Strengthening vital statistics in Brazil: investigation of ill-defined causes of death and implications

on mortality statistics

GPEAS Universidade Federal de Minas Gerais

Conference “Global Health Metrics and Evaluation: Data, Debates, Directions”Seattle, June 17-19 2013

Elisabeth França1, Fátima Marinho2

Lenice H Ishitani1, Renato Teixeira1, Celia L Szwarcwald3

1.Federal University of Minas Gerais, Brazil; 2. PAHO/WHO; 3. Oswaldo Cruz Foundation

GPEAS/UFMG

Introduction (1)Mortality Information System (MIS) in Brazil

. Created in 1975 by the Ministry of Heath

. Death certificate(DC): international form (ICD)

→ should be issued by the attending physician (or a coroner under suspicious conditions)

. Automatic selection program (SCB) for the underlying cause of death

. Cleaning and compilation: Municipal, States and National levels electronic data file transfer

. Available on the Internet: www.datasus.gov.br

.

Quality of causes of death data in the MIS:. North and the Northeast regions: 20%-30% of IDCD until 2003;. South and Southeast: <10%.

Political – administrative division: •5 regions•27 states•5540 municipalities

Introduction (2)

GPEAS/UFMG

Introduction (3)

• In 2005, the Brazilian government implemented a project to decrease the ill-defined causes of death (IDCD) from chapter XVIII ICD-10, mainly in states and municipalities in the poorest regions;

• In this project, deaths due to IDCD were investigated and reclassified into a defined cause;

• A question: Is cause of death distribution among IDCD similar to those of recorded data apart from injuries?

• This study aims to compare the distribution of causes of death between the investigated IDCDs and the recorded data.

GPEAS/UFMG

Investigation of IDCD in Brazil

• In the MoH project, for each death certificate with IDCD all attempts were made by health-service professionals to trace existing information about the final disease and cause of death;

• Sources of information: hospital records, municipality health departments, autopsies, family health program records, linkage between health information systems (e.g. hospital information system), and verbal autopsy questionnaires (2009-2010);

• Underlying cause of death: assigned using the available evidence.

Source: CGIAE/DASIS/SVS-MoH

Percentage of IDCD

2004

2008

2011

Reduction of deaths due to ill-defined causes, by municipalities2004, 2008 and 2011

Investigation of IDCD in Brazil –Results (1)

GPEAS/UFMG

Investigation of IDCD in Brazil –Results (2)

Proportions of ill-defined causes of death according to States. Northeast region, Brazil, 1996-2010.Ano SE AL CE Bahia Maranhão PE PI Paraíba RN1996 32.1 41.2 30.9 28.6 40.1 27.1 34.1 50.4 29.91997 33.0 38.2 28.9 27.8 39.6 24.7 32.3 51.9 29.71998 32.0 34.8 24.0 28.2 40.0 24.7 32.7 52.9 29.51999 31.7 34.4 21.9 29.9 40.7 24.6 31.4 53.5 29.52000 29.7 29.1 20.2 29.7 36.1 22.8 30.7 46.5 27.62001 26.4 28.0 21.5 26.7 39.5 21.0 29.6 45.1 28.02002 23.5 28.2 25.5 25.4 40.3 19.0 25.9 40.5 27.02003 23.8 27.2 26.1 25.7 37.4 17.7 26.2 34.9 24.92004 10.6 25.2 24.8 24.8 36.6 16.2 24.3 29.7 20.02005 9.6 13.5 19.1 25.3 16.6 10.0 22.1 15.6 8.52006 8.2 10.4 6.2 14.9 10.3 5.9 6.5 11.2 5.02007 7.2 7.0 5.1 14.1 8.1 5.3 4.3 8.2 3.62008 6.6 6.7 5.0 14.5 7.5 5.2 3.0 7.6 3.42009 7.6 8.0 5.4 14.5 6.5 5.5 3.4 8.2 3.82010 6.2 8.9 5.5 15.6 6.6 5.5 4.8 8.3 3.1

Source: MIS/MoH

GPEAS/UFMG

Investigation of IDCD in Brazil –Results (3)

Recorded deaths

n n % n % n %

2006 1,031,691 95,280 9.2 24,947 26.2 15,212 61.0

2007 1,047,824 96,078 9.2 24,649 25.7 15,997 64.9

2008 1,077,007 95,166 8.8 26,151 27.5 17,089 65.3

2009 1,103,088 94,836 8.6 26,822 28.3 17,150 63.9

2010 1,136,947 97,314 8.6 29,487 30.3 19,304 65.5

Total 5,396,557 478,674 8.9 132,056 27.6 84,751 64.2

Ill-defined causes of death (IDCD) according to investigation and reclassification. Brazil, 2006 -

2010

*Among investigated deaths

YearInvestigated IDCD Reclassified IDCD*IDCD

GPEAS/UFMG 9

GPEAS/UFMG 10

Distribution of causes of death among reclassified ill-defined conditions by regions. Brazil, 2010.

n % n % n % n % n % n %Infectious diseases 44 3.8 295 3.4 228 3.5 31 1.9 78 5.4 676 3.5Neoplasms 135 11.7 1,061 12.4 392 6.0 128 8.0 76 5.3 1,792 9.3Endocrine diseases 132 11.4 1,032 12.0 615 9.4 140 8.7 55 3.8 1,974 10.2Mental and behavioural disorders 61 5.3 486 5.7 509 7.8 131 8.1 45 3.1 1,232 6.4Diseases of the circulatory system 487 42.1 3,750 43.8 2,666 40.8 680 42.2 599 41.8 8,182 42.4Diseases of the respiratory system 89 7.7 640 7.5 442 6.8 123 7.6 232 16.2 1,526 7.9Diseases of the digestive system 52 4.5 291 3.4 229 3.5 88 5.5 168 11.7 828 4.3Diseases of the genitourinary system 9 0.8 78 0.9 73 1.1 17 1.1 17 1.2 194 1.0Maternal conditions 3 0.3 23 0.3 41 0.6 7 0.4 2 0.1 76 0.4Perinatal conditions 18 1.6 24 0.3 35 0.5 18 1.1 10 0.7 105 0.5Congenital malformations 6 0.5 23 0.3 28 0.4 9 0.6 6 0.4 72 0.4External causes 78 6.7 547 6.4 926 14.2 154 9.6 91 6.4 1,796 9.3Total 1,156 100.0 8,567 100.0 6,538 100.0 1,610 100.0 1,433 100.0 19,304 100.0

BrazilCause-of-death North Northeast Southeast South Centre-West

GPEAS/UFMG 11

GPEAS/UFMG

Investigation of ill-defined causes of death in Brazil –Results in 2010

Cause-of-death

(n) (%) n %Infectious diseases 676 3.5 48,488 4.7 0.7Neoplasms 1,792 9.3 176,402 17.0 0.5Diseases of the blood and immune system 92 0.5 6,290 0.6 0.8Endocrine diseases 1,974 10.2 67,863 6.5 1.6Mental and behavioural disorders 1,232 6.4 11,374 1.1 5.8Diseases of the nervous system 613 3.2 24,468 2.4 1.3Chapter 7 8 0 28 0 15.4Chapter 8 4 0 122 0 1.8Diseases of the circulatory system 8,182 42.4 317,674 30.6 1.4Diseases of the respiratory system 1,526 7.9 119,334 11.5 0.7Diseases of the digestive system 828 4.3 57,239 5.5 0.8Chapter 12 54 0.3 3,282 0.3 0.9Chapter 13 80 0.4 4,396 0.4 1.0Diseases of the genitourinary system 194 1.0 24,613 2.4 0.4Maternal conditions 76 0.4 1,422 0.1 2.9Perinatal conditions 105 0.5 23,723 2.3 0.2Congenital malformations 72 0.4 9,869 1.0 0.4Chapter 19 0 0 20 0 0External causes 1,796 9.3 141,360 13.6 0.7Total 19,304 100.0 1,037,967 100.0 1.0*IDCD: ill-defined causes of death**All causes apart from IDCD (n=97,314) and unclassified deaths (n=1,666)***%IDCD / %defined causes

Ratio***

Distribution of causes of death among ill-defined causes and recorded data. Brazil, 2010.IDCD investigated and reclassified*

Defined causes (DC) among recorded data**

GPEAS/UFMG

Investigation of ill-defined causes of death in Brazil –Results in 2010

Age Ratio n % n %

< 01 316 1.6 38,103 3.7 0.401-04 126 0.7 6,341 0.6 1.105-09 70 0.4 3,833 0.4 1.010-14 92 0.5 5,284 0.5 0.915-19 240 1.2 17,899 1.7 0.720-24 320 1.7 26,431 2.5 0.725-29 410 2.1 27,002 2.6 0.830-34 504 2.6 27,562 2.7 1.035-39 623 3.2 29,250 2.8 1.140-44 844 4.4 36,702 3.5 1.245-49 1,085 5.6 47,871 4.6 1.250-54 1,132 5.9 59,595 5.7 1.055-59 1,237 6.4 70,070 6.8 0.960-64 1,462 7.6 78,437 7.6 1.065-69 1,475 7.6 87,602 8.4 0.970-74 1,769 9.2 103,357 10 0.975-79 1,904 9.9 109,025 10.5 0.980-84 1,968 10.2 108,696 10.5 1.085 + 3,661 19.0 151,738 14.6 1.3Total*** 19,304 100.0 1,037,967 100.0 1.0* Ill-defined causes**Defined causes (DC)***Missing age included (n=65 for IDCD and n=3,169 for recorded data)

IDCD Recorded data (%)

Comparing age distribution among reclassified IDCD* and recorded data (DC)**. Brazil, 2010.

GPEAS/UFMG

Investigation of ill-defined causes of death in Brazil –Results in 2010

Garbage codes Recorded data (DC) Reclassified IDCD

Ill-defined circulatory codes/all circulatory diseases 6.0 7.1

Ill-defined cancer codes/all cancer 5.6 7.7

Ill-defined injury codes/all injuries 14.8 16.3

Ill-defined digestive codes/all digestive diseases 17.5 11.8

Ill-defined respiratory codes/all respiratory diseases 7.7 8.7

*Codes ICD-10 I47.2,I49.0,I46,I50,I51.4,I51.5,I51.6,I51.9,I70.9 (Cardiovascular disease)

*Codes ICD-10 C76, C80, C97 (Cancer)

*Codes ICD-10 Y10-Y34 and Y87.2 ( Injury)

*Codes ICD-10 K92, K76.9, K92.0-K92.2 (Digestive)

*Codes ICD-10 J96.9, J98 ( Respiratory)

Percentage of garbage codes* among recorded data (DC) and reclassified IDCD. Brazil, 2010.

GPEAS/UFMG

Investigation of ill-defined causes of death in Brazil Conclusion

The distribution of the cause of death after investigation of IDCD was different from those in the observed (DC) data;

There are regional differences;

In order to minimize bias, these differences must be taken into consideration when redistributing ill-defined causes;

The investigation of IDCD may provide the basis for a methodology to be used in the correction of the data and also leads to an improvement in the quality of the mortality data.