Date Published: May 14, 2019
Publisher: Public Library of Science
Author(s): Robert Kalyesubula, Innocent Mutyaba, Tracy Rabin, Irene Andia-Biraro, Patricia Alupo, Ivan Kimuli, Stella Nabirye, Magid Kagimu, Harriet Mayanja-Kizza, Asghar Rastegar, Moses R. Kamya, Chiara Lazzeri.
Sub-Saharan Africa suffers from a dual burden of infectious and non-communicable diseases. There is limited data on causes and trends of admission and death among patients on the medical wards. Understanding the major drivers of morbidity and mortality would help inform health systems improvements. We determined the causes and trends of admission and mortality among patients admitted to Mulago Hospital, Kampala, Uganda.
The medical record data base of patients admitted to Mulago Hospital adult medical wards from January 2011 to December 2014 were queried. A detailed history, physical examination and investigations were completed to confirm the diagnosis and identify comorbidities. Any histopathologic diagnoses were made by hematoxylin and eosin tissue staining. We identified the 10 commonest causes of hospitalization, and used Poisson regression to generate annual percentage change to describe the trends in causes of hospitalization. Survival was calculated from the date of admission to the date of death or date of discharge. Cox survival analysis was used to identify factors associate with in-hospital mortality. We used a statistical significance level of p<0.05. A total of 50,624 patients were hospitalized with a median age of 38 (range 13–122) years and 51.7% females. Majority of patients (72%) had an NCD condition as the primary reason for admission. Specific leading causes of morbidity were HIV/AIDS in 30% patients, hypertension in 14%, tuberculosis (TB) in 12%), non-TB pneumonia in11%) and heart failure in 9.3%. There was decline in the proportion of hospitalization due to malaria, TB and pneumonia with an annual percentage change (apc) of -20% to -6% (all p<0.03) with an increase in proportions of admissions due to chronic kidney disease, hypertension, stroke and cancer, with apc 13.4% to 24%(p<0.001). Overall, 8,637(17.1%) died during hospitalization with the highest case fatality rates from non-TB pneumonia (28.8%), TB (27.1%), stroke (26.8%), cancer (26.1%) and HIV/AIDS (25%). HIV-status, age above 50yrs and being male were associated with increased risk of death among patients with infections. Admissions and case fatality rates for both infectious and non-infectious diseases were high, with declining trends in infectious diseases and a rising trend in NCDs. Health care systems in sub-Saharan region need to prepare to deal with dual burden of disease.
The disease burden in developing countries is continuing to grow faster than the budget allocation for healthcare. In low income countries (LIC) medical admissions account for about 40% of total hospital admissions compared to 12–30% in high income countries[1,2]. This may be a reflection of disparities in socioeconomic conditions and healthcare systems, or differences in biological and/or environmental factors[3–5]. One factor which exacerbated the healthcare crisis in sub-Saharan Africa (SSA) was the advent of the HIV/AIDS epidemic which disproportionately affects the region [2,6,7]. Interventions, such as antiretroviral therapy for the treatment of HIV/AIDS, health education, access to clean water, and mass vaccinations, however, have decreased morbidity and mortality from communicable diseases. The improved life expectancy and adoption of western lifestyles in LICs have led to the emergence of non-communicable diseases (NCDs), a new threat to public health[9,10].
We conducted a retrospective cohort study of patients admitted to Mulago National Referral Hospital adult medical wards from January 2011 to December 2014 using an electronic patient data registry. Mulago National Referral Hospital is one of the two national referral hospitals in a country with a population close to 40 million. It has 1500 bed-capacity and provides specialized care for patients referred from district and regional referral hospitals. In 2007, the Directorate of Medicine established sub-specialist run units to cater to the increasing specialized care needs. Consultants, physicians and senior house officers run these units. Patients undergo preliminary evaluation and investigations in the accident and emergency unit before admission to the appropriate specialized unit. On average, 15,000 emergency medical visits are made to Mulago National Referral Hospital annually and between 900–1200 patients are admitted to the medical wards per month.
During the study period, there were 50,716 patient hospitalizations. We excluded 92 for lack of complete admission date. Of the remaining 50,624 patients, 23% were admitted in 2011, 27.2% in 2012, 25.7% in 2013, and 24.1% in 2014, 51.7% of these patients were female. The median age was 38 years (range13-122) About two thirds of patients were residents of urban and periurban areas (Kampala Capital City and its suburbs) (Fig 1 and Table 1).
In this retrospective cohort study of patients admitted to Mulago Hospital adult medical wards we found the leading diagnoses among hospitalized patients to be infections with HIV-AIDS, Tuberculosis and Malaria. The leading NCD diagnoses among hospitalized patients were hypertension, heart failure and diabetes mellitus.
We found the leading discharge diagnoses in a national referral hospital to be HIV-infection, hypertension, tuberculosis and heart failure. Among all of the characterized diagnoses, non-TB pneumonia, TB, stroke, cancer and chronic kidney disease had the highest case fatality rates. There is an increasing trend of NCDs as a major cause of admissions over the 4-year period of study. There is an urgent need for Ugandan health care system to increase the focus on early detection and management of NCDs, while still maintaining current efforts to manage infectious diseases.