Based on experiences from work executed within an action
„Pilot projects on morbidity statistics”
According to the methodology specified in the guidebook
„Principles and guidelines for diagnosis-specific morbidity statistics”
Agnieszka Broś
Piotr Woch

I.
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IV.
V.
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Duration: 15 November 2009 - 14 May 2011
The reference year: 2006
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Aims:
1. Inventory and description of all potential national sources for diagnosis- specific morbidity data which can be used to provide information about diseases listed in the Diagnosis-specific morbidity – European shortlist ,
SHORTLIST agreed by Eurostat: 60 diseases divided into 20 groups + 1 group covering
„external causes of mortality and morbidity” (accidents, assault, poisoning, complications of medical procedures, etc.).
2. Elaboration of the methodology for producing best national estimates
3. Pilot data collection and testing of the proposed methodology, taking into account the results of former Eurostat projects.
4. Preparation of the final report on the action.

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Centre for Health Statistics in the Statistical Office in Krakow – leading role in the project
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Series of working meetings and consultations with external experts
(from National Institute of Public Health, Oncology Centre, National Health Fund, Institute of Psychiatry and Neurology, Centre for Health Information Systems)
…on all steps of the project
 discussion of templates for data sources
 description and assessment of data sources
 analysis of available figures for required measures
(incidence, prevalence)
Problematic issues discussed with EUROSTAT

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Inventory of national data sources for diagnosis-specific morbidity statistics – template for general overview of the potential data sources
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Broad description and evaluation of the data sources inventoried
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Relationships between the measures (items on Shortlist) and data sources (potential and finally kept)

First step - identification of all potential data sources
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Register of tuberculosis
Notifications of sexually transmitted diseases
Notifications and registration of HIV/AIDS
Notifications of infectious diseases, infections and poisoning
Reports of influenza cases and suspicions of the influenza
National Cancer Register
General in-patient morbidity study
General out-patient morbidity study
Psychiatric morbidity study (out-patient & in-patient)

First step - identification of all potential data sources
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Database of provided health care benefits in the framework of the in-patient and out-patient specialist care – NHF (National Health
Fund)
Population Health Status Survey in Poland (2004)
Statistical survey of mortality
Police’ databases (on road traffic accidents, attempted suicides, crimes)
Central Register of Occupational Diseases
Databases on disabled people (The Social Insurance Institution & The
Agricultural Insurance Fund)

Inventory of national data sources for diagnosis-specific morbidity data (I)
DIVISION & ASSESSMENT
Name of the source
Register of tuberculosis
Notification of sexually transmitted diseases
Notification and registration of
HIV/AIDS
Notifications of infectious diseases, infections and poisoning
National Cancer Register
General hospital morbidity study
General out-patient morbidity study
Psychiatric out-patient morbidity study
Psychiatric in-patient morbidity study
Database of provided health care benefits in the framework of the in-patient and specialist care - NHF
Reporting of influenza cases and suspicion of the influenza
MAIN DATA SOURCES
General assessment
4
2
4
4
4
4
4
4
4
4
3
ADDITIONAL SOURCES
Name of the source
The Population Health Status Survey in
Poland
Statistical survey of the mortality
Database on road traffic accidents
Database on attempted suicides
Database on crimes
Central Register of Occupational Diseases
Database on disabled people - SII
Database on disabled people - ASIF
Assessment criteria: relevance, accuracy, timeliness & punctuality, accessibility & clarity comparability (geographical and over time), coherence
Assessment scale: 1 - poor, 5 - very good
General assessment
2
1
2
1
1
2
3
2

FURTHER DIVISION BASED ON PREVIOUS ASSESSMENT
Highest rated (mark: 4) – used during project
DATA SOURCES
Name of the source
Register of tuberculosis
General assessment
4 Main advantages:
Notification and registration of HIV/AIDS
Notifications of infectious diseases, infections and poisonings
National Cancer Register
General hospital morbidity study
4
4
4
4
• confirmation of each case through medical diagnosis
• continuity of data supply
General out-patient morbidity study 4
Psychiatric out-patient morbidity study
Psychiatric in-patient morbidity study
Database of provided health care benefits in the framework of the in-patient and specialist care - NHF
4
4
4
• whole population covered

FURTHER DIVISION BASED ON PREVIOUS ASSESSMENT
Lowest rated (mark: 1-2) - rejected
ADDITIONAL SOURCES
Name of the source
General assessment
Database on attempted suicides -
General Headquarter of Police
Database on crimes - General
Headquarter of Police
Central Register of Occupational
Diseases – Institute of Occupational
Medicine
Database on disabled people –
The Social Insurance Institution
2
1
2
1
Database on disabled people –
The Agriculture Social Insurance Fund
1
Main disadvantages:
• Lack of cases’ confirmation through
medical diagnosis (police’s data)
• Reference to population groups, not to general population
(databases on disabled people,
Register on Occupational Diseases)

Possible ways to approach the production of best estimates (proposed by Eurostat)
and their usage during the realization of project:
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 a one to one relation - with a direct connection between the source and the required measure (for a position of the shortlist of diseases),
 the most frequent one combination of data from various sources
 only for several diseases adjustment of data source in order to find the "perfect figure”
 period prevalence on the basis of „Data on out-patient and in-patient morbidity – NHF”
 incidence per episode on the basis of „General out-patient morbidity study”
All calculated figures inserted in a table for data submission for Eurostat .

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Data requirements: incidence by episode, period prevalence
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Potential data sources:
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Register of tuberculosis,
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General hospital morbidity study
General out-patient morbidity study
Database of provided health care benefits in the framework of the in-patient and out-patient specialist care – NHF
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Incidence by episode – calculated on the basis of TB cases reported to the
Register of tuberculosis
Period prevalence – calculated on the basis of data from National Health
Fund

Incidence by episode Period prevalence
Register of tuberculosis
APPLIED
All TB cases subjected to the obligatory reporting
Under-registration:
• changeability in annual incidence occurred
– lack of stability in the scope of detecting and registration,
• insufficient knowledge about diagnostic procedures among physicians detected TB among children
Unsatisfactory proportion of cases confirmed by bacteriological tests
NHF database
APPLIED
All patients treated in hospitals and by specialists
No information on GP’s patients
General hospital morbidity study
REJECTED
General outpatient morbidity study
Hospital study: only in-patients
Out-patient study: no data on out-patients cured in specialist care

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Data requirements: incidence by person, period prevalence (5 years)
Potential data sources:
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National Cancer Register (NCR)
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General hospital morbidity study
Database of provided health care benefits in the framework of the hospital and outpatient specialist care – NHF
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NCR as a basis for calculation:
Cancer incidence - diagnosis of disease with histological or cytological symptoms or proved by imaging examination or clinic imaging. There can be a few primary cancer sites for a single person.
5-year prevalence – the number of people living with cancer disease, who have been diagnosed within the last 5 years. Total prevalence should be calculated on the basis of cancer registry data. The NCR does not possesses a long enough horizon of data (20-30 years) to determine the total prevalence, thus 5-year prevalence is applied.

Incidence by episode Period prevalence
National Cancer
Registry
APPLIED
National Cancer
Registry
APPLIED
Obligatory reporting: doctors → 16 regional registries (verification, completion) → NCR (next control and medical verification; publishing annual report
5-year prevalence was estimated by NCR on the basis of incidence data and the 5-year survival rates calculated for the Polish population for patients diagnosed in 2000-2002
Estimated coverage of the NCR exceeds 85%:
• before estimation: M – 63,9; W - 60,9 (in thous.)
• after estimation: M – 75,2; W - 72,0 (in thous.)
General hospital morbidity study
REJECTED
Hospital study: only in-patients
Non-uniform under-registration across the country (high intervoivodship differences)
Registration completeness depends on the cancer site
(location) and age group considered
NHF database REJECTED
No information on GP’s patients

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Data requirements: incidence by person, period prevalence
Potential data sources:
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General hospital morbidity study
Database of provided health care benefits in the framework of the hospital and out-patient specialist care – NHF
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Acute myocardial infarction can be diagnosed based on clinical characteristics, electrocardiographic (ECG), biochemical and pathological. The guidelines apply to people with symptoms of ischemia and persistent ST segment elevation in the ECG
(STEMI). In most of these patients stated a significant increase in levels of biochemical markers of myocardial necrosis and the formation of the typical heart attack pathological Q wave (according to the guidelines of the European Society of
Cardiology - ESC).

Incidence by person Period prevalence
General hospital morbidity study
NHF database
APPLIED
APPLIED
Statistical survey on mortality
Combination of data from 2 sources:
General hospital morbidity study: number of discharged patients with AMI (including deaths in hospitals)
Mortality data: number of deaths due to AMI outside the hospital (including persons not previously treated for the
AMI in the hospital)
All patients treated in hospitals and by specialists in outpatient settings
No information on GP’s patients

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Data requirements: incidence by person, period prevalence, point prevalence
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According to „Clinical recommendations for dealing with diabetes in 2010”, diagnostics, education and treatment of diabetes are conducted mailnly in primary
care by GPs and in the specialised care by medical professionals. In case of complications, exacerbations and inability to achieve therapeutic effects in an outpatient care, there is a need for in-patient treatment
As a part of the specialist care – there are made the specialist diagnostics of all types diabetes and treatment of monogenic diabetes and diabetes co-occurring with other diseases.
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Both - incidence by person and period prevalence - were estimated on the basis of
the General out-patient morbidity study - the only one source of data on diabetes mellitus from primary out-patient care.

Incidence by person Period prevalence
General outpatient morbidity study
APPLIED
General outpatient morbidity study
Data are provided by primary care physicians/ family doctors by whom DM is mainly diagnosed
No data by sex and 5-year age groups available, only data for 0-18 and 19+ age groups
APPLIED
NHF database
REJECTED
No information on GP’s patients
Figure from this source 36,9% smaller than the number from General outpatient morbidity study
Point prevalence
NO DATA SOURCE

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Data requirements: period prevalence
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Dementia case – recognized on the basis of clinical symptoms by a psychiatrist who orders proper pharmaceutical, psychological and psychoterapeutic treatment.
Cases under consideration include:
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Dementia in Alzheimer’s disease [F00, G30],
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Vascular dementia (effect of brain infarction) [F01],
Dementia in other diseases elsewhere classified (Pick’s, Creutzfeld-Jakob’s,
Huntington’s diseases, HIV) [F02]
Unspecified dementia [F03]
These diagnoses can be derived from psychiatric in-patient morbidity study which is based on individual statistical cards of patients.
Psychiatric out-patient morbidity study – wider range of codes [additionally: F04,
F05, F06, F07, F09]; no identification of patients (only data on the aggregated level)

Period prevalence
NHF database (outpatients only)
Psychiatric in-patient morbidity study
APPLIED
NHF – patients with a diagnosis corresponding to the required range of
ICD-10 codes [F00-F03, G30] – counted only once (identified by PESEL number)
Psychiatric in-patient study:
• the required ICD-10 codes available,
• individual records derived from statistical cards
Psychiatric out-patient morbidity study
REJECTED
Psychiatric in-patient morbidity study
Connection of these data sources is improper
Reasons:
Out-patient morbidity study –
• wider range of codes than required
• possibility of double-counting – a patient using in-patient and out-patient psychiatric care in the same calendar year
• no possibility for identification an individual patient

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Data requirements: incidence by person, period prevalence, point prevalence
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Cases of HIV/AIDS are defined in the system of reporting communicable diseases. The basis of diagnosis are clinical symptoms and/or immunological confirmation.
HIV infection – diagnosis based on laboratory criteria for HIV infection or AIDS diagnosis. There are detailed laboratory criteria for diagnosis, different for children under the age of 18 months and for the rest of people – adults, adolescents and children over 18 months.
AIDS – includes persons infected with HIV who have any of 28 clinical conditions listed in the European case definition for AIDS applied for epidemiological surveillance (European AIDS surveillance case definition)
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HIV/AIDS register (notification and registration of HIV/AIDS) – was found as the best data source

HIV/AIDS – a one to one relationship
Incidence by episode Period prevalence
Register of
HIV/AIDS
APPLIED
Under-registration of seropositive cases:
• unawareness of disease
• confidentiality (sum of data in age groups ≠ total )
Register of
HIV/AIDS
APPLIED
Adjustment = all registered – deceased
(from the beginning of registration to the end of 2005)
Point prevalence
General hospital morbidity study
REJECTED
Difficulties in estimation of the number of seropositive cases:
• no proper indication of new (first time) cases overestimation
• no all HIV/AIDS cases are hospitalized underestimation
Register of
HIV/AIDS
APPLIED
Adjustment = all registered as of 30 December
2006 – deceased (from the beginning of registration to the end of 2006)

INCOMPLETE DATA IN AGE AND GENDER
GROUPS
Incidence by episode
Sum of numbers in age groups ≠ total number
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HIV/AIDS
Those listed on a register may retain their anonymity (age, gender)
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Land transport accidents’ victims
For some cases no information on age and gender
NO RELAIBLE DATA SOURCE IDENTIFIED
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Incidence and prevalence
Pneumonia [J12-J18]
Accidental falls [W00-W19]
Accidental poisoning [X40-X49]
Intentional self harm (incl. suicidal attempt)
[X60-X84]
Assault [X85-Y09]
Medical and surgical complications
[Y40-Y66, Y69-Y84]
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Period prevalence
Rheumatoid arthritis [M05, M06]
Arthrosis [M15-M19]

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Goal: regular morbidity data collection within the ESS
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Task Force on morbidity statistics (TF MORB) was established
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Fit existing methodological tools to that goal by
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Analysis of results of 16 pilot studies in MS (stress on quality, reliability and comparability across MS)
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10 MS before 2009 (AT, CY, CZ, EE, HU, LT, LV, MT, SL, SI); for 6 MS (BE, DE, NL, RO, PL, FI) final report sent by autumn 2011
If needed, revise the existing methodology: guidelines, shortlist of diseases
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Deliverables discussed at a Technical Group MORB meeting
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Finalisation of the documents by November 2012