Training of Certifiers in the United States

Donna L. HoyertRobert N. Anderson

National Center for Health Statistics (NCHS)

US Vital Statistics SystemDecentralized systemState vital statistics laws and regulations57 registration areas

Funeral directors, physicians, medical examiners or coroners

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Scale2.4 million deaths annually 700,000-800,000 practicing physicians, medical examiners, and coronersSkewed distribution of certification

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Training in Decentralized SystemNot NCHS’ responsibility to train certifiersNCHS 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 StatisticsAttendees:

Federal vital statistics staffState vital statistics staffProfessional organization representatives

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Workshop Recommendations

Need broad-based educational training of certifiers

Multiple approachesMultiple encounters

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Workshop Recommendations

Training message:Importance of cause-of-death statisticsValue of statistics in improving the practice of medicineMechanics 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 contributionInternship and residency- key time to begin training physicians

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Follow through on Workshop Recommendations

Recommendations concerning training &:Medical schoolInternship & residency Licensure & board certificationPracticing physiciansMedical examiners and coronersHospitalsInformation dissemination and softwareOther areas

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Workshop Results

Workshop reports widely distributedResolutions of supportNotices of initiative in variety of publicationsNCHS produced additional training materialStates may have increased effortsOther promising developments withered

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Training MaterialsInstructions on death certificateLaminated instructionsHandbooks etc.ExhibitsPresentationsWeb page

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Instructions on death certificateExamples and some instructionsPurpose: 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 instructions2 separate pages of instructionsPurpose: To provide certifiers with a quick and handy reference

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Handbooks and other publications

NCHS handbooksSeries report CAP manualsJournal articles

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Handbooks

Text, instructions, examplesPurpose: To provide more detailed instructions tailored to physician or medical examiner and coroner

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Other publicationsText, instructions, examplesPurpose: To distribute instructions and examples in medical professional’s own language differently

ExhibitMain panel, 4 table top panels, variety of educational handoutsPurpose: 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 information is used to improve quality of lifeand increase life expectancy for Americans

Accurate death certificates are importantfor improving the health status of the Nation

National Center for Health StatisticsNational Committee on Vital and Health Statistics

National Association for Public Health Statistics and Information Systems

Mortality trends in the United States

Acc id en t d ea th r a t esa r e g rea t er th an r a t esfo r m an y cau s es a tyo un ger a ge gr ou p san d in c rea s em od er a t el y w it h age.HIV d ea th r a t es p ea kfo r age grou p s 25 -34an d 35 -4 4 . Can cerd ea t h ra t es in cr ea s eq u ick ly w it h age bef o r elev el in g off a t 75 -8 4an d 85 +. Hea r t d isea sed ea t h ra t es ar e h ighrel a t ive t o o th er ca u s esfo r ch ild ren u n der 1 ,lo w fo r ages 1 -4 an d 5-14 an d in c rea s e fo rea ch su b seq uen t age

Contribution in months to improvement in life expectancy

Mortality Trends 1979-97Age-adjusted rate per 100,000 standard populationRate per 100,000 live births

Congenital anomalies

SIDS

Disorders relatingtoshortgestationand unspecified lowbirthweight RDS

Newbornaffectedbymaternal complicationsof pregnancy

Age -ad ju s t ed d ea th ra tes for Ch ron icobs t ru ct ive p u lm on ary d is e as e s an d a llie dco nd it ion s h ave in cre ased fa ir ly s tead ily s in ce1979 wh ile ra tes for HIV in cre asedd ram a t ica lly from 1987 t o 1 995 an d h aved ro pp ed s in ce . Rat es for can ce r h ave b eenre lat ive ly s t ab le b u t h ave d ecre as ed s in ce1990 . Ra tes h ave d ecre ased fo r h e ar t d isea se,s t ro k e, an d accid en t s .

Heartdisease

Stroke

Rate per 100,000 live births

Major causes of death influencing the change inlife expectancy between 1995 and 1996

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

HIV infection

Heart disease

Cancer

Homicide

Suicide

Stroke

Diabetes

COPD

Hepatitis

0 0.5 1 1.5 2-0.5-1

Lif e e xp e cta ncy in c rea sed fr o m 75 .8 ye ars in 19 95 t o 7 6.1 yea rs in 1 996 fo r a to t al c han ge of0 .3 ye ars (i.e ., 3 .6 m on ths ). Th e to t al ch an ge is t he com b in a t ion of i nc r ea s in g mo rt a lit y fo rs o m e cau ses an d d ec r eas ing mo rta lit y fo r o t h er cau ses . T h is cha r t sh o ws th e co n t r ibu t ion o fs p ec if ic c au s es , bo t h p os i t ive an d n ega t iv e, to t h e o ver a ll im p rov em en t in life expe ct an cy.

Death rates for selected causes by age, 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

Heartdisease

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

Infant mortality rates for SIDS by month, US 1989-96

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

Sou rce: CDC /NCHS, National Vital Stat ist ics Syste m.

SIDS m o rt a lit y ra t es fo llow a sea son a l p a t ter n with h igh ra t es in t h e win t er a nd lowra tes in t h e su m m er . In fan t m o rt a lit y r a tes fo r SIDS d ec rea sed ab ou t 44 per cen t

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

1000Inf an ts

Inf an t m or ta lit y ra te s ha ve d ecr ea sed fo re a ch o f t h es e cond it ion s s in ce 1 995 .De cr ea se s fo r SIDS a nd RDS have beenr e lat ively r ap id in re ce n t yea rs ; r a tes f orco ng en it al a no m al ie s a n d ne wbo rn a ffec te db y m at ern al co m p lic at io ns o f pr eg n an cyh a ve g en er a lly dec re as ed s in c e 1 979 . Rat esfo r d is or d er s r elat ing to sho rt ges ta t io n andun sp ecif ie d low bi rt hw e ight h ave been m o rev ar ia b le.

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 PresentationsTailored instructional presentation and power pointPurpose: To train certifiers

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Web PageLinks to training resourcesPurpose: To help disseminate information

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

Thank you for your attention.