ABSTRACT

Background:

Unspecified causes of death are among the traditional indicators of quality of information.

Objective:

To verify the performance of the 60 cities in the Data for Health Initiative project and to analyze the reclassification of unspecified external causes of death (UEC).

Methods:

Using the 2017 records from the Mortality Information System, the proportion and percent change in UEC were compared after investigation between project cities and other cities, and the percent of reclassification to specific external causes was calculated.

Results:

The project cities comprised 52% (n = 11,759) of the total UEC in Brazil, of which 64.5% were reclassified after investigation, whereas the other cities reclassified 31% of UEC. Results were similar for men, youth, blacks, metropolitan cities, the Southeast region, and deaths attested by forensic institutes. In the project cities, pedestrian traffic accidents were external causes with greater reclassification. In men, the UEC was reclassified to homicides (23.8%) and accident of terrestrial transportation (ATT) (11.1%), with motorcyclists (4.4%) and pedestrians (4.3%) being the most prominent. In women, these causes were changed to other accident causes (20.8%), ATT (10.6%) and homicides (7.9%). UEC changed to ATT (18.3%) in the age groups of 0-14 years old and to homicides (32.5%) in the age groups of 15-44 years.

Conclusion:

The project cities obtained better results after investigation of UEC, enabling analysis of the reclassification to specific causes by sex and age groups.

Keywords:
Cause of death; Mortality registries; External causes; Data accuracy; Information systems; Death certificates

INTRODUCTION

Cause-of-death statistics are important sources of information to monitor population health and to establish public policy. However, death certificates (DC) do not always provide accurate evidence about the circumstance. Unknown, nonspecific causes, or garbage causes (GC) are among the traditional quality indicators of mortality reporting¹1. Rao C, Lopez AD, Yang G, Begg S, Ma J. Evaluating national cause-of-death statistics: principles and application to the case of China. Bull World Health Organ. 2005;83(8):618-25.^{)- (3}3. Cendales R, Pardo C. Quality of death certification in Colombia. Colombia Med. 2018;49(1):121-7. http://dx.doi.org/10.25100/cm.v49i1.3155
http://dx.doi.org/10.25100/cm.v49i1.3155... . Many of these DC conceal the true underlying cause of death⁴4. Soares Filho AM, Cortez-Escalante JJ, França E. Revisão dos métodos de correção de óbitos e dimensões de qualidade da causa básica por acidentes e violências no Brasil. Ciênc. Saúde Coletiva. 2016;21(12):3803-18. http://dx.doi.org/10.1590/1413-812320152112.13682015
http://dx.doi.org/10.1590/1413-812320152... , and clarification is needed through field investigations.

Redistribution of GC to defined causes is essential for the calculation of estimates made by the Global Burden of Disease (GBD) study⁵5. Murray CJL, Ezzati M, Flaxman AD, Lim S, Lozano R, Michaud C, et al. GBD 2010: design, definitions, and metrics. Lancet. 2012;380(9859):2063-66. http://dx.doi.org/10.1016/S0140-6736(12)61899-6
http://dx.doi.org/10.1016/S0140-6736(12)... ^{), (6}6. GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1736-88. https://doi.org/10.1016/S0140-6736(18)32203-7
https://doi.org/10.1016/S0140-6736(18)32... ^). Periodically reviewed, GC include ill-defined (IDC) and unspecific causes belonging to different chapters of the International Classification of Diseases (ICD), which are, therefore, of little use from a public health perspective⁷7. Ishitani LH, Teixeira RA, Abreu DMX, Paixão LMMM, França EB. Qualidade da informação das estatísticas de mortalidade: códigos garbage declarados como causas de morte em Belo Horizonte, 2011-2013. Rev Bras Epidemiol. 2017;20(Supl 1):34-45. http://dx.doi.org/10.1590/1980-5497201700050004
http://dx.doi.org/10.1590/1980-549720170... ^{), (8}8. GBD 2016 Brazil Collaborators. Burden of disease in Brazil, 1990-2016: a systematic subnational analysis for the Global Burden of Disease Study 2016. Lancet. 2018;392(10149):760-75. https://doi.org/10.1016/S0140-6736(18)31221-2
https://doi.org/10.1016/S0140-6736(18)31... ^).

In 2016, Brazil recorded more than 1.3 million deaths, 33.6% with some type of GC, and 155,861 external causes, with 15.4% unspecified external causes (UEC). In about 80% of these cases, the DC was issued by institutes of forensic medicine (IFM) in the Northeast and Southeast regions⁹9. Brasil. Ministério da Saúde. Painel de monitoramento da mortalidade por causas básicas inespecíficas ou incompletas (Garbage Codes) [Internet]. 2018 [citado em 21 dez. 2018]. Disponível em: http://svs.aids.gov.br/dantps/centrais-de-conteudos/paineis-de-monitoramento/mortalidade/codigos-garbage/?s=MSQyMDE3JDIkMSQzNSQ3NiQxJDEkMCQyNzAwMCQwJDAkNiQyJDcwMDAwMSQwJDI=
http://svs.aids.gov.br/dantps/centrais-d... . The identification of external causes between IDC¹⁰10. França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, Szwarcwald CL. Causas mal definidas de óbito no Brasil: método de redistribuição baseado na investigação do óbito. Rev Saúde Pública. 2014;48(4):671-81. http://dx.doi.org/10.1590/S0034-8910.2014048005146
http://dx.doi.org/10.1590/S0034-8910.201... ^{)- (12}12. Campos D, França E, Loschi RH, Souza MFM. Uso da autópsia verbal na investigação de óbitos com causa mal definida em Minas Gerais, Brasil. Cad Saude Publica. 2010;26(6):1221-33. http://dx.doi.org/10.1590/S0102-311X2010000600015
http://dx.doi.org/10.1590/S0102-311X2010... and the frequency of UEC, considered quality indicators of the records produced by IFM, indicate insufficient access to public services and quality of health care¹³13. Cerqueira D. Mortes violentas não esclarecidas e impunidade no Rio de Janeiro. Econ Apl. 2012;16(2):201-35. http://dx.doi.org/10.1590/S1413-80502012000200001
http://dx.doi.org/10.1590/S1413-80502012... ^{)- (15}15. Cunha CC, Teixeira R, França E. Avaliação da investigação de óbitos por causas mal definidas no Brasil em 2010. Epidemiol Serv Saúde. 2017;26(1):19-30. http://dx.doi.org/10.5123/s1679-49742017000100003
http://dx.doi.org/10.5123/s1679-49742017... .

In assessing levels and patterns of mortality from external causes, it is vital to mitigate information bias due to its under-enumeration in the Mortality Information System (MIS). The estimation of external causes, based on data retrieval, allows to generate more reliable indicators, while managers undertake structuring actions to reduce unspecified causes of death⁴4. Soares Filho AM, Cortez-Escalante JJ, França E. Revisão dos métodos de correção de óbitos e dimensões de qualidade da causa básica por acidentes e violências no Brasil. Ciênc. Saúde Coletiva. 2016;21(12):3803-18. http://dx.doi.org/10.1590/1413-812320152112.13682015
http://dx.doi.org/10.1590/1413-812320152... .

Brazil has been expanding MIS data quality improvement and, since 2005, the reduction of IDC has been its main focus¹⁰10. França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, Szwarcwald CL. Causas mal definidas de óbito no Brasil: método de redistribuição baseado na investigação do óbito. Rev Saúde Pública. 2014;48(4):671-81. http://dx.doi.org/10.1590/S0034-8910.2014048005146
http://dx.doi.org/10.1590/S0034-8910.201... ^{), (12}12. Campos D, França E, Loschi RH, Souza MFM. Uso da autópsia verbal na investigação de óbitos com causa mal definida em Minas Gerais, Brasil. Cad Saude Publica. 2010;26(6):1221-33. http://dx.doi.org/10.1590/S0102-311X2010000600015
http://dx.doi.org/10.1590/S0102-311X2010... ^{), (15}15. Cunha CC, Teixeira R, França E. Avaliação da investigação de óbitos por causas mal definidas no Brasil em 2010. Epidemiol Serv Saúde. 2017;26(1):19-30. http://dx.doi.org/10.5123/s1679-49742017000100003
http://dx.doi.org/10.5123/s1679-49742017... . Implemented in 2017, the Data for Health project aims to improve the diagnosis of cause of death in Brazil in cooperation with death surveillance teams from 60 municipalities through the investigation of GC. The UEC investigation uses as central source of information collection the IFM, recognized for having detailed technical data, often not transcribed to the DC¹⁶16. Simões EMS, Reichenheim ME. Confiabilidade das informações de causa básica nas declarações de óbito por causas externas em menores de 18 anos no município de Duque de Caxias, Rio de Janeiro, Brasil. Cad Saúde Pública. 2001;17(3):521-31. http://dx.doi.org/10.1590/S0102-311X2001000300008
http://dx.doi.org/10.1590/S0102-311X2001... ^{), (17}17. Mello Jorge MHP, Gotlieb SLD, Laurenti R. O sistema de informações sobre mortalidade: problemas e propostas para o seu enfrentamento, II - mortes por causas externas. Rev Bras Epidemiol. 2002;5(2):212-23. http://dx.doi.org/10.1590/S1415-790X2002000200008
http://dx.doi.org/10.1590/S1415-790X2002... .

This paper therefore aims to verify the performance of the 60 cities of the Health Data project and to analyze the reclassification of unspecified external causes of mortality after investigations.

METHODS

From the 2017 MIS records, an evaluative study of the investigations of deaths by UEC was conducted in the sixty cities of the Data for Health project, comparing the results of these cities before and after the intervention, and also using the other Brazilian cities as a comparative group.

The selection of the sixty cities in the project activities was made by adhesion agreement. From different population sizes, from all regions of the country, the cities had teams to investigate deaths reported in 2017. Composed of service professionals with experience in investigation of records, the team retrieved data in notifying units, such as IFM and hospitals, according to reference protocol for field work, using standard investigation form. From a list of deaths with GC considered a priority, deaths occurring in residents of the municipality were identified. Cities with up to 500 GC deaths per year should investigate all cases.

In some Brazilian cities not participating in the project, there was a continuation of the investigation routine of epidemiological deaths from UEC, with active search in reports of the IFM and sometimes civil police and press, but carried out without standardized protocol. The capitals have a systematic search activity for traffic accident victims in MIS, which may not translate into qualification of mortality data. In all cities in the country, the ICD-10 chapter 18 death investigations with IDC - infant deaths and maternal causes - were maintained in accordance with the death surveillance guidance policies set out in institutional documents and ordinances of the Ministry of Health¹⁸18. Brasil. Ministério da Saúde. Portaria nº 1.119, de 5 de junho de 2008. Diário Oficial da União [Internet]. 6 jun. 2008 [citado em 2 set. 2019]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2008/prt1119_05_06_2008.html
http://bvsms.saude.gov.br/bvs/saudelegis... ^{), (19}19. Brasil. Ministério da Saúde. Portaria nº 72, de 11 de janeiro de 2010. Diário Oficial da União [Internet]. 12 jan. 2010 [citado em 2 set. 2019];7:29. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2010/prt0072_11_01_2010.html
http://bvsms.saude.gov.br/bvs/saudelegis... .

The priority research UEC and object of analysis of this work were grouped according to GBD 2015²⁰20. GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 198-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1459-544. https://doi.org/10.1016/S0140-6736(16)31012-1
https://doi.org/10.1016/S0140-6736(16)31... for the ICD-10²¹21. Organização Mundial de Saúde. Classificação estatística internacional de doenças e problemas relacionados à saúde-décima revisão. 9a ed. São Paulo: Edusp; 2003. into: unspecified ATT (V87.0; V87.1; V87.4-V88.1; V88.4-V89.9); accident with unspecified transportation (V99); other unspecified accident causes (X59); unspecified homicide (Y09); and undetermined intention (Y10-Y34). It is noteworthy that a group of UEC was not the object of this study, as it is considered non-priority in the protocol: W76; X40-X44; X47.0; X49; Y85-Y86; Y87.1-Y87.9; Y89. In the reclassification, the defined causes were the ATT (pedestrians: V01-V04 and V06-V09, cyclist: V10-V19, motorcyclist: V20-V29, vehicle occupant: V30-V79, V87.2 and V87.3, and other specified ATT: V05 and V80-V86), other traffic accidents (V88.2, V88.3 and V90-V98), other specified accident causes (W00-W75, W77- X39, X45, X46, X47.1-X47.8, X48, X50-X58), suicides (X60-X84, Y87.0), specified homicides (X85-Y08), legal intervention (Y35), and other external causes (Y40-Y84, Y88, Y90-Y98). In addition, reclassification to natural and ill-defined causes (A00-R99) was verified. Figure 1 shows a schematic representation flowchart of the external cause reclassification process.

The criterion to consider alteration of the cause of death was the change of the original underlying cause after the investigation, in MIS, according to the reclassification method proposed by França et al. ⁽¹⁰10. França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, Szwarcwald CL. Causas mal definidas de óbito no Brasil: método de redistribuição baseado na investigação do óbito. Rev Saúde Pública. 2014;48(4):671-81. http://dx.doi.org/10.1590/S0034-8910.2014048005146
http://dx.doi.org/10.1590/S0034-8910.201... .

In the characterization of the UEvC, the following variables were also analyzed: gender (male; female), age group (0 to 14; 15 to 44; 45 to 74; 75 or more), race/color (white; black), population size of the municipality (<50 thousand; 50 to 100 thousand; ≥ 100 thousand), metropolitan region (yes; no) and large regions (North; Northeast; Southeast; South; Midwest), place of occurrence (hospital/other health facilities; domicile/street and others), and certificate (IFM; others).

Intervention performance was analyzed by comparing results from participating cities (Project cities) and non-project participants (Other cities). Statistical inference was estimated for each proportion by 95% confidence intervals (95%CI). The hypothesis of no difference (H0) of proportions was refuted when the confidence intervals did not overlap, that is, the alternative hypothesis (H1) was assumed that the proportions were significantly different in the comparisons. The interval estimation is given by the following formula:

This study was approved by the Research Ethics Committee of the Universidade Federal de Minas Gerais (CAEE 75555317.0.0000.5149). The study used non-nominal secondary data, according to Resolution No. 510 of April 7, 2016, which provides for research standards²²22. Brasil. Ministério da Saúde. Resolução nº 510, de 7 de abril de 2016. Diário Oficial da União [Internet]. 2016 maio 24 [citado em 29 ago. 2019]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/cns/2016/res0510_07_04_2016.html
http://bvsms.saude.gov.br/bvs/saudelegis... .

RESULTS

From the 60 cities in the project, 48 are in metropolitan regions and, of these, 20 are capital cities; and 52 have a population of over 100,000. In these municipalities reside 35% of the Brazilian population, distributed in the five regions, mainly Southeast and Northeast. These cities registered 31% (n = 34,558) of deaths from external causes in 2017, and of these 34% (n = 11,759) were originally UEC. In cities not participating in the project, there were 10,972 deaths from these causes (Table 1 and Figure 1). Ignored data of the analyzed variables ranged from 0.1% to 3%.

Research in the 60 cities corrected deaths from external causes from 34,558 to 35,745 (3%) due to migration of events between natural and unnatural causes, where 453 external causes were reclassified into natural causes, and 1,640 natural causes were reclassified as external causes (Figure 1).

From the total UEC, 64.5% (95%CI 63.7; 65.4) changed the cause after investigation in the project cities and 31% (95%CI 30.2; 31.9) in the other cities (data not shown). These differences were repeated for the variables gender, age group, race/color, place of occurrence and attestant. The largest proportions of changes in the project cities were observed in males (67.7%), age group 15 to 44 years old (73.2%), black race (67.6%) and attestant IFM (69, 1%) (Table 1).

The cities of the project also had higher proportions of changes in undetermined intent deaths (71.3%, 95%CI 70.4; 72.2) and ATT or unspecified traffic accidents (42.2%, 95%CI 38.4; 46.0), in municipalities with more than 100 thousand inhabitants (64.5%, 95%CI 63.7; 65.4), metropolitan areas (65.5%, 95%CI 64.6, 66.4) and the Midwest (85.2%, 95%CI 81.1; 89.3) and Southeast (69.7%, 95%CI 68.8; 70.7). It is noteworthy that the data by region and type of UEC were not presented in table (Table 1).

After reclassification of external causes of mortality, the cities of the project presented a higher percentage variation for all types of defined external causes when compared to other cities, with statistically significant differences, except for other traffic accidents and other external causes. In the project cities, the variation was higher in legal intervention (616.8%), in accidents with pedestrian (72.5%), cyclists (71.8%), and motorcyclists (50.5%); while the percentage variation of specified suicides and homicides was 45.5% and 16%, respectively. There was a reduction of 71.2% (95%CI −73.3; −69.0) of undetermined external causes in the project cities, and 39.5% in other cities (95%CI −41.3; − 37,7). The latter group also exhibited a decrease in unspecified ATT/transportation and other unspecified accident causes (Table 2).

In the project cities, other accident causes and unspecified homicides were the UEC that remained with a higher proportion without clarification, for both gender (Table 3). In men, the UEC were mainly reclassified to specified homicides (23.8%, n = 2,177) and ATT (11.1%, n = 1,016), with emphasis on motorcycle (4.4%, n = 399) and pedestrian (4.3%, n = 389) accidents. Specified homicides were clarified in 27% (n = 2,114) of undetermined intentions and 20.3% (n = 57) of unspecified homicides. Other unspecified accident causes migrated to other specified accident causes (6.4%, n = 31) and motorcycle accident (4.4%, n = 21). Unspecified ATT/unspecified transport accidents changed to motorcycle accident (21.9%, n = 123) and motor vehicle occupant (8.7%, n = 49).

In females, the UEC migrated mainly to other specified accident causes (20.8%, n = 544), ATT (10.6%, n = 276), mainly pedestrians, and specified homicides (7.9%, n = 205). Undetermined intentions were reclassified especially to other specified accident causes (24.3%; n = 522) and specified homicides (8.8%; n = 144). Unspecified homicides clarified changed to specified homicides (35.7%) in their entirety. Other unspecified accident causes migrated to other specified ones (6.5%; n = 21). Unspecified ATT/unspecified transportation accidents were reclassified to motorcycle (20.2%, n = 20) and pedestrian (13.1%, n = 13) accidents (Table 3).

Regarding age group, in the 0-14 age group, informed UEC migrated mainly to ATT (18.3%), especially pedestrians (n = 29), other specified accident causes (n = 36) and specified homicides (n = 31). In the 15-44 age group, migration occurred mainly for specified homicides (32.5%, n = 1,929) and legal intervention (9.7%, n = 575), while in the 45-74 age group, occurred for other specified accident causes (18.8%, n = 638) and specified homicides (11.2%, n = 381). And in the 75 years and older group, the main changes happened for other specified accident causes (29.6%, n = 607) and pedestrians (4.6%, n = 94). The UEC groups that remained with the highest proportion without clarification were undetermined intentions (38.2%, n = 784) and other unspecified accident causes (18.7%, n = 384) in the 75 years and older group, and unspecified homicides (7%, n = 414) and unspecified ATT/traffic accidents (7.2%, n = 425) aged 15 to 44 years (Table 4).

DISCUSSION

The performance in improving the diagnosis of UEC of death was, on average, 2.1 times higher in the project cities than in the other cities. This performance is repeated mainly in men, youth and black people, from metropolitan cities, Southeast and Midwest regions of the country, and for deaths attested by the IFM.

In the 60 cities, reclassification of causes after investigation corrected deaths from external causes by 3%, while study GBD²³23. Institute for Health Metrics and Evaluation. GBD Results Tool [Internet]. 2016 [citado em 2 jan. 2019]. Disponível em: http://ghdx.healthdata.org/gbd-results-tool
http://ghdx.healthdata.org/gbd-results-t... ⁾ corrected by 9% for Brazil. In addition to reclassifying all GC, it is noteworthy that GBD also corrects underreporting of deaths. Opposed to the results obtained in the project cities, the GBD also estimated a higher proportion of traffic accidents and lower homicides for 2016.

In men, the UEC were reclassified mainly for homicide and ATT, especially those involving motorcyclists and pedestrians. In women, they migrated to other specified accident causes, ATT, especially pedestrians, and homicides. The clarification of undetermined intentions in the state of Rio de Janeiro resulted in the largest increase, especially of traffic accidents and homicides in 2014²⁴24. Lopes AS, Passos VMA, Souza MFM, Cascão AM. Melhoria da qualidade do registro da causa básica de morte por causas externas a partir do relacionamento de dados dos setores Saúde, Segurança Pública e imprensa, no estado do Rio de Janeiro, 2014. Epidemiol Serv Saúde. 2018;27(4):e2018058. http://dx.doi.org/10.5123/s1679-49742018000400011
http://dx.doi.org/10.5123/s1679-49742018... . These differences may indicate heterogeneity in the results of investigations conducted in different areas of Brazil, due to different demographic and socioeconomic characteristics.

Regarding age, the UEC migrated mainly to ATT in the 0-14 age group, to homicides at 15-44 years old, and to other specified accident causes in the other age groups. Pedestrian accidents are among the ATTs with higher percentage increase after investigation at all ages, similar to that estimated by the GBD²³23. Institute for Health Metrics and Evaluation. GBD Results Tool [Internet]. 2016 [citado em 2 jan. 2019]. Disponível em: http://ghdx.healthdata.org/gbd-results-tool
http://ghdx.healthdata.org/gbd-results-t... study This demographic profile found in the clarification of the UEC is similar to the findings in the state of Rio de Janeiro and in Belo Horizonte and in places where data from external causes are routinely investigated through the retrieval of information from IFM and newspapers⁷7. Ishitani LH, Teixeira RA, Abreu DMX, Paixão LMMM, França EB. Qualidade da informação das estatísticas de mortalidade: códigos garbage declarados como causas de morte em Belo Horizonte, 2011-2013. Rev Bras Epidemiol. 2017;20(Supl 1):34-45. http://dx.doi.org/10.1590/1980-5497201700050004
http://dx.doi.org/10.1590/1980-549720170... ^{), (14}14. Villela LCM, Rezende EM, Drumond EF, Ishitani LH, Carvalho GML. Utilização da imprensa escrita na qualificação das causas externas de morte. Rev Saúde Pública. 2012;46(4):730-6. http://dx.doi.org/10.1590/S0034-89102012005000041
http://dx.doi.org/10.1590/S0034-89102012... ^{), (24}24. Lopes AS, Passos VMA, Souza MFM, Cascão AM. Melhoria da qualidade do registro da causa básica de morte por causas externas a partir do relacionamento de dados dos setores Saúde, Segurança Pública e imprensa, no estado do Rio de Janeiro, 2014. Epidemiol Serv Saúde. 2018;27(4):e2018058. http://dx.doi.org/10.5123/s1679-49742018000400011
http://dx.doi.org/10.5123/s1679-49742018... .

Different scenarios in the municipalities and multiple study designs have an impact on the reclassification of the cause. In addition to the repertoire of non-specific causes, other conditions determine its success, such as the species and composition of data retrieve sources. Since 1990, most research conducted in different parts of the country has been restricted to events of undetermined intent and unspecified accidents, with the IFM as the central source⁴4. Soares Filho AM, Cortez-Escalante JJ, França E. Revisão dos métodos de correção de óbitos e dimensões de qualidade da causa básica por acidentes e violências no Brasil. Ciênc. Saúde Coletiva. 2016;21(12):3803-18. http://dx.doi.org/10.1590/1413-812320152112.13682015
http://dx.doi.org/10.1590/1413-812320152... ^). In these institutes, police reports, autopsy reports and referral files were available from health facilities¹⁶16. Simões EMS, Reichenheim ME. Confiabilidade das informações de causa básica nas declarações de óbito por causas externas em menores de 18 anos no município de Duque de Caxias, Rio de Janeiro, Brasil. Cad Saúde Pública. 2001;17(3):521-31. http://dx.doi.org/10.1590/S0102-311X2001000300008
http://dx.doi.org/10.1590/S0102-311X2001... ^{), (17}17. Mello Jorge MHP, Gotlieb SLD, Laurenti R. O sistema de informações sobre mortalidade: problemas e propostas para o seu enfrentamento, II - mortes por causas externas. Rev Bras Epidemiol. 2002;5(2):212-23. http://dx.doi.org/10.1590/S1415-790X2002000200008
http://dx.doi.org/10.1590/S1415-790X2002... ^{), (25}25. Drumond M Jr, Lira MMTA, Freitas M, Nitrini TMV, Shibao K. Avaliação da qualidade das informações de mortalidade por acidentes não especificados e eventos com intenção indeterminada. Rev Saúde Pública. 1999;33(3):273-80. http://dx.doi.org/10.1590/S0034-89101999000300008
http://dx.doi.org/10.1590/S0034-89101999... ^{), (26}26. Matos SG, Proietti FA, Barata RCB. Confiabilidade da informação sobre mortalidade por violência em Belo Horizonte, MG. Rev Saúde Pública. 2007;41(1):76-84. http://dx.doi.org/10.1590/S0034-89102007000100011
http://dx.doi.org/10.1590/S0034-89102007... .

Certain data sources, by their own characteristics, result in unique diagnoses, such as police inquiries that favor the identification of homicides¹⁷17. Mello Jorge MHP, Gotlieb SLD, Laurenti R. O sistema de informações sobre mortalidade: problemas e propostas para o seu enfrentamento, II - mortes por causas externas. Rev Bras Epidemiol. 2002;5(2):212-23. http://dx.doi.org/10.1590/S1415-790X2002000200008
http://dx.doi.org/10.1590/S1415-790X2002... ^{), (24}24. Lopes AS, Passos VMA, Souza MFM, Cascão AM. Melhoria da qualidade do registro da causa básica de morte por causas externas a partir do relacionamento de dados dos setores Saúde, Segurança Pública e imprensa, no estado do Rio de Janeiro, 2014. Epidemiol Serv Saúde. 2018;27(4):e2018058. http://dx.doi.org/10.5123/s1679-49742018000400011
http://dx.doi.org/10.5123/s1679-49742018... ^{)- (26}26. Matos SG, Proietti FA, Barata RCB. Confiabilidade da informação sobre mortalidade por violência em Belo Horizonte, MG. Rev Saúde Pública. 2007;41(1):76-84. http://dx.doi.org/10.1590/S0034-89102007000100011
http://dx.doi.org/10.1590/S0034-89102007... , and news from newspapers that favor the capture of ATT accidents¹⁴14. Villela LCM, Rezende EM, Drumond EF, Ishitani LH, Carvalho GML. Utilização da imprensa escrita na qualificação das causas externas de morte. Rev Saúde Pública. 2012;46(4):730-6. http://dx.doi.org/10.1590/S0034-89102012005000041
http://dx.doi.org/10.1590/S0034-89102012... . Medicalrecords are an important source for clarifying causes, especially inspecialized units⁷7. Ishitani LH, Teixeira RA, Abreu DMX, Paixão LMMM, França EB. Qualidade da informação das estatísticas de mortalidade: códigos garbage declarados como causas de morte em Belo Horizonte, 2011-2013. Rev Bras Epidemiol. 2017;20(Supl 1):34-45. http://dx.doi.org/10.1590/1980-5497201700050004
http://dx.doi.org/10.1590/1980-549720170... and associated with home investigation²⁷27. França EB, Cunha CC, Vasconcelos AMN, Escalante JJC, Abreu DX, Lima RB, Morais Neto OL. Avaliação da implantação do programa "Redução do percentual de óbitos por causas mal definidas" em um estado do Nordeste do Brasil. Rev Bras Epidemiol. 2014;17(1):119-34. http://dx.doi.org/10.1590/1415-790X201400010010eng
http://dx.doi.org/10.1590/1415-790X20140... . It is observed greater efficiency ofusing multiple sources in redefining the causes of death⁴4. Soares Filho AM, Cortez-Escalante JJ, França E. Revisão dos métodos de correção de óbitos e dimensões de qualidade da causa básica por acidentes e violências no Brasil. Ciênc. Saúde Coletiva. 2016;21(12):3803-18. http://dx.doi.org/10.1590/1413-812320152112.13682015
http://dx.doi.org/10.1590/1413-812320152... . Note thatthis study found natural and ill-defined causes reclassified to external causes. By coinciding with previous findings¹⁵15. Cunha CC, Teixeira R, França E. Avaliação da investigação de óbitos por causas mal definidas no Brasil em 2010. Epidemiol Serv Saúde. 2017;26(1):19-30. http://dx.doi.org/10.5123/s1679-49742017000100003
http://dx.doi.org/10.5123/s1679-49742017... ^{), (24}24. Lopes AS, Passos VMA, Souza MFM, Cascão AM. Melhoria da qualidade do registro da causa básica de morte por causas externas a partir do relacionamento de dados dos setores Saúde, Segurança Pública e imprensa, no estado do Rio de Janeiro, 2014. Epidemiol Serv Saúde. 2018;27(4):e2018058. http://dx.doi.org/10.5123/s1679-49742018000400011
http://dx.doi.org/10.5123/s1679-49742018... , it contradicts studies that disregard external causes in the redistribution of IDC, as other authors have pointed out¹⁰10. França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, Szwarcwald CL. Causas mal definidas de óbito no Brasil: método de redistribuição baseado na investigação do óbito. Rev Saúde Pública. 2014;48(4):671-81. http://dx.doi.org/10.1590/S0034-8910.2014048005146
http://dx.doi.org/10.1590/S0034-8910.201... ^{), (12}12. Campos D, França E, Loschi RH, Souza MFM. Uso da autópsia verbal na investigação de óbitos com causa mal definida em Minas Gerais, Brasil. Cad Saude Publica. 2010;26(6):1221-33. http://dx.doi.org/10.1590/S0102-311X2010000600015
http://dx.doi.org/10.1590/S0102-311X2010... ^{), (28}28. Mello Jorge MHP, Gotlieb SLD, Laurenti R. O Sistema de Informação de Mortalidade: problemas e propostas para o seu enfrentamento, I - causas naturais. Rev Bras Epidemiol. 2002;5(2):197-211. http://dx.doi.org/10.1590/S1415-790X2002000200007
http://dx.doi.org/10.1590/S1415-790X2002... ^{), (29}29. Teixeira CLS, Klein CH, Bloch KV, Coeli CM. Reclassificação dos grupos de causas prováveis dos óbitos de causa mal definida, com base nas autorizações de internação hospitalar no Sistema Único de Saúde, estado do Rio de Janeiro, Brasil. Cad Saúde Pública. 2006;22(6):1315-24. http://dx.doi.org/10.1590/S0102-311X2006000600020
http://dx.doi.org/10.1590/S0102-311X2006... ^).

Some hypotheses have been enumerated about the explanatory conditions for IFMs not incorporating information necessary to define the death circumstance in the DC. The technical-legal character of the institutional management of deaths with unnatural causes certified by an institute linked to the Secretariat of Security and Justice, the IFM, which is distinct from the epidemiological purpose of the health sector, may play a central role. Dissonant logics conditiondifferent rhythms and criteria in the process of defining the diagnosis by external causes, so essential to the elaboration of public policies. Prosecutors are alleged to be punitive for possible failures in the exercise of their profession for the use of DC in lawsuits; in turn, the clarification of the cause of death would depend on examinations and the performance of the police inquiry⁴4. Soares Filho AM, Cortez-Escalante JJ, França E. Revisão dos métodos de correção de óbitos e dimensões de qualidade da causa básica por acidentes e violências no Brasil. Ciênc. Saúde Coletiva. 2016;21(12):3803-18. http://dx.doi.org/10.1590/1413-812320152112.13682015
http://dx.doi.org/10.1590/1413-812320152... ^{), (15}15. Cunha CC, Teixeira R, França E. Avaliação da investigação de óbitos por causas mal definidas no Brasil em 2010. Epidemiol Serv Saúde. 2017;26(1):19-30. http://dx.doi.org/10.5123/s1679-49742017000100003
http://dx.doi.org/10.5123/s1679-49742017... ^{), (16}16. Simões EMS, Reichenheim ME. Confiabilidade das informações de causa básica nas declarações de óbito por causas externas em menores de 18 anos no município de Duque de Caxias, Rio de Janeiro, Brasil. Cad Saúde Pública. 2001;17(3):521-31. http://dx.doi.org/10.1590/S0102-311X2001000300008
http://dx.doi.org/10.1590/S0102-311X2001... ^{), (24}24. Lopes AS, Passos VMA, Souza MFM, Cascão AM. Melhoria da qualidade do registro da causa básica de morte por causas externas a partir do relacionamento de dados dos setores Saúde, Segurança Pública e imprensa, no estado do Rio de Janeiro, 2014. Epidemiol Serv Saúde. 2018;27(4):e2018058. http://dx.doi.org/10.5123/s1679-49742018000400011
http://dx.doi.org/10.5123/s1679-49742018... . These questions reinforce the importance of actively seeking autopsy results and establishing flows and procedures for reporting information on the DC issued by the IFM, until the MIS reaches satisfactory levels of data quality on causes of death.

In addition, it is necessary to improve both the completion of the appropriate sequence of death causes in the DC, as well as the codification and selection of the underlying cause, besides medical and police information in the documents for the referral of bodies for autopsy, which is essential to the effective work of the coroner¹⁴14. Villela LCM, Rezende EM, Drumond EF, Ishitani LH, Carvalho GML. Utilização da imprensa escrita na qualificação das causas externas de morte. Rev Saúde Pública. 2012;46(4):730-6. http://dx.doi.org/10.1590/S0034-89102012005000041
http://dx.doi.org/10.1590/S0034-89102012... ^{), (26}26. Matos SG, Proietti FA, Barata RCB. Confiabilidade da informação sobre mortalidade por violência em Belo Horizonte, MG. Rev Saúde Pública. 2007;41(1):76-84. http://dx.doi.org/10.1590/S0034-89102007000100011
http://dx.doi.org/10.1590/S0034-89102007... ^{), (30}30. Messias KLM, Bispo JP Jr, Pegado MFQ, Oliveira LC, Peixoto TG, Sales Madeline AC, et al. Qualidade da informação dos óbitos por causas externas em Fortaleza, Ceará, Brasil. Ciênc Saúde Coletiva. 2016;21(4):1255-67. http://dx.doi.org/10.1590/1413-81232015214.07922015
http://dx.doi.org/10.1590/1413-812320152... . Result from incorrect ordering of the causal chain, GC-coded DCs may provide evidence of the valid cause of death from underlying causes noted in the DC lines, corresponding to those that contributed to death³¹31. Foreman KJ, Naghavi M, Ezzati M. Improving the usefulness of US mortality data: new methods for reclassification of underlying cause of death. Popul Health Metr. 2016; 14:14. https://doi.org/10.1186/s12963-016-0082-4
https://doi.org/10.1186/s12963-016-0082-... .

The experience of other countries points out ways to deal with all these issues, such as the establishment of a deadline of up to 6 days after death to fill the sequence of causes in the DC, favoring the incorporation of examinations and police investigation results. The implementation of a prior death certificate for civil registration purposes, without initial mention to the cause of death²⁴24. Lopes AS, Passos VMA, Souza MFM, Cascão AM. Melhoria da qualidade do registro da causa básica de morte por causas externas a partir do relacionamento de dados dos setores Saúde, Segurança Pública e imprensa, no estado do Rio de Janeiro, 2014. Epidemiol Serv Saúde. 2018;27(4):e2018058. http://dx.doi.org/10.5123/s1679-49742018000400011
http://dx.doi.org/10.5123/s1679-49742018... , could be a possibility to assist in the correct registration of external causes. As well as an online death certification system combined with medical training programs³²32. Miki J, Rampatige R, Richards N, Adair T, Cortez-Escalante J, Vargas-Herrera J. Saving lives through certifying deaths: assessing the impact of two interventions to improve cause of death data in Perú. BMC Public Health. 2018;18(1):1329. https://doi.org/10.1186/s12889-018-6264-1
https://doi.org/10.1186/s12889-018-6264-... . Finally, information systems need to work together to ensure cooperation and integration of service provision by public institutions. Access to legal documents through certification of vital events is the fundamental purpose of the systems, as they provide evidence of event characteristics based on which governments determine rights³³33. Jackson D, Wenz K, Muniz M, Abouzahr C, Schmider A, Braschi MW, et al. Civil registration and vital statistics in health systems. Bull World Health Organ. 2018;96(12):861-3. https://doi.org/10.2471/BLT.18.213090
https://doi.org/10.2471/BLT.18.213090... .

Although the underreporting of external causes is not the object of this paper, it is important to highlight that it is a subinformation dimension, although smaller when considering the correction of mortality data. Investigation of active search of death described IFM as a source of information for at least 2% of deaths recovered and not reported in MIS in 2012, remaining the biggest challenge to reach rural and remote municipalities³⁴34. Frias PG, Szwarcwald CL, Morais Neto OL, Leal MC, Cortez-Escalante JJ, Souza PRB Jr, et al. Utilização das informações vitais para a estimação de indicadores de mortalidade no Brasil: da busca ativa de eventos ao desenvolvimento de métodos. Cad Saúde Pública. 2017;33(3):e00206015. http://dx.doi.org/10.1590/0102-311x00206015
http://dx.doi.org/10.1590/0102-311x00206... ^{)- (36}36. Almeida WS, Szwarcwald CL. Adequação das informações de mortalidade e correção dos óbitos informados a partir da Pesquisa de Busca Ativa. Ciênc Saúde Coletiva. 2017;22(10):3193-203. http://dx.doi.org/10.1590/1413-812320172210.12002016
http://dx.doi.org/10.1590/1413-812320172... , probably areas with poor socioeconomic and access to services indicators, especially health and public security agencies³⁷37. Melo CM, Bevilacqua PD, Barletto M, França EB. Qualidade da informação sobre óbitos por causas externas em município de médio porte em Minas Gerais, Brasil. Cad Saúde Pública. 2014;30(9):1999-2004. http://dx.doi.org/10.1590/0102-311X00187213
http://dx.doi.org/10.1590/0102-311X00187... .

Possible limitations of this study refer to regional differences in MIS quality and coverage and to the geographic distribution of the population from the project municipalities, which are different from other cities. The quality of the investigations and the validity of the reclassified causes was also not assessed. The use of protocol and the results presented here indicate, however, greater reliability of this type of planned investigation, which allowed a significant reduction of the UEC.

The UEC needs explanations on issues not fully understood, such as why the medical expert does not use all the information found in the IFM to define the probable cause of death. The characterization of the interests of 2 distinct sectors (public security and health) and the mediations of the interinstitutional structure of these rationalities in the actions and interactions of professionals would form a set of evidence for informed decision making in the production of quality death records by IFM³⁸38. Dias RISC, Barreto JOM, Vanni T, Candido AMSC, Moraes LH, Gomes MAR. Estratégias para estimular o uso de evidências científicas na tomada de decisão. Cad Saúde Colet. 2015;23(3):316-22. http://dx.doi.org/10.1590/1414-462X201500030005
http://dx.doi.org/10.1590/1414-462X20150... . The promotion of the evidence-based interinstitutional health-justice dialogue can be an incentive for the formulation of a intersector national policy of qualified registration of death by accidents and violence, with consequent reduction of the need for investigations by health managers. In addition, planned GC research makes it possible to identify misconduct and conduct at the local level, as well as systematizing knowledge about the best collaborative practices of surveillance and forensic expertise services.

CONCLUSION

The findings of this study indicated that the cities participating in the Data for Health project obtained a greater - statistically significant - reduction in the UEC after investigation when compared to the others, which did not implement a systematic intervention to recover the cause of death records of 2017. The UEC reclassification has corrected the under-enumeration of defined causes of accidents and violence - in particular homicides, other accident causes and traffic accidents - thus impacting on improved health information; therefore, continuity and expansion of this type of intervention is recommended.

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