Concordance between COVID-19 mortality statistics derived from clinical audit and death certificates in euroOstergoeurotland county, Sweden

Objectives: Despite early notions that correct attribution of deaths caused by SARS-CoV-2 infection is critical to the understanding of the COVID-19 pandemic, three years later, the accuracy of COVID-19 death counts is still contested. We aimed to compare official death statistics with cause-of-death as-sessments made in a clinical audit routine by experienced physicians having access to the full medical record.Study design: Health service quality evaluation.Methods: In Oeurostergoeurotland county (pop. 465,000), Sweden, a clinical audit team assessed from the start of the pandemic the cause of death in individuals having deceased after testing positive for SARS-CoV-2. We estimated the concordance between official data on COVID-19 deaths and data from the clinical audit using correlations (r) between the cause-of-death categories and discrepancies between the absolute numbers of categorised deaths. Results: The concordance between the data sources was poor regarding whether COVID-19 was the underlying or a contributing cause of death. Grouping of the causes increased the correlations to acceptable strength. Also including deaths implicated by a positive SARS-CoV-2 test in the clinical cat-egorisation of COVID-19 deaths reduced the difference in absolute number of deaths; with these mod-ifications, the concordance was acceptable before the COVID-19 vaccination program was initiated (r = 0.97; symmetric mean absolute percentage error (SMAPE) = 19%), while a difference in the absolute numbers of deaths remained in the vaccination period (r = 0.94; SMAPE = 35%).Conclusions: This study highlights that carefulness is warranted when COVID-19 death statistics are used in health service planning and resonates a need for further research on cause-of-death recording methodologies.& COPY; 2023 The Author(s). Published by Elsevier Ltd on behalf of The Royal Society for Public Health. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Automated summary

Despite the importance of accurate attribution of deaths caused by SARS-CoV-2 infection, the accuracy of COVID-19 death counts is still contested. This study compares official death statistics with cause-of-death assessments made by experienced physicians, highlighting the need for carefulness when using COVID-19 death statistics.