Statistics on causes of death (COD)

Directorate F: Social Statistics and Information Society Unit F-5: Health and food safety statistics Doc. ESTAT/F5/08/HEA/12-2 WORKING GROUP "PUBLIC HEALTH STATISTICS" Luxembourg 18-19 November 2008 Item 9 of the agenda Statistics on causes of death (COD) 9.2 Main project finalised or with important achievements in 2008 Annex 2 Glossary on COD statistics

Glossary of s Used in Causes of Death Statistics Introduction Causes of death (COD) statistics is an area with an extensive specialised terminology, and the range of terms used can cause confusion. At international level, the difficulties are further complicated, where misunderstandings can arise due to people from different countries using the same term with different meanings. Questions then come up such as: Do post-mortem and autopsy mean the same thing? What precisely do we mean by electronic death certificate? Do we have an agreed meaning for alcohol-related death? This glossary is intended to ease some of these difficulties. Where possible, a clear and unambiguous definition has been provided for each term. Some of these definitions were taken from an already existing source, and some were agreed after discussion by the Task Force that produced the glossary. Where the same term is used in different ways, we have listed the different meanings. We expect that the most frequent users of this glossary will be the producers of causes of death statistics, but it should also be of use to interested users of these statistics. It is intended that the proposed definitions are used as reference definitions when talking about COD at international level. The glossary was produced by a Task Force consisting of producers of COD statistics from Bulgaria, Ireland, Malta, the Netherlands, the United Kingdom (England and Wales) and Eurostat. We agreed a list of the most commonly used terms, and then met over two days, to agree reference definitions. The initial definitions were then edited and finally agreed over the following months. The glossary was then updated to reflect comments from the Causes of Death Technical Group. 1

List of terms currently covered by the COD Glossary Aetiology Alcohol-related deaths Antecedent cause Autopsy Avoidable causes of death Birth weight Bridge coding Causes of Death, "European Shortlist" Census Certification (medical) Certifier Civil registration COD statistics office Coding Comparability ratio Competing causes Contributing condition (cause) Coroner Correspondence table Coverage Data year Death certificate Demographic data Drug-related deaths Dual coding Electronic death certification European Statistics Code of Practice Excess death External causes Fetal death (deadborn fetus) General principle Gestational age Hospital ICD - International Statistical Classification of Diseases and Related Health Problems ICD-10 chapters ICD-10 three and four character levels ICD-10 updates Ill-defined causes of death Inquest Late Maternal death Life expectancy Linkage Live birth Main condition Manner of death Manual coding Maternal death Medical certificate of cause of death 2

Mentioned causes Mode of dying Modification rules Mortality Forum Multiple cause coding Natural death / non-natural death Necropsy Neonatal period Nosologist Notification Nursing and residential care facilities Originating Antecedent cause Partnership on Public Health Statistics Perinatal period Population register Post-mortem Examination Potential years of life lost Pregnancy-related death Premature mortality Probability of dying Query Residents (resident population) Risk factor Risk of dying Road map for COD statistics Section Selection rules Sequelae Sequence Smoking related deaths Trivial conditions Underlying causes of death (UCD) Underlying cause coding Undetermined intent 3

Other related glossaries UN Glossary of Classification s United Nations Statistics Division http://unstats.un.org/unsd/class/family/glossary_short.htm Glossary of statistical terms OECD http://stats.oecd.org/glossary/ ISI glossary of statistical terms European Commission http://ec.europa.eu/comm/eurostat/research/index.htm?http://europa.eu.int/en/comm/eurostat/r esearch/isi/&1 Eurostat s Metadata Server (RAMON), includes Eurostat Concept and s Database (CODED), also other glossaries and metadata http://ec.europa.eu/eurostat/ramon/index.cfm?targeturl=dsp_pub_welc Link to Health Metrics Network glossary http://www.who.int/healthmetrics/tools/logbook/en/move/web/index.html 4

COD glossary Aetiology The part of medical science dealing with the causes and origins of diseases. Also used as a synonym for cause of a disease. Etiology (synonym) $analysis $etiology Alcohol-related deaths There is not an agreed international definition. Different definitions might be used at national level. The cause of death codes used and the disease names should always be indicated in statistical tables and surveys on alcohol-related deaths. Eurostat uses in its 'Atlas on Mortality in the European Union' (2004) the following grouping: malignant neoplasm of lip, oral cavity, pharynx, malignant neoplasm of oesophagus, alcohol abuse (including alcoholic psychosis), and chronic liver disease (entries 8, 9, 29, and 44 of the Causes of Death, "European Shortlist". The 'Atlas on Mortality in the European Union' is available at: http://epp.eurostat.ec.europa.eu/cache/ity_offpub/atlas/en/atlas-en.htm The following positions from the Causes of Death, "European Shortlist" are included in Mortality associated with alcoholism part of the Eurostat's Atlas of mortality in the European union (2004): 08 Malignant neoplasm of lip, oral cavity, pharynx (ICD-10: C00-C14, ICD-9: 140-149, ICD-8: 140-149); 09 Malignant neoplasm of oesophagus (ICD-10: C15, ICD-9: 150, ICD-8: 150); 29 Alcohol abuse (including alcoholic psychosis) (ICD-10: F10, ICD-9: 291, 303, ICD-8: 291, 303); 44 Chronic liver disease (ICD-10: K70, K73-K74, ICD-9: 571.0-571.9, ICD-8: 571.0-571.9). The Nomesco's (Nordic Medico Statical Committee) definition on Deaths caused by alcohol (narcotics and medicaments) is available at: www.ssb.no/english/subjects/03/01/10/dodsarsak_en/tab-2007-10-19-12-en.html WHO uses the following explanations in Health for all data base (http://www.euro.who.int/hfadb): 5

The mortality from combined, selected causes of death which are known from literature to be related to alcohol consumption. It has to be pointed out that it is relatively rough indicator and it is NOT the estimate of alcohol-attributable mortality, which is more complex and difficult to calculate. Some known alcohol-related causes are not included, as they are not available separately in the mortality data files reported to WHO (mainly when causes were coded using ICD-9 Basic Tabulation List or the list of 175 causes used in countries of former USSR). In addition, for some country-years some components of the sum may be missing causing trend breaks. This simple pooling of alcohol-related deaths (irrespective of what is the actual proportion of deaths due to alcohol in each cause) can help to better rank countries by alcohol-related mortality and can be used to better track trends in deaths associated with alcohol than using separate causes. WHO: The WHO HFADB indicator on mortality from selected alcohol-related causes includes: cancer of oesophagus and larynx (cancer of liver is not available in the 175 list); alcohol dependence syndrome (alcoholic psychoses not available in BTL); chronic liver disease and cirrhosis; all external causes. ICD-9: 150, 161, 303, 571, E800-E999. BTL: 090, 100, 215, 347, E47-E56 List 175: 46, 52, 75, 122,123, 160-175 ICD-10: C15, C32, F10, K70, K73, K74, K76, V00-V99, W00-W99, X00-X99, Y00-Y99. Causes of Death, "European Shortlist"; Smoking Related Deaths $analysis $etiology 6

Antecedent cause Any disease or condition which has given rise to another disease or condition in the morbid train of events leading to death. Medical certificate of cause of death; Originating antecedent cause Australian Bureau of Statistics $etiology $classification Autopsy An autopsy is a medical procedure that consists of a thorough examination of a human corpse to determine the cause and manner of a person's death and to evaluate any disease or injury that may be present. It involves the cutting up of the body. Exclusively external examination of the body without section is excluded. An autopsy can be the result of a legal procedure or due to medical reasons. In some countries, autopsy does not imply the cutting up of the body, but merely denotes an external visual inspection of the deceased. This meaning is to be avoided in international communications. Post-mortem examination (synonym); Section (synonym); Necropsy (synonym) $collection 7

Avoidable causes of death There is not an agreed international definition for "avoidable" causes; different definitions are used in different studies at national and international level. The cause of death code and disease name should be always indicated in statistical tables and surveys on avoidable causes of deaths. In 1976 Rutstein et al. identified and published tables of avoidable causes in order to be able to measure outcomes of medical care. (: European Community Atlas of Avoidable deaths Volume two www.statistics.gov.uk/about/consultations/downloads/pam.pdf). The EC atlas The European Community Atlas of "avoidable death" was published for the first time in 1988. It described mortality from 17 conditions in 10 countries in 1974-1978. The second edition describes "avoidable mortality" in the European Community (EC) in 1980-1984 and changes in "avoidable mortality" between 1974-1978 and 1980-1984 in two volumes. In the second edition, the 10 countries that originally collaborated on the project have been joined by Spain and Portugal. The statistics were collected and homogenized by a European Community Working Group and the two volumes were published by Oxford University Press in 1991-1992. (Holland WW. ed. The European Community atlas of avoidable deaths, Commission of the European Communities Health Services Research Series 3, Oxford; Oxford University Press, 1988 and Holland WW. ed. The European Community atlas of avoidable deaths, volume II, 2nd edn., Commission of the European Communities Health Services Research Series 9, Oxford; Oxford University Press, 1993.) : http://lazarus.elte.hu/hun/buszke/ksh/camp94.htm Simonato (1998) grouped avoidable conditions into 3 categories: 1. Causes avoidable through primary prevention, i.e. by reducing the incidence of the disease. This category includes causes whose etiology is in part attributable to lifestyle factors (such as alcohol and/or tobacco consumption) and/or to occupational risk factors. It also includes deaths from injury and poisoning, which are influenced in part by legal and societal measures such as traffic safety and crime reduction policies. 2. Causes amenable to secondary prevention through early detection and treatment. This group includes causes of death for which screening modalities have been established such as cancer of breast and cervix, as well as causes for which death is avoidable through early detection combined with adequate treatment, such as skin cancer. 3. Causes amenable to improved treatment and medical care. This group includes infectious diseases, deaths from which are avoidable largely through antibiotic treatment and immunization as well as causes that require medical and/or surgical intervention such as hypertension, appendicitis, deaths of which are related to complex interactions within the health care system, such as accurate diagnosis, transport to hospital, adequate medical and surgical care. Lefèvre H., Jougla E., Pavillon G., Le Toullec A.: Gender differences in premature mortality and avoidable deaths (http://www.hal.inserm.fr/inserm-00086215) The study is focused on "avoidable" causes of death. These types of deaths are greatly related to risk behaviours such as alcohol abuse, tobacco abuse or dangerous driving. Specific causes of death closely related to risk behaviours are classified as "avoidable": lung and upper airways cancers, cirrhosis, alcoholic psychosis, traffic accidents, aids and suicide. Amenable deaths - Nolte and McKee (2004) conducted a comprehensive review of avoidable 8

mortality methodology but their primary focus was on the use of avoidable mortality as a measure of health system performance. For this reason, they only selected causes of death that could be categorized as amenable to secondary prevention or causes amenable to improved treatment and medical care in their studies of amenable mortality or mortality that is amenable to medical prevention or treatment. In other words amenable mortality can be considered a subset of all avoidable mortality. $analysis $etiology Birth weight The first weight of the fetus or newborn obtained after birth. For live births, birth weight should preferably be measured within the first hour of life before significant postnatal weight loss has occurred. While statistical tabulations include 500 g groupings for birth weight, weights should not be recorded in those groupings. The actual weight should be recorded to the degree of accuracy to which it is measured. The definitions of low, very low, and extremely low birth weight do not constitute mutually exclusive categories. Below the set limits they are all-inclusive and therefore overlap (i.e. low includes very low and extremely low, while very low includes extremely low ). Low birth weight Less than 2500 g (up to and including 2499 g). Very low birth weight Less than 1500 g (up to and including 1499 g). Extremely low birth weight Less than 1000 g (up to and including 999 g). Gestational age ICD-10, International Statistical Classification of Diseases and related Health Problems $collection $presentation $perinatal 10 th revision, 2 nd edition, volume 2, page 129f. 9

Bridge coding An exercise in which the same group of deaths are independently classified according to two different classifications or coding methods. Usually, the group of deaths are all or a sample of one year s deaths. The different classifications can be ICD-9/ICD-10 or Manual coding/automated Coding, or different ICD- 10 updates. By comparing the resulting differences in the underlying cause of death statistics between the two methods, we can better understand the impact of introducing a classification change on cause-specific mortality trends. Guidelines for bridge coding studies: http://circa.europa.eu/public/irc/dsis/health/library?l=/methodologiessandsdatasc/causessofsde ath/icd-10_updates/guidelines_2007pdf/_en_1.0_&a=d $processing 10

Causes of Death, "European Shortlist" (final list, August 1998) The European shortlist of Causes of Death (COD) is a tool for international comparisons of mortality data, primarily for analysis at regional level and for the analysis of long-term results, such as retrospective studies and mortality projections. The European shortlist covers 65 COD. It is based on the International Statistical Classification of Diseases and Related Health Problems (ICD) of the World Health Organisation. The 65-list is compatible with the three most recent ICD versions (ICD-8, ICD- 9 and ICD-10). The causes of death selected in the 65-list have been chosen after careful examination of many lists being used by the Member States and the World Health Organisation. It includes the most relevant COD for the EU. The basis on which the causes were selected for this list were: - of relevance with respect to EU mortality patterns; - of relevance for national and sub-national health programmes; - of relevance for desegregation by regional (NUTS 2) level; - of special importance to mortality trend and projections; - subject of 'frequently asked questions'. ICD-10 Eurostat RAMON $classification $presentation http://ec.europa.eu/eurostat/ramon/ 11

Census A census is a survey conducted on the full set of observation objects belonging to a given population or universe. A census is the process of obtaining information about every member of a given population (not necessarily a human population). The most common use of the term is for population and housing censuses. The term can also be used in the context of causes of death statistics when information is collecting and compiling for all deceased persons. CODEDhttp://ec.europa.eu/eurostat/ramon/ publication: Economic Commission for Europe of the United Nations (UNECE), "inology on Statistical Metadata", Conference of European Statisticians Statistical Standards and Studies, No. 53, Geneva, 2000 $collection Handbook of Vital Statistics Systems and Methods, Volume 1: Legal, Organisational and Technical Aspects, United Nations Studies in Methods, Glossary, Series F, No. 35, United Nations, New York 1991. Certifier The certifier is the person who completes the death certificate entirely or only the medical part of the death certificate. In most cases, certifiers are physicians but in some countries they can have other qualifications. In case of external causes and / or sudden or suspicious death, the certification could be made by a forensic physician or in some countries by legal professionals such as coroners in England, Ireland and Wales. Coroner; death certificate; medical certificate of cause of death; notification TF $collection 12

Civil registration The system with which a government records the vital events of its citizens. Civil registration is defined as the continuous, permanent, compulsory and universal recording of the occurrence and characteristics of vital events pertaining to the population as provided through decree or regulation in accordance with the legal requirements of a country. Civil registration is carried out primarily for the purpose of establishing the legal documents provided by the law. These records are also a main source of vital statistics. Vital events that are typically recorded include live birth, death, foetal death, marriage, divorce, annulment of marriage, judicial separation of marriage, adoption, legitimisation and recognition. Among the legal documents that are derived from civil registration are birth certificates, death certificates, and marriage certificates. In many countries all the mentioned events are registered that occur in the country, not only those of the (resident) population. E Population register; Resident population UN $collection http://unstats.un.org/ UNSD/demographic/s ources/civilreg/defaul t.htm COD (Causes of Death) statistics office The institution in charge of the production of official statistics on causes of death. Depending on the country, this can be the National Statistical Office, the Public Health Institute or the Ministry of Health. In some countries, COD statistics are produced by co-operation between different government offices. $organisational 13

Coding Coding is a word with different meanings in data processing. In the production of causes of death data, coding is the replacement of written text with numeric or alphanumeric codes, to facilitate storage and retrieval of information. By coding, the variability of the real world is reduced by attributing the case to one class of a classification. Coding has an additional advantage, as the meanings of codes can be apparent across languages. In the context of causes of death the classification that is meant is mostly the ICD, but other classifications exist, for example, occupational classification for the deceased's employment. Sometimes the process of coding is also called classification. Coding may also refer to the process through which information is used to create additional data fields, such as the selection of the underlying cause of death, or the use of occupation and employment status to code to a socio-economic classification. Underlying cause coding; multiple cause coding; manual coding $classification 14

Comparability ratio A measure, expressed as a ratio, indicating the net effect of a change in classification (e.g. from ICD-9 to ICD-10, or ICD-10 updates) or method (e.g. manual vs. automated coding) on a particular cause of death. Comparability ratios are the most usual way of presenting the results of a bridge coding study. Comparability ratio for a particular cause of death = (Number of deaths assigned to that cause using new method of classification) / (Number of deaths assigned to that cause using old method of classification) For example, if the bridge coding study is examining a change from ICD-9 to ICD-10,and the comparability ratio for pneumonia is 0.7, that indicates that only 70% as many deaths have been coded to pneumonia using ICD-10 as were coded to pneumonia using ICD-9. Bridge coding $analysis 15

Competing causes The term competing causes is used in different ways. (1) Referring to: two or more causally unrelated, etiologically specific diseases listed in part I. This may be a source of error on the medical part of the death certificate (2) Referring to the fact that if a person is cured (and will not die) from one disease, (s)he is eligible to attract another fatal disease. It is possible by using multi-decrement (or causeelimination) life tables to investigate the impact on life expectancy if deaths from a particular cause were to be eliminated from a population. Life expectancy is not automatically improved however simply by releasing a population from the burden of a particular cause of death. Should a cause be removed, other causes will then compete for the space it leaves. The effect of competing causes can be assessed through competing risk analysis. $etiology $analysis $classification Contributing condition (cause) Any cause of death that is neither the immediate, intervening, originating antecedent nor underlying is a contributory cause of death. These are other significant conditions that contributed to the fatal outcome, but were not related to the disease or condition initiating the train of events directly leading to death (should be reported in part II). Medical certificate of cause of death; immediate COD; intervening COD; originating COD; antecedent COD; underlying COD ISTAT glossary (http://ec.europa.eu/comm/eurostat/deathcert/) ICD-10 2 nd Edition Vol. 2, page35 $etiology $analysis $classification 16

Coroner The public official who is responsible for the investigation of violent, sudden or suspicious death. Coroners only exist in certain countries, such as England, Wales and Ireland. In many countries violent or suspicious (and sometimes sudden) deaths are to be seen by a legal physician. This person is not to be called a coroner, as the qualification and authority is different. Certifier; Inquest $collection Correspondence table Is a tool for the linking of classifications. A correspondence table systematically explains where, and to what extent, the categories in one classification may be found in other classifications, or in earlier versions of the same classification. Methodologically, correspondence tables describe the way in which the value sets of classifications are related, by describing how the units classified to the groups defined for one classification would be classified in other classifications. A correspondence table provides the link between different versions of a classification, e.g. from ICD-9 to ICD-10. However, a one-to-one link between versions might not always be possible, or only for a limited number of codes of the classification and/or at a more aggregated level. An example for a correspondence table for selected entries of the ICD is the Causes of Death, "European Shortlist". A correspondence table is a conceptual mapping between classifications, and a bridge coding is a numerical mapping between classifications. ICD; linkage; Causes of Death, "European Shortlist"; Bridge coding http://unstats.un.org/unsd/class/family/glossary_short.htm $analysis $processing $classification 17

Coverage The extent to which the real, observed population matches the ideal or normative population. A population is the domain from which observations for a particular topic can be drawn. Under-coverage results from the omission of units belonging to the target population, while over-coverage occurs due to the inclusion of elements that do not belong to the target population. E.g. for COD statistics, all deaths of residents occurring in a given year should be covered. However, information about residents dying abroad might not be included in all countries (resulting in under-coverage), and deaths of non-residents might be included (resulting in over-coverage). An understanding of coverage is required to facilitate the comparison of data. Coverage issues are often explained through the use of tables showing linkages (e.g. part or full correspondence) and can also be used to explain the ratio of coverage. The rules and conventions of coverage are largely determined by concept definitions, scope rules, information requirements and, in the case of statistical collections and classifications, collection and counting units and the collection methodology. Residents/non residents CODEDhttp://ec.europa.eu/eurostat/ramon/ UN glossary of classification terms: - http://unstats.un.org/unsd/class/family/glossary_short.htm $analysis 18

Data year Year on which the statistical data report. COD statistics refer to the deaths during a given period, normally one year. Accordingly, data year (or reference year) should refer to the calendar year in which the death occurred. Depending on national registration systems, some countries have a system based on year of registration of the death, or a combination of the two. Reference year (synonym); statistical year (synonym) Adapted from CODEDhttp://ec.europa.eu/eurostat/ramon/ $analysis $presentation Death certificate The death certificate is a prescribed form on which the fact of death of a person is recorded. It provides important personal information about the deceased and about the circumstances and causes of death. However, this information varies from country to country. Some countries have separate forms for administrative and medical information. There also exist two international models for the medical information: (1) the international form of the medical certificate of cause of death, and (2) the certificate of cause of perinatal death (both WHO). Medical certificate of cause of death 1) Adapted from the Physicians' Handbook on Medical Certification of Death. 2003 Revision. 2) ICD-10 Vol. 2 $collection 19

Demographic data Demographic data covers information such as date of birth, date of death, sex, place of residence, marital status. In some countries, this information is collected through the death certificate, in others, it comes from population registers. The demographic information which in many countries is asked in an additional box of the death certificate is not part of the medical part of the international certificate of death recommended by WHO. However, its intended use is to provide a frame to collect important information as recommended by WHO and EUROSTAT. Adapted from ISTAT Manual on certification of causes of death in Europe $collection $processing Drug-related deaths The EMCDDA definition of drug-related deaths refers to those deaths that are caused directly by the consumption of drugs of abuse. Those deaths occur generally shortly after the consumption of the substance(s). www.emcdda.europa.eu/?nnodeid=1419 European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) $etiology $analysis 20

Dual coding Dual coding has several meanings. In ICD-10 Vol. 2, dual coding refers to dagger-asterisk combinations and other optional dual coding. In the context of bridge coding, it refers to the process of coding data twice for two different classifications or methods in order to determine comparability. It can also refer to the independent manual coding of the same deaths, using the same classification methods, by different coders and/or different COD statistics offices. This is usually an exercise in measuring the quality and consistency of Cause of Death coding. Bridge coding; double coding (synonym); correspondence table ICD-10 Vol. 2 (page 22) $classification $processing Electronic death certification This term refers to a fully electronic certification of the medical certificate of cause of death, i.e. the certifier completes and signs off an electronic form (on the computer). The form is then electronically sent to the relevant authorities. In some countries the certifier completes the medical certificate on paper but all the information on this certificate is later entered in electronic format by somebody else, and all this information is available electronically to the compiler of the statistics. While this is not electronic death certification, it is a system that shares many of the benefits of electronic death certification. Death certificate $collection 21

European Statistics Code of Practice The European Statistics Code of Practice sets the framework for high-quality statistics. It builds upon a common European Statistical System definition of quality in statistics and targets all relevant areas from the institutional environment, the statistical production processes to our output: European official statistics. http://ec.europa.eu/eurostat/quality Eurostat $organisational Excess death Based on some model M of death frequencies (optionally specified by COD), the expected number of Deaths (E) in a certain region and certain time period can be calculated. The observed number of deaths (O) in the same region and period can be compared. O minus E is the excess death, O divided by E is the Excess Mortality Ratio, The model M can be very simple (e.g., the averages number of deaths in the same region of the last 3 or 5 periods), or more sophisticated (e.g. involving seasonal corrections, age standardisation, socio-economic class, etc.) N Mortality Ratio TF $analysis 22

External causes Causes included in chapter XX of ICD-10. Deaths due to accidents and violence including environmental events, circumstances and conditions as the cause of injury, poisoning, and other adverse effects. Broad categories include accidents, suicides, medical misadventures or abnormal reactions, homicide, legal intervention, and injury from war operations. Note, that as medical science advances, some other diseases, e.g. Infectious diseases, certain nutritional disease, certain cancers (mesothelioma due to asbestos) can be considered to be external causes of death. There is confusion about this term, as chapter XX is sometimes, erroneously, considered a list of external causes of death, while it is only a list of external causes of injury, poisoning,.... In ICD revisions before 10, the list of external causes was not part of the ICD proper, but a separate list. Natural death / non-natural death ICD-10, ISTAT Glossary $classification Fetal death (deadborn fetus) Fetal death is death prior to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy; the death is indicated by the fact that after such separation the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Stillbirth ICD-10: International Statistical Classification of Diseases and related Health Problems: 10 th revision, 2 nd edition, volume 2 (page 129) $presentation $perinatal 23

General principle A term used by ICD-10 for the selection of the underlying cause. It states " [ ] that when more than one condition is entered on the certificate, the condition entered alone on the lowest used line of Part I should be selected only if it could have given rise to all the conditions entered above it." The general principle is amended by selection rules. (In ICD-9 the term was General Rule, and was worded differently; before that the term did not exist). N Selection rules; modification rules ICD-10 Vol. 2 $classification page 34, section 4.1.5 24

Gestational age The duration of gestation is measured from the first day of the last normal menstrual period. Gestational age is expressed in completed days or completed weeks (e.g. events occurring 280 to 286 completed days after the onset of the last normal menstrual period are considered to have occurred at 40 weeks of gestation). Gestational age is frequently a source of confusion, when calculations are based on menstrual dates. For the purposes of calculation of gestational age from the date of the first day of the last normal menstrual period and the date of delivery, it should be borne in mind that the first day is day zero and not day one; days 0-6 therefore correspond to completed week zero ; days 7-13 to completed week one ; and the 40th week of actual gestation is synonymous with completed week 39. Where the date of the last normal menstrual period is not available, gestational age should be based on the best clinical estimate. In order to avoid misunderstanding, tabulations should indicate both weeks and days. Pre-term: Less than 37 completed weeks (less than 259 days) of gestation. : From 37 completed weeks to less than 42 completed weeks (259 to 293 days) of gestation. Post-term: 42 completed weeks or more (294 days or more) of gestation. Birth weight ICD-10: International Statistical Classification of Diseases and related Health Problems: 10 th revision, 2 nd edition $collection $analysis $perinatal $presentation Volume 2, page 130 25

Hospital Hospitals are licensed establishments primarily engaged in providing medical, diagnostic, and treatment services that include physician, nursing, and other health-services to in-patients and the specialised accommodation services required by in-patients. Hospitals might also provide out-patient services as a secondary activity. In some countries, health facilities need in addition a minimum size (such as number of beds) in order to be registered as a hospital. Hospitals could be the place where the death occurred. The SHA definition of hospitals should be taken into consideration when the information on place of death is to be provided. System of health accounts (SHA). SHA page 137 http://forum.europa.eu.int/public/irc/dsis/health/library - Methodologies and data collections health accounts $misc ICD - International Statistical Classification of Diseases and Related Health Problems The ICD is a classification of the WHO and is used by all EU countries to classify causes of death. The version currently in use is the Tenth Revision (ICD-10). This was endorsed by the Forty-third World Health Assembly in May 1990 and came into use in WHO Member States as from 1994.The classification is the latest in a series which has its origins in the 1850s. The ICD is used to classify diseases and other health problems recorded on many types of health and vital records, including death certificates and hospital records. In addition to enabling the storage and retrieval of diagnostic information for clinical and epidemiological purposes, these records also provide the basis for the compilation of national mortality and morbidity statistics. Causes of Death, "European shortlist" WHO http://www.who.int/classifications/icd/en/ $classification 26

ICD-10 chapters ICD-10 is divided into 21 chapters. The classification uses an alphanumeric coding scheme with one letter followed by two or three numbers. Each letter is associated with a particular chapter but four chapters use more than one letter in the first position of their codes and two letters are also used across two chapters. Sometimes still called three or four digit levels, from the time that ICD codes were allnumeric (ICD-9 and earlier). ICD-10; ICD-10 three and four character levels ICD-10 $classification ICD-10 three and four character levels Each chapter of the ICD-10 is subdivided into homogeneous blocks of three-character categories: a letter followed by two numbers. Some of the three-character categories are for single conditions, while others are for groups of diseases with some common characteristic. Most of the three-character categories are further subdivided by means of a fourth numeric character after a decimal point. The four-character sub-categories may identify different sites or varieties if the three-character category is for a single disease, or individual diseases if the three-character category is for a group of conditions. For example: C43 Malignant melanoma of skin, C43.4 Malignant melanoma of scalp and neck B18 Chronic viral hepatitis, B18.2 Chronic viral hepatitis C These three and four character levels are also referred to as the three and four digit levels of ICD-10. ICD-10; ICD-10 Chapters ICD-10 $classification 27

ICD-10 updates The first edition of ICD-10 was published in the early 1990s. Prior to ICD-10, updates were not made between ICD revisions. The WHO ICD-10 International Conference (1989) recommended that "WHO should endorse the concept of an updating process between revisions and give consideration as to how an effective updating mechanism could be put in place." http://www.who.int/classifications/icd/updates/en/index.html and the document "Background to the ICD-10 updating process and its impact on statistics" (in CIRCA - http://forum.europa.eu.int/public/irc/dsis/health/library Methodologies and data collections Causes of Death) ICD WHO $classification http://www.who.int/classificati ons/icd/updates/en/index.html Ill-defined causes of death The block R95-R99 of ICD-10 is titled Ill-defined and unknown causes of mortality. This block contains Sudden Infant Death Syndrome (R95) which is often presented separately in COD statistics. Note that the Modification Rule A titled Senility and other ill-defined Conditions refers to conditions classified to R00-R94 and R96-R99 and also the following: I46.9 Cardiac arrest, unspecified I95.9 Hypotension, unspecified I99 Other and unspecified disorders of circulatory system J96.0 Acute respiratory failure J96.9 Respiratory failure, unspecified P28.5 Respiratory failure of newborn ICD-10 $classification 28

Inquest In countries which have a coronial system, such as England, Wales and Ireland, the inquest is the official public enquiry presided over by a coroner (and in some cases involving a jury) into the causes of a sudden, violent or unexplained death. Other countries may have similar legal procedures. Coroner $classification Late Maternal death A late maternal death is the death of a woman from direct or indirect obstetric causes more than 42 days but less than one year after termination of pregnancy. ICD-10: International Statistical Classification of Diseases and related Health Problems: 10 th revision, 2 nd edition, volume 2, page 134. $presentation $perinatal 29

Life expectancy Period life expectancy at birth is an estimate of the average number of years a new-born baby would survive if he or she experienced current age-specific mortality rates for that time period throughout his or her life. For geographical comparisons of life expectancy, the figure reflects mortality among those living in an area in each time period, rather than mortality among those born in each area. Life expectancy at older ages is the average number of years still to be lived by a person who has reached a certain exact age, if subjected throughout the rest of his or her life to the current mortality conditions (age-specific probabilities of dying). The term life expectancy is usually taken to mean life expectancy at birth, i.e. if no age is specified. Life expectancy does not represent the number of years a baby born a particular country or area could actually expect to live, both because death rates are likely to change in the future and because many of those born in a country or area may live elsewhere for at least some part of their lives. Life expectancy at birth is also not a guide to the remaining expectation of life at any given age. For example, if female life expectancy was 80 years for a particular area, life expectancy of women aged 75 years in that area would exceed 5 years. This reflects the fact that survival from a particular age depends only on the mortality rates beyond that age, whereas survival from birth is based on mortality rates at every age. Eurostat, SDDS (Special Data Dissemination Standard) - Demographic statistics $analysis 30

Linkage The term linkage is used in different contexts. (1) In ICD-10 Vol. 2 Table 1. Linkage here means that some specific combinations of selected cause and other conditions are to be coded with one code. (2) When different (versions of) classifications are linked. (3) When data from different data sources are linked, either at record level (record linkage) or at aggregated level (stochastic linkage). For this type of linkage, also the terms (record) matching and (table) joining are in use. E Correspondence table (for meaning 2) TF $classification $processing Live birth Live birth is the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each product of such a birth is considered liveborn. ICD-10: International Statistical Classification of Diseases and related Health Problems: 10 th revision, 2 nd edition, volume 2, page 129. $processing $perinatal 31

Main condition This term is used for morbidity coding. The condition to be used for single-morbidity analysis is the main condition treated or investigated during the relevant episode of health care. It is defined as the condition, diagnosed at the end of the episode of health care, primarily responsible for the patient's need for treatment of investigation. If there is more than one such condition, the one held most responsible for the greatest use of resources should be selected. underlying cause of morbidity ICD-10 Vol. 2 $classification Page 96 Manner of death Manner of death helps to clarify the modality/intention surrounding death. The most common options for the classification of this variable are: Natural, Accident, Poisoning, Suicide, Homicide and Undetermined. Natural death / non-natural death; cause of death; mode of death ISTAT Glossary $collection $classification 32

Manual coding Coding done by humans rather than automated coding done by computers. Automated coding; coding $classification $processing Maternal death A maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. Maternal deaths should be subdivided into two groups: Direct obstetric deaths: those resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above. Indirect obstetric deaths: those resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by physiologic effects of pregnancy. In order to improve the quality of maternal mortality data and provide alternative methods of collecting data on deaths during pregnancy or related to it, as well as to encourage the recording of deaths from obstetric causes occurring more than 42 days following termination of pregnancy, the Forty third World Health Assembly in 1990 adopted the recommendation that countries consider the inclusion on death certificates of questions regarding current pregnancy and pregnancy within one year preceding death. $presentation $perinatal ICD-10: International Statistical Classification of Diseases and related Health Problems: 10 th revision, 2 nd edition $perinatal Volume 2, page 134f. 33

Medical certificate of cause of death Also referred to as medical part of death certificate. Part of the death certificate where the medical information is provided. The recommended WHO international form of medical certificate of cause of death contains 2 parts: Part I for the diseases related to the train of events leading directly to death, and Part II for unrelated but contributory conditions. Death certificate ICD-10 $collection Vol. 2, page 31 Medical certification of Death Medical certification of death is the completion of the medical certificate of cause of death by the certifier. In general, information on the diseases or conditions leading to death is entered as text. It also includes information as to time and date of death as well as a certifier section including signatures. Medical certificate of cause of death; certification (medical), certifier Adapted from the Physicians' Handbook on Medical Certification of Death. 2003 Revision. $collection 34

Mentioned causes Mentioned causes are all causes or conditions stated on the medical certificate of cause of death (either in part I or in part II). Medical certificate of cause of death $classification Mode of dying This is a term used by ICD-10. It refers to the final stage of the dying process, usually one of a very limited number of possibilities: e.g. respiratory failure (arrest), circulatory, cerebral failure (arrest). The mode of dying needs to be clearly distinguished from the diseases and conditions causing the death. ICD-10 specifies that the mode of dying should not be entered on the medical certificate of cause of death. This mode of dying is not of interest for COD statistics, and certifiers should be stimulated to provide more information, whenever possible. ICD-10 $collection $classification Vol. 2, page 31 35

Modification rules Modification rules are intended to improve the usefulness and precision of mortality data. The cause of death selected as the originating antecedent cause may not be the most useful or informative. In some circumstances therefore, the ICD allows for the originating cause to be superseded by one or more suitable for expressing the underlying cause in the tabulation of statistics. For example, there are some categories for combinations of conditions, or there may be overriding epidemiological reasons for giving precedence to other conditions on the certificate. E.g. if senility or some generalized disease, such as hypertension, has been selected, this is less useful than if a manifestation or result of ageing or disease had been chosen. The modification rules specify when such selection processes should be applied. Underlying cause of death ICD-10 $classification Vol. 2, pages 33 and 42 Mortality Forum The Mortality Forum is an international discussion network on problems experienced in connection with ICD-10 mortality coding. The discussion group has a high level of activity and a large number of members from many different countries. The group has about 100 members at present, representing about 35 countries or organizations. http://www.nordclass.uu.se/verksam/mortfore.htm. Mortality Forum website http://www.nordclass.uu.se/index_e.htm $organisational 36

Multiple cause coding Multiple causes are all those diseases, morbid conditions or injuries which either resulted in or contributed to death and the circumstances of the accident or violence which produced any such injuries. Multiple cause coding replaces the written text from the medical certificate of cause of death with an ICD-10 code for each condition. The use of dagger-asterisk combinations and external cause-injury combinations are not considered to be multiple cause coding. Coding; Mentioned Causes $classification Natural death / non-natural death Natural death / non-natural death are terms used only in the context of data collection. It is not an ICD-10 distinction but it is often used by countries as a distinction for who can certify the death or whether further investigation is required. Natural deaths are commonly understood as causes not related to violence, poisoning or most external causes. However, the term is not well defined, and is not used in statistical dissemination. E Manner of death; external causes TF $collection 37

Necropsy See Autopsy $collection Neonatal period The neonatal period commences at birth and ends 28 completed days after birth. Neonatal deaths (deaths among live births during the first 28 completed days of life) may be subdivided into early neonatal deaths, occurring during the first seven days of life, and late neonatal deaths, occurring after the seventh day but before 28 completed days of life. Age at death during the first day of life (day zero) should be recorded in units of completed minutes or hours of life. For the second (day 1), third (day 2) and through 27 completed days of life, age at death should be recorded in days. ICD-10: International Statistical Classification of Diseases and related Health Problems: 10 th revision, 2 nd edition $presentation $perinatal Volume 2, page 131 38

Nosologist Nosology is the branch of medical science dealing with the classification of diseases. The coders of cause of death from medical certificates are thus sometimes referred to as nosologists. Nosologist is a recognised profession in some countries, not in others. $misc Notification The term can be used in different contexts: (1) Infectious diseases mandatory notification system to health authorities for some infectious diseases, not necessarily resulting in death (2) COD in some countries the statement to the civil authorities that a certain person has died and the statement of the causes of death are done by one person and on one form. In this case it is customary to use the terms (medical part of the) death certificate. In other countries the civil and medical statements are done separately, with the terms notification of death and cause of death certificate, respectively. E Death registration TF $collection 39