A viral social media post (which has been removed by Twitter) has brought a lot of new attention to the issue of the underlying “cause of death” for COVID-associated deaths. We think this is an important issue as well and want to provide some corrections and context based on the data we have seen.
1) This data is not “new”: The CDC has published this information for several months at least, and what’s correct is that 6% of COVID deaths had zero comorbidities and listed COVID as the only cause of death.
2) It’s incorrect to say that because only 6% had no other contributing factors, the rest didn’t die of COVID. The other contributing factors range from minor to major, but that does not eliminate COVID. Declaring that the other 94% of deaths were not COVID deaths is a very misleading and erroneous analysis of the data.
3) “Comorbidities” are common for other causes of death as well, meaning it’s common that there are multiple contributing factors to deaths from other diseases. The reality is that health conditions classified as comorbidities contributing to mortality are common among many Americans, and downplaying the deaths with comorbidities as unrelated to COVID is not accurate. A lot of otherwise healthy folks have something that could be classified as a comorbidity.
4) There is a real issue with wide variance in how states count COVID deaths, as well as variability by countries. As an example, the UK had to revise the way they counted them because some people who had fully recovered from COVID but later died of something completely unrelated were being included in the counts.
5) Anyone deep diving into this issue should be aware of a practice called “Death Certificate Matching.” The practice is used by many different states and municipalities right now in assessing COVID death counts. Arizona and other states have been doing this and disclosing the practice. Hospitals get reimbursed by CMS (the U.S. Centers for Medicare & Medicaid Services) the same way that other insurers do–through Medical Billing Codes (ICD-10 Codes). The purpose of the codes is to provide a full picture of what the patient was treated for and any possible factors relating to the care they received at a hospital. This ensures the insurer is getting the full picture and is more likely to approve the claim. A person can have the COVID-19 code that merely indicates a positive test and be receiving care for something completely unrelated. Normally this would not be an issue, as it’s important to show the full clinical picture of a patient. However, this has inadvertently created an incentive for hospitals to count every possible COVID patient, regardless of whether it drove the primary treatment or not.
This is an important issue that raises ethical concerns about how to count deaths, especially when hospitals are struggling financially and need every penny they can get from CMS for COVID-related care to compensate for lost revenue due to government-enforced healthcare procedure delays/reductions. Death Certificate Matching is an important issue for bioethicists to address and hopefully come to a consensus on what is the best practice for counting deaths in a standardized way across the U.S.
6) The issue of properly accounting for the cost of lives due to any cause brings up a very important issue that needs to be discussed: the impacts of COVID policies on health and life that are not caused by COVID itself, but by secondary effects. Many people avoided life-saving critical care during the early “flatten the curve” movement, and some are still afraid to go to the hospital, either because they are worried about infection or because they cannot have family members with them. Sadly, we are seeing spikes in teen suicide, increased overdoses in an opioid epidemic that pre-dates COVID, increases in domestic abuse and violent crime, and also mysteriously-excess deaths in age groups that COVID does not account for. Some of these can be explained by the aforementioned reasons, but we don’t have a real-time data dashboard on those causes of death like we do with COVID. Imagine if we did! This highlights the importance of focusing on preserving life at all levels of society and trying to prevent as much death as possible from ALL causes, not just COVID. That is a balancing act that must be considered by policy makers and citizens alike.