Cause of Death Data

Background – Sources – Common

Quality Issues
 Outline

• Background
• Sources of cause of death data
• Certification and coding
• Analysis of cause of death data
• Uses of cause of death data
• International indicators using cause of death data
 Learning Objectives

By the end of the session the participants will:

• Understand how cause of death data are generated
• Know how to conduct basic cause of death analyses
• Know how to calculate international cause of death indicators
CAUSE OF DEATH DATA
What Are the Top 10 Causes of Death?
 Using Cause of Death Data for Prioritization
Top 10 Causes of Death Globally, 2013

Ischemic heart disease

Cerebrovascular disease

Chronic obstructive pulmonary disease

Lower respiratory infections

HIV/AIDS and tuberculosis

Alzheimer disease and other dementias

Tracheal, bronchus and lung cancer

Road injuries

HIV/AIDS

Diabetes mellitus

-1% 1% 3% 5% 7% 9% 11% 13% 15%

Percent of total deaths

Data source: Global Burden of Disease Study, 2013

Why is Cause of Death Data Important?
 Why is Cause of Death Data Important?
Who needs COD data?
National/international
agencies
Local public health
managers
Epidemiologists and
health services
researchers
Institutional managers
and clinical auditors
Medical and legal
practitioners
What kinds of data? Why?
Global and cause-specific Standardised, comparable
mortality estimates estimates over time and
ICD coding place
Top-ranking causes of Monitoring trends over
death and public health time and evaluating public
priorities health interventions
Relating to specific Interpreting particular
populations and situations in terms of
subgroups mortality patterns
Patterns of deaths within Monitoring trends over
institutions and health time and within
care systems departments
Individual causes for Following-up
particular cases consequences of
individual deaths

Source: Byass P. Who needs cause of death data? PLoS medicine. 2007;4(11):1715
 How Can We Use COD Data?

• To study and explain trends / differences in overall

mortality
• To guide resource allocation for intervention
programs, biomedical and sociomedical research
• To monitor public health programs, health risks, and
health interventions
• To provide clues for epidemiological research
 Cause of Death Data Needs to...

• Be comparable
• Over time
• Between countries
• Provide an overview of total mortality burden
• Identify vulnerable populations (where possible)
• Be disaggregated by age and sex
• Include numbers, rates and proportions
 Underlying Cause of Death

• Mainly interested in underlying cause of death

• Defined as:
• The disease or injury which initiated the sequence or chain of
events leading directly to death (WHO 1994)
• What this means:
• Where you would intervene to prevent the death
 Accident

Underlying cause: public health

Immediate causes: clinical care and prevention
SOURCES OF CAUSE OF
DEATH DATA
Where Do We Get COD Data From?
 Where do we get COD data from?

• Health facilities
• Biased source
• Police records
• Coroners records
• Verbal autopsy
• Lay reporting and community records
• Village registrar
• Church leaders
Data Sources and Uncertainty

Source: Carter K. 2013. Mortality and Causes of Death in the Pacific. UQ. Brisbane
 ‘Gold standard’ for COD data

Complete Registration of Births and Death

Each death has medically assigned

“Underlying cause of death”

Deaths certified using the WHO standard

Cause of Death Certificate

Cause of death is coded using ICD-10

classification
 Underlying cause of death

Source: University of Melbourne. Handbook for doctors on cause of death certification (in development)
 Mortality Coding

• Each death is counted, assigned a cause of death, and

coded once
• Specific rules and principles for mortality coders to follow
• Standard and comparable
• These become our COD statistics
• Primarily interested in underlying cause of death
 Mortality Coding: ICD-10

• Coding transforms text on death certificates into

unique alpha-numeric codes
• Coded data can be aggregated into national statistics
and compared
• between districts/provinces
• countries
• over time, etc.
• ICD 10: clear coding rules and processes for cause of
death information
Source: University of Melbourne. Handbook for doctors on cause of death certification (in development)
 Relevant ICD-10 Codes

Source: http://apps.who.int/classifications/icd10/browse/2016/en
ANALYSIS OF CAUSE OF
DEATH DATA
 General Guidelines

• Statistical tabulations by age, sex and ICD code

• Key lists of ICD codes:
• Condensed lists (general [1] and infant/child [3])
• Provide items for each ICD chapter
• Condense full range of ICD three-character categories into a
manageable number of items
• Selected lists (general [2] and infant/child [4])
• Items within most ICD chapters for conditions and external causes
• Locally designed lists
• Adapted for national requirements
 Disaggregation by Age and Sex
• Cause of death differs by age among children and by age and
sex among adults
• More meaningful to disaggregate
• Recommended groups for analysis: 5 year age groups by sex.
For under 5 deaths, separate between those < 1 year and from 1
year to < 5 years.
• For summarizing or presenting patterns, may want to use larger
groupings
• < 5 years (combined sexes)
• 5-14 years (combined sexes)
• 15-59 years (by male and female)
• 60+ years (by male and female)
 Smaller Populations/Data Sets

• Aggregate over time (3 or 5 years)

• Use slightly broader age groups (<5, 5-14, 15-59, 60+)
• For children where the causes of death do not differ
greatly – no need to disaggregate by sex
 Key Measures of Causes of Death

Measure Definition
Proportional mortality by The proportion of deaths (as a percent)
cause attributed to a specific underlying CoD (as
defined by the International Classification
of Diseases version 10, ICDv10)

Cause-specific mortality rate Number of deaths in a specific age group

for a defined period attributed to a specific
underlying CoD (as defined by ICDv10)
divided by the total (mid-period)
population in that age group. Usually
reported per 100,000 population.
 Proportional Mortality

• Definition: Proportion of total deaths due to a specific

cause
• Often calculated as the proportion of deaths for which
cause is known (in many cases cause of death not
known for entire population)
• Disaggregation:
• By age for children
• By age and sex in adults
 Proportional Mortality

= Number of deaths from a specific disease x 100

Total number of deaths

• Numerator: Number of deaths from a specific disease

• Denominator: Total deaths in a given period of time
• Usually expressed as a percent
 Proportional Mortality Example

• Globally, there were 54,863,765 deaths in 2013

• 38,267,197 were due to non-communicable diseases
(NCDs)
• 11,809,640 were due to communicable, maternal,
neonatal or nutritional diseases
% of deaths due to NCDs= 38,267,197 x 100 = 69.7%
54,863,765

% of deaths due to CDs= 11,809,640 x 100 = 21.5%

54,863,765
Example: Proportional Mortality, Malaysia
 Cause-specific Mortality Rates

= Number of deaths from a specific cause x 100,000

Mid year population

• Numerator: Number of deaths from a

specified cause during a specified period
• Denominator: total population at risk (mid-
year estimate) in the same period
• Usually per 100,000
 Cause-specific Mortality Rates

• Definition: Number of deaths from a specific cause

divided by the total population
• Disaggregation:
• By age for children
• By age and sex in adults
• Age standardization needed if wide adult age
groupings (e.g. 15-59) used
• Rates affected by population age distribution
• The older the population, the higher the rate of NCDs
• A word of caution: some causes may be
undercounted, analyse with care
 Example: Cause Specific Mortality Rates

Source: http://www.who.int/whosis/whostat/EN_WHS09_Table2.pdf
 Sustainable Development Goals

• Goal 3.4: By 2030, reduce by one third premature

mortality from non-communicable diseases through
prevention and treatment and promote mental health
and well-being
• Goal 3.5: By 2020, halve the number of global deaths
and injuries from road traffic accidents
 SDG: Suicide mortality rate
• Numerator: number of suicides in a specific time/place
• Denominator: population in the specific time/place
• Usually expressed per 100,000
• Recommended dis-aggregations
• Age
• Place of residence
• Sex
• Socioeconomic status
• ICD codes: X60 – X84
 SDG: Road Traffic Deaths

• Numerator: number of road traffic deaths in a specific

time/place
• Denominator: population in same time/place
• Expressed per 100,000
• Age-standardized so it can be compared across
countries
• Recommend disaggregating by age, sex and
geography
• ICD codes: V01 – V99
 WHO 100 Core Indicators
• TB mortality rate
• Numerator: estimated number of deaths due to TB
• Denominator: population

• AIDS-Related Mortality Rate

• Numerator: estimated number of deaths due to AIDS-related
causes
• Denominator: population

• Malaria Mortality Rate

• Numerator: estimated number of deaths deaths due to malaria
• Denominator: population
 Example: TB in Turkey

• 384 deaths due to TB in 2013

• 2013 population: 76,054,617

TB mortality rate = 384/76,054,657 = 0.000005

Expressed per 100,000 = 0.000005 * 100,000

= 0.5 per 100,000 population

 Analysis of Leading Causes of Death
Top 10 Causes of Death Globally, 2013
Ischemic heart disease

Cerebrovascular disease

Chronic obstructive pulmonary disease

Lower respiratory infections

HIV/AIDS and tuberculosis

Alzheimer disease and other dementias

Tracheal, bronchus and lung cancer

Road injuries

HIV/AIDS

Diabetes mellitus

-1% 1% 3% 5% 7% 9% 11% 13% 15%

Percent of total deaths

Data source: Global Burden of Disease Study, 2013

 Analysis of Leading Causes of Death

• Not as meaningful when deaths are grouped across all

ages and both sexes
• Tips for making your leading cause of death tables
more useful
• Make sure the total number of deaths is reported
• Reporting separately for males and females; and by broad age
group
• Lists are only comparable if they use the same disease categories.
Tabulate and report your deaths using the General mortality list 1
• Report the proportion of deaths for which cause of death data was
known alongside your tables
 What About Unknown Causes of Death?

• In many countries, a large proportion of deaths do not

have a cause assigned to them
• This also includes deaths were the cause of death is
clearly incorrect
• When looking at the leading causes of death, it is also
useful to include these in your analysis
• Gives a sense of how much we don’t know
• Provides impetus to improve CRVS system
Example output from ANACONDA
Leading Causes of Death in South Africa

Statistics South Africa. Mortality and causes of death in South Africa, 2008: Findings
from death notification. Statistical release P0309.3. Nov 2010
 Exercise: Top Ten Causes of Death

• Using the attached excel sheet causes of death

• Calculate the proportional mortality for each cause
• Use it to rank the top ten causes of death
• Repeat this exercise for the different age groups 
• What is different when you compare the different age groups? 
Do you think it’s valuable to look at this within age groups or
only overall?
 Calculate Probability of Dying from
Specific Causes
• Use life tables
• Probability of dying would normally be calculated for
selected groups of diseases
• Enter deaths due to the disease into the deaths
column
• Add up the number of theoretical deaths in the ages
you are interested in (ndx) divided by the theoretical
population (survivors – l) at the beginning of that age
interval
 SDG: Non-communicable Diseases

• Probability of dying of cardiovascular disease (CVD),

cancer, diabetes or chronic respiratory disease
between the ages of 30 and 70
• Calculate using a life table with cause-specific probabilities of
death (not taught here)
• Relevant ICD codes: I00-I99, C00-C97, E10-E14, and J30-J98
Using Your Cause of Death Data