Under-recording of ethanol intoxication and poisoning in cause-of-death data: causes and consequences

In the present study we examined how consistently and completely the role of acute alcohol (ethanol) intake as a cause of death is reported on death certificates, how complete and specific the statistical recording of cause-of-death data on acute alcohol-induced deaths is, and how the information ultimately appears in the national mortality statistics. Data on all alcohol-positive deaths with blood alcohol concentration of ≥ 0.5‰ (g/kg) in Finland in 2005 (N = 2348) were reviewed. Overall, a concentration-dependent association was found between forensic-toxicologically determined blood alcohol concentrations and acute alcohol-specific cause-of-death diagnoses. Based on a medico-legal re-evaluation of death certificates, acute alcohol-specific causes were found to be underreported nationally at a rate of 8%. For accidental alcohol poisonings alone, the figure was about 1%. This underreporting was not corrected during recording of the cause-of-death data, though individual corrections and changes were observed. Especially, recording of multiple causes suffers from this underreporting of acute alcohol-specific causes. ICD-10 seems to do well in fulfilling the demands for a specific classification of uncomplicated alcohol poisoning. In combined alcohol-drug poisonings, however, ICD-10 shows a bias towards drugs over alcohol, even when alcohol has been specified and reported as the most toxic component by the medico-legal pathologist. Since the national statistics is based on the underlying causes, this state of affairs is likely to result in the underestimation of the role of acute alcohol intake as a cause of death. This observation of underreporting of acute alcohol-specific causes on death certificates should result in a harmonisation of education and principles and practices used in death certification. To increase the coverage and specificity of mortality statistics, based on the underlying causes of death, the coding of all components of alcohol-drug combinations and their classification according to the most important intoxicant or combination of intoxicants is recommended.     

Desorption atmospheric pressure photoionization-mass spectrometry in routine analysis of confiscated drugs

A comprehensive study was made, where desorption atmospheric pressure photoionization (DAPPI) was applied to the direct analysis of confiscated drugs and pharmaceuticals of various forms and matrices. The analyzed samples included herbal products [Catha edulis (khat), Psilocybe mushrooms, opium and Spice], designer drugs in tablet and powder form [e.g. meta-chlorophenylpiperazine (mCPP), 3-fluoromethamphetamine (3-FMA), methylenedioxypyrovalerone (MDPV) and methylone], and anabolic steroids in oil and tablets. The analyses were performed with ion trap mass spectrometer in MS and MS(2) modes and the obtained spectra were compared with GC-MS results. Contamination of the mass spectrometer was avoided by careful adjustment of the distance of the sample from the mass spectrometer inlet. DAPPI proved to be a fast and specific analysis technique, which does not require any sample preparation, and which therefore suits well to this type of forensic analysis.     

Cause-of-death query in validation of death certification by expert panel; effects on mortality statistics in Finland, 1995

The correctness of selection, coding and registration of underlying cause-of-death is important for the quality of mortality statistics. One measure to improve quality is the query to the certifier for verification of the underlying cause-of-death. In Finland, 3478 death certificates, 7.1% of total 49074 certifications in 1995, were considered questionable by statisticians. The expert panel at Statistics Finland was able to resolve 2813 (80.9%) of them. However, 665 (19.1%) certificates needed to be further queried from the certifier. Of these, 318 (47.8%) were re-assigned to another ICD-9 category or to the applicable three-digit category within the main category of heart and vascular diseases, resulting in changes from a 17.00-fold increase in rheumatic heart diseases (ICD-9 codes 390-398) to a decrease of about one-half (0.45-fold change) in unspecified neoplasms (codes 235-239). However, a statistically significant impact on national mortality statistics was not observed in any of applied ICD categories. Among all questionable death certificates, most prone to query of the certifier, and with a statistical significance of P<0.05, were those with no cause-of-death specified, those stating underlying cause-of-death as non-specified neoplasms (with a observed/expected ratio, O/E, of 1.69), and heart and vascular diseases (1.45), with its subcategories of ischaemic heart diseases (1.33) and other heart diseases (2.92). Death certificate validation, by expert panel consultations and query to the certifiers, and the importance of estimation of the validity of cause-of-death information on death certificates are strongly pointed out in a continuous strive for correct and reliable mortality statistics.     

Fatal alcohol poisoning: medico-legal practices and mortality statistics

Compilation of mortality statistics from death certificate data is based on international and national conventions which in certain situations result in the underlying cause-of-death other than that established and reported by the physician. The present study compares all fatal alcohol poisonings in 1997 as registered on forensic toxicological grounds at the accredited central laboratory and as presented in the national cause-of-death statistics, according to the underlying cause-of-death, by applying international statistical rules and principles in ICD-10. Four groups were formed, and case frequencies in each group were obtained from forensic toxicological data, group "T51" for acute poisonings due to alcohol alone, and group "Comb" for acute alcohol poisonings combined with some drug, medicament or other biological substance, and from cause-of-death statistics data, group "X45", for deaths from alcohol poisoning, and group "F102" for those medico-legal fatal alcohol poisoning deaths which at the statistics office were inferred to be due to alcoholism. The study shows that in Finland the officially compiled statistics on fatal alcohol poisonings, when compared with medico-legal statements based on forensic toxicological examinations, were underrepresented by 31.4% in 1997. About two-thirds of this underrepresentation is explained by preferring, as the underlying cause-of-death, alcoholism to acute alcohol poisoning, and about one-third by preferring, in cases of acute combined poisonings, the drug component to the alcohol. From 1998 onwards, more emphasis has been put on the alcohol component when coding medico-legally proven accidental deaths from simultaneous poisoning with alcohol and a medicinal agent. This change in coding practices presumably explains the subsequent decline in the annual underrepresentation rate of alcohol poisoning in mortality statistics to the level of 15-16%. It is concluded that the present ICD rules inevitably lead to underrepresentation of alcohol poisonings in the mortality statistics, and conceptual and practical proposals for future procedures are made.     

Sentences and prosecutors’ demands for aggravated drunk driving in Finland

ABSTRACT

Sentences and prosecutors’ demands for aggravated drunk driving are categorised into three classes: The sentence is more lenient than, is compatible with, or is harsher than the prosecutor’s demand. The probability of a sentence falling into one of the three ordered categories is explained by a cumulative logit model. The following circumstances affect the probability of a more lenient or harsher sentence, in decreasing order of importance: driving a truck, facing at least four counts, having a legal assistant, and being present in the trial. The hypothesis that factors known by the prosecutor, at the time of writing the demand, should not systematically affect sentences is refuted. The judges assess circumstances differently than the prosecutors. The prosecutors’ role is nevertheless prominent in the sense that the sentences follow, to a great extent, their demands. Notable gender effects of the actors in the courtroom are found.     

Why Do the Finns Trust the Police?

Ideological trends in the criminal policy of the Nordic countries since the 1960s are analysed. Although criminal policy in these countries is not unified, one can argue for the existence of a 'Scandinavian criminal policy' characterized by several common features concerning historical tradition, intensive cooperation and a similar approach to crime prevention and control. The following trends and characteristics are examined in some detail: the cycle from criticism of the treatment ideology to a reappraisal of the role of the criminal justice system and the function of penal sanctions; the differentiation of criminal policy strategies (e.g. social and situational crime prevention, cost-benefit thinking, criminal law policy, sanctions policy). Discernible tendencies towards more unified or, at least, more harmonized criminal policies on the international and European level are also examined. Active participation in this developmental process is encouraged to ensure that the fundamental principles of Scandinavian criminal policy are properly utilized.     

The validity of death certificates: routine validation of death certification and its effects on mortality statistics

The 3478 death certificates (7.1% of all annual death certificates) of this study comprise those national death certificates in 1995 submitted for validation to the panel representing both medical and nosological expertise. As such, it is highly selected and represents, from the nosological point of view, the most inconsistently filled-in portion of Finnish death certificates. The routine validation procedure is essentially based on exploitation of the extra medical information, i.e. the case history, on the Finnish death certificate form. Altogether, 2813 (80.9%) out of 3478 certificates could be adjusted at the primary panel session; the rest required further clarification. The re-assignment of cause of death by the panel and the impact of panel adjustments on the national mortality statistics is assessed here by comparing the initial death certification and the finally registered underlying cause of death grouped into ICD-9 major categories with special reference to the subcategories of neoplasm, cardiovascular disease (HVD) and unnatural death. A statistically significant decline (p<0.0001) in deaths, both in the category of symptoms, signs and ill-defined conditions and in the pulmonary circulation disease subcategory of HVD with 37.6 and 35.1%, respectively, was observed. The decrease of 11.1% in the benign or NUD neoplasm subcategory and the increase of 8.6 and 7.0% in the categories of endocrine disease, and musculo-skeletal and connective tissue disease, respectively, are essential observations as to the quality of the cause of death register. The effect on the HVD major category was practically nil. At the HVD-subcategorial level, a decrease of 14.0% for diseases of the veins and lymphatics and other circulatory diseases and an increase of 3.5% for hypertensive diseases (HYP) were the two next most obvious alterations to the diseases of the pulmonary circulation, but were without statistical significance. For ischaemic heart disease and other subcategories, the effects were minor. The unnatural deaths as a whole increased in the final statistics with only 0.9%. In the study data, categorial changes ranged from the decrease of 75.2% for symptoms, signs and ill-defined conditions to the increase of 77.3% for endocrine diseases. In conclusion, the Finnish death certificate form, death certification practices and cause of death validation procedure seem to serve the coding of causes of death for mortality statistics appropriately. The results of the study form a relevant reference background to evaluation of epidemiological studies on mortality.     

Fatal drug poisonings: medico-legal reports and mortality statistics

The entire fatal drug poisoning panorama in Finland is considered in terms of three catergories: accidental, self-inflicted and undetermined (whether accidental or with intent to harm) deaths. The study material consisted of all 500 deaths in 1997 that medical examiners, after examination(s) at the Forensic Toxicology Division (FTD) of the Department of Forensic Medicine, University of Helsinki, officially certified as resulting from drug poisoning. These deaths were matched with data on the same deaths registered at Statistics Finland (SF), the national mortality statistics office. The SF register included 72 additional instances of deaths resulting from drug poisoning. In all but two of these cases, the cause-of-death determination was based on a medico-legal inquest with autopsy and forensic toxicological examination(s) and was certified, in most of the cases, as due to the alcohol component in multiple-toxicant combinations. Reclassifying these deaths at SF to the category of drug component is in accordance with current International Classification of Diseases (ICD-10) regulation of coding "to the medicinal agent when combined with alcohol"; the principle and practice, which is recommended to be amended to equalize the status of alcohol and drug when explicitly stated by a forensic examiner as the principal toxicant in combined poisonings. With regard to manner-of-death, the agreement rates between medico-legally proven deaths from drug poisoning and those registered at SF were 79.8% for accidents, 98.5% for suicides and 0% (nil) for undetermined deaths, at the level of three-character external cause codes (E-code). All deaths originally certified as undetermined were re-assigned, most frequently to the category of accidental death. Since within an advanced and sophisticated medico-legal system, a medical examiner's evidence-based statement, even when the conclusion reached is undetermined (as to intent), should be taken as a compelling argument, the practice of reclassification cannot be considered advisable because assembled information is lost. Concerning the assigned drug-specific groups, the agreement according to the manner-of-death between certifications and registrations was fairly good. From among the accidents, however, opioid poisonings were re-assigned in 11 (29.7%) cases, mostly to the drug abuse/dependence categories, i.e. they were considered as natural deaths by the statistics office. The drug-specific observations were possible only by using the codes from the Anatomical Therapeutic Chemical (ATC) classification of drugs. This is why the incorporation of ATC codes into the ICD system, whenever reasonable, is recommended.