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Why Ontario's sluggish death reporting system frustrates public health experts

Reporting deaths more quickly could help save lives in a crisis, experts say
Chenier funeral
Pallbearers load Jason Chenier's body into a hearse following the fallen Vale miner's funeral June 13. Photo by Marg Seregelyi.

Ontario publishes statistics about death more slowly than nearly any other province, and much more slowly than other peer countries. 

That frustrates public health experts, who say that Ontario's sluggish processes miss the chance to spot emerging public health issues quickly, something the University of Toronto's Colin Furness calls "an absolutely gigantic mistake."

Many other jurisdictions are much faster. 

American mortality data, for example, is very current because of the way U.S. doctors get paid, Furness says. 

"Despite the fact that the U.S. is far more decentralized than we are and way bigger, they should have a way more massive problem counting deaths, but in fact they do a really remarkable job. When I've been looking at the impact of COVID, I almost always just use U.S. data."

On Nov. 9, officials in Scotland published mortality data for the week ending on Nov. 5, broken down by cause. England and Wales have a similar turnaround time.

And some Canadian jurisdictions are very prompt: British Columbia publishes death totals by region at the end of each month, for example.

"It's certainly something that if other provinces have been able to do, then it's something that the Ontario government should be able to do as well," says the University of Toronto's Tara Moriarty. 

Both Furness and Moriarty say they would rather be able to be able to work with newer mortality data, even if it has a few flaws and gaps, than more perfect data years after the actual event. 

"Get the data out quickly and occasionally redo something," Furness says. "You can always be transparent and say 'This may be missing x, y, or z,' but do it in a timely way."

In national weekly death statistics, Ontario's most recent numbers are from the week of June 17, making it the third-slowest province after Manitoba and Nova Scotia. 

"Ontario relies on health care professionals and funeral homes to collect accurate death information," wrote Ministry of Public and Business Service Delivery spokesperson Joey Wu. "Ontario’s process also relies on municipalities to review the information before the death registration documents are sent to the province for registration."

The ministry oversees the Office of the Registrar-General. 

"The Vital Statistics Act requires that after the end of each calendar year, the Registrar General publish an Annual Report that includes the number of births, marriages, deaths, stillbirths, adoptions and changes of name registered during the calendar year preceding the one that has ended. Vital event datasets are considered incomplete until all events that occurred during a reporting year are properly registered, which must account for events that are submitted for registration up to 365 days after the event occurred."

Preliminary numbers are released sooner than this, she wrote. 

But up-to-date information about death is key to understanding — and responding to — many public health issues, experts say. 

During the early phase of the pandemic, in early-mid 2020, for example, there was alarm over "excess mortality": deaths seemed to have increased over normal levels by more than what the official COVID death toll could account for. 

The question of why was important, and there seemed to be several explanations: people reluctant to go to pandemic-struck hospitals may have delayed treatment for heart attacks until it was too late, for example, medical conditions may have been missed that might have been caught in less stressed conditions, or isolated people might have been felled by drugs or alcohol

Quantifying the problem is crucial to understanding it, of course, and in Ontario this turned out to be very hard to do. 

The province's chief coroner resorted to counting cremations — cremations in Ontario must be reported to the coroner, more or less in real time — and found that in March and April of 2020 there had been about 1,500 more cremations than could be accounted for through known COVID deaths. 

This was an improvised response to a crisis, but the problem with it was that it used cremation numbers as a proxy for all deaths without being able to know how the pandemic might have changed the ratio of burials to cremations. 

Moriarty calls having to take this approach "ridiculous."

"The actual numbers just need to be released. Otherwise, what happens is that you get the cremation data being used. 

"It's so indirect, and it's so silly. It's just such a waste of time, and also lives. There are lives that could be saved if we were willing to report data quickly and try to act on it."

Furness agrees. 

"It probably was fairly accurate — the problem is, we wouldn't know how accurate. The poorer you are, the more likely you are to get COVID because of occupational risk and crowded housing, and the poorer you are, the more likely you are to be cremated, because it's less expensive than burial. So the bias is tilted in the same direction. So it was probably pretty useful data.

"But still, it's a pretty poor cousin to actually knowing what the numbers are."

Furness and Moriarty both point to other public health issues, like the opioid crisis, which public health systems could respond to far better if they were armed with up-to-date information about deaths. 

"We can be potentially very agile in terms of responding to things in real time," Moriarty says. "There are lives that could be saved if we were willing to report data quickly and try to act on it."

"That seems like an easy win, to help people do something that can prevent serious outcomes, including death. That's not a win you leave on the table."

Across Ontario, 352 people died on Jan. 1, 2018. By the end of February of that year, only 60 per cent of those deaths had been registered; one was registered at the end of December, 361 days after it had actually happened.

"I am kind of surprised that no politicians have woken up to this, because it's an easy low-hanging fruit for (them) to find some area in which bureaucrats are performing poorly, and berate them for it publicly," Furness says. "That's how politicians get popular, or it's one of the ways, so it does really surprise me that there's been there's been no willingness to do it."

"There's an easy administrative fix here: you tell them they've got to do it faster."

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