Cause of death documentation, are we getting it right?

1. Cause of death documentation, are we getting it right? A case study of cause of death documentation available from death certificates in a teaching hospital in Ghana. Ruth Owusu MGCP, Dennis Laryea MGCP, Collins Frimpong MGCP, Joshua Arthur MPH

2. Outline • Introduction • Methods • Results • Discussion • Recommendations • Acknowledgements • References

3. Introduction • The most effective public health intervention to prevent death, is to prevent the underlying cause of death (UCOD) from occurring. • Accurate and reliable information on UCOD needed for policymakers/health authorities to implement interventions to decrease morbidity and mortality. • Are we providing policymakers with accurate and reliable statistics on the underlying causes of death (UCOD)?

4. Introduction • The Underlying Cause of Death (UCOD) is: • “(a) the disease or injury which initiated the train of morbid events leading directly to death, or (b) the circumstances of the accident or violence which produced the fatal injury”.(WHO,2010) • Etiologically specific, • Excludes mechanisms/mode of dying

5. Introduction • Concept of UCOD not well appreciated by clinicians • Immediate cause of death (ICOD) better appreciated by clinicians • Why UCOD? • primary tabulation of national mortality data • international comparisons • Most effective Public Health intervention

6. Introduction • Death certificates are main source of cause of death information globally • The “cause of death” section of the death certificate is designed to point out: • Immediate cause of death • Sequence from the underlying cause of death to the immediate cause of death • Any other conditions not directly leading to death but contributing to death • Duration of the reported conditions.

7. Introduction International form of medical certificate of death

8. Introduction • UCOD should be entered on the lowest used line of Part I • UCOD is selected and coded using ICD-10 (usually by non-clinicians) • Accurate and complete filling of death certificate by clinicians will facilitate the selection of the underlying cause of death.

9. Introduction • Routine mortality surveillance in KATH revealed common errors in death certificate completion. • To help provide feedback to clinicians to improve practice we set out to: • Document some errors of completion of death certificates likely to affect accurate selection of UCOD • Assess frequencies of these errors • Make recommendations towards improving accurate filling of death certificates

10. Methods • Study site: KomfoAnokye Teaching Hospital (1,300-bed tertiary facility) • A retrospective review of mortality surveillance data in 2015 (4583 deaths) • Excluded neonatal deaths (771) • Systematic sampling done to select 510 out of 3812 deaths • Data entered and analyzed with Epi Info 7 • Four types of errors of DC completion pre-specified for analysis

11. Methods • Pre-specified errors of completion: • Sequencing error (illogical cause of death sequence) • Mechanism of death/non-specific causes of death without acceptable underlying cause of death • Two or more competing underlying causes listed • Underlying cause of death placed in Part II • Pre-specified errors were determined by 2 physicians and if no agreement, a third physician brought in.

12. Methods • Did not assess diagnostic accuracy of the cause of death by attending clinician. • Did not include death certificates from pathologists or coroner

13. Methods: Did not assess errors such as: • wrong/ non-standard abbreviations • time intervals not recorded (approximate interval between presumed onset and date of death for each condition listed in Part I) • Inadequate level of detail on condition

14. Results • 344(67.5%) out of 510 deaths had death certificates completed by attending clinicians. • Out of 344, 56 (16.3%) had illogical cause-of-death causal sequence (sequencing error) • 53 (15.4 %) had mechanism of death/non-specific causes listed without an acceptable underlying cause of death, • 37 (10.8 %) had underlying cause of death placed in part II of the death certificate. • 16 (4.7 %) had two or more competing causes listed • In all, 126 ( 36.6%) had at least one of the 4 types of error

15. Results: Sequencing error Example 1 I a) Hepatic encephalopathy I b) lobar pneumonia Example 2: I a) Pulmonary Tuberculosis I b) Cerebral toxoplasmosis

16. Results: Sequencing error Example 3 I a) Extrapulmonary TB I b) Electrolyte imbalance Example 4 I a) Presumed stage 4 Retroviral Infection I b) Severe acute malnutrition

17. Results: Mechanism of death/non-specific causes Example 1 I a) Cardiogenic shock I b) Heart failure Example 2: I a) Biventricular failure I a) Respiratory failure Example 3: I a) Multiple organ dysfunction syndrome

18. Results: Mechanism of death/Non-specific causes: Example 4: I a) Septic shock Example 5: I a) Acute-on-chronic kidney disease I b) Uraemic encephalopathy

19. Results: Two or more competing causes Example 1 I a) Diabetic nephropathy I b) Hypertension II. Status epilepticus, aspiration pneumonia Example 2 I a) Right hemispheric CVA with left hemiparesis I b) Systemic hypertension, Diabetes Mellitus

20. Results: Two or more competing causes Example 3 I a) Newly diagnosed HIV infection I b) Chronic hepatitis B infection

21. Results: Underlying cause placed in Part II Example 1 1a) Altered mental state with recurrent seizures 1b) Cerebral toxoplasmosis II. Retroviral disease Example 2 I a) Paralytic ileus I b) Spontaneous bacterial peritonitis II. Alcoholic liver cirrhosis

22. Results: Underlying cause placed in Part II Example 3 I a) Respiratory arrest/Cardiac arrest I b) Severe Infection II Burns 96% (full thickness) Example 4 I a) Sepsis I b) Gangrene of left foot II. Type 2 Diabetes mellitus with nephropathy

23. Discussion • To get accurate mortality data from death certificates we need: • Diagnostic accuracy • UCoD and sequence of events from UCoD to immediate cause of death should be well completed on death certificate (with time intervals, no abbreviations) • Inclusion of WHO-recommended level of detail • No deliberate falsification of diagnoses/ omission of diagnoses • Selection of UCoD and coding (usually by non-clinician) should be accurate • Errors can occur at any level • This work focused on the second one only.

24. Discussion • The results indicated that at least 36% had one major error likely to affect accurate selection of UCOD. • Consistent with previous studies using similar categories of major errors ranging from 16% to 33% • Errors in sequencing (16.3%) and errors in reporting mechanisms of death/unspecific causes (15.4%) the most frequent errors • Consistent with previous studies in South Africa, Greece, Australia, Taiwan and Canada. • Different from study in Nepal which had 2 or more competing causes as most frequent (ICU patients)

25. Discussion Various reasons found for these errors in other studies: • Several co-morbidities which can concurrently lead to death (especially in elderly patients) • Copying of the admission and discharge diagnoses directly onto the DC by clinician who did not attend to deceased • Difficulty in finding specific etiology in some conditions like sepsis • Poor knowledge of Death Certificate completion • Low perceived importance of the Death Certificate

26. Discussion • Educational interventions used in previous studies proved useful in improving DC accuracy • Use of printed materials on death certificate completionalone led to a led to significant drop in Kansas USA though not much improvement seen in similar intervention in Australia • Interactive sessions have been shown to perform much better. • Studies in Canada, UK and Kansas, USA showed that interactive workshops/seminars resulted in significant decrease in major errors .

27. Recommendations • In KATH, we propose that during mortality meetings discussions be held on the correct completion of death certificates for the mortality cases discussed. • COD documentation should be discussed during orientation for new medical personnel

28. Acknowledgement • Hannah Marfo and Emmanuel Adomako– HI officers, PHU, KATH: Data collection and entry • Ward-In charges, KATH

29. References • World Health Organization. International statistical classification of diseases and related health problems. - 10th revision, Volume 2 Instruction Manual, edition 2010. •  Slater DN. Certifying the cause of death: an audit of wording inaccuracies. J ClinPathol 1993: 46(3):232-4 • B Swift, K West. Death certification: an audit of practice entering the 21st Century. J ClinPathol2002;55:275–279. • Cheng T-J, Lee F-C, Lin S-J, et al. Improper cause-of-death statements by specialty of certifying physician: a cross-sectional study in two medical centres in Taiwan. BMJ Open 2012;2:e001229. • Haque et al. Death certificate completion skills of hospital physicians in a developing country. BMC Health Services Research 2013 13:205. • Myer KA, Farquhar DRE. Improving the accuracy of death certification. CMAJ 1998;158:1317e23.

30. References • Bobbi S. Pritt, Nicholas J. Hardin, Jeffrey A. Richmond, and Steven L. Shapiro (2005) Death Certification Errors at an Academic Institution. Archives of Pathology & Laboratory Medicine: November 2005, Vol. 129, No. 11, pp. 1476-1479. • Burger EH, van der Merwe L, Volmink J. Errors in the completion of death notification form. S Afr Med J 2007;97:1077e81. • KatsakioriPF, Panagiotopoulou EC, Sakellaropoulos GC, Papazafiropoulou A, Kardara M.  Errors in death certificates in a rural area of Greece. Rural and Remote Health (Internet) 2007; 7: 822. Available: http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=822 (Accessed 7 July 2016) • Maharjan L, Shah A, Shrestha KB et al. Errors in cause-of-death statement on death certificates in intensive care unit of Kathmandu, Nepal. BMC Health Services Research (2015) 15:507 • Selinger CP, Ellis RA, Harrington MG. A good death certificate: improved performance by simple educational measures. Postgraduate Medical Journal. 2007;83(978):285-286. doi:10.1136/pgmj.2006.054833.

31. Thank you.