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A training package on certification of causes of death for European professionals

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Title: A training package on certification of causes of death for European professionals


1
A 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

2
The 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.

3
Project 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.

4
Project outputs
  • Technical report (English)
  • Manual (English and French)
  • Web-based e-learning tool (English)
  • Leaflet (English and French)

5
Technical 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

6
Survey 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

7
Survey 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

8
MANUAL contact person at EurostatSabine.GAGEL
_at_cec.eu.int
9
Manual 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)

10
Implementation 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.

11
Implementation 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.

12
WEB-BASED E-LEARNING TOOLcontact person at
EurostatSabine.GAGEL_at_cec.eu.int
13
Some 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.

14
Web-tool main features
15
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16
Tutorial Introduction
17
Tutorial II Multiple choice test
18
Tutorial III Multiple choice test
19
Tutorial Case History
20
Tutorial Case History
21
Tools Dynamic Certificate
22
Tools Hints on how to add specificity
23
Tools Quick Tips
24
WEB-BASED E-LEARNING TOOL- ADMINISTRATION
contact person at EurostatSabine.GAGEL_at_cec.eu
.int
25
Local Administrator Home
26
Local Administrator Load and define D. C. - I
27
Local Administrator Load and define D. C. - II
28
LEAFLET contact person at EurostatSabine.GAGE
L_at_cec.eu.int
29
Leaflet 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

30
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31
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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)

33
Box 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)

34
Importance of providing the best medical opinion I
35
Importance of providing the best medical opinion
II
36
IV 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

37
Conclusions
  • 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

38
Future 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)

39
Future 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).
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