The impact of transition from paper to electronic death records on use of garbage codes in Norway

Abstract Background In 2018, electronic death certification was gradually introduced in the Norwegian Cause of Death Registry (NCoDR) and made mandatory from 2022. This may have affected the use and pattern of ill-defined death codes, so-called garbage codes, reported as the underlying cause of death. This study aimed to assess whether the transition to electronic certification changed the magnitude and pattern of garbage codes in NCoDR. Methods The analyses included all deaths with a registered underlying cause of death in the period 2018-2023 (n = 248 225). A garbage code was defined according to the definition used by the Global Burden of Disease study. Trends and patterns of garbage codes were assessed and its association with type of certificate (paper/electronic) estimated using a modified Poisson regression model adjusting for sex, age and place of death. Results In the complete study period, 22.6% of the deaths were registered with a garbage code as the underlying cause of death. The probability of garbage was 21% lower in electronic compared to paper certificates (adjusted relative risk 0.79, 95% CI 0.78-0.80). This difference was stable over time and led to an overall decrease in the proportion of garbage codes with increasing use of electronic certifications, mainly driven by more specific coding. The five most common garbage codes were I50 (Heart failure), J18 (Pneumonia, organism unspecified), I64 (Unspecified stroke), R96 (Other sudden death, cause unknown) and X59 (Accidental exposure to unspecified factor), accounting for more than one third of the garbage codes in the study period. Conclusions The transition from paper to electronic certification led to an improvement in cause of death registration through a reduction in the use of garbage codes, although garbage codes remain a considerable problem. An electronic system can provide guidance and feedback to the certifying physician, thereby providing opportunities for further improvement in data quality. Key messages • The shift from paper-based to electronic certification in the Norwegian Cause of Death registry enhanced data quality through a reduction in the use of garbage codes. • Electronic certification provides opportunities for further improvement in data quality.