DEATH CERTIFICATION ERRORS: PRACTICAL PROBLEMS IN EVERYDAY PRACTICE

Background and AimDeath certificate (DC) data provides a basis for public health policies and statistics and contributes to the evaluation of a pandemic's evolution. This study aimed to evaluate the quality of the COVID‐19‐related DC completion.MethodsA descriptive‐analytical study was conducted to review a total of 339 medical records and DCs issued for COVID‐19 cases from February 20 to September 21, 2020. A univariate analysis (χ 2 as an unadjusted analysis) was performed, and multiple logistic regression models (odd ratio [OR] and 95% confidence interval [CI] as adjusted analyses) were used to evaluate the associations between variables.ResultsErrors in DCs were classified as major and minor. All of the 339 examined DCs were erroneous; more than half of DCs (57.8%) had at least one major error; all of them had at least one minor error. Improper sequencing (49.3%), unacceptable underlying causes of death (UCOD) (33.3%), recording more than one cause per line (20.1%), listing general conditions instead of specific terms (11.2%), illegible handwriting (8.3%), competing causes (6.2%), and mechanisms (3.8%) were most common major errors, respectively. Absence of time interval (100%), listing mechanism allying with UCOD (51.6%), using abbreviations (45.4%), missing major comorbidities (16.5%), and listing major comorbidities in part I (16.5%) were most common minor errors, respectively.ConclusionThe rate of both major and minor errors was high. Using automated tools for recording and selecting death cause(s), promoting certifiers' skills on DC completion, and applying quality control mechanisms in DC documentation can improve death data and statistics.

The Automated Classification of Medical Entities (ACME) system objectively assessed the appropriateness of underlying cause-of-death certification and assignment

Quality of death certification based on the documented underlying cause of death: A retrospective study

ObjectiveThis study was conducted to evaluate the concordance between the underlying causes of death (UCOD) on the death certificates written by three emergency physicians (EPs). We investigated errors on the death certificates committed by each EP.MethodsThis study included 106 patients issued a death certificate in the emergency department of an academic hospital. Three EPs reviewed the medical records retrospectively and completed 106 death certificates independently. The selection of the UCOD on the death certificates by each EP (EP-UCOD) was based on the general principle or selection rules. The gold standard UCOD (GS-UCOD) was determined for each patient by unanimous consent between three EPs. We also compared between the EP-UCOD and the GS-UCOD. In addition, we compared between UCODs of three EPs. The errors on the death certificates were investigated by each EP.ResultsThe rates of concordance between EP-UCOD and the GS-UCOD were 86%, 81%, and 67% for EP-A, EP-B, and EP-C, respectively. The concordance rates between EP-A and EP-B were the highest overall percent agreement (0.783), and those between EP-A and EP-C were the lowest overall percent agreement (0.651). Although each EP had differences in the errors they committed, none of them listed the mode of dying as UCOD.ConclusionThis study confirmed that each EP wrote death certificates indicating different causes of death for the same decedents; however, the three EPs made fewer errors on the patients’ death certificates compared with those reported in previous studies.

Quality of death certificates in Quemoy, Taiwan.

Impact of using multiple causes of death codes to compute site-specific, death certificate-based cancer mortality statistics in the United States

BackgroundCause of death (COD) information taken from death certificates is often inaccurate and incomplete. However, the accuracy of Underlying CODs (UCODs) recorded on death certificates has not been comprehensively described when multiple diseases are present.MethodsA total of 450 consecutive autopsies performed at a geriatric hospital in Japan between February 2000 and August 2002 were studied. We evaluated the concordance rate, sensitivity, and specificity of major UCODs (cancer, heart disease, and pneumonia) reported on death certificates compared with a reference standard of pathologist assessment based on autopsy data and clinical records. Logistic regression analysis was performed to assess the effect of sex, age, comorbidity, and UCODs on misclassification.ResultsThe concordance rate was relatively high for cancer (81%) but low for heart disease (55%) and pneumonia (9%). The overall concordance rate was 48%. Sex and comorbidity did not affect UCOD misclassification rates, which tended to increase with patient age, although the association with age was also not significant. The strongest factor for misclassification was UCODs (P < 0.0001). Sensitivity and specificity for cancer were very high (80% and 96%, respectively), but sensitivity for heart disease and pneumonia was 60% and 46%, respectively. Specificity for each UCOD was more than 85%.ConclusionsResearchers should be aware of the accuracy of COD data from death certificates used as research resources, especially for cases of elderly patients with pneumonia.

BackgroundIdentifying a single disease as the underlying cause of death (UCOD) is an oversimplification of the clinical-pathological process leading to death. The multiple causes of death (MCOD) approach examines any mention of a disease in death certificates. Taking diabetes as an example, the study investigates: patterns of death certification, differences in mortality figures based on the UCOD and on MCOD, factors associated to the mention of diabetes in death certificates, and potential of MCOD in the analysis of the association between chronic diseases.MethodsThe whole mortality archive of the Veneto Region-Italy was extracted from 2008 to 2010. Mortality rates and proportional mortality were computed for diabetes as the UCOD and as MCOD. The position of the death certificate where diabetes was mentioned was analyzed. Conditional logistic regression was applied with chronic liver diseases (CLD) as the outcome and diabetes as the exposure variable. A subset of 19,605 death certificates of known diabetic patients (identified from the archive of exemptions from medical charges) was analyzed, with mention of diabetes as the outcome and characteristics of subjects as well as other diseases reported in the certificate as predictors.ResultsIn the whole mortality archive, diabetes was mentioned in 12.3 % of death certificates, and selected as the UCOD in 2.9 %. The death rate for diabetes as the UCOD was 26.8 × 105 against 112.6 × 105 for MCOD; the UCOD/MCOD ratio was higher in males. The major inconsistencies of certification were entering multiple diseases per line and reporting diabetes as a consequence of circulatory diseases. At logistic regression the mention of diabetes was associated with the mention of CLD (mainly non-alcohol non-viral CLD). In the subset of known diabetic subjects, diabetes was reported in 52.1 %, and selected as the UCOD in 13.4 %. The probability of reporting diabetes was higher with coexisting circulatory diseases and renal failure and with long duration of diabetes, whereas it was lower in the presence of a neoplasm.ConclusionsThe use of MCOD makes the analysis of mortality data more complex, but conveys more information than usual UCOD analyses.

Diversity in death certification: A case vignette approach

Introduction: Analysis of COPD mortality based only on the underlying cause of death (UCOD) derived from death certificates underestimates disease burden. We analyzed the burden of COPD, as well as the pattern of reporting COPD and its co-morbidities in death certificates, using multiple-cause of death (MCOD) records.Methods: All 220,281 death certificates of decedents aged ≥40 years in the Veneto region (northeastern Italy) were analyzed through 2008–2012. The UCOD was selected by the Automated Classification of Medical Entities software. COPD was defined by ICD-10 codes J40-J44 and J47 based either on the UCOD or on any mention of COPD in death certificates (MCOD). Annual age-standardized COPD death rates were computed for 40–85 year-old subjects.Results: COPD was mentioned in 7.9% (and selected as the UCOD in 2.7%) of death certificates. In about half of these, COPD was mentioned in Part II only. After circulatory and neoplastic diseases, the most frequent chronic diseases reported in certificates with any mention of COPD were diabetes (15.2%) and dementia/Alzheimer (8.9%). Between 2008 and 2012, age-standardized death rates (/100,000/year) decreased from 39.8 to 34.0 in males and from 12.7 to 11.3 in females in the UCOD analyses. These trends were confirmed, although figures were three times greater, in the MCOD analyses.Conclusions: MCOD analysis should be adopted to fully evaluate the burden of COPD-related mortality. Our findings support a decreasing trend in COPD-related mortality in northeastern Italy between 2008 and 2012, in line with other recent studies in Europe and beyond.

We studied changes in death statistics by deaths from diabetes mellitus (DM) after introduction of mandatory online death certificate (DC) submission in Norway. Information on deaths with DM mentioned in the DCs from year 2017 (DCs submitted on paper) to 2022 (DCs submitted online) was collected from the Norwegian Cause of Death Registry (NCoDR), Sex, age, year of death and type of DC (paper (pDC) vs electronic (eDC)) was registered. In DCs with DM as underlying cause of death (UCOD), all codes (International classification of diseases, 10th revision (ICD-10)), their original position in the DC and place of death were collected. DM was classified as type-1, type-2 and other. Differences between 2017 and 2022 according to use of unspecified DM diagnoses, number of changed diagnoses after automated processing, correct positioning of UCOD in DC, total number of diagnoses, and use of ill- defined diagnoses were analyzed. Generalized linear models for binomial outcome with log link were used to fit mortality data and test differences between electronic and paper registration systems, two-sample t-test and linear regressions for analysis of differences in number of diagnoses. 229 807 deaths were registered, including 3 864 DM deaths. Online DC submission increased from 0 in 2017 to 95% in 2022. In 2022, DCs with DM as UCOD showed significant less use of unspecified diabetes diagnoses (Relative risk,RR: 0.18, 95% confidence interval (CI): 0.14-0.22), reduced need for change of diagnoses after automated processing (RR: 0.52, CI: 0.46-0.59), reduced number of diagnoses (CI: -0.7 to -0.38), and less use of ill-defined diagnoses (RR: 0.83, CI: 0.71-0.97). The introduction of online cause of death submission in Norway improved the quality of registration of deaths from diabetes.

Errors and misreporting on death certificates are common, along with potential inaccuracies in cause-of-death coding. We characterized and compared fatalities by animal-encounter mentions reported as underlying cause of death (UCD) with animal-encounter mentions reported as multiple cause of death (MCD) to determine factors associated with misreporting UCD. We analyzed fatality data from 1999-2016 from the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research by UCD and MCD animal-encounter mentions (International Classification of Diseases, 10th Revision codes W53-59, X20-27 and X29, T63.0-63.6, T63.8-63.9, and T78.2-78.4). We examined differences in reporting by age, sex, race, autopsy (yes, no, unknown), allergic reactions, and toxicities. The number of animal-encounter mentions by UCD was 3638 (202 average per year) and by MCD was 4280 (238 average per year), a difference of 18% (n = 642; 36 average per year) by MCD analysis. The number of nonvenomous animal-encounter mentions increased 20% (from 2138 UCD to 2567 MCD), and the number of venomous animal-encounter mentions increased 14% (from 1500 UCD to 1713 MCD). Decedents aged ≥65 had the highest additional number of animal-encounter mentions among all age groups, primarily encounters with other reptiles (n = 113), other mammals (n = 71), and dogs (n = 42). Of 642 MCD additional animal-encounter mentions, heart disease (n = 211, 33%) and infections (n = 146, 23%) represented more than half of the UCD. Of 553 dog-encounter fatalities, 165 (30%) were among children aged ≤4. Animal-encounter fatalities, analyzed by UCD alone, may be underreported. An initiating animal injury, complicated by comorbidities and fatality, may obscure the causal chain, resulting in misreporting UCD. Ongoing training for medical certifiers is recommended, highlighting accurate identification of UCD and contributing causes in the causal chain of death.

Asthma-related mortality in the United States, 1999 to 2015: A multiple causes of death analysis

4699 Background: Norway has one of the highest PC mortality rates world-wide. Two processes affect the quality and comparability of cause of death statistics: the information basis and handling of the information (codification process). In Statistics Norway (SN) the codification process is manual and information both from the death certificate, autopsy reports, queries to physicians and routinely collected information from the national Cancer Registry of Norway is used. To investigate the impact of SN registration routines on the Norwegian PC mortality rates we compared the underlying cause of death (UCOD) selected by SN to the UCOD selected by ACME. Methods: From the files of SN and Cancer Registry of Norway a total of 2012 Norwegian men with a diagnosis of PC and who died in 1996 were identified. Death certificates were collected from SN and recoded according to ACME specifications with use of death certificate information only. The UCOD selected by ACME was compared to the UCOD selected by SN. Age standardized PC mortality rates (World Population) were calculated. Results: In only 29 cases ACME could not select an UCOD. These cases were coded manually. Using ACME as described the age standardized (World Population) PC mortality rate in Norway for 1996 would have been 24.0 as compared to the figure of 24.8 based on UCODs identified by SN. Overall, ACME selected PC as UCOD in 1124 cases as compared to 1161 according to SN. In 1081 cases both ACME and SN selected PC as UCOD. Conclusions: On a case level there are noticeable differences between the automated coding system ACME and Statistics Norway regarding selection of PC as underlying cause of death. Overall, however, the registration routines do not fully explain the high PC mortality rate in Norway. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Aventis Norway

Common errors in reporting cause-of-death statement on death certificates: A systematic review and meta-analysis