bradshaw 2006

8/12/2019 Bradshaw 2006

1/11

ObjectiveTo review the quality of the coding of the cause of death (COD) statistics and assess the mortality information needs ofthe City of Cape Town.MethodsUsing an action research approach, a study was set up to investigate the quality of COD information, the accuracy ofCOD coding and consistency of coding practices in the larger health subdistricts. Mortality information needs and the best way ofpresenting the statistics to assist health managers were explored.FindingsUseful information was contained in 75% of death certificates, but nearly 60% had only a single cause certified; 55%of forms were coded accurately. Disagreement was mainly because routine coders coded the immediate instead of the underlyingCOD. An abridged classification of COD, based on causes of public health importance, prevalent causes and selected combinationsof diseases was implemented with training on underlying cause. Analysis of the 2001 data identified the leading causes of deathand premature mortality and illustrated striking differences in the disease burden and profile between health subdistricts.

ConclusionAction research is particularly useful for improving information systems and revealed the need to standardize the codingpractice to identify underlying cause. The specificity of the full ICD classification is beyond the level of detail on the death certificatescurrently available. An abridged classification for coding provides a practical tool appropriate for local level public health surveillance.Attention to the presentation of COD statistics is important to enable the data to inform decision-makers.

KeywordsMortality/statistics; Data collection/methods; Death certificates; Cause of death; South Africa (source: MeSH, NLM).

Mots clsMortalit/statistique; Collecte donnes/mthodes; Certificat dcs; Cause dcs; Afrique du Sud ( source: MeSH, INSERM).

Palabras claveMortalidad/estadstica; Recoleccin de datos/mtodos; Certificado de defuncin; Causa de muerte; Sudfrica(fuente: DeCS, BIREME).

Bulletin of the World Health Organization 2006;84:211-217.

Voir page 215 le rsum en franais. En la pgina 216 figura un resumen en espaol.

IntroductionPaccaud recently identified the generallack of interest in routine health infor--mation systems and highlighted the un--derresearched and underfunded natureof cause of death (COD) statistics inparticular.1In a review of the quality ofnational COD statistics, Mathers et al.

identified the need for improvement in ahigh proportion of countries that submitdata to WHO as well as the high numberof countries in sub-Saharan Africa thatdo not submit any data.2Tere is grow--ing recognition, however, of the impor--tance of health information systems andthe integral role of mortality statisticsneeded for monitoring public health,

a Burden of Disease Research Unit, Medical Research Council , PO Box 19070, Tygerberg 7505, South Africa. Correspondence to Dr Bradshaw (email: [email protected]).b Department of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.c City of Cape Town, Cape Town, South Africa.Ref. No. 05-028589(Submitted: 9 January 2006 Final revised version received: 1 February 2006 Accepted: 1 February 2006)

Making COD statistics useful for public health at local levelin the city of Cape TownDebbie Bradshaw,aPamela Groenewald,aDavid E Bourne,bHassan Mahomed,bBeatrice Nojilana,aJohan Daniels,c& Jo Nixon b

.216

allocating resources and developingpublic health policy.3Reporting on theoutcome of a workshop held in Africa,Rao et al. highlight the need for coun--tries in sub-Saharan Africa to review theirvital registration systems and develop aplan to improve COD statistics.4

South Africa, a middle-income

country, has a well-established nationalvital registration system administeredby the Department of Home Affairs.Te national statistical office, StatisticsSouth Africa, is responsible for compil--ing the death statistics, after coding theCOD information certified by medicalpractitioners on the death notificationform. In common with most developingcountries, the COD statistics in South

Africa suffer from under-registration ofdeaths and misclassification of causes.5,6Changes to the death notification formto elicit the underlying COD as pro--posed in the International statistical clas--sification of diseases and related health

problems, tenth revision (ICD-10) wereintroduced in 1998 as part of a broader

strategy to improve vital registration.79

An element of success resulted, with thecoverage of adult death registration im--proving to over 90%.10Te adoption ofICD-10 as a coding standard resulted inthe 1996 COD statistics being processed

with bridge coding of ICD-9 and ICD-10.11 Te application of the software

Automated Classification of MedicalEntities (ACME 2004.2) to identify the

8/12/2019 Bradshaw 2006

2/11

Special Theme Estimating MortalityCOD statistics in Cape Town Debbie Bradshaw et al.

underlying COD facilitated the produc--tion of a report on the causes of death for19972003.12,13Despite these improve--ments the national statistical system failsto provide timely statistics that can beutilized at district level.

In contrast to the rest of the country,Cape own has a well-established systemof routinely compiling death statistics.14Based on the same source documentsas are used in the national system, theunderlying COD information is coded,captured and processed by the local mu--nicipalities. Te City of Cape own isnow a single municipality with 11 healthsubdistricts but previously comprisedsix municipalities (one of which wasalso called the City of Cape own).During the period of transition in local

government, the health information wascoordinated by a Metropolitan HealthInformation Group but data collectiontook place in the six separate municipali--ties. In 1999, this group identified theneed to review the collection of deathstatistics and establish whether there wasa need to change from ICD-9 to ICD-10 coding, which had been adopted as anational standard. Tey approached theresearchers to investigate the quality oftheir coding and advise them. An actionresearch approach was adopted, as it wasconsidered that the participatory char--acter would facilitate implementationof the findings.15Here we describe theinvestigation, an abridged classificationthat was developed and the initial statis--tics compiled after the introduction ofthe abridged list.

MethodsA rapid appraisal of the qua lity ofcoding was undertaken. Te key roleplayers in running the system from thethen two major municipalities, the City

of ygerberg (JD) and the City of Capeown (HM), were joined by research--ers to set up the study team. Te teamreported regularly to the MetropolitanHealth Information Group and on occa--sion to the health management team.

In the first phase of the rapid ap--praisal, a sample of death forms wasselected systematically from the formsprocessed at the end of 1999 in eachoffice. Te sample size of 50 forms fromeach health subdistrict was pragmaticand was expected to yield 550 forms out

of the approximately 20 000 deaths peryear. Te quality of the COD informa--tion was subjectively assessed by one of

training and nosological experience. Tequality of the information was scored ona scale as follows: adequate:where there is at least

one clearly stated diagnosis, or morethan one diagnosis with an immedi--ate and underlying COD;

incomplete:where a vague diagnosiswith no underlying cause is listed;

poor:with no proper diagnosis, e.g.natural cause or unnatural cause.

In addition, the frequency and pattern ofmultiple causes of death were described

ers would need to apply rules to identifyunderlying causes and also identify com--mon comorbidity.

Te agreement between the ex--perienced coder (JN) and the routinecoder on these forms was assessed atsingle cause level, as well as the ICD-9Basic abulation List (BL) level of 56aggregate causes that is used by the mu--nicipalities to report statistics. Becausethe forms had personal identifiers they

were treated as strictly confidential andkept in envelopes, which were lockedaway when not in use.

Table 1. Level of agreement according to cause of death (ICD-9 Basic Tabulation List)

Cause of death Agreement (%) Total number(ICD-9 Basic Tabulation List) of cases

Intestinal infectious diseases 17 6Tuberculosis 73 26Other bacterial diseases 50 4Other infectious and parasitic diseases 59 32Malignant neoplasm of lip, oral and pharynx 100 1Malignant neoplasm of digestive organs 90 20Malignant neoplasm of respiratory organs 87 23Malignant neoplasm of bone, skin, and breast 60 5Malignant neoplasm of genitourinary organs 58 12Malignant neoplasm of other, unspecified site 16 12Malignant neoplasm of lymphatic and 100 2

haemapoetic systemsCarcinoma in situ 100 1Other and unspecified neoplasm 100 2Endocrine and metabolic diseases 18 17Nutritional deficiencies 100 1Diseases of blood and blood forming organs 0 1Diseases of nervous system 63 8Hypertensive diseases 13 24Ischaemic heart disease 76 33Diseases of pulmonary circulation 85 13Cerebrovascular disease 84 25Other diseases of circulatory system 42 7Other diseases of respiratory system 76 42Diseases of other parts of the digestive system 46 11Diseases of urinary system 81 25Direct obstetric causes 100 1Diseases of musculoskeletal system 0 1

Congenital anomalies 40 5Certain conditions in perinatal period 67 15Signs and symptoms and ill-defined conditions 68 38Transport accidents 92 26Misadventure during medical care 20 5Accidental fall 16 6Accidents caused by fire and flames 100 7Other accidents, including late effects 25 12Suicide and self-inflicted injury 100 5Homicide and injury inflicted by other 98 53Other violence 50 8Overall 67 523

8/12/2019 Bradshaw 2006

3/11

Special Theme Estimating MortalityDebbie Bradshaw et al. COD statistics in Cape Town

praisal, retrospective data collected overthe two-year period (July 1997June1999) in the two major municipalities,ygerberg and Cape own, were anal--ysed to investigate the coding practicesused and the trend in the ill-defined

category. Te remaining municipalitieswere omitted for expediency as theyworked very closely with the ygerbergteam and were considered to have a verysimilar coding practice.

In the final process of the rapidappraisal, routine mortality reports pro--duced for health managers were exam--ined and discussions were held with thehealth managers to determine whatinformation was required by healthmanagers to assist with health servicesplanning and management and how it

could best be presented.

FindingsQuality of COD informationIn total, 536 death forms were sampledfor assessment. Tere were between 38and 51 forms from each of the 11 healthsubdistricts. It was found that 75% (95%confidence interval (CI) = 7179) of theforms had adequate information while13% (95% CI = 1016) had incompleteinformation and 11% (95% CI = 814)

had poor information.

Multiple causesFifty-nine percent of the cases had only asingle COD written on the form, while26% had two causes including com--mon combinations such as stroke withhypertension and tuberculosis (B) withhuman immunodeficiency virus (HIV).Only 2% had four causes on the certifi--cate. Tis finding suggests that there ismuch scope for improving the qualityof medical certification so as to providesufficient details to allow for accurateidentification of the underlying cause.

Agreement of codingTe agreement between the underlyingCOD identified by the researcher andthat coded by the municipality could notbe assessed for 13 cases where the sampleforms could not be matched with theroutine data from the same period. Outof the remaining 523 cases, 55% (95%CI = 5159) of the codes agreed exactly

at the three-digit level of ICD-9. Whenassessed at the level of BL group, 67%(95% CI = 6371) of the cases agreed.

ing to the COD: able 1 shows the levelof agreement in each BL group.

Te reason for disagreement tendednot to be a result of coding errors butrather that the municipality coders hadcoded the immediate cause instead ofthe underlying cause. When discussed

with the coders it was found that, withthe exception of identifying lung cancer

or HIV/acquired immune deficiencysyndrome (AIDS) as underlying causesin the municipality of Cape own, thestandard practice was to code the im--mediate cause.

Analysis of retrospective data re--vealed similar proportions for the twomajor municipalities at the single ICD-9cause level. However, there were notice--ably different coding practices for the less

well-defined conditions such as injurieswith unknown intent.

Reporting and utilization of thestatisticsTe data collected by each municipalityare presented in several formats and aremade available to several key meetingsand processes for planning. Key indica--tors, such as the infant, under-5-year-oldand crude mortality rates as well as thetop 10 causes of death for children andadults, are collated on a routine basis andreported from time to time to the healthmanagement committee. Te informa--tion was used by management in situ--

ation analysis assessments but has notbeen used in a specific quantitative wayto monitor the impact of programmes.

municipalities produced annual reportsthat were distributed widely and madeavailable to the general public, and theseincluded a description of mortalitypatterns. South African municipalitieshave gone through a period of intenserestructuring over the last 10 years andthese reports were produced in a limited

way, thus reducing public access to mor--

tality information. It was also observedthat there is much scope to enhance thepresentation of the statistics to highlightthe conditions that result in prematuremortality or to highlight inequalities inhealth.

Development and implementa--tion of an abridged classificationfor codingExamination of the applications of thedeath data revealed that the list of CODallowed by ICD-9 or ICD-10 is beyond

the specificity of information recordedon many of the forms processed andmore than what is required for generalpublic health surveillance. In light ofthis, and using ICD-10 as a basis, theteam developed an abridged classificationor shortlist for coding COD statisticsat local level (able 2, web version only,http://www.who.int/bulletin). Te mostprevalent causes of death in Cape own,e.g. ischaemic heart disease and B, as

well as causes of concern to the healthauthority, e.g. malaria, were used as

criteria for inclusion. Other causes weregrouped into appropriate categoriesto ensure that a sufficiently detailed

Fig. 1.Leading causes of death, Cape Town, 2001 (n= 23 185)

Homicide

WHO 06.19

Percentage of total deaths

0 2 4 6 8 10 12

10.6Ischaemic heart disease 8.1

HIV/AIDSa 7.4Hypertensive heart disease 6.4

Tuberculosis 5.9Diabetes mellitus 5.3

Stroke 4.7Lower respiratory infections 3.9

Road traffic 3.7Trachea/bronchi/lung cancer 3.6

Chronic obstructive pulmonary disease 3.5Renal failure 2.0Septicaemia

Pulmonary heart and circulatory disease 1.5Breast cancer 1.4

Asthma 1.4Perinatal conditions 1.3

Colorectal cancer 1.3Suicide and self-inflicted 1.2

Fires 1.1

1.5

aHIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome.

8/12/2019 Bradshaw 2006

4/11


still be possible and compatible withthe burden of disease categories usedin the South African national burdenof disease study.16Te list includes se--lected combinations of diseases, such asHIV/AIDS and B, which are difficult

to attribute to a single underlying cause.Te inclusion of selected combinationsof comorbidity was to assist the codersso that they would not have to select asingle cause. Whi le sim pli fyi ng thetask of coding, this would enable amore detailed analysis of such data, whichis becoming increasingly important.

All the clerks involved in codingCOD attended a training workshoporganized by the team and were trainedin the ICD concept of underlyingCOD. Te abridged classification was

introduced with access to the full ICDlist as back-up. A support system was es--tablished, with local health professionalsbecoming resource persons for difficultcases. Te list was modified on the basisof their inputs during the workshop,drawing on their extensive experience.Te workshop was also used to reiteratethe procedures for confidential handlingof the forms and the data.

Te abridged classification was im--plemented in all municipalities for thedeaths from July 2000. Access to a medi--cally qualified person to advise on morecomplicated causes of deaths was lackingin some municipalities, and this gap wasresolved by providing all the coders withaccess to a medically trained resourceperson. After a period of six weeks ofimplementation of the new code list, thecoders reported no problems.

Presentation of statistics toinform public healthTe data for calendar year 2001 were

examined and analysed.17

After basiccleaning of the data to remove duplicaterecords, 23 185 records were available foranalysis. Some evidence of underregistra--tion of deaths was observed when com--pared with the number obtained from ademographic projection. However, thecoverage for all ages was well over 90%.17Eight per cent of the deaths were attrib--utable to ill-defined causes (code 2799).

Although relatively high, the proportionis lower than the 13% for the countryas a whole.18

Tere were 619 deaths attributed toboth HIV/AIDS and B (code 1020),1088 deaths attributed to HIV/AIDS

752 deaths attributed to B (codes10111019). In accordance with ICDrules, HIV has been identified as theunderlying cause for those deaths thatare attributed to both diseases. Tesestatistics were presented separately toallow the B managers to access thisinformation.

After an initial presentation of the2001 data to health managers, it wasdecided to adopt one of the approachesin a burden of disease study and redis--tribute the ill-defined causes to specificcauses on a pro rata basis by age and sexfor the 2001 data set.19Tis facilitatesa clearer picture of the main causes ofdeath in the city that can be used toinform evaluation and planning, andclearly demonstrates that homicide wasthe most common COD in Cape own,followed by ischaemic heart disease,

HIV/AIDS, hypertensive heart diseaseand B (Fig. 1.). Te leading causes re--flect the quadruple burden that has beenobserved in South Africa with the tradi--tional double burden of infections andchronic diseases experienced in manydeveloping countries, accompanied bythe additional injury burden and that ofHIV/AIDS.

ogether with the health managers,it was also decided that a measure of pre--mature mortality would be useful to rankthe causes of death from a prevention

perspective. Te years of life lost againstan ideal life expectancy were calculatedusing the approach used by WHO in the

also decided to age standardize the rates toallow for the differences in age structureof the subdistricts and for comparativepurposes the WHO standard was selected.20

A comparison of the age-standardizedpremature mortality rates across the 11subdistricts in Cape own revealed strikingdifferences in the premature mortality

rates as well as the COD profile (Fig. 2).Injuries, causes related to poverty andHIV/AIDS feature prominently in thedistricts with large informal settlements.In contrast, noncommunicable diseasesaccount for the majority of diseases inthe more affluent subdistricts.

A full report of the data was distrib--uted to the health managers and publichealth practitioners.17Profiles for eachdistrict were compiled,21 as well as ananalysis of inequalities in health.22On

the basis of feedback, a summary reportwas compiled to give an overview of theCOD in Cape own and our interpreta--tion of the statistics.23Tis was circulated

widely. Te findings were presented toseveral management forums, includingthe health portfolio committee of theelected metropolitan council.

ConclusionA standard classification of diseases andinjury is essential for the systematiccollection and study of causes of death

a fact recognized as early as the 17thcentury.24 Te rapid appraisal of thecoding practice of a well-established

Fig. 2.Age-standardized premature mortality rates by cause group formetropolitan Cape Town and subdistricts, 2001

25 000

Yearsoflife

lost

per100

000

population

Injuries

WHO 06.20

Noncommunicable diseases

Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS)

Infectious diseases (excluding HIV/AIDS), maternal, perinatal and nutritional conditions

Athlone

20 000

15 000

10 000

5000

0

Health subdistricts

Blaauwb

ergCen

tral

Helderb

erg

Khayeli

tsha

Mitche

llsPlain

Nyanga

Oostenb

erg

SouthP

eninsula

Tygerbe

rgEast

Tygerbe

rgWest

CapeTo

wn

8/12/2019 Bradshaw 2006

5/11


abridged classification based on ICD-10and compatible with the South Africannational burden of disease list. Te list, tobe used for coding, was considered easierto apply than the full ICD-10 list andbetter matched to the quality of the cer--

tification. By creating codes for selectedcomorbidities that occur frequently,the task of coding has been simplifiedand is easier to standardize, yet allowsfor the analysis of common multipleconditions. Analysis of the data basedon the abridged list demonstrates that itis feasible to implement, and attentionto the presentation of the statistics hasenhanced access to the information byhealth planners and other stakeholders.

Te abridged list has provided apractical tool for use at district level as

demonstrated by its implementationin the adjacent health region. Withina year, the semi-rural health region ofBoland Overberg has, with limited ad--ditional resources, set up a system and for the first time ever obtained aCOD profile for the health districts inthe region.25Tis has generated interestfrom the province to extend the system

to all six health districts. While the clas--sification was designed for use in a par--ticular setting, the national public healthsurveillance requirements were kept inmind. Nonetheless, the list may requirefurther adaptation as it is adopted in

additional settings.Te quality of the COD statisticsdepends largely on the details providedby the medical practitioners. Te needto improve this information is a majorchallenge that has also been identified byBah at a national level.26Te problemis ubiquitous, even in well-resourcedsettings.27,28It is possible that, as data areseen to be used to inform policy, doctorsmight provide more details on the deathcertificate. However, there is a need for amore proactive strategy to train doctors

about the public health importance ofsuch data and how to certify accuratelythe COD. As has been pointed out previ--ously, it is important that the timing ofthe training curriculum is appropriateand that use is made of the programmeof continued professional education.29,30Efforts to develop resource materials tosupport such training are likely to have

a wide impact.Tis initiative has demonstrated that

the action research model is an extremelysuccessful approach to assess a routinehealth information system and has en--abled effective implementation of the

recommendations of the research. Suchan abridged classification is designedfor public health surveillance and maynot meet the needs of all research. Untilsuch time as the quality of certificationimproves, the abridged list could providea practical tool that is appropriate forlocal level surveillance and can be usedin other settings that have the necessaryfoundation but limited resources. O

AcknowledgementsTe health sections of the municipalities

are thanked for their participation in thestudy, and the staff who were respon--sible for coding the causes of death arethanked for their ongoing efforts to pro--vide health statistics for Cape own.

Competing interests:none declared.

Rsum

Rendre les statistiques relatives aux causes de dcs exploitables des fins de sant publique lchelledune ville, le Cap en Afrique du SudObjectiftudier la qualit du codage des statistiques relativesaux causes de dcs et valuer les besoins en matire de donnesde mortalit de la ville du Cap.Mthodes Une tude a t organise selon une dmarchede recherche pragmatique pour valuer la qualit des donnesrelatives aux causes de dcs, lexactitude de leur codage etla cohrence des procdures de codage dans les sous-districtssanitaires les plus tendus. Les besoins en matire de donnesde mortalit, ainsi que la meilleure manire de prsenter cesstatistiques pour aider les gestionnaires dans le domaine sanitaire,ont t examins.

Rsultats 75 % des certificats de dcs contenaient desinformations utiles, mais seulement 60 % environ de ces certificatsindiquaient une cause de dcs unique et certifie et 55 %des formulaires taient cods avec exactitude. Les problmesrsultaient principalement du fait que les personnes charges ducodage de mortalit de routine enregistraient sous forme codela cause immdiate du dcs au lieu de la cause sous-jacente.Une classification sommaire des causes de dcs, reposant sur

limportance de ces causes sous langle de la sant publique, surleur prvalence et sur une slection de pathologies associes, at introduite, en parallle avec une formation lidentificationdes causes sous-jacentes. Lanalyse des donnes pour lanne2001 a permis de dterminer les causes principales de dcs et demortalit prmature et a fait ressortir des diffrences frappantesentre les charges et les profils de morbidit des diffrents districtssanitaires.ConclusionLa recherche pragmatique se rvle particulirementutile pour amliorer les systmes dinformation et met en lumirela ncessit de normaliser les procdures de codage dsignant

la cause sous-jacente. Les certificats de dcs actuellementdisponibles ne permettent pas datteindre le niveau de dtail requispar la classification CIM intgrale. Lutilisation dune classificationsommaire pour le codage offre un outil pratique et adapt lasurveillance en sant publique au niveau local. Il importe de veiller ce que la prsentation des statistiques relatives aux causes dedcs permette aux dcideurs dutiliser ces donnes.

8/12/2019 Bradshaw 2006

6/11


Resumen

Estadsticas sobre las causas de defuncin: utilidad para la salud pblica a nivel local en Ciudad del CaboObjetivoExaminar la calidad de la codificacin de las estadsticassobre las causas de defuncin (CDD) y evaluar las necesidades deinformacin sobre la mortalidad en Ciudad del Cabo.

MtodosUtilizando un enfoque de investigacin-accin, se pusoen marcha un estudio para investigar la calidad de la informacinsobre las CDD, la exactitud de la codificacin de las CDD y lacoherencia de las prcticas de codificacin en los subdistritosde salud de mayor tamao. Se estudiaron las necesidades deinformacin sobre la mortalidad y la mejor manera de presentarlas estadsticas para ayudar a los administradores sanitarios.ResultadosUn 75% de los certificados de defuncin contenaninformacin til, pero en casi un 60% de los casos slo se certificabauna sola causa; el 55% de los formularios se haban codificadocon precisin. Las discordancias se deban principalmente a quelos codificadores codificaban la causa inmediata, no la subyacente.Se aplic una clasificacin abreviada de CDD, basada en causas

relevantes para la salud pblica, causas prevalentes y determinadas

combinaciones de enfermedades, con capacitacin para determinarla causa subyacente. El anlisis de los datos de 2001 permitiidentificar las causas principales de muerte y mortalidad prematura

y puso de relieve diferencias sorprendentes en la carga y ladistribucin de la morbilidad entre los subdistritos de salud.Conclusin La investigacin-accin, una alternativaparticularmente valiosa para mejorar los sistemas de informacin,revel la necesidad de normalizar las prcticas de codificacinseguidas para identificar las causas subyacentes. La especificidaddel conjunto de la clasificacin CIE supera el nivel de detallede los certificados de defuncin actualmente disponibles. Unaclasificacin abreviada de la codificacin brinda un instrumentoprctico adecuado para vigilar la salud pblica a nivel local. Esimportante prestar atencin a la presentacin de las estadsticassobre las CDD si se desea que las autoridades basen sus decisionesen datos slidos.

References

1. Paccaud F. Routine statistics: more interest is needed. J Epidemiol CommunityHealth2003;57:476-7.

2. Mathers CD, Ma Fat D, Inoue M, Rao C, Lopez AD. Counting the dead andwhat they die from: an assessment of the global status of COD data. Bull

World Health Organ2005;83:171-7.3. AbouZhar C, Boerma T. Health information systems: the foundations of publichealth. Bull World Health Organ2005;83:578-83.

4. Rao C, Bradshaw D, Mathers CD. Improving death registration and statisticsin developing countries: lessons from sub-Saharan Africa. South Afr J Demogr2004;9:79-97.

5. Botha JL, Bradshaw D. African vital statistics a black hole? S Afr Med J1985;67:977-81.

6. Bradshaw D, Dorrington RE, Sitas F. The level of mortality in South Africa in1985 what does it tell us about health? S Afr Med J1992;82:237-40.

7. International statistical classification of diseases and related health problems.Tenth revision. Vol. 1. Geneva: World Health Organization; 1992.

8. Bradshaw D, Kielkowski D, Sitas F. New birth and death registration forms a foundation for the future, a challenge for health workers? S Afr Med J1998;88:971-4.

9. Cassim MM. Vital registration infrastructure initiative. Pretoria: Departmentsof Health, Home Affairs and Statis tics South Africa. Available from: http://www.doh.gov.za/nhis/index.html

10. Dorrington RE, Bourne D, Bradshaw D, Laubscher R, Timeaeus IM. Theimpact of HIV/AIDS on adult mortality in South Africa: MRC technical report.Cape Town: Medical Research Council;2001. Available from: http://www.mrc.ac.za/bod/index.htm

11. Recorded deaths, 1996. Pretoria: Statistics South Africa;2000. Report No.03-09-10 (1996).12. Instruction manual Part 2c: ICD-10 ACME decision tables for classifying

underlying causes of death. Hyattsville (MD): US Department of Health andHuman Services, Public Health Services, National Centre for Health Statistics;2001.

13. Mortality and causes of death in South Africa, 19972003: findings fromdeath notification. Pretoria: Statistics South Africa; 2005. Statistical releaseP0309.3. Aavailable from: http://www.statssa.gov.za/publications/P03093/P03093.pdf

14. Bradshaw D, Schneider M. Vital registration and statistics in South Africa:case study metropolitan Cape Town. Technical report. Cape Town: MedicalResearch Council; 1995.

15. Meyer J. Qualitative research in health care: using qualitative methods inhealth related action research. BMJ2000;320:178-81.

16. Bradshaw D, Groenewald P, Laubscher R, Nannan N, Nojilana B, Norman R,et al. Initial burden of disease estimates for South Africa, 2000. S Afr Med J2003;93:682-8.

8/12/2019 Bradshaw 2006

7/11


17. Groenewald P, Bradshaw D, Nojilana B, Bourne D, Nixon J, Mahomed H, et al.Cape Town mortality 2001 COD and premature mortality. Part 1. MRC

technical report. Cape Town: Medical Research Council; 2003. Available from:http://www.mrc.ac.za/bod/mortalityct2001part1.pdf

18. Causes of death in South Africa, 19972001: advanced release of recordedcauses of death (P0309.2). Pretoria: Statistics South Africa;2002. Availablefrom: http://www.statssa.gov.za/publications/P03092/P030922001.pdf

19. Murray CJL, Lopez AD, editors.The global burden of disease: a comprehensive

assessment of mortality and disability from diseases, injuries and risk factors

in 1990 and projected to 2020. Cambridge (MA): Harvard School of PublicHealth on behalf of the World Health Organization and the World Bank;1996. Global Burden of Disease and Injury Series, Vol. 1.

20. Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJL, Lozano R, Inoue M.Age standardization of rates: a new WHO standard. Geneva: World HealthOrganization;2005. GPE Discussion Paper Series, No. 31;available from:http://www3.who.int/whosis/discussion_papers/pdf/paper31.pdf

21. Groenewald P, Bradshaw D, Nojilana B, Bourne D, Nixon J, Mahomed H, et al.Cape Town mortality 2001. COD profiles for each subdistrict. Part 3. MRC

technical report. Cape Town: Medical Research Council;2003. Available from:http://www.mrc.ac.za/bod/mortalityct2001part3.pdf

22. Scott V, Sanders D, Reagan G, Groenewald P, Bradshaw D, Nojilana B, et al.An equity lens lessons and challenges. Part 2. MRC technical report. Cape

Town: Medical Research Council;2003. Available from: http://www.mrc.ac.za/bod/mortalityct2001part2.pdf

23. Groenewald P, Bradshaw D, Nojilana B, Bourne D, Nixon J, Mahomed H,et al. Cape Town mortality 2001. COD in Cape Town key findings. MRCpolicy brief. Cape Town: Medical Research Council;2004. Available from:http://www.mrc.ac.za/bod/ctmortalitysummaryreport.pdf

24. Application of the international classification of diseases to neurology. 2nded. Geneva: World Health Organization; 1997.

25. Groenewald P, van Niekerk M, Jefferies D, van der Merwe W.COD and prematuremortality in the Boland Overberg region 2004

. Worcester: Boland OverbergRegional Health Office, Provincial Administration of Western Cape; 2005.26. Bah S. A note on the quality of medical certification of deaths in South

Africa. S Afr Med J2003;93:239.27. Myers KA, Farquhar DR. Improving the accuracy of death certification. CMAJ

1998;158:1317-23.28. Pritt BS, Hardin NJ, Richmond JA, Shapiro SL. Death certification errors at an

academic institution. Arch Pathol Lab Med2005;129:1276-9.29. Kielkowski D, Steinberg M, Barron PM. Life after death Mortality statistics

and the public health. S Afr Med J1989;76:672-5.30. Bradshaw D, Kielkowski D, Sitas F. New birth and death registration forms

A foundation for the future, a challenge for health workers? S Afr Med J1998;88:971-4.

8/12/2019 Bradshaw 2006

8/11


Table 2. Cape metropole mortality short list: June 2005(Deaths due to notifiable conditions should be followed up through thenotification system)

Code Disease or condition Comment

Certain infectious and parasitic diseases

1001 Diarrhoea and gastroenteritis, presumed infectious1002 Schistosomiasis/Bilharzia1009 Other intestinal infectious diseases Includes typhoid, salmonella, shigellosis1011 Pulmonary tuberculosis1013 Tubercular meningitis1019 Other TBa Includes pleural effusion1020 HIV/AIDSband TB1021 HIV/AIDS and other infectious disease Includes pneumonia with HIV/AIDS and pneumocystis carinii pneumonia1022 HIV/AIDS and cancer Includes Karposis sarcoma, lymphoma with HIV/AIDS1023 HIV/AIDS and other chronic disease1024 HIV/AIDS1030 Malaria1040 Meningococcal infection Includes meningococcal septicaemia and meningococcal meningitis

1050 Septicaemia1099 Other infectious and parasitic diseases Includes measles, hepatitis

Neoplasms

1101 Malignant neoplasm of the oesophagus1102 Malignant neoplasm of the stomach1103 Malignant neoplasm of colon, rectum and anus1104 Malignant neoplasm of liver and intrahepatic

bile ducts1105 Malignant neoplasm of pancreas1110 Malignant neoplasms of the trachea, bronchus

and lung1120 Malignant melanoma of skin

1130 Malignant neoplasm of breast1131 Malignant neoplasm of cervix uteri1132 Malignant neoplasm of ovary1140 Malignant neoplasm of prostate1141 Malignant neoplasm of bladder1150 Malignant neoplasm of meninges, brain and other

parts of central nervous system1160 Leukaemia1169 Other malignant neoplasm of lymphatic and Includes Hodgkins lymphoma, non-Hodgkins lymphoma,

haematopoeitic system multiple myeloma1170 Malignant neoplasm of kidney1190 Remainder malignant neoplasms Includes primary site unknown1195 Benign neoplasms

1199 Other neoplasms not classified elsewhere

Diseases of blood and blood forming organs and certaindisorders involving the immune mechanism (excludes HIV)

1299 Anaemias and other diseases of bloodand bloodforming organs

Endocrine, nutritional and metabolic diseases

1301 Diabetes mellitus Includes with septicaemia and/or renal and/or heart failure but withoutstroke/CVAcor ischaemic heart disease

1303 Diabetes and stroke/CVA With stroke/CVA no mention of IHD,dwith or without hypertension1304 Diabetes and ischaemic heart disease With myocardial infarction, no mention of stroke, with or without

hypertension1305 Diabetes mellitus and stroke/CVA and IHD With stroke and myocardial infarction, with or without hypertension1310 Malnutrition Includes kwashiorkor, marasmus1399 Remainder of endocrine, nutritional and metabolic

disorders

8/12/2019 Bradshaw 2006

9/11



Mental and behavioural disorders

1401 Mental and behavioural disorders due to substance Includes alcoholismabuse

1499 Remainder of mental and behavioural disorders

Diseases of the nervous system

1501 Meningitis Excludes TB and meningococcal meningitis1510 Alzheimers disease1520 Parkinsons disease1530 Epilepsy1599 Remainder of diseases of nervous system

Diseases of the eye and adnexa

1699 Diseases of the eye and adnexa

Diseases of the ear and mastoid process

1799 Diseases of the ear and mastoid process

Diseases of the circulatory system1801 Acute rheumatic fever and chronic rheumatic heart

disease1810 Hypertensive disease Includes hypertension with heart failure or renal failure1830 Ischaemic heart disease Includes myocardial infarction, atherosclerosis, coronary heart disease,

angina with or without hypertension1840 Heart failure1850 Pulmonary heart and circulatory disease Includes pulmonary embolism1869 Other heart disease Includes cardiomyopathy1870 Cerebrovascular diseases Includes stroke/CVA/intracerebral haemorrhage/bleeding with or

without hypertension1899 Remainder of the diseases of circulatory system

Diseases of the respiratory system

1901 Pneumonia Excludes pneumocystis carinii pneumonia1910 Bronchitis Includes chronic and acute1920 Chronic obstructive airways disease1930 Asthma1940 Emphysema1950 Respiratory failure1999 Other diseases of the respiratory system

Diseases of the digestive system

2001 Gastric and duodenal ulcer2010 Cirrhosis of the liver2020 Diseases of liver2030 Diseases of the pancreas

2040 Diseases of the oesophagus2050 Appendicitis, abdominal hernia, cholecystitis/

cholelithiasis2099 Remainder of diseases of the digestive system

Diseases of the skin and subcutaneous tissue

2199 Diseases of the skin and subcutaneous tissue

Diseases of the musculoskeletal system and connective tissue

2299 Diseases of the musculoskeletal system andconnective tissue

Diseases of the genitourinary system

2301 Renal failure

2399 Remainder of diseases of the genitourinary systemPregnancy, childbirth and the puerperium

2499 Pregnancy childbirth and the puerperium All maternal related deaths

(Table 2, cont.)

8/12/2019 Bradshaw 2006

10/11



Certain conditions originating in the perinatal period

2501 Short gestation and low birthweight2510 Respiratory distress syndrome Includes hyaline membrane disease2520 Infections in the perinatal period Excludes HIV2599 Other perinatal conditions not elsewhere classified

Congenital malformations, deformations andchromosomal abnormalities

2699 Congenital malformations, deformations andchromosomal abnormalities

Symptoms, signs and abnormal clinical and laboratoryfindings not elsewhere classified

2799 Symptoms, signs and abnormal clinical and laboratory Includes senility, sudden death, natural causes cot death / SIDSfindings not elsewhere classified

External causes of morbidity and mortality

2801 Motor vehicle accidents involving pedestrians

2809 Motor vehicle accidents other2810 Railway2829 Other transport2830 Accidental drowning2840 Exposure to smoke, fire or flames or explosion Excludes homicide2850 Suicide/intentional self-harm2860 Assault by firearm2861 Assault by sharp object2869 Assault by other/unspecified2880 Iatrogenic/misadventures during surgical and

medical care2890 Injury unspecified means, undetermined cause Includes unnatural death2899 Other external causes Includes falls, undetermined at autopsy

aTB = tuberculosis.b HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome.c CVA = cerebral vascular accident.d IHD = Ischemic heart disease.

(Table 2, cont.)

8/12/2019 Bradshaw 2006

11/11

bradshaw 2006

Documents