As the United States struggles to track coronavirus deaths amid irregular tests, delayed laboratory results, and inconsistent reporting standards, a more insidious problem could thwart its quest for an exact death toll.
Up to 1 in 3 death certificates in the country were already false before COVID-19, said Bob Anderson, head of the mortality statistics division at the National Center for Health Statistics in an interview with the USA TODAY Network.
“I’m always worried about getting good data. I think that kind of thing can be a problem even in a pandemic, “said Anderson.
Experts say the inaccuracies are part of a disparate state-by-state system of medical examiners, coroners, and doctors with disparate medical histories, and in some cases none.
And the problem is about to get worse. The pandemic will undoubtedly flood already overworked and sometimes untrained civil servants who fill out the forms.
Accurate death certificates are paramount to local health officials trying to determine where to focus resources to fight the spread of the coronavirus, said Dr. Umair Shah, executive director of the Harris County public health department, Texas, which includes Houston.
“This death represents an ecosystem of people,” said Shah.
Improper reporting of deaths has been a long-standing problem noted by many researchers, study after study.
A 2017 review of Missouri hospitals, for example, found that almost half of the death certificates indicated an incorrect cause of death. A Vermont study found that 51% of death certificates had major errors. Almost half of the doctors surveyed by the Centers for Disease Control and Prevention in 2010 admitted knowingly reporting an inaccurate cause of death.
Death certificates regularly lack enough detail to pinpoint the cause of death, Anderson said.
“For example, cardiac arrest is not an acceptable cause of death because everyone dies of cardiac arrest,” said Anderson. “It just means that your heart has stopped. “
Lack of expertise
The widespread inaccuracy of information on death certificates is largely due to the different levels of expertise of those filling out the forms, experts said.
Doctors, coroners, medical examiners and, in some states, other medical personnel, such as nurse practitioners, can legally sign death certificates, said Dr. Sally Aiken, President of the National Association of Medical Examiners and practicing forensic scientist in Spokane County, Washington.
Coroners and medical examiners are responsible for homicide, accident and suicide certificates, said Aiken. Doctors complete the form when natural deaths, such as those caused by COVID-19, occur in a hospital. But forensic scientists and coroners do this if the person died at home or in another non-medical setting.
Forensic pathologists are generally medical specialists who can perform autopsies.
However, coroners are not always doctors. In some states, such as Alabama and Georgia, the only requirement for a coroner is that he is not a major criminal to be elected to office.
However, even those with medical expertise are regularly mistaken. In Vermont, there is no coroner. If death is natural or occurs in a hospital or community, doctors, nurse practitioners or medical assistants complete death certificates. And the medical examiner’s office, which investigates violent deaths, examines approximately 5,000 certificates each year to find and correct errors.
When the state medical examiner’s office compared 601 death certificates completed between July 1, 2015 and January 31, 2016 with medical records, they found that 51% had major errors.
Lauri McGovirn, a forensic scientist who worked on this exam, said that some doctors did not fill out death certificates regularly, so they were not familiar with the process. For others, it was an administrative chore.
“It makes you wonder in other states where they don’t have the type of resources or money to examine each death certificate what their error rate is,” said McGovirn.
Shortage of workers
In addition to the expertise gaps, there is a serious shortage of forensic scientists nationwide.
In a recent report to Congress, the Department of Justice said that 700 additional medical examiners were needed. The same report noted that in addition to staff, “budgets, resources and supplies are too inconsistent to ensure that the investigation of deaths is of the same quality in the United States.”
Dr. Ray Fernandez has been the chief medical examiner for Nueces County, Texas for 19 years. He knows what shortage means – a punishing workload.
Although he hired another full-time pathologist and two part-time pathologists several years ago, he and his colleagues each perform 200 to 300 autopsies per year, regularly meeting the recommendation of the National Association of Medical Examiners maximum of 325 per year.
The organization temporarily suspended this workload limit due to COVID-19, but Fernandez said that the more medical examiners take care of cases, the more likely they are to make mistakes.
“COVID-19,” he said, “is impacting the system at a time when it is already in crisis with a shortage of people doing the work. “
To further complicate efforts to curb the spread of the coronavirus, many forensic pathologists and coroners refuse to attribute a death to COVID-19 without a positive test before the person dies. Some medical examiners do post-mortem tests if they can afford it. But with insufficient testing, this is not always possible.
Dr. James Gill, vice president of the National Association of Medical Examiners and chief medical examiner for the state of Connecticut, said he sent his staff to funeral homes to dab the nose of the deceased, who is then analyzed by an outside laboratory.
The family of the deceased and the first responders who have cared for them need laboratory results to know if they should be isolated or sought treatment, said Gill.
“You have to remember, however, that even if we take a sample from a deceased person, these results can affect the living,” said Gill.
The National Center for Health Statistics, where Anderson works, updated its website on April 1 to clarify that those completing death certificates should register COVID-19 as a probable cause if testing is not possible and if corroborated by medical records or circumstances.
Despite this, Anderson said, some doctors will simply list the cause of death as pneumonia when the pneumonia likely occurred after COVID-19 infection. But he hopes fewer will.
“The fact is that many of these deaths will not be autopsied and post mortem tests will not be done, so we will have to rely on second-hand accounts and symptoms,” said Anderson. . “We might miss some. “
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