Elizabeth M Begier, MD, MPH Assistant Commissioner Bureau of Vital Statistics NYC Department of Health & Mental Hygiene NAPHSIS June 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 US o US 2006 : 199/100,000 Population o 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 o 94% overestimated for decedents 75–84 years o 137% overestimated for decedents >85 years How NYC identified the Problem

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 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 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,

Data Quality: focus on natural causes 2.October, 2008 City Health Information (CHI) - Improving Cause of Death Reporting –Published, Oct

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 2006 NYC 2006 USA 2006

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

Death Certificate vs. Medical Records Data SourcePart I aPart I bPart I cPart II Underlying Cause Death Certificate Acute renal Failure Coronary Artery Disease →Heart Disease Medical Record Respira- tory Failure PneumoniaParkin- son’s Disease AMI, Acute renal failure, Anemia, CAD, Hypertension, CHF →Parkinson’s Disease

Death Certificate vs. Medical Records Data SourcePart I aPart I bPart 1 cPart 1 dPart II Underlying Cause Death Certificate Atherosclerotic Heart Disease →Heart Disease Medical Record 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 Intervention Examples – NAME* * National Association of Medical Examiners website, Writing Cause of Death Statements 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”

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

Comparison of proportion of heart disease deaths 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

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

Examples of Well Documented Cases

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)

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 Intervention Examples – 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

Cause of Death Section of Electronic Death Registration System

NYC Hospitals US NYC

NYC vs. US: Age-adjusted death rate per 100,000 population, 2006 Cause of DeathNYCUSA Diseases of heart Malignant neoplasms Influenza and pneumonia 3018 Cerebrovascular diseases 2044 Chronic lower respiratory diseases 1740 Nephritis, nephrotic syndrome and nephrosis 614 Intentional self-harm (suicide) 511 Chronic liver disease and cirrhosis 59 Septicemia 511 Alzheimer's disease 323 Parkinson's disease 26