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By Chris Kaiser, Cardiology Editor, MedPage Today Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse PlannerHeart disease deaths are over-reported in the U.S.A hospital-level intervention to reduce heart disease over-reporting led to substantial changes in other leading causes of death, changing the leading cause of premature death.Hospitals in the U.S. tend to over-report death from heart disease, researchers found, but a simple intervention can improve the quality of cause-of-death reporting.
Hospitals involved in the intervention reduced their reports of heart disease as the leading underlying cause of death from 69% before the intervention to 32% afterwards -- a relative decline of 54%, according to Teeb Al-Samarrai, MD, of the Santa Clara County Department of Public Health in San Jose, Calif., and colleagues.
As reports of heart disease deaths declined, there were increases in four other conditions as leading underlying causes of death, the most dramatic being a 252% relative increase for reported deaths from chronic lower respiratory disease (absolute increase from 2% to 5%), they reported in the latest issue of the CDC's Preventing Chronic Disease.
The other three causes of death that spiked after the intervention were: Influenza and pneumonia -- 193% relative increase, going from 4% to 11% Cerebrovascular disease -- 115% relative increase, going from 2% to 4%Malignant neoplasms -- 48% relative increase, going from 11% to 16%
However, the hospitals not involved in the intervention saw minimal relative changes in leading causes of death -- all 6% or less.
The investigators also determined that the postintervention changes were not an effect of a trend that might have begun before the intervention. A secondary analysis revealed that between 2000 and 2009 (pre-intervention), deaths from heart disease at the hospitals that subsequently were involved in the intervention remained steady -- around 60% to 71%.
Al-Samarrai, who was formerly with the CDC, and colleagues noted that they took on this study because the quality of the information on death certificates "affects the usefulness of vital statistics for public health action."
Lack of physician training serves as the greatest contributor of poor quality of mortality data, they wrote, adding that "Cause-of-death assignment practices also appear to vary by region."
One group for which determining the cause of death is particularly difficult is patients of advanced ages, the researchers noted. "This suggests that inaccurate reporting of cause of death for patients aged 85 or older reflects not only lack of training but also the complexity and challenge of identifying a single underlying condition or clear sequence of events leading to death. Death certificates force physicians to simplify what might be a complex medical situation."
"As the population lives longer and multiple chronic medical conditions become more common, documenting which disease is the underlying cause of death will become more challenging," they continued. "Therefore, using the current 1-cause-to-1-death model for cause-of-death coding might not be appropriate when describing mortality among persons ages 85 or older."
To assess whether the situation could be improved, the investigators performed an intervention consisting of training and communication with staff at eight hospitals in New York City. The pre-intervention period was from July though December 2009. Postintervention spanned January to June 2010.
The total number of deaths at the intervention hospitals was similar in the pre- and postintervention periods (2,120 and 2,069, respectively).
In the pre-intervention period, the total number of deaths attributed to heart disease in the intervention hospitals ranged from 58% to 80%. This dropped in the postintervention period by 28 to 53 percentage points -- to a range of 26% to 44%, researchers noted.
In a subgroup analyses, researchers found that sex and race/ethnicity had no impact on the ranking of leading cause of death.
When researchers restricted for cause of premature death (ages 35 to 74), however, malignant neoplasm took the lead over heart disease (26% versus 25%). No such change was seen in the nonintervention hospitals.
After the intervention, influenza and pneumonia as a leading cause of death moved from third to second; no change occurred in the nonintervention hospitals. Importantly, the largest increase in influenza and pneumonia deaths occurred among those 85 years or older.
When Al-Samarrai and colleagues controlled for age, heart disease as the leading cause of death declined in the intervention group from 36% to 17%. In the nonintervention hospitals, however, this number increased from 16% to 18%.
"To our knowledge, this is the first study to investigate the impact of reducing heart disease over-reporting on other leading causes of death," Al-Samarrai and colleagues wrote. No prior study had demonstrated a reduction in heart disease death concomitant with an increase in other leading causes of death, they added.
The intervention in this study has been expanded to more New York City hospitals, "with preliminarily positive results."
The limitations of the study include the fact that death certificates were not validated, individual physician understanding of death certificates was not evaluated, standardizing for race/ethnicity could have hidden reporting differences, and results may not apply to other settings.
Preventing Chronic Disease is a publication of the CDC.
The authors had no financial or conflicts of interest to disclose.
From the American Heart Association:
Chris Kaiser
Cardiology Editor
Chris has written and edited for medical publications for more than 15 years. As the news editor for a United Business Media journal, he was awarded Best News Section. He has a B.A. from La Salle University and an M.A. from Villanova University. Chris is based outside of Philadelphia and is also involved with the theater as a writer, director, and occasional actor.
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