Table 2

Characteristics of evaluation studies on educational interventions to improve death certification

Title	Type of study	Year & location	Training duration	Intervention	Participants	Evaluation method	Summary of results
Improving death certificate completion: A Trial of Two Training Interventions28	Randomised controlled trial and before and after evaluation of 2 training interventions	2006†, US	45 min workshop	Group 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 program	Scoring 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
		2006†, US	45 min workshop	Group II: printed instruction material as a handout that outlined the guidelines.
Improving the accuracy of death certification29	Before and after evaluation	1996 * (three seminars over 6 months), Canada	75 min	Seminar 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 certificates	Internal medicine residents	Audit 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 die30	Before and after evaluation	2007†, Canada	Half-day	Workshop on death counts video, Coroners Act tutorial, death certification process review, small group discussion on case scenarios, mock death certification and presentation	Community (family) physicians	Scoring 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
	Before and after evaluation	2007†, Canada	Half-day		Community (family) physicians	Pre- and post- intervention questionnaire survey
Evaluating an educational intervention to improve the accuracy of death certification among trainees from various specialties31	Before and after evaluation	2007†, Spain (Over an 18 month period)	90 min	Interactive workshops on current legislation on and most common errors in death certification, distinction between causes and mechanisms of death, recommendations to improve certification	Medical 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 workshop	Significant reduction in the proportion of certificates with errors
A pilot programme to improve causes of death certification in primary care of Catalonia, Spain32	Before and after evaluation	2006†, Spain	90 min	Theoretical and practical seminar including regulations and criteria on how to certify causes of death	Primary care physicians: 96 general practitioners, 33 family and community medicine specialists, 15 paediatricians	Scoring of death certificates filled out using the same 3 case scenarios before and at the end of seminar	Significant 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 1992–199633	Before and after evaluation	1992–1996*, Spain	2 h	Workshops of theoretical and practical components on usefulness of mortality statistics and the International WHO norms of certification	Medical students, interns, doctors	Scoring 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 measures34	Before and after evaluation	2004*, UK		Feedback 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 feedback	Senior house officers (SHOs), staff grades, specialist registrars, consultants. New SHOs during re-audit	Audit of actual death certificates filled out over a 4 month period before and those filled out over a 3 month period after intervention	Significant 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 death35	Before and after evaluation	1996†, Spain	Two sessions of 45 min	Theoretical seminar: detailed explanation of death certificates and WHO's international criteria for certification of causes of death	44 doctors	Audit 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 death36	Before and after evaluation	1993*, Spain	60 min	Theoretical 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 death	6th year medical students	Scoring of death certificates filled out using 6 case scenarios before intervention and 6 other case scenarios after intervention	Significant 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 death37	Before and after evaluation	1985*, Spain		Theoretical seminar: usefulness of mortality statistics and death certification according to WHO's international criteria for certification of causes of death	Physicians (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 attitudes38	Non-randomised controlled trial	1989†, UK		A 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 group	Two 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 alcohol	In 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
	Non-randomised controlled trial	1989†, UK				Self-administered questionnaire survey on knowledge and attitude of recording alcohol abuse
An evaluation of an educational intervention to improve death certification practice39	Before and after evaluation	1991*, Australia		Reading the educational material which highlights common misconceptions in death certificate completion	Resident staff	Audit 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
	Before and after evaluation	1991*, Australia			Resident staff	Pre- and post-intervention questionnaire survey
Randomised comparison of death certification with and without guidelines40	Randomised controlled trial	2000†, France		Providing guidelines in addition to examples on death certificates to intervention group	Two groups each of general practitioners and specialists	Scoring of death certificates filled out using 10 case scenarios by each group	No 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 video41	Randomised controlled trial	1995*, UK	15 min	A 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 numbers	A 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’
	Randomised controlled trial	1995*, UK	15 min	Usual lecture only for control group

↵* Year(s) the evaluation conducted or covered.
↵† Year the article published.