Elizabeth M Begier, MD, MPH Assistant Commissioner Bureau of Vital Statistics NYC Department of Health & Mental Hygiene NAPHSIS June 9, 2010 Intervening

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

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

* * * * * * * * * *

Institution (* intervention institution)

Pro

po

rtio

n d

eath

s d

ue

to H

D

0

10

20

30

40

50

60

70

80

90

100

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

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

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

0

10

20

30

40

50

60

70

80

Heart Disease

Pro

port

ion o

f al

l D

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

3

0.8

5.7

0

1

2

3

4

5

6

% % % %

Septicemia Alzheimer's Parkinson's StrokeDisease

Pro

po

rtio

n o

f a

ll D

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


ATHEROSCLEROTIC HEART DISEASE

→ HD



→ HD



→ HD



→ HD



→ HD



CONGESTIVE HEART FAILURE

→ HD


CHF ASHD → HD


MYOCARDIAL INFARCTION


→ 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


ACUTE MYOCARDIAL INFARCTION

DIABETES MELLITUS → HD


ASHD PRE RENAL AZOTEMIA

→ HD



DIABETES MELLITUS → HD



LOBAR PNEUMONIA

→ HD



LOBAR PNEUMONIA

→ HD



URINARY TRACT INFECTION SECONDARY TO E. COLI

→ HD


CHF ASHD AIDS, ETIOLOGY UNKNOWN

→ HD

CARDIORESPIRATORY ARREST

CORONARY ARTERY ATHEROSCLEROSIS

STOMACH CANCER

→ HD

CARDIORESPIRATORY FAILURE


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

0.1

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

po

rtio

n o

f d

eath

s d

ue

to h

eart

dis

ease

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

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

Facility (* indicates intervention hospital)

Pro

po

rtio

n d

eath

s d

ue

to h

eart

dis

ease

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

Ave

rag

e n

um

ber

of

con

dit

ion

s g

iven

on

dea

th

cert

ific

ate

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)

0

0.5

1

1.5

2

2.5

3

3.5

Jan - Mar 2009 Apr - Jun 2009 Jul - Sept 2009 Oct - Dec 2009 Jan - Mar 2010

Ave

rag

e n

um

ber

of

con

dit

ion

s re

po

rted

on

dea

th c

erti

fica

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


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


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


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)

0

10

20

30

40

50

60

70

80

90

100

HO

SP

ITA

L X

Institution

% o

f H

eart

Dis

ease

Dea

ths

per

Ho

spit

al

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Cu

mu

lati

ve %

of

Hea

rt D

isea

se D

eath

s

% 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

Documents

Elizabeth M Begier, MD, MPH Assistant Commissioner Bureau of Vital Statistics NYC Department of Health & Mental Hygiene NAPHSIS June 9, 2010 Intervening