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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. Talk Overview. Identification of problem Intervention design

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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


Talk overview
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


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


Nyc us 15 leading causes of death with dissimilar age adjusted rates per 100 000
NYC/US 15 Leading Causes of Death with Dissimilar Age-Adjusted Rates (per 100,000)


Pareto chart proportion of deaths due to heart disease at hospitals reporting 50 deaths nyc 2008
Pareto Chart: Proportion of Deaths due to Heart Disease at Hospitals reporting >50 deaths, NYC 2008

NYC average

US


Nyc intervention initiation

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


Intervention hospital requirements
Intervention Hospital Requirements reporting

  • 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


Self trainings
Self Trainings reporting


Data quality focus on natural causes

Improving Cause of Death - e reportingLearning

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


Data quality focus on natural causes1

October, 2008 reportingCity 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



What does cause of death mean
What Does Cause of Death Mean? reporting

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


Hospital X reporting

2006

NYC

2006

USA

2006


Cause of death literals
Cause of Death: Literals reporting

  • 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


Death certificate vs medical records
Death Certificate vs. reportingMedical Records


Death certificate vs medical records1
Death Certificate vs. reportingMedical Records


Other topics in in service
Other Topics in In-service reporting

  • Uses and importance of death certificate data

  • How to write cause of death statements including multiple examples


Data quality hospital intervention examples name
Data Quality: Hospital Intervention reportingExamples – 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



Qualitative information on root causes of problem
Qualitative Information on Root Causes of Problem reporting

  • No training in documenting COD

  • External influences

    • Funeral directors

    • Admitting staff at hospitals

  • Previous rejections

    • DOHMH Registration Unit, a.k.a. “Burial Desk”


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


Future monitoring
Future Monitoring and Non-intervention Hospitals reporting >50 deaths, NYC 2009

  • 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


Why use average number of conditions in cod section per death certificate
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


New indicator average numbers of conditions per certificate
New Indicator: Average Numbers of Conditions per Certificate Death 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


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


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



Other nyc lower intensity cause of death data quality interventions
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


Summary
Summary Interventions

  • 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


Acknowledgments
Acknowledgments Interventions

  • Regina Zimmerman

  • Ann Madsen

  • Victoria Foster

  • Ram Koppaka

  • NYC staff working to improve quality of cause of death reporting


END Interventions



References
References Interventions

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


Intervention plan for 8 over reporting hospitals
Intervention Plan for 8 InterventionsOver-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


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


Characteristics of a well documented cause of death
Characteristics of a Well-Documented Cause of Death Specific Hospitals

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


Characteristics of a well documented cause of death1
Characteristics of a Well-Documented Cause of Death Specific Hospitals

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


3 major reasons for rejecting a death certificate
3 Major Reasons for Rejecting a Death Certificate Specific Hospitals

Potential Medical Examiner Investigation

Reported only mechanisms of death, e.g.,

Cardiopulmonary arrest

Cardiac arrest

Respiratory arrest

Asystole

Not using BLACK ink


Cause of death literals for part ii
Cause of Death: Specific Hospitals“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


Cause of death literals for part ii1
Cause of Death: Specific Hospitals“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


Characteristics of a well documented cause of death2
Characteristics of a Well-Documented Cause of Death Specific Hospitals

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


Characteristics of a well documented cause of death3
Characteristics of a Well-Documented Cause of Death Specific Hospitals

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


Most recent condition Specific Hospitals(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)


Data quality hospital intervention examples name1
Data Quality: Hospital Intervention Specific HospitalsExamples – 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


Cause of death section of electronic death registration system
Cause of Death Section of Specific HospitalsElectronic Death Registration System


NYC Specific Hospitals

US

NYC Hospitals



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