title: Death certificates underestimate infections as proximal causes of death in the U.S.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Medicine, University of Michigan, Ann Arbor, Michigan, United States of America.
authors.forename: Sushant
authors.initials: S
authors.lastname: Govindan
authors.affiliation: Department of Medicine, University of Michigan, Ann Arbor, Michigan, United States of America.
authors.forename: Letitia
authors.initials: L
authors.lastname: Shapiro
authors.affiliation: Department of Medicine, University of Michigan, Ann Arbor, Michigan, United States of America; VA Center for Clinical Management Research, HSR&D Center for Excellence, Ann Arbor, Michigan, United States of America; Institute for Social Research, Ann Arbor, Michigan, United States of America.
authors.forename: Kenneth M
authors.initials: KM
authors.lastname: Langa
authors.affiliation: Department of Medicine, University of Michigan, Ann Arbor, Michigan, United States of America; VA Center for Clinical Management Research, HSR&D Center for Excellence, Ann Arbor, Michigan, United States of America; Institute for Social Research, Ann Arbor, Michigan, United States of America.
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Iwashyna
mesh_terms: D002423:Cause of Death; D003644:Death Certificates; D006760:Hospitalization; D006801:Humans; D007239:Infections / Q000401:mortality* / Q000628:therapy; D006278:Medicare / Q000706:statistics & numerical data; D014481:United States