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Transcript of Elizabeth M Begier, MD, MPH Assistant Commissioner Bureau of Vital Statistics NYC Department of...
Elizabeth M Begier, MD, MPHAssistant Commissioner Bureau of Vital Statistics
NYC Department of Health & Mental Hygiene
NAPHSISJune 9, 2010
Intervening on Poor Quality of Cause of Death Data:
The NYC Experience
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
NYC among highest reported heart disease (HD) death rates in USo US 2006 : 199/100,000 Populationo 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 yrso 94% overestimated for decedents 75–84 yearso 137% overestimated for decedents >85 years
How NYC identified the Problem
NYC USCause of Death 2006 2006Diseases of heart I00-I09,I11,I13,I20-I51 254.7 199.4Influenza and pneumonia J10-J18 29.9 17.7Cerebrovascular diseases I60-I69 19.8 43.6Chronic lower respiratory diseases J40-J47 16.5 40.4Septicemia A40-A41 4.5 10.9Alzheimer's disease G30 2.8 22.7
NYC/US 15 Leading Causes of Death with Dissimilar Age-Adjusted Rates (per 100,000)
Figure 1. Proportion of deaths due to heart disease at NYC hospitals reporting > 50 deaths, 2008
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* * * * * * * * * *
Institution (* intervention institution)
Pro
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to H
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50
60
70
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Proportion of Deaths due to HD
cumulative HD percentage
cumulative death percentage
May 11, 2010Bureau of Vital StatisticsNew York City Department of Health and Mental Hygiene
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
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
Self Trainings
Data Quality: focus on natural causes
1. Improving Cause of Death - eLearning– Contracted with
vendor• Developed content• Tested content using
additional focus groups
– CME accreditation– Posted, 2008
http://www.nyc.gov/html/doh/media/video/icdr/index.html
Data Quality: focus on natural causes
2. October, 2008 City Health Information (CHI) - Improving Cause of Death Reporting
– Published, Oct. 2008
http://www.nyc.gov/html/doh/downloads/pdf/chi/chi27-9.pdf
Example Slides from Hospital Inservice
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
Hospital X Appears to OVER REPORT Deaths Attributed to Heart Disease
70.0
39.4
26.0
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20
30
40
50
60
70
80
Heart Disease
Pro
port
ion o
f al
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eath
s
Hospital X2006
NYC2006 USA
2006
Hospital X Appears to UNDER REPORT
Deaths Attributable to Other Coniditions (note: all 2008 data are preliminary)
0.6
0 0
1.9
0.70.4 0.3
3
1.4
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5.7
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% % % %
Septicemia Alzheimer's Parkinson's StrokeDisease
Pro
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ea
ths
Hospital X Proportion- 2006-2008 NYC Proportion-2006 USA Proportion- 2006
Proportion of Deaths Caused by Heart Disease (HD),
Hospital X, 2004–2008
• Proportion due to HD has increased 18% since 2004
YEAR 2004 2005 2006 2007 2008
CAUSE OF DEATH Deaths % Deaths % Deaths % Deaths % Deaths % All HD Deaths 208 56.5 212 62.4 204 63.9 250 70.6 245 70
CHRONIC ISCHEMIC HEART DISEASE 171 46.5 183 53.8 176 55.2 222 62.7 226 64.6 ACUTE MI 24 6.5 18 5.3 25 7.8 21 5.9 14 4 HEART FAILURE 7 1.9 2 0.6 3 0.9 3 0.8 2 0.6 HYPERTENSIVE HEART DISEASE 3 0.8 3 0.9 0 0 2 0.6 2 0.6
OTHER HEART DISEASES 3 0.8 6 1.8 0 0 2 0.6 1 0.3 TOTAL, ALL CAUSES 368 100 340 100 319 100 354 100 350 100
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
Causes of Death Random Sample of 2008 Hospital X HD Death
Certificates
HD Underlying Cause with Only HD Mentions (no other medical conditions)
Represents 64% of Total HD Deaths
PartI_a PartI_b PartI_c PartI_d PartII Underlying
Cause CARDIOPULMONARY ARREST
ASHD → HD
CARDIOPULMONARY ARREST
ASHD → HD
CARDIOPULMONARY ARREST
ATHEROSCLEROTIC HEART DISEASE
→ HD
CARDIOPULMONARY ARREST
ATHEROSCLEROTIC HEART DISEASE
→ HD
CARDIOPULMONARY ARREST
ATHEROSCLEROTIC HEART DISEASE
→ HD
CARDIOPULMONARY ARREST
ATHEROSCLEROTIC HEART DISEASE
→ HD
CARDIOPULMONARY ARREST
ATHEROSCLEROTIC HEART DISEASE
→ HD
CARDIOPULMONARY ARREST
ATHEROSCLEROTIC HEART DISEASE
CONGESTIVE HEART FAILURE
→ HD
CARDIOPULMONARY ARREST
CHF ASHD → HD
CARDIOPULMONARY ARREST
MYOCARDIAL INFARCTION
ATHEROSCLEROTIC HEART DISEASE
→ HD
Causes of Death Random Sample of 2008 Hospital X HD Death
Certificates
HD Underlying Cause with HD and Other Condition Mentions Represents 36% of Total HD Deaths
PartI_a PartI_b PartI_c PartI_d PartII Underlying
Cause CARDIAC ARREST ATHEROSCLEROTIC
HEART DISEASE HYPERTENSION ENDSTAGE
RENAL DISEASE
→ HD
CARDIOPULMONARY ARREST
ACUTE MYOCARDIAL INFARCTION
DIABETES MELLITUS → HD
CARDIOPULMONARY ARREST
ASHD PRE RENAL AZOTEMIA
→ HD
CARDIOPULMONARY ARREST
ATHEROSCLEROTIC HEART DISEASE
DIABETES MELLITUS → HD
CARDIOPULMONARY ARREST
ATHEROSCLEROTIC HEART DISEASE
LOBAR PNEUMONIA
→ HD
CARDIOPULMONARY ARREST
ATHEROSCLEROTIC HEART DISEASE
LOBAR PNEUMONIA
→ HD
CARDIOPULMONARY ARREST
ATHEROSCLEROTIC HEART DISEASE
URINARY TRACT INFECTION SECONDARY TO E. COLI
→ HD
CARDIOPULMONARY ARREST
CHF ASHD AIDS, ETIOLOGY UNKNOWN
→ HD
CARDIORESPIRATORY ARREST
CORONARY ARTERY ATHEROSCLEROSIS
STOMACH CANCER
→ HD
CARDIORESPIRATORY FAILURE
ATHEROSCLEROTIC HEART DISEASE
PEPTIC ULCER DISEASE
→ HD
Death Certificate vs.Medical Records
Data Source Part I a Part I b Part I c Part II
Underlying Cause
Death Certificate
Acute renal Failure
Coronary Artery Disease
→ Heart Disease
Medical Record
Respira-tory Failure
Pneumonia Parkin-son’s Disease
AMI, Acute renal failure, Anemia, CAD, Hypertension, CHF
→ Parkinson’s Disease
Death Certificate vs.Medical Records
Data Source Part I a Part I b Part 1 c Part 1 d Part II
Underlying Cause
Death Certificate
Atherosclerotic Heart Disease
→ Heart Disease
MedicalRecord
Respiratory Failure
Presumed Sepsis
Infected Graft and Gangrenous Toe
Peripheral Vascular Disease
Excision of Infected Graft and Fem-Pop Bypass, Diabetes Mellitus
→ Peripheral Vascular Disease Combined with Diabetes Mellitus
Other Topics in In-service
• Uses and importance of death certificate data
• How to write cause of death statements including multiple examples
Data Quality: Hospital InterventionExamples – NAME*
* 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
Part I A. Septic shock B. Gram-negative sepsis C.
Part I A. Gram-negative pseudomonas sepsis B. Urinary bladder infection C. Indwelling catheter for neurogenic bladder D. Multiple sclerosis
Intervention Results
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”
Figure 2. Proportion of heart disease deaths at intervention and non-intervention hospitals reporting more than 50 deaths, 2008
0.633 0.627
0.494
0.401
0.3090.318 0.308 0.307 0.312 0.307
0
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0.2
0.3
0.4
0.5
0.6
0.7
Jan - Mar 2009 Apr - Jun 2009 Jul - Sept 2009 Oct - Dec 2009 Jan - Mar 2010
Pro
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eath
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to h
eart
dis
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Intervention hospitals
Non-intervention hospitals
Proportion of Heart Disease Deaths reported at Intervention and Non-intervention Hospitals
reporting >50 deaths, NYC 2009–2010
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
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
• 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
Figure 3. Comparison of proportion heart disease deaths and average number of conditions reported on the death certificate in NYC hospitals and nursing homes reporting >25 deaths,
2008
0.00
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0.90
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Facility (* indicates intervention hospital)
Pro
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1.50
2.00
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Ave
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of
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iven
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Proportion of deaths due to heart disease
Average number of conditions given on death certificate
Linear (Average number of conditions given on death certificate)
Comparison of proportion of heart disease deaths and average numbers of conditions reported per certificate
for facilities reporting >25 deaths, NYC 2008
Figure 4. Average number of conditions reported on the death certificate at intervention and non-intervention hospitals, 2009-2010 (preliminary)
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3
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Jan - Mar 2009 Apr - Jun 2009 Jul - Sept 2009 Oct - Dec 2009 Jan - Mar 2010
Ave
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ber
of
con
dit
ion
s re
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rted
on
dea
th c
erti
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te
Intervention hospitals
Non-intervention hospitals
Average number of conditions reported on death certificates at intervention and non-
intervention hospitals, NYC 2009–2010
Figure 5. Average number of conditions reported on the death certificate, 2009-2010
2.00
2.10
2.20
2.30
2.40
2.50
2.60
2.70
2.80
2.90
3.00
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr
Average number of conditions reported ondeath certificate
Linear (Average number of conditionsreported on death certificate)
Average number of conditions reported on death certificate by month, NYC 2009–2010
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
• 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
• Regina Zimmerman
• Ann Madsen
• Victoria Foster
• Ram Koppaka
• NYC staff working to improve quality of cause of death reporting
END
Summary 2008 Hospital X Cause of Death
Review
• High magnitude of HD death reporting - suggests over-reporting
• The majority of HD deaths have no other contributing
causes - a strong indicator of poor quality reporting • Further investigation to determine the accuracy of
Hospital death certificates is warranted • The DOHMH is working with a number of hospitals to
set up Action Plans to improve Cause of Death reporting
Examples of Well Documented Cases
Obs # PartI_a PartI_b PartI_c PartI_d PartII
Underlying Cause
1 Cardiac Arrest
Gastric hemorrhage Gastric Ulcer →
Gastric Ulcer with Hemorrhage
2 Rupture of the Pericardium
Acute Myocardial Infarction
Atherosclerotic Coronary Artery
Disease
Chronic Obstructive Pulmonary Disease,
Smoking →
Atherosclerotic Coronary Artery
Disease 3
Cardiogenic Shock Bacterial Sepsis
Bacterial Infection- Unknown Etiology
Hypoplastic Left Heart and Chronic
Lung Disease →
Bacterial Infection-
Unknown Etiology 4 Cardiopulmonary
Arrest Bacterial
Pneumonia Parkinson Dementia →
Parkinson’s Disease
5
Aspiration Pneumonia
Alzheimer’s Disease
Chronic Obstructive Pulmonary Disease,
Atherosclerosis →
Alzheimer’s
Disease 6
Cardiopulmonary Arrest
Acute Intracranial
Bleeding (Non-Traumatic) Hypertension →
Acute Intracranial Bleeding (Non-
Traumatic)
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
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
Proportion of Deaths Due To Select Causes in US, NYC and NYC Specific Hospitals
(note: hospital specific data are preliminary 2008)
0%
20%
40%
60%
80%
100%Parkinson's disease G20-G21
Alzheimer's disease G30
Septicemia A40-A41
Chronic lower respiratorydiseases J40-J47
Cerebrovascular diseases I60-I69
Influenza and pneumonia J10-J18
Diseases of heart I00-I09,I11,I13,I20-I51
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
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
3 Major Reasons for Rejecting a Death Certificate
1) Potential Medical Examiner Investigation
2) Reported only mechanisms of death, e.g., » Cardiopulmonary arrest» Cardiac arrest» Respiratory arrest» Asystole
3) Not using BLACK ink
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
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
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
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
Most recent condition (Cardiac tamponade) ½ hour
Next oldest condition (Ruptured Myocardial infarction) 8 hour
Next oldest condition (Atherosclerotic coronary artery disease)
15 years
Pre/co-existing conditions likely contributing to death but not resulting in the cause above (Heavy Smoker)
Oldest (original, initiating) condition (Hypercholesterolemia)
30 years
Data Quality: Hospital InterventionExamples – NAME*
Part I A. Gastrointestinal hemorrhage
B. Undetermined natural causes C.
Part I A. Gastrointestinal hemorrhage B. Probable peptic ulcer disease C.
* 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
Pareto Chart of Heart Disease Deaths Percent of Deaths Reported as Due to Heart Disease,
by Institution, NYC, 2008 (Preliminary)
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HO
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% of Heart Disease Deaths in EachHospital
Cumulative % of NYC Total Deaths
Cumulative % of NYC Heart DiseaseDeaths
NYC Hospitals
US
NYC
NYC vs. US: Age-adjusted death rate per 100,000 population, 2006
Cause of Death NYC USA
Diseases of heart 255 200
Malignant neoplasms 158 181
Influenza and pneumonia 30 18
Cerebrovascular diseases 20 44
Chronic lower respiratory diseases 17 40
Nephritis, nephrotic syndrome and nephrosis 6 14
Intentional self-harm (suicide) 5 11
Chronic liver disease and cirrhosis 5 9
Septicemia 5 11
Alzheimer's disease 3 23
Parkinson's disease 2 6