Improving the quality of cause of death data for public health policy: are all 'garbage' codes equally problematic?

All countries need accurate and timely mortality statistics to inform health and social policy debates and to monitor progress towards national and global health development goals. In many countries, however, civil registration and vital statistics (CRVS) systems are poorly developed. Consequently, the statistics they produce are not fit for purpose. In part, this arises because the physicians certifying cause of death (COD) have either not been adequately trained in how to complete a death certificate according to the current International Statistical Classification of Diseases – Version 10 (ICD-10) [1], or they fail to appreciate the public health importance of what is often perceived as a largely administrative task [2]. This can be reinforced by cultural attitudes and perceptions among hospital administrators, who are generally unaware of the critical contribution that accurate medical certification of CODs makes to generating essential public health intelligence that can be used for planning. Unsurprisingly, these system deficiencies usually result in a high proportion of CODs being assigned to ‘garbage’ codes [3]. These have little or no public health value because they are too vague, are an immediate or intermediate COD, or are impossible as an underlying cause of death (UCOD). For example, septicaemia is often chosen as the underlying or precipitating COD when it is, in fact, the immediate cause arising from a many possible UCODs including communicable or non-communicable diseases, or an injury [3]. Prevention strategies would differ markedly depending on the UCOD; hence the importance of correct certification. Garbage codes bias a country’s true pattern of mortality. Studies of the quality of mortality statistics carried out in Thailand [4], Sri Lanka [5], and Iran [6], for example, have repeatedly found that the population’s likely true mortality pattern was considerably different from the pattern reported by the CRVS system. These discrepancies have been largely attributed to physicians’ extensive use of garbage codes.