Assessing the policy utility of routine mortality statistics: a global classification of countries.

Objective: To evaluate the utility and quality of death registration data across countries. Methods: We compiled routine death and cause of death statistics data from 2015-2019 from national authorities. We estimated completeness of death registration using the Adair-Lopez empirical method. The quality of cause of death data was assessed by evaluating the assignment of usable causes of death among people younger than 80 years. We grouped data into nine policy utility categories based on data availability, registration completeness and diagnostic precision. Findings: Of an estimated 55 million global deaths in 2019, 70% of deaths were registered across 156 countries, but only 52% had medically certified causes and 42% of deaths were assigned a usable cause. In 54 countries, which are mostly high-income, there is complete and high-quality mortality data. In a further 29 countries, located across different regions, death registration is complete, but cause of death data quality remains suboptimal. Additionally, 37 countries possess functional death registration systems with cause of death data of poor to moderate quality. In 30 countries, death registration ranges from limited to nascent completeness, accompanied by poor or unavailable cause of death data. Furthermore, 38 countries lack accessible data altogether. Conclusion: By implementing more proactive death notification processes, expanding the use of digitized data collection platforms, streamlining data compilation procedures and improving data quality assessment, governments could enhance the policy utility of mortality data. Encouraging the routine application of automated verbal autopsy methods is crucial for accurately determining the causes of deaths occurring at home.

Estimating causes of community death of adults in Myanmar from a nationwide population sample: Application of verbal autopsy.

In Myanmar 84% of deaths occur in the community, of which half are unregistered and none have a reliable cause of death (COD) recorded. Since 2018, Myanmar has introduced improved registration practices and verbal autopsy (VA) to assess whether such methods can produce policy relevant information on community COD. Community health midwives and public health supervisors grade II collected VAs on over 80,000 deaths which occurred between January 2018 and December 2019 in a nationwide sample of 42 townships in Myanmar. Electronic methods were used to collect and consolidate data. The most probable COD was assigned using the SmartVA Analyze 2.0 computer algorithm. Completeness of VA death reporting increased to 71% in 2019. Most adult (12+ years) deaths (82%) were due to non-communicable diseases, primarily stroke, ischemic heart disease and chronic respiratory disease, for both men and women. VA results were consistent with Global Burden of Disease (GBD) Study estimates, except for cirrhosis in men, which was more common, and had a younger age distribution of death than the GBD. Large scale implementation of improved death registration practices and COD diagnosis using VA is feasible and provides plausible, timely, disaggregated and policy relevant information on the leading causes of community death. Addressing the burden of non-communicable diseases, particularly cirrhosis in young men, is an important public health priority in Myanmar. Improving completeness of VA death reporting in poorly performing townships and in neonates, children and women will further improve the policy utility of the VA data.

Comparative performance of national civil registration and vital statistics systems: a global assessment.

Objective: To assess the current state of the world's civil registration and vital statistics systems based on publicly available data and to propose strategic development pathways, including priority interventions, for countries at different levels of civil registration and vital statistics performance. Methods: We applied a performance assessment framework to publicly available data, using a composite indicator highly correlated with civil registration and vital statistics performance which we then adjusted for data incomparability and missing values. Findings: Globally, civil registration and vital statistics systems score on average 0.70 (0-1 scale), with substantial variations across countries and regions. Scores ranged from less than 0.50 in emerging systems to nearly 1.00 in the most developed systems. Approximately one fifth of the world's population live in the 43 countries with low system performance (< 0.477). Irrespective of system development, health sector indicators consistently scored lower than other determinants of civil registration and vital statistics performance. Conclusion: From our assessment, we provide three main recommendations for how the health sector can contribute to improving civil registration and vital statistics systems: (i) enhanced health sector engagement in birth and death notification; (ii) a more systematic approach to training cause of death diagnostics; and (iii) leadership in the implementation of verbal autopsy methods. Four different civil registration and vital statistics improvement pathways for countries at different levels of system development are proposed, that can constitute a blueprint for regional civil registration and vital statistics strengthening activities that countries can adapt and refine to suit their capabilities, resources, and particular challenges.

Global analysis of birth statistics from civil registration and vital statistics systems.

Objective: To assess civil registration and vital statistics completeness for births in World Health Organization's Member States and identify data completeness gaps. Methods: For the 194 Member States, we sourced birth registration data from the United Nations Children's Fund database of national surveys, and, where available, vital registration reports. We acquired publicly available vital statistics compiled by national authorities. We determined civil registration completeness as the percentage of living children younger than five years whose births have been reported as registered. We evaluated vital statistics completeness against the United Nations World Population Prospects' live birth estimates, and grouped countries into seven categories based on their civil registration and vital statistics completeness. Findings: Globally, civil registration completeness for births was 77%, exceeding vital statistics completeness for births at 63%. Twenty countries had limited civil registration (25% to 74% completeness) and had nascent or no vital statistics data (completeness < 25%) for births. Five countries had nascent or no civil registration and vital statistics for births. Twenty countries had functional civil registration (75% to 94% completeness) but nascent or no available vital statistics. Approximately half (96) of the countries had complete civil registration and vital statistics for births, but contributed to only 22% of global births. Conclusion: The gap in completeness between civil registration data and vital statistics for births is most pronounced in countries with lower civil registration completeness. Enhancing data transfer processes for birth registration, along with targeted investments to elevate registration rates, is crucial for yielding comprehensive fertility statistics for governmental planning.

Effect of the COVID-19 pandemic on life expectancy in Australia, 2020-22.

BACKGROUND: Australia provides a valuable international case study of life expectancy during the pandemic. In contrast to many other countries, it experienced relatively stringent restrictions and low COVID-19 mortality during 2020-21, followed by relaxation of these restrictions when high vaccination rates were achieved. This study measures Australia's life expectancy trends and the contributions of age group and causes of death, during the pandemic. METHODS: Trends in life expectancy at birth in Australia and its states and territories were measured from 2020 to 2022. The contributions of age group and cause of death to these trends were measured using decomposition methods. Life expectancy was compared with other high-income countries. RESULTS: Australia's life expectancy fell by more than half a year in 2022, following a sharp increase in 2020 and moderate decline in 2021. For the 3 years 2020 to 2022, life expectancy was 0.13 years (95% confidence interval 0.07-0.19) higher for males and 0.09 years (0.03-0.14) higher for females versus 2017-19. Australia's life expectancy increase in 2020 was larger than that in the vast majority of other high-income countries, but its decline in 2022 was greater than in other countries whose life expectancy rose in the first year of the pandemic. The small negative contribution of COVID-19 deaths to life expectancy in Australia was more than offset by lower non-communicable disease mortality. There were only small differences in life expectancy change between the states with the most stringent restrictions (Victoria and New South Wales) and the rest of Australia. CONCLUSIONS: Australia's life expectancy trends during 2020-22 were relatively favourable compared with other high-income countries, with the exception of its sharp decline in 2022 once restrictions were loosened.

Cardiovascular disease mortality based on verbal autopsy in low- and middle-income countries: a systematic review.

Objective: To conduct a systematic review of verbal autopsy studies in low- and middle-income countries to estimate the fraction of deaths due to cardiovascular disease. Method: We searched MEDLINE®, Embase® and Scopus databases for verbal autopsy studies in low- and middle-income countries that reported deaths from cardiovascular disease. Two reviewers screened the studies, extracted data and assessed study quality. We calculated cause-specific mortality fractions for cardiovascular disease for each study, both overall and according to age, sex, geographical location and type of cardiovascular disease. Findings: We identified 42 studies for inclusion in the review. Overall, the cardiovascular disease cause-specific mortality fractions for people aged 15 years and above was 22.9%. This fraction was generally higher for males (24.7%) than females (20.9%), but the pattern varied across World Health Organization regions. The highest cardiovascular disease mortality fraction was reported in the Western Pacific Region (26.3%), followed by the South-East Asia Region (24.1%) and the African Region (12.7%). The cardiovascular disease mortality fraction was higher in urban than rural populations in all regions, except the South-East Asia Region. The mortality fraction for ischaemic heart disease (12.3%) was higher than that for stroke (8.7%). Overall, 69.4% of cardiovascular disease deaths were reported in people aged 65 years and above. Conclusion: The burden of cardiovascular disease deaths outside health-care settings in low- and middle-income countries is substantial. Increasing coverage of verbal autopsies in these countries could help fill gaps in cardiovascular disease mortality data and improve monitoring of national, regional and global health goals.

Large Discrepancies in Dementia Mortality Reported in Vital Statistics: The Need for Improved Data to Inform Policy.

PURPOSE: There is limited understanding of the intercountry comparability of dementia mortality data. This study compares reported dementia mortality in national vital statistics between countries and over time. In countries with low dementia reporting, this study identifies other causes to which dementia may be misclassified. METHODS: Using the World Health Organization (WHO) Mortality Database, we calculated the ratio of reported to expected (Global Burden of Disease estimated) age-standardized dementia death rates in 90 countries from 2000 to 2019. Other causes to which dementia may be misclassified were identified as having relatively high cause fractions compared with other countries. PATIENTS: No patients were involved. RESULTS: There is a large intercountry variation in reported dementia mortality rates. The ratio of reported to expected dementia mortality exceeded 100% in high-income countries but was below 50% in other super regions. In countries with low reported dementia mortality, cardiovascular diseases, ill-defined causes, and pneumonia have relatively high cause fractions and may be misclassified from dementia. DISCUSSION: Large discrepancies in dementia mortality reporting between countries, including often implausibly low reported mortality, makes comparison extremely difficult. Improved guidance for and training of certifiers and the use of multiple cause-of-death data can help strengthen the policy utility of dementia mortality data.

Improving the quality of external cause of death data in Brazil: evaluation and validation of a new form to investigate garbage codes.

Garbage codes, such as external causes with no specific information, indicate poor quality cause of death data. Investigation of garbage codes via an effective instrument is necessary to convert them into useful data for public health. This study analyzed the performance and suitability of the new investigation of deaths from external causes (IDEC) form to improve the quality of external cause of death data in Brazil. The performance of the IDEC form on 133 external garbage codes deaths was compared with a stratified matched sample of 992 (16%) investigated deaths that used the standard garbage codes form. Consistency between these two groups was checked. The percentage of garbage codes from external causes reclassified into valid causes with a 95% confidence interval (95%CI) was analyzed. Reclassification for specific causes has been described. Qualitative data on the feasibility of the form were recorded by field investigators. Investigation using the new form reduced all external garbage codes by -92.5% (95%CI: -97.0; -88.0), whereas the existing form decreased garbage codes by -60.5% (95%CI: -63.5; -57.4). The IDEC form presented higher effectivity for external-cause garbage codes of determined intent. Deaths that remained garbage codes mainly lacked information about the circumstances of poisoning and/or vehicle accidents. Despite the fact that field investigators considered the IDEC form feasible, they suggested modifications for further improvement. The new form was more effective than the current standard form in improving the quality of defined external causes.

Premature cardiovascular disease mortality with overweight and obesity as a risk factor: estimating excess mortality in the United States during the COVID-19 pandemic.

BACKGROUND: The United States has experienced high levels of excess mortality during the COVID-19 pandemic and also has high prevalence of overweight and obesity, which increases the risk of severe infection and death from the virus. This study uses multiple cause of death data to estimate excess premature cardiovascular disease mortality in the USA in 2020 for which overweight and obesity was a risk factor. METHODS: The contribution of overweight and obesity to premature (35-74 years) cardiovascular disease mortality was measured as cardiovascular disease reported on the death certificate with one or more of diabetes, chronic kidney disease, obesity, lipidemias or hypertensive heart disease (DKOLH-CVD). Excess mortality was calculated as the difference between actual and expected age-standardised death rates. Expected deaths were estimated using negative binomial regressions of monthly deaths during 2010-19. RESULTS: Excess DKOLH-CVD mortality in March-December 2020 was 29% (95% uncertainty interval 28-31%) for males and 30% (28-32%) for females, much higher than for all causes (males 19% (18-21%), females 16% (14-17%)). Excess mortality was higher where two or more DKOLH conditions (males 40% (37-43%), females 41% (37-44%)) or obesity (males 42% (38-45%), females 47% (43-51%)) were reported. One-half of excess DKOLH-CVD mortality was reported as due to COVID-19, lower than the four-fifths of excess all-cause deaths. For home deaths, just over 10% of excess mortality for each cause classification was reported as due to COVID-19. CONCLUSIONS: Excess premature cardiovascular disease mortality in the USA for which overweight and obesity was a risk factor was considerably higher than for all causes, exacerbating adverse pre-pandemic trends. The contribution of COVID-19 to excess mortality appears significantly under-reported for home deaths.

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.

Improving the quality of external cause of death data in Brazil: evaluation and validation of a new form to investigate garbage codes / Melhorando a qualidade dos dados de causa externa de morte no Brasil: avaliação e validação de um novo formulário para investigar códigos garbage / Mejora en la calidad de los datos de causa externa de muerte en Brasil: evaluación y validación de un nuevo formulario para investigar códigos garbage

Garbage codes, such as external causes with no specific information, indicate poor quality cause of death data. Investigation of garbage codes via an effective instrument is necessary to convert them into useful data for public health. This study analyzed the performance and suitability of the new investigation of deaths from external causes (IDEC) form to improve the quality of external cause of death data in Brazil. The performance of the IDEC form on 133 external garbage codes deaths was compared with a stratified matched sample of 992 (16%) investigated deaths that used the standard garbage codes form. Consistency between these two groups was checked. The percentage of garbage codes from external causes reclassified into valid causes with a 95% confidence interval (95%CI) was analyzed. Reclassification for specific causes has been described. Qualitative data on the feasibility of the form were recorded by field investigators. Investigation using the new form reduced all external garbage codes by -92.5% (95%CI: -97.0; -88.0), whereas the existing form decreased garbage codes by -60.5% (95%CI: -63.5; -57.4). The IDEC form presented higher effectivity for external-cause garbage codes of determined intent. Deaths that remained garbage codes mainly lacked information about the circumstances of poisoning and/or vehicle accidents. Despite the fact that field investigators considered the IDEC form feasible, they suggested modifications for further improvement. The new form was more effective than the current standard form in improving the quality of defined external causes.

Códigos garbage (códigos inespecíficos ou incompletos), como causas externas sem informações específicas, indicam dados de má qualidade sobre a causa da morte. É necessário investigar os códigos garbage com um instrumento efetivo para convertê-los em dados úteis para a saúde pública. Este estudo analisou o desempenho e a adequação do novo formulário de investigação de óbitos por causas externas (IDEC) para melhorar a qualidade dos dados de causa externa de morte no Brasil. O desempenho deste formulário em 133 óbitos com códigos garbage de causas externas foi comparado com uma amostra estratificada e pareada de 992 (16%) óbitos investigados que utilizaram o formulário padrão de códigos garbage existente. A consistência entre esses dois grupos foi verificada. Analisou-se o percentual de códigos garbage de causas externas reclassificados em causas válidas com um intervalo de 95% de confiança (IC95%). A reclassificação para causas específicas foi descrita. Dados qualitativos sobre a viabilidade do formulário foram registrados por pesquisadores de campo. A investigação com o novo formulário reduziu todos os códigos garbage de causas externas em -92,5% (IC95%: -97,0; -88,0) enquanto o formulário existente diminuiu os códigos garbage em -60,5% (IC95%: -63,5; -57,4). O formulário IDEC foi mais eficaz para os códigos garbage de causa externa sem intenção indeterminada. As mortes que permaneceram como códigos garbage careciam principalmente de informações detalhadas sobre as circunstâncias do envenenamento e dos acidentes de trânsito. O formulário IDEC foi considerado viável pelos investigadores de campo, no entanto, eles sugeriram modificações para um maior aperfeiçoamento. O novo formulário foi mais eficaz do que o formulário padrão atual na melhoria da qualidade das causas externas definidas.

Códigos garbage (códigos inespecíficos o incompletos), como causas externas inespecíficas, son los indicadores de datos de mala calidad sobre la causa de muerte. Es necesario investigar los códigos garbage con un instrumento eficaz para convertirlos en datos útiles para la salud pública. Este estudio analizó el desempeño y la adecuación del nuevo formulario de investigación de muertes por causas externas (IDEC) para mejorar la calidad de los datos de causa externa de muerte en Brasil. El desempeño de este formulario en 133 muertes con códigos garbage de causas externas se comparó con una muestra estratificada y emparejada de 992 (16%) muertes investigadas que usaron el formulario estándar de códigos garbage existente. Se comprobó la consistencia entre estos dos grupos. Se analizó el porcentaje de códigos garbage por causas externas reclasificados en causas válidas con un intervalo del 95% de confianza (IC95%). Se procedió a una reclasificación por causas específicas. Los datos cualitativos sobre la viabilidad del formulario fueron registrados por investigadores de campo. La investigación con el nuevo formulario tuvo una reducción de todos los códigos garbage de causas externas en -92,5% (IC95%: -97,0; -88,0), mientras que el formulario existente redujo todos los códigos garbage de causas externas en -60,5% (IC95%: -63,5; -57,4). El formulario IDEC fue el más efectivo para códigos garbage de causa externa sin intención indeterminada. Las muertes que quedaron como códigos garbage carecían principalmente de información detallada sobre las circunstancias de envenenamiento y de accidentes de tránsito. Los investigadores de campo confirmaron la viabilidad del formulario IDEC, además de sugerir modificaciones para mejorarlo. El nuevo formulario fue el más efectivo que el formulario estándar actual en cuanto a la mejora de la calidad de las causas externas definidas.

Estimation of national and subnational all-cause mortality indicators in Nepal, 2017.

BACKGROUND: Despite the civil registration and vital statistics (CRVS) system in Nepal operating for several decades, it has not been used to produce routine mortality statistics. Instead, mortality statistics rely on irregular surveys and censuses that primarily focus on child mortality. To fill this knowledge gap, this study estimates levels and subnational differentials in mortality across all ages in Nepal, primarily using CRVS data adjusted for incompleteness. METHODS: We analyzed death registration data (offline or paper-based) and CRVS survey reported death data, estimating the true crude death rate (CDR) and number of deaths by sex and year for each province and ecological belt. The estimated true number of deaths for 2017 was used with an extension of the empirical completeness method to estimate the adult mortality (45q15) and life expectancy at birth by sex and subnational level. Plausibility of subnational mortality estimates was assessed against poverty head count rates. RESULTS: Adult mortality in Nepal for 2017 is estimated to be 159 per 1000 for males and 116 for females, while life expectancy was estimated as 69.7 years for males and 73.9 years for females. Subnationally, male adult mortality ranges from 129 per 1000 in Madhesh to 224 in Karnali and female adult mortality from 89 per 1000 in Province 1 to 159 in Sudurpashchim. Similarly, male life expectancy is between 64.9 years in Karnali and 71.8 years in Madhesh and female male life expectancy between 69.6 years in Sudurpashchim and 77.0 years in Province 1. Mountain ecological belt and Sudurpashchim and Karnali provinces have high mortality and high poverty levels, whereas Terai and Hill ecological belts and Province 1, Madhesh, and Bagmati and Gandaki provinces have low mortality and poverty levels. CONCLUSIONS: This is the first use of CRVS system data in Nepal to estimate national and subnational mortality levels and differentials. The national results are plausible when compared with Global Burden of Disease and United Nations World Population Prospects estimates. Understanding of the reasons for inequalities in mortality in Nepal should focus on improving cause of death data and further strengthening CRVS data.

Validation studies of verbal autopsy methods: a systematic review.

BACKGROUND: Verbal autopsy (VA) has emerged as an increasingly popular technique to assign cause of death in parts of the world where the majority of deaths occur without proper medical certification. The purpose of this study was to examine the key characteristics of studies that have attempted to validate VA cause of death against an established cause of death. METHODS: A systematic review was conducted by searching the MEDLINE, EMBASE, Cochrane-library, and Scopus electronic databases. Included studies contained 1) a VA component, 2) a validation component, and 3) original analysis or re-analysis. Characteristics of VA studies were extracted. A total of 527 studies were assessed, and 481 studies screened to give 66 studies selected for data extraction. RESULTS: Sixty-six studies were included from multiple countries. Ten studies used an existing database. Sixteen studies used the World Health Organization VA questionnaire and 5 studies used the Population Health Metrics Research Consortium VA questionnaire. Physician certification was used in 36 studies and computer coded methods were used in 14 studies. Thirty-seven studies used high level comparator data with detailed laboratory investigations. CONCLUSION: Most studies found VA to be an effective cause of death assignment method and compared VA cause of death to a high-quality established cause of death. Nonetheless, there were inconsistencies in the methodologies of the validation studies, and many used poor quality comparison cause of death data. Future VA validation studies should adhere to consistent methodological criteria so that policymakers can easily interpret the findings to select the most appropriate VA method. PROSPERO REGISTRATION: CRD42020186886.

Assessing the Diagnostic Accuracy of Physicians for Home Death Certification in Shanghai: Application of SmartVA.

Approximately 30% of deaths in Shanghai either occur at home or are not medically attended. The recorded cause of death (COD) in these cases may not be reliable. We applied the Smart Verbal Autopsy (VA) tool to assign the COD for a representative sample of home deaths certified by 16 community health centers (CHCs) from three districts in Shanghai, from December 2017 to June 2018. The results were compared with diagnoses from routine practice to ascertain the added value of using SmartVA. Overall, cause-specific mortality fraction (CSMF) accuracy improved from 0.93 (93%) to 0.96 after the application of SmartVA. A comparison with a "gold standard (GS)" diagnoses obtained from a parallel medical record review investigation found that 86.3% of the initial diagnoses made by the CHCs were assigned the correct COD, increasing to 90.5% after the application of SmartVA. We conclude that routine application of SmartVA is not indicated for general use in CHCs, although the tool did improve diagnostic accuracy for residual causes, such as other or ill-defined cancers and non-communicable diseases.

Mortality surveillance in Brazil: factors associated with certification of unspecified external cause of death.

This article aims to analyze the association between characteristics of death - type of certifier and place of death - and the odds of an external cause death being certified as unspecified in Brazil. Cross-sectional study of deaths due to external causes from the Mortality Information System, 2017. Unspecified external cause (UEC) is the outcome variable in the models. Type of certifier physician, place of death and the interaction of these variables were the explanatory variables. Confounders were controlled by multiple logistic regression. UEC were the initial underlying cause for 22% of the 159,720 deaths from external causes in Brazil and 31% of hospital deaths issued by coroners. After adjustment for confounders, the odds of UEC in a hospital death certified by a coroner was 98% greater (OR=1.98; 95%CI: 1.53; 2.56) than in a home/street death issued by another certifier. This was greater than the odds for certifications by coroners (OR=1.23; 95%CI: 1.14; 1.33) and hospital deaths (OR=1.44; 95%CI: 1.32; 1.58). External causes certified by coroners and/or occurring in hospitals have a higher presence of UEC than other deaths; and indicate the need for coordinated initiatives by the health and public security sectors.