Elizabeth M Begier, MD, MPH Assistant Commissioner Bureau of Vital Statistics

1. Intervening on Poor Quality of Cause of Death Data:The NYC Experience Elizabeth M Begier, MD, MPH Assistant Commissioner Bureau of Vital Statistics NYC Department of Health & Mental Hygiene NAPHSIS June 9, 2010

2. Talk Overview • Identification of problem • Intervention design • Intervention results • Plans for future monitoring of cause of death data quality • Other cause of death data quality interventions in NYC

3. How NYC identified the Problem • NYC among highest reported heart disease (HD) death rates in US • US 2006 : 199/100,000 Population • NYC 2006: 255/100,000 Population • Yet rates of HD risk factors (hypertension, cholesterol, smoking, obesity) largely comparable or better in NYC than nationally. • 2003 NYC validation study: death certificates over-estimated HD mortality >50% for decedents 35–74 yrs • 94% overestimated for decedents 75–84 years • 137% overestimated for decedents >85 years

4. NYC/US 15 Leading Causes of Death with Dissimilar Age-Adjusted Rates (per 100,000)

5. Pareto Chart: Proportion of Deaths due to Heart Disease at Hospitals reporting >50 deaths, NYC 2008 NYC average US

6. Targeting 8 hospitals responsible for over 25% of HD death reporting Initial conference call with Medical Director, Regulatory Affairs, Quality Assurance and Admitting Directors Provide hospital-specific data to initiate Action Plan NYC Intervention Initiation

7. Intervention Hospital Requirements • Conduct and provide to us death certificate work flow assessment for hospital • Conduct chart reviews for 30 2009 death certificates to compare certificates' cause of death to chart information (random sample from us) • Ensure staff/physicians involved in death certification complete “Improving Cause of Death Reporting” e-learning (self-training) • Physicians/staff involved in death certification required to attend in-service by NYC Vital Statistics • Revise policy and procedures as needed

8. Self Trainings

9. Improving Cause of Death - eLearning Contracted with vendor Developed content Tested content using additional focus groups CME accreditation Posted, 2008 Data Quality: focus on natural causes http://www.nyc.gov/html/doh/media/video/icdr/index.html

10. October, 2008 City Health Information (CHI) - Improving Cause of Death Reporting Published, Oct. 2008 Data Quality: focus on natural causes http://www.nyc.gov/html/doh/downloads/pdf/chi/chi27-9.pdf

11. Example Slides from Hospital Inservice

12. What Does Cause of Death Mean? Intended meaning for COD reporting: • The underlying event or condition that set into motion the events that resulted in death • The original or initiating condition Not the mechanism: • e.g., “cardiopulmonary arrest” which is not a medical condition

13. Hospital X 2006 NYC 2006 USA 2006

16. Cause of Death: Literals • Randomly sampled 50 Death Certificates with Heart Disease as underlying cause: • 64% documented only Heart Disease Mentions in Part I and Part II • 36% documented other contributing causes with an underlying cause of Heart Disease

19. Death Certificate vs.Medical Records

20. Death Certificate vs.Medical Records

21. Other Topics in In-service • Uses and importance of death certificate data • How to write cause of death statements including multiple examples

22. Data Quality: Hospital InterventionExamples – NAME* Part I A. Septic shock B. Gram-negative sepsisC. Part I A. Gram-negative pseudomonas sepsis B. Urinary bladder infectionC. Indwelling catheter for neurogenic bladder D. Multiple sclerosis * National Association of Medical Examiners website, Writing Cause of Death Statements http://thename.org/index.php?option=com_content&task=view&id=113&Itemid=58

23. Intervention Results

24. Qualitative Information on Root Causes of Problem • No training in documenting COD • External influences • Funeral directors • Admitting staff at hospitals • Previous rejections • DOHMH Registration Unit, a.k.a. “Burial Desk”

25. Proportion of Heart Disease Deaths reported at Intervention and Non-intervention Hospitals reporting >50 deaths, NYC 2009–2010

26. Future Monitoring • Monitoring of Quality of Cause of Death data • Average Number of Conditions reported in COD section per Death Certificate • Will use indicator to monitor COD quality citywide and by facility, including in reports to facilities

27. Why use Average Number of Conditions in COD section per Death Certificate? • Indicator reflects level of detail and specificity reported by physicians • Includes conditions from Part I (causal sequence) and Part II (other conditions contributing to death) • Use conditions rather than lines completed as often more than one condition entered per line • Allows us to measure improvements at hospitals that not over-reporting heart disease • Facilities might begin falsifying cause of death for true heart disease deaths if track HD only

28. New Indicator: Average Numbers of Conditions per Certificate • Negatively correlated with deviation from average rate of heart disease citywide • Facilities with high proportions of death due to heart disease tend to have low average number conditions reported on death certificate • In intervention hospitals, cause of death section for most heart disease deaths included only: • Cardiopulmonary Arrest on the line 1 • Atherosclerotic Cardiovascular Disease on line 2 • No other conditions in other lines of Part I or Part II

29. Comparison of proportion of heart disease deaths and average numbers of conditions reported per certificate for facilities reporting >25 deaths, NYC 2008

30. Average number of conditions reported on death certificates at intervention and non-intervention hospitals, NYC 2009–2010

31. Average number of conditions reported on death certificate by month, NYC 2009–2010

32. Other NYC Lower Intensity Cause of Death Data Quality Interventions • Requiring COD elearning for all EDRS users • Currently implementing among MDs/hospital staff • Developing EDRS application to lock users out if not taken elearning • Minimizing burial desk rejections • Hospital-specific reports cards • Physician pocket card on COD • Designing death work sheet for facilities • Altering EDRS COD interface and built-in COD edits • Telephone assistance during weekdays • Educating funeral directors about important of cause of death information

33. Summary • NYC identified problem of substantial over-reporting of heart disease • Heart disease over-reporting associated with overall poor quality death certificates, with one or few conditions reported • Intervention successfully reduced over-reporting and increased detail on certificates • NYC now hopes to intervene citywide with mandatory e-learning and other lower intensity interventions

34. Acknowledgments • Regina Zimmerman • Ann Madsen • Victoria Foster • Ram Koppaka • NYC staff working to improve quality of cause of death reporting

35. END

37. Examples of Well Documented Cases

38. References Gwynn, Charon R. et al. Contributions of a Local Health Examination Survey to the Surveillance of Chronic and Infectious Diseases in New York City, American Journal of Public Health; January 2009, Vol 99 No. 1 Agarwal, R. et al. Death Certificates Over-report In-hospital Coronary Heart Disease Deaths in NYC: Results of a Validation Study, submitted for publication

39. Intervention Plan for 8 Over-Reporting Hospitals • Hospitals to: • Evaluate hospital policy and work-flow procedures • Notify staff involved in process of data’s importance • Require following trainings: • Improving Cause of Death Reporting eLearning • DOHMH Data Quality In-Service • Hospital staff review random sample 2009 certificates to compare chart on COD on certificate • Revise policy and procedures

40. Proportion of Deaths Due To Select Causes in US, NYC and NYC Specific Hospitals(note: hospital specific data are preliminary 2008)

41. Characteristics of a Well-Documented Cause of Death DOs Part I Conditions listed: Clearly Specifically Succinctly If you are not the patient attending, view medical chart and speak to attending to obtain needed information Part II Record other significant conditions and events not in the causal chain, but possibly or definitely related to death

42. Characteristics of a Well-Documented Cause of Death DON’Ts Mechanisms are not and can not be underlying causes of death: Cardiopulmonary arrest Respiratory arrest Asystole Nonspecific causes are not and can not be underlying causes of: death: Sepsis Paraplegia Hypotension Renal failure Seizures Pulmonary edema Rarely should you have only 1 condition listed in Part I

43. 3 Major Reasons for Rejecting a Death Certificate Potential Medical Examiner Investigation Reported only mechanisms of death, e.g., Cardiopulmonary arrest Cardiac arrest Respiratory arrest Asystole Not using BLACK ink

44. Cause of Death: “Literals” for Part II • List all co-morbid conditions and events not in the causal chain above • The literals greatly affect the ICD-10 and in turn the mortality statistics we produce

45. Cause of Death: “Literals” for Part II • Indicate the sequence of clinical conditions leading to the death starting with • The immediate cause - the condition that immediately preceded cessation of cardiac activity Followed by • The intermediate cause - clinical event or condition that immediately preceded and led to the immediate cause of death • The intermediate cause – clinical event or condition that immediate preceded the intermediate cause above • Finish with the underlying cause

46. Characteristics of a Well-Documented Cause of Death DOs Part I • Conditions listed - clearly, specifically and succinctly - describe the causal sequence of conditions or events that led to death Part II • Record other significant conditions and events not in the causal chain, but possibly or definitely related to death

47. Characteristics of a Well-Documented Cause of Death DON’Ts • Mechanisms (e.g. cardiopulmonary arrest, respiratory arrest, asystole) are not and can not be underlying causes of death • Nonspecific causes (e.g. sepsis, paraplegia, hypotension, renal failure, seizures, pulmonary edema) are not and can not be underlying causes of death

48. Most recent condition (Cardiac tamponade) ½ hour Next oldest condition (Ruptured Myocardial infarction) 8 hour Next oldest condition (Atherosclerotic coronary artery disease) Oldest (original, initiating) condition (Hypercholesterolemia) 15 years 30 years Pre/co-existing conditions likely contributing to death but not resulting in the cause above (Heavy Smoker)

49. Data Quality: Hospital InterventionExamples – NAME* Part I A. Gastrointestinal hemorrhage B. Undetermined natural causesC. Part I A. Gastrointestinal hemorrhage B. Probable peptic ulcer diseaseC. * National Association of Medical Examiners website, Writing Cause of Death Statements http://thename.org/index.php?option=com_content&task=view&id=113&Itemid=58

50. Cause of Death Section of Electronic Death Registration System