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PLoS One. 2012;7(1):e30336. doi: 10.1371/journal.pone.0030336. Epub 2012 Jan 17.

Factors associated with physician agreement on verbal autopsy of over 11,500 injury deaths in India.

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Centre for Global Health Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada.

Erratum in

  • PLoS One. 2013;8(11). doi:10.1371/annotation/7e655300-7920-4c75-b999-b2e32bfc2e8c.



Worldwide, injuries account for 9.8% of all deaths. The majority of these deaths occur in low- and middle-income countries where vital registration systems are often inadequate. Verbal autopsy (VA) is a tool used to ascertain cause of death in such settings. Validation studies for VA using hospital diagnosed causes of death as comparisons have shown that injury deaths can be reliably diagnosed by VA. However, no study has assessed the factors that may affect physicians' abilities to code specific causes of injury death using VA.


This study used data from over 11,500 verbal autopsies of injury deaths from the Million Death Study (MDS) in which 6.3 million people in India were monitored from 2001-2003 for vital events. Deaths that occurred in the MDS were coded by two independent physicians. This study focused on whether physician agreement on the classification of injury deaths was affected by characteristics of the deceased and respondent. Agreement was analyzed using three primary methods: 1) kappa statistic; 2) sensitivity and specificity analysis using the final VA diagnosed category of injury death as gold standard; and 3) multivariate logistic regression using a conceptual hierarchical model. The overall agreement for all injury deaths was 77.9% with a kappa of 0.74 (99% CI 0.74-0.75). Deaths in the injury categories of "transport", "falls", "drowning" and "other unintentional injury" occurring outside the home were associated with greater physician agreement than those occurring at home. In contrast, self-inflicted injury deaths that occurred outside the home were associated with lower physician agreement.


With few exceptions, most characteristics of the deceased and the respondent did not influence physician agreement on the classification of injury deaths. Physician training and continued adaptation of the VA tool should focus on the reasons these factors influenced physician agreement.

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