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State Program ''Disease Prevention 2010'', Subcomponent ''Analyses of Outcomes (Cardio-Vascular Causes) of the Reproductive Age Mortality Survey''

GERAMOS – 06. Cardiovascular Mortality

Analysis is performed by Georgian Society of Hypertension

Rapport is prepared by Writing Group:
  • Bezhan Tsinamdzgvrishvili
  • Dali Trapaidze
  • Tamar Abesadze
  • Lela Sturua
  • Nino Sharashidze 
A death registration system enables a nation to obtain the mortality statistics that are fundamental measure of the Public Health. Mortality statistics compiled from a death registration system, however, can be distorted by incomplete reporting of deaths or by inaccurate reporting of cause of death. An independent classification of deaths occurring in a sample population is usually necessary to evaluate the accuracy of a death registration system.

The discrepancies between clinical and autopsy (,,gold standard”) diagnosis where then analyzed, major diagnostic errors (errors involving the cause of death) are often detected. Clinical-pathological discrepancies may have a significant impact on mortality.

In Georgia since 2002 “Autopsy study is obligatory only in cases if there is a doubt about death caused by especially dangerous infection. In all other cases autopsy is performed   by will of decedent  declared in his/her  life  or his/her relative’s or  legal representative’s consent”. (Health Care Law, Paragraph 153)

Level of  autopsy indicator in Georgia is critically low. In 2009 number of cases in adult population amount to 128 (90 of them inpatient).

In document of World Health Organization Regional Office for Europe and National Center for Disease Control and Public Health  2009 - ,,Assessment of Non-communicable Diseases. Prevention and Control in Primary Health Care Level Seeting” health care associated problems are outlined:

  • Failure of country level conventional epidemiological surveys
  • Accumulation of data based not at autopsy specimen analysis
  • Inferiority in draw  up a mortality related medical records
  • As death identification procedure became stringent, physician protection raised (by exclusion of violent death), on the other hand number of deaths due to unknown reason in data base increased.
Due to the State of the art any activity directed to verification of the causes of death in Georgia is of paramaunt importance.

The Ministry of Labor, Health and Social Affairs (MOLHSA) has requested the US Agency for International Development (USAID) to help organize a comprehensive study of reproductive age mortality rates among women aged 15-49. Healthy Women in Georgia/JSI Research and Training Institute in collaboration with US Center for Disease Control (CDC) inAtlanta and The National Center for Disease Control and Public Health of MOLSHA of Georgia are working jointly to design and execute the  Reproductive Age Mortality (RAMOS) Study.

In addition to providing important data on death of reproductive age women, this study is providing insights into specific problems and needs in health information systems (HSS) and vital events registry in Georgia. RAMOS – study is an effective method, that could be used to update data on maternal mortality in Georgiawhile efforts are made to improve on maternal death and this in the health facilities.

This information can determine whether deaths in certain subpopulations or deaths due to specific causes may be misclassified.

The subpopulation of reproductive age women, in particularly, raises unique problems in classifying cause of death.

One  function of a mortality review is the to determine the medical or pathological cause of death, which may or may not be reflected on the death certificate. Death certificates, medical records and autopsy reports are the basis for the determination.

Results from RAMOS are most useful for evaluating the magnitude of maternal mortality and other causes of death among WRA (Women Reproductive Age), assessing the importance or burden of maternal causes of deaths relative to other causes of deaths , and conducting a needs assessment for health care service quality improvement to prevent deaths in WRA.

Maternal mortality is an event  that occurs on young population in reproductive and also in productive ages. In most developing countries, between a third of deaths of women in their reproductive years  can be attributed to pregnancy-related causes. These premature deaths are responsible by breaking the structure of unaccountable families since of role that the women play into their families and communities.

Maternal Mortality surveillance is an important state function and should interacted into routine maternal and child health program activities.

Reviews conclusions, recommendations and implementation of prevention strategies should all be linked through the agencies responsible for the health of women in the State. 

  • A state on  a large cohort of women identified the following risk factors for developing  pre-eclampsia: multiparty,  multiple pregnancy, history of chronic Hypertension, gestational diabetes, maternal age over 35 years fetal malformation and obesity.
  • Generally mortality due to direct obstetric causes prevail in the structure of the maternal death causes. For example, Ghana --- RAMOS. Underlying causes of maternal deaths – 81,6%direct maternal deaths, 17%-indirect maternal deaths.
By the results of GERAMOS-06 indirect causes are superior.

Pregnancy – related deaths are caused by one of the following:

  • Complications of the pregnancy itself.
  • A chain of events initiated by the pregnancy.
  • The aggravation of on unrelated condition or event by the physiologic effects of pregnancy.
The target population for the RAMOS study included all women ages 15 to 49 with a permanent residence in Georgia who died in 2006. 

All cases were studied by verbal autopsy questionnaire .918 interviews were carried out in households. CVD caused death was detected   in 106 cases – (11, 6%), Neoplasma 417 (45,4%),  external causes of mortality. 146 (15, 9%). In 45-59 and 40-44 age groups CVDcaused mortality takes first and second positions respectively. In 58, 8 % of them death was detected at home, in 35, 5% - in medical facilities and in 3, 8% -in transit to medical care.

Cardiovascular diseases (CVD) including stroke, heart attack and heart failure is the leading cause of death and disability worldwide, raised blood pressure is a major cause of CVD, responsible for 62% of stroke and 49% of coronary heart disease cases.

In accordance to RAMOS – study’s main aim (Death causes in pregnancy and one year after delivery) interviews with medical professionals and revision of medical records were carried out in medical facilities where medical assistance was rendered last time due to fatal disease or condition.

Data obtained in households were used for detection of last medical assistance’s location and realization of  so called “facility  phase “ of the study.

Reproductive age women CVD mortality analysis was planed by Georgian Society of Hypertension in scope of Early Detection and Screening Promotion component of   Governmental Diseases Prevention program 2010.

In agreement with RAMOS study administration  analysis of certain modules  of verbal autopsy questionnaires ( passport section, module 1 - filter , module 2- other causes, module 3 – health care  accessibility(A), module 3 – reproductive history (I), module 3 – life-style risk factors (L) ) from data base was performed.

Analysis of abovementioned modules of the main instrument of the study - verbal autopsy questionnaire serves as a basis for work out of special questionnaires aimed for revision of medical records.

Standard procedure of questionnaire work out (workshop with experts and expertise aimed for questionnaire formation) was carried out.

Group of experts took part in work out of questionnaire:

  1. Prof. Bejan Tsinamdzgvrishvili, Cardiologist
  2. Dali Trapaidze, Cardiologist
  3. Tamar Abesadze, Cardiologist
  4. Ilia Tavzarashvili, Pathologist
  5. Marina Baidauri – Regulation issues
  6. Lela Sturua   -   Public Health
  7. Khatuna Kereselidze – Gynecologist
  8. Marina Shakhnazarova – Medical Statistitian
  9. Nia Giunashvili – Public Health
  10. Eka Tsertsvadze - Public Health
Considering CVDmortality and failure of diseases management in country focus of activities was directed on medical service (health care service) accessibility, assessment of referrals rate and organizational issues. As regards the questionnaires for primary health care facilities

(Which was absent in maternal mortality survey), importance of   risk factors and generally CVD risk verification in outpatient records was emphasized.

Reproductive anamnesis accentuation in questionnaire by recommendation of expert-gynecologist was made; Recommendation of morphologist considered strong separation of main disease caused death and direct causes of death.

Field activities were conducted in Tbilisi, Imereti, Adjaria, Samegrelo, Qvemo and Shida Qartli, Kakheti, Guria, Mckheta-Mtianeti and Samtskhe-Javakheti regions.

The final product of study is CVDmanagement protocol - State standard in reproductive age women, which will be integrated in recommendations of pregnant patronage.

To create abovementioned product Ramos survey’s general outcomes as well as CVD mortality study results will be considered; particularly:

  1. In 2006 one third of early  maternal mortality and 60% of  late maternal mortality was caused by pregnancy provoked exacerbation of prior diseases, first of all congenital or Acquired CVD
  2. In structure of causes of reproductive age women CVD mortality first place takes apoplexy with history oh hypertension (57%).In 92% of all individuals who died in hospital hemorrhage stroke and in 1, 5%- ischemic stroke was detected. In 7% reason was unspecified.
  3. Among CVDmortality causes acute MI (18%), sudden cardiac death (13%) were detected: In 12% of cases death cause remained unknown.
  4. Age group 40-49 accounts 80% of all CVD caused deaths (40-44 -28%; 45-49 -52%)
  5. Out patient medical records are absent in primary care facilities in vast majority (83%) of investigated cases; Hence, women of this age group dies without her personal CVD risk verification.
  6. Disadvantages of medical record’s storage in primary care facilities were found.
  7. In 41 % of cases deaths in hospitals are detected, however only one autopsy was performed
  8. In inpatient records patient’s reproductive history is ignored, with extremely rare exception. 
  9. Defects in fill up of death certificates are found. Mainly error is: indication of terminal status only for identification of death causes (as heart or respiratory failure) and absence of information about pregnancy or post-delivery status at the moment of death.  
  10. Disadvantages in organization of hospitalization on emergency of neurology patients are found, as technical potential of hospitals are not considered by emergency teams. .
  11. It is significant that chest pain protocol is often ignored in diagnostics of MI by emergency team (for example, because of lack of ECG recorder)
  12. Significant disadvantages in providing of primary health care services to rural population.
In 2010 December 7 AHA /ASA primary care guidelines for ischemic as well as hemorrhage strokes were published. By existing data 75% of all registered cases of strokes are found to be first events. Hence, primary preventive strategy is of paramount importance: BP and blood cholesterol monitoring, smoking cessation, screening and treatment of atrial  fibrillation are associated with 80% reduction of risk of stroke. 

Main strategy is identification of individuals with high risk of stroke by general practitioners and other physicians and appropriate risk management (screening, referral, preventive treatment for example with Aspirin and so on)

RAMOS may be customized to address the needs of researchers and communities. Types of data that can be collected during a RAMOS study include the following:

  • Risk-factors for death.
  • Outcomes of the pregnancy.
  • avoidable factors or barriers to health care access and
  • Impact on the family.
Intracerebral hemorrhage is one of rigorous problems of public health. For risk stratification age and arterial hypertension is superior (50-70%)

In epidemiological studies it has been shown that reduction of diastolic BP by 5-6 mm is associated with stroke risk decrease by 38% and reduction of systolic BP by 10mm decreases  recurrent stroke risk by 28%.

A qualitative analysis takes into account the medical and non-medical factors that contribute to a death. 

Women:

  • Her personal risks (e.g. substance abuse).
  • Her knowledge about symptoms associated with complications.
  • Her previous experience and comfort with receiving care and with the health care system.
Health care provider:

  • The provider’s knowledge and skills.
  • The resources of the health care facility.
  • The skills and schedules of staff.
  • The attitude and courtesy of staff.
Health care system:

  • The women’s care or lack of access to the health care system.
  • The availability of health education, prenatal care, and family planning services.
  • The availability of levels of service appropriate to the women’s needs.
  • Appropriate credentialing by relevant groups of individuals and institutions that provide care
Policy:

  • The availability of federal or state financed and insurance coverage.
RAMOS outcomes  also can have an influence on evaluation of the routine death registration in the community.

However, periodic death review may be helpful to monitor trends in maternal mortality in setting where there is no routine death registration, and it may allow evaluation of the effectiveness of reproductive health care services over time.

Key users of the information are: healthcare providers, programmers and policy-makers who provide services to pregnant women and communities.

Although this study has two distinct phases and can be labor—intensive, the RAMOS method is very effective in providing a rich amount of data to determine the relative burden and risk factors for various causes’ death among WRA, including pregnancy-related deaths.

The first level occurs when a woman or her family either does not recognize there is a health problem or fails to seek health care when a problem is recognized. Examples of these barriers include:

  1. a lack of knowledge or understanding of normal pregnancy and the signs  and symptoms of pregnancy complications and making a decision not to seek care due to lack of comfort with a health care system perceived as not culturally appropriate
By latest evidence adequate antihypertensive treatment is a protective factor against cognitive impairment and vascular dimension in above mentioned population.

Women reproductive history is of great importance in stratification of CVDcomplication risk. By latest evidences complicated pregnancy is a risk for cardiac dysfunction in future.

UU Ultrasound data obtained during pregnancy for adequate antenatal supervision   are affected in women with HELLP syndrome or pre-eclampsy and correlated with cardiac dysfunction in future

Pre- delivery or antenatal supervision by existed evidence is not improves delivery outcomes, but support heath of women and fetus. 

In Georgia there is  foor antenatal visit schemes for low risk pregnants. During first visit consultation of general practitioner   is recomended. In state protocol it is indicated , that during first visit or until 13 weeks  pregnant requiered edditional  supervision should be identificated. For this group of pregnant even routine  ECG cheking is not considered, that may complicate risk assement. 

The quality of  implemantation of State Standards for Diseases manegement in medical service delivary is of great importance in analysis of fatal CVDend-points.

Georgian Societyof Hypertension, as professional assassiation undretakes obligation for evaluative and monitoring studies in field of Health Care.

Assessment of implamantation of National recomandations in primary health care  in 2010 showed , that only 8% of physicians are  skilled  in algorythms of diseases manegment and generally awared about this guidlines .

By the opinion of society working groop advocation and lobbing of abovementioned outcomes in dission makers of health care.system is nessecary 

Integration of results of assement survey conducted by Georgian Society of Hypertension in document of USAID ,,Assessment of Non-Communicable Disease Screening Practices and Selected Matrnal Newborn Practices inWomen of Reproductive Age in Albenia, Armenia, Georgia and Russia” as a key information is of paramaunt importance. Our report is now in phase of  forming and our information would be abstracted by writing group

Main directions of Recomendation for CVD manegement improvement:

  • Active identification of diseases and intensification of risk assessement in primary health care
  • Activation of manifasted  CVDfatal and non-fatal complication prevention strategy and diseases manaegement according State standards.
  • Improvement of quality of medical records fill in procedure, keep of storage rules, to provide accessibility to medical records of scintific- practical significance for the purpose of  assessment of effectivenes and monitoring of individual and population level interventions.
The RAMOS method provides a rich source of data useful to inform the many stakeholders in maternal health, including women and their family’s community planners and health care providers.

Urgent nessessity of   educational interventions in medical professionals   and advocating of abovementioned recommendation at rural side is of special emphasis 

And finally, medical audit of mortality proved to be especialy sensitive for exposure of disadvanteges of chronic diseases management in Georgian population; recomendations CVDrisk assessement in WRA group eill be integrated in State standard of diseases management.

Obtained evidences about medical audit of mortality will serve as a basis for  updating and revising practical guidelines for cardiovascular diseases and procedures.  The practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis management and prevention of diseases or conditions.    The practice guidelines represent a consesus of expect opinion after a through and systematic revew of the available current evidence and are intended to improve patient care.

22.12.2010
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