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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 3  |  Page : 117-123

Disease mortality audit in a Nigerian tertiary care center


Department of Morbid Anatomy/Histopathology, Delta State University, Abraka; Department of Pathology, Delta State University Teaching Hospital, Oghara, Nigeria

Date of Submission16-May-2019
Date of Decision18-Apr-2021
Date of Acceptance26-Sep-2019
Date of Web Publication29-Oct-2021

Correspondence Address:
Dr. Obiora Jude Uchendu
Department of Morbid Anatomy/Histopathology, Delta State University, Abraka; Department of Pathology, Delta State University Teaching Hospital, Oghara
Nigeria
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DOI: 10.4103/smj.smj_51_19

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  Abstract 


Background: Mortality audit is in developing countries is sparse despite its importance in guiding decision-making toward reversing the present high death rate. Objective: The study aims to study the profile of in-hospital mortality in a Nigerian hospital. Materials and Methods: This is a retrospective review of the records of all in-hospital mortalities at Delta State University Teaching Hospital, Nigeria, from 2016 to 2018. Information extracted from the records included age, sex, year, and cause of death. The causes were further classified with Global Burden of Disease 2017 classification. Analysis was with SPSS version 21. Results: A total of 1044 mortalities were recorded during the 3-year period, giving a mortality rate of 12.6%, with a male to female ratio of 1.3:1 and a mean age of 42.36 ± 25.23. The peak fatality were in early neonatal and 50–54 years of age group accounting for 96 (9.1%) and 87 (8.3%) cases, respectively. Communicable, maternal and nutritional diseases, noncommunicable diseases and injuries accounted for 276 (26.4%), 642 (61.5%), and 126 (12.1%) fatalities, respectively. The leading causes of fatality are stoke (17.1%), road injuries (7.7%), neonatal disorders (7.6%), HIV/AIDS (6.0%), chronic kidney disease (5.7%), diabetes mellitus (4.6%), chronic liver disease (4.4%), maternal disorders (2.6%), upper digestive system diseases (2.3%), and breast cancer (2.3%). Conclusion: The mortality pattern show male predominance, peak at neonatal period and preponderance of noncommunicable diseases, road injury and HIV/AIDS-related deaths. Increased government funding, universal health coverage, public education, and lifestyle modification are paramount to reducing mortality.

Keywords: Disease, fatality, in-hospital mortality


How to cite this article:
Uchendu OJ. Disease mortality audit in a Nigerian tertiary care center. Sahel Med J 2021;24:117-23

How to cite this URL:
Uchendu OJ. Disease mortality audit in a Nigerian tertiary care center. Sahel Med J [serial online] 2021 [cited 2021 Nov 28];24:117-23. Available from: https://www.smjonline.org/text.asp?2021/24/3/117/329518




  Introduction Top


Mortality audit is one of the fundamental parameters of assessing the health of the population. It is relevant in assessing the impact of health interventions and policies, evaluating the quality of care provided by health facilities and also in guiding future planning and resource allocation and in prioritizing health interventions.[1]

Death registration, which is the gold standard in estimating mortality, is worst in Africa and Asia, attributed to paucity of registration centers, and human personnel factors.[2],[3] Hospital mortality (defined as death occurring during hospital stay) is very important source of causes of death data in such counties, despite the potential bias when the true population is compared with those with access to hospital care.[4] Its advantages however include correct death certification (since this is usually done by qualified medical doctors) and its availability in many more centers across the country. Furthermore, it can serve as a measure of the quality of care in a hospital and as a bench mark for comparing the level of care provided by various hospitals.[5]

At present, mortality statistics of in-hospital patients in Delta State, Nigeria, are sparse and lacking. This study therefore aims to study the pattern of mortality among admitted patients to Delta State University Teaching Hospital (DELSUTH), the apex referral center in Delta State, Nigeria.


  Materials and Methods Top


Study setting

Delta state is located in the South-Southern geopolitical region of Nigeria. It has numerous hospitals at primary and secondary levels of care. It has only one state owned tertiary care Hospital, DELSUTH, which serves as a referral center for other hospitals in the state and some communities in neighboring states. The study is an institutional-based study, conducted in DELSUTH.

Study design

This is a descriptive retrospective study of disease specific mortality of in-patients in DELSUTH.

Study duration

The study period was from January 1, 2016, to December 31, 2018.

Study design

All deaths that occurred within the hospital during the study are considered for the study. As a routine, staff of the Hospital Health Information Management Department usually go round the hospital wards and mortuary to extract the death summary of patients on a daily bases. These deaths were confirmed and certified either by Clinicians using clinical evidence or by Pathologist, using autopsy studies. This information is compiled in the hospital mortality ledger.

The name, age, sex, date of admission, date of death, and cause of death of these patients were extracted from the mortality ledger and used for the study. The underlying cause of death was sorted using the Global Burden of Disease (GBD) Classification 2017, a highly consistent and comprehensive method of estimating morbidity and mortality.[6] The diseases are classified into three levels. On the 1st level, they are classified into three groups, namely communicable diseases, maternal, perinatal, and nutritional disorders; noncommunicable diseases; and intentional or unintentional injuries. On the second level and third level classification, these major groups were further broken down to more specific disease causes.

Inclusion criteria

All deaths among in-patients in the hospital were considered for this study.

Exclusion criteria

Cases of indeterminate/unknown causes were excluded from the study. Patients brought into the hospital already dead were excluded from the study.

Statistical analysis

This information was subsequently analyzed using Statistical Package for the Social Sciences (SPSS) software, version 22 (IBM Corp. Armonk.NY. Released 2013). The specific mortality rates were calculated as: Number of death × 100%/number of admissions. The results were presented as tables and charts.

Ethical approval

The approval of the DELSUTH's Hospital Research and Ethics Committee was obtained on the May 30, 2019, and the reference number is DELSUTH/HREC/2019/021/0383.


  Results Top


A total of 1044 mortalities were recorded from 8265 patients admitted during the 3-year period, giving a mean crude mortality rate of 12.6%. The number of deaths in 2016, 2017, and 2018 were 244 (23.4%), 440 (42.2%), and 360 (34.5%) cases, respectively. Five hundred and eighty (55.6%) fatalities were male whereas 464 (44.4) were female, giving a male to female ratio of 1.3:1. This is shown in [Table 1].
Table 1: Year-wise mortality rate

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The age distribution of fatality in 2016–2018 is shown in [Table 2]. The age groups with peak fatality were in early neonatal and in 50–54 years accounting for 96 (9.1%) and 87 (8.3%) cases. The mean age of fatality in 2016, 2017, 2018 and the entire study period are 39.51 ± 26.53, 41.23 ± 25.38, 45.65 ± 23.82, and 42.36 ± 25.23, respectively.
Table 3: Causesofdeathbyfirstlevelglobalburdenofdiseaseclassification

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Age-wise distribution of diseases in the 1st level GBD classification is shown in [Table 3]. Communicable, maternal and nutritional diseases; noncommunicable diseases and injuries accounted for 276 (26.4%), 642 (61.5%), and 126 (12.1%) fatalities, respectively. The male to female ratio for communicable, maternal, and nutritional diseases; noncommunicable diseases and injuries are 1.2:1; 1.1:1, and 2.4:1, respectively.{Table 3}

[Table 4] shows the distribution of diseases using the 2nd level of GBD 2017 classification. Of the group I diseases, maternal and neonatal disorders; HIV/AIDS and sexually transmitted disease; respiratory infections and tuberculosis; and neglected tropical diseases and malaria accounted for 106 (10.2%), 63 (6.0%), 34 (3.3%), and 18 (1.7%) of the in-hospital fatalities, respectively. Of the noncommunicable diseases, cardiovascular diseases; diabetes and kidney disease; cancer and digestive diseases accounted for 240 (23.0%), 138 (13.2%), 137 (13.1%), and 106 (10.2%) deaths, respectively. Among injury fatalities, transport injuries; unintentional injuries; and self-harm and interpersonal violence accounted for 80 (7.7%), 30 (2.9%), and 16 (1.5%) of hospital deaths.
Table 4: SecondlevelGDBclassificationofmortality

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[Table 5] depicts the distribution of common specific disease mortality using the 3rd level GBD 2017 classification. The leading causes of fatality are stoke (17.1%), road injuries (7.7%), neonatal disorders (7.6%), HIV/AIDS (6.0%), chronic kidney disease (5.7%), diabetes mellitus (4.6%), chronic liver disease (4.4%), maternal disorders (2.6%), upper digestive system diseases (2.3%), and breast cancer (2.3%).
Table 5: Commonspecificcausesofdeathusing3rdlevelglobalburdenofdiseaseclassification

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  Discussion Top


To the best of my knowledge, this is the first comprehensive in-hospital mortality audit in DELSUTH. Although death is an inevitable traumatic event, this audit has enormous benefit to the society. Apart from providing a baseline mortality statistics, the prevailing mortality trend is a fair guide to the hospital has fared in terms of quality of patient's care.[7]

In this study, the mortality showed significant variation with the lowest rate being in the 1st year of the study. Although there may be many possible explanations, it is an important index of the quality and trend of care over the study period and provided a reference for comparing our center with other health-care facilities.[8] It is also a wake-up call for the hospital to re-strategize to curb worsening health outcome. The crude mortality in this study is similar to what was observed in Southeastern Nigeria,[9] but lower that the figures seen in other parts of Nigeria and outside Nigeria.[10],[11],[12],[13]

We observed a higher male fatality in this study. This is however a general observation in most African studies.[7],[9],[10],[11],[12],[14] The explanation to this is the biologic survival advantage conferred by nature on women over men. It has also been proven that men are less conscious of their health than women and consequently seek health care very late in the course of illness, resulting in relatively higher fatality.[14]

The peak of fatality in this study was at the neonatal period, accounting for 10.3% of all deaths. This high proportion of neonatal death is unacceptable, although other reports in sub-Sahara Africa has the highest neonatal mortality rate across the globe.[15] It is a general belief that the age group is a highly vulnerable time for a child, direct leading causes are generally due to neonatal sepsis, birth asphyxia, prematurity/low birth weight, and birth trauma.[16] This trend may be fuelled by flaw in the quality of care, and the state of health of neonates at the time of referral to the hospital from primary and secondary care centers. Greater commitment toward patient care, ensuring adequate specialized personnel and equipment as well as educating the peripheral centers on early referral will go a long way in reversing this trend. Interestingly, the second fatality peak was in the sixth decade which tarries with the current average life expectancy of the Nigerian population (54.5 years).[17]

Using the 1st level GBD 2017 classification, the study has shown that most of the fatalities are caused by group II disease (noncommunicable diseases). This is however at variance with some studies in Nigerian[9],[10],[11] and other African centers where the leading cause of mortality are group I disease (communicable disease, maternal and nutritional disease).[18],[19] These study is probably a shift reflecting the epidemiologic transition theory that is applied to change in mortality trend in developed countries from infectious diseases to noncommunicable diseases and injuries.[18] Noncommunicable diseases have been shown to be on the rise in low- and middle-income countries, where over 75% of such deaths occur.[19] The relatively high proportion of injury-related death agrees with earlier study highlighting the disproportionally high rate of injuries in low- and middle-income countries.[20]

Cardiovascular disease is the highest cause of mortality in this study, accounting for 23% of deaths. This in in agreement with report from the World Health Organization, that cardiovascular disease (CVS) is the largest cause of mortality across the globe, accounting for 17.7 million deaths annually.[21] The risk factors are physical inactivity, obesity, poorly managed hypertension, unhealthy diet, cigarette smoking, alcohol abuse, stressful life, and urbanization.[22] In a study in Benin City, 16.1% of deaths in medical ward were due to hypertensive complications.[23] In South Eastern Nigeria, a study showed that 16% of hospital mortality was secondary to due to cerebrovascular accident.[9]

Diabetes and kidney disease are the second leading cause of death, accounting for 13.2% of deaths. The high burden of kidney disease in Nigeria is related to the increasing prevalence of obesity, hypertension, and diabetes mellitus.[24] This disease mortality may be attributed to the high cost of managing renal disease and the paucity of dialysis centers in the country. The high incidence of diabetes mortality is attributed to late detection and poor management and the trending predisposition arising from calorie-rich diet and sedentary lifestyle.[25]

Cancer mortality is the 3rd leading cause of hospital mortality in this study accounting for 13.1% of deaths, which is comparable with report from Osunkwo et al.[10] of National Hospital Abuja but higher than 3.5%, 4.7%, and 7.3% reported by Nwafor in Southeastern Nigeria,[9] Akinde in Lagos, Nigeria,[26] and Adeolu in IleIfe, Nigeria,[27] respectively. Considering the burden of cancer death in this region however, there is need for the increased government funding of the health sector government with emphasis on cancer screening, diagnosis and treatment.

Maternal and neonatal disorders are causes of preventable fatality, accounting for 10.2% of cases in this study. Maternal death in this study is paradoxically lower than the global report that placed Nigeria as having the worst maternal mortality across the globe.[28],[29] This is possibly because of erroneous classification of medical causes of death during pregnancy and childbirth into other classes during this analysis. Since these deaths are generally preventable, improving quality of care, use of qualified personnel as well as timely management and treatment can make a lot of difference in their mortality trend.

Infectious diseases still remains a problem in sub-Sahara Africa because of related social, economic, environmental, and ecologic factors.[30] HIV/AIDS fatalities (6%) in this study, is lower than 8.3% and 13% reported in Northern Nigeria,[11] Southeastern Nigeria, respectively.[9] As at 2014, sub-Sahara Africa has the highest number of people living with HIV/AIDS, a trend mostly attributed to risky sexual behavior.[31] Prevention and surveillance program, free HIV testing and provision of HIV drugs will go a long way in reversing this trend.

Among injuries, transport-related injuries are top cause of death accounting for 8.8% of all deaths. This is similar to other studies in this region.[9],[11] These fatalities were predominantly road injuries (7.7%). Being a tertiary center, it is more likely to attract severe injuries and consequently worse prognosis. However, it is a pointer to the deplorable nature of the roads, recklessness of road users and the laxity of law enforcement agencies.

The top 10 causes of death in this study are stoke, road injuries, neonatal disorders, HIV/AIDS, chronic kidney disease, diabetes mellitus, chronic liver disease, maternal disorders, upper digestive system diseases, and breast cancer. This is similar to studies in other parts of the country.

Limitation of the study

I could not have access to most patient case notes because of the on-going renovation exercise in the hospital. Autopsy rate is about three cases per year, in this center and most of the diagnoses were basically clinical. The mean interval between admission and death could not be calculated because the data for this study were based on already retrieved information by staff of records department.


  Conclusion Top


The mortality pattern in this study showed male predominance, a peak at neonatal period and preponderance of noncommunicable diseases, road injury, and HIV/AIDS-related deaths. Increased government funding, universal health coverage, public education, and lifestyle modification are paramount to reducing mortality.

Financial support and sponsorship

Self.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

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



 

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