Comparing hospital discharge records with death certificates: Can the differences be explained?

STUDY OBJECTIVE: The quality of mortality statistics is important for epidemiological research. Considerable discrepancies have been reported between death certificates and corresponding hospital discharge records. This study examines whether differences between the death certificate's underlying cause of death and the main condition from the final hospital discharge record can be explained by differences in ICD selection procedures. The authors also discuss the implications of unexplained differences for mortality data quality. DESIGN: Using ACME, a standard software for the selection of underlying cause of death, the compatibility between the underlying cause of death and the final main condition was examined. The study also investigates whether data available in the hospital discharge record, but not reported on the death certificate, influence the selection of the underlying cause of death. SETTING: Swedish death certificates for 1995 were linked to the national hospital discharge register. The resulting database comprised 69 818 people who had been hospitalised during their final year of life. MAIN RESULTS: The underlying cause of death and the main condition differed at Basic Tabulation List level in 54% of the deaths. One third of the differences could not be explained by ICD selection procedures. Adding hospital discharge data changed the underlying cause in 11% of deaths. For some causes of death, including medical misadventures and accidental falls, the effect was substantial. CONCLUSION: Most differences between underlying cause of death and final main condition can be explained by differences in ICD selection procedures. Further research is needed to investigate whether unexplained differences indicate lower data quality.     

Place, time and certified cause of death in people who die after hospital admission for myocardial infarction or stroke

BACKGROUND: Two areas of uncertainty about routine statistics for mortality after hospital admission for myocardial infarction (MI) or stroke are i) whether most deaths occur in the admission episode itself rather than after discharge, and ii) whether most deaths are certified on death certificates as, respectively, MI or stroke. METHODS: Use of linked hospital and mortality statistics to analyse the time, place and certified cause of death in people aged 35-74 after admission for MI or stroke. RESULTS: Of 7,964 deaths within a year of admission for MI, 5,686 (71.4%) occurred within 30 days of admission. Of these, 4,856 (85.4%) occurred during the initial hospital admission. Of 7,070 deaths within a year of admission for stroke, 4,905 (69.4%) were within 30 days, and 4,509 (91.9%) of these occurred during the initial admission. As expected, deaths at longer intervals than 30 days occurred mainly after discharge. Of deaths within 30 days of MI and stroke, 85.2% and 80.0%, respectively, were certified with MI or stroke as the underlying cause of death. CONCLUSION: In-hospital death rates alone, calculated without record linkage to death certificates, would have identified most deaths that occurred within 30 days of admission. Nonetheless, linkage added to completeness of ascertainment even within this time period. Data without linkage are unreliable in identifying deaths at longer time intervals. Routine mortality statistics for MI and stroke, as the underlying cause, reliably included most deaths that occurred within 30 days of admission for each respective disease.     

Zur Validität der Herz-Kreislauf-Mortalitäts-Statistik der ehemaligen DDR

It has been known already for a long time that in the GDR the mortality rates for coronary heart disease (CHD) and cerebrovascular accidents (CVA) had been considerably underestimated. Instead of these diagnoses very often such general conditions like atherosclerosis and hypertension have been coded as underlying cause of death. We carried out, therefore, two validation studies in order to check whether and to what extent violations of the WHO coding rules were responsible for that. In the first study all hospital deaths which occurred in the GDR between 1985 and 1989 have been compared with the corresponding data of the official mortality statistics (record-linkage-database). In the second study 4.154 death certificates have been manually checked and recoded. Among the hospitalized patients who died from an acute myocardial infraction (AMI) the AMI was coded as underlying cause of death at the death certificate only in 57 % (men) and 54 % (women), respectively. Among cases of CHD these proportions were 66 % and 62 %, respectively, and among cases of CVA 46 % and 44 %, respectively. In the second study among those deaths with AMI as one of the three possible diagnoses at the death certificate AMI was coded as underlying cause of death in men in 46 % and in women in only 30 %. For CHD these proportions were 71 % and 59 %, respectively, and for CVA 44 % and 46 %, respectively. Both studies confirm that in the GDR the selection rules recommended by WHO have often been ignored when coding the death certificates of death cases from AMI, CHD and CVA. Based on the results of the two studies the following correction factors for the official mortality rates are proposed for men and women, respectively: AMI 1.8/2.3; CHD 1.5/1.6; CVA 2.2/2.3.     

Preventing type 2 diabetes mellitus in Qatar by reducing obesity,smoking, and physical inactivity: mathematical modeling analyses

Cause of death statistics are an important tool for quality control of the health care system. Their reliability, however, is controversial. Comparing death certificates with their corresponding medical records is implemented only occasionally but may point to quality problems. We aimed at exploring the agreement between information in the cause of death statistics and hospital discharge diagnoses at death. Selection of disease categories was based on ICD-10 Tabulation List for Morbidity and ICD-10 Mortality Tabulation List 2. Index cases were defined as deaths having occurred among Swiss residents 2010–2012 in a hospital and successfully linked to the Swiss National Cohort. Rare, external and ill-defined causes were excluded from comparison, leaving 53,605 deaths from vital statistics and 47,311 deaths from hospital discharge statistics. For 95% of individuals, respective information from the 2000 census could be retrieved and used for multiple logistic regression. For 83% of individuals the underlying cause of death could be traced among hospital diagnoses and for 77% the principal hospital diagnosis among the cause of death information. Mirroring different evaluation of complex situations by individual physicians, rates of agreement varied widely depending on disease/cause of death, but were generally in line with similar studies. Multiple logistic regression revealed however significant variation in reporting that could not entirely be explained by age or cause of death of the deceased suggesting differential exploitation of available diagnosis information. Substantial regional variation and lower agreement rates among socially disadvantaged groups like single, less educated, or culturally less integrated persons suggest potential for improving reporting of diagnoses and causes of death by physicians in Switzerland. Studies of this kind should be regularly conducted as a quality monitoring.     

Quality of data on myocardial infarction deaths, Brazil

OBJECTIVE: To evaluate the quality of data on acute myocardial infarction deaths from mortality information systems. METHODS: Data on in-hospital acute myocardial infarction mortality collected from database of the Mortality Information System (SIM) and Hospital Information System (SIH), in 2000, were analyzed. Then data collected from medical records from two hospitals affiliated to the Unified Health System (SUS) in Rio de Janeiro, Brazil, were also analyzed. Medical records, death certificates, and hospital admission forms (AIH) were compared using the World Health Organization criteria of acute myocardial infarction diagnosis. Agreement among different sources was analyzed using Cohen's Kappa statistics and intraclass correlation coefficient. RESULTS: In-hospital death registries in SIM are much larger than in SIH/SUS. There were identified three mechanisms that could explain most of the observed discrepancy: missing hospital admission forms (32.9%), different main diagnosis registered in SIH/SUS (19.2%), and under reporting of deaths in hospital admission forms (3.3%). The medical records review could confirm the diagnoses of acute myocardial infarction in 67.1% of all deaths reported in death certificates. The sensitivity of data on acute myocardial infarction deaths in death certificates was about 90% for both health information systems analyzed. CONCLUSIONS: There is a need for actions to improve the quality of data registered in SIH/SUS such as standardization of criteria for issuing hospital admission forms during hospital emergencies and training local staff on registration systems.     

Non-referral of unnatural deaths to coroners and non-reporting of unnatural deaths on death certificates in Taiwan: implications of using mortality data to monitor quality and safety in healthcare.

BACKGROUND: Mortality data has often been used to monitor the quality of cardiac care. OBJECTIVE: To investigate the under-reporting of unnatural deaths in mortality data. METHOD: All patients with a main discharge diagnosis of injury (ICD-9-CM code 800-999) who died in 2003 or 2004 were identified through record linkage between hospital discharge claims data and cause of death data in Taiwan. Percentages of unnatural deaths that had been referred to the coroner and in which injury-related information was reported on the death certificate were estimated. RESULTS: Of 4086 known or suspected unnatural deaths, only 57% (2346/4086) were referred to the coroner, and in 71% (2889/4086) injury-related information was reported on the death certificate. The percentages of referral and reporting were lowest for deaths related to complications in medical and surgical care. In deaths related to fracture of the femur and the effects of a foreign body, many doctors report injury-related information on the death certificate but do not refer the certification of cause of death to the coroner. CONCLUSIONS: The sensitivity of using mortality data alone to detect known or suspected unnatural deaths varied according to the types of injury and external causes. Monitoring cause of death data linked with hospital discharge record data could provide a better system for discovering these unnatural deaths.     

Can regional variation in "avoidable" mortality be explained by deaths outside hospital? A study from Sweden, 1987-90.

STUDY OBJECTIVE: This study aimed to calculate the proportion of deaths outside hospital in Sweden for some conditions for which the acute medical management may be important to the outcome and to analyse whether the proportion of deaths outside hospital can explain regional variations in mortality from these causes of death. DESIGN: The place of death was registered on all death certificates in Sweden during the period 1987-90. The proportion of deaths outside hospital was calculated at the national level for selected causes of death. Variation in cause-specific mortality among the 26 administrative health areas in Sweden was analysed. Death rate ratios were calculated with standardisation for age and sex using the national rate as standard. The correlation between the proportion of deaths outside hospital in each health area and the cause specific mortality irrespective of place of death was calculated. For areas with a significantly high death rate the ratios for mortality outside hospital as well as in hospital were analysed in order to decide which component of mortality represented a high mortality risk. SETTING AND PARTICIPANTS: All death registration in Swedish citizens and other residents in Sweden aged under 70 years between 1987 and 1990 which gave diabetes, asthma, ischaemic heart disease, cerebrovascular diseases, or ulcer of the stomach or duodenum as the underlying cause of death. MAIN RESULTS: For asthma (58%) and ischaemic heart disease (54%), most deaths occurred outside hospital. For most causes of death, however, no correlation was found among the health areas between the proportion of deaths outside hospital and the SMR for mortality irrespective of the place of death. A high death rate was associated with a high proportion of deaths outside hospital, for diabetes in one area in the north of Sweden (Norrbotten) and for ulcer of the stomach and duodenum in one large municipality (Göteborg). CONCLUSIONS: The high proportion of deaths outside hospital at the national level for some of the conditions studied suggests that in-depth studies of the process preceding death and the functioning of medical care are needed. In most cases, however, no evidence was found that regional variation in mortality could be explained by death outside hospital. The results for diabetes in Norbotten and ulcer of stomach and duodenum in Göteborg indicate that in-depth studies on the quality of care are required.     

Diabetes mellitus mortality among elderly as an underlying or secondary cause of death

OBJECTIVE:To analyze diabetes mellitus-related mortality among elderly and the rate of undereporting of diabetes mellitus as a cause of death when statistical data on diabetes exclusively on the underlying cause of death are considered. METHODS:A total of 2.974 death certificates of elderly people living in a housing project in the city of Rio de Janeiro were revised. The study period was 1994. Of them, 291 deaths were due to diabetes mellitus, 150 as the underlying and 141 as the secondary cause of death. The proportion of deaths where diabetes was stated as the underlying cause in relation to the total of diabetes deaths was calculated globally and categorized by sex and age groups. RESULTS:Of the 291 deaths studied, 138 (47.4%) were men and 153 (52.6%) were women. Mortality rates showed a continuous age increase and were higher among men, though sex difference was smaller when only the underlying cause was considered. It was found a higher proportion of deaths (22%) occurring at home. Overall rate of diabetes deaths as the underlying cause was 51.5%, with higher rates seen in women. CONCLUSIONS:The analysis of mortality statistics based exclusively on the underlying cause of death can yield misleading profiles due to unrandomized underreporting. There is a need of further studies with diabetic elderly cohorts for a more accurate mortality analysis in this population group.     

Reliability of death certificate diagnoses

Consistency between death certificates and clinical records from 5 general hospitals in Kuwait was studied for 470 deaths with the following underlying or associated causes: hypertensive (HYP), ischaemic heart diseases (IHD), cerebrovascular diseases (CVD) and diabetes mellitus (DM). Direct causes were not considered since they are of little interest analytically. Only deaths with definite or most probable ascertainment were included. One cardiologist, who was provided with the WHO criteria and relevant documents on death certification, independently reviewed the records. To test the reviewer's bias and the reliability of his judgement, an adjudication process was effected by having one senior cardiologist re-review a random subsample of 140 records. The two reviewers showed good agreement. Specific diagnoses criteria for deciding the underlying cause of death in multiple morbid conditions by the reviewer were followed. Due to possible reviewer bias, we aimed at measuring the difference between initial certifiers and the reviewer rather than measuring the diagnostic accuracy of initial certifiers in reference to the reviewer. The agreement 'index kappa showed poor agreement between original and revised certificates. The original certificates underestimated CVD as an underlying cause of death by 69.2%, DM by 60%, IHD by 33.5% and HYP by 31.8% in our sample. Associated causes were also consistently underestimated by initial certifiers as compared with the reviewer. This bias calls for basing mortality statistics in Kuwait on hospital death committees' reports rather than on initial certifier death certificates, use of multiple-causes of death instead of one underlying cause and adequate training of the medical profession on the value and process of death certification.     

Paracoccidioidomycosis-related mortality trend, state of S?o Paulo, Brazil: a study using multiple causes of death]

OBJECTIVE: To investigate mortality in which paracoccidioidomycosis appears on any line or part of the death certificate. METHOD: Mortality data for 1985-2005 were obtained from the multiple cause-of-death database maintained by the S?o Paulo State Data Analysis System (SEADE). Standardized mortality coefficients were calculated for paracoccidioidomycosis as the underlying cause-of-death and as an associated cause-of-death, as well as for the total number of times paracoccidioidomycosis was mentioned on the death certificates. RESULTS: During this 21-year period, there were 1 950 deaths related to paracoccidioidomycosis; the disease was the underlying cause-of-death in 1 164 cases (59.69%) and an associated cause-of-death in 786 (40.31%). Between 1985 and 2005 records show a 59.8% decline in the mortality coefficient due to paracoccidioidomycosis as the underlying cause and a 53.0% decline in the mortality as associated cause. The largest number of deaths occurred among men, in the older age groups, and among rural workers, with an upward trend in winter months. The main causes associated with paracoccidioidomycosis as the underlying cause-of-death were pulmonary fibrosis, chronic lower respiratory tract diseases, and pneumonias. Malignant neoplasms and AIDS were the main underlying causes when paracoccidioidomycosis was an associated cause-of-death. The decision tables had to be adapted for the automated processing of causes of death in death certificates where paracoccidioidomycosis was mentioned. CONCLUSIONS: Using the multiple cause-of-death method together with the traditional underlying cause-of-death approach provides a new angle on research aimed at broadening our understanding of the natural history of paracoccidioidomycosis.     

Cause-specific mortality: understanding uncertain tips of the disease iceberg.

STUDY OBJECTIVE--To determine the extent to which individual diseases, when recorded as being present shortly before death, were certified as causes of death. DESIGN--Retrospective cohort study in which the "subjects" were computerised linked records. SETTING--Six districts in the Oxford Regional Health Authority area (covering a population of 1.9 million people). SUBJECTS--Linked abstracts of hospital records and death certificates for people who died within four weeks and, for some diseases, within one year of hospital admission. MAIN OUTCOME MEASURES--The percentage of people with each disease for whom the disease was recorded as the underlying cause of death, was recorded elsewhere on the death certificate, or was not certified as a cause of death at all. RESULTS--Three broad patterns of certification are distinguished. Firstly, there were diseases that were usually recorded on death certificates when death occurred within four weeks of hospital care of them. Examples included lung cancer (on 91% of such death certificates), breast cancer (92%), leukaemia and lymphoma (90%), anterior horn cell disease (89%), multiple sclerosis (89%), myocardial infarction (90%), stroke (93%), aortic aneurysm (87%), and spina bifida (89%). These diseases were also usually certified as the underlying cause of death. Secondly, there were diseases which, when present within four weeks of death, were commonly recorded on death certificates but often not as the underlying cause of death. Examples included tuberculosis (on 76% of such certificates; underlying cause on 54%), thyroid disease (49%; 21%), diabetes mellitus (69%; 30%) and hypertension (43%; 22%). Thirdly, there were conditions which, when death occurred within four weeks of their treatment, were recorded on the death certificate in a minority of cases only. Examples of these included fractured neck of femur (on 25% of such certificates), asthma (37%), and anaemia (22%). Not surprisingly, there was "convergence" in certification practice towards the common cardiovascular and respiratory causes of death. There was also evidence that conditions regarded as avoidable causes of death may not have been certified when present at death in some patients. CONCLUSION--When uses are made of mortality statistics alone, it is important to know which category of certification practice the disease of interest is likely to be in. Linkage between morbidity and mortality records, and multiple cause analysis of mortality, would considerably improve the ability to quantify mortality associated with individual diseases.     

Certification of cause of death in French diabetic patients.

STUDY OBJECTIVE--The aim was to assess the level of mortality related to diabetes in France. In other countries, an underrecording of diabetes on the death certificates of diabetic patients has been reported. DESIGN AND SETTING--Estimated death rate of diabetic patients was calculated using (a) the actual number of death certificates where diabetes was registered either as an underlying or as a contributory cause of death, and (b) estimates of the prevalence of diabetes in the population, by sex and age group, from which expected numbers of diabetic deaths were determined. Standardised mortality ratios were calculated using 1988 French mortality statistics as reference. MAIN RESULTS--The estimated standardised mortality ratio for diabetic subjects, with diabetes registered as the underlying cause, was 0.36. This standardised mortality ratio increased to 0.92 if both the underlying and contributory causes were considered. The estimated death rate, by sex and age group, implies that diabetes has a protective effect between the ages of 45 and 64 years, particularly in men. CONCLUSIONS--Evidence suggests that diabetes is completely omitted on the death certificates of many diabetic subjects, especially for those between the ages of 45 and 64 years. Using mortality statistics underestimates the prevalence of diabetes and its effects on public health. The difference in diabetes mortality between countries will not be reliable until there is a better registration of the causes of death in diabetic patients, and contributory as well as the underlying cause are coded and published.     

The increase of diabetes mortality burden among Brazilian adults.

OBJECTIVE: To estimate diabetes-related deaths among Brazilian adults between 1999 and 2003 and to investigate demographic factors associated with reporting diabetes as an associated cause of death. METHODS: All deaths with diabetes as the underlying or associated cause were identified using the Brazilian Mortality Data System. Analysis was performed by sex, age, year, state of residence, and place of death. Mortality rates were age standardized by the 2000 Brazilian population. FINDINGS: A total of 237 946 deaths (8.8%) were related to diabetes; in 4.2% of deaths it was the underlying cause and in 4.6% it was an associated cause. Between 1999 and 2003, age-standardized mortality rates for diabetes as the underlying cause increased 14% among males and 9% among females, while mortality with diabetes as an associated cause increased 22% and 28%, respectively. Diabetes appeared more often as an associated cause in death certificates among older individuals and in those residing in S?o Paulo State; it appeared less often as an associated cause among women, brown- and black-skinned populations, and in deaths occurring outside hospitals. Cardiovascular diseases accounted for 54.5% of the underlying causes of death when diabetes was an associated cause. CONCLUSION: Diabetes was related to almost 9% of the deaths in the South and Southeast regions of Brazil. Mortality from diabetes is increasing, especially deaths with diabetes as an associated cause. The probability of having diabetes as the underlying cause of death is greater among women and nonwhite individuals. Our results reinforce the importance of using multiple causes of death to monitor diabetes, because half the individuals with the disease will die of another cause, especially cardiovascular diseases.     

Reliability of cause-specific mortality rate statistics: case of Lithuania

OBJECTIVES: To evaluate the reliability of cause-specific mortality rate statistics. STUDY DESIGN: The underlying causes of death among different demographic groups in a territorial unit of Lithuania were verified and the data were compared with the corresponding official statistics. METHODS: Community-based autopsy and expert analysis of medical records. RESULTS: The study contingent consisted of 1474 permanent residents aged 0-101 years [809 (54.9%) males and 665 (45.1%) females] who had died in hospital (n=546, 37%) and out of hospital (n=928, 63%) in 1989-1991. The underlying cause of death was verified in 98.6% of cases by full autopsy (69.9%) and expert analysis of medical records (28.7%). Circulatory system diseases were found to be implicated in 44.4% of all deaths (35.9% of males and 54.7% of females), malignant neoplasms were the cause of 19.4% of deaths (21.5 and 16.8%, respectively) and external causes were responsible for 19.4% of deaths (27.3 and 9.8%, respectively). Cause-specific mortality rates were sex and age dependent. CONCLUSIONS: The proportion of circulatory system diseases in the cause-specific mortality structure was found to be significantly lower, and that of external causes (injury and poisoning) was found to be higher than the corresponding proportions presented by official Lithuanian statistics. Verified cardiovascular death rates corresponded with those in the European Union as a whole.     

An audit of a British sample of death certificates in which anorexia nervosa is listed as a cause of death

OBJECTIVE: Anorexia nervosa is associated with an increased mortality rate. National mortality statistics based on statutory death certification are potentially an important source of information. However, there are reasons to believe that these statistics may be subject to significant errors. An audit of the quality of information and diagnosis was conducted on death certificates in which anorexia nervosa was mentioned. METHOD: The current study examined data from death certificates of people who died in England and Wales between 1993 and 1999. RESULTS: There were 230 such deaths, but only 128--just over one half--were rated as likely to be deaths associated with true anorexia nervosa. DISCUSSION: National mortality statistics derived from death certificates are a flawed source of information on deaths from anorexia nervosa when taken at face value. There may be both underreporting and overreporting. Detailed examination may improve their usefulness by reducing the overerreporting. It seems likely that the association of deaths with anorexia nervosa is systematically underreported.     

Impact of HIV infection on mortality and accuracy of AIDS reporting on death certificates.

To assess the impact of HIV infection on mortality and the accuracy of AIDS reporting on death certificates, we analyzed data from 6704 homosexual and bisexual men in the San Francisco City Clinic cohort. Identification of AIDS cases and deaths in the cohort was determined through multiple sources, including the national AIDS surveillance registry and the National Death Index. Through 1990, 1518 deaths had been reported in the cohort and 1292 death certificates obtained. Of the 1292 death certificates, 1162 were for known AIDS cases, but 9% of the AIDS cases did not have HIV infection or AIDS noted on the death certificate. Only 0.7% of the decedents had AIDS listed as a cause of death and had not been reported to AIDS surveillance. AIDS and HIV infection was the leading cause of death in the cohort, with the highest proportionate mortality ratio (85%) and standardized mortality ratio (153 in 1987), and the largest number of years of potential life lost (32,008 years). The devastating impact of HIV infection on mortality is increasing and will require continued efforts to prevent and treat HIV infection.     

Multiple-cause coding of death from myocardial infarction: population-based study of trends in death certificate data

BACKGROUND: Data on long-term trends in mortality are generally unavailable for multiple-cause coding of deaths. We wanted to know whether multiple-cause coding of deaths for myocardial infarction contributes much to the interpretation of death certificate data on mortality rates for this condition. METHODS: We analysed all causes of death on death certificates in the former Oxford health service region from 1979 to 1998. RESULTS: Of 69,333 death certificates that included myocardial infarction as a cause of death, it was the underlying cause of death in 93.6 per cent. The ratio of 'mentions' to 'underlying cause' was broadly similar over the study period, during which time there were substantial falls in mortality rates. There were significant changes to the ratios, associated with timing of changes to coding rules; but their effects were small. The ratio of mentions to underlying cause was similar in men and women and in different age groups. CONCLUSION: The underlying cause of death was a robust and almost complete measure of certified deaths for myocardial infarction.     

Evaluation of the quality of information on the basic cause of death of infants in Rio Grande do Sul (Brazil)

The validity of the official information on the cause of infant deaths was studied in the Brazilian cities of Porto Alegre and Pelotas in 1985. Using data collected for a population-based case-control study of infant mortality due to infectious diseases or malnutrition, a comparison was made between the causes of death reported on the death certificates and those obtained after a careful review of case-notes and a medical interview with the parents of the decreased infants. Official death certificates showed an excess of deaths attribute to bronchopneumonia (ICD 485X) and septicemia (ICD 038.9), and an underestimation of the number of deaths due to diarrheal diseases (ICD 009.1) and of sudden infant deaths (ICD 798.0). The overall rate of agreement between official and revised certificates, in terms of groups of causes of death, was only 27.9%. Lower respiratory infections, which were the leading infectious cause of infant death according to official statistics, were superseded by diarrheal diseases after this revision.     

Surveillance of sentinel occupational mortality in the District of Columbia: 1980 to 1987.

Epidemiological surveillance of sentinel occupationally related deaths commonly relies on computerized analyses of mortality data obtained from vital statistics records. A computer search of death records in the District of Columbia for the period 1980 to 1987 identified 15 cases that noted asbestosis, silicosis, coal worker's pneumoconiosis, or primary cancer of the pleura/mesothelioma as the underlying cause of death. A manual review of the death certificates for the same period identified three times as many cases (n = 48) with any mention of these conditions. Problems with performing surveillance of these events using death certificates include the lack of sufficient information to identify mesotheliomas and the failure to code and computerize all contributing causes of death.     

Proportion of cancer deaths occurring in hospital, Canada, 1994-2000

BACKGROUND: Most terminally ill cancer patients would prefer not to die in hospital, but only a minority achieve their wish. Our objective was to examine the proportion of cancer deaths occurring in Canadian hospitals. METHODS: The two sources of data (1994-2000) were: 1) all hospital separations (HS) with a primary diagnosis of cancer and discharge as 'dead'; 2) all death certificates (DC) with cancer as underlying cause of death. Proportions of hospital deaths were estimated with two different numerators: 1) hospital cancer deaths from HS data, and 2) deaths with hospital as location from DC data; the denominator for both were all cancer deaths identified from the DC data. RESULTS: Proportions of hospital deaths from HS data decreased from 55% to 40% over 1994-2000, was slightly lower for females, decreased with age, but varied widely among provinces. Proportions of hospital deaths from DC data started at 80% and showed a small downward trend over the years. While age, sex, and cancer site distributions stayed the same, the proportion of hospital deaths from DC date again varied among provinces. For provinces with the home category completed on the DC data, 1999-2000, Alberta had most home deaths at 15.6% and PEI least at 5.7%. INTERPRETATION: This is the first Canada-wide data on place of death for terminal cancer, which is important for determining and comparing present-day practices, as well as for planning for the future.