Improving the quality of external cause of death data in Brazil: evaluation and validation of a new form to investigate garbage codes

Martins Soares Filho, Adauto; Lima, Raquel Barbosa de; Merchan-Hamann, Edgar; Souza, Maria de Fátima Marinho de; Mikkelsen, Lene; Mahesh, Pasyodun Koralage Buddhika; Adair, Tim

doi:10.1590/0102-311XEN097222

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ARTICLE • Cad. Saúde Pública 39 (3) • 2023 • https://doi.org/10.1590/0102-311XEN097222 copy

Improving the quality of external cause of death data in Brazil: evaluation and validation of a new form to investigate garbage codes

Melhorando a qualidade dos dados de causa externa de morte no Brasil: avaliação e validação de um novo formulário para investigar códigos garbage

Mejora en la calidad de los datos de causa externa de muerte en Brasil: evaluación y validación de un nuevo formulario para investigar códigos garbage

Authorship SCIMAGO INSTITUTIONS RANKINGS

Garbage codes, such as external causes with no specific information, indicate poor quality cause of death data. Investigation of garbage codes via an effective instrument is necessary to convert them into useful data for public health. This study analyzed the performance and suitability of the new investigation of deaths from external causes (IDEC) form to improve the quality of external cause of death data in Brazil. The performance of the IDEC form on 133 external garbage codes deaths was compared with a stratified matched sample of 992 (16%) investigated deaths that used the standard garbage codes form. Consistency between these two groups was checked. The percentage of garbage codes from external causes reclassified into valid causes with a 95% confidence interval (95%CI) was analyzed. Reclassification for specific causes has been described. Qualitative data on the feasibility of the form were recorded by field investigators. Investigation using the new form reduced all external garbage codes by -92.5% (95%CI: -97.0; -88.0), whereas the existing form decreased garbage codes by -60.5% (95%CI: -63.5; -57.4). The IDEC form presented higher effectivity for external-cause garbage codes of determined intent. Deaths that remained garbage codes mainly lacked information about the circumstances of poisoning and/or vehicle accidents. Despite the fact that field investigators considered the IDEC form feasible, they suggested modifications for further improvement. The new form was more effective than the current standard form in improving the quality of defined external causes.

Keywords:
Cause of Death; Certification; External Causes; Mortality Registries

Characteristics	Cases with IDEC form		Current standard procedure *
	Cases with IDEC form		Matched sample
	n	%	n	%
Age group (years)
0-24	21	15.8	159	16.0
25-44	30	22.6	227	22.9
45-54	12	9.0	92	9.3
55-64	14	10.5	107	10.8
65-74	18	13.5	132	13.3
75 or more	36	27.1	275	27.7
Ignored	2	1.5	-	-
Sex
Male	86	64.7	643	64.8
Female	46	34.6	349	35.2
Ignored	1	0.8	-	-
Investigated deaths
Undetermined intent (Y10-Y34)	72	54.1	542	54.6
All other garbage codes **	61	45.9	450	45.4
Region
Northeast	24	18.0	178	17.9
Southeast	99	74.4	713	71.9
South/Central-West	10	7.5	101	10.2
Total	133	100.0	992	100.0

	Cases with IDEC form *		Current standard procedure **
	Cases with IDEC form *		Matched sample
	n	%	n	%
Total garbage codes before	133	100.0	992	100.0
Valid code after	123	92.5	600	60.5
Garbage code after	10	7.5	392	39.5
Percentage change (CI) ***	-92.5 (-97.0; -88.0)		-60.5 (-63.5; -57.4)
Remained garbage code (CI)	7.5 (3.0; 12.6)		39.5 (36.5; 42.6)
Ratio of change (CI) ^#	-		1.53 (1.52; 1.53)
Undetermined intent (Y10-Y34)
Total before	72	100.0	542	100.0
Valid code after	66	91.7	432	79.7
Garbage code after	6	8.3	110	20.3
Percentage change (CI)	-91.7 (-98.1; -85.3)		-79.7 (-83.1; -76.3)
Remained garbage code (CI)	8.3 (1.9; 14.7)		20.3 (16.9; 23.7)
Ratio of change (CI) ^#	-		1.15 (1.12; 1.18)
All other garbage codes ^##
Total before	61	100.0	450	100.0
Valid code after	57	93.4	168	37.3
Garbage code after	4	6.6	282	62.7
Percentage change (CI)	-93.4 (-99.7; -87.2)		-37.3 (-41.8; -32.9)
Remained garbage code (CI)	6.6 (0.3; 12.8)		62.7 (58.2; 67.1)
Ratio of change (CI) ^#	-		2.50 (2.39; 2.65)

Causes before investigation	Causes after investigation
	Pedestrian	Cyclist	Motorcyclist	Motor vehicle	Unintentional injuries		Self-harm	Interpersonal violence	Other injuries	No injuries	Remaining garbage codes	Total
	Pedestrian	Cyclist	Motorcyclist	Motor vehicle	Fall	Others	Self-harm	Interpersonal violence	Other injuries	No injuries	Remaining garbage codes	%	n
Unspecified road injuries	33.3	11.1	22.2	27.8	-	-	-	-	-	-	5.6	100.0	18
Transport injuries unspecified	-	-	60.0	20.0	20.0	-	-	-	-	-	-	100.0	5
Unintentional injuries unspecified	33.3	-	29.6	7.4	18.5	-	-	-	3.7	-	7.4	100.0	27
Interpersonal violence unspecified	10.0	-	-	-	10.0	-	-	80.0	-	-	-	100.0	10
Undetermined intention	2.8	-	1.4	4.2	55.6	2.8	12.5	8.3	-	5.6	6.9	100.0	72
Others injuries by garbage code	-	-	-	-	-	-	-	-	-	-	100.0	100.0	1
Unintentional injury	16.7	-	66.7	-	-	16.7	-	-	-	-	-	100.0	6
Self-harm	-	-	-	-	-	-	100.0	-	-	-	-	100.0	2
Interpersonal violence	-	-	-	-	-	-	-	100.0	-	-	-	100.0	10
No injuries	-	-	-	-	16.7	-	8.3	-	8.3	50.0	16.7	100.0	12
Chapter 19	-	-	-	-	-	-	100	-	-	-	-	100.0	1
Total
%	11.6	1.2	12.2	6.7	29.9	1.8	7.9	14.6	1.2	6.1	6.7	100.0
n	19	2	20	11	49	3	13	24	2	10	11		164

Causes before investigation	Causes after investigation
	Pedestrian	Cyclist	Motorcyclist	Motor vehicle	Other road injuries	Unintentional injuries		Self-harm	Interpersonal violence	Other injuries	No injuries	Remaining garbage codes	Total
	Pedestrian	Cyclist	Motorcyclist	Motor vehicle	Other road injuries	Fall	Others	Self-harm	Interpersonal violence	Other injuries	No injuries	Remaining garbage codes	%	n
Unspecified road injuries	12.3	5.3	47.4	17.5	-	3.5	-	-	-	-	-	14.0	100.0	57
Transport injuries unspecified	12.5	1.6	10.9	4.7	-	-	-	-	-	-	-	70.3	100.0	64
Unintentional injuries unspecified	5.8	2.3	6.9	2.9	1.2	22.0	2,3	0.6	2.3	0.6	-	53.2	100.0	173
Interpersonal violence unspecified	-	-	-	-	-	-	-	-	11.3	5.2	-	83.5	100.0	115
Undetermined intention	7.7	0.2	1.5	2.4	-	36.2	2,6	6.5	14.2	1.7	6.8	20.3	100.0	542
Other injuries by garbage codes	-	-	-	-	-	-	-	-	-	-	-	100.0	100.0	41
Total
%	6.8	0.9	5.4	3.1	0.2	23.8	1.8	3.6	9.5	1.6	3.7	39.5	100.0
n	67	9	54	31	2	236	18	36	94	16	37	392		992

PLACE OF INVESTIGATION	TYPES OF CAUSES INVESTIGATED	FIELD INVESTIGATOR’S COMMENT
PLACE OF INVESTIGATION	TYPES OF CAUSES INVESTIGATED	STRENGTHS	DIFFICULTIES/ASPECTS TO BE IMPROVED	SUGGESTIONS
3 hospitals	Most deaths referred to femur fracture due to fall from one’s own height or bed	Standardization of the instrument for investigating death from external causes; High potential for retrieving information that supports the definition of the cause of death and circumstance of the event.	General Average investigation time of each death using the form was 30 minutes; Form too long; it is suggested to revise the form to be simpler and more objective, facilitating the work of researchers; Some questions seem to repeat themselves or they are not clearly saying which source or data type they refer to. Specific Lacks note on the medical record about: possible aggression or neglect; gender, race, marital status, and degree of study (information little valued in injuries); Poisoning information is rarely found in forensic institutes and hospitals; Without access to information from the technical-scientific police expertise of the event scene in the municipality; The following variables are not included in the records of the forensic medical office or other health services: sexual orientation, gender identity, death motivation (e.g., racism, femicide, homophobia), and perpetrator of violence; The form has few lines to write a detailed account of the event and it is not very hospital specific.	Inclusion of variable To collect information from the media and/or social networks, which are potential sources of information; Occupation; Medical record; Author of violence should include agent/police; Modifying “civil police” to “police” is more comprehensive. Exclusion of variables Name of father, age, address, end reductive information within parentheses in some variables; Item 22 since the causes of death in the coroner’s registry are the same as those transcribed to the death certificate.
2 forensic institutes	Different types of garbage codes of accidents and violence, and ill-defined causes
1 hospital and 1 forensic institute	Different types of garbage codes of accidents and ill-defined causes

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[1] Correspondence
T. Adair Melbourne School of Population and Global Health, University of Melbourne. Level 5, 333 Exhibition St., Melbourne / VIC - 3000, Australia. timothy.adair@unimelb.edu.au