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 2015
Istat, Aula Magna
Elementi chiave della strategia europea di riduzione del danno
• 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.
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
Roma, 26 gennaio 2015
3
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:
Coding Each
Specimen based on Istat D4
Part 1:
Line a (Underlying cause)
Line b (complications)
Line c
Line d
Hiv infection
___________________________________
Kaposi’s sarcoma
___________________________________
Pneumonia
___________________________________
___________________________________
Septicemia
Part 2 (Other causes
Contributing)
Heroin dependency for many years
___________________________________
___________________________________
Condition: Icd-10
codes
B24
C46
J18.9
A41.9
F11.2
SELECTION
Process
UC: B24
Traditionally,
final
are based
on
In Italy
an average
ofstatistics
4,2
conditions
are reported.
HIV disease
Since
2003 data
also
this information
UNDERLYING CAUSE OF DEATH
is available
One
for
each
record
defined as:
The International
Classification
ofDEATH
Diseases (Icd) contains instruction
MULTIPLE
CAUSES OF
the disease
of injuryand
which
the train
for(a)
coding
each condition
for initiated
the selection
of the Underlying
In Italy,
until 2003
data
only this
information
of events
leading
directly
to death,
or
cause.
was published
(b) the circumstances
of the accident or
violence which produced the fatal injury
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 poisoning
X421): narcotics and psychodysleptics [hallucinogens], not elsewhere classified;
X412antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not
elsewhere classified
Intentional self-poisoning
X621): 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)
2)
in combination with the T-codes: T40.0-9: Poisoning by narcotics and psychodysleptics [hallucinogens];
in combination with T code: T43.6 Poisoning by psychotropic drugs, Psychostimulants with abuse potential.
5
Numero di decessi
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
Trends per genere ed età Anni 1992-2011
Geografia
Mortalità indotta da droghe per macroarea e anno di decesso.
Poolazione residente, anni 1992-2010. Tassi std.di mortalità per 1.000.000 abitanti
Drug-related deaths in selected age groups as
underlying and multiple cause. Years 2009-2011
Underlying cause of death
deaths
crude standardiz
rate
ed rate
Multiple cause of death
deaths
Ratio
Multiple/
Underlying
crude standardiz
rate
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
1,03
1.606
1,39
1,36
1,3
Total
2006-2008
1.193
1,03
9
Associations of conditions with drug-related causes.
Methods
Age-standardized relative risk (RR) was used to measure association among drug related cause and
the other conditions reported on the death certificate
The relative risk can be seen as a measure of the strength of association of a certain cause with drugrelated condition.
Cause A
mentioned
Cause A not
mentioned
Mention of drug-related
cause
D̂dA
D̂dA
Dd
Without mention of drugrelated cause
D̂d A
D̂dA
Dd
Dˆ dA Dˆ dA pˆ dA
RR 
/

Dd Dd
pˆ dA
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
Assumed that RR is approximately log-normally distributed:
CI 95% (ln RR )  ln RR  1.96SE (ln RR )
where
ES (ln RR ) 
(1  pˆ dA ) (1  pˆ dA )

Dˆ dA
Dˆ dA
Associations of conditions with drug-related causes.
1.293 cases, Italy 2009-2011
Prevalence
Prevalence in
in drug
non-drug
users
users deaths
deaths
Icd10
Condition
A00-B99
Infectious and parasitic diseases
Agestandardized
RR
Certificates
mentioning
the
CI95%
condition
among drug
users deaths
23,8
9,4
3,4
3,2-3,7
308
7,1
1,2
5,9
4,8-7,2
92
18,2
2,5
10,7
9,7-11,8
235
14,2
4,0
6,8
6,2-7,5
184
F10
Mental and behavioural disorders (excluded those included in
EMCDDA)
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
B20-B24
AIDS
B15-B19,
B94.2
F01-F99
Viral hepatitis
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
16,2
6,2
3,6
3,2-4,0
209
2,7
2,0-3,6
43
19,5 14,3-26,7
14
K70, K73-K74
Cirrhosis, fibrosis and chronic hepatitis
K70
Alcoholic liver disease
3,3
1,3
K73
Chronic hepatitis, not elsewhere classified
1,1
0,2
38,6
33,6
1,1
1,1-1,2
499
1,3
0,1
9,1
5,4-15,2
17
52,6
14,0
2,4
2,2-2,6
680
R00-R99
R75
V00-Y99
Symptoms signs and ill-defined causes
Laboratory evidence of human immunodeficiency virus [HIV]
External causes of death (excluded those included in EMCDDA)
Roma, 26 gennaio 2015
12
Co-morbidity approach
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
DIAGNOSI PRINCIPALE
definita come la malattia che alla dimissione viene identificata
come la principale responsabile del trattamento e delle procedure
fornite dall’ospedale.
DIAGNOSI SECONDARIA
Definite 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
• Le Diagnosi sono codificate direttamente in ospedale
13
Number of hospital discharges for drug-related disorders
12,000
10,000
8,000
6,000
4,000
2,000
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
• From 10,968 in 1999 to 5,857 in 2012 (-46.6%)
• Sharp decrease between 1999 and 2003, smoothed afterwards
Crude Standardized
rates (a)
rates (a)
1999
19.3
18.5
2012
9.8
10.2
Number of patients treated in outpatient facilities for drug-related disorders
(a) per 100,000 residents
14
Trends by age
Age-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
15-64 years
Gender
males
Main diagnosis
crude standardized
discharges
rate
rate
All diagnosis
crude standardized
discharges
rate
rate
2006-2008
11,407
19.4
21.7
35,617
60.6
66.7
5,460
9.3
10.4
16,382
27.9
30.8
total
16,867
14.4
16.1
51,999
2009-2011
44.2
48.9
males
9,831
16.6
18.6
30,663
51.6
57.3
females
6,591
11.0
12.2
14,716
24.7
27.2
16,422
13.8
15.4
45,379
38.1
42.3
females
total
• 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
Age
15-44
45-54
55-64
• Hospitalizations with
mention of drug use or
poisoning is 2.8 higher
than the number based
3.1
on the Main diagnosis
3.0
Gender gap: std rates
3.1 •
higher for men (1.5
3.1
times for main diag., 2.1
2.2
times for all diag.)
Ratio
All/Main
2.8
Main diagnosis
crude
discharges
rate
13,834
2,222
811
19.3
9.1
3.8
All diagnosis
crude
discharges
rate
2006-2008
40,721
8,625
2,653
Ratio
All/Main
56.8
35.4
12.4
2.9
3.9
3.3
46.3
36.8
13.6
2.8
3.0
2.2
2009-2011
15-44
45-54
55-64
11,801
3,265
1,356
16.8
12.4
6.1
32,611
9,727
3,041
16
Drug-related hospitalizations by substance (dependence, abuse or poisoning)
15-64 years - All diagnosis.
Ratios All diagnosis / Main diagnosis
Standardized hospitalization rates for drug-related disorders
per 100,000 residents (absolute numbers in the bars)
50
40
17,722
16,207
30
5,374
9,130
20
Ratios Males / Females
10
5,461
Mixed or unspecified
substances
Cannabis, Amphetamine
and other psychostimulant
Cocaine
7,803
Opioid type (Heroin,
Methadone, Opium, etc.)
19,773
15,908
2006-2008
2009-2012
0
100%
90%
80%
34.1%
35.7%
Mixed or unspecified
substances
70%
60%
10.3%
50%
17.6%
12.0%
17.2%
Cocaine
38.0%
35.1%
Opioid type (Heroin,
Methadone, Opium, etc.)
2006-2008
2009-2012
40%
30%
20%
Cannabis, Amphetamine
and other psychostimulant
10%
0%
17
Associations of conditions with drug-related diagnosis (1)
ICD9CM
code Condition
042
070
112
295
296
298
300
301
303
307
309
Prevalence in Prevalence in
hospitalizations hospitalizations
Age
for drug
NOT for drug standardized
disorders
disorders
RR
INFECTIOUS AND PARASITIC DISEASES (001-139)
Human immunodeficiency virus [HIV]
disease
7.77
Viral hepatitis
11.38
Candidiasis
1.51
MENTAL DISORDERS (290-319)
Schizophrenic disorders
4.86
Affective psychoses
10.70
Other nonorganic psychoses
3.65
Neurotic disorders
7.75
Personality disorders
19.37
Alcohol dependence syndrome
8.31
Special symptoms or syndromes, not
elsewhere classified
3.35
Adjustment reaction
1.63
Roma, 26 gennaio 2015
Hospital
discharge
records with
mention of the
condition
among
hospitalizations
for drug
CI95%
disorders
0.53
0.76
0.10
13.08 12.63-13.53
12.55 12.19-12.91
15.11 13.98-16.34
3,528
5,162
684
0.73
0.93
0.29
0.87
0.54
0.33
5.57
11.51
11.11
11.42
28.92
21.81
5.32-5.82
11.20-11.83
10.55-11.70
11.10-11.74
28.28-29.58
21.08-22.57
2,204
4,854
1,656
3,518
8,790
3,772
0.27
0.13
17.08 16.36-17.82
12.81 11.91-13.77
1,520
741
18
Associations of conditions with drug-related diagnosis (2)
Prevalence in
Prevalence in
hospitalizations hospitalizations
Age
for drug
NOT for drug standardized
disorders
disorders
RR
ICD9CM
code Condition
Hospital
discharge
records with
mention of the
condition
among
hospitalizations
for drug
CI95%
disorders
DISEASES OF THE NERVOUS SYSTEM AND SENSE ORGANS (320-389)
345
Epilepsy
346
Migraine
1.68
12.78
0.63
0.19
2.57
100.07
2.39-2.76
97.91-102.27
762
5,799
3.12
4.70
1.33
1.29-1.38
1,417
1.00
1.20
2.34
0.26
1.09
1.16
3.84
1.68
2.24
3.50-4.21
1.57-1.80
2.12-2.37
456
545
1,062
6.27
1.90
3.35
3.23-3.47
2,845
2.44
1.39
1.84
1.74-1.95
1,107
2.31
1.38
0.01
0.05
313.35 288.93-339.84
28.02
25.79-30.45
1,050
627
DISEASES OF THE CIRCULATORY SYSTEM (390-459)
401
Essential hypertension
DISEASES OF THE RESPIRATORY SYSTEM (460-519)
486
Pneumonia, organism unspecified
491
Chronic bronchitis
518
Other diseases of lung
DISEASES OF THE DIGESTIVE SYSTEM (520-579)
571
Chronic liver disease and cirrhosis
SYMPTOMS, SIGNS, AND ILL-DEFINED CONDITIONS (780-799)
780
General symptoms
965
INJURY AND POISONING (800-999)
Poisoning by analgesics, antipyretics, and
antirheumatics
969
Poisoning by psychotropic agents
SUPPLEMENTARY CLASSIFICATION OF FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES (V01-V82)
V02
Carrier or suspected carrier of infectious diseases
1.12
Roma, 26 gennaio 2015
0.18
5.76
5.25-6.31
19
510
Riferimenti bibliografici
Istat, Navigando tra le fonti demografiche e sociali, 2009
http://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=classificazion
e&lingua=italiano
Roma, 26 gennaio 2015
20
Grazie per l’attenzione
[email protected]
Roma, 26 gennaio 2015
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