality of people older those who are able to work (Table 4). The rate of the pathologico-anatomic verification of the causes of death is rather high. The cases of accidental alcohol intoxication are reflected in the statistics of forensic medicine subordinated to the procurator's office. Autopsy data from these institutions are not provided to the National Statistical Committee of Belarus.
TABLE 4. MORTALITY FROM DIGESTIVE DISEASES IN ADULT POPULATION OF MINSK-CITY (PER 1000 INDIVIDUALS OF APPROPRIATE AGE) AND THE RATE OF AUTOPSY PROVED DIAGNOSIS (% OF AUTOPSIES)
2007 2008 2009 2010 % pathologico-anatom. verification
Diseases work. age populati on retire d work . age popu l. retire d work age popu l. retire d work age popu l. retire d 200 7 200 8 200 9 201 0
Digestive organ diseases 0,4 1,3 0,4 1,5 0,4 1,5 0,5 1,2 92,5 79,4 81,3 81,6
Gastric and duodenal ulcer 0,01 0,1 0,02 0,08 0,01 0,1 0,04 0,07 9,6 95,8 96,2 92,9
Alcoholic liver disease (cirrhosis
hepatitis, fibrosis) 0,06 0,1 0,05 0,1 0,06 0,1 0,08 0,1 63,6 65,7 76,9 82,3
Liver fibrosis and cirrhosis (except alcoholic) 0,2 0,6 0,2 0,6 0,2 0,6 0,2 0,4 70,9 74,3 75,5 72,9
Accidenta l alcohol intoxicati on 0,22 0,27 0,23 0,21 0,21 0,24 0,63 0,35
Annual mortality from acute pancreatitis in Minsk is 0,08 per 1000 adult population (8 per 100.000).
During a small 4-year period under study, variability of mortality indices was observed with no clear-cut tendency (Table 4). Nevertheless, the mortality from gastric and duodenal ulcer in the working age population increased. The mortality from alcoholic liver disease and acute alcohol intoxication was variable, with the highest mortality rate noted in 2010. Table 4 presents the data per 1000 population, which seem to be insignificant and not so sad, but it is abstract statistics. Every individual case of death is a real tragedy, as well as irretrievable town losses. Table 5 presents more real situation with absolute numbers of deaths among people able to work and among men. Of total number of deaths from all digestive diseases, 49,6% of adult people and 60,7% of men died at employment age in 2010; among them, 30,4 % and 67,9% died from gastric and duodenal ulcer, respectively. Non-infectious enteritis and colitis mostly caused the death of patients older those who are able to work (81 %), women making 57,2% of these people. Death due to alcoholic liver disease, liver fibrosis and cirrhosis was more frequent among the working patients (70% and 58,6%) and among men (66% and 63,4%, respectively); pancreatitis caused 59% and 73% of deaths; acute alcohol intoxication in 75,9% for working age and 75,3% for men. Mortality from oncologic diseases was naturally more frequent in patients older the employment age (78%), in men it was equal to 55,1%.
TABLE 5. NUMBER OF DEATHS FROM SOME DIGESTIVE DISEASES IN ADULT POPULATION
OF MINSK-CITY IN 2007-2010
2007 2008 2009 2010
a; tw (O tw c IE i— o S <D 13 . o c m E 13 . o c <D E 13 . o c <D E
Diseases 03 4-J o 4-J D a. o a. c m E (O c IE i— o £ c m E 03 4-J o 4-J . <L) on (0 on c IE i— o c m E <L) n (0 n C IE i— o £ 03 4-J o 4-J . <L) on (0 n c IE o c m E <L) n (0 n C IE o £ 03 4—' o 4-J . <L) (0 n c IE o c m E 0! n (0 n C IE o £
A 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Digestive diseases
(as a
whole) 383 438 531 333 962 459 565 333 1003 482 598 368 1072 532 651 405
gastric and
duodenal
ulcer 50 15 31 12 48 18 32 16 52 15 29 12 56 17 38 16
gastritis and
duodeniti
s 2 2 1 1 1 1 4 1 2 1 2 1 2 1
appendix diseases 2 2 2 1 1 1 1 1 1 1
hernia 6 1 3 7 1 4 1 4 1 1 1 8 1 2 1
non-
infectious
enteritis
and colitis 109 10 46 10 130 10 55 10 131 10 49 7 145 13 62 12
ileus,
paralytic ileus 7 1 3 1 9 3 7 3 6 1 2 . 4 1 2 1
alcoholic
liver
disease
(cirrhosis, hepatitis, fibrosis) 107 67 78 54 102 65 68 42 117 77 73 57 147 103 97 71
liver
fibrosis
and
cirrhosis
(except alcoholic) 409 237 258 176 483 267 286 187 494 278 316 206 505 296 320 225
other
liver
diseases 25 15 12 9 27 14 16 9 22 10 15 9 31 16 13 10
gallstone disease 14 2 4 2 13 1 5 1 12 2 4 1 11 2 0
cholecysti tis 3 2 3 2 3 1 0 5 0
other gall bladder
and bile
ducts
diseases 4 3 2 2 8 4 2 D 3 0 3 1 3 1
acute
pancreati tis and
other
pancreati c diseases 107 69 70 54 102 67 70 55 122 74 87 63 122 72 89 58
other
digestive diseases 40 16 22 12 29 13 15 9 32 11 19 10 32 10 20 8
accidenda l alcohol intoxicati on 351 263 277 224 347 275 274 236 338 253 268 220 336 255 253 205
oncologic digestive diseases 1234 308 723 244 1396 347 767 247 1308 306 723 238 1354 298 746 224
The picture of the morbidity from digestive diseases in the adult population of Minsk would be incomplete without the indices of the morbidity from oncologic diseases. As seen from Table 6, during 2001-2010, there is a trend to a decrease of oncologic diseases of the esophagus and the stomach, while the colon and rectum cancer is markedly increased. Detection of oncologic diseases changes in the course of time, with the age being an important factor in the development of cancer. In general, oncologic diseases are more common in elderly people. The data estimated for the adult population of Minsk (as calculated for an averaged therapeutic district) are presented for the year of 2010. During this year, average number of individuals who got ill was 2-2,5; 8-9 individuals were followed up at the Oncologic Dispensary and 1 person (as minimum) died. In general, the mortality rate decreases, while the number of population of Minsk according to the statistical data is growing. The lethality rate also decreases due to improved treatment and detection of diseases at an early stage, but the number of deaths is growing (Table 5).
TABLE 6. STATISTICAL DATA OF ONCOLOGIC DIGESTIVE DISEASES IN MINSK-CITY
(PER 100.000 POPULATION)
Site Morbidity Contingents Mortality Lethality
2001 2005 2010 2001 2005 2010 2001 2005 2010 2001 2005 2010
Lip 0,8 0,8 1,0 10,5 10,1 9,3 0,3 0 0,2 2,9 0,0 2,2
Esophagus 3,1 3,2 2,9 2,6 3,3 4,6 2,3 2,3 2,3 88,5 69,7 50,0
Stomach 30,3 29,6 28,4 88,6 93,8 103,4 23,9 21,5 20,7 27,0 22,9 20,0
Colon 21,1 26,8 30,4 80,4 106,1 143,2 14,3 13,6 16,8 17,8 12,8 11,7
Rectum 17,6 19,8 20,4 63,9 78,0 96,8 12,7 10,4 11,5 19,9 13,3 11,9
Liver (Rep. of Belarus) 4,4
Pancreas (Rep. of Belarus) 9,5
Total 72,9 80,2 97,0 246,0 291,3 357,3 53,5 47,8 51,5 21,7 16,4 14,4
Adult population 117,0 427,7 61,6 14,4
In 2010, primary disability of the adult population in Minsk due to digestive diseases amounted to 1, 3 cases per 10 000 population.
Conclusions:
In conclusion, it should be marked that the given data present estimates of statistically recorded cases based on official reports of morbidity and mortality issued by health care bodies, but these data may not reflect real situation due to certain reasons. It concerns, first of all, alcohol-associated pathology. Negative effect of alcohol on the morbidity and mortality from digestive diseases is obvious. Morbidity and mortality in working age people and excessive mortality in men are of greatest concern.
Since alcohol consumption is, to a certain extent, a regulated factor, there exists a real possibility to decrease alcohol-associated mortality. Taking into account that alcohol-associated lethal outcomes are potentially preventable, there is an urgent need for the development of alternative organizational (interdepartmental) programs aimed at preventing alcohol consumption in the groups of a particular risk, whose number is gradually increasing.
Allowing for the directions of the activity of health care bodies and establishments for 2012 on improving the quality of dispensary observation over the working age patients, the need for extending the powers and redistribution of duties among doctors and nurses and among doctors and feldshers (doctors' assistants) with higher education becomes obvious. Patients with duodenal diseases may form a group of observation for these health care professionals.
Study materials can be used for organizing health promoting events in the working age population, especially among men. They can serve as convincing, scientifically grounded recommendations for this part of the population encouraging people to promote health in their everyday life. People shouldn't only rely on the health care provided by the government, they should take greater responsibility for their own health. According to L. Tolstoy, "an effort is a precondition of moral perfection". Every intelligent man with a certain level of general and medical culture can learn how to avoid falling victim to serous health problems and to maintain his or her well-being leading a healthy life. As famous A. Schweitzer wrote, "personal example is not simply the best method of persuasion but the only one".
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