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Table 3 Summary of findings

From: Effectiveness of training interventions to improve quality of medical certification of cause of death: systematic review and meta-analysis

Impact of Medical Certification of Cause of Death (MCCOD) training interventions in improving the quality of MCCOD

Patient or population: Physicians or prospective physicians

Setting: Global

Intervention: Generic academic training in training curricula

Comparison: Pre-intervention parameters of MCCOD quality

Outcomes

Anticipated absolute effects* (95% CI)

Risk difference (95% CI)

№ of certificates assessed (studies)

Certainty of the evidence (GRADE)

Comments regarding similar studies that did not meet the meta-analysis inclusion criteria

Risk with pre-intervention

Risk with post-intervention

No time interval

832 per 1000

275 per 1000 (250 to 300)

0.33 (0.30 to 0.36)

3596 (3 observational studies)

Moderatea

In one study in Canada, 83 and 146 death certificates were assessed with 69.2% and 75.9% error percentages. In one Indian study, the related percentages were 29.2% and 27.5%. In another two Indian studies with just 75 and 80 death certificate assessments, the percentages were 100% versus 22.6%, and 85% versus 0.0%, respectively

Presence of abbreviations

328 per 1000

53 per 1000 (43 to 59)

0.16 (0.13 to 0.18)

3596 (3 observational studies)

Moderatea

In the above Canadian study, the error percentages were 19.9% and 18.1%. In the three Indian studies, the related percentages were 21.9.% versus 33.3%; 86.3% versus 29.3%; and 22.5% versus 0.0%, respectively

Improper sequence

349 per 1000

63 per 1000 (52 to 70)

0.18 (0.15 to 0.20)

4335 (3 observational studies)

Moderatea

In the above Canadian study, the error percentages were 15.8% and 6%. In the three Indian studies, the related percentages were 25% versus 59%; 89.3% versus 36%; and 60% versus 3.75%, respectively

Multiple causes

265 per 1000

40 per 1000 (34 to 45)

0.15 (0.13 to 0.17)

4204 (3 observational studies)

Moderate a

In one study in Papua New Guinea, the respective percentages were 16.3% and 7.9%

Ill-defined underlying cause of death

363 per 1000

55 per 1000 (44 to 62)

0.15 (0.12 to 0.17)

4455 (3 observational studies)

Lowa,b

In one Sri Lankan study, ill-defined underlying cause of death was observed to be higher post-intervention (10.6% versus 4.4%)

  1. GRADE Working Group grades of evidence. High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
  2. CI Confidence interval
  3. aDue to being non-randomised studies and since in some studies, pre- and as post-analyses were not done immediately close to the intervention; the bias due to confounding was marked as ‘serious’
  4. bFunnel plot not fully symmetrical in one study that underwent meta-analysis
  5. *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)