Accidents and undetermined deaths: re-evaluation of nationwide samples from the Scandinavian countries

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Abstract

Background

National mortality statistics should be comparable between countries that use the World Health Organization’s International Classification of Diseases. Distinguishing between manners of death, especially suicides and accidents, is a challenge. Knowledge about accidents is important in prevention of both accidents and suicides. The aim of the present study was to assess the reliability of classifying deaths as accidents and undetermined manner of deaths in the three Scandinavian countries and to compare cross-national differences.

Methods

The cause of death registers in Norway, Sweden and Denmark provided data from 2008 for samples of 600 deaths from each country, of which 200 were registered as suicides, 200 as accidents or undetermined manner of deaths and 200 as natural deaths. The information given to the eight experts was identical to the information used by the Cause of Death Register. This included death certificates, and if available external post-mortem examinations, forensic autopsy reports and police reports.

Results

In total, 69 % (Sweden and Norway) and 78 % (Denmark) of deaths registered in the official mortality statistics as accidents were confirmed by the experts. In the majority of the cases where disagreement was seen, the experts reclassified accidents to undetermined manner of death, in 26, 25 and 19 % of cases, respectively. Few cases were reclassified as suicides or natural deaths. Among the extracted accidents, the experts agreed least with the official mortality statistics concerning drowning and poisoning accidents. They also reported most uncertainty in these categories of accidents. In a second re-evaluation, where more information was made available, the Norwegian psychiatrist and forensic pathologist increased their agreement with the official mortality statistics from 76 to 87 %, and from 85 to 88 %, respectively, regarding the Norwegian and Swedish datasets. Among the extracted undetermined deaths in the Swedish dataset, the two experts reclassified 22 and 51 %, respectively, to accidents.

Conclusion

There was moderate agreement in reclassification of accidents between the official mortality statistics and the experts. In the majority of cases where there was disagreement, accidents were reclassified as undetermined manner of death, and only a small proportion as suicides.

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Most cited references 26

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Suicide as an outcome for mental disorders. A meta-analysis.

Erica Harris, Peter B. Barraclough, Christopher C. Harris (1997)

Mental disorders have a strong association with suicide. This meta-analysis, or statistical overview, of the literature gives an estimate of the suicide risk of the common mental disorders. We searched the medical literature to find reports on the mortality of mental disorders. English language reports were located on MEDLINE (1966-1993) with the search terms mental disorders', 'brain injury', 'eating disorders', 'epilepsy', 'suicide attempt', 'psychosurgery', with 'mortality' and 'follow-up studies', and from the reference lists of these reports. We abstracted 249 reports with two years or more follow-up and less than 10% loss of subjects, and compared observed numbers of suicides with those expected. A standardised mortality ratio (SMR) was calculated for each disorder. Of 44 disorders considered, 36 have a significantly raised SMR for suicide, five have a raised SMR which fails to reach significance, one SMR is not raised and for two entries the SMR could not be calculated. If these results can be generalised then virtually all mental disorders have an increased risk of suicide excepting mental retardation and dementia. The suicide risk is highest for functional and lowest for organic disorders with substance misuse disorders lying between. However, within these broad groupings the suicide risk varies widely.

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Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.

E Burton, Lee Goldman, Kristin K. McDonald … (2003)

Substantial discrepanies exist between clinical diagnoses and findings at autopsy. Autopsy may be used as a tool for quality management to analyze diagnostic discrepanies. To determine the rate at which autopsies detect important, clinically missed diagnoses, and the extent to which this rate has changed over time. A systematic literature search for English-language articles available on MEDLINE from 1966 to April 2002, using the search terms autopsy, postmortem changes, post-mortem, postmortem, necropsy, and posthumous, identified 45 studies reporting 53 distinct autopsy series meeting prospectively defined criteria. Reference lists were reviewed to identify additional studies, and the final bibliography was distributed to experts in the field to identify missing or unpublished studies. Included studies reported clinically missed diagnoses involving a primary cause of death (major errors), with the most serious being those likely to have affected patient outcome (class I errors). Logistic regression was performed using data from 53 distinct autopsy series over a 40-year period and adjusting for the effects of changes in autopsy rates, country, case mix (general autopsies; adult medical; adult intensive care; adult or pediatric surgery; general pediatrics or pediatric inpatients; neonatal or pediatric intensive care; and other autopsy), and important methodological features of the primary studies. Of 53 autopsy series identified, 42 reported major errors and 37 reported class I errors. Twenty-six autopsy series reported both major and class I error rates. The median error rate was 23.5% (range, 4.1%-49.8%) for major errors and 9.0% (range, 0%-20.7%) for class I errors. Analyses of diagnostic error rates adjusting for the effects of case mix, country, and autopsy rate yielded relative decreases per decade of 19.4% (95% confidence interval [CI], 1.8%-33.8%) for major errors and 33.4% (95% [CI], 8.4%-51.6%) for class I errors. Despite these decreases, we estimated that a contemporary US institution (based on autopsy rates ranging from 100% [the extrapolated extreme at which clinical selection is eliminated] to 5% [roughly the national average]), could observe a major error rate from 8.4% to 24.4% and a class I error rate from 4.1% to 6.7%. The possibility that a given autopsy will reveal important unsuspected diagnoses has decreased over time, but remains sufficiently high that encouraging ongoing use of the autopsy appears warranted.

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Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register-based study of all suicides in Denmark, 1981-1997.

Preben Mortensen, Esben Agerbo, Ping Qin (2003)

Suicide risk was addressed in relation to the joint effect of factors regarding family structure, socioeconomics, demographics, mental illness, and family history of suicide and mental illness, as well as gender differences in risk factors. Data were drawn from four national Danish longitudinal registers. Subjects were all 21,169 persons who committed suicide in 1981-1997 and 423,128 live comparison subjects matched for age, gender, and calendar time of suicide by using a nested case-control design. The effect of risk factors was estimated through conditional logistic regression. The interaction of gender with the risk factors was examined by using the log likelihood ratio test. The population attributable risk was calculated. Of the risk factors examined in the study, a history of hospitalization for psychiatric disorder was associated with the highest odds ratio and the highest attributable risk for suicide. Cohabiting or single marital status, unemployment, low income, retirement, disability, sickness-related absence from work, and a family history of suicide and/or psychiatric disorders were also significant risk factors for suicide. Moreover, these factors had different effects in male and female subjects. A psychiatric disorder was more likely to increase suicide risk in female than in male subjects. Being single was associated with higher suicide risk in male subjects, and having a young child with lower suicide risk in female subjects. Unemployment and low income had stronger effects on suicide in male subjects. Living in an urban area was associated with higher suicide risk in female subjects and a lower risk in male subjects. A family history of suicide raised suicide risk slightly more in female than in male subjects. Suicide risk is strongly associated with mental illness, unemployment, low income, marital status, and family history of suicide. The effect of most risk factors differs significantly by gender.

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Author and article information

Contributors

Ingvild Maria Tøllefsen: 0047 22851020 , 0047 22 85 13 00 , uxtlli@ous-hf.no , i.m.tollefsen@medisin.uio.no

Journal

Journal ID (nlm-ta): BMC Public Health

Journal ID (iso-abbrev): BMC Public Health

Title: BMC Public Health

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2458

Publication date (Electronic): 27 May 2016

Publication date PMC-release: 27 May 2016

Publication date Collection: 2016

Volume: 16

Electronic Location Identifier: 449

Affiliations

[ ]Department of Acute Medicine, Oslo University Hospital Ullevaal, Box 4950, Nydalen, N-0424 Oslo Norway

[ ]Department of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Box 1072, Blindern, N-0316 Oslo Norway

[ ]Department of Surgical Sciences, Uppsala University, Box 256, 751 05 Uppsala, Sweden

[ ]Department of Social Medicine and Public Health Research, Copenhagen University, Nørregade 10, Copenhagen K, DK-1165 Denmark

[ ]Division of Mental Health and Addiction, Oslo University Hospital Ullevaal, Box 4950, Nydalen, N-0424 Oslo Norway

[ ]Amalievej 23, Frederiksberg, DK 1875 Denmark

[ ]Stockholm Centre for Psychiatric Research and Education, Department of Clinical Neuroscience, Karolinska Institutet, Sweden, Norra Stocholms psychiatri S:t Görans sjukhus, Stockholm, SWE-112 81 Sweden

[ ]Norwegian Institute of Public Health, Box 4404, Nydalen, N-0403 Oslo Norway

[ ]Institute of Clinical Medicine, University of Oslo, Box 1072, Blindern, N- 0316 Oslo Norway

[ ]Division of Medicine, Department of Acute Medicine, Oslo University Hospital Ullevaal, Box 4950, Nydalen, N-0424 Oslo Norway

Article

Publisher ID: 3135

DOI: 10.1186/s12889-016-3135-5

PMC ID: 4882827

PubMed ID: 27229154

SO-VID: c54642d2-cc00-44f4-bd55-8b8d5359562a

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 10 July 2015

Date accepted : 13 May 2016

Funding

Funded by: This study was supported by the South-Eastern Norway Regional Health Authority.

Award ID: Grant number: 2008072.

Award Recipient : Øivind Ekeberg

Custom metadata

ScienceOpen disciplines: Public health

Keywords: accidents,autopsy,reclassification,suicide statistics,undetermined deaths

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ScienceOpen disciplines: Public health

Keywords: accidents, autopsy, reclassification, suicide statistics, undetermined deaths

Accidents and undetermined deaths: re-evaluation of nationwide samples from the Scandinavian countries

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Abstract

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Global Health Next Generation Network

Most cited references 26

Suicide as an outcome for mental disorders. A meta-analysis.

Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.

Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register-based study of all suicides in Denmark, 1981-1997.

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