Development and Evaluation of Rehabilitation Service Areas for the United States.

BACKGROUND: Geographic areas have been developed for many healthcare sectors including acute and primary care. These areas aid in understanding health care supply, use, and outcomes. However, little attention has been given to developing similar geographic tools for understanding rehabilitation in post-acute care. The purpose of this study was to develop and characterize post-acute care Rehabilitation Service Areas (RSAs) in the United States (US) that reflect rehabilitation use by Medicare beneficiaries. METHODS: A patient origin study was conducted to cluster beneficiary ZIP (Zone Improvement Plan) code tabulation areas (ZCTAs) with providers who service those areas using Ward's clustering method. We used US national Medicare claims data for 2013 to 2015 for beneficiaries discharged from an acute care hospital to an inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term care hospital (LTCH), or home health agency (HHA). Medicare is a US health insurance program primarily for older adults. The study population included patient records across all diagnostic groups. We used IRF, SNF, LTCH and HHA services to create the RSAs. We used 2013 and 2014 data (n = 2,730,366) to develop the RSAs and 2015 data (n = 1,118,936) to evaluate stability. We described the RSAs by provider type availability, population, and traveling patterns among beneficiaries. RESULTS: The method resulted in 1,711 discrete RSAs. 38.7% of these RSAs had IRFs, 16.1% had LTCHs, and 99.7% had SNFs. The number of RSAs varied across states; some had fewer than 10 while others had greater than 70. Overall, 21.9% of beneficiaries traveled from the RSA where they resided to another RSA for care. CONCLUSIONS: Rehabilitation Service Areas are a new tool for the measurement and understanding of post-acute care utilization, resources, quality, and outcomes. These areas provide policy makers, researchers, and administrators with small-area boundaries to assess access, supply, demand, and understanding of financing to improve practice and policy for post-acute care in the US.

Racial Disparities in Type of Heart Failure and Hospitalization.

Heart failure (HF) is one of the leading causes of hospitalization and readmissions. Our study aimed to examine racial disparities in heart failure patients including onset, mortality, length of stay (LOS), direct costs, and readmission rates. This is a secondary data analysis. We analyzed the risk-adjusted inpatient data of all patients admitted with HF to one health academic center. We compared five health outcomes among three racial groups (white, black, and Hispanic). There were 1006 adult patients making 1605 visits from 10/01/2011 to 09/30/2015. Most black patients were admitted in younger age than other racial groups which indicates the needs for more public health preventions. With risk adjustments, the racial differences in LOS and readmission rates remain. We stratified health outcomes by race/ethnic and type of HF. The findings suggest that further studies to uncover underlying causes of these disparities are necessary. Using risk-adjusted hospitalization data allows for comparisons of quality of care across three racial groups. The study suggests that more prevention and protection services are needed for African American patients with heart failure.

Variation in Functional Status After Hip Fracture: Facility and Regional Influence on Mobility and Self-Care.

BACKGROUND: Recent reports show substantial geographic variation in postacute health care spending. Little is known about variation in functional outcomes after postacute rehabilitation for patients with hip fracture. We examined variation in mobility and self-care after hip fracture rehabilitation across inpatient rehabilitation facilities (IRFs), hospital referral regions (HRRs) and states. METHODS: Retrospective cohort study using data from the Centers for Medicare and Medicaid Services (CMS) from 2006 to 2009. Study sample included 149,258 records from patients 66 years and older at 1,166 IRFs located within 292 HRRs and across 50 states. Hip fracture cases were defined by CMS impairment group codes (08.11, 08.12). Hierarchical generalized linear models were used to assess discharge mobility and self-care functional status, adjusting for individual patient characteristics and the random effect of IRFs, HRRs, and states. RESULTS: Variation in discharge mobility status as assessed by the intraclass correlation percentage (ICC%) was 8.8% across IRFs, 4.0% across HRRs, and 1.8% across states. For self-care, the ICCs were 10.2% across IRFs, 4.8% across HRRs, and 2.4% across states. The range of discharge mobility scores (maximum functional status rating to minimum functional status rating) showed a 9.6-point difference for IRFs, 6.5 for regions, and 2.6 for states. Range of discharge self-care scores were 13.1 for IRFs, 6.8 for HRRs, and 3.4 for states. CONCLUSION: Variation in functional status following postacute hip fracture rehabilitation appears to occur primarily at the level of facilities rather than geographic location.

Improving the Collection of Race, Ethnicity, and Language Data to Reduce Healthcare Disparities: A Case Study from an Academic Medical Center.

Well-designed electronic health records (EHRs) must integrate a variety of accurate information to support efforts to improve quality of care, particularly equity-in-care initiatives. This case study provides insight into the challenges those initiatives may face in collecting accurate race, ethnicity, and language (REAL) information in the EHR. We present the experience of an academic medical center strengthening its EHR for better collection of REAL data with funding from the EHR Incentive Programs for meaningful use of health information technology and the Texas Medicaid 1115 Waiver program. We also present a plan to address some of the challenges that arose during the course of the project. Our experience at an academic medical center can provide guidance about the likely challenges similar institutions may expect when they implement new initiatives to collect REAL data, particularly challenges regarding scope, personnel, and other resource needs.

Melanoma Disparities among US Hispanics: Use of the Social Ecological Model to Contextualize Reasons for Inequitable Outcomes and Frame a Research Agenda.

Cutaneous melanoma is a significant public health concern, accounting for thousands of deaths annually in the US. Early detection and diagnosis are critical given the poor prognosis and limited treatment options of advanced-stage disease. While non-Hispanic whites have higher incidence rates of melanoma, Hispanics are typically diagnosed at later disease stages and suffer higher morbidity and mortality. Currently, there is a paucity of literature investigating the root causes underlying these trends among Hispanics. Given that Hispanics are the most rapidly expanding demographic segment in the US, it is essential for cancer control efforts to elucidate the major determinants of their poor melanoma outcomes. Herein, we use the social ecological model as a framework to explore the multitude of influences on melanoma disparities among Hispanics and provide recommendations for planning future studies and interventions.

Geographic and facility variation in inpatient stroke rehabilitation: multilevel analysis of functional status.

OBJECTIVE: To examine geographic and facility variation in cognitive and motor functional outcomes after postacute inpatient rehabilitation in patients with stroke. DESIGN: Retrospective cohort design using Centers for Medicare and Medicaid Services (CMS) claims files. Records from 1209 rehabilitation facilities in 298 hospital referral regions (HRRs) were examined. Patient records were analyzed using linear mixed models. Multilevel models were used to calculate the variation in outcomes attributable to facilities and geographic regions. SETTING: Inpatient rehabilitation units and facilities. PARTICIPANTS: Patients (N=145,460) with stroke discharged from inpatient rehabilitation from 2006 through 2009. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Cognitive and motor functional status at discharge measured by items in the CMS Inpatient Rehabilitation Facility-Patient Assessment Instrument. RESULTS: Variation profiles indicated that 19.1% of rehabilitation facilities were significantly below the mean functional status rating (mean ± SD, 81.58±22.30), with 221 facilities (18.3%) above the mean. Total discharge functional status ratings varied by 3.57 points across regions. Across facilities, functional status values varied by 29.2 points, with a 9.1-point difference between the top and bottom deciles. Variation in discharge motor function attributable to HRR was reduced by 82% after controlling for cluster effects at the facility level. CONCLUSIONS: Our findings suggest that variation in motor and cognitive function at discharge after postacute rehabilitation in patients with stroke is accounted for more by facility than geographic location.

Geographic disparities in mammography capacity in the South: a longitudinal assessment of supply and demand.

OBJECTIVE: Studies have shown that there is sufficient availability of mammography; however, little is known about geographic variation in capacity. The purpose of this study was to determine the locations and extent of over/undersupply of mammography in 14 southern states from 2002 to 2008. DATA SOURCES: Mammography facility data were collected from the U.S. Food and Drug Administration (FDA). Population estimates, used to estimate the potential demand for mammography, were obtained from GeoLytics Inc. STUDY DESIGN: Using the two-step floating catchment area method, we calculated spatial accessibility at the block group level and categorized the resulting index to represent the extent of under/oversupply relative to the potential demand. PRINCIPAL FINDINGS: Results show decreasing availability of mammography over time. The extent of over/undersupply varied significantly across the South. Reductions in capacity occurred primarily in areas with an oversupply of machines, resulting in a 68 percent decrease in the percent of women living in excess capacity areas from 2002 to 2008. The percent of women living in poor capacity areas rose by 10 percent from 2002 to 2008. CONCLUSIONS: Our study found decreasing mammography availability and capacity over time, with substantial variation across states. This information can assist providers and policy makers in their business planning and resource allocation decisions.

Regional variation in stroke rehabilitation outcomes.

OBJECTIVE: To examine and describe regional variation in outcomes for persons with stroke receiving inpatient medical rehabilitation. DESIGN: Retrospective cohort design. SETTING: Inpatient rehabilitation units and facilities contributing to the Uniform Data System for Medical Rehabilitation from the United States. PARTICIPANTS: Patients (N=143,036) with stroke discharged from inpatient rehabilitation during 2006 and 2007. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Community discharge, length of stay (LOS), and discharge functional status ratings (motor, cognitive) across 10 geographic service regions defined by the Centers for Medicare and Medicaid Services (CMS). RESULTS: Approximately 71% of the sample was discharged to the community. After adjusting for covariates, the percentage discharged to the community varied from 79.1% in the Southwest (CMS region 9) to 59.4% in the Northeast (CMS region 2). Adjusted LOS varied by 2.1 days, with CMS region 1 having the longest LOS at 18.3 days and CMS regions 5 and 9 having the shortest at 16.2 days. CONCLUSIONS: Rehabilitation outcomes for persons with stroke varied across CMS regions. Substantial variation in discharge destination and LOS remained after adjusting for demographic and clinical characteristics.

Health insurance coverage in the Houston-Galveston area under the patient protection and affordable care act.

This study projects the number of nonelderly people who could gain coverage under the Patient Protection and Affordable Care Act (PPACA) for the period from 2014 through 2020 in the 13-county Houston-Galveston area region. The major PPACA provisions aimed at expanding coverage as well as the populations targeted by those provisions are described. Projections of the impact of PPACA on coverage in the area are based on estimates of growth in the size of targeted populations in each county and the anticipated responses of those populations to the major provisions of PPACA. The projections indicate that, if fully implemented, PPACA could cut the uninsurance rate in the region by half, from 26% in 2010 to 13% in 2020. This change translates into health insurance coverage for approximately 2 million additional people, from the current 4.2 million to a projected 5.9 million. The number of Medicaid enrollees could increase by an estimated 600,000 (a 79% increase), although private insurance coverage, which could increase by as much as 1 million enrollees (a 30% increase), will remain the primary source of coverage for most people. Coverage gains from PPACA will vary considerably by county, depending on the age-income-citizenship characteristics of the population, current uninsurance rates, and the rate of population growth.

The socio-spatial neighborhood estimation method: an approach to operationalizing the neighborhood concept.

The literature on neighborhoods and health highlights the difficulty of operationalizing "neighborhood" in a conceptually and empirically valid manner. Most studies, however, continue to define neighborhoods using less theoretically relevant boundaries, risking erroneous inferences from poor measurement. We review an innovative methodology to address this problem, called the socio-spatial neighborhood estimation method (SNEM). To estimate neighborhood boundaries, researchers used a theoretically informed combination of qualitative GIS and on-the-ground observations in Texas City, Texas. Using data from a large sample, we assessed the SNEM-generated neighborhood units by comparing intra-class correlation coefficients (ICCs) and multi-level model parameter estimates of SNEM-based measures against those for census block groups and regular grid cells. ICCs and criterion-related validity evidence using SF-36 outcome measures indicate that the SNEM approach to operationalization could improve inferences based on neighborhoods and health research.

Trends in health care spending for immigrants in the United States.

The suspected burden that undocumented immigrants may place on the U.S. health care system has been a flashpoint in health care and immigration reform debates. An examination of health care spending during 1999-2006 for adult naturalized citizens and immigrant noncitizens (which includes some undocumented immigrants) finds that the cost of providing health care to immigrants is lower than that of providing care to U.S. natives and that immigrants are not contributing disproportionately to high health care costs in public programs such as Medicaid. However, noncitizen immigrants were found to be more likely than U.S. natives to have a health care visit classified as uncompensated care.

Allostatic load among non-Hispanic Whites, non-Hispanic Blacks, and people of Mexican origin: effects of ethnicity, nativity, and acculturation.

OBJECTIVES: We investigated ethnic differences in allostatic load in a population-based sample of adults living in Texas City, TX, and assessed the effects of nativity and acculturation status on allostatic load among people of Mexican origin. METHODS: We used logistic regression models to examine ethnic variations in allostatic load scores among non-Hispanic Whites, non-Hispanic Blacks, and people of Mexican origin. We also examined associations between measures of acculturation and allostatic load scores among people of Mexican origin only. RESULTS: Foreign-born Mexicans were the least likely group to score in the higher allostatic load categories. Among individuals of Mexican origin, US-born Mexican Americans had higher allostatic load scores than foreign-born Mexicans, and acculturation measures did not account for the difference. CONCLUSIONS: Our findings expand on recent research from the National Health and Nutrition Examination Survey with respect to ethnicity and allostatic load. Our results are consistent with the healthy immigrant hypothesis (i.e., newer immigrants are healthier) and the acculturation hypothesis, according to which the longer Mexican immigrants reside in the United States, the greater their likelihood of potentially losing culture-related health-protective effects.

Disparities in utilization of outpatient rehabilitative care following hip fracture hospitalization with respect to race and ethnicity.

OBJECTIVE: To compare the prevalence of discharge home to self-care after hip fracture hospitalization among the elderly in 3 racial groups: whites, Hispanics, and blacks. DESIGN: Secondary data analysis. SETTING: US hospitals. PARTICIPANTS: Patients (N=34,203) aged 65 and older with Medicare insurance discharged after hip fracture hospitalization between 2001 and 2005. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Discharge home to self-care. RESULTS: Bivariate analyses showed higher rates of discharge home to self-care among minorities, 16.4% for Hispanics, 8.7% for blacks, and 5.9% for whites. Hispanics had 3-fold higher odds of being discharged home to self-care, and blacks had about 50% higher odds of being discharged home to self-care after adjusting for age, sex, Klabunde's comorbidity index, income, year of admission, type of hip fracture, surgical stabilization procedure, and length of hospital stay. CONCLUSIONS: The higher rate of discharge home to self-care among minorities underscores the risk of suboptimal outpatient rehabilitative care among minorities with hip fracture.

Ethnic differences in in-hospital place of death among older adults in California: effects of individual and contextual characteristics and medical resource supply.

BACKGROUND: : Substantial ethnic differences have been reported in the probability that death will occur in a hospital setting rather than at home, in a hospice, or in a nursing home. To date, no study has investigated the role of both individual characteristics and contextual characteristics, including local health care environments, to explain ethnic differentials in end-of-life care. OBJECTIVES: : The study purpose is to examine ethnic differences in the association between death as a hospital in-patient and individual and contextual characteristics, as well as medical resource supply. RESEARCH DESIGN: : This study employed a secondary data analysis. SUBJECTS: : We used data from the California Death Statistical Master file for the years 1999-2001, which included 472,382 complete cases. These data were geocoded and linked to data from the US Census Bureau and the American Hospital Association. RESULTS: : Death as an in-patient was most common for Asian (54%) and Hispanic immigrants (49%) and least common for non-Hispanic whites (36%) and US-born Asians (41%). Medical resource supply variables are of considerable importance in accounting for ethnic differentials in the probability of dying in a hospital. Residual differences in in-hospital site of death were largest for immigrant populations. CONCLUSIONS: : There are sizeable ethnic differentials in the probability that a death will occur in a hospital in California. These differences are substantially mediated by sociodemographic characteristics of the decedent and local medical care supply. One implication of these findings is that variation exists in the efficiency and quality of end of life care delivered to ethnic minorities.

The validity of race and Hispanic origin reporting on death certificates in the United States.

OBJECTIVES: This report presents the results of an evaluation study of the validity of race and Hispanic origin reporting on death certificates in the United States and its impact on race- and Hispanic origin-specific mortality estimates. METHODS: The National Longitudinal Mortality Study (NLMS) was used to evaluate death certificate classification of race and Hispanic origin by comparing death certificate with survey race-ethnicity classifications for a sample of decedents identified in NLMS. NLMS consists of a series of annual Current Population Survey files (1973 and 1978-1998) linked to death certificates for years 1979-1998. To identify and measure the effect of race-ethnicity misclassification on death certificates on mortality estimates, pooled 1999-2001 vital statistics mortality data and population data from the 2000 census were used to estimate and compare observed and corrected (for death certificate misclassification) race-ethnicity specific death rates. RESULTS: Race and ethnicity reporting on the death certificate continues to be excellent for the white and black populations. It remains poor for the American Indian or Alaska Native (AIAN) population but is reasonably good for the Hispanic and Asian or Pacific Islander (API) populations. Decedent characteristics such as place of residence and nativity have an important effect on the quality of reporting on the death certificate. The effects of misclassification on mortality estimates were most pronounced for the AIAN population, where correcting for misclassification reverses a large AIAN over white mortality advantage to a large disadvantage. Among the Hispanic and API populations, adjustment for death certificate misclassification did not significantly affect minority-majority mortality differentials.

Neighborhood composition and cancer among Hispanics: tumor stage and size at time of diagnosis.

BACKGROUND: We have previously reported that cancer incidence for lung, female breast, and colon and rectum for Hispanics decreases with increasing percentage of Hispanics at the census tract. In contrast, cervical cancer incidence increases with increasing percentage of Hispanics at the census tract. METHODS: In this study, we investigate the hypothesis that Hispanics living in census tracts with high percentages of Hispanics are diagnosed with more advanced cancer, with respect to tumor size and stage of diagnosis. Data from the Surveillance, Epidemiology, and End Results registry and the U.S. Census Bureau were used to estimate the odds of diagnosis at a "late" stage (II, III, IV) versus "early" stage (I) and breast cancer tumor size among Hispanics as a function of census tract percent Hispanic. Hispanic ethnicity in the Surveillance, Epidemiology, and End Results registry was identified by medical record review and Hispanic surname lists. The study also used income of Hispanics living in the census tract and controlled for age at diagnosis and gender. RESULTS: We found that Hispanics living in neighborhoods with higher density of Hispanic populations were more likely to be diagnosed with late-stage breast, cervical, or colorectal cancer, and to have a larger tumor size of breast cancer. CONCLUSIONS: Our findings suggest that the benefits of lower cancer incidence in high tract percent Hispanics are partially offset by poorer access and reduced use of screening in conjunction with lower income, poorer health insurance coverage, and language barriers typical of these communities.

Advancing the science of health disparities research.

Research to eliminate health disparities in the United States is best approached from the perspective of population health. The objectives of this paper are to: (a) describe how ongoing research at the eight national Centers for Population Health and Health Disparities (CPHHD) is using a population health perspective and a community-based approach to advance the field of health disparities research; and (b) to discuss potential implications of such research for health policies that target some of the determinants of population health.

Neighborhood Deprivation is associated with lower levels of serum carotenoids among adults participating in the Third National Health and Nutrition Examination Survey.

OBJECTIVE: This study tested the hypothesis that neighborhood deprivation will be associated with lower levels of serum carotenoids in comparison with wealthy residential areas. DESIGN: Cross-sectional, nationally representative survey data were used to assess the relationship between neighborhood level socioeconomic status and serum carotenoids. SUBJECTS: Seventeen thousand two participants aged 17 years and older from the Third National Health and Nutrition Examination Survey were linked with 1990 census data. MAIN OUTCOME MEASURES: Serum levels of lycopene, beta-carotene, alpha-carotene, lutein/zeaxanthin, and beta-cryptoxanthin. STATISTICAL ANALYSIS: Multivariate linear regression was used to model the association of serum carotenoids and neighborhood deprivation, which is a summary index of 11 indicators for tract level socioeconomic status. Adjustments are made for individual level age, sex, years of education, household income, employment, race/ethnicity, body mass index, serum cotinine, alcohol use, physical activity, and serum cholesterol. RESULTS: Multivariate analysis revealed a negative and statistically significant association between high levels of neighborhood deprivation and beta-carotene (beta=-2.98 microg/dL [-0.06 micromol/L], P=0.00), alpha-carotene (beta=-1.28 microg/dL [-0.02 micromol/L], P=<0.0001), lutein/zeaxanthin (-1.69 microg/dL [-0.03 micromol/L], P=0.00, beta-cryptoxanthin (beta=-1.34 microg/dL [-0.02 micromol/L], P<0.0001), and total carotenoids (beta=-8.20 microg/dL, P=<0.0001). Lycopene was not related to neighborhood deprivation. Adjusted mean levels of carotenoids for high deprivation neighborhoods were lower than neighborhoods with low deprivation: beta-carotene=8.72 microg/dL [0.16 micromol/L] vs 20.64 microg/dL [0.38 micromol/L], alpha-carotene=0.44 microg/dL [0.008 micromol/L] vs 5.56 microg/dL [0.10 micromol/L], lutein/zeaxanthin=13.79 microg/dL [0.24 micromol/L] vs 20.55 microg/dL [0.36 micromol/L], beta-cryptoxanthin=4.57 microg/dL [0.08 micromol/L] vs 9.93 microg/dL [0.18 micromol/L], lycopene=22.07 microg/dL [0.41 micromol/L] vs 25.63 microg/dL [0.48 micromol/L], and total=49.56 microg/dL vs 82.36 microg/dL. CONCLUSIONS: Neighborhood deprivation was associated with lower serum levels of carotenoids. There was a substantial disparity between low deprivation and high deprivation residential areas with respect to fruit and vegetable intake.

Trends and disparities in regionalization of pancreatic resection.

BACKGROUND: The current recommendation is that pancreatic resections be performed at hospitals doing >10 pancreatic resections annually. OBJECTIVE: To evaluate the extent of regionalization of pancreatic resection and the factors predicting resection at high-volume centers (>10 cases/year) in Texas. METHODS: Using the Texas Hospital Inpatient Discharge Public Use Data File, we evaluated trends in the percentage of patients undergoing pancreatic resection at high-volume centers (>10 cases/year) from 1999 to 2004 and determined the factors that independently predicted resection at high-volume centers. RESULTS: A total of 3,189 pancreatic resections were performed in the state of Texas. The unadjusted in-hospital mortality was higher at low-volume centers (7.4%) compared to high-volume centers (3.0%). Patients resected at high-volume centers increased from 54.5% in 1999 to 63.3% in 2004 (P = 0.0004). This was the result of a decrease in resections performed at centers doing less than five resections/year (35.5% to 26.0%). In a multivariate analysis, patients who were >75 (OR = 0.51), female (OR = 0.86), Hispanic (OR = 0.58), having emergent surgery (OR = 0.39), diagnosed with periampullary cancer (OR = 0.68), and living >75 mi from a high-volume center (OR = 0.93 per 10-mi increase in distance, P < 0.05 for all OR) were less likely to be resected at high-volume centers. The odds of being resected at a high-volume center increased 6% per year. CONCLUSIONS: Whereas regionalization of pancreatic resection at high-volume centers in the state of Texas has improved slightly over time, 37% of patients continue to undergo pancreatic resection at low-volume centers, with more than 25% occurring at centers doing less than five per year. There are obvious demographic disparities in the regionalization of care, but additional unmeasured barriers need to be identified.

Ascertainment of Hispanic ethnicity on California death certificates: implications for the explanation of the Hispanic mortality advantage.

OBJECTIVES: We determined the size and correlates of underascertainment of Hispanic ethnicity on California death certificates. METHODS: We used 1999 to 2000 vital registration data. We compared Hispanic ethnicity reported on the death certificate to Hispanic ethnicity derived from birthplace for the foreign-born and an algorithm that used first and last name and percentage of Hispanics in the county of residence for the US-born. We validated death certificate nativity by comparing data with that in linked Social Security Administration records. RESULTS: Ethnicity and birthplace information was concordant for foreign-born Hispanics, who have mortality rates that are 25% to 30% lower than those of non-Hispanic Whites. Death certificates likely underascertain deaths of US-born Hispanics, particularly at older ages, for persons with more education, and in census tracts with lower percentages of Hispanics. Conservative correction for under-ascertainment eliminates the Hispanic mortality advantage for US-born men. CONCLUSIONS: Hispanic ethnicity is accurately ascertained on the California death certificate for immigrants. Immigrant Hispanics have lower age-adjusted mortality rates than do non-Hispanic Whites. For US-born Hispanics, the mortality advantage compared with non-Hispanic Whites is smaller and may be explained by underreporting of Hispanic ethnicity on the death certificate.