You can hardly go to a conference about state budgets without someone calling health care a "monster," and then talking about how it's "devouring" state revenues in an alarming fashion. States are trying to fight this growing bill on many fronts, including spending money on anti-obesity programs, prenatal care, smoking cessation, public education on various topics and attempting to allocate Medicaid dollars most effectively. It seems indisputable that policymakers trying to determine the best places to put the public's money should be informed by the best available data.
Unfortunately one of the most significant sources of information used by policymaker - mortality statistics - can be fatally flawed. These are the numbers produced by the federal government that indicate how many people die of heart disease, cancer, accidents, etc. But they're often based on information provided on inaccurate death certificates. Cause of death tends to be more accurate for violent fatalities - shootings, suicides or trauma - but when it comes to natural causes, it's a very different story.
Studies that compare death certificates with subsequent autopsy results consistently find that 20 to 40 percent of the time, there's disagreement on the cause of death, or a contributing factor is unmentioned on the certificate. Of course, autopsies are often done for more complex cases, which may inflate those numbers, but they're still unquestionably far too high. Robert Anderson, chief of the mortality statistics branch for the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics told us, "We know there are problems. But it's really difficult to tell how bad things are."
Not only is this important for states and localities in deciding where to allocate health-care dollars, but collecting these death certificates and ensuring their accuracy is a managerial state and local function that influences the expenditure of health-care dollars at all levels of government - an enormous responsibility.
Some causes of death-blood clots to the lungs, for example - are underreported, according to experts, and this may divert attention from the problem that could increase efforts at prevention. Similarly, maternal deaths directly related to pregnancy or childbirth are "substantially underestimated when death certificates alone are used to identify deaths," according to a Maryland Department of Health and Mental Hygiene study.
One contributing factor to spotty cause-of-death reporting is that many places require that death certificates be promptly filled out. In Michigan, for example, death certificates must be completed and submitted within 48 hours after a death because it's required for burial.
Autopsies provide an important alternative source of information about the cause of death. But the number of autopsies has declined from approximately 15 percent of deaths in 1980 to nearly 7 percent today. Fewer autopsies are performed partly because they're expensive, and hospitals aren't directly reimbursed for them under Medicare. On the dark side, some experts speculate that hospitals might not encourage autopsies because they might uncover medical variances with diagnoses, which could lead to malpractice suits.
What's more, "most physicians receive very little training in filling out death certificates," says Jeffrey Jentzen, director of autopsy and forensic services at the University of Michigan. Randy Hanzlick, chief medical examiner in Fulton County, Ga., agrees: "The first time that someone sees a death certificate is when a patient dies."
Fortunately better training from hospitals, public health departments or medical schools is one solution that states and localities can utilize. A 2007 study in the UK found that stepping up education for individuals completing death certificates significantly improved rates of accuracy. The CDC has developed training materials on its Web page, but the CDC's Anderson says he believes they haven't had sufficient distribution.
Electronic death registration also can help obtain more accurate data. Nearly half the states have electronic systems in place and others are moving in this direction. Funding for these systems, however, is scarce, and states are far from having the majority of deaths reported this way.
A third route to better reporting may simply be eliminating the requirement to show cause of death for elderly patients, who may have four or five diseases, each competing to deliver the final blow. Thanks to lack of clarity, many of these deaths are merely attributed to heart failure. In fact, the National Institutes of Health reports that national mortality statistics may overestimate the frequency of coronary heart disease as a cause of death by as much as twofold in older people.
"Writing down 'old age' is not an acceptable cause of death, and most places will not accept that. We've been rethinking that recently," says Anderson. "We've been trying to get some international consensus on whether that's acceptable and at what age it becomes acceptable. I have mixed feelings about it myself. I'm not going to quibble with old age as a cause of death for a 105-year-old person, but not an 80-year-old."