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Characteristics of Death Certifiers and Institutions Where Death is Pronounced -- Fulton County, Georgia, 1991

Information from death certificates (DCs) is used to measure health status and to set public health priorities at all levels in the United States. However, because of limitations in the training of physicians who certify deaths, the completeness and accuracy of cause-of-death information varies (1-3). To develop a basis for targeting education of physicians who certify deaths, CDC, in cooperation with the Fulton County (Georgia) Vital Records Office, reviewed a consecutive series of 500 DCs filed in Fulton County (1990 population: 648,951) from April 10 through May 2, 1991, to characterize the number and proportion of personal physicians (PPs) (defined as physician certifiers not acting in the capacity of medical examiners or coroners {MECs}) and MECs certifying death, as well as other factors. This report summarizes the results of that review.

In Georgia, DCs are filed in the county where death occurs. The 500 DCs included 306 (61.2%) filed for Fulton County residents. The DCs included deaths that occurred in January (three), February (11), March (75), and April (411) 1991. During the study, 13 hospitals and 23 long-term-care facilities (LTCFs {i.e., nursing homes and extended-care facilities not associated with hospitals}) were in operation in Fulton County.

PPs and MECs certified deaths pronounced at 23 institutions located in the county. Thirteen institutions were hospitals; four, LTCFs; and six, MEC offices in six Atlanta-area metropolitan counties, including Fulton County (although the incident leading to death may have occurred outside Fulton County, the death itself occurred in Fulton County). The number of persons certifying deaths in each institution ranged from one to 79. A total of 292 deaths were pronounced in the 13 hospitals (range: 2-103; mean: 30 deaths per hospital). Six deaths were pronounced at four of the LTCFs.

PPs certified 401 (80.2%) deaths and attributed 400 (99.9%) to natural causes. MECs certified 99 (19.8%) deaths and attributed 70 (70.7%) to natural causes. During the study period, 273 (12%) PPs certified 401 deaths; of these 273 PPs, 181 (66.3%) certified one death each. Each PP certified a mean of 1.5 (range: 1-13) deaths. The largest number of deaths (13) were certified by a PP at a hospital for terminally ill cancer patients. Of the 99 deaths certified by MECs, 95 (96.0%) were certified by eight medical examiners from two counties; coroners from four adjacent counties each certified one death. The mean number of certifications per MEC was 8.3; the largest number of certifications by a single MEC was 20.

Of the 401 persons whose deaths were certified by PPs, 290 (72.3%) were inpatients at institutions, 84 (20.9%) were pronounced dead on arrival at emergency departments, and 27 (6.7%) died in emergency departments. Standard procedure at the hospital where the largest number (103) of deaths was pronounced was for resident house staff to complete the DC. Reported by: R Hanzlick, MD, Dept of Pathology and Laboratory Medicine, Emory Univ School of Medicine, Atlanta. Surveillance and Programs Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC.

Editorial Note

Editorial Note: Based on a meeting of experts cosponsored by CDC and the National Committee on Vital and Health Statistics in 1991, recommendations were developed for more accurate and consistent completion of DCs in physician-education programs (4). In particular, the recommendations suggested that, because most physicians are likely to certify only a small number of deaths, educational efforts should be aimed at physicians and institutions most likely to be pronouncing and certifying deaths. The findings in Fulton County characterize physicians and institutions involved in certifying deaths in a defined geographic area and may assist in the design of educational programs to increase the accuracy and completeness of DCs. In particular, these findings indicate that death-certification education efforts may be most effective if they are hospital based and targeted to all hospitals to reach appropriate PP certifiers and focus on the certification of inpatient deaths from natural causes. Because results from this study indicate that MECs certified nearly 20% of all deaths, education efforts for MECs could improve the accuracy and completeness of a substantial proportion of DCs.

Hospital-based efforts could include 1) training in death certification and registration before permanent or resident physician privileges are granted; 2) requiring physicians who certify the cause of death to complete approved training within a specified time after their first death certification; and 3) training a designated group of physicians to certify all deaths in the institution in consultation with the attending physician and after review of the medical record and other documents (5).


  1. Kircher T. Autopsy and mortality statistics: making a difference. JAMA 1992;267:1264-8.

  2. Hanzlick R, Parrish RG. The failure of death certificates to record the performance of autopsies {Letter}. JAMA 1993;269:47.

  3. Hanzlick R. Improving accuracy of death certificates {Letter}. JAMA 1993;269:2850.

  4. NCHS. Report of the second workshop on improving cause-of death statistics. (Virginia Beach, Virginia). Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, April 1991.

  5. National Center for Health Statistics. Physician's handbook on medical certification of death. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1987; DHHS publication no. (PHS)87-1108.

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