Is training doctors in medical certification effective? Evidence from a prospective study in the Philippines

Background Correct certification of causes of death by physicians according to International Classification of Diseases (ICD) rules is essential to generate mortality statistics of the quality needed to guide public health policy debates and reliably monitor the impact of health interventions. Several efforts to train doctors have been undertaken in the Philippines to improve Medical Certification of Causes of Death (MCCOD). However, there is very little evidence about the long-term effects of training interventions for medical certification. Objective To test whether there were measurable long-term impacts of this large-scale training intervention for improving medical certification and reducing different types of certification errors. Method We assessed the quality of 2100 MCCOD completed before face-to-face training with those written by the same doctors 6 months after the training. An assessment tool was used to evaluate the quality of MCCOD. Results Less than 1% of the 2100 MCCOD assessed prior to the training were completely error-free, increasing to 19.2% 6 months after the training. On average, the number of errors per certificate fell from 2.2 pre-training to 1.3, six months after training. Importantly, there was a 38% decrease in writing ill-defined causes on the last line, which is particularly important for the policy utility of data. Conclusion Training doctors in correct medical certification can have a long-term impact on medical certification practices. Implications Shorter, more focused, trainings that address the most common medical certification errors could have an even greater impact on medical certification practices.

Registration and medical certification of deaths in the Indian States: A comparative analysis of data of CRS and MCCD reports (2010-2019)

BackgroundThe medical certification of cause of death (MCCD) under Civil Registration System (CRS) has been implemented in the States/UTs in a phased manner to provide data on cause of death but due to incomplete coverage and inadequate quality of civil registration data and medically certified data system, use of this data has been compromised. The completeness of registration of death (CoRD) and completeness of medically certified deaths were assessed from 2010 to 2019 at state level to understand their current status and trend over time and also to identify gaps in data to improve data quality.MethodsCoRD and CoMeRD for each year for each state was calculated from the CRS reports and MCCD reports respectively for the period 2010-2019. Data were analyzed nationally as per geographical region and individual state. Union Territories excluding Delhi and Telangana have not been considered in this analysis.ResultsThe CoRD in India have increased in the CRS from 66.9% in 2010 to 92 percent in 2019, a significant increase of 37.7% over 9 years (P<0.001) whereas India has not witnessed a substantial increase in the CoMeRD in MCCD which has increased from 17.1% in 2010 to only 20.6% in 2019. Among the 29 States, 18 (62%) had CoRD >95 percent in 2019, with 15 states recording 100 percent of CoRD however just 3 states (10.3%) have CoMeRD more than 50% namely Goa (100%), Manipur (67.3%) and Delhi (61.7%).Interpretation & conclusionsDespite the significant progress made in CoRD in India, importance of medical certification cannot be undermined; critical differences between the States within the CRS and MCCD remain a cause of concern. Concentrated efforts to assess the strengths and weaknesses at the State level of the MCCD and CRS processes, quality of data and plausibility of information generated are needed in India.

Generating cause of death information to inform health policy: implementation of an automated verbal autopsy system in the Solomon Islands

Background Good quality cause of death (COD) information is fundamental for formulating and evaluating public health policy; yet most deaths in developing countries, including the Solomon Islands, occur at home without medical certification of cause of death (MCCOD). As a result, COD data in such contexts are often of limited use for policy and planning. Verbal autopsies (VAs) are a cost-effective way of generating reliable COD information in populations lacking comprehensive MCCOD coverage, but this method has not previously been applied in the Solomon Islands. This study describes the establishment of a VA system to estimate the cause specific mortality fractions (CSMFs) for community deaths that are not medically certified in the Solomon Islands. Methods Automated VA methods (SmartVA) were introduced into the Solomon Islands in 2016. Trained data collectors (nurses) conducted VAs on eligible deaths to December 2020 using electronic tablet devices and VA responses were analysed using the Tariff 2.0 automated diagnostic algorithm. CSMFs were generated for both non-inpatient deaths in hospitals (i.e. ‘dead on/by arrival’) and community deaths. Results VA was applied to 914 adolescent-and-adult deaths with a median (IQR) age of 62 (45–75) years, 61% of whom were males. A specific COD could be diagnosed for more than 85% of deaths. The leading causes of death for both sexes combined were: ischemic heart disease (16.3%), stroke (13.5%), diabetes (8.1%), pneumonia (5.7%) and chronic-respiratory disease (4.8%). Stroke was the top-ranked cause for females, and ischaemic heart disease the leading cause for males. The CSMFs from the VAs were similar to Global Burden of Disease (GBD) estimates. Overall, non-communicable diseases (NCDs) accounted for 73% of adult deaths; communicable, maternal and nutritional conditions 15%, and injuries 12%. Six of the ten leading causes reported for facility deaths in the Solomon Islands were also identified as leading causes of community deaths based on the VA diagnoses. Conclusions NCDs are the leading cause of adult deaths in the Solomon Islands. Automated VA methods are an effective means of generating reliable COD information for community deaths in the Solomon Islands and should be routinely incorporated into the national mortality surveillance system.

The impact of errors in medical certification on the accuracy of the underlying cause of death

Background Correct certification of cause of death by physicians (i.e. completing the medical certificate of cause of death or MCCOD) and correct coding according to International Classification of Diseases (ICD) rules are essential to produce quality mortality statistics to inform health policy. Despite clear guidelines, errors in medical certification are common. This study objectively measures the impact of different medical certification errors upon the selection of the underlying cause of death. Methods A sample of 1592 error-free MCCODs were selected from the 2017 United States multiple cause of death data. The ten most common types of errors in completing the MCCOD (according to published studies) were individually simulated on the error-free MCCODs. After each simulation, the MCCODs were coded using Iris automated mortality coding software. Chance-corrected concordance (CCC) was used to measure the impact of certification errors on the underlying cause of death. Weights for each error type and Socio-demographic Index (SDI) group (representing different mortality conditions) were calculated from the CCC and categorised (very high, high, medium and low) to describe their effect on cause of death accuracy. Findings The only very high impact error type was reporting an ill-defined condition as the underlying cause of death. High impact errors were found to be reporting competing causes in Part 1 [of the death certificate] and illegibility, with medium impact errors being reporting underlying cause in Part 2 [of the death certificate], incorrect or absent time intervals and reporting contributory causes in Part 1, and low impact errors comprising multiple causes per line and incorrect sequence. There was only small difference in error importance between SDI groups. Conclusions Reporting an ill-defined condition as the underlying cause of death can seriously affect the coding outcome, while other certification errors were mitigated through the correct application of mortality coding rules. Training of physicians in not reporting ill-defined conditions on the MCCOD and mortality coders in correct coding practices and using Iris should be important components of national strategies to improve cause of death data quality.

Improving quality of medical certification of causes of death in health facilities in Tanzania 2014–2019

Background Monitoring medically certified causes of death is essential to shape national health policies, track progress to Sustainable Development Goals, and gauge responses to epidemic and pandemic disease. The combination of electronic health information systems with new methods for data quality monitoring can facilitate quality assessments and help target quality improvement. Since 2015, Tanzania has been upgrading its Civil Registration and Vital Statistics system including efforts to improve the availability and quality of mortality data. Methods We used a computer application (ANACONDA v4.01) to assess the quality of medical certification of cause of death (MCCD) and ICD-10 coding for the underlying cause of death for 155,461 deaths from health facilities from 2014 to 2018. From 2018 to 2019, we continued quality analysis for 2690 deaths in one large administrative region 9 months before, and 9 months following MCCD quality improvement interventions. Interventions addressed governance, training, process, and practice. We assessed changes in the levels, distributions, and nature of unusable and insufficiently specified codes, and how these influenced estimates of the leading causes of death. Results 9.7% of expected annual deaths in Tanzania obtained a medically certified cause of death. Of these, 52% of MCCD ICD-10 codes were usable for health policy and planning, with no significant improvement over 5 years. Of certified deaths, 25% had unusable codes, 17% had insufficiently specified codes, and 6% were undetermined causes. Comparing the before and after intervention periods in one Region, codes usable for public health policy purposes improved from 48 to 65% within 1 year and the resulting distortions in the top twenty cause-specific mortality fractions due to unusable causes reduced from 27.4 to 13.5%. Conclusion Data from less than 5% of annual deaths in Tanzania are usable for informing policy. For deaths with medical certification, errors were prevalent in almost half. This constrains capacity to monitor the 15 SDG indicators that require cause-specific mortality. Sustainable quality assurance mechanisms and interventions can result in rapid improvements in the quality of medically certified causes of death. ANACONDA provides an effective means for evaluation of such changes and helps target interventions to remaining weaknesses.

Adjusting Reported COVID-19 Deaths for the Prevailing Routine Death Surveillance in India

In India, the “low mortality” narrative based on the reported COVID-19 deaths may be causing more harm than benefit. The extent to which COVID-19 deaths get reported depends on the coverage of routine death surveillance [death registration along with medical certification of cause of death (MCCD)] and the errors in MCCD. In India, the coverage of routine death surveillance is 18.1%. This is compounded by the fact that COVID-19 death reporting is focused among reported cases and the case detection ratio is low. To adjust for the coverage of routine death surveillance and errors in MCCD, we calculated a correction (multiplication) factor at national and state level to produce an estimated number of COVID-19 deaths. As on July 31, 2020, we calculated the infection fatality ratio (IFR) for India (0.58:100–1.16:100) using these estimated COVID-19 deaths; this is comparable with the IFR range in countries with near perfect routine death surveillance. We recommend the release of excess deaths data during COVID-19 (at least in states with high death registration) and post-mortem COVID-19 testing as a surveillance activity for a better understanding of under-reporting. In its absence, we should adjust reported COVID-19 deaths for the coverage of routine death surveillance and errors in MCCD. This way we will have a clear idea of the true burden of deaths and our public health response will never be inadequate. We recommend that “reported” or “estimated” is added before the COVID-19 death data and related indicators for better clarity and interpretation.

Evaluation of Medical Certification of Cause of Death of Tertiary Cancer Hospitals of Northern India

BackgroundMedical Certification of Cause of Death (MCCD) can provide valuable health status data regarding disease incidence, prevalence and mortality in a community. It can guide local health policy and help in setting priorities. On the contrary, incomplete and inaccurate MCCD data can significantly impair the precision of a national health information database. In the current study, the accuracy of death certificates at two tertiary cancer care hospitals in Northern India, has been evaluated.MethodsThis retrospective study has been conducted at Tata Memorial Centres namely, Mahamana Pandit Madan Mohan Malaviya Cancer Centre and Homi Bhabha Cancer Hospital, Varanasi, India on MCCD over a period of two and a half years. Medical records and death certificates of all the deceased were examined. The demographic characteristics, administrative details, co-morbidities and cause of death from death certificates were collected using an approved standardized form. The accuracy of this information was validated using the medical records. Errors in the death certificates were classified according to Haque’s grading scale.1Results778 deaths occurred during the study period between May 2018 to December 2020, and all certificates were accessed for analysis. Only 30 (4%) certificates were error-free. 591(75.9%) death certificates had an inappropriate immediate cause of death. 231(29.7%) death certificates had incorrectly labelled mode of death, such as cardiopulmonary arrest as the immediate cause of death. 585 (75.2%) death certificates had an incorrect underlying cause of death. Majority of the death certificates were prepared by the post MBBS junior residents and this was significantly associated with higher certification errors.ConclusionA high rate of errors was identified in the death certificates completed at our hospitals. Inaccurate death certificates related to cancers can potentially influence the cancer statistics of the defined region and thereby affect policymaking for cancer prevention and control. There is a pressing need for appropriate intervention/s to resolve this important issue. In an attempt to improve the quality of certification, it is envisaged to conduct training for all consultants and residents in proper death certification.

Comparing medical cannabis use in 5 US states: a retrospective database study

Background US states have been adopting their own medical cannabis laws since 1996. There is substantial variability in the medical cannabis programs between states, and these differences have not been thoroughly investigated in the literature. The objective of the study was to compare medical cannabis patient characteristics across five states to identify differences potentially caused by differing policies surrounding condition eligibility. Methods We conducted secondary analyses following a retrospective study of a registry database with data from 33 medical cannabis evaluation clinics in the US, owned and operated by CB2 Insights. This study narrowed the dataset to include patients from five states with the largest samples: Massachusetts (n = 27,892), Colorado (n = 16,434), Maine (n = 4591), Connecticut (n = 2643), and Maryland (n = 2403) to conduct an in-depth study of the characteristics of patients accessing medical cannabis in these states, including analysis of variance to compare average ages and number of conditions and chi-squared tests to compare proportions of patient characteristics between states. Results Average ages varied between the states, with the youngest average in Connecticut (42.2) and the oldest in Massachusetts (47.0). Males represented approximately 60% of the patients with data on gender in each state. The majority of patients in each state had cannabis experience prior to seeking medical certification. Primary medical conditions varied for each state, with chronic pain, anxiety, and back and neck problems topping the list in varying orders for Massachusetts, Maine, and Maryland. Colorado had 78.7% of patients report chronic pain as their primary condition, and 70.4% of patients in Connecticut reported post-traumatic stress disorder as their primary medical condition. Conclusion This study demonstrated the significant impact that policy has on patients’ access to medical cannabis in Massachusetts, Colorado, Maine, Connecticut, and Maryland utilizing real-world data. It highlights how qualifications differ between the five states and brings into question the routes through which patients in states with stricter regulations surrounding eligible conditions choose to seek treatment with cannabis. These patients may turn to alternative treatments, or to the illicit or recreational cannabis markets, where permitted.

IntelligenceGym — is an effective tool to improve cognitive functions in the elderly

Aim. The aim of our study was to verify the effectiveness of the innovative IntelligenceGym training in improving cognitive abilities in the elderly.Material and methods. We developed an original training method that requires interaction between motor and cognitive functions. In our study 123 women and 89 men, aged 68–76 were examined. The inclusion criteria were Mini-Mental State Examination (MMSE) scores of 23 to 25 at inclusion, autonomy in walking, medical certification to participate in light physical activity. We have proposed to the participants to attend IntelligenceGym training one hour twice a week for 24 weeks. Cognitive performance was assessed before and after intervention included MMSE, Forward and Backward Digit Span Test, Rey’s Auditory Verbal Learning test (RAVLT), TMT-A, TMT-B. Moreover, motor performance was tested by using the Time Up and Go (TUG) test.Results.The cognitive assessment after IntelligenceGym training showed statistically significant improvement in all the scores tested (t-test performed). The results showed that participants of the IntelligenceGym training had particularly improved performance in Digit Span, MMSE and TMT-B tests and also improvements in motor TUG test.Conclusion. These findings indicate that the IntelligenceGym training is an efficient tool to improve cognitive performance in older adults with borderline or mild cognitive deficiency.

Aeromedical Implications of Cerebral Cavernomas

BACKGROUND: Cavernomas, cavernous angiomas, or cerebral cavernous malformations are clusters of endothelium-lined blood vessels usually found in the brain. With the increasing use of radiological imaging, these are being detected incidentally in asymptomatic aircrew. The UK Civil Aviation Authority (CAA) experience of cavernomas is described and the aeromedical concerns, that is, the risk of epilepsy, hemorrhage, and the development of a neurological deficit, are considered.METHODS: A search of the CAA database between 1990 and 2020 was performed for the term cavernoma. The gender, age at diagnosis, class of certification held, clinical presentation, location, and size of the lesion were noted. A PubMed literature review for papers with complications of cavernoma was performed.RESULTS: Six cases of cavernoma have been declared to the CAA: five professional pilots and one private pilot. Five were men and one was a woman. The age range was between 38 and 60 yr, with a mean of 48 yr. Two cases presented with clinical symptoms and four were asymptomatic. Complication rates for seizure and hemorrhage were extracted from the published literature together with the significance of other factors such as cavernoma size, family history, multiplicity, and the development of new lesions.DISCUSSION: A policy for the medical certification of aircrew with cavernomas that have presented with clinical symptoms and those that are detected incidentally is proposed.Jagathesan T, OBrien M. Aeromedical implications of cerebral cavernomas. Aerosp Med Hum Perform. 2021; 92(2):120123.