In Reply Our study used death certificate data to describe geographic variation among counties in levels and trends of mortality due to alcohol use disorders, drug use disorders, self-harm, and interpersonal violence. Drs Rockett and Connery identify cause-of-death misclassification as a potential limitation of these data and note that the degree and effect of misclassification may vary by cause, location, and time period. We agree that more research is warranted exploring differences in the quality of death certificate data within the United States and the potential effect of these differences on patterns of cause-specific mortality. Many of the variables they suggest exploring—the nature of the medicolegal death investigation system, autopsy rates, caseloads, etc—do not, to our knowledge, exist at the county level in a form that can be readily analyzed. Constructing these data sets will be an important precursor to further analysis of the potential effect of these factors on patterns of cause-specific mortality at the county level.
Dwyer-Lindgren L, Naghavi M, Murray CJL. Variation in Deaths From Intentional Injury and Substance Use—Reply. JAMA. 2018;320(6):601–602. doi:10.1001/jama.2018.7339
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