Death Certification Practices Research Articles

Bridging the gap: Assessing death certification competency in Bulgarian healthcare education

BACKGROUND: In Bulgaria, procedural protocols following a citizen’s death are governed by an intricate network of normative documents. Despite the presumed alignment between international and national guidelines, practical experiences reveal shortcomings in the proficiency of healthcare providers, particularly in cases involving prior medical interventions or systemic vulnerabilities.
 AIM: This study aimed to assess the readiness of final-year medical students and early-career physicians in navigating death certification intricacies, including their responses, documentation precision, and postmortem procedures for bereaved families, with implications for national health statistics.
 MATERIALS AND METHODS: By employing a mixed-methods approach, this study distributed questionnaires to sixth-year medical students and practicing physicians, including those in emergency medicine centers and general practice. Data collection included paper-based and digital questionnaires, ensuring anonymity and ethical compliance. Statistical analysis, employing parametric (t-test) and nonparametric (Chi-square) tests, forms the basis for actionable recommendations and educational material development.
 RESULTS: This study included 143 participants, of which 41% expressed apprehension about managing out-of-hospital deaths. Approximately 44% claimed familiarity with death certification regulations, with students displaying higher theoretical confidence but lacking practical knowledge. Remarkably, 74% of physicians never received formal training in death certification. Discrepancies in issuing death certificates, timing, and notification procedures were identified.
 CONCLUSION: Findings reveal varying practices among physicians according to their specialties. Issues related to documentation, timing, and notification were prevalent. The study emphasizes the need for improved training, particularly for medical students. Emergency medicine doctors exhibited higher preparedness levels. Medical students and early-career physicians urgently require enhanced education in death certification preparedness. Incorporating these topics into medical curricula, offering specialized courses, and disseminating instructional materials can significantly enhance effectiveness. Future studies should assess the quality and accuracy of recorded causes of death, which affect healthcare statistics, public service, and legal procedures, underscoring the societal and administrative significance of death certification practices.

Sudden Unexpected Infant Deaths: 2015-2020.

Although the US infant mortality rate reached a record low in 2020, the sudden infant death syndrome (SIDS) rate increased from 2019. To understand if the increase was related to changing death certification practices or the coronavirus disease 2019 (COVID-19) pandemic, we examined sudden unexpected infant death (SUID) rates as a group, by cause, and by race and ethnicity. We estimated SUID rates during 2015 to 2020 using US period-linked birth and death data. SUID included SIDS, unknown cause, and accidental suffocation and strangulation in bed. We examined changes in rates from 2019 to 2020 and assessed linear trends during prepandemic (2015-2019) using weighted least squares regression. We also assessed race and ethnicity trends and quantified COVID-19-related SUID. Although the SIDS rate increased significantly from 2019 to 2020 (P < .001), the overall SUID rate did not (P = .24). The increased SIDS rate followed a declining linear trend in SIDS during 2015 to 2019 (P < .001). Other SUID causes did not change significantly. Our race and ethnicity analysis showed SUID rates increased significantly for non-Hispanic Black infants from 2019 to 2020, widening the disparities between these two groups during 2017 to 2019. In 2020, <10 of the 3328 SUID had a COVID-19 code. Diagnositic shifting likely explained the increased SIDS rate in 2020. Why the SUID rate increased for non-Hispanic Black infants is unknown, but warrants continued monitoring. Interventions are needed to address persistent racial and ethnic disparities in SUID.

Is the Rise in Reported Dementia Mortality Real? Analysis of Multiple-Cause-of-Death Data for Australia and the United States.

Official statistics in Australia and the United States show large recent increases in dementia mortality rates. In this study, we assessed whether these trends are biased by an increasing tendency of medical certifiers (predominantly physicians) to report on the death certificate that dementia was a direct cause of death. Regression models of multiple-cause-of-death data in Australia (2006–2016) and the United States (2006–2017) were constructed to adjust dementia mortality rates for changes in death certification practices. Compared with official statistics, the recent increase in adjusted age-standardized dementia death rates was less than half as large in Australia and about two-thirds as large in the United States. Further adjustment for changes in reporting of dementia anywhere on the death certificate implied even lower increases in dementia mortality. Declines in reporting of cardiovascular diseases as comorbid conditions also contributed to rises in dementia mortality rates. The increasing likelihood of dementia’s being reported as directly leading to death largely explains recent increases in dementia mortality rates in both countries. However, studies have found that reported dementia on death certificates remains low compared with clinical evaluations of its prevalence. Improved guidance and training for certifiers in reporting of dementia on death certificates will help standardize mortality statistics within and between countries.

Impact of a Drug Overdose Decedent Toxicology Testing Legislative Mandate on Informing Coroner Death Investigation and Certification Practices.

To (a) determine the impact of Kentucky's (KY's) mandate requiring postmortem toxicology testing of coroner cases; (b) identify the influence of coroner experience and training, jurisdiction size, budget, and location on postmortem testing requests; (c) identify facilitators/barriers for postmortem toxicology testing requests and listing the specific drugs involved in drug-poisoning deaths on death certificates. A modified Dillman approach was used to deliver the survey to KY's elected coroners between April and May 2016. Responses stratified by identified influence factors were compared using χ2 tests and Fisher exact tests. Fifty-eight percent of coroners reported that drug overdose investigations had changed since the mandate was enacted. Statistically significant differences in responses were found when stratified. Sixty-three percent of coroners reported always using testing results to complete death certificates. Uptake of the mandate for postmortem toxicology testing of all decedents is not yet complete. Without uptake of the mandate, surveillance efforts may result in undercounting of drug overdose deaths and the involvement of specific drugs. Mandates for enhanced training and modification of funding structure for medico-legal death investigations could facilitate uptake.

Assessing the quality of medical death certification: a case study of concordance between national statistics and results from a medical record review in a regional hospital in the Philippines

BackgroundMedical certificates of cause of death (MCCOD) issued by hospital physicians are a key input to vital registration systems. Deaths certified by hospital physicians have been implicitly considered to be of high quality, but recent evidence suggests otherwise. We conducted a medical record review (MRR) of hospital MCCOD in the Philippines and compared the cause of death concordance with certificates coded by the Philippines Statistics Authority (PSA).MethodsMCCOD for adult deaths in Bohol Regional Hospital (BRH) in 2007–2008 and 2011 were collected and reviewed by a team of study physicians. Corresponding MCCOD coded by the PSA were linked by a hospital identifier. The study physicians wrote a new MCCOD using the patient medical record, noted the quality of the medical record to produce a cause of death, and indicated whether it was necessary to change the underlying cause of death (UCOD). Chance-corrected concordance, cause-specific mortality fraction (CSMF) accuracy, and chance-corrected CSMF were used to examine the concordance between the MRR and PSA.ResultsA total of 1052 adult deaths were linked between the MRR and PSA. Median chance-corrected concordance was 0.73, CSMF accuracy was 0.85, and chance-corrected CSMF accuracy was 0.58. 74.8% of medical records were deemed to be of high enough quality to assign a cause of death, yet study physicians indicated that it was necessary to change the UCOD in 41% of deaths, 82% of which required addition of a new UCOD.ConclusionsMedical records were generally of sufficient quality to assign a cause of death and concordance between the PSA and MRR was reasonably high, suggesting that routine mortality statistics data are reasonably accurate for describing population level causes of death in Bohol. While overall agreement between the PSA and MRR in major cause groups was sufficient for public health purposes, improvements in death certification practices are recommended to help physicians differentiate between treatable (immediate) COD and COD that are important for public health surveillance.

The quality of medical death certification of cause of death in hospitals in rural Bangladesh: impact of introducing the International Form of Medical Certificate of Cause of Death

BackgroundAccurate and timely data on cause of death are critically important for guiding health programs and policies. Deaths certified by doctors are implicitly considered to be reliable and accurate, yet the quality of information provided in the international Medical Certificate of Cause of Death (MCCD) usually varies according to the personnel involved in certification, the diagnostic capacity of the hospital, and the category of hospitals. There are no published studies that have analysed how certifying doctors in Bangladesh adhere to international rules when completing the MCCD or have assessed the quality of clinical record keeping.MethodsThe study took place between January 2011 and April 2014 in the Chandpur and Comilla districts of Bangladesh. We introduced the international MCCD to all study hospitals. Trained project physicians assigned an underlying cause of death, assessed the quality of the death certificate, and reported the degree of certainty of the medical records provided for a given cause. We examined the frequency of common errors in completing the MCCD, the leading causes of in-hospital deaths, and the degree of certainty in the cause of death data.ResultsThe study included 4914 death certificates. 72.9% of medical records were of too poor quality to assign a cause of death, with little difference by age, hospital, and cause of death. 95.6% of death certificates did not indicate the time interval between onset and death, 31.6% required a change in sequence, 13.9% required to include a new diagnosis, 50.7% used abbreviations, 41.5% used multiple causes per line, and 33.2% used an ill-defined condition as the underlying cause of death. 99.1% of death certificates had at least one error. The leading cause of death among adults was stroke (15.8%), among children was pneumonia (31.7%), and among neonates was birth asphyxia (52.8%).ConclusionPhysicians in Bangladeshi hospitals had difficulties in completing the MCCD correctly. Physicians routinely made errors in death certification practices and medical record quality was poor. There is an urgent need to improve death certification practices and the quality of hospital data in Bangladesh if these data are to be useful for policy.

A survey of medical examiner death certification of vignettes on death in epilepsy: Gaps in identifying SUDEP

ObjectiveLack of standardized terminology on death certificates (DCs) of SUDEP type cases may obscure the presence of epilepsy in these deaths. Most DCs for individuals dying unexpectedly with epilepsy are certified by medical examiners (MEs). The purpose of this study was to gauge death certification practices of MEs when interpreting SUDEP cases and assess implications for valid surveillance of SUDEP. Materials and methodsA survey consisting of clinical vignettes describing deaths in individuals with epilepsy was sent to medical examiners. Respondents were asked to indicate how they would certify death on a DC. Similar text responses were aggregated and coded according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) coding system. ResultsA total of 847 responses on 11 cases were received. Depending upon the vignette, the proportion of responses within each case that did not have an ICD-10 seizure code ranged from 3% to 62%. G40.9 (Epilepsy, unspecified) resulted from 43% of responses, and R56.8 (Other and unspecified convulsion) resulted from 38% of responses. ConclusionThe survey indicates that a high proportion of DCs do not have a seizure code and would not be identified utilizing these ICD-10 codes. The complicated nature of deaths in SUDEP, unclear circumstances surrounding a given death, and the lack of familiarity with SUDEP by surviving relatives may all contribute to variable terminology used to certify SUDEP deaths. Our results emphasize the need for collaboration between neurologists and forensic pathologists to develop a more uniform approach to death certification in SUDEP that will facilitate SUDEP research and inform relatives of individuals who die of SUDEP.

Additive Effects of Cointoxicants in Single-Opioid Induced Deaths.

A forensic drug database (FDD) was used to capture comprehensive data from all drug-related deaths in West Virginia, with deaths also included from the northern New England states of Maine, Vermont, and New Hampshire. All four states serve predominantly rural populations under two million and all have similar state medical examiner systems that employ statewide uniform death certification policies and practices. This study focused on 1482 single opioid deaths (fentanyl, hydrocodone, methadone, and oxycodone) in the FDD from 2007-2011. We modeled relationships between the opioid concentrations and the presence or absence of the following commonly occurring non-opioid cointoxicants: benzodiazepines (alprazolam and diazepam), alcohol, tricyclic antidepressants, selective serotonin reuptake inhibitors, and diphenhydramine. Additional covariates of state, age, body mass index, and sex were included. Results showed that the presence of alcohol, benzodiazepines, and antidepressants were each associated with statistically significant lower concentrations of some but not all of the opioids studied, which may obscure the interpretation of postmortem toxicology results alone. Fentanyl concentrations appeared to be the least associated with the presence or absence of the variables studied, and cointoxicant alcohol appeared to be associated with lower concentrations in opioid concentrations than were most of the other factors in the model studied. These findings underscore the importance of documenting all potential cointoxicants in opioid-related deaths.

High Israeli mortality rates from diabetes and renal failure - Can international comparison of multiple causes of death reflect differences in choice of underlying cause?

BackgroundThe age-adjusted mortality rate in Israel is low compared to most Western countries although mortality rates from diabetes and renal failure in Israel are amongst the highest, while those from cardiovascular diseases (CVD) are amongst the lowest. This study aims to assess validity of choice of underlying causes (UC) in Israel by analyzing Israeli and international data on the prevalence of these diseases as multiple causes of death (MCOD) compared to UC, and data on comorbidity (MCOD based).MethodsAge-adjusted death rates were calculated for UC and MCOD and the corresponding ratio of multiple to underlying cause of death (SRMU) for available years between 1999 and 2012. Comorbidity was explored by calculating cause of death association indicators (CDAI) and frequency of comorbid disease. These results were compared to data from USA, France, Italy, Australia and the Czech Republic for 2009 or other available year.ResultsMortality rates for all these diseases except renal failure have decreased in Israel between 1999 and 2012 as UC and MCOD. In 2009, the SRMU for diabetes was 2.7, slightly lower than other Western countries (3.0–3.5) showing more frequent choice as UC. Similar results were found for renal failure. In contrast, the SRMU for ischemic heart disease (IHD) and cerebrovascular disease were 2.0 and 2.6, respectively, higher than other countries (1.4–1.6 and 1.7–1.9, respectively), showing less frequent choice as UC. CDAI data showed a strong association between heart and cerebrovascular disease, and diabetes in all countries. In Israel, 40 % of deaths with UC diabetes had IHD and 24 % had cerebrovascular disease. Renal disease was less strongly associated with IHD.ConclusionThis international comparison suggests that diabetes and renal failure may be coded more frequently in Israel as UC, sometimes instead of heart and cerebrovascular disease. Even with some changes in coding, mortality rates would be high compared to other countries, similar to the comparatively high diabetes prevalence in Israel at older ages and high rate of end-stage renal failure.This study highlights the importance of physician training on death certification practice and need for further progress towards automation in recording and coding death causes.Electronic supplementary materialThe online version of this article (doi:10.1186/s13584-015-0027-6) contains supplementary material, which is available to authorized users.

Death certification practice in Qatar

To evaluate the knowledge and practice of death certification among physicians in Qatar. Cross-sectional study. Knowledge and practice of death certification were assessed in a group of 317 physicians, selected at random, using a self-administered questionnaire. Only 22.7% of physicians had received formal training in death certification. More than 60% of physicians knew which healthcare workers were entitled to complete the cause of death section of the form, and 37% of physicians were aware of the conditions for referral to a forensic physician. The most common difficulties facing physicians, when completing death certification forms, were dealing with complicated cases (47.3%), lack of training (43.5%) and failure to understand the terms used in the form (39.6%). Only 21.5% of physicians identified the cause of death correctly in the case scenario; 53.2% of physicians made major errors and 62.8% made minor errors. Lack of training appears to play a major role in the poor completion of death certification forms. Educational/administrative interventions and training activities are needed.

OP28 Trends in Mortality from Stroke, and Stroke Subtypes, in the Oxford Region 1979-2011

BackgroundA decline in mortality rates from stroke has been observed in many industrialised countries in recent decades. We were interested in whether any of the observed decline in stroke, and...

Engaging physicians in improved cause of death certification: evaluation of an education intervention

BackgroundAccurate cause of death (CoD) data is one of the most important public health datasets that informs burden of disease assessments. Clinicians lack understanding of the nature of public health utilisation of CoD information. Furthermore, medical schools do not provide sufficient guidance to their students on correct death certification practices. The aim of this paper is to present the results of an education intervention designed to educate doctors on correct death certification. MethodsWe developed a training curriculum, a handbook, and a set of teaching aids to train doctors in correct death certification practice. We used these materials in interactive workshops with 38 doctors in Fiji. The impact of the training was evaluated by pre-intervention and post-intervention tests using a vignette approach. It was also evaluated by assessing accuracy of death certification by these doctors 5 months after the workshops. FindingsThe findings suggested that the percentage of correctly entered death certificates increased from 33·3% (65 of 195) in pre-intervention to 69·2% (132 of 195) in post-intervention (p<0·0001). In certificates that had been wrongly entered, clinically improbable sequences accounted for the highest proportion of errors both in pre-intervention and post-intervention tests (63·6% [124 of 195] and 30·8% [60 of 195], respectively). The follow-up study showed 72·7% (136 of 187) accuracy in death certification by the same doctors, confirming a substantial change in practice. InterpretationThe training package was effective in bringing about substantial change in accuracy of death certification. A slightly modified package was subsequently used by the authors to train a group of doctors from 11 Pacific countries as trainers. We recommend the use of these materials in a wide variety of settings to train doctors in correct death certification practices. Without this sort of campaign to educate doctors in CoD certification, country CoD data will continue to be of little use for informing burden of disease assessments and health policy priorities. FundingUniversity of Queensland Health Information Systems Knowledge Hub funded by AusAID.

Studying Sudden and Unexpected Infant Deaths in a Time of Changing Death Certification and Investigation Practices: Evaluating Sleep-Related Risk Factors for Infant Death in New York City

We describe an approach for quantifying and characterizing the extent to which sudden and unexpected infant deaths (SUIDs) result from unsafe sleep environments (e.g., prone position, bedsharing, soft bedding); and present data on sleep-related infant deaths in NYC. Using a combination of vital statistics and medical examiner data, including autopsy and death scene investigation findings, we analyzed any death due to accidental threat to breathing (ATB) (ICD-10 W75 & W84), and deaths of undetermined intent (UND) (Y10-Y34) between 2000 and 2003 in NYC for the presence of sleep-related factors (SRF). Homicide deaths were excluded as were SIDS, since in NYC SIDS is not a certification option if environmental factors were possibly contributors to the death. All 19 ATB and 69 (75%) UND had SRFs as per the OCME investigation. Black infants and infants born to teen mothers had higher SRF death rates for both ATB and UND deaths. Bedsharing was the most common SRF (53%-ATB; 72%-UND deaths); the majority of non-bedsharing infants were found in the prone position (60%-ATB; 78%-UND deaths). We found a high prevalence of SRFs among ATB and UND deaths. This is the first local study to illustrate the importance of knowing how SUIDs are certified in order to ascertain the prevalence of infant deaths with SRFs. Advancing the research requires clarity on the criteria used by local medical examiners to categorize SUIDs. This will help jurisdictions interpret their infant mortality statistics, which in turn will improve education and prevention efforts.

Statewide Systematic Evaluation of Sudden, Unexpected Infant Death Classification: Results from a National Pilot Project

The Centers for Disease Control and Prevention funded seven states, including Kentucky, to clarify statewide death certification practices in sudden, unexpected infant death and compare state performances with national expectations. Accurate assignment of the cause and manner of death in cases of sudden, unexpected infant death is critical for accurate vital statistics data to direct limited resources to appropriate targets, and to implement optimal and safe risk reduction strategies. The primary objectives are to (1) Compare SUID death certifications recommended by the KY medical examiners with the stated cause of death text field on the hard copy death electronic death certificates and (2) Compare KY and national SUID rates. Causes of death for SUID cases recommended by the medical examiners and those appearing on the hard copy and electronic death certificates in KY were collected retrospectively for 2004 and 2005. Medical examiner recommendations were based upon a classification scheme devised by them in 2003. Coroners hard copy death certificates and the cause of death rates in KY were compared to those occurring nationally. Eleven percent of infants dying suddenly and unexpectedly did not undergo autopsy during the study interval. The KY 2003 classification scheme for SIDS is at variance with the NICHD and San Diego SIDS definitions. Significant differences in causes of death recommended by medical examiners and those appearing on the hard copy and electronic death certificates were identified. SIDS rates increased in KY in contrast to decreasing rates nationally. Nationwide adoption of a widely used SIDS definition, such as that proposed in San Diego in 2004 as well as legislation by states to ensure autopsy in all cases of sudden unexpected infant death are recommended. Medical examiners’ recommendations for cause of death should appear on death certificates. Multidisciplinary pediatric death review teams prospectively evaluating cases before death certification is recommended. Research into other jurisdictions death certification process is encouraged.

Accidental drug deaths in Fulton County, Georgia, 2002: characteristics, case management and certification issues.

Historically, the duty of the medical examiner in assigning cause and manner of death in drug-related death cases has been fraught with controversial challenges. The lack of standardization in certifying drug-related deaths may involve differences among practicing forensic pathologists in their approach to such cases. The central objectives of the present study include characterization of current drug death patterns and the variability among medical examiners with respect to autopsy performance and death certification practices in one county medical examiner's office. Death certificates, scene information/investigative reports, autopsy reports, and toxicological laboratory results for each of the 100 cases of drug-related death occurring in 2002 in Fulton County, Georgia were reviewed. Comparison of overall autopsy rates and autopsy rates in drug-related death cases for each medical examiner individually and for the group collectively was performed. In examining cocaine-related deaths (most common), statistical analysis was performed for comparison of drug concentrations (cocaine and benzoylecgonine) between deaths certified as cocaine toxicity (poisoning) versus cocaine-complicating disease or causing an adverse event such as cerebral hemorrhage. Causes of accidental drug deaths included cocaine 40%, mixed drug intoxication 37%, opioids 10%, ethanol 7%, and prescription medication (nonopioid) 5%. Overall total autopsy rates in 2002 for each of the 6 independent medical examiners ranged from 51% to 69% (mean 64%), whereas autopsy rates in drug-related death ranged from 55% to 91% (mean 81%). In review of the subset of 40 cocaine-related deaths, 25% were certified as cocaine toxicity (poisoning), with the remaining 75% certified as cocaine-complicating disease or causing and adverse event. Autopsy rates in cocaine-related deaths were as follows: cocaine toxicity 80%, cocaine-complicating disease 77.3%, and cocaine causing adverse event 62.5%. Thirty-eight percent of cocaine-related deaths were considered to be of "low suspicion" for drug involvement at the time the death was reported to the medical examiner with the remaining 62% being of "high suspicion". Autopsy rates were somewhat lower in the low suspicion group (67%) versus the high suspicion group (72%). Comparison of drug levels between cocaine-related death certification groups was performed. No statistically significant difference was shown in drug levels (cocaine, P > 0.3; benzoylecgonine, P > 0.2) between deaths certified as cocaine toxicity versus those certified as cocaine-complicating disease or causing adverse event. In Fulton County, accidental drug deaths in 2002 most often involved cocaine either alone or in combination with opiates and/or alcohol. Cocaine, opiates, or both were involved in greater than three-fourths (77%) of all drug-related deaths. The majority of all decedents were black (57%) and male (76%) with an average age of 42.2 years. Cocaine and ethanol were more frequently detected in black decedents, whereas opiates and polydrug abuse were more common in white decedents throughout the period studied. Preliminary investigation showed a high index of suspicion for the specific drug involved in virtually all opiate and alcohol cases, and in 62% of cocaine-related cases. Overall, the 100 accidental drug deaths in 2002 accounted for 7.5% of all deaths investigated and certified by the Fulton County Medical Examiner's Office. Our study provides further evidence to support the lack of correlation between serum drug levels and the mechanism of drug toxicity in cocaine-related deaths. No statistically significant differences were shown in parent cocaine or benzoylecgonine concentrations between those cases certified as toxicities or poisonings versus those cases certified as aggravating underlying disease or causing an adverse event. In addition, 62% of the cocaine-related death cases were considered initially to be of high suspicion for drug-related death, thus emphasizing the strong importance of scene information/investigative reports in evaluating drug-death cases and in formulating plans of action to handle each individual case. Among the drug-death cases handled by 6 staff medical examiners at the Fulton County Medical Examiner's Office, variation existed in autopsy performance and death certification practices. These issues are discussed in the context of the National Association of Medical Examiners' (NAME) Position Paper on Cocaine, NAME Forensic Autopsy Performance Standards, and other relevant literature. Most variations relate to completeness of the cause-of-death statement (whether or not comorbid conditions are included) rather than classification of manner of death within the office. However, specific wording in the cause of death may have significant ramifications regarding drug-related mortality statistics processed by the vital statistics system, with possible under-representation of drug-related deaths in single-cause mortality data.

Death certification practices of forensic physicians within the Strathclyde region of Scotland, UK

Data relating to the perceived and actual cause of death, in those dying in the community is sparse. This in part is related to how each country deals with death investigations and certification of death. Under common law in Scotland, sudden unexpected deaths are referred to the Procurator Fiscal. Autopsy is not always the final arbiter of truth. While actual figures are not available at present, anecdotally the police indicate that general practitioners (GPs) are often declining to attend or certify in the vast majority of cases. The purpose of this prospective observational study was to examine the certification practice of the forensic physicians working for Strathclyde Police. In conclusion, the results from this short study indicate that in cases where the cause of death for an individual, who died suddenly in the community and where an autopsy is deemed necessary, forensic physicians are no better or worse than a pathologist in predicting the underlying reason.

The impact of the variation in death certification and coding practices on trends in mortality from ischaemic heart disease.

This review examines the literature relating to the effect of death certification practices, coding and the terminology used by certifiers on trends in mortality from ischaemic heart disease (IHD). The review identifies factors that affect mortality trends in a number of countries and discusses methods for assessing the impact of these issues on trends in mortality from IHD. The review found that although the magnitude of the effects of the issues on trends in mortality from ischaemic heart disease varied among countries and sub-populations, miscertification and the resultant assignment of misleading ICD codes, particularly for ill-defined cardiovascular conditions, were important factors affecting the IHD mortality trends. In light of these findings, it is essential to monitor regularly the accuracy of death certificates for IHD and consider necessary adjustments in analysing mortality trends from IHD.

The validity of death certificates: routine validation of death certification and its effects on mortality statistics

The 3478 death certificates (7.1% of all annual death certificates) of this study comprise those national death certificates in 1995 submitted for validation to the panel representing both medical and nosological expertise. As such, it is highly selected and represents, from the nosological point of view, the most inconsistently filled-in portion of Finnish death certificates. The routine validation procedure is essentially based on exploitation of the extra medical information, i.e. the case history, on the Finnish death certificate form. Altogether, 2813 (80.9%) out of 3478 certificates could be adjusted at the primary panel session; the rest required further clarification. The re-assignment of cause of death by the panel and the impact of panel adjustments on the national mortality statistics is assessed here by comparing the initial death certification and the finally registered underlying cause of death grouped into ICD-9 major categories with special reference to the subcategories of neoplasm, cardiovascular disease (HVD) and unnatural death. A statistically significant decline ( p<0.0001) in deaths, both in the category of symptoms, signs and ill-defined conditions and in the pulmonary circulation disease subcategory of HVD with 37.6 and 35.1%, respectively, was observed. The decrease of 11.1% in the benign or NUD neoplasm subcategory and the increase of 8.6 and 7.0% in the categories of endocrine disease, and musculo-skeletal and connective tissue disease, respectively, are essential observations as to the quality of the cause of death register. The effect on the HVD major category was practically nil. At the HVD-subcategorial level, a decrease of 14.0% for diseases of the veins and lymphatics and other circulatory diseases and an increase of 3.5% for hypertensive diseases (HYP) were the two next most obvious alterations to the diseases of the pulmonary circulation, but were without statistical significance. For ischaemic heart disease and other subcategories, the effects were minor. The unnatural deaths as a whole increased in the final statistics with only 0.9%. In the study data, categorial changes ranged from the decrease of 75.2% for symptoms, signs and ill-defined conditions to the increase of 77.3% for endocrine diseases. In conclusion, the Finnish death certificate form, death certification practices and cause of death validation procedure seem to serve the coding of causes of death for mortality statistics appropriately. The results of the study form a relevant reference background to evaluation of epidemiological studies on mortality.

Homicide or suicide: the killing of suicidal persons by law enforcement officers

This paper presents 15 deaths of suicidal persons in Oregon and Florida who, by their behavior, sufficiently provoked law enforcement officers into killing them. Four deaths were certified as suicide, one as undetermined and ten as homicide. All of the deaths are individually described in detail and their case characteristics are presented in a table. The method of study is a descriptive analysis of the case characteristics, including 21 variables which are determined to be relevant to the classification of death. The variables were grouped into six categories: (a) personal information; (b) criminal behavior during the fatal incident; (c) dangerous behavior during the fatal incident; (d) toxicological data; (e) mental illness information; and (f) certification data. From the analysis, reasons for the opinions on manner of death classification are presented. All incidents were perceived as life-threatening to law officers, family members, or hostages. All victims were male except one, and all were Caucasian except two. All victims resisted arrest and verbally threatened homicide during the fatal incident. Two-thirds of the victims took hostages. All victims possessed an apparent handgun or other weapon (knife, iron bar). All victims posed their weapon and threatened others during the incident, 60% of victims actually used the weapon with apparent intent to inflict damage to others. 40% of victims were intoxicated with alcohol but other drug-involvement was uncommon. Seven of 15 had previous attempts, 40% had medically documented psychiatric diagnoses and 60% had reasonable historical evidence of psychiatric diagnoses, most commonly depression or substance abuse. One of the co-authors presents the case for some of the deaths to be certified as suicides, whereas two present the case for all to be certified as homicide. A brief discussion of psychiatric issues is also presented concerning individuals who use others to commit and who may engage in dangerous and/or criminal behavior to do so. A major conclusion is that there is lack of a unified opinion on death certification procedures for individuals who have provoked law enforcement officers to kill them. For such cases, it is recommended that professional organizations of medical examiners/coroners develop guidelines to promote consistency in death certification practices including manner of death classification and selection of death certificate wording so that police-assisted suicide may be appropriately reported and studied. Language: en

Coronary Heart Disease Mortality and Sudden Death: Trends and Patterns in 35- to 44-Year-old White Males, 1970–1990

Trends in coronary heart disease mortality and sudden death were studied in 35- to 44-year-old white male residents of Allegheny County, Pennsylvania. Deaths coded as any cardiac or vascular disease, diabetes, unexplained sudden death, and other rubrics were eligible for investigation, and the cause of death was validated by physicians examining multiple data sources about the deaths. During 1970-1990, 1,424 white male deaths were investigated, with 903 validated as coronary heart disease. In that time span, white male coronary heart disease mortality fell from 93.4 to 36.7 per 100,000 population per year, a 60% decline. Little proportionate change was seen in characteristics of the deaths, which were predominantly sudden and out-of-hospital. Diabetes mellitus history increased proportionately over time, largely because diabetics' mortality rates, unlike those of all other subgroups, did not fall. These observations support the contention that the decline in coronary heart disease mortality relates to risk factor modification more than to improvements in the treatment of coronary heart disease. Differences in death certification practices must be considered when interpreting and comparing vital statistics data.