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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)