Cause of death certificates in nursing homes: Does quality matter? A retrospective review from two counties in Norway.

AIMS: One half of Norwegians die in nursing homes, where death certificates (DCs) are completed by two types of physicians: in-house physicians or physicians on call. The aims of this study were to examine differences in the quality of DCs due to type of physician and to uncover possible implications of errors for the public statistics. METHODS: DCs from the year 2013 from nursing homes in the catchment area of Akershus University Hospital were examined with regard to logical deficiencies, garbage code diagnoses and type of certifying physician. In one third of cases, the registered causes of death were compared to information in the medical records. RESULTS: A total of 873 DCs from 24 nursing homes were evaluated. Physicians on call certified 46% of all deaths. Logical deficiencies were found in 34% of all DCs and were more common in DCs from physicians on call. Garbage code diagnoses were used in every third DC, with 'sudden death' or 'cause of death unknown' preferred by physicians on call and 'unspecified pneumonia' preferred by in-house physicians. Comparisons against medical records uncovered missing information in 49% and 35% of DCs from physicians on call and in-house physicians, respectively. A dementia diagnosis was frequently overlooked by both physician types. Garbage code diagnoses were more common in DCs with missing information from medical records. CONCLUSIONS: Error rates in DCs in nursing homes in Norway are high. The results raise concerns about the validity of public cause of death statistics.

Forensic autopsies in Norway 1996-2017: A retrospective study of factors associated with deaths undergoing forensic autopsy.

AIMS: Forensic autopsies are important for the investigation of deaths with a legal or public-health interest, as well as being a source for cause-of-death statistics. The aim of this study was to investigate the use of forensic autopsies in Norway, with a special emphasis on geographical variation. METHODS: Data from the Norwegian Cause of Death Registry for the years 1996-2017 included 920,232 deaths and 37,398 forensic autopsies. We used logistic regression to identify factors that were associated with the proportion of forensic autopsies, grouped according to the registered cause of death. Explanatory variables were age and sex, place of death, police district, population size and urbanity level of the municipality and distance to the autopsy facility. RESULTS: The proportion of deaths undergoing forensic autopsy was 4.1%, with the highest being homicides (96.6%) and the lowest being deaths from natural causes (1.7%). Variation between police districts was 0.9-7.8%, and the span persisted during the study period. The most important explanatory variables across the strata were place of death (there were few autopsies of deaths in health-care facilities), police district and age of the deceased. Distance to the autopsy facility, sex, population size and the level of urbanity had only a minor influence. The variation between police districts was not fully accounted for by the other investigated factors. CONCLUSIONS: Unjustified differences in the frequency of autopsies may lead to insufficient investigation of possible unnatural deaths. In worst-case scenarios, homicides or other criminal cases might remain undetected. It may also introduce spurious shifts in the cause-of-death statistics.

Garbage codes in the Norwegian Cause of Death Registry 1996-2019.

BACKGROUND: Reliable statistics on the underlying cause of death are essential for monitoring the health in a population. When there is insufficient information to identify the true underlying cause of death, the death will be classified using less informative codes, garbage codes. If many deaths are assigned a garbage code, the information value of the cause-of-death statistics is reduced. The aim of this study was to analyse the use of garbage codes in the Norwegian Cause of Death Registry (NCoDR). METHODS: Data from NCoDR on all deaths among Norwegian residents in the years 1996-2019 were used to describe the occurrence of garbage codes. We used logistic regression analyses to identify determinants for the use of garbage codes. Possible explanatory factors were year of death, sex, age of death, place of death and whether an autopsy was performed. RESULTS: A total of 29.0% (290,469/1,000,128) of the deaths were coded with a garbage code; 14.1% (140,804/1,000,128) with a major and 15.0% (149,665/1,000,128) with a minor garbage code. The five most common major garbage codes overall were ICD-10 codes I50 (heart failure), R96 (sudden death), R54 (senility), X59 (exposure to unspecified factor), and A41 (other sepsis). The most prevalent minor garbage codes were I64 (unspecified stroke), J18 (unspecified pneumonia), C80 (malignant neoplasm with unknown primary site), E14 (unspecified diabetes mellitus), and I69 (sequelae of cerebrovascular disease). The most important determinants for the use of garbage codes were the age of the deceased (OR 17.4 for age ≥ 90 vs age < 1) and death outside hospital (OR 2.08 for unknown place of death vs hospital). CONCLUSION: Over a 24-year period, garbage codes were used in 29.0% of all deaths. The most important determinants of a death to be assigned a garbage code were advanced age and place of death outside hospital. Knowledge of the national epidemiological situation, as well as the rules and guidelines for mortality coding, is essential for understanding the prevalence and distribution of garbage codes, in order to rely on vital statistics.

Injury death certificates without specification of the circumstances leading to the fatal injury - the Norwegian Cause of Death Registry 2005-2014.

BACKGROUND: For injury deaths, the underlying cause of death is defined as the circumstances leading to the injury. When this information is missing, the ICD-10 code X59 (Exposure to unspecified factor) is used. Lack of knowledge of factors causing injuries reduces the value of the cause of death statistics. The aim of this study was to identify predictors of X59-coded deaths in Norway, and to assess methods to identify the true underlying cause of injury deaths. METHODS: We used data from the Norwegian Cause of Death Registry from 2005 to 2014. We used logistic regression to identify determinants of X59-coded deaths. For redistribution of the X59 deaths, we used a multinomial logistic regression model based on the cases where injury circumstances were known. The data were divided into training and test sets. The model was developed on the training set and assessed on the test set before it was applied to the X59 deaths. The models used death certificate information on the nature of injury and demographic characteristics as predictor variables. Furthermore, we mailed a query to the certifying physicians of X59 deaths reported in the year 2015, where we asked for additional information on the circumstances leading to the fatal injury. RESULTS: There were 24,963 injury deaths reported to the Cause of Death Registry of Norway 2005-2014. Of these, 6440 (25.8%) lacked information on the circumstances leading to the death. The strongest predictor for a X59 death was the nature of injury (hip fracture), followed by lack of information on the scene of injury. Applying our redistribution algorithm, we estimated that 97% of the X59-coded deaths were accidental falls. The strongest covariate was the nature of injury, followed by place of death and age at death. In 2015, there were 591 X59-coded deaths. Queries were sent to the certifying doctors in 559 cases. Among the informative replies to the query, 88% of the deaths were reclassified to accidental falls. CONCLUSIONS: A large proportion of injury deaths in Norway lack information on the circumstances leading to the fatal injury. Typically, these deaths represent accidental falls causing hip fracture in elderly individuals.

Pathology-related cases in the Norwegian System of Patient Injury Compensation in the period 2010-2015. / Patologirelaterte saker i pasientskadeordningen i perioden 2010 ­ 15.

BACKGROUND: The Norwegian System of Patient Injury Compensation (NPE) processes compensation claims from patients who complain about malpractice in the health services. A wrong diagnosis in pathology may cause serious injury to the patient, but the incidence of compensation claims is unknown, because pathology is not specified as a separate category in NPE's statistics. Knowledge about errors is required to assess quality-enhancing measures. We have therefore searched through the NPE records to identify cases whose background stems from errors committed in pathology departments and laboratories. MATERIAL AND METHOD: We have searched through the NPE records for cases related to pathology for the years 2010 ­ 2015. RESULTS: During this period the NPE processed a total of 26 600 cases, of which 93 were related to pathology. The compensation claim was upheld in 66 cases, resulting in total compensation payments amounting to NOK 63 million. False-negative results in the form of undetected diagnoses were the most frequent grounds for compensation claims (63 cases), with an undetected malignant melanoma (n = 23) or atypia in cell samples from the cervix uteri (n = 16) as the major groups. Sixteen cases involved non-diagnostic issues such as mix-up of samples (n = 8), contamination of samples (n = 4) or delayed responses (n = 4). INTERPRETATION: The number of compensation claims caused by errors in pathology diagnostics is low in relative terms. The errors may, however, be of a serious nature, especially if malignant conditions are overlooked or samples mixed up.

Medical autopsies after deaths outside hospital.

BACKGROUND: Little is known about which cases of death outside hospital are currently investigated by way of a medical (clinical) autopsy. Against this background, medical autopsies after death outside hospital that were performed at the Department of Pathology, Akershus University Hospital, are presented in this article. MATERIAL AND METHOD: Medical autopsies performed after deaths occurring outside hospital in the years 2007-11 were reviewed. Age, gender, type of requisitioning agent, time of death (first or second half of the year), mode of death and clinical information were noted. The autopsy result was translated into ICD-10 codes (International Classification of Diseases, version 10). Information on the number of autopsies of deaths that occurred outside hospital in Norway in the period 2007-2010 was retrieved from the Cause of Death Registry. RESULTS: In the period in question, Akershus University Hospital performed a total of 89 medical autopsies after deaths that occurred outside hospital. The deceased included 60 men and 29 women, with a median age of 58.5 and 60 years respectively. The annual number increased from 13 in 2007 to 26 in 2011, and tended to increase towards the end of the year. Figures from the Cause of Death Registry showed that the number of autopsies after deaths that occurred outside hospital also increased nationwide. The most frequent causes of death included cardiovascular diseases, external causes or alcoholism. Forensic toxicological examination contributed to the result in 34 of 43 investigations, and revealed three suicides. INTERPRETATION: Medical autopsies after deaths outside hospital differed from autopsies undertaken after deaths that had occurred in hospital. The increase in autopsies undertaken after deaths outside hospital must be seen in the context of the increase in the total number of such deaths. The fact that more requisitions for autopsies are made in the latter half of the year may indicate that restricted budgets for forensic post mortems have caused medical autopsies to be requested to clarify the cause of death instead.

Dead infants and unmarried women--from forensic pathology reports 1910-12.

The lack of access to contraceptives and poor control over their own pregnancies represented a major problem for women 100 years ago. An unwanted pregnancy could lead to social exclusion and loss of paid work, and clandestine births and infanticide thus posed a social problem. A review of the archives of the Norwegian Board of Forensic Medicine in the period 1910 to 1912 shows that one-fifth of all expert opinions were related to infants and pregnancy. Autopsies performed on children constituted over one-third of all forensic autopsies during this period. Although the reports provide a timely reminder of the value of hard-earned rights in Norway, the lack of control over their own sexuality and unwanted pregnancies are unfortunately still the reality for a large proportion of the world's women.

Does quality control of death certificates in hospitals have an impact on cause of death statistics?

BACKGROUND: The effects of inaccurate death certificates on cause of death statistics are uncertain. Since 2008, Akershus University Hospital has systematically corrected all death certificates. The effects of these corrections on the total cause of death statistics from the hospital were studied. MATERIAL AND METHOD: ICD-10 codes for the underlying cause of death on the original and the corrected death certificates issued by Akershus University Hospital were retrieved from the Cause of Death Registry for the period 1 May 2008-31 December 2009, once the Cause of Death Registry had processed the death certificates with the aid of the computer program ACME (Automatic Classification of Medical Entities). RESULTS: Altogether 1,001 deaths were investigated (547 men and 454 women). A total of 223 death certificates were corrected. This entailed changing the underlying cause of death in 176 cases. Death certificates for women were corrected most frequently. In 121 cases, the changes entailed a change of disease chapter in ICD-10. The corrections caused a significant reduction in the number of unspecific diagnoses, such as sepsis, cardiac arrest, pneumonia with no further specification, renal failure and fractures without any specific cause. There was a significant exchange of individuals within all the large diagnostic groups, with the exception of cancer. Because of the balancing effect of exchanges within and between the disease chapters, this generated only minor effects on general statistics on causes of death. INTERPRETATION: The continuous correction of death certificates in the hospital was important for adjustments at the individual level and as a quality control of cause of death statistics, but had only minor effects on the general statistics from the hospital.

«The child has lived and breathed.¼ Forensic examinations of newborns 1910-1912.

One hundred years ago, forensic examination of deceased infants was not an uncommon task for doctors in Norway. The key questions were whether the infant had been born alive and whether the manner of death could be explained. The decomposition of the corpses, which had often lain hidden long before they were examined, posed a considerable problem. Notwithstanding the known shortcomings in the criteria used for assessment of breathing (the lung flotation test), and the fact that the bodies were often severely decomposed, the lung flotation test and the supposed signs of asphyxiation were used indiscriminately. This absence of association between theoretical knowledge and practice may have had its origin in societal conditions in which clandestine birth and the killing of newborns was not uncommon.

Cytology and human papillomavirus testing 6 to 12 months after ASCUS or LSIL cytology in organized screening to predict high-grade cervical neoplasia between screening rounds.

We carried out a prospective study comparing the performance of human papillomavirus (HPV) E6/E7 mRNA (PreTect HPV-Proofer; NorChip, Klokkarstua, Norway) and DNA (Amplicor HPV test; Roche Diagnostics, Basel, Switzerland) triage testing of women 6 to 12 months after atypical-squamous-cells-of-undetermined-significance (ASCUS) or low-grade-squamous-intraepithelial-lesion (LSIL) cytology in organized screening to predict high-grade cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) between screening rounds. Between January 2005 and April 2008, 692 study women with screening-detected ASCUS/LSIL cytology 6 to 12 months earlier returned for HPV mRNA and DNA testing and repeat cytology. The median follow-up time was 3 years, using existing health care facilities. Follow-up test results were available for 625 women. Of the 145 CIN2+ cases detected during the study period, 95 (65.5%) were HPV mRNA positive 6 to 12 months after screening-detected ASCUS/LSIL, 44 (30.4%) were HPV mRNA negative, and 6 (4.1%) were invalid. The corresponding HPV DNA results were 139 (95.9%), 5 (3.4%), and 1 (0.7%), respectively. The cumulative incidences of CIN2+ 3 years after a negative HPV mRNA and DNA test were 10.3% (95% confidence interval [CI], 7.2 to 13.3%) and 1.8% (95% CI, 0.0 to 3.6%), respectively. The cumulative incidences of CIN2+ 3 years after positive HPV mRNA and DNA tests were 52.8% (95% CI, 40.1 to 60.1%) and 41.3% (95% CI, 35.5 to 46.6%), respectively. In conclusion, both positive HPV mRNA and DNA test results have a high enough long-term prediction of CIN2+ risk to consider referral to colposcopy as good practice when performed in delayed triage of women with ASCUS/LSIL cytology. In addition, the low CIN2+ risk among women with a negative Amplicor HPV test in our study confirms its safe use in a clinical setting.