Cause of death often dead wrong

Hundreds of thousands of death certificates filed every year in the United States are wrong, meaning we don’t really know what’s killing Americans.

Map shows reported heart-death rates by county.

Map shows reported heart-death rates by county.

Hundreds of thousands of death certificates filed every year in the United States are wrong, meaning we don’t really know what’s killing Americans.

The erroneous death certificates cause medical researchers to look at the wrong health threats, and mislead people to the real diseases that run in their families.

More than 2.4 million Americans die each year, and each one has an official cause of death on a death certificate. But medical experts think that about one third of them are incorrect, fraudulent or even just guesses.

“I’ve been preaching for years to anyone who will listen that death certificates are worthless,” said Dr. Stephen Geller, former chief of pathology at New York’s Mount Sinai Medical Center.

The most common error is blaming some form of heart disease for other kinds of deaths. Every day, overburdened doctors and coroners routinely stamp “cardiac arrest” or one of a variety of heart diseases onto death certificates for people they’ve not examined or even seen.

In several major cities, coronary disease is improperly blamed for nearly half of all mortalities. Some places have rates of fatal heart disease that are three times higher than others — not because of real heart problems but because of bad reporting.

“Heart disease has become the default diagnosis of death in this country. There are a not-inconsequential number of deaths for which the cause is completely wrong,” said Robert Anderson, chief of mortality data for the National Center for Health Statistics.

Dan Rohling, a retired funeral home director in Southern California, said, “If you’re trying to get a doctor to sign a death certificate, but he’s uncertain or confused about what to write, all you have to do is say ‘ASHD.’ That stands for atherosclerotic heart disease.

“If the deceased is over 60, the doctor will probably say ‘Oh, yeah’ and then sign it. That happens, I know, because I’ve done it,” Rohling added.

The Scripps study found that the state of New York has the nation’s highest rate of fatal heart disease — 32 per cent of all deaths. Heart failure was blamed for 44 per cent of all deaths on Staten Island, 42 per cent in Queens and 40 per cent in Brooklyn.

New York officials have doubted the accuracy of these numbers for many years, and in 2004 cited 40 funeral homes for illegally filling in the cause of death and signing a doctor’s name to death certificates. The city issued 57 health code violations and issued fines totaling US$53,000.

Several funeral homes admitted writing “atherosclerotic heart disease” when doctors were not available to sign death certificates.

The Health Department released the records this year only after Scripps filed a request under the state’s Freedom of Information Law.

But most death certificates are completed by hospital staff and not at funeral homes.

“My gut tells me the crux of the matter is not with the funeral home directors. They are just a contributing factor,” said Lorna Thorpe, New York City’s deputy health commissioner and the city’s top epidemiologist.

A joint New York City and federal investigation of deaths in 2003 found that coronary heart disease had been overstated by 51 per cent among people aged 35 to 74 and by about 200 per cent among people 75 or older.

The Scripps study of 4.9 million mortality records from 2005 and 2006 provided by the Centers for Disease Control and Prevention found that some states are good at determining why people die. One of the best is Colorado where 13 percent of all deaths are autopsied, the nation’s highest statewide autopsy rate, and only 20 per cent of deaths are attributed to heart disease, one of that nation’s lowest coronary rates.

“I have never heard these statistics before, but they are certainly good to hear,” said Dr. Michael Doberson, Arapahoe County coroner in the Denver metro area. “A lot of it has to do with education.

“The death investigation system across the country is a patchwork of different practices. We, as a nation, certainly could be better at this.”

Another example of wildly varying diagnosis is cancer, which is blamed for 28 per cent of all deaths in urban Fairfax County, Va., near Washington, D.C. But cancer is blamed for just 19 per cent of all deaths in Salt Lake City and for even fewer deaths in Salt Lake’s suburban counties.

Among smaller communities nationwide, cancer rates range from more than 40 per cent of all deaths to fewer than seven per cent.

Reports of death by stroke and other cerebral vascular diseases range from nine per cent in Orangeburg, S.C., to three per cent in the Bronx, N.Y. In smaller communities, the rate of stroke deaths ranges from nearly 17 per cent to less than one per cent.

Experts say the variations in death rates for such major causes of death are greater than can be explained by differences in age, race or other risk factors for illness that typically change with geography.

“There are some legitimate variations in the death rates from some of the major causes of death, the more obvious diseases, but many of the death certificates on which these statistics are based are meaningless, because physicians complete them without knowing the real cause of death,’’ said Dr. Kenneth Iserson, an emergency medicine specialist at the University of Arizona.

“We simply don’t know how wrong the statistics from death certificates might be. We may not be identifying some new disease patterns that are emerging.”

The Scripps review echoes a 2001 report published by the federal Agency for Healthcare Research and Quality that analyzed dozens of academic studies and found that as many as a third of all death certificates are likely to include an incorrect cause, and that 50 per cent of autopsies reveal medical information that wasn’t known before a patient died.

“Health care guidelines and policies are based on these faulty data from the death certificates, from selective autopsies and from insurance claims data that we also know is skewed to bring in the most dollars,” said Dr. Elizabeth Burton, chief of the autopsy lab at Baylor Medical Center in Dallas.

“The result is we’re spending too much money in the wrong places and not enough on diseases that kill more than the numbers show.”

Dr. Eric Mitchell, the coroner for Shawnee County (Topeka), Kan., fears that inaccuracies will increase as baby boomers begin to die, further stressing the system of death review.

“We are going to have an increase in these inaccuracies because of the overload,’’ Mitchell said. “It’s going to be difficult to track and figure out death because we have no standards to apply and no quality control.

“When these increasing inaccuracies start creeping into the national health data, they will probably affect health policy, and that is disturbing.”

In Phoenix, Dr. Doug Campos-Outcalt, an instructor in both family medicine and public health at the University of Arizona College of Medicine, said, “For the major conditions and diseases, what we mainly follow from the death certificates are trends, so as long as the system is consistently inaccurate, the relative changes in mortality are probably still captured. But what is missed are the more subtle medical problems and some of the underlying causes of death, like smoking or obesity.

“On the other hand, if the official death investigation system is not well-staffed or funded, you don’t get very good investigations, a lot of undetermined cause of death statements, and unanswered questions for families and the justice system, as well as public health.”

In the end it will take new laws and education to improve the accuracy of death certificates.

“If I sign a death certificate with blue ink, the registrar won’t accept it. But if you put down a bogus diagnosis, nobody cares,” said Dr. Keyvan Ravakhah, head of medicine at Huron Hospital in East Cleveland, Ohio. “Death certificates are terrible. They are so inaccurate because no one is trained to do them.”

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