a training package on certification of causes of death for european professionals monica pace istat...
TRANSCRIPT
A training package on A training package on certification of causes of death certification of causes of death
for European professionalsfor European professionals
Monica PaceMonica Pace
ISTAT - Italian National Institute of Statistics,ISTAT - Italian National Institute of Statistics,Central Directorate on Social StatisticsCentral Directorate on Social Statistics
- “Management of Health Classifications” Unit - - “Management of Health Classifications” Unit -
[email protected]@istat.it
WHO-FIC Education CommitteeWHO-FIC Education CommitteeWHO-FIC – IFHRO Joint CommitteeWHO-FIC – IFHRO Joint Committee
Alexandria, VirginiaAlexandria, VirginiaMay 4-6, 2006May 4-6, 2006
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.
The Project “Development of an EU training package on certification of causes of death”
Project AimsProject Aims
To provide a common training background for European To provide a common training background for European physicians in the completion of the medical part of death physicians in the completion of the medical part of death certificate certificate
To address to CoD certifying professionals and To address to CoD certifying professionals and students, by recognizing their central role in the mortality students, by recognizing their central role in the mortality data production data production
To comply with the WHO guidelines and EUROSTAT To comply with the WHO guidelines and EUROSTAT CoD task force recommendations. CoD task force recommendations.
To develop a strong interaction with all the participating To develop a strong interaction with all the participating countries on the products’ structure and contentscountries on the products’ structure and contents
To develop generalized products requiring subsequent To develop generalized products requiring subsequent national adaptations by each country to own certificate’ national adaptations by each country to own certificate’ format, certification practices and laws.format, certification practices and laws.
Project outputsProject outputs
Technical reportTechnical report (English) (English)
ManualManual (English and French) (English and French)
Web-based e-learning toolWeb-based e-learning tool (English) (English)
LeafletLeaflet (English and French) (English and French)
Questionnaire: 51 questionsQuestionnaire: 51 questions Experts from 40 countries/regions; 37 of these sent Experts from 40 countries/regions; 37 of these sent
answers backanswers back Review of existing training tools:Review of existing training tools:
– 9 manuals or booklets9 manuals or booklets– 4 web-sites4 web-sites– 6 leaflets6 leaflets
Collection of 340 published studiesCollection of 340 published studies Collection of 23 original national death certificatesCollection of 23 original national death certificates
Technical Report in pills
Survey on EU certification practices Survey on EU certification practices and harmonizationand harmonization
80% of the c-r agree on the need to collect more details 80% of the c-r agree on the need to collect more details on autopsies on autopsies
78% have at least a question on autopsy78% have at least a question on autopsy 70% collect information on “place of accident”70% collect information on “place of accident” 65% receive certificates without any medical information65% receive certificates without any medical information 57% collect information on “occupational accident or 57% collect information on “occupational accident or
disease”disease” 51% believe that the role of Part II of the certificate, or 51% believe that the role of Part II of the certificate, or
an item on other significant conditions contributing to an item on other significant conditions contributing to the death, is not well understood by physiciansthe death, is not well understood by physicians
27% collect information on pregnancy27% collect information on pregnancy 24% collect information on recent surgery24% collect information on recent surgery 81% of the countries/regions consider European 81% of the countries/regions consider European
harmonization feasible harmonization feasible 78% consider European harmonization necessary 78% consider European harmonization necessary
Survey on training Survey on training practicespractices
97% of the countries/regions are unsatisfied by the training 97% of the countries/regions are unsatisfied by the training courses for physicians (31/32)courses for physicians (31/32)
65% believe that the guidelines they use need to be 65% believe that the guidelines they use need to be improvedimproved
67% declare to have training for students67% declare to have training for students 77% are unsatisfied by the training courses for students 77% are unsatisfied by the training courses for students
(24/31)(24/31) 36% 36% declare to have training for physicians/certifying declare to have training for physicians/certifying
professionalsprofessionals Almost all the experts agree that the following items should Almost all the experts agree that the following items should
be included in the training (see Techn. Rep. for a complete be included in the training (see Techn. Rep. for a complete list):list): an explanation of causes of death data as a major public an explanation of causes of death data as a major public
health indicator;health indicator; the concept of the causes of death sequence and the the concept of the causes of death sequence and the
selection of the initial cause;selection of the initial cause; a list of imprecise causes to avoid;a list of imprecise causes to avoid; examples presentation;examples presentation; the problem of contributory causes;the problem of contributory causes; practical training of the real case studies and feedback on practical training of the real case studies and feedback on
answersanswers
MANUALMANUAL
contact person at Eurostat:contact person at Eurostat:
Manual main featuresManual main features 5 Chapters:5 Chapters:
Introduction Introduction definitions and best practicesdefinitions and best practices external causes of deathexternal causes of death 54 correctly completed case histories 54 correctly completed case histories glossary glossary list of imprecise causes and hints on how to improve specificitylist of imprecise causes and hints on how to improve specificity
4 Annexes:4 Annexes: National Mortality data flow (to be adapted)National Mortality data flow (to be adapted) Eurostat recommendationsEurostat recommendations National laws on vital statistics (to be adapted)National laws on vital statistics (to be adapted) Short guide to National implementationShort guide to National implementation
8 Boxes:8 Boxes: five boxes on best certification practicesfive boxes on best certification practices one box on how to report neoplasm one box on how to report neoplasm two more boxes on external causes of death (traffic accidents and two more boxes on external causes of death (traffic accidents and
accidents in medical care)accidents in medical care)
Particular attention was addressed on the need to adapt the Particular attention was addressed on the need to adapt the manual to the National laws and regulations: for this purpose manual to the National laws and regulations: for this purpose “warnings” or specific notes were added where needed“warnings” or specific notes were added where needed
The inclusion of additional information (pregnancy, place of The inclusion of additional information (pregnancy, place of death, place of accident, manner of death, autopsies, etc…) in death, place of accident, manner of death, autopsies, etc…) in a new training package for Europe represents a factual effort a new training package for Europe represents a factual effort in giving a common basis for European certification criteria, in giving a common basis for European certification criteria, fulfilling international guidelines and making an effort to put fulfilling international guidelines and making an effort to put European-agreed recommendations into practice. These European-agreed recommendations into practice. These information were presented into the manual as an “additional information were presented into the manual as an “additional information box” added below the WHO form. Each country information box” added below the WHO form. Each country should decide how to deal with such a box, based upon should decide how to deal with such a box, based upon National needs.National needs.
Several reference-marks to specific case histories were Several reference-marks to specific case histories were included into the fluent text, into the boxes and into the last included into the fluent text, into the boxes and into the last chapter too in order to provide examples of well-completed chapter too in order to provide examples of well-completed death certificates for each item treated in the manualdeath certificates for each item treated in the manual
Flexibility to the manual implementation was introduced by the Flexibility to the manual implementation was introduced by the two-levels of detail offered…. two-levels of detail offered….
Implementation strategies Implementation strategies II
In fact, the manual can be fully translated/adapted in In fact, the manual can be fully translated/adapted in the extended version as it is now, or implemented the extended version as it is now, or implemented in a basic condensed way which could include: in a basic condensed way which could include:
introduction; introduction; national death certificate form;national death certificate form; six or eight “quick tips boxes” their number six or eight “quick tips boxes” their number
depending on National laws for certifying the depending on National laws for certifying the external causes of death;external causes of death;
some case histories; some case histories; general hints on how to add specificity on selected general hints on how to add specificity on selected
group of diseases or conditions;group of diseases or conditions; annexes.annexes.
Implementation strategies IIImplementation strategies II
WEB-BASED WEB-BASED E-LEARNING E-LEARNING
TOOLTOOL
contact person at Eurostat:contact person at Eurostat:[email protected] [email protected]
Some Web-based tool specific aspectsSome Web-based tool specific aspects Specific attention was devoted to e-learning aspects to organize Specific attention was devoted to e-learning aspects to organize
the didactic pathways and some navigation optionsthe didactic pathways and some navigation options A balance between interactivity and usability was sought in A balance between interactivity and usability was sought in
order to provide a product using the web potentiality, but not order to provide a product using the web potentiality, but not excluding non-expert usersexcluding non-expert users
The web-tool contents definition implied:The web-tool contents definition implied: an adaptation of what was already developed for the manual, an adaptation of what was already developed for the manual, the definition of new specifically developed funtionality; this is the definition of new specifically developed funtionality; this is
particularly true for the exercises (tests and case histories). particularly true for the exercises (tests and case histories). Particular attention was given to the companion documentation Particular attention was given to the companion documentation
(guides and helps) fully integrated into the web site, in order to (guides and helps) fully integrated into the web site, in order to facilitate the use and spreading of this product;facilitate the use and spreading of this product;
A high level of parameterization was introduced in the product: A high level of parameterization was introduced in the product: the result is in our opinion a truly “generalized” product that the result is in our opinion a truly “generalized” product that allow easy national adaptations. allow easy national adaptations.
Multiple evaluations of the web-tool were performed by about 50 Multiple evaluations of the web-tool were performed by about 50 different European professionals including physicians, medical different European professionals including physicians, medical schools professors, IT engineers, IT programmers, e-learning schools professors, IT engineers, IT programmers, e-learning experts, statisticians, nosologists, represented by SB members, experts, statisticians, nosologists, represented by SB members, experts from Italy, England, Norway, Sweden; try-out experts from Italy, England, Norway, Sweden; try-out responders; EUROSTAT experts.responders; EUROSTAT experts.
Web-tool main featuresWeb-tool main features
Tutorial: Introduction
Tutorial II: Multiple choice test
Tutorial III: Multiple choice test
Tutorial: Case History
Tutorial: Case History
Tools: Dynamic Certificate
Tools: Hints on how to add specificity
Tools: Quick Tips
WEB-BASED WEB-BASED E-LEARNING TOOLE-LEARNING TOOL
- ADMINISTRATION –- ADMINISTRATION –
contact person at Eurostat:contact person at Eurostat:[email protected] [email protected]
Local Administrator: Home
Local Administrator: Load and define D. C. - I
Local Administrator: Load and define D. Local Administrator: Load and define D. C. - IIC. - II
LEAFLETLEAFLET
contact person at Eurostat: contact person at Eurostat:[email protected] [email protected]
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
Leaflet: main featuresLeaflet: main features
Steering board compositionSteering board composition Gerard Pavillon Gerard Pavillon (France)(France) Mary HeanueMary Heanue (Ireland)(Ireland) Monika BeneMonika Bene (Hungary)(Hungary) Lois CookLois Cook (UK)(UK) Renzo Pace AsiakRenzo Pace Asiak (Malta)(Malta) Jacques BonteJacques Bonte Expert privèExpert privè
ISTAT work teamISTAT work team Monica PaceMonica Pace (Researcher, (Researcher, Project LeaderProject Leader)) Roberta CrialesiRoberta Crialesi(Head of Health Statistics Section)(Head of Health Statistics Section) Luisa FrovaLuisa Frova (Head of Mortality by Cause Unit)(Head of Mortality by Cause Unit) Silvia BruzzoneSilvia Bruzzone (Researcher, Project Coordinator)(Researcher, Project Coordinator) Stefano MarchettiStefano Marchetti (Researcher, Web site project)(Researcher, Web site project) Giuseppe Sindoni Giuseppe Sindoni (Researcher, e-learning aspects, data-base supervision, (Researcher, e-learning aspects, data-base supervision,
consultant on try-out methodologies - DCMT)consultant on try-out methodologies - DCMT) Francesco GrippoFrancesco Grippo (Assistant Researcher)(Assistant Researcher) Simona CinqueSimona Cinque (Assistant Researcher) (Assistant Researcher) Marilena PappagalloMarilena Pappagallo (Assistant Researcher) (Assistant Researcher) Simona PennazzaSimona Pennazza (Assistant Researcher) (Assistant Researcher) Gennaro Di FraiaGennaro Di Fraia (Assistant Researcher) (Assistant Researcher) Silvana SolaSilvana Sola (Assistant Researcher)(Assistant Researcher) Antonella CiccareseAntonella Ciccarese (A(Administrative secretary)dministrative secretary)
IT Private expertsIT Private experts Luigi Arlotta Luigi Arlotta (Web project and development)(Web project and development) Alessia Ciuffo Alessia Ciuffo (Data-base project and development)(Data-base project and development) Paola Albergamo Paola Albergamo (Web design and development)(Web design and development)
Box 6 - Neoplasm reporting Box 6 - Neoplasm reporting check-listcheck-list
Please remember to specify:Please remember to specify: Whether benign, malignant or uncertain behaviour;Whether benign, malignant or uncertain behaviour; The primary site if known;The primary site if known; If the primary site is unknown; If the primary site is unknown; The morphological type if known;The morphological type if known; Site(s) of metastases Site(s) of metastases andand primary site if known; primary site if known; The expression “metastatic from site” defines the primary site(s);The expression “metastatic from site” defines the primary site(s); The expression “metastatic to site” defines the secondary site(s);The expression “metastatic to site” defines the secondary site(s); Possibly avoid non-specific terminology such as Possibly avoid non-specific terminology such as
“carcinomatosis”, “carcinosis”, “growth”, “malignancy”, etc…;“carcinomatosis”, “carcinosis”, “growth”, “malignancy”, etc…; Identify leukemia as “acute”, “sub-acute” or “chronic”, and define Identify leukemia as “acute”, “sub-acute” or “chronic”, and define
the involved cell type.the involved cell type. ((See case histories N. 11-15See case histories N. 11-15))
Importance of providing the Importance of providing the best medical opinion Ibest medical opinion I
Importance of providing the Importance of providing the best medical opinion IIbest medical opinion II
IV ENDOCRINE, NUTRITIONAL IV ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERSAND 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
DiabetesDiabetes Nature of complication or Nature of complication or manifestation in a particular manifestation in a particular sitesite
DiabetesDiabetes mellitusmellitus TypeType I or II diabetes I or II diabetes
With Complication(s);With Complication(s); e.g. nephropathy, e.g. nephropathy, peripheral vascular diseaseperipheral vascular disease
GoitreGoitre Type Type Simple Toxic Simple Toxic Diffuse Diffuse UninodularUninodular MultinodularMultinodular
ConclusionsConclusions
This project represents a real effort in the This project represents a real effort in the improvement of quality and comparability of improvement of quality and comparability of mortality statistics in Europemortality statistics in Europe
The intent has been to provide a common set The intent has been to provide a common set of existing rules on certification of causes of of existing rules on certification of causes of death in the respect of International guidelines death in the respect of International guidelines and of National practices and laws as well and of National practices and laws as well
Management of the web-tool is a crucial point Management of the web-tool is a crucial point that could be done at three different levels: on that could be done at three different levels: on the EUROSTAT server for all countries, on a the EUROSTAT server for all countries, on a different central server for all countries, or on different central server for all countries, or on each interested country server. The decision each interested country server. The decision on this aspect deserves particular attention for on this aspect deserves particular attention for its consequences in terms of technical its consequences in terms of technical management as well as in terms of economic management as well as in terms of economic resources to be allocated for each solution by resources to be allocated for each solution by different European or National Institutionsdifferent European or National Institutions
Future perspectives IFuture perspectives I Dissemination and sensitization of the European countries to Dissemination and sensitization of the European countries to
adopt the developed products is a critical point now because adopt the developed products is a critical point now because such a work deserves to be implemented and used to be such a work deserves to be implemented and used to be effective (EUROSTAT recommendations 30-32) effective (EUROSTAT recommendations 30-32)
Collaboration with WHO should be sought and specific Collaboration with WHO should be sought and specific campaigns should be done to reach this goal in the next few campaigns should be done to reach this goal in the next few years (EUROSTAT recomm. 33-36)years (EUROSTAT recomm. 33-36)
A system to keep the collected information updated for all A system to keep the collected information updated for all European countries should be organized, and some European countries should be organized, and some suggestions came from this project (EUROSTAT suggestions came from this project (EUROSTAT recommendation 21)recommendation 21)
One of the most interesting and promising results of this One of the most interesting and promising results of this project is the possibility to load a national death certificate project is the possibility to load a national death certificate instead of limiting the training to the “neutral” international instead of limiting the training to the “neutral” international death certificate form. Such a new approach opens new death certificate form. Such a new approach opens new possibilities in the effectiveness of training on certification of possibilities in the effectiveness of training on certification of causes of death, and most important, offers a first causes of death, and most important, offers a first experimental use of IT technology in Europe to train certifiers experimental use of IT technology in Europe to train certifiers to complete an electronic image of their National certificate. to complete an electronic image of their National certificate. This innovation could represents the first step towards the This innovation could represents the first step towards the electronic death certificate (EUROSTAT recommendation 22)electronic death certificate (EUROSTAT recommendation 22)
The use of the WHO international death The use of the WHO international death certificate form and the definition and future use certificate form and the definition and future use of agreed additional information (EUROSTAT of agreed additional information (EUROSTAT recommendations 15-20) may represent a first recommendations 15-20) may represent a first step towards the European Death Certificatestep towards the European Death Certificate
The infant mortality certification issue still remain The infant mortality certification issue still remain to be defined and future efforts should be done in to be defined and future efforts should be done in this direction both on the definition of a common this direction both on the definition of a common informative basis (for certificate format, age of informative basis (for certificate format, age of reference, etc...) as well as on the certification reference, etc...) as well as on the certification practices (EUROSTAT recommendations 11-14).practices (EUROSTAT recommendations 11-14).
Future perspectives IIFuture perspectives II