Introduction
To the epidemiologist, the most important event and the least equivocal measure of
health is death, which could be called the absolute opposite of health.
Mortality statistics reveal much about the health of the population: Ones derived
statistics and life expectation at birth and at various subsequent ages is often cited
as an indicator of population health when comparisons are made over time and between
nations for designing intervention programs, allocation of resources and indicating
priorities. It is essential to know the frequency of disease or death. But this is
not static, and is changing. It is also important to decide whether the observed change
reflects change in incidence, in case fatality or both. It is equally important to
determine whether that observed trend in mortality is genuine or is it due to change
in nomenclature or classification of disease, changes in accuracy of diagnosis or
changes in the statistical classification or allocation of priorities.(1)
Traditionally and universally, most epidemiological studies begin with mortality data,
which is relatively easy to obtain and, in many countries, reasonably accurate. Many
countries have routine systems for collection of mortality data and causes of death
are important and widely used for number of purposes they may employ in explaining
trends and differentials in overall mortality, indicating priorities of actions and
in the assessment and monitoring of public health.(2)
Although diseases have not changed significantly through human history, their patterns
have. It is said that every decade produces its own pattern of disease.
The pattern of diseases in developing countries is very different than those in developed
ones. In a typical developing country, most deaths result from infectious and parasitic
diseases, abetted by malnutrition. In India, about 40% of deaths are from infectious,
parasitic and respiratory diseases as compared with 8% in developed countries. Diarrheal
diseases are widespread. Cholera has shown a declining trend. Malaria and kala azar,
which showed a decline in the 1960s, have staged a comeback. Japanese encephalitis
and meningococcal meningitis have shown an increasing trend. There is no appreciable
change in the prevalence of tuberculosis, filariasis, viral encephalitis diarrheas
and dysentery and disorders of malnutrition and under nutrition. On the other hand,
an increase in the frequency of new health problems such as coronary heart disease
hypertension, cancer diabetes and accidents has been noted.(2)
The Medical Records Department in a teaching hospital has a system of compilation
and retention of records; yet, the acquisition of meaningful statistics from these
records for health care planning and review is lacking. Mortality data from hospitalized
patients reflect the causes of major illnesses and care-seeking behavior of the community
as well as the standard of care being provided. Records of vital events like death
constitute an important component of the Health Information System. Hospital-based
death records provide information regarding the causes of deaths, case fatality rates
and age and sex distribution, which are of great importance in planning health care
services. There is a paucity of information about direct causes of child mortality
in developing countries.(1) This information also provides the basis for patient care
and helps the administration in managing day-to-day hospital affairs. The present
study was aimed to study the trend and mortality pattern in a tertiary care hospital
and an attempt was made to determine whether epidemiological transition is present
in mortality data.
Materials and Methods
A retrospective analysis was done with records of patients who died in Shree Chattrapati
Shivaji Maharaj Sarvopachar Rugnalaya, a tertiary care hospital attached to Dr. V.M.
Govt Medical College, Solapur, Maharashtra. All case records of indoor patients after
discharge or death, except deaths of medico legal cases, are submitted in the Medical
Record Section that works under the Department of P.S.M. of Dr. V.M. Medical College,
Solapur. All deaths that occurred during the 5-year period, i.e., 2005-2009, except
medico legal deaths, were considered for analysis. Case sheets of deaths for years
2005-2009, i.e., the 5-year period, were analyzed to study the trend and pattern of
disease causing deaths. The underlying cause of death was recorded with great accuracy
and was classified as the I.C.D. 10th revision. Name, age, sex, date of admission,
place of residence, date of death and underlying cause of death were used for analysis.
Results
In 5 years, i.e., from 2005 to 2009, a total 6123 deaths were registered in the Medical
Records Section. Mortality rate per 1000 indoor admissions was calculated. It was
less in 2005 and increased in 2006 and remained stable till 2009. The mortality trend
was studied, which was linear, and was statistically significant (χ2 = 5.737, P =
0.01). The linear trend equation was calculated [Table 1].
Table 1
Year-wise mortality rate
The trend line equation for mortality rate is Y = 34.59 + 0.0547× (X - 2007)
where Y= mortality rate, X= year
Maximum deaths were seen in the month of August in all 5 years, and minimum were seen
in February. The seasonal index of mortality was maximum in the rainy season, i.e.,
in the months of July-August-September-October, followed by the summer season, i.e.,
in the months of March-April-May. It was minimum in the winter season, i.e., November-December-January-February
in all 5 years [Figure 1].
Figure 1
Month-wise seasonal index of deaths in 2005-2009
Consistently, urban deaths were more than rural deaths, which may be due to easy accessibility
in emergency conditions for severe and moribund patients in the urban area in all
the 5-years period [Figure 2]. Male deaths were more than female deaths during 2005-2009,
and the difference was statistically significant. Sixty percent of the deaths were
in males and 40% in females [Figure 3].
Figure 2
Year-and place-wise distribution of deaths
Figure 3
Year-and sex-wise distribution of deaths
The major proportion of hospital deaths were seen in the early neonatal period, which
were maximum in 2008 (37.17%) and minimum in 2006 (26.3%). Late neonatal deaths were
very less. Nearly 1/5 of the hospital deaths were in patients aged 60 years and above
(18.91- 22.2%). The proportional mortality rate for adults, i.e., for patients aged
15-60 years, was in the range of 29.94-34%. It was maximum in 2007 (34%). The proportion
of infant deaths was in the range of 33.75-44.4%, and was maximum in 2008 and minimum
in 2006 [Table 2].
Table 2
Proportional mortality rate by age in 2005-2009
Cause of death was coded as per the I.C.D 10th revision, and 975, 1251, 1153, 1209
and 1135 deaths for the years 2005, 2006, 2007, 2008 and 2009 were coded, respectively,
and nearly 6-7% deaths could not be classified due to some technical difficulties.
Joshi et al. mentioned that 18% of the deaths could not be classified.
In the 5-year period, i.e., from 2005 to 2009, the proportion of deaths due to communicable
diseases showed a declining trend from 2006 to 2009. It ranged from 25% to 32% in
these years, while the proportion of deaths of non-communicable diseases showed an
increasing trend. The range was from 68% to 74.9%. Maximum proportion of non-communicable
diseases (NCD) was in 2005 and 2009. Among the communicable diseases, the most common
cause of death was tuberculosis (39.7-47.8%), followed by infection specific to the
perinatal period (9.44-14.4%). Among the non-communicable diseases, the most common
cause of death was conditions originating in the perinatal period, such as prematurity
and low birth weight excluding infections in the perinatal period (42.4-51.8%), followed
by cardiovascular diseases and diseases of the digestive system (21.3-26.6%) [Table
3].
Table 3
Year-wise deaths of communicable and non-comminicable diseases
Discussion
In the present study, the mortality trend was linear for the period 2005-2009. A similar
finding was reported by Joshi et al.(3) A log linear increased death rate for aged
men and women from 5 years of age was seen. Last(1) mentioned that the mortality trend
with time was usually either upward or downward, and a seasonal trend of deaths was
observed in the present study, but was not seen by Roy et al.(4)
Preponderance of male deaths (60%) over female deaths, similar to the present study,
was a finding of many authors.(1–10)
The age curve of mortality has general features in common everywhere, with variation
depending upon environmental factors. Mortality is high during the first year of life,
which drops to the lowest level in childhood and then gradually begins to climb during
the third and fourth decades,(1) which is very well documented by the present study.
Highest neonatal mortality was found by some authors.(4
7)
The significant decline in early neonatal mortality found by Verma et al.(11) is different
from the finding of the present study, where proportionate mortality rate for early
neonate increased from 2006 to 2009. Infant deaths were less in various studies.(8–10)
Pediatric deaths in the present study were 44.6-51.15% in the 5-year period, which
were more than that reported by other authors(6
9–12) but similar in the study of Luiz Cesar Peres.(7) Deaths in patients of the age
15-60 years were nearly similar in the CRS report(9) but more (57%) in the report
by Bhatia et al.(10) But, a similar proportion of deaths in patients aged 60 years
and above was noted.
Chronic non-communicable diseases are assuming increasing importance among the adult
populations in both developed and developing countries. They are the leading causes
of deaths and there is an upward trend of non-communicable diseases due to many reasons
such as change in lifestyle and behavior.(2) The present study also reveals epidemiological
transition where proportion of non-communicable deaths were increasing in 5 years
(68% in 2007 to 74.85% in 2009). The average proportion of deaths by NCD were 71%,
which is similar to that in developed countries like Europe and America.(2) Co-existence
of the disease pattern of both industrialized and developing countries indicating
epidemiological transition similar to the present study was seen by Luiz Cesar Peres.(6)
He found the percentage of cardiovascular deaths to be 21.3%, infectious and parasitic
deaths to be 19.2%, gastrointestinal tract (GIT)-related deaths to be 6% and congenital
malformation nearly similar to the present study, but perinatal deaths (10.8%) were
less and neoplasm (12.8%) and respiratory system deaths (6.6%) were more than in the
present study. In a review study of pediatric deaths by Luiz cesar Peres,(7) more
perinatal deaths (51.0%) more congenital malformation deaths (24.4%) and less infectious
and parasitic deaths (11.9%), less GIT and similar chronic non communicable diseases
(CND) and cancer deaths were found. Omran(13) found a changing pattern of disease
and a high prevalence of deaths due to infectious and parasitic diseases probably
due lower socioeconomic status similar to the present study. But, cardiovascular deaths
ranked second in his study. Bhatia et al.,(10) Mari Bhat,(14) Yang et al.(15) and
Saha et al.(5) found that the percentage of communicable deaths was decreasing and
that of non-communicable deaths was increasing, a finding similar to the present study.