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Posts Tagged ‘Death certificate’

Curator: Larry H Bernstein, MD, FCAP

Cause of Death: How Good is the Reliability of the Data Collected?

This is a report on the high error rate in recording of death certificates, which were a standard of quality and a standard for

understanding disease classification since the work of Rokitanski, Virchow, John Hunter, Benjamin Castleman, Averill Liebow, and others.
The autopsy report had a defined structure, and it highlights the pathogenic sequence.  Autopsy rates were high at times of pandemic.
Hand-written reports from the 19th century are still in exitence at the Bellevue Hospital, the first hospital in US to have an ambulance service.
Modern medicine has advanced substantially, but one has to be concerned with whether

  • we can get a true picture of death rates when autopsy rate have plunged to less than 20 percent over the last four decades.

I present the recent article in Medscape Medical News by Diedre Henderson, May 10, 2013 titled Cause of Death: 50% of Medical Residents Fib.

Some 48.6% to 58.4% of residents from more than half of the residency programs in New York City have
knowingly entered the incorrect cause of death on death certificates — errors that have implications

  • for epidemiology,
  • public health research, and
  • disease surveillance — according to result from a recent study.

Barbara A. Wexelman, MD, MBA, from St. Luke’s–Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York City, and coauthors
report their findings in an article published in the May 9 issue of Preventing Chronic Disease, published by the Centers for Disease Control and Prevention.

As fewer autopsies are performed, Dr. Wexelman and coauthors note,

  • death certificates have become even more important sources of information about how Americans die.

Public health researchers rely on death certificates to gauge the leading causes of death and to identify disease outbreaks, and

  • the certificates also influence funding policies and research priorities.

In most teaching hospitals, it falls to resident physicians to complete the forms. To examine their experiences and opinions, the researchers conducted an anonymous, Internet-based, 32-question survey of New York City’s 70 internal medicine, emergency medicine, and general surgery residency programs in May and June 2010. Some 521 residents from 38 residency programs responded to the survey; 178 of the residents were termed “high-volume” respondents, meaning they had completed 11 or more death certificates in the previous 3 years.

Forced to Do It

“Almost half of all respondents (48.6%) and 58.4% of high-volume respondents reported they

  • had identified a cause of death on a death certificate that did not represent the true cause of death.

More than half of the residents (54.0%) reported they were unable to list what they felt to be the correct cause of death

  • after guidance from the admitting department in their hospital,” Dr. Wexelman and colleagues write.

“Of all respondents,

  • 70% believed they were forced to identify an alternate cause of death when
    • the patient died of septic shock (compared with 83.5% of high-volume respondents), and
  • 34.2% believed they were forced to identify an alternate cause when the patient died of
    • acute respiratory distress syndrome (compared with 44.3% of high-volume respondents),”
      the researchers continue.

Only 20.8% of respondents knew

  • they could hedge the death determination by calling it “probable,” “presumed,” or “undetermined.”

When the death certificate system

  • would not accept the true cause of death or
  • hospital admitting staff overruled them,
  • 64.6% of respondents reported cardiovascular disease,
  • 19.5% pneumonia, and
  • 12.4% cancer as the cause of death.

Study participation was voluntary, and residents with stronger feelings about the accuracy of death certificates
may have been more interested in participating. Other study limitations include the potential for recall bias.

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“Residents routinely reported diagnoses on death certificates that did not match their medical judgments.
These errors may have lasting effects on the public health priorities of the community.

Reform is needed both in the training and education of residents and in the system itself,” the authors conclude.

Support for this study was provided by Columbia University College of Physicians and Surgeons.

Prev Chronic Dis. 2013;10:120288. Full text

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