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Table 4 Factors affecting UCD determinations in Hong Kong and Shanghai: Extracts from interviews

From: The incomparability of cause of death statistics under “one country, two systems”: Shanghai versus Hong Kong

Themes Study areas Quotations
Location of death Hong Kong “In Hong Kong, most deaths outside hospital are reportable deaths whose UCD are based on a coroner’s investigation. The procedure of certifying a death certificate for a reportable death is more complicated compared with a natural death in hospital. Also, the property value may be depreciated if a death happens in a residential property. Thus, proportion of death outside hospital in Hong Kong is lower than places where doctors can certify death certificates based on clinical history.” (Pathologist, Hong Kong)
Shanghai “It is quite common that elderly people are bedridden due to cerebrovascular disease or injury, and then die at home.” (A community doctor, Shanghai)
Physicians’ and coders’ perceptions of causal sequence of morbid events leading to death Hong Kong “I think pneumonia and sepsis are acceptable causes of death, especially as Hong Kong is an aging society, it is difficult to identify the underlying cause of death among several causes of death across a patient’s life course.” (Medical practitioner, Hong Kong)
“Although a lot of old patients have a history of ischemic heart disease or stroke, they may die from pneumonia or septicemia during the latest admission. I am not so sure that the causal relationship between pneumonia or septicemia and an existing chronic disease. I think, in those cases, pneumonia or septicemia is the most precise cause of death…” (Cardiologist, Hong Kong)
“… chronic heart failure, respiratory failure, pneumonia, urinary tract infections, sepsis, and chronic renal failure are the most common dying symptoms or conditions. These diseases are the most direct causes of death…. As for existing chronic diseases, such as stroke, now about one-third of cases can recover.” (Neurologist, Hong Kong)
“Some clinic practitioners have different perceptions of cause of death from ours. They care more about how a patient dies, especially during the last stage. We work with the Department of Health to train doctors how to certify death certificates. But we still have a long way to go.” (Clinical pathologist, Hong Kong)
“When a patient’s blood culture test result is positive, the diagnosis of sepsis is clear. I do not think that there is any problem to certify sepsis as cause of death.” (Medical practitioner, Hong Kong)
Shanghai “It is quite common for patients to die from pulmonary infection and other infections directly. But I will certify their existing chronic diseases on death certificates as well.” (Medical practitioner, Shanghai)
“According to Rule 3, pneumonia can be a complication of any disease. We believe that to date, people usually cannot die from pneumonia without underlying chronic diseases except for the elderly and young children. Thus, these underlying chronic diseases should be the underlying cause of death.” (Official in Shanghai CDC, Shanghai)
“We do not think that pneumonia and septicemia are specific enough as UCD.” (Official, Shanghai Center for Disease Control and Prevention, Shanghai)
Implications of the selected UCD for the professional performance of doctors Hong Kong “We are asked to identify the accurate cause of death. The causal relationship between the acute infection and existing chronic conditions is ambiguous. If the diagnosis is not accurate, this diagnosis may cause some trouble.” (Medical practitioner, Hong Kong)
Shanghai “The relationships between doctors and patients are intensive in these years. If a patient dies from serious chronic diseases, it can be accepted by their family. But if a patient dies from infections in hospital, we may be blamed by some patients’ families. … Nosocomial infection is quite common. Why do we need to put ourselves in trouble?” (Cardiologist, Shanghai)
Institutional influence on the procedure of quality control of cause of death statistics Hong Kong “A lot of death certificates were only certified pneumonia or sepsis, and some cases mentioned chronic diseases in Part II. It is very common in Hong Kong. We code UCD based on the information from death certificates. … We usually do not review clinical records for confidential reasons.” (Official, Department of Health, Hong Kong)
Shanghai “We do not think that pneumonia and septicemia are specific enough as UCD. So if a case only mentions pneumonia or septicemia, we will review the clinical history. From my experience, most of these cases have a more specific chronic disease which initiates the chain leading to death.”
(Medical practitioner, Shanghai)