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Unveiling the Burden of Miscoding and Misclassification in Stroke Mortality: Analysis of Multiple Cause-of-Death Data
Lucero Cahuana-Hurtado1, Héctor Gómez-Dantés2, Vanessa De la Cruz-Góngora3
1School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru.
Background:
The prevalence of risk factors for cerebrovascular diseases in Mexico is increasing although stroke mortality declined from 1990 to 2010, without meaningful changes afterward. While improving access to adequate prevention and care could explain this trend, miscoding and misclassification in death certificates need to be assessed to unveil the true burden of stroke in Mexico. Practices in death certification along with the presence of multi-morbidity could contribute to this distortion. Analyses of multiple causes of death could reveal ill-defined stroke deaths, providing a glimpse of this bias.
Methods:
Cause-of-death information from 4,262,666 death certificates in Mexico from 2009 to 2015, was examined to determine the extent of miscoding and misclassification on the true burden of stroke. Age-standardized mortality rates per 100,000 inhabitants (ASMR) were calculated for stroke as underlying and multiple causes of death, by sex and state. Deaths were classified following international standards as ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and unspecified, which were kept as an independent category to measure miscoding. To approximate misclassification, we compared ASMR under three misclassification scenarios: (1) current (the status quo); (2) moderate, which includes deaths from selected causes mentioning stroke; and (3) high which includes all deaths mentioning stroke. National and subnational data were analyzed to search for geographical patterns.
Results:
The burden of stroke in Mexico is underreported due to miscoding and misclassification. Miscoding is an important issue since almost 60% of all stroke deaths are registered as unspecified. Multiple cause analysis indicates that stroke ASMR could increase 39.9%-52.9% of the current ASMR under moderate and high misclassification scenarios, respectively. Both problems indicate the need to improve death codification procedures and cause-of-death classification.
Conclusions:
Miscoding and misclassification lead to underestimation of the burden of stroke in Mexico. Stroke deaths are underreported when other important causes coexist, being diabetes the most frequent.
Insights
Stroke deaths in Mexico are underreported due to significant miscoding and misclassification on death certificates. Improving death codification is crucial to accurately reflect the true burden of cerebrovascular diseases.
Area of Science:
- Public Health
- Epidemiology
- Medical Statistics
Background:
- Risk factors for cerebrovascular diseases are rising in Mexico.
- Stroke mortality rates have stagnated since 2010, despite earlier declines.
- Inaccurate death certification practices may obscure the true stroke burden.
Purpose of the Study:
- To assess the extent of miscoding and misclassification in stroke deaths in Mexico.
- To determine the impact of these errors on reported stroke mortality rates.
- To highlight the need for improved death certification and cause-of-death classification.
Main Methods:
- Analysis of 4,262,666 death certificates in Mexico (2009-2015).
- Calculation of age-standardized mortality rates (ASMR) for stroke as underlying and multiple causes.
- Comparison of ASMR under three misclassification scenarios (current, moderate, high).
Main Results:
- Significant underreporting of stroke burden due to miscoding and misclassification.
- Nearly 60% of stroke deaths are coded as unspecified.
- Stroke ASMR could increase by 39.9%-52.9% under moderate to high misclassification scenarios.
Conclusions:
- Miscoding and misclassification lead to a substantial underestimation of stroke burden in Mexico.
- Stroke deaths are frequently underreported when comorbidities like diabetes are present.
- Enhanced death codification procedures are essential for accurate public health surveillance.
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