Method of study of morbidity

MORBIDITY OF POPULATION AS A MEDICAL AND SOCIAL PROBLEM.

EPIDEMIOLOGICAL METHODS OF MORBIDITY STUDY

 

Morbidity of population is a collapsible concept that includes values, which are characterizing the level of different diseases and their structure among all population or its separate groups on the given territory.

In the complex of medical values of the health the morbidity takes a special place, its medical and social value is determinate by the fact that disease is the principal reason of death, temporal and permanent disability that by the turn results big economical losses of society, the negative influence on the health of future generations and diminishment of population quantity.

Materials about the level and structure of the morbidity in different regions, and also in separate sexual-age groups, especially in a dynamics for the definite period of time, are necessary for aimed programs development as for strengthening of health, in particular in planning of network developing of curing and prophylactic establishments and medical personnel training.

Also it is important  that the values of the morbidity are one of the most informing criteries of activity of organs and establishments of the health protection and efficiency of conducting of medical, prophylactic, social and other measures care.

Finally, their studying  determinate the ways of prophylactic of different diseases.

The statistics of morbidity in a great deal complements the statistics of death rate at estimation of population health and takes important advantage comparative with it, mainly effectiveness. At the same time, unlike the demographic phenomens (birth, death), which are easily determinated, the studying of morbidity is connected with considerable difficulties. The disease can have the indefinite beginning  as well as the end indefinite in time. It’s possible to observe “erased” forms of disease, bacillus carrying, that can be difficult to distinguish the disease and the morphological, skeletal changes etc.

Besides the population does not always appeal for medical help. The disease mostly becomes accessible for registration only when the patient applies for it. As a result plenitude of information about morbidity foremost depends from the volume and character of medicare, its availability and quality.

The main methods for studying the morbidity are those one, which foresee the use of such given:

– appeals for medical help in medical establishments;

– medical examinations of separate groups of population;

– about the reasons of death;

– questioning of population;

– special selective researches.

• at insufficient availability of medicare (for example, in rural locality);

• bad level of medical culture of population;

• insufficient authority among the population of medical establishment on the whole or separate doctors etc.

The study of morbidity from materials of appeals aloud us most to take into account the so-called “acute” diseases more compleately. This method does not need additional facilities.

At the studying of morbidity from data of medical examinations, plenitude of information about morbidity depends on:

• their systematic providing;

• participation of doctors of necessary specialties;

• sufficient diagnostic providing;

• the control of timeliness and plenitude of examinations.

 Using  this method the most complete account before the unknown chronical diseases is provided, or those,  which the population actively does not apply to the medical establishments. The advantage of this method is also exposure of initial forms and stages of diseases, clarification of diagnosis of some chronical diseases etc.

The studying of morbidity from data of death reasons is the additional method for two mentioned above. It is especially actual in relation to the account of those diseases, which are possible to be registered only at the appeal for the getting the medical certificate about the death (the question is about the patients, that had never appeal to the medical establishments and died at home), and also suddenly diseases which are  given high lethality and were not exposed by the both first methods (heart attacks, strokes, traumas etc.)

If during previous years the methods of morbidity studying from data of appeals and medical examinations were leading, in modern terms, in case of the considerable number of private medical establishments and especially at introduction of elements of insurance medicine, the most complete information about the morbidity can be obtained from datas of the special selective researches and questioning of population.

The advantage of the questioning method is the possibility of account of diseases, with which the population does not apply on those or other reasons for medical help, and also finding out of opinion of man in relation to the disease.

At the same time the subjectivity connected with the self-diagnostics and also with the considerable quantity of wrong answers for the questions of questionnaire is appropriated to it.

Studying of the morbidity with the use of separately each of the indicated datas does not give the picture of actual exhaustive prevalence of pathology. Special selective, deep researches answer these tasks more completely. During their conducting the regional, sexual-age features of the morbidity are determined at different levels of the medical providing.

The selective special researches, including the morbidity of population, make it possible to obtain more detailed and high-quality information in more short terms and for less facility. Wide distribution of them is proposed by Program of reformation of state statistics on a period till 2000, by Decision of Cabinet of Ministers of Ukraine №971 from June, 22, 1999.

The selective special researches are part of the programs of deep study of health, which are used during enumeration population.

The last researches of this kind were timed in Ukraine to the All-union censuses of population in 1970 and 1989. Because of  the wide-Ukrainian census of population in 2001 duty full research of morbidity is planned within the limits of the general program of determination the Ukraine population health.

In most foreign countries the selective study of document about hospitalization of patients and questioning of selective groups in population with application of questionnaire method are used for description of morbidity.

The study of general morbidity from data of general practitioners, organs of social insurance etc. is held only in some countries.

In Great Britain, where the state system of health care exists, researches of general morbidity on the basis of records of general practitioners are conducted.

Most economic developed countries use other information – questioning (interview) of selective groups of population. So, in the USA permanent researches of health of population, since 1958, include the study of morbidity on the selective aggregate of families by a questionnaire which contains over 40 questions in relation to family members: their diseases, got medicare, used medicines etc. The method of conducting such researches in the USA at the years is perfected every year, a few specialized “Centers of the control of morbidity” are engaged in their co-ordination, which, apply an interview by phone, and also departures of the special brigades which conduct the instrumental methods of inspection, besides the questioning of population.

Japan conducts the study of morbidity by means of the method of questioning the population of selected districts. Answers about the suffered diseases which took place only 2 months before the questioning are registered.

Researches, which are conducted in Denmark, France, are also based on questioning of population after the special questionnaire.

The necessary condition at the study of health of population, in particular morbidity, is the standardization of approach of doctors of different countries to determination and formulation of diagnoses, that enables to compare morbidity in time and in different regions.

As it’s known, there are about 5000 diagnostic terms, which are used by doctors in practice. Evidently, statistical development of information about morbidity is not possible without the rationally built groupment, that is the classification and nomenclature of diseases.

The project of international nomenclature and classification of diseases was ratified in 1900 at International statistical conference in Paris, which collected representatives from 26 countries. In future international classifications from time to time were looked through and were changed accordingly with progress of medical science. It took place approximately every 10 years.

Since 1962, International classification of diseases, traumas and reasons of death (ICD) is used in our country. ICD is periodically looked through and adopted by the special committee of experts on medical statistics and subcommittee of diseases classification of World health care organization (WHCO).

International statistical classification of diseases of the last Tenth revision (ICD-10) was ratified by the forty-third Assembly of WHCO January, 1, 1993. In obedience to the decision of the Assembly the document has a new name “International statistical classification of diseases and close problems of health protection”, though the comfortable abbreviation ICD is preserved.

The basic principles of construction of International classification of diseases, traumas and reasons of death are the community of etiology or pathogenesis of diseases or combination of locally-etiologic and local–pathogenetic principles. Every class of diseases is distributed on groups, and groups – on headings.

The basic innovation of ICD-10 is the using of alphabet-digital code (that replaces previous digital), when two numbers of the code are reflected the certain letter of the Roman alphabet, and at a necessity of the greater working out in detail of heading – its third number.

For example, class of diseases of the endocrine system, disorders of feed and metabolitical disturbances is marked by a three-digit code from Е00 to Е90. In the turn the diseases of thyroid have the codes from Е00 to Е07, diabetes mellitus — Е10-Е14 etc.

Code example after separate subheadings:

Thyreotoxicosis (hyperthyreosis) – Е05, including:

Thyreotoxicosis with a diffuse goiter- Е05.0;

Thyreotoxicosis with a toxic one-node goiter- Е05.1;

Thyreotoxicosis with a toxic multi-node goiter – Е05.2.

In Ukraine the ICD-10 introduction in curing and prophylactic establishments was begun from 1999, according to the Decision of Cabinet of Ministers after №326 from 01.05.93 “About conception of construction of national statistics of Ukraine and Government program of transition on the international system of account and statistics”.

There are such kinds of morbidity at its study from the data of appeals for medical help:

1. general morbidity – the account of all diseases (sharp and chronic) which are registered at the population of certain territory for certain period of time;

2. infectious morbidity – the special account of acute diseases, connected with the necessity of the operative conducting of nonepidemical measures;

3. morbidity on the major nonepidemical diseases falls due the special account as a result of their epidemiology and social value (malignant new formations, tuberculosis, venereal, psychical diseases etc.);

4. hospital or “hospitalized” morbidity enables to learn composition of patients which were treated in permanent establishment;

5. morbidity with the temporal disability of workers and employees is selected as a result of its social and economic value.

Each of these types of morbidity is studied after certain registration documents and is estimated on different values (table 3).

The general morbidity takes into account prevalence of all diseases among all population on  whole and separate diseases in it’s certain groups on the given territory as a result of appeals.

Values of the general morbidity enable to estimate the levels of morbidity, that were exposed and registered in ambulatory-policlinic establishments during a calendar year.

General morbidity is studied on the basis of current registration all primary appeals of patients.

The first appeal at the chronic diseases is considered the primary appeal in this year.

At the acute diseases, which can take place  several time during a year, the first appeal concerning every case is taken into account.

The case of disease or trauma concerning which the patient appealed to medical establishment is taken for unit of supervision at study of general morbidity.

Two documents are the source about general morbidity: “Statistical coupon for registration of final (specified) diagnoses” (f.№ 025-2/о) and “Coupon of ambulatory patient” (f. № 025-6/о, f. 025-7/о).

The separate “Statistical coupon for registration of final (specified) diagnoses” with the mark “+” is filled on every case of acute disease. Code „1″ is marked alongside with the name of diagnosis in “Coupon of ambulatory patient” at the sharp diseases. Thus, a several cases of acute diseases can be registered at one man for a year.

The diagnoses of chronic diseases are registered only one time for a year. If a diagnosis is set for the first time in life of patient – note “+” in the “Statistical coupon for registration of final (specified) diagnoses” or code of “2” in “Coupon of ambulatory patient.” If the diagnosis of chronic disease is set earlier, at the first visit of doctor each next year in the “Statistical coupon for registration of final (specified) diagnoses” the mark of “-” or code 3 in “Coupon of ambulatory patient”.

Information of the mentioned registration documents above is basis for drafting of “Report about the number of the diseases, registered at patients which live in the district of maintenance of medical establishment” (f. № 12).

There are such basic values of general morbidity:

— primary morbidity (Іпсіdепсе) – the level of t first registered diseases for a calendar year on this territory; all sharp and first set for a year chronic diseases are taken into account also:

— general morbidity, or prevalence of diseases (Рrеvаlепce) – the level of all registered diseases for a calendar year: sharp and chronic (registered at the first appeal in a current year, and exposed both in current and in previous years);

— structure primary and general morbidity of population.

There are  terms recommended by MHCO.

Using of “Coupon of ambulatory patient” extends possibilities of analysis of morbidity. It is possible to define the values of frequency of sharpening of chronic diseases also, separately level of the first registered sharp and chronic diseases etc by this document.

Infectious morbidity

There is the special account and accounting about the infectious diseases in our country. It is conducted with the purpose of prevention of distribution and appearence of epidemic flashes, and also prevention of the professional and food poisonings.

Such diseases are to be registrated and taking into account obligatory: abdominal typhus, paratyphus, other infections, caused by salmonellosis, brucellosis, all forms of dysentery etc. The list of diseases, which changes periodically, is regulated by MHP (Ministry of Health Protection) of Ukraine.

The order of extraordinary reports at especially dangerous infections in the case of appearance of them on territory of our country is set also.

The special account is demanded also for exposed infected and patient with AIDS, that is regulated by the special instructional-methodical documents.

Every case of disease or suspicion on it is a unit of supervision at the study of infectious morbidity. “Urgent report about the infectious disease, food, acute professional poisoning” (f. № 058/о) is filled at the exposure of them, and it is a basic document for the study of epidemic morbidity.

The doctor of policlinic or other medical establishment must fill in the urgent report, regardless patient address. It is necessary to operate in the same way at the exposure of infectious disease at the person hospitalized for treatment to permanent establishment, or at the change of diagnosis of patient, that already is on treatment. The doctor of first-aid fills the urgent report.

In rural locality, besides the doctors of rural district hospitals and ambulatories, the managers of medical assistant-accoucheur units must report about these diseases.

The urgent reports in curing and prophylactic establishments are registered in the magazine of registration of infectious diseases. The medical establishment, that had done it, must fullfill a new urgent report on a patient about  change of diagnosis of infections disease and send it to the sanitary-epidemiology station according with the place of exposure of disease.

All urgent reports must be directed to the sanitary-epidemiology station during 12 hours which provides the epidemiology inspection of center of infectious disease according with place of it’s exposure (regardless of place of patient residence).

The following values are used for the analysis of infectious morbidity:

• frequency of the exposed diseases (correlation of their number to the quantity of population of this territory; values are calculated per 100 thousands of population);

• seasonality (data about the number of diseases on monthes are taken as a basis. The indices of seasonal vibrations are correlation of data during month to average annuals);

• frequency of hospitalization and plenitude of it embrace (in the first case it is correlation of number of hospitalized persons to the quantity of population, in the second — the correlation of the number of  hospitalized persons to the  number of exposed diseases in percents);

• frequency of diseases after age, sex, profession (correlation of diseases number in the each group to the quantity of population of this group):

• number of exposed bacillus carriers on 1000 inspected persons.

Morbidity on the major nonepidemic diseases

Some nonepidemic diseases are the subject of the special account:

·                   malignant new formations;

·                   psychical diseases;

·                   venereal diseases;

·                   active tuberculosis;

·                   difficult mycosis.

The necessity of the special account of the indicated diseases is conditioned by:

·                   the high level of distribution;

·                   considerable frequency of death rate at some of them;

·                   epidemiology meaningfulness;

·                   a social conditionality.

As a rule, early exposure and comprehensive inspection, active dynamic supervision about patients, special treatment and exposure of contacts are necessary at these diseases.

There are two basic documents for registration of nonepidemic diseases:

1. The report about a patient, to which the diagnosis of active tuberculosis, venereal disease, tryhofitis, microsporias, favus, scab, trachoma, and psychical disease is set for the first time in life (f. № 089/о).

2.The report about a patient, with diagnosis of cancer or other malignant new formation set for the first time in life (f. № 089/о).

They are filled by the doctors of all curing and prophylactic establishments which for the first time set the indicated diseases at the appeal of patients to the policlinic, at the examination of them in permanent establishment, at the visit of patient at home or at a prophylactic medical examination.

Both noted documents are passed to the proper type specialized dispensaries (tuberculosis, oncologic, dermo-venerology, psychoneurological) which conduct an account and analysis each of it’s type, calculating the values of frequency and structure of exposed pathology on the whole and on separate classes, groups, nosology forms.

MHP of Ukraine confirmed a new registration statistical form № 025/3-0 “Report about a patient with the set diagnosis of heart attack of myocardium, stroke with high blood pressure, diabetes mellitus” with the purpose of perfection of registration of separate diseases in medical establishments by the order № 218 from 21.10.93.

A document is making by  doctors of policlinic, doctors of first-aid and urgent medical help, pathologists, judicial medical expert and mailed in a three-day term to regional (city) cardiodyspansery (heart attack of myocardium, stroke with blood pressure high) and endocrinology dispensary (diabetes mellitus).

Hospital, “hospitalizated” morbidity

This type of morbidity aloud  to conduct the account of patients that had been treated in permanent establishments during the year.

The unit of supervision during it’s study  is every case of hospitalization of patient concerning the disease, and information source is the “Statistical card of patient, that left permanent establishment”.

This document is filled by a treating doctor at registration of the “Medical card of in-patient” in the day of his leaving or in the case of death.

Information about morbidity of  hospitalized patients makes it possible to do the conclusions about its timeliness, durability and results of treatment, the volume of hospital help that was given etc.

Data about the “hospitalized” morbidity are taken into account at planning of bed fund, determination of necessity in different types of stationary help.

Morbidity of the hospitalized patients is studied on such values:

• frequency of hospitalization (the relation of number of hospitalized concerning the certain disease or all hospitalized in a calculation on the quantity of population, that lives on this territory);

• level of hospitalization after age, sex, the place of residence (relation of number of the hospitalized patients of this group in a calculation on the quantity of population of this group);

• structure of hospitalization (specific case of every disease among the common amount of the hospitalized patients; it is possible to calculate the structure of hospitalized after age, sex, the place of residence);

• medium duration of treatment (relation of number of the bed-days conveyed by patients in permanent establishment, to the number of the patients that left): this value is expedient to connect with the age of patients, diagnoses, the results of treatment and to analyze separately for written out from permanent establishment and deceased patients.

Morbidity with the temporal disability

The morbidity with the temporal disability is studied among working persons and is taken into account the cases of diseases, the result of which is missing of work time. This type of morbidity makes from 25 to 75 % of primary appeals for medical help.

The morbidity of working persons brings societies over considerable economic losses. That results the large social-economic value of  this problem.

Official statistics of temporal disability in communication with the diseases were entered in USSR in 1925.

The case of disability is unit of account.

The registration document for registration of each case of temporal disability of  a worker during the year is a bulletin.

A worker must give to administration of enterprise or organization the bulletin given by medical establishment after convalescence. The bulletin must contains the data about  patient  and every page in it is marked — number of the case of disability, name, surname of patient, his address, place of work, diagnosis, surname of doctor, durability of release from work.

“Report about the reasons of temporal disability” (f. № 23-ТD) is made on the basis of the registration data. It contains the data about the number of cases and calendar days of disability in relation to the most widespread diseases, in connection with the care of patient, with vacation at pregnancy and births, sanatoria-resort treatment etc.

A report is made by medical-sanitary parts, medical bases of health protection, district hospitals, policlinics and ambulatories, city and central district hospitals, other curing and prophylactic establishments of the system of MHP in Ukraine regardless of department subordination.

Medical establishments make a report about the reasons of temporal disability of working persons on enterprises, in establishments, organizations, which are on territory served by them.

The city and regional information-analytic centers of medical statistics make lists of selective circle of enterprises and organizations, overcoming not less ЗО % working persons in each of basic industries of national economy. Enterprises which have the basis of health protection are included in lists mainly. The general requirement to the enterprises, which are in the selective circle, is their proof vital functions in the conditions of competition.

All medical establishments, without the exception, reports after a form № 23-ТD about the reasons of temporal disability of workers of health protection.

The basis for drafting of report is the bulletin, handed over in a current period. All sick-leave authorizations, given out by medical establishments both after job and domiciliary works and employee, and also after the place of their sojourn in the period of business trip, vacation etc., are included on it.

Primary reports about temporal disability are made on every industry of national economy separately (nuclear power plants, coal, chemical, petrochemical and easy industry, machine building and metallurgy, health protection etc.) and send to the district (city) central hospitals.

District (city) central hospitals make the taken reports on basic industries of this district (cities) and give them to organ of management by the health protection territory (Republics Crimea, regions, cities Kiev and Sevastopol). They send the territorial taken report to Management of statistics of territory and information-analytic center of medical statistics of MHP of Ukraine.

Morbidity of working persons with the temporal disability is analyzed on such basic values:

The deep account morbidity with the temporal disability is conducted mainly on large enterprises for finding out of influencing of work terms on a health working, estimations of efficiency of health measures.

The account of diseases of working persons, which means establishment a card for every working person, that contains about all cases of disability for a year with their basic descriptions (diagnosis, duration, place of delivery of bulletin) is placed in its basis.

 

Such account makes possible to get additional information about:

·        those, who was ill often or during a long period of time for a year;

·        specific part of persons which were ill for a year;

·        specific part of working persons, which were not ill during a calendar year (index of health).

 

Such criteries are used at the selection of group those that often and during a long period time are ill:

·        etiologic factor;

·        number of cases of disability;

·        number of days of disability.

 

The group of persons, which often were ill, is determined at presence of:

• 4th and more of cases of the etiologic connected diseases for a current year,

• 6th and more of cases of etiologic unconnected diseases for a current year.

 

The group of persons, that were ill during a long period of time during a current year, include those who:

• had sick-leave authorizations by duration more than 40 days in connection with the etiologic connected diseases;

• had sick-leave authorizations by duration more than 60 days and more in connection with the etiological  unconnected diseases.