Post on 27-May-2015
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Mortality Information System
Fatima Marinho, MD, MPH, PhDHealth and Analysis (HSD/HA)
Pan American Health Organization (PAHO/WHO)
Topics
• Sources and data base
• Quality of death information in The Americas % under-registration, % ill defined,
% garbage codes
• Distribution major causes of death
• Examples of data quality problems
• Challenges
Sources
• National Offices of Statistics• Mexico, Ecuador, El Salvador, Peru
• Civil Registration offices• Costa Rica, Argentina, Chile
• Ministry of Health• Republica Dominicana, Brazil, Colombia
Main Variables/Annual data request to the countries *
•Deaths: Individual data on each death, with the following specifications:•Sex•Underlying cause of death•Age (in hours for the first day, in days for the first month, in months for the first year, and complete years after one year of age)•Other available causes
*Since 2009 this extensive set has been requested
Major civil division of residence of the decedent•Certification of the cause (s) of death: physician or nonmedical•Educational attainment of decedent (instruction or education level) •Ethnicity of the decedent•Place of occurrence of the death (hospital, residence, public thoroughfare, etc)•Date of death
Seasonality of Respiratory Deaths
Why evaluate data quality?Why evaluate data quality?
• Accuracy of the information for policy• Availability of the data doesn’t guarantee
quality• The source per se is not a guarantee of
quality, for example, hospital statistics • Poor quality of the data poor decision
lost of opportunity to identify problems and intervention in order to improve the population health
Challenges for using mortality data
• Incomplete series of data registries• Poor certification of cause of death• Poor availability and opportunity of the data• Poor use of the data• Poor value of cause of death codification • There is a tendency to codify the cause of death
according what is expected to be more frequent• Late registration of death
Total defunciones
• En 2007 hubo un total de 5 736 164* defunciones en los 32 países de la Región de las Américas con datos para ese año (53,1% hombres y 46,9% mujeres).
• La tasa de mortalidad ajustada por edad para la población total fue 5,8 por 1 000 habitantes (7,1 por 1 000 en hombres y 4,7 por 1 000 en mujeres).
*Dato corregido para subregistro
La mortalidad captada fue de 5 085 260
USA responde por mitad de las defunciones captadas
Percentage of years
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
CanadaUnited States of America
ChileMexico
Trinidad and TobagoCosta Rica
BarbadosPuerto Rico
VenezuelaColombia
PanamaEcuador
El SalvadorGuatemala
UruguayDominica
Dominican RepublicParaguay
Saint Kitts and NevisCuba
BelizeBermudaSurinameArgentina
Antigua and BarbudaSaint LuciaNicaragua
PeruBritish Virgin Islands
BrazilBahamas
Saint Vincent andTurks and Caicos Islands
Cayman IslandsGuyana
JamaicaMontserrat
AnguillaGrenada
HondurasFrench Guiana
GuadeloupeVirgin Islands (USA)
MartiniqueNetherlands Antilles
ArubaHaiti
Bolivia
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
0
5
10
15
20
25
30
35
40
45
50
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
CIE-7 CIE-8
CIE-9 CIE-10
Timeliness1950-2010
Number of countries in The Region with mortality data by cause, 1950-2010
Under- registration %completeness
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
45/48 Countries and Territories in the
Americas have a Vital Statistics System working
% ill-defined causes of death Subregion
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
circa 2009
% ill-defined causes of death by country
circa 2009
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
% ill-defined causes of death Selected countries, 2000-2009
0.0
5.0
10.0
15.0
20.0
25.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Cuba
Estados Unidos de América
México
Colombia
Chile
Nicaragua
Panamá
Brasil
Paraguay
El Salvador
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
2005 2006 2007 2008 2009
% % % % %
Other ill-defined and unspecified causes of mortality (R99)
40.4 41.6 42.5 45.3 46.5
Unattended death (R98) 26.5 20.7 17.9 21.8 20.3
Senility (R54) 9.3 10.7 10.3 9.6 8.5
Other symptoms and signs involving the circulatory and respiratory systems (R09)
8.2 7.1 7.1 6.9 7.6
Other sudden death, cause unknown(R96)
2.7 2.6 3.3 3.8 4.2
Remainder 11.2 15.3 16.9 12.6 12.3
Number of deaths 196919
175695
179553
143577
137622
% ill-defined causes of deathAmericas 2005-2009
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
% ill-defined causes of deathBrazil 2005-2009
2005 2006 2007 2008 2009
% % % % %
Other ill-defined and unspecified causes of mortality (R99)
35.9 41.6 42.0 44.1 43.8
Unattended death (R98) 46.1 38.2 35.1 34.9 33.1
Other symptoms and signs involving the circulatory and respiratory systems (R09)
9.4 8.7 8.8 7.5 8.9
Senility (R54) 2.6 4.1 4.3 4.3 4.7
Other general symptoms and signs(R68)
1.7 3.3 3.7 3.3 3.3
Remainder 2.2 3.3 3.5 3.5 3.6
Number of deaths 104455
85543 80244 79784 78994
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
% ill-defined causes of deathCuba 2005-2009
2005 2006 2007 2008 2009
% % % % %
Other ill-defined and unspecified causes of mortality (R99)
45.8 54.0 49.8 44.2 40.6
Senility (R54) 18.2 17.6 19.3 24.1 23.1
Other sudden death, cause unknown(R96)
19.2 15.2 14.2 13.5 16.8
Unattended death (R98) 3.6 0.9 4.5 3.7 4.4
Other general symptoms and signs(R68)
4.6 4.7 3.9 3.5 3.0
Remainder 6.4 4.7 4.7 5.9 8.1
Number of deaths 637 635 643 764 794
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
% ill-defined causes of deathPeru 2003-2007
2005 2006 2007 2008 2009
% % % % %
Other ill-defined and unspecified causes of mortality (R99)
27.6 44.6 77.8 78.1 74.6
Senility (R54) 18.3 8.9 0.0 0.0 0.0
Other symptoms and signs involving the circulatory and respiratory systems (R09)
11.4 19.5 0.0 0.0 0.0
Shock, not elsewhere classified (R57) 10.8 5.1 0.0 0.0 1.6
Unattended death (R98) 4.4 7.9 0.0 8.3 11.6
Remainder 27.5 14.0 22.2 13.7 12.2
Number of deaths 2149 1814 18 630 189
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
% under-registration and % ill-defined causes of death Americas, 2007-2009
Source: Health situation in the Americas – Basic Indicators 2011
Nicaragua
JamaicaCayman Islands
Americas
In the Second Annual Report of the Registrar General of Great Britain in 1840, William Farr presented the statistics of causes of death (CoD), defined as:
“diseases, which terminate in the extinction of existence,” but Farr highlighted the concern that “…the attention of the observer was less attracted to this class of facts, and overlooking the proximate cause, that is, the internal morbid process…”
In that report, he also criticized the use of vague categories like “sudden death,” “natural death,” “visitation of God,” and “old age,” but he admitted that in some cases, no particular cause of death could be identified
All these criticisms remain relevant today
Causes of death?
Even with a physician-completed death certificate, assignment of the underlying cause of death can be problematic
Underlying cause of death (ICD)a) the disease or injury which initiated the train of morbid
events leading directly to death or
a) b) the circumstances of the accident or violence which produced the fatal injury”
The most effective public health objective is to prevent the precipitating from operating
From the stand point of prevention of death is necessary to break the chain of events or to effect a cure at some point
many deaths assigned to causes that cannot or should not be considered underlying causes of death
“often called garbage codes (GCs)”
In 1996, Murray and Lopez introduced the term “garbage coding” for the practice of assigning deaths to causes that are not useful for public health analysis of cause-of-deathdata as part of the assessment of the Global Burden of Disease (GBD)
Typology of Garbage Codes
Four categories were identified:
1.Causes that cannot or should not be considered as underlying causes of death (Type 1)
chapter 18 of ICD-10 or R codes essential primary hypertension and atherosclerosis. causes that are described as the long-term sequelae of disease, such as paraplegia and tetraplegia
2. Intermediate causes of death (Type 2): heart failure, septicemia, peritonitis, osteomyelitis, or pulmonary embolism.
3. Immediate causes of death (Type 3): final steps in a disease pathway leading to death. disseminated intravascular coagulation or defibrination syndrome . Cardiac arrest and respiratory failure
4. Unspecified causes (Type 4): injuries are coded to unspecified factors or intent
Source: Algorithms for enhancing public health utility of nationalcauses of death data IHME
•the likelihood that a condition can be an underlying cause of death
•the need for codes that provide a location for unspecified or ambiguous causes of death
•the need for codes that represent causes that are not underlying but intermediate or final events in the chain leading to death
This typology has been developed taking into consideration the following:
Source: Algorithms for enhancing public health utility of nationalcauses of death data IHME
Garbage Codes Subregion and country
Source: Algorithms for enhancing public health utility of nationalcauses of death data IHME
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0%
VIRCUBCRI
COLCHLSURTTOJAMMEXBMUVENUSAKNABRABLZNICTCABHSPRYPANGUY
AIAECUPRI
DOMURYCYMATGBRBABWLCA
GRDSLV
MSRVCTGTMVGBARG
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
circa 2009
12%
6%
59%
23%
Type 1 Causes that cannot or should not be considered as ucd
Type 3 Immediate
Type 2 Intermediate
Type 4 Unspecified causes
Causes %
Heart failure (I50) 19.0
Other sepsis (A41) 9.6
Essential (primary) hypertension (I10)
6.7
Chronic kidney disease (N18)
6.0
Malignant neoplasm, without specification of site (C80)
5.7
Exposure to unspecified factor (X59)
3.7
Unspecified kidney failure (N19)
3.5
Pneumonitis due to solids and liquids (J69)
3.1
Other diseases of digestive system (K92)
2.9
Cardiac arrest (I46) 2.7
Remainder 39.3
• Intermediate causes are the most important gc (60%)
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
Type 1 Causes that cannot or should not be considered as ucd
%
Essential (primary) hypertension (I10)
57.7
Atherosclerosis (I70) 15.9
Cerebral palsy (G80) 5.3
Hyperplasia of prostate (N40)
2.8
Remainder 18.3
Type 2 Intermediate causes
%
Heart failure (I50) 31.9
Other sepsis (A41) 16.1
Chronic kidney disease (N18)
10.1
Unspecified kidney failure (N19)
5.8
Remainder 36.1
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
Type 3 Immediate causes of death
%
Respiratory failure, not elsewhere classified (J96)
50.1
Cardiac arrest (I46) 45.1
Disseminated intravascular coagulation [defibrination syndrome] (D65)
2.8
Remainder 1.9
Type 4 Unspecified causes %
Malignant neoplasm, without specification of site (C80)
24.9
Exposure to unspecified factor (X59)
16.2
Complications and ill-defined descriptions of heart disease (I51)
12.8
Unspecified event, undetermined intent (Y34)
6.9
Remainder 39.3
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
Cause of death and Epidemiologic transition in the
Region
Estados Unidos
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
1950
1952
1954
1956
1958
1960
1962
1964
1966
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
Group I Communicable Group II Non communicable Group III Injuries Ill defined
Transición Epidemiológica en EU
Fuente: Sistema de inforamción de Mortaldiad HA/HSD/OPS
0
10
20
30
40
50
60
70
80
90
100
1930 1940 1950 1960 1970 1980 1990 2000 2009
Group I Communicable Group II No Communicable Group III Injuries Group IV Ill Defined
Transición Epidemiológica en Brasil
Fuente: Sistema de inforamción de Mortaldiad HA/HSD/OPS
México
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
1955
1957
1959
1961
1963
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
Group I Communicable Group II Non communicable Group III Injuries Ill defined
Transición Epidemiológica en México
Fuente: Sistema de inforamción de Mortaldiad HA/HSD/OPS
Guatemala
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
1963
1965
1967
1969
1971
1975
1977
1979
1981
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
Group I Communicable Group II Non communicable Group III Injuries Ill defined
Transición Epidemiológica en Guatemala
Fuente: Sistema de inforamción de Mortaldiad HA/HSD/OPS
Rango 1 2 3 Países Año Argentina 2009
Influenza y neumonía Enfermedades isquémicas
del corazón Enfermedades
cerebrovasculares Belice 2008
Diabetes mellitus Enfermedades isquémicas
del corazón Eventos de intención no
determinada Brasil 2009 Enfermedades
cerebrovasculares Enfermedades isquémicas
del corazón Influenza y neumonía Canadá 2007
Enfermedades isquémicas del corazón
Neoplasia maligna de la tráquea, de los bronquios
y del pulmón Demencia y enfermedad
de Alzheimer Chile 2008 Enfermedades
cerebrovasculares Enfermedades isquémicas
del corazón Cirrosis y otras
enfermedades del hígado Colombia 2008 Enfermedades
isquémicas del corazón Agresiones/homicidios Enfermedades
cerebrovasculares Costa Rica 2009 Enfermedades
isquémicas del corazón Enfermedades
cerebrovasculares Enfermedades hipertensivas
Cuba
2009 Enfermedades
isquémicas del corazón Enfermedades
cerebrovasculares
Neoplasia maligna de la tráquea, de los bronquios
y del pulmón Ecuador 2009
Diabetes mellitus Enfermedades
cerebrovasculares Influenza y neumonía El Salvador 2008
Agresiones/homicidios Enfermedades del sistema
urinario Enfermedades isquémicas
del corazón Estados Unidos de América
2007 Enfermedades
isquémicas del corazón
Neoplasia maligna de la tráquea, de los bronquios
y del pulmón Demencia y enfermedad
de Alzheimer Guatemala 2008
Influenza y neumonía Agresiones/homicidios
Ciertas afecciones originadas en el período
perinatal
Américas 2007 Enfermedades
isquémicas del corazón Enfermedades
cerebrovasculares Diabetes mellitus
The three leading causes of death in the Americas
Source: Mortality Information System - PAHO
Rango 1 2 3 Países Año Guyana 2006 Enfermedades
isquémicas del corazón Enfermedades
cerebrovasculares Diabetes mellitus Islas del Caribe No-Latino
2008 Enfermedades
isquémicas del corazón Enfermedades
cerebrovasculares Diabetes mellitus México 2009
Diabetes mellitus Enfermedades isquémicas
del corazón Cirrosis y otras enfermedades del
hígado Nicaragua 2009
Diabetes mellitus Enfermedades isquémicas
del corazón Cirrosis y otras enfermedades del
hígado Panamá 2009 Enfermedades
isquémicas del corazón Enfermedades
cerebrovasculares Diabetes mellitus Paraguay 2009 Enfermedades
cerebrovasculares Enfermedades isquémicas
del corazón Ciertas afecciones originadas en el
período perinatal Perú 2007
Influenza y neumonía Enfermedades isquémicas
del corazón Enfermedades cerebrovasculares Puerto Rico 2007 Enfermedades
isquémicas del corazón Diabetes mellitus Demencia y enfermedad de
Alzheimer República Dominicana
2004 Enfermedades isquémicas del corazón
Enfermedades cerebrovasculares
Ciertas afecciones originadas en el período perinatal
Suriname 2007 Enfermedades cerebrovasculares
Enfermedades isquémicas del corazón Diabetes mellitus
Territorios franceses
2005 Enfermedades cerebrovasculares Diabetes mellitus Neoplasia maligna de la próstata
Trinidad y Tobago
2007 Enfermedades isquémicas del corazón Diabetes mellitus Enfermedades cerebrovasculares
Uruguay 2004 Enfermedades cerebrovasculares
Enfermedades isquémicas del corazón
Neoplasia maligna de la tráquea, de los bronquios y del pulmón
Venezuela 2007 Enfermedades isquémicas del corazón
Enfermedades cerebrovasculares Agresiones/homicidios
Américas 2007 Enfermedades
isquémicas del corazón Enfermedades
cerebrovasculares Diabetes mellitus
The three leading cause of death in the Americas
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
%
Insulin-dependent diabetes mellitus E10 Non-insulin-dependent diabetes mellitus E11
Malnutrition-related diabetes mellitus E12 Other specified diabetes mellitus E13
Unspecified diabetes mellitus E14
Diabetes MellitusAmericas, 2000-2009
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
Diabetes MellitusBrazil, 2000-2009
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
%
Insulin-dependent diabetes mellitus E10 Non-insulin-dependent diabetes mellitus E11
Malnutrition-related diabetes mellitus E12 Other specified diabetes mellitus E13
Unspecified diabetes mellitus E14
Diabetes MellitusMexico, 2000-2009
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
%
Insulin-dependent diabetes mellitus E10 Non-insulin-dependent diabetes mellitus E11
Malnutrition-related diabetes mellitus E12 Other specified diabetes mellitus E13
Unspecified diabetes mellitus E14
Diabetes MellitusCuba, 2000-2009
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
2001 2002 2003 2004 2005 2006 2007 2008 2009
%
Insulin-dependent diabetes mellitus E10 Non-insulin-dependent diabetes mellitus E11
Malnutrition-related diabetes mellitus E12 Unspecified diabetes mellitus E14
Adjusted mortality rates due to CVD dropped 43.7% from 2000 to 2007, very higher than the average of the Region. The CVD mortality trend for Belize wasn’t showed individually in the Americas profile.
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
Mortality total and due to cardiovascular diseases Belize, 2000-2007
Mortality due to cardiovascular diseases by major group of causes
Limitations to compare Argentina mortality rates due to Ischaemic heart disease to other countries
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
35
57
27
42
43
35
21
44
22
22
10
3
37
29
9
53
7
26
52
12
31
19
17
10
14
0% 20% 40% 60% 80% 100%
Argentina
Canada
Ecuador
Guatemala
Americas
Ischaemic (I20-I25) Cerebrovascular (I60-I69)
Hypertensive (I10-I15) Cardiac Arrest (I46)+Heart faillure (I50)
Other
Mortality due to cardiovascular diseases by major group of causes
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
Cardiovascular diseases mortalitySelected countries
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
Diabetes mellitus mortality Selected countries
Source: PAHO/WHO. Mortality Information System; Washington DC:2011
What do we need?
• Unify criteria for measuring quality (definitions, standards)
• Encourage the development and consolidation of a critical
mass of research on causes of death …..
Evaluation in The Region
• Policy focused on countries with major needs
• Promote the use of standards to improve the quality of
information
• Use and dissemination of statistics locally corrected