Publications by authors named "Alan D Lopez"

262 Publications

Improving methods to measure comparable mortality cause (IMMCMC) gold standard verbal autopsy dataset.

BMC Res Notes 2021 Nov 23;14(1):422. Epub 2021 Nov 23.

Department of Health Metrics Science, University of Washington, Seattle, WA, USA.

Objectives: Gold standard cause of death data is critically important to improve verbal autopsy (VA) methods in diagnosing cause of death where civil and vital registration systems are inadequate or poor. As part of a three-country research study-Improving Methods to Measure Comparable Mortality by Cause (IMMCMC) study-data were collected on clinicopathological criteria-based gold standard cause of death from hospital record reviews with matched VAs. The purpose of this data note is to make accessible a de-identified format of these gold standard VAs for interested researchers to improve the diagnostic accuracy of VA methods.

Data Description: The study was conducted between 2011 and 2014 in the Philippines, Bangladesh, and Papua New Guinea. Gold standard diagnoses of underlying causes of death for deaths occurring in hospital were matched to VAs conducted using a standardized VA questionnaire developed by the Population Health Metrics Consortium. 3512 deaths were collected in total, comprised of 2491 adults (12 years and older), 320 children (28 days to 12 years), and 702 neonates (0-27 days).
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http://dx.doi.org/10.1186/s13104-021-05834-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8609765PMC
November 2021

Global antibiotic consumption and usage in humans, 2000-18: a spatial modelling study.

Lancet Planet Health 2021 Nov 11. Epub 2021 Nov 11.

Oxford Centre for Global Health Research, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. Electronic address:

Background: Antimicrobial resistance (AMR) is a serious threat to global public health. WHO emphasises the need for countries to monitor antibiotic consumption to combat AMR. Many low-income and middle-income countries (LMICs) lack surveillance capacity; we aimed to use multiple data sources and statistical models to estimate global antibiotic consumption.

Methods: In this spatial modelling study, we used individual-level data from household surveys to inform a Bayesian geostatistical model of antibiotic usage in children (aged <5 years) with lower respiratory tract infections in LMICs. Antibiotic consumption data were obtained from multiple sources, including IQVIA, WHO, and the European Surveillance of Antimicrobial Consumption Network (ESAC-Net). The estimates of the antibiotic usage model were used alongside sociodemographic and health covariates to inform a model of total antibiotic consumption in LMICs. This was combined with a single model of antibiotic consumption in high-income countries to produce estimates of antibiotic consumption covering 204 countries and 19 years.

Findings: We analysed 209 surveys done between 2000 and 2018, covering 284 045 children with lower respiratory tract infections. We identified large national and subnational variations of antibiotic usage in LMICs, with the lowest levels estimated in sub-Saharan Africa and the highest in eastern Europe and central Asia. We estimated a global antibiotic consumption rate of 14·3 (95% uncertainty interval 13·2-15·6) defined daily doses (DDD) per 1000 population per day in 2018 (40·2 [37·2-43·7] billion DDD), an increase of 46% from 9·8 (9·2-10·5) DDD per 1000 per day in 2000. We identified large spatial disparities, with antibiotic consumption rates varying from 5·0 (4·8-5·3) DDD per 1000 per day in the Philippines to 45·9 DDD per 1000 per day in Greece in 2018. Additionally, we present trends in consumption of different classes of antibiotics for selected Global Burden of Disease study regions using the IQVIA, WHO, and ESAC-net input data. We identified large increases in the consumption of fluoroquinolones and third-generation cephalosporins in North Africa and Middle East, and south Asia.

Interpretation: To our knowledge, this is the first study that incorporates antibiotic usage and consumption data and uses geostatistical modelling techniques to estimate antibiotic consumption for 204 countries from 2000 to 2018. Our analysis identifies both high rates of antibiotic consumption and a lack of access to antibiotics, providing a benchmark for future interventions.

Funding: Fleming Fund, UK Department of Health and Social Care; Wellcome Trust; and Bill & Melinda Gates Foundation.
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http://dx.doi.org/10.1016/S2542-5196(21)00280-1DOI Listing
November 2021

Understanding longevity in Hong Kong: a comparative study with long-living, high-income countries.

Lancet Public Health 2021 Nov 10. Epub 2021 Nov 10.

School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health (D(2)4H), Hong Kong Science Park, Hong Kong Special Administrative Region, China.

Background: Since 2013, Hong Kong has sustained the world's highest life expectancy at birth-a key indicator of population health. The reasons behind this achievement remain poorly understood but are of great relevance to both rapidly developing and high-income regions. Here, we aim to compare factors behind Hong Kong's survival advantage over long-living, high-income countries.

Methods: Life expectancy data from 1960-2020 were obtained for 18 high-income countries in the Organisation for Economic Co-operation and Development from the Human Mortality Database and for Hong Kong from Hong Kong's Census and Statistics Department. Causes of death data from 1950-2016 were obtained from WHO's Mortality Database. We used truncated cross-sectional average length of life (TCAL) to identify the contributions to survival differences based on 263 million deaths overall. As smoking is the leading cause of premature death, we also compared smoking-attributable mortality between Hong Kong and the high-income countries.

Findings: From 1979-2016, Hong Kong accumulated a substantial survival advantage over high-income countries, with a difference of 1·86 years (95% CI 1·83-1·89) for males and 2·50 years (2·47-2·53) for females. As mortality from infectious diseases declined, the main contributors to Hong Kong's survival advantage were lower mortality from cardiovascular diseases for both males (TCAL difference 1·22 years, 95% CI 1·21-1·23) and females (1·19 years, 1·18-1·21), cancer for females (0·47 years, 0·45-0·48), and transport accidents for males (0·27 years, 0·27-0·28). Among high-income populations, Hong Kong recorded the lowest cardiovascular mortality and one of the lowest cancer mortalities in women. These findings were underpinned by the lowest absolute smoking-attributable mortality in high-income regions (39·7 per 100 000 in 2016, 95% CI 34·4-45·0). Reduced smoking-attributable mortality contributed to 50·5% (0·94 years, 0·93-0·95) of Hong Kong's survival advantage over males in high-income countries and 34·8% (0·87 years, 0·87-0·88) of it in females.

Interpretation: Hong Kong's leading longevity is the result of fewer diseases of poverty while suppressing the diseases of affluence. A unique combination of economic prosperity and low levels of smoking with development contributed to this achievement. As such, it offers a framework that could be replicated through deliberate policies in developing and developed populations globally.

Funding: Early Career Scheme (RGC ECS Grant #27602415), Research Grants Council, University Grants Committee of Hong Kong.
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http://dx.doi.org/10.1016/S2468-2667(21)00208-5DOI Listing
November 2021

Generating cause of death information to inform health policy: implementation of an automated verbal autopsy system in the Solomon Islands.

BMC Public Health 2021 Nov 13;21(1):2080. Epub 2021 Nov 13.

University of Washington, Seattle, USA.

Background: Good quality cause of death (COD) information is fundamental for formulating and evaluating public health policy; yet most deaths in developing countries, including the Solomon Islands, occur at home without medical certification of cause of death (MCCOD). As a result, COD data in such contexts are often of limited use for policy and planning. Verbal autopsies (VAs) are a cost-effective way of generating reliable COD information in populations lacking comprehensive MCCOD coverage, but this method has not previously been applied in the Solomon Islands. This study describes the establishment of a VA system to estimate the cause specific mortality fractions (CSMFs) for community deaths that are not medically certified in the Solomon Islands.

Methods: Automated VA methods (SmartVA) were introduced into the Solomon Islands in 2016. Trained data collectors (nurses) conducted VAs on eligible deaths to December 2020 using electronic tablet devices and VA responses were analysed using the Tariff 2.0 automated diagnostic algorithm. CSMFs were generated for both non-inpatient deaths in hospitals (i.e. 'dead on/by arrival') and community deaths.

Results: VA was applied to 914 adolescent-and-adult deaths with a median (IQR) age of 62 (45-75) years, 61% of whom were males. A specific COD could be diagnosed for more than 85% of deaths. The leading causes of death for both sexes combined were: ischemic heart disease (16.3%), stroke (13.5%), diabetes (8.1%), pneumonia (5.7%) and chronic-respiratory disease (4.8%). Stroke was the top-ranked cause for females, and ischaemic heart disease the leading cause for males. The CSMFs from the VAs were similar to Global Burden of Disease (GBD) estimates. Overall, non-communicable diseases (NCDs) accounted for 73% of adult deaths; communicable, maternal and nutritional conditions 15%, and injuries 12%. Six of the ten leading causes reported for facility deaths in the Solomon Islands were also identified as leading causes of community deaths based on the VA diagnoses.

Conclusions: NCDs are the leading cause of adult deaths in the Solomon Islands. Automated VA methods are an effective means of generating reliable COD information for community deaths in the Solomon Islands and should be routinely incorporated into the national mortality surveillance system.
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http://dx.doi.org/10.1186/s12889-021-12180-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8590305PMC
November 2021

The impact of errors in medical certification on the accuracy of the underlying cause of death.

PLoS One 2021 8;16(11):e0259667. Epub 2021 Nov 8.

Institute for Health Metrics and Evaluation (IHME), University of Washington, Seattle, Washington, United States of America.

Background: Correct certification of cause of death by physicians (i.e. completing the medical certificate of cause of death or MCCOD) and correct coding according to International Classification of Diseases (ICD) rules are essential to produce quality mortality statistics to inform health policy. Despite clear guidelines, errors in medical certification are common. This study objectively measures the impact of different medical certification errors upon the selection of the underlying cause of death.

Methods: A sample of 1592 error-free MCCODs were selected from the 2017 United States multiple cause of death data. The ten most common types of errors in completing the MCCOD (according to published studies) were individually simulated on the error-free MCCODs. After each simulation, the MCCODs were coded using Iris automated mortality coding software. Chance-corrected concordance (CCC) was used to measure the impact of certification errors on the underlying cause of death. Weights for each error type and Socio-demographic Index (SDI) group (representing different mortality conditions) were calculated from the CCC and categorised (very high, high, medium and low) to describe their effect on cause of death accuracy.

Findings: The only very high impact error type was reporting an ill-defined condition as the underlying cause of death. High impact errors were found to be reporting competing causes in Part 1 [of the death certificate] and illegibility, with medium impact errors being reporting underlying cause in Part 2 [of the death certificate], incorrect or absent time intervals and reporting contributory causes in Part 1, and low impact errors comprising multiple causes per line and incorrect sequence. There was only small difference in error importance between SDI groups.

Conclusions: Reporting an ill-defined condition as the underlying cause of death can seriously affect the coding outcome, while other certification errors were mitigated through the correct application of mortality coding rules. Training of physicians in not reporting ill-defined conditions on the MCCOD and mortality coders in correct coding practices and using Iris should be important components of national strategies to improve cause of death data quality.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0259667PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8575485PMC
November 2021

Diversity of epidemiological transition in the Pacific: Findings from the application of verbal autopsy in Papua New Guinea and the Solomon Islands.

Lancet Reg Health West Pac 2021 Jun 27;11:100150. Epub 2021 Apr 27.

The University of Melbourne, Melbourne School of Population and Global Health, Australia.

Background: Cause of death data are essential for rational health planning yet are not routinely available in Papua New Guinea (PNG) and Solomon Islands. Indirect estimation of cause of death patterns suggests these populations are epidemiologically similar, but such assessments are not based on direct evidence.

Methods: Verbal autopsy (VA) interviews were conducted at three sites in PNG and nationwide in Solomon Islands. Training courses were also facilitated to improve data from medical certificates of cause of death (MCCODs) in both countries. Data were categorised into broad groups of endemic and emerging conditions to aid assessment of the epidemiological transition.

Findings: Between 2017 and 2020, VAs were collected for 1,814 adult deaths in PNG and 819 adult deaths in Solomon Islands. MCCODs were analysed for 662 deaths in PNG and 1,408 deaths in Solomon Islands. The VA data suggest lower NCD mortality (48.8% versus 70.3%); higher infectious mortality (27.0% versus 18.3%) and higher injury mortality (24.5% versus 11.4%) in PNG compared to Solomon Islands. Higher infectious mortality in PNG was evident for both endemic and emerging infections. Higher NCD mortality in Solomon Islands reflected much higher emerging NCDs (43.6% vs 21.4% in PNG). A similar pattern was evident from the MCCOD data.

Interpretation: The cause of death patterns suggested by VA and MCCOD indicate that PNG is earlier in its epidemiological transition than Solomon Islands, with relatively higher infectious mortality and lower NCD mortality. Injury mortality was also particularly high in PNG.This study was funded by Bloomberg Philanthropies.
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http://dx.doi.org/10.1016/j.lanwpc.2021.100150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315473PMC
June 2021

Improving the Policy Utility of Cause of Death Statistics in Sri Lanka: An Empirical Investigation of Causes of Out-of-Hospital Deaths Using Automated Verbal Autopsy Methods.

Front Public Health 2021 26;9:591237. Epub 2021 May 26.

University of Washington, Seattle, WA, United States.

Setting public health policies and effectively monitoring the impact of health interventions requires accurate, timely and complete cause of death (CoD) data for populations. In Sri Lanka, almost half of all deaths occur outside hospitals, with questionable diagnostic accuracy, thus limiting their information content for policy. To ascertain whether SmartVA is applicable in improving the specificity of cause of death data for out-of-hospital deaths in Sri Lanka, and hence enhance the value of these routinely collected data for informing public policy debates. SmartVA was applied to 2610 VAs collected between January 2017 and March 2019 in 22 health-unit-areas clustered in six districts. Around 350 community-health-workers and 50 supervisory-staffs were trained. The resulting distribution of Cause-Specific-Mortality-Fractions (CSMFs) was compared to data from the Registrar-General's-Department (RGD) for out-of-hospital deaths for the same areas, and to the Global-Burden-of-Disease (GBD) estimates for Sri Lanka. Using SmartVA, for only 15% of deaths could a specific-cause not be assigned, compared with around 40% of out-of-hospital deaths currently assigned garbage codes with "very high" or "high" severity. Stroke (M: 31.6%, F: 35.4%), Ischaemic Heart Disease (M: 13.5%, F: 13.0%) and Chronic Respiratory Diseases (M: 15.4%, F: 10.8%) were identified as the three leading causes of home deaths, consistent with the ranking of GBD-Study for Sri Lanka for all deaths, but with a notably higher CSMF for stroke. SmartVA showed greater diagnostic specificity, applicability, acceptability in the Sri Lankan context. Policy formulation in Sri Lanka would benefit substantially with national-wide implementation of VAs.
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http://dx.doi.org/10.3389/fpubh.2021.591237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8187752PMC
June 2021

How reliable are self-reported estimates of birth registration completeness? Comparison with vital statistics systems.

PLoS One 2021 8;16(6):e0252140. Epub 2021 Jun 8.

Institute of Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America.

Background: The widely-used estimates of completeness of birth registration collected by Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) and published by UNICEF primarily rely on registration status of children as reported by respondents. However, these self-reported estimates may be inaccurate when compared with completeness as assessed from nationally-reported official birth registration statistics, for several reasons, including over-reporting of registration due to concern about penalties for non-registration. This study assesses the concordance of self-reported birth registration and certification completeness with completeness calculated from civil registration and vital statistics (CRVS) systems data for 57 countries.

Methods: Self-reported estimates of birth registration and certification completeness, at ages less than five years and 12-23 months, were compiled and calculated from the UNICEF birth registration database, DHS and MICS. CRVS birth registration completeness was calculated as birth registrations reported by a national authority divided by estimates of live births published in the United Nations (UN) World Population Prospects or the Global Burden of Disease (GBD) Study. Summary measures of concordance were used to compare completeness estimates.

Findings: Birth registration completeness (based on ages less than five years) calculated from self-reported data is higher than that estimated from CRVS data in most of the 57 countries (31 countries according to UN estimated births, average six percentage points (p.p.) higher; 43 countries according to GBD, average eight p.p. higher). For countries with CRVS completeness less than 95%, self-reported completeness was higher in 26 of 28 countries, an average 13 p.p. and median 9-10 p.p. higher. Self-reported completeness is at least 30 p.p. higher than CRVS completeness in three countries. Self-reported birth certification completeness exhibits closer concordance with CRVS completeness. Similar results are found for self-reported completeness at 12-23 months.

Conclusions: These findings suggest that self-reported completeness figures over-estimate completeness when compared with CRVS data, especially at lower levels of completeness, partly due to over-reporting of registration by respondents. Estimates published by UNICEF should be viewed cautiously, especially given their wide usage.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0252140PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8186773PMC
October 2021

Generating age-specific mortality statistics from incomplete death registration data: two applications of the empirical completeness method.

Popul Health Metr 2021 06 7;19(1):29. Epub 2021 Jun 7.

Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Seattle, WA, 98121, USA.

Background: The study aims to assess two approaches that apply the empirical completeness method to generate age-specific mortality statistics from incomplete death registration systems.

Methods: We use the empirical completeness method to calculate all-age death registration completeness, which is used with a model life table to generate mortality statistics and age-specific completeness using (1) the conventional method and (2) the equivalent deaths method. The results are compared with a capture-recapture (C-RC) study and three alternative mortality estimates for Brazilian states, and C-RC studies in Thailand, Oman and Vietnam, which independently estimate the level and age pattern of mortality or completeness.

Results: The empirical completeness method produces similar estimates of all-age completeness of registration to the C-RC studies. Compared with C-RC studies, at 15-59 years, the conventional method's estimates of mortality and completeness are more concordant, while at 60-84 years the equivalent death method's estimates are closer. Estimates of life expectancy from the two approaches each have similar concordance with the C-RC studies. For male adult mortality in Brazilian states, there is relatively strong average correlation of this study's estimates with three alternative estimates.

Conclusions: The two approaches produce mortality statistics from incomplete data that are mostly concordant with C-RC studies, and can be most usefully applied to subnational populations.
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http://dx.doi.org/10.1186/s12963-021-00262-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8186206PMC
June 2021

Public health utility of cause of death data: applying empirical algorithms to improve data quality.

BMC Med Inform Decis Mak 2021 06 2;21(1):175. Epub 2021 Jun 2.

Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.

Background: Accurate, comprehensive, cause-specific mortality estimates are crucial for informing public health decision making worldwide. Incorrectly or vaguely assigned deaths, defined as garbage-coded deaths, mask the true cause distribution. The Global Burden of Disease (GBD) study has developed methods to create comparable, timely, cause-specific mortality estimates; an impactful data processing method is the reallocation of garbage-coded deaths to a plausible underlying cause of death. We identify the pattern of garbage-coded deaths in the world and present the methods used to determine their redistribution to generate more plausible cause of death assignments.

Methods: We describe the methods developed for the GBD 2019 study and subsequent iterations to redistribute garbage-coded deaths in vital registration data to plausible underlying causes. These methods include analysis of multiple cause data, negative correlation, impairment, and proportional redistribution. We classify garbage codes into classes according to the level of specificity of the reported cause of death (CoD) and capture trends in the global pattern of proportion of garbage-coded deaths, disaggregated by these classes, and the relationship between this proportion and the Socio-Demographic Index. We examine the relative importance of the top four garbage codes by age and sex and demonstrate the impact of redistribution on the annual GBD CoD rankings.

Results: The proportion of least-specific (class 1 and 2) garbage-coded deaths ranged from 3.7% of all vital registration deaths to 67.3% in 2015, and the age-standardized proportion had an overall negative association with the Socio-Demographic Index. When broken down by age and sex, the category for unspecified lower respiratory infections was responsible for nearly 30% of garbage-coded deaths in those under 1 year of age for both sexes, representing the largest proportion of garbage codes for that age group. We show how the cause distribution by number of deaths changes before and after redistribution for four countries: Brazil, the United States, Japan, and France, highlighting the necessity of accounting for garbage-coded deaths in the GBD.

Conclusions: We provide a detailed description of redistribution methods developed for CoD data in the GBD; these methods represent an overall improvement in empiricism compared to past reliance on a priori knowledge.
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http://dx.doi.org/10.1186/s12911-021-01501-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8170729PMC
June 2021

Monitoring progress with national and subnational health goals by integrating verbal autopsy and medically certified cause of death data.

BMJ Glob Health 2021 05;6(5)

Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.

Introduction: The measurement of progress towards many Sustainable Development Goals (SDG) and other health goals requires accurate and timely all-cause and cause of death (COD) data. However, existing guidance to countries to calculate these indicators is inadequate for populations with incomplete death registration and poor-quality COD data. We introduce a replicable method to estimate national and subnational cause-specific mortality rates (and hence many such indicators) where death registration is incomplete by integrating data from Medical Certificates of Cause of Death (MCCOD) for hospital deaths with routine verbal autopsy (VA) for community deaths.

Methods: The integration method calculates population-level cause-specific mortality fractions (CSMFs) from the CSMFs of MCCODs and VAs weighted by estimated deaths in hospitals and the community. Estimated deaths are calculated by applying the empirical completeness method to incomplete death registration/reporting. The resultant cause-specific mortality rates are used to estimate SDG Indicator 23: mortality between ages 30 and 70 years from cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. We demonstrate the method using nationally representative data in Myanmar, comprising over 42 000 VAs and 7600 MCCODs.

Results: In Myanmar in 2019, 89% of deaths were estimated to occur in the community. VAs comprised an estimated 70% of community deaths. Both the proportion of deaths in the community and CSMFs for the four causes increased with older age. We estimated that the probability of dying from any of the four causes between 30 and 70 years was 0.265 for men and 0.216 for women. This indicator is 50% higher if based on CSMFs from the integration of data sources than on MCCOD data from hospitals.

Conclusion: This integration method facilitates country authorities to use their data to monitor progress with national and subnational health goals, rather than rely on estimates made by external organisations. The method is particularly relevant given the increasing application of routine VA in country Civil Registration and Vital Statistics systems.
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http://dx.doi.org/10.1136/bmjgh-2021-005387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8169488PMC
May 2021

How advanced is the epidemiological transition in Papua New Guinea? New evidence from verbal autopsy.

Int J Epidemiol 2021 May 2. Epub 2021 May 2.

Melbourne School of Population and Global Health, University of Melbourne, Carlton, VIC, Australia.

Background: Reliable cause of death (COD) data are not available for the majority of deaths in Papua New Guinea (PNG), despite their critical policy value. Automated verbal autopsy (VA) methods, involving an interview and automated analysis to diagnose causes of community deaths, have recently been trialled in PNG. Here, we report VA results from three sites and highlight the utility of these methods to generate information about the leading CODs in the country.

Methods: VA methods were introduced in one district in each of three provinces: Alotau in Milne Bay; Tambul-Nebilyer in Western Highlands; and Talasea in West New Britain. VA interviews were conducted using the Population Health Metrics Research Consortium (PHMRC) shortened questionnaire and analysed using the SmartVA automated diagnostic algorithm.

Results: A total of 1655 VAs were collected between June 2018 and November 2019, 87.0% of which related to deaths at age 12 years and over. Our findings suggest a continuing high proportion of deaths due to infectious diseases (27.0%) and a lower proportion of deaths due to non-communicable diseases (NCDs) (50.8%) than estimated by the Global Burden of Disease Study (GBD) 2017: 16.5% infectious diseases and 70.5% NCDs. The proportion of injury deaths was also high compared with GBD: 22.5% versus 13.0%.

Conclusions: Health policy in PNG needs to address a 'triple burden' of high infectious mortality, rising NCDs and a high fraction of deaths due to injuries. This study demonstrates the potential of automated VA methods to generate timely, reliable and policy-relevant data on COD patterns in hard-to-reach populations in PNG.
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http://dx.doi.org/10.1093/ije/dyab088DOI Listing
May 2021

Estimating causes of out-of-hospital deaths in China: application of SmartVA methods.

Popul Health Metr 2021 05 4;19(1):25. Epub 2021 May 4.

Institute for Health Metrics and Evaluation, University of Washington, Seattle, USA.

Background: Most deaths in China occur at home, making it difficult to collect reliable cause of death (CoD) information. Verbal autopsy (VA) was applied using the SmartVA tool to a sample of home deaths in China to explore its feasibility as a means of improving the quality of CoD data.

Methods: The study was carried out in 22 districts in 9 provinces, located in north-east, central, and western areas of China during 2017 and 2018. Trained interviewers selected suitable respondents in each household to collect information using the Population Health Metrics Research Consortium (PHMRC) shortened and validated electronic VA questionnaire on tablets. The CoD was diagnosed from the interview data using the SmartVA-Analyze 2.0 software (Tariff 2.0).

Results: Non-communicable diseases (NCDs) dominated the leading causes of death in all age groups and for both sexes. After redistribution of undetermined causes, stroke (24%), ischemic heart diseases (IHD) (21%), chronic respiratory diseases (11%), and lung cancer (6%) were the leading causes of death. The cause fractions for level-one cause categories and ranking of specific causes were similar between SmartVA and results from the Global Burden of Disease (GBD) study.

Conclusion: Evidence from this large pilot study suggests that SmartVA is a feasible and plausible tool and could be a valuable tool to improve the quality and standardization of CoD information across China.
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http://dx.doi.org/10.1186/s12963-021-00256-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8097770PMC
May 2021

Improving cause of death certification in the Philippines: implementation of an electronic verbal autopsy decision support tool (SmartVA auto-analyse) to aid physician diagnoses of out-of-facility deaths.

BMC Public Health 2021 03 22;21(1):563. Epub 2021 Mar 22.

School of Population and Global Health, University of Melbourne, Parkville, VIC, Australia.

Background: The majority of deaths in the Philippines occur out-of-facility and require a medical certificate of cause of death by Municipal Health Officers (MHOs) for burial. MHOs lack a standardised certification process for out-of-facility deaths and when no medical records are available, certify a high proportion of ill-defined causes of death. We aimed to develop and introduce SmartVA Auto-Analyse, a verbal autopsy (VA) based electronic decision support tool in order to assist the MHOs in certifying out-of-facility deaths.

Method: We conducted a stakeholder consultation, process mapping and a pre-test to assess feasibility and acceptability of SmartVA Auto-Analyse. MHOs were first asked to conduct an open-ended interview from the family members of the deceased, and if they were not able to arrive at a diagnosis, continue the interview using the standardised SmartVA questionnaire. Auto-Analyse then presented the MHO with the three most likely causes of death. For the pilot, the intervention was scaled-up to 91 municipalities. We performed a mixed-methods evaluation using the cause of death data and group discussions with the MHOs.

Results: Of the 5649 deaths registered, Auto-Analyse was used to certify 4586 (81%). For the remaining 19%, doctors believed they could assign a cause of death based on the availability of medical records and the VA open narrative. When used, physicians used the Auto-Analyse diagnosis in 85% of cases to certify the cause of death. Only 13% of the deaths under the intervention had an undetermined cause of death. Group discussions identified two themes: Auto-Analyse standardized the certification of home deaths and assisted the MHOs to improve the quality of death certification.

Conclusion: Standardized VA combined with physician diagnosis using the SmartVA Auto-Analyse support tool was readily used by MHOs in the Philippines and can improve the quality of death certification of home deaths.
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http://dx.doi.org/10.1186/s12889-021-10542-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986549PMC
March 2021

Routine mortality surveillance to identify the cause of death pattern for out-of-hospital adult (aged 12+ years) deaths in Bangladesh: introduction of automated verbal autopsy.

BMC Public Health 2021 03 12;21(1):491. Epub 2021 Mar 12.

School of Population and Global Health, University of Melbourne, Parkville, VIC, Australia.

Background: In Bangladesh, a poorly functioning national system of registering deaths and determining their causes leaves the country without important information on which to inform health programming, particularly for the 85% of deaths that occur in the community. In 2017, an improved death registration system and automated verbal autopsy (VA) were introduced to 13 upazilas to assess the utility of VA as a routine source of policy-relevant information and to identify leading causes of deaths (COD) in rural Bangladesh.

Methods: Data from 22,535 VAs, collected in 12 upazilas between October 2017 and August 2019, were assigned a COD using the SmartVA Analyze 2.0 computer algorithm. The plausibility of the VA results was assessed using a series of demographic and epidemiological checks in the Verbal Autopsy Interpretation, Performance and Evaluation Resource (VIPER) software tool.

Results: Completeness of community death reporting was 65%. The vast majority (85%) of adult deaths were due to non-communicable diseases, with ischemic heart disease, stroke and chronic respiratory disease comprising about 60% alone. Leading COD were broadly consistent with Global Burden of Disease study estimates.

Conclusions: Routine VA collection using automated methods is feasible, can produce plausible results and provides critical information on community COD in Bangladesh. Routine VA and VIPER have potential application to countries with weak death registration systems.
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http://dx.doi.org/10.1186/s12889-021-10468-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952220PMC
March 2021

Smoking and epidemics of respiratory infections.

Bull World Health Organ 2021 Feb 28;99(2):164-165. Epub 2020 Oct 28.

Melbourne School of Population and Global Health, The University of Melbourne, Victoria, Australia.

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http://dx.doi.org/10.2471/BLT.20.273052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856358PMC
February 2021

An egalitarian society? Widening inequalities in premature mortality from non-communicable diseases in Australia, 2006-16.

Int J Epidemiol 2021 07;50(3):783-796

Global Burden of Disease Group, Melbourne School of Population and Global Health, University of Melbourne, Carlton, VIC, Australia.

Background: The recent slowdown in life expectancy increase in Australia has occurred concurrently with widening socioeconomic and geographical inequalities in all-cause mortality risk. We analysed whether, and to what extent, mortality inequalities among specific non-communicable diseases (NCDs) in Australia at ages 35-74 years widened during 2006-16.

Methods: Registered deaths that occurred during 2006-16 in Australia were analysed. Inequalities were measured by area socioeconomic quintile [ranging from Q1 (lowest) to Q5 (highest)] and remoteness (major cities, inner regional, outer regional/remote/very remote). Age-standardized death rates (ASDR) for 35-74 years were calculated and smoothed over time.

Results: NCD mortality inequalities by area socioeconomic quintile widened; the ratio of Q1 to Q5 ASDR for males increased from 1.96 [95% confidence interval (CI) 1.91-2.01] in 2011 to 2.08 (2.03-2.13) in 2016, and for females from 1.78 (1.73-1.84) to 1.96 (1.90-2.02). Moreover, Q1 NCD ASDRs did not clearly decline from 2011 to 2016. CVD mortality inequalities were wider than for all NCDs. There were particularly large increases in smoking-related mortality inequalities. In 2016, mortality inequalities were especially high for chronic respiratory diseases, alcohol-related causes and diabetes. NCD mortality rates outside major cities were higher than within major cities, and these differences widened during 2006-16. Higher mortality rates in inner regional areas than in major cities were explained by socioeconomic factors.

Conclusions: Widening of inequalities in premature mortality rates is a major public health issue in Australia in the context of slowing mortality decline. Inequalities are partly explained by major risk factors for CVDs and NCDs: being overweight or obese, lack of exercise, poor diet and smoking. There is a need for urgent policy responses that consider socioeconomic disadvantage.
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http://dx.doi.org/10.1093/ije/dyaa226DOI Listing
July 2021

Effectiveness of training interventions to improve quality of medical certification of cause of death: systematic review and meta-analysis.

BMC Med 2020 12 11;18(1):384. Epub 2020 Dec 11.

Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie street, Melbourne, 3053, Australia.

Background: Valid cause of death data are essential for health policy formation. The quality of medical certification of cause of death (MCCOD) by physicians directly affects the utility of cause of death data for public policy and hospital management. Whilst training in correct certification has been provided for physicians and medical students, the impact of training is often unknown. This study was conducted to systematically review and meta-analyse the effectiveness of training interventions to improve the quality of MCCOD.

Methods: This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO; Registration ID: CRD42020172547) and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. CENTRAL, Ovid MEDLINE and Ovid EMBASE databases were searched using pre-defined search strategies covering the eligibility criteria. Studies were selected using four screening questions using the Distiller-SR software. Risk of bias assessments were conducted with GRADE recommendations and ROBINS-I criteria for randomised and non-randomised interventions, respectively. Study selection, data extraction and bias assessments were performed independently by two reviewers with a third reviewer to resolve conflicts. Clinical, methodological and statistical heterogeneity assessments were conducted. Meta-analyses were performed with Review Manager 5.4 software using the 'generic inverse variance method' with risk difference as the pooled estimate. A 'summary of findings' table was prepared using the 'GRADEproGDT' online tool. Sensitivity analyses and narrative synthesis of the findings were also performed.

Results: After de-duplication, 616 articles were identified and 21 subsequently selected for synthesis of findings; four underwent meta-analysis. The meta-analyses indicated that selected training interventions significantly reduced error rates among participants, with pooled risk differences of 15-33%. Robustness was identified with the sensitivity analyses. The findings of the narrative synthesis were similarly suggestive of favourable outcomes for both physicians and medical trainees.

Conclusions: Training physicians in correct certification improves the accuracy and policy utility of cause of death data. Investment in MCCOD training activities should be considered as a key component of strategies to improve vital registration systems given the potential of such training to substantially improve the quality of cause of death data.
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http://dx.doi.org/10.1186/s12916-020-01840-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7728523PMC
December 2020

Mortality surveillance and verbal autopsy strategies: experiences, challenges and lessons learnt in Papua New Guinea.

BMJ Glob Health 2020 12;5(12)

Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.

Full notification of deaths and compilation of good quality cause of death data are core, sequential and essential components of a functional civil registration and vital statistics (CRVS) system. In collaboration with the Government of Papua New Guinea (PNG), trial mortality surveillance activities were established at sites in Alotau District in Milne Bay Province, Tambul-Nebilyer District in Western Highlands Province and Talasea District in West New Britain Province.Provincial Health Authorities trialled strategies to improve completeness of death notification and implement an automated verbal autopsy methodology, including use of different notification agents and paper or mobile phone methods. Completeness of death notification improved from virtually 0% to 20% in Talasea, 25% and 75% using mobile phone and paper notification strategies, respectively, in Alotau, and 69% in Tambul-Nebilyer. We discuss the challenges and lessons learnt with implementing these activities in PNG, including logistical considerations and incentives.Our experience indicates that strategies to maximise completeness of notification should be tailored to the local context, which in PNG includes significant geographical, cultural and political diversity. We report that health workers have great potential to improve the CRVS programme in PNG through managing the collection of notification and verbal autopsy data. In light of our findings, and in consultation with the main government CRVS stakeholders and the National CRVS Committee, we make recommendations regarding the requirements at each level of the health system to optimise mortality surveillance in order to generate the essential health intelligence required for policy and planning.
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http://dx.doi.org/10.1136/bmjgh-2020-003747DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716660PMC
December 2020

Estimating global injuries morbidity and mortality: methods and data used in the Global Burden of Disease 2017 study.

Inj Prev 2020 10 24;26(Supp 1):i125-i153. Epub 2020 Aug 24.

Department of Pharmacy, Adigrat University, Adigrat, Ethiopia.

Background: While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria.

Methods: In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced.

Results: GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes.

Conclusions: GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future.
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http://dx.doi.org/10.1136/injuryprev-2019-043531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571362PMC
October 2020

Are cause of death data fit for purpose? evidence from 20 countries at different levels of socio-economic development.

PLoS One 2020 24;15(8):e0237539. Epub 2020 Aug 24.

Global Burden of Disease Group, University of Melbourne, Melbourne, Australia.

Background And Objective: Many countries have used the new ANACONDA (Analysis of Causes of National Death for Action) tool to assess the quality of their cause of death data (COD), but no cross-country analysis has been done to verify how different or similar patterns of diagnostic errors and data quality are in countries or how they are related to the local cultural or epidemiological environment or to levels of development. Our objective is to measure whether the usability of COD data and the patterns of unusable codes are related to a country's level of socio-economic development.

Methods: We have assessed the quality of 20 national COD datasets from the WHO Mortality Database by assessing their completeness of COD reporting and the extent, pattern and severity of garbage codes, i.e. codes that provide little or no information about the true underlying COD. Garbage codes were classified into four groups based on the severity of the error in the code. The Vital Statistics Performance Index for Quality (VSPI(Q)) was used to measure the overall quality of each country's mortality surveillance system.

Findings: The proportion of 'garbage codes' varied from 7 to 66% across the 20 countries. Countries with a high SDI generally had a lower proportion of high impact (i.e. more severe) garbage codes than countries with low SDI. While the magnitude and pattern of garbage codes differed among countries, the specific codes commonly used did not.

Conclusions: There is an inverse relationship between a country's socio-demographic development and the overall quality of its cause of death data, but with important exceptions. In particular, some low SDI countries have vital statistics systems that are as reliable as more developed countries. However, in low-income countries, where most people die at home, the proportion of unusable codes often exceeds 50%, implying that half of all cause-specific mortality data collected is of little or no use in guiding public policy. Moreover, the cause of death pattern identified from the data is likely to seriously under-represent the true extent of the leading causes of death in the population, with very significant consequences for health priority setting. Garbage codes are prevalent at all ages, contrary to expectations. Further research into effective strategies deployed in these countries to improve data quality can inform efforts elsewhere to improve COD reporting systems.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0237539PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7446871PMC
October 2020

The role of overweight and obesity in adverse cardiovascular disease mortality trends: an analysis of multiple cause of death data from Australia and the USA.

BMC Med 2020 08 4;18(1):199. Epub 2020 Aug 4.

Melbourne School of Population and Global Health, The University of Melbourne, Level 5, Building 379, 207 Bouverie Street, Carlton, Victoria, 3010, Australia.

Background: In recent years, there have been adverse trends in premature cardiovascular disease (CVD) mortality rates (35-74 years) in the USA and Australia. Following long-term declines, rates in the USA are now increasing while falls in Australia have slowed rapidly. These two countries also have the highest adult obesity prevalence of high-income countries. This study investigates the role of overweight and obesity in their recent CVD mortality trends by using multiple cause of death (MCOD) data-direct individual-level evidence from death certificates-and linking the findings to cohort lifetime obesity prevalence.

Methods: We identified overweight- and obesity-related mortality as any CVD reported on the death certificate (CVD MCOD) with one or more of diabetes, chronic kidney disease, obesity, lipidemias or hypertensive heart disease (DKOLH-CVD), causes strongly associated with overweight and obesity. DKOLH-CVD comprises 50% of US and 40% of Australian CVD MCOD mortality. Trends in premature age-standardized death rates were compared between DKOLH-CVD and other CVD MCOD deaths (non-DKOLH-CVD). Deaths from 2000 to 2017 in the USA and 2006-2016 in Australia were analyzed. Trends in in age-specific DKOLH-CVD death rates were related to cohort relative lifetime obesity prevalence.

Results: Each country's DKOLH-CVD mortality rate rose by 3% per annum in the most recent year, but previous declines had reversed more rapidly in Australia. Non-DKOLH-CVD mortality in the USA increased in 2017 after declining strongly in the early 2000s, but in Australia it has continued declining in stark contrast to DKOLH-CVD. There were larger increases in DKOLH-CVD mortality rates at successively younger ages, strongly related with higher relative lifetime obesity prevalence in younger cohorts.

Conclusions: The increase in DKOLH-CVD mortality in each country suggests that overweight and obesity has likely been a key driver of the recent slowdown or reversal of CVD mortality decline in both countries. The larger recent increases in DKOLH-CVD mortality and higher lifetime obesity prevalence in younger age groups are very concerning and are likely to adversely impact CVD mortality trends and hence life expectancy in future. MCOD data is a valuable but underutilized source of data to track important mortality trends.
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http://dx.doi.org/10.1186/s12916-020-01666-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7401233PMC
August 2020

Measuring the completeness of death registration in 2844 Chinese counties in 2018.

BMC Med 2020 07 3;18(1):176. Epub 2020 Jul 3.

National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27# Nanwei Road, Xicheng District, Beijing, 100050, China.

Background: Death registration completeness has never been assessed at the county level in China. Such analyses would provide critical intelligence to monitor the performance of the vital registration system and yield adjustment factors to correct death registration data, thereby increasing their policy utility.

Methods: We estimated the completeness of death registration for 31 provinces and 2844 counties of China in 2018 based on death data from the China Cause of Death Reporting System (CDRS) by using the empirical completeness method. We computed the root mean square difference (RMSD) of county-level completeness compared with provincial-level completeness to study intra-provincial variations. A two-level (province and county) logistic regression model was fitted to explore the association between county-level registration completeness and a set of covariates reflecting socioeconomic status, healthcare quality, and specific strategies and regulations designed to improve registration.

Results: In 2018, the overall death registration completeness for the CDRS in China was 74.2% (95% uncertainty interval [UI] 66.2-80.4), with very little difference for males and females. Geographical differences in completeness were higher across counties than across provinces. The county-level completeness ranged from 2.4% (95% UI 1.0-5.0%) in Burang County, Tibet, to 100.0% (95% UI 99.9-100.0%) in Guandu District, Yunnan. The coastal provinces of Jiangsu, Guangdong, and Fujian, with higher overall completeness, contained counties with low completeness; conversely, the underdeveloped provinces of Guangxi and Guizhou, with lower overall completeness, included some counties with high completeness. GDP, education, population density, minority population, healthcare access, and registration strategies were important drivers of the geographical differences in registration completeness.

Conclusions: There are marked inequalities in registration completeness at the county level and within provinces in China. The socioeconomic condition, the implementation of specific registration-enhancing initiatives, and the availability and quality of medical care were the primary drivers of the observed geographical variation. A more strategic approach, with more research, is required to identify the main reasons for death under-reporting, especially in the poorer performing counties, to guide remedial action.
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http://dx.doi.org/10.1186/s12916-020-01632-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7333385PMC
July 2020

Global injury morbidity and mortality from 1990 to 2017: results from the Global Burden of Disease Study 2017.

Inj Prev 2020 10 24;26(Supp 1):i96-i114. Epub 2020 Apr 24.

Faculty of Health Sciences - Health Management and Policy, American University of Beirut, Beirut, Lebanon.

Background: Past research in population health trends has shown that injuries form a substantial burden of population health loss. Regular updates to injury burden assessments are critical. We report Global Burden of Disease (GBD) 2017 Study estimates on morbidity and mortality for all injuries.

Methods: We reviewed results for injuries from the GBD 2017 study. GBD 2017 measured injury-specific mortality and years of life lost (YLLs) using the Cause of Death Ensemble model. To measure non-fatal injuries, GBD 2017 modelled injury-specific incidence and converted this to prevalence and years lived with disability (YLDs). YLLs and YLDs were summed to calculate disability-adjusted life years (DALYs).

Findings: In 1990, there were 4 260 493 (4 085 700 to 4 396 138) injury deaths, which increased to 4 484 722 (4 332 010 to 4 585 554) deaths in 2017, while age-standardised mortality decreased from 1079 (1073 to 1086) to 738 (730 to 745) per 100 000. In 1990, there were 354 064 302 (95% uncertainty interval: 338 174 876 to 371 610 802) new cases of injury globally, which increased to 520 710 288 (493 430 247 to 547 988 635) new cases in 2017. During this time, age-standardised incidence decreased non-significantly from 6824 (6534 to 7147) to 6763 (6412 to 7118) per 100 000. Between 1990 and 2017, age-standardised DALYs decreased from 4947 (4655 to 5233) per 100 000 to 3267 (3058 to 3505).

Interpretation: Injuries are an important cause of health loss globally, though mortality has declined between 1990 and 2017. Future research in injury burden should focus on prevention in high-burden populations, improving data collection and ensuring access to medical care.
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http://dx.doi.org/10.1136/injuryprev-2019-043494DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571366PMC
October 2020

Born to fail: flaws in replication design produce intended results.

BMC Med 2020 03 26;18(1):73. Epub 2020 Mar 26.

Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Avenue Suite 600, Seattle, WA, 98121, USA.

We recently published in BMC Medicine an evaluation of the comparative diagnostic performance of InSilicoVA, a software to map the underlying causes of death from verbal autopsy interviews. The developers of this software claim to have failed to replicate our results and appear to have also failed to locate our replication archive for this work. In this Correspondence, we provide feedback on how this might have been done more usefully and offer some suggestions to improve future attempts at reproducible research. We also offer an alternative interpretation of the results presented by Li et al., namely that, out of 100 verbal autopsy interviews, InSilicoVA will, at best, correctly identify the underlying cause of death in 40 cases and incorrectly in 60 - a markedly inferior performance to alternative existing approaches.
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http://dx.doi.org/10.1186/s12916-020-01517-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098125PMC
March 2020

ANACONDA: a new tool to improve mortality and cause of death data.

BMC Med 2020 03 9;18(1):61. Epub 2020 Mar 9.

Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, 3053, Australia.

Background: The need to monitor the Sustainable Development Goals (SDGs) and to have access to reliable and timely mortality data has created a strong demand in countries for tools that can assist them in this. ANACONDA (Analysis of National Causes of Death for Action) is a new tool developed for this purpose which allows countries to assess how accurate their mortality and cause of death are. Applying ANACONDA will increase confidence and capacity among data custodians in countries about their mortality data and will give them insight into quality problems that will assist the improvement process.

Methods: ANACONDA builds on established epidemiological and demographic concepts to operationalise a series of 10 steps and numerous sub-steps to perform data checks. Extensive use is made of comparators to assess the plausibility of national mortality and cause of death statistics. The tool calculates a composite Vital Statistics Performance Index for Quality (VSPI(Q)) to measure how fit for purpose the data are. Extracts from analyses of country data are presented to show the types of outputs.

Results: Each of the 10 steps provides insight into how well the current data is describing different aspects of the mortality situation in the country, e.g. who dies of what, the completeness of the reporting, and the amount and types of unusable cause of death codes. It further identifies the exact codes that should not be used by the certifying physicians and their frequency, which makes it possible to institute a focused correction procedure. Finally, the VSPI(Q) allows periodic monitoring of data quality improvements and identifies priorities for action to strengthen the Civil Registration and Vital Statistics (CRVS) system.

Conclusions: ANACONDA has demonstrated the potential to dramatically improve knowledge about disease patterns as well as the functioning of CRVS systems and has served as a platform for galvanising wider CRVS reforms in countries.
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http://dx.doi.org/10.1186/s12916-020-01521-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7061487PMC
March 2020

Reducing ignorance about who dies of what: research and innovation to strengthen CRVS systems.

BMC Med 2020 03 9;18(1):58. Epub 2020 Mar 9.

Melbourne School of Population and Global Health, University of Melbourne, Carlton, VIC, 3053, Australia.

The Sustainable Development Goal (SDG) agenda offers a major impetus to consolidate and accelerate development in civil registration and vital statistics (CRVS) systems. Strengthening CRVS systems is an SDG outcome in itself. Moreover, CRVS systems are the best - if not essential - source of data to monitor and guide health policy debates and to assess progress towards numerous SDG targets and indicators. They also provide the necessary documentation and proof of identity for service access and are critical for disaster preparedness and response. While there has been impressive global momentum to improve CRVS systems over the past decade, several challenges remain. This article collection provides an overview of recent innovations, progress, viewpoints and key areas in which action is still required - notably around the need for better systems and procedures to notify the fact of death and to reliably diagnose its cause, both for deaths in hospital and elsewhere.
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http://dx.doi.org/10.1186/s12916-020-01526-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7061482PMC
March 2020

Where there is no hospital: improving the notification of community deaths.

BMC Med 2020 03 9;18(1):65. Epub 2020 Mar 9.

Melbourne School of Population and Global Health, The University of Melbourne, Carlton, VIC, 3053, Australia.

Background: Globally, an estimated two-thirds of all deaths occur in the community, the majority of which are not attended by a physician and remain unregistered. Identifying and registering these deaths in civil registration and vital statistics (CRVS) systems, and ascertaining the cause of death, is thus a critical challenge to ensure that policy benefits from reliable evidence on mortality levels and patterns in populations. In contrast to traditional processes for registration, death notification can be faster and more efficient at informing responsible government agencies about the event and at triggering a verbal autopsy for ascertaining cause of death. Thus, innovative approaches to death notification, tailored to suit the setting, can improve the availability and quality of information on community deaths in CRVS systems.

Improving The Notification Of Community Deaths: Here, we present case studies in four countries (Bangladesh, Colombia, Myanmar and Papua New Guinea) that were part of the initial phases of the Bloomberg Data for Health Initiative at the University of Melbourne, each of which faces unique challenges to community death registration. The approaches taken promote improved notification of community deaths through a combination of interventions, including integration with the health sector, using various notifying agents and methods, and the application of information and communication technologies. One key factor for success has been the smoothing of processes linking notification, registration and initiation of a verbal autopsy interview. The processes implemented champion more active notification systems in relation to the passive systems commonly in place in these countries.

Conclusions: The case studies demonstrate the significant potential for improving death reporting through the implementation of notification practices tailored to a country's specific circumstances, including geography, cultural factors, structure of the existing CRVS system, and available human, information and communication technology resources. Strategic deployment of some, or all, of these innovations can result in rapid improvements to death notification systems and should be trialled in other settings.
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http://dx.doi.org/10.1186/s12916-020-01524-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7061465PMC
March 2020

Automated verbal autopsy: from research to routine use in civil registration and vital statistics systems.

BMC Med 2020 03 9;18(1):60. Epub 2020 Mar 9.

Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia.

Background: The majority of low- and middle-income countries (LMICs) do not have adequate civil registration and vital statistics (CRVS) systems to properly support health policy formulation. Verbal autopsy (VA), long used in research, can provide useful information on the cause of death (COD) in populations where physicians are not available to complete medical certificates of COD. Here, we report on the application of the SmartVA tool for the collection and analysis of data in several countries as part of routine CRVS activities.

Methods: Data from VA interviews conducted in 4 of 12 countries supported by the Bloomberg Philanthropies Data for Health (D4H) Initiative, and at different stages of health statistical development, were analysed and assessed for plausibility: Myanmar, Papua New Guinea (PNG), Bangladesh and the Philippines. Analyses by age- and cause-specific mortality fractions were compared to the Global Burden of Disease (GBD) study data by country. VA interviews were analysed using SmartVA-Analyze-automated software that was designed for use in CRVS systems. The method in the Philippines differed from the other sites in that the VA output was used as a decision support tool for health officers.

Results: Country strategies for VA implementation are described in detail. Comparisons between VA data and country GBD estimates by age and cause revealed generally similar patterns and distributions. The main discrepancy was higher infectious disease mortality and lower non-communicable disease mortality at the PNG VA sites, compared to the GBD country models, which critical appraisal suggests may highlight real differences rather than implausible VA results.

Conclusion: Automated VA is the only feasible method for generating COD data for many populations. The results of implementation in four countries, reported here under the D4H Initiative, confirm that these methods are acceptable for wide-scale implementation and can produce reliable COD information on community deaths for which little was previously known.
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http://dx.doi.org/10.1186/s12916-020-01520-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7061477PMC
March 2020
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