Evaluation of the quality of mortality information by unspecified accidents and events of undetermined intent]

INTRODUCTION: Mortality data are important for monitoring violence, making it possible to assess the trends and the impact of interventions towards its reduction. The objective of the study is to assess the quality of the filling out and codification of the death certificates for unspecified accidents and events of undetermined intent in the city of S. Paulo in 1996. METHODS: Death certificates on which the underlying cause of death (UCD) given was an unspecified accident (ICD-10 X59) or an event of undetermined intent (ICD-10 Y10-Y34) were selected for investigation at the Legal Medicine Institute (IML). After consulting the police reports which accompany the corpses to the IML, the autopsy reports and other legal forms, these were analysed and the UCD was recoded. RESULTS: For unspecified accidents, 53.2% were changed to a specified cause: 15.1% due to pedestrians injured in traffic accidents, 17.5% due to other traffic accidents and 14.5% due to falls. Homicides and suicides constituted 9.8%. In 20.9% no additional information was found. For events of undetermined intent, 2/3 had no clarification; in 1/3 of the cases, the underlying cause changed to falls (10.6%), homicides (7.5%) and pedestrians injured in transport accidents (6. 7%). CONCLUSIONS: The quality of mortality information by external causes in the City of S. Paulo is not satisfactory. The IML has not used all the available information to fill out the death certificates. The findings reveal that the instruction of the World Health Organization and the Brazilian Center for the Classification of Diseases to codify as accidents those events for which there is no information on the death certificate about the external cause, does not seem to be appropriate. In that category 66.0% of the deaths were found to have been inferred incorrectly as accidental. The improvement of the quality of mortality data due to external causes may contribute to the monitoring of violence and may give support to decisions leading to its reduction whatever the form that violence may take.     

Underlying cause of death from external causes: validation of official data in Recife, Pernambuco, Brazil]

OBJECTIVE: To validate the underlying cause of death recorded on the death certificates for individuals under 20 years of age who died from external causes in 1995 in Recife, Pernambuco, Brazil. METHODS: We divided the study into two stages, coding and validation. In both stages we compared the official data concerning causes of death to the data we obtained during our study. We grouped the death certificates into 5 broad categories according to the cause of death; we later subdivided them into 14 categories. We also individually compared the death certificates applying the four-digit system of the International Classification of Diseases, Ninth Revision (ICD-9). We assessed the agreement between the official data and our data in terms of sensitivity and the kappa coefficient. We took as the standard the categorization of the cause of death that we had made during our investigation. RESULTS: In the coding stage, considering all the external causes of death, the overall agreement between the official data and our study data was 94% for the 5 categories, 92% for the 14 categories, and 81% for the four-digit ICD-9 system. In the validation stage the overall agreement was 94% for the 5 categories, 91% for the 14 categories, and 73% for the four-digit ICD-9 system. CONCLUSIONS: Our results suggest that for the death certificates to be reliable, the Institute of Legal Medicine must fill them out following recommended standards. In addition, hospitals and police departments must use greater care in completing the transfer slips that accompany the bodies that are sent to the Institute. More accurate data need to be generated and disseminated for a society to better understand its patterns of violence.     

Apgar score associated with mode of delivery in São Paulo State, Brazil

This paper analyzes Apgar score associated with mode of delivery for live births in S?o Paulo State, Brazil, 2003. Based on data from the State Data Analysis System Foundation (SEADE), logistic regression was analyzed for live births with low Apgar score (0 to 6) at the fifth minute of life per mode of delivery, adjusted for obstetric, demographic, and social factors. Birth weight, gestational age at delivery, number of prenatal visits, maternal age, marital status, and years of schooling were statistically significant, and (as expected) all exposure categories were associated with low Apgar score. In the unadjusted model, the odds ratio (OR) for low Apgar was 0.890 (95%CI: 0.836-0.948) for cesarean section compared to vaginal delivery. Nevertheless, in the adjusted model the OR was 1.045 (95%CI: 0.977-1.117) for cesarean section compared to vaginal delivery. Adjusted for obstetric, demographic, and social factors, mode of delivery was not statistically significant for low Apgar.     

Forty years of increasing suicide mortality in Poland: Undercounting amidst a hanging epidemic?

ABSTRACT: BACKGROUND: Suicide rate trends for Poland, one of the most populous countries in Europe, are not well documented. Moreover, the quality of the official Polish suicide statistics is unknown and requires in-depth investigation. METHODS: Population and mortality data disaggregated by sex, age, manner, and cause were obtained from the Polish Central Statistics Office for the period 1970-2009. Suicides and deaths categorized as 'undetermined injury intent,' 'unknown causes,' and 'unintentional poisonings' were analyzed to estimate the reliability and sensitivity of suicide certification in Poland over three periods covered by ICD-8, ICD-9 and ICD-10, respectively. Time trends were assessed by the Spearman test for trend. RESULTS: The official suicide rate increased by 51.3% in Poland between 1970 and 2009. There was an increasing excess suicide rate for males, culminating in a male-to-female ratio of 7:1. The dominant method, hanging, comprised 90% of all suicides by 2009. Factoring in deaths of undetermined intent only, estimated sensitivity of suicide certification was 77% overall, but lower for females than males. Not increasing linearly with age, the suicide rate peaked at ages 40-54 years. CONCLUSION: The suicide rate is increasing in Poland, which calls for a national prevention initiative. Hangings are the predominant suicide method based on official registration. However, suicide among females appears grossly underestimated given their lower estimated sensitivity of suicide certification, greater use of "soft" suicide methods, and the very high 7:1 male-to-female rate ratio. Changes in the ICD classification system resulted in a temporary suicide data blackout in 1980-1982, and significant modifications of the death categories of senility and unknown causes, after 1997, suggest the need for data quality surveillance.     

Preventing type 2 diabetes mellitus in Qatar by reducing obesity,smoking, and physical inactivity: mathematical modeling analyses

Cause of death statistics are an important tool for quality control of the health care system. Their reliability, however, is controversial. Comparing death certificates with their corresponding medical records is implemented only occasionally but may point to quality problems. We aimed at exploring the agreement between information in the cause of death statistics and hospital discharge diagnoses at death. Selection of disease categories was based on ICD-10 Tabulation List for Morbidity and ICD-10 Mortality Tabulation List 2. Index cases were defined as deaths having occurred among Swiss residents 2010–2012 in a hospital and successfully linked to the Swiss National Cohort. Rare, external and ill-defined causes were excluded from comparison, leaving 53,605 deaths from vital statistics and 47,311 deaths from hospital discharge statistics. For 95% of individuals, respective information from the 2000 census could be retrieved and used for multiple logistic regression. For 83% of individuals the underlying cause of death could be traced among hospital diagnoses and for 77% the principal hospital diagnosis among the cause of death information. Mirroring different evaluation of complex situations by individual physicians, rates of agreement varied widely depending on disease/cause of death, but were generally in line with similar studies. Multiple logistic regression revealed however significant variation in reporting that could not entirely be explained by age or cause of death of the deceased suggesting differential exploitation of available diagnosis information. Substantial regional variation and lower agreement rates among socially disadvantaged groups like single, less educated, or culturally less integrated persons suggest potential for improving reporting of diagnoses and causes of death by physicians in Switzerland. Studies of this kind should be regularly conducted as a quality monitoring.     

On the influence of data source in aggregated data studies: a comparative study of suicide information based on death certificates and judicial files.

STUDY OBJECTIVE--The aim was to assess the differences in suicide data obtained from different database sources. DESIGN--Death certificate based data on suicidal deaths were compared with the information obtained from the non-natural death investigation files at the Public Prosecutor's Office. SETTING--The study was confined to the time period of 1981-1984 and to the residents of the district of Leuven (Belgium) who died in the district. MAIN RESULTS--Differences were found in the number of suicidal deaths reported as well as in the demographic variables, the distribution of suicide methods, and the place of death. Sixty percent of the records in both databases could be matched for all variables studied (age, gender, civil state, place of death, and suicide method), and another 10% if only place of death was allowed to differ. For 4.5% of the cases in the judicial files and for 8% of the records in the official statistics database no corresponding record from the other data source could be found. Based on simple probability statistics [P(missing record)+P(different information[present)] the possible minimum global information bias could be estimated to range from 7 to 42%. CONCLUSIONS--Different epidemiological pictures of suicide mortality may result from studying different data sources.     

Social vulnerability and health status: a household survey in the central area of a Brazilian metropolis

The self-rated health in a sample of adults living in the central area of S?o Paulo, Brazil, was studied by comparing a group of residents in census tracts without social vulnerability, identified using an indicator developed by the SEADE Foundation, and a group of residents in census tracts with middle, high or very high social vulnerability. Subject age and sex were used as control variables while family income, education level, degree of happiness, adequacy of income, satisfaction with the neighborhood and sense of discrimination were the intervening variables selected. After adjustment in the hierarchical model the self-rated health status was inversely associated with social vulnerability, age and sense of discrimination, and directly related to income, education level and degree of happiness. Satisfaction with the neighborhood and adequacy of income lose significance after adjustment. The degree of happiness is the variable with the greatest strength of association with health status even after controlling for other variables.     

Chickenpox-related mortality trends in the state of S?o Paulo, Brazil, 1985-2004: a multiple cause approach]

OBJECTIVE: To study mortality trends related to chickenpox, as either the underlying or associated cause-of-death (recorded in any field of the medical section of the death certificate), in S?o Paulo, Brazil. METHODS: Mortality data for 1985-2004 were obtained from the multiple cause-of-death database maintained by the S?o Paulo State Data Analysis System (SEADE). Causes-of-death were processed using the Multiple-Causes-of-Death Tabulator. RESULTS: During this 20-year period, chickenpox was identified as the underlying cause-of-death in 1 037 deaths and an associated cause in 150. The mortality coefficients were higher for chickenpox as the underlying, as opposed to the associated cause, and these declined in the analyzed period; whereas a slight increase was observed in mortality due to chickenpox as an associated cause. Seventy-six percent of the deaths were of children under 10 years of age, with the highest incidence among those under 1 year. Most deaths occurred from July to January (86.8% of 1 187 deaths), with a peak in October. In the state's capital city, the mortality coefficients for chickenpox as underlying cause and as associated cause were 47% and 50% higher, respectively, than in the rest of the state. Where chickenpox was identified as the underlying cause, pneumonias and septicemias were the major associated causes; where it was the associated cause, AIDS or neoplasia were most often the underlying cause. CONCLUSIONS: Although chickenpox as the underlying cause-of-death has declined, the present study indicates that certain groups are at risk of chickenpox-related mortality, namely children 1-4 years of age and individuals with AIDS or neoplasia.     

Einblicke in die Datenlage zur Kindesvernachlässigung und Kindesmisshandlung in Deutschland

The present database concerning the extent of neglect and abuse of children in Germany and accordingly the endangerment of their health and well-being has to be considered as deficient. Yet the degree of danger is indicated by sporadic empirical research as well as the police statistics on criminality, the health statistics and the official statistics on child and youth welfare. In contrast to the general public opinion the analyses of the available data have shown a stagnation in the infanticide rate at a historically low level and even a decline in infanticide in recent years. Meanwhile, according to statistics the sensitivity to the threats of neglect and abuse of children is increasing. Especially the clarification of the order for protection in the Child and Youth Welfare Act (§ 8a SGB VIII) contributed to the raised interest and attention from child and youth welfare services. However, these contexts are insufficiently researched, which makes an improvement of the database inevitable. Therefore, a continuous registration and documentation of cases of child neglect and abuse is necessary. A promising option to attain a significant database is a routine collection of data in the context of an official statistic by the child and youth welfare departments.     

Status of cardiovascular disease in Puerto Rico

For the last 40 years diseases of the heart has ranked as the primary cause of death in Puerto Rico, being cancer the second. In the National Vital Statistics of the Department of Health of Puerto Rico for the year 2002, cancer is listed as the main cause of death and diseases of the heart ranks as the second most frequent. This unexpected change is mainly due a new classification by ICD-10, that now substitutes ICD-9, in association to a change introduced by using the 2000 population census rather than the 1990 census used until 1999. Additional relevant information concerning life expectancy at birth, death by specific causes in the last 5 years and statistics about invasive surgical and medical services rendered to cardiovascular patients in the year 2003 are included. A summary of the situation concerning postgraduate training programs in Puerto Rico in different cardiovascular subspecialties is also included.     

Inpatient care quality: analyzing Swedish hospitals with stroke as a tracer

Mortality statistics are an important source of information concerning variations in time and place, identification of risk factors and the evaluation of treatment programs. In this study, a new death certificate was completed "blind" on the basis of hospital records from the last episode of care, across a random sample of 1,376 cases. The results showed that the overlap between the official register's underlying cause of death and that of a panel was 72 per cent at the three-digit level. The official underlying cause of death from cerebrovascular diseases (CVD) was 72 cases in this sample, while 93 were deemed to have CVD by a panel. Additionally, of the 1,233 cases originally reported as non-CVD, the panel deemed non-CVD to be the true underlying cause in 1,176 cases. The paper concludes that CVD was most often correctly reported as the underlying cause of death in the investigated ages up to 75 years but plain differences were found between specialities and in different hospital size.     

医院就诊数据疾病诊断自动编码和分类统计工具的建立与评价

目的 建立ICD-10自动编码和分类统计软件工具,快速实现医院就诊数据疾病诊断的ICD-10编码和分类统计,并对其适用性进行客观评价。方法 采用模块化思想,使用精确匹配和正则匹配相结合的方式进行编码分析和分类统计;采用某三甲医院2015年12月份的就诊数据,以其原始ICD编码为标准进行适用性评价。结果 该软件具有数据导入、编码匹配、分类统计等业务功能,字典管理、模板管理、权限管理等管理功能;导入数据耗时38 s,完成ICD-10编码耗时456 s,完成统计报表耗时61 s;ICD编码初始成功率为83.3%,编码符合率为90.9%,分类统计结果准确率为100%。结论 本研究建立的疾病诊断自动编码分析工具简便、快速、准确、可行,为提高空气污染人群就诊影响等研究数据质量提供有效支持。     

Paracoccidioidomycosis-related mortality trend, state of S?o Paulo, Brazil: a study using multiple causes of death]

OBJECTIVE: To investigate mortality in which paracoccidioidomycosis appears on any line or part of the death certificate. METHOD: Mortality data for 1985-2005 were obtained from the multiple cause-of-death database maintained by the S?o Paulo State Data Analysis System (SEADE). Standardized mortality coefficients were calculated for paracoccidioidomycosis as the underlying cause-of-death and as an associated cause-of-death, as well as for the total number of times paracoccidioidomycosis was mentioned on the death certificates. RESULTS: During this 21-year period, there were 1 950 deaths related to paracoccidioidomycosis; the disease was the underlying cause-of-death in 1 164 cases (59.69%) and an associated cause-of-death in 786 (40.31%). Between 1985 and 2005 records show a 59.8% decline in the mortality coefficient due to paracoccidioidomycosis as the underlying cause and a 53.0% decline in the mortality as associated cause. The largest number of deaths occurred among men, in the older age groups, and among rural workers, with an upward trend in winter months. The main causes associated with paracoccidioidomycosis as the underlying cause-of-death were pulmonary fibrosis, chronic lower respiratory tract diseases, and pneumonias. Malignant neoplasms and AIDS were the main underlying causes when paracoccidioidomycosis was an associated cause-of-death. The decision tables had to be adapted for the automated processing of causes of death in death certificates where paracoccidioidomycosis was mentioned. CONCLUSIONS: Using the multiple cause-of-death method together with the traditional underlying cause-of-death approach provides a new angle on research aimed at broadening our understanding of the natural history of paracoccidioidomycosis.     

Mortality in childbearing-age women in Campinas, São Paulo (1985-1994)

To provide a profile of the main health problems in childbearing-age women, we studied all 3,086 death certificates from the SEADE Foundation for women from 10 to 49 years of age and residing in the municipality of Campinas, from January 1, 1985, to December 31, 1994. The primary cause of death was identified and classified according to the 10th review of the ICD. Population data were obtained from the Laboratory for Epidemiological Analyses and Research, UNICAMP. One-fourth of the deaths were cardiovascular in origin, one-fifth were from external causes, and almost 20% were due to neoplasms. Maternal mortality was the ninth cause of death. External causes predominated in the 10-to-34-year age group, as compared to cardiovascular diseases and neoplasms in the 35-to-49-year group. Most alarming were the predominance of traffic accidents among causes of death in women up to age 34 (greater than AIDS during the study period) and the high mortality rate from homicides.     

Disease classification: measuring the effect of the Tenth Revision of the International Classification of Diseases on cause-of-death data in the United States

The purpose of this paper is to describe the statistical impact of the Tenth Revision of the International Classification of Diseases (ICD-10) on cause-of-death data for the United States. ICD-10 was implemented in the U.S. effective with deaths occurring in 1999. The paper is based on cause-of-death information from a large sample of 1996 death certificates filed in the 50 States and the District of Columbia. Cause-of-death information in the sample includes underlying cause of death classified by both ICD-9 and ICD-10. Preliminary comparability ratios by cause of death presented in this paper indicate the extent of discontinuities in cause-of-death trends from 1998 to 1999 resulting from implementing ICD-10. For some leading causes (for example, septicaemia, influenza and pneumonia, Alzheimer's disease, and nephritis, nephrotic syndrome and nephrosis) the discontinuity in trend is substantial. Results of this study, although preliminary, are essential to analysing trends in mortality statistics between ICD-9 and ICD-10. In particular, the results provide a means for interpreting changes between 1998, which is the last year in which ICD-9 was used, and 1999, the year in which ICD-10 was implemented for mortality in the United States. Published in 2003 by John Wiley & Sons, Ltd.     

Comparability of cause of death between ICD-9 and ICD-10: preliminary estimates.

OBJECTIVES: This report presents preliminary results describing the effects of implementing the Tenth Revision of the International Classification of Diseases (ICD-10) on mortality statistics for selected causes of death effective with deaths occurring in the United States in 1999. The report also describes major features of the Tenth Revision (ICD-10), including changes from the Ninth Revision (ICD-9) in classification and rules for selecting underlying causes of death. Application of comparability ratios is also discussed. METHODS: The report is based on cause-of-death information from a large sample of 1996 death certificates filed in the 50 States and the District of Columbia. Cause-of-death information in the sample includes underlying cause of death classified by both ICD-9 and ICD-10. Because the data file on which comparability information is derived is incomplete, results are preliminary. RESULTS: Preliminary comparability ratios by cause of death presented in this report indicate the extent of discontinuities in cause-of-death trends from 1998 through 1999 resulting from implementing ICD-10. For some leading causes (e.g., Septicemia, Influenza and pneumonia, Alzheimer's disease, and Nephritis, nephrotic syndrome and nephrosis), the discontinuity in trend is substantial. The ranking of leading causes of death is also substantially affected for some causes of death. CONCLUSIONS: Results of this study, although preliminary, are essential to analyzing trends in mortality between ICD-9 and ICD-10. In particular, the results provide a means for interpreting changes between 1998, which is the last year in which ICD-9 was used, and 1999, the year in which ICD-10 was implemented for mortality in the United States.     

A medical cause of death validation study of adult Aboriginal deaths in the Northern Territory of Australia in 1992

Judged on the criterion of equity, premature adult Aboriginal mortality is the most serious public health problem faced in Australia today. There have been a number of published epidemiological studies that have analysed Aboriginal cause of death data, but this is the first study to formally validate such data. The study sample included all adult Aboriginal people who lived and died in the Northern Territory in 1992, excluding residents of the Alice Springs region. The appropriateness of underlying cause of death codes was assessed by a single reviewer in light of death certificates, medical records, postmortem records and interviews with key health professional informants. Data were collected on 220 deaths. 8% (17 out of 220) of deaths were classified erroneously at the ICD-9 chapter level. Errors in death certification accounted for 64% (11 out of 17) of the chapter errors and diagnostic and coding errors for 18% (3 out of 17) each. The overall impact on mortality statistics was less severe because some cross-chapter classification errors cancelled each other out. Misclassification errors aggregated mainly in chapter VII (circulatory diseases) of the ICD-9 classification which was overcounted by 3.2%, and chapter VIII (respiratory diseases) which was overcounted by 1.3%. Before correction for misclassification error, circulatory diseases were judged to cause the highest proportion of deaths, whereas after correction, respiratory diseases accounted for the highest proportion. Despite this, the overall quality of the medical cause of death statistics was of a sufficiently good standard from a public health perspective to broadly inform health policy. Future attempts to improve the validity of medical cause of death statistics for Australian Aboriginal people should focus on the education of medical practitioners about the purpose and process of death certification.     

Deaths related to lead poisoning in the United States, 1979-1998

This study was conducted to describe trends in US lead poisoning-related deaths between 1979 and 1998. The predictive value of relevant ICD-9 codes was also evaluated. Multiple cause-of-death files were searched for records containing relevant ICD-9 codes, and underlying causes and demographic characteristics were assessed. For 1979-1988, death certificates were reviewed; lead source information was abstracted and accuracy of coding was determined. An estimated 200 lead poisoning-related deaths occurred from 1979 to 1998. Most were among males (74%), Blacks (67%), adults of age >/=45 years (76%), and Southerners (70%). The death rate was significantly lower in more recent years. An alcohol-related code was a contributing cause for 28% of adults. Only three of nine ICD-9 codes for lead poisoning were highly predictive of lead poisoning-related deaths. In conclusion, lead poisoning-related death rates have dropped dramatically since earlier decades and are continuing to decline. However, the findings imply that moonshine ingestion remains a source of high-dose lead exposure in adults.     

A validation of information on occupation--data from a nested case-control study

OBJECTIVES: To evaluate the validity of information about employment obtained from self-respondents and proxies in a nested case-control study. METHODS: We interviewed 230 self-respondents and 652 proxies covering 237 cancer cases and 645 controls. Questions about employment as a bus driver, other jobs, and residence were asked. Golden standard was employment data obtained from personnel records. RESULTS: All categories of respondents tended to over-report the length of employment, and respondents aged above 70 years had significantly decreased odds ratio for disagreement between interview and company files compared with respondents below the age of 60 years. There were no significant differences in whether the respondent was a case or control as there were no differences in whether the respondent was a self-respondent or a proxy. The validity of the reported employment time was statistically independent of the interval between death and proxy contact. Compared with the self-responders, the proxies reported significantly fewer jobs and residential areas. CONCLUSIONS: In general, data obtained from cases and controls not knowing that the study was about cancer and without the interviewer's knowing who were cases and who were controls appeared good. The quality of information obtained from proxies appeared good as well. There seems to be no problem in interviewing very old people about a specific job when they are mentally prepared for it. The time interval between death and proxy contact was without importance.