Management in Health, Vol 13, No 4 (2009)

Font Size:  Small  Medium  Large

Hospital Morbidity through Cervical Cancer - Romania, 2009

 

Marius Ciutan, MD
Specialist in PHHSM, NSPHHSM-National School of Public Health and Health Services Management, Bucharest, Romania

Nona Delia Chiriac, MD
Researcher, senior specialist in PHHSM, NSPHHSM-National School of Public Health and Health Services Management, Bucharest, Romania

 

Abstract: Cancer is responsible for a large share of deaths, worldwide as well as in Romanaia, and induces high costs (for individuals, health system and society), proved to be one of the most burdensome diseases.

Lately, problems induced by cancer in women are increasing, due to the raise in incidence, but mainly to the high mortality rate of cervix cancer. Hospitals having obstetrics-gynecology departments are the main medical units who provide specialized services for diagnosis, staging and treatment of cervix cancer; the most of cervix cancers cases are recorded in hospital care sector, and the analysis of hospital morbidity may offer a pretty fair picture of the phenomenon. The present paper presents some results of the analysis of the hospital morbidity trough cervix cancer, in hospitals who reported clinical data at patient level, during the first eight months of the year 2009.

 

Key words: geographic distribution of hospitalizations, the profile of hospitalization, surgical procedures for cervix cancer in hospital

 

 

Introduction

Cancer represents, after cardiovascular diseases, the most frequent and lethal group of non communicable diseases. In spite of the positive results of researches from last decades concerning cancer treatment, epidemiologic indicators remain high for certain anatomical sites of cancer. If, for men, lung cancer and bronchus cancer remain the most frequent form of malignancy, in females the cervix cancer dominates in the hierarchy of malignant diseases.

The problems induced by cancer in females are increasing, due to the raise in incidence, but mainly to the high mortality rate of cervical cancer. In this domain, concerted efforts of specialists and of the scientific community have led to efficient and effective methods for detection and treatment, a major emphasis being placed on health education and raise the awareness of women regarding issues related to genital cancers and in particular to cervical cancer.

As consequences of these successes, governments are trying to reduce the magnitude of the phenomenon, through national programs for screening and immunization against HPV infection.

Yearly, in Romania over 3400 women are diagnosed with cervical cancer. According to WHO statistics (European Health For All Database) released in July 2008, Romania is situated on the first place in Europe as frequency of cervical cancer- 29.9 cases at 100,000 women- as well as mortality rate due to this type of cancer-12 cases/100000 women- the last being to 2 times higher comparing to the majority of countries from Central and Eastern Europe, and six times higher than the average in the EU member states [1].

In Romania, the National Program for screening for active early detection of cervical cancer will attempt to identify more women in early stages of the disease (age between 25-64 years old), thus insuring for them more chances for the treatment of the disease.

The aim of this program is to prevent and to fight the cervical cancer, and from his objectives could be enumerated: the decrease of the incidence of invasive types of the disease and the reduction of the mortality caused by cervical cancer. The Ministry of Health estimates that, until the end of the year, will be tested approximately 200000 women [2].

Also, as consequence of governments intention to immunize in mass the girls of school age, is hoped that this cohort will be immune to further attacks of HPV strains proved to have a clear role in causing the cervical cancer.

Thus, through these national programs, all three levels of healthcare are equally involved in the attempt of the incidence reduction.

Hospitals having obstetrics-gynecology departments are the main medical units who provide specialized services for diagnosis, staging and treatment of cervix cancer; the most of cervical cancers cases are recorded in hospital care, and the analysis of hospital morbidity may offer a pretty fair picture of the phenomenon.

 

Aim:

The general purpose of the present study was to provide evidence concerning the magnitude of the phenomenon caused by the cervical cancer, in Romanian hospital care sector, during the first eight months of the year 2009.

 

Objectives:

                    To accomplish this aim, we followed the research objectives:

                    description of hospitalizations with a diagnosis of cervical cancer, according to the district, area of residence and insured status;

                    identification of hospitalization pattern for cervical cancer cases.

 

Methodology

The present study is a transversal analysis regarding aspects of hospital activity, using secondary data, based on case mix data contained in DRGNational database, for 2009.

Criteria for inclusion: any discharge having a principal or a secondary diagnosis like Malignant tumor of cervix, affecting:

                    exocervix (code diagnosis ICD10 AM C53.0)

                    exocervix (code diagnosis ICD10 AM C53.0)

                    overlapping lesion of cervix uteri

                    cervix uteri, unspecified

 

Results. Discussions

1. Description of cases after the district, residence and insured status

During the first eight months of 2009, in Romanian hospitals who had contracted hospital care services with District Insurance Houses and reported patient level clinical data, were recorded 14,639 hospitalization episodes (inpatient cases) having as principal diagnosis or secondary diagnosis cervical cancer.

These episodes were recorded for 8,347 patients, each of them having an average of 1.75 hospitalization episodes for cancer of cervix.

Distribution of cases with cervical cancer by district

The geographic distribution of cases reveals inequities from the point of view of their home district. There is a wide variety of the number of cases per district, the highest number being recorded for patients from Bucharest (1077 hospitalization episodes) and the lowest for Covasna (147 episodes).

Cartogram 1 highlights the districts and the color intensity is more pronounced as the number of hospitalization episodes is higher; so the districts are divided into four inter--quartile intervals after the number of episodes:

                    over 440 episodes;

                    between 440- 345 episodes;

                    between 345- 250 episodes;

                    under 250 episodes.

 

Cartogram 1. Number of cases having Malignant cervical tumor as diagnosis, by district, Romania, first eight months of 2009

Source: DRG National Data base 2009

 

The 10 districts with over 440 episodes are different spread within the country; they are both border districts and districts in mountain areas, from all the 8 development regions (Bucharest, Brasov, Maramures, Botosani, Prahova, Dolj, Arges, Neamt, Hunedoara, Teleorman).

The fewest hospitalization episodes were recorded, as well, in border districts or in mountain areas (Satu Mare, Sibiu, Mehedinti, Bistrita-Nasaud, Vrancea, Harghita, Salaj, Ialomita, Tulcea, Ilfov, Covasna).

The geographic distribution shows a wide variability of districts and does not reveal zonal or regional aggregations, from this point of view.

 

Residence

From the total of 15.000 hospitalization episodes, about 58% were for patients living in urban areas, and 42% from rural areas (figure 1).

 

Insured status

Only 5 cases had private health insurance, while most of the cases (98%) had compulsory health insurance; only 2% from all cases had no medical insurance at all (figure 1).

 

2. The identification of hospitalization pattern for cases with cervical cancer

 

Type of admission

Over half of patients with cervical cancer (50,2%) were admitted based on a referral from the specialist physician in ambulatory care, and almost one third (29,9%) were admitted in emergency (figure 1).

 

Figure 1. Percentage of cases with cervical cancer after the medical specialty of the department, Romania, first eight months of 2009

Source: DRG National Data base 2009

 

These figures highlight the fact that in Romania the diagnosis and specialized treatment for cervical cancer is performed based on the prescription of a specialist physicians, as well as through emergency admissions; probably an important percentage of emergencies is represented by cases with advanced severity of disease.

Nevertheless, the supposition and diagnosis of cervical cancer is made even in the family doctors office, almost two tenths (about 19%) from admissions being based on the referral from the family doctor.

 

Type of department

The analysis of cases by the type of the department was performed taking into account two aspects: the ability of the department to treat acute cases and the medical specialty of the department.

The specific of this disease justifies the admission and treatment of cases with cervical cancer on acute care departments, where exists necessary resources for diagnosis, staging and specific treatment. Only 2% from all cases episodes were hospitalized on chronic care departments (figure 2).

 

Figure 2. The proportion of hospitalization for cervix cancer, by department, first eight months of 2009

 

The structure of cases by the medical specialty of the department (figure 2) highlights the high percentage (76%) of cases on departments specialized for cervical cancer care, like: oncology (40%), radiotherapy (20%) and obstetrics- gynecology (16%).

Almost one third (32%) from all cases were diagnosed and/ or treated in departments specialized in medical oncology; on surgical oncology departments and gyneco-oncology- departments were solved 6%, and 2% from all episodes. Other cases were reported by general surgery (7%), internal medicine (5%), urology (4%) departments etc.

One explanation for cases reported in other departments than oncology, radiotherapy or obstetrics- gynecology is that many of these cases were admitted as emergency; other explanation could be that these patients had an another principal diagnosis than cervical cancer responsible for the episode of hospital care.

 

Type of surgical procedure

The treatment of cervical cancer is based on surgery and radiotherapy; cases with metastasis could benefit on different chemotherapy schemes with satisfactory results and after the evaluation of individual situation.

According to the stage of the disease, the surgical treatment in cervical cancer contains both conservative and radical approaches.

During the year 2009, for all 14,639 episodes of hospital care were performed 3,197 surgical procedures (for 22% of cases); the high percentage (78%) of non surgical cases is due to the fact that many patients had multiple episodes of hospital care during the year, one specific episode corresponding to a different stage in the management of the disease: diagnosis, staging, radiotherapy, chemotherapy and so on.

More than half of these interventions were represented by three main procedures (table 3):

                    abdominal radical hysterectomy with radical excision of pelvic lymphatic nodes (22.5%);

                    biopsy of cervix (17%) and

                    abdominal hysterectomy with bilateral salpingo-oophorectomy (11.5%).

It is to be noticed that the most common surgical procedure is a highly radical one and this could show that patients access hospital care in a late stage of the disease.

Also, should be emphasized the low percentage (0.7%) of the cone biopsy of cervix; although this procedure is used both for diagnosis and treatment of the disease in selected si-tuations like:

                    high grade cervical

                    recurrent cervical dysplasia;

                    likelihood of cervical cancer.

 

Type of discharge

The analysis of the episodes by the type of discharge reveals the fact that discharge at request and transfer between hospitals represent rare modes of separation for patients with cervical cancer.

Also it can be noticed the low specific mortality rate of patients with cervical cancer, 1-2 out of 100 hospitalization episodes ending with the death of the patient.

 

Table 1. Number and percentage of cases according to the type of separation (discharge), Romania, first eight months of 2009

TYPE OF DISCHARGE

No. of cases

% from all cases

Discharged

14081

96.2

Discharged at request

232

1.6

Death

224

1.5

Transfer between hospitals

102

0.7

Total

14639

100

 

 

Status at discharge

If it is detected and treated only in late stages of the disease, the cervical cancer is a malignant illness with sever prognosis. And, for this reason, early detection must represent the main strategy for the treatment.

 

Table 2. Number and percentage of cases by the status at discharge, Romania, first eight months of 2009

STATUS AT DISCHARGE

Number of episodes

% from all episodes

% cumulative frequency

death

224

1.5

1.5

worsen

174

1.2

2.7

stationary

4673

31.9

34.6

improved

7693

52.6

87.2

healed

1875

12.8

100.0

Total

14639

100

 

Source: DRG National Data base 2009

 

The healing, or, at least, the improvement of health status is mentioned at almost two thirds (66%) from all hospitalization episodes, while more than 1/3 (34%) of all episodes ended with death, or resulted in a worst condition or nothing have changed in the health status (table 2).

Hospital mortality rate with values over 1.5% for cervical cancer cases was recorded in Harghita (6.7), Sibiu (5.5), Satu Mare (4.9), Hunedoara (4.4), Buzau (4.2), Alba (3.4), Calarasi (3.0) (see cartogram 2). In geographic profile, the most hospital deaths were recorded in districts like: Bucharest (57), Maramures (14), Cluj (14), Sibiu (12), Hunedoara (11), Timis (10) (see cartogram 2).

 

Table 3. Number and percentage of cases according to the surgical procedure, Romania, first eight months of 2009

SURGICAL PROCEDURE (SP)

No.

%

%

valid

%

cumulative

abdominal radical hysterectomy with radical excision of pelvic lymphatic nodes

719

4.9

22.5

22.5

biopsy of cervix

543

3.7

17.0

39.5

abdominal hysterectomy with bilateral salpingo-oophorectomy

368

2.5

11.5

51.0

abdominal hysterectomy with radical excision of pelvic lymphatic nodes

130

0.9

4.1

55.1

percutaneous nephrostomy

120

0.8

3.8

58.8

Endoscopic replacement of ureteric stent

82

0.6

2.6

61.4

Exploratory laparotomy

74

0.5

2.3

63.7

Dilation & curettage of uterus [D&C]

72

0.5

2.3

65.9

Endoscopic insertion of ureteric stent

59

0.4

1.8

67.8

Cystoscopy

58

0.4

1.8

69.6

Total abdominal hysterectomy

45

0.3

1.4

71.0

Biopsy of endometrium

34

0.2

1.1

72.1

Nephrostomy

30

0.2

0.9

73.0

Control of postoperative hemorrhage, not elsewhere classified

25

0.2

0.8

73.8

Subtotal abdominal hysterectomy

25

0.2

0.8

74.6

Removal of pyelostomy or nephrostomy tube

23

0.2

0.7

75.3

Cone biopsy of cervix

22

0.2

0.7

76.0

Radical excision of pelvic lymph nodes for gynecological malignancy

22

0.2

0.7

76.7

Repair of incisional hernia

21

0.1

0.7

77.3

Radical abdominal hysterectomy

20

0.1

0.6

77.9

Other SP

705

4.8

22.1

100.0

No SP

11442

78.2

-

-

TOTAL NUMBER OF CASES

14639

100.0

100.0

-

Source: DRG National Data base 2009

 

Cartograme 2. Number of deaths (figures attached to each district) and percentage of hospital deaths (no. of deaths/100 hospitalization episodes) for cases havingMalignant cervical tumor, by district, Romania, first eight months of 2009

Source: DRG National Data base 2009

 

Conclusions

In Romania, hospitalizations for diagnosis Malignant tumor of cervix uteri represent a small part of the total volume of hospital activity (14,639 episodes, representing only 3.6% from all 4,047,900 discharges in first eight months of 2009) .

The profile of cases, designed as result of this analysis, can be drawn as follows: patients both from urban and rural areas (U/R=1.4) without any geographic aggregation; most of the cases (98%) had medical insurance and have been hospitalized in acute care departments, based on a referral from the specialist physician or as emergency; hospital care for these cases is provided in specialized departments like: oncology, radiotherapy, obstetrics-gynecology, and for a large part of these cases the health status is improved or even healing occurred (66% of cases).

From the patients with surgical treatments, more than half had one of the following three most common procedures: abdominal radical hysterectomy with radical excision of pelvic lymphatic nodes, biopsy of cervix and abdominal hysterectomy with bilateral salpingo-oophorectomy.

As one can notice, the hospital solves in high degree the cases with cervical cancer; for the global assessment of issues related to cervical cancer, it still needs to be stressed that these numbers represent only the hospital care from the total management of the disease.

An important role is owned by the family medicine and secondary ambulatory care, mainly for patients screening (suspect, diagnose) for referral to hospital.

But, most certain, the most important for an efficient and efficacy management of this disease is the preventive medicine.

European models for efficient management, like integrated networks for healthcare could be a solution for this moment and preventive strategies must be the cornerstone for health policies in Romania for this disease, but not only.

 

 

References

1.       Press National Agency, AGERPRES, Screening Health Program for Cervix Cancer , June 4th 2009, http://www.romedic.ro/program-de-screening-pentru-cancerul-de-col-uterin-0N12375

2.       Romanian Ministry of Health, Regulations for implementing the Health Program for Cervix Cancer, 2009

3.       CIUTAN, M., CHIRIAC, N., The territorial distribution and use of emergency hospitals, Romania 2007, Management in Health, year XIII, No. 1, 2009.

 



Journal published by SNSPMS