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PubMed1999

Perceived value of the American Board of Surgery certificate: a survey of 2,000 Fellows of the American College of Surgeons.

BACKGROUND: This study was undertaken to identify perceptions of surgeons of the value of the American Board of Surgery (ABS) certificate. STUDY DESIGN: Two-thousand Fellows of the American College of Surgeons received a 30-item survey designed to identify their demographics and their assessments of the functional and financial value of the certificate. Functional value was assessed using a 5-point scale in the areas of professional recognition, personal satisfaction, court proceedings, job security, mobility, and advancement, whether the certificate was necessary to obtain an academic or a clinical position, and whether it served as an indicator of depth or breadth of surgical knowledge or of clinical competence. Perceived professional lifetime financial value of the certificate was also assessed. RESULTS: Return response rate was 37.2%. The ABS certificate was perceived to be most valuable in obtaining an academic or a clinical position and playing a significant role in court proceedings. It was perceived as least valuable in indicating breadth of knowledge and clinical competence. Sixty-seven percent responded that certified surgeons should earn more, and 49% estimated the certificate's lifetime financial value as more than $500,000. Sixty-two percent of surgeons approved of continuing the recertification process every 10 years. CONCLUSIONS: The ABS certificate is perceived as an objective credentialing instrument that affords diplomates power, status, an opportunity to obtain an academic or clinical position, job mobility, protection in court proceedings, and greater income. Although it is perceived as an instrument that could aid a career, it is not viewed as an indicator of a person's clinical competence.

Attitude of Health Personnel↗
PubMed1999

Ill-defined and multiple causes on death certificates--a study of misclassification in mortality statistics.

Biases can distort, limit or inhibit the value of mortality data as an epidemiological re source. From 9500 deaths occurring in Naples (Italy during 1994, a random sample of 372 death certificates reporting ill-defined causes and multiple causes of death was extracted. The code for the underlying cause on the death certificate (assigned code) was compared with the cause reattributed with the aid of interview of the certifying physician or clinical records (modified code). The aim was to investigate the extent of misclassification of 'underlying cause' in deaths attributed to ill-defined and/or multiple causes and the shortcomings in the ICD-IX. Ill-defined underlying causes of death (7.0% of death certificates) were cardiovascular diseases, tumours with no specified site or nature, symptoms, signs, ill-defined conditions and senility. There was disagreement between the initially assigned code and the modified code in 53.8% of ill-defined underlying causes; discordance was high for the certificates filled in by the family physician. Multiple causes of death were observed in 23.6% of certificates; of these 59.2% concerned subjects aged 75 years and over at death. Diabetes was always listed in association with other pathologies but neoplasms and traumas were generally listed alone. Disagreement between codes occurred in 48 (54.5%) certificates indicating multiple causes. In 10 of them, death was established as due to a concurrence of causes. As regards ill-defined causes of death, the authors concluded that specific training on certifying procedures would be insufficient on their own; the physician should be made aware that certification is a fundamental requirement for building up epidemiological data. Evidence-based educational interventions are needed. As regards multiple causes of death, multicausal analysis may be indicated for deaths due to a concurrence of causes.

Age Factors↗
PubMed1998

How well do birth certificates describe the pregnancies they report? The Washington State experience with low-risk pregnancies.

OBJECTIVES: Birth certificates are a major source of population-based data on maternal and perinatal health, but their value depends on the accuracy of the data. This study assesses the validity of information recorded on the birth certificates for women in Washington State who were considered to be low risk at entry into care. METHODS: Birth certificates were matched to data abstracted from prenatal and intrapartum clinic and hospital records of a sample of 1937 Washington State obstetrical patients who were considered to be low risk at the beginning of their pregnancies. Accuracy of a variety of pregnancy characteristics (e.g., complications, procedures) on the birth certificate was analyzed using percentage agreement and sensitivity with record abstracts as the "gold standard." Next, we weighted the data from each source to produce estimates of pregnancy characteristics in the population. We compared these estimates from the two data sources to see whether they provide similar pictures of this subpopulation. RESULTS: Missing data for specific items on the birth certificates ranged from 0% to 24%. The birth certificate accurately captured gravidity and parity, but was less likely to report prenatal and intrapartum complications. The population estimates of the two data sources were significantly different. CONCLUSIONS: Because birth certificates significantly underestimated the complications of pregnancies, number of interventions, number of procedures, and prenatal visits, use of these data for health policy development or resource allocation should be tempered with caution.

Adult↗
PubMedDate not supplied

Birth certificate methods in five hospitals.

This study evaluated the methods of data collection of birth certificate information by five high-delivery hospitals in northern Texas. Research purposes were to identify sources and methods of birth certificate data collection and identify the most-reliable methods. This descriptive study involved interviews of each hospital's data collectors and review of 1999 Texas birth certificate data. Medical record clerks, whose training varied, but usually consisted of orientation by another medical record clerk, collected birth certificate data within 24 hours of birth. There was no standard method for training, nor was there a minimum level of education required. In four of the five hospitals studied, a birth certificate clerk collected most of the information with limited input from other medical sources. The information obtained on birth certificates therefore varied according to the collector and the priority placed upon the accuracy of information. Birth certificate data contain questionable reliability, which undermines data use in research, funding, and policy decisions.

Bias↗
PubMed1998

Are we underestimating rates of vaginal birth after previous cesarean birth? The validity of delivery methods from birth certificates.

Previous studies of birth certificates have not fully evaluated how accurately they identify delivery methods that have a historical component, such as repeat cesarean and vaginal birth after previous cesarean (VBAC). The authors used linked Georgia birth certificates for first and second deliveries to examine the accuracy of four reported delivery methods in the second pregnancy: vaginal (without previous cesarean), VBAC, primary cesarean, and repeat cesarean, as well as an indicator of a previous cesarean. From the immediate birth certificates, the delivery method for each of the two births was classified as vaginal (V) or cesarean section (CS), which produced possible sequences of V-V, CS-V, V-CS, and CS-CS. The delivery method for the second births to 106,049 women from 1989 through 1992 was reviewed, taking into account the historical information from the linked certificates regarding the first births. Only 42.0% of women with a CS-V sequence were correctly designated on the second birth certificate as a VBAC; 79.3% of women with a V- CS sequence were correctly designated as primary cesarean. From 1980 through 1988, birth certificates contained a check box indicating a previous cesarean (but no VBAC box). During this period, only 75.5% of 25,491 women with a previous cesarean were so designated on the birth certificate. These findings suggest that cross-sectional vital records data substantially underestimate VBAC and primary cesarean rates.

Birth Certificates↗
PubMed1989

The international comparability of cancer mortality data. Results of an international death certificate study.

In preparation for the 10th revision of the International Classification of Diseases (ICD-10), a two-part study was undertaken to assess the international comparability of the coding, by the 9th revision (ICD-9), of death certificates mentioning cancer, to see whether there had been improvement since the 8th revision (ICD-8). Part I repeated a 1978 study in which nine countries coded the same 1,234 United States death certificates mentioning cancer by ICD-9. The proportion of disagreements in coding the underlying cause of death fell about 35% between 1978 and the present study. This reduction was probably due to the new more detailed rules for coding cancer death certificates given in ICD-9. To combat the criticism of the possible bias associated with using United States death certificates only, in Part II of the study, each of seven countries submitted about 100 certificates translated into English which had posed problems in coding cancer. Discrepancies in assigning the underlying cause of death were found for 54% of these problem certificates. The major types of problems identified were coding when multiple cancer sites were mentioned on the death certificate, whether to select heart disease or cancer as the underlying cause of death, and the interpretation of the coding rules. Better rules for ICD-10 must be provided for both physicians and coders if international comparability of cancer mortality data is to be achieved.

Abstracting and Indexing↗
PubMed1996

"Inaccuracy' in death certification--where are we now?

BACKGROUND: This review aims to document and analyse aspects of death certification that are relevant to public health. METHODS: A literature review on death certification primarily used the computerized Index Medicus (1981 to mid-1995), and concentrated on completing death certificates, accuracy, standards, education and procedural requirements. Further sentinel publications pre-dating this were identified from the main literature base. RESULTS: The uses of mortality data, historical and procedural context for recording death, the philosophy of Underlying Cause of Death and its relationship to the truth, the extent and impact of "inaccuracy', the certificate and the certifier, and possible ways forward are discussed. It is argued that the question "How inaccurate are cause of death data?' is harder to answer than the literature suggests. Deriving a useful estimate is difficult because of inter-study differences in (1) definition, measurement (how and by whom?) and practical importance of error, and standards used; (2) focus (e.g. death certificate or mortality data), observing everyday practice or simulation exercises, diagnostic and/or semantic issues. CONCLUSION: The traditional perspective on improving the quality of death certification has not worked. There is a need for reorientated thinking rather than just urging more education. Evidence-based educational interventions are needed. The flaws in the theoretical framework of cause of death and the routine nature of death certification are unavoidable, but require consideration. Certifiers need practical feedback mechanisms, integral to continuing quality assurance at all levels and fostering an understanding of the construction of mortality data. Continued development should be a core public health medicine role.

Cause of Death↗
PubMed2002

Anesthesiologist board certification and patient outcomes.

BACKGROUND: Board certification is often used as a surrogate indicator of provider competence, although few outcome studies have demonstrated its validity. The aim of this study was to compare the outcomes of patients who underwent surgical procedures under the care of an anesthesiologist with or without board certification. METHODS: Medicare claims records for 144,883 patients in Pennsylvania who underwent general surgical or orthopedic procedures between 1991 and 1994 were used to determine provider-specific outcome rates adjusted to account for patient severity and case mix, and hospital characteristics. Outcomes of 8,894 cases involving midcareer anesthesiologists, 11-25 yr from medical school graduation, who lacked board certification were compared with all other cases. Midcareer anesthesiologist cases were studied because this group had sufficient time to become certified during an era when obtaining certification was already considered important, and consequently had the highest rate of board certification. Mortality within 30 days of admission and the failure-to-rescue rate (defined as the rate of death after an in-hospital complication) were the two primary outcome measures. RESULTS: Adjusted odds ratios for death and failure to rescue were greater when care was delivered by noncertified midcareer anesthesiologists (death = 1.13 [95% confidence interval, 1.00, 1.26], P < 0.04; failure to rescue = 1.13 [95% confidence interval, 1.01, 1.27], P < 0.04). Adjusting for international medical school graduates did not change these results. CONCLUSIONS: When anesthesiology board certification is very common, as in midcareer practitioners, the lack of board certification is associated with worse outcomes. However, the poor outcomes associated with noncertified providers may be a result of the hospitals at which they practice and not necessarily their manner of practice.

Adult↗
PubMed1994

A demonstration of validity for certification by the American Board of Anesthesiology.

PURPOSE: To investigate the validity of the certification process of the American Board of Anesthesiology. Specifically, does board certification in anesthesiology identify physicians judged to be clinically superior by evaluators who are not part of the certification process? METHOD: All 154 U.S. anesthesiology program directors (or faculty members they chose to represent them), unaware of the study's intent, were asked whether they would permit each of their residents completing training in 1991 to administer three increasingly complex anesthetic regimens to the directors themselves. This clinical skills rating was compared with the residents' performances in the certification process in 1992. A list of personal characteristics was also provided to the directors so they could identify reasons for less-than-optimal clinical skills ratings. A total of 1,310 residents participated in the certification process in 1992. RESULTS: A total of 146 programs responded. The directors would have accepted anesthetic care for all three increasingly complex operations from 828 (63.2%) of their own residents; for only the two less complex procedures, from 262 (20%); and for only the least complex procedure, from 127 (9.7%). In addition, 93 residents (7.1%) would not have been accepted to administer anesthesia to their directors for any of these operations. Certification success rates for these groups were 74.6%, 53.8%, 44.9%, and 49%, respectively (p < .00001). The personal characteristics believed important to the practice of anesthesiology were strongly linked to the clinical skills ratings; these included motivation, adaptability, clinical judgment, manual dexterity, several work habits, response to criticism, and handling of stressful situations. CONCLUSION: These data support validity for certification in anesthesiology and identify characteristics considered necessary for high-quality practice of the specialty.

Anesthesiology↗
PubMed1998

Board certification: associations with physicians' demographics and performances during medical school and residency.

PURPOSE: To examine the associations between board certification and both physicians' demographics and their performances during medical school and residency. METHOD: Data were prospectively collected for 1,186 medical students in three major specialty areas for the Jefferson Medical College's graduating classes of 1976 through 1985. RESULTS: Older students and underrepresented minorities were less likely to achieve certification. Overall, physicians who achieved board certification had performed better during medical school and residency than had those without certification. The prediction of board certification using academic performance indicators is limited, particularly for older and minority groups. CONCLUSIONS: This study demonstrated an overall positive relationship between physicians' board certification status and their past academic performances. The potential impact of the increases of both older students and minority physicians on rates of board certification needs to be considered by specialty boards and other policymakers.

Adult↗
PubMedDate not supplied

The reliability and validity of birth certificates.

OBJECTIVES: To summarize the reliability and validity of birth certificate variables and encourage nurses to spearhead data improvement. DATA SOURCES: A Medline key word search of reliability and validity of birth certificate, and a reference review of more than 60 articles were done. STUDY SELECTION: Twenty-four primary research studies of U.S. birth certificates that involved validity or reliability assessment. DATA EXTRACTION: Studies were reviewed, critiqued, and organized as either a reliability or a validity study and then grouped by birth certificate variable. DATA SYNTHESIS: The reliability and validity of birth certificate data vary considerably by item. Insurance, birthweight, Apgar score, and delivery method are more reliable than prenatal visits, care, and maternal complications. Tobacco and alcohol use, obstetric procedures, and delivery events are unreliable. Birth certificates are not valid sources of information on tobacco and alcohol use, prenatal care, maternal risk, pregnancy complications, labor, and delivery. CONCLUSIONS: Birth certificates are a key data source for identifying causes of increasing U.S. infant mortality but have serious reliability and validity problems. Nurses are with mothers and infants at birth, so they are in a unique position to improve data quality and spread the word about the importance of reliable and valid data. Recommendations to improve data are presented.

Alcohol Drinking↗
PubMed1996

Information on death certificates: cause for concern?

AIMS: To assess the frequency with which the cause of death on death certificates included the relevant details requested of certifying doctors, especially in deaths due to malignant disease, but also including certain other deaths where specific information would be expected to be included. METHODS: Consecutive series of certificates attributing death to malignancy, pneumonia, an acute cerebrovascular event, and renal failure were inspected and compared with the categories identified in the International Classification of Disease. Review of clinical notes and of laboratory data was used to determine the number of cases in which detailed histological diagnoses were available. RESULTS: A histological diagnosis was available in 79.1% of cases of deaths due to malignancy, but was recorded on only 23.6% of certificates. Haematologists performed best (69.6%) and general surgeons worst (2.8%). The sites of primary tumours were recorded in detail in only 23 of 89 cases of tumours of the large bowel (22/36), lung (1/35) and stomach (0/18). In cases of pneumonia the causative organism was recorded in only 4 of 330. In cases of an acute cerebrovascular event one of 70 was recorded as being due to haemorrhage. A distinction between cerebral or precerebral arterial occlusion (embolism/thrombosis) and cerebral haemorrhage was not recorded in any of the other cases. In cases of renal failure a cause was not recorded in 75 of 95. CONCLUSIONS: Despite consistent encouragement to record all relevant details on death certificates this study shows that doctors fail to do so in most cases. Such a failure diminishes information available to the Office of Population Censuses and Surveys, affecting mortality statistics and gives further cause for concern about standards of certification. Means by which the standard of certification might be improved are discussed, including screening of certificates by a medically qualified person prior to registration.

Acute Disease↗
PubMed1989

Incidence of sickness certification. Proposal for use as a health status indicator.

Cause-, sex-, and age-specific incidences of sickness certification in a total population are reported. The population at risk of having a sickness certificate issued was 106,019 employed persons 16-69 years of age. The annual incidence of sickness certification was estimated at 580 per 1,000 employed persons per year (females 596, males 568). The most frequent causes of sickness certification, according to diagnostic groups, were diseases of the respiratory system, musculoskeletal/connective tissue diseases, mental disorders, and injuries. Adjusted for age, injuries were found to be less frequent causes of sickness certification among females than males (p less than 0.001), while the reverse was true for mental disorders (p less than 0.01). Among single diagnoses, "other nonarticular rheumatism" (including myalgia) was more frequent among females than males, while the opposite was true for "backpain without radiating symptoms" (p less than 0.001). Comparisons with morbidity studies indicate that diagnoses stated on initial certificates, issued to employed persons in the total population, give a reflection of a population's health problems. This suggests that sickness certification may provide a basis for a health status indicator which may prove useful in planning and evaluation of occupational health, general practice, and community health.

Adolescent↗
PubMedDate not supplied

Certificate programs in continuing professional education.

BACKGROUND: Career-long learning is a concept at the heart of professional disciplines such as nursing. Nursing shortages, especially in some areas of practice, have stimulated the need for in-depth education and training in specific knowledge content areas. One approach to career-long learning is certificate programs. METHOD: Factors, trends, and strategies to consider in creating certificate programs are reviewed, and guidelines for developing certificate programs are presented. FINDINGS: Certificate programs are increasingly in demand by both employers and nurses. Certificate programs provide individuals with a chance to refresh their study skills and raise their abilities and levels of confidence for mastering new learning. Certificate programs also serve as a recruitment and retention strategy for hospitals and agencies. CONCLUSION: Certificate programs are a viable continuing professional education activity and offer opportunities for nurses to develop specific skill sets and in-depth knowledge in specialized areas of nursing practice.

Certification↗
PubMed2000

Validation of death certificate diagnosis of out-of-hospital coronary heart disease deaths in Olmsted County, Minnesota.

OBJECTIVE: To evaluate the validity of death certificate diagnosis of out-of-hospital (OOH) coronary heart disease (CHD) and sudden cardiac death (SCD) in Olmsted County, Minnesota, between 1981 and 1994. METHODS: In this review of the medical records, autopsy reports, and coroner's files, OOH deaths with heart disease as the underlying cause of death on the death certificate were classified into CHD (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] codes 410-414) and non-CHD (other ICD-9-CM heart disease codes) deaths. A 10% random sample (n = 174) of these death certificates was reviewed by physicians, and published validation criteria were applied to classify these deaths into validated CHD or non-CHD categories. Sudden cardiac death was defined as validated CHD that occurred at an OOH location with less than 24 hours between symptom onset and death. RESULTS: The death certificate definition of OOH CHD death (ICD-9-CM codes 410-414) had high sensitivity and positive predictive value of 91% and 96%, respectively. The specificity and the negative predictive value were slightly lower at 86% and 72%, respectively. The sensitivity of death certificate diagnosis of CHD for validated SCD was 89%, and the positive predictive value was 77%. Using a more restrictive definition of SCD, that is, less than 1 hour between the onset of symptoms and death, the positive predictive value of CHD codes for SCD was lower at 52%. CONCLUSIONS: In Olmsted County, the positive predictive values of death certificate diagnosis for OOH CHD and SCD are high. Relying on death certificate diagnoses results in about 5% underestimation of the true CHD rates, whereas their use as a surrogate for SCD yields a 16% overestimation of the true SCD rates.

Autopsy↗
PubMed1990

Quality assurance and certification program for an aminoglycoside monitoring service.

A Quality Assurance Program (QAP) should both evaluate and improve the quality of a service. In order to train newly employed pharmacists and ensure provision of a consistently high level of clinical service, a pharmacist training program for an Aminoglycoside Monitoring Service (AMS) and a QAP involving pharmacist certification was established. The certification program consists of a pretest, a reading/information package, an "on the job" training requirement and a posttest which pharmacists work through at their own speed. Certification requires completion of 45 hours of supervised AMS activity and a score of 90 percent on the posttest. Yearly recertification is required. As an integral part of the QAP, the clinical coordinator reviews the AMS monitoring forms monthly for specific performance standard indicators. Problems are identified and dealt with on an individual basis. The program is not mandatory, however, all pharmacists have elected to complete certification. Seven pharmacists and three pharmacy residents have participated in the certification program. All seven pharmacists and one resident received certification. A questionnaire completed by the pharmacists indicated that all felt certification was necessary and contributed to standardization and consistency of the AMS.

Aminoglycosides↗
PubMed1997

Competency, board certification, credentialing, and specialization: who benefits?

Pharmacists are concerned with the rapid changes in the healthcare system and what the requirements will be for a pharmacist in the near future. The emergence of board certification, credentialing, and other certification programs for pharmacists are causing significant concern among pharmacists. Pharmacists must assess certification programs and decide on the value of certification to their careers and to the patients they serve. Employers of pharmacists and those paying for healthcare and pharmacy services must also evaluate the value of pharmacists certification. Perhaps the most direct and significant benefit of pharmacist certification lies in the ability of the pharmacist to provide better and more comprehensive care to patients or selected groups of patients (eg, diabetic patients). Better and more comprehensive care provided by a pharmacist benefits the patient, other healthcare professionals, the healthcare system generally, and payers of healthcare and pharmacy services. Demonstrated competence of the pharmacist to provide pharmaceutical care is essential to achieving this benefit. Board certification of pharmacists in current board-recognized specialty areas of nutrition support pharmacy, pharmacotherapy, psychiatric pharmacy, nuclear pharmacy, and oncology pharmacy totaled 2075 board certified pharmacists in the United States as of January 1997.

Certification↗
PubMed2000

Comparing Swedish hospital discharge records with death certificates: implications for mortality statistics.

BACKGROUND: The quality of mortality statistics is of crucial importance to epidemiological research. Traditional editing techniques used by statistical offices capture only obvious errors in death certification. In this study we match Swedish hospital discharge data to death certificates and discuss the implications for mortality statistics. METHODS: Swedish death certificates for 1995 were linked to the national hospital discharge register. The resulting database comprised 69 818 individuals (75% of all deaths), 39 872 (43%) of whom died in hospital. The diagnostic statements were compared at Basic Tabulation List level. RESULTS: The last main diagnosis and the underlying cause of death agreed in 46% of cases. Agreement decreased rapidly after discharge. For hospital deaths, the main diagnosis was reported on 83% of the certificates, but only on 46% of certificates for non-hospital deaths. Malignant neoplasms and other dramatic conditions showed the best agreement and were often reported as underlying causes. Conditions that might follow from some other disease were often reported as contributory causes, while symptomatic and some chronic conditions were often omitted. In 13% of cases, an ill-defined main condition was replaced by a more specific cause of death. CONCLUSIONS: There is no apparent reason to question the death certificate if the main diagnosis and underlying cause agree, or if the main diagnosis is a probable complication of the stated underlying cause. However, cases in which the main diagnosis cannot be considered a complication of the reported underlying cause should be investigated, and assessments made of the feasibility and cost-effectiveness of routinely linking hospital records to death certificates.

Adolescent↗