Death certification: issues and interventions

doi:10.4236/ojpm.2011.13022

Paper Menu >>

Journal Menu >>

Vol.1, No.3, 167-170 (2

doi:10.4236/ojpm.2011.13022

011) Open Journal of Preventive Medicine

Death certification: issues and interventions

Dan Middleton1*, Robert Anderson2, Tiffini Billingsly3, Nombulelo Bande Mangaliso Virgil3,

Yolanda Wimberly3, Robin Lee1

1Health Investigations Branch, Division of Health Studies, Agency for Toxic Substances and Disease Registry, Atlanta, USA;

*Corresponding Aut hor: dcm2@cdc.gov

2National Center for Health Statistics, Center for Disease Control and Prevention, Atlanta, USA;

3Morehouse School of Medicine, Atlanta, USA.

Received 21 August 2011; revised 7 October 2011; accepted 27 October 2011.

ABSTRACT

A review of the literature suggests that errors in

death certification are common . We re viewed the

published literature to clarify what is known and

what remains to be learned before evidence-

based changes in medical education can be re-

commended. We searched the National Library

of Medicine’s PubMed database for articles that

addressed death certificate accuracy and identi-

fied 159 articles of interest published from 1996

to 2010. Among these 159 articles, we found 83

that were relevant to our goals and objectives.

Cause of death certification has been shown to

be problematic and several interventions have

been shown to improve its accuracy, especially if

the intervention is interactive. However these

studies have focused on short term gains rather

than on long term retention and performance,

leaving a significant data gap. We suggest a

study design that could address this data gap.

Keywords: Cause of Death; Death Certification

1. INTRODUCTION

1.1. Background

Death certificates contain a medical section that is

usually completed by the attending physician, or in spe-

cial cases by a medical examiner or coroner. A nosolo-

gist then codes the “cause of death” (COD) information

for statistical purposes. The coded data can then be used

to rank causes of death among specific groups [1] and

combined with other data to identify exposures associ-

ated with fatal diseases, assess diagnostic testing, and

determine the risk and effectiveness of therapeutic tech-

niques. The accuracy of such analyses depends largely

on the raw COD data that physicians record on individ-

ual death certificates.

1.2. Model Death Certificates

The Centers for Disease Control and Prevention’s Na-

tional Center for Health Statistics (NCHS) provides a

two part standard certificate of death as a model for

States to follow [1]. The first part is for reporting the

chain of events that lead directly to the death. The COD

listed in this section elicits the certifying physician’s

opinion on the decedents’ underlying COD, defined as

“the disease or injury which initiated the train of morbid

events leading directly to death, or the circumstances of

the accident or violence which produced the fatal in-

jury.”

The second part of the standard certificate contains

information on all other diseases, conditions, or injuries

that contributed to death. These are commonly referred

to as the multiple causes or contributing CODs.

This content and format of the standard certificate is

followed by each U.S. state with only minor variations.

This provides uniform data across the States that can be

compared and aggregated for national statistics. While

the standard certificate has promoted consistency in the

kinds of data collected, it has not resolved the issues

associated with ensuring accurate COD information.

1.3. Goals and Objectives

We propose to review what is known about the quality

of COD data from death certificates, including:

a) overall accuracy;

b) physicians’ awareness of death certificate uses and

importance; and

c) educational interventions designed to improve

death certification and COD data.

After summarizing these key issues according to cur-

rent knowledge, we describe the “next steps” for making

progress in the accuracy of death certificates. These

D. Middleton et al. / Open Journal of Preve ntive Medicine 1 (2011) 167-170

168

“next steps” are vital for public health progress.

2. METHODS

We searched the National Library of Medicine’s Pub-

Med database for articles published in English between

January 1996 and August 2010. The search term used

was “death certificate accuracy”. We also explored the

references cited by these articles.

3. FINDINGS

3.1. Summary

We found 154 articles in the PubMed search and 5

additional articles of interest among the references.

Among these 159 articles, we identified 83 that were

relevant to our goals and objectives. Four articles ad-

dressed physician attitudes. The remaining 79 articles

focused on accuracy (n = 71), educational interventions

(n = 7), or both (n = 1). We used this literature to pro-

vide examples and citations for salient points.

3.2. Death Certificate Accuracy

Generally speaking, accuracy concerns relate to either

listing an incorrect COD or omitting important informa-

tion. In 2001, Smith Sehdev and Hutchins [2] compared

clinical and autopsy COD statements for 494 cases be-

tween June 1995 and February 1997 at Johns Hopkins

Medical Institutions [2]. They compared the CODs for

accuracy based on guidelines created by the College of

American Pathologists and the NCHS. The authors re-

ported that 41% of the death certificates contained im-

properly completed COD statements; 24% had major

discrepancies between the clinicians’ and the patholo-

gists’ COD. The authors concluded that the COD state-

ments on death certificates were not reliable sources of

information for nation a l mortality statistics.

Using mock death certificates, Lakkireddy et al. [3]

evaluated the COD statements completed by 590 resi-

dents from various training programs nationwide. For a

sample case of in-hospital death due to urosepsis, they

found 45% of the residents incorrectly identified a car-

diovascular event as the primary COD.

Selikoff and Seidman [4] looked at asbestos-related

diseases using the “best evidence” for 17,800 asbestos

insulation workers in th e United States and Canada from

1967-1986. “Best evidence” was defined to include his-

topathology, autopsy and medical records. They found

that 11.9% of lung cancers related to asbestos and 38%

of mesotheliomas would have been missed had their

assessment been limited to only death certificate data.

There was also discordance between death certificates

and best evidence for asbestos-related kidney cancer.

Pritt et al. [5] reviewed 50 clinical summaries for pa-

tients treated at the University of Vermont between

January 2002 and December 2003. Mock death certifi-

cates were created using the information available and

then compared to the originals. They found that 34% of

the original death certificates had omissions or listed the

wrong COD or manner of death.

Data from the Framingham Heart Study indicate that

coronary heart disease as a COD may have been overes-

timated. Death certificates attributed 24% more deaths to

coronary heart disease (overall) than did a panel of three

physicians. For persons at least 85 years of age, death

certificates attributed more than twice as many deaths to

coronary heart disease than did the physician panel [6].

Problems with death certification are not limited to the

United States. Nielsen et al. [7] compared the death cer-

tificates and autopsy results for 433 hospital patients at

the University of Iceland. They found significant dis-

crepancies between the two documents in 50% of these

patients. The immediate COD was incorrect on 25% of

the certificates. D’Amico et al. [8] investigated the ex-

tent of misclassification of the underlying COD attrib-

uted to ill-defined and/or multiple causes in Naples, Italy.

They found a discordance of approximately 54% for

both ill-defined and multiple COD when comparing the

initial disease coding to the coding provided after inter-

viewing the certifying physician and reviewing the

medical records of deceased patients.

In addition to problems with accuracy, certifying phy-

sicians often do not understand how to properly report

COD in the standard format. Two common problems in

the first part of COD certification are reporting multiple

conditions per line (contrary to the instructions) and re-

porting illogical causal sequences. Fo r ex ample, Lu et al.

[9] note that hypertension and acute myocardial infarct-

tion are often reported as the cause of diabetes. A look at

detailed mortality data for 2007 from the National Vital

Statistics System (data available from: http://www.cdc.

gov/nchs/deaths.htm) shows that illogical sequences

appear on 30% of all U.S. d eath certificates and multiple

conditions are reported on the same line in the first part

of COD certification for 9% of all deaths.

3.3. Physician Awareness

One factor that potentially limits physician perform-

ance is their awareness of the importance of death cer-

tificates and how they are used. While the literature con-

cerning physicians’ awareness is sparse, researchers have

questioned whether physicians are aware of the public

health importance of death certificate data [2,10,11].

Degani et al. [10] asked 123 third year medical stu-

dents at Mercer University School of Medicine to iden-

tify what is significant about death certificates. Prior to

D. Middleton et al. / Open Journal of Preve ntive Medicine 1 (2011) 167-170

169

an intervention, 36% of respondents listed legal impor-

tance and 23% listed statistical importance. Post-inter-

vention, the proportion who listed legal importance

dropped to 19%, while the proportion listing statistical

importance rose to 44%. Other purposes that were sug-

gested included research, documentation, insurance, and

decedents’ families as significant reasons for completing

the death certificate.

3.4. Educational Interventions

Given the widespread inaccuracies, various intervene-

tions have been attempted to improve the accuracy of

death certificates. Aung et al. [12] provide an overview

of various interventions published between 1989 and

2007. For example, Lakkireddy et al. [13] studied inter-

nal medicine residents. Death certificates were scored

using the Mid America Heart Institute (MAHI) Death

Certificate Scoring System. The MAHI system was

based on guidelines from the College of American Pa-

thologists, the National Association of Medical Examin-

ers, and the NCHS. Two hundred residents were divided

into an interactive workshop group and a printed educa-

tional materials group. After the interventions, the COD

score in the workshop group increased from 15% to 91%

and the COD score in the printed materials group in-

creased from 16% to 55%. The researchers concluded

that an educational intervention improved medical resi-

dents’ accuracy in completing COD statements. More

specifically, the interactive workshop yielded better re-

sults than did the more passive printed educational mate-

rials.

Villar and Perez-Mendez [14] performed a study in

Spain over 18 months in which 166 medical trainees

from various specialties attended a 90-minute seminar

on completing death certificates. Prior to the intervention

71% of the certificates had errors. The most common

error was listing a mechanism of death instead of the

cause. After the intervention the error rate was reduced

to 9%; none of the participants listed a mechanism of

death after the intervention. Th e autho rs conclu ded that a

simple educational intervention can dramatically im-

prove the accuracy of death certificates completed by

physicians.

4. DISCUSSION

The common shortcomings of COD information on

death certificates have been well-documented. Currently,

it appears that few medical schools or residency training

programs provide formal training in death certification,

relying on a vague expectation that the topic will be

covered “on the job” in hospital wards or during inten-

sive care rotations.

While nosologists use an established system of rules

to code deaths not stated clearly and properly, these cor-

rective procedures do not always result in accurate cod-

ing [15]. At times the certifier must be contacted for

clarification; while this may improve the coding, it is

likely to be time consuming.

In general, studies of death certificate accuracy have

compared the COD recorded on the death certificate to

one generated by an expert panel of physicians who re-

viewed the medical record and/or autopsy findings. We

note that such comparisons could overestimate the fre-

quency of inaccuracies. For example, medical records

are often incomplete and tend to be more oriented to the

reason for hospital admission and treatment. They do not

always contain information that elicits the appropriate

underlying COD. Similarly, autopsy reports tend to fo-

cus on the immediate COD rather than the underlying

COD. Overall, these reports can be used for comparison,

but should not be assumed to represent a true “gold

standard” [16].

Regardless, COD certification is known to be prob-

lematic and several interventions have been shown to

improve its accuracy, especially if the intervention is

interactive. However these studies have focused on short

term gains and not on long term retention and perform-

ance, creating a significant data gap in what is known

about the value of educational interventions. To address

this gap, we recommend an interventional study (or

studies) to resolve this issue.

A group of physicians-in-training would undergo

pre-interven tion testing, an educational interven tion, and

post-intervention testing. In contrast to previous studies,

the physicians-in-training would also be retested after a

longer period of time (e.g. one year later) to assess their

long term retention and performance. Careful study de-

sign and analyses will allow researchers to assess the

intervention’s short term effectiveness and the long term

retention of key concepts and performance one or more

years after the educational intervention.

Generally speaking, changes in medical training sho uld

be evidence-based. Information on the long term reten-

tion described above is needed to overcome the inertia

that prevents the allocation of time and resources for

death certification training in medical residency pro-

grams. By clarifying this remaining data gap, we hope to

stimulate research that will lead to improved death certi-

fication and more accurate vital statistics.

REFERENCES

[1] CDC (2003) Physicians handbook on medical certifica-

tion of death. U.S. Depart ment of H ea lt h a nd Hu man S er -

vices, Centers for Disease Control and Prevention (CDC).

D. Middleton et al. / Open Journal of Preve ntive Medicine 1 (2011) 167-170

170

Publication No. 2003-1108, Hyattsville.

[2] Smith-Sehdev, A.E. and Hutchins, G.M. (2001) Prob-

lems with proper completion and accuracy of the cause-

of-death statement. Archives of Internal Medicine, 161,

277-284. doi:10.1001/archinte.161.2.277

[3] Lakkireddy, D.R., Gowda, M.S., Murray, C.W., Basara-

kodu, .K.R. and Vacek, J.L. (2004) Death certificate com-

pletion: How well are physicians trained and are cardio-

vascular causes overstated? American Journal of Medi-

cine, 117, 492-498. doi:10.1016/j.amjmed.2004.04.018

[4] Selikoff, I.J. and Seidman, H. (1992) Use of death cer-

tificates in epidemiological studies, including occupa-

tional hazards: Variations in discordance of different as-

bestos-associated diseases on best evidence ascertain-

ment. American Journal of Industrial Medicine, 22 , 481-

492. doi:10.1002/ajim.4700220403

[5] Pritt, B.S., Hardin, N.J., Richmond, J.A. and Shapiro, S.L.

(2005) Death certification errors at an academic institu-

tion. Archives of Pathology and Laboratory Medicine,

129, 1476-1479.

[6] Lloyd-Jones, D.M., Martin, D.O., Larson, M.G. and,

Levy, D. (1998) Accuracy of death certificates for coding

coronary heart disease as the cause of death. Annals of

Internal Medicine, 129, 1020-1026.

[7] Nielsen, G.P., Bjornsson, J. and Jonasson, J.G. (1991)

The accuracy of death certificates. Implications for health

statistics. Virchows Archiv. A, Pathological Anatomy and

Histopathology, 419, 143-146. doi:10.1007/BF01600228

[8] D'Amico, M., Agozzino, E., Biagino, A., Simonetti, A.

and Marinelli, P. (1999) Ill-defined and multiple causes

on death certificates—a study of misclassification in

mortality statistics. European Journal of Epidemiology,

15, 141-148. doi:10.1023/A:1007570405888

[9] Lu, T.H., Hsu, P.Y., Bjorkenstam, C. and Anderson, R.N.

(2006) Certifying diabetes-related cause-of-death: A

comparison of inappropriate certification statements in

Sweden, Taiwan and the USA. Diabetologia, 49, 2878-

2881. doi:10.1007/s00125-006-0470-6

[10] Degani, A.T., Patel, R.M., Smith, B.E. and Grimsley, E.

(2009) The effect of student training on accuracy of com-

pletion of death certificates. Medical Education Online,

14, 17. doi:10.3885/meo.2009.Res00315

[11] O’Donovan, B.G., Armstrong, P., Byrne, M.C. and Mur-

phy, A.W. (2010) A mixed-methods prospective study of

death certification in general practice. Family Practice,

27, 351-355. doi:10.1093/fampra/cmq012

[12] Aung, E., Rao, C. and Walker, S. (2010) Teaching cause-

of-death certification: Lessons from international expe-

rience. Postgraduate Medical Journal, 86, 143-152.

doi:10.1136/pgmj.2009.089821

[13] Lakkireddy, D.R., Basarakodu, K.R., Vacek, J.L., Kon-

dur, A.K., Ramachandruni, S.K., Esterbrooks, D.J., et al.

(2007) Improving death certificate completion: A trial of

two training interventions. Journal of General Internal

Medicine, 22, 544-548. doi:10.1007/s11606-006-0071-6

[14] Villar, J. and Perez-Mendez, L. (2007) Evaluating an

educational intervention to improve the accuracy of death

certification among trainees from various specialties.

BMC Health Services Research, 7, 183.

doi:10.1186/1472-6963-7-183

[15] Hanzlick, R. (2006) Cause of Death and the Death Cer-

tificate. College of American Pathologists. Northfield, Il-

linois, 235.

[16] Johansson, L.A., Westerling, R. and Rosenberg, H.M.

(2006) Methodology of studies evaluating death certifi-

cate accuracy were flawed. Journal of Clinical Epidemi-

ology, 59, 125-131. doi:10.1016/j.jclinepi.2005.05.006