Death Certificate Completion Research Articles

Subnotificação da mortalidade materna no Estado do Paraná, Brasil: 1991-2005

The objective of this article was to analyze the underreporting of maternal deaths in Paraná State, Brazil, from 1991 to 2005, identifying details on the basic causes that keep maternal deaths hidden and problems with completing items 43 and 44 on death certificates during a recent period (2003-2005). Data were obtained from the database of the Paraná State Committees for the Prevention of Maternal Mortality, which investigate maternal deaths using the Reproductive Age Mortality Survey (RAMOS). According to the data, maternal mortality decreased by 26% in 15 years, but the level of underreporting remained the same, generating adjustment factors ranging from 1.6 to 1.8. In conclusion, medical schools and the State medical board should provide more incisive and comprehensive orientation on completing death certificates in order to minimize this underreporting. The Paraná State Committees for the Prevention of Maternal Mortality help correct underreporting of maternal deaths by identifying their real causes and determinants and defining strategies to reduce them. More effective measures to reduce avoidable maternal deaths are still needed in the State.

Though Rare, Long-Term Care Autopsies Are Valuable

Though Rare, Long-Term Care Autopsies Are Valuable

Errors in death certificates in a rural area of Greece

A death certificate is the formal document in which a physician records the time, cause and circumstances under which the death of an individual has occurred. Morbidity and mortality statistics are mainly based on the analysis of these certificates, and inaccuracies in the detail may lead to biased estimation in several epidemiological parameters. The aim of this study was to examine the quality of cause of death in death certificates in a rural area of Greece, and to identify factors that may be associated with inaccuracies in the completion of these death certificates. All death certificates archived in the municipality of Tritaia during the period 1999-2006 were examined. Statistical analysis was performed by comparing the proportions of the unpaired case. The state of independence among the various variables was investigated by considering the class of discrete graphical models. In total, 516 death certificates were examined; 5.6% (29/516) were excluded because of insufficient demographic data. The remaining 487 death certificates were analyzed with the following findings: 51.5% were for males and 48.5% females (median age 82 years, range 5-103 years; and 83 years, range 0-104, respectively); and 39.4% (192/487) were correctly completed. In 168 the mechanism of death was given; in 72 multiple causal sequences were given; in 22 a single/not precise cause was given; and in 33 a single causal sequence with incorrect order was given. In all, 20.1% were completed by a physician of the regional health centre. Gender was not associated with the presence of error (p = 0.352). Errors were present in 63.8% (270/423) of the death certificates in deceased individuals > or =60 years and in 39.1% (25/64) of the death certificates in individuals < or =59 years (p<0.001). In 19.7% of the erroneously completed death certificates, the certifier was a physician working in primary health care. The presence of errors in death certificates decreased from 74.6% in 1999 to 51.8% in 2006 (p = 0.004). Giving the mechanism instead of the cause of death was the most frequent type of error. A statistically significant increase in the presence of errors was observed as the age of the descendent increased. During these 8 years, there has been a statistically significant decrease in errors. However, efforts should be made by trainers and physicians in order to improve the accuracy of the information in death certificates. If this is accomplished, cause-of-death statistics will be more accurate and so enable better health planning.

Evaluating an educational intervention to improve the accuracy of death certification among trainees from various specialties

BackgroundThe inaccuracy of death certification can lead to the misallocation of resources in health care programs and research. We evaluated the rate of errors in the completion of death certificates among medical residents from various specialties, before and after an educational intervention which was designed to improve the accuracy in the certification of the cause of death.MethodsA 90-min seminar was delivered to seven mixed groups of medical trainees (n = 166) from several health care institutions in Spain. Physicians were asked to read and anonymously complete a same case-scenario of death certification before and after the seminar. We compared the rates of errors and the impact of the educational intervention before and after the seminar.ResultsA total of 332 death certificates (166 completed before and 166 completed after the intervention) were audited. Death certificates were completed with errors by 71.1% of the physicians before the educational intervention. Following the seminar, the proportion of death certificates with errors decreased to 9% (p < 0.0001). The most common error in the completion of death certificates was the listing of the mechanism of death instead of the cause of death. Before the seminar, 56.8% listed respiratory or cardiac arrest as the immediate cause of death. None of the participants listed any mechanism of death after the educational intervention (p < 0.0001).ConclusionMajor errors in the completion of the correct cause of death on death certificates are common among medical residents. A simple educational intervention can dramatically improve the accuracy in the completion of death certificates by physicians.

Inaccuracy, Underreporting of Injury, and Lack of Training in Death Certificates

OBJECTIVE: Death certificates are a common data source for injury research, but their legitimacy depends on proper completion by physicians (MDs). We sought to assess MD accuracy and training in completion of death certificates. METHODS: We tested the ability of 361 MDs at a University hospital to complete a sample death certificate. The test was conducted via an anonymous web-based system. We questioned MDs regarding the type of death certificate instruction they had received. The test included a description of a patient with a death due to intracranial bleeding after a fall, and the MDs completed a mock death certificate. Language: en

Análise da qualidade da informação sobre causa básica de óbitos neonatais registrados no Sistema de Informações sobre Mortalidade: um estudo para Maceió, Alagoas, Brasil, 2001-2002

Analysis of the quality of information on basic causes of neonatal deaths in Brazil is crucially important, since it allows one to estimate how many deaths are avoidable and provide support for policies to decrease neonatal mortality. The current study aimed to evaluate the reliability and validity of the Mortality Information System (MIS) for discriminating between basic causes of neonatal deaths and defining percentages of reducible causes. The basic causes of early neonatal deaths in hospitals in Maceió, Alagoas State, were analyzed, and the causes recorded in medical records were compared to the MIS data in order to measure reliability and validity. The modified SEADE Foundation and Wigglesworth classifications were compared to analyze the capacity for reduction of neonatal mortality. Maternal causes predominated in the medical records, as compared to respiratory disorders on the death certificates and in the MIS. The percentage of avoidable deaths may be much higher than observed from the MIS, due to imprecision in completing death certificates. Based on the MIS, the greatest problems are in early diagnosis and treatment of neonatal causes. However, the results show that the most pressing problems relate to failures in prenatal care and lack of control of diseases.

The Editor writes

There are several significant strands running through this issue of JICS, most prominently hospital-acquired infection (HAI), manpower issues and resuscitation. After the publication of the latest paper 1 on selective decontamination of the digestive tract, there is renewed interest in evaluating its role in the UK where MRSA is endemic. The ICS and ICS Foundation support the SuDDICU trial, and Rick Van Saene and his colleagues re-evaluate the potential role of SDD for intensive care in the UK. One of the CATs reviews the Bonten SDD paper. Roxana Curtis won the 2008 medical student essay award from the ICS research committee with her review of catheterrelated blood stream infection. Two further articles in this issue survey methods for reducing HAI, namely oral hygiene and the use of PICC lines to replace central lines. ‘Surviving Sepsis’ as currently practised in Scotland is reviewed. There is an interesting study, albeit on cardiac surgery patients, suggesting that the correlation between central and mixed venous oxygen saturations may not have the fidelity we hope when using ScvO2 to guide resuscitation using early goal-directed therapy. The trainee committee of the ICS has expressed concern about the route for trainees from a non-anaesthetic background to become consultants, because although 15% of our trainees are not anaesthetists, only 4% of consultant posts are currently held by non-anaesthetists. Chris Rigg has surveyed cardiac ICUs making pertinent observations about the role of cardiac intensive care in ICM training. And although not directly related, there is a fascinating article about veterinary critical care, which incidentally has the best photos of any edition! Andrew Quinn and his colleagues have summarised the proposed differences in death certification and further demonstrated the difficulties in accurate and consistent completion of death certificates. Som Sarkar and his colleagues review aspects of current practice of percutaneous tracheostomy, timely in view of the TRACman trial which has just been presented in Brussels. The concept and current state of hypotensive resuscitation is well reviewed by Kathryn Jackson in a shortened version of her dissertation for the UK DICM. There is another survey of the management of burns patients with inhalational injury, showing the need for consensus guidelines for their management. Jonathan Handy comments on GIFTASUPs, questioning the relevance of hyperchloraemic acidosis and pointing out some of the potential disadvantages of balanced salt solutions. Two case reports explore metabolic issues as well, one questioning the importance of metformin-associated lactic acidosis, the other reviewing ethylene glycol poisoning. There are our regular features as well ‐ more CATs, Society reports, a book review and letters. I hope you enjoy reading our latest issue. As always, thanks are due to our reviewers, proof-reader and publisher.

Inaccuracy, Underreporting of Injury, and Lack of Training in Death Certificates

OBJECTIVE: Death certificates are a common data source for injury research, but their legitimacy depends on proper completion by physicians (MDs). We sought to assess MD accuracy and training in completion of death certificates. METHODS: We tested the ability of 361 MDs at a University hospital to complete a sample death certificate. The test was conducted via an anonymous web-based system. We questioned MDs regarding the type of death certificate instruction they had received. The test included a description of a patient with a death due to intracranial bleeding after a fall, and the MDs completed a mock death certificate. Language: en

Confiabilidade da informação sobre mortalidade por violência em Belo Horizonte, MG

To determine reliability of data encoding for death due to violence; to assess the agreement between cause of death in the Mortality Information System and cause selected from the Forensic Medicine Institute database; and to assess the impact of adding information of non-specified injuries and undetermined death events subsequently obtained from Forensic Medicine Institute in the mortality statistics due to violence. A random sample of 411 death certificates due to violence was obtained in Belo Horizonte, Southeastern Brazil, between 1998 and 2000. Based on data from death certificates and Forensic Medicine Institute database, causes of death were coded and the agreement between this information and that from Mortality Information System was assessed. Also, in all certificates including "non-specified injury" and "undetermined death events," the impact of adding information from Forensic Medicine Institute was assessed in the classification of cause of death. Coding agreement was significant (Kappa=0.782; 95% CI: 0.744; 0.819) and of the underlying cause was moderate to significant (Kappa=0.602; 95% CI: 0.563; 0.641). There were 12.9% and 5.7% misclassification of suicides and murders, respectively, for those causes classified as "non-specified injury" and "undetermined death events," which were overall reduced to 47.3% and 59.8% respectively. There is a need for further improving the process of underlying cause coding and selection. Also medical examiners need to provide more complete death certificates and medical and police information provided with bodies for Forensic Medicine Institute autopsy should be more complete, especially in those cases of road traffic injuries and falls.

Improving Death Certificate Completion: A Trial of Two Training Interventions

The death certificate is an important medical document that impacts mortality statistics and health care policy. Resident physician accuracy in completing death certificates is poor. We assessed the impact of two educational interventions on the quality of death certificate completion by resident physicians. Two-hundred and nineteen internal medicine residents were asked to complete a cause of death statement using a sample case of in-hospital death. Participants were randomized into one of two educational interventions: either an interactive workshop (group I) or provided with printed instruction material (group II). A total of 200 residents completed the study, with 100 in each group. At baseline, competency in death certificate completion was poor. Only 19% of residents achieved an optimal test score. Sixty percent erroneously identified a cardiac cause of death. The death certificate score improved significantly in both group I (14±6 vs 24±5, p<0.001) and group II (14±5 vs 19±5, p<0.001) postintervention from baseline. Group I had a higher degree of improvement than group II (24±5 vs 19±5, p<0.001). Resident physicians’ skills in death certificate completion can be improved with an educational intervention. An interactive workshop is a more effective intervention than a printed handout.

Evaluation of Death Certificate-Based Surveillance for Traumatic Brain Injury—Oklahoma 2002

Death certificate data are used to estimate state and national incidence of traumatic brain injury (TBI)-related deaths. This study evaluated the accuracy of this estimate in Oklahoma and examined the case characteristics of those persons who experienced a TBI-related death but whose death certificate did not reflect a TBI. Data from Oklahoma's vital statistics multiple-cause-of-death database and from the Oklahoma Injury Surveillance System database were analyzed for TBI deaths that occurred during 2002. Cases were defined using the Centers for Disease Control and Prevention (CDC) ICD-10 code case definition. In multivariate analysis using a logistic regression model, we examined the association of case characteristics and the absence of a death certificate for persons who experienced a TBI-related death. Overall, sensitivity of death certificate-based surveillance was 78%. The majority (62%) of missed cases were due to listing "multiple trauma" as the cause of death. Death certificate surveillance was more likely to miss TBI-related deaths among traffic crashes, falls, and persons aged > or = 65 years. After adding missed cases to cases captured by death certificate surveillance, traffic crashes surpassed firearm fatalities as the leading external cause of TBI-related death. Death certificate surveillance underestimated TBI-related death in Oklahoma and might lead to national underreporting. More accurate and detailed completion of death certificates would result in better estimates of the burden of TBI-related death. Educational efforts to improve death certificate completion could substantially increase the accuracy of mortality statistics.

Accurately Assessing Elderly Fall Deaths Using Hospital Discharge and Vital Statistics Data

Historically, fatal injury monitoring and surveillance have relied on mortality data derived from death certificates (DC). However, problems associated with utilizing DC have been well documented. Recently, access to and utilization of hospital discharge data (HDD) have offered a new and important secondary source of data regarding in-hospital deaths. However, studies have shown that discrepancies between the HDD and the corresponding DC often exist. This discrepancy was especially evident when comparing HDD to the vital statistics data (VSD) for deaths by falls among those aged 65 and over in 19 states. This was a retrospective forensic review of elderly (age 65 and over) fall-associated fatalities (E880-E888) identified from HDD and VSD in Allegheny County, Pennsylvania, between 1997 and 1998. Seventy-seven cases were identified, with the original manner of death listed as natural (34), suicide (1), and accidental (42) on the DC. Following a forensic review of the cases, the manner of the death on the DC should have been changed from natural to accidental in 28% (n = 12) of the cases, representing an undercount in the VSD. Undercounts were due to a failure of clinicians to account for the significance of a fall event that contributed to subsequent pathology and death. In addition, in that 22% (n = 17) of the HDD fall-associated deaths, the fall did not contribute directly or sequentially to the underlying cause of death, thereby representing an overcount in the HDD. Based on these findings we recommend (1) elderly fall surveillance systems should only count HDD E-coded falls that demonstrate a serious traumatic injury which directly or subsequently results in death, (2) all in-hospital fall-associated deaths should be reported to and reviewed by coroner/Medical Examiner offices for determination of the cause and manner of death, and (3) physicians should be better educated in properly completing death certificates.

The Use of Verbal Autopsy in Attributing Cause of Death from Epilepsy

Verbal autopsy (VA) is a method used increasingly in low-income countries to ascertain the likely cause of death. Originally developed for use in pediatrics and infectious disease, it is also useful in situations with poor data on adult mortality. Using information on cause of death ascertained through interviews with relatives or other associates of the deceased, assessment of the likely cause of death is performed by expert clinicians. Methodological issues related to the VA method include robustness when dealing with less-frequent causes of death; use of open or closed mortality classification; and possible selection bias in assessing cause of death. However, alternatives, including death certification, share many sources of imprecision. The clear advantage of the VA method is that it does not depend on access to clinic services, although clinical experts are used for the classification process. Even this may be challenged by the development of algorithms for the automatic coding of cause of death. VA has not been systematically applied to studies of causes of death in developed countries where physicians are available to complete death certificates. However, in studies of sudden unexplained death in developed countries, techniques similar to VA are used to ascertain circumstances surrounding death to be able to potentially classify it as sudden and unexplained. Thus, family and friends of the deceased are potentially valuable contributors, using the VA methodology: VA is useful in low-income countries to estimate the burden of epilepsy on all-cause mortality and, in industrialized nations it offers insights into sudden death from epilepsy.

Death Certification in Long-term Care

Increasing public and legal scrutiny of nursing facilities and the growing proportion of US deaths that occur there 1 Committee on Care at the End of Life, Division of Health Care Services, Institute of Medicine. in: Field M. Cassel C. Approaching Death Improving Care at the End of Life. National Academy Press, Washington, DC1997 Google Scholar have led to increased concerns among physicians about completion of death certificates. We would like to acknowledge these concerns and offer some background information and suggestions.

Accurate Completion of Death Certificates: The Need for Formalised Training in the Nigerian Medical Curriculum

Research of medical schools initiative attempting to orient medical students towards future role in society can only serve in pursuance of WHO objectives for medical education. Medical teachers see the natural process of death as an anathema and pay little attention to the subject in both pathology and clinical courses. Doctors and consequently medical students have the notion that their primary responsibility is to save lives and if possible prolong life possibly in perpetuity. The death of a patient is seen as an indictment. Therefore, in the medical school curriculum little emphasis is placed on the training of last offices. A medical school has responded to the need in this area by the use of a dynamic curriculum in which as part of the medical jurisprudence course the future role of doctors are highlighted. A cross sectional survey of 127 final year medical students aptitude to filling the death certificate was carried out by administering a 14 item self administered questionnaires with the filling of a death certificate. These were Medical and Dental Students of the College of Medicine, University of Lagos, who had completed rotations in pathology and Clinical medicine. The aim of the study was to assess the knowledge in performance of last offices and test skills in death certification. Results show that about 96% of the students had no formal teaching in the filling of death certificates. A large percentage, over 70% of them had never seen a death certificate filled. Among the 38 students who had seen or had been taught how to complete death certificates, 23 (18.1%) of the total students surveyed and (61%) of those who had seen certificates filled did this at the Third Year 400 Level of their studies during pathology posting while less than 1% or only 10/38 (27%) of them had seen this event during their clinical years. Of the cadre of medical staff who the students had observed filling death certificates, more Registrars (72%) were responsible for this activity than others. Over 85% of the students were aware of the importance of death certification. We recommend the inclusion of formal training on death certificate completion in Medical School curriculum in Nigeria to enhance the accuracy of health statistics. KEY WORDS: Death certificate, medical students, medical education, Nigeria Nigerian Journal of Health and Biomedical Sciences Vol.4(1) 2005: 76-81

Quality Assurance Review of Death Certificates

Although quality assurance programs for medical examiners are required by the National Association of Medical Examiners' Inspection and Accreditation Checklist, quality assurance programs specifically targeting death certificate completion have not been addressed. The Fulton County Medical Examiner, Atlanta, GA, has implemented a pilot quality assurance program for death certificate information, and this report contains information about 1 year's experience with the program. All death certificates are reviewed by the case medical examiner(s) and chief medical examiner prior to their release to funeral homes. Death certificates with errors are retained for quality assurance and review purposes, and needed corrections are made before death certificates are released. During a 1-year period, death certificates with errors were collected and then reviewed and tabulated by type of error. Between May 26, 2003, and May 25, 2004, the Fulton County Medical Examiner certified 1267 deaths. Of these, 47 (4%) were found to contain errors that were corrected and an additional 52 (4%) had been amended for various reasons. The most common errors were misspellings in causes of death or poor or incomplete wording in injury-related information. Forty-seven percent of errors involved omitted, incomplete, or incorrect information that was potentially significant. The most common reason for amended certificates was unexpected detection of acute intoxications among people with significant cardiovascular disease. Quality assurance review of death certificates can assist in preventing the release of death certificates with incomplete, erroneous, or omitted information and may also be useful as an educational forum regarding completion of the death certificate.

Incomplete and Inaccurate Death Certification by Medical Students in Nigeria, the Need for Guidance

The study aimed to find out the level of knowledge of medical death certification of final year medical students, Objective - (1) To assess their knowledge of death certification (2) find out at what level of their training they came in contact with death certificates (3) who normally fills death certificate (4) if they can fill death certificate correctly (5) if there is need for formalized training session on death certificate in the medical school. Materials and Methods - This was a cross sectional survey of 50 final year medical students of Obafemi Awolowo College of Health Science, Olabisi Onabanjo University, (O.A.C.H.S. O.O.U.) who had completed their rotations in pathology and clinical posting and these students were chosen at random. This was carried out by administering self-structured 15 item questionnaires to the students and they were also given death certificate to fill out on a clinical scenario. Results – About 63% students had no formal teaching in the filling of death certificate and over 55% of them had never seen a death certificate filled. Among the 45% of student who had seen death certificate filled, less than 25% of them did so at various levels of their pathological and clinical postings. The students saw more house offices filling death certificate than other cadre of doctors. 50% of them would want to be trained on death certification at morbid anatomy postings. Over 80% of the students were aware of the importance and indications for death certification. Conclusion – The inclusion of formal training in death certificate completion in the medical school curriculum of the Obafemi Awolowo College of health Science, Olabisi Onabanjo University Ogun State, would be desirable. Key Words: Death Certification, Medical Students, School Curriculum Nigerian Medical Practitioner Vol.46(4) 2004: 84-86

Death certificate completion: How well are physicians trained and are cardiovascular causes overstated?

To determine the ability of residents in completing death certificates correctly. A total of 4800 residents were asked to complete a survey and cause-of-death statement using a sample case of in-hospital death due to urosepsis, of whom 590 residents (12%) responded. A scoring scale designed based on instructions from the National Association of Medical Examiners and the American College of Pathologists was used to measure responses quantitatively. Overall performance was poor, with only 23% (n = 137) of responses in the optimal scoring range. The average score was influenced significantly by level of residency training, as well as previous experience, prior formal training, and awareness of the guidelines regarding death certificate completion. Optimal scores correlated with level of residency training and prior formal training in death certificate completion, suggesting the benefits of experience and instruction. Forty-five percent (n = 267) of respondents incorrectly identified a cardiovascular event as the primary cause of death. The residents in this study demonstrated suboptimal performance in death certificate completion. Cardiovascular events were often incorrectly identified as the primary cause of death. Formal training can improve performance and should be emphasized in medical schools and residencies.

The discrepancy between observational studies and randomized trials of menopausal hormone therapy: did expectations shape experience?

Differences between observational and randomized studies of the effects of menopausal hormone therapy (HT) on coronary heart disease (CHD) have been attributed to the fact that women who choose to use HT tend to be healthier than those who do not. Although this bias should affect all clinical outcomes with modifiable risk factors, estimates for stroke and pulmonary embolism were unaffected. The authors sought possible explanations for this isolated discrepancy in CHD findings. Unlike the randomized Women's Health Initiative (WHI) trial, the observational Nurses' Health Study (NHS) did not try to detect silent myocardial infarctions. Many women present with atypical ischemic symptoms. Hormone therapy users who believe that HT reduces CHD risks might not interpret ischemic symptoms as related to CHD, might not seek medical attention, and might present differently to their physicians, all of which could lead to more unrecognized myocardial infarctions among HT users in the NHS. In addition, persons completing death certificates and NHS physicians interpreting death certificates were not blinded to the use of HT. If persons assigning cause of death knew the patient had used HT and believed that HT prevented CHD, they might have been more likely to assign a condition other than CHD as the cause of death. If HT users were 20% less likely to have their infarctions recognized and their deaths attributed to CHD, a true increase in CHD due to HT use would appear to be a reduction in CHD. Combining these reporting biases with socioeconomic differences between users and nonusers could explain discrepancies. Beliefs held by patients, clinicians, and investigators might have affected the ascertainment of CHD outcomes in observational studies.

Factors associated with errors in death certificate completion: A national study in Taiwan

To identify characteristics of certifying physicians and the deceased that are associated with errors in death certificate completion in Taiwan, we retrospectively reviewed 4123 systematically sampled death certificates issued in 1994. Multivariate analyses were used to assess the associations of various characteristics of the certifying physicians and the deceased with four types of error. Of the 4123 death certificates reviewed, 2525 (61%) were completed correctly. In 289 (7%), only the mechanism(s) of death was given (Major Error 1); in 146 (4%), multiple causal sequences were given in part I (Major Error 2); in 800 (19%), a single causal sequence was given but was not specific enough (Minor Error 1); and in 363 (9%), a single causal sequence was given but the order was incorrect (Minor Error 2). Multiple logistic regression analyses revealed that the probability of error in death certification increased as the age of the deceased increased, the age of the certifier decreased, and the level of the hospital decreased. These findings suggest that training in death certificate completion should focus on younger certifiers and those working at lower level teaching hospitals and nonteaching hospitals. Given the high rate of Minor Error 1, physicians should be reminded to state information as specifically as possible to render cause-of-death statistics more informative.