title: Patterns of hospital transfer for self-poisoned patients in rural Sri Lanka: implications for estimating the incidence of self-poisoning in the developing world.
abstract: OBJECTIVE
  Most data on self-poisoning in rural Asia have come from secondary hospitals. We aimed to: assess how transfers from primary to secondary hospitals affected estimates of case-fatality ratio (CFR); determine whether there was referral bias according to gender or poison; and estimate the annual incidence of all self-poisoning, and of fatal self-poisoning, in a rural developing-world setting.
  
  
  METHODS
  Self-poisoning patients admitted to Anuradhapura General Hospital, Sri Lanka, were reviewed on admission from 1 July to 31 December 2002. We audited medical notes of self-poisoning patients admitted to 17 of the 34 surrounding peripheral hospitals for the same period.
  
  
  RESULTS
  A total of 742 patients were admitted with self-poisoning to the secondary hospital; 81 died (CFR 10.9%). 483 patients were admitted to 17 surrounding peripheral hospitals. Six patients (1.2%) died in peripheral hospitals, 249 were discharged home, and 228 were transferred to the secondary hospital. There was no effect of gender or age on likelihood of transfer; however, patients who had ingested oleander or paraquat were more likely to be transferred than were patients who had taken organophosphorus pesticides or other poisons. Estimated annual incidences of self-poisoning and fatal self-poisoning were 363 and 27 per 100,000 population, respectively, with an overall CFR of 7.4% (95% confidence interval 6.0-9.0).
  
  
  CONCLUSIONS
  Fifty per cent of patients admitted to peripheral hospitals were discharged home, showing that CFRs based on secondary hospital data are inflated. However, while incidence of self-poisoning is similar to that in England, fatal self-poisoning is three times more common in Sri Lanka than fatal self-harm by all methods in England. Population based data are essential for making international comparisons of case fatality and incidence, and for assessing public health interventions.
authors.affiliation: South Asian Clinical Toxicology Research Collaboration, Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, England. eddlestonm@eureka.lk
authors.forename: Michael
authors.initials: M
authors.lastname: Eddleston
authors.forename: K
authors.initials: K
authors.lastname: Sudarshan
authors.forename: M
authors.initials: M
authors.lastname: Senthilkumaran
authors.forename: K
authors.initials: K
authors.lastname: Reginald
authors.forename: Lakshman
authors.initials: L
authors.lastname: Karalliedde
authors.forename: Lalith
authors.initials: L
authors.lastname: Senarathna
authors.forename: Dhammika
authors.initials: D
authors.lastname: de Silva
authors.forename: M H
authors.initials: MH
authors.lastname: Rezvi Sheriff
authors.forename: Nick A
authors.initials: NA
authors.lastname: Buckley
authors.forename: David
authors.initials: D
authors.lastname: Gunnell
mesh_terms: D000328:Adult; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D008297:Male; D010360:Patient Transfer; D011041:Poisoning / Q000453:epidemiology* / Q000401:mortality; D012017:Referral and Consultation; D012424:Rural Population; D013188:Sri Lanka / Q000453:epidemiology; D013406:Suicide, Attempted / Q000706:statistics & numerical data*