Abstract
BACKGROUND: Through application of the verbal autopsy (VA) approach, trained fieldworkers collect information about the probable cause of death (COD) by using a standardized questionnaire to interview family members who were present at the time of death. The physician-certified VA (PCVA), an independent review of this questionnaire data by up to three physicians trained in VA coding, is currently recommended by the World Health Organization (WHO) and is widely used in the INDEPTH Network. Even given its appropriateness in these contexts, a large percentage of causes of death assigned by VAs remains undetermined. As physicians often do not agree upon a final COD classification, there remains substantial room to improve the standard VA method, potentially leading to a reduction in physician discordance in COD coding. METHODS: We present an extension of the current method of PCVA and compare it to the standard WHO-recommended procedure. We used VA data collected in the Nouna Health and Demographic Surveillance Site (NHDSS) between 2009 and 2010 using a locally-adapted version of an INDEPTH standard verbal autopsy questionnaire. Until 2009, physicians in the NHDSS followed the WHO method (Method 1). As an extension of Method 1, starting in 2010, the use of a panel of physicians was added to the coding process in the case where a third physician's final conclusions resulted in an undetermined COD (Method 2). Two independent samples of VA questionnaires were compared for the year 2009 (using Method 1) and the year 2010 (using Method 2). RESULTS: The WHO-recommended method used for 2009 yielded a high level of undetermined CODs, where the final coding was "undetermined" in 50.8% of all questionnaires due to disagreement among participating physicians (Method 1). By introducing a panel of physicians in 2010 for cases where the principal physicians disagreed on the cause of death, the revised method significantly reduced the proportion of undetermined CODs to 1.5% (Method 2). CONCLUSIONS: As the extended method of PCVA significantly improved the accuracy of the VA procedure, we suggest the adoption of this method for those countries where alternatives like computer-based VA coding are not available. Based on the results of our study, further research should be pursued.