A Method for Reclassifying Cause of Death in Cases Categorized as “Event of Undetermined Intent”

Below: Russian trends in standardized death rates per 100,000 residents for non-transport accidents, suicides, homicides, and external deaths due to events of undetermined intent

Below:  Distributions of the three imputed causes of death (both sexes) depending on constraints on the estimated classification probability, per 1000 cases

Background

We present a method for reclassifying external causes of death categorized as “event of undetermined intent” (EUIs) into non-transport accidents, suicides, or homicides. In nations like Russia and the UK the absolute number of EUIs is large, the EUI death rate is high, or EUIs comprise a non-trivial proportion of all deaths due to external causes. Overuse of this category may result in (1) substantially underestimating the mortality rate of deaths due to specific external causes and (2) threats to the validity of studies of the patterns and causes of external deaths and of evaluations of the impact of interventions meant to reduce them.

Methods

We employ available characteristics about the deceased and the event to estimate the most likely cause of death using multinomial logistic regression. We use the set of known non-transport accidents, suicides, and homicides to calculate an mlogit-based linear score and an estimated classification probability (ECP). This ECP is applied to EUIs, with varying levels of minimal classification probability. We also present an optional second step that employs a population-level adjustment to reclassify deaths that remain undetermined (the proportion of which varies based on the minimal classification probability). We illustrate our method by applying it to Russia. Between 2000 and 2011, 521,000 Russian deaths (15 % percent of all deaths from external causes) were categorized as EUIs. We used data from anonymized micro-data on the ~3 million deaths from external causes. Our reclassification model used 10 decedent and event characteristics from the computerized death records.

Results

Results show that during this period about 14 % of non-transport accidents, 13 % of suicides, and 33 % of homicides were officially categorized as EUIs. Our findings also suggest that 2011 levels of non-transport accidents and suicides would have been about 24 % higher and of homicide about 82 % higher than that reported by official vital statistics data.

Conclusions

Overuse of the external cause of death classification “event of undetermined intent” may indicate questionable quality of mortality data on external causes of death. This can have wide-ranging implications for families, medical professionals, the justice system, researchers, and policymakers. With our classification probability set as equal to or higher than 0.75, we were able to reclassify about two-thirds of EUI deaths in our sample. Our optional additional step allowed us to redistribute the remaining unclassified EUIs. Our method can be applied to data from any nation or sub-national population in which the EUI category is employed.

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Unnatural Deaths in Shanghai from 2000 to 2009: A Retrospective Study of Forensic Autopsy Cases at the Shanghai Public Security Bureau

Below:  Forensic Cases in Shanghai from SPSB (2000–2009)

Shanghai is the most developed city in China and has a soaring population. This study uses forensic epidemiology to determine the relationship between unnatural deaths and the development in Shanghai, based on recently released forensic autopsy cases from the 2000s at the Shanghai Public Security Bureau (SPSB). There were 5425 accidental deaths, 2696 homicides, 429 suicides, 186 natural deaths, and 1399 deaths of undetermined cause. There was a male-to-female ratio of 2.02:1, and the average age was 40.9±18.7 years. Traffic accidents (84.2%) were the number one cause of accidental deaths, which decreased during the study period. Sharp force injury (50.6%) was the leading cause of homicides, different from Western countries, where firearms are the leading cause. Hanging (24.5%) was the leading cause of suicides, whereas drug and chemical intoxication was the leading cause in the previous decade; pesticide ingestion decreased in the 2000s. In addition to traffic accidents, manual strangulation was the leading cause of death in childhood fatalities. Children under age 2 were vulnerable to homicides. In the 2000s, there were a large number of drug overdoses, and illegal medical practices and subway-related deaths first appeared in Shanghai. A new type of terrorist attack that involved injecting people with syringes in public places was reflected in the SPSB archives. The forensic epidemiology and changes in unnatural deaths in this decade reflected their relationship with the law, policy and changes in Shanghai. Illegal medical practices, subway-related deaths and terrorist attacks were closely related to the development in Shanghai. Identifying the risks of unnatural deaths will improve public health.

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