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The quality of medical death certification of cause of death in hospitals in rural Bangladesh: impact of introducing the International Form of Medical Certificate of Cause of Death.

ABSTRACT: Accurate and timely data on cause of death are critically important for guiding health programs and policies. Deaths certified by doctors are implicitly considered to be reliable and accurate, yet the quality of information provided in the international Medical Certificate of Cause of Death (MCCD) usually varies according to the personnel involved in certification, the diagnostic capacity of the hospital, and the category of hospitals. There are no published studies that have analysed how certifying doctors in Bangladesh adhere to international rules when completing the MCCD or have assessed the quality of clinical record keeping.The study took place between January 2011 and April 2014 in the Chandpur and Comilla districts of Bangladesh. We introduced the international MCCD to all study hospitals. Trained project physicians assigned an underlying cause of death, assessed the quality of the death certificate, and reported the degree of certainty of the medical records provided for a given cause. We examined the frequency of common errors in completing the MCCD, the leading causes of in-hospital deaths, and the degree of certainty in the cause of death data.The study included 4914 death certificates. 72.9% of medical records were of too poor quality to assign a cause of death, with little difference by age, hospital, and cause of death. 95.6% of death certificates did not indicate the time interval between onset and death, 31.6% required a change in sequence, 13.9% required to include a new diagnosis, 50.7% used abbreviations, 41.5% used multiple causes per line, and 33.2% used an ill-defined condition as the underlying cause of death. 99.1% of death certificates had at least one error. The leading cause of death among adults was stroke (15.8%), among children was pneumonia (31.7%), and among neonates was birth asphyxia (52.8%).Physicians in Bangladeshi hospitals had difficulties in completing the MCCD correctly. Physicians routinely made errors in death certification practices and medical record quality was poor. There is an urgent need to improve death certification practices and the quality of hospital data in Bangladesh if these data are to be useful for policy.

SUBMITTER: Hazard RH

PROVIDER: S-EPMC5625830 | biostudies-other | 2017 Oct

REPOSITORIES: biostudies-other

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The quality of medical death certification of cause of death in hospitals in rural Bangladesh: impact of introducing the International Form of Medical Certificate of Cause of Death.

Hazard Riley H RH Chowdhury Hafizur Rahman HR Adair Tim T Ansar Adnan A Quaiyum Rahman A M AM Alam Saidul S Alam Nurul N Rampatige Rasika R Streatfield Peter Kim PK Riley Ian Douglas ID Lopez Alan D AD

BMC health services research 20171002 1

<h4>Background</h4>Accurate and timely data on cause of death are critically important for guiding health programs and policies. Deaths certified by doctors are implicitly considered to be reliable and accurate, yet the quality of information provided in the international Medical Certificate of Cause of Death (MCCD) usually varies according to the personnel involved in certification, the diagnostic capacity of the hospital, and the category of hospitals. There are no published studies that have ...[more]

PMID: 28969690

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Project description:BackgroundIn Mexico, the vital registration system relies on information collected from death certificates to generate official mortality figures. Although the death certificate has high coverage across the country, there is little information regarding its validity. The objective of this study was to assess the concordance between the underlying cause of death in official statistics obtained from death certificates and a gold standard diagnosis of the same deaths derived from medical records of hospitals.MethodsThe study sample consisted of 1,589 deaths that occurred in 34 public hospitals in the Federal District and the state of Morelos, Mexico in 2009. Neonatal, child, and adult cases were selected for causes of death that included infectious diseases, noncommunicable diseases, and injuries. We compared the underlying cause of death, obtained from medical death certificates, against a gold standard diagnosis derived from a review of medical records developed by the Population Health Metrics Research Consortium. We used chance-corrected concordance and accuracy as metrics to evaluate the quality of performance of the death certificate.ResultsAnalysis considering only the underlying cause of death resulted in a median chance-corrected concordance between the cause of death in medical death certificates versus the gold standard of 54.3% (95% uncertainty interval [UI]: 52.2, 55.6) for neonates, 38.5% (37.0, 40.0) for children, and 66.5% (65.9, 66.9) for adults. The accuracy resulting from the same analysis was 0.756 (0.747, 0.769) for neonates, 0.683 (0.663, 0.701) for children, and 0.780 (0.774, 0.785) for adults. Median chance-corrected concordance and accuracy increased when considering the mention of any cause of death in the death certificate, not just the underlying cause. Concordance varied substantially depending on cause of death, and accuracy varied depending on the true cause-specific mortality fraction composition.ConclusionsAlthough we cannot generalize our conclusions to Mexico as a whole, the results demonstrate important problems with the quality of the main source of information for causes of death used by decision-makers in settings with highly technological vital registration systems. It is necessary to improve death certification procedures, especially in the case of child and neonatal deaths. This requires an important commitment from the health system and health institutions.

Project description:BackgroundCorrect certification of cause of death by physicians (i.e. completing the medical certificate of cause of death or MCCOD) and correct coding according to International Classification of Diseases (ICD) rules are essential to produce quality mortality statistics to inform health policy. Despite clear guidelines, errors in medical certification are common. This study objectively measures the impact of different medical certification errors upon the selection of the underlying cause of death.MethodsA sample of 1592 error-free MCCODs were selected from the 2017 United States multiple cause of death data. The ten most common types of errors in completing the MCCOD (according to published studies) were individually simulated on the error-free MCCODs. After each simulation, the MCCODs were coded using Iris automated mortality coding software. Chance-corrected concordance (CCC) was used to measure the impact of certification errors on the underlying cause of death. Weights for each error type and Socio-demographic Index (SDI) group (representing different mortality conditions) were calculated from the CCC and categorised (very high, high, medium and low) to describe their effect on cause of death accuracy.FindingsThe only very high impact error type was reporting an ill-defined condition as the underlying cause of death. High impact errors were found to be reporting competing causes in Part 1 [of the death certificate] and illegibility, with medium impact errors being reporting underlying cause in Part 2 [of the death certificate], incorrect or absent time intervals and reporting contributory causes in Part 1, and low impact errors comprising multiple causes per line and incorrect sequence. There was only small difference in error importance between SDI groups.ConclusionsReporting an ill-defined condition as the underlying cause of death can seriously affect the coding outcome, while other certification errors were mitigated through the correct application of mortality coding rules. Training of physicians in not reporting ill-defined conditions on the MCCOD and mortality coders in correct coding practices and using Iris should be important components of national strategies to improve cause of death data quality.

Project description:Student tutorials are now firmly anchored in medical education. However, to date there have only been isolated efforts to establish structured teacher training for peer tutors in medicine. To close this gap, a centralized tutor training program for students, culminating in an academic certificate, was implemented at Heidelberg University Medical School. The program also counts within the scope of the post-graduate Baden-Württemberg Certificate in Academic Teaching (Baden-Württemberg Zertifikat für Hochschuldidaktik).Based on a needs assessment, a modular program comprised of four modules and a total of 200 curricular units was developed in cooperation with the Department for Key Competencies and Higher Education at Heidelberg University and implemented during the 2010 summer semester. This program covers not only topic-specific training sessions, but also independent teaching and an integrated evaluation of the learning process that is communicated to the graduates in the form of structured feedback. In addition, to evaluate the overall concept, semi-structured interviews (N=18) were conducted with the program graduates.To date, 495 tutors have been trained in the basic module on teaching medicine, which is rated with a mean overall grade of 1.7 (SW: 0.6) and has served as Module I of the program since 2010. A total of 17% (N=83) of these tutors have gone on to enroll in the subsequent training modules of the program; 27 of them (m=12, f=15) have already successfully completed them. Based on qualitative analyses, it is evident that the training program certificate and its applicability toward the advanced teacher training for university instructors pose a major incentive for the graduates. For successful program realization, central coordination, extensive coordination within the medical school, and the evaluation of the attained skills have proven to be of particular importance.The training program contributes sustainably to both quality assurance and professionalism, as well as to solving the issue of resources in medical education. The introduction and continued development of similar programs is desirable.

Project description:BackgroundValid cause of death data are essential for health policy formation. The quality of medical certification of cause of death (MCCOD) by physicians directly affects the utility of cause of death data for public policy and hospital management. Whilst training in correct certification has been provided for physicians and medical students, the impact of training is often unknown. This study was conducted to systematically review and meta-analyse the effectiveness of training interventions to improve the quality of MCCOD.MethodsThis review was registered in the International Prospective Register of Systematic Reviews (PROSPERO; Registration ID: CRD42020172547) and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. CENTRAL, Ovid MEDLINE and Ovid EMBASE databases were searched using pre-defined search strategies covering the eligibility criteria. Studies were selected using four screening questions using the Distiller-SR software. Risk of bias assessments were conducted with GRADE recommendations and ROBINS-I criteria for randomised and non-randomised interventions, respectively. Study selection, data extraction and bias assessments were performed independently by two reviewers with a third reviewer to resolve conflicts. Clinical, methodological and statistical heterogeneity assessments were conducted. Meta-analyses were performed with Review Manager 5.4 software using the 'generic inverse variance method' with risk difference as the pooled estimate. A 'summary of findings' table was prepared using the 'GRADEproGDT' online tool. Sensitivity analyses and narrative synthesis of the findings were also performed.ResultsAfter de-duplication, 616 articles were identified and 21 subsequently selected for synthesis of findings; four underwent meta-analysis. The meta-analyses indicated that selected training interventions significantly reduced error rates among participants, with pooled risk differences of 15-33%. Robustness was identified with the sensitivity analyses. The findings of the narrative synthesis were similarly suggestive of favourable outcomes for both physicians and medical trainees.ConclusionsTraining physicians in correct certification improves the accuracy and policy utility of cause of death data. Investment in MCCOD training activities should be considered as a key component of strategies to improve vital registration systems given the potential of such training to substantially improve the quality of cause of death data.

Project description:BACKGROUND:Accurate and timely cause of death (COD) data are essential for informed public health policymaking. Medical certification of COD generally provides the majority of COD data in a population and is an essential component of civil registration and vital statistics (CRVS) systems. Accurate completion of the medical certificate of cause of death (MCCOD) should be a relatively straightforward procedure for physicians, but mistakes are common. Here, we present three training strategies implemented in five countries supported by the Bloomberg Philanthropies Data for Health (D4H) Initiative at the University of Melbourne (UoM) and evaluate the impact on the quality of certification. METHODS:The three training strategies evaluated were (1) training of trainers (TOT) in the Philippines, Myanmar, and Sri Lanka; (2) direct training of physicians by the UoM D4H in Papua New Guinea (PNG); and (3) the implementation of an online and basic training strategy in Peru. The evaluation involved an assessment of MCCODs before and after training using an assessment tool developed by the University of Melbourne. RESULTS:The TOT strategy led to reductions in incorrectly completed certificates of between 28% in Sri Lanka and 40% in the Philippines. Following direct training of physicians in PNG, the reduction in incorrectly completed certificates was 30%. In Peru, the reduction in incorrect certificates was 30% after implementation and training on an online system only and 43% after training on both the online system and basic medical certification principles. CONCLUSIONS:The results of this study indicate that a variety of training strategies can produce benefits in the quality of certification, but further improvements are possible. The experiences of D4H suggest several aspects of the strategies that should be further developed to improve outcomes, particularly key stakeholder engagement from early in the intervention and local committees to oversee activities and support an improved culture in hospitals to support better diagnostic skills and practices.

Project description:This study used the InterVA-4 computerised model to assign probable cause of death (CoD) to verbal autopsies (VAs) generated from two rural areas, with a difference in health service provision, within the Matlab Health and Demographic Surveillance site (HDSS). This study aimed to compare CoD by gender, as well as discussing possible factors which could influence differences in the distribution of CoD between the two areas.Data for this study came from the Matlab the HDSS maintained by the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) since 1966. In late 1977, icddr,b divided HDSS and implemented a high-quality maternal, newborn and child health and family planning (MNCH-FP) services project in one half, called the icddr,b service area (SA), in addition to the usual public and private MNCH-FP services that serve the other half, called the government SA. HDSS field workers registered 12,144 deaths during 2003-2010, and trained interviewers obtained VA for 98.9% of them. The probabilistic model InterVA-4 probabilistic model (version 4.02) was used to derive probable CoD from VA symptoms. Cause-specific mortality rates and fractions were compared across gender and areas. Appropriate statistical tests were applied for significance testing.Mortality rates due to neonatal causes and communicable diseases (CDs) were lower in the icddr,b SA than in the government SA, where mortality rates due to non-communicable diseases (NCDs) were lower. Cause-specific mortality fractions (CSMFs) due to CDs (23.2% versus 18.8%) and neonatal causes (7.4% versus 6%) were higher in the government SA, whereas CSMFs due to NCDs were higher (58.2% versus 50.7%) in the icddr,b SA. The rank-order of CSMFs by age group showed marked variations, the largest category being acute respiratory infection/pneumonia in infancy, injury in 1-4 and 5-14 years, neoplasms in 15-49 and 50-64 years, and stroke in 65+ years.Automated InterVA-4 coding of VA to determine probable CoD revealed the difference in the structure of CoD between areas with prominence of NCDs in both areas. Such information can help local planning of health services for prevention and management of disease burden.

Project description:BACKGROUND:The failure rate on certification examinations of The College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada (RCPSC) is significantly higher for international medical graduates than for Canadian medical school graduates. The purpose of the current study was to generate evidence that supports or refutes the validity of hypotheses proposed to explain the lower success rates. METHODS:We conducted retrospective analyses of admissions and certification data to determine the factors associated with success of international medical graduate residents on the certification examinations. International medical graduates who entered an Ontario residency program between 2005 and 2012 and had written a certification examination by the time of the analysis (2015) were included in the study. Data available at the time of admission for each resident, including demographic characteristics, previous experiences and previous professional experiences, were collected from each of the 6 Ontario medical schools and matched with certification examination results provided by The CFPC and the RCPSC. We developed logistic regression models to determine the association of each factor with success on the examinations. RESULTS:Data for 900 residents were analyzed. The models revealed resident age to be strongly associated with performance across all examinations. Fluency in English, female sex and the Human Development Index value associated with the country of medical school training had differential associations across the examinations. INTERPRETATION:The findings should contribute to an improved understanding of certification success by international medical graduates, help residency programs identify at-risk residents and underpin the development of specific educational and remedial interventions. In considering the results, it should be kept in mind that some variables are not amenable to changes in selection criteria.

Project description:BackgroundMonitoring medically certified causes of death is essential to shape national health policies, track progress to Sustainable Development Goals, and gauge responses to epidemic and pandemic disease. The combination of electronic health information systems with new methods for data quality monitoring can facilitate quality assessments and help target quality improvement. Since 2015, Tanzania has been upgrading its Civil Registration and Vital Statistics system including efforts to improve the availability and quality of mortality data.MethodsWe used a computer application (ANACONDA v4.01) to assess the quality of medical certification of cause of death (MCCD) and ICD-10 coding for the underlying cause of death for 155,461 deaths from health facilities from 2014 to 2018. From 2018 to 2019, we continued quality analysis for 2690 deaths in one large administrative region 9 months before, and 9 months following MCCD quality improvement interventions. Interventions addressed governance, training, process, and practice. We assessed changes in the levels, distributions, and nature of unusable and insufficiently specified codes, and how these influenced estimates of the leading causes of death.Results9.7% of expected annual deaths in Tanzania obtained a medically certified cause of death. Of these, 52% of MCCD ICD-10 codes were usable for health policy and planning, with no significant improvement over 5 years. Of certified deaths, 25% had unusable codes, 17% had insufficiently specified codes, and 6% were undetermined causes. Comparing the before and after intervention periods in one Region, codes usable for public health policy purposes improved from 48 to 65% within 1 year and the resulting distortions in the top twenty cause-specific mortality fractions due to unusable causes reduced from 27.4 to 13.5%.ConclusionData from less than 5% of annual deaths in Tanzania are usable for informing policy. For deaths with medical certification, errors were prevalent in almost half. This constrains capacity to monitor the 15 SDG indicators that require cause-specific mortality. Sustainable quality assurance mechanisms and interventions can result in rapid improvements in the quality of medically certified causes of death. ANACONDA provides an effective means for evaluation of such changes and helps target interventions to remaining weaknesses.

Dataset Information

The quality of medical death certification of cause of death in hospitals in rural Bangladesh: impact of introducing the International Form of Medical Certificate of Cause of Death.

Publications

The quality of medical death certification of cause of death in hospitals in rural Bangladesh: impact of introducing the International Form of Medical Certificate of Cause of Death.

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