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Objectives. To determine how deaths of infants with genetic diagnoses are described in national mortality statistics. Methods. We present a retrospective cohort study of mortality data, obtained from the National Death Index (NDI), and clinical data for 517 infants born from 2011 to 2017 who died before 1 year of age in the United States. Results. Although 115 of 517 deceased infants (22%) had a confirmed diagnosis of a genetic disorder, only 61 of 115 deaths (53%) were attributed to International Classification of Diseases, 10th Revision codes representing congenital anomalies or genetic disorders (Q00-Q99) as the underlying cause of death because of inconsistencies in death reporting. Infants with genetic diagnoses whose underlying causes of death were coded as Q00-Q99 were more likely to have chromosomal disorders than monogenic conditions (43/61 [70%] vs 18/61 [30%]; P Conclusions. Genetic disorders, although a leading cause of infant mortality, are not accurately captured by vital statistics. Public Health Implications. Expanded access to genetic testing and further clarity in death reporting are needed to describe properly the contribution of genetic disorders to infant mortality.

Background In Bangladesh, a poorly functioning national system of registering deaths and determining their causes leaves the country without important information on which to inform health programming, particularly for the 85% of deaths that occur in the community. In 2017, an improved death registration system and automated verbal autopsy (VA) were introduced to 13 upazilas to assess the utility of VA as a routine source of policy-relevant information and to identify leading causes of deaths (COD) in rural Bangladesh. Methods Data from 22,535 VAs, collected in 12 upazilas between October 2017 and August 2019, were assigned a COD using the SmartVA Analyze 2.0 computer algorithm. The plausibility of the VA results was assessed using a series of demographic and epidemiological checks in the Verbal Autopsy Interpretation, Performance and Evaluation Resource (VIPER) software tool. Results Completeness of community death reporting was 65%. The vast majority (85%) of adult deaths were due to non-communicable diseases, with ischemic heart disease, stroke and chronic respiratory disease comprising about 60% alone. Leading COD were broadly consistent with Global Burden of Disease study estimates. Conclusions Routine VA collection using automated methods is feasible, can produce plausible results and provides critical information on community COD in Bangladesh. Routine VA and VIPER have potential application to countries with weak death registration systems.

Objectives Cause-of-death information, reported by frontline clinicians after a patient’s death, is an irreplaceable source of public health data. However, systematic bias in cause-of-death reporting can lead to over- or underestimation of deaths attributable to different causes. New York City consistently reports higher rates of deaths attributable to pneumonia and influenza than many other US cities and the country. We investigated systematic erroneous reporting as a possible explanation for this phenomenon. Methods We reviewed all deaths from 2 New York City hospitals during 2013-2014 in which pneumonia or influenza was reported as the underlying cause of death (n = 188), and we examined the association between erroneous reporting and multiple extrinsic factors that may influence cause-of-death reporting (patient demographic characteristics and medical comorbidities, time and hospital location of death, type of medical provider reporting the death, and availability of certain diagnostic information). Results Pneumonia was erroneously reported as the underlying cause of death in 163 (86.7%) reports. We identified heart disease and dementia as the more likely underlying cause of death in 21% and 17% of erroneously reported deaths attributable to pneumonia, respectively. We found no significant association between erroneous reporting and the multiple extrinsic factors examined. Conclusions Our results underscore how erroneous reporting of 1 condition can lead to underreporting of other causes of death. Misapplication or misunderstanding of procedures by medical providers, rather than extrinsic factors influencing the reporting process, are key drivers of erroneous cause-of-death reporting.

WHO mortality statistics overlook land motor-vehicle accident (LMVA)-related drowning. The aim of the study was to provide an overview of the prevalence and trends of fatal LMVA-related drowning in Finland, plus the main crash settings, victims' demographic characteristics, and contributing factors leading to such deaths.A descriptive, retrospective, population-based study of drowning deaths associated with LMVA among Finnish residents of all ages, 1971-2013. LMVA-related drownings and applicable variables were extracted from the Statistics Finland (SF) mortality database by cross-analysis of ICD injury- and external cause-of-death codes.During the study period, 538 LMVAs leading to drowning occurred among Finnish residents (2.5/1 000 000/year; 4.9% of all unintentional drownings, 3.7% of all LMVA). Three main settings, ones responsible for over 95% of LMVA-related drownings, were recognized: traffic vehicle accidents involving a passenger car; non-traffic vehicle accident involving a snowmobile; and non-traffic accidents involving agricultural, industrial, or construction vehicles. Alcohol use was a contributing factor for death in40% of the victims, whereas severe injuries were reported in less than 6%.Because transport safety is crucial to prevent any vehicle entering the water, placing LMVA-related drowning in the category of transport accidents is warranted. Once the vehicle becomes submersed, however, prevention measures to avoid death by drowning remains decisive.

Since the emergence of the COVID-19 pandemic, the mortality statistics are constantly changing globally. Mortality statistics analysis has vital implications to implement evidence-based policy recommendations. This study aims to study the demographic characteristics, patterns, determinants, and the main causes of death during the first half of 2020, in the Kingdom of Saudi Arabia (KSA). Methodology: A retrospective descriptive study targeted all death (29,291) registered in 286 private and governmental health settings, from all over KSA. The data was extracted from the ministry of health’s death records after the ethical approval. The International Classification of Diseases (ICD-10) and WHO grouping, were used to classify the underlying causes of deaths. The collected data were analyzed using the appropriate tables and graphs. Results: 7055 (24.9%) died at the middle age (40–59 year), and 19,212 (65.6%) were males, and 18,110 (61.8%) were Saudi. The leading causes of deaths were non-communicable diseases (NCDs) 15,340 (62.1%), mainly Cardiovascular diseases (CVDs) 10,103 (34.5%). There was a significant relationship between the main causes of deaths and sex (p < 0.05) and nationality (p = 0.01). Conclusion: NCDs mainly CVDs are the leading cause of death. The COVID-19 mortalities were mainly in males, and old age > 55 year. The lockdown was associated with a reduction in the NCDs and Road traffic accidents mortalities.

Objectives Inaccuracies in cause-of-death information in death certificates can reduce the validity of national death statistics and result in poor targeting of resources to reduce morbidity and mortality in people with HIV. Our objective was to measure the sensitivity, specificity, and agreement between multiple causes of deaths from death certificates obtained from the National Death Index (NDI) and causes determined by expert physician review. Methods Physician specialists determined the cause of death using information collected from the medical records of 50 randomly selected HIV-infected people who died in San Francisco from July 1, 2016, through May 31, 2017. Using expert review as the gold standard, we measured sensitivity, specificity, and agreement. Results The NDI had a sensitivity of 53.9% and a specificity of 66.7% for HIV deaths. The NDI had a moderate sensitivity for non–AIDS-related infectious diseases and non–AIDS-related cancers (70.6% and 75.0%, respectively) and high specificity for these causes (100.0% and 94.7%, respectively). The NDI had low sensitivity and high specificity for substance abuse (27.3% and 100.0%, respectively), heart disease (58.3% and 86.8%, respectively), hepatitis B/C (33.3% and 97.7%, respectively), and mental illness (50.0% and 97.8%, respectively). The measure of agreement between expert review and the NDI was lowest for HIV (κ = 0.20); moderate for heart disease (κ = 0.45) and hepatitis B/C (κ = 0.40); high for non–AIDS-related infectious diseases (κ = 0.76) and non–AIDS-related cancers (κ = 0.72); and low for all other causes of death (κ < 0.35). Conclusions Our findings support education and training of health care providers to improve the accuracy of cause-of-death information on death certificates.

Background The vital registration system is universally recognized as the main source of mortality data which is essential for policy formulation, proper interventions and resource allocation to address priority health challenges. To improve availability and quality of mortality statistics by strengthening the vital registration system, understanding the current vital registration system is essential. This study identified challenges in generating reliable mortality statistics in the vital registration system of Myanmar. Methods Qualitative methods were used to collect data in two selected townships of Mandalay Region. Grey literature related to the management of mortality registration was reviewed; in-depth interviews of sixteen key informants and fourteen focus group discussions were conducted with those involved in death registration at the local level, such as healthcare providers, local administrators and knowledgeable adults in households where deaths occurred during the past three years. Thematic analysis was performed to identify system barriers in the death registration process. Results Weaknesses in the death registration system are classified in three areas: a) administrative which includes the lack of enforcement of mandatory death registration, limited issuance of death certificates and no formal mandatory notification of death events by households and; b) technical which includes absence of proper and regular on-the-job trainings, ineffective cause-of-death certification practice for deaths in the communities and the absence of routine data plausibility checks at the local level; and c) societal which includes poor community awareness and inadequate participation in death registration. Conclusion The study highlighted challenges in the death registration system at the operational level, which undermines the achievement of a satisfactory level of completeness and accuracy of mortality data. We recommend establishing a strong legal framework, improving technical capacities and raising public awareness and cooperation to strengthen the system that can generate reliable mortality statistics. Electronic supplementary material The online version of this article (10.1186/s12889-019-6671-y) contains supplementary material, which is available to authorized users.

Background The study aims to assess two approaches that apply the empirical completeness method to generate age-specific mortality statistics from incomplete death registration systems. Methods We use the empirical completeness method to calculate all-age death registration completeness, which is used with a model life table to generate mortality statistics and age-specific completeness using (1) the conventional method and (2) the equivalent deaths method. The results are compared with a capture-recapture (C-RC) study and three alternative mortality estimates for Brazilian states, and C-RC studies in Thailand, Oman and Vietnam, which independently estimate the level and age pattern of mortality or completeness. Results The empirical completeness method produces similar estimates of all-age completeness of registration to the C-RC studies. Compared with C-RC studies, at 15-59 years, the conventional method’s estimates of mortality and completeness are more concordant, while at 60-84 years the equivalent death method’s estimates are closer. Estimates of life expectancy from the two approaches each have similar concordance with the C-RC studies. For male adult mortality in Brazilian states, there is relatively strong average correlation of this study's estimates with three alternative estimates. Conclusions The two approaches produce mortality statistics from incomplete data that are mostly concordant with C-RC studies, and can be most usefully applied to subnational populations.

During the Russian influenza pandemic, which reached the United States in late 1889, US public health officials attempted to document the number of deaths associated with this disease outbreak. A historical perspective illuminates the complex categories used to classify deaths from influenza-associated diseases; substantial changes in weekly, monthly, and yearly death totals; and thoughtful efforts by health officials to measure the epidemic as it happened. The 1114 influenza deaths reported by the Connecticut State Board of Health in the 3 years after the January 1890 outbreak must be supplemented by the notable increases in the number of deaths from respiratory diseases, which elevates the likely toll to more than 7000 deaths during the epidemic. Whereas historians of public health have primarily examined efforts to control communicable diseases, this case study of mortality statistics reported by town officials and analyzed by the Connecticut State Board of Health demonstrates how officers of the local boards of health also responded to unexpected outbreaks of a familiar disease such as influenza. Understanding how organizations measured influenza-associated mortality illustrates an important stage in the development of American public health and also makes an important contribution to studying pandemics in history.

Mortality statistics based on underlying cause of death are challenged by increased life expectancy and the growing share of population reaching ages associated with frequent multi-morbidity (with death likely resulting from interactions between multiple diseases). We provide a novel way of analysing causes of death: accounting for all causes mentioned on death certificates and summarizing this information along two dimensions emblematic of ageing populations-multi-morbidity and frailty. We implement this classification for all deaths at ages 50+ in Italy in 2014. Multi-morbid processes represent the majority of deaths, rising from 43 per cent at ages 50-54 to 63 per cent at ages 85-89. Multi-morbidity at death is more frequent among males, although age patterns are identical for both sexes. About one in four deaths involves frailty symptoms, rising to 45 per cent at ages 95+. Mortality rates involving frailty are very similar for both sexes. Supplementary material is available for this article at: https://doi.org/10.1080/00324728.2020.1820558.

Researchers are struggling to tally mortality statistics as the pandemic rages. Here’s how they gauge the true toll of the coronavirus outbreak. Researchers are struggling to tally mortality statistics as the pandemic rages. Here’s how they gauge the true toll of the coronavirus outbreak.

We believe that forensic medicine should play a significant role in the COVID-19 pandemic. Forensic pathologists should ask and answer various questions through autopsy cases during the COVID-19 period, thus providing a significant contribution to science. Some of the potential roles of forensic medicine in this issue include: determining the exact cause of death among the deceased who were SARS-CoV-2 positive, contribution to the accuracy of mortality statistics, understanding pathological mechanisms of COVID-19, tracking the presence of the virus over time, survival of the virus after death as well as dealing with medicolegal issues. A detailed multidisciplinary analysis of autopsy samples would undoubtedly help understand this new illness and its clinical management. Therefore, autopsies during the COVID-19 pandemic should not be an exception, but certainly a rule.

Mortality rates have significant differences between regions of the Russian Federation. Standardized mortality rates (SMR) are influenced by many factors, including diagnosis criteria and causes of death.Analysis of coefficient of variation of SMR from malignant neoplasms compared with other causes of death in the subjects of Russian Federation.The study formed 3 comparison groups: malignant neoplasms, other causes and causes of death, presented in ICD-10 to indicate conditions that do not have clear diagnostic criteria and rules for its use, as well as unspecified and not recommended for use in mortality statistics. To calculate SMR out of 79 reasons selected from the «Brief nomenclature of causes of death of Russian Statistic Bureau (RosStat)», the European standard was used. The accuracy of differences between the groups was evaluated using one-way analysis of variance with pairwise comparison and Bonferroni correction.In the group of malignant neoplasms, there were significant differences in the coefficients of SMR variability between the subgroup of neoplasms with an exact indication of localization and the subgroup of malignant neoplasms of other and inaccurately defined localizations. However, even the causes of death from malignant neoplasms that do not have sufficiently clear application criteria have a significantly less pronounced coefficient of SMR variability compared to the other two groups. The causes of death, starting in the RosStat nomenclature with the words «other diseases», and the causes associated with the diseases presented in ICD-10 to indicate conditions that do not have clear diagnostic criteria and rules of its use, as well as unspecified and not recommended for use, had practically the same high level of SMR variability coefficient. A certain contribution to the differences in regional SMR indicators from specific causes can be affected by the inconsistency of the criteria for diagnosing diseases and choosing the initial cause of death.To obtain the correct indicators of mortality from individual causes / groups of causes, we need unified generally accepted definitions and rules for the application of conditions presented in ICD-10, which do not have clear diagnostic criteria, as well as unspecified; and as well as rejection of statistics not recommended for use because of the initial causes of mortality.Показатели смертности населения имеют существенные различия между регионами Российской Федерации. На стандартизованные коэффициенты смертности (СКС) влияют многие факторы, включая критерии установления диагноза и причины смерти.Анализ коэффициента вариации СКС от злокачественных новообразований по сравнению с другими причинами смерти в субъектах РФ.В исследовании сформированы 3 группы сравнения: злокачественные новообразования, другие/прочие причины и причины смерти, представленные в МКБ-10 для обозначения состояний, не имеющих четких критериев диагностики и правил применения, а также неуточненных и не рекомендованных к применению в статистике смертности. Для расчета СКС от 79 причин, отобранных из «Краткой номенклатуры причин смерти Росстата», использовали Европейский стандарт. Достоверность различий между группами оценивали с помощью однофакторного дисперсионного анализа с попарным сравнением и поправкой Бонферрони.В группе злокачественных новообразований имелись достоверные различия коэффициентов вариабельности СКС между подгруппой новообразований с точным указанием локализации и подгруппой злокачественных новообразований других и неточно обозначенных локализаций. Однако даже причины смерти от злокачественных новообразований, не имеющих достаточно четких критериев применения, имеют значительно менее выраженный коэффициент вариабельности СКС по сравнению с двумя другими группами. Причины смерти, начинающиеся по номенклатуре Росстата со слов «другие заболевания», и причины, связанные с заболеваниями, представленными в МКБ-10 для обозначения состояний, не имеющих четких критериев диагностики и правил применения, а также неуточненных и не рекомендованных к применению, имели практически одинаковый высокий уровень коэффициента вариабельности СКС. Определенный вклад в различия региональных показателей СКС от конкретных причин может влиять несогласованность критериев диагностики заболеваний и выбора первоначальной причины смерти.Для получения корректных показателей смертности населения от отдельных причин/групп причин требуются единые общепринятые дефиниции и правила применения в качестве первоначальных причин смерти, представленных в МКБ-10 состояний, не имеющих четких критериев диагностики, а также неуточненных, и отказ от нерекомендованных к применению в статистике смертности.

Objective To analyse mortality statistics in the United Kingdom during the initial phases of the severe acute respiratory coronavirus 2 (SARS-CoV-2) pandemic and to understand the impact of the pandemic on national mortality. Methods Retrospective review of weekly national mortality statistics in the United Kingdom over the past 5 years, including subgroup analysis of respiratory mortality rates. Results During the early phases of the SARS-CoV-2 pandemic in the first months of 2020, there were consistently fewer deaths per week compared with the preceding 5 years. This pattern was not observed at any other time within the past 5 years. We have termed this phenomenon the “SARS-CoV-2 paradox.” We postulate potential explanations for this seeming paradox and explore the implications of these data. Conclusions Paradoxically, but potentially importantly, lower rather than higher weekly mortality rates were observed during the early stages of the SARS-CoV-2 pandemic. This paradox may have implications for current and future healthcare utilisation. A rebound increase in non-SARS-CoV-2 mortality later this year might coincide with the peak of SARS-CoV-2 admissions and mortality.

Background and purpose Despite evidence of the benefits of radiotherapy (RT) in the treatment of cancer patients, its underutilisation has been reported for various tumour sites. The aim of this study was to estimate survival shortfall, ‘years of potential life lost’ (YPLL) and ‘disability-adjusted life years lost’ (DALY) to demonstrate the impact of radiotherapy underutilisation in Australia. Materials and methods Optimal and actual RT utilisation (RTU) was compared to assess RT underutilisation to estimate 5-year overall survival shortfall using 2006 data from New South Wales (NSW) for 26 common tumour sites. 5-year overall survival shortfall is defined as number of people not surviving for 5-years due to RT underutilisation [=benefit proportion × shortfall [(optimal-actual RTU)/optimal RTU] proportion × No. of new cases]. YPLL = survival shortfall × estimated years of life lost per person (overall life expectancy − median age at death for specific cancer). DALY = (Years lived with disability + Years of life lost) × survival shortfall. Results The total number of new cases with cancer in 2006 in NSW was 20,741. Optimal RTU was 48% while actual RTU was 26%, resulting in estimated of 411 deaths due to underutilisation. Each death resulted in an average of 10.4 YPLL and 17.5 DALY. It was estimated RT underutilisation resulted in a total of 4,289 YPLL and 7,192 DALY overall. Conclusion This study illustrates the value of considering different mortality statistics, which include measures of the burden of cancer deaths on both the population and patients.

Background Although death certificates (DCs) provide valuable health information which may help to guide local health policies and priorities, there is little information concerning their validity in Thailand. First-year general practitioners (GPs) have a major role in DC completion, especially in provincial general hospitals. The aim of this study was to evaluate the accuracy and factors influencing the accuracy of DCs completed by first-year GPs in Thailand, compared with the cause of death (COD) derived from medical records by experts. Methods This retrospective study was conducted at 14 provincial general hospitals in Thailand during the June 2011 to May 2012 study period. Medical records and DCs completed by first-year GPs who graduated from 16 Thai medical schools were sampled. The cause of death recorded on the DCs was compared with the medical conditions and histories derived from patient medical records. A cross-sectional survey of the 210 GPs who completed the DCs reviewed in this study was also conducted. Respondent GPs’ demographic characteristics, factors associated with COD, and COD coding system were evaluated. Results Five hundred and sixty-three medical records and corresponding DCs were included. Of those, 36.9% of DCs were found to be correct. Common mistakes included incorrect sequence of events leading to death (32.4%), and mode of death use (26.2%). Of the 210 GPs, 155 questionnaires were completed and returned. The mean time spent on recording COD and completing DCs in the medical school curriculum was 2.1 ± 0.9 h and only 27.7% of participants had experience in completing DCs by themselves during medical school. Mean medical school GPA was significantly higher in the correctly completed DC GPs group than in the incorrectly completed DC GPs group (3.3 ± 0.4 vs. 3.2 ± 0.3; p = 0.03). However, no significant difference was found for other factors associated with COD between groups. Conclusions This is the first study documenting gaps and disparities in DC accuracy, and factors influencing completion of DCs among first-year GPs in Thailand, based on a clinical assessment of medical records. GPs made errors on 63.1% of DCs. This finding suggests that proven education, system-related support, and additional training interventions specific to DC completion are required. Electronic supplementary material The online version of this article (10.1186/s12913-018-3289-1) contains supplementary material, which is available to authorized users.

Objective:Errors in cause and manner of death on death certificates are common and affect families, mortality statistics, and public health research. The primary objective of this study was to characterize errors in the cause and manner of death on death certificates completed by non–Medical Examiners. A secondary objective was to determine the effects of errors on national mortality statistics.Methods:We retrospectively compared 601 death certificates completed between July 1, 2015, and January 31, 2016, from the Vermont Electronic Death Registration System with clinical summaries from medical records. Medical Examiners, blinded to original certificates, reviewed summaries, generated mock certificates, and compared mock certificates with original certificates. They then graded errors using a scale from 1 to 4 (higher numbers indicated increased impact on interpretation of the cause) to determine the prevalence of minor and major errors. They also compared International Classification of Diseases, 10th Revision (ICD-10) codes on original certificates with those on mock certificates.Results:Of 601 original death certificates, 319 (53%) had errors; 305 (51%) had major errors; and 59 (10%) had minor errors. We found no significant differences by certifier type (physician vs nonphysician). We did find significant differences in major errors in place of death ( P < .001). Certificates for deaths occurring in hospitals were more likely to have major errors than certificates for deaths occurring at a private residence (59% vs 39%, P < .001). A total of 580 (93%) death certificates had a change in ICD-10 codes between the original and mock certificates, of which 348 (60%) had a change in the underlying cause-of-death code.Conclusions:Error rates on death certificates in Vermont are high and extend to ICD-10 coding, thereby affecting national mortality statistics. Surveillance and certifier education must expand beyond local and state efforts. Simplifying and standardizing underlying literal text for cause of death may improve accuracy, decrease coding errors, and improve national mortality statistics.

Breast cancer is the most common malignancy in women worldwide and Chile, being the leading cause of female cancer death. A wide variation in mortality has been reported, with geographic clusters of higher risk.To spatially analyze mortality from breast cancer in women in the Metropolitan Region in 2015.Ecological study of location. We used death records in 2015 (C50 according to ICD10) and population projections of the Statistics Institute to estimate mortality rates. We calculated crude breast cancer mortality rates and standardized mortality ratios and performed a spatial epidemiological analysis of breast cancer mortality in women, estimating the global and local Moran I index to assess spatial autocorrelation. We present the results in maps according to the 2016 pre-census cartography.There were 622 deaths from breast cancer in the Metropolitan Region in 2015. The mean age was 66 years (SD: 15.5). 92.4% of deaths were registered in urban or central areas. However, the highest mortality rates were observed in peripherical districts. No global spatial autocorrelation was observed in the region (Morans I 0.007 p = 0.134). However, at the local level, four districts differ significantly from their neighbors.The risk of dying from breast cancer in the Metropolitan Region of Chile is concentrated in women from peripherical communes. Four districts in the region present different risks from their neighboring districts. It is necessary to investigate local realities to prevent deaths from this pathology.El cáncer de mama es la neoplasia maligna más común en las mujeres en todo el mundo y en Chile, siendo la primera causa de muerte oncológica femenina. Se ha reportado amplia variación en la mortalidad, con focos geográficos de mayor riesgo.Analizar espacialmente la mortalidad por cáncer de mama en mujeres de la Región Metropolitana en 2015.Estudio ecológico. Se utilizaron los datos de los registros de defunciones del año 2015 (C50 según CIE10), y las proyecciones poblacionales del Instituto Nacional de Estadísticas. Se calcularon tasas de mortalidad por cáncer de mama brutas y razones de mortalidad estandarizadas. Se realizó un análisis epidemiológico espacial estimando el índice I de Moran Global y Local para evaluar autocorrelación espacial. Los resultados se presentan en mapas (cartografía pre-censo 2016).Se registraron 622 defunciones por cáncer de mama en la Región Metropolitana en 2015. La edad promedio de las mujeres fallecidas fue de 66 años (desviación estándar: 15,5). El 92,4% de las muertes se registró en zonas centrales o urbanas. Sin embargo, las mayores tasas de mortalidad se observaron en comunas periféricas. No se observó autocorrelación espacial global en la región (I de Moran de 0,007; p = 0,134). A nivel local, cuatro comunas se diferencian de forma significativa de sus vecinas.El riesgo de morir por cáncer de mama en la Región Metropolitana de Chile se concentra en comunas periféricas. Cuatro comunas de la región presentan riesgos diferentes de sus comunas vecinas, por lo que es necesario explorar factores que explican la desigual distribución de las muertes.

ObjectiveTo examine the accuracy of mortality statistics in Palestine, to identify gaps and to provide evidence-based recommendations to improve mortality statistics in Palestine.Study design and settingA retrospective death registry-based study that examined a stratified random sample of death notification forms (DNFs) of patients who died in hospitals in Palestine was reported in 2012. We randomly selected 600 deceased from the Cause of Death Registry: 400 from the West Bank and 200 from the Gaza Strip. Analysis was based on the randomly selected deaths that we were able to retrieve the medical records for; 371 deaths in the West Bank and 199 deaths in the Gaza Strip.ResultsData in the Palestinian Health Information Centre (PHIC) registry had a low degree of accuracy: less than half of the underlying causes stated the correct cause of death. In general, deaths due to malignant neoplasms were more accurately reported on DNFs than other causes of death, and metabolic diseases (including diabetes) were the most problematic. Issues with coding and classification at the PHIC were most apparent for perinatal conditions and congenital anomalies.ConclusionProcedures for coding and classification at the PHIC deviate considerably from the international norms defined in the International Statistical Classification of Diseases and Related Health Problems (ICD) and account to a considerable extent for the discrepancies between the cause of death determined on the medical data on the death extracted from the deceased patient’s hospital records and the cause of death coded by the PHIC. We recommend the introduction of international coding software for coding and classification, and a review to improve data handling in hospitals, especially those with electronic patient records.

The COVID-19 pandemic has had a substantial impact on government services in many areas, including Civil Registration and Vital Statistics (CRVS). However, the pandemic has also highlighted the importance of recording of mortality and causes of death, with some potentially positive impacts for longer term CRVS strengthening, including: (1) increasing online provision of registration services (2) reporting of mortality statistics from settings which had not previously done so (3) improved intersectoral cooperation, particularly with the health sector, improving the ability to record deaths and (4) increased awareness among governments and public of the importance of mortality statistics. Now, it is pressing for national governments, and international organizations working to strengthen CRVS systems, to evaluate the effectiveness of strategies adopted over the last year, and use lessons learnt to catalyse broader sustainable CRVS improvement strategies, providing governments with essential data on mortality and causes of death into the future.

Background: Precise cause of death (CoD) ascertainment is crucial in any cancer screening trial to avoid bias from misclassification due to excessive recording of diagnosed cancer as a CoD in death certificates instead of non-cancer disease that actually caused death. We estimated whether there was bias in CoD determination between screening (SA) and control arms (CA) in a population-based prostate cancer (PCa) screening trial. Methods: Our trial is the largest component of the European Randomized Study of Screening for Prostate Cancer with more than 80,000 men. Randomly selected deaths in men with PCa (N = 442/2568 cases, 17.2%) were reviewed by an independent CoD committee. Median follow-up was 16.8 years in both arms. Results: Overdiagnosis of PCa was present in the SA as the risk ratio for PCa incidence was 1.19 (95% confidence interval (CI) 1.14-1.24). The hazard ratio (HR) for PCa mortality was 0.94 (95% CI 0.82-1.08) in favor of the SA. Agreement with official CoD registry was 94.6% (k = 0.88) in the SA and 95.4% (k = 0.91) in the CA. Altogether 14 PCa deaths were estimated as false-positive in both arms and exclusion of these resulted in HR 0.92 (95% CI 0.80-1.06). Conclusions: A small differential misclassification bias in ascertainment of CoD was present, most likely due to attribution bias (overdiagnosis in the SA). Maximum precision in CoD ascertainment can only be achieved with independent review of all deaths in the diseased population. However, this is cumbersome and expensive and may provide little benefit compared to random sampling. (C) 2016 Elsevier Ltd. All rights reserved.

The aim of this study was to compare in-hospital deaths in different hospital settings between 1850 and 2000 in Vienna. We reviewed 120 autopsy records for each of the selected years from the Clinical Institute of Pathology of the Medical University Vienna and two community hospitals. In 2000 the autopsy rate was 37.5 % at the community hospitals and 52.5 % at the university hospital. The mean age of those being dissected was significantly lower compared with those not being dissected in the community hospital. Infections were the leading cause of death during the nineteenth and early twentieth century, after 1950 the rate of cardiovascular diseases and cancer increased. In the year 2000 the majority of patients with an underlying malignant disease died because of cardiovascular disease. Causes of death vary between institutions. They should be reported as accurately as possible in order to create a cogent basis for central mortality statistics.

One of the most frequently used indicators for the quality of mortality statistics is the use of R-codes as the cause of death (COD) in death certificates. The aim of this study was to analyse the coding of ill-defined and unknown causes of death in the Republic of Serbia (RS). The data for this descriptive study, covering a ten-year period (2006-2015), were obtained from the National Mortality Register. Since population and economic features differ widely between regions in RS, we compared the Belgrade region (BR) with other regions (Or). We estimated the frequency of certain types of death investigation methods regarding R00-99-coded deaths. The frequency of R-codes, by subcategories, and code-specific mortality rates were calculated by region for each year. The use of R-codes was significantly lower in BR than in Or (OR 0.85; 95% CI, 0.84-0.66; p 0.001). The most frequent method of determining COD was external examination of the body, both in BR and Or (60.7% and 85.5%, respectively). The rate of forensic autopsies in BR was 38.1% while in Or it was only 3.6%. Clinical autopsies were performed in 1% of deaths in BR, compared to 0.5% in Or. Our results suggest that in BR the use of R-codes compared to other CODs has decreased over the past years while there has been an increasing trend in autopsy proportions; in Or the frequency of R-codes, as well as of autopsy proportions, has remained unchanged.

An index of fatal toxicity for new psychoactive substances has been developed based solely on information provided on death certificates. An updated index of fatal toxicity (Tf), as first described in 2010, was calculated based on the ratio of deaths to prevalence and seizures for the original five substances (amphetamine, cannabis, cocaine/crack, heroin and 3,4-methylenedioxymethylamphetamine)*. These correlated well with the 2010 index. Deaths were then examined for cases both where the substance was and was not found in association with other substances. This ratio (sole to all mentions; S/A) was then calculated for deaths in the period 1993 to 2016. This new measure of fatal toxicity, expressed by S/A, was well-correlated with the index Ln (Tf) of the original reference compounds. The calculation of S/A was then extended to a group of new psychoactive substances where insufficient prevalence or seizure data were available to directly determine a value of Tf by interpolation of a graph of Tf versus S/A. Benzodiazepine analogues had particularly low values of S/A and hence Tf. By contrast, γ-hydroxybutyrate/γ-butyrolactone, α-methyltryptamine, synthetic cannabinoid receptor agonists and benzofurans had a higher fatal toxicity.

Aims and methods: Being easily available and having good coverage and comparability, official mortality statistics are used very widely. This in turn is because the definitions of mortality and methods of pertinent data collection are coordinated worldwide by the World Health Organization. In Estonia, registered cerebrovascular mortality has dropped 50% since 2000. A less dramatic decrease has been observed in nearly all EU Member States. To find out if this development can be explained by changing certification and coding practices, we counted all mentions of cerebrovascular diseases in the Estonian Causes of Death Registry database between 2004 and 2013 and analyzed the selection of the underlying cause of death. Results: We found that the sharp decrease in registered cerebrovascular mortality was by a half due to an increased selection of hypertension as the underlying cause of death. In cases where a cerebrovascular disease was mentioned and selected the underlying cause of death, the mean number of diagnoses per record was 2.45, in cases where a cerebrovascular disease was mentioned, but hypertension selected the underlying cause of death, the mean number of diagnoses was 3.15. Conclusions: The choice of the underlying cause of death registered in official statistics depends on the level of details provided in a death certificate, as well as updates to coding rules and use of modern quality assurance instruments in data production.

Purpose– The purpose of the paper is to investigate the potential relationships between emergency-care flow, patient mortality and healthcare costs using a patient-flow model.Design/methodology/approach– The researchers used performance data from one UK NHS trust collected over three years to identify periods where patient flow was compromised. The delays’ root causes in the entire emergency care system were investigated. Event time-lines that disrupted patient flow and patient mortality statistics were compared.Findings– Data showed that patient mortality increases at times when accident and emergency (A&E) department staff were struggling to admit patients. Four delays influenced mortality: first, volume increase and mixed admissions; second, process delays; third, unplanned hospital capacity adjustments and finally, long-term capacity restructuring downstream.Research limitations/implications– This is an observational study that uses process control data to find times when mortality increases coincide with other events. It captures contextual background to whole system issues that affect patient mortality.Practical implications– Managers must consider cost-decisions and flow in the whole system. Localised, cost-focused decisions can have a detrimental effect on patient care. Attention must also be paid to mortality reports as existing data-presentation methods do not allow correlation analysis.Originality/value– Previous studies correlate A&E overcrowding and mortality. This method allows the whole system to be studied and increased mortality root causes to be understood.

Background: Public reporting of percutaneous coronary intervention (PCI) outcomes may create disincentives for physicians to provide care for critically ill patients, particularly at institutions with worse clinical outcomes. We thus sought to evaluate the procedural management and in-hospital outcomes of patients treated for acute myocardial infarction before and after a hospital had been publicly identified as a negative outlier. Methods: Using state reports, we identified hospitals that were recognized as negative PCI outliers in 2 states (Massachusetts and New York) from 2002 to 2012. State hospitalization files were used to identify all patients with an acute myocardial infarction within these states. Procedural management and in-hospital outcomes were compared among patients treated at outlier hospitals before and after public report of outlier status. Patients at nonoutlier institutions were used to control for temporal trends. Results: Among 86 hospitals, 31 were reported as outliers for excess mortality. Outlier facilities were larger, treating more patients with acute myocardial infarction and performing more PCIs than nonoutlier hospitals ( P P =0.50) after public report of outlier status. The likelihood of in-hospital mortality decreased at outlier institutions (RR, 0.83; 95% CI, 0.81–0.85) after public report, and to a lesser degree at nonoutlier institutions (RR, 0.90; 95% CI, 0.87–0.92; interaction P P Conclusions: Large hospitals with higher clinical volume are more likely to be designated as negative outliers. The rates of percutaneous revascularization increased similarly at outlier and nonoutlier institutions after report of outlier status. After outlier designation, in-hospital mortality declined at outlier institutions to a greater extent than was observed at nonoutlier facilities.

Abstract. Background: There may be various reasons for differences in suicide rates between countries and over time within a country. One reason can be different registration practices. Aims: The purpose of this study was to describe and compare the present procedures for mortality and suicide registration in the three Scandinavian countries and to illustrate potential sources of error in the registration of suicide. Method: Information about registration practices and classification procedures was obtained from the cause of death registers in Norway, Sweden, and Denmark. In addition, we received information from experts in the field in each country. Results: Sweden uses event of undetermined intent more frequently than Denmark does, and Denmark more frequently than Norway. There seems to be somewhat more uncertainty among deaths classified as ill-defined and unknown cause of mortality in Norway, compared with the other two countries. Sweden performs more forensic autopsies than Norway, and Norway more than Denmark. In Denmark, in cases of a suspected unnatural manner of death, a thorough external examination of the deceased is performed. Conclusion: Differences in the classification of causes of death and in postmortem examinations exist in Scandinavian countries. These differences might influence the suicide statistics in Scandinavia.

In compiling official mortality statistics, rules for selecting the underlying cause of death have changed twice in the last 20 years in England. Mortality statistics for most types of cancer were not greatly affected, but there were significant effects on coding for cancers of colon, liver, breast, prostate, testis and bladder, and for lymphoma and leukaemia.

Objective We sought to quantify the evolution of smoking-attributable mortality (SAM) in Germany and explore the impact of demographic ageing. Methods Smoking and mortality statistics from 1992 to 2013 were obtained from the German Statistical Office, from which SAM was calculated separately for each cause of death. The impact of demographic ageing was explored by comparing actual (crude) and age-standardised SAM. In order to estimate the impact of demographic ageing on future SAM, a forward projection until 2035 was modelled (assuming continuation of recent trends in smoking rates and constant cause-specific mortality rates). Results Total SAM only slightly declined from 139 000 cases in 1992 to 125 000 cases in 2013 (−10%), despite a decrease in age-adjusted SAM by 33%. Differences between actual and age-standardised SAM were particularly striking in men. While the age-standardised SAM in men decreased nearly by half, SAM remained more or less stable in women. The forward projection of SAM suggests that demographic ageing will lead to a further steady increase in SAM within the next two decades, for both, men and women. Conclusions Especially in men, actual SAM hardly declined despite a sharp drop in age-standardised SAM, indicating that decreases were largely compensated by demographic ageing. The increasing number of deaths resulting from the ageing population will lead to a steady increase in SAM in the near future if no efforts are taken to curb smoking.

Craniopharyngioma is histologically benign and associated with high survival rates but poor quality of life. The SEER Program is among the most cited data sources regarding malignancies in the United States. SEER began collecting data regarding craniopharyngiomain 2004. SEER-STAT v7.0.5 was utilized to identify patients (January 1, 2004–December 31, 2008) with ICD-O-3 codes for craniopharyngioma. Age was categorized into 3 groups: ≤19, 20–34, and ≥35 years, as was surgical intervention: none, subtotal resection, and gross total/radical resection. Demographic, initial treatment, and follow-up data were collected. 635/662 (95.9 %) patients had complete data. Incidence per million patient-years by age group was 1.9, 1.1, and 1.9, respectively (p

Death certificates are the source for mortality statistics and are used to set public health goals. Accurate death certificates are vital in tracking outcomes of cancer. Deaths may be certified by physicians or other medical professionals, coroners, or medical examiners. Idaho is one of 3 states that participated in a Centers for Disease Control and Prevention-funded study to assess the concordance between cancer-specific causes of death and primary cancer site among linked cancer registry/death certificate data. We investigated variability in the accuracy of cancer death certificates by characteristics of death certifiers, including certifier type (physician vs coroner), physician specialty, years of experience as death certifier, and number of deaths certified. This study showed significant differences by certifier type/physician specialty in the accuracy of cancer mortality measured by death certificates. Nonphysician coroners had lower accuracy rates compared with physicians. Although nonphysician coroners certified less than 5% of cancer deaths in Idaho, they were significantly less likely to match the primary site from the cancer registry. Results from this study may be useful in the future training of death certifiers to improve the accuracy of death certificates and cancer mortality statistics.

Purpose: Quality-Adjusted Life Expectancy (QALE) is a summary measure of mortality and health-related quality of life (HRQOL) across different stages of life. This study developed a method to calculate state-level QALE for U.S. adults. Methods: Population HRQOL data came from the Behavioral Risk Factor Surveillance System (BRFSS). Using age-specific deaths from the Mortality Summary File, this study constructed life tables to estimate life expectancy and QALE for all 50 States and the District of Columbia by sex and race from 1993 through 2008. Results: From 1993 to 2008, the QALE of an U.S. adult at 18 years old had increased from 51.2 to 52.3 years. In 2006, states with the highest QALE were Hawaii (56.2), Minnesota (55.2), North Dakota (54.9), Iowa (54.7), and Nebraska (54.4), while the states with the lowest QALE were West Virginia (47.1), Mississippi (48.2), Alabama (48.5), Kentucky (48.5), and Oklahoma (49.0). Conclusions: Because population HRQOL values and mortality statistics are available from existing and publicly accessible data and because formulas for the calculation of QALE and its standard error are easy to incorporate in a spreadsheet, State and local Health Departments can calculate QALE as a routine surveillance measurement for tracking their population’s health over time.

Mortality statistics represent important endpoints in epidemiological studies. The diagnostic validity of cerebral stroke and ischemic heart disease recorded as the underlying cause of death in Norwegian mortality statistics was assessed by using mortality data of participants in the Bergen Clinical Blood Pressure Study in Norway and autopsy records from the Gade Institute in Bergen. In the 41 years of the study (1965-2005) 4,387 subjects had died and 1,140 (26%) had undergone a post mortem examination; 548 (12%) died from cerebral stroke and 1,120 (24%) from ischemic heart disease according to the mortality statistics, compared to 113 (10%) strokes and 323 (28%) coronary events registered in the autopsy records. The sensitivity and positive predictive value of fatal cerebral strokes in the mortality statistics were 0.75, 95% confidence interval (CI) [0.66, 0.83] and 0.86 [0.77, 0.92], respectively, whereas those of coronary deaths were 0.87 [0.84, 0.91] and 0.85 [0.81, 0.89] respectively. Cohen's Kappa coefficients were 0.78 [0.72, 0.84] for stroke and 0.80 [0.76, 0.84] for coronary deaths. In addition to female gender and increasing age at death, cerebral stroke was a negative predictor of an autopsy being carried out (odds ratio (OR) 0.69, 95% CI [0.54, 0.87]), whereas death from coronary heart disease was not (OR 1.14, 95% CI [0.97, 1,33]), both adjusted for gender and age at death. There was substantial agreement between mortality statistics and autopsy findings for both fatal strokes and coronary deaths. Selection for post mortem examinations was associated with age, gender and cause of death.

Cancer is characterized by disturbed homeostasis of self-renewing cell populations, and their ability to seed and grow in multiple microenvironments. This overarching cellular property of metastatic cancer emerges from the contentious cancer stem cell hypothesis that underpins the more generic hallmarks of cancer (Hanahan and Weinberg, 2000) and its subsequent add-ons. An additional characteristic, metabolic flexibility, is related to concepts developed by Warburg and to subsequent work by mid 20th century biochemists who elucidated the bioenergetic workings of mitochondria. Metabolic flexibility may circumvent limitations inherent in the increasingly popular but erroneous view that aerobic glycolysis is a universal property of cancer cells. Cancer research in the second half of the 20th century was largely the domain of geneticists and molecular biologists using reductionist approaches. Integrated approaches that address cancer cell hierarchy and complexity, and how cancer cells adapt their metabolism according to their changing environment are now beginning to emerge, and these approaches promise to address the poor mortality statistics of metastatic cancer.

This article reports on social inequalities in female mortality by region and cause of death for women aged 25-59 years in England and Wales in the period 2001-03. It is the first official compilation of detailed mortality statistics for women based on the National Statistics Socio-economic Classification (NS-SEC). It is part of a series of articles measuring inequalities in adult mortality. The results demonstrate a strong socio-economic effect on the mortality of women in all regions. This pattern remained consistent between regions. There were marked differences in the socio-economic gradient by cause. Mortality rates for women in the least and most advantaged NS-SEC classes were similar for breast cancer. In contrast, compared to women in the most advantaged class, mortality rates were three times as high for the least advantaged women for lung cancer and cerebrovascular disease, around five times as high for ischaemic heart disease and all digestive diseases, and six times as high for respiratory diseases.

Objective Mortality statistics are important for epidemiological research. We examine if discrepancies between death certificate (DC) and hospital discharge condition (HDC) indicate certification errors. Study Design and Setting From 39,872 hospital deaths in Sweden in 1995, we randomly selected 600 “cases,” where DC and HDC were incompatible, and 600 compatible “controls,” matched on sex, age, and underlying cause of death. We obtained case summaries for 1,094 (91%) of these. Using a structured protocol, we assessed the accuracy of DCs. Results Regression analysis indicated diagnostic group and “case” or “control” as the variables that most affected the accuracy. Malignant neoplasm “controls” had the highest accuracy (92%), and benign and unspecified tumor “cases,” the lowest (20%). For all diagnostic groups except one, compatible “controls” had better accuracy than incompatible “cases.” The exception, chronic obstructive lung disease, had low accuracy for both “cases” (54%) and “controls” (52%). Conclusion Incompatibility between DC and HDC indicates a greater risk of certification errors. For some diagnostic groups, however, DCs are often inaccurate even when DC and HDC are compatible. By requesting additional information on incompatible cases and all deaths in high-risk diagnostic groups, producers of mortality statistics could improve the accuracy of the statistics.

The structural deficits and problems associated with application of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) were investigated. For this purpose, mortality statistics in Japan were examined for bias in the proportions of death causes classified using the ICD-10 four-character subcategory system, particularly the large distribution of cases classified under the .9 (unspecified) codes. The results showed that most deaths due to the 3 major causes were coded into the .9 subcategories. For example, 97.6% of the 607,065 deaths between 1995 and 2007 classified as I21 (acute myocardial infarction) were coded as I21.9 (acute myocardial infarction, unspecified). This suggests that the quality of the data recorded on many death certificates is poor. Thus, to ensure that the fourth-digit-level subcategories of the ICD-10 code system are effectively used to represent mortality data and actual causes of death in Japan, future studies should address the following objectives:(1) to minimize the discrepancy between the ICD classification terms and the names of diseases actually used in clinical practice, and (2) to actively raise awareness among physicians about the need to accurately record death causes on death certificates, since these records form the basis for determining mortality statistics in Japan.

The National Center for Health Statistics (NCHS) reported the United States life tables, 2001 for US total, male and female populations on the basis of 2001 mortality statistics, the 2000 decennial census and the data from the Medicare program [E. Arias, United State life tables, 2001, Natl. Vital Stat. Rep. 52 (2004) 1-40]. The life tables show life expectancy, survival and death rate at each year between birth and 100 years of age. In this study formulas expressing survival probability and life expectancy in US adults, men and women are constructed from the data of the NCHS. A model of the 'probacent'-probability equation previously published by the author is employed in the study. Analysis of the formula-predicted values and the NCHS-reported data indicates that the formulas are accurate and reliable with a close agreement. The formula representing a generalized lognormal distribution might be useful for biomedical investigation, and epidemiological and demographic studies in US adults, men and women.

Background In Austria, mortality from diseases of the circulatory system and malignant neoplasms is high and varies among the federal states. Lower mortality in some states indicates a preventive potential in those states with higher mortality. Methods We computed the number of premature deaths, for women and men separately, from the two leading causes of death, diseases of the circulatory system (ICD-10: I00-I09) and cancer (ICD-10: C00-C97), in the nine Austrian federal states between 2010-2012. The potentially preventable deaths per federal state and sex were calculated by subtracting expected deaths from observed deaths. Results The western federal states had the lowest death rates, and thus the smallest preventive potential. In death from circulatory diseases and from cancer the differences between women and men varied remarkably between the federal states. For circulatory diseases among all federal states the highest difference in percent was given in Vorarlberg (6.2 %) with more potentially preventable deaths for men. For cancer, Burgenland had the highest difference (8.6 %) in comparison with the other federal states, again with the higher preventive potential for men. Conclusions Intervention programs as lifestyle modification interventions as well as improvements in health care services provision, should focus on the characteristics of the specific federal state, which are setting-oriented and account for social determinants including sex/gender differences and economic factors. Relevant data gathering is therefore, urgently needed.

Background Death certificates provide an invaluable source for mortality statistics which can be used for surveillance and early warnings of increases in disease activity and to support the development and monitoring of prevention or response strategies. However, their value can be realised only if accurate, quantitative data can be extracted from death certificates, an aim hampered by both the volume and variable nature of certificates written in natural language. This study aims to develop a set of machine learning and rule-based methods to automatically classify death certificates according to four high impact diseases of interest: diabetes, influenza, pneumonia and HIV. Methods Two classification methods are presented: i) a machine learning approach, where detailed features (terms, term n-grams and SNOMED CT concepts) are extracted from death certificates and used to train a set of supervised machine learning models (Support Vector Machines); and ii) a set of keyword-matching rules. These methods were used to identify the presence of diabetes, influenza, pneumonia and HIV in a death certificate. An empirical evaluation was conducted using 340,142 death certificates, divided between training and test sets, covering deaths from 2000–2007 in New South Wales, Australia. Precision and recall (positive predictive value and sensitivity) were used as evaluation measures, with F-measure providing a single, overall measure of effectiveness. A detailed error analysis was performed on classification errors. Results Classification of diabetes, influenza, pneumonia and HIV was highly accurate (F-measure 0.96). More fine-grained ICD-10 classification effectiveness was more variable but still high (F-measure 0.80). The error analysis revealed that word variations as well as certain word combinations adversely affected classification. In addition, anomalies in the ground truth likely led to an underestimation of the effectiveness. Conclusions The high accuracy and low cost of the classification methods allow for an effective means for automatic and real-time surveillance of diabetes, influenza, pneumonia and HIV deaths. In addition, the methods are generally applicable to other diseases of interest and to other sources of medical free-text besides death certificates.

WOS: 000356175100002, PubMed ID: 26058703, Background: The Turkish government has implemented several reforms to improve the Turkish Statistical Institute Death Reporting System (TURKSTAT-DRS) since 2009. However, there has been no assessment to evaluate the impact of these reforms on causes of death statistics. This study attempted to analyse the impact of these reforms on the TURKSTAT-DRS for Turkey, and in the case of Izmir, one of the most developed provinces in Turkey. Methods: The evaluation framework comprised three main components each with specific criteria. Firstly, data from TURKSTAT for Turkey and Izmir for the periods 2001-2008 and 2009-2013 were assessed in terms of the following dimensions that represent quality of mortality statistics (a. completeness of death registration, b. trends in proportions of deaths with ill-defined causes). Secondly, the quality of information recorded on individual death certificates from Izmir in 2010 was analysed for a. missing information, b. timeliness of death notifications and c. characteristics of deaths with ill-defined causes. Finally, TURKSTAT data were analysed to estimate life tables and summary mortality indicators for Turkey and Izmir, as well as the leading causes-of-death in Turkey in 2013. Results: Registration of adult deaths in Izmir as well as at the national level for Turkey has considerably improved since the introduction of reforms in 2009, along with marked decline in the proportions of deaths assigned ill-defined causes. Death certificates from Izmir indicated significant gaps in recorded information for demographic as well as epidemiological variables, particularly for infant deaths, and in the detailed recording of causes of death. Life expectancy at birth estimated from local data is 3-4 years higher than similar estimates for Turkey from international studies, and this requires further investigation and confirmation. Conclusion: The TURKSTAT-DRS is now an improved source of mortality and cause of death statistics for Turkey. The reliability and validity of TURKSTAT data needs to be established through a detailed research program to evaluate completeness of death registration and validity of registered causes of death. Similar evaluation and data analysis of mortality indicators is required at regular intervals at national and sub-national level, to increase confidence in their utility as primary data for epidemiology and health policy.

Statistics on causes of death are important for epidemiologic research. Studies that evaluate the source data often give conflicting results, which raise questions about comparability and validity of methods.For 44 recent evaluation studies we examined the methods employed and assessed the reproducibility.Thirty studies stated who reviewed the source data. Six studies reported reliability tests. Twelve studies included all causes of death, but none specified criteria for identifying the underlying cause when several, etiologically independent conditions were present. We assessed these as not reproducible. Of 32 studies that focussed on a specific condition, 21 provided diagnostic criteria such that the verification of the focal diagnosis is reproducible. Of 16 that discussed the difference between dying "with" and "from" a condition, eight described how competing causes had been handled. For these eight, the selection of a principal cause is reproducible, but in three the selection strategy conflicts with the international instructions issued by the World Health Organization.Methods and criteria are often insufficiently described. When described, they sometimes disagree with the international standard. Explicit descriptions of methods and criteria would contribute to methodologic improvement and would allow readers to assess the generalizability of the conclusions.

Available maternal mortality statistics do not allow valid international comparisons. Our objective was to uniformly measure underreporting of mortality from pregnancy in official statistics from selected regions within the U.S. and Europe, and to provide comparable revised profiles of pregnancy-related mortality.We developed a standardized enhanced method to uniformly identify and classify pregnancy-associated deaths from 2 U.S. states, Massachusetts and North Carolina, and 2 European countries, Finland and France, for the years 1999-2000. Identification method included the use of all data available from the death certificate as well as computerized linkage of births and deaths registers. All cases were reviewed and classified by an international panel of experts.Four-hundred-and-four pregnancy-associated deaths were identified and reviewed. Underestimation of mortality causally related to pregnancy based on International Classification of Diseases cause-of-death codes alone varied from 22% in France to 93% in Massachusetts. Underreporting was greater in the regions with lower initial maternal mortality ratios. The distribution of causes of pregnancy-related mortality was specific to each region. The leading causes of death were cardiovascular conditions in Massachusetts; hemorrhage, pregnancy-induced hypertension, and peripartum cardiomyopathy in North Carolina; noncardiovascular medical conditions in Finland; and hemorrhage in France.This study shows the limitations of maternal mortality statistics based on International Classification of Diseases cause-of-death codes alone. Linkage of births and deaths registers should routinely be used in the ascertainment of pregnancy-related deaths. In addition, extension of the definition of a maternal death should be considered. Beyond pregnancy-related mortality ratios, considering the specific distribution of causes-of-death is important to define prevention strategies.

The Back to Sleep Campaign was initiated in 1994 to implement the American Academy of Pediatrics' (AAP) recommendation that infants be placed in the nonprone sleeping position to reduce the risk of the Sudden Infant Death Syndrome (SIDS). This paper offers a challenge to the Back to Sleep Campaign (BTSC) from two perspectives: (1) the questionable validity of SIDS mortality and risk statistics, and (2) the BTSC as human experimentation rather than as confirmed preventive therapy.The principal argument that initiated the BTSC and that continues to justify its existence is the observed parallel declines in the number of infants placed in the prone sleeping position and the number of reported SIDS deaths. We are compelled to challenge both the implied causal relationship between these observations and the SIDS mortality statistics themselves.

The correctness of selection, coding and registration of underlying cause-of-death is important for the quality of mortality statistics. One measure to improve quality is the query to the certifier for verification of the underlying cause-of-death. In Finland, 3478 death certificates, 7.1% of total 49074 certifications in 1995, were considered questionable by statisticians. The expert panel at Statistics Finland was able to resolve 2813 (80.9%) of them. However, 665 (19.1%) certificates needed to be further queried from the certifier. Of these, 318 (47.8%) were re-assigned to another ICD-9 category or to the applicable three-digit category within the main category of heart and vascular diseases, resulting in changes from a 17.00-fold increase in rheumatic heart diseases (ICD-9 codes 390-398) to a decrease of about one-half (0.45-fold change) in unspecified neoplasms (codes 235-239). However, a statistically significant impact on national mortality statistics was not observed in any of applied ICD categories. Among all questionable death certificates, most prone to query of the certifier, and with a statistical significance of P