For each of the selected districts, the National Registration Department provided a list of all deaths that occurred in the year 2013. For each death, the details of identity, address, reporting institution, and cause of death as determined at registration were given to the District Health Office (DHO) for reinvestigation of the cause of death using two potential approaches. Firstly; all deaths were followed up with a household visit to conduct verbal autopsy (VA) interviews to collect information to ascertain and verify the registered cause(s) of death. Secondly, deaths that had occurred in hospitals were also followed back to review medical records (MR) to verify the registered cause(s) of death. Ethical approval for this study was obtained from the Malaysian Medical Research Ethic Committee with the registration number NMRR-13-1369-18,689. Informed written consent was taken from interviewee before face-to-face interview. Consent was also obtained from the interviewee to review the medical records of the deceased for deaths that had occurred in a medical facility.
As described in the methods section, the study findings on reclassification of causes of death from the medically certified and non-medically certified deaths were used to develop adjusted cause-specific mortality estimates for Malaysia. Tables 2 and 3 show the estimated leading causes of death for males and females for 2013 from the study. Ischaemic heart disease emerged as the leading cause of death among males in Malaysia, estimated to cause 12,656 (15.4%) of all male deaths. Cerebrovascular disease and chronic obstructive pulmonary disease are second and third on the list respectively, causing 13.7 and 8.5% of all male deaths. For females, cerebrovascular disease was the leading condition causing 11,057 (18.3%) deaths, followed by Ischaemic heart disease and lower respiratory infections causing 12.7 and 11.5% of deaths respectively.
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From another perspective, comparison of the mortality estimates from this study with national mortality estimates developed for Malaysia in 2013 as part of the Institute of Health Metrics and Evaluation (IHME) Global Burden of Disease (GBD) study [17] also show certain important differences. Tables 5 and 6 display comparisons of age-standardised mortality rates per 100,000 population in 2013 between the study estimates and the IHME GBD estimates for males and females. Taking the study estimates as the reference, the IHME GBD estimated ASDRs are substantially higher or lower than the study estimated ASDRs for several of the leading causes, notably ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and diabetes in both males and females. Similarly, there were significant differences in the IHME GBD estimated ASDRs for tuberculosis and colorectal cancers in males, and for lower respiratory infections and hypertensive disease in females. These comparisons highlight the potential differences arising from the analytical approach of using local empirical data for mortality estimation as in this study, as compared to the statistical modelling approach to mortality estimation, as used in the IHME GBD study.
From a policy perspective, the marked differences between the estimated mortality rates from this study and similar estimates for Malaysia in 2013 from the IHME GBD 2013 Study require careful attention. The estimates derived from this study are based on field research, which involved rigorous processes for data collection, management and analysis, as described in this article. These field research methods create confidence in the resultant mortality estimates, and a sense of political relevance and ownership which enhance their utilisation for national health policy and research. In contrast, the IHME GBD estimates for several causes are based on statistical models constructed from a dataset of mortality and cause of death patterns from a wide range of countries across the world [32] and may not always be applicable to the Malaysian context. Also, the estimation methods apply model-based reassignment strategies for deaths originally assigned ill-defined and non-specific codes in national datasets, as opposed to the empirical reassignment strategies adopted for our study estimates [33]. The IHME GBD model-based estimates for Malaysia could be biased from these aspects. Future mortality estimation exercises for Malaysia could take into account the findings from the research reported here as local inputs for the statistical models which have been extensively used in more recent analyses reported by the GBD Study Collaborators [34,35,36,37,38]. 2ff7e9595c
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