Training of Certifiers in the United

States

Donna L. Hoyert
Robert N. Anderson

National Center for Health

Statistics (NCHS)
US Vital Statistics System
Decentralized system
State vital statistics laws and
regulations
57 registration areas

Funeral directors, physicians,

medical examiners or coroners

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 Scale
2.4 million deaths annually
700,000-800,000 practicing
physicians, medical examiners,
and coroners
Skewed distribution of
certification

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Training in Decentralized System
Not NCHS’ responsibility to train
certifiers
NCHS helps facilitate training
but does more

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 Workshops on Improving
Cause-of-Death Statistics
Sponsors: NCHS & National Committee
on Vital and Health Statistics
Attendees:
Federal vital statistics staff
State vital statistics staff
Professional organization
representatives

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 Workshop Recommendations
Need broad-based educational training of
certifiers
Multiple approaches
Multiple encounters

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Workshop Recommendations
Training message:
Importance of cause-of-death statistics
Value of statistics in improving the
practice of medicine
Mechanics of completing the death
certificate

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 Workshop Recommendations
Training Timing:
Medical school- Minimal orientation to
process but emphasis on importance of
statistics and physician contribution
Internship and residency- key time to
begin training physicians

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 Follow through on Workshop
Recommendations
Recommendations concerning training &:
Medical school
Internship & residency
Licensure & board certification
Practicing physicians
Medical examiners and coroners
Hospitals
Information dissemination and software
Other areas
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 Workshop Results
Workshop reports widely distributed
Resolutions of support
Notices of initiative in variety of
publications
NCHS produced additional training
material
States may have increased efforts
Other promising developments withered

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 Training Materials
Instructions on death certificate
Laminated instructions
Handbooks etc.
Exhibits
Presentations
Web page

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Instructions on death certificate
Examples and some
instructions
Purpose: To make sure
instructions are
available to every
certifier who is
completing a death
certificate

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Instructions in an electronic death
registration system
NCHS recommendations for help
screens, prompts, and queries on an
electronic death certificate developed in
1999
Above recommendations were
incorporated into the Death edit
specifications for 2003 revision
(http://www.cdc.gov/nchs/data/dvs/FinalDeathSpecs2-22-05.pdf)

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Laminated instructions
2 separate pages of instructions
Purpose: To provide certifiers
with a quick and handy
reference

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Handbooks and other
publications
NCHS handbooks
Series report
CAP manuals
Journal articles

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 Handbooks

Text, instructions, examples

Purpose: To provide more
detailed instructions tailored to
physician or medical examiner
and coroner
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 Other publications
Text, instructions, examples
Purpose: To distribute instructions and
examples in medical professional’s own
language differently
 Exhibit
Main panel, 4 table top panels,
variety of educational handouts
Purpose: To bring and distribute
training materials directly to
certifiers and to educate them
about the importance of
accurate cause-of-death
certification

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Illustration: Old Exhibit Display

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 National Center for Health Statistics
Nation al C ommittee on Vital an d Health Statistics
National Association for Public Health Statistics and Information Systems

Accurate death certificates are important

for improving the health status of the Nation
Cause-of-death inform ation is used to improve quality of life
and increase life expectancy for Am ericans
76
Life expectancy in years

75

74

73

72

71

70
1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1995
 Mortality trends in the United States
Major causes of death influencing the change in Mortality Trends 1979-97
life expectancy between 1995 and 1996 R ate per 1 00,000 live births Age-adjusted rate per 100,000 standard population
1 000 1000
HIV in fection Inf an ts All ag e gro u p s
Heart d isease Hea rt d iseas e
Conge nital anomalies
Can cer 100 Cancer
SIDS
Homicide Ac cidents
100 Stro ke
Diso rde rs relating to s hort ge s tation
Suicide a nd un sp ecified low b irth weight
RDS 10 CO PD
Stroke
Newbo rn affected by maternal comp lications
of preg na ncy HIV
Diabetes

COPD 10 1
1980 1985 1990 1995 199 1980 1985 1990 1995 1997
Hepatitis
Inf an t m or ta lit y ra te s ha ve d ecr ea se d fo r Age -ad ju s t ed d ea t h r a t es f or Ch r on ic
-1 -0.5 0 0.5 1 1.5 2 e a ch o f t h es e cond it ion s s in ce 1 99 5 . o bs t r u ct ive p u lm on ar y d is e as e s a n d a llie d
Contribution in month s to improvement in life expectancy De cr ea se s fo r SIDS a nd RD S h ave be en co n d it io n s h a ve in cr e as e d fa ir ly s t ea d ily s in ce
r e lat ivel y r ap id i n re ce n t yea rs ; r a t es f or 1 97 9 w h ile r a t es f or H IV in cr e as e d
Lif e e xp e cta nc y in c r ea s ed fr o m 7 5 . 8 y e ar s in 19 9 5 t o 7 6.1 yea r s in 1 99 6 f o r a to t al c h a n ge of c o ng en it al a no m al ie s a n d ne wbo rn a ff ec te d d r a m a t ica lly fr o m 19 8 7 t o 1 9 95 a n d h a ve
0 .3 y e ar s (i.e ., 3 .6 m o n th s ). Th e to t al c h a n g e is t h e co m b in a t ion of i nc r ea s in g m o r t a lit y fo r b y m at er n al co m p lic at io ns o f pr eg n an cy d r o p p e d s in ce . Rat es f or ca n ce r h ave b e en
s o m e ca u ses a n d d ec r ea s in g m o r ta lit y fo r o t h er ca u ses . T h is ch a r t sh o ws th e c o n t r ib u t io n o f h a ve g en er a lly d ec re as ed s in c e 1 979 . Rat es r e lat ive ly s t ab le b u t h ave d ecr e as ed s in ce
s p ec if ic c au s es , bo t h p os itive a n d n eg a tiv e, to t h e o ver a ll i m p ro v em en t in lif e ex p e ct an c y. f o r d is or d er s r el at in g t o s ho rt ges t a t io n a nd 1 99 0 . Ra t es h a ve d e cr e as e d fo r h e ar t d is ea s e,
Sou rc e: C DC/N CH S, Na tio nal Vit al Stat ist ics Syste m u n sp ecif ie d lo w bi rt hw e ight h ave be en m o re s t r o k e, a n d a ccid e n t s .
Sou rc e: CDC/NCHS, Natio nal Vital Stat ist ics Syste m. Prelimin ary data are basis for 19 97 da ta.
v ar ia b le.

Death rates for selected causes by age, 1997 Infant mortality rates for SIDS by month, US 1989-96
Rate per 100,000 po pul ation Rate per 1 00,000 live births
1 0000 250
Hea rt d is e a s e Acc id en t d ea th r a t es
a r e g r ea t er th a n r a t es
f o r m a n y c a u s es a t 200
1000 Ca nc e r yo u n g er a ge gr o u p s
a n d in c r ea s e
m o d er a t el y w it h a g e. 150
100 HIV d ea th r a t es p ea k
Ac c id e nts f o r a g e g r o u p s 2 5 -3 4
a n d 3 5 -4 4 . Ca n cer 100
10 d ea t h r a t es in cr ea s e
q u ic k ly w it h a ge b ef o r e
lev el in g o f f a t 7 5 -8 4 50
1 a n d 8 5 +. Hea r t d is ea s e
HIV d ea t h r a t es a r e h igh
r el a t ive t o o th er ca u s es 0
Jan Jul Ja n Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul
0.1 f o r ch ild r en u n d er 1 ,
Under 11-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ lo w f o r a g es 1 -4 a n d 5 - 1989 1990 1991 1992 1993 1994 1995 1 996
1 4 a n d in c r ea s e f o r SIDS m o r t a lit y r a t es f o llo w a s ea s o n a l p a t ter n with h ig h r a t es in t h e win t er a n d lo w
ea c h s u b s eq u en t a g e r a tes in t h e s u m m er . In f a n t m o r t a lit y r a tes f o r SIDS d ec r ea s ed a b o u t 4 4 p er c en t
S ou rce : C DC /NCH S, Nat ion al Vita l Stat istics S ystem , p reli min ar y d ata .
Sou rce: CDC /NCHS, National Vital Stat ist ics Syste m.
Some Exhibit Locations
American College of Physicians
American Academy of Physicians
American Society of Internal Medicine
American Public Health Association
American College of Cardiology
American Society of Clinical Oncology
National Medical Association
National Association of Medical Examiners
National Association for Public Health
Statistics and Information Systems
American Geriatrics Society
American Academy of Family Physicians
National Funeral Directors Association

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Training Presentations
Tailored instructional
presentation and power point
Purpose: To train certifiers

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 Web Page
Links to training resources
Purpose: To help disseminate
information

URL:
http://www.cdc.gov/
nchs/about/major/dvs/
handbk.htm
Thank you for your attention.