Overreporting of Deaths From Coronary Heart Disease in New York City Hospitals, 2003

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1 ORIGINAL RESEARCH Overreporting of Deths From Coronry Hert Disese in New York City Hospitls, 2003 Reen Agrwl, MD, MPH; Jennifer M. Norton, PhD; Kevin Konty, MS, MA; Regin Zimmermn, PhD, MPH; Mleek Glover, ScD; Akki Lekichvili, PhD; Henry McGruder, PhD; Ann Mlrcher, PhD; Michele Csper, PhD; George Mensh, MD; Lorn Thorpe, PhD Suggested cittion for this rticle: Agrwl R, Norton JM, Konty K, Zimmermn R, Glover M, Lekichvili A, et l. Overreporting of deths from coronry hert disese in New York City hospitls, Prev Chronic Dis 2010;7(3). Accessed [dte]. PEER REVIEWED Astrct Introduction New York City hs one of the highest reported deth rtes from coronry hert disese in the United Sttes. We sought to mesure the ccurcy of this rte y exmining deth certifictes. Methods We conducted cross-sectionl vlidtion study y using rndom smple of deth certifictes tht recorded inhospitl deths in New York City from Jnury through June 2003, strtified y neighorhoods with low, medium, nd high coronry hert disese deth rtes. We strcted dt from hospitl records, nd n independent, linded medicl tem reviewed these dt to vlidte cuse of deth. We computed comprility rtio (coronry hert disese deths recorded on deth certifictes divided y vlidted coronry hert disese deths) to quntify greement etween deth certificte determintion nd clinicl judgment. Results Of 491 smpled deth certifictes for in-hospitl deths, medicl chrts were strcted nd reviewed y the expert pnel for 444 (90%). The comprility rtio for coronry hert disese deths mong decedents ged 35 to 74 yers ws 1.51, indicting tht deth certifictes overestimted coronry hert disese deths in this ge group y 51%. The comprility rtio incresed with ge to 1.94 for decedents ged 75 to 84 yers nd to 2.37 for decedents ged 85 yers or older. Conclusion Coronry hert disese ppers to e sustntilly overreported s cuse of deth in New York City mong in-hospitl deths. Introduction Coronry hert disese (CHD) is the leding cuse of deth for dults in the United Sttes, nd stroke rnks third (1). In New York City, n unusul pttern of high CHD deth rtes nd low stroke deth rtes hs een oserved; the ge-djusted CHD deth rte in 2003 ws 1.7 times the ntionl rte, nd the ge-djusted stroke deth rte ws hlf the ntionl rte (1,2). This pttern is unexpected, given tht risk fctors for CHD nd stroke re similr nd tht the prevlence in New York City of most common CHD risk fctors, such s hypertension, hyperlipidemi, oesity, nd smoking, is similr to or lower thn tht in the rest of the country (3). New York City CHD deth rtes hve een consistently higher thn ntionl CHD deth rtes for more thn 3 decdes despite stedy CHD deth rte declines ntionlly nd in New York City (Figure). Misreporting cuse of deth on deth certifictes my e contriuting to New York City s oserved high CHD deth Centers for Disese Control nd Prevention 1

2 rte. Studies hve suggested tht such misreporting my e common. A study of 2 Texs militry hospitls found tht 37% of deth certifictes reported different cuse of deth thn did utopsy (4). A Swedish study found tht 54% of deth certifictes reported different cuse of deth thn did chrt review (5). The level of misreporting vries y cuse of deth. For CHD, British study found tht deth certifictes hve low sensitivity for CHD deths compred with utopsy findings (6). A study of Frminghm Hert Study prticipnts found tht deth certifictes ttriuted 24% more deths to CHD thn did physicin pnel tht reviewed medicl records (7). The Atherosclerosis Risk in Communities (ARIC) study lso found tht deth certifictes overestimted CHD deths y 20% compred with physicin review pnel (8). We sought to determine whether locl physicin reporting ptterns of CHD on deth certifictes contriute to the oserved pttern of high-chd, low-stroke deth rtes oserved in New York City. Our investigtion ws designed to determine the ccurcy of deth certificte reporting of CHD s cuse of deth in New York City y using methods employed y the ARIC study in other jurisdictions. We did not directly ddress ccurcy of deth certificte reporting of stroke in this nlysis. Methods Study design nd popultion We developed the study design y using the methods of the ARIC study, which evluted CHD reporting on deth certifictes in 4 geogrphiclly distinct US communities y using linded medicl record review process (8). A completed determintion of reserch sttus form ws sumitted to the Centers for Disese Control nd Prevention (CDC), which determined tht this study would not require institutionl review ord pprovl. We ssessed New York City deth certifictes dted Jnury through June 2003, including those for which the decedent 1) ws resident of New York City, 2) died in one of the city s 70 hospitls, nd 3) hd n underlying cuse of deth on his or her deth certificte tht corresponded to suset of codes ssocited with CHD or stroke from the Interntionl Clssifiction of Diseses, 10th revision (ICD-10) nd corresponding to the ICD-9 codes used in the ARIC vlidtion study (Tle 1). A dt set with 13,144 eligile deth certifictes, including 7,674 for in-hospitl Figure. Age-djusted deths from coronry hert disese in New York City (NYC) versus the United Sttes overll. ICD indictes the revisions of the Interntionl Clssifiction of Diseses tht were used to ctegorize cuse of deth. US dt for 1950 through 2002 from Ntionl Hert, Lung, nd Blood Institute, US dt for 2003 through 2006 from Centers for Disese Control nd Prevention. NYC dt from NYC Deprtment of Helth nd Mentl Hygiene, Bureu of Vitl Sttistics. NYC popultion dt from 1971 through 2003 census estimtes. NYC popultion dt from 1961 through 1969 from liner interpoltion. deths, ws otined from the New York City Deprtment of Helth nd Mentl Hygiene (DOHMH), Bureu of Vitl Sttistics. We took strtified rndom smple sed on New York City neighorhoods with low, medium, or high ge-djusted CHD deth rtes in 2001; ech strtum contined roughly one-third of the smpled popultion. This study ws restricted to 491 in-hospitl deths to mximize fesiility of dt collection. In-hospitl deths were ctegorized s inptient, emergency deprtment (ED), outptient, nd ded on rrivl (DOA). Dt collection Hospitls provided medicl records for the smpled decedents. We strcted informtion from ech record nd entered it into stndrdized computer-sed strction form developed y using EpiInfo version (CDC, Atlnt, Georgi). This form contined pre-populted fields for demogrphic dt reported on the deth certifictes. Informtion strcted from the medicl chrt included time from onset of symptoms to deth, presence of chest pin, history of CHD, nd mediction use. We photocopied electrocrdiogrm results (ECGs), test results for crdic enzymes, nd medicl dischrge summries. Externl review Two externl tems were ssemled, ech consisting of 2 Centers for Disese Control nd Prevention

3 2 physicin epidemiologists, trined nd certified in the ARIC protocol for vlidtion of CHD events. They were linded to the cuse of deth listed on the deth certificte nd used cse summry reports generted from the medicl record strction, ECGs, nd medicl dischrge summries to nswer 5 yes/no questions out ech cse: 1) Ws there known nontherosclerotic or noncrdic process or event tht ws proly lethl?, 2) Ws there definite myocrdil infrction (MI) for which the ptient ws hospitlized within 4 weeks of deth?, 3) Ws there prole MI for which the ptient ws hospitlized within 4 weeks of deth?, 4) Ws there history of chest pin within 72 hours of deth?, nd 5) Ws there history of ever hving hd chronic ischemic hert disese such s coronry insufficiency or ngin? When initil responses to questions differed within ech tem, the 2 reviewers discussed the cse until they greed on finl determintion. Cse definitions Deth certificte CHD deths were defined s ICD- 10 codes I20-I25 nd I51.6. Deth certificte non-chd deths were defined s ll other ICD-10 codes included in the study (Tle 1). We used n lgorithm sed on the ARIC methods, incorporting the reviewer responses to the 5 yes/no questions descried ove, to develop 2 definitions of CHD: definite CHD nd possile CHD. Definite CHD ws defined s 1) no known nontherosclerotic or noncrdic process or event tht ws proly lethl nd 2) t lest 1 of the following conditions: definite MI for which the ptient ws hospitlized within 4 weeks of deth, history of chest pin within 72 hours of deth, or history of chronic ischemic hert disese such s coronry insufficiency or ngin pectoris. The definite CHD vlidtion definition relies hevily on informtion ville in the medicl record. To ccount for the possiility tht deth my e due to CHD even if relevnt informtion is not clerly documented in the chrt, we used second cse definition, possile CHD. Possile CHD ws defined s 1) no known nontherosclerotic or noncrdic process or event tht ws proly lethl nd 2) deth certificte with consistent underlying cuse of deth (ICD-10 codes I20-I25 nd I51.6). This definition is more sensitive, excluding only those deths with clerly recorded cuse other thn CHD. Dt nlysis The gol of dt nlysis ws to estimte the degree to which CHD deths were reported on deth certifictes when mesured ginst the stndrd of externl medicl chrt review. To otin this mesurement, we clculted comprility rtios (CRs) s the numer of CHD deths defined y the deth certificte divided y the numer of CHD deths defined y review of the medicl record. We lso clculted sensitivity, flse-positive rte (FPR), nd positive predictive vlue (PPV). The finl dt set contined records tht were strcted nd vlidted (n = 444). Oservtions were ssigned initil weights equl to their inverse proility of selection, which vried y strt. The trget popultion consisted of ll New York City in-hospitl decedents with smpled ICD-10 codes (n = 7,800) who died during the study period. We used post-strtifiction weighting to ccount for differences in rce/ethnicity nd sex distriutions etween the smple nd the trget popultion. To ccount for the complex smpling design, we computed vrince estimtes for CRs y using jckknife estimtor for strtified smples (9). For direct comprison to the ARIC study of inptient deths (excluding ED, outptient, nd DOA deths), we lso clculted survey weights nd outcome mesures for the inptient supopultion. Findings were similr for the inptient-only nd comprehensive smples; thus, detiled results re presented only for the lrger inhospitl smple. Results Of the 491 eligile cses, 444 records (90%) were strcted from hospitl chrts nd ssessed y the reviewers. Chrts were unville for the remining 47 cses. Of the 444 decedents, 345 were inptients; 70 were ED ptients or outptients; 23 were DOA, nd 6 died in other or unknown plces in the hospitl (Tle 2). Most were women (54%), ged 75 yers or older (66%), non-hispnic white (55%), nd died in privte hospitl (89%). Reviewer disgreement efore djudiction on ech of the 5 vlidtion questions rnged from 5% to 31%. The sensitivity of deth certifictes for definite CHD deths ws 0.87, the FPR ws 0.66, nd the PPV ws 0.46 (Tle 3). The overll CR for definite CHD ws 1.91 (95% confidence intervl [CI], ). The CR incresed with ge, from 1.51 for decedents ged 35 to 74 yers to Centers for Disese Control nd Prevention 3

4 for decedents ged 85 yers or older. The CR ws 1.83 for women nd 2.01 for men; it ws 2.08 for whites, 2.14 for lcks, nd 1.30 for Hispnics. When the roder possile CHD definition ws used, the sensitivity ws 0.91, the PPV ws 0.66, nd the FPR ws The CR for possile CHD deths ws 1.37 (95% CI, ). When dt were strtified y neighorhoods with low, medium, nd high CHD deth rtes, the CR incresed progressively from low to high strt. The CR for definite CHD in the low strtum ws 1.82 (95% CI, ), in the medium strtum ws 2.06 (95% CI, ), nd in the high strtum ws 2.79 (95% CI, ). This trend remined consistent in the inptient popultion (CR rnge, ) nd when using the possile CHD vlidtion definition for oth the totl in-hospitl popultion (CR, ) nd the inptient-only popultion (CR, ). Discussion These results demonstrte sustntil overreporting of CHD s cuse of deth on deth certifictes in New York City for in-hospitl deths, when mesured ginst the stndrd of medicl record review. The CR for definite CHD ws 1.51 for in-hospitl decedents nd 1.33 for inptient decedents (in-hospitl deths excluding DOA, outptient, nd ED deths) ged 35 to 74 yers. The inptient popultion is comprle to the inptient popultion in the ARIC study, which exmined deths mong decedents ged 35 to 74 yers in 4 other sites cross the country. The ARIC study found modest underreporting of CHD deths on deth certifictes compred with chrt review y using the sme vlidtion definition for definite CHD (CR, 0.9). These results indicte tht overreporting of CHD on deth certifictes my contriute to the elevted CHD deth rtes oserved in New York City. The study design ws sed on the methods of the ARIC vlidtion study ut differs from the ARIC study in 3 wys. First, the ARIC study ws conducted from 1987 through 1995, when ICD-9 ws used to code cuse of deth, wheres this study ws conducted in 2003 y using ICD-10 codes. Given the high correspondence etween ICD-9 nd ICD-10 for CHD (10), the chnge in clssifiction system is unlikely to ccount for the differences in the CRs etween ARIC nd this study. Second, stroke deths reported on deth certifictes were not included in ARIC ut were included in our study. Including stroke deths could hve resulted in greter opportunity for flse or true negtives. Flse negtives would hve resulted in lower CR. However, our smple included only smll numer of stroke deths, nd ll were clssified s true negtives. Therefore, the inclusion of stroke deths did not ffect our comprison with ARIC. Third, this study included high proportion of decedents ged 75 yers or older, mny of whom hd multiple chronic medicl prolems; the presence of these comoridities mde vlidtion especilly difficult, s evidenced y the rnge of initil disgreement etween the reviewers on the 5 vlidtion questions. Difficulty in vlidting cuse of deth ws lso due to conflicting, sprse, or missing informtion in hospitl chrts. When reviewers were uncertin how to nswer question, they chose no, frequently resulting in vlidted No CHD clssifiction. This in turn yielded fewer vlidted CHD deths, possily inflting the CR. To our knowledge, this is the first study to exmine CHD reporting on in-hospitl deth certifictes in New York City. The findings hve implictions for pulic helth nd vitl registrtion prctice. Further work is needed to etter understnd ptterns of deth certificte completion for in-hospitl deths. Providers who re most knowledgele out the ptient do not lwys complete the deth certificte; tht tsk my e ssigned to residents or fellows who re not properly instructed in completion, leding to inccurte reporting (11). In ddition, providers who complete the deth certificte my not hve ll relevnt ptient informtion ville t tht time. In prticulr, physicins in the ED hve limited informtion t the time of deth certificte completion. Externl reviewers my hve hd the enefit of pthology or lortory reports unville to the provider t the time of deth certificte completion. Lck of informtion out DOA, outptient, nd ED decedents my ccount for the difference etween inptient nd in-hospitl CRs. Other resons for CHD overreporting on deth certifictes my e more specific to New York City. New York City hs centrl registrtion process, ut the rest of the stte hs pproximtely 1,500 locl registrrs, similr to most other helth jurisdictions. Therefore, ny is in reporting, such s misunderstnding regrding how deth certifictes should e completed, my e compounded. For exmple, in the pst the New York City uril desk rejected deth certifictes for improper completion of cuse of deth. This rejection process no longer occurs, ut the fer of hving Centers for Disese Control nd Prevention

5 deth certificte rejected my still led mny physicins to complete certifictes with common nd cceptle cuses of deth, such s CHD. Second, New York City requires deth certifictes to e registered within 72 hours of deth. This time pressure my result in more frequent reporting of certin cuses of deth tht re esier to ssume in decedent with mny comoridities, such s older decedents. Third, the lrge numer of teching hospitls in New York City my compound the prolem of providers who re less fmilir with the decedent s medicl history eing responsile for completing deth certifictes. This study highlights the possiility tht New York City s oserved high rte of CHD my e prtly due to misreporting of CHD on deth certifictes. Deth certificte ccurcy my e improved y physicin eduction. The city s Bureu of Vitl Sttistics hs developed n online tool to educte providers in ll phses of their creers out deth certificte completion, nd other eduction mterils re eing developed (12). As the success of these efforts re evluted, it will e importnt to monitor trends in the reporting of CHD deths on deth certifictes nd to ssess ny chnges in the CHD deth rtes tht could e due to chnges in reporting prctices. Menwhile, CHD is the leding cuse of deth in New York City, nd efforts to reduce its urden remin top pulic helth priority. Hving ccurte dt will help DOHMH meet its mission to protect nd promote the helth of ll New Yorkers. Acknowledgments Dt collection for this study ws prtilly supported y the Centers for Disese Control nd Prevention, Epidemiology Progrm Office. Author Informtion Corresponding Author: Reen Agrwl, MD, MPH, Division of Generl Internl Medicine, Montefiore Medicl Center, 111 E 210th St, Bronx, NY Telephone: E-mil: rgrwl@montefiore.org. At the time of the study, Dr Agrwl ws ffilited with the New York City Deprtment of Helth nd Mentl Hygiene, New York, New York. Author Affilitions: Jennifer M. Norton, Kevin Konty, Regin Zimmermn, New York City Deprtment of Helth nd Mentl Hygiene, New York, New York; Mleek Glover, Akki Lekichvili, Henry McGruder, Ann Mlrcher, Michele Csper, Centers for Disese Control nd Prevention, Atlnt, Georgi; George A. Mensh, PepsiCo, Purchse, New York; Lorn Thorpe, CUNY School of Pulic Helth t Hunter College, New York, New York. At the time of the study, Dr Mensh ws ffilited with the Centers for Disese Control nd Prevention, Atlnt, Georgi, nd Dr Thorpe ws ffilited with the New York City Deprtment of Helth nd Mentl Hygiene, New York, New York. Norton, Kevin Konty, Regin Zimmermn, Lorn Thorpe. References 1. Hoyert DL, Heron MP, Murphy SL, Kung H. Deths: finl dt for Ntl Vitl Stt Rep 2006;54(13): New York City Deprtment of Helth nd Mentl Hygiene. Annul mortlity dt file New York (NY): Bureu of Vitl Sttistics; Gwynn RC, Grg RK, Kerker BD, Frieden TR, Thorpe LE. Contriutions of locl helth exmintion survey to the surveillnce of chronic nd infectious diseses in New York City. Am J Pulic Helth 2009;99(1): Sely DM, Clrk B, Cin SJ. Accurcy of deth certifiction in two tertiry cre militry hospitls. Mil Med 1999;164(12): Johnsson LA, Westerling R. Compring hospitl dischrge records with deth certifictes: cn the differences e explined? J Epidemiol Community Helth 2002;56(4): Sington JD, Cottrell BJ. Anlysis of the sensitivity of deth certifictes in 440 hospitl deths: comprison with necropsy findings. J Clin Pthol 2002;55(7): Lloyd-Jones DM, Mrtin DO, Lrson MG, Levy D. Accurcy of deth certifictes for coding coronry hert disese s the cuse of deth. Ann Intern Med 1998;129(12): Cody SA, Sorlie PD, Cooper LS, Folsom AR, Rosmond WA, Conwill DE. Vlidtion of deth certificte dignosis for coronry hert disese: the Atherosclerosis Risk in Communities (ARIC) Study. J Clin Epidemiol 2001;54(1): Berger YG. A jckknife vrince estimtor for unistge strtified smples with unequl proilities. Biometrik 2007;94(4): Centers for Disese Control nd Prevention 5

6 10. Finl comprility rtios for 113 selected cuses of deth. Ntionl Center for Helth Sttistics. ftp:// ftp.cdc.gov/pu/helth_sttistics/nchs/dtsets/ Comprility/icd9_icd10/. Accessed Jnury 24, Lkkireddy DR, Gowd MS, Murry CW, Bsrkodu KR, Vcek JL. Deth certificte completion: how well re physicins trined nd re crdiovsculr cuses overstted? Am J Med 2004;117(7): Improving cuse of deth reporting. New York City Deprtment of Helth nd Mentl Hygiene. Accessed Decemer 11, Tles Tle 1. ICD-9 nd ICD-10 Codes Used to Report CHD s Cuse of Deth on Deth Certifictes, New York City, 2003 Description of ICD-9 Code ICD-9 ICD-10 Description of ICD-10 Code Included in ARIC study Dietes mellitus 250 E10 Insulin-dependent dietes mellitus Dietes mellitus 250 E11 Non insulin-dependent dietes mellitus Dietes mellitus 250 E12 Mlnutrition-relted dietes mellitus Dietes mellitus 250 E13 Other specified dietes mellitus Dietes mellitus 250 E14 Unspecified dietes mellitus Essentil hypertension 401 I10 Essentil hypertension Hypertensive hert disese 402 I11 Hypertensive hert disese Angin pectoris 413 I20 Angin pectoris Acute MI 410 I21 Acute MI Acute MI 410 I22 Susequent MI I23 Certin current complictions following cute MI Other cute nd sucute IHD 411 I24 Other cute IHD Old MI, other forms of chronic IHD 412, 414, I25 Chronic IHD Crdic dysrhythmis 427 I46-I49 Crdic rrest; proxysml tchycrdi; tril firilltion; other crdic rrhythmis Hert filure 428 I50 Hert filure Ill-defined descriptions nd complictions of hert disese 429 ut not I51 Ill-defined complictions of hert disese Atherosclerosis 440 I70 Atherosclerosis Acute edem of lung, unspecified J81 Pulmonry edem Sudden deth, cuse unknown 798 R96 Other sudden deth, cuse unknown Other ill-defined nd unknown 799 R99 Other ill-defined nd unknown cuse Arevitions: ICD-9, Interntionl Clssifiction of Diseses, 9th revision; ICD-10, Interntionl Clssifiction of Diseses, 10th revision; CHD, coronry hert disese; ARIC, Atherosclerosis Risk in Communities; MI, myocrdil infrction; IHD, ischemic hert disese. The ARIC study evluted coronry hert disese reporting on deth certifictes in 4 geogrphiclly distinct US communities using linded medicl record review process (8). No nlogous code. (Continued on next pge) 6 Centers for Disese Control nd Prevention

7 Tle 1. (continued) ICD-9 nd ICD-10 Codes Used to Report CHD s Cuse of Deth on Deth Certifictes, New York City, 2003 Description of ICD-9 Code ICD-9 ICD-10 Description of ICD-10 Code Not included in ARIC study Surchnoid hemorrhge 430 I60 Surchnoid hemorrhge Intrcererl hemorrhge 431 I61 Intrcererl hemorrhge Other nd unspecified intrcrnil hemorrhge 432 I62 Other nontrumtic intrcrnil hemorrhge Cererl rtery occlusion with infrction I63 Cererl infrction Acute ut ill-defined cererovsculr disese 436 I64 Stroke, not specified s hemorrhge or infrction Occlusion nd stenosis of precererl rteries 433 I65 Occlusion nd stenosis of precererl rteries Occlusion of cererl rteries 434 I66 Occlusion of cererl rteries Other nd ill-defined cererovsculr disese 437 I67 Other cererovsculr diseses Other nd ill-defined cererovsculr disese 437 I68 Cererovsculr disese in diseses clssified elsewhere Lte effects of cererovsculr disese 438 I69 Sequele of cererovsculr disese Arevitions: ICD-9, Interntionl Clssifiction of Diseses, 9th revision; ICD-10, Interntionl Clssifiction of Diseses, 10th revision; CHD, coronry hert disese; ARIC, Atherosclerosis Risk in Communities; MI, myocrdil infrction; IHD, ischemic hert disese. The ARIC study evluted coronry hert disese reporting on deth certifictes in 4 geogrphiclly distinct US communities using linded medicl record review process (8). No nlogous code. Tle 2. Chrcteristics of Decedents for Whom Cuse of Deth Ws Reported s CHD on Deth Certifictes, New York City, 2003 Chrcteristic No. (n = 444) Weighted No. (n = 7,800) Weighted % Sex Demogrphic Chrcteristics Women 249 4, Men 195 3, Age, y < < , , Rce/ethnicity Non-Hispnic white 276 4, Non-Hispnic lck 103 1, Hispnic 34 1, Other/missing/unknown Arevitions: CHD, coronry hert disese; ED, emergency deprtment; DOA, ded on rrivl; ICD-10, Interntionl Clssifiction of Diseses, 10th revision. Percentges my not totl 100 ecuse of rounding. More thn 1 ICD code my e recorded per record. (Continued on next pge) Centers for Disese Control nd Prevention 7

8 Tle 2. (continued) Chrcteristics of Decedents for Whom Cuse of Deth Ws Reported s CHD on Deth Certifictes, New York City, 2003 Chrcteristic No. (n = 444) Weighted No. (n = 7,800) Weighted % Hospitl type Mortlity Chrcteristics Privte 406 6, Pulic Plce of deth Inptient 345 5, Outptient/ED/DOA 93 1, Other plce Unknown 1 15 <1 Deth certificte cuse of deth ICD-10: I20-I , ICD-10: I21 only 63 1, ICD-10: I25 only 300 4, Other (not I20-I25) 79 2, Arevitions: CHD, coronry hert disese; ED, emergency deprtment; DOA, ded on rrivl; ICD-10, Interntionl Clssifiction of Diseses, 10th revision. Percentges my not totl 100 ecuse of rounding. More thn 1 ICD code my e recorded per record. Tle 3. Vlidtion Mesures of Deth Certificte Accurcy for Reporting CHD, New York City, 2003 Chrcteristic Sensitivity Positive Predictive Vlue Flse-Positive Rte c Comprility Rtio d (95% CI) Definite CHD e Age, y ( ) ( ) ( ) Arevition: CHD, coronry hert disese; CI, confidence intervl. CHD defined y deth certificte nd y vlidtion divided y CHD defined y vlidtion. CHD defined y deth certificte nd y vlidtion divided y CHD defined y deth certificte. c CHD defined y deth certificte ut not y vlidtion divided y ll deth certifictes vlidted s not CHD. d CHD defined y deth certificte divided y CHD deths defined y vlidtion. e Defined s 1) no known nontherosclerotic or noncrdic process or event tht ws proly lethl nd 2) t lest 1 of the following conditions: definite myocrdil infrction for which the ptient ws hospitlized within 4 weeks of deth, history of chest pin within 72 hours of deth, or history of chronic ischemic hert disese such s coronry insufficiency or ngin pectoris. f Inptient smple is equivlent to the in-hospitl smple excluding outptient, emergency deprtment, nd ded on rrivl deths. g Defined s 1) no known nontherosclerotic or noncrdic process or event tht ws proly lethl nd 2) deth certificte with consistent underlying cuse of deth. (Continued on next pge) 8 Centers for Disese Control nd Prevention

9 Tle 3. (continued) Vlidtion Mesures of Deth Certificte Accurcy for Reporting CHD, New York City, 2003 Chrcteristic Sensitivity Positive Predictive Vlue Flse-Positive Rte c Comprility Rtio d (95% CI) Sex Definite CHD e (continued) Women ( ) Men ( ) Rce/ethnicity Non-Hispnic white ( ) Non-Hispnic lck ( ) Hispnic ( ) Totl in-hospitl ( ) Totl inptient f ( ) Age, y Possile CHD g ( ) ( ) ( ) Sex Women ( ) Men ( ) Rce/ethnicity Non-Hispnic white ( ) Non-Hispnic lck ( ) Hispnic ( ) Totl in-hospitl ( ) Totl inptient f ( ) Arevition: CHD, coronry hert disese; CI, confidence intervl. CHD defined y deth certificte nd y vlidtion divided y CHD defined y vlidtion. CHD defined y deth certificte nd y vlidtion divided y CHD defined y deth certificte. c CHD defined y deth certificte ut not y vlidtion divided y ll deth certifictes vlidted s not CHD. d CHD defined y deth certificte divided y CHD deths defined y vlidtion. e Defined s 1) no known nontherosclerotic or noncrdic process or event tht ws proly lethl nd 2) t lest 1 of the following conditions: definite myocrdil infrction for which the ptient ws hospitlized within 4 weeks of deth, history of chest pin within 72 hours of deth, or history of chronic ischemic hert disese such s coronry insufficiency or ngin pectoris. f Inptient smple is equivlent to the in-hospitl smple excluding outptient, emergency deprtment, nd ded on rrivl deths. g Defined s 1) no known nontherosclerotic or noncrdic process or event tht ws proly lethl nd 2) deth certificte with consistent underlying cuse of deth. Centers for Disese Control nd Prevention 9