An accessible method for teaching doctors about death certification.
The World Health Organization (WHO) recommends that data on
mortality in its member countries are collected utilising the Medical
Certificate of Cause of Death published in the instruction volume of the
ICD-10. However, investment in health information processes necessary to
promote the use of this certificate and improve mortality information is
lacking in many countries. An appeal for support to make improvements
has been launched through the Health Metrics Network's MOVE-IT
strategy (Monitoring of Vital Events--Information Technology) (WHO
2011). Despite this international spotlight on the need for capture of
mortality data and in the use of the ICD-10 to code the data reported on
such certificates, there is little cohesion in the way that certifiers
of deaths receive instruction in how to complete the death certificate,
which is the main source document for mortality statistics. Complete and
accurate documentation of the immediate, underlying and contributory
causes of death of the decedent on the death certificate is a
requirement to produce standardised statistical information and to the
ability to produce cause-specific mortality statistics that can be
compared between populations and across time. This paper reports on a
research project conducted to determine the efficacy and accessibility
of the certification module of the WHO's newly-developed web based
training tool for coders and certifiers of deaths. Involving a
population of medical students from the Fiji School of Medicine and a
pre- and post-research design, the study entailed completion of death
certificates based on vignettes before and after access to the training
tool. The ability of the participants to complete the death certificates
and analysis of the completeness and specificity of the ICD-10 coding of
the reported causes of death were used to measure the effect of the
students' learning from the training tool. The quality of death
certificate completion was assessed using a Quality Index before and
after the participants accessed the training tool. In addition, the
views of the participants about accessibility and use of the training
tool were elicited using a supplementary questionnaire. The results of
the study demonstrated improvement in the ability of the participants to
complete death certificates completely and accurately according to best
practice. The training tool was viewed very positively and its
implementation in the curriculum for medical students was encouraged.
Participants also recommended that interactive discussions to examine
the certification exercises would be an advantage.
Keywords (MeSH): Death Certificates; Causes of Death; Data Collection; Training Techniques; Quality Improvement; Medical Staff.
Supplementary keyword: Health Information Management.
(Study and teaching)
Medical personnel (Information management)
Registers of births, etc. (Management)
|Publication:||Name: Health Information Management Journal Publisher: Health Information Management Association of Australia Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 Health Information Management Association of Australia Ltd. ISSN: 1833-3583|
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Complete and accurate death certificates, which document the immediate, underlying, intervening and contributory causes of death of the decedent, underpin the production of high quality statistical data and the ability to produce cause-specific mortality statistics. By using the WHO-recommended Medical Certificate of Cause of Death and coding the data using the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) (World Health Organization [WHO] 2008), it is possible to produce mortality statistics that are comparable between countries, national and subnational populations, for specific population groups and over time. The correct reporting of the underlying cause of death, and the coding of it, informs decision-making within hospitals and ministries of health and provides evidence for epidemiological and research studies. The data can also be used to assess the efficacy of public health interventions and set priorities for disease management (Byass 2007). However, a literature review by Aung, Rao and Walker reported little in the way of standardised education for medical officers in correct completion of the death certificate (Aung, Rao & Walker 2010). The authors note that the key challenges are in ensuring new medical graduates understand the importance of death certification and correct documentation practices and in ensuring that a method for periodic updating of knowledge for all certifiers is available.
In response to these challenges, the WHO, in collaboration with a number of experts from the WHO Family of International Classifications Network (WHO 2011a), has recently developed a web-based training tool regarding the use of the ICD-10 (WHO 2011b). The training tool is also available for download and as a CD ROM version. The aim of the development was to make training in the standardised use of the ICD-10 more readily accessible to individuals and groups that require coder and certifier education and to improve the source documentation from which data for coding are abstracted. The training tool includes modules for:
* structure of the classification and how to code
* each chapter of the ICD-10, including relevant medical science, structure of the chapter, what is included in the chapter, tricks and traps, practical exercises
* rules and guidelines for coding morbidity and mortality data
* death certification
* confidentiality and ethics
* data quality
* statistical presentation.
The tool has been designed with three major types of users in mind: coders (who may not have medical knowledge), doctors and other certifiers of deaths, and managers or users of coded data. Depending on the type of user, the tool will recommend a training pathway. For example, managers will get summary information about the ICD-10 and the coding process but not details about how to apply the classification to code morbidity and mortality data; doctors will not be shown the medical science sections; non-medical coders are recommended to complete the full training tool. The choice of what to learn depends on the user, but the tool provides assistance in making an appropriate selection. It is also possible to select specific modules according to the interests of the user. To complete the full training, including completion of coding exercises, will take approximately 40 hours.
The training tool has recently been posted on the WHO classifications website (http://apps.who.int/classifications/apps/icd/icd10training/). Prior to this, field testing of the coding modules by a variety of students with differing coding experience had been undertaken. A formal assessment of the medical science and coding content was undertaken by external reviewers. However, before finalisation of the first edition of the training tool, little testing of the efficacy of the certification modules had been undertaken to assess whether use of the tool as a standalone method for learning about completion of death certificates is appropriate. Therefore, the overall aim of this research project was to test the efficacy of the training tool using a pre- and post-test design by having participants complete death certificates before and after participating in the web based training. Additionally, a survey was used to collect information about the views of the participants about the training tool to assess its relevance to users and ease of access and completion.
This research aimed to evaluate the tool for use in teaching medical students about death certification requirements. The research partners included:
* The National Centre for Health Information Research and Training (NCHIRT) at the Queensland University of Technology. NCHIRT conducts regular international training sessions in the use of the ICD-10 for morbidity and mortality reporting and is a member of the Australian Collaborating Centre for the Family of International Classifications Network. Centre staff assisted with the development of the training tool.
* The Health Information Systems Knowledge Hub (HISHub) at the University of Queensland, which is an initiative that aims to build knowledge, evidence and expertise to inform health policy dialogue in health information systems relevant to Asia and the Pacific.
* The Fiji School of Medicine (FSMed) at the Fiji National University, which is the Pacific's leading medical educational institution.
These partners are working together to support the capacity of Pacific Island countries to understand and manage their health systems and their increasing need for reliable mortality statistics and cause of death data produced by functioning vital registration systems (Carter et al. 2010).
A series of vignettes were developed by the authors and were used by final year medical students from the FSMed to complete death certificates. The vignettes were initially drafted by one of the researchers who had medical qualifications (RR). They were then assessed to ensure they were culturally appropriate and represented common diseases and clinical practices in Fiji by the researcher from the FSMed (IW). The third researcher (SW) assessed the vignettes from a coding and reporting perspective. The three researchers collaborated to develop the correct certificates for each vignette. The medical specialties covered by the vignettes were infectious and parasitic diseases; neoplasms; endocrine, nutritional and metabolic diseases; mental and behavioural disorders; diseases of the circulatory system; congenital malformations, deformations and chromosomal abnormalities; respiratory diseases; digestive diseases; pregnancy, childbirth and the puerperium; symptoms and signs and injuries and external causes of morbidity and mortality.
The importance of the development of culturally-appropriate materials as well as the cultural sensitisation and preparation of the researchers was an important aspect of the methodology and the overall strategy of the activity. This is because Fiji has a multicultural population incorporating cultural traditions of Pacific Islander, European, South Asian, and East Asian origins. Death may evoke strong emotional responses in both Fijian and Indo-Fijian communities and the researchers were cognisant of this. Consideration was given to the ethnically diverse group and language of the participants in the teaching styles of the researchers. Recognition of the importance and the respectful treatment of 'death' knowledge from a cultural perspective was highlighted and carefully acknowledged.
The FSMed provides undergraduate medical education for students from across the Pacific Islands. Medical students in their final year who were undertaking their final week of education at the university were asked to voluntarily participate in this research as part of a four half-day workshop devoted to health information issues. There were 56 students in the MBBS 6 group of 2010, 23 of whom consented to participate in the full research study. Males accounted for 41.7% of participants and 58.3% were females. The countries of origin of the participants were Fiji (79.2%), Solomon Islands (8.3%), East Timor (4.2%), Kiribati (4.2%) and Vanuatu (4.2%). The majority of the participants were aged 24 (45.8%) or 25 (29.2%) years, with a range from 23-31 years.
Prior to the pre-test, students were given a presentation about medical certification of causes of death, presented by a medical officer who works for the Health Information Systems Hub (RR), and focussed on the role of the doctor in completing the death certificate and how the resultant mortality data are used. Specific details about the death certificate and how to complete it were not covered in the presentation. The medical students were then asked to give informed consent for participation in the study before completing the pre-test, which included 13 vignettes covering the range of specialities and causes of death. For each vignette, the participants were asked to complete a medical certificate of cause of death to the best of their ability. The WHO-recommended death certificate was used as the template as this is similar to the death certificate used routinely in Fiji.
Participants were then introduced to the WHO training tool and provided with the web address to access the certification module. The participants completed the death certification module in the FSMed computer laboratory. At the end of the week, the participants were provided with a post-test, which again contained a series of 13 vignettes from which they were asked to complete the respective death certificates. The vignettes used in the post-test differed from those in the pre-test but were of similar complexity and based on the same medical specialities.
Upon completion of the certificates, each student was asked to complete a short questionnaire seeking their demographic details and asking about their previous death certification experience, their views of the efficacy and ease of use of the web-based training tool and whether they felt that it was an appropriate method for teaching medical students about correct completion of the death certificate prior to them commencing medical practice. A further question explored whether the training tool would be a useful adjunct to medical school education and if so, which year of their medical degree program would be most suitable for the training tool to be introduced.
A final presentation, provided by a member of staff from the National Centre for Health Information Research and Training (SW), was used to reinforce the students' learning and to provide specific details about documentation issues and uses of health information for policy and practice. Participants were given the opportunity to ask questions about any aspect of death certification that remained unclear.
Data preparation and analysis
In order to assess changes in death certification behaviour between the pre- and post-tests, the death certificates created by each student were coded using the ICD-10 2008 edition by coding experts from the NCHIRT. The underlying causes of death were assigned using the ICD-10 coding rules, and codes for multiple causes were also assigned. Multiple causes reflect all causes of death reported on the death certificate, whether in Part I or Part II. Coding multiple causes in addition to uniquely identifying the underlying cause, provides richer detail for use in analysing cause specific deaths and is also necessary for assessing the sequence of events leading to the death to ensure the underlying cause is correctly selected. Therefore, multiple causes are an important requirement in completing the death certificate.
The certifier should report the sequence of events leading to the death in Part I, with the underlying cause of death on the lowest used line and the immediate cause on line 1(a). The WHO-recommended certificate is shown in Figure 1.
[FIGURE 1 OMITTED]
The underlying cause, used for tabulation and reporting purposes, is defined as '(a) the disease or injury that initiated the train of morbid events leading directly to death, or (b) the circumstances of the accident or violence that produced the fatal injury' (WHO 2008). The purpose of uniquely identifying the underlying cause is to identify the precipitating factor that could potentially have been prevented. Conditions thought to have been contributory but not part of the sequence of events leading to the death can be reported in Part II of the certificate. The ICD-10 instruction volume includes a series of rules and guidelines to standardise selection of the underlying cause of death to support international comparability of reported mortality data. Coders, who assign a code for the underlying cause based on these rules, assess the reported sequence and assign an underlying cause code from a public health perspective. The final underlying cause may not always equate to the medical underlying cause. In determining the underlying cause, a coder takes account of the duration of each cause between its onset and the death, whether any conditions in the sequence are missing or reported in an incorrect causal sequence, if conditions are reported in the wrong part of the certificate and whether necessary detail is supplied to assign specific codes. The completeness of the reported causes, the documentation of a mode (rather than a cause) of death (e.g. heart failure rather than a specific disease entity), the legibility of the handwriting of the certifier, use of abbreviations and reporting more than one condition on each line of the certificate all affect the ability of the coder to interpret the certificate and influence the quality of the coding of the causes of death.
A Quality Index to assess the quality of the death certificate completion was developed based on the rules and guidelines in Volume 2 of the ICD-10 and on best practice in completion of death certificates, as outlined in the training tool. Scores were assigned by the researcher from NCHIRT (SW), based on the coded data and the certificate completion. The Quality Index provided a numerical 'score' for various aspects of the certificate, as shown in Table 1.
Using the Quality Index, an assessment was made of the results of the pre and post-tests. Each certificate was given a possible score out of a total of 15, with the lower the score the more correctly the certificate was completed. The pre and post scores were then tallied out of a total of 195 (15 marks x 13 certificates) and percentages calculated.
Overall, there were no significant differences demonstrated in the results according to gender, age or ethnicity and thus disaggregated data are not presented.
Previous knowledge of death certification practices
One third of the participants indicated that they had received some form of education about death certification during their undergraduate education and prior to accessing the web-based training; however, this was limited. The education they had experienced was categorised as:
* attended a death and watched a more senior doctor complete a death certificate (n=8)
* attended a death and required to complete the death certificate myself (n=5)
* listened to a lecture about how to complete a death certificate (n=1)
* shown a death certificate but no instruction about how to fill it in (n=1)
* no previous education on certification (n=8).
No formal instruction about the requirements for completion of the death certificate was provided by the Fiji School of Medicine during any year of medical school education.
Across all aspects of quality considered, the students demonstrated improvement in death certificate completion revealed by an average error rate reduction of 11.25 percentage points, with a range from 61.15 percentage points improvement for the poorest performing student in the pre-test to 3.08 percentage points improvement for the best performing student in the pre-test. Quality assessment results for each student are shown in Appendix 1. The pre-test scores ranged from 198 (76.15% error rate) down to 32 (12.31% error rate). The student with the highest error rate did not complete all of the pre-test certificates in the allocated time, hence was allocated an overall 'worse' score. This student's results have been removed from further analysis. The student with the second highest error rate scored 74 (28.46% error rate). The post-test scores showed improvement for every student, with the overall scores ranging from 45 (17.31% error rate) down to the student completing the certificates most competently with a score of 20 (7.69% error rate).
Considering the various quality aspects used to calculate the Quality Index, pre and post-test error rates are depicted in Figure 2. The average error rate across all categories in the pre-test was 33.14% and in the post-test was 20.27%, an improvement in quality across all categories of 12.88 percentage points. Reviewing the specific quality aspects, improvements in quality demonstrated after the training tool was completed ranged from 26.42 percentage points improvement in reporting durations between onset and death for each cause, down to 0.67 percentage points improvement in legibility. In addition to the reporting of durations, greatest improvement was seen in the use of fewer abbreviations (19.40 percentage points improvement), reporting of a legitimate sequence of events in Part I (19.06 percentage points improvement), the reporting of only one cause per line (18.06 percentage points improvement) and in reporting a disease and not a mode of death (17.3 percentage points improvement). Least improvement was seen in legibility, although this was also lowest on the pre-test results, and in conditions reported in the wrong part of the death certificate (1.67 percentage points improvement).
[FIGURE 2 OMITTED]
Evaluation of the training tool
The participants were asked about their views of the web-based training tool: 95.8% found it easy to use and provided positive comments, such as 'Easy because instructions were clear and scenarios were very straightforward', 'Easily accessible--very informative, can repeat training tool if we want to' and, 'It had very clear instructions and the examples and questions were very useful. Made a lot of sense--I wanted to change a lot of answers from the pre-test'.
The length of time that participants spent completing the death certification module ranged from 15 minutes to one hour, with the majority taking 40 minutes or less to complete it. Nearly all students noted that they had completed the full module, including the exercises and questions. Difficulties with pages loading from the Internet were cited by one student as the reason for not completing the module.
All of the participants agreed that the web-based training had assisted them in understanding how to complete the death certificate according to international best practice. When asked if they had suggestions for improvements, they suggested:
* need for additional, more difficult, exercises; a greater variety of causes of death
* need to modify certain exercises in the training material that included a mode of death reported in Part I of the death certificate in the answer
* ability to have group discussions about the exercises would be beneficial, in addition to completing the tool on a computer
* need to ensure that the tool is widely advertised because of its utility for self-directed learning
* need for a CD ROM version to address slow Internet access issues.
Finally the participants were asked whether they felt that information about completion of the death certificate should be included in the curriculum for medical students. The response was overwhelmingly positive, with all students believing that this would be beneficial. Of all students, 56.52% thought that this should be included in the fourth or fifth year of training, before they go on trainee internships or clinical placement blocks.
In order to implement the most effective health policies and make appropriate decisions about allocation of resources, decision-makers require high-quality, cause-specific mortality data on causes of death. The utility of mortality data is often limited by the use of nonspecific cause of death codes, such as those for heart failure, which is actually a mode of death and not a cause. However, the major problem is not with the quality of the coding, but with the specificity and completeness of the documentation on the death certificate, the source document for coding purposes. The death certificate contains a section relating to the medical causes of death and is generally completed by either the decedent's treating doctor or a legal official such as a coroner. The importance of the standardised collection of mortality data, in particular relating to causes of death, cannot be overestimated. Mortality can be viewed as a general indicator of the health and welfare of the population and its subgroups. The ability to identify diseases of concern and groups at highest risk allows healthcare resources to be directed to areas of greatest need. Epidemiological studies can highlight links between risk factors and specific causes of death and can be used to identify the magnitude of a risk.
Interest in the ability of countries to strengthen health information systems is escalating internationally, particularly in their ability to record and report births and deaths and to ensure causes of death are also reported. The Health Metrics Network (HMN), a global partnership aimed at strengthening national health information systems, operates through a network of global, regional and country partners to improve systems to monitor and record vital events, including birth and death registration and reporting of causes of death. The so-called HMN MOVE-IT (Monitoring of Vital Events--Information Technology) initiative is helping to integrate stand alone civil registration and vital statistics collections within overall National Statistics Development Systems in countries that lack such processes (WHO 2011). With such improvements in data collection and reporting, countries will be better able to monitor progress towards the Millennium Development Goals (MDGs) (United Nations Development Program 2000) and identify gaps requiring attention. This research study reports on a means to support the MOVE-IT strategy by assessing a web-based training tool that makes information about death certification easily available internationally.
Although the results of this study demonstrated an improvement in the completion of death certificates by each of the students that participated, there is room for further improvement, particularly in the areas of reporting of the correct and complete sequences from underlying cause through intervening causes to the immediate cause of death. This error category showed the highest error rate overall in both pre and posttests--64.55% and 55.18% respectively. Other aspects of quality that need to be reinforced are the necessity to report duration for each cause (i.e. the interval between the onset of a condition and the death) and the requirement to ensure that all conditions are reported specifically (e.g. type of diabetes, cause of injury, type of pneumonia). These are important items for coders who are required to interpret the certificate and assign codes to reflect the underlying cause of death. The WHO publishes rules and guidelines in the ICD-10 that instruct coders in the way to determine and assign the underlying cause, even where the death certificate is not adequately completed; however, this process is greatly simplified if certifiers understand the death certificate and implement the requirements for its completion. Complete documentation of a sequence of events from the originating cause, possibly incorporating one or more intervening causes, to the immediate cause of death makes interpretation of the certificate easier. Having recorded durations for each reported condition also assists in identifying the timeline from originating cause to immediate cause. Although the originating cause may not end up being selected as the underlying cause, because of the precedence placed by WHO on identifying potentially preventative causes, the coding rules can be more easily and accurately applied if the sequence is appropriately documented.
Only one participant reported problems with Internet access and slowness of pages loading. The training tool developers spent considerable time planning the tool to ensure it works efficiently on computers with low bandwidth access to the Internet. This aimed to ensure that it is easily available even in those countries where access to the Internet is slow or intermittent. The training tool has now also been uploaded to the Pacific Open Learning Health Net (http://www.polhn.com/), which is a website operated by the WHO Representative Office in the South Pacific in Suva that assists healthcare workers in ten Pacific Island countries through computer networking and distance education.
As well as this, the option to purchase a CD ROM or downloadable version will also assist if Internet access is poor.
The authors conclude that the web-based training package fulfils the requirements for easy access to education on death certification and improves understanding of the requirements to complete the medical certificate of cause of death recommended by the WHO. The results of this research indicate that it may be optimal to use the training tool for initial education, followed by didactic sessions to reinforce concepts. However, if face-to-face courses are not feasible, the training tool provides a good way of providing the necessary information about how death certificates should be completed. The participants in the research indicated their belief that all medical students at the FSMed should complete the web-based training as part of their curriculum, optimally in year 4 or 5 of their study prior to going out on clinical placement blocks. Further research is now needed to assess the utility of the training tool for practicing clinicians and doctors in the field. Additional work to determine whether people who have used the training tool retain the knowledge they have gained over time is needed so that recommendations for updates to the training tool and methods to prompt doctors to undertake refresher training are needed. However, the positive responses to the training tool have also encouraged the researchers to extend their outreach to other Pacific Island countries to improve understanding of causes of death in these countries that do not have well-functioning death certification practices.
This research was supported by funds to the Health Information Systems Knowledge Hub from AusAID, the Australian Government Overseas Aid Program.
The authors thank the staff and MBBS 6 students of the Fiji School of Medicine, Fiji National University for their hospitality and willingness to participate in the research and acknowledge the role of the Health Information Systems Hub, University of Queensland in facilitating the pilot.
Aung, E., Rao, C. and Walker, S. (2010). Teaching cause-of-death certification: lessons from international experience. Postgraduate Medical Journal 86:143-152.
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Carter, K., Rao, C., Taylor, R. and Lopez, A. (2010). Routine mortality and cause of death reporting and analysis systems in seven Pacific Island countries. Health Information Systems Knowledge Hub (Ed.) Documentation Note series. Brisbane, University of Queensland.
United Nations Development Program (UNDP) (2000). What are the Millennium Development Goals? Available at: http://www.undp. org/mdg/basics.shtml (accessed July 2011). New York, UNDP.
World Health Organization (WHO) Representative Office in the South Pacific (2009). Pacific Open Learning Health Net. Available at: http://www.polhn.com/ (accessed February 2011). Suva, WHO.
World Health Organization (WHO) (2011). Monitoring of vital events. Available at: http://www.who.int/healthmetrics/move_it/en/index.html (accessed June 2011) Geneva, WHO.
World Health Organization (WHO) (2008). International Statistical Classification of Diseases and Related Health Problems (2008 edition). Geneva, WHO.
World Health Organization (WHO) (2011a). The WHO-FIC Network. Available at: http://www.who.int/classifications/ network/en/ (accessed March 2011). Geneva, WHO.
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Sue Walker BAppSc(MRA), GradDip(Public Health), MHlthSc
Director, National Centre for Health Information Research & Training
School of Public Health
Queensland University of Technology
Tel: +61 7 3138 5873
Fax: +61 7 3138 5515
Rasika Rampatige MBBS, MSc, MD
Senior Research Officer, Health Information Knowledge Hub
Australian Centre for International and Tropical Health
School of Population Health
The University of Queensland
Iris Wainiqolo MBBS, MPH
Lecturer, Epidemiology/Biostatistics Unit
Fiji School of Medicine
Fiji National University
Audrey Aumua BA(Educ),PGCert(Int Hlth), MPublicPolicy
Manager, Health Information Knowledge Hub
Australian Centre for International and Tropical Health
School of Population Health
The University of Queensland
Appendix 1: Student results, Quality Index error rate changes pre-tests and post-tests TOTAL TOTAL QUALITY QUALITY QUALITY STUDENT INDEX SCORE INDEX % INDEX SCORE NUMBER PRE-TEST PRE-TEST POST-TEST 1 56 28.72 37 2 57 29.23 21 3 49 25.13 33 4 65 25.00 45 5 74 28.46 30 6 61 23.46 42 7 53 20.38 24 8 52 20.00 27 9 50 19.23 37 10 43 16.54 35 11 198 76.15 39 12 38 14.62 27 13 49 18.85 24 14 45 17.31 28 15 46 17.69 22 16 41 15.77 28 17 44 16.92 22 18 47 18.08 32 19 54 20.77 35 20 48 18.46 24 21 54 20.77 31 22 60 23.08 34 23 32 12.31 20 Average all students 57.22 22.91 30.30 CHANGE QUALITY (PRE- TO CHANGE STUDENT INDEX % POST-TEST, QUALITY NUMBER POST-TEST RAW SCORES) INDEX 1 18.97 19.00 9.74 2 8.08 36.00 21.15 3 12.69 16.00 12.44 4 17.31 20.00 7.69 5 11.54 44.00 16.92 6 16.15 19.00 7.31 7 9.23 29.00 11.15 8 10.38 25.00 9.62 9 14.23 13.00 5.00 10 13.46 8.00 3.08 11 15.00 159.00 61.15 12 10.38 11.00 4.23 13 9.23 25.00 9.62 14 10.77 17.00 6.54 15 8.46 24.00 9.23 16 10.77 13.00 5.00 17 8.46 22.00 8.46 18 12.31 15.00 5.77 19 13.46 19.00 7.31 20 9.23 24.00 9.23 21 11.92 23.00 8.85 22 13.08 26.00 10.00 23 7.69 12.00 4.62 Average all students 11.66 26.91 11.25
Table 1: Quality Index Mode of death 0--mode of death not reported in Part I 1--mode of death reported in Part I Sequence 0--legitimate sequence used in Part I 1--sequence in Part I is not legitimate Durations 0--durations reported accurately and in correct sequence 1--durations incorrectly reported or sequence of durations incorrect Completeness of documentation 0--all causes of death reported completely 1--causes of death reported correctly but lack necessary specificity 2--some causes reported incorrectly and causes lack specificity Missing causes 0--no causes of death missing 1--missing causes of death in Part II 2--missing causes of death in Part I 3--missing causes of death in both Part I and Part II Abbreviations 0--abbreviations not used 1--abbreviations used Legibility 0--handwriting is legible 1--handwriting is difficult to read Different sequence, same UCOD 0--correct sequence reported 1--a different sequence is reported in Part I but the same UCOD is selected 2--a different sequence is reported in Part I and a different UCOD is selected Conditions reported in wrong part of certificate 0--all causes reported in correct part of certificate 1--conditions that should have been in Part II were reported in Part I 2--conditions that should have been reported in Part I were reported in Part II More than one condition reported on a line 0--one condition reported per line in Part I 1--more than one condition reported per line in Part I
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