Rasika Rampatige

The effect of continuing professional education on health care outcomes: lessons for dementia care

BACKGROUND This review presents an overview of the published literature on the effectiveness of continuing professional education (CPE), which includes continuing medical education (CME) of different health care professionals in healthcare settings, for improving patient management and patient outcomes. This review summarizes key articles published on the subject, including those relating to dementia care. METHODS A literature search was carried out using the National Library of Medicines PubMed database, Cochrane database and Eric databases. RESULTS Studies on CPE generally provide conflicting evidence on their effectiveness in bringing about a change in professional practices and healthcare outcomes. However interactive, multifaceted interventions, and interventions with repeated inputs appear more effective in bringing about positive changes than traditional non-interactive techniques. There are relatively few studies specifically concerning CPE and dementia care. CONCLUSION This review shows that CPE in dementia care needs to be targeted carefully. Much can be learnt from examining education approaches in the wider professional and medical education literature.

Systematic review of statistics on causes of deaths in hospitals: strengthening the evidence for policy-makers

Abstract Objective To systematically review the reliability of hospital data on cause of death and encourage periodic reviews of these data using a standard method. Methods We searched Google Scholar, Pubmed and Biblioteca Virtual de la Salud for articles in English, Spanish and Portuguese that reported validation studies of data on cause of death. We analysed the results of 199 studies that had used medical record reviews to validate the cause of death reported on death certificates or by the vital registration system. Findings The screened studies had been published between 1983 and 2013 and their results had been reported in English (n = 124), Portuguese (n = 25) or Spanish (n = 50). Only 29 of the studies met our inclusion criteria. Of these, 13 had examined cause of death patterns at the population level – with a view to correcting cause-specific mortality fractions – while the other 16 had been undertaken to identify discrepancies in the diagnosis for specific diseases before and after medical record review. Most of the selected studies reported substantial misdiagnosis of causes of death in hospitals. There was wide variation in study methodologies. Many studies did not describe the methods used in sufficient detail to be able to assess the reproducibility or comparability of their results. Conclusion The assumption that causes of death are being accurately reported in hospitals is unfounded. To improve the reliability and usefulness of reported causes of death, national governments should do periodic medical record reviews to validate the quality of their hospital cause of death data, using a standard.

Assessing the reliability of causes of death reported by the Vital Registration System in Sri Lanka: medical records review in Colombo.

Information on causes of death is critical for informed decision making in the health sector. This paper reports findings from a study that measured the accuracy of registered causes of death and quality of medical records for a sample of deaths occurring in hospitals in Colombo, Sri Lanka. Five physicians, trained in medical certification of cause of death, reconstructed death certificates for hospital deaths from medical records and assessed the quality of medical records for this purpose. The majority of medical records were found to be of average quality. Concordance between the underlying cause of death in the vital registration data and that from the ‘gold standard’ (medical records review) diagnosis was 41.4% (n=249). The sensitivity of all leading causes of death and positive predictive value were below 67%. Major misclassification errors were found in identifying deaths due to vascular diseases and diabetes mellitus. Certified causes of death in Sri Lanka are frequently incorrect, thus limiting their value for health policy and for monitoring progress towards development goals. Sri Lanka, and other countries at a similar level of statistical development, should consider periodically conducting research to evaluate the quality of cause of death reporting at both local and national levels.

Causes of death in Tonga: quality of certification and implications for statistics

BackgroundDetailed cause of death data by age group and sex are critical to identify key public health issues and target interventions appropriately. In this study the quality of local routinely collected cause of death data from medical certification is reviewed, and a cause of death profile for Tonga based on amended data is presented.MethodsMedical certificates of death for all deaths in Tonga for 2001 to 2008 and medical records for all deaths in the main island Tongatapu for 2008 were sought from the national hospital. Cause of death data for 2008 were reviewed for quality through (a) a review of current tabulation procedures and (b) a medical record review. Data from each medical record were extracted and provided to an independent medical doctor to assign cause of death, with underlying cause from the medical record tabulated against underlying cause from the medical certificate. Significant associations in reporting patterns were evaluated and final cause of death for each case in 2008 was assigned based on the best quality information from the medical certificate or medical record. Cause of death data from 2001 to 2007 were revised based on findings from the evaluation of certification of the 2008 data and added to the dataset. Proportional mortality was calculated and applied to age- and sex-specific mortality for all causes from 2001 to 2008. Cause of death was tabulated by age group and sex, and age-standardized (all ages) mortality rates for each sex by cause were calculated.ResultsReported tabulations of cause of death in Tonga are of immediate cause, with ischemic heart disease and diabetes underrepresented. In the majority of cases the reported (immediate) cause fell within the same broad category as the underlying cause of death from the medical certificate. Underlying cause of death from the medical certificate, attributed to neoplasms, diabetes, and cardiovascular disease were assigned to other underlying causes by the medical record review in 70% to 77% of deaths. Of the 28 (6.5%) deaths attributed to nonspecific or unknown causes on the medical certificate, 17 were able to be attributed elsewhere following review of the medical record. Final cause of death tabulations for 2001 to 2008 demonstrate that noncommunicable diseases are leading adult mortality, and age-standardized rates for cardiovascular diseases, neoplasms, and diabetes increased significantly between 2001 to 2004 and 2005 to 2008. Cause of death data for 2001 to 2008 show increasing cause-specific mortality (deaths per 100,000) from 2001-2004 to 2005-2008 from cardiovascular (194-382 to 423-644 in 2005-2008 for males and 108-227 to 194-321 for females) and other noncommunicable diseases that cannot be accounted for by changes in the age structure of the population. Mortality from diabetes for 2005 to 2008 is estimated at 94 to 222 deaths per 100,000 population for males and 98 to 190 for females (based on the range of plausible all-cause mortality estimates) compared with 2008 estimates from the global burden of disease study of 40 (males) and 53 (females) deaths per 100,000 population.DiscussionCertification of death was generally found to be the most reliable data on cause of death in Tonga available for Tonga, with 93% of the final assigned causes following review of the 2008 data matching those listed on the medical certificate of death. Cause of death data available in Tonga can be improved by routinely tabulating data by underlying cause and ensuring contributory causes are not recorded in Part I of the certificate during data entry to the database. There is significantly more data on cause of death available in Tonga than are routinely reported or known to international agencies.

Disability, noncommunicable disease and health information

Noncommunicable diseases (NCDs) are a major cause of preventable disability worldwide.1 While actions to monitor NCDs have gained significant momentum in the global health agenda, similar developments to monitor and manage the growing burden of NCD-related disability have been relatively slow. The global NCD action plan was developed to support country efforts in addressing the devastating social, economic and public health impacts of NCDs.2 The NCD action plan includes nine voluntary targets and a monitoring framework. However, the monitoring framework has been criticized for its focus on mortality while neglecting adequate measures of morbidity and disability.3 This has resulted from focusing on existing data within health information systems, rather than on identifying appropriate data for measuring disease burden. Indeed, the issue of the chronicity of NCDs seems absent in most monitoring and evaluation frameworks, with an implicit assumption that the only outcome of interest for countries is premature mortality.

Hospital cause-of-death statistics: what should we make of them?

is the preferred standard for generating cause-of-death statistics. Most deaths whose cause is certified occur in hospitals. Although not all hospitals have the same diagnos -tic tools, it seems reasonable to expect hospital-based certifying physicians to correctly identify patients’ underlying causes of death, since hospitals usually have established clinical protocols for monitoring disease progression. After all, if physicians in hospitals cannot correctly ascertain their patients’ cause of death, who can?Cause-of-death statistics from hospitals are routinely amalgamated – along with mortality statistics from other sources – to constitute the es-sential statistics on the health of a population. Such statistics are widely used by governments, researchers, do-nors and global development agencies, often uncritically, on the assumption that they reliably capture a country’s epidemiological profile. They are used to periodically review health priorities, set research agendas and monitor progress towards national and global health and development goals. We take for granted that such data are correct. But are they?That the answer is a resounding no is only a part of the problem. More wor -rying perhaps is the fact that custodians of national mortality data systems fail to grasp the importance of periodically assessing the accuracy of hospital cause-of-death data. Physicians in hospitals may lack the time, incentives, diagnostic facilities or training to correctly certify causes of death and seldom understand that their diagnoses guide national health priorities. Medical records’ de-partments, which code death certificates and compile the data into cause-of-death tables by age and sex, are often understaffed, lack rigorous statistical protocols for checking data quality, and may not appreciate the epidemiological and statistical importance of their work. Thus, hospital cause-of-death data, even from advanced tertiary hospitals, can be expected to contain errors. But how common are these errors and are they serious enough to make the data unsuitable for informing public policy and research?Remarkably, the quality of hospital-based mortality data has seldom been investigated. In a recent review, Ram-patige et al.

Use of Smartphone for Verbal Autopsy: Results From a Pilot Study in Rural China

Traditionally, verbal autopsies (VA) are collected on paper-based questionnaires and reviewed by physicians for cause of death assignment, it is resource intensive and time consuming. The Population Health Metrics Research Consortium VA questionnaires was made available on an Android-based application and cause of death was derived using the Tariff method. Over one year, all adult deaths occurring in 48 villages in 4 counties were identified and a VA interview was conducted using the smartphone VA application. A total of 507 adult deaths were recorded and VA interviews were conducted. Cardiovascular disease was the leading cause of death (35.3%) followed by injury (14.6%) and neoplasms (13.5%). The total cost of the pilot study was USD28 835 (USD0.42 per capita). The interviewers found use of smartphones to conduct interviews to be easier. The study showed that using a smartphone application for VA interviews was feasible for implementation in rural China.

New challenges for verbal autopsy: Considering the ethical and social implications of verbal autopsy methods in routine health information systems.

Verbal autopsy (VA) methods are designed to collect cause-of-death information from populations where many deaths occur outside of health facilities and where death certification is weak or absent. A VA consists of an interview with a relative or carer of a recently deceased individual in order to gather information on the signs and symptoms the decedent presented with prior to death. These details are then used to determine and assign a likely cause-of-death. At a population level this information can be invaluable to help guide prioritisation and direct health policy and services. To date VAs have largely been restricted to research contexts but many countries are now venturing to incorporate VA methods into routine civil registration and vital statistics (CRVS) systems. Given the sensitive nature of death, however, there are a number of ethical, legal and social issues that should be considered when scaling-up VAs, particularly in the cross-cultural and socio-economically disadvantaged environments in which they are typically applied. Considering each step of the VA process this paper provides a narrative review of the social context of VA methods. Harnessing the experiences of applying and rolling out VAs as part of routine CRVS systems in a number of low and middle income countries, we identify potential issues that countries and implementing institutions need to consider when incorporating VAs into CRVS systems and point to areas that could benefit from further research and deliberation.

Health information systems and disability in the Lao PDR: A qualitative study

The Convention on the Rights of Persons with Disabilities provides an opportunity to strengthen disability-related health information. This study analysed the health information system in Lao PDR and sought evidence of interventions to improve disability-related health information. The study was based on a literature review and key informant interviews (N = 17) informed by the Health Metrics Networks Framework and Standards and the Performance of Routine Information System Management framework. The Lao health information system is in an embryonic stage with health data often incomplete, inaccurate and poorly used. Indicators related to disability or functioning are not included, and capacity to diagnose the health condition of disability is limited. No studies of health information interventions were found. As a State Party to the CRPD, the Lao PDR has a legal obligation to collect health-related information on people with disabilities. Given the nascent stage of development of the health information system in the Lao PDR and diagnostic capacity, indicators related to basic functioning and access to services should be integrated into household level surveys. As the health information system further develops, small, incremental changes in the type of disability information and rehabilitation and the way it is collected can be implemented. Copyright

Health information systems and disability in the Lao PDR: a qualitative study

The Convention on the Rights of Persons with Disabilities provides an opportunity to strengthen disability-related health information. This study analysed the health information system in Lao PDR and sought evidence of interventions to improve disability-related health information. The study was based on a literature review and key informant interviews (N = 17) informed by the Health Metrics Networks Framework and Standards and the Performance of Routine Information System Management framework. The Lao health information system is in an embryonic stage with health data often incomplete, inaccurate and poorly used. Indicators related to disability or functioning are not included, and capacity to diagnose the health condition of disability is limited. No studies of health information interventions were found. As a State Party to the CRPD, the Lao PDR has a legal obligation to collect health-related information on people with disabilities. Given the nascent stage of development of the health information system in the Lao PDR and diagnostic capacity, indicators related to basic functioning and access to services should be integrated into household level surveys. As the health information system further develops, small, incremental changes in the type of disability information and rehabilitation and the way it is collected can be implemented. Copyright