Training of Certifiers in the United States

Donna L. HoyertRobert N. Anderson

National Center for Health Statistics (NCHS)

US Vital Statistics System

Decentralized system

State vital statistics laws and regulations

57 registration areas

Funeral directors, physicians, medical examiners or coroners

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Scale

2.4 million deaths annually

700,000-800,000 practicing physicians, medical examiners, and coroners

Skewed distribution of certification

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Training in Decentralized System

Not NCHS’ responsibility to train certifiers

NCHS helps facilitate training but does more

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Workshops on Improving Cause-of-Death Statistics

Sponsors: NCHS & National Committee on Vital and Health Statistics

Attendees:Federal vital statistics staff

State vital statistics staff

Professional organization representatives

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Workshop Recommendations

Need broad-based educational training of certifiers

Multiple approaches

Multiple encounters

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Workshop Recommendations

Training message:Importance of cause-of-death statistics

Value of statistics in improving the practice of medicine

Mechanics of completing the death certificate

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Workshop Recommendations

Training Timing:

Medical school- Minimal orientation to process but emphasis on importance of statistics and physician contribution

Internship and residency- key time to begin training physicians

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Follow through on Workshop Recommendations

Recommendations concerning training &:

Medical school

Internship & residency

Licensure & board certification

Practicing physicians

Medical examiners and coroners

Hospitals

Information dissemination and software

Other areas 9

Workshop Results

Workshop reports widely distributed

Resolutions of support

Notices of initiative in variety of publications

NCHS produced additional training material

States may have increased efforts

Other promising developments withered

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Training Materials

Instructions on death certificate

Laminated instructions

Handbooks etc.

Exhibits

Presentations

Web page

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Instructions on death certificate

Examples and some instructions

Purpose: To make sure instructions are available to every certifier who is completing a death certificate

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Instructions in an electronic death registration system

NCHS recommendations for help screens, prompts, and queries on an electronic death certificate developed in 1999

Above recommendations were incorporated into the Death edit specifications for 2003 revision (http://www.cdc.gov/nchs/data/dvs/FinalDeathSpecs2-22-05.pdf)

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Laminated instructions

2 separate pages of instructions

Purpose: To provide certifiers with a quick and handy reference

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Handbooks and other publications

NCHS handbooks

Series report

CAP manuals

Journal articles

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Handbooks

Text, instructions, examples

Purpose: To provide more detailed instructions tailored to physician or medical examiner and coroner

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Other publicationsText, instructions, examples

Purpose: To distribute instructions and examples in medical professional’s own language differently

Exhibit

Main panel, 4 table top panels, variety of educational handouts

Purpose: To bring and distribute training materials directly to certifiers and to educate them about the importance of accurate cause-of-death certification

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Illustration: Old Exhibit Display

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701970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1995

Cause-of-death informationisusedtoimprovequality of lifeand increaselifeexpectancy forAmericans

Accurate death certificates are importantfor improvingthe health status of the Nation

NationalCenter for Health StatisticsNational CommitteeonVital and HealthStatistics

National Association for PublicHealth Statistics and Information Systems

Mortality trends in theUnited States

Accident death ratesare greater than ratesfor many causes atyounger age groupsand increasemoderately with age.HIV death rates peakfor age groups 25-34and 35-44. Cancerdeath rates increasequickly with age beforeleveling off at 75-84and 85+. Heart diseasedeath rates are highrelative to other causesfor children under 1,low for ages 1-4 and 5-14 and increase foreach subsequent age

Contribution in months to improvement in life expectancy

MortalityTrends1979-97Age-adjusted rate per 100,000 standard populationRate per 100,000 live births

Congenital anomalies

SIDS

Disorders relating to short gestationand unspecified low birthweight RDS

Newborn affected bymaternal complicationsof pregnancy

Age-adjusted death rates for Chronicobstructive pulmonary diseases and alliedconditions have increased fairly steadily since1979 while rates for HIV increaseddramatically from 1987 to 1995 and havedropped since. Rates for cancer have beenrelatively stable but have decreased since1990. Rates have decreased for heart disease,stroke, and accidents.

Heartdisease

Stroke

Rate per 100,000 live births

Majorcausesof deathinfluencing thechange inlifeexpectancy between1995 and1996

Sou rc e: C DC/N CH S, National Vital Stat ist ics System

HIV infection

Heart d isease

Cancer

Homicide

Suicide

Stroke

Diabetes

COPD

Hepatitis

0 0.5 1 1.5 2-0.5-1

Lif e expectancy increased from 75.8 years in 1995 to 76.1 years in 1996 for a total change of0.3 years (i.e., 3.6 months). The total change is the combination of i ncreasing mortality forsome causes and decreasing mortality for other causes. This chart shows the contribution ofspecif ic causes, both positive and negative, to the overall improvement in life expectancy.

Deathratesfor selectedcausesbyage,1997

Sou rce : C DC /NCH S, Nat ional Vita l Stat istics System, preli minar y data .

Rate per 100,000 population

Accidents

HIV

Heart disease

Under 11-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+0.1

1

10

100

1000

10000

Cancer

InfantmortalityratesforSIDS by month, US1989-96

Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul

1989 1990 1991 1992 1993 1994 1995 1996

0

50

100

150

200

250

Source: CDC /NCHS, National Vital Stat ist ics System.

SIDS mortality rates follow a seasonal pattern with high rates in the winter and lowrates in the summer. Infant mortality rates for SIDS decreased about 44 percent

Sourc e: CDC/NCHS, National Vital Stat ist ics System. Preliminary data are basis for 1997 da ta.

1

10

100

1000

HIV

All age groups

1980 1985 1990 1995 199710

100

1000Infants

Inf ant mor tality rates have decreased foreach of these cond itions s ince 1995.Decreases for SIDS and RDS have beenrelatively rapid in recent years; rates f orcongenital anomalies and newborn affectedby maternal complications of pregnancyhave generally decreased since1979. Ratesfor disorders relating to short gestation andunspecif ied low birthweight have been morevariable.

Cancer

COPD

Accidents

1980 1985 1990 1995 199

Some Exhibit LocationsAmerican College of PhysiciansAmerican Academy of PhysiciansAmerican Society of Internal MedicineAmerican Public Health AssociationAmerican College of CardiologyAmerican Society of Clinical OncologyNational Medical AssociationNational Association of Medical ExaminersNational Association for Public Health Statistics and Information SystemsAmerican Geriatrics SocietyAmerican Academy of Family PhysiciansNational Funeral Directors Association

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Training Presentations

Tailored instructional presentation and power point

Purpose: To train certifiers

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Web PageLinks to training resources

Purpose: To help disseminate information

URL:http://www.cdc.gov/nchs/about/major/dvs/handbk.htm

Thank you for your attention.