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WHO Mortality Reference Group: Annual Report, 2006-2007
National Center for Health Statistics, CCHS, Centers for Disease Control and Prevention, Hyattsville, MD, USA, and EPC, National Board of Health and Welfare, Stockholm, Sweden This paper presents the activities and status of the WHO Mortality Reference Group (MRG) for 2006-2007. The WHO created the MRG as a component of the International Classification of Diseases (ICD) updating process. Comprised of members from Collaborating Centres and regional offices, the MRG meets largely in person to review problems encountered in the application of ICD-10 to mortality. In its ninth year of work, the MRG deliberated about 90 problems and has made recommendations to the Update and Revision Committee for further action. Many issues are still under review. This document is not issued to the general public, and all rights are reserved by the World Health Organization (WHO). The document may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written permission of WHO. No part of this document may be stored in a retrieval system or transmitted in any form or by any means - electronic, mechanical or other - without the prior written permission of WHO. The views expressed in documents by named authors are solely the responsibility of those authors. Introduction
This is the ninth annual report of the Mortality Reference Group (MRG), established at the 1997 meeting of the Centre Heads as part of an updating mechanism for the International Classification of Diseases (ICD). The first annual report was presented at the WHO Centre Heads meeting in Cardiff, Wales, October 17-22, 1999. In its first seven years, the MRG dealt with more than 280 issues related to updating and clarifying ICD-10 as it applies to mortality classification and coding. The MRG settled about 180 questions selected largely from the Mortality Forum and submitted recommendations to the Update and Revision Committee (URC) for consideration. This report describes the background of the MRG, the problems decided in the ninth year, and the problems presently under consideration. The report includes three annexes: Annex I is the Terms of Reference and work plan for the MRG, Annex II is a list of the members of the MRG, and Annex III lists the topics decided since 1998. Basis for the MRG
Provisions for the MRG are described in two documents: the WHO long-term strategy document (WHO/HST/ICD/C/97.39) and the Centre Heads’ Report for 1997 (WHO/HST/ICD/C/97.65). Briefly, for updating the ICD, WHO- - working with the Centre Heads- - established two separate bodies: the MRG and URC. The MRG discusses issues raised in the Mortality Forum or those referred from other sources including the Centre Heads and WHO. The MRG can make decisions regarding the application and interpretation of ICD to mortality and submits recommendations on ICD updates and changes to the URC. The decisions requiring no change in the ICD are forwarded for the URC's information and to have these decisions documented in the same place as those that do involve changes in the ICD. WHO designated membership of the MRG and the Chair in 1998, based on nominations from Collaborating Centres. Lars Age Johansson succeeded Harry M. Rosenberg as chair of the MRG in February 2002. In 2006-2007, membership remained similar to 2005-2006 with a few additions. Decisions during the first eight years
In the first eight years (1998-2006), the MRG reached over 200 decisions. Table 1 shows the subset of the decisions that were sent on to the URC for information as well as for voting. The MRG forwarded 179 decisions to the URC: 117 recommendations for changes in the ICD and 62 decisions requiring no change in the ICD. The total number of issues either withdrawn by the MRG or referred back by the URC for additional work during the first eight years was 14. Decisions during the ninth year
In the ninth year, the MRG met in Georgetown, District of Columbia, USA May 7-8, 2007 and Trieste, Italy October 25-26, 2007. The MRG relied on e-mail communication and entries to the MRG closed-area of the ICD Update and Revision Platform (ICD-10+ Platform) to carry forward discussions and action between face-to-face meetings. The MRG discussed about 90 issues this year. The MRG forwarded 31 decisions to the URC (Table 1): 21 decisions (12 major and 9 minor) to the URC for further action and 10 decisions involving no change to the ICD for the URC’s information. The MRG reached closure or was approaching a resolution on about 18 additional issues during the ninth year while discussion on other issues continue. Table 1. Issues potentially resulting in change considered by the MRG Each of the recommendations is listed in Annex III. For recent issues, more detail is available at the ICD-10+ Platform (http://extranet.who.int/icdrevision). Additional issues that were not submitted to the URC were resolved at the Georgetown meeting or later than the deadline for submission of recommendations to the URC. The MRG continues to work on new issues as well as issues held over from previous years. Increasingly, the ongoing issues are complex and more difficult to resolve quickly. The 21 recommendations for change address a number of situations including clarifications of instructions (e.g., diabetes complications) and appropriate codes (e.g., tsunami victims). The 10 issues for which decisions entailed no recommended change to the ICD include improving international tools for automated coding (e.g., Mortality Medical Data System (MMDS)) by reflecting international consensus for specific issues (e.g., diseases causing paralysis or inability to control bladder) and reaffirming current practices (e.g., autoimmune hepatitis). Issues under review by the MRG
Approximately 70 other specific issues and general topics related to improving data quality are under active review by the MRG. The problems, background, and current status of the MRG issues are available on request to the Chair of the MRG. Procedural considerations
For the MRG to carry out its mission, it is essential that each issue be carefully studied and deliberated. Decisions are made through a democratic process, with attempts to achieve consensus. This requires preparing and distributing background and current information bearing on the problem, conducting discussions in real time about the issues, communicating by email in the interim, using teleconferences when needed, entries to the ICD-10+ Platform, and fully documenting meetings, actions taken, and agendas. Since the face-to-face meetings were more efficient than teleconferences, the MRG largely replaced teleconferences with face-to-face meetings in 2003. This year, the MRG was the first group to test the closed group areas of the ICD-10+ Platform and provided WHO with feedback on its functionality. The MRG continues to monitor issues related to member usage of the closed group area of the ICD-10+ Platform. Conclusion
In the ninth year, the MRG met twice in person, communicated extensively by e-mail, posted proposals and comments on the ICD-10+ Platform, did considerable work on a number of problems outside the committee meetings, circulated documentation for issues under consideration; and comprehensively documented its activities. During the ninth year, a total of about 90 problems were reviewed by the MRG. Closure was reached for 49 of these and 31 were forwarded to the URC. Twenty-one recommendations for change were made to the URC in 2007. Decisions on 10 issues did not involve changes in the ICD and the remaining recommendations were not resolved in time to submit in 2007. Annex I: Mortality Reference Group Terms of Reference
The objective of the Mortality Reference Group (MRG) is to improve international comparability of mortality data by establishing standardized application of the ICD. To identify and solve problems related to the interpretation and application of ICD to coding and classification of mortality. - To establish standardized application of mortality coding rules and guidelines by a) making decisions regarding the interpretation of rules and guidelines for mortality, and b) deliberating on updates to the classification and the rules and guidelines. Such updates include both clarifications and correction of errors - To develop recommendations for ICD updates through a democratic process which attempts to achieve consensus - To submit annual recommendations to the Update and Revision Committee (URC) by the end of April. To support the development and application of international software for mortality coding and classification To address issues of analysis and assessment of mortality statistics To provide documentation of discussions and decisions in a database. The MRG will endeavour to ensure that its membership reflects the widest possible representation from centres and WHO regional offices. The chair and co-chair are elected by the MRG for terms of two years. The election is submitted to the Secretariat for confirmation. The MRG will work through email and the ICD Update and Revision Platform, meet in person at least twice a year, and use telephone conferences as needed. Once a recommendation to the Update and Revision Committee (URC) has been agreed to by the MRG, members will support the recommendation. Decisions from the MRG which are endorsed by the URC and the Centre Heads should be available from the WHO ICD home page. Continue to hold periodic meetings: one face-to-face meeting at WHO-FIC Network annual meeting and one roughly 6 months later, and telephone conferences as needed (2007 and 2008) Prioritise issues and problems for review (2007 and 2008) Make recommendations to the Update and Revision Committee (by April 2008) Prepare annual report for WHO-FIC Network meeting (August 1, 2008) Respond to URC requests to review material on URC platform (2007 and 2008) Contribute to development of list of causes eligible to be leading causes of death Develop and disseminate quality assurance procedures and best practices for mortality classification. Develop and disseminate best practices or instructions for multiple cause-of-death coding. Annex II: Mortality Reference Group Membership
Annex III: Decisions Made by the WHO Mortality Reference Group
Recommended to URC in 1999 and approved by URC recommended change in 2001 was withdrawn; Informed URC in 2002 of no change decision approved in principle by URC in 2001 (URC/MRG working on details in 2002 and URC approved in 2002) returned to MRG by URC in 2000, modification resubmitted 2001 and approved by URC in 2001 Recommended to URC in 2001 and approved by URC in 2001 Recommended to URC in 2001 and approved by URC in 2001 Recommended to URC in 2001 (folded into other initiatives) Recommended to URC in 2002 and approved by URC in 2002 Submitted to URC in 2002 and approved by URC in 2002 Submitted to URC in 2002 and approved by URC in 2002 Submitted to URC in 2002 and approved by URC in 2002 Submitted to URC in 2002 and approved by URC in 2002 Submitted to URC in 2002 and approved by URC in 2002 2002: Recent complications caused by No change 2002: J21 Apply the same linkages for No change acute bronchitis (J20) and acute bronchiolitis (J21)? obvious consequence of Waldenstrom=s macroglobulinaemia? unspecified) due to D45 (Polycythaemia vera) sequence 2002: I77.6 (Arteritis, unspecified) due No change 2002: Cardiac arrhythmia, unspecified No change a part of the natural history of a disease reported in Part II 2002: K74.6 (Cirrhosis of liver) due to No change disease” and “coronary heart disease” 2003: Hemiplegia due to hypertension- No change (Agent Orange, asbestos, dust, pesticide) resulting in disease due to Degenerative disease of the nervous system, unspecified, an acceptable sequence approved by URC in 2003; MRG submit further recommendation responding to 2003 URC comments in 2004 (URC 0255) ; provide more clarification and resubmitted in 2004; Approved by URC in 2004 2002-03: (Acute) pseudomembraneous Major Submitted to URC in 2003 (URC 0166); held over to address comments and resubmitted in 2004; Approved by URC in 2004 2002-03: Thrombosis or embolism and Minor Withdrew in 2003 to complete additional work 2002-03: Alcoholic and non-Alcoholic Minor Held over for MRG to liaise with WHO in getting more info from MONICA and WHO cardiovascular disease group; Submitted to URC in 2005 (URC 0337); referred to Nordic Centre to resubmit Submitted to URC in 2003 (URC 0203); held over for German Centre to draft list of subcategories and resubmit in 2004; Approved by URC in 2004 2003-04: Intracerebral haemorrhage & Minor 2002-03: Rule 3 tables & Alzheimer’s No change Submitted to URC in 2005; Approved by URC in 2005 Submitted to URC in 2005; Approved by URC in 2005 Submitted to URC in 2005; Approved by URC with modifications in 2005 Submitted to URC in 2005; Approved by URC in 2005 Submitted to URC in 2005; Approved by URC with modifications in 2005 Submitted to URC in 2005; Approved by URC in 2005 2004-05: Underlying cause and record No change 2004-05: Cerebrovascular diseases and No change approved in general in 2006 but referred back to MRG for work on index; MRG resubmitted in 2007 Submitted to URC in 2006; URC approved in 2006 with modifications Submitted to URC in 2006; URC approved in 2006 with modifications Submitted to URC in 2006; URC referred back in 2006 for more work Submitted to URC in 2006; URC approved in 2006 2005: Code for ischaemic heart failure Major Submitted to URC in 2006; URC approved in 2006 with modifications Submitted to URC in 2006; URC approved in 2006 Submitted to URC in 2006; URC approved in 2006 Submitted to URC in 2006; URC approved in 2006 with modifications Submitted to URC in 2006; URC approved in 2006 with modifications 2005: Code for sclerosing mesenteritis Major Submitted to URC in 2006; URC approved in 2006 Submitted to URC in 2006; MRG withdrew in 2006 Submitted to URC in 2006; URC referred back in 2006; MRG resubmit in 2007 Submitted to URC in 2006; URC approved in 2006 with modifications 2004-07: Intoxication & liver disease death term to death occurring during pregnancy & puerperium 2003-2007: Inclusion of subcategories Major 2004-07: Diseases causing paralysis or No change

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