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Improving Quality of Cause of Death

For the past few years, NAPHSIS has advocated for funding for the Vital Statistics Cooperative Program, which is used to generate national vital statistics at the National Center for Health Statistics (NCHS). We meet with Congressional offices and discuss the importance of more, better, faster data to inform public health policy and the ways in which sustained funding will help enable us to meet those goals.

This year, NAPHSIS has asked federal lawmakers to provide $5 million for NCHS to fund states to train medical certifiers (primarily physicians, coroners, and medical examiners) in reporting cause and manner of death and to modernize reporting systems, as many of the early adopters of the electronic vital records systems currently need upgrades to their software. However, even the newest electronic systems require accurate reporting of cause of death on death certificates, an issue that was brought into the spotlight recently in the Washington Post, when it was reported that a coroner from Pennsylvania began classifying heroin overdose deaths as homicides in his county.

Accurate reporting of the cause and manner of death is essential for the collection of the best possible public health data to inform health policy. For deaths due to disease (natural causes), the person who reports the cause of death on the death certificate is usually the attending physician. But for deaths due to suicide, homicide, unintentional injury, unattended deaths, or when the manner of death is unclear, cause and manner of death become the responsibility of medico-legal professionals. These are either appointed medical examiners, usually forensic pathologists, or elected officials, generally called coroners.

The problem of accurate reporting is evident in the recent decision of this county coroner to report deaths that were due to an overdose of an illegal drug as homicides rather than as accidental deaths. The rationale for this decision was that drug dealers who provided the illegal drugs caused the deaths of their customers and therefore committed murder. However, this definition of homicide is not the one accepted by most medico-legal professionals. In fact, the National Association of Medical Examiners, in their guide for medical examiners and coroners defines homicide as a death that results from:

''...a volitional act committed by another person to cause fear, harm, or death. Intent to cause death is a common element but is not required for classification as homicide.''

By this definition, an unintentional drug overdose does not qualify as a homicide. However, when the county coroner enters the manner of death as a homicide on the death certificate, that information is reported to the state health department and NCHS for use in calculating county, state, and national vital statistics. Consistent misreporting of cause and manner of death can lead to misrepresentation of public health threats. Specifically, this coroner's decision will greatly decrease reporting of the county's rate of accidental drug overdose deaths and will artificially increase the county's rate of homicide, leading to the false conclusion that the county does not have a serious drug overdose problem. The result may be counter-productive to the coroner's aim of drawing attention to the significant number of drug overdose deaths in his county.

While drug-related overdose deaths may be under-reported, one reason being because of the stigma associated with drug use, drug overdose deaths are not the only cause of death where under-reporting is a problem, especially when the death record is public information. Suicides and other causes of death that may be embarrassing to next-of-kin may also be under-reported. For deaths due to natural causes, some underlying causes of death may also be under-reported, for example, diabetes. It is important that physicians report not just the immediate cause of death but also the entire causal chain that led to the death, as well as any other significant conditions that may have contributed to the death, but did not directly cause it. In addition, completion of the question on the death certificate about whether a woman who died was pregnant at the time of her death or within 42 days or a year of her death is also important for accurate ascertainment of maternal mortality, which otherwise may be under-reported.

Without complete and correct information about cause of death, we cannot accurately identify and address public health problems at the local, state, and national level. It is critical that we properly train those who are responsible for completing the medical portion of the death certificate and ensure that they understand the importance of accurate reporting and how the information they provide will be used for public health purposes. This is why investing in training of medical certifiers will result in better quality cause of death data to target public health interventions.


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