Pattern and outcome of medical admissions in a Nigerian rural teaching hospital (2009-2012)

Background: Medical diseases vary depending on the locality and it reflects the pattern of medical admissions into a medical centre. We set out to collect, analyse, present the report of results from Igbinedion University Teaching Hospital to the wider scientific community on pattern and outcome of patients in medical wards in the hospital between January 2009 to December 2012. This we believe would reflect the relative pattern, trend of diseases burden and relative importance of diseases in the hospital locality. Methods: The study was a retrospective descriptive study where data of admission cases in both male and female medical wards were collected (from the admission register with occasional reference to some patients’ case notes) and analysed. Results: A total of 1066 patients were admitted during the study period, Male patients constituted 52.5% while female were 47.5% (Male: Female ratio 1.11:1 , age range 14-99 years) while under 20 years, Under 30 years and Elderly constituted 30.1%, 59.3% and 12.5% respectively. Malaria, hypertension, Vaso-occlussive Crisis in Sickle Cell Diseases, Peptic Ulcer Disease, Gastroenteritis and Enteric Fever were the most common diseases admitted during the study period. Infectious and parasitic diseases was found to constitute the majority of diseases admitted. 81.2%, 4.6% and 1.6% of admitted patients were discharged, referred and died respectively. Discussions and Conclusion: The large proportion of patients in younger age groups was likely due to the university community that is located in the same town with the teaching hospital. Elderly patients accounted for 11.1% of total hospitalization similar to value gotten in another Teaching Hospital. The study showed essentially that Infectious diseases constituted the bulk of admission with malaria being the largest single disease. Non-Communicable Diseases (NCDs) were also prominent. Majority of the patients were discharged home with lesser outcome of referral, death and transfer etc.

Keywords: Diagnosis, medical patients, outcome, pattern of diseases, tertiary health centre

Tertiary health institutions play a very important role in health care delivery systems where they handle referrals from primary and secondary health institutions and treat more serious illness than other levels of health care delivery systems. Furthermore, they are relevant in training undergraduate and postgraduate medical professionals.

Medical diseases vary depending on the locality, so also cases that present to the health care system and medical admissions constitute a very significant part of general admissions in many hospitals. ^[1] Though there is a global epidemiological transition to where noncommunicable diseases (NCDs) constitute majority of diseases, some teaching hospitals still have significant proportion of infectious disease burden even in urban areas, where it is expected that level of affluence and urbanization would have influenced otherwise according to global trend. ^[2],[3]

Studies as extensive in term of duration and depth of outcome analysis as this had not been done before or disseminated to a wider population using the study population at the institution we used. This is an opportunity to communicate the pattern and outcome of medical disease seen at Igbinedion University Teaching Hospital, and this will serve as a reference for comparison with other centers, especially considering the peculiarity of the facility as a rural teaching hospital.

Hospital admissions are a reflection of common diseases in the society. This clinical audit would help reveal the disease burden in the surrounding communities, where the tertiary institution serves. Though it may not be the true incidence of disease at the community level, it would, however, serve as a reflection of the pattern and trend of diseases in the community. ^[5] Iceberg phenomenon and health seeking behavior of people in the surrounding communities would have effect on some presentation to the hospital, the result to an extent would reflect the relative pattern, trend of diseases burden and relative importance of diseases in Ovia North-East Local Government Area (LGA) and environs served by the hospital. ^[6]

Audits of patients in term of disease pattern and outcome are very useful in health care planning and performance evaluation of a hospital in a bid to improving services.

It forms part of necessary data in the State and National Health Information Systems that can be used to enhance the country’s population health. ^[5] Although with some limitations, hospital data analysis assesses the quality of health-care delivery and provides approximate measures of mortality and morbidity. ^[3],[4]

This study was undertaken to determine the profile of admissions and outcome into the medical wards at the Igbinedion University Teaching Hospital between January 2009 and December 2012.

The study was done in Igbinedion University Teaching Hospital, Okada located in Ovia North-East LGA. The hospital started out as Igbinedion Hospital and Medical Research Center on 4 ^th of May 1993 and was upgraded to a Teaching Hospital on 1 ^st July 2002 to provide a training ground for her mother university, provide healthcare services to the community and still operate as a research center. The medical ward has 20 functional bed spaces for both males and females.

Ovia North-East LGA has a population of 155,344 (males – 80,433, females – 74,911) according to the 2006 National Census with 15 years and above accounting for 101,919. However, patients from neighboring LGAs like Ovia South-West and the neighboring Ondo state patronize the hospital. ^[5]

The hospital is the third tertiary institution in Edo state with a population of 3,233,366 (National Population Commission, 2006). ^[7] It is one of the few private tertiary hospitals affiliated to a university in the country and not situated in an urban area or very close to one.

The study was a descriptive retrospective study. Admission case reports in both male and female medical wards in Igbinedion University Teaching Hospital, Okada between January 2009 and December 2012 were used. An annex of the hospital situated in Benin about 80 km from Okada was excluded from the survey. Day cases, consultation in Medical Outpatient Department and clinical observation in the Accident and Emergency Unit were also excluded.

Medical wards admitted patients above 14 years who had mainly various medical conditions. Such patients came in as a transfer through Accident and Emergency (casualty) Unit or the General Outpatient Department/Medical Outpatient Department.

Medical ward patients’ register, usually, recorded by the nurses in the wards were primarily used to gather the study data. However, some confusing or suspiciously conflicting entries had to be further scrutinized by checking the patients’ case notes to verify such information. Information that could not be retrieved was acknowledged as missing. Frequencies of diagnosis were more than the patients because of patients with multiple diagnoses.

International Statistical Classification of Diseases (ICD-10) were used to classify the disease pattern to allow for standardization, giving the results more usefulness for comparison with other centers. ^[8] (See box below for ICD -10 Classification).

International statistical classification of diseases categories

The study was approved by the Ethical Review Committee of the hospital, and the preliminary results were initially presented during a session of the hospital clinical meeting.

A total of 1066 patients was admitted into both male and female wards between 2009 and 2012 [Table 1].

Male patients constituted 560 (52.5%) while female were 506 (47.5%) giving a male:female ratio of 1.11:1 [Figure 1]. Age range of patients admitted was 14-99 years.

Below 20 years constituted, the largest proportion of the patients in each of the study years and the total pool of patients admitted 2009-2012, while <30 years of age constituted 59.3% (66.3% in 2009, 56.9% in 2010, 56.7% in 2011, and 53% in 2012). Elderly patients (61 years and above) accounted for 8.7% in 2009, 10.9% in 2010, 14.2% in 2011, and 16% in 2012, accounted for 10.98% of the 1066 patients in the period under review [Table 2].

Pattern of diseases admitted

Diseases with the highest frequencies admitted during the study period included malaria, hypertension, vaso-occlusive crisis in sickle cell diseases, peptic ulcer diseases (PUDs), gastroenteritis, and enteric fever [Table 3]. They are also the very common diseases in each of the study years.

Annual admission of NCDs such as hypertension, sickle cell diseases, PUDs, asthma, congestive heart failure, cerebrovascular accident, and diabetes mellitus (DM) admitted were 2009 – 105 (22.3%); 2010 – 73 (24.0%); 2011 – 103 (37.2%); and 2012 – 75 (27.2%) with total of 459 (34.6%) which cannot be said to be rising or decreasing pattern.

With ICD-10, infectious and parasitic diseases constituted the largest proportion of diseases in each of the study years and the whole of the study period [Table 4]. This was followed by digestive diseases (10.5%) and circulatory diseases (7.6%) [Table 4].

Outcome of admission

Discharge constituted the largest proportion of outcome of patients admitted into the medical ward between 2009 and 2012 (range 76.5-84.4%) while escape was extremely rare. The solitary case seen in 2009 was a patient who escaped so as to avoid paying discharge bill.

Similarly, over the study period, referral rate ranges between 3.0% and 6.4% which were patients sent to other tertiary institutions on patients’ request or for further management [Table 5]. About 0.19% were transferred to other departments in the hospital for further management, and all such transfers were in 2011.

Outcome of admission is also depicted graphically in [Figure 2].

Mortality rate was 1.09%, 1.02%, 1.95%, and 3.00%, respectively, during the study period rising slightly step wisely, and a mean mortality rate during study period was 1.77%. Over the same study period, the total number of days on admission was 2036 while average number of days on admission was 1.39 days and a decreasing pattern between 2009 and 2012. The discharge rate between 2009 and 2012 was 81.39% [Table 6].

The large proportion of younger age groups among the patients admitted was likely due to the university community that is located in the same town with the teaching hospital. These younger age groups are likely to have a strong impact on the disease pattern seen and outcome.

Elderly patients accounted for 11.1% of total hospitalization into the medical wards in the University Of Ilorin Teaching Hospital between 2001 and 2004 compared to ours which was 12.5% between 2009 and 2012. ^[9] Most of the patients seen were below 30 years which constitute the undergraduate age groups. This is understandable because of the university community which the hospital also serves.

In this study, we however found that majority of diseases presenting to the hospital are infectious and parasitic in nature. Furthermore, the important role of NCDs in-patients admission has been documented by some hospital-based study from some other tertiary institution in Nigeria. ^{[1],[3],[6],[9]} and was also revealed by our study. A large proportion of admissions were infectious and parasitic in nature.

The pattern of our finding is similar to other hospital-based studies in South Africa, where infectious diseases dominated the medical admissions. ^[10],[11] It points out the burden of infectious diseases at this center.

According to Demographic Health Survey (2008), Malaria currently accounts for nearly 110 million clinically diagnosed cases/year and 30% hospitalizations. ^[12] This was reflected in our finding where the burden of admission was malaria in all the years under study, and also the total pattern of disease seen. It was also the largest proportion of infectious disease admitted

The World Health Report 2011 had indicated that NCDs (cardiovascular diseases, DM, cancers, mental illness, osteoarthritis, and injuries) account for almost 60% of deaths and 46% of the global burden of disease. ^[1] About 75% of the total deaths due to NCDs occur in developing countries. NCDs are associated with affluence and urbanization. ^[2],[13]

With further field study in the community to seek out diagnosis hidden by iceberg phenomenon, we may not be able to say categorically whether the surrounding community has not made epidemiological transition. ^[14]

Although NCDs such as hypertension, asthma, and PUDs constituted 15.5% compared with infections and parasitic disease with 56.4% during the study period, If the patients’ population have not made the epidemiological transition then is it that the urbanization and affluence have not made adequate impact to elicit such transition since the environs of the hospital still largely have trapping of a rural area or just iceberg phenomenon as earlier mentioned.

Ekpenyong et al. found disease-specific prevalence risk for certain NCDs like hypertension −14.4% and respiratory disorders −10% in their study conducted in South-South geopolitical zone of Nigeria specifically in Uyo metropolis. ^[15] The prevalence of hypertension and respiratory diseases among patients attended to in this hospital was as followed 6.6% and 7% (range 4.5-8.6%), respectively. It reflects the important role of hypertension as NCDs as being shown by some other studies too. ^{[15],[16],[17],[18]}

In a similar study of a tertiary institution, in Northern Nigeria, a total of 3369 patients was admitted into the medical ward between January 2001 and December 2003 of which 2518 (74.7%) were discharged or referred and 851 patients died with mortality rate of 25.3%. ^[19] This study also revealed a high proportion of patients discharge if considering only discharge (81.2%) but a combination of discharge and referral (85.8%). Our mortality rate (1.77%) was however low compared to that study in Northern Nigeria. This may be explained by the high proportion of acute infectious diseases seen over the study period.

Furthermore, because the spectrum of diseases that presented to us was mainly nonchronic infectious diseases, and lesser proportion of NCDs would possibly explain the very short hospital stay. We expect a longer duration of hospital stay, if more chronic illness from the patient catchment areas presents to the hospital.

Cases of Discharge against Medical Advice (DAMA) constituted an appreciable percentage of outcomes which could be due to financial reason and literacy levels.

Even though, the study is mainly descriptive and observational in nature it would be useful to the hospital administrators and researchers.

We strongly believe further studies would be necessary to unravel specific reasons about cases of “DAMA” in this center. Furthermore, the prevalence of communicable and NCDs in the community served by the hospital needs to be explored considering the lower level of NCDs presenting to the hospital.

The study was an attempt to report the pattern and outcome of medical admissions in Igbinedion University Teaching Hospital, Okada between 2009 and 2012. Infectious diseases constituted the bulk of admission with malaria being the largest single disease. NCDs were also prominent although to a lesser proportion. Majority of the patients were discharged home with lesser outcome of the referral, death, and transfer.

DOI: 10.4103/1755-6783.149500

[Figure 1], [Figure 2]

[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]