Standard Certificate Of Death Research Articles

Quantifying drug overdose deaths: A troubled path from start to finish.

Between 1999 and 2019, according to the Centers for Disease Control and Prevention (CDC), nearly 450,000 people died from overdoses involving prescribed opioids. This review examines how drug overdose deaths are compiled by the CDC using the coding system of the International Classification of Diseases (ICD). When it comes to drug-involved deaths, the ICD may not tell the whole story or even the right story. To learn why, the authors examined the CDC's source data and the standard death certificate. In fatal drug overdose cases, death certificates are issued often before the results of post-mortem toxicology are known by the certifier. The CDC believes that this delay in the death investigation process may account for errors when, for example, certifiers list ambiguous terms such as "suspected acute drug intoxication" or "possible drug overdose" as a cause of death. When incomplete data are coded according to the ICD, the error is passed along while potentially useful information is lost. The result may reflect accurately the annual total of drug-involved overdose deaths while obscuring the lethality of individual substances, consumed alone or in combination, which contributed to, or caused, drug-involved deaths. The true cause of most fatal drug overdoses-polysubstance abuse-often is lost in this process. A key objective of this paper is to describe the process used by the CDC to report drug-involved mortality and how the current iteration of the ICD may be ill-suited for this important task.

Stakeholders’ Perspectives on Quality of Death Registration And Possibility of Introducing Verbal Autopsy Into Kurdistan Region of Iraq

Aim : To explore stakeholders’ perspectives on the quality of death registration and possibility of introducingverbal autopsy into the Kurdistan Region, Iraq.Methods: Qualitative interviews conducted with 15 stakeholders from the Ministry of Health, Directoratesof Health, and Medico-legal Institutes of Erbil, Sulaymaniyah, and Duhok of the Kurdistan Region ofIraq. Stakeholders were selected through the purposeful sampling method. Responses were analyzed usingqualitative content analysis and thematic analysis. Responses were categorized into three main categories:strengths, gaps, and suggestions for improving the death registration in the Kurdistan Region.Results: The strong points in favor of the current death registration were: easy and good practice, it was easyfor people to get a certificate, the existence of laws and regulations related to death registration, having a“standard death certificate,” and follow-up and monitoring of the process of death registration at the Medicolegal Institutes. The gaps were incompleteness and inaccuracy in most of the locations, staff ignorance, nochecking of data, missing cases, no use of the data, and no standardized process for compiling data.The stakeholders emphasized on implementing the existing rules and regulations, building staff capacity,systematic processes for data management, and follow-up and monitoring as strategies for improvement.All the stakeholders reported that verbal autopsy is appropriate for solving problems related to cause-ofdeath data. However, the feasibility of verbal autopsy will be a challenge for several reasons, including thecurrent economic crisis.

Pregnant? Validity of the Pregnancy Checkbox on Death Certificates in 4 States, and Characteristics Associated With Pregnancy Checkbox Errors

(Am J Obstet Gynecol. 2020;222:269.e1–269.e8) The maternal mortality rate (MMR) in the United States appears to be increasing, potentially due to the adoption of the US standard certificate of death. This new death certificate was implemented in 2003 and includes a pregnancy checkbox. While the checkbox was added due to underreporting of maternal mortality, it also makes possible the misclassification of maternal deaths. One review found a 15% false-positive rate, or cases without evidence of pregnancy. This study’s aim was to assess the validity of the pregnancy checkbox following a quality assurance process among 4 states examining deaths during 2016.

Value and disvalue of the pregnancy checkbox on death certificates in the United States–impact on newly released 2018 maternal mortality data

Maternal mortality is a sentinel health indicator. To improve the identification of maternal deaths, a pregnancy question was added during the 2003 revision of the US standard death certificate. Its adoption across all states in the United States took 16 years (2003-2018), and therefore the National Center for Health Statisticsdid not provide the national maternal mortality rate between 2007 and 2018. During this time, researchers raised questions about the accuracy of the checkbox information, particularly regarding its contribution to overreporting of maternal deaths in the United States. Checkbox errors were especially evident for women aged >40 years and for nonspecific causes of death. In January 2020, the NCHS resumed the reporting of maternal mortality data and provided the 2018 figures using a new coding method (ie, the 2018 method). Despite internal analyses suggesting the presence of both high false positive and high false negative pregnancy checkbox errors, the National Center for Health Statistics reported identification of 658 maternal deaths nationwide and a maternal mortality rate of 17.4 deaths per 100,000 live births for 2018. The 2018 coding method restricts the entry of checkbox information to decedents aged 10-44 years; the information cannot, therefore, be entered for women aged >45 years when no pregnancy-related cause of death information is indicated on the death certificate. Reported deaths with a pregnancy or obstetrical condition entered in the cause ofdeath section of the death certificate continue to be coded as maternal deaths regardless of age. The 2018 method likely corrects errors introduced by the use of the checkbox for women aged >45 years, but whether it provides accurate maternal mortality figures remains unknown. We call for efforts to urgently and systematically validate the pregnancy checkbox information. Post hoc coding adjustments cannot substitute for providing accurate and actionable maternal mortality data.

Population-level factors associated with maternal mortality in the United States, 1997\u20132012

BackgroundIn contrast to peer nations, the United States is experiencing rapid increases in maternal mortality. Trends in individual and population-level demographic factors and health trends may play a role in this change.MethodsWe analyzed state-level maternal mortality for the years 1997–2012 using multilevel mixed-effects regression grouped by state, using publicly available data including whether a state had adopted the 2003 U.S. Standard Certificate of Death, designed to simplify identification of pregnant and recently pregnant decedents. We calculated the proportion of the increase in maternal mortality attributable to specific factors during the study period.ResultsMaternal mortality was associated with higher population prevalence of obesity and high school non-completion among women of childbearing age; these factors explained 31.0% and 5.3% of the attributable increase in maternal mortality during the study period, respectively. Among delivering mothers, prevalence of diabetes (17.0%), attending fewer than 10 prenatal visits (4.9%), and African American race (2.0%) were also associated with higher maternal mortality, as was time-varying state adoption of the 2003 death certificate (31.1%).ConclusionsOur findings indicate that, in addition to better case ascertainment of maternal deaths, adverse changes in chronic diseases, insufficient healthcare access, and social determinants of health represent identifiable risks for maternal mortality that merit prompt attention in population-directed interventions and health policies.

Intelligent Mortality Reporting With FHIR.

One pressing need in the area of public health is timely, accurate, and complete reporting of deaths and the diseases or conditions leading up to them. Fast Healthcare Interoperability Resources (FHIR) is a new HL7 interoperability standard for electronic health record, while Sustainable Medical Applications and Reusable Technologies (SMART)-on-FHIR enables third-party app development that can work "out of the box." This paper demonstrates the feasibility of developing SMART-on-FHIR applications that enables medical professionals to perform timely and accurate death reporting within multiple different USA State jurisdictions. We explored how the information on a standard certificate of death can be mapped to resources defined in the FHIR standard Draft Standard for Trial Use Version 2 and common profiles. We also demonstrated analytics for potentially improving the accuracy and completeness of mortality reporting data.

Intelligent Mortality Reporting with FHIR.

One pressing need in the area of public health is timely, accurate, and complete reporting of deaths and the conditions leading up to them. Fast Healthcare Interoperability Resources (FHIR) is a new HL7 interoperability standard for electronic health record (EHR), while Sustainable Medical Applications and Reusable Technologies (SMART)-on-FHIR enables third-party app development that can work "out of the box". This research demonstrates the feasibility of developing SMART-on-FHIR applications to enable medical professionals to perform timely and accurate death reporting within multiple different jurisdictions of US. We explored how the information on a standard certificate of death can be mapped to resources defined in the FHIR standard (DSTU2). We also demonstrated analytics for potentially improving the accuracy and completeness of mortality reporting data.

Changes in Pregnancy Mortality Ascertainment

To estimate mortality ratios for all reported pregnancy deaths in the United States, 1999-2005, and to estimate the effect of the 1999 implementation of International Classification of Diseases, Tenth Revision (ICD-10) and adoption of the U.S. Standard Certificate of Death, 2003 Revision, on the ascertainment of deaths resulting from pregnancy. We combined information on pregnancy deaths from the National Vital Statistics System and the Pregnancy Mortality Surveillance System to estimate maternal (during or within 42 days of pregnancy) and pregnancy-related (during or within 1 year of pregnancy) mortality ratios (deaths per 100,000 live births). Data for 1995-1997, 1999-2002, and 2003-2005 were compared in order to estimate the effects of the change to ICD-10 and the inclusion of a pregnancy checkbox on the death certificate. The maternal mortality ratio increased significantly from 11.6 in 1995-1997 to 13.1 for 1999-2002 and 15.3 in 2003-2005; the pregnancy-related mortality ratio increased significantly from 12.6 to 14.7 and 18.1 during the same periods. Vital statistics identified significantly more indirect maternal deaths in 2002-2005 than in 1999-2002. Between 2002 and 2005, mortality ratios increased significantly among 19 states using the revised death certificate with a pregnancy checkbox; ratios did not increase in states without a checkbox. Changes in ICD-10 and the 2003 revision of the death certificate increased ascertainment of pregnancy deaths. The changes may also have contributed to misclassification of some deaths as maternal in the vital statistics system. Combining data from both systems estimates higher pregnancy mortality ratios than from either system individually.

566: Patterns of pregnancy-associated death in Ohio: effect of the adoption of 2003 U.S. death certificate standard

In 2005, the US pregnancy-related mortality ratio (PRMR) was 15.1 per 100,000 live births. African American women had a PRMR greater than three times that of Caucasians. To assess how Ohio compares nationally, and evaluate the effect of the implementation of the 2003 US Standard Death Certificate, data from 2003-2008 were examined for patterns of pregnancy-associated death in Ohio.

Limitations of conventionally derived chronic liver disease mortality rates: Results of a comprehensive assessment

Standard death certificate-based methods for ascertaining deaths due to chronic liver disease (CLD), such as the U.S. vital statistics approach, rely on a limited set of diagnostic codes to define CLD. These codes do not include viral hepatitis or consider hepatocellular carcinoma (HCC) deaths, and thus, underestimate the true burden of CLD mortality. Deaths associated with CLD may be further misunderstood because of the inherent limitations of death record information. Using a comprehensive list of CLD-related codes to search death records, we investigated the CLD mortality rate and associated etiologies (derived from medical records) in a large managed care health plan. From the 16,970 deaths among health plan members in 2000, we confirmed 355 (2.1%) as CLD related, including 75 with HCC. The age-adjusted CLD mortality rate using the comprehensive codes was 11.9 per 100,000 compared with 6.3 per 100,000 using only conventional codes. Based on medical records, the underlying CLD was attributed to alcoholic liver disease (ALD) in 44% of deaths, HCV infection with ALD in 16%, HCV without ALD in 18%, and chronic HBV infection in 7%. Only 64% of HCV-associated, 48% of HBV-associated, and 64% of ALD-associated deaths ascertained by medical record had that specific etiology mentioned on the death certificate. CLD mortality burden was almost doubled by using a comprehensive list of mortality codes and considering HCC deaths as CLD related. Furthermore, the contributions of viral hepatitis and ALD to CLD mortality may be underestimated if based solely on death records.

Report on the 2003 revision of the U.S. Standard Certificate of Death.

The National Center for Health Statistics (NCHS) is responsible for publishing Standard Certificates of Birth and Death for the United States of America. The standard certificates are revised roughly every 10 years. The revision process is designed to ensure that the standard certificates meet, as nearly as possible, the use for which they are intended at all levels: individual, local, state, and federal. The authors report on the most recent revision of the U.S. Standard Certificate of Death, recording the process and the role of the National Association of Medical Examiners in the process. Changes recommended during revision include requesting known aliases of a decedent and rearrangement of the certificate to provide more room for those items requesting dates and for describing how the injury occurred. New items have been added asking for information regarding traffic fatalities, the role of tobacco use in causing death, and whether female decedents were pregnant. Once approved by the Department of Health and Human Services, the new standard certificate will be made available to the states. Each state will have 2 years to adapt the U.S. Standard Certificate of Death to its use and to implement new state death certificates on January 1, 2003.

Educational Inequality in Adult Mortality: An Assessment with Death Certificate Data from Michigan

Education was added to the U.S. Standard Certificate of Death in 1989. The current study uses Michigan's 1989-1991 death certificates, together with the 1990 Census, to evaluate the quality of data on education from death certificates and to examine educational differences in mortality rates. With log-rates modeling, we systematically analyze the variability in educational differences in mortality by race and sex across the adult life cycle. The relative differences in mortality rates between educational levels decline with age at the same pace for all sex and race categories. Women gain a slightly greater reduction in mortality than men by reaching the secondary-education level, but a modestly smaller reduction by advancing beyond it. Blacks show a reduction in predicted mortality rates comparable to whites' by moving from the secondary to the postsecondary level of education but experience less reduction than whites by moving from the primary to the secondary level. Thus, the secular decline in mortality rates that generally accompanies historical improvements in education might actually be associated with an increase in the relative differences between blacks' and whites' mortality. We discuss limitations of the data and directions for future research.

History of Smoking from the Washington State Death Certificate

Beginning in 1988, a question added to the Washington State death certificate asked whether the decedent had smoked during the last 15 years of life. We analyzed death certificate data to evaluate the effectiveness of this question in identifying groups with high smoking rates and occupations with high rates of respiratory disease death among nonsmokers. We obtained statistical death certificate data from the Washington State Department of Health for resident deaths occurring between 1988 and 1991. Analyses included information on age, sex, race/ethnicity, marital status, underlying cause of death, high school graduation, smoking during the last 15 years of life, and occupation. Based on logistic regression analysis, we found that male sex, youth, divorced status, or death from lung cancer, chronic obstructive lung disease, or ischemic heart disease predicted a higher risk of smoking during the last 15 years of life. Hispanic ethnicity, single or widowed status, high school graduation, or death from breast cancer, diabetes, motor vehicle accidents, other accidents, or homicide predicted a lower risk of smoking. In farming occupations, there was an excess number of chronic obstructive lung disease deaths among nonsmokers. Findings from this study suggest that patterns of smoking during the last 15 years of life among decedents can provide useful public health surveillance information. The collection of risk factor information, such as smoking, should be recommended for the U.S. standard death certificate. Questions on smoking should be both simple and answerable by informants who may not have known the decedent for a lifetime. Additional studies on the accuracy of smoking history from the death certificate should be conducted.

A new hierarchical classification of causes of infant deaths in England and Wales.

In 1986 The Office of Population Censuses and Surveys (OPCS) introduced new certificates for stillbirths and neonatal deaths. This allowed certifiers more flexibility in the completion of the certificate, and the number and ordering of the causes given. Tabulations have been published of the fetal and maternal causes of death mentioned on the certificates for every year from 1986 to 1991 in annual reference volumes. It has not been possible either to derive a single cause group for each death, however, or to compare the information available on neonatal deaths with that on postneonatal deaths, which are still derived from the standard death certificate. The aim of the work described here was to adapt previous classifications to derive a single cause grouping for stillbirths and infant deaths which would provide the maximum information about preventability and yet meet the national and international responsibilities of OPCS. The methods used and the tests carried out on the validity and consistency of the chosen classification are described.

Proposed New Death Certificate Is Only as Good a Data Source as Physician Who Fills It Out

CHANGES in the national death certificate model, which became effective on January 1, are likely to help physicians provide more complete and accurate information, particularly in the "cause-of-death" section, according to Harry M. Rosenberg, MD, chief, Mortality Statistics Branch, National Center for Health Statistics, Hyattsville, Md. Officials meet to revise the US Standard Certificate of Death and other vital statistics certificates every 10 years, striving to improve the quality of health statistics, Rosenberg says. They send the revised copies as recommendations to the 50 states. State officials have the option to accept or reject the changes for their own certificates, although their revisions must be approved by federal officials. Most states already have included many of this year's recommendations in their own certificates, according to George Tolson, a statistician at the National Center for Health Statistics. <h3>Seeking Better Data</h3> Death certificate entries are used to determine death rates by cause,

The 1989 revisions of the US Standard Certificates of Live Birth and Death and the US Standard Report of Fetal Death.

The US Standard Certificates and Reports are models used by state vital statistics offices to develop documents for the collection of data about vital events. The 1989 revisions incorporate some major modifications to previous versions. Both the Standard Certificate of Live Birth and the Standard Report of Fetal Death utilize a checkbox format to elicit information on medical and other risk factors affecting the pregnancy, complications of labor and/or delivery, obstetric procedures, method of delivery, congenital anomalies, and abnormal conditions of the newborn. Revisions to the Standard Certificate of Death include modifications to the medical certification section and the addition of decedent's educational attainment. Items requesting information about Hispanic origin are added to all of these documents. The rationale behind these changes and their intended use are discussed.

Underrecording of Infant Homicide in the United States

Homicide rates for infants dropped suddenly between 1967 and 1969. The abrupt nature of this decline suggested the change was artifactual. Investigation suggests that two classification revisions instituted at this time were causes of this decline: changes in related codes set forth in the Eighth Revision of the International Classification of Diseases, Adapted, and revision of the standard certificate of death in 1968. Infant homicides may have been disproportionately underrecorded after 1968. (Am J Public Health 1983; 73:195-197.)

Demographic implications of the New United States certificates

To assist in developing uniform reporting of vital events among the fifty states, Puerto Rico, and the Virgin Islands, the United States government prepares standard certificates of birth, fetal death, death, marriage, and divorce. These model forms are revised, with the assistance of the states, approximately every ten years. Revisions are now being prepared by the National Center for Health Statistics which will become effective beginning January 1, 1968. Important new source material for demography will be introduced.Most changes will appear in the Standard Certificate of Live Birth and in the Standard Certificate of Fetal Death. An item on education of father and mother will provide detailed national data on education and fertility. The date of the last live birth to the mother and the date of the last fetal death will provide information on previous pregnancy outcome and on child-spacing. The recording of state file numbers for mates born alive and dead in the same delivery will make it easier to match live birth and fetal death certificates for the preparation of detailed tabulations on multiple births. Several new items related to maternal and child health have also been added. No significent changes were planned for the Standard Certificate of Death.The Standard Certificate of Marriage will include as new items the education of the bride and groom, the date on which the last marriage, if any, ended, and specification of the officiant as a religious or civil official. The Standard Certificate of Divorce or Annulment will obtain information on the education of husband and wife, the approximate date on which the couple separated, the mode of dissolution of the previous marriage, and the total number of living children. It is anticipated that most of the new items will be included in the certificates of all the states. The National Center for Health Statistics will provide detailed tabulations related to these items, beginning with data year 1968.Demographers are making an increased use of vital records and at the same time are extending their contacts with state health departments; in some states collaborative projects have been undertaken. Because of the importance of the source documents, which in some cases have not been exploited fully, demographers should increase their contact with the state vital statistics offices which develop, collect, and process the records. By indicating an interest in vital registration and by making their research needs known, demographers can encourage the acceptance of new concepts and collaborate in the improvement of vital records for demographic research purposes.