Overview of the SmartVA

Questionnaire and Tariff

SmartVA Questionnaire Modules

PART A- PART B- PART C- INJURY PART C- SIGNS AND

GENERAL PHYSICIAN SECTION SYMPTOMS (AGE
MODULE ENQUIRY •Questions about injuries SPECIFIC MODULE)
• Adult: aged 12 years old and
•The general module •OPEN-ENDED that may have led to the above
includes NARRATIVE: Asks the death of the deceased. • Child: aged 29 days-11 years
administrative respondents all that •Injuries that led directly to old
information on the they know about the the death of the deceased • Neonate: aged 28 days or
deceased illness leading to the below
death of the deceased
•Review of health
record
PART A-GENERAL MODULE
• VA ID number
• Name
• Sex
• Location of death (home, en-route to hospital)
• Date of birth
• Date of death
• Age (if do not know DoB and/or DoD)
• Age group (if don’t know DoB/DoD or age)
PART B- PHYSICIAN ENQUIRY
• Open-ended narrative

• Review of health record, if any (available)- information from the health/medical

record may be recorded in the space provided
PART C
• Injury Question
Note: The injury section
will not be asked if the
deceased was a neonate.

• Age-specific questions on signs and symptoms

Assignment of Cause of death
• If there is not enough information from the PART B of the
questionnaire (physician review) to assign a cause of death, the
physician will continue to PART C of the questionnaire
• Once PART C is completed and the VA submitted, the SmartVA
analysis will be conducted to assist the physician assign a cause of
death
• SmartVA uses an automated algorithm called Tariff to assign up to
three causes of death from the VA questionnaire information with
their likelihood
• How does Tariff work…?
 How does TARIFF work?
A TARIFF score measures the relative likelihood that a given
symptom results in a specific cause of death.

But, how do we know how

likely it is that a symptom
results in a particular cause
of death?
This Photo by Unknown Author is
licensed under CC BY-NC
PHMRC Gold standard study
• Population Health Metrics Research Consortium (PHMRC) collected 12,535
VA interviews where the underlying cause of each death was determined
previously by medical certification including clinical diagnoses via lab tests,
xray, etc. Interviewers with no knowledge of this determination interviewed
family members.

• Sites included: Bohol, Philippines; Dar es Salaam, Tanzania; Mexico City,

Mexico; Andhra Pradesh, India; Uttar Pradesh, India; Pemba Island, Tanzania

• For more information:

http://www.healthdata.org/verbal-autopsy/publications
How does TARIFF work?
With Endorsement Rates
Example for calculating Tariff score (Smart VA does this automatically)

Acute
Causes: Esophageal
Maternal Myocardial
Diabetes Cancer Based on the
cause Infarction
Symptoms: Gold Standard
dataset, 20% of
Ulcer oozed deaths caused
pus 51% 0% 0% 1% by esophageal
cancer had
‘lump in the
Lump in the neck’ reported
4% 20% 4% 1%
neck as a symptom
in the VA
Convulsions questionnaire
11% 0% 50% 5%
How does TARIFF work?
With Endorsement Rates
Example for calculating Tariff score (Smart VA does this automatically)

The formula for a tariff for

Causes: Median Interquartile cause/symptom pair (i,j) is the following:
across range
Symptoms: causes

Ulcer oozed pus 1% 3%

Example:
Lump in the neck 3% 2% Tariff of “lump in the neck” for
esophageal cancer:
= (20 - 3) / 2 = 8.5
Convulsions 8% 6%
How does TARIFF work?
For breast cancer, ‘Did [name] have any ulcers (pits) in the breast?’ is more highly predictive of breast cancer (and has a higher tariff score) than ‘Pain greater than 24 hours’ which may be associated with many other
conditions

Some symptom Tariff scores

Symptom for Breast cancer
Did [name] have any ulcers (pits) in the
64
breast?
Did [name] have any swelling or lump
38
in the breast?
Did Decedent Have Cancer? 17.5
Did [name] have a lump in the neck? 4.5
Pain greater than 24 hours 1.5
Did [name] have pain upon
1.5
swallowing?
 How does TARIFF work?

For each symptom,

there is a fixed Tariff
The Tariff scores for all The highest ranked
score for each cause of
reported symptoms cause is the
death.
are summed.
If this symptom is assigned cause of
This results in a ranking
endorsed (respondent
of causes of death
death for that
answers ‘Yes’) then the deceased
based on these Tariff
tariff score for all individual.
scores.
causes of death is
recorded.
How does TARIFF work?
For example, there are only 3 possible causes of death and respondents are asked only four symptom questions

Tariff Matrix AIDS Malaria Fall For the symptom

‘Suffered a fall’ the
Suffered a fall 0 0 32 Tariff score for the
Cause of Death ‘Fall’ is
Diagnosed w TB 5 0 0 32

Fever 1 1.4 -1 Whereas for cause of

death for ‘AIDS’ and
Was [name] in any ‘Malaria’ the Tariff
0 0 1.5
way paralysed? score is 0
How does TARIFF work?
However the tariff score is only important if the symptom is endorsed – i.e. the respondent answers “Yes” to the symptom question.

Tariff Matrix AIDS Malaria Fall

Each questionnaire item gets
Suffered a fall 0 0 32 a score, according to the
number of times it was
Diagnosed w TB 5 0 0 endorsed by the respondent
(i.e., respondents answered
Fever 1 1.4 -1 “yes” to a question about
the presence of a symptom
Was [name] in any during a VA interview
0 0 1.5
way paralysed?
How does TARIFF work?
For this example, assume the respondent answered “Yes” to ‘Diagnosed with TB’ and ‘Had fever’ but “No” to the other questions

Tariff Matrix AIDS Malaria Fall Endorsed?

Suffered a fall 0 0 32 No

Diagnosed w TB 5 0 0 Yes

Fever 1 1.4 -1 Yes

Was [name] in any 0 0 1.5

way paralysed? No
How does TARIFF work?
•When we sum the tariff scores for the symptom questions that were endorsed, AIDS had the
highest score and is assigned cause of death (assuming there are only these three causes of death)

Tariff Matrix AIDS Malaria Fall Endorsed?

Suffered a fall 0 0 32 No

Diagnosed w TB 5 0 0 Yes

Fever 1 1.4 -1 Yes

Was [name] in any 0 0 1.5

way paralysed? No

Cause specific 6 1.4 -1

Tariff Score
How does TARIFF work?
• This is a very simple example – usually verbal autopsies have many
more symptom and health care experience questions as well as more
possible causes of death
• The tariff scores for all the questions that are endorsed will be
summed and the cause with the highest Tariff rank will be assigned.
• The SmartVA software will produce up to three possible causes with
likelihood that it was that cause
• SmartVA software can assign cause of death for 33 adult, 21 child and
6 neonatal causes – most of the causes of public health importance!
Output Example
NOTES:

• The SmartVA software will produce up to three

possible causes with likelihood that it was that
cause.

The possible causes are not to be considered as

the entries in the 3 lines in part I of the Death
Certificate.

One of those possible causes can be considered

by the Physicians as the UCoD to be written on the
Death Certificate. Physicians, however may add
details, as necessary when they write the UCoD on
the Death Certificate.
When Tariff causes are not acceptable
UCOD
• SmartVA is limited and cannot assign all possible causes
• There are some causes that tariff cannot predict (e.g. some cancers such as liver cancer or specific
causes of maternal death, some infectious diseases)
• Sometimes there is insufficient information from the VA to produce a specific cause of
death and then the tariff cause might be:
• An aggregate cause (e.g. ‘Other infectious diseases, other cardiovascular diseases, Other NCD,
Other cancers, Other injuries)
• For some causes where symptoms are difficult to define tariff will assign a less specific cause – e.g.
Chronic respiratory for both COPD and asthma
• External causes need more information that tariff produces for the MCCOD
• For neonatal deaths Tariff may produce a cause ‘stillbirth’ which is not a legitimate COD
• Where there are almost no endorsements and little information provided through the
questionnaire, tariff may assign a cause ‘Undetermined’
Assigning a cause using tariff
• Physicians should use the tariff causes as a guide – they do not need to
choose one of the (up to) three causes provided
• Physicians should ask further questions to try to come up with a more
accurate UCOD
• Some examples…
1. Chronic Respiratory – physicians can ask further questions to clarify if
the deceased used a puffer (preventive medicine) regularly? If so,
they can assign Asthma as the UCOD
2. Other Cancers – physicians cab ask further questions to clarify if the
family knew about the primary cancer site – liver or renal cancer
External causes
• TARIFF will only provide FALL as a possible cause of death , Physician
based on the interview may include the details of the Fall, like fall
from where and the activity of the deceased when the fall happened.
• Tariff will provide ROAD TRAFFIC ACCIDENT– the Physician can
enquire of the circumstances of the accident
• Tariff will provide SUICIDE or HOMICIDE – the Physician can ask about
the mode of suicide/homicide.
• Tariff may produce OTHER INJURIES – but the physician may already
know what the type injury is from the endorsed questions.
Other cancers/Other CVD/Other NCD
• TARIFF may provide OTHER CANCER but the physician can review the
endorsed questions and ask further questions to ascertain the type of
cancer
• TARIFF may provide OTHER CARDIOVASCULAR DISEASE – the
physician can ask further questions to identify the type of CVD
• TARIFF may provide ‘OTHER NON-COMMNICABLE DISEASES’ – the
physician may have an idea from their questioning what the COD
might be and ask additional questions to try to narrow this down.
Maternal causes
• TARIFF can only provide MATERNAL causes
• The physician can enquire further to understand the maternal
condition causing death
Undetermined cause
• Sometimes TARIFF will return UNDETERMINED cause of death
• This means that not enough questions have been endorsed for the
computer algorithm to apply a cause with any amount of certainty
• The doctor can try asking additional questions to try to determine the
cause of death
• For some deaths (even those that occur in hospital) the exact cause of
death may not be possible to assign