Death certificate completion skills of hospital physicians in a developing country

Abstract

BackgroundDeath certificates (DC) can provide valuable health status data regarding disease incidence, prevalence and mortality in a community. It can guide local health policy and help in setting priorities. Incomplete and inaccurate DC data, on the other hand, can significantly impair the precision of a national health information database. In this study we evaluated the accuracy of death certificates at a tertiary care teaching hospital in a Karachi, Pakistan.MethodsA retrospective study conducted at Aga Khan University Hospital, Karachi, Pakistan for a period of six months. Medical records and death certificates of all patients who died under adult medical service were studied. The demographic characteristics, administrative details, co-morbidities and cause of death from death certificates were collected using an approved standardized form. Accuracy of this information was validated using their medical records. Errors in the death certificates were classified into six categories, from 0 to 5 according to increasing severity; a grade 0 was assigned if no errors were identified, and 5, if an incorrect cause of death was attributed or placed in an improper sequence.Results223 deaths occurred during the study period. 9 certificates were not accessible and 12 patients had incomplete medical records. 202 certificates were finally analyzed. Most frequent errors pertaining to patients’ demographics (92%) and cause/s of death (87%) were identified. 156 (77%) certificates had 3 or more errors and 124 (62%) certificates had a combination of errors that significantly changed the death certificate interpretation. Only 1% certificates were error free.ConclusionA very high rate of errors was identified in death certificates completed at our academic institution. There is a pressing need for appropriate intervention/s to resolve this important issue.

Death Certification: Errors and Interventions

“…[13][14][15][16] Autopsy remains the standard against which clinician death certification accuracy is assessed. 3,[1][2][3][4][5][6][7][8][9][10][11][12][17][18] Despite many diagnostic medical advances, recent studies still report autopsy to reveal major missed diagnoses in roughly 17.7%-29% of cases. 3,[17][18][19] Even in cases in which autopsy was not performed, review of death certificates and corresponding medical records by autopsy pathologists reportedly reveals certification errors in up to 48%¬96% of cases, of which 34%-51% are major errors.…”

“…Both nationally and internationally, it has been reported that medical students and non-pathology residents are poorly trained in death certification. 1,4,[21][22][23] In one survey of 590 residents from various US institutions, 76% reported having received no formal training in death certification principals, and when asked to complete a cause of death statement based on a sample scenario of a hospital urosepsis death, 77% performed suboptimally, with 45% incorrectly attributing the death to a cardiovascular event. 21 At our institution, death certification inaccuracies cannot be attributed to resident inexperience per se, as only fellows and attending faculty are tasked with certification; however, the death certification training provided to trainees who ultimately become fellows and attending faculty is admittedly limited.…”

“…Errors in death certification are common, with frequencies ranging from 17.7%-96% in hospital-based studies. [1][2][3][4][5] Errors occur even at institutions where autopsy pathologists trained in death certification are an available resource. Such errors can range in severity from spelling errors and incomplete demographic information to reporting the wrong cause and/ or manner of death altogether.…”

Concordance between administrative data and clinical review for mortality in the randomized on/off bypass follow-up study (ROOBY-FS)

“…In some cases, improper rank-assignment of disease processes can lead to gross misinterpretation of cause of death. 20,21 Of note, an investigation very similar to the current study was conducted by Magliano et al using the Australian NDI (ANDI) and registry data extraction for patients with acute coronary syndrome who enrolled in the Long-term Intervention with Pravastatin in Ischemic Disease (LIPID) Trial. 22 This multi-center study, conducted in Australia and New Zealand, prospectively collected data on patient demise and cause of death; as such, physician-adjudicated outcomes were considered the gold standard by which to compare the ANDI dataset.…”

“…The over‐utilization of cardiovascular death may be particularly evident in cases where the patient has a multitude of co‐morbid conditions or an underlying disease that predisposes to cardiovascular disease—such as diabetes. In some cases, improper rank‐assignment of disease processes can lead to gross misinterpretation of cause of death …”