Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the intestine that includes Crohn’s disease (CD) and ulcerative colitis (UC) which etiology is still unknown. However, it has been postulated that it is a multifactorial disease with genetics [
According to the study of Global Burden of Disease 2016 in Mexico, the total of disability adjusted life years (DALYs) due to IBD (16,289 (100%)), 11,903 (73.1%) are due to years of life lost (YLLs) for premature mortality and 4,386 (26.9%) are due to years lived with disease (YLDs). IBD represents 0.037% of the total YLDs in Mexico for any cause, which is similar to the YLDs caused by maternal abortion (0.036%), uterine cancer (0.03%), ovarian cancer (0.034%), and colon and rectal cancer (0.047%). The highest rates of YLDs from IBD in the world come from the United Kingdom (92.0 YLDs per 100,000), United States (US) (73.5 YLDs per 100,000), and Croatia (42.7 YLDs per 100,000). Mexico has 3.41 YLDs per 100,000. In terms of death rates, the highest comes from Germany (2.64 deaths per 100,000), Belgium (2.41 deaths per 100,000), and the United Kingdom (2.37 deaths per 100,000), while Mexico has a death rate of 0.34 deaths per 100,000 [
IBD is considered an expanding global health problem, as its incidence and prevalence have increased constantly through the last 20 years in adults [
In developing nations like Mexico, population-based epidemiological studies providing incidence rates between age groups are scarce [
This is a quantitative and cross-sectional study. Secondary data sources analysis is performed through Dynamic Cubes of the General Direction of Health Information (DGIS for its Spanish acronym) of Mexico, from 2004 to 2015. The search was done looking for Crohn’s disease (K.50) or ulcerative colitis (K.51) according to their corresponding classification in the International Classification of Diseases (ICD)-10 as principal causes of hospital discharges and deaths, classified by sex, age, and state where data were registered.
Access to the DGIS information was obtained through the Dynamic Cubes platform, which is an electronic repository of national integrated databases. This platform contains information from different periods of time, related to the number of hospital discharges and deaths from different public institutions that offer health services in Mexico. For all institutions, information about hospital discharges was reported for the years between 2004 and 2015, and information about deaths was reported between 2004 and 2013. In both cases, information was reported from the following institutions: Mexican Health Ministry (
The database was built using annual information of hospital discharges (2004–2015) and deaths (2004–2013) in every Mexican state, categorized by CD or UC, sex, and age. Data were added in order to obtain the total numbers on a nationwide scale. Afterwards, histograms and linear graphs were used to represent data and analyze their behavior through time. The same database was exported to SPSS v24, where an evaluation of data distribution was made using the Shapiro–Wilk test (
The total number of hospital discharges (2004–2015) and deaths (2004–2013) for each state was ordered in a descending manner through quartiles. From this list, data were categorized in states with very high, high, low, or very low number of hospital discharges and deaths. To represent the geographic distribution of data, reference maps were obtained, assigning one different color to each category.
This study was performed in accordance with the principles expressed in the Helsinki Declaration. This study was approved by the Ethical and Medical Committee from the National Institute of Medical Sciences and Nutrition Salvador Zubirán.
The number of HD and deaths reported for UC and CD in each one of the years studied is shown in Figure
Number of hospital discharges (a) and deaths (b) reported for ulcerative colitis and Crohn’s disease.
The number of reported deaths for CD and UC increased until 2011 but then started to decrease. The number of deaths reported for IBD in 2011 was almost two times greater than those reported in 2004. This increase was 2.08 times for UC and 1.7 times for CD. In the case of CD, the greatest increase in the number of deaths was found between 2006 and 2011 (151.7%) and its decrease afterwards was of 42.6%. On the other hand, UC had the greatest increase between 2007 and 2011 (121.4%) and a decrease afterwards of 41.4%.
Figure
Number of hospital discharges classified by group of age and sex for ulcerative colitis (a) and Crohn’s disease (b).
Table
The number of hospital discharges and deaths reported for inflammatory bowel disease (IBD), ulcerative colitis (UC), and Crohn’s disease (CD) in Mexico.
Hospital discharges (2004-2015) | Deaths (2004-2013) | |||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Women | Men | Total | Women | Men | Total | |||||||||||||||
UC | CD | UC | CD | IBD | UC | CD | UC | CD | IBD | |||||||||||
% | % | % | % | % | % | % | % | % | % | |||||||||||
Mexico | 7,496 | 41 | 2,167 | 11.9 | 6,640 | 36.3 | 1,973 | 10.8 | 18,276 | 100 | 118 | 16.9 | 244 | 34.9 | 88 | 12.6 | 250 | 35.7 | 700 | 100 |
Aguascalientes | 145 | 1.9 | 24 | 1.1 | 134 | 2.0 | 22 | 1.1 | 325 | 1.8 | 4 | 3.4 | 1 | 0.4 | 3 | 3.4 | 3 | 1.2 | 11 | 1.6 |
Baja California | 253 | 3.4 | 44 | 2.0 | 181 | 2.7 | 54 | 2.7 | 532 | 2.9 | 1 | 0.8 | 1 | 0.4 | 2 | 2.3 | 2 | 0.8 | 6 | 0.9 |
Baja California Sur | 88 | 1.2 | 12 | 0.6 | 82 | 1.2 | 12 | 0.6 | 194 | 1.1 | 1 | 0.8 | 1 | 0.4 | 1 | 1.1 | 0 | 0 | 3 | 0.4 |
Campeche | 28 | 0.4 | 18 | 0.8 | 22 | 0.3 | 10 | 0.5 | 78 | 0.4 | 5 | 4.2 | 3 | 1.2 | 3 | 3.4 | 3 | 1.2 | 14 | 2.0 |
Chiapas | 92 | 1.2 | 46 | 2.1 | 66 | 1.0 | 38 | 1.9 | 242 | 1.3 | 2 | 1.7 | 7 | 2.9 | 3 | 3.4 | 5 | 2 | 17 | 2.4 |
Chihuahua | 448 | 6.0 | 58 | 2.7 | 334 | 5.0 | 52 | 2.6 | 892 | 4.9 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 1 | 0.4 | 1 | 0.1 |
Mexico City | 1,460 | 19.5 | 489 | 22.6 | 1,178 | 17.7 | 452 | 22.9 | 3,579 | 19.6 | 0 | 0.0 | 3 | 1.2 | 3 | 3.4 | 2 | 0.8 | 8 | 1.1 |
Coahuila | 465 | 6.2 | 103 | 4.8 | 393 | 5.9 | 58 | 2.9 | 1,019 | 5.6 | 13 | 11.0 | 11 | 4.5 | 9 | 10.2 | 7 | 2.8 | 40 | 5.7 |
Colima | 31 | 0.4 | 15 | 0.7 | 69 | 1.0 | 14 | 0.7 | 129 | 0.7 | 3 | 2.5 | 29 | 11.9 | 3 | 3.4 | 22 | 8.8 | 57 | 8.1 |
Durango | 102 | 1.4 | 49 | 2.3 | 171 | 2.6 | 32 | 1.6 | 354 | 1.9 | 1 | 0.8 | 9 | 3.7 | 1 | 1.1 | 9 | 3.6 | 20 | 2.9 |
Mexico | 375 | 5.0 | 88 | 4.1 | 377 | 5.7 | 71 | 3.6 | 911 | 5.0 | 0 | 0.0 | 2 | 0.8 | 1 | 1.1 | 8 | 3.2 | 11 | 1.6 |
Guanajuato | 335 | 4.5 | 83 | 3.8 | 321 | 4.8 | 98 | 5.0 | 837 | 4.6 | 0 | 0.0 | 2 | 0.8 | 1 | 1.1 | 4 | 1.6 | 7 | 1.0 |
Guerrero | 44 | 0.6 | 20 | 0.9 | 78 | 1.2 | 23 | 1.2 | 165 | 0.9 | 3 | 2.5 | 2 | 0.8 | 1 | 1.1 | 2 | 0.8 | 8 | 1.1 |
Hidalgo | 95 | 1.3 | 23 | 1.1 | 86 | 1.3 | 27 | 1.4 | 231 | 1.3 | 1 | 0.8 | 7 | 2.9 | 1 | 1.1 | 8 | 3.2 | 17 | 2.4 |
Jalisco | 865 | 11.5 | 181 | 8.4 | 676 | 10.2 | 135 | 6.8 | 1,857 | 10.2 | 0 | 0.0 | 2 | 0.8 | 3 | 3.4 | 4 | 1.6 | 9 | 1.3 |
Michoacán | 236 | 3.1 | 64 | 3.0 | 242 | 3.6 | 60 | 3.0 | 602 | 3.3 | 1 | 0.8 | 0 | 0.0 | 3 | 3.4 | 2 | 0.8 | 6 | 0.9 |
Morelos | 86 | 1.1 | 23 | 1.1 | 82 | 1.2 | 32 | 1.6 | 223 | 1.2 | 7 | 5.9 | 1 | 0.4 | 3 | 3.4 | 2 | 0.8 | 13 | 1.9 |
Nayarit | 45 | 0.6 | 18 | 0.8 | 52 | 0.8 | 14 | 0.7 | 129 | 0.7 | 0 | 0.0 | 0 | 0.0 | 1 | 1.1 | 1 | 0.4 | 2 | 0.3 |
Nuevo León | 425 | 5.7 | 165 | 7.6 | 458 | 6.9 | 161 | 8.2 | 1,209 | 6.6 | 5 | 4.2 | 1 | 0.4 | 1 | 1.1 | 1 | 0.4 | 8 | 1.1 |
Oaxaca | 109 | 1.5 | 31 | 1.4 | 122 | 1.8 | 29 | 1.5 | 291 | 1.6 | 1 | 0.8 | 1 | 0.4 | 0 | 0.0 | 0 | 0 | 2 | 0.3 |
Puebla | 247 | 3.3 | 49 | 2.3 | 240 | 3.6 | 64 | 3.2 | 600 | 3.3 | 5 | 4.2 | 4 | 1.6 | 2 | 2.3 | 0 | 0 | 11 | 1.6 |
Querétaro | 63 | 0.8 | 17 | 0.8 | 76 | 1.1 | 24 | 1.2 | 180 | 1.0 | 5 | 4.2 | 3 | 1.2 | 1 | 1.1 | 0 | 0 | 9 | 1.3 |
Quintana Roo | 46 | 0.6 | 23 | 1.1 | 39 | 0.6 | 26 | 1.3 | 134 | 0.7 | 3 | 2.5 | 1 | 0.4 | 5 | 5.7 | 2 | 0.8 | 11 | 1.6 |
Sinaloa | 110 | 1.5 | 51 | 2.4 | 118 | 1.8 | 58 | 2.9 | 337 | 1.8 | 4 | 3.4 | 3 | 1.2 | 1 | 1.1 | 1 | 0.4 | 9 | 1.3 |
San Luis Potosí | 153 | 2.0 | 42 | 1.9 | 128 | 1.9 | 29 | 1.5 | 352 | 1.9 | 8 | 6.8 | 4 | 1.6 | 10 | 11.4 | 6 | 2.4 | 28 | 4.0 |
Sonora | 292 | 3.9 | 94 | 4.3 | 203 | 3.1 | 108 | 5.5 | 697 | 3.8 | 4 | 3.4 | 0 | 0.0 | 2 | 2.3 | 1 | 0.4 | 7 | 1.0 |
Tabasco | 98 | 1.3 | 26 | 1.2 | 85 | 1.3 | 29 | 1.5 | 238 | 1.3 | 0 | 0.0 | 8 | 3.3 | 2 | 2.3 | 6 | 2.4 | 16 | 2.3 |
Tamaulipas | 279 | 3.7 | 56 | 2.6 | 235 | 3.5 | 50 | 2.5 | 620 | 3.4 | 0 | 0.0 | 1 | 0.4 | 2 | 2.3 | 3 | 1.2 | 6 | 0.9 |
Tlaxcala | 45 | 0.6 | 12 | 0.6 | 39 | 0.6 | 12 | 0.6 | 108 | 0.6 | 1 | 0.8 | 0 | 0.0 | 0 | 0.0 | 4 | 1.6 | 5 | 0.7 |
Veracruz | 255 | 3.4 | 124 | 5.7 | 234 | 3.5 | 95 | 4.8 | 708 | 3.9 | 20 | 16.9 | 137 | 56.1 | 10 | 11.4 | 131 | 52.4 | 298 | 42.6 |
Yucatán | 57 | 0.8 | 47 | 2.2 | 51 | 0.8 | 47 | 2.4 | 202 | 1.1 | 20 | 16.9 | 0 | 0.0 | 10 | 11.4 | 10 | 4 | 40 | 5.7 |
Zacatecas | 124 | 1.7 | 72 | 3.3 | 68 | 1.0 | 37 | 1.9 | 301 | 1.6 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0 | 0 | 0.0 |
The geographic representation of the number of hospital discharges for IBD from 2004–2015 is shown in Figure
Geographic distribution of the number of hospital discharges reported in Mexico for ulcerative colitis and Crohn`s disease from 2004 to 2015.
Geographic distribution of the number of hospital deaths reported in Mexico for ulcerative colitis and Crohn`s disease from 2004 to 2013.
In Figure
Change in the number of hospital discharges and deaths for inflammatory bowel disease (IBD) through time.
Hospital discharges | ||||||
---|---|---|---|---|---|---|
Median (IR) | Number | |||||
2004 | 2015 | 2004 | 2015 | % of change 2004–2015 | ||
UC | 18.5 (33.75–9.75) | 30.5 (69.25–13.5) | 0.051 | 787 | 1,577 | 100.3% |
CD | 4.5 (10.25–2.25) | 9 (18–5.25) | 0.009 | 253 | 492 | 95% |
IBD | 24.5 (47–13.25) | 44 (87–17.75) | 0.033 | 1040 | 2,069 | 99% |
Deaths | ||||||
2004 | 2011 | 2004 | 2011 | % of change 2011–2013 | ||
UC | 0 (1-0) | 1 (1-0) | 0.040 | 17 | 29 | 70.5% |
CD | 0 (1-0) | 1 (1-0) | 0.064 | 36 | 75 | 108.3% |
IBD | 0.5 (1-0) | 1 (3-0) | 0.056 | 53 | 104 | 96.2% |
2011 | 2013 | 2011 | 2013 | % of change 2011–2013 | ||
UC | 1 (1-0) | 0 (1-0) | 0.050 | 29 | 17 | 41.4% |
CD | 1 (1-0) | 0 (1-0) | 0.251 | 75 | 43 | 42.7% |
IBD | 1 (3-0) | 0.5 (2-0) | 0.126 | 104 | 60 | 42.3% |
IR: interquartile range, UC: ulcerative colitis, CD: Crohn’s disease.
Additionally, a decrease in the number of hospital discharges was reported for IBD from 2011 until 2013. This difference was only statistically significant for UC (
To our best knowledge, this is the first study that showed a significant increase in the number of hospital discharges for IBD in Mexico from 2004 to 2015, while the number of deaths presented a peak in 2011 and then started to decrease. It is important to mention that IBD affects Mexican people without sex predominance, frequently between 15 and 44 years old. States with a greater number of hospital discharges were concentrated in the north and center of the country, while states with the greatest number of deaths were located in the north and south of the country.
In this study, from 2004 to 2015, although UC was three times more frequent than CD, hospital discharges for CD increased 108.4% from 2009 while for UC, there was an increase of 55.6% in the same period of time. This behavior was similar to those reported in the US, where until 2004, hospital discharges for CD increased more than 2-fold during a 35-year period, while for UC it increased only slightly [
We found no sex predominance regarding IBD diagnosis, which is according to previous studies around the world [
Hospital discharges were located in the north and center of the country, which is consistent with a previous study that reported about the severity and incidence of IBD that has been associated with geographic distribution [
Hospital death registries reported for UC in Mexico increased significantly from 2004 to 2011, whereas deaths for CD did not. The GBD study has already estimated the number of deaths caused by IBD until 2016, but if we compare the 411.59 (280.32-460-97) deaths estimated by the GBD for 2013 [
One important limitation of this study is that hospital discharges and deaths due to IBD without considering other hospital discharges or deaths in which IBD in any of its variants contributed to either of both possible outcomes without being the final main cause. Besides, this study has not considered the cases that occurred in private hospitals or outpatient clinics from public or private health services, so the number reported in this study may be underestimating the real picture.
The data considers the whole country and the majority of institutions that give health services. This represents a unique opportunity to analyze the temporary and geographic trends of IBD in Mexico. Additionally, registries from hospital discharges attributed to IBD as the principal cause could be an approximate indicator of their national frequency and can, therefore, be used as parameters for morbidity [
There are some potential reasons that could explain this increase in the frequency of hospital discharges and deaths attributed to CD and UC in specific regions in Mexico such as lack of IBD clinics in most of the hospitals located at countryside explained by low rate of medical treatment optimization that produces severe disease activity and consequently higher hospitalizations and surgeries related to IBD. It is important to mention that most of the hospitals belong to social security and government systems where they have access to all kinds of medical treatment including biological therapy. However, most of the specialists were afraid of using biological therapy in IBD patients.
This is the first Mexican study that analyzes the nationwide frequency of hospital discharges and deaths attributed to IBD in recent years. Hospital discharges increased significantly between 2004 and 2015 as well. The number of deaths had a frequency peak in 2011 and then started to decrease over time. The states with a greater number of hospital discharges were located in the north and center part of the country, while the states with a greater number of deaths were distributed both in the north and in the south of Mexico.
The data used to support the findings of this study are included within the article.
This work was presented as a poster and the abstract was published in the American Journal of Gastroenterology in the following link:
The authors declare they have no conflicts of interest.
The authors thank Dr. Rafael Lozano Ascencio for his encouragement to do this research and Joel Toledo for his helpful comments.