Diversity in death certification: A case vignette approach

Previous studies have revealed high rates of errors in death certification, but few have discussed the nature of these errors. To explore the diversit y among physicians in death certification and its relationship with the com plexity of the causal sequence of death, we asked 145 physicians attending a continuing medical education course to complete the cause-of-death sectio n on dummy death certificates of four case vignettes. The difficulty in det ermining the causal sequence of death varied from relatively simple to comp lex. Variations in death certification were classified according to wording , diagnostic semantics, combinations of expressions, correctness of certifi cation format, and concordance with the referent underlying cause of death (UCOD). Given the same case history information, physicians showed great va riation in wording and diagnostic semantics in death certification. The rat es of correct certification format and concordance with referent UCOD varie d with the level of complexity of the causal sequence of death. The greates t source of diversity was choosing between an acute condition of a chronic disease and the chronic disease itself, and between competing prominent com orbidities. Experience in death certification was significantly associated with correct certification format but not with concordance with referent UC OD. Knowledge of death certification was not associated with correct certif ication format or concordance with referent UCOD. Our findings indicate tha t the traditional concept of UCOD tabulation and using a single standard IC D code in evaluating the quality of death certification oversimplifies a co mplex situation. Variations in death certification, especially the selectio n of UCOD, were due to differences in interpreting the information rather t han differences in knowledge of death certification. (C) 2001 Elsevier Scie nce Inc. All rights reserved.