Underreporting of Alcohol-Related Mortality on Death Certificates of Young U.S. Army Veterans

CDC recently evaluated death certificates of young, male U.S. Army Veterans to determine to what extent alcohol-related mortality was accurately reported (1). As part of the Vietnam Experience Study, CDC obtained death certificates and other available medical and legal records pertaining to the cause of death of 426 veterans who had served in Vietnam, Germany, Korea, or the United States during the Vietnam era (2,3). All deaths occurred after the men were discharged from active duty, from 1967 through 1983.

A nosologist, a specialist in the classification of diseases and causes of death, recoded each original death certificate in accordance with the Ninth Revision of the International Classification of Diseases (ICD-9) (4). A CDC medical panel, without having access to the original death certificates, completed an abbreviated version of the standard death certificate for each decedent on the basis of only the supplementary medical and legal records. Using ICD-9 codes, the panel assigned 1) an underlying cause of death, i.e., the single disease or injury that directly led to death, and 2) contributory causes of death, i.e., all other significant medical conditions that indirectly led to death.

For the analysis of alcohol-related mortality, both the coded death certificates and the coded findings of the medical panel were examined for alcohol-specific ICD-9 diagnoses (Table 1). Alcohol-related deaths were counted on the basis of multiple- cause-of-death analysis, a method that takes into account all contributory causes as well as the underlying cause of death noted by the death certifier (5,6).

In the total count of alcohol-related deaths, a death due to a natural cause (ICD-9 codes 001-799) was included if an alcohol-specific diagnosis such as alcoholic liver disease, was listed anywhere on the death record. An external-cause death, i.e., death due to injury or poisoning (ICD-9 codes E800-E989), was included if an alcohol- specific diagnosis was cited as a contributory cause of death. For example, a fatal motor vehicle injury was included if an excessive level of alcohol was detected in the blood or if nondependent abuse of alcohol was listed as a contributory cause. An external-cause death was included if unintentional poisoning by alcohol (E860.0- E860.9) was cited as the underlying cause.

The panel determined that there were 133 alcohol-related deaths, or more than six times the number (21 deaths) recorded by the original death certifiers (Table 2). The discrepancy was largely attributable to the omission by the original death certifiers of alcohol-specific contributory causes due to deaths due to external causes. The original death certifiers reported 12 alcohol-related external-cause deaths, whereas the medical panel recorded 103 alcohol-related external-cause deaths, 94 of which were associated with blood alcohol levels greater than or equal to100 mg/dl. Reported by: Biometrics Br, Div of Injury Epidemiology and Control; Agent Orange Projects, Div of Chronic Disease Control, Center for Environmental Health, CDC.

Editorial Note

Editorial Note: Reducing alcohol-related mortality is a widely stated public health objective (7,8). Interventions are aimed at a variety of diseases and injuries that are associated with heavy alcohol consumption but that are not necessarily attributable to the chronic condition called "alcoholism." A reliable tabulation of the various types of alcohol-related deaths is essential for surveillance purposes and for the evaluation of prevention initiatives.

Official U.S. mortality data traditionally have been compiled by the National Center for Health Statistics according to the underlying cause of death, a tabular system in which only one disease or injury is taken into account (6). Reports based on the underlying cause of death alone are thought to underestimate alcohol-related mortality because they do not reflect alcohol-specific contributory conditions. Multiple-cause-of-death analysis has been proposed as a means of providing a more complete assessment of alcohol-related mortality than is available through underlying-cause analysis alone (9).

As shown in this study, even when a multiple-cause analysis is applied to official cause-of-death records, alcohol-related deaths are still grossly underestimated. There are shortcomings in official mortality reporting that are more fundamental than the failure to take into account all listed conditions (10). Among the problems are the apparent omission of diagnostic information available at the time of death or obtained after death.

The frequent omission of excessive blood alcohol levels was a major shortcoming in the death certificates analyzed by CDC. This omission was particularly significant for a population of young U.S. males, because in this population injury is the leading cause of death (11).

In this investigation, almost one-third of a nationwide sample of deaths among young U.S. Army veterans were attributed to alcohol-related causes. An effective public health response must include 1) programs to prevent alcohol-related problems and 2) a reliable system for monitoring trends in all types of alcohol-related mortality. Results of this study suggest that persons who are responsible for certifying the cause of death on death certificates should be encouraged or required to report excessive blood alcohol levels obtained in the postmortem period. More broadly, the results support recommendations for a two-phase, death-certifying process designed to improve the quality of cause-of-death information: a first phase for legal purposes, to allow for disposition of the deceased and initiation of appropriate claims, and a second phase for medical certification, deferred until all antemor and postmortem diagnostic information has been reviewed (12,13).

References

1. Pollock DA, Boyle CA, DeStefano F, Moyer LA, Kirk ML. Underreporting of alcohol-related mortality on death certificates of young U.S. Army veterans. JAMA 1987;258:345-8.

2. CDC. Postservice mortality among Vietnam veterans. JAMA 1987;257:790-5.

3. CDC. Postservice mortality among Vietnam veterans. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, 1987.

4. World Health Organization. Manual of the international statistical classification of diseases, injuries, and causes of death, ninth revision. Geneva: World Health Organization, 1977.

5. Goodman RA, Manton KG, Nolan TF Jr, Bregman DJ, Hinman AR. Mortality Data analysis using a multiple-cause approach. JAMA 1982;247:793-6.

6. Israel RA, Rosenberg HM, Curtin LR. Analytical potential for multiple cause-of-death data. Am J Epidemiol 1986;124:161-79.

7. Public Health Service. Promoting health/preventing disease: objectives for the nation. Washington, DC: US Department of Health and Human Services, 1980.

8. World Health Organization. Problems related to alcohol consumption. Geneva, Switzerland: World Health Organization, 1980. (Technical report series 650).

9. Van Natta P, Malin H, Bertolucci D, Kaelber C. The influence of alcohol abuse as a hidden contributor to mortality. Alcohol 1985;2:535-9.

10. Comstock GW, Markush RE. Further comments on problems in death certification. Am J Epidemiol 1986;124:180-1.

11. Committee on Trauma Research (Commission on Life Sciences, National Research Council), Institute of Medicine. Injury in America: a continuing public health problem. Washington, DC: National Academy Press, 1985.

12. Carter JR. The problematic death certificate (Editorial). N Engl J Med 1985;313:1285-6.

13. Gay GA. 1989 revisions of the US standard certificates and reports. Am J Public Health 1987;77:602.

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