Table 2

Characteristics of evaluation studies on educational interventions to improve death certification

TitleType of studyYear & locationTraining durationInterventionParticipantsEvaluation methodSummary of results
Improving death certificate completion: A Trial of Two Training Interventions28Randomised controlled trial and before and after evaluation of 2 training interventions2006†, US45 min workshopGroup I: interactive workshop using the guidelines for optimal completion of death certificates.Internal medicine residents, assigned to group I or II using an internet based randomisation programScoring of death certificates filled out using a different sample case before intervention and 1 week after intervention by each group
  • Both groups showed a significant improvement in all areas of death certificate scored

  • An interactive workshop is a more effective intervention than a printed handout

Group II: printed instruction material as a handout that outlined the guidelines.
Improving the accuracy of death certification29Before and after evaluation1996 * (three seminars over 6 months), Canada75 minSeminar on process of and terminology in death certification, interactive completion of death certificate based on 10 case scenarios and identification of errors in mock death certificatesInternal medicine residentsAudit of actual death certificates filled out over a 12 month period before and those filled out over a 6 month period after intervention
  • Significant reduction in proportion of certificates with at least one major error

  • No significant change in the overall rate of minor errors

Death duties: Workshop on what family physicians are expected to do when patients die30Before and after evaluation2007†, CanadaHalf-dayWorkshop on death counts video, Coroners Act tutorial, death certification process review, small group discussion on case scenarios, mock death certification and presentationCommunity (family) physiciansScoring of death certificates filled out using case scenarios before intervention and 3 months after intervention;
  • Decline in use of mechanisms of death and increased use of more specific diseases as the underlying cause of death

  • Improvement in knowledge on death certification and the Coroners Act

Pre- and post- intervention questionnaire survey
Evaluating an educational intervention to improve the accuracy of death certification among trainees from various specialties31Before and after evaluation2007†, Spain (Over an 18 month period)90 minInteractive workshops on current legislation on and most common errors in death certification, distinction between causes and mechanisms of death, recommendations to improve certificationMedical trainees (family/ internal/ critical care medicine, anaesthesiology, general surgery)Scoring of death certificates filled out using the same case scenario before and at the end of workshopSignificant reduction in the proportion of certificates with errors
A pilot programme to improve causes of death certification in primary care of Catalonia, Spain32Before and after evaluation2006†, Spain90 minTheoretical and practical seminar including regulations and criteria on how to certify causes of deathPrimary care physicians: 96 general practitioners, 33 family and community medicine specialists, 15 paediatriciansScoring of death certificates filled out using the same 3 case scenarios before and at the end of seminarSignificant reduction in the proportion of certificates with errors, especially in immediate cause, intermediate cause, underlying cause, other processes and use of all information and errors such as cardiopulmonary arrest, abbreviations, making up causes and use of lower case letters
Learning and satisfaction in the workshops of pre- and postgraduate medicine for the improvement of the accuracy of certifications of causes of death 1992–199633Before and after evaluation1992–1996*, Spain2 hWorkshops of theoretical and practical components on usefulness of mortality statistics and the International WHO norms of certificationMedical students, interns, doctorsScoring of death certificates filled out before and after intervention
  • Good initial qualifications were improved after the intervention

  • Statistically significant improvements in the groups of indicators of concept and result of certification

A good death certificate: improved performance by simple educational measures34Before and after evaluation2004*, UKFeedback on audit findings collectively in a clinical meeting and individually. The topic was highlighted during the induction of new doctors. Those unable to attend were sent paper copies of the feedbackSenior house officers (SHOs), staff grades, specialist registrars, consultants. New SHOs during re-auditAudit of actual death certificates filled out over a 4 month period before and those filled out over a 3 month period after interventionSignificant reduction in the proportion of certificates not meeting legal criteria as well as that of certificates with mistakes and omissions
Evaluation of seminars on international criteria for medical certification of cause of death35Before and after evaluation1996†, SpainTwo sessions of 45 minTheoretical seminar: detailed explanation of death certificates and WHO's international criteria for certification of causes of death44 doctorsAudit of actual death certificates filled out over a 6 month period before and those filled out over a 6 month period after intervention
  • Significantly improved legibility

  • Significantly less confusion on the mechanism of death

  • ‘Clinical sequence’ and ‘more than 1 diagnosis per line’ did not vary significantly

  • Significant improvement in overall certification

Efficacy of an informative seminar in the certification of causes of death36Before and after evaluation1993*, Spain60 minTheoretical seminar: importance of mortality statistics and the role of a doctor in improving the quality of statistics; WHO's international criteria and procedure for certification of the causes of death6th year medical studentsScoring of death certificates filled out using 6 case scenarios before intervention and 6 other case scenarios after interventionSignificant improvement in the majority of indicators on quality of death certification (underlying cause of death, logical sequence, multiple cause of death, use of abbreviations and lower case letters)
The efficacy of an information seminar on certification of the causes of death37Before and after evaluation1985*, SpainTheoretical seminar: usefulness of mortality statistics and death certification according to WHO's international criteria for certification of causes of deathPhysicians (60% are general practitioners)Scoring of death certificates filled out before and after intervention
  • Significant improvement in the median score from mock death certification

  • Improvement in the quality of all variables analysed

  • Notable increase in the percentage of logical sequences (77% to 91%)

  • Increase in correctly given main cause (53% to 66%)

Alcohol and death certification: influencing current practice and attitudes38Non-randomised controlled trial1989†, UKA letter to the intervention group at the start of their posting, informing them of changes to the coroner's rules and the importance of recording alcohol abuse in case notes and death certificates. No informatory letter in the control groupTwo cohorts of pre-registration housemen: an earlier group (control) and the following group (intervention)Review of case notes and death certificates filled out over a 3 month period by each cohort for appropriate reference to alcoholIn the intervention group (compared to control group),
  • Significant improvement in recording details in the alcohol history

  • More knowledge of the coroners' rules

  • Less proportion of housemen expressed reluctance to record alcohol related information

Self-administered questionnaire survey on knowledge and attitude of recording alcohol abuse
An evaluation of an educational intervention to improve death certification practice39Before and after evaluation1991*, AustraliaReading the educational material which highlights common misconceptions in death certificate completionResident staffAudit of actual death certificates (filled out over a 1 month period each) before and after intervention
  • Fewer major certification errors (no statistical significance)

  • Increased % of correct responses to the questionnaire items

Pre- and post-intervention questionnaire survey
Randomised comparison of death certification with and without guidelines40Randomised controlled trial2000†, FranceProviding guidelines in addition to examples on death certificates to intervention groupTwo groups each of general practitioners and specialistsScoring of death certificates filled out using 10 case scenarios by each groupNo notable differences in the quality of the certification, although intervention group had slightly better results for the majority of the criteria considered
Death certification: production and evaluation of a training video41Randomised controlled trial1995*, UK15 minA video (in addition to the usual lecture on death certification) for intervention group;First year medical students assigned to one of two groups using random numbersA test of knowledge and skills in completing death certificates using case scenarios (under examination conditions) in both groups 1 week after the intervention.
  • The intervention group performed slightly better than the control group (only about 5% better overall score)

  • Highly effective in conveying the message ‘distress to relatives is an important consequence of inaccurate death certification’

Usual lecture only for control group
  • * Year(s) the evaluation conducted or covered.

  • Year the article published.