A comparison of death recording by health centres and civil registration in South Africans receiving antiretroviral treatment

Abstract

IntroductionThere is uncertainty regarding the completeness of death recording by civil registration and by health centres in South Africa. This paper aims to compare death recording by the two systems, in cohorts of South African patients receiving antiretroviral treatment (ART).MethodsCompleteness of death recording was estimated using a capture–recapture approach. Six ART programmes linked their patient record systems to the vital registration system using civil identity document (ID) numbers and provided data comparing the outcomes recorded in patient files and in the vital registration. Patients were excluded if they had missing/invalid IDs or had transferred to other ART programmes.ResultsAfter exclusions, 91,548 patient records were included. Of deaths recorded in patients files after 2003, 94.0% (95% CI: 93.3–94.6%) were recorded by civil registration, with completeness being significantly higher in urban areas, older adults and females. Of deaths recorded by civil registration after 2003, only 35.0% (95% CI: 34.2–35.8%) were recorded in patient files, with this proportion dropping from 60% in 2004–2005 to 30% in 2010 and subsequent years. Recording of deaths in patient files was significantly higher in children and in locations within 50 km of the health centre. When the information from the two systems was combined, an estimated 96.2% of all deaths were recorded (93.5% in children and 96.2% in adults).ConclusionsSouth Africa's civil registration system has achieved a high level of completeness in the recording of mortality. However, the fraction of deaths recorded by health centres is low and information from patient records is insufficient by itself to evaluate levels and predictors of ART patient mortality. Previously documented improvements in ART mortality over time may be biased if based only on data from patient records.

All-cause mortality in HIV-positive adults starting combination antiretroviral therapy

“…With the linkage data from South Africa this problem is less important: bias will only arise if patients with an ID differ systematically from those without ID and the effect of this bias cannot be minimised by the covariates included in the model. One study found that patients with ID are similar to the patients without ID in terms of their demographic and baseline clinical characteristics [9]. …”

“…Deaths among patients lost to follow-up are not generally recorded, leading to underestimation of overall, programme-level mortality. Several correction methods to reduce this bias have been proposed [6–8], which rely on vital status information of a sample of patients lost to follow-up obtained through tracing or data linkages with civil registries [4,5,9]. …”

“…In that study, a two-stage approach was used to adjust for biases in mortality estimation resulting from loss to follow-up. Initially, correction factors were determined based on data from programmes tracing patients lost to follow-up in Kenya [15] and from linkages with population registries in South Africa [9]. Then the correction factors were applied to adjust mortality rates from other regions [8].…”

Precarious transition: a mortality study of South African ex-miners

“…During 1996–2001, approximately 84% of adult deaths were recorded by the vital registration system [34]. The proportion of adult deaths that were recorded increased to approximately 93% after 2001 as a result of intensified efforts of the post-apartheid government to maintain more accurate death records [35]. It is therefore unlikely that many deaths were missed.…”

Life expectancy trends in adults on antiretroviral treatment in South Africa

“…South Africa is in a unique position within Africa, being the only country with both a large HIV burden and a well-functioning death notification system, which is estimated to record around 95% of all adult deaths [7]. This makes it possible to obtain reasonably accurate estimates of mortality, which are not biased by the high loss to follow-up observed in many ART cohorts in developing countries [8].…”