NEW YORK — It is one of a doctor’s most important final acts in caring for a patient, even though the patient is no longer around to appreciate it.
I refer, of course, to filling out the death certificate, a document that has myriad benefits for the living: establishing a legal basis for life insurance and estate settlements; providing critical information to survivors and descendants in an era of burgeoning advances in genetics; advancing knowledge about diseases, accidents and other causes of death; and much else.
For all these reasons, the accuracy of the certificates should be a paramount concern for public health, both nationally and internationally. And that is why two recent studies of doctors in New York City teaching hospitals are so unsettling.
The studies, published in the May issue of the journal Preventing Chronic Disease, support what researchers have long suspected: that heart disease is overreported as a cause of death, while diseases like pneumonia and cancer tend to be underreported. Equally disturbing, one of the studies suggests that the health system is far too cavalier about the accuracy of death certificates.
That study surveyed resident doctors in specialty training in 26 hospitals where about 40 percent of the city’s deaths occur. Of 521 respondents, 54 percent said they had knowingly reported what they believed was an inaccurate cause of death. Only one-third of the respondents believed that the system accurately documents the cause of death.
The reasons varied. Some doctors said they had never learned the proper procedures or were too busy to fill out the documents correctly. Because of restrictions in duty hours, many resident doctors had to enter a cause even though they did not know the patients — they just assumed care through transfers at the end of work shifts.
Some said data codes forced them to enter diagnoses that did not match their medical judgments: The electronic system rejected causes like sepsis from infection or acute respiratory distress syndrome, and hospital administrators instructed the doctors to certify another cause of death.
Frustrated with the system and the time pressures, doctors may take the easy way out by “just putting something down that would be easily accepted,” an author of the study, Dr. Keith Rose of St. Luke’s-Roosevelt Hospital Center in Manhattan, said in an interview.
Particularly disturbing is that most doctors said they had no formal training in filling out death certificates, either in medical school or in their residency programs.
Since the study was conducted — in spring 2010, based on respondents’ experience in the preceding three years — the New York City Department of Health and Mental Hygiene says it has been a national leader in improving the quality of death-certificate information. In 2009 the department introduced a training program in eight hospitals that accounted for 10 percent of all deaths in New York City.
The second study, which followed doctors in that program, dealt directly with the issue of overreporting heart disease as the cause of death, particularly among older patients. Heart disease is considered the nation’s leading killer, and doctors may list it by default without evaluating other possibilities. The practice tends to obscure the incidence of other serious ailments.
A health department team led by Dr. Teeb Al-Samarrai found that heart disease dropped 54 percent as a cause of death in the hospitals where the program was given, compared with a decrease of 6 percent or less in hospitals where it was not.
The educational effort also led to an increase in four other categories. Influenza and pneumonia almost tripled as causes of death — rising to 11 percent of certified deaths, from 4 percent. Chronic lower respiratory disease rose to 5 percent from 2 percent. Cerebrovascular disease, including strokes and aneurysms, rose to 4 percent from 2 percent. And cancer rose to 16 percent from 11 percent.
In general, a government medical examiner must be informed in cases of criminal neglect or violence, drug and chemical overdose and poisoning, workplace accidents, sudden death when in apparent good health, a death in which no physician has cared for the patient in the preceding 31 days and injuries like falls, among other causes. Eventually, the certified cause of death becomes part of a long statistical trail, from the local physician to city and state health officials, and then is listed among the official vital statistics of the United States. And once in a while, an absurd entry, usually a result of miscoding — Alzheimer’s disease in a 2-year-old, prostate cancer in a woman, cervical cancer in a man — is caught and corrected.
The accuracy of death certificates has myriad benefits for the living, but giving these vital documents their due is often little more than an afterthought.