HJAR Nov/Dec 2020

HEALTHCARE JOURNAL OF ARKANSAS I  NOV / DEC 2020 39 Joseph W. Thompson, MD, MPH President and Chief Executive Officer Arkansas Center for Health Improvement opioid-related deaths. Of individuals who died and did not have an obvious known cause like cancer, trauma or a known drug- related cause, 45 percent had a history of opioid use in the previous 12 months, and 22 percent had received high-dose opioid prescriptions (more than 50 morphine mil- ligram equivalents per day). However, while many of the deaths had causes that were questionable or unknown, none of the death certificates listed substance abuse as a po- tential contributing cause. The CDC is seeking to improve death re- porting. It has provided guidance to state and local governments on how to report COVID-19-related deaths and is working to improve the interoperability of state elec- tronic death registration systems. Oppor- tunities also exist for the Arkansas General Assembly and the federal government to act: establishing credential requirements for coroners, providing more funding to counties to ensure coroners have adequate training and resources, increasing COVID-19 testing capacity, prioritizing healthcare ac- cess for vulnerable populations and stan- dardizing death reporting across states and counties. The need for accurate, timely data on the reasonsAmericans are dying has nev- er been greater. n determined or is pending investigation. Accurate death reporting is extremely important in studying COVID-19. It allows the identification of conditions—such as dia- betes, obesity and chronic obstructive pul- monary disease—that cause those who have them to be at increased risk of dying if they contract COVID-19. Unfortunately, the death toll from this new disease has likely been underreported. Health experts believe that in February and March, before the disease reached epidemic levels in the United States, many COVID-19 deaths were mistakenly attributed to influenza or described only as pneumonia. Other issues that likely have contributed to underreporting include poli- cies and protocols that vary between states and counties; limited resources; inadequate healthcare access among low-income, mi- nority and immigrant populations; and, in states likeArkansas, coroners whomay have limited medical knowledge. Kaiser Health News reported in Septem- ber that a review of California Department of Health data found that about 125,000 Cali- fornians died from March through July, or about 14,200 more than the average deaths for those months in the previous three years. About 9,200 of those 125,000 deaths were reported as COVID-19 deaths, but that still left about 5,000 excess deaths—far more than could be accounted for by California’s population growth. Misconceptions about COVID-19 death reporting have been common. In August, the Centers for Disease Control and Preven- tion noted that in 6 percent of reported CO- VID-19 deaths, the disease was listed as the only cause of death. Some misunderstood this to mean that only 6 percent of reported COVID-19 deaths actually resulted fromCO- VID-19, when in fact COVID-19 was at least a contributing cause in all of the deaths. Very few deaths from natural causes have only one cause. Many of the same issues that likely have caused COVID-19 deaths to be underreport- ed also may have caused overdose deaths to be underreported during our nation’s ongoing opioid crisis. A 2018 study by the University of Pittsburgh found that many states were likely underreporting overdose deaths, because coroners and medical ex- aminers were failing to list the drug con- tributing to the cause of death on death certificates. The researchers estimated that this occurred in about 25 percent of drug overdoses in Arkansas. A 2019 Arkansas Center for Health Im- provement analysis of death certificates in Arkansas for people ages 12-50 demon- strated the potential for underreporting of “Many of the same issues that likely have caused COVID-19 deaths to be underreported also may havecausedoverdosedeathstobeunderreported during our nation’s ongoing opioid crisis.”