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Int J Adolesc Med Health 2010;22(4):561-566 __________________________________________________________________________________________

Adolescent profile: Hospital record based study


Sandeep Sachdeva, MD (CHA), DNB, DHA, Mahesh C Kapilashrami, MD (PSM) and Tilak R Sachdev, MD (PSM) Department of Community Medicine, PGIMS, Rohtak, Haryana, National Institute of Health and Family Welfare, Munirka, New Delhi and Department of Community Medicine, VMMC and Safdarjung Hospital, New Delhi, India

Abstract: A discharge case record (ICD-10) based retrospective study for a calendar year was carried out in one of the biggest tertiary care hospitals of Delhi, India. Of 5856 adolescent admissions, 53.77% were males and 46.22% were females. The respective proportion of adolescent admission and death recorded was 7.5% and 5.2%. The average monthly adolescent admissions were 488 (range: 304-648), and 47% of admissions happened through the emergency department. The outcome was 5499 (93.9%) adolescents were discharged alive, and 353 (6.02%) died during hospital stay. The average loss for adolescents was 6.8 days. The top three causes of morbidity were injuries (12.70%), burns (6.18%), or nonspecific signs and symptoms (5.51%), With regard to mortality, of 353 adolescent deaths recorded, the leading causes were 123 (34.84%) burns, 29 (8.21%) injuries, and 22 (6.23%) tuberculosis. Keywords: Adolescence, hospital, ICD-10, discharge record, morbidity, mortality Correspondence: Sandeep Sachdeva, MD (CHA), DNB, DHA, Dept of Community Medicine, Pt BD Sharma, PGIMS, Rohtak124001, Haryana, India. E-mail: drsandeepsachdeva@gmail.com Submitted May 20, 2010. Revised: July 10, 2010. Accepted: July 20, 2010

INTRODUCTION

The term adolescent, meaning to emerge or to achieve identity has its origin from the Latin word adolescence (1,2). Adolescents account for more than 1/5th of the worlds population, and in India, this age group constitutes nearly 21% of total population (3). A hospital record-based retrospective study was carried out in one of the biggest tertiary care hospitals of New Delhi to determine the morbidity and mortality profiles of hospitalized adolescents. The present study was unique from the perspective that although various hospitals in India annually publish statistics related to their in-patient and out-patients, there is

neither collation nor reporting of data separately for the adolescent age-group (1019 years) based on the WHO-International Classification of Diseases. Most studies carried out earlier covered children up to 12/15 years of age or 15-24 years separately.
METHODS

The Safdarjung hospital is a public funded institution attached to a medical college and has bed strength of more than 1,500 with a monthly turnover of about 8,000 inpatients. The hospital runs 16 regular OPDs and as many as 53 special clinics in almost all fields of medicine/surgery and allied branches including nuclear medicine,

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acupuncture, and ayurveda (Indian system of medicine); with a daily attendance of more than 5,000 patients. Safdarjung is one of the 2,500 selected hospitals of the country, nominated for the collection of data on Medically Certified Cause of Death (MCCD) by the Vital Statistics Division of the office of Registrar General of India and is also a recognized training center of the Government of India for imparting training to Medical Record Officers (MRO) and technicians on the Health Management Information System (HMIS) and the WHOInternational statistical classification of diseases (ICD). The completed discharge case records of in-patients from all departments are sent to the medical record department (MRD) for coding according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10th revision) (4), compiling, collating, reporting and preserved for future reference. Disease codes are entered in the appropriate column in discharge case sheets against each diagnosis. The MRD ensures completeness of cases sheets by holding regular meeting with concern department in the event of partially filled case sheets forwarded to them. Because an electronic database of patient records was not established in the hospital at the time of study, the central admission register for the calendar year 2000 was screened to short-list all the adolescents in the age group 10-19 years with their registration numbers on a structured proforma by a single investigator during the period April-August 2002, after taking permission from a competent authority. The short-listed adolescent cases were then retrieved from the MRD for recording selected socio-demographic profile-age, gender, residence, religion, marital status; time and mode of admission, length of stay, discharge status, department of care and primary diagnosis (ICD-10

code). The data were then entered into an Microsoft Excel sheet, analyzed by calculating descriptive statistics and the chisquare (2) test to determine statistical significance at p < .05.
RESULTS

Total admissions (all ages) reported by the hospital in the year 2000 were 77,946 excluding newborn (5). Of these, adolescent admissions recorded by investigator were 5,971. For the purpose of this study, the adolescent admissions that were cancelled (46), repeat admission with the same problem (10), or whose case records could not be traced despite the best efforts (59) were not considered, for a total of 115. Hence, the total number of adolescents in the age group of 10-19 years considered for this study was 5,856. Thus, the proportion of adolescent admissions to total admissions was 7.5% (5,856/77,946). The hospital reported 6,751deaths during the same period (5), of which the number of adolescent deaths recorded by the investigator was 353. The proportion of adolescent deaths to total deaths was 5.2% (353/6,751). Socio-demographic characteristics The number of adolescents in the age-group 10-13 years (early stage), 14-15 years (mid stage), and 16-19 years (late stage) years was 27.28% (1,598), 16.13% (945), and 56.57% (3,313), respectively. Of 5856 adolescent admissions, more than half, 3,149 (53.77%) were males and 2707 (46.22%) were females. Males out-numbered females during all stages of adolescence, except during late stage. The participants included 5,319 (90.82%) Hindus, 525 (8.9%) Muslims, and 12 (0.02%) followers of Christianity. Nearly 75% adolescent were residents of Delhi and the rest from outside the state; 932 (15.91%) were married and of these, all were females.

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Month and mode of admission The average monthly adolescent admissions were 488 with lowest 304 (5.19 %) admissions recorded in the month of April and highest 648 (11.06 %) during September. Nearly 47% adolescent admissions happened through emergency department (ED). Department wise discharge were as follows, surgery (20.73%), general medicine (17.67%), obstetric and gynecology (15.88%), burns and plastic surgery (10.62%), pediatrics (8.81%), pediatric surgery (5.80%), ENT (5.79%), orthopedics (5.73%), neurology (1.61%), eye (0.99%) and others (6.33%) respectively. Morbidity profile The morbidity profile was grouped as per ICD-10 classification in decreasing order of frequency and more than 1/5th of all cases 1278 (21.28%) were due to injury, poisoning, burns, or certain other consequences of external causes. This was followed by physiological process and related health problems of pregnancy and childbirth 814 (13.9%) and diseases of the digestive system 673 (11.49%) (table 1). The 10 main causes of morbidity were injuries (12.70%), burns (6.18%), nonspecific signs and symptoms (5.51%), tuberculosis (3.21%), appendicitis (3.10%), poisoning (1.92%), paralytic ileus with intestinal obstruction (1.87%), suppurative otitis media (1.63%), inguinal hernia (1.40%) and typhoid fever (1.34%). The remaining 61% cases did not figure in the first 10 leading causes of morbidity. Further, gender exploration revealed that injuries were 4 to 6 times more common among males than females in all three stages of adolescence, whereas tuberculosis was more prevalent among females than males in all stages. Other diseases that affected more females than adolescent males were burns (mid and late stage) and

suppurative otitis media (mid stage of adolescence). The remaining disease conditions were more prevalent among male than female adolescents. A statistically significant association was found between male and female adolescents in all stages of adolescence due to the 10 leading causes of disease conditions (2 = 56.18, early stage; 58.4, mid stage; and 239 late stage), p < .05).

Teenage pregnancy Of 2,707 female adolescents, 814 (30.0%) were admitted to the obstetrics and gynecology department for delivery (600 (22.0%)) and pregnancy related issues (214 (8.0%)). Within this subcategory, abortion, false labor, maternal hypertension, and hemorrhage accounted for 8.5%, 7.0%, 5.0%, and 2.0% of female adolescent admissions. Mortality profile Of the 353 adolescent deaths recorded in this study, 123 (34.84%) were due to burns followed by 29 (8.21%) injuries, and 22 (6.23%) tuberculosis. The other causes of mortality in order of frequency were 14 (3.96%) rheumatic heart diseases, 10 (2.83%) viral encephalitis, 9 (2.54%) pneumonia, 8 (2.26%) lymphoid leukemia, 8 (2.26%) meningitis, 6 (1.69%) aplastic anemia, and 6 (1.69%) peritonitis. These 10 leading causes of mortality were responsible for 235 (66.57%) of the total deaths recorded amongst adolescents. There was a statistical significant difference due to the case fatality rate in all stages of adolescence due to burns only (p < .05). The general case fatality rate (GCFR) during the specified period expressed as percentage of deaths among adolescents, irrespective of any particular disease condition, accounted for the maximum during the month of January (10%) and the lowest in June (2.0%).

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Table 1. Profile of hospitalized adolescents


SN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Diseases and related health problems Injury, burns, poisoning and certain other consequences of external causes Pregnancy, childbirth and puerperium Diseases of digestive system Certain infectious and parasitic diseases Non-specific signs/symptoms Diseases of respiratory system Diseases of the skin and subcutaneous tissues Diseases of nervous system Diseases of the genito-urinary system Disorder of blood and blood forming organs Neoplasms Diseases of the circulatory system Congenital malformation and deformation Diseases of Musculo-skeletal system Diseases of the ear and mastoid process Miscellaneous groups ICD-10 code S00-T98 O00-O99 K00-K93 A00-B99 R00-R99 J00-J99 L00-L99 G00-G99 N00-N99 D50-D89 C00-D48 I00-I99 Q00-Q99 M00-M99 H60-H95 _ N 1278 814 673 489 323 279 253 232 194 186 163 148 139 127 117 441 5,856 Percent 21.82 13.90 11.49 08.35 05.51 04.76 04.32 03.96 03.31 03.17 02.78 02.52 02.37 02.16 01.99 07.53 100

TOTAL

Length of stay (LOS) and outcome The average LOS for the adolescents was 6.8 (range 1-33) days and was inversely proportional to stages of adolescences; 7.4, 6.8, and 6.4 days for early, mid, and late adolescence (p > .05). Marget (6) reported LOS among hospitalized adolescent as 5.2 days in the United States (US). The outcome of 5,856 adolescent admissions was 5,499

(93.9%) discharged alive, 353 (6.02%) died. Only 4 (0.06%) male adolescents left against medical advice. Overall, this was suggestive of the high quality of care rendered by this premiere institution. The proportion of males to females discharged alive or who died was similar for both sexes. This observation was statistically non-significant (2 = 0.91, p > .05).

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DISCUSSION

Adolescents are the healthiest age group of the population. This study describes various morbidity and mortality profiles among adolescents from a tertiary care teaching institution in Delhi, India for the calendar year 2000. Epidemiologically, an episode of hospital admission can be compared to the concept of an iceberg phenomenon in the natural history of diseases, wherein only serious, difficult, or cases presenting with diagnostic dilemmas are admitted to hospital. Although the findings emerging from the present study cannot be generalized, in a developing country like India, where the registration of vital events is unsatisfactory and notification of diseases inadequate, hospital data constitute a basic and primary source of the information about morbidity and mortality prevalent in the community. All hospitals in India do not collect and publish data explicitly for adolescents. The authors to their best efforts could not retrieve any study among adolescents (10-19 years of age) with ICD-10 in context of Indian setting, but the findings agree with others done at various international platforms. In the present study, 7.5% of adolescent admissions compared to total admissions was similar to the 7.0% among 12-19 yearolds reported in 1980 (US), but higher in comparison with the 5.0% in 10-19 year olds in 1991, 2000 (US), or 6.81% in Taiwan (68). On the parallel front, the present study reported a total death rate (death to discharges among all age group) as 8.6% that was slightly higher (6.8%) than in a tertiary care teaching center in Nigeria (9). In the present study, a higher male admission was noted in the early (10-13 years) and mid (14-15 years) adolescent stage than late (16-19 years) in comparison with females, which happened especially for obstetric issues. A similar observation was noted in the Oxford region (10). With regard to the month of admissions, the

maximum (11.6%) admissions were during September, although it is difficult to pinpoint the factors/reasons behind this phenomenon. However, a study conducted in the pediatric age group by Basu in West Bengal (India) also reported maximum admissions in this month (11). Nearly 47% of adolescent admissions happened through the emergency department and was similar to the 45% in the age group of 1-17 years reported in the US (12). The finding that more than one-fifth of adolescent admissions were due to injury, burns, poisoning, and certain other consequences of external causes is suggestive of various behavioral factors playing a critical role in this endeavor. Injuries were prevalent more than fourfold among male than females, which was statistically significant (p < .05) during all stages of adolescence, followed by the physiological process of pregnancy and related issues. This evidence is comparable with other studies (13-15). Most of these cases may be preventable by taking appropriate safety, educational and counseling measures.
CONCLUSIONS

This study presents a snapshot of adolescent health, based on final primary discharge diagnosis from a tertiary care teaching and training institution in Delhi, India for a calendar year with 7.5% and 5.2% adolescent discharges and deaths and varied pattern of morbidity and mortality profile as per ICD-10 family of classification with higher load due to preventable external causes.
ACKNOWLEDGMENTS

Source of funding and conflict of interest: None.


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