ArticlePopulation health metrics2024
Beyond the underlying cause of death: an algorithm to study multi-morbidity at death.
Article in Population health metrics, 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 8 papers.
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Who cites it
8 citing papers in PubMed.
- Mortality Dynamics in Low-Mortality Countries: An Introduction to the Special Issue.European journal of population = Revue europeenne de demographie · 2026Article
- Nationwide estimates of all-cause and cause-specific mortality among individuals with gender dysphoria in Sweden, 2001-2023: a register-based cohort study.EClinicalMedicine · 2026Article
- Decline and Resurgence of Cardiovascular-Kidney-Metabolic Syndrome-Related Deaths Involving Malnutrition in the United States, 1999 to 2023.Journal of the American Heart Association · 2026Article
- Heterogeneity in proportional cardiovascular co-listing on cancer death certificates in the United States: a national multiple cause-of-death analysis, 1999-2020.Cardio-oncology (London, England) · 2026Article
- Mortality in a cohort of transport for London workers.Scientific reports · 2026Article
- Multi-Morbidity at Death and the US Disadvantage in Mortality.European journal of population = Revue europeenne de demographie · 2025Article
- Are contributory causes of death in part 2 of the death certificate mediators of chains of morbid events leading to death?Population health metrics · 2025Article
- Validity of the Leading Causes of Death Classification for Premature Mortality in Inflammatory Bowel Disease: A Population-Based Comparison with ICD-10 Coding in Ontario, Canada.Clinical epidemiology · 2025Article
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Authors and funding
8 authors.
Funding
Abstract
backgroundIn countries with high life expectancy, a growing share of the population is living with several diseases, a situation referred to as multi-morbidity. In addition to health data, cause-of-death data, based on the information reported on death certificates, can help monitor and characterize this situation. This requires going beyond the underlying cause of death and accounting for all causes on the death certificates which may have played various roles in the morbid process, depending on how they relate to each other.
methodsApart from the underlying cause, the cause-of death data available in vital registration systems do not differentiate all other causes. We developed an algorithm based on the WHO rules that assigns a "role" to each entry on the death certificate. We distinguish between the following roles: originating (o), when the condition has initiated a sequence of events leading directly to death; precipitating (p), when it was caused by an originating condition or one of its consequences; associated (a), when it contributed to death but was not part of the direct sequence leading to death; ill-defined (i), i.e., conditions such as symptoms or signs or poorly informative causes. We applied this algorithm to all death records in four countries (Italy, France, Spain and the US) in 2017.
resultsThe average number of originating causes is similar in the four countries. The proportion of death certificates with more than one originating cause-a situation typical of multi-morbidity-ranges from 10% in the US to 18% in Spain. All ages combined, the proportion of deaths with at least one associated cause is higher in Italy (41%) and in the US (42%) than in France (29%) and in Spain (27%). It is especially high in the US at all adult ages. Variations in the average number of causes between the four countries are mainly due to precipitating and ill-defined causes.
conclusionsThe output of our algorithm sheds light on cross-country differences in the average number of causes on death certificates. It also opens the door for improvements in the methods used for multiple cause-of-death analysis.
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