Introduction The linked birth/infant death data set (linked file) is released in two formats - period data and birth cohort data. This documentation is for the 2002 period linked file. Beginning with 1995 data, the period linked files have formed the basis for all official NCHS linked file statistics. Differences between period and birth cohort data are outlined below. Period data - The numerator for the 2002 period linked file consists of all infant deaths occurring in 2002 linked to their corresponding birth certificates, whether the birth occurred in 2001 or 2002. The denominator file for this data set is the 2002 natality file, that is, all births occurring in 2002. NCHS accepted late filed birth certificates to be used specifically for the 2002 linked file. This reduced the number of unlinked records and increased the number of births in the denominator file. Birth cohort data - The numerator for the 2001 birth cohort linked file consists of deaths to infants born in 2001 whether the death occurred in 2001 or 2002. The denominator file is the 2001 natality file, that is, all births occurring in 2001. The 2002 period linked birth/infant death data set includes several data files. The first file includes all US infant deaths which occurred in the 2002 data year linked to their corresponding birth certificates, whether the birth occurred in 2001 or in 2002 - referred to as the numerator file. The second file contains information from the death certificate for all US infant death records which could not be linked to their corresponding birth certificates - referred to as the unlinked death file. The third file is the 2002 NCHS natality file for the US (plus late filed records mentioned above), which is used to provide denominators for rate computations. These same three data files are also available for Puerto Rico, the Virgin Islands, and Guam. Changes Beginning with the 1995 Data Year In part to correct for known biases in the data, changes were made to the linked file beginning with the 1995 data year, and these changes remain effective for 2002 data. A weight has been added to the linked numerator file to correct in part for biases in percent of records linked by major characteristics (see section on Percent of records linked below). The number of infant deaths in the linked file are weighted to equal the sum of the linked plus unlinked infant deaths by age at death and state. The formula for computing the weights is as follows: number of linked infant deaths + number of unlinked infant deaths ----------------------- number of linked infant deaths A separate weight is computed for each State of residence of birth and each age at death category (<1 day, 1-27 days, 28 days-1year). Thus, weights are 1.0 for states which link all of their infant deaths. The denominator file is not weighted. Weights are not computed for the Puerto Rico, Virgin Islands, and Guam file. An imputation for not-stated birthweight has been added to the data set, to reduce potential bias in the computation of birthweight-specific infant mortality rates. Basically, if birthweight is not-stated and the period of gestation is known, birthweight is assigned the value from the previous record with the same period of gestation, race, sex, and plurality. Imputed values are flagged. The addition of this imputation has reduced the percent of not-stated responses for birthweight from 3.85 to 1.32 in the numerator file, and from 0.07 to 0.04 in the denominator file, thus reducing (but not eliminating) the potential for underestimation when computing birthweight-specific infant mortality rates. Changes Beginning with the 2002 Data Year A new item has been added to the 2002 US numerator file which informs the data user about the manner of death as reported in the manner of death section of the death certificate. See the record layout for details. Comparisons of infant mortality data from the linked file with infant mortality data from the vital statistics mortality file Although the time periods are the same, numbers of infant deaths and infant mortality rates by characteristics are not always identical between the period linked file and the vital statistics mortality file. The differences can be traced to three different causes: 1) geographic differences; 2) additional quality control; and 3) weighting. Geographic differences - To be included in the linked file for the 50 States and D.C., the birth and death must both occur inside the 50 States and D.C. In contrast, for the vital statistics mortality file, deaths which occur in the 50 States and D.C. to infants born inside and outside of the 50 States and D.C. are included. Similarly, to be included in the linked data file for Puerto Rico, the Virgin Islands, and Guam, the birth and death must both occur in Puerto Rico, the Virgin Islands or Guam. In contrast, for the vital statistics mortality file, deaths which occurred in Puerto Rico, the Virgin Islands, and Guam to infants born inside and outside of Puerto Rico, the Virgin Islands and Guam are included. Additional quality control - The second reason for differences between the two files is that the linkage process subjects infant death records to an additional round of quality control review. Every year, a few records are voided from the file at this stage because they are found to be fetal deaths, deaths at ages greater than 1 year, or duplicate death certificates. Weighting - The third reason is the weighting procedures added to the 1995 and subsequent linked files. Beginning with 1995 data, linked file records are now weighted to compensate for the 1-3 percent of infant death records which could not be linked to their corresponding birth certificates. Although every effort has been made to design weights which will accurately reflect the distribution of deaths by characteristics, weighting may contribute to small differences in numbers and rates by specific variables between the linked file and the vital statistics mortality files. In most cases, differences between numbers of infant deaths and infant mortality rates between the linked file and those computed from the vital statistics mortality file are negligible. Methodology The methodology used to create the national file of linked birth and infant death records takes advantage of two existing data sources: 1. State linked files for the identification of linked birth and infant death certificates; and 2. NCHS natality and mortality computerized statistical files, the source of computer records for the two linked certificates. Virtually all States routinely link infant death certificates to their corresponding birth certificates for legal and statistical purposes. When the birth and death of an infant occur in different States, copies of the records are exchanged by the State of death and State of birth in order to effect a link. In addition, if a third State is identified as the State of residence at the time of birth or death, that State is also sent a copy of the appropriate certificate by the State where the birth or death occurred. The NCHS natality and mortality files, produced annually, include statistical data from birth and death certificates that are provided to NCHS by States under the Vital Statistics Cooperative Program (VSCP). The data have been coded according to uniform coding specifications, have passed rigid quality control standards, have been edited and reviewed, and are the basis for official U.S. birth and death statistics. To initiate processing, NCHS obtained matching birth certificate numbers from States for all infant deaths that occurred in their jurisdiction. We used this information to extract final, edited mortality and natality data from the NCHS natality and mortality statistical files. Individual birth and death records were selected from their respective files and linked into a single statistical record, thereby establishing a national linked record file. After the initial linkage, NCHS returned to the States where the death occurred computer lists of unlinked infant death certificates for follow up linking. If the birth occurred in a State different from the State of death, the State of birth identified on the death certificate was contacted to obtain the linking birth certificate. State additions and corrections were incorporated, and a final, national linked file was produced. Characteristics of the natality and mortality data from which the linked file is constructed are described in detail in the Technical Appendices and Addenda included in this document. Characteristics of the Unlinked File For the 2002 linked file 1.0% of all infant death records could not be linked to their corresponding birth certificates. Unlinked records are included in a separate data file in this data set. The unlinked record file uses the same record layout as the numerator file of linked birth and infant death records. However, except as noted below, tape locations 1-210, reserved for information from the matching birth certificate, are blank since no matching birth certificate could be found for these records. The sex field (tape location 79) contains the sex of infant as reported on the death certificate, rather than the sex of infant from the birth certificate, which is not available. The race field (tape location 36-37) contains the race of the decedent as reported on the death certificate rather than the race of mother as reported on the birth certificate as is the case with the linked record file. The race of mother on the birth certificate is generally considered to be more accurate than the race information from the death certificate (see section on Comparison of race data from birth and death certificates in the Mortality Technical Appendix included in this documentation). Also, date of birth as reported on the death certificate is used to generate age at death. This information is used in place of date of birth from the birth certificate, which is not available. Documentation table 6 shows counts of unlinked records by race and age at death for each State of residence. The user is cautioned in using table 6 that the race and residence items are based on information reported on the death certificate; whereas, tables 1-5 present data from the linked file in which the race and residence items are based on information reported on the birth certificate. (see section on Comparison of race data from birth and death certificates in the Mortality Technical Appendix included in this documentation). Percent of Records Linked The 2002 linked file includes 27,722 linked infant death records and 294 unlinked infant death records. The linked file is weighted to the sum of linked plus unlinked records, thus the total number of weighted infant deaths by place of occurrence is 28,016. While the overall percent linked for infant deaths in the 2002 file is 99.0%, there are differences in percent linked by certain variables. These differences have important implications for how the data are analyzed. Table 1 shows the percent of infant deaths linked by State of occurrence of death. While most States link a high percentage of infant deaths, linkage rates for some States are well below the national average. Note in particular the percent linked for the Alaska (93.9), Oklahoma (95.8), and Texas (96.8). When a high percentage of deaths remain unlinked, unweighted infant mortality rates computed for these States are underestimated. It is for this reason that weights were added to the file to correct for biases in the data due to poor data linkage for particular states. In general, a slightly higher percentage of postneonatal (28 days to under 1 year) than neonatal (less than 28 days) deaths were linked (99.3 and 98.7, respectively.) While the weighting protocol has been designed to correct for possible bias due to variations in match rates by characteristics, no statistical method can correct perfectly for data limitations. Therefore, variations in the percent of records linked should be taken into consideration when comparing infant mortality rates by detailed characteristics. Geographic classification Geographic codes in this data set are based on the results of the 1990 census. Because of confidentiality concerns, only those counties and cities with a population size of 250,000 or more are separately identified in this data set. Users should refer to the geographic code outline in this document for the list of available areas and codes. For events to be included in the linked file, both the birth and death must occur inside the 50 States and D.C. in the case of the 50 States and D.C. file; or in Puerto Rico, the Virgin Islands or Guam in the case of the Puerto Rico, Virgin Islands and Guam file. In tabulations of linked data and denominator data events occurring in each of the respective areas to nonresidents are included in tabulations that are by place of occurrence, and excluded from tabulations by place of residence. These exclusions are based on the usual place of residence of the mother. This item is contained in both the denominator file and the birth section of the numerator (linked) file. Nonresidents are identified by a code 4 in location 11 of these files. Table 1. Percent of infant deaths linked by state of occurrence of death: United States, 2002 linked file United States 99.0 Nebraska 100.0 Alabama 100.0 Nevada 99.5 Alaska 93.9 New Hampshire 100.0 Arizona 99.6 New Jersey 97.9 Arkansas 99.7 New Mexico 99.4 California 97.9 New York State 99.1 Colorado 100.0 New York City 98.9 Connecticut 100.0 North Carolina 99.9 Delaware 100.0 North Dakota 100.0 District of Columbia 99.5 Ohio 99.7 Florida 99.6 Oklahoma 95.8 Georgia 100.0 Oregon 100.0 Hawaii 100.0 Pennsylvania 99.7 Idaho 100.0 Rhode Island 100.0 Illinois 97.3 South Carolina 100.0 Indiana 98.4 South Dakota 100.0 Iowa 99.4 Tennessee 99.9 Kansas 99.2 Texas 96.8 Kentucky 99.7 Utah 99.3 Louisiana 97.5 Vermont 100.0 Maine 98.3 Virginia 99.7 Maryland 99.6 Washington 99.8 Massachusetts 97.2 West Virginia 100.0 Michigan 99.7 Wisconsin 100.0 Minnesota 100.0 Wyoming 100.0 Mississippi 100.0 Puerto Rico 99.4 Missouri 100.0 Virgin Islands 100.0 Montana 98.7 Guam 100.0 Demographic and Medical Classification The documents listed below describe in detail the procedures employed for demographic classification on both the birth and death records and medical classification on death records. These documents, while not absolutely essential to the proper interpretation of the data for a number of general applications, should nevertheless be studied carefully prior to any detailed analysis of demographic or medical data variables. In particular, there are a number of exceptions to the ICD rules in multiple cause-of-death coding which, if not treated properly, may result in faulty analysis of the data. Volumes 1, 2 and 3 of the ICD-10 may be purchased from the World Health Organization (WHO) Publication Center USA, 49 Sheridan Avenue, Albany, New York, 12210 (http://www.who.int/whosis/icd10/index.html). Many of the instruction manuals listed below are available electronically on the NCHS website at: http://www.cdc.gov/nchs/about/major/dvs/im.htm. In addition, users who do not already have access to these documents may request them from the Chief, Mortality Medical Classification Branch, Division of Vital Statistics, National Center for Health Statistics, P.O. Box 12214, Research Triangle Park, North Carolina 27709. The technical appendices for natality and mortality included in this document also provide information on the source of data, coding procedures, quality of the data, etc. A. National Center for Health Statistics. Vital statistics, Instructions for Classifying the Underlying Cause-of-Death, 2004. NCHS Instruction Manual, Part 2a. Hyattsville, Maryland: Public Health Service. B. National Center for Health Statistics. Vital statistics, Instructions for Classifying Multiple Cause-of-Death, 2004. NCHS Instruction Manual, Part 2b. Hyattsville, Maryland: Public Health Service. C. National Center for Health Statistics. Vital statistics, ICD-10 ACME Decision Tables for Classifying Underlying Causes-of-Death, 2004. NCHS Instruction Manual, Part 2c. Hyattsville, Maryland: Public Health Service. D. National Center for Health Statistics. Vital statistics, ICD-10 TRANSAX Disease Reference Tables for Classifying Multiple Causes-of-Death, 2002. NCHS Instruction Manual, Part 2f. Hyattsville, Maryland: Public Health Service. E. National Center for Health Statistics. Vital statistics, Classification and Coding Instructions for Live Birth Records, 1999. NCHS Instruction Manual, Part 3a. Hyattsville, Maryland: Public Health Service. F. National Center for Health Statistics. Vital statistics, Demographic Classification and Coding Instructions for Death Records, 1999-2001. NCHS Instruction Manual, Part 4. Hyattsville, Maryland: Public Health Service. G. National Center for Health Statistics. Vital statistics, Computer Edits for Natality Data, Effective 1993. NCHS Instruction Manual Part 12. Hyattsville, Maryland: Public Health Service. H. National Center for Health Statistics. Vital statistics, Computer Edits for Mortality Data, Effective 2004. NCHS Instruction Manual Part 11. Hyattsville, Maryland: Public Health Service. Underlying Cause of Death Data Mortality statistics by cause of death are compiled from entries on the medical certification portion of the death certificate. The U.S. Standard Certificate of Death is shown in the Mortality Technical Appendix which is included in this documentation. Causes of death include "all those diseases, morbid conditions or injuries which either resulted in or contributed to death and the circumstances of the accident or violence which produced these injuries". The medical certification of death is divided into two sections. In Part I, the physician is asked to provide the causal chain of morbid conditions that led to death, beginning with the condition most proximate to death on line (a) and working backwards to the initiating condition. The lines (a) through (d) in Part I are connected by the phrase "due to, or as a consequence of." They were designed to encourage the physician to provide the causally related sequence of medical conditions that resulted in death. Thus, the condition on line (a) should be due to the condition on line (b), and the condition on line (b) should be a consequence of the condition on line (c), etc., until the full sequence is described back to the originating or initiating condition. If only one step in the chain of morbid events is recorded, a single entry on line (a) is adequate. Part I of the medical certification is designed to facilitate the selection of the underlying cause of death when two or more causes are recorded on the certificate. The underlying cause of death is defined by the WHO in the ICD-10 as "(a) the disease or injury which initiated the chain of morbid events leading directly to death, or (b) the circumstances of the accident or violence that produced the fatal injury" and is generally considered the most useful cause from a public health standpoint. Part II of the cause-of-death section of the death certificate solicits other conditions that the certifier believed contributed to death, but were not in the causal chain. While some details of the death certificate vary by State, all States use the same general format for medical certification outlined in the U.S. Standard Certificate. The U.S. Standard Certificate, in turn, closely follows the format recommended by the WHO. If the death certificate is properly completed, the disease or condition listed on the lowest used line in Part I is usually accepted as the underlying cause of death. This is an application of "The General Principle." The General Principle is applied unless it is highly improbable that the condition on the lowest line used could have given rise to all of the diseases or conditions listed above it. In some cases, the sequence of morbid events entered on the death certificate is not specified correctly. A variety of errors may occur in completing the medical certification of death. Common problems include the following: The causal chain may be listed in reverse order; the distinction between Part I and Part II may have been ignored so that the causal sequence in Part I is simply extended unbroken into Part II; or the reported underlying cause is unlikely, in an etiological sense, to have caused the condition listed above it. In addition, sometimes the certifier attributes the death to uninformative causes such as cardiac arrest or pulmonary arrest. To resolve the problems of incorrect or implausible cause-of-death statements, the WHO designed standardized rules to select an underlying cause of death from the information available on the death certificate that is most informative from a public health perspective. The rules for the Tenth Revision as updated by WHO since the publication of ICD-10 are described in NCHS instruction manual Part 2A. Coding rules beyond the General Principle are invoked if the cause-of-death section is completed incorrectly or if their application can improve the specificity and characterization of the cause of death in a manner consistent with the ICD. The rules are applied in two steps: selection of a tentative underlying cause of death, and modification of the tentative underlying cause in view of the other conditions reported on the certificate in either Part I or Part II. Modification involves several considerations by the medical coder: determining whether conditions in Part II could have given rise to the underlying cause, giving preference to specific terms over generalized terms, and creating linkages of conditions that are consistent with the terminology of the ICD. For a given death, the underlying cause is selected from the condition or conditions recorded by the certifier in the cause-of-death section of the death certificate. NCHS is bound by international agreement to make the selection of the underlying cause through the use of the ICD-10 classification structure, and the selection and modification rules contained in this revision of the ICD. These rules are contained in a computer software program called ACME (Automated Classification of Medical Entities). ACME does exactly what a coder would do to select the underlying cause of death. The ACME program has been used for final mortality data since 1968. The WHO selection rules take into account the certifier’s ordering of conditions and their causal relationships to systematically identify the underlying cause of death. The intent of these rules is to improve the usefulness of mortality statistics by giving preference to certain classification categories over others and consolidating two or more conditions on the certificate into a single classification category. In addition to changes due to the implementation of a new ICD revision, rules for coding a cause of death may occasionally require modification at other times, when evidence suggests that such modifications will improve the quality of cause-of-death data. These changes may affect comparability of data between years for select causes of death. For example, between 2001 and 2002 a change in the coding rules was implemented which resulted in some deaths that would have previously been assigned to Atelectasis, instead being assigned to maternal complications. This change accounts for part (around half) of the large increase in maternal complications from 2001-2002. Multiple Cause of Death Data The limitations of the underlying cause concept and the need for more comprehensive data suggested the need for coding and tabulating all conditions listed on the death certificate. Coding all listed conditions on the death certificate was designed with two objectives in mind. First, to facilitate studies of the relationships among conditions reported on the death certificate, which require presenting each condition and its location on the death certificate in the exact manner given by the certifier. Secondly, the coding needed to be carried out in a manner by which the underlying cause-of-death could be assigned using the WHO coding rules. Thus, the approach in developing multiple cause data was to provide two fields: 1) entity axis and 2) record axis. For entity axis, NCHS suspends the provisions of the ICD that create linkages between conditions for the purpose of coding each individual condition, or entity, with minimum regard to other conditions present on the death certificate. Record axis is designed for the generation of person-based multiple cause statistics. Person-based analysis requires that each condition be coded within the context of every other condition on the same death certificate and modified or linked to such conditions as provided by ICD-10. By definition, the entity data cannot meet this requirement since the linkage provisions modify the character and placement of the information originally recorded by the certifier. Essentially, the axis of the classification has been converted from a entity basis to a record (or person) basis. The record axis codes are assigned in terms of the set of codes that best describe the overall medical certification portion of the death certificate. This translation is accomplished by a computer system called TRANSAX (Translation of Axis). TRANSAX selectively uses the traditional linkage and modification rules for mortality coding. Underlying cause linkages which simply prefer one code over another for purposes of underlying cause selection are not included. Each entity code on the record is examined and modified or deleted as necessary to create a set of codes that are free of contradictions and are the most precise within the constraints of ICD-10 and medical information on the record. Repetitive codes are deleted. The process may 1) combine two entity axis categories together to a new category thereby eliminating a contradiction or standardizing the data; or 2) eliminate one category in favor of another to promote specificity of the data or resolve contradictions. The following examples from ICD-10 illustrate the effect of this translation: Case 1: When reported on the same record as separate entities, cirrhosis of liver and alcoholism are coded to K74.6 (Other and unspecified cirrhosis of liver) and F10.2 (Mental and behavioral disorders due to use of alcohol; dependence syndrome), respectively. Tabulation of records with K74.6 would imply that such records had no mention of alcohol. A preferable code would be K70.3 (Alcoholic cirrhosis of liver) in lieu of both K74.6 and F10.2. Case 2: If "gastric ulcer" and "bleeding gastric ulcer" are reported on a record they are coded to K25.9 (Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation) and K25.4 (Gastric ulcer, chronic or unspecified with hemorrhage), respectively. A more concise code is K25.4 which shows both the gastric ulcer and the bleeding. Entity Axis Codes The original conditions coded for selection of the underlying cause-of-death are reformatted and edited prior to creating the public-use data file. The following paragraphs describe the format and application of entity axis data. 1. Format. Each entity-axis code is displayed as an overall seven byte code with subcomponents as follows: 1. Line indicator: The first byte represents the line of the death certificate on which the code appears. Six lines (1-6) are allowable with the fourth and fifth denoting one or two written in "due to"'s beyond the three lines provided in Part I of the U.S. standard death certificate. Line "6" represents Part II of the death certificate. 2. Position indicator: The next byte indicates the position of the code on the line, i.e., it is the first (1), second (2), third (3) .... eighth (8) code on the line. 3. Cause category: The next four bytes represent the ICD-10 cause code. 4. The last byte is blank. A maximum of 20 of these seven byte codes are captured on a record for multiple cause purposes. This may consist of a maximum of 8 codes on any given line with up to 20 codes distributed across three or more lines depending on where the subject conditions are located on the certificate. Codes may be omitted from one or more lines, e.g., line 1 with one or more codes, line 2 with no codes, line 3 with one or more codes. In writing out these codes, they are ordered as follows: line 1 first code, line 1 second code, etc. ----- line 2 first code, line 2 second code, etc. ----- line 3 ---- line 4 ----- line 5 ----- line 6. Any space remaining in the field is left blank. The specifics of locations are contained in the record layout given later in this document. 2. Edit. The original conditions are edited to remove invalid codes, reverify the coding of certain rare causes of death, and assure age/cause and sex/cause compatibility. Detailed information relating to the edit criteria and the sets of cause codes which are valid to underlying cause coding and multiple cause coding are provided in NCHS Instruction Manual Part 11. 3. Entity Axis Applications. The entity axis multiple cause data file is appropriate for analyses that require that each condition be coded as a stand alone entity without linkage to other conditions and/or require information on the placement of such conditions in the death certificate. Within this framework, the entity data are appropriate to examine relationships among conditions and the validity of traditional assumptions in underlying cause selection. Additionally, the entity data provide in certain categories a more detailed code assignment that could be excluded in creating record axis data. Where such detail is needed for a study, the user should use entity data. Finally, the researcher may not wish to be bound by the assumptions used in the axis translation process. The main limitation of entity axis data is that it does not necessarily reflect the best code for a condition when considered within the context of the medical certification as a whole. As a result, certain entity codes can be misleading or even contradict other codes in the record. For example, category K80.2 is titled "Calculus of gallbladder without cholecystitis." Within the framework of entity codes this is interpreted to mean that the codable entity itself contained no mention of cholecystitis rather than that cholecystitis was not mentioned anywhere on the record. Tabulation of records with a "K80.2" as a count of persons having Calculus of gallbladder without cholecystitis would therefore be erroneous. This illustrates the fact that under entity coding the ICD-10 titles cannot be taken literally. The user should study the rules for entity coding as they relate to his/her research prior to use of entity data. The user is further cautioned that the inclusion notes in ICD-10 that relate to modifying and combining categories are seldom applicable to entity coding (except where provided NCHS Instruction Manual Part 2b). In tabulating the entity axis data, one may count codes with an individual code representing the number of times the condition(s) appears in the file. In this kind of tabulation of morbid conditions, the counts among categories may be added together to produce counts for groups of codes. Alternatively, subject to the limitations given above, one may count persons having mention of the disease represented by a code or codes. In this instance it is not correct to add counts for individual codes to create person counts for groups of codes. Since more than one code in the researcher’s interest may appear together on the certificate, totaling must account for higher order interactions among codes. Up to 20 codes may be assigned on a record; therefore, a 20-way interaction is theoretically possible. All totaling must be based on mention of one or more of the categories under investigation. Record Axis Codes The following paragraphs describe the format and application of record-axis data. Part 2f of the Instruction Manual Series (ICD-10 TRANSAX Disease Reference Tables for classifying Multiple Causes-of-Death) describes the TRANSAX process for creating record axis data from entity axis data. 1. Format. Each record (or person) axis code is displayed in five bytes. Location information is not relevant. The Code consists of the following components: 1. Cause category: The first four bytes represent the ICD-10 cause code. 2. The last byte is blank. Again, a maximum of 20 codes are captured on a record for multiple cause purposes. The codes are written in a 100-byte field in ascending code number (5 bytes) order with any unused bytes left blank. 2. Edit. The record axis codes are edited for rare causes and age/cause and sex/cause compatibility. Likewise, individual code validity is checked. The valid code set for record axis coding is the same as that for entity coding. 3. Record Axis Applications. The record axis multiple cause data are the basis for NCHS core multiple cause tabulations. Location of codes is not relevant to this data, and conditions have been linked into the most meaningful categories for the certification. The most immediate consequence for the user is that the codes on the record already represent mention of a disease assignable to that particular ICD-10 category. This is in contrast to the entity code which is assigned each time such a disease is reported on different lines of the certification. Secondly, the linkage implies that within the constraints of ICD-10 the most meaningful code has been assigned. The translation process creates for the user a data file that is edited for contradictions, duplicate codes, and imprecisions. In contrast to entity axis data, record axis data are classified in a manner comparable to underlying cause of death classification thereby facilitating joint analysis of these variables. A potential disadvantage of record axis data is that some detail is sacrificed in a number of the linkages. The user can take the record axis codes as literally representing the information conveyed in ICD-10 category titles. While knowledge of the rules for combining and linking and coding conditions is useful, it is not a prerequisite to meaningful analysis of the data as long as one is willing to accept the assumptions of the axis translation process. The user is cautioned, however, that due to special rules in mortality coding, not all linkage notes in ICD-10 are used. (NCHS Instruction Manual Part 2f). The user should proceed with caution in using record axis data to count conditions as opposed to people with conditions, since linkages have been invoked and duplicate codes have been eliminated. As with entity data, person-based tabulations that combine individual cause categories must take into account the possible interaction of up to 20 codes on a single certificate. Additional Information In using the NCHS multiple cause data files, the user is urged to review the information in this document and its references. The instructional material does change from year to year and ICD revision to ICD revision. The user is cautioned that coding of specific ICD-10 categories should be checked in the appropriate instruction manual. What may appear on the surface to be the correct code by ICD-10 may in fact not be correct as given in the instruction manuals. If on the surface it is not obvious whether entity axis or record axis data should be employed in a given application, detailed examination of NCHS Instruction Manual Part 2f and its attachments will probably provide the necessary information to make a decision. It allows the user to determine the extent of the trade-offs between the two sets of data in terms of specific categories and the assumption of axis translation. In certain situations, a combination of entity and record axis data may be the more appropriate alternative.