Understanding the Fluctuations in Korea's Suicide Rates: A Change-Point Analysis and Interrupted Time Series Analysis.

BACKGROUND: Korea has witnessed significant fluctuations in its suicide rates in recent decades, which may be related to modifications in its death registration system. This study aimed to explore the structural shifts in suicide trends, as well as accidental and ill-defined deaths in Korea, and to analyze the patterns of these changes. METHODS: We analyzed age-adjusted death rates for suicides, deaths due to transport accidents, falls, drowning, fire-related incidents, poisonings, other external causes, and ill-defined deaths in Korea from 1997 to 2021. We identified change-points using the 'breakpoints' function from the 'strucchange' package and conducted interrupted time series analyses to assess trends before and after these change-points. RESULTS: Korea's suicide rates had three change-points in February 2003, September 2008, and June 2012, characterized by stair-step changes, with level jumps at the 2003 and 2008 change-points and a sharp decline at the 2012 change-point. Notably, the 2003 and 2008 spikes roughly coincided with modifications to the death ascertainment process. The trend in suicide rates showed a downward slope within the 2003-2008 and 2008-2012 periods. Furthermore, ill-defined deaths and most accidental deaths decreased rapidly through several change-points in the early and mid-2000s. CONCLUSION: The marked fluctuations in Korea's suicide rate during the 2000s may be largely attributed to improvements in suicide classification, with potential implications beyond socio-economic factors. These findings suggest that the actual prevalence of suicides in Korea in the 2000s might have been considerably higher than officially reported.

Ischemic heart disease-related mortality in Brazil, 2006 to 2020. A study of multiple causes of death.

CONTEXT: Both the aging of the population and the increase in noncommunicable diseases may influence the progression and outcomes culminating in death, changing the evolution of ischemic heart diseases (IHDs) and their associated causes. Using the multiple causes of death method could help understand the magnitude of these relationships and enable better targeting of investments in health. OBJECTIVES: To evaluate the mortality from IHD in Brazil between 2006 and 2020 using the method of multiple causes and identify differences in the distribution pattern of IHD mortality by sex and geographic region. METHODS: Based on information extracted from death certificates (DCs) obtained from the database of the Department of Informatics of the Unified Health System (DATASUS), we used the multiple causes method to analyze the causes of death associated with IHD when IHD was defined as the underlying cause of death (UC) and the causes of death listed as the UC when IHD was recorded in any other lines of the DC, from 2006 to 2020, in Brazil. Subsequently, the proportion of these causes of death and differences between sexes and geographic regions were evaluated, with statistical relevance analyzed using the chi-square test, and the dependence between factors illustrated using stacked bar charts and small-world network graphs. RESULTS: When IHD was listed as the UC of death, the most frequent associated causes of death were, in descending order of frequency, acute myocardial infarction (AMI), arterial hypertension (AH), chronic ischemic heart disease (CHID), heart failure (HF), and diabetes mellitus (DM). When IHD was mentioned in any line of the DC, the most frequent UCs of death were AMI followed by DM, CIHD, chronic obstructive pulmonary disease (COPD), stroke, dyslipidemia, and, in the year 2020, COVID-19. The most frequent cause of death in women were DM as the UC and associated cause of death, AH as the UC, and CIHD and Alzheimer's disease as associated causes of death, while the most frequent causes of death in men were substance dependence as the UC and associated cause of death, and cancer as an associated cause of death. The most frequent causes of death were DM and stroke in the North and Northeast, dyslipidemia and obesity in the Midwest, Alzheimer's disease in the South and Southeast, and atherosclerotic heart disease (AHD) and COPD in the South. CONCLUSIONS: Several diseases - including AMI, AH, CIHD, HF, and DM - were the most frequent associated causes of death when IHD was recorded as the UC. In contrast, AMI, DM, CIHD, COPD, and stroke were the most frequent UCs when IHD was listed as an associated cause of death. The degree of these associations varied between sexes and geographic regions.

The rise of home death in the COVID-19 pandemic: a population-based study of death certificate data for adults from 32 countries, 2012-2021.

Background: During the coronavirus 2019 disease (COVID-19) pandemic, health systems had to respond to the needs of COVID-19 patients, while caring for patients with other life-threatening conditions. Pandemics, such as the COVID-19 pandemic, stir global health and mortality patterns. This is likely to include trends in dying places. In this paper, we examine trends in place of death for adults in 32 countries, comparing the initial COVID-19 pandemic years (2020-2021) with the eight years before the pandemic (2012-2019). Methods: Data on place of death for all adults (18 years and over) that died from 1 January 2012 to 31 December 2021 were requested (47 countries approached, 32 included). The classification of place of death varied widely between countries. "Home" was the most common category, the remaining category groups comprised "hospital or health institution", "other defined", and "ill-defined". We analysed place of death data in an aggregate form, by sex, age group, and selected underlying causes of death (cancer, dementia, and COVID-19). Findings: The study included 100.7 million people (51.5% male, 68.0% with ≥70 years), 20.4% died from cancer and 5.8% from dementia; 30.8% of deaths took place at home. The percentage of home deaths rose from 30.1% in 2012-2013 to 30.9% in 2018-2019 and further to 32.2% in the pandemic (2020-2021). Home deaths increased during the pandemic in 23 countries. In most countries the rise was greater in women and cancer; age differences were not consistent. Interpretation: Our study shows that there was a rise in home deaths during the pandemic, but with variability across countries, sex, age, and causes of death. The sex difference observed in most countries may have several explanations, including more engagement of women in discussions about end of life care planning and hospital admission avoidance. A higher rise of home deaths among people dying of cancer may be explained by the more predictable disease trajectory compared to non-malignant conditions, as well as earlier and better integrated palliative care. Funding: This work is part of the EOLinPLACE Project, which has received funding from the European Research Council (ERC) under the European Union's Horizon 2020 research and innovation programme (grant agreement No 948609).

Multicausal analysis of mortality due to diabetes mellitus in Spain, 2016-2018.

OBJECTIVES: This study aimed to assess multicausal mortality due to diabetes from 2016-2018 in Spain. Specific objectives were to quantify the occurrence of diabetes as an underlying cause or as any registered cause on the death certificate. MATERIALS AND METHODS: A cross-sectional descriptive study taking a multicausal approach. RESULTS: Diabetes appears as an underlying cause of 2.3% of total deaths in Spain, and as any cause in 6.2%. In patients in whom Diabetes appears as an underlying cause on the death certificates, the 15 most frequent immediate causes are cardiovascular diseases in men(prevalence ratio 1,59)and women (PR1,31). In men, the causes associated with diabetes as any cause were skin diseases(prevalence ratio 1.33), followed by endocrine diseases(prevalence ratio 1.26)and genitourinary diseases (prevalence ratio1.14). In women, the causes associated with the presence of diabetes as any cause were endocrine (prevalence ratio 1.13)and genitourinary (prevalence ratio 1.04)diseases. CONCLUSIONS: In patients in whom diabetes appears as an underlying cause on the death certificates, the 15 most frequent immediate causes are cardiovascular diseases. In men, the causes associated with the presence of diabetes as any cause of death are skin, endocrine and genitourinary diseases. In women, the causes associated with diabetes as any cause are endocrine and genitourinary.

EOLinPLACE: an international research project to reform the way dying places are classified and understood.

Background: Whenever possible, a person should die where they feel it is the right place to be. There is substantial global variation in home death percentages but it is unclear whether these differences reflect preferences, and there are major limitations in how the place of death is classified and compared across countries. Objectives: EOLinPLACE is an international interdisciplinary research project funded by the European Research Council aiming to create a solid base for a ground-breaking international classification tool that will enable the mapping of preferred and actual places towards death. Design: Mixed-methods observational research. Methods and analysis: We combine classic methods of developing health classifications with a bottom-up participatory research approach, working with international organizations representing patients and informal carers [International Alliance of Patients' Organizations (IAPO) and Eurocarers]. First, we will conduct an international comparative analysis of existing classification systems and routinely collected death certificate data on place of death. Secondly, we will conduct a mixed-methods study (ethnography followed by longitudinal quantitative study) in four countries (the Netherlands, Portugal, Uganda and the United States), to compare the preferences and experiences of patients with life-threatening conditions and their families. Thirdly, based on the generated evidence, we will build a contemporary classification of dying places; assess its content validity through focus groups with patients, carers and other stakeholders; and evaluate it in a psychometric study to examine construct validity, reliability, responsiveness, data quality and interpretability. Ethics: Approved by the ethics committee of the University of Coimbra, Faculty of Medicine (CE-068-2022) and committees in each of the participating countries. Discussion: The findings will provide a deeper understanding of the diversity in individual end-of-life pathways. They will enable key developments such as measurement of progress towards achievement of preferences when care can be planned. The project will open new directions in how to care for the dying. Trial registration: Research Registry UIN 9213.

Need for Improved Timeliness of Reporting on Drug Overdose Fatalities: The HEALing Communities Study.

OBJECTIVE: Timely data on drug overdose deaths can help identify community needs, evaluate the effectiveness of interventions, and allocate resources. We identified variations in death investigation and reporting systems within and between states that affect the timeliness and accuracy of death certificate information. METHODS: The HEALing Communities Study (HCS) is a community-engaged, data-driven approach to combating the opioid crisis in 67 communities in 4 states: Kentucky, Massachusetts, New York, and Ohio. HCS conducted a survey of coroners and medical examiners to understand variability in drug overdose death data. We compared survey results in Massachusetts, New York, and Ohio with national data to investigate the completeness of provisional death counts by type of death investigation system. RESULTS: Communities in each HCS state had different ways of collecting and reporting mortality data. Completion of death certificates for drug overdoses ranged from <2 weeks in 23% (7 of 31) of those surveyed to more than 3 months in 10% (3 of 31) of those surveyed. Variabilities in the timeliness of reporting drug overdose deaths were not associated with type of coroner or medical examiner office in each state, urban versus rural setting, or specificity of drug information on the death certificate. CONCLUSION: Having specific drug information on the death certificate may increase death certificate quality, comparability, and accuracy. We recommend the following: (1) all coroners and medical examiners should be trained on conducting death investigations, interpreting toxicology reports, and completing death certificates; (2) 1 office in each state should oversee all coroners and medical examiners to increase data consistency; and (3) communities should identify and address barriers to timely death certification.

Frequency and types of errors in clinician-composed death certificates for patients with or without autopsy in a hospital population.

BACKGROUND: Death certificate (DC) errors are common. At our institution, all deaths have a preliminary death certificate (PDC) written by a clinician and then revised by a pathologist prior to the clinician signing the final death certificate (FDC). In autopsy cases, the FDC is signed by the pathologist who performs the autopsy. METHODS: A total of 100 in-hospital deaths (50 with autopsy and 50 without) occurred in 2020 were arbitrarily selected from a tertiary care center. All PDCs and FDCs were compared to identify/classify errors as major (incorrect cause of death (COD) or significant contributing factors) or minor (abbreviations, inappropriate non-essential contributing factors, immediate/intermediate COD errors). Frequency of PDC errors was compared by autopsy status, duration of hospital stay and PDC author. RESULTS: Ninety percent of cases had at least one PDC error and 39% had a major error. Major errors were more common in autopsy cases (50% versus 28%, P = 0.035), although minor/overall errors were not. Error rates did not significantly differ for the other variables assessed. CONCLUSIONS: There is significance of having a pathologist review and revise DCs before they are signed. The increased frequency in major errors in cases with autopsy suggests that autopsy findings provided additional information to elucidate COD.

Concordance between COVID-19 mortality statistics derived from clinical audit and death certificates in Östergötland county, Sweden.

OBJECTIVES: Despite early notions that correct attribution of deaths caused by SARS-CoV-2 infection is critical to the understanding of the COVID-19 pandemic, three years later, the accuracy of COVID-19 death counts is still contested. We aimed to compare official death statistics with cause-of-death assessments made in a clinical audit routine by experienced physicians having access to the full medical record. STUDY DESIGN: Health service quality evaluation. METHODS: In Östergötland county (pop. 465,000), Sweden, a clinical audit team assessed from the start of the pandemic the cause of death in individuals having deceased after testing positive for SARS-CoV-2. We estimated the concordance between official data on COVID-19 deaths and data from the clinical audit using correlations (r) between the cause-of-death categories and discrepancies between the absolute numbers of categorised deaths. RESULTS: The concordance between the data sources was poor regarding whether COVID-19 was the underlying or a contributing cause of death. Grouping of the causes increased the correlations to acceptable strength. Also including deaths implicated by a positive SARS-CoV-2 test in the clinical categorisation of COVID-19 deaths reduced the difference in absolute number of deaths; with these modifications, the concordance was acceptable before the COVID-19 vaccination program was initiated (r = 0.97; symmetric mean absolute percentage error (SMAPE) = 19%), while a difference in the absolute numbers of deaths remained in the vaccination period (r = 0.94; SMAPE = 35%). CONCLUSIONS: This study highlights that carefulness is warranted when COVID-19 death statistics are used in health service planning and resonates a need for further research on cause-of-death recording methodologies.

Place of death among foreign-born individuals: a national population-based register study.

Background: Relatively little is known about where foreign-born individuals die in Sweden and how birth region might influence place of death. Thus, there is a need for population-based studies investigating place of death and associated factors among foreign-born individuals. Objectives: The aim of this study was to identify variations in place of death among foreign-born individuals residing in Sweden and to compare place of death between the foreign- and domestic-born population. We also examine the association between place of death, underlying cause of death and sociodemographic characteristics among the foreign-born population. Design: A population-based register study. Methods: All deceased individuals ⩾18 years of age in Sweden with a registered place of death between 2012 and 2019 (n = 682,697). Among these, 78,466 individuals were foreign-born. Univariable multinomial logistic regression modelling and multivariable multinomial logistic regression analyses were performed. Results: Overall, hospital was the most common place of death among the foreign-born population. However, there were variations in place of death related to region of birth. Compared to domestic-born, a higher proportion of foreign-born individuals dies at home, the majority of whom were born on the African continent. Conclusion: Region of birth is one of the several factors associated with place of death among foreign-born individuals. Further research is needed to explore both preferences and barriers to place of death among foreign-born individuals.

Mortality in children with epilepsy: Cohort study using the clinical practice research datalink.

OBJECTIVE: To estimate Mortality Rate (MR) in UK children with epilepsy (CWE) compared to children without epilepsy (CWOE), describe causes of death, determine Mortality Rate Ratios (MRRs) for cause-specific mortality, and to analyse the contribution of co-morbidities (respiratory disease, neoplasm, and congenital disorders) to mortality rate. METHOD: Retrospective cohort study of children born between 1998 and 2017, using linked data from the Clinical Practice Research Datalink Gold (Set 18). Epilepsy diagnoses were identified using previously validated codes. Causes of death were defined as natural or non-natural. Epilepsy-related deaths in CWE were those where underlying or contributing cause of death was epilepsy, status epilepticus, seizures, ill-defined/unknown cause or sudden death. We used Cox proportional hazard analysis to investigate associations of epilepsy and mortality. RESULTS: There were 1,191,304 children followed for 13,994,916 person-years (median: 12) if which 9665 (0.8%) had epilepsy. Amongst CWE, 3.4% died. MR of CWE was 4.1 (95%CI 3.7-4.6)/1,000 person-years. CWE had an increased adjusted all-cause mortality (MRR 50.9,95%CI 44.8-57.7) compared to CWOE. Amongst the 330 deaths in CWE, 323 (98%) were natural, 7 (2%) non-natural, 80 (24%) epilepsy-related. MRR of non-natural deaths was 2.09 (95%CI 0.92,4.74, p = 0.08). SIGNIFICANCE: Amongst CWE, 3.4% died during the study period. All-cause mortality rate in CWE was 4/1,000 person-years representing a fifty-fold increased mortality risk, after taking into account sex and socioeconomic status, compared to similarly aged children who did not have epilepsy. Causes of death mostly were not seizure-related. Non-natural death in CWE was uncommon.

What can death records tell us about multimorbidity?

BACKGROUND: Multimorbidity has been measured from many data sources which show that prevalence increases with age and is usually greater among women than men and in more recent periods. Analyses of multiple cause of death data have shown different patterns of multimorbidity associated with demographic and other characteristics. METHODS: Deaths in Australia among over 1.7 million decedents aged 55+ were stratified into three types: medically certified deaths, coroner-referred deaths with natural underlying causes and coroner-referred deaths with external underlying causes. Multimorbidity was measured by prevalence of ≥2 causes and analysed over three periods based on administrative changes: 2006-2012, 2013-2016 and 2017-2018. Poisson regression was used to examine the influence of gender, age and period. RESULTS: The prevalence of deaths with multimorbidity was 81.0% for medically certified deaths, 61.1% for coroner-referred deaths with natural underlying causes and 82.4% for coroner-referred deaths with external underlying causes. For medically certified deaths, multimorbidity increased with age: incidence rate ratio (IRR 1.070, 95% CI 1.068, 1.072) was lower for women than men (0.954, 95% CI 0.952, 0.956) and changed little over time. For coroner-referred deaths with natural underlying causes, multimorbidity showed the expected pattern increasing with age (1.066, 95% CI 1.062, 1.070) and being higher for women than men (1.025, 95% CI 1.015, 1.035) and in more recent periods. For coroner-referred deaths with external underlying causes, there were marked increases over time that differed by age group due to changes in coding processes. CONCLUSION: Death records can be used to examine multimorbidity in national populations but, like other data sources, how the data were collected and coded impacts the conclusions.

Changes in the Place of Death and Implications for End-of-Life Care Policy: A Population-Based Observational Study.

Background: Death in hospital rather than at home is becoming more prevalent, even among terminally ill patients receiving home-based care. Identifying trends in places of death is crucial to care policy, especially for aging populations as in Taiwan. Aim: To identify changes in the places of natural death of Taiwanese individuals for various causes of death. Design: A population-based observational study was conducted. Setting: Anonymous data for the period 2000-2020 from the Death Database of Taiwan's National Center for Health Statistics Data were obtained and analyzed. Results: In 2000, 60.1% of natural deaths occurred in the home, whereas in 2020, this percentage was only 36.8%; conversely, the percentage of deaths in hospital increased from 34.4% in 2000 to 56.1% in 2020. Deaths in a nursing home or long-term care facility were found to account for only 3.8% of all natural deaths in 2020. Dementia was the cause of death for which the proportion of institutional deaths was highest, although this proportion was <10% for most years. We applied the joinpoint regression model to estimate trend changes in places of death. During the study period, the places of death in Taiwan changed significantly, the average annual percent changes for hospital deaths over the 21-year period was 2.54% (confidence interval [CI]: 2.04 to 3.03), and for home deaths was -2.69% (CI: -3.26 to -2.13). Conclusions: The detailed findings of this national study can offer insight into potential future clinical burdens and lead to better health policy decisions for Taiwan.

Evaluation of errors in death certification by medical officers in an acute hospital.

OBJECTIVES: To identify the frequency and types of errors in the Medical Certificate Cause of Death (MCCD) completed by hospital medical officers for deceased older patients. METHODS: Among 127 deaths in a tertiary hospital acute geriatric unit between 1 July 2021 and 30 June 2022, a cause of death was documented for 116 patients (mean age 87.8, SD 5.7 years, 47% female, 39% from a nursing home). The MCCD was evaluated for errors as compared to national guidelines based on five criteria: mechanism without underlying cause; competing causes; improper sequencing; incomplete data; and use of abbreviations. The level of training of the documenting medical officer and whether the MCCD was completed out of usual working hours was evaluated with respect to errors. RESULTS: At least one error was present in 60 (52%) of the MCCD evaluated, and there were two or more errors in 16 (14%). Most commonly, documenting competing causes of death was found in 45 (39%) of all MCCD, followed by missing data (10%) and improper sequencing (9%). MCCDs were mostly completed by postgraduate year (PGY) 1 or 2 medical officers (78%) and out-of-hours (in 72%). There was no significant difference in frequency of errors between junior and senior medical officers (p = 0.52) or if it was completed within or out-of-hours (p = 0.14). CONCLUSIONS: The MCCD for deceased hospital patients often contained an error. Major improvement in the quality of death certification is needed among all medical officers.

[Places of death of COVID-19 patients: an observational study based on evaluated death certificates from the city of Muenster, Germany (2021)]. / Sterbeorte von COVID-19-Patienten: eine Observationsstudie auf Grundlage ausgewerteter Todesbescheinigungen der Stadt Münster (2021).

INTRODUCTION: The places of death of COVID-19 patients have so far hardly been investigated in Germany. METHODS: In a places of death study in Westphalia (Germany), statistical evaluations were carried out in the city of Muenster on the basis of all death certificates from 2021. Persons who had died with or from a COVID-19 infection were identified by medical information on cause of death and analyzed with descriptive statistical methods using SPSS. RESULTS: A total of 4044 death certificates were evaluated, and 182 deceased COVID-19 patients were identified (4.5%). In 159 infected patients (3.9%), the viral infection was fatal, whereby the distribution of places of death was as follows: 88.1% in hospital (57.2% in the intensive care unit; 0.0% in the palliative care unit), 0.0% in hospice, 10.7% in nursing homes, 1.3% at home, and 0.0% in other places. All infected patients < 60 years and 75.4% of elderly patients ≥ 80 years died in hospital. Only two COVID-19 patients, both over 80 years old, died at home. COVID-19 deaths in nursing homes (17) affected mostly elderly female residents. Ten of these residents had received end-of-life care from a specialized outpatient palliative care team. DISCUSSION: The majority of COVID-19 patients died in hospital. This can be explained by the rapid course of the disease with a high symptom burden and the frequent young age of the patients. Inpatient nursing facilities played a certain role as a place of death in local outbreaks. COVID-19 patients rarely died at home. Infection control measures may be one reason why no patients died in hospices or palliative care units.

Flaws and uncertainties in pandemic global excess death calculations.

Several teams have been publishing global estimates of excess deaths during the COVID-19 pandemic. Here, we examine potential flaws and underappreciated sources of uncertainty in global excess death calculations. Adjusting for changing population age structure is essential. Otherwise, excess deaths are markedly overestimated in countries with increasingly aging populations. Adjusting for changes in other high-risk indicators, such as residence in long-term facilities, may also make a difference. Death registration is highly incomplete in most countries; completeness corrections should allow for substantial uncertainty and consider that completeness may have changed during pandemic years. Excess death estimates have high sensitivity to modelling choice. Therefore different options should be considered and the full range of results should be shown for different choices of pre-pandemic reference periods and imposed models. Any post-modelling corrections in specific countries should be guided by pre-specified rules. Modelling of all-cause mortality (ACM) in countries that have ACM data and extrapolating these models to other countries is precarious; models may lack transportability. Existing global excess death estimates underestimate the overall uncertainty that is multiplicative across diverse sources of uncertainty. Informative excess death estimates require risk stratification, including age groups and ethnic/racial strata. Data to-date suggest a death deficit among children during the pandemic and marked socioeconomic differences in deaths, widening inequalities. Finally, causal explanations require great caution in disentangling SARS-CoV-2 deaths, indirect pandemic effects and effects from measures taken. We conclude that excess deaths have many uncertainties, but globally deaths from SARS-CoV-2 may be the minority of calculated excess deaths.

[The patient has died now what? : Step by step-what happens with patients after their death?] / Patient tot was nun? : Schritt für Schritt ­ was passiert mit dem Patienten nach seinem Tod?

The determination of a person's death, the subsequent post-mortem examination and the creation of the death certificate are part of regular medical work. The post-mortem examination, which is exclusively a medical duty, must be carried out immediately after the determination of death and includes in particular the definition of the cause of death and the type of death, which, in the case of a non-natural or unexplained death, entails further investigations by the police or public prosecutor and sometimes also forensic examinations. This article aims to shed more light on the possible processes after the death of a patient.

Accuracy of mortality indicators due sepsis-associated deaths in the Federal District / Acurácia dos indicadores de mortalidade devido a sepse dos óbitos ocorridos no Distrito Federal / Precisión de los indicadores de mortalidad por sepsis de las defunciones ocurridas en el Distrito Federal

Background: Sepsis currently represents a challenge for health systems, this fact may be related to the spread of bacterial resistance, the increase in the population of elderly, immunosuppressed individuals, and the improvement of emergency care, favoring the survival of critically ill patients. This article aimed to evaluate the accuracy of mortality indicators due to sepsis in 2018. Method: Validation study of death certificates that occurred in the Federal District in 2018. Declarations whose basic causes of death identified were classified as garbage codes were identified, which were investigated by a multidisciplinary team, capable of reclassifying them with codes that allow for the improvement of health data. In order to assess accuracy, sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios of death certificates from sepsis were calculated, with 95% confidence intervals. Results: A total of 6.244 statements were evaluated, of which 233 (3.74%) presented sepsis as the underlying cause before being investigated and only 35 (0.56%) maintained it after the investigation. The filling of statements with sepsis as the underlying cause by physicians showed a sensitivity of 0.9% (95%CI: 0.6 to 1.3) and a specificity of 92.0% (95%CI: 90.9 to 93.1). Conclusion: The low accuracy of the declarations demonstrates the non-reliability of the underlying cause of death from sepsis, especially the completion of death certificates that occurred in the Federal District in 2018.(AU)

Justificativa: A sepse, atualmente, representa um desafio para os sistemas de saúde, tal fato pode estar relacionado com a disseminação da resistência bacteriana, o aumento da população de idosos, os indivíduos imunossuprimidos, e a melhoria do atendimento de emergência, favorecendo a sobrevivência de pacientes críticos. Este artigo teve por objetivo avaliar a acurácia dos indicadores de mortalidade devido à sepse em 2018. Método: Estudo de validação da causa básica dos óbitos ocorridos no Distrito Federal em 2018. Foram identificadas as declarações de óbito cujas causas básicas de morte apontadas foram classificadas como garbage code sepse, as quais foram investigadas por uma equipe multidisciplinar, capacitada para reclassificá-las com códigos que permitem o aprimoramento dos dados em saúde. A fim de avaliar a acurácia, foram calculados os valores de sensibilidade, especificidade, valores preditivos positivo e negativo, razões de verossimilhança positiva e negativa das declarações dos óbitos por sepse, com intervalos de confiança de 95%. Resultados: Um total de 6.244 declarações foram avaliadas, das quais 233 (3,74%) apresentavam a sepse como causa básica antes de serem investigadas e apenas 35 (0,56%) mantiveram-na após a investigação. O preenchimento das declarações com a sepse enquanto causa básica pelos médicos apresentou sensibilidade de 0,9% (IC95%: 0,6 a 1,3) e especificidade de 92,0% (IC95%: 90,9 a 93,1). Conclusão: A baixa acurácia das declarações demonstra a não fidedignidade da causa básica de óbito por sepse, sobretudo, do preenchimento das declarações dos óbitos ocorridos no Distrito Federal em 2018.(AU)

Justificación: Sepsis representa en la actualidad un desafío para los sistemas de salud, este hecho puede estar relacionado con propagación de resistencias bacterianas, aumento de la población de ancianos, inmunodeprimidos, y mejora de la atención de urgencias, favoreciendo la supervivencia de los pacientes críticos. Este artículo tuvo como objetivo evaluar la precisión de los indicadores de mortalidad por sepsis en 2018. Método: Estudio de validación de causa básica de muertes ocurridas en Distrito Federal en 2018. Se identificaron actas de defunción cuyas causas básicas de muerte fueron clasificadas como sepsis código basura y fueron investigadas por un equipo multidisciplinario capacitado para reclasificarlas con códigos que permitan la mejora de datos de salud. Para evaluar la precisión, se calcularon sensibilidad, especificidad, valores predictivos positivo y negativo y razones de verosimilitud positiva y negativa de certificados de defunción por sepsis, con intervalos de confianza del 95%. Resultados: se evaluaron 6.244 declaraciones, de las cuales 233 (3,74%) tenían como causa básica la sepsis antes de ser investigadas y solo 35 (0,56%) mantuvieron después de investigación. Realización de declaraciones con sepsis como causa subyacente por parte de los médicos mostró sensibilidad del 0,9% (95%IC: 0,6 a 1,3) y especificidad del 92,0% (95%IC: 90,9 a 93,1). Conclusión: Baja precisión de las declaraciones demuestra la poca confiabilidad de la causa subyacente de muerte por sepsis, especialmente la finalización de los certificados de defunción ocurridos en Distrito Federal en 2018.(AU)

IPPASOS: The first digital forensic information system in Greece.

OBJECTIVE: This article describes the first digital clinical information system tailored to support the operational needs of a forensic unit in Greece and to maintain its archives. METHOD: The development of our system was initiated towards the end of 2018, as a close collaboration between the Medical School of the University of Crete and the Forensic Medicine Unit of the University Hospital of Heraklion, Crete, where forensic pathologists assumed active roles during the specification and testing of the system. RESULTS: The final prototype of the system was able to manage the life cycle of any forensic case by allowing users to create new records, assign them to forensic pathologists, upload reports, multimedia and any required files; mark the end of processing, issue certificates or appropriate legal documents, produce reports and generate statistics. For the first 4 years of digitised data (2017-2021), the system recorded 2936 forensic examinations categorised as 106 crime scene investigations, 259 external examinations, 912 autopsies, 102 post-mortem CT examinations, 804 histological examinations, 116 clinical examinations, 12 anthropological examinations and 625 embalmings. CONCLUSION: This research represents the first systematic effort to record forensic cases through a digital clinical information system in Greece, and to demonstrate its effectiveness, daily usability and vast potential for data extraction and for future research.

Evaluation of Medical Certification of Cause of Death in Tertiary Cancer Hospitals in Northern India.

BACKGROUND: Medical certification of cause of death (MCCD) provides valuable data regarding disease burden in a community and for formulating health policy. Inaccurate MCCDs can significantly impair the precision of national health information. OBJECTIVE: To evaluate the accuracy of cause of death certificates prepared at two tertiary cancer care hospitals in Northern India during the study period (May 2018 to December 2020). METHOD: A retrospective observational study at two tertiary cancer care hospitals in Varanasi, India, over a period of two and a half years. Medical records and cause of death certificates of all decedents were examined. Demographic characteristics, administrative details and cause of death data were collected using the WHO recommended death certificates. Accuracy of death certification was validated by electronic medical records and errors were graded. RESULTS: A total of 778 deaths occurred in the two centres during the study period. Of these, only 30 (3.9%) certificates were error-free; 591 (75.9%) certificates had an inappropriate immediate cause of death; 231 (29.7%) certificates had incorrectly labelled modes of death as the immediate cause of death; and 585 (75.2%) certificates had an incorrect underlying cause of death. The majority of certificates were prepared by junior doctors and were significantly associated with higher certification errors. CONCLUSION: A high rate of errors was identified in death certification at the cancer care hospitals during the study period. Inaccurate MCCDs related to cancers can potentially influence cancer statistics and thereby affect policy making for cancer control. IMPLICATIONS: This study has identified the pressing need for appropriate interventions to improve quality of certification through training of doctors.

Is training doctors in medical certification effective? Evidence from a prospective study in the Philippines.

BACKGROUND: Correct certification of causes of death by physicians according to International Classification of Diseases (ICD) rules is essential to generate mortality statistics of the quality needed to guide public health policy debates and reliably monitor the impact of health interventions. Several efforts to train doctors have been undertaken in the Philippines to improve Medical Certification of Causes of Death (MCCOD). However, there is very little evidence about the long-term effects of training interventions for medical certification. OBJECTIVE: To test whether there were measurable long-term impacts of this large-scale training intervention for improving medical certification and reducing different types of certification errors. METHOD: We assessed the quality of 2100 MCCOD completed before face-to-face training with those written by the same doctors 6 months after the training. An assessment tool was used to evaluate the quality of MCCOD. RESULTS: Less than 1% of the 2100 MCCOD assessed prior to the training were completely error-free, increasing to 19.2% 6 months after the training. On average, the number of errors per certificate fell from 2.2 pre-training to 1.3, six months after training. Importantly, there was a 38% decrease in writing ill-defined causes on the last line, which is particularly important for the policy utility of data. CONCLUSION: Training doctors in correct medical certification can have a long-term impact on medical certification practices. IMPLICATIONS: Shorter, more focused, trainings that address the most common medical certification errors could have an even greater impact on medical certification practices.