Moussa M A, Shafie M Z, Khogali M M, el-Sayed A M, Sugathan T N, Cherian G, Abdel-Khalik A Z, Garada M T, Verma D
Department of Community Medicine, Faculty of Medicine, Kuwait University, Safat.
J Clin Epidemiol. 1990;43(12):1285-95. doi: 10.1016/0895-4356(90)90094-6.
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 under-estimated 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 under-estimated 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.
对科威特5家综合医院470例死亡病例的死亡证明与临床记录之间的一致性进行了研究，这些病例的潜在或相关病因如下：高血压（HYP）、缺血性心脏病（IHD）、脑血管疾病（CVD）和糖尿病（DM）。由于直接病因在分析上意义不大，因此未予考虑。仅纳入确定或极有可能确诊的死亡病例。一名心脏病专家在获得世界卫生组织关于死亡证明的标准和相关文件后，独立审查了这些记录。为检验审查者的偏差及其判断的可靠性，通过让一名资深心脏病专家重新审查140份记录的随机子样本进行了裁决过程。两位审查者显示出良好的一致性。审查者遵循了用于确定多种疾病情况下根本死因的具体诊断标准。由于可能存在审查者偏差，我们旨在衡量初始证明者与审查者之间的差异，而非参照审查者衡量初始证明者的诊断准确性。一致性指数kappa显示原始证明与修订后证明之间的一致性较差。在我们的样本中，原始证明将CVD作为根本死因的低估率为69.2%，DM为60%，IHD为33.5%，HYP为31.8%。与审查者相比，初始证明者对相关病因的估计也一直偏低。这种偏差要求科威特的死亡率统计以医院死亡委员会的报告而非初始证明者的死亡证明为依据，采用多死因而非单一根本死因，并对医疗行业进行关于死亡证明的价值和流程的充分培训。
