Death certificates underestimate infections as proximal causes of death in the U.S.

TitleDeath certificates underestimate infections as proximal causes of death in the U.S.
Publication TypeJournal Article
Year of Publication2014
AuthorsGovindan, S, Shapiro, L, Langa, KM, Iwashyna, TJ
JournalPLoS One
Date Published2014
ISSN Number1932-6203
KeywordsCause of Death, Death Certificates, Hospitalization, Humans, Infections, Medicare, United States

BACKGROUND: Death certificates are a primary data source for assessing the population burden of diseases; however, there are concerns regarding their accuracy. Diagnosis-Related Group (DRG) coding of a terminal hospitalization may provide an alternative view. We analyzed the rate and patterns of disagreement between death certificate data and hospital claims for patients who died during an inpatient hospitalization.

METHODS: We studied respondents from the Health and Retirement Study (a nationally representative sample of older Americans who had an inpatient death documented in the linked Medicare claims from 1993-2007). Causes of death abstracted from death certificates were aggregated to the standard National Center for Health Statistics List of 50 Rankable Causes of Death. Centers for Medicare and Medicaid Services (CMS)-DRGs were manually aggregated into a parallel classification. We then compared the two systems via 2×2, focusing on concordance. Our primary analysis was agreement between the two data sources, assessed with percentages and Cohen's kappa statistic.

RESULTS: 2074 inpatient deaths were included in our analysis. 36.6% of death certificate cause-of-death codes agreed with the reason for the terminal hospitalization in the Medicare claims at the broad category level; when re-classifying DRGs without clear alignment as agreements, the concordance only increased to 61%. Overall Kappa was 0.21, or "fair." Death certificates in this cohort redemonstrated the conventional top 3 causes of death as diseases of the heart, malignancy, and cerebrovascular disease. However, hospitalization claims data showed infections, diseases of the heart, and cerebrovascular disease as the most common diagnoses for the same terminal hospitalizations.

CONCLUSION: There are significant differences between Medicare claims and death certificate data in assigning cause of death for inpatients. The importance of infections as proximal causes of death is underestimated by current death certificate-based strategies.


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Endnote Keywords

Medicare claims/Infection/death certificate/cause of death/survey methods

Endnote ID


Alternate JournalPLoS One
Citation Key8104
PubMed ID24878897
PubMed Central IDPMC4039437
Grant ListK08 HL091249 / HL / NHLBI NIH HHS / United States
R01 AG030155 / AG / NIA NIH HHS / United States
U01 AG009740 / AG / NIA NIH HHS / United States
U01 AG09740 / AG / NIA NIH HHS / United States