Changes in COVID-19-related death certification practices and quality of cause-of-death reporting in the United States from 2020 to 2023

This study examined changes in COVID-19-related death certification practices (ie, reporting COVID-19 in Part I of the death certificate) and the quality of cause-of-death (COD) reporting (acceptable and rejected causal sequences) in the United States from 2020 to 2023. In 2020, 2021, 2022, and 2023, 385 293, 463 273, 246 196, and 76 024 death certificates, respectively, mentioned COVID-19. COVID-19 was selected as the underlying COD in 91%, 90%, 76%, and 65% of these certificates, corresponding to reporting COVID-19 in Part I in 93%, 91%, 78%, and 67% of certificates, respectively. Acceptable causal sequences were reported in 51%, 51%, 45%, and 41% of certificates, whereas rejected causal sequences were reported in 21%, 22%, 23%, and 23%, respectively. Using 2020 as the reference year, the adjusted odds ratios (95% confidence intervals) for 2023 were 0.18 (0.18, 0.18) for reporting COVID-19 in Part I, 0.77 (0.76, 0.78) for reporting acceptable causal sequences, and 1.14 (1.12, 1.16) for reporting rejected causal sequences. In conclusion, COVID-19-related death certification practices changed substantially over the study period, paralleling the decline in the virulence of SARS-CoV-2. The quality of COVID-19-related COD reporting declined modestly from 2020 to 2023.