Verbal autopsy (VA) has emerged as an increasingly popular technique to assign cause of death in parts of the world where the majority of deaths occur without proper medical certification. The ...purpose of this study was to examine the key characteristics of studies that have attempted to validate VA cause of death against an established cause of death.
A systematic review was conducted by searching the MEDLINE, EMBASE, Cochrane-library, and Scopus electronic databases. Included studies contained 1) a VA component, 2) a validation component, and 3) original analysis or re-analysis. Characteristics of VA studies were extracted. A total of 527 studies were assessed, and 481 studies screened to give 66 studies selected for data extraction.
Sixty-six studies were included from multiple countries. Ten studies used an existing database. Sixteen studies used the World Health Organization VA questionnaire and 5 studies used the Population Health Metrics Research Consortium VA questionnaire. Physician certification was used in 36 studies and computer coded methods were used in 14 studies. Thirty-seven studies used high level comparator data with detailed laboratory investigations.
Most studies found VA to be an effective cause of death assignment method and compared VA cause of death to a high-quality established cause of death. Nonetheless, there were inconsistencies in the methodologies of the validation studies, and many used poor quality comparison cause of death data. Future VA validation studies should adhere to consistent methodological criteria so that policymakers can easily interpret the findings to select the most appropriate VA method.
CRD42020186886.
Reducing maternal mortality is a key focus of development strategies and one of the indicators used to measure progress towards achieving the Sustainable Development Goals. In the absence of medical ...certification of the cause of deaths that occur in the community, verbal autopsy (VA) methods are the only available means to assess levels and trends of maternal deaths that occur outside health facilities. The 2016 World Health Organization VA Instrument facilitates the identification of eight specific causes of maternal death, yet maternal deaths are often unsupervised, leading to sparse and generally poor symptom reporting to inform a reliable diagnosis using VAs. There is little research evidence to support the reliable identification of specific causes of maternal death in the context of routine VAs. We recommend that routine VAs are only used to capture the event of a maternal death and that more detailed follow-up interviews are used to identify the specific causes.
The majority of low- and middle-income countries (LMICs) do not have adequate civil registration and vital statistics (CRVS) systems to properly support health policy formulation. Verbal autopsy ...(VA), long used in research, can provide useful information on the cause of death (COD) in populations where physicians are not available to complete medical certificates of COD. Here, we report on the application of the SmartVA tool for the collection and analysis of data in several countries as part of routine CRVS activities.
Data from VA interviews conducted in 4 of 12 countries supported by the Bloomberg Philanthropies Data for Health (D4H) Initiative, and at different stages of health statistical development, were analysed and assessed for plausibility: Myanmar, Papua New Guinea (PNG), Bangladesh and the Philippines. Analyses by age- and cause-specific mortality fractions were compared to the Global Burden of Disease (GBD) study data by country. VA interviews were analysed using SmartVA-Analyze-automated software that was designed for use in CRVS systems. The method in the Philippines differed from the other sites in that the VA output was used as a decision support tool for health officers.
Country strategies for VA implementation are described in detail. Comparisons between VA data and country GBD estimates by age and cause revealed generally similar patterns and distributions. The main discrepancy was higher infectious disease mortality and lower non-communicable disease mortality at the PNG VA sites, compared to the GBD country models, which critical appraisal suggests may highlight real differences rather than implausible VA results.
Automated VA is the only feasible method for generating COD data for many populations. The results of implementation in four countries, reported here under the D4H Initiative, confirm that these methods are acceptable for wide-scale implementation and can produce reliable COD information on community deaths for which little was previously known.
Accurate and timely data on cause of death are critically important for guiding health programs and policies. Deaths certified by doctors are implicitly considered to be reliable and accurate, yet ...the quality of information provided in the international Medical Certificate of Cause of Death (MCCD) usually varies according to the personnel involved in certification, the diagnostic capacity of the hospital, and the category of hospitals. There are no published studies that have analysed how certifying doctors in Bangladesh adhere to international rules when completing the MCCD or have assessed the quality of clinical record keeping.
The study took place between January 2011 and April 2014 in the Chandpur and Comilla districts of Bangladesh. We introduced the international MCCD to all study hospitals. Trained project physicians assigned an underlying cause of death, assessed the quality of the death certificate, and reported the degree of certainty of the medical records provided for a given cause. We examined the frequency of common errors in completing the MCCD, the leading causes of in-hospital deaths, and the degree of certainty in the cause of death data.
The study included 4914 death certificates. 72.9% of medical records were of too poor quality to assign a cause of death, with little difference by age, hospital, and cause of death. 95.6% of death certificates did not indicate the time interval between onset and death, 31.6% required a change in sequence, 13.9% required to include a new diagnosis, 50.7% used abbreviations, 41.5% used multiple causes per line, and 33.2% used an ill-defined condition as the underlying cause of death. 99.1% of death certificates had at least one error. The leading cause of death among adults was stroke (15.8%), among children was pneumonia (31.7%), and among neonates was birth asphyxia (52.8%).
Physicians in Bangladeshi hospitals had difficulties in completing the MCCD correctly. Physicians routinely made errors in death certification practices and medical record quality was poor. There is an urgent need to improve death certification practices and the quality of hospital data in Bangladesh if these data are to be useful for policy.
Verbal autopsy (VA) is increasingly being considered as a cost-effective method to improve cause of death information in countries with low quality vital registration. VA algorithms that use ...empirical data have an advantage over expert derived algorithms in that they use responses to the VA instrument as a reference instead of physician opinion. It is unclear how stable these data driven algorithms, such as the Tariff 2.0 method, are to cultural and epidemiological variations in populations where they might be employed.
VAs were conducted in three sites as part of the Improving Methods to Measure Comparable Mortality by Cause (IMMCMC) study: Bohol, Philippines; Chandpur and Comila Districts, Bangladesh; and Central and Eastern Highlands Provinces, Papua New Guinea. Similar diagnostic criteria and cause lists as the Population Health Metrics Research Consortium (PHMRC) study were used to identify gold standard (GS) deaths. We assessed changes in Tariffs by examining the proportion of Tariffs that changed significantly after the addition of the IMMCMC dataset to the PHMRC dataset.
The IMMCMC study added 3512 deaths to the GS VA database (2491 adults, 320 children, and 701 neonates). Chance-corrected cause specific mortality fractions for Tariff improved with the addition of the IMMCMC dataset for adults (+ 5.0%), children (+ 5.8%), and neonates (+ 1.5%). 97.2% of Tariffs did not change significantly after the addition of the IMMCMC dataset.
Tariffs generally remained consistent after adding the IMMCMC dataset. Population level performance of the Tariff method for diagnosing VAs improved marginally for all age groups in the combined dataset. These findings suggest that cause-symptom relationships of Tariff 2.0 might well be robust across different population settings in developing countries. Increasing the total number of GS deaths improves the validity of Tariff and provides a foundation for the validation of other empirical algorithms.
Gold standard cause of death data is critically important to improve verbal autopsy (VA) methods in diagnosing cause of death where civil and vital registration systems are inadequate or poor. As ...part of a three-country research study-Improving Methods to Measure Comparable Mortality by Cause (IMMCMC) study-data were collected on clinicopathological criteria-based gold standard cause of death from hospital record reviews with matched VAs. The purpose of this data note is to make accessible a de-identified format of these gold standard VAs for interested researchers to improve the diagnostic accuracy of VA methods.
The study was conducted between 2011 and 2014 in the Philippines, Bangladesh, and Papua New Guinea. Gold standard diagnoses of underlying causes of death for deaths occurring in hospital were matched to VAs conducted using a standardized VA questionnaire developed by the Population Health Metrics Consortium. 3512 deaths were collected in total, comprised of 2491 adults (12 years and older), 320 children (28 days to 12 years), and 702 neonates (0-27 days).
Almost all countries without complete vital registration systems have data on deaths collected by hospitals. However, these data have not been widely used to estimate cause of death (COD) patterns in ...populations because only a non-representative fraction of people in these countries die in health facilities. Methods that can exploit hospital mortality statistics to reliably estimate community COD patterns are required to strengthen the evidence base for disease and injury control programs. We propose a method that weights hospital-certified causes by the probability of death to estimate population cause-specific mortality fractions (CSMFs).
We used an established verbal autopsy instrument (VAI) to collect data from hospital catchment areas in Chandpur and Comilla Districts, Bangladesh, and Bohol province, the Philippines, between 2011 and 2014, along with demographic covariates for each death. Hospital medical certificates of cause of death (death certificates) were collected and mapped to the corresponding cause categories of the VAI. Tariff 2.0 was used to assign a COD for community deaths. Logistic regression models were created for broad causes in each country to calculate the probability of in-hospital death, given a set of covariate values. The reweighted CSMFs for deaths in the hospital catchment population, represented by each hospital death, were calculated from the corresponding regression models.
We collected data on 4228 adult deaths in the Philippines and 3725 deaths in Bangladesh. Short time to hospital and education were consistently associated with in-hospital death in the Philippines and absence of a disability was consistently associated with in-hospital death in Bangladesh. Non-communicable diseases (excluding stroke) and stroke were the leading causes of death in both the Philippines (33.9%, 19.1%) and Bangladesh (46.1%, 21.1%) according to the reweighted method. The reweighted method generally estimated CSMFs that fell between those derived from hospitals and those diagnosed by Tariff 2.0.
Statistical methods can be used to derive estimates of cause-specific probability of death in-hospital for Bangladesh and the Philippines to generate population CSMFs. In regions where hospital death certification is of reasonable quality and routine verbal autopsy is not applied, these estimates could be applied to generate cost-effective and robust CSMFs for the population.
Abstract Background An optimal pharmacological strategy for fast-track cardiac anesthesia (FTCA) is unclear. This study evaluated the effectiveness and safety of an FTCA program using methadone and ...non-opioid adjuvant infusions (magnesium, ketamine, lidocaine, and dexmedetomidine) in patients undergoing coronary artery bypass grafting. Methods This retrospective, multicenter observational study was conducted across private and public teaching sectors. We studied patients managed by a fast-track protocol or via usual care according to clinician preference. The primary outcome was the total mechanical ventilation time in hours adjusted for hospital, body mass index, category of surgical urgency, cardiopulmonary bypass time and EuroSCORE II. Secondary outcomes included successful extubation within four postoperative hours, postoperative pain scores, postoperative opioid requirements, and the development of postoperative complications. Results We included 87 patients in the fast-track group and 88 patients in the usual care group. Fast-track patients had a 35% reduction in total ventilation hours compared with usual care patients ( p = 0.007). Thirty-five (40.2%) fast-track patients were extubated within four hours compared to 10 (11.4%) usual-care patients (odds ratio: 5.2 95% CI: 2.39–11.08; p < 0.001). Over 24 h, fast-track patients had less severe pain ( p < 0.001) and required less intravenous morphine equivalent (22.00 mg 15.75:32.50 vs. 38.75 mg 20.50:81.75; p < 0.001). There were no significant differences observed in postoperative complications or length of hospital stay between the groups. Conclusion Implementing an FTCA protocol using methadone, dexmedetomidine, magnesium, ketamine, lignocaine, and remifentanil together with protocolized weaning from a mechanical ventilation protocol is associated with significantly reduced time to tracheal extubation, improved postoperative analgesia, and reduced opioid use without any adverse safety events. A prospective randomized trial is warranted to further investigate the combined effects of these medications in reducing complications and length of stay in FTCA. Trials registration The study protocol was registered in the Australian New Zealand Clinical Trials Registry ( https://www.anzctr.org.au/ACTRN12623000060640.aspx , retrospectively registered on 17/01/2023).
PDF
