Morbosità e mortalità: un approccio multicausa al fenomeno della droga

Roberta Crialesi, Alessandra Burgio, Francesco Grippo, Marilena Pappagallo

Migliorare la comprensione del fenomeno droga: quali dati per le politiche

Roma, 26 gennaio 2015Istat, Aula Magna

• La riduzione della perdita di vite umane causata dal consumo di stupefacenti è una priorità strategica delle politiche di lotta alla droga e uno degli obiettivi di salute pubblica dell’Unione europea

• Valutare scientificamente le conseguenze dirette e indirette dell’uso di droghe non è semplice. Nel corso degli ultimi anni, le politiche di riduzione del danno hanno stimolato l’adozione di approcci basati su dati incontrovertibili.

• Uno degli approcci più innovativi per fornire un quadro realistico dell’impatto delle droghe sulla salute della popolazione italiana è quello basato sulla comorbidity e sulla cause multiple di decesso

• Occorrono indicatori innovativi per misurare, in modo più accurato, la reale dimensione del fenomeno estendendo l’osservazione a tutti i casi, direttamente o indirettamente, collegati all’abuso di droghe.

Elementi chiave della strategia europea di riduzione del danno

Roma, 26 gennaio 2015 2

Obiettivi dello studio

• Analizzare la mortalità indotta da droga e l’ospedalizzazione dei pazienti tossicodipendenti per descrivere l’evoluzione nel tempo dei principali indicatori secondo il genere, l’età e le macro aree di residenza

• Utilizzare l’approccio per cause multiple per

fornire nuovi indicatori basati su tutte le informazioni riportate sia nel certificato di morte sia nelle SDO

valutare statisticamente le associazioni tra l’abuso di droga e altre condizioni patologiche

3Roma, 26 gennaio 2015

In Italy an average of 4,2 conditions are reported.

The International Classification of Diseases (Icd) contains instruction for coding each condition and for the selection of the Underlying cause.

Causes of Death Register

• Refers to all cases occurred in Italy• Certifying physician reports a sequence of conditions leading to death on the death form:

Part 1:

Line a (Underlying cause) ___________________________________

Line b (complications) ___________________________________

Line c ___________________________________

Line d ___________________________________

Part 2 (Other causes ___________________________________

Contributing) ___________________________________

Hiv infection

Kaposi’s sarcoma

Heroin dependency for many years

Pneumonia

Septicemia

Coding Each Condition: Icd-10 codes

B24

C46

J18.9

A41.9

F11.2

SELECTION Process

UC: B24

HIV disease

In Italy, until 2003 data only this information was published

Traditionally, final statistics are based on UNDERLYING CAUSE OF DEATH

One for each record defined as: (a) the disease of injury which initiated the train

of events leading directly to death, or (b) the circumstances of the accident or violence

which produced the fatal injury

Since 2003 data also this informationis available

MULTIPLE CAUSES OF DEATH

Specimen based on Istat D4

4

Drug-induced mortality: selection of Icd codes

(EMCDDA selction B for international comparison and time series)

ICD-10: years 2003, 2006-2011 

Mental and behavioural disorders due to psychoactive substance use

F11: opioids; F12: cannabinoids, F14: cocaine;F15: other stimulants, including caffeine;F16: hallucinogens;F19: other psychoactive substances

Accidental poisoningX421): narcotics and psychodysleptics [hallucinogens], not elsewhere classified;X412antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not

elsewhere classified

Intentional self-poisoningX621): narcotics and psychodysleptics [hallucinogens], not elsewhere classified;X612): antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not

elsewhere classified.

Poisoning undetermined intent

Y121): psychodysleptics [hallucinogens], not elsewhere classified, undetermined intent;

Y112): antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified, undetermined intent.

1) in combination with the T-codes: T40.0-9: Poisoning by narcotics and psychodysleptics [hallucinogens]; 2) in combination with T code: T43.6 Poisoning by psychotropic drugs, Psychostimulants with abuse potential.

5

Numero di decessi droga-indotti avvenuti in Italia registrati nel database ISTAT sulle cause di morte (popolazione presente). Anni 1980-2011 Confronto con Emcdda

6

Num

ero

di d

eces

si

Trends per genere ed età Anni 1992-2011

Mortalità indotta da droghe per macroarea e anno di decesso.Poolazione residente, anni 1992-2010. Tassi std.di mortalità per 1.000.000 abitanti

Geografia

 Underlying cause of death

 Multiple cause of death

Ratio Multiple/

Underlyingdeaths crude rate

standardized rate deaths crude

ratestandardiz

ed rate

15-44 year 605 0,87 816 1,18 1,3

45-54 175 0,67 398 1,53 2,3

55-64 33 0,15 79 0,36 2,4

 Total 15- 64

   

males 692 1,19 1,17 1.115 1,91 1,84 1,6

females 121 0,21 0,20 178 0,30 0,29 1,5

Total 813 0,69 0,69 1.293 1,10 1,07 1,6

Drug-related deaths in selected age groups as underlying and multiple cause. Years 2009-2011

Total 2006-2008

1.193 1,03 1,03 1.606 1,39 1,36 1,3

9

MethodsAge-standardized relative risk (RR) was used to measure association among drug related cause and the other conditions reported on the death certificateThe relative risk can be seen as a measure of the strength of association of a certain cause with drug-related condition.

)(ln96.1ln)(ln%95 RRSERRRRCI

Assumed that RR is approximately log-normally distributed:

where

Proportion of estimated deaths with a specific condition A among those WITH mention of drug-related cause

Proportion of estimated deaths with a specific condition A among those WITHOUT mention of drug-related cause

Cause A mentioned

Cause A not mentioned

Mention of drug-related cause

Without mention of drug-related cause

dAD̂

AdD̂

AdD̂

AdD̂

dD

dD

Ad

dA

d

Ad

d

dA

p

p

D

D

D

DRR

ˆ

ˆˆ/

ˆ

Ad

Ad

dA

dA

D

p

D

pRRES

ˆ)ˆ1(

ˆ)ˆ1(

)(ln

Associations of conditions with drug-related causes.

Associations of conditions with drug-related causes.1.293 cases, Italy 2009-2011

Icd10 ConditionPrevalence in

drug users deaths

Prevalence in non-drug

users deaths

Age-standardized

RR CI95%

Certificates mentioning

the condition among drug

users deaths

A00-B99 Infectious and parasitic diseases 23,8 9,4 3,4 3,2-3,7 308

B20-B24 AIDS 7,1 1,2 5,9 4,8-7,2 92

B15-B19, B94.2

Viral hepatitis 18,2 2,5 10,7 9,7-11,8 235

F01-F99 Mental and behavioural disorders (excluded those included in EMCDDA)

14,2 4,0 6,8 6,2-7,5 184

F10 Mental and behavioural disorders due to use of alcohol 9,6 0,9 17,5 15,4-20,0 124

I00-I99 Diseases of the circulatory system 40,4 48,0 1,1 1,0-1,2 522

I33 Acute and subacute endocarditis 0,9 0,1 7,0 3,9-12,6 11

I38 Endocarditis, valve unspecified 1,2 0,3 2,0 1,0-3,9 15

J00-J99 Diseases of the respiratory system 32,6 24,6 1,2 1,1-1,3 422

K00-K92 Diseases of the digestive system 22,1 16,1 1,8 1,6-1,9 286

K70, K73-K74 Cirrhosis, fibrosis and chronic hepatitis 16,2 6,2 3,6 3,2-4,0 209

K70 Alcoholic liver disease   3,3 1,3 2,7 2,0-3,6 43

K73 Chronic hepatitis, not elsewhere classified   1,1 0,2 19,5 14,3-26,7 14

R00-R99 Symptoms signs and ill-defined causes 38,6 33,6 1,1 1,1-1,2 499

R75 Laboratory evidence of human immunodeficiency virus [HIV]   1,3 0,1 9,1 5,4-15,2 17

V00-Y99 External causes of death (excluded those included in EMCDDA) 52,6 14,0 2,4 2,2-2,6 680

Roma, 26 gennaio 2015 12

Schede di Dimissione Ospedaliera (SDO)

• La diagnosi principale è utilizzata per la costruzione di indicatori statistici (come per le cause di morte)

•International Classification of Diseases 9th Revision, Clinical Modification (ICD9CM)

•Diagnosi principale e fino a 5 Diagnosi secondarie

• In media sono riportate 2.5 diagnosi per ricoveri ordinary e 1,6 per day hospital

• Le Diagnosi sono codificate direttamente in ospedale

DIAGNOSI PRINCIPALEdefinita come la malattia che alla dimissione viene identificata come la principale responsabile del trattamento e delle procedure fornite dall’ospedale.

DIAGNOSI SECONDARIADefinite come quelle condizioni che coesistono al momento del ricovero o che si sviluppano in seguito a tale momento e che influenzano il trattamento ricevuto e/o la durata della degenza

Co-morbidity approach

13

Number of hospital discharges for drug-related disorders

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

2,000

4,000

6,000

8,000

10,000

12,000

• From 10,968 in 1999 to 5,857 in 2012 (-46.6%)• Sharp decrease between 1999 and 2003, smoothed afterwards

Crude rates (a)

Standardized rates (a)

1999 19.3 18.5

2012 9.8 10.2(a) per 100,000 residents

Number of patients treated in outpatient facilities for drug-related disorders

14

Trends by ageAge-specific hospitalization rates for drug-related disorders per 100,000 residents

• Higher hospitalization rates in the age group 25-44 years• followed by 15-24 years before 2009 and 45-54 years too afterwards• Age gaps reduced over time

Roma, 26 gennaio 2015 15

Drug-related hospitalizations 15-64 years. Main diagnosis and All diagnosis. Years 2006-2008, 2009-2011

Main diagnosis All diagnosis

Age dischargescrude

ratedischarges

crude rate

2006-2008

15-44 13,834 19.3 40,721 56.8 2.945-54 2,222 9.1 8,625 35.4 3.955-64 811 3.8 2,653 12.4 3.3

2009-2011

15-44 11,801 16.8 32,611 46.3 2.845-54 3,265 12.4 9,727 36.8 3.055-64 1,356 6.1 3,041 13.6 2.2

Ratio All/Main

15-64 years

Main diagnosis All diagnosis

Gender dischargescrude

ratestandardized

ratedischarges

crude rate

standardized rate

2006-2008

males 11,407 19.4 21.7 35,617 60.6 66.7 3.1

females 5,460 9.3 10.4 16,382 27.9 30.8 3.0

total 16,867 14.4 16.1 51,999 44.2 48.9 3.12009-2011

males 9,831 16.6 18.6 30,663 51.6 57.3 3.1

females 6,591 11.0 12.2 14,716 24.7 27.2 2.2

total 16,422 13.8 15.4 45,379 38.1 42.3 2.8

Ratio All/Main

• All diagnosis: Decreasing std rates… …due to the decrease in the age group

15-44 years… …while rates slightly increase after 45

years of age

• Hospitalizations with mention of drug use or poisoning is 2.8 higher than the number based on the Main diagnosis

• Gender gap: std rates higher for men (1.5 times for main diag., 2.1 times for all diag.)

16

Drug-related hospitalizations by substance (dependence, abuse or poisoning) 15-64 years - All diagnosis.

Ratios All diagnosis / Main diagnosis

0

10

20

30

40

50

2006-2008 2009-2012

Mixed or unspecifiedsubstances

Cannabis, Amphetamineand other psychostimulant

Cocaine

Opioid type (Heroin,Methadone, Opium, etc.)

19,773

9,130

5,374

17,722

15,908

7,803

5,461

16,207

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2006-2008 2009-2012

Mixed or unspecifiedsubstances

Cannabis, Amphetamineand other psychostimulant

Cocaine

Opioid type (Heroin,Methadone, Opium, etc.)38.0% 35.1%

17.6%17.2%

10.3% 12.0%

34.1% 35.7%

Standardized hospitalization rates for drug-related disorders per 100,000 residents (absolute numbers in the bars)

Ratios Males / Females

17

Associations of conditions with drug-related diagnosis (1)

ICD9CM code Condition

Prevalence in hospitalizations

for drug disorders

Prevalence in hospitalizations

NOT for drug disorders

Age standardized

RR CI95%

Hospital discharge

records with mention of the

condition among

hospitalizations for drug

disorders

INFECTIOUS AND PARASITIC DISEASES (001-139)

042Human immunodeficiency virus [HIV] disease 7.77 0.53 13.08 12.63-13.53 3,528

070 Viral hepatitis 11.38 0.76 12.55 12.19-12.91 5,162112 Candidiasis 1.51 0.10 15.11 13.98-16.34 684

MENTAL DISORDERS (290-319)295 Schizophrenic disorders 4.86 0.73 5.57 5.32-5.82 2,204296 Affective psychoses 10.70 0.93 11.51 11.20-11.83 4,854298 Other nonorganic psychoses 3.65 0.29 11.11 10.55-11.70 1,656300 Neurotic disorders 7.75 0.87 11.42 11.10-11.74 3,518301 Personality disorders 19.37 0.54 28.92 28.28-29.58 8,790303 Alcohol dependence syndrome 8.31 0.33 21.81 21.08-22.57 3,772

307Special symptoms or syndromes, not elsewhere classified 3.35 0.27 17.08 16.36-17.82 1,520

309 Adjustment reaction 1.63 0.13 12.81 11.91-13.77 741

Roma, 26 gennaio 2015 18

Associations of conditions with drug-related diagnosis (2)

ICD9CM code Condition

Prevalence in hospitalizations

for drug disorders

Prevalence in hospitalizations

NOT for drug disorders

Age standardized

RR CI95%

Hospital discharge

records with mention of the

condition among

hospitalizations for drug

disordersDISEASES OF THE NERVOUS SYSTEM AND SENSE ORGANS (320-389)

345 Epilepsy 1.68 0.63 2.57 2.39-2.76 762346 Migraine 12.78 0.19 100.07 97.91-102.27 5,799

DISEASES OF THE CIRCULATORY SYSTEM (390-459)

401 Essential hypertension 3.12 4.70 1.33 1.29-1.38 1,417DISEASES OF THE RESPIRATORY SYSTEM (460-519)

486 Pneumonia, organism unspecified 1.00 0.26 3.84 3.50-4.21 456491 Chronic bronchitis 1.20 1.09 1.68 1.57-1.80 545518 Other diseases of lung 2.34 1.16 2.24 2.12-2.37 1,062

DISEASES OF THE DIGESTIVE SYSTEM (520-579)

571 Chronic liver disease and cirrhosis 6.27 1.90 3.35 3.23-3.47 2,845SYMPTOMS, SIGNS, AND ILL-DEFINED CONDITIONS (780-799)

780 General symptoms 2.44 1.39 1.84 1.74-1.95 1,107INJURY AND POISONING (800-999)

965Poisoning by analgesics, antipyretics, and antirheumatics 2.31 0.01 313.35 288.93-339.84 1,050

969 Poisoning by psychotropic agents 1.38 0.05 28.02 25.79-30.45 627SUPPLEMENTARY CLASSIFICATION OF FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES (V01-V82)

V02 Carrier or suspected carrier of infectious diseases 1.12 0.18 5.76 5.25-6.31 510

Roma, 26 gennaio 2015 19

20

Istat, Navigando tra le fonti demografiche e sociali, 2009http://www3.istat.it/dati/catalogo/20100325_01/Navigando_tra_le_fonti_demografiche_sociali.pdf

WHO. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). Geneva: WHO; 1992.

Emcdda methods and definitions http://www.emcdda.europa.eu/stats07/DRD/methods

Istat. Cause di morte. Anno vari. http://www.istat.it/it/archivio/

Emcdda, Data, drug related death and mortality http://www.emcdda.europa.eu/stats/archive.

Istat. Cause multiple di morte. Anno 2008. http://www.istat.it/it/archivio/66021

Istat, I.Stat, Salute e sanità, Ricorso ai servizi sanitari, Ospedalizzazione per disturbi psichici http://dati.istat.it/

Ministero della Salute, La classificazione delle malattie ICD9CM. http://www.salute.gov.it/ricoveriOspedalieri/paginaMenuRicoveriOspedalieri.jsp?menu=classificazione&lingua=italiano

Riferimenti bibliografici

Roma, 26 gennaio 2015

Grazie per l’attenzione

crialesi@istat.it

Roma, 26 gennaio 2015 21