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Errors on death certificates

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  • Errors on death certificates


    The mystery of death: Autopsy rates in Concho Valley below state average

    Thomas Hargrove and Trish Choate Standard-Times Washington Bureau
    Saturday, August 8, 2009

    It?s hard to tell what?s really killing the Concho Valley.

    The more often counties order autopsies, the less likely officials are to chalk up local deaths to vague causes like ?cardiac arrest? or unexplained heart disease. But autopsy rates in most Concho Valley counties are well below the state average.

    The scenario of low autopsy rates and high heart deaths is repeated many times across the nation. The result? The official cause of death is dead wrong at least a third of the time, medical experts agree.

    A Texas forensic pathologist estimated a minimum of 40 percent of death certificates are in error ? and it is that faulty data that researchers tap into for studies that determine what kills us, and therefore what health care issues should get spending priorities.

    ?Medical examiners all know that it borders on useless,? said Dr. Vincent Di Maio, a National Association of Medical Examiners Board member and San Antonio physician.

    A seven-month investigation by the Standard-Times and Scripps Howard News Service into 4.9 million national death files provided by the Centers for Disease Control and Prevention uncovered a confusing patchwork of information on the big killers such as heart disease, stroke and even cancer.

    The study included each of the 313,607 deaths reported in Texas in 2005 and 2006.

    One of the puzzling contrasts turned up was between Tom Green County and Kimble County to the south.

    If you have a weak heart, don?t skip a beat in Kimble County.

    People who die in Kimble County are 26 percent more likely to die from heart disease than their Concho Valley neighbors in Tom Green County.

    At least, that?s what the data says.

    Similar variations that just don?t make sense crop up from state to state and among counties within the same state.

    A higher consumption of chicken-fried steak or cheese enchiladas in Kimble County probably isn?t the issue. Experts say the variations in death rates for the big killers are greater than can be explained by differences in age, race or other risk factors for illness that typically change with geography.

    Assigning cause of death in Texas ? and across the United States ? is often flawed by a lack of medical information and clouded by mistaken assumptions.


    In Texas, medical examiners or justices of the peace decide who will get an autopsy, but medical professionals in nursing homes, hospice facilities and hospitals can sign off on a death certificate when appropriate.

    An autopsy can also be requested by family members, but they must foot the bill instead of the taxpayer.

    Since no Concho Valley counties have a medical examiner?s office, the duty of death investigator or coroner falls to the justices of the peace.

    The first year in office, a justice of the peace receives 80 hours of education on a range of judicial topics. Thereafter, 40 hours a year is required.

    Justice of the Peace Peggy Ragsdale of Kimble County said she absolutely did not feel prepared for a role as death investigator when she took office in 1994.

    ?They don?t give you a whole lot of training in the JP school. They sit there and read the book to you,? Ragsdale said. ?And then you take it from there.?

    The Standard-Times and Scripps review echoes a 2001 report published by the federal Agency for Healthcare Research and Quality that analyzed dozens of academic studies and found that as many as a third of all death certificates are likely to include an incorrect cause ? and that 50 percent of autopsies reveal medical information that wasn?t known before the patient died.

    ?Health care guidelines and policies are being based on these faulty data from the death certificates,? said a pathologist who helped write that report, Dr. Elizabeth Burton, chief of the autopsy lab at Baylor Medical Center in Dallas. ?The result is we?re spending too much of the money in the wrong places and not enough on diseases that kill more than the numbers show.?

    Nationally, experts say the most common error on death certificates is blaming some form of heart disease for deaths in reality caused by other conditions or diseases.

    ?Heart disease is very often the default cause of death in this country,? said Robert Anderson, chief of mortality studies at the National Center for Health Statistics.

    Many experts believe anything above 25 percent for a heart disease death rate is suspect, and the true national average is about 20 percent.

    But some counties in Texas reported fatal coronary diseases at twice the rate of others. And the Standard-Times/Scripps study found 33 Texas counties reported heart death rates of 30 percent or more.

    Kimble County, with a rate of 31.06 percent, was among them.

    ?Unless the doctor can give me a cause of death, I?m not going to question it. I?m going to send them? for autopsy, Ragsdale said.

    In Tom Green County, the attributed cause of death is heart disease in 24.57 percent of deaths.

    Justice of the Peace Russell S. Smith of Tom Green County said if the cause of death is unknown and foul play isn?t indicated, then he can?t attribute a death to heart disease.

    ?Cardiac arrest could come from having liver failure,? Smith said. ?In many of these cases where you don?t do autopsies, with us, it would be unknown causes.?

    On the other hand, Smith went to the emergency room recently for a death investigation, and the physician told him the woman had a heart attack, Smith said.

    ?So that one will be myocardial infarction,? he said.


    The study found puzzling variations nationwide in heart death rate.

    Texas reports that 23.8 percent of all deaths result from heart disease, well above the 18 percent reported in Alaska or the 20 percent reported in Colorado.

    But it?s well below the more than 32 percent reported in the state of New York or the nearly 30 percent reported by Rhode Island.

    ?First of all, most doctors don?t even need to know how to fill out a death certificate,? said Di Maio, who retired as Bexar County?s chief medical examiner two years ago.

    Case in point: cardiopulmonary arrest as cause of death.

    ?Cardiopulmonary arrest means your heart stops and your lungs stop,? Di Maio said. ?Everybody who dies, their heart and lungs stop. It doesn?t mean anything.?

    Despite funding limitations, Texas has one of the nation?s highest rates of autopsy ? the physical examination that usually determines the true cause of death.

    But 14 Texas counties autopsy 2 percent or less of all deaths, including six area counties: Coke, Concho, Glasscock, Sutton, McCulloch and Schleicher.

    Tom Green County?s autopsy rate is 3.70 percent.

    ?I don?t know how to explain that except we have a lot of really elderly people,? Smith said, adding the county is a retirement center. ?Hospice is doing a lot of these deaths.?

    Just over 12 percent of the state?s population is 65 or older; Tom Green County is slightly higher with 13.4 percent, according to the Census Bureau.

    In Kimble County, the same statistic is 20.9 percent.

    Funding can figure large in decisions about whether to send a body for an autopsy, said Robert Byers, managing director and chief investigator for the Lubbock County Medical Examiner?s Office.

    The tab for an autopsy could run from about $1,700 to $4,000 or more, depending on tests ordered and the complexity of the post-mortem examination.

    Then add transportation costs for the body, often $500 to $600.

    ?I don?t want to talk about the investigation of a particular case,? Smith said. ?But I will tell you that at this time, I do have special tests being done for poisons to make sure there weren?t any.?

    The tests mean that autopsy will be more expensive, he said.

    ?But I never batted an eye, and our county doesn?t have any money,? Smith said.

    State and national health authorities said the differing rates in reported causes of death in Texas are deeply disturbing and are probably related more to errors by medical officials than to any differences in the health or background of people from one place to another.

    ?I think most pathologists wish more hospitals were doing autopsies,?
    said Dr. Roger Metcalf, spokesman for the Tarrant County Medical Examiner?s office, which conducts autopsies for some counties in the Concho Valley, including Tom Green County.

    The Tarrant County facility in Fort Worth conducts 2,500 autopsies a year and has served about 60 counties, Metcalf said. The office is primarily interested in finding out if a death was caused by foul play.

    If investigators decide a death was natural, they typically don?t pinpoint the exact cause, Metcalf said.

    ?At that point, our guys are really out of it,? Metcalf said.

    Across Texas, that didn?t used to be the case. But 20 years ago, Texas hospitals began trimming costs by cutting down on medical autopsies.

    ?It?s become more noticeable,? Metcalf said.

    The only way to know what?s really killing Texans is to conduct more autopsies, Metcalf said.

    Scripps Howard News Service reporters Lee Bowman and Isaac Wolf contributed to this story. Contact Texas regional reporter Trish Choate at 202... or

    Causes of death

    Counties of the Concho Valley, numbers of deaths and percentages of causes attributed by death certificate

    County Deaths Heart Cancer Stroke Lung Accident Suicide

    Coke 113 19.47 23.89 2.65 12.39 0.88 0.88

    Concho 61 24.59 26.23 14.75 8.2 1.64 4.92

    Crockett 66 30.3 15.15 1.52 12.12 10.61 3.03

    Irion 20 20 15 10 0 10 0

    Kimble 132 31.06 23.48 5.3 9.09 4.55 0

    Mason 90 24.44 17.78 6.67 10 4.44 1.11

    McCulloch 208 25.48 20.67 6.25 8.17 3.85 0.96

    Menard 67 25.37 19.4 11.94 8.96 5.97 1.49

    Reagan 47 14.89 29.79 10.64 12.77 2.13 2.13

    Runnels 292 25.68 17.81 5.82 9.25 6.51 0

    Schleicher 57 26.32 8.77 12.28 10.53 5.26 0

    Sterling 21 4.76 9.52 14.29 4.76 4.76 4.76

    Sutton 57 19.3 28.07 3.51 8.77 8.77 0

    Tom Green 1917 24.57 21.07 5.22 8.4 4.17 1.62

    U.S. 4,874,281 25 22.96 5.76 7.69 5.02 2.11