Istat - Italian National Statistical Institute

SWC - Division for integrated system for health, social assistance and welfare

Viale Liegi, 13 00198 Rome Italy

Data on causes of death (CoD) provide information on mortality patterns and form a major element of public health information.

CoD data refer to the underlying cause which - according to the World Health Organisation (WHO) - is "the disease or injury which initiated the train of morbid events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury".

COD data are derived from death certificates. The medical certification of death is an obligation in Italy. The information provided in the medical certificate of cause of death is coded into the International Classification of Diseases (ICD) codes according to the rules specified in the ICD.

Eurostat's CoD statistics build on standards set out by the World Health Organisation (WHO) in the International Classification of Diseases (ICD).

The regional breakdown is based on the Nomenclature of Territorial Units for Statistics (NUTS 2).

Classification and updates applied by years

Public Health, Causes of death.

Concepts and definitions are described in the Commission regulation (EU) No 328/2011 in articles 2 and 3.

Usual residency refers to the Italian legal residency registered at Civil Registry and it is the place where a person normally spends the daily period of rest, regardless of temporary absences.

In Italy there is a definition applied in the survey on spontaneous abortion: stillbirths are fetal deaths with a gestational age of more than 180 days.
Nevertheless, the official information source used to report stillbirths, that is Birth Delivery Certificate (Decree of Ministry of Health 349/2001), collects data about stillbirths irrespective of the duration of pregnancy. This information source collects, in addition, all the characteristics used to classify and group stillbirths (gestational age, weight, crown-heel) according to the Commission Regulation (EU) No 328/2011.

The characteristics collected are: gestational age, weight, crown-heel.

The statistical units are the deceased persons and the stillborns, respectively.

All deaths and stillbirths occurring in Italy, distinguishing residents and non-residents.

Neonates of non-resident mothers are not considered residents as the residence of newborns is the residence of the mother.

Non-residents are included in national statistics if they die in our country.
About stillbirths, our national statistics include events occurred in Italy from non-resident mothers.

Residents dying abroad are not included as our national statistics refer only to deaths that occurred in the country. 

The statistical data on causes of death refers to Italy.

Region of occurrence and residence (Nuts2) are indicated.

Italian data are available from 1994 onwards.

Note that because 2011 data is the first data collection with a legal basis (and few changes in the requested variables and breakdowns), the data before and after 2011 could not always be comparable (in part due to the different groupings of causes of death). Moreover, the time series for data on stillbirths starts in 2011, and no information on previous data is available.

Not applicable.

The unit is a number.

Data refer to the calendar year (i.e. all deaths occurring during the year). 

CoD data was submitted to Eurostat based on a gentleman's agreement established in the framework of Eurostat's Working Group on "Public Health Statistics" until data with the reference year 2010.

A Regulation on Community Statistics on Public Health and health and Safety at work (EC) No 1338/2008 was signed by the European Parliament and the Council on 16 December 2008. This Regulation is the framework of the data collection on the domain.

Within the context of this framework Regulation, a Regulation on Community statistics on public health and health and safety at work, as regards statistics on causes of death (EU) No 328/2011 was signed by the European Parliament and the Council on 5 April 2011. 

CoD data according to this regulation is submitted to Eurostat since the reference year 2011.

Common specifications with the World Health Organisation (WHO) were used in the data collection up to 2010; in addition, Eurostat asks for NUTS level 2. From 2011 onwards, Eurostat changed the specifications to take into account the data collected through Regulation No 328/2011.

Regulation (EC) No 223/2009 on European statistics (recital 24 and Article 20(4)) of 11 March 2009 (OJ L 87, p. 164), stipulates the need to establish common principles and guidelines ensuring the confidentiality of data used for the production of European statistics and the access to those confidential data with due account for technical developments and the requirements of users in a democratic society.

Information on Istat confidentiality policy is available on the Istat website: ISTAT - Methods and it tools - analyse.

All cells corresponding to marginal totals by cause with less than 3 deaths are considered 'confidential'. To ensure statistical confidentiality, we apply a different treatment depending on the type of output.
For the data warehouse, we have designed tables that are not at risk of disclosure (in some cases we have aggregated them at the territorial level).

Regarding the aggregated file by cause for research purposes, each 'confidential' cell is collapsed by grouping all causes.

Annually, about 24 months after the end of the reference period.

Not applicable.

In line with the Community legal framework and the European Statistics Code of Practice Eurostat disseminates European statistics on Eurostat's website (see item 10 - 'Accessibility and clarity') respecting professional independence and in an objective, professional, and transparent manner in which all users are treated equitably. The detailed arrangements are governed by the Eurostat protocol on impartial access to Eurostat data for users.

At the national level, aggregated data are simultaneously disseminated free of charge to all users in electronic form (website, Istat data warehouse).

Annual.

At the Eurostat level, news releases are online.

At the National level, it is not applicable.

Causes of death data are disseminated in many different publications "multi-source".

Among the most relevant there are:

• "Noi Italia";
• "Italian Statistical Yearbook";
• "BES. Benessere Equo Sostenibile";
• "Il benessere equo e sostenibile dei territori".

Please consult free data online:

Health For All: See this website.

• I.Stat.
• Istat.Data.

Not available.

According to national laws, techniques have been adopted to protect the confidentiality of the microdata.

Given the sensitivity of the data, microdata access is limited to the projects included in the National Statistical Program (PSN) approved by law.

For the reference years 2019-2021, a release was disseminated.

For the reference year 2020, a press release was released.

For the reference year 2020, the provisional data were released.

For the reference year 2020, only concerning March and April, a report was released:

Only for data of the reference years 2011-2013, a release was disseminated.

Only for data of the reference year 2014, a release was disseminated.

For data of the reference year 2012, a release was disseminated.

A relevant publication is also the following: "La mortalità dei bambini ieri e oggi: l’Italia post-unitaria a confronto con i Paesi in via di sviluppo" .

Not available.

Process documents are available at this website.

All the concepts are provided.

The official quality documentation on causes of death statistics is available on the Istat official quality documentation system (SIQual).

Since the 1990s, Istat has adopted a systematic approach to ensure quality in both statistical information and service to the community: Please visit this website.

In 2015, an audit was carried out to evaluate the causes of death statistics system.

The overall assessment was positive, the system's aims are clear and well-defined and shown on a wiki page. The audit revealed that there were no problems with the survey's coverage and reference list. Furthermore, any attempt to reduce the statistical burden was performed.

Regarding IT, the validated data are systematically stored on an Oracle DB and adequately protected following the standards of the Institute. Links to SIQual accompany the data released on the web, the Istat official quality documentation system.

The main users are public national and local government, public research institutes, and private researchers.

Data are mainly used to support the decisions about public policies on health and to study mortality (trend, risk factors, etc)

Sometimes users ask for more detailed data (e.g. nuts3 level, microdata), but generally, these requests cannot be met for confidentiality reasons.

Users' views and opinions are not regularly collected, but the Committee of Statistical Information Users (CUIS) is consulted during the National Statistical Programme (NSP) meeting to highlight possible weaknesses in the data. In general, users are satisfied.

All data requested are sent and disseminated on Eurostat's website.

1. For mandatory variables:

 100%.

2. For voluntary variables:

 76% (19/25).

3. For additional variables:

• External CoD

 It is provided for general and neonatal deaths, not for stillbirths.

• Place of occurrence for external CoD

  It is not provided.

• Activity for external CoD

  It is not provided.

As the data collection is total population-based, the sampling error is not applicable. Many efforts are spent to detect and to obtain the missing models by the non-respondent municipalities, reaching a coverage level of about 100%. An editing and imputation procedure is applied to data to check and correct the measurement errors and item non-responses. Significant investments (tools to support encoding, training coders, etc.) are continuously made to improve the quality of causes of death coding.

Not applicable. Data collection is from administrative sources.

Not applicable.

See 13.1.

The coverage error is about 0,3%.

Not applicable.

Not applicable. Data collection is from administrative sources.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

24 months.

From data collection with the reference year 2011 onwards, Istat meets the Implementing Regulation (EC) No. 328/2011 deadline, Article 4. COD 2019 data arrived in early 2022 because many problems slowed down the data production process in 2021. COD 2020 data arrived in early 2023 because many problems slowed down the data production process in 2021 and 2022.

The scheduled date for delivery/release of the data is respected.

The data are geographically comparable because all data processing is managed centrally by Istat. Moreover, the geographical coverage is complete and the missing events are negligible.

Not applicable.

Since the tenth revision of the ICD was adopted in 2003, data between 1994 and 2002 and from 2003 onwards are not always comparable. Moreover time series for data on stillbirths starts in 2011 and no information on previous data is available.

• General mortality: since 2003.
• Stillbirths: since 2011.

Two different data sources for collecting mortality data in Italy are carried out by the National Institute of Statistics (Istat):

1. “Deleted to death from population registers” (Demographic Statistics or DS).
2. “Causes of death” (CoD). 

The DS survey refers to cancellations due to death from the Population register of all residents in Italy, including those who died abroad. The CoD statistics, on the other hand, refer to all deaths occurring in Italy (for both residents and non-residents).

The discrepancies found between the DS and CoD data are mainly due to the different data sources: the collection of an administrative record of cancellations for the DS data versus a data collection of death certificates filled in by doctors for the CoD data, and the different populations to which these two different data sources belong; in fact, residents dying abroad are only covered by the DS.

Not applicable, only annual data are available.

Not applicable.

Italian data on causes of death are internally consistent.

The main costs concern the recording and coding phases. Nevertheless increasing the use of IT tools allowed to reduce costs. 

Not applicable.

There is no systematic revision of the previous year's data. Data are occasionally revised, e.g. when "NUTS" changes.

Not applicable.

For each death, a death certificate is filled in by a physician. He must indicate "all diseases, morbid or traumatic conditions that led or contributed to death, and the circumstances of the accident or violence that provoked these traumatisms" in the health section of the certificate, hereby also reporting other relevant information linked to the death. Once the doctor has completed the health section, the form is sent to the relevant municipality. The registrar must complete the certificate with the socio-demographic data of the dead person. In particular, other than the dates of birth and death this information concerns the place of birth and residence, marital status, educational level, profession, branch of economic activity, citizenship, and individual code of the deceased. If a death has occurred during the first year of life, the form is slightly different and, as regards the demographic section, the requested information mainly refers to the condition of the parents. Having been filled out in duplicate, the form follows two different paths: one copy is sent to the ASL (where the death occurred), whereas the other copy, before being sent to Istat, is sent to the Prefectures.

Annual.

Italian statistics on causes of death are produced by a centralized data coding and processing system.

Causes of death are coded by an automated coding system (ACS), that requires alphanumerical registration of the health section of the death certificate. Only causes rejected by this system are manually coded. Since the reference year 2003 data on multiple causes have also been coded.

Not applicable because we do not have any statistics on certification training or post-mortem exam courses attended by certifiers. We also do not handle any post-mortem queries.

Table on certification (Percentage)

• Stillbirths

The source of the stillbirth data is the Birth Delivery Certificate for which the Ministry of Health is responsible (Decree of Ministry of Health 349/2001). This information source collects data about births, stillbirths, and congenital anomalies at birth, irrespective of the duration of pregnancy.

• Neonates

Istat has a different death certificate for neonatal and infant deaths (all deaths under 1 year of age). Please visit this website.

An editing and imputation procedure is applied to check and correct the measurement errors and item non-responses. The procedure is based on both deterministic (health and socio-demographic data) and probabilistic approaches (socio-demographic data), to input incorrect and missing data.

Description of coding procedure (central level, distributed among other bodies, etc.):

Coding is performed centrally using the Iris automated coding system. The percentage of rejects of Iris is about 20%. Any certificates that are rejected are reviewed manually by trained coders.

Description of the procedures to detect errors (i.e.errors such as potential inconsistency in the death certificate or error due to mistake when filling the death certificates):

Inconsistencies between the cause of death and other information on the death certificate (age, sex, manner of death) are detected with online alerts during coding, so the coders can check the original death certificate and correct it. At the end of the year, a consistency check is also run for the detection of inconsistencies.

Description of the measures taken to solve detected errors:

Errors detected are corrected manually by expert coders.

Coding performed by a certifier:

Certifiers do not perform coding in Italy.

Estimation of the percentage of autopsy from which information is available for coding:

Not applicable.

Description of double coding exercises and rate of codification errors for the underlying cause of death:

Not applicable.

ICD codes for the underlying cause (% of the Total)

* The increase compared to previous years is due to the adoption of ICD10 version 2019 (according to which certificates with cardiac arrest as UC must be classified as deaths due to unknown cause R99).

Unknown country/region (%) for residents and non-residents who died in the country

We use external sources such as demographic event data from the registry office.
For stillbirths, we use hospital discharge information as an external source to validate the coverage of deliveries.

The imputation procedures are based on deterministic (health and socio-demographic data) and probabilistic approaches (socio-demographic data), to input incorrect and missing data.
Most probabilistic procedures are based on the Nearest-neighbour Imputation Methodology (NIM, developed by Statistics Canada).

• Age: 9.4%;
• Gender: 0.7%;
• Residence: 1.2%;
• Civil status: 2.3%;
• Educational level: 31.5%.

Not applicable.

Not applicable.

None.