0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Problems With Proper Completion and Accuracy of the Cause-of-Death Statement FREE

Ann E. Smith Sehdev, MD; Grover M. Hutchins, MD
[+] Author Affiliations

From the Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, Md.


Arch Intern Med. 2001;161(2):277-284. doi:10.1001/archinte.161.2.277.
Text Size: A A A
Published online

Background  Mortality statistics are largely based on death certificates, so it is important that the data on the death certificate is accurate. At our institution, clinicians complete cause-of-death statements (CODs) prior to autopsy. Since May 1995, separate CODs have been included in autopsy face sheets.

Methods  Clinical and autopsy-based CODs filled out separately on 494 cases between June 1995 and February 1997 were compared for proper reporting and accuracy using the published guidelines and definitions of immediate, intermediate, and underlying causes of death put forth by the College of American Pathologists and the National Center for Health Statistics.

Results  Of the 494 death certificates, 204 (41%) contained improperly completed CODs. Of these, 49 (24%) contained major discrepancies between clinicians' and pathologists' CODs. Of the 494 death certificates, 290 (59%) had properly completed CODs. Of the 290 properly completed CODs, 141 (49%) contained disagreements: 73 (52%) on underlying CODs; 44 (31%) on immediate CODs; and 47 (33%) on other significant conditions (part II).

Conclusions  The reliability and accuracy of CODs remain a significant problem. Despite its limitations, the autopsy remains the best standard against which to judge premortem diagnoses. The CODs of the death certificate may be improved if death certificates are completed in conjunction with the postmortem examination and amended when the autopsy findings show a discrepancy.

Figures in this Article

THE INFORMATION from death certificates, specifically the cause-of-death statements (CODs), is the basis for our national mortality database. The National Center for Health Statistics (NCHS) uses this database to help with surveillance of disease and proper allocation of funds for public health programs and research, and to help prioritize governmental decisions and actions in regard to health care. Because health statistics, national mortality and morbidity statistics, and data on disease prevalence in society are largely derived from death certificates, it is important to ensure proper completion and accuracy of the cause-of-death section of the death certificate.1

At The Johns Hopkins Medical Institutions, Baltimore, Md, it is practice of the clinician to complete the cause-of-death section of the death certificate at the time of death of the patient even if an autopsy is to be performed. In 1991, during the Second Workshop on Improved Cause-of-Death Statistics, the NCHS and the National Committee on Vital and Health Statistics (NCVHS) recommended adding CODs to autopsy reports.2 Since May 1995, a cause-of-death section has been included in the autopsy face sheet of all postmortem examinations at The Johns Hopkins Medical Institutions. As a result, residents and faculty in the pathology department have been instructed on the importance of the proper completion and accuracy of the cause-of-death section of the death certificate.

Completed CODs from 494 autopsies performed at The Johns Hopkins Medical Institutions between June 1995 and February 1997 were selected for study. All clinical and autopsy-based CODs were first evaluated by the first author (A.E.S.) for consistency of reporting and adherence to instructions for proper completion. The CODs were subsequently evaluated by one of us (G.M.H.) for validation and confirmation of the accuracy of the findings. Proper completion of the CODs was determined using the published guidelines and definitions of immediate, intermediate, and underlying causes of death put forth by the College of American Pathologists and the NCHS3 (Table 1).

Table Graphic Jump LocationTable 1. Guidelines and Definitions* for Proper Completion of the Cause-of-Death Statement as Put Forth by the CAP and the NCHS

The "properly" completed clinical and autopsy-based CODs were subsequently compared for accuracy of diagnoses using the postmortem examination in conjunction with clinical information as the standard for comparison. The overall disagreements between clinical and autopsy-based CODs were subclassified into the following categories: disagreement on immediate cause of death, disagreement on underlying cause of death, and/or disagreement on other significant conditions. The categories of disagreement were further subclassified into whether the disagreement involved the same organ system or a different organ system.

The "improperly" completed CODs were further analyzed for the presence of major discrepancies between the clinicians' and the pathologists' CODs. These major discrepancies included either (1) a major finding listed in the autopsy as immediate or underlying cause of death that was not listed in the clinician's cause of death, or (2) a disease or manifestation of disease listed in the clinician's cause of death that was not validated by postmortem examination.

Overall, 204 (41%) of the CODs were improperly completed (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, and Figure 6). Of these, the CODs improperly completed by clinicians (n = 191) significantly outnumbered those improperly completed by pathologists (n = 27) (Table 2). The most common mistakes made by clinicians included (1) using "mechanisms" as the immediate cause of death in 64 cases (34%); (2) not qualifying nonspecific processes in 90 cases (47%); (3) listing the underlying and immediate causes of death out of order in 35 (18%); and (4) placing underlying or immediate causes of death in part II (other significant conditions contributing to death but not resulting in the underlying cause of death given in part I) in 39 (20%). Other mistakes included using abbreviations, listing other significant conditions (part II) in part I, and listing incidental findings in part II.

Place holder to copy figure label and caption
Figure 1.

Mechanisms of death should not be used in cause-of-death statements. What is the underlying cause of death?

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Abbreviations should not be used anywhere in cause-of-death statements. What else is wrong with this cause-of-death statement?

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Citing a nonspecific process as the underlying cause of death without qualification, ie, unspecified etiology.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Nonsequential listing of conditions. What is the underlying cause of death? The immediate cause of death?

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

The underlying cause of death (disease or condition that initiated the morbid train of events leading to death) is listed in Part II.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

Hypertension is another significant condition that likely contributed to but did not cause death. What is the underlying cause of death?

Graphic Jump Location
Table Graphic Jump LocationTable 2. Comparison of Proper Completion of 494 Separate Clinical and Autopsy-Based Cause-of-Death Statements*

Of the 494 CODs reviewed, 290 (59%) were properly completed according to the guidelines of the College of American Pathologists and the standards set forth by the NCHS. Of those 290 CODs, 141 (49%) contained disagreements between the clinical and postautopsy versions with many CODs containing more than 1 disagreement. The most common discrepancy involved the underlying cause of death, with 73 CODs (52%) containing disagreements, 35 (48%) of which were assigned to the same organ system and 38 (52%) of which were assigned to a different organ system. Of the 44 CODs (31%) that contained discrepancies regarding the immediate cause of death, 18 (41%) were assigned to the same organ system, and 26 (59%) were assigned to a different organ system. In 47 CODs (33%) there was disagreement on other significant conditions when listed by both clinicians and pathologists. Of the CODs improperly completed, 49 (24%) contained major discrepancies, including either a major finding listed in the pathologists' immediate or underlying COD that was not listed by the clinician, or an entity listed by the clinician that was not validated by postmortem examination (eg, pulmonary embolus) (Table 3).

Table Graphic Jump LocationTable 3. Comparison of the Accuracy of 494 Clinical Cause-of-Death Statements With Those Based on Clinical and Autopsy-Derived Information*

Based on the results of this study, CODs are not reliable or accurate sources of information on which to base national mortality statistics (Figure 7, Figure 8, Figure 9, and Figure 10). Several studies from around the world have addressed this topic and reached similar conclusions.413 In each of these studies, it is emphasized that information gathered from death certificates plays a key role in determining disease prevalence in society and ultimately has a significant effect on decision-making processes regarding the distribution of resources in the fields of medicine and health.

Place holder to copy figure label and caption
Figure 7.

Disagreement in the underlying cause of death. Disagreement is confined to the same organ system.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 8.

Disagreements on the immediate and underlying causes of death. Disagreements involve different organ systems.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 9.

Significant finding listed in autopsy face sheet that was not listed in clinician's cause of death.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 10.

Finding listed in clinician's cause of death statement that was not validated by autopsy.

Graphic Jump Location

In a study done in London, Ontario, Jordan and Bass7 reviewed 426 death certificates to determine if they met the criteria for proper completion. In addition, the authors looked at which clinical department each death occurred in, whether staff physicians or residents completed the death certificate, and whether a coroner was involved and an autopsy was performed. Of the 426 certificates reviewed, 45% were filled out correctly and 23% contained only minor errors (inappropriate information and absence of time intervals). Of the 32% of death certificates with major errors, the most frequent error was incorrect sequencing (22%), which resulted from recording information out of order or in an illogical fashion when read vertically down the death certificate. The second most common major error was recording 2 causes of death in part I (17%). The most serious type of error, according to this study, was listing a mechanism as a cause of death without an explanation. This error occurred in 10% of death certificates. In 1993, Hanzlick6 reviewed 56 death certificates completed over a 10-day period: 35 (63%) of the certificates showed either an omission or underlying COD that was nonspecific or in need of further explanation. In 32 (91%) of the incorrectly completed certificates, the immediate cause of death was cited in terms of a mechanism.

In 1981, Cameron and McGoogan4,5 performed a prospective study of 1152 autopsies and compared the certified clinical diagnoses with autopsy findings to assess the diagnostic accuracy (or inaccuracy) of death certification. In their study, the main clinical diagnosis was confirmed in 61% of cases. The clinical diagnoses, which were not confirmed at autopsy, were either disproved (27% of cases) or determined to be subsidiary to the cause of death (12% of cases). In a study by Kircher et al,9 272 autopsy reports were reviewed of 3884 decedents in Connecticut in 1980. In this study the researchers compared the International Classification of Diseases, Ninth Revision (ICD-9) disease categories of the underlying cause of death listed by the clinicians with that listed by the nosologically coded autopsy. Kircher et al9 reported that a major disagreement (underlying cause of death assigned to different major ICD-9 categories) occurred in 29% of cases. In 1991, Nielsen et al13 published a study comparing accuracy of death certificates on all autopsies performed in 1976 and 1986 at the University of Iceland, Reykjavík. These authors reported a 50% overall disagreement between the death certificate and autopsy diagnosis with a disagreement on COD in 25% of total cases. Of interest, the authors found that the overall accuracy of premortem diagnoses remained unchanged between the years 1976 and 1986, during which time nonobstetric ultrasound and computed tomography were reportedly introduced into practice in Iceland.

It has been suggested that clinicians may not be aware of the importance of the COD in the generation of health statistics. In Hanzlick's attempt6 to improve accuracy of death certificates, he sent form letters to 32 physicians who had improperly completed CODs. The letter included a listing of omissions and the suggestion that the physician consider amending the certificate. Instructions for amending were provided, and a contact number was included. After 30 days, however, only 1 physician had amended a COD. This suggested that clinicians might not consider amendment to be necessary or a priority.

Recently there have also been several publications designed to help educate physicians regarding the proper completion of the death certificate and the standard definitions of immediate, intermediate, and underlying cause of death.14,15 In 1987, Kircher and Anderson16 published a special communication in JAMA to help provide medical students, house staff, and physicians with information regarding the proper completion of the death certificate and the standard definitions of immediate, intermediate, and underlying cause of death. In October 1989, a national conference sponsored by NCHS and NCVHS made several recommendations to improve the accuracy of death certificates.17 Their suggestions included increasing training of house staff and medical students, developing quality improvement programs, revising the format of the death certificate, and encouraging amendment of death certificates when indicated. Currently, the medical students at our institution receive instruction in death certificate completion during their second-year curriculum as well as during a transitional course given in their last year of training, prior to entering residency. In addition, for the past 5 years, our institution has required that all new members of the house staff receive specific instruction regarding death certification. Third, it has been the practice at our institution that admissions personnel review each completed death certificate to find and address inaccuracies in completion. This latter policy has been in place for approximately the past 10 years. Despite these implementations and attempts at clinician education, the proper completion of the CODs remains a significant problem at our institution, suggesting that further guidance is needed on death certification. In 1993, Hanzlick published a letter emphasizing this fact.18 In his letter, Hanzlick writes that many problems in CODs may result from inconsistency in wording, variations in certification style, and confusion regarding published examples of recommendations and guidelines. In an effort to educate and provide consistency, Hanzlick and the Autopsy Committee of the College of American Pathologists3 published The Medical Cause of Death Manual in 1994.

From our present study's comparison of clinical and autopsy-based CODs, it seems that education of the pathology faculty and house staff does help to improve the proper completion of the CODs. At our institution it is part of the initial training of any house officer in anatomic pathology to receive instruction regarding the importance of the proper completion and accuracy of CODs through the use of a prosector's manual, the COD manual,3 and various didactic methods. In addition, the house officer works closely with a more senior resident in the formulation of the COD. Finally, all completed autopsy-based CODs after release by a faculty member are re-reviewed by the director of the autopsy service for quality assurance. This study suggests not only that education of clinical house staff can help to improve the proper completion of CODs but also that pathologists may play an important educational role in promoting standardization and accuracy of death certification.

Based on the findings of this study as well as other studies, the autopsy remains a highly valuable educational and diagnostic tool that plays an invaluable role in the final step in clinical investigation.19 Despite its limitations, the autopsy, in conjunction with clinical information, remains the best standard by which to judge premortem diagnoses.4,9,13,20 It has been suggested that, for quality improvement, a team approach between the certifying physician and the physician trained and experienced in death certification may help reduce the errors in death certificate completion.8 Ultimately, the reliability and accuracy of CODs may be improved if death certificates were completed in conjunction with the postmortem examination and amended when the autopsy findings show a discrepancy.21

Accepted for publication July 11, 2000.

Presented in part at the annual meeting of the US and Canadian Academy of Pathologists, Boston, Mass, March 1998.

Corresponding author: Ann E. Smith Sehdev, MD, Carnegie 400, Department of Pathology, The Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287-6901.

Maudsley  GWilliams  EMI Inaccuracy in death certification: where are we now? J Public Health Med. 1996;1859- 66
Link to Article
National Committee on Vital and Health Statistics, Report of the second workshop on improving cause-of-death statistics.  Presented at: National Center for Health Statistics April 21-23, 1991 Virginia Beach, Va
Hanzlick  R The Medical Cause of Death Manual: Instructions For Writing Cause of Death Statements For Deaths Due to Natural Causes.  Northfield, Ill College of American Pathologists1994;
Cameron  HMMcGoogan  E A prospective study of 1152 hospital autopsies, I: inaccuracies in death certification. J Pathol. 1981;133273- 283
Link to Article
Cameron  HMMcGoogan  E A prospective study of 1152 hospital autopsies, II: analysis of inaccuracies in clinical diagnoses and their significance. J Pathol. 1981;133285- 300
Link to Article
Hanzlick  R Improving accuracy of death certificates [letter]. JAMA. 1993;2692850
Link to Article
Jordan  JMBass  MJ Errors in death certificate completion in a teaching hospital. Clin Invest Med. 1993;16249- 255
Kaplan  JHanzlick  R Improving the accuracy of death certificates [letter]. JAMA. 1993;2701426
Link to Article
Kircher  TNelson  JBurdo  H The autopsy as a measure of accuracy of the death certificate. N Engl J Med. 1985;3131263- 1269
Link to Article
Maclaine  GDHMacarthur  EBHeathcote  CR A comparison of death certificates and autopsies in the Australian Capital Territory. Med J Aust. 1992;156462- 468
McKelvie  PA Medical certification of causes of death in an Australian metropolitan hospital: comparison with autopsy findings and a critical review. Med J Aust. 1993;158816- 821
Moussa  MAAShafie  MZKhogali  MM  et al.  Reliability of death certificate diagnoses. J Clin Epidemiol. 1990;431285- 1295
Link to Article
Nielsen  GPBjornsson  JJonasson  JG The accuracy of death certificates: implications for health statistics. Virchows Arch A Pathol Anat Histopathol. 1991;419143- 146
Link to Article
Hanzlick  R Protocol for writing cause-of-death statements for deaths due to natural causes. Arch Intern Med. 1996;15625- 26
Link to Article
Hanzlick  R Principle for including or excluding "mechanisms" of death when writing cause-of-death statements. Arch Pathol Lab Med. 1997;121377- 380
Kircher  TAnderson  RE Cause of death: proper completion of the death certificate. JAMA. 1987;258349- 352
Link to Article
Barber  JB Improving accuracy of death certificates. J Natl Med Assoc. 1992;841007- 1008
Hanzlick  R Death certificates: the need for further guidance. Am J Forensic Med Pathol. 1993;14249- 252
Link to Article
Feinstein  AR Epidemiologic and clinical challenges in reviving the necropsy. Arch Pathol Lab Med. 1996;120749- 752
AMA Council on Scientific Affairs, Autopsy: a comprehensive review of current issues. Arch Pathol Lab Med. 1996;120721- 726
Smith  AEHutchins  GM Case of the month: making amends. Arch Intern Med. 1998;1581739- 1740
Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Mechanisms of death should not be used in cause-of-death statements. What is the underlying cause of death?

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Abbreviations should not be used anywhere in cause-of-death statements. What else is wrong with this cause-of-death statement?

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Citing a nonspecific process as the underlying cause of death without qualification, ie, unspecified etiology.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Nonsequential listing of conditions. What is the underlying cause of death? The immediate cause of death?

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

The underlying cause of death (disease or condition that initiated the morbid train of events leading to death) is listed in Part II.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

Hypertension is another significant condition that likely contributed to but did not cause death. What is the underlying cause of death?

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.

Disagreement in the underlying cause of death. Disagreement is confined to the same organ system.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 8.

Disagreements on the immediate and underlying causes of death. Disagreements involve different organ systems.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 9.

Significant finding listed in autopsy face sheet that was not listed in clinician's cause of death.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 10.

Finding listed in clinician's cause of death statement that was not validated by autopsy.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Guidelines and Definitions* for Proper Completion of the Cause-of-Death Statement as Put Forth by the CAP and the NCHS
Table Graphic Jump LocationTable 2. Comparison of Proper Completion of 494 Separate Clinical and Autopsy-Based Cause-of-Death Statements*
Table Graphic Jump LocationTable 3. Comparison of the Accuracy of 494 Clinical Cause-of-Death Statements With Those Based on Clinical and Autopsy-Derived Information*

References

Maudsley  GWilliams  EMI Inaccuracy in death certification: where are we now? J Public Health Med. 1996;1859- 66
Link to Article
National Committee on Vital and Health Statistics, Report of the second workshop on improving cause-of-death statistics.  Presented at: National Center for Health Statistics April 21-23, 1991 Virginia Beach, Va
Hanzlick  R The Medical Cause of Death Manual: Instructions For Writing Cause of Death Statements For Deaths Due to Natural Causes.  Northfield, Ill College of American Pathologists1994;
Cameron  HMMcGoogan  E A prospective study of 1152 hospital autopsies, I: inaccuracies in death certification. J Pathol. 1981;133273- 283
Link to Article
Cameron  HMMcGoogan  E A prospective study of 1152 hospital autopsies, II: analysis of inaccuracies in clinical diagnoses and their significance. J Pathol. 1981;133285- 300
Link to Article
Hanzlick  R Improving accuracy of death certificates [letter]. JAMA. 1993;2692850
Link to Article
Jordan  JMBass  MJ Errors in death certificate completion in a teaching hospital. Clin Invest Med. 1993;16249- 255
Kaplan  JHanzlick  R Improving the accuracy of death certificates [letter]. JAMA. 1993;2701426
Link to Article
Kircher  TNelson  JBurdo  H The autopsy as a measure of accuracy of the death certificate. N Engl J Med. 1985;3131263- 1269
Link to Article
Maclaine  GDHMacarthur  EBHeathcote  CR A comparison of death certificates and autopsies in the Australian Capital Territory. Med J Aust. 1992;156462- 468
McKelvie  PA Medical certification of causes of death in an Australian metropolitan hospital: comparison with autopsy findings and a critical review. Med J Aust. 1993;158816- 821
Moussa  MAAShafie  MZKhogali  MM  et al.  Reliability of death certificate diagnoses. J Clin Epidemiol. 1990;431285- 1295
Link to Article
Nielsen  GPBjornsson  JJonasson  JG The accuracy of death certificates: implications for health statistics. Virchows Arch A Pathol Anat Histopathol. 1991;419143- 146
Link to Article
Hanzlick  R Protocol for writing cause-of-death statements for deaths due to natural causes. Arch Intern Med. 1996;15625- 26
Link to Article
Hanzlick  R Principle for including or excluding "mechanisms" of death when writing cause-of-death statements. Arch Pathol Lab Med. 1997;121377- 380
Kircher  TAnderson  RE Cause of death: proper completion of the death certificate. JAMA. 1987;258349- 352
Link to Article
Barber  JB Improving accuracy of death certificates. J Natl Med Assoc. 1992;841007- 1008
Hanzlick  R Death certificates: the need for further guidance. Am J Forensic Med Pathol. 1993;14249- 252
Link to Article
Feinstein  AR Epidemiologic and clinical challenges in reviving the necropsy. Arch Pathol Lab Med. 1996;120749- 752
AMA Council on Scientific Affairs, Autopsy: a comprehensive review of current issues. Arch Pathol Lab Med. 1996;120721- 726
Smith  AEHutchins  GM Case of the month: making amends. Arch Intern Med. 1998;1581739- 1740
Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 109

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles