Consultancy of Vital Data at the State Department of Health in Rio de Janeiro Rio de Janeiro (RJ), Brazil.

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1 DOI: / Origial Article / Artigo Origial Use of primary diagosis durig hospitalizatio i the Uified Health System (Sistema Úico de Saúde) to qualify iformatio regardig the uderlyig cause of atural deaths amog the elderly* Uso do diagóstico pricipal das iterações do Sistema Úico de Saúde para qualificar a iformação sobre causa básica de mortes aturais em idosos Agela Maria Cascão I,II, Maria Helea Prado de Mello Jorge III, Atoio José Leal Costa IV, Paulie Lorea Kale IV ABSTRACT: Itroductio: Ill-defied causes of death are commo amog the elderly owig to the high frequecy of comorbidities ad, cosequetly, to the difficulty i defiig the uderlyig cause of death. Objective: To aalyze the validity ad reliability of the primary diagosis i hospitalizatio to recover the iformatio o the uderlyig cause of death i atural deaths amog the elderly whose deaths were origially assiged to ill-defied cause i their Death Certificate. The hospitalizatios occurred i the state of Rio de Jaeiro, i Methods: The databases obtaied i the Iformatio Systems o Mortality ad Hospitalizatio were probabilistically liked. The followig data were calculated for hospitalizatios of the elderly that evolved ito deaths with a atural cause: cocordace percetages, Kappa coefficiet, sesitivity, specificity, ad the positive predictive value of the primary diagosis. Deaths related to ill-defied causes were assiged to a ew cause, which was defied based o the primary diagosis. Results: The reliability of the primary diagosis was good, accordig to the total percetage of cosistecy (50.2), ad fair, accordig to the Kappa coefficiet (k = 0.4; p < ). Diseases related to the circulatory system ad eoplasia occurred with the highest frequecy amog the deaths ad the hospitalizatios ad preseted a higher cosistecy of positive predictive values per chapter ad groupig of the Iteratioal Classificatio of Diseases. The recovery of the iformatio o the primary cause occurred i 22.6 of the deaths with ill-defied causes ( = 14). Coclusio: The methodology developed ad applied for the recovery of the iformatio o the atural cause of death amog the elderly i this study had the advatage of effectiveess ad the reductio of costs compared to a ivestigatio of the death that is recommeded i situatios of o-liked ad low positive predictive values. Moitorig the mortality profile by the cause of death is ecessary to periodically update the predictive values. Keywords: Elderly. Mortality. Primary cause of death. Hospitalizatio. Iformatio systems. Reproducibility of tests. *This paper was part of the first author s PhD thesis i Public health, titled Mortality amog the Elderly: the developmet of a methodology to recover iformatio regardig uderlyig cause, defeded i April 2014 at the Istitute of Public Health Studies at the Uiversidade Federal do Rio de Jaeiro. I Cosultacy of Vital Data at the State Departmet of Health i Rio de Jaeiro Rio de Jaeiro (RJ), Brazil. II PhD program i Public Health at the Istitute of Public Health Studies at the Uiversidade Federal do Rio de Jaeiro Rio de Jaeiro (RJ), Brazil. III School of Publich Health at the Uiversidade de São Paulo São Paulo (SP), Brazil. IV Istitute of Public Health Studies at the Uiversidade Federal do Rio de Jaeiro Rio de Jaeiro (RJ), Brazil. Correspodig author: Agela Maria Cascão. Uiversidade Federal do Rio de Jaeiro. Istitute of Public Health Studies. Praça Jorge Machado Moreira, Ilha do Fudão, Cidade Uiversitária, CEP: , Rio de Jaeiro, RJ, Brazil. agelacascao@uol.com.br Coflict of iterests: othig to declare Fiacial support: This study is a part of the research project Health Iformatio from the School of Public Health at the Uiversidade de São Paulo, a project fiaced by the Coselho Nacioal de Desevolvimeto Cietífico e Tecológico (CNPq) (Natioal Coucil of Scietific ad Techological Developmet), process umber 2006/8. 713

2 Cascão, A.M. et al. RESUMO: Itrodução: Causas mal defiidas de morte destacam-se etre idosos devido à alta frequêcia de comorbidades e cosequete dificuldade de defiir a causa básica. Objetivo: Aalisar a validade e a cofiabilidade da iformação diagóstico pricipal da iteração hospitalar para recuperação da causa de morte atural de idosos que tiveram origialmete causas mal defiidas como causa básica as Declarações de Óbito, ocorridas o estado do Rio de Jaeiro, em Métodos: As bases de dados obtidas dos Sistemas de Iformações sobre Mortalidade e de Iteração Hospitalar foram relacioadas probabilisticamete. Foram calculados percetuais de cocordâcia, coeficiete Kappa, sesibilidade, especificidade e valor preditivo positivo do diagóstico pricipal da iteração de idosos que evoluíram para óbito por causas aturais. Óbitos por causas mal defiidas tiveram uma ova causa defiida a partir do diagóstico pricipal. Resultados: A cofiabilidade do diagóstico pricipal foi boa, segudo a cocordâcia percetual total (50,2), e razoável, coforme o coeficiete Kappa (k = 0,4; p < 0,0001). Doeças do aparelho circulatório e eoplasias ocorreram com maior frequêcia etre os óbitos e as iterações e apresetaram maior cocordâcia e valores preditivos positivos por capítulo e agrupameto da Classificação Iteracioal de Doeças. A recuperação da causa básica ocorreu em 22,6 dos óbitos por causas mal defiidas ( = 14). Coclusão: A metodologia desevolvida e aplicada para recuperação da causa atural de óbito etre idosos este estudo tem como vatages a efetividade e a redução dos custos proveietes de uma ivestigação do óbito. Esta é recomedada as situações de registros ão relacioados e de baixo valor preditivo positivo. O moitorameto do perfil de mortalidade por causas é ecessário para atualização periódica dos valores preditivos. Palavras-chave: Idoso. Mortalidade. Causa básica de morte. Hospitalização. Sistemas de iformação. Reprodutibilidade dos testes. INTRODUCTION The steady rise of the elderly populatio growth rate i Brazil calls for public social ad health policies aimed at this populatio cotiget 1,2, which i itself justifies a more detailed study regardig the mortality that affects the elderly. I 2010, the populatio cotiget of elderly people i the coutry was 10.8 ad, i the state of Rio de Jaeiro, approximately With the populatio agig, the higher rate of morbidity ad mortality moves from the yougest part of the populatio to the elderly 2. There is a sigificat icrease i the occurrece of cardiovascular disease, eoplasias, ad respiratory diseases, the mai causes of hospitalizatios ad deaths amog the elderly 3-5. Ill-defied causes ca also be highlighted amog the mai causes of deaths 4,6, partially owig to the difficulty i idetifyig the uderlyig cause of the morbidity process, because of the complex chai of evets that lead to death i the elderly 7 populatio ad the high frequecy of comorbidities i this age stratum 8. Socioecoomic, demographic, ad geographic iequalities such as educatio level, race/color, size of the muicipality, ad per capita gross domestic product also have show to be liked to ill-defied causes of death i elderly people 9. Strategies to qualify the causes of death have bee developed ad utilized to improve the descriptio of the health status 10-13, subsidizig measures of prevetio 14, particularly for the elderly

3 Use of Primary Diagosis Durig Hospitalizatio i the Uified Health System (Sistema Úico de Saúde) to Qualify Iformatio Regardig the Uderlyig Cause of Natural Deaths amog the Elderly I Brazil, the Mortality Iformatio System (SIM) is uiversal ad has a broad coverage. The Death Certificate is the basic form that provides, amog other iformatios, the cause of death. The official source for the hospital morbidity is the Hospitalizatio System from the Uified Health System (SIH-SUS), which, therefore, does ot iclude private hospitalizatio services. I the Authorizatio for Hospitalizatio (AIH) the basic documet from the SIH-SUS, the mai affectio beig treated or ivestigated is iformed, ad it is uderstood as the primary diagosis. The SIH-SUS is a importat source of iformatio ad it has bee icreasigly used i studies cocerig the qualificatio of the SIM ad i moitorig idicators for the aalysis of the health status i the populatio. The aim of this study is to assess the reliability ad the validity of the primary diagosis of the AIH to retrieve the uderlyig cause of atural death of the elderly idividuals who origially had ill-defied cause assiged as their uderlyig cause of death i the Death Certificate of the state of Rio de Jaeiro, i METHODS This study is liked to the research Health Iformatio from the School of Public Health of the Uiversidade de São Paulo, with the participatio of techicias from the State Departmet of Health i Rio de Jaeiro (SESRJ). This is a case series study coverig deaths of elderly idividuals (aged 60 ad older) 16 owig to atural causes ad which occurred durig hospitalizatio i the SUS healthcare facilities. The maximum duratio of the hospitalizatio whe the discharge was due to death was equivalet to oe year i this study. Data were obtaied from the iformatio system SIM ad SIH-SUS, both from the SESRJ, ad were probabilistically liked usig the software RecLik II 17. The followig record likages were coducted: stadardizatio of commo fields (ame of idividual, age, date of birth, date of death, ad discharge due to death, home address); defiitio of the strategy for blockig the databases to optimize the compariso of records (blockig expressios: SOUDEX (PBL OCO) + SOUDEX (UBLOCO) + SEXO + CODMUNIRES + C NES); applicatio of algorithms for the approximate compariso of the chai of characters, which take ito cosideratio possible phoetic ad typig errors; maual review of probable pairs (matchig or o-matchig). After the process for probabilistic likage, 15,804 records were cosidered as probable matchig pairs 18. Distributio of related records accordig to uderlyig cause ad primary diagosis by groups of causes were described (chapters from the 10th revisio of the Iteratioal Statistical Classificatio of Diseases ad Related Health Problems, ICD 10) 19. Agreemet ad validity of the primary diagosis were aalyzed (chapters from ICD 10 Chap). The followig was excluded from the aalysis: records of hospitalizatios that evolved ito death due to uderlyig causes classified as exteral causes of morbidity ad mortality, which correspod to uatural causes, accidets or violece (Chap. XX), 715

4 Cascão, A.M. et al. aalyzed i aother paper 18 ; pregacy, childbirth, ad the puerperium (Chap. XV), certai coditios origiatig i the periatal period (Chap. XVI), causes which are icompatible with the age group aalyzed; ijury, poisoig ad certai other cosequeces of exteral causes (Chap. XIX); ad factors ifluecig health status ad cotact with health services (Chap. XXI), as they caot be certified with a uderlyig cause of death. For the reliability ad validity aalyses, biary variables that refer to the uderlyig cause of death ad the primary diagosis of the hospitalizatio were created: yes, classified i a chapter or specific groupig of the ICD 10; o, classified i other chapters or groupigs. Iitially, for the reliability aalyses cocerig the primary diagosis ad the uderlyig cause of death accordig to the chapter from ICD 10, the followig was calculated: percetage ad positive percetage agreemet 20 (< 25 poor; from 25.0 to 49.0 regular; from 50.0 to 74.0 good; ad 75.0 very good) 21 ad the Kappa coefficiet (< 0.00 poor; 0.00 to 0.20 superficial; 0.21 to 0.40 fair; 0.41 to 0.60 moderate; 0.61 to 0.80 substatial; 0.81 to 1.00 early perfect) 22. For the causes (chapter from ICD 10) that preseted the highest agreemet betwee the primary diagosis ad uderlyig cause, the percetage ad positive percetage agreemet were calculated by group of cause (ICD 10). The validity of the primary diagosis by cause (chapter from the ICD 10) was assessed by sesitivity ad specificity 23, with the gold stadard beig the origial uderlyig cause i the Death Certificate. Positive predictive value (PPV) was calculated to assess the quality of the primary diagosis i recogizig the uderlyig cause of death. Later, for the deaths with a uderlyig cause that was origially certified as a ill-defied cause (Chap. XVIII Symptoms, sigs ad abormal cliical ad laboratory fidigs, ot elsewhere classified ill-defied ) ad whose primary diagosis iformed for the hospitalizatio belogs to the group of causes (chapters from ICD) that, i the previous aalysis, preseted acceptable reliability, validity, ad PPV had their uderlyig cause modified for the purpose of aalysis i this study. The computer program Stata (versio 12) was utilized. This study was approved by the Research Ethics Committee from the Istitute of Public Health Studies at the Uiversidade Federal do Rio de Jaeiro, uder protocol umber , o October 3, RESULTS I 2006, i the state of Rio de Jaeiro, 119,513 o-fetal deaths occurred, with 73,323 (61.3) beig amog elderly people, of which 54.9 (40,227) had bee hospitalized i a public facility or through SUS. As for the SUS hospitalizatios, 25.4 (178,190) were elderly idividuals, ad i 12.7 (22,580) of them, the discharge i the AIH (Hospitalizatio Authorizatio) was due to death. After comparig the databases, it was possible to idetify 70.0 (15,807) of commo records (related records). The 6,773 records urelated to those from SIM represeted 30.0 of the hospitalizatios of elderly idividuals with a discharge related to death. 716

5 Use of Primary Diagosis Durig Hospitalizatio i the Uified Health System (Sistema Úico de Saúde) to Qualify Iformatio Regardig the Uderlyig Cause of Natural Deaths amog the Elderly Table 1 cotais a descriptio of the related ad urelated records by age, sex, ad primary diagosis. Deaths related to atural ad exteral causes were icluded. Takig ito cosideratio that data tabulatio was coducted accordig to the iformatio from the primary diagosis, deaths related to exteral causes are cotaied withi the iformatio o the group of causes: ijury, poisoig ad certai other cosequeces of exteral causes (Chap. XIX). Related ad urelated records preset a higher frequecy i the age group 70 to 79 years (Table 1). Males were predomiat amog the related records (50.2) ad females amog the urelated records (52.4). Diseases of the circulatory (Chap. IX) ad the respiratory systems (Chap. X) held the first two positios i the rakig of primary diagosis, regardless of the success of the lik. The third ad fourth positios were held by eoplasia (Chap. II) ad certai ifectious ad parasitic diseases (Chap. I), respectively, with this order beig iverted amog the o-liked records (Table 1). For the reliability ad validity aalysis, after the exclusios, the study populatio correspoded to 15,074 liked records, whose uderlyig causes of death were classified betwee Chapters I ad XVIII of the ICD 10. For the uderlyig cause as well as the primary diagosis of the related records, the three groups of causes with the highest frequecy were diseases of the circulatory system (Chap. IX), eoplasias (Chap. II), ad diseases of the respiratory system (Chap. X). The followig were i fourth place: edocrie, utritioal, ad metabolic diseases (Chap. IV) ad certai ifectious ad parasitic diseases (Chap. I), for the uderlyig cause ad the primary diagosis, respectively (Table 2). The total agreemet betwee the uderlyig cause (SIM) ad the primary diagosis (SIH), accordig to the ICD chapters, was 50.2; ad the Kappa coefficiet was aroud 0.4 (p < ) ad cosidered, respectively, good (criteria used by Mello Jorge et al. 21 ) ad fair (Ladis e Koch apud Szklo ad Nieto) 22,23. The highest values of positive percetage agreemet (ot cosiderig the records for egative cocordace) betwee the uderlyig cause ad the primary diagosis, ot icludig diseases of the eye ad adexa (Chap. VII) due to its low frequecy, correspod to the two mai groups of causes, diseases of the circulatory system (Chap. IX) at 49.6 ad eoplasias (Chap. II) at 49.2 (Table 2). As for the validity of the primary diagosis, the sesitivity varied from 7.0 to ad the specificity from 83.8 to The specificity of the primary diagosis preseted values higher tha the sesitivity for all of the ICD chapters. The primary diagosis was equal to the uderlyig cause of death i of records, whe they were certified as diseases of the eye ad adexa (Chap. VII); however, they represet oly two matchig pairs pairs i a total of 15,074 records (0.01). The specificity was for the primary diagosis whe the causes beloged to the same chapter. The sesitivity of the primary diagosis for the remaiig chapters was low, uder 62. Specifically for the deaths due to ill-defied causes (Chap. XVIII), a low positive percetage agreemet ad low sesitivity represet good results, that is, the positive percetage agreemet is a better-defied cause. For the eoplasms (Chap. II) ad the diseases of the cardiovascular system (Chap. IX), the sesitivities were, respectively, 51.5 ad 61.6; ad the specificities also high, although ot 717

6 Cascão, A.M. et al. Table 1. Hospitalizatio records, liked ad o-liked to the death record by demographic ad hospitalizatio characteristics, Rio de Jaeiro, Demographic ad hospitalizatio characteristics Age (years) Sex Liked () ( = ) No-liked () ( = 6.773) 60 to to ad over Female Male Primary diagosis (ICD 10 chapters) I Certai ifectious ad parasitic diseases II Neoplasms III Diseases of the blood ad immue system disorders IV Edocrie, utritioal ad metabolic diseases V Metal ad behavioral disorders VI Diseases of the ervous system VII Diseases of the eye ad adexa IX Diseases of the circulatory system X Diseases of the respiratory system XI Diseases of the digestive system XII Diseases of the ski ad subcutaeous tissue XIII Diseases of the musculoskeletal system ad coective tissue XIV Diseases of the geitouriary system XVII Cogeital malformatios XVIII Ill-defied causes XIX Ijuries/poisoig/ other exteral cosequeces XX Exteral causes XXI Factors ifluecig health status ad cotact with health services Source: Hospitalizatio System from the Uified Health System (Sistemas de Iformações sobre Mortalidade e de Iteração Hospitalar do Sistema Úico de Saúde - SIH-SUS). 718

7 Use of Primary Diagosis Durig Hospitalizatio i the Uified Health System (Sistema Úico de Saúde) to Qualify Iformatio Regardig the Uderlyig Cause of Natural Deaths amog the Elderly Table 2. Uderlyig cause ad primary diagosis for the hospitalizatio of elderly idividuals, matchig pairs, positive total cocordace, sesitivity, specificity, ad positive predictive value, Rio de Jaeiro, Chapters (ICD 10) UC PD CP PC TC SE SP PPV I Certai ifectious ad parasitic diseases 686 1, II Neoplasms 2,883 1,624 1, III Diseases of the blood ad immue system disorders IV Edocrie, utritioal, ad metabolic diseases V Metal ad behavioral disorders VI Diseases of the ervous system VII Diseases of the eye ad adexa VIII Diseases of the ear ad mastoid process IX Diseases of the circulatory system X Diseases of the respiratory system XI Diseases of the digestive system XII Diseases of the ski ad subcutaeous tissue XIII Diseases of the musculoskeletal system ad coective tissue XIV Diseases of the geitouriary system ,641 1, ,391 4,623 3, ,391 3,407 1, XVII Cogeital malformatios XVIII Ill-defied causes Total 15,074 15,074 7, UC: uderlyig cause; PD: primary diagosis; CP: cocordat pairs; TC: total cocordace; PC: positive cocordace; SE: sesitivity; SP: specificity; PPV: positive predictive value. Source: Hospitalizatio System from the Uified Health System (Sistemas de Iformações sobre Mortalidade e de Iteração Hospitalar do Sistema Úico de Saúde - SIH-SUS) 719

8 Cascão, A.M. et al. the highest, respectively, 98.9 ad For every 100 hospitalizatios with a primary diagosis classified as eoplasia (Chap. II) ad diseases of the cardiovascular system (Chap. IX), aroud 92 ad 72, respectively, had a medical certificate of cause of death which declared uderlyig causes from the same groups of causes (ICD chapters). The direct relatio betwee PPV ad frequecy of deaths i the study populatio ca be observed i Table 2. Cosiderig the frequecy of the causes of death ad hospitalizatios classified as eoplasias ad diseases of the cardiovascular system, ad the respective values of sesitivity, specificity, ad PPV at the ICD chapter level, the groupig aalysis for eoplasias (Chap. II) ad diseases of the circulatory system (Chap. IX) were repeated. The results are preseted, respectively, i Tables 3 ad 4. Amog the 1,486 matchig pairs classified as eoplasia, 18 groupigs were idetified, correspodig to a total cocordace of approximately 81.0 (Table 3). Overall, the positive percetage agreemet were high, with the values beig higher for eoplasias of the lymphatic ad hematopoietic tissue, of breasts ad male geital orgas. The sesitivity ad the specificity by groupigs were cosidered good, with few exceptios. The two groupigs with the highest frequecy for the uderlyig cause of death ad primary diagosis were maligat eoplasms of the digestive orgas (C15-C26) ad maligat eoplasms of the respiratory system (C30-C39), which preseted the highest percetage of agreemet, respectively, 27.2 e The sesitivity ad the predictive value of the primary diagosis of these groupigs were high. The primary diagosis classified i the groupig of maligat eoplasms of the lymphatic, hematopoietic, ad related tissues (C81-C96) preseted the highest sesitivity (94.1) ad a high PPV (93.1). The followig groupigs preseted high values of sesitivity ad PPV: maligat eoplasms of breast (C50), maligat eoplasms of female geital orgas (C51-C58), ad maligat eoplasms of the male geital orga (C60-C63) with percetages of 89,6; 80,3 e 85,5, ad 90,9; 94,4 e 92,6, respectively. With regard to the 3,320 matchig pairs which were classified as diseases of the circulatory system, ie groupigs were foud with a total cocordace of 72.1 (Table 4). The agreemet, sesitivity, ad PPV percetage values per groupig from the chapter of diseases of the circulatory system were well below those foud for the eoplasms. However, the cardiovascular diseases groupig (I60-I69) stads out by showig higher positive percetage of agreemet, sesitivity, ad specificity ad a fair PPV. The PPV of the ischemic heart diseases (I20-I25) was the secod highest of this chapter, with the remaiig groupigs showig values below 62 (Table 4). Amog the 62 liked records with deaths related to ill-defied causes (Chap. XVIII), 14 had a primary diagosis classified withi the two groups of causes with the highest PPV: 3 i eoplasias (Chap. II) ad 11 i diseases of the circulatory system (Chap. IX). Cosiderig oly the large groups of causes (ICD chapter), it would be possible to reclassify the uderlyig cause as well-defied i 22.6 of deaths due to ill-defied causes (14 deaths) of the study populatio (Table 5). With regard to the groupigs with higher PPV amog these groups of causes (chapters), it would be possible to recover iformatio of three deaths: oe related to maligat 720

9 Use of Primary Diagosis Durig Hospitalizatio i the Uified Health System (Sistema Úico de Saúde) to Qualify Iformatio Regardig the Uderlyig Cause of Natural Deaths amog the Elderly Table 3. Uderlyig cause ad primary diagosis for the hospitalizatio of elderly idividuals owig to eoplasia, matchig pairs, positive total cocordace, sesitivity, specificity, ad positive predictive value, Rio de Jaeiro, Chapter II Groupigs Neoplasias (ICD 10) Maligat eoplasms, lip, oral cavity, ad pharyx (C00-C14) Maligat eoplasms, digestive orgas (C15-C26) Maligat eoplasms, respiratory system ad itrathoracic orgas (C30-C39) Maligat eoplasms, boe ad articular cartilage (C40-C41) UC PD CP PC TC SE SP PPV Maligat eoplasms, ski (C43-C44) Maligat eoplasms, coective ad soft tissue (C45-C49) Maligat eoplasms, breast (C50) Maligat eoplasms, female geital orgas (C51-C58) Maligat eoplasms of male geital orgas (C60-C63) Maligat eoplasms, uriary orgas (C64-C68) Maligat eoplasms, eye, brai, ad cetral ervous system (C69-C72) Maligat eoplasms, edocrie glads ad related structures (C73-C75) Maligat eoplasms, secodary ad illdefied (C76-C80) Maligat eoplasms, lymphoid/ haematopoietic/related tissue (C81-C96) Maligat eoplasms of idepedet (primary) multiple sites (C97) I situ eoplasms (D00-D09) Beig eoplasms (D10-D36) Neoplasms of ucertai or ukow behavior (D37-D48) Total 1,486 1,486 1, UC: uderlyig cause; PD: primary diagosis; CP: cocordat pairs; TC: total cocordace; PC: positive cocordace; SE: sesitivity; SP: specificity; PPV: positive predictive value. Source: Hospitalizatio System from the Uified Health System (Sistemas de Iformações sobre Mortalidade e de Iteração Hospitalar do Sistema Úico de Saúde - SIH-SUS). 721

10 Cascão, A.M. et al. eoplasms i the femiie geital orgas (C51-C58), oe related to the maligat eoplasms i the male geital orgas (C60-C63), ad oe related to beig eoplasms (D10-D36). For diseases of the circulatory system, 11 iformatio o deaths would be recovered, with 2 beig related to ischemic heart diseases (I20-I25), 1 related to pulmoary heart disease ad diseases of pulmoary circulatio, 5 related to other forms of heart diseases (I30-I52), ad 3 as cerebrovascular diseases (I60-I69), as see i Table 5. DISCUSSION I this study, 70.0 of elderly deaths with hospitalizatio i SUS ad discharge owig to death were liked ( = ). Some hypothesis that were raised to explai the lack of a likage betwee records i the aalysis of uatural causes from these Table 4. Uderlyig cause ad primary diagosis for the hospitalizatio of elderly idividuals owig to circulatory system diseases, matchig pairs, positive total cocordace, sesitivity, specificity ad positive predictive value, Rio de Jaeiro, Chapter IX Groupigs Circulatory system diseases (ICD 10) Circulatory System Diseases UC PD CP PC TC SE SP PPV Chroic rheumatic heart diseases (I05-I09) Hypertesive diseases (I10-I15) Ischemic heart diseases (I20-I25) Pulmoary heart disease ad diseases of pulmoary circulatio (I26-I28) Other forms of heart disease (I30-I52) Cerebrovascular diseases (I60-I69) Diseases of arteries, arterioles ad capillaries (I70-I79) Diseases of veis, lymphatic vessels ad lymph odes (I80-I89) Other ad uspecified disorders of the circulatory system (I95-I99) Total 3,320 3,320 2, UC: uderlyig cause; PD: primary diagosis; CP: cocordat pairs; TC: total cocordace; PC: positive cocordace; SE: sesitivity; SP: specificity; PPV: positive predictive value. Source: Hospitalizatio System from the Uified Health System (Sistemas de Iformações sobre Mortalidade e de Iteração Hospitalar do Sistema Úico de Saúde - SIH-SUS). 722

11 Use of Primary Diagosis Durig Hospitalizatio i the Uified Health System (Sistema Úico de Saúde) to Qualify Iformatio Regardig the Uderlyig Cause of Natural Deaths amog the Elderly same databases 18 are applied to this study: the iclusio of health facilities i selectig the deaths from the SIM i 2006, which might o loger have a agreemet with SUS; typographical errors i at least oe of the databases for the iformatio o the mai variable for the lik (ame of the deceased), which were ot cosidered as liked records; very commo ames with the remaiig variables selected for the lik beig ot eough cosistet to be cosidered a matchig lik; ad iformatio error for type of discharge, origially iformed as beig death, whe actually the discharge was urelated to the death of the elderly idividual. The related ad o-related records did ot show a sigificat differece i terms of demographic characteristics, regardig sex, age, ad primary diagosis. Table 5. Number of deaths with a ill-defied uderlyig cause accordig to the primary diagosis for the hospitalizatio of elderly idividuals, Rio de Jaeiro, Primary Diagosis ICD 10 Chapter ad Groupig Sigs ad symptoms regardig the circulatory ad respiratory systems ICD 10: ROO-R09 Geeral sigs ad symptoms ICD 10: R50-R69 Ill-defied ad ukow causes ICD 10: R95-R99 Chapter II Neoplasms Maligat eoplasms, female geital orgas 1 1 (C51-C58) Maligat eoplasms of male geital orgas 1 1 (C60-C63) Beig (D10-D36) 1 1 Chapter IX Diseases of the circulatory system Ischemic heart diseases (I20-I25) Pulmoary heart disease ad diseases of pulmoary 1 1 circulatio (I26-I28) Other forms of heart disease (I30-I52) Cerebrovascular diseases (I60-I69) Remaiig causes Total Source: Hospitalizatio System from the Uified Health System (Sistemas de Iformações sobre Mortalidade e de Iteração Hospitalar do Sistema Úico de Saúde - SIH-SUS). Total 723

12 Cascão, A.M. et al. Based o the compariso of the SIM ad SIH-SUS databases, the researchers observed a predomiace of diseases of the cardiovascular system, eoplasms, ad diseases of the respiratory system, amog the deaths ad hospitalizatios, which are the most frequet causes of hospitalizatio ad hospital deaths amog the elderly 3,5,6. The percetage of agreemet betwee the uderlyig cause ad the primary diagosis for the groups of causes (ICD chapter) was cosidered good ad, whe the agreemet by chace (Kappa coefficiet) was elimiated, it was cosidered fair. The reliability betwee the primary diagosis ad the uderlyig cause varied betwee the groups of causes (ICD chapters) ad, therefore, substitutig the uderlyig ill-defied causes for the primary diagosis should ot be idiscrimiate. For all of the primary diagosis, the agreemet with the atural uderlyig causes of death is ot expected to be elevated. The priciples that guide the defiitio of the primary diagosis ad the uderlyig cause of death are differet. The primary diagosis of the AIH is the oe that motivated the hospitalizatio, trascribed directly from the medical records, uder the resposibility of the record services coducted at the service uits. The uderlyig cause of atural death is defied as the disease or ijury that iitiated the chai of evets leadig to death 19, with the completio of the Death Certificate beig uder the resposibility of the doctor. Takig these defiitios ito cosideratio, it is possible to assume that the primary diagosis is more reliable to defie the atural termial cause of death istead of the uderlyig cause, ulike the exteral causes 18. I this study, the agreemet betwee the primary diagosis ad the uderlyig cause varied accordig to the ICD chapter, beig outstadigly higher for diseases of the circulatory system, whe compared to the remaiig groups of causes, although the value is oly approximately The quality of the AIH data should also be carefully aalyzed, as there are o explicit rules for their issuace ad completio, or stadardized or regular traiig for the teams 13. Problems regardig the quality of iformatio i medical records ad the codificatio of primary diagosis also affect the quality of data i the SIH-SUS 24. Aother issue is the occurrece of comorbidities amog the elderly, which partly justifies the difficulty i defiig the uderlyig cause of death ad ca also justify the lack of agreemet betwee the uderlyig cause ad the primary reaso for hospitalizatio. As for the accuracy of the primary diagosis, low sesitivity ad high specificity levels were foud, except for diseases of the eye ad adexa (which had a sesitivity ad specificity of early 100.0), whose frequecy of deaths is isigificat. The PPV ca be cosidered a good criterio to recommed the replacemet of the origial ill-defied cause by the primary diagosis. I this study, the PPV represets the total umber of idividuals with the same uderlyig cause, amog the records cotaiig a primary diagosis that has bee classified i oe of the groups of causes, chapter or specific groupig of the ICD. If the cause of death of a elderly idividual that was hospitalized i a SUS facility was ill-defied, it would be possible to use the primary diagosis for the hospitalizatio i which the death occurred, ad if this correspoded to oe of the groups of causes with elevated PPV, it would be possible to replace the origial uderlyig cause 724

13 Use of Primary Diagosis Durig Hospitalizatio i the Uified Health System (Sistema Úico de Saúde) to Qualify Iformatio Regardig the Uderlyig Cause of Natural Deaths amog the Elderly of death. The PPV, i additio to beig directly iflueced by the frequecy of deaths with the same uderlyig cause i the populatio, is also positively liked to the specificity 23. Based o the results of this study, it is recommeded that the state of Rio de Jaeiro employ this substitutio for the primary diagosis of the cardiovascular disease ad eoplasias. A limitatio of the study was to esure the quality of the iformatio cocerig the primary diagosis ad the defied uderlyig cause, these problems ca rage from completig the respective forms to the codificatio ad typig of the data. Additioally, the selectio of the age group 60 years ad over i the SIH-SUS database i 2006 excludes elderly idividuals who, durig the hospitalizatio, were aged 59 years, but whose death occurred at the age of 60 years, which represets a loss of iformatio whe likig the database to the SIM data. The methodology that was developed ad applied i this study to recover the iformatio o the atural cause of death amog the elderly has the advatage of effectiveess ad reductio of costs whe compared to the type of ivestigatio o the deaths that would be recommeded i situatios of o-likage or low PPV of the primary diagosis. Moitorig of the mortality profile by the causes of death is ecessary for the periodic update of the PPV. However, it must be reiforced that the correct completio of the uderlyig cause i the medical certificate of cause of death ad more precise iformatio cocerig the causes of death eable the costructio of more reliable health idicators ad more effective itervetios, i additio to sparig qualificatio methodologies of the causes of death. Traiig o how to properly complete the Death Certificate should be icluded ad/or reiforced i medical schools, ad specific orms for fillig out the primary ad secodary diagosis should be commuicated to the professioals resposible for iputtig this iformatio ito the SIH/SUS. CONCLUSIONS The primary diagosis of the AIH is reliable ad valid for the purpose of recoverig the iformatio o the uderlyig cause of atural death amog the elderly whose deaths were iitially assiged to ill-defied causes. The simple ad cost-effective methodology for the databases likage eables to obtai more qualified health iformatio ad idicators. However, the most effective way to obtai valid health iformatio ad idicators is to esure the quality of iformatio o the primary diagosis ad the uderlyig defied cause. Its mai issues may rage from completig the respective forms to the codificatio ad typig of data. ACKNOWLEDGMENTS The authors would like to thak DATASUS for makig the SIH/SUS database available ad the Coselho Nacioal de Desevolvimeto Cietífico e Tecológico (CNPq) for the fiacial support uder the process umber 2006/8. 725

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