PCH Cheung, PLS Ip

Abstract

Five years' data on hospital discharges were used to study patterns of adolescent physical morbidity. Discharge diagnostic categories and their specialties were analysed at each year of age from 10 to 19 years. Adolescents accounted for 4.7% of the total discharges with an annual discharge rate of 32.8 per 1,000 (USA 56.5) compared to 90.1 for all ages. Problematic areas included injury, poisoning, pregnancy, psychosomatic complaints, suicide and self-inflicted injuries. Discharge rates of pregnancy related disorders and, injuries and poisoning were 74 and 114 per 10,000 respectively for teenagers aged 15 to 18 (U.S. 276 and 136 respectively). For ages 10 to 19, these two categories accounted for 40% of the total discharges. Data on three categories (Symptoms, Signs and Ill-defined Conditions, Injury and Poisoning, and Suicide and Self-inflicted Injury) were further analysed. Adolescents aged 10 to 19 had a significantly higher proportion of discharges in each of these three categories (p<0.001) when compared to other ten year age groups. Medical and paediatric specialties were most frequently utilized (36%), followed by surgery (26%), orthopaedics (21%) and obstetrics and gynecology (9%). Among the common diagnosis were those socially and behaviourally associated. These call for collaborative tackling strategies from various levels of adolescent workers.

Introduction

Data on adolescent issues could be derived from reports published by a variety of organizations.^1-4 Surveys from these organizations tend to involve their areas of special interest. For instance, information on adolescent sexual behavior could be obtained from the Youth Sexuality Study by the Family Planning Association.¹ Current trends in drug abuse are reported by the Narcotics Division.² Opinion surveys by the Federation of Youth Groups³ include a multitude of topics on employment, political issues, family and values, drugs, sex, runaways and so on. Information on disease pattern is also readily available from the Hospital Authority statistical report⁴ which contains vital statistics like age and sex structure, mortality rates and patterns, and leading causes of serious illnesses. Despite this overview of general health status of our society based on broader age groupings, disease morbidity of the adolescent age group is generally insufficient. A better understanding of the magnitude of health problems faced by adolescents in Hong Kong will go a long way to enhance the quality of care one delivers. To illustrate the distinctive patterns of adolescent morbidity, we analysed hospital discharge data for each year from age 10 to 19.

Methods

Coding for hospital discharges is uniformly performed by the hospital coding team using the International Classification of Diseases, 9^th Revision, Clinical Modification (ICD-9-CM). Data fields included age, sex, diagnosis, specialties, time period and number of discharges. The statistics on adolescent hospital use were based on computer data from 1.1.93 to 31.12.97. Data involved number of discharges rather than number of individuals being discharged, reflecting hospital utilization. Data on principal diagnosis and specialties were analysed in relation to individual one-year age groupings from age 10 to age 19. Three diagnostic categories with significant psychosocial overtones were analysed with respect to ten year age groupings of 0-9, 10-19, 20-29, etc. These three diagnostic categories were Symptoms, Signs and Ill-defined Conditions, Injury and Poisoning, and Suicide and Self-Inflicted Injury. These three categories as well as the category of Complications of Pregnancy, Childbirth, and the Puerperium were analysed with respect to their number of discharges in an attempt to define the trends of these categories over the five year period.

Population demographics were retrieved from the Hong Kong Census and Statistics Department.⁵ Chi square test of homogeneity was used for statistical purpose.

Result

Adolescents aged 10 to 19 accounted for 4.7% of the total hospital discharges. Male to female ratio was 1.35:1. Their annual hospital utilization was 32.8 per 1,000 adolescent population as compared to the total hospital utilization of 90.1 per 1,000 population of all ages for the district. As the age of adolescents increased, the number of discharges for boys remained rather constant but there was an increase for girls, which was mostly from discharges due to Complications of Pregnancy, Childbirth and Puerperium (fig. 1). There was a gender difference with more boys discharged with Injury and Poisoning (M : F = 2.7:1) but more girls with Symptoms, Signs and Ill-defined Conditions and Suicide and Self-Inflicted Injury (M : F = 1 :1.3 and 1: 4.3 respectively).

Fig. 1 Number of discharges by age and sex (1993-97)

Injury and Poisoning accounted for the highest proportion of discharges at 33%. This was followed by Symptoms, Signs and Ill-defined Conditions 11%, Digestive Diseases 10%, Respiratory Diseases 9%, and Complications of Pregnancy, Childbirth and Puerperium 7% (Table I). Injury and Poisoning together with Complications of Pregnancy, Childbirth and Puerperium accounted for 40% of the total discharges. When compared to other 10 year age groups, adolescents aged 10 to 19 had a significantly higher proportion of discharges in the following categories: Symptoms, Signs and Ill-defined Conditions, Injury and Poisoning, and Suicide and Self-Inflicted Injury (Table II).

Trend of discharges of four diagnostic categories was depicted in fig. 2. There was a general increase in the number of discharges in Injury and Poisoning and Symptoms, Signs and Ill-defined Conditions whereas the number of discharges remained relatively constant for Suicide and Self-Inflicted Injury and Complications of Pregnancy, Childbirth, and the Puerperium.

Paediatric and medical discharges accounted for the highest proportion of discharges (36%) followed by surgical (26%), orthopaedics (21%) and obstetrics and gynaecology (9%) (Table III).

Fig. 2 Trends of four diagnostic categories

Discussions

To promote better care for adolescents in sickness or in health, local health information is of fundamental importance. This serves multiple purposes - as a benchmark for data comparison both locally and abroad, as a monitor for the trend of disease profiles, as a tool in education, for advocacy, for service needs and health planning.

Annual discharge rate for adolescents was 32.8 per 1000 population whereas it was 90.1 per 1000 for persons of all ages. The corresponding figures overseas were 56.5 and 138.2 in a study from U.S.⁶ They accounted for 4.7% of the total hospital discharges. This low hospital utilization has created a false impression that adolescents are a healthy group of people with low morbidity and mortality not warranting significant medical attention. This simplistic view has failed to address the long term consequences of behaviours initiated in adolescence⁷ and the medical problems that would arise in adulthood. Findings from diagnostic categories were summarized in the following sections.

Injury and Poisoning

Injuries and poisoning could be classified as unintentional or intentional. The bulk of the injuries were unintentional and there is a general consensus that injuries are among one of the most preventable of all childhood conditions.⁸ A local study found that up to 80% of injuries presenting to an accident and emergency department could be preventable.⁹ Injuries are the leading cause of loss of productive years of life.¹⁰ Furthermore, unintentional injuries were the commonest cause of death in children locally between the ages of one and fourteen.¹¹ In our study, this category topped the discharge diagnoses from age 10 to 17, and it was the most common diagnostic category accounting for one third of all adolescent discharges. Injuries included fractures, dislocation, sprain, strain, open wound and internal injuries, burns, etc. The discharge rate of 114 per 10,000 at ages 15 to 18 from our study was comparable to a U.S. study⁶ of 136 per 10,000. The implication for prevention is apparent.

Poisoning included drug overdose cases which could also be classified as intentional or unintentional. Intentional drug overdoses were included in the category Suicide and Self-inflicted Injuries and will be reviewed in the subsequent discussion. Drug dependence and alcoholic intoxication were not included in this category as these were classified under the Mental Disorders category. Comparing to other 10 year age groups, adolescents aged 10-19 had a significantly higher proportion of discharges from this category of Injury and Poisoning (table II) with a male to female ratio of 2.7 : 1.

Complications of Pregnancy, Childbirth, and the Puerperium

Physical complications of teenage pregnancies such as anaemia, hypertension, premature births, low birth weight infants, higher maternal mortality rate are well known to obstetricians and paediatricians. Closer spacing of subsequent pregnancies and problems with postneonatal morbidity and mortality are other associated phenomena. Compromised education and career prospects as well as higher rate of divorce are just some of the other socioeconomic disadvantages.^12,13 The discharge rate, which offers a reflection of teenage sexual activity, is a quarter of that of a U.S. study.⁶ Obviously, data on abortions performed illegally in Hong Kong or across the border in Mainland China would not be reflected in the hospital discharge statistics. Nevertheless, obstetrics discharge data would offer a better comparison with overseas figures. This is because coding for other diagnostic categories would be affected by factors such as different admission criteria of individual hospitals and perception of medical officers on the principal diagnosis. Seven percent of the total discharges were from this category. The discharge rate doubled from age 15 to 16 and from 16 to 17, whjch might be related to the protection of females juveniles below the age of 16 in Hong Kong. This category overtook Injury and Poisoning as the most common category of discharge diagnoses from the age of 18 and above. This demonstrated a need to change in our focus on the service provision to the involved female adolescents who need intense psychosocial support as well as dedicated health care from multiple professionals.

Pregnancy related disorders, injuries and poisoning

For ages 10 to 19, the number of discharges from the two categories of Complication of Pregnancy, Childbirth, and the Puerperium and Injury and Poisoning accounted for 40% of the total discharges. This is similar to U.S. figures of 24%, 51% and 65% for respective ages of 10-14, 15-18 and 19-24.⁶

Suicide and Self-Inflicted Injury

Discharges from this category were coded by the Ecodes (external) which would follow any principal diagnosis of intentional self-harm. Suicide was the third leading cause of death for young people in U.S.¹⁴ Among the external causes of death listed in the supplementary classification, Suicide and Self-inflicted Injury was the leading cause of death for all ages.⁴ However, age subdivisions made it difficult to interpret data for adolescents. For instance, Suicide and Self-inflicted Injury was the third leading external cause of death after transport accidents and other accidents for age five to 14; but it was the leading external cause of death for age 15 to forty-four.⁴ In the current study, adolescents had a significantly higher proportion (p<0.001) of discharges with this diagnostic category when compared to other ten year age groups [Table II]. Regional annual prevalence of Suicide and Self-inflicted Injury from this study was 0.75 per 1,000. Females out-numbered males with a ratio of 4.3 to 1. Many of these cases were psychosocially related and could be intervened with appropriate measures.¹⁵

Symptoms, Signs and Ill-defined Conditions

An interesting feature in this category was that it included non-specific diagnoses such as abdominal pain, chest pain, palpitations, hyperventilation, headache and other psychosomatic complaints. Again, adolescents top the list (p <0.001, Table II). Another feature was the often multiple investigations these patients underwent in hospital without arriving at any definitive diagnosis. These discharges were therefore coded according to their symptoms, signs or as ill-defined conditions. A previous local study examining five psychosomatic complaints¹⁶ showed a gender difference of male to female ratio of 1 to 1.85. The current study showed a lower female preponderance (M:F 1: 1.3). This could be explained by the fact that there were other non-psychosomatic conditions included in this category with insignificant gender differences. The discharge rate was much higher compared to a U.S. study.⁶ We speculate that this may be due to the requirement of defined illnesses or services for fiscal reimbursement.

Trends of the four diagnostic categories

(Injury and Poisoning, Symptoms, Signs and Ill-defined Conditions, Suicide and Self-Inflicted Injury and Complications of Pregnancy, Childbirth, and the Puerperium)

Limited information could be drawn from the current study about the trends of the above categories over the short five year period. Nevertheless, there was a general increase in the number of discharges in two (Injury and Poisoning and Signs and Ill-defined Condition) of the above four categories (fig. 2) but the increase was not significant statistically. This study had identified these areas of concern. A territory-wide data collection and an ongoing monitoring over longer periods on these categories would be of importance. Moreover, monitoring of mortality and morbidities trends should involve areas such as accidental deaths, suicide, violent crimes, alcohol and other drug use, sexual activities and teenage pregnancy.

Specialties

When the adolescent age increased, there was a corresponding general increase in the number of injuries, poisoning, pregnancy and mental disorders (Table I). Paediatric and medical discharges accounted for the highest proportion of discharges (36%) followed by surgical (26%), orthopaedics (21%) and obstetrics and gynaecology (9%) (Table III). Most paediatric departments in Hong Kong admit children up to their fifteenth birthday. If paediatricians are to care for older adolescents, they should be well equipped to handle the problems discussed above. Service needs and health planning would require data analysis of specialty discharges. Table III gives an estimate of the volume of work involved in each specialty for each adolescent year.

Conclusion

This paper revealed the distinctive patterns of adolescent morbidity comparable to that of United States in 1991⁶ and United Kingdom 1993.¹⁷ Many of the morbidities identified were socially and behaviourally based. Emphasis should be placed in the better delivery of health care to Hong Kong adolescents.

Overseas experience had alerted paediatricians to expand the traditional emphasis of managing physical diseases and health monitoring to address psychosocial and behavioral problems more effectively. Therefore, these so called "new morbidities" of recent decades call for effective tackling strategies.¹⁸ These include clarifying the expanded areas of paediatric competence, developing interviewing skills, establishing a comprehensive model, bettering paediatric counseling skills, allocating realistic consultation times, improving referral skills and a revision of resource allocation.

One needs to bear in mind that these morbidities of adolescents are the presenting symptoms and products of longstanding maladjustment in the process of early childhood development. These problems are rooted in the community which may very well appear to be dwelling beyond the realms of hospital paediatricians but which paediatricians should owe a professional duty of "looking beyond the obvious"¹⁹ and strive to improve their skills in prevention, detection and management of adolescent problems.

Media derived increase of adolescent health problems are presumptive impressions whereas health data from various sectors are piecemeal in nature. Most paediatric units admit children up to their fifteenth birthday in Hong Kong. It is hoped that the current paper would stimulate further discussions on areas such as the readiness and proficiency of local pediatricians to care for adolescents in their late teens, and also to serve the purpose of a benchmark for future reference.

Acknowledgement

The authors would like to thank Mr. Stephen An and Dr. Joyce Tang for their assistance in data collection and analysis.

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