June 25, 2019
The Bottom Line: Some Texas physicians are concerned that the state’s death statistics are not as accurate as they should be. Like in many states, Texas’ death reporting system feeds inconsistent information into the state’s vital statistics database. As a result, distorted death statistics inaccurately portray how people are dying, which could have negative public health implications.
Why do Texans die? Accurate reporting on cause of death helps inform physicians, public health experts, and others about how to protect people from preventable deaths, among other benefits. However, Texas’ data collecting has flaws, and physicians caution that inaccurate death-certificate reporting could have a long-term impact on population health.
June’s Texas Medical Association (TMA) Texas Medicine magazine reports the National Center for Health Statistics estimates nearly one-third (20% to 30%) of the causes of death listed on death certificates are inaccurate. Texas, like most other states, has an inconsistent death reporting system, differing somewhat by county. In larger counties, a professional medical examiner’s office investigates deaths, while deaths not under medical care in rural counties are investigated by justices of the peace (JPs). Only 15 of the state’s 254 counties have populations large enough to support a medical examiner’s office. A medical examiner completes an autopsy and writes a death certificate for anyone who dies by violence or suspected foul play. JPs, who are elected officials, are not required to have medical training. “You can imagine trained medical professionals having errors,” said Dwayne Wolf, MD, deputy chief medical examiner for the Harris County medical examiner’s office. “People with no medical training are more likely to have even worse errors.”
Even training for physicians on how to complete death certificates is inconsistent, and many doctors and JPs might list the wrong factors as the cause of death. One doctor says physicians can make a best judgment about what killed a patient and expect to be accurate 92% to 93% of the time, but that margin of error actually may be larger.
“The only way to know how a patient died is through autopsy,” said Frank Papa, DO, associate dean for curricular design and faculty development at Texas College of Osteopathic Medicine in Fort Worth. But the number of autopsies for those who died of natural causes in hospitals has declined dramatically, according to J. Keith Pinckard, MD, Travis County’s chief medical examiner. And budget-conscious JPs must justify the estimated $2,500 fee per autopsy they must pay medical examiners in larger counties (plus transportation fees). Therefore, finances limit the number of autopsies performed in Harris County, Dr. Wolf said, creating a “financial disincentive” to pay for autopsies. Doctors do note, though, that many JPs do have experience investigating deaths.
Due to these various factors, nobody knows for sure what’s actually killing people, in many cases. Texas also no longer has a scientific way to check physicians when they list a cause of death, Dr. Papa said. Dr. Pinckard agrees, citing doctors’ confusion between mechanism of death and the actual cause of death.
“A death certificate might be filled out that says ‘cardiac arrest’ [as a cause of death],” he said. “Well, technically everyone who dies has cardiac arrest, so that’s not really a cause of death. That’s a mechanism. The question you’re trying to answer is why they had a cardiac arrest. You really want to get at the underlying disease.”
All of this concerns Umair Shah, MD, executive director of Harris County Public Health and a member of TMA’s Committee on Infectious Diseases. He said accurate documentation is a foundation of the state’s vital statistics.
“Our systems of assessment and intervention – and ultimately measures of potential success – are based on [death statistics],” Dr. Shah said. “So we have to assure the absolute integrity of those.”
Doubts arose in 2018 about state death data surrounding Texas’ maternal mortality statistics, based on earlier pregnancy-related deaths. Case-by-case review showed the data misreported the number of deaths. Errors on death certificates may have been at least partly to blame, according to a May 2018 study in Obstetrics and Gynecology prepared by Texas Maternal Mortality and Morbidity Task Force members.
Local health departments also use death certificate data to identify influenza-related deaths during flu season and to track the number of tobacco-related deaths. “We recognize there are limitations to [the data], and so we try to interpret it within those limitations,” says Philip Huang, MD, director of Dallas County Health and Human Services and a member of TMA’s Council on Science and Public Health.
Death investigation procedures – and the potential for errors – vary by county.
To improve the system, the state introduced the new Texas Electronic Vital Events Registrar (TxEVER) system in January 2019, but physicians report technical difficulties in filling out online death certificates in the new system.
Doctors like Kimberley Molina, MD, deputy chief medical examiner for Bexar County, call for greater education among physicians and medical students about why death statistics are important and why filling out death certificates accurately is so vital.
“If we can just educate all the players,” Dr. Molina said, “that would go a long way.”
TMA is the largest state medical society in the nation, representing nearly 53,000 physician and medical student members. It is located in Austin and has 110 component county medical societies around the state. TMA’s key objective since 1853 is to improve the health of all Texans.
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Contact: Brent Annear (512) 370-1381; cell: (512) 656-7320; email: brent.annear[at]texmed[dot]org
Marcus Cooper (512) 370-1382; cell: (512) 650-5336; email: marcus.cooper[at]texmed[dot]org
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