qut digital repository: this is the …eprints.qut.edu.au/31612/1/c31612.pdf · registration and...

This is the author version published as: This is the accepted version of this article. To be published as : This is the author version published as:

QUT Digital Repository: http://eprints.qut.edu.au/

Aung, Eindra and Rao, Chalapati and Walker, Sue M. (2010) Teaching cause-of-death certification : lessons from international experience. Postgraduate Medical Journal, 86(1013). pp. 143-152.

© Copyright 2010 B M J Group

089821 Aung

Teaching cause-of-death certification: lessons from international experience 1

Teaching cause-of-death certification: lessons from

international experience

Eindra Aung1, Chalapati Rao2, Sue Walker3

1Research Officer, Health Information Systems Knowledge Hub, School of Population

Health, The University of Queensland, Herston, QLD 4006, Australia, E-mail:

[email protected], 2School of Population Health, The University of Queensland,

Herston, QLD 4006, Australia, E-mail: [email protected], 3Director, National Centre for

Health Information Research and Training, School of Public Health, Queensland

University of Technology, Kelvin Grove, QLD 4059, Australia, E-mail:

[email protected]

Correspondence to: Eindra Aung, Research Officer, Health Information Systems

Knowledge Hub, School of Population Health, The University of Queensland, Level 2,

Public Health Building, Herston Road, Herston, QLD 4006, Australia, E-mail:

[email protected], Telephone: +61 7 3365 5436, Fax: +61 7 3365 5442

Keywords or phrases suitable for use in an index

Death certification; Education; Intervention; Evaluation

Word Count: 3,846

089821 Aung


ABSTRACT

Background and Objective

The accuracy of cause-of-death statistics substantially depends on the quality of cause-of-

death information in death certificates, primarily completed by medical doctors.

Deficiencies in cause-of-death certification have been observed across the world, and

over time. Despite educational interventions targeting to improve the quality of death

certification, their intended impacts are rarely evaluated. This review aims to provide

empirical evidence that could guide the modification of existing educational programs, or

the development of new interventions, which are necessary to improve the capacity of

certifiers as well as the quality of cause-of-death certification, and thereby, the quality of

mortality statistics.

Design

A literature review using keywords: death; certification; education/training

Data Sources

The primary search through PubMed. Reference lists in individual articles from the

primary search and also manual searching of other databases such as Google Scholar and

OpenDOAR.

Eligibility Criteria for Selecting Studies

Evaluation studies which assessed educational interventions for medical students and

doctors on correct completion of death certificates

089821 Aung


Results

All educational interventions identified in this review improved certain aspects of death

certification although the statistical significance of evaluation results varies with the type

of intervention: printed educational material alone being the intervention with the least

educational impact and interactive workshops being the most effective intervention.

Conclusions

Pragmatic education on best practice for cause-of-death certification is a basic step to

ensure accurate information for each individual case, leading to the production of high

quality mortality statistics for epidemiology, public health policy and research.

Development of new educational interventions or modification of existing programs

should be based on evidence of the benefits from current and past interventions provided

under varying circumstances.

Systematic review registration

Not registered

089821 Aung


BACKGROUND

Complete and accurate death certificates are essential for the medico-legal management

of individual cases of death.[1] They are also the foundation of high-quality mortality

data in the form of standardized, comparable cause-specific mortality statistics over time

and place.[2] Such data is required for decision-making within clinical departments,

hospitals and health care systems. Analysis of mortality trends and differentials form the

basis for evidence-based epidemiological evaluations, which are subsequently used to

assess the impact of public health interventions, and set disease control priorities at

national and international levels.

There are three basic sources for population level mortality data. These are civil

registration and vital statistics systems; sample surveys; and population censuses.[3] Of

these, the optimal source of routine and timely mortality and cause-of-death data is the

civil registration system, in which deaths are registered under legal and administrative

provisions. Data quality is determined by the degree of coverage of the resident

population by civil registration, the completeness and timeliness of the registration data,

and the quality of reporting and investigation into the cause(s) of death in each case. The

quality of cause-of-death statistics needs detailed assessment in terms of the reliability

and validity of the data [5], which are dependent on accuracy in the certification, coding

[6] and statistical presentation [7] of causes of death.

Causes of in-hospital deaths are certified by attending physicians or medical residents.

For deaths outside hospitals, many countries require certification of death and its cause

089821 Aung


by medically qualified practitioners. Where this is not possible or where there are

medico-legal implications, certification is conducted by coroners, sometimes supported

by medical examiners or forensic pathologists. In many developing countries, however,

causes of out-of-hospital deaths (with and/or without medico-legal implications) are often

recorded by local registrars through household enquiry or may not be recorded at all.

Therefore, despite the importance of cause-specific mortality data at various levels, only

countries with complete medical certification of deaths have the potential to derive good-

quality data from civil registration systems.[4] An international analysis revealed that

only 31 out of 192 countries in the world produced high quality cause-of-death statistics

for 2004.[8] Even this categorisation was based on a crude index of data quality, i.e.

proportion of deaths classified to symptoms, signs or ill-defined conditions being less

than 10%. In several of these 31 countries, detailed small-scale studies have identified

problems with data validity, when registered causes were compared with reference

diagnoses from pathological autopsies or medical record chart reviews.[9, 10, 11, 12, 13,

14]

A fundamental issue that leads to poor quality statistics is the inadequacy of information

on causes of death recorded on the death certificate. In the past few decades, a range of

interventions have been implemented in different countries to improve the quality of

cause-of-death information on the death certificate. These include improvements in death

certificate formats; training programs for physicians and medical students on completion

of death certificates; provision of self-learning educational materials; implementation of

089821 Aung


cause-of-death query systems; periodic peer auditing of death certificates; and increasing

autopsy rates.[6, 15, 16, 17, 18, 19, 20, 21]

It has been observed that inadequate performance of doctors in the medical certification

of cause of death is a principal reason for inaccurate data.[22, 23, 24, 25, 26, 27] The

main objective of this paper is to use findings from a detailed review of literature on

educational interventions to improve the quality of death certification. The specific

objectives of the review are firstly to analyse information about evaluation studies

reporting quantitative impact measures of education on improving the quality of death

certification; and secondly to provide a descriptive assessment of qualitative observations

focussing on the timing, content and duration of training programs, and the overall utility

of different training methods. These quantitative and qualitative findings provide

empirical evidence that could guide the modification of existing training programs, or the

development of new interventions, which are necessary to improve the quality of cause-

of-death certification, and thereby, the quality of mortality statistics.

METHODS

Search strategy

A comprehensive literature search was conducted to identify published articles on the

subject of training and education in completing death certificates. The search strategy

was implemented on electronic databases, and the primary search was conducted on the

PubMed database (1951- April 2009). The query translation on the search terms in

PubMed was as follows:

089821 Aung


("death"[MeSH Terms] OR "death"[All Fields]) AND

("certification"[MeSH Terms] OR "certification"[All Fields]) AND

("education"[Subheading] OR "education"[All Fields] OR "training"[All Fields]

OR "education"[MeSH Terms] OR "training"[All Fields]).

Screening and selection

Articles identified from this initial search were screened for specific content about

education on death certification, and such articles were selected for more detailed review.

At the next stage, the selected articles were scrutinsed for information on quantitative

evaluation of any educational program on cause-of-death certification. Articles which

provided these details were selected for the detailed quantitative analysis on comparative

effectiveness of educational interventions. Reference lists for these articles were also

scrutinised to identify additional articles with the relevant information. All articles

identified following the initial screening were included in the qualitative assessment of

effectiveness of educational interventions to improve cause-of-death certification.

Analytical methods

In the articles eligible for the quantitative analysis, information was abstracted regarding

the study design employed, type of educational intervention being assessed, nature of

participants, duration of training program, and the methods used for statistical evaluation.

The qualitative analyses focussed on content related to educational needs of participants,

the type and subject matter covered in the education programs, and other specific aspects

that require attention in designing educational interventions.

089821 Aung


RESULTS

Search results

Out of 129 articles that were identified from the initial PubMed search, information on

training or education regarding death certification was available in 58 articles, for which

either abstracts or full texts were available. The other 71 articles were discarded since

they either did not include information relevant to the objectives of this review, or the

abstract or the full-text article could not be accessed. Several types of information related

to death certification education were mentioned in these 58 articles, and Table 1 provides

a summary of these articles according to information types. The articles were grouped

into three broad categories: those reporting on important outcomes, those with

recognition and description of educational needs in death certification, and those focusing

on specialised training or specific circumstances.

As can be seen from Table 1, almost half of the articles from the PubMed search clearly

stated that more education or better education was needed, while another 10 articles

implied the same in the form of statements noting the inadequacy of education in death

certification. Several articles listed the educational needs for cause-of-death certification

in more detail, and a few articles provided descriptions of specific interventions, or for

educational purposes, the death certification procedure in special circumstances such as

for cocaine-related deaths. Similarly, several articles underscored the importance of

consultation with or referral to a medical examiner or coroner when required, while

others mentioned specialised education needs and interventions for these personnel.

Articles also identified specific problems, errors or inaccuracies in death certification,

089821 Aung


with some of them also describing an association between characteristics of specific

groups of certifiers (e.g. age, professional experience, specialty of certifiers, death

certification training received and demography) with such problems. A few of the

reviewed articles pointed out that inaccuracy in death certificates persisted despite

training.

Table 1: Articles from PubMed search containing information on education in death

certification

Type of Information

Number of

Articles

(N=58)§

Important outcomes

Evaluation of educational interventions on death certification 11

Description of an education intervention/guidelines 4

Assessment of accuracy in death certification 16

Association between certifiers’ characteristics and death certification 10

Discussion related to education needs

Inadequate education in death certification 10

The need for more/ better education 26

General or specific education needs/ training requirements 8

The need to consult or refer to medical examiner/ coroner 3

Persistence of inaccuracies in death certificates despite education 6

Description of specific circumstances or specialised training

Death certification in specific diseases/ circumstances 11

Training of medical examiners/ coroners/ forensic pathologists 7

Training of funeral directors on death certification 1

§Thirty-two articles contain more than one type of information.

089821 Aung


The PubMed review identified only 11 articles with abstract or full-text available in

English that were related to the formal evaluation of an educational intervention to

improve death certificate completion. Through additional search, 3 more articles on the

evaluation of an educational intervention to improve accuracy in completing death

certificates were identified. Out of these 14 articles on evaluation, 5 articles were in

Spanish, with translated abstracts in English. With the help of a translator, key results

from these Spanish articles for which we have access to full text in Spanish are included

in this review. Figure 1 shows steps involved in the selection of these 14 evaluation

studies.

Figure 1: Flowchart of PubMed literature review and selection of articles for

analyses

129 articles identified from PubMed database

129 records screened

71 records excluded as not relevant or inaccessible

58 full-text articles or abstracts assessed for eligibility

47 full-text articles or abstracts excluded for not

containing evaluation studies

11studies met criteria for quantitative analysis

14 studies included in quantitative analysis

3 studies identified from other sources

Iden

tifi

cati

on

Scr

een

ing

Elig

ibil

ity

Incl

ud

ed

089821 Aung


Table 2: Characteristics of evaluation studies on educational interventions to improve death certification Title Type of

Study Year & Location

Training Duration

Intervention Participants Evaluation Method Summary of results

Improving death certificate completion: A Trial of Two Training Interventions [28]

Randomised controlled trial and before and after evaluation of 2 training interventions

2006** US

45 minute workshop

Group I: interactive workshop using the guidelines for optimal completion of death certificates. Group II: printed instruction material as a handout that outlined the guidelines.

Internal medicine residents, assigned to Group I or II using an internet-based randomization program

Scoring of death certificates filled out using a different sample case before intervention and 1 week after intervention by each group

Both groups showed a significant improvement in all areas of death certificate scored

An interactive workshop is a more effective intervention than a printed handout

Improving the accuracy of death certification [29]

Before and after evaluation

1996 *(3 seminars over 6 months) Canada

75 minutes Seminar on process of and terminology in death certification, interactive completion of death certificate based on 10 case scenarios and identification of errors in mock death certificates

Internal medicine residents

Audit of actual death certificates filled out over a 12-month period before and those filled out over a 6-month period after intervention

Significant reduction in proportion of certificates with at least one major error

No significant change in the overall rate of minor errors

Death duties: Workshop on what family physicians are expected to do when patients die [30]


2007** Canada

Half-day Workshop on Death Counts Video, Coroners Act tutorial, Death certification process review, Small group discussion on case scenarios, mock death certification and presentation

Community (family) physicians

Scoring of death certificates filled out using case scenarios before intervention and 3 months after intervention; Pre- and Post-intervention questionnaire survey

Decline in use of mechanisms of death and increased use of more specific diseases as the underlying cause of death

Improvement in knowledge on death certification and the Coroners Act

Evaluating an educational intervention to improve the accuracy of death certification among trainees from various specialties [31]


2007** Spain (Over an 18-month period)

90 minutes Interactive workshops on current legislation on and most common errors in death certification, distinction between causes and mechanisms of death, recommendations to improve certification

Medical trainees (family/ internal/ critical care medicine, anaesthesiology, general surgery)

Scoring of death certificates filled out using the same case scenario before and at the end of workshop

Significant reduction in the proportion of certificates with errors

089821 Aung


Title Type of Study

Year & Location

Training Duration


A pilot program to improve causes of death certification in primary care of Catalonia, Spain [32]


2006** Spain

90 minutes Theoretical and practical seminar including regulations and criteria on how to certify causes of death

Primary care physicians: 96 general practitioners, 33 family and community medicine specialists, 15 paediatricians

Scoring of death certificates filled out using the same 3 case scenarios before and at the end of seminar

Significant reduction in the proportion of certificates with errors, especially in immediate cause, intermediate cause, underlying cause, other processes and use of all information and errors such as cardiopulmonary arrest, abbreviations, making up causes and use of lower-case letters

Learning and satisfaction in the workshops of pre- and post-graduate medicine for the improvement of the accuracy of certifications of causes of death 1992-1996 [33]


1992-1996* Spain

2 hours Workshops of theoretical and practical components on usefulness of mortality statistics and the International WHO norms of certification

Medical students, interns, doctors

Scoring of death certificates filled out before and after intervention

Good initial qualifications were improved after the intervention

Statistically significant improvements in the groups of indicators of concept and result of certification

A good death certificate: improved performance by simple educational measures [34]


2004* UK

Feedback on audit findings collectively in a clinical meeting and individually. The topic was highlighted during the induction of new doctors. Those unable to attend were sent paper copies of the feedback.

Senior house officers (SHOs), staff grades, specialist registrars, consultants. New SHOs during re-audit

Audit of actual death certificates filled out over a 4-month period before and those filled out over a 3-month period after intervention

Significant reduction in the proportion of certificates not meeting legal criteria as well as that of certificates with mistakes and omissions

089821 Aung


Title Type of Study

Year & Location

Training Duration


Evaluation of seminars on international criteria for medical certification of cause of death [35]


1996** Spain

2 sessions of 45 minutes

Theoretical seminar: detailed explanation of death certificates and WHO’s international criteria for certification of causes of death

44 doctors Audit of actual death certificates filled out over a 6-month period before and those filled out over a 6-month period after intervention

Significantly improved legibility

Significantly less confusion on the mechanism of death

‘Clinical sequence’ and ‘more than 1 diagnosis per line’ did not vary significantly.

Significant improvement in overall certification

Efficacy of an informative seminar in the certification of causes of death [36]


1993* Spain

60 minutes Theoretical seminar: importance of mortality statistics and the role of a doctor in improving the quality of statistics; WHO’s international criteria and procedure for certification of the causes of death

6th year medical students

Scoring of death certificates filled out using 6 case scenarios before intervention and 6 other case scenarios after intervention

Significant improvement in the majority of indicators on quality of death certification (underlying cause of death, logical sequence, multiple cause of death, use of abbreviations and lower case letters)

The efficacy of an information seminar on certification of the causes of death [37]


1985* Spain

Theoretical seminar: usefulness of mortality statistics and death certification according to WHO’s international criteria for certification of causes of death

Physicians (60% is General Practitioners)

Scoring of death certificates filled out before and after intervention

Significant improvement in the median score from mock death certification

Improvement in the quality of all variables analysed

Notable increase in the percentage of logical sequences (77% to 91%)

Increase in correctly-given main cause (53% to 66%)

089821 Aung


Title Type of Study

Year & Location

Training Duration


Alcohol and Death Certification: influencing current practice and attitudes [38]

Non-randomised controlled trial

1989** UK

A letter to the intervention group at the start of their posting, informing them of changes to the coroner's rules and the importance of recording alcohol abuse in case notes and death certificates. No informatory letter in the control group.

Two cohorts of pre-registration housemen: an earlier group (control) and the following group (intervention)

Review of case notes and death certificates filled out over a 3-month period by each cohort for appropriate reference to alcohol Self-administered questionnaire survey on knowledge and attitude of recording alcohol abuse

In the intervention group (compared to control group), Significant improvement in

recording details in the alcohol history

More knowledge of the coroners’ rules

Less proportion of housemen expressed reluctance to record alcohol-related information

An evaluation of an educational intervention to improve death certification practice [39]


1991* Australia

Reading the educational material which highlights common misconceptions in death certificate completion

Resident staff Audit of actual death certificates (filled out over a 1-month period each) before and after intervention Pre- and post-intervention questionnaire survey

Fewer major certification errors (no statistical significance)

Increased % of correct responses to the questionnaire items

Randomised comparison of death certification with and without guidelines [40]

Randomised controlled trial

2000** France

Providing guidelines in addition to examples on death certificates to intervention group

2 groups each of general practitioners and specialists

Scoring of death certificates filled out using 10 case scenarios by each group

No notable differences in the quality of the certification although intervention group had slightly better results for the majority of the criteria considered

Death certification: production and evaluation of a training video [41]

Randomised controlled trial

1995* UK

15 minutes A video (in addition to the usual lecture on death certification) for Intervention group; Usual lecture only for Control group

First year Medical students assigned to one of two groups using random numbers

A test of knowledge and skills in completing death certificates using case scenarios (under examination conditions) in both groups 1 week after the intervention.

The intervention group performed slightly better than the control group (only about 5% better overall score).

Highly effective in conveying the message "distress to relatives is an important consequence of inaccurate death certification"

* Year(s) the evaluation conducted or covered ** Year the article published

089821 Aung


Characteristics of evaluation studies

Table 2 summarizes the broad features of the 14 evaluation studies that report

quantitative evidence on the effectiveness of educational interventions. The 14 articles

are from 6 countries, and were published between 1989 and 2007. The majority of these

studies conform to the ‘before-after comparison’ study design, probably the simplest

method for evaluating educational interventions. The wide range of educational

interventions tested (printed materials, videos, theoretical seminars and interactive

workshops delivered in various combinations), and the spectrum of participants (interns,

residents, specialists and community physicians) in the different studies typify the

challenges encountered in education delivery in this area.

In all of the studies but one, a major criterion for assessment was improvement in the

recording of underlying causes of death. However, the methods for assessing the

improvement in death certification practices differed between studies. Only 5 out of the

14 studies assessed the improvement by auditing actual death certificates completed over

a one to six month period of time after the educational intervention. The other 9 studies

based their assessment on scoring of mock death certificates completed using case

scenarios. Among these, only two studies reported on the conduct of a post-intervention

assessment after a certain period of time (1 month and 3 months respectively). It is

reasonable to infer that post-intervention assessments conducted after a time interval,

rather than at the end of the seminar, are more effective in assessing the effects of the

intervention in the long-term. Similarly, auditing of actual death certificates completed

089821 Aung


over a certain period of time is more likely to capture change in actual death certification

practices compared to scoring of mock death certificates.

Effectiveness of interventions based on printed materials

The evidence contained in these articles suggests that printed educational material alone

is probably the intervention with least educational impact although slightly better death

certification practices were observed. While a letter to medical interns in the United

Kingdom (UK) in 1989 instructing them of the rules for recording alcohol abuse in case

notes and on death certificates did result in significant improvement [38], another study

in Australia found that reading educational material alone reduced major certification

errors, but did not demonstrate a statistically significant change in certification practice

among residents [39]. A randomised controlled trial in France tested the utility of

certification examples with accompanying certification guidelines in comparison to

certification examples alone, and found no notable differences in the quality of

certification. However, the group that received guidelines had slightly better results for

the majority of the criteria considered.[40] Finally, a recent, randomised controlled trial

in the United States compared the impact of an interactive workshop with that of printed

educational material, and found that the workshop format proved to be the more effective

intervention.[28] This has highlighted the need for education to be more than merely the

provision of reading materials.

089821 Aung


Use of training videos

The use of video as an educational tool also has limited impact on the quality of death

certification with only a slightly better overall score in the intervention group reported in

one of the studies. A randomised controlled trial evaluated the impact of a video in

addition to a lecture, in comparison with the lecture alone, in two groups of

undergraduate medical students in the UK, and found that the video resulted in only a

marginally significant improvement (p=0.046).[41] A video could potentially be more

useful, as observed from a ‘before-after comparison’ study in Canada where it was used

in conjunction with a tutorial, group discussion and mock death certification during a

half-day workshop for community physicians.[30] However, the combination of

educational methods, skills and experience of participants, and duration of the program

probably influenced the overall outcome of each of these studies evaluating educational

videos.

Audit of certification practice

Feedback on accuracy, comprehensiveness and adherence to the requirements for death

certification is a useful adjunct educational intervention. This was assessed during a

detailed ‘audit – intervention – re-audit’ study evaluating quality of death certification in

the elderly care department of a district general hospital in the UK. Initially, results of a

retrospective audit of every death certificate issued during a 4-month period were

disseminated to hospital staff during a clinical governance meeting, in the form of

anonymous feedback. In addition, individualised performance data was provided to each

certifier. Further, doctors recruited to the hospital during the study period received

089821 Aung


instruction on death certification during induction training. A re-audit carried out 3

months after the feedback demonstrated improvements in accuracy and legitimacy (i.e.

meeting the legal requirements) in death certification.[34] An important aspect of this

study lies in the use of official death certificates in the audit, which provides a realistic

assessment of certification practice.

Training programs

Interactive workshops are probably the most effective form of education in improving the

quality of death certification, as borne out from several before-after comparison studies

(two in Canada [29, 30] and six in Spain [31, 32, 33, 35, 36, 37]). Five of these studies

evaluated interactive workshops or seminars with theoretical and practical components,

[29, 30, 31, 32, 33], while the other three evaluated seminars which only had a theoretical

component [35, 36, 37]. Overall, seven studies reported statistically significant

improvement in the quality of death certification. The remaining study also reported

improvement, but without any statistical measures.[30] In summary, all the educational

interventions identified in our review improved certain aspects of death certification, and

the statistical significance of evaluation results for each type of intervention is shown in

Figure 2.

Figure 2: Statistical significance of improvements in death certification after

educational interventions

089821 Aung


Timing of education

The review provided useful insights into the issues regarding the appropriate stage of

medical education at which the principles and practices of death certification should be

taught. For instance, several authors observed that despite education on death

certification as part of traditional undergraduate medical training and the availablity of

guidelines on death certificate completion, inaccuracies in death certification

persisted.[26, 42, 43, 44, 45, 46, 47, 48] Pain and colleagues reasoned that students at an

early stage of medical training may find it difficult to either see the relevance of death

certification to themselves, or to understand the clinical scenarios outlined.[41] This is

substantiated by findings from a university teaching hospital in the UK, where inaccurate

completion of the death certificates by junior doctors occurred despite most of them

having graduated from the same university, where death certification was part of their

course.[46] According to comments made by house officers and general practitioners in

a study by Maudsley et al, undergraduate training on death certification was regarded as

too early and not reinforced subsequent to graduation.[49] This suggests that merely

teaching undergraduate medical students without follow-up training during their

residency is not effective in improving the accuracy of death certification. This

statement was supported by a number of authors. Weeramanthri et al rationalised the

need to target medical residents for proper death certification training, in view of the

opportunity for practical experience in completing death certificates and the expected

persistence of good practices learnt during residency.[39] Similarly, Pritt et al stated the

need for gaining death certification experience throughout one’s residency, and

recommended an annual course in death certification for all resident staff, to avoid

089821 Aung


acquiring bad habits without proper training and reinforcement.[50] Kircher et al also

indicated the need for education of medical students through teaching, self-study and

examination questions as well as the importance of providing proper guidance in

completing death certificates during their residency.[51] However, given the competing

demands faced by residents, optimal use of the time available for teaching on completion

of death certificates is important.[42]

Content of educational interventions

Regarding curriculum, the review identified that instruction and training on this subject is

widely perceived to be inadequate, and that there is a need for evidence-based, well-

designed and organized education on cause-of-death certification.[52, 53, 54, 55, 56, 57,

58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70] In particular, several articles identified

and classified major errors in death certification, and highlighted major topical areas in

which doctors need to be trained.[26, 46, 50, 71, 72, 73, 74] In this regard, death

certification training curricula or guidelines have been published by a number of

countries, and are widely accessible through the internet.[75, 76, 77, 78, 79, 80, 81] To

achieve greater harmonisation in death certification among European countries, the

Statistical Office of the European Communities (Eurostat) conducted a regional survey

on training practices in cause-of-death certification, and the results were used in

developing a basic common training package on good death certification procedures.[60]

In the international context, the Education Committee of the World Health Organization

Family of International Classifications (WHO-FIC) Network has developed a core

curriculum for guiding the development of training for certifiers of causes of death, key

089821 Aung


elements of which are listed in Table 3.[82] While providing guidance for standardised

curriculum, these knowledge clusters are sufficiently broad to permit country-specific

adaptations to meet local education needs. Indeed, standardisation in training of certifiers

of causes of death and procedures for the collection of cause-of-death data has been

recommended to improve the comparability of epidemiological data.[6] Quality

assurance of data through reliability assessments of certification and/or coding, supported

by validation studies comparing death certificate diagnoses with those from medical

records are also necessary to improve the utility of cause-specific mortality data, and

these are additional aspects that could be touched upon during training programs.

Table 3: Minimum requirements for the content of training in certifying causes of

death [82]

Knowledge Cluster Content 1. Medical science related to

ascertaining cause(s) of death

Concept of aetiology and risk factors Patho-physiology Forensic medicine Post mortem examination and autopsy

2. Principles for certifying causes of death

Structure of WHO medical certificate of cause of death (parts I and II)

Concept of underlying cause of death Importance of best medical opinion Appropriate exercises in death certification

3. Certification rules for specific causes of death

External causes of death e.g. suicides, drowning, alcohol related deaths, drug overdose; poisoning

Guidelines for reporting peri-natal deaths Certifying deaths from cancers, diabetes, asthma,

4. Legal/ethical issues Legal requirements regarding death certification General privacy and confidentiality principles Professional ethics

5. Uses of data on causes of death

Clinical education Medical and epidemiological research Statistical outputs for health situation and trend analysis Health program evaluation and planning

089821 Aung


DISCUSSION

Certifying causes of death is a technical matter that requires specific knowledge to meet

the legal, clinical and epidemiological purposes of this function. The use of information

on causes of death has evolved over time, and changes in legislation have generally

increased the need for proof of the cause of death. This is particularly relevant to exclude

the possibility of foul play, or where present, to aid forensic enquiry into the

circumstances resulting in death. However, the latter instances comprise only a small

proportion of all deaths. Knowledge of disease processes leading to death has continued

to grow with technological improvements in diagnostic abilities, and appropriate

documentation of the chain of events in chronological and patho-physiological sequence

requires attention to specifically identify the underlying cause of death used for

tabulation, reporting and comparative purposes. Hence, adequate education in these

aspects is essential, as well as ongoing orientation to changes in certification

requirements. The key challenges in the provision of such education are firstly the need

to provide fresh medical graduates with an understanding of principles of death

certification from legal and epidemiological perspectives in addition to the clinical

aspects, and secondly, to periodically update knowledge among a wide pool of certifiers,

in the form of refresher training. In this regard, Maudsley and Williams declared that

exploring alternative methods of providing instruction on death certificate completion

was required.[49] This article reviews the state of the art in interventions for providing

education on cause-of-death certification, and provides a platform for developing suitable

options to serve such a variety of educational needs.

089821 Aung


The review provides useful insight into the variety of methods used to impart knowledge

on this subject to a range of recipients including interns, specialists, community

physicians, and even funeral directors, who although they do not hold formal

responsibilities for death certification, often have an important role to play in this process

in many countries. Although the number of studies conducted to formally evaluate the

impact of specific training interventions is few, a common theme that emerges from the

review is that interactive workshops are the most effective form of education. This has

been consistently observed from different study designs (before-after comparisons and

randomised controlled trials), for different professional groups (interns, general

practitioners, specialists) and for different durations of training (45 minutes to half-day

sessions). However, while interactive workshops can be organised for students or

hospital staff, engaging community or remote-area physicians in a similar manner could

pose significant challenges. Therefore, the findings from the review that other training

methods such as videos and different types of printed materials are also useful methods,

although their effectiveness ranks lowest among the studies, are encouraging. European

initiatives in developing self-study tools and interactive training websites have broadened

the range of methods for disseminating information and providing education on cause-of-

death certification.[83]

Another limitation from the review is that all the 14 articles that report quantitative

evaluations of educational interventions are from developed countries. In fact, only 6 of

the 58 articles from the initial search were from developing countries, and all of these 6

articles only stated the urgent need for education without discussing the effectiveness of

089821 Aung


educational interventions. However, given the universality of problems with death

certification, it is possible that there are similar articles from developing countries in

medical or public health journals that are not indexed in PubMed, or are not accessible

through the other search engines employed in this review. In summary, there is a need for

studies comparing different instructional methods in various settings to identify and

implement suitable and cost-effective interventions.

Apart from direct educational interventions, there are other approaches to improve the

quality of cause-of-death certification. For instance, the Australian Bureau of Statistics

implements a mechanism to raise queries on certificates that include inconsistent or

questionable data, requiring the certifier to verify or expand on the diagnoses provided,

with subsequent correction of the coding from the original certificate.[84] Periodic audit

of death certificates with feedback to certifiers has also been proposed as a method for

improving the quality of information on causes of death.[19] However, the primary

purpose of such querying or audit processes is to verify reported causes of death with a

view to refining mortality statistics, rather than to actually imparting knowledge on death

certification, and therefore such processes do not fall directly in the sphere of formal

education. On the other hand, audit processes with feedback given to certifiers may have

educational value and the evidence suggested giving feedback individually to the

certifiers as well as during a clinical meeting was beneficial.[34] The effectiveness of

such interventions (especially in settings where formal training is difficult or not feasible)

should be scientifically evaluated in further research.

089821 Aung


CONCLUSIONS

The need for accuracy in the recording of causes of death on medical death certificates

cannot be overemphasised. Good education on best practice for cause-of-death

certification is a basic step required to ensure production of high quality mortality

statistics. The challenges in imparting suitable education on this important aspect to

medical certifiers in many countries located in Africa, the Middle East, Asia-Pacific and

Latin American regions are considerable. Even in developed countries, there is room for

improvement in cause-of-death certification by new medical graduates as well as by

practising medical personnel. This review has identified that a range of educational

interventions exist, and have potential benefit in varying circumstances. Therefore,

suitable needs assessment research should be conducted to tailor educational delivery to

meet the requirements of medical personnel operating in different environments.

Judicious use of electronic media and self study materials supported by interactive

education and audit/feedback processes is necessary to achieve the wide range of

coverage required for overall improvements in the accuracy and reliability of cause-

specific mortality data.

ACKNOWLEDGEMENTS

We thank Dr. Eliana Jimenez, Lecturer, the Australian Centre for International and

Tropical Health, School of Population Health, the University of Queensland, for

translation of key information in articles available only in Spanish. We also thank Dr.

Lene Mikkelsen, Consultant, Health Information Systems Knowledge Hub, School of

089821 Aung


Population Health, the University of Queensland for her comments on the initial draft of

the research outline.

COMPETING INTERESTS

All authors declare that the answer to the questions on your competing interest form -

http://resources.bmj.com/bmj/authors/checklists-forms/competing-interests - are all No

and therefore have nothing to declare.

FUNDING

Supported, in part, by Australian Agency for International Development (AusAID)

COPYRIGHT LICENCE STATEMENT

The Corresponding Author has the right to grant on behalf of all authors and does grant

on behalf of all authors, an exclusive licence (or non-exclusive for government

employees) on a worldwide basis to the BMJ Publishing Group Ltd and its Licensees to

permit this article (if accepted) to be published in Postgraduate Medical Journal and any

other BMJPGL products to exploit all subsidiary rights, as set out in our licence

(http://pmj.bmj.com/ifora/licence.pdf).

ETHICS APPROVAL

Ethics approval was not necessary for this work and, therefore, not sought.

089821 Aung


REFERENCES

1.Huffman GB. Death certificates: why it matters how your patient died. Am Fam Physician

1997 Oct 1;56(5):1287-8, 90.

2.Byass P. Who needs cause-of-death data? PLoS Med 2007 Nov 20;4(11):e333.

3.United Nations Secretariat DoIEaSA. Approaches to the collection of mortality data in the

context of data needs. Population Studies. New York, N.Y: United Nations; 1984. p. 33-44.

4.Mathers CD, Fat DM, Inoue M, Rao C, Lopez AD. Counting the dead and what they died

from: an assessment of the global status of cause of death data. Bull World Health Organ 2005

Mar;83(3):171-7.

5.Rao C, Lopez AD, Yang G, Begg S, Ma J. Evaluating national cause-of-death statistics:

principles and application to the case of China. Bull World Health Organ 2005 Aug;83(8):618-

25.

6.Jougla E, Pavillon G, Rossollin F, De Smedt M, Bonte J. Improvement of the quality and

comparability of causes-of-death statistics inside the European Community. EUROSTAT Task

Force on "causes of death statistics". Rev Epidemiol Sante Publique 1998 Dec;46(6):447-56.

7.ICD-10 international statistical classification of diseases and related health problems: tenth

revision, Volume 2, Instruction Manual. 2nd ed. Geneva: World Health Organization; 2004.

8.Mahapatra P, Shibuya K, Lopez AD, Coullare F, Notzon FC, Rao C, et al. Civil registration

systems and vital statistics: successes and missed opportunities. Lancet 2007 Oct 26.

9.Moriyama IM, Dawber TR, Kannel WB. Evaluation of diagnostic information supporting

medical certification of deaths from cardiovascular disease. In: Haenzel W, editor.

Epidemiological approaches to the study of cancer and other chronic diseases. Washington:

Government Printing Office; 1966.

089821 Aung


10.Alderson MR, Meade TW. Accuracy of diagnosis on death certificates compared with that in

hospital records. Br J Prev Soc Med 1967 Feb;21(1):22-9.

11.Gittelsohn A, Senning J. Studies on the reliability of vital and health records: I. Comparison

of cause of death and hospital record diagnoses. Am J Public Health 1979 Jul;69(7):680-9.

12. Lahti RA, Penttila A. The validity of death certificates: routine validation of death

certification and its effects on mortality statistics. Forensic Sci Int 2001 Jan 1;115(1-2):15-32.

13.Nashelsky MB, Lawrence CH. Accuracy of cause of death determination without forensic

autopsy examination. Am J Forensic Med Pathol 2003;24(4):313-9.

14.Johansson LA, Westerling R. Comparing Swedish hospital discharge records with death

certificates: implications for mortality statistics. Int J Epidemiol 2000 Jul;29(3):495-502.

15.Medical aspects of death certification. A joint report of the Royal College of Physicians and

the Royal College of Pathologists. J R Coll Physicians Lond 1982 Oct;16(4):206-18.

16. Rosenberg HM. Improving cause-of-death statistics. Am J Public Health 1989

May;79(5):563-4.

17.Tangcharoensathien V, Faramnuayphol P, Teokul W, Bundhamcharoen K, Wibulpholprasert

S. A critical assessment of mortality statistics in Thailand: potential for improvements. Bull

World Health Organ 2006 Mar;84(3):233-8.

18.Weeramanthri TS. A medical cause of death validation study of adult aboriginal deaths in the

Northern Territory of Australia in 1992. Public Health 1997 Nov;111(6):429-33.

19.Meel BL. Certification of deaths at Umtata General Hospital, South Africa. J Clin Forensic

Med 2003 Mar;10(1):13-5.

20.Maudsley G, Williams EM. "Inaccuracy' in death certification--where are we now? J Public

Health Med 1996 Mar;18(1):59-66.

089821 Aung


21.Hanzlick R. Improving the accuracy of death certificates. JAMA 1995 Aug 16;274(7):537-8.

22.Jimenez-Cruz A, Leyva-Pacheco R, Bacardi-Gascon M. [Errors in the certification of deaths

from cancer and the limitations for interpreting the site of origin]. Salud Publica Mex 1993 Sep-

Oct;35(5):487-93.

23. Ashley J, Devis T. Death certification from the point of view of the epidemiologist.

Population Trends 1992;67:22-8.

24.Balkau B, Papoz L. Certification of cause of death in French diabetic patients. J Epidemiol

Community Health 1992 Feb;46(1):63-5.

25.Laurenti R, Aylin P, Coleman MP. Accuracy of statements of the cause of death on death

certificates and the international comparability of mortality statistics In: Coleman MP, Aylin P,

Great Britain. Office for National Statistics., editors. Studies on medical and population subjects.

London; 2000. p. 1-9.

26.Smith Sehdev AE, Hutchins GM. Problems with proper completion and accuracy of the

cause-of-death statement. Arch Intern Med 2001 Jan 22;161(2):277-84.

27.Hoel DG, Ron E, Carter R, Mabuchi K. Influence of death certificate errors on cancer

mortality trends. J Natl Cancer Inst 1993 Jul 7;85(13):1063-8.

28.Lakkireddy DR, Basarakodu KR, Vacek JL, Kondur AK, Ramachandruni SK, Esterbrooks

DJ, et al. Improving death certificate completion: a trial of two training interventions. J Gen

Intern Med 2007 Apr;22(4):544-8.

29.Myers KA, Farquhar DR. Improving the accuracy of death certification. CMAJ 1998 May

19;158(10):1317-23.

30.Myers KA, Eden D. Death duties: workshop on what family physicians are expected to do

when patients die. Can Fam Physician 2007 Jun;53(6):1035-8.

089821 Aung


31.Villar J, Perez-Mendez L. Evaluating an educational intervention to improve the accuracy of

death certification among trainees from various specialties. BMC Health Serv Res 2007;7:183.

32.Abos R, Perez G, Rovira E, Canela J, Domenech J, Bardina JR. [A pilot program to improve

causes of death certification in primary care of Catalonia, Spain]. Gac Sanit 2006 Nov-

Dec;20(6):450-6.

33.Cirera Suarez L, Martinez Lopez C, Contreras Gil J, Navarro Sanchez C. [Learning and

satisfaction in the workshops of pre- and post-graduate medicine for the improvement of the

accuracy of certifications of causes of death 1992-1996]. Rev Esp Salud Publica 1998 May-

Jun;72(3):185-95.

34.Selinger CP, Ellis RA, Harrington MG. A good death certificate: improved performance by

simple educational measures. Postgrad Med J 2007 Apr;83(978):285-6.

35.Ruiz Ramos M, Cortes Majo MC. [Evaluation of seminars on international criteria for

medical certification of cause of death]. Aten Primaria 1996 Oct 15;18(6):324-6.

36. Miron Canelo JA, Saenz Gonzalez MC. [Efficacy of an informative seminar on the

certification of causes of death]. Rev Esp Salud Publica 1995 Mar-Apr;69(2):227-32.

37.Gispert R, Arnau JM, Segura A, Procupet A, Domenech J. [The efficacy of an information

seminar on certification of the causes of death]. Gac Sanit 1988 Jul-Aug;2(7):185-9.

38.Bell G, Cremona A. Alcohol and death certification: influencing current practice and

attitudes. Br J Addict 1989 Dec;84(12):1523-5.

39.Weeramanthri T, Beresford W, Sathianathan V. An evaluation of an educational intervention

to improve death certification practice. Aust Clin Rev 1993;13(4):185-9.

089821 Aung


40.Pavillon G, Jougla E, Chérié-Challine L, Hatton F. Randomised comparison of death

certification with and without guidelines. In: Coleman MP, Aylin P, Great Britain. Office for

National Statistics., editors. Studies on medical and population subjects. London; 2000. p. 10-20.

41.Pain CH, Aylin P, Taub NA, Botha JL. Death certification: production and evaluation of a

training video. Med Educ 1996 Nov;30(6):434-9.

42.Cross SS, Laidler P. Computer-assisted learning in morbid anatomy. A stimulation of autopsy

procedures and death certification. Med Sci Law 1990 Apr;30(2):115-8.

43.Armour A, Bharucha H. Nosological Inaccuracies in death certification in Northern Ireland. A

comparative study between hospital doctors and general practitioners. Ulster Med J 1997

May;66(1):13-7.

44. Kelly SA, Gradwell E. The teaching of death certification. J Clin Pathol 1992

Oct;45(10):942-3.

45.Lu TH, Shih TP, Lee MC, Chou MC, Lin CK. Diversity in death certification: a case vignette

approach. J Clin Epidemiol 2001 Nov;54(11):1086-93.

46.Swift B, West K. Death certification: an audit of practice entering the 21st century. J Clin

Pathol 2002 Apr;55(4):275-9.

47.James DS, Bull AD. Information on death certificates: cause for concern? J Clin Pathol 1996

Mar;49(3):213-6.

48.McKelvie PA. Medical certification of causes of death in an Australian metropolitan hospital.

Comparison with autopsy findings and a critical review. Med J Aust 1993 Jun 21;158(12):816-8,

20-1.

49.Maudsley G, Williams EM. Death certification by house officers and general practitioners--

practice and performance. J Public Health Med 1993 Jun;15(2):192-201.

089821 Aung


50.Pritt BS, Hardin NJ, Richmond JA, Shapiro SL. Death certification errors at an academic

institution. Arch Pathol Lab Med 2005 Nov;129(11):1476-9.

51.Kircher T, Anderson RE. Cause of death. Proper completion of the death certificate. J Am

Med Rec Assoc 1987 Nov;58(11):47-51.

52.Messite J, Stellman SD. Accuracy of death certificate completion: the need for formalized

physician training. JAMA 1996 Mar 13;275(10):794-6.

53.Bah S. Improving the quality of cause-of-death statistics in South Africa--some practical

steps. S Afr Med J 2005 Dec;95(12):902-3.

54.Sibai AM. Mortality certification and cause-of-death reporting in developing countries. Bull

World Health Organ 2004 Feb;82(2):83.

55.Lakkireddy DR, Gowda MS, Murray CW, Basarakodu KR, Vacek JL. Death certificate

completion: how well are physicians trained and are cardiovascular causes overstated? Am J Med

2004 Oct 1;117(7):492-8.

56.Bowen KA, Marshall WN, Jr. Pediatric death certification. Arch Pediatr Adolesc Med 1998

Sep;152(9):852-4.

57.Alempijevic D, Savic S. [Education of medical examiners qualified for death certification].

Srp Arh Celok Lek 2006 Oct;134 Suppl 2:135-8.

58.Goodin J, Hanzlick R. Mind your manners. Part II: General results from the National

Association of Medical Examiners Manner of Death Questionnaire, 1995. Am J Forensic Med

Pathol 1997 Sep;18(3):224-7.

59.Cirera Suarez L, Navarro Sanchez C, Barber Valles X, Contreras Gil J, Martinez Lopez C,

Garcia Rodriguez J. [Principal requirements in medical training for certification of deaths in

Spain]. Aten Primaria 2002 Apr 15;29(6):348-55.

089821 Aung


60.Pace M, Bruzzone S, Frova L, Pappagallo M. Review of the existing information about death

certification practices, certificate structures and training tools for certification of causes of death

in Europe: Italian National Institute of Statistics.

61.Keirns CC, Carr BG. From the emergency department to vital statistics: cause of death

uncertain. Acad Emerg Med 2008 Aug;15(8):768-75.

62.Mahapatra P, Chalapati Rao PV. Cause of death reporting systems in India: a performance

analysis. Natl Med J India 2001 May-Jun;14(3):154-62.

63.Rockett IR, Lian Y, Stack S, Ducatman AM, Wang S. Discrepant comorbidity between

minority and white suicides: a national multiple cause-of-death analysis. BMC Psychiatry 2009

Mar 18;9(1):10.

64.Rockett IR, Wang S, Lian Y, Stack S. Suicide-associated comorbidity among US males and

females: a multiple cause-of-death analysis. Inj Prev 2007 Oct;13(5):311-5.

65.Moriyama IM. Problems in measurement of accuracy of cause-of-death statistics Am J Public

Health 1989 Oct;79(10):1349-50.

66.Comstock GW, Markush RE. Further comments on problems in death certification. Am J

Epidemiol 1986 Aug;124(2):180-1.

67.Hanzlick R. Death certificates. The need for further guidance. Am J Forensic Med Pathol

1993 Sep;14(3):249-52.

68.Magrane BP, Gilliland MG, King DE. Certification of death by family physicians. Am Fam

Physician 1997 Oct 1;56(5):1433-8.

69.Swain GR, Ward GK, Hartlaub PP. Death certificates: let's get it right. Am Fam Physician

2005 Feb 15;71(4):652, 5-6.

089821 Aung


70.Devis T, Rooney C. Death Certification and the epidemiologist. Health Statistics Quarterly

1999;1:21-33.

71.Johansson LA, Bjorkenstam C, Westerling R. Unexplained differences between hospital and

mortality data indicated mistakes in death certification: an investigation of 1,094 deaths in

Sweden during 1995. J Clin Epidemiol 2009 Apr 11.

72.Lu TH, Shau WY, Shih TP, Lee MC, Chou MC, Lin CK. Factors associated with errors in

death certificate completion. A national study in Taiwan. J Clin Epidemiol 2001 Mar;54(3):232-

8.

73.Hunt R, Barr P. Errors in the certification of neonatal death. J Paediatr Child Health 2000

Oct;36(5):498-501.

74.Weeramanthri T, Beresford B. Death certification in Western Australia--classification of

major errors in certificate completion. Aust J Public Health 1992 Dec;16(4):431-4.

75.Manual on certification of causes of death in Europe. 2003 [cited 4 August 2009]; Available

from:

http://circa.europa.eu/Public/irc/dsis/health/library?l=/methodologiessandsdatasc/causessofsdeath

/training_certification&vm=detailed&sb=Title

76.Information paper: Cause of death certification. 2008 [cited 4 August 2009]; Available from:

http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/1205.0.55.0012008?OpenDocument

77.Physicians’ and coroners’ handbook on medical certification of death and stillbirth. 2004

[cited 4 August 2009]; Available from:

http://www.llbc.leg.bc.ca/public/PubDocs/bcdocs/377077/pchandbook2004.pdf

089821 Aung


78.A handbook for physicians and medical examiners: medical certification of death and

stillbirth. 2000, 2002 [cited 4 August 2009]; Available from:

http://www.cpsns.ns.ca/publications/medical-certification-death.PDF

79.A guide to certifying causes of death. 2001 [cited 4 August 2009]; Available from:

http://www.nzhis.govt.nz/moh.nsf/pagesns/216/$File/deathcerts.pdf

80.Physicians' handbook on medical certification of death. 2003 [cited 4 August 2009];

Available from: http://www.cdc.gov/nchs/data/misc/hb_cod.pdf

81.Medical examiners' and coroners' handbook on death registration and fetal death reporting.

2003 [cited 4 August 2009]; Available from: http://www.cdc.gov/nchs/data/misc/hb_me.pdf

82.Core Curriculum for Certifiers of Underlying Cause of Death. 2006 [cited 4 August 2009];

Available from: http://www.cdc.gov/nchs/data/icd9/CurriculumCertification03-08-078.pdf

83. e-learning web site for death certification. [cited 4 August 2009]; Available from:

http://ec.europa.eu/eurostat/health/deathcert/index.cfm?section=1

84.Information Paper: ABS Causes of Death Statistics: Concepts, Sources and Methods, 2006.

[cited 4 August 2009]; Available from:

http://www.abs.gov.au/AUSSTATS/[email protected]/Lookup/3317.0.55.002Main%20Features72006?o

pendocument&tabname=Summary&prodno=3317.0.55.002&issue=2006&num=&view=

089821 Aung


FIGURE LEGENDS

Figure 1: Flowchart of PubMed literature review and selection of articles for

analyses

Figure 2: Statistical significance of improvements in death certification after

educational interventions

APPENDICES

Text Box 1

Main Messages

Education for certifiers of deaths should be recognised as a fundamental

requirement for high quality mortality statistics

Education in the form of interactive workshops is recommended as the most

effective method for providing instruction on completion of death certificates

Provision of feedback regarding the quality of death certification to individual

certifiers, including queries from the statistics office, leads to improvements in

quality

Education regarding death certification needs to be provided both to new medical

graduates and then periodically to practicing clinicians to reinforce knowledge

Training certifiers using the standardised curriculum from the WHO-FIC Network

has the potential to improve the consistency in death certification practices and

subsequently the comparability of epidemiological data

089821 Aung


Text Box 2

Current Research Questions

What are the specific training needs in the context of individual countries, in

terms of person, time and space?

At what point in their professional life should medical officers be taught about

death certification?

What alternative interventions other than formal training would be efficient in

improving the quality of death certification?

What is the feasible package of interventions that would meet the training needs

as well as improve death certification in individual countries?

Text Box 3

Key References

ICD-10 international statistical classification of diseases and related health

problems: tenth revision, Volume 2, Instruction Manual. 2nd ed. Geneva: World

Health Organization; 2004.

Lakkireddy DR, Basarakodu KR, Vacek JL, Kondur AK, Ramachandruni SK,

Esterbrooks DJ, et al. Improving death certificate completion: a trial of two

training interventions. J Gen Intern Med 2007 Apr;22(4):544-8.

Myers KA, Farquhar DR. Improving the accuracy of death certification. CMAJ

1998 May 19;158(10):1317-23.

089821 Aung


Selinger CP, Ellis RA, Harrington MG. A good death certificate: improved

performance by simple educational measures. Postgrad Med J 2007

Apr;83(978):285-6.

Villar J, Perez-Mendez L. Evaluating an educational intervention to improve the

accuracy of death certification among trainees from various specialties. BMC

Health Serv Res 2007;7:183.

Multiple Choice Questions

1. The optimal source of information on causes of death is:

A. Hospital statistics FALSE

B. Demographic surveys FALSE

C. Civil registration and vital statistics systems TRUE

D. Disease-specific registers/registries FALSE

2. The quality of mortality statistics is directly affected by:

A. Coverage of national survey on behavioural risk factors FALSE

B. Timeliness of vital registration data TRUE

C. Completeness of vital registration data TRUE

D. Accuracy of cause-of-death information on death certificates TRUE

089821 Aung


3. In the reviewed literature, which of the following is the most common approach

used to evaluate educational interventions on death certification?

A. Randomised controlled trials FALSE

B. Non-randomised controlled trials FALSE

C. Post-intervention feedback mechanisms FALSE

D. Before and after comparisons TRUE

4. Overall outcome of educational interventions on death certification:

A. Can be improved by proper combination of different educational methods

TRUE

B. Is independent of skills and experience of participants FALSE

C. Is influenced by timing and duration of the intervention TRUE

D. Is evaluated for all interventions FALSE

5. Which of the following is/are useful method(s) for imparting knowledge on death

certification in different circumstances?

A. Printed educational materials TRUE

B. Educational videos TRUE

C. Data audit and feedback on certification performance TRUE

D. Formal face-to-face training TRUE

qut digital repository: this is the …eprints.qut.edu.au/31612/1/c31612.pdf · registration and...

Documents