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Diabetes Reporting as a Cause of Death

Results from the Translating Research Into Action for Diabetes (TRIAD) study

¹ Departments of Internal Medicine and Epidemiology, University of Michigan, Ann Arbor, Michigan
² Departments of Internal Medicine and Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
³ Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
⁴ Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
⁵ Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
⁶ Department of Medicine, University of California, Los Angeles, California
⁷ Deep South Center on Effectiveness at the Birmingham Veterans Affairs Medical Center and the University of Alabama at Birmingham, Birmingham, Alabama
⁸ Indiana University School of Medicine, Indianapolis, Indiana
⁹ Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia

Address correspondence and reprint requests to William H. Herman, MD, MPH, Internal Medicine/Metabolism, Endocrinology, and Diabetes, 1500 East Medical Center Dr., 3920 Taubman Center, Ann Arbor, MI 48109-0354. E-mail: wherman{at}umich.edu

OBJECTIVE—To determine the frequency of reporting of diabetes on death certificates of decedents with known diabetes, define factors associated with reporting of diabetes, and describe trends in reporting over time.

RESEARCH DESIGN AND METHODS—Data were obtained from 11,927 participants with diabetes who were enrolled in the Translating Research Into Action for Diabetes study, a multicenter prospective observational study of diabetes care in managed care. Data on decedents (n = 540) were obtained from the National Death Index. The primary dependent variable was the presence of ICD-10 codes for diabetes on the death certificate. Covariates included age at death, sex, race/ethnicity, education, income, duration of diabetes, type of diabetes, diabetes treatment, smoking status, and number of comorbidities.

RESULTS—Diabetes was recorded on 39% of death certificates and as the underlying cause of death for 10% of decedents with diabetes. Diabetes was significantly less likely to be reported on the death certificates of decedents with diabetes dying of cancer. Predictors of recording diabetes anywhere on the death certificate included longer duration of diabetes and insulin treatment. Longer duration of diabetes, insulin treatment, and fewer comorbidities were associated with recording of diabetes as the underlying cause of death.

CONCLUSIONS—Diabetes is much more likely to be reported on the death certificates of diabetic individuals who die of cardiovascular causes. Reporting of diabetes on death certificates has been stable over time. Death certificates underestimate the prevalence of diabetes among decedents and present a biased picture of the causes of death among people with diabetes.

Abbreviations: NDI, National Death Index • TRIAD, Translating Research Into Action for Diabetes

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