burden of disease research unit cause of death statistics from vital registration debbie bradshaw...
TRANSCRIPT
Burden of Disease Research Unit
Cause of death statistics
from vital registration
Debbie Bradshaw
WHO-FIC Collaborating Centre (Under designation)
Outline of presentation
• Illustrate the public health value of cause of death statistics – City of Cape Town
• Process of collecting cause of death statistics• ascertaining the cause of death• underlying cause of death• ICD coding• cause of death statistics
• Quality of cause of death certification
Cause of death profile in Cape Town, 2004
Source: Western Cape BOD project using City of Cape Town mortality data
Age specific HIV death rates, Cape Town 2001 - 2006
HIV Males
0
50
100
150
200
0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75+
HIV Females
0
50
100
150
200
0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75+
2001
2004
2006
Source: Western Cape BOD project using City of Cape Town mortality data
Age-standardised death rates (per 100 000 population)
Cape Town, 2001 – 2006
0
20
40
60
80
100
120
2001 2002 2003 2004 2005 2006
Ischaemic heart disease Stroke
Diabetes mellitus Hypertensive heart disease
Source: Western Cape BOD project using City of Cape Town mortality data
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Kha
yelit
sha
Eas
tern
Mitc
hels
Pla
in
Klip
fon
tein
Tyg
erb
erg
We
ste
rn
Nor
ther
n
So
uth
ern
Ca
pe T
ow
n
Dea
ths
pe
r 1
00 0
00
HIV/AIDS Other Communicable/mat/peri/nutrition Non-communicable diseases Injuries
Age-standardised death rates (per 100 000 population)
by broad cause for sub-districts of Cape Town, 2006
Source: Groenewald et al, 2008
Leading causes of premature mortality, Cape Town 2006
2006
16.1
14.4
8.4
5.3
4.1
3.7
3.4
3.4
2.9
2.5
0 5 10 15 20
HIV/AIDS
Homicide
Tuberculosis
Road traffic
Lower Respiratory infections
Ischaemic heart disease
Stroke
Diabetes Mellitus
Low birth weight and RDS
Diarrhoeal Diseases
Percentage
Percentage of total Years of Life Lost
(YLLs)
Source: Western Cape BOD project using City of Cape Town mortality data
Public health importance of mortality data
• Monitor the health of the population– Leading causes of death– Mortality rates (geographic variations)– Trends over time
• Inform decisions about health policy and strategy– Prevent premature deaths– Service provision – Health budgets
• Evaluate health service outcomes
Attending doctor: • Establish diagnosis • Complete death certificate (International form – WHO)
Coding by Statistical Office:• Code causes of death (ICD code for each cause listed)• Classify cause of death (select a single underlying cause of death for
stats according to ICD selection rules)• Check validity, query
Analysis by Statistical Office:• Tabulate and disseminate data
Source: Adapted from Johansson LA, 2008
Main stages in production of cause of death statistics
G MEDICAL CERTIFICATE OF CAUSE OF DEATH Part 1 Enter the diseases, injuries or complications that caused the death. Do not enter the mode of dying, such as cardiac or respiratory arrest, shock, or heart failure. List only one cause on each line. IMMEDIATE CAUSE (a) …………………………...……… (Final disease or condition Due to, (or as a consequence of) resulting in death Sequentially list condition, if any, leading to (b) ………………………….………. immediate cause. Enter Due to, (or as a consequence of) UNDERLYING CAUSE last (c) …………………………………. Due to, (or as a consequence of) (d) ……………………………….. Part 2 Other significant conditions contributing to death but not resulting in underlying cause given in Part 1 .……………………………… __________________________________________________________________________________
Approximate interval between onset and death (Days/Months/Years) ………………. ……………….. ………………. ………………. ……………….
FOR OFFICE USE ONLY ICD-10
Immediate cause on top line
Any causal sequence with underlying cause
at the bottom
Contributing cause but not in causal sequence
in Part 2
According to ICD-10:
• The Immediate Cause is the final disease, injury or complication directly causing the death. It should be noted that the mechanism of death or terminal event (for example, cardiac arrest or respiratory arrest) is not considered to be a cause of death. The mechanism of death should not be reported as the immediate cause of death as it is a statement not specifically related to the disease process, and it merely attests to the fact of death.
• The Underlying Cause of Death is the disease or injury that started the sequence of events leading directly to death or the circumstances of the accident or violence that produced the fatal injury. In the case of a violent death, the form of external violence or accident is antecedent to the injury entered, although the two events may be almost simultaneous.
• Part II is for reporting all other significant diseases, conditions, or injuries that contributed to death but which did not result in the underlying cause of death given in Part I.
A 75-year-old female had a 15-year history of non-insulin-dependent diabetes mellitus, a 13-year history of mild hypertension treated with thiazide diuretics, and an uncomplicated myocardial infarction 6 years prior to the present illness. She was found disoriented at her home and brought to hospital. On admission she was noted to be unresponsive, without focal neurologic signs, and severely dehydrated with a blood pressure of 90/60. Initial laboratory tests disclosed severe hyperglycemia, hyperosmolarity, azotemia, and mild ketosis without acidosis. A diagnosis of hyperosmolar nonketotic coma was made. The patient was treated with fluids, electrolytes, insulin and broad-spread antibiotics. Within 72 hours, the patient’s hypersomolar, hyperglycemic state was resolved. However, she remained anuric with progressive azotemia. The patient died on the 8th hospital day in severe renal failure.
G MEDICAL CERTIFICATE OF CAUSE OF DEATH Part 1 Enter the diseases, injuries or complications that caused the death. Do not enter the mode of dying, such as cardiac or respiratory arrest, shock, or heart failure. List only one cause on each line. IMMEDIATE CAUSE (a) …………………………...……… (Final disease or condition Due to, (or as a consequence of) resulting in death Sequentially list condition, if any, leading to (b) ………………………….………. immediate cause. Enter Due to, (or as a consequence of) UNDERLYING CAUSE last (c) …………………………………. Due to, (or as a consequence of) (d) ……………………………….. Part 2 Other significant conditions contributing to death but not resulting in underlying cause given in Part 1 .……………………………… __________________________________________________________________________________
Approximate interval between onset and death (Days/Months/Years) ………………. ……………….. ………………. ………………. ……………….
FOR OFFICE USE ONLY ICD-10
Acute renal failure
Hyperosmolar nonketotic coma
Diabetes mellitus, non-insulin dependent
Hypertension, Previous myocardial infarction
5 Days
8 Days
15 Years
Female aged 77 years, stumbled and fell over while cleaning the house and sustained a fracture of the neck of the left femur. She had an operation for insertion of a pin the following day. Four weeks later her condition deteriorated, she developed hypostatic pneumonia and died two days later.
G MEDICAL CERTIFICATE OF CAUSE OF DEATH Part 1 Enter the diseases, injuries or complications that caused the death. Do not enter the mode of dying, such as cardiac or respiratory arrest, shock, or heart failure. List only one cause on each line. IMMEDIATE CAUSE (a) …………………………...……… (Final disease or condition Due to, (or as a consequence of) resulting in death Sequentially list condition, if any, leading to (b) ………………………….………. immediate cause. Enter Due to, (or as a consequence of) UNDERLYING CAUSE last (c) …………………………………. Due to, (or as a consequence of) (d) ……………………………….. Part 2 Other significant conditions contributing to death but not resulting in underlying cause given in Part 1 .……………………………… __________________________________________________________________________________
Approximate interval between onset and death (Days/Months/Years) ………………. ……………….. ………………. ………………. ……………….
FOR OFFICE USE ONLY ICD-10
Terminal Hypostatic Pneumonia
Fractured Left Neck of Femur
Accidental fall while cleaning at home
2 Days
4 weeks
4 weeks
G MEDICAL CERTIFICATE OF CAUSE OF DEATH Part 1 Enter the diseases, injuries or complications that caused the death. Do not enter the mode of dying, such as cardiac or respiratory arrest, shock, or heart failure. List only one cause on each line. IMMEDIATE CAUSE (a) …………………………...……… (Final disease or condition Due to, (or as a consequence of) resulting in death Sequentially list condition, if any, leading to (b) ………………………….………. immediate cause. Enter Due to, (or as a consequence of) UNDERLYING CAUSE last (c) …………………………………. Due to, (or as a consequence of) (d) ……………………………….. Part 2 Other significant conditions contributing to death but not resulting in underlying cause given in Part 1 .……………………………… __________________________________________________________________________________
Approximate interval between onset and death (Days/Months/Years) ………………. ……………….. ………………. ………………. ……………….
FOR OFFICE USE ONLY ICD-10
Cancer
Diabetes
G MEDICAL CERTIFICATE OF CAUSE OF DEATH Part 1 Enter the diseases, injuries or complications that caused the death. Do not enter the mode of dying, such as cardiac or respiratory arrest, shock, or heart failure. List only one cause on each line. IMMEDIATE CAUSE (a) …………………………...……… (Final disease or condition Due to, (or as a consequence of) resulting in death Sequentially list condition, if any, leading to (b) ………………………….………. immediate cause. Enter Due to, (or as a consequence of) UNDERLYING CAUSE last (c) …………………………………. Due to, (or as a consequence of) (d) ……………………………….. Part 2 Other significant conditions contributing to death but not resulting in underlying cause given in Part 1 .……………………………… __________________________________________________________________________________
Approximate interval between onset and death (Days/Months/Years) ………………. ……………….. ………………. ………………. ……………….
FOR OFFICE USE ONLY ICD-10
Stroke
Pneumonia
G MEDICAL CERTIFICATE OF CAUSE OF DEATH Part 1 Enter the diseases, injuries or complications that caused the death. Do not enter the mode of dying, such as cardiac or respiratory arrest, shock, or heart failure. List only one cause on each line. IMMEDIATE CAUSE (a) …………………………...……… (Final disease or condition Due to, (or as a consequence of) resulting in death Sequentially list condition, if any, leading to (b) ………………………….………. immediate cause. Enter Due to, (or as a consequence of) UNDERLYING CAUSE last (c) …………………………………. Due to, (or as a consequence of) (d) ……………………………….. Part 2 Other significant conditions contributing to death but not resulting in underlying cause given in Part 1 .……………………………… __________________________________________________________________________________
Approximate interval between onset and death (Days/Months/Years) ………………. ……………….. ………………. ………………. ……………….
FOR OFFICE USE ONLY ICD-10
Cardiac arrest
Terminology that should be avoided
• Ill-defined / non-specific conditions– Old age– Headache– “Natural causes”
• Mechanisms of death– Heart failure– Kidney failure– Dehydration– Hypoxia– Sepsis
Things that should not be on the certificate
• Abbreviations– DM II– MI– MS– HONK
• Stories– The patient presented three days ago with severe
abdominal pain, but the family says it’s been going on for a long time. At surgery extensive peritoneal sepsis of unknown cause was found.
In the case of Human Immunodeficiency Virus
– Check hospital notes for HIV-tests or treatment
– Underlying COD: Human immunodeficiency virus– Intermediate COD: Acquired Immunodeficiency syndrome– Immediate COD: Tuberculosis / Cryptococcal Meningitis, etc.
Processing information from the medical certificate
• Code each cause according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10)
• Apply ICD-10 rules to establish the Underlying cause of death
• Check the validity of the information – and query or correct
• Check consistency of data eg prostate cancer for female
ICD – 10
A00 CholeraA00.0 Cholera due to Vibrio cholerae 01, biovar choleraeA00.1 Cholera due to Vibrio cholerae 01, biovar eltorA00.9 Cholera, unspecified
Z99 Dependence on enabling machines and devices, not elsewhere classifiedZ99.0 Dependence on aspiratorZ99.1 Dependence on respiratorZ99.2 Dependence on renal dialysisZ99.3 Dependence on wheelchairZ99.8 Dependence on other enabling machines and devicesZ99.9 Dependence on unspecified enabling machine and device
ICD – 10 ChaptersA00 – B99 Certain infectious and parasitic diseasesC00 – D48 NeoplasmsD50 – D89 Diseases of the blood and immune mechanismE00 – E90 Endocrine, nutritional and metabolic disordersF00 – F99 Mental and behavioural disordersG00 – G99 Diseases of the nervous systemH00 – H59 Diseases of the eye and adnexaH60 – H95 Diseases of the ear and mastoid processI00 – I99 Diseases of the circulatory J00 – J99 Diseases of the respiratory diseasesK00 – K93 Diseases of the digestive systemL00 – L99 Diseases of the skin and subcutaneous tissueM00 – M99 Diseases of the musculoskeletal system N00 – N99 Diseases of the genitourinary systemO00 – O99 Pregnancy, children and puerperiumP00 – P99 Perinatal conditionsQ00 – Q99 Congenital malformationsR00 – R99 Symptoms and signs not elsewhere definedS00 – T99 Nature of injuryV01 – Y98 External causes of morbidity and mortalityZ00 – Z99 Reasons for encounter with health service
Problems with cause of death statistics
Errors can occur at all stages of production:– Diagnosis – Death certification
• Errors (mechanism of death/no UC, competing causes, incorrect sequence)
• Insufficient information
– Coding – Classification (incorrect or inconsistent application of ICD selection rules)
– Analysis
TB - male
0
100
200
300
400
500
600
7000
5-9
15-1
9
25-2
9
35-3
9
45-4
9
55-5
9
65-6
9
75-7
9
85+
1996
2000/01 sample
TB - female
0
50
100
150
200
250
300
0
5-9
15-1
9
25-2
9
35-3
9
45-4
9
55-5
9
65-6
9
75-7
9
85+
1996
2000/01 sample
HIV - males
0
200
400
600
800
1000
0
5-9
15-1
9
25-2
9
35-3
9
45-4
9
55-5
9
65-6
9
75-7
9
85+
1996
2000/01 sample
HIV - females
0
200
400
600
800
1000
0
5-9
15-1
9
25-2
9
35-3
9
45-4
9
55-5
9
65-6
9
75-7
9
85+
1996
2000/01 sample
HIV - males
0
200
400
600
800
1000
0
5-9
15-1
9
25-2
9
35-3
9
45-4
9
55-5
9
65-6
9
75-7
9
85+
1996
2000/01 sample
HIV - females
0
200
400
600
800
1000
0
5-9
15-1
9
25-2
9
35-3
9
45-4
9
55-5
9
65-6
9
75-7
9
85+
1996
2000/01 sample
Source: Groenewald et al, 2005
Death certification quality in Cape Winelands and Overberg:
Percentage ill-defined causes of death by sub-district
0
5
10
15
20
25
30
Per
cen
tag
e
2004 26 10 7 14 12 15 10
2005 27 10 7 12 8 14 7
2006 20 13 9 9 17 13 10 10 10
Breede River Winelands
Breede Valey Drakenstein Stellenbosch Witzenberg Cape Agulhas Overstrand Swellen Theewaters
Review of certificates in Vangaurd: Major errors
• Incorrect sequencing in Part 1
• Competing causes of death in Part 1
• Lack of a proper underlying cause of death
• A mechanism of death, without an underlying cause of death
• One or more major errors in DNF
28.7%
15.3%
14.8%
13.5%
43.4%
Source: Burger et al., 2007
Review of certificates in Vangaurd : Minor errors
• Absence of a time estimate between onset of disease and death
• Use of abbreviations
• Recording of inappropriate information
• Illegible handwriting
• One or more minor errors in DNF
81.5%
23.7%
13.0%
2.5%
86.1%Source: Burger et al., 2007
Characteristic OR 95% CI p-value
Sex 0.8017
Male 1.0 -
Female 1.0 0.8-1.4
Age 0.1260
Neonates 1.0 -
1 mth – 4 yrs 1.4 0.1-21.4
5-14 2.5 0.1-122.3
15-24 7.3 0.3-203.4
25-34 3.2 0.1-78.7
35-44 4.5 0.2-108.7
45-54 5.3 0.2-124.9
55-64 3.8 0.2-90.4
65-74 6.2 0.3-147.3
75+ 7.0 0.3-168.0
Serious major errors and associated factors, Academic Hospital in Cape Town
Characteristic OR 95% CI p-value
Department 0.5375
Casualty 1.0 -
Medical general 1.8 1.2-2.8
Medical specialised 2.0 1.2-3,2
Surgical 1.4 0.9-2.2
Neonates 3.3 0.2-62.8
Cause of death<0.00
1
Neoplasms 1.0 -
Circulatory 3.4 2.1-5.5
Infectious/parasitic 4.3 2.3-8.0
Respiratory 4.7 2.5-9.0
Endocrine/nutrtional/metab
17.2 8.7-34.0
Digestive 6.3 3.1-12.9
Perinatal conditions 3.4 0.8-15.0
Genitourinary 17.
3 7.8-38.2
Other 5.8 2.9-11.5
Source: Nojilana et al., 2008
not recorded on death certificate
recorded on death certificate
Tested for HIV
not tested for HIV
HIV +ve
HIV -ve
recorded on death certificate
not reported on death certificate
71
33 38
6 32
15 17
Potentially HIV/AIDS related causes*
0 6
242HIV test information from medical record for sub-sample
Brief intervention for internsProportion with adequate score
N Pre-test%
Post-test%
McNemar’sp-value
Overall group 24 13 88 <0.0001
Intervention group
13 15 84 0.0027
Control group 11 9 91 0.0027
Source: Pieterse et al., 2008
http://who.int/bookorders
www.healthmetricsnetwork.org
Determinants of HealthSocio-economic and demographic factorsEnvironmental and behavioural risk factors
Service seeking behaviours
Health System Inputs Outputs OutcomesPolicy Information Coverage Financing Service Utilisation
Human resources (availability Organisation and quality)
Health status
Mortality
Morbidity/Disability
Well-being
Domains of Measurement
Source: Health Metrics Network
AcknowledgementBOD Unit and collaborators
Dr Pam GroenewaldDr Lene BurgerMs Desiree PieterseMs Beatrice Nojilana
WHO-FIC Collaborating CentreMs Lyn HanmerDr Pam GroenewaldMr Malute TshivaseMs Margie SchneiderProf Jenny JelsmaMr David BourneMe Sedick Isaacs
Local, provincial and national governmentCity of Cape TownWestern Cape Department of HealthDepartment of Home Affairs Statistics South Africa