Original Articles
Validation of death certificate diagnosis of out-of-hospital sudden cardiac death

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Abstract

The validity of death certificate diagnosis of out-of-hospital sudden cardiac death (OOH-SCD) was studied among 108,676 30- to 74-year-old residents in 5 Minnesota communities using 6-year mortality data (1985 to 1990). Among 4,244 total deaths, location of death was listed on the certificate as out of hospital in 2,035 cases. Of those, 911 were judged not to have OOH-SCD because they had actually been admitted to the hospital or were noncardiovascular deaths. Among the remaining 1,124, 254 were diagnosed as OOH-SCD using a thorough, physician-based procedure that used clinical records, autopsy reports, and an informant (next-of-kin) interview. We used only death certificate information to define OOH-SCD simply and inexpensively as ICD-9 code 427.5 (cardiac arrest) plus location of death listed as out-of-hospital. Compared with the physician diagnosis, sensitivity was only 24%, whereas specificity was 85%. When the definition of OOH-SCD was expanded to include ICD codes 410-414 (acute myocardial infarction and chronic coronary artery disease), sensitivity improved to 87%, whereas specificity became 66%. However, even with this higher sensitivity and specificity, only 27% of the cases labeled OOH-SCD by death certificate agreed with the physician diagnosis. Death certificate diagnosis of OOH-SCD included many erroneous cases, and may not have been suitable for study of etiologic factors, such as cardiac dysrhythmias. Death certificate diagnosis may be useful to assess population time trends in OOH-SCD, provided that misclassification (false-positive rate) remains constant over time.

Section snippets

Study participants

The MHHP was a community trial of cardiovascular disease prevention conducted during the 1980s in 3 intervention and 3 matched control communities located in Minnesota, North Dakota, and South Dakota. The MHHP research design2 and its morbidity and mortality results have been published elsewhere.3 In the state of Minnesota, mortality surveillance data before 1985 (1980 to 1984) could not be used because the location of death was not reliably determined. Thus, analysis presented here is based on

Results

Of the total 4,244 deaths documented between 1985 and 1990, the death certificate information identified 2,035 that occurred out of hospital (48%) (Table I). Of the 4,244 deaths, 10% happened in the outpatient setting, emergency room, or on arrival to the hospital, and 38% took place in private homes, nursing homes, medical offices, or prisons.

Table II gives the distribution of death certificate diagnosis of all out-of-hospital deaths. In 19% of the 2,035 cases, the first contributory

Discussion

The main objective of this study was to determine the level of agreement between alternative methods to assess OOH-SCD: (1) economical forms of ascertainment based on death certificate information alone (ICD-9 codes plus location of death); and (2) a more labor and time-intensive standard approach based on physician review of paper death certificate, autopsy reports, medical records, and informant interview. The economical methods performed poorly, but may nevertheless be useful for some

Acknowledgements

We wish to thank William L. Baker and Lois Murphy for their technical assistance.

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This study was supported by a Grant RO1 HL 25523 from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.

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