Validity of InterVA model versus physician review of verbal autopsy for tracking tuberculosis-related mortality in Ethiopia.
In most African countries where a legitimate vital registration system is lacking, physicians often review verbal autopsy (VA) data to determine the cause of death, while there are concerns about the routine practicality, accuracy, and reliability of this procedure. In Ethiopia where the burden of tuberculosis (TB) remains unacceptably high, reliable VA data are needed to guide intervention strategies. This study aimed to validate the InterVA model against the physician VA in tracking TB-related mortality in Ethiopia.
From a sample of deaths in Addis Ababa, Ethiopia, VAs were conducted on TB-related mortality, physician-certified verbal autopsy (PCVA) through multiple steps to ascertain the causes of death. InterVA model was used to interpret the causes of death. Estimates of TB-related deaths between physician reviews and the InterVA model were compared using Cohen's Kappa (k), Receiver-operator characteristic (ROC) curve analysis, sensitivity, and specificity to compare agreement between PCVA and InterVA.
A total of 8952 completed PCVA were used. The InterVA model had an optimal likelihood cut-off point sensitivity of 0.64 (95% CI: 59.0-69.0) and specificity of 0.95 (95% CI: 94.9-95.8). The area under the ROC curve was 0.79 (95% CI: 0.78-0.81). The level of agreement between physician reviews and the InterVA model to identifying TB-related mortality was moderate (k = 0.59, 95% CI: 0.57-0.61).
The InterVA model is a viable alternative to physician review for tracking TB-related causes of death in Ethiopia. From a public health perspective, InterVA helps to analyze the underlying causes of TB-related deaths cost-effectively using routine survey data and translate to policies and strategies in resource-constrained countries.
Bisrat H
，Manyazewal T
，Mohammed H
，Shikur B
，Yimer G
... -
《BMC INFECTIOUS DISEASES》
Causes and circumstances of maternal death: a secondary analysis of the Community-Level Interventions for Pre-eclampsia (CLIP) trials cohort.
Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials.
The CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12-49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient.
Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193-268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0·56 [95% CI 0·43-0·66]) or InterVA-5 (κ=0·44 [0·30-0·57]), and InterVA-4 and InterVA-5 (κ=0·72 [0·60-0·84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0·48 [0·38-0·58]), poor for physician review versus InterVA-5 (κ=0·36 [0·27-0·46]), and good for InterVA-4 versus InterVA-5 (κ=0·69 [0·59-0·79]). The most commonly assigned COMCATs by InterVA-5 were emergencies (68 [48%] of 143 deaths) and health systems (62 [43%] deaths), and by physician review (India only) were health systems (seven [44%] of 16 deaths) and inevitability (five [31%] deaths); agreement between InterVA-5 and physician review (India data only) was poor (κ=0·04 [0·00-0·15]).
Our findings indicate that InterVA-5 is less accurate than InterVA-4 at ascertaining causes and circumstances of maternal death, when compared with physician review. Our results suggest a need to improve the next iteration of InterVA, and for researchers and clinicians to preferentially use InterVA-4 when recording maternal deaths.
University of British Columbia (grantee of the Bill & Melinda Gates Foundation).
Aukes AM
，Arion K
，Bone JN
，Li J
，Vidler M
，Bellad MB
，Charantimath U
，Goudar SS
，Hoodbhoy Z
，Katageri G
，Macuacua S
，Mallapur AA
，Munguambe K
，Qureshi RN
，Sacoor C
，Sevene E
，Sheikh S
，Valá A
，Lewis G
，Bhutta ZA
，von Dadelszen P
，Magee LA
，CLIP Trials Study Group
... -
《Lancet Global Health》
ResearchGate
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