Title: A training package on certification of causes of death for European professionals
1A training package on certification of causes of
death for European professionals
WHO-FIC Education Committee WHO-FIC IFHRO Joint
Committee Alexandria, Virginia May 4-6, 2006
- Monica Pace
- ISTAT - Italian National Institute of Statistics,
- Central Directorate on Social Statistics
- - Management of Health Classifications Unit -
- mopace_at_istat.it
2The Project Development of an EU training
package on certification of causes of death
- Financed in the framework of the European
Statistical Programme 2003-2007 - Leader Institution Istat (Italian National
Institute of Statistics) - Duration 18 months (Dec 2002 June 2004)
- Involved countries all EU 15 Member States,
EEA/EFTA (European Economic Area / European Free
Trade Association) countries and CEEC (Central
and Eastern Europe Countries Candidate
Countries and Western Balkan Countries or CARDS
Countries) for a total of 40 countries/regions. - The training package has been adopted by the
Eurostat Technical Meeting on causes of death
(CoD) statistics in October 2004. - The Eurostat Working Group on Public Health
Statistics has expressed its support to the
implementation and use of the EU training
package. - Member States should now take action for
national adaptation, translation and use of the
tool.
3Project Aims
- To provide a common training background for
European physicians in the completion of the
medical part of death certificate - To address to CoD certifying professionals and
students, by recognizing their central role in
the mortality data production - To comply with the WHO guidelines and EUROSTAT
CoD task force recommendations. - To develop a strong interaction with all the
participating countries on the products
structure and contents - To develop generalized products requiring
subsequent national adaptations by each country
to own certificate format, certification
practices and laws.
4Project outputs
- Technical report (English)
- Manual (English and French)
- Web-based e-learning tool (English)
- Leaflet (English and French)
5Technical Report in pills
- Questionnaire 51 questions
- Experts from 40 countries/regions 37 of these
sent answers back - Review of existing training tools
- 9 manuals or booklets
- 4 web-sites
- 6 leaflets
- Collection of 340 published studies
- Collection of 23 original national death
certificates
6Survey on EU certification practices and
harmonization
- 80 of the c-r agree on the need to collect more
details on autopsies - 78 have at least a question on autopsy
- 70 collect information on place of accident
- 65 receive certificates without any medical
information - 57 collect information on occupational accident
or disease - 51 believe that the role of Part II of the
certificate, or an item on other significant
conditions contributing to the death, is not well
understood by physicians - 27 collect information on pregnancy
- 24 collect information on recent surgery
- 81 of the countries/regions consider European
harmonization feasible - 78 consider European harmonization necessary
7Survey on training practices
- 97 of the countries/regions are unsatisfied by
the training courses for physicians (31/32) - 65 believe that the guidelines they use need to
be improved - 67 declare to have training for students
- 77 are unsatisfied by the training courses for
students (24/31) - 36 declare to have training for
physicians/certifying professionals - Almost all the experts agree that the following
items should be included in the training (see
Techn. Rep. for a complete list) - an explanation of causes of death data as a major
public health indicator - the concept of the causes of death sequence and
the selection of the initial cause - a list of imprecise causes to avoid
- examples presentation
- the problem of contributory causes
- practical training of the real case studies and
feedback on answers
8MANUAL contact person at EurostatSabine.GAGEL
_at_cec.eu.int
9Manual main features
- 5 Chapters
- Introduction
- definitions and best practices
- external causes of death
- 54 correctly completed case histories
- glossary
- list of imprecise causes and hints on how to
improve specificity - 4 Annexes
- National Mortality data flow (to be adapted)
- Eurostat recommendations
- National laws on vital statistics (to be adapted)
- Short guide to National implementation
- 8 Boxes
- five boxes on best certification practices
- one box on how to report neoplasm
- two more boxes on external causes of death
(traffic accidents and accidents in medical care)
10Implementation strategies I
- Particular attention was addressed on the need to
adapt the manual to the National laws and
regulations for this purpose warnings or
specific notes were added where needed - The inclusion of additional information
(pregnancy, place of death, place of accident,
manner of death, autopsies, etc) in a new
training package for Europe represents a factual
effort in giving a common basis for European
certification criteria, fulfilling international
guidelines and making an effort to put
European-agreed recommendations into practice.
These information were presented into the manual
as an additional information box added below
the WHO form. Each country should decide how to
deal with such a box, based upon National needs. - Several reference-marks to specific case
histories were included into the fluent text,
into the boxes and into the last chapter too in
order to provide examples of well-completed death
certificates for each item treated in the manual - Flexibility to the manual implementation was
introduced by the two-levels of detail offered.
11Implementation strategies II
- In fact, the manual can be fully
translated/adapted in the extended version as it
is now, or implemented in a basic condensed way
which could include - introduction
- national death certificate form
- six or eight quick tips boxes their number
depending on National laws for certifying the
external causes of death - some case histories
- general hints on how to add specificity on
selected group of diseases or conditions - annexes.
12WEB-BASED E-LEARNING TOOLcontact person at
EurostatSabine.GAGEL_at_cec.eu.int
13Some Web-based tool specific aspects
- Specific attention was devoted to e-learning
aspects to organize the didactic pathways and
some navigation options - A balance between interactivity and usability was
sought in order to provide a product using the
web potentiality, but not excluding non-expert
users - The web-tool contents definition implied
- an adaptation of what was already developed for
the manual, - the definition of new specifically developed
funtionality this is particularly true for the
exercises (tests and case histories). - Particular attention was given to the companion
documentation (guides and helps) fully integrated
into the web site, in order to facilitate the use
and spreading of this product - A high level of parameterization was introduced
in the product the result is in our opinion a
truly generalized product that allow easy
national adaptations. - Multiple evaluations of the web-tool were
performed by about 50 different European
professionals including physicians, medical
schools professors, IT engineers, IT programmers,
e-learning experts, statisticians, nosologists,
represented by SB members, experts from Italy,
England, Norway, Sweden try-out responders
EUROSTAT experts.
14Web-tool main features
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16Tutorial Introduction
17Tutorial II Multiple choice test
18Tutorial III Multiple choice test
19Tutorial Case History
20Tutorial Case History
21Tools Dynamic Certificate
22Tools Hints on how to add specificity
23Tools Quick Tips
24WEB-BASED E-LEARNING TOOL- ADMINISTRATION
contact person at EurostatSabine.GAGEL_at_cec.eu
.int
25Local Administrator Home
26Local Administrator Load and define D. C. - I
27Local Administrator Load and define D. C. - II
28LEAFLET contact person at EurostatSabine.GAGE
L_at_cec.eu.int
29Leaflet main features
- Single A4 sheet of paper folded into three parts
and colour printed on both pages - Can be easily protected with plastic for a
prolonged use - Recall the main topics and guidelines in death
certification - Only the WHO international death certificate is
shown for clarity purposes - Few, relevant and useful concepts
- Few, relevant and useful examples
- Pleasant graphic impact appealing and easy to
remember - Ready-to-use tool to be used in the moment of
certification in order to avoid the most common
mistakes - Easy dissemination, low costs the target should
be easily reached
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32- Steering board composition
- Gerard Pavillon (France)
- Mary Heanue (Ireland)
- Monika Bene (Hungary)
- Lois Cook (UK)
- Renzo Pace Asiak (Malta)
- Jacques Bonte Expert privè
- ISTAT work team
- Monica Pace (Researcher, Project Leader)
- Roberta Crialesi (Head of Health Statistics
Section) - Luisa Frova (Head of Mortality by Cause Unit)
- Silvia Bruzzone (Researcher, Project
Coordinator) - Stefano Marchetti (Researcher, Web site project)
- Giuseppe Sindoni (Researcher, e-learning
aspects, data-base supervision, consultant on
try-out methodologies - DCMT) - Francesco Grippo (Assistant Researcher)
- Simona Cinque (Assistant Researcher)
- Marilena Pappagallo (Assistant Researcher)
- Simona Pennazza (Assistant Researcher)
- Gennaro Di Fraia (Assistant Researcher)
33Box 6 - Neoplasm reporting check-list
- Please remember to specify
- Whether benign, malignant or uncertain behaviour
- The primary site if known
- If the primary site is unknown
- The morphological type if known
- Site(s) of metastases and primary site if known
- The expression metastatic from site defines the
primary site(s) - The expression metastatic to site defines the
secondary site(s) - Possibly avoid non-specific terminology such as
carcinomatosis, carcinosis, growth,
malignancy, etc - Identify leukemia as acute, sub-acute or
chronic, and define the involved cell type. - (See case histories N. 11-15)
34Importance of providing the best medical opinion I
35Importance of providing the best medical opinion
II
36IV ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS
- General information to be reported by the
certifier in order to add specificity to the
endocrine, nutritional and metabolic disorders - Nature of the disease process or disturbance of
function e.g. corticoadrenal insufficiency e.g
congenital syndrome of iodine deficiency - Type of deficiency, etc. e.g. pure
hyperglyceridaemia - Severity, where appropriate.
- See also case histories N. 5 7
37Conclusions
- This project represents a real effort in the
improvement of quality and comparability of
mortality statistics in Europe - The intent has been to provide a common set of
existing rules on certification of causes of
death in the respect of International guidelines
and of National practices and laws as well - Management of the web-tool is a crucial point
that could be done at three different levels on
the EUROSTAT server for all countries, on a
different central server for all countries, or on
each interested country server. The decision on
this aspect deserves particular attention for its
consequences in terms of technical management as
well as in terms of economic resources to be
allocated for each solution by different European
or National Institutions
38Future perspectives I
- Dissemination and sensitization of the European
countries to adopt the developed products is a
critical point now because such a work deserves
to be implemented and used to be effective
(EUROSTAT recommendations 30-32) - Collaboration with WHO should be sought and
specific campaigns should be done to reach this
goal in the next few years (EUROSTAT recomm.
33-36) - A system to keep the collected information
updated for all European countries should be
organized, and some suggestions came from this
project (EUROSTAT recommendation 21) - One of the most interesting and promising results
of this project is the possibility to load a
national death certificate instead of limiting
the training to the neutral international death
certificate form. Such a new approach opens new
possibilities in the effectiveness of training on
certification of causes of death, and most
important, offers a first experimental use of IT
technology in Europe to train certifiers to
complete an electronic image of their National
certificate. This innovation could represents the
first step towards the electronic death
certificate (EUROSTAT recommendation 22)
39Future perspectives II
- The use of the WHO international death
certificate form and the definition and future
use of agreed additional information (EUROSTAT
recommendations 15-20) may represent a first step
towards the European Death Certificate - The infant mortality certification issue still
remain to be defined and future efforts should be
done in this direction both on the definition of
a common informative basis (for certificate
format, age of reference, etc...) as well as on
the certification practices (EUROSTAT
recommendations 11-14).