Vol.1, No.3, 167-170 (2
opyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
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.
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
1.1. 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-
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
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
“next steps” are vital for public health progress.
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.
3.1. 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
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
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-
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
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.
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