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Published online December 4, 2007
Diabetes Care 31:508-510, 2008
DOI: 10.2337/dc07-1994
© 2008 by the American Diabetes Association
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Epidemiology/Health Services Research
Original Research

Are Primary Care Physicians More Likely to Record Diabetes on Death Certificates?

Laura N. McEwen, PHD1, Nathan E. Pomeroy, MD, MPH1, Kingsley Onyemere, MD1 and William H. Herman, MD, MPH1,2

1 Department of Internal Medicine/Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan
2 Department of Epidemiology, University of Michigan, Ann Arbor, Michigan

Address correspondence and reprint requests to Laura N. McEwen, PhD, UMHS TRIAD, P.O. Box 131337, Ann Arbor, MI 48113-1337 . E-mail: lmattei{at}med.umich.edu

Abbreviations: PCP, primary care physician • TRIAD, Translating Research Into Action for Diabetes


   INTRODUCTION
TOP
 INTRODUCTION
RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
 References
 
Diabetes is recorded on the death certificate of decedents with known diabetes only 38–48% of the time (1–9). Few studies have examined whether recording of diabetes on death certificates is associated with the antemortem relationship between the decedent and the certifying physician. One study of 292 diabetic decedents with histories of ischemic heart disease found that if the certifying physician was the personal physician, diabetes was recorded 48% of the time, versus 33% for another physician and 8% for a medical examiner (2). Another study found that for 104 patients with diabetes who died in the hospital, there was no relationship between the level of training of the certifying physician and the recording of diabetes (7). Our objective was to examine whether primary care physicians (PCPs) are more likely than other physicians to record diabetes on the death certificates of decedents with known diabetes.


   RESEARCH DESIGN AND METHODS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
RESULTS--
 CONCLUSIONS--
 References
 
The Translating Research Into Action for Diabetes (TRIAD) study has been described in detail elsewhere (10). This study was limited to the Michigan study site. Patients aged ≥18 years were sampled (n = 1,650). The institutional review board approved the study, and all participants provided informed consent.

A baseline survey was administered to TRIAD participants either by computer-assisted telephone interview or by mail, and medical records were reviewed. TRIAD decedents were identified from phone calls from friends and relatives of the decedent, returned mailings, and internet searches using the Social Security Index Web site (11). Deaths were verified by matching first and last name, social security number, date of birth, and sex of the decedent with death certificates obtained from the State of Michigan Vital Statistics Office.

Vital status was determined for participants as of February 2007. One dichotomous dependent variable, the presence of the word "diabetes" in either part I or part II of the death certificate, was investigated. The primary independent variable was whether or not the certifying physician was the decedent's PCP. This was defined by matching the first and last name of the certifying physician with the first and last name of the PCP as recorded by the health plan. Covariates obtained from either the survey or medical record review included age, sex, race, education, income, age at diabetes diagnosis, duration of diabetes, type of diabetes, diabetes treatment, smoking status, and Charlson comorbidity index (12).

Bivariate analyses were performed using t tests for continuous variables and {chi}2 tests for categorical variables. We constructed a multivariate model with all covariates and estimated adjusted conditional predicted probabilities for each variable. All analyses were performed using SAS version 9.1.3 (SAS Institute, Cary, NC).


   RESULTS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
CONCLUSIONS--
 References
 
Of 327 decedents, 123 (38%) had diabetes listed in either part I or part II of the death certificate. Table 1 shows the distribution of the characteristic of the entire population of decedents and those with diabetes listed and not listed on the death certificate. If the PCP was the certifying physician, diabetes was recorded 70% of the time versus 29% of the time if the certifying physician was not the PCP (P < 0.0001). Compared with those without diabetes recorded, those with diabetes recorded on the death certificate were younger (P = 0.06), were more likely to be male (P = 0.14), and had a longer duration of diabetes (P = 0.06). If a patient died as an inpatient (P = 0.14) or had an autopsy done (P = 0.70), he/she was less likely to have diabetes recorded on the death certificate.


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  		Table 1— Characteristics of participants who died between January 2000 and February 2007 (n = 327) stratified by whether diabetes was listed anywhere on the death certificate

 
In multivariable analyses, recording of diabetes was most strongly associated with the PCP as the certifying physician (70 [95% CI 68–72] vs. 30% [26–30], P < 0.0001). The conditional predicted probabilities of recording diabetes anywhere on the death certificate were younger age at death (aged 69 years at death 40% [37–44] vs. aged 79 years at death 31% [28–34], P = 0.07) and longer duration of diabetes (<5 years 21% [19–23] {referent}, 5–14 years 47% [44–50] {P = 0.01}, 15 years 37% [34–40] {P = 0.64}). No other covariates in the multivariable model were significant.

In subanalyses looking only at the characteristics of those decedents for whom the certifying physician was not the PCP, diabetes was not more likely to be listed on the death certificate if the patient died as an inpatient, died on a weekday between 8 A.M.–5 P.M., or had an autopsy.


   CONCLUSIONS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
References
 
Our results are consistent with previous studies showing that only 38–48% of decedents with diabetes have diabetes recorded anywhere on the death certificate (1–9). We found a very strong association between recording of diabetes on the death certificate and the certifying physician being the PCP after adjusting for all covariates. Our results confirm that younger age and longer duration of diabetes are associated with recording of diabetes on death certificates (1–3,13). Decedents having a postmortem examination and dying as an inpatient were less likely to have diabetes recorded on the death certificate, consistent with previous reports (6,14,15).

Our results extend the observation of Andresen et al. (2) to a larger, more representative population with diabetes and demonstrate a stronger association between PCPs as certifying physicians and the recording of diabetes on death certificates. Attribution of death to diabetes as the underlying cause, a contributing cause, or a significant condition contributing to death is often a subjective judgment on the part of the certifying physician. We hypothesize that non-PCP certifying physicians may not be as familiar with the decedent's medical history and that lack of awareness of diabetes as an underlying condition rather than lack of perception of diabetes as a step in the causal pathway leading to death may account for underreporting.


   Acknowledgments
 
This study was jointly funded by the Centers for Disease Control and Prevention (Division of Diabetes Translation) and the National Institute of Diabetes and Digestive and Kidney Diseases.


   Footnotes
 
Published ahead of print at http://care.diabetesjournals.org on 4 December 2007. DOI: 10.2337/dc07-1994.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C Section 1734 solely to indicate this fact.

Received for publication October 15, 2007. Accepted for publication November 21, 2007.


   References
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
 References
 

  1. McEwen LN, Kim C, Haan M, Ghosh D, Lantz PM, Mangione CM, Safford MM, Marrero D, Thompson TJ, Herman WH, the TRIAD Study Group: Diabetes reporting as a cause of death: results from the Translating Research Into Action for Diabetes (TRIAD) study. Diabetes Care 29:247–253, 2006[Abstract/Free Full Text]
  2. Andresen EM, Lee JA, Pecoraro RE, Koepsell TD, Hallstrom AP, Siscovick DS: Underreporting of diabetes on death certificates, King County, Washington. Am J Public Health 83:1021–1024, 1993[Abstract/Free Full Text]
  3. Bild DE, Stevenson JM: Frequency of recording of diabetes on U.S. death certificates: analysis of the 1986 National Mortality Survey. J Clin Epidemiol 45:275–281, 1992[Medline]
  4. Morgan CL, Currie CJ, Peters JR: Relationship between diabetes and mortality: a population study using record linkage. Diabetes Care 23:1103–1107, 2000[Abstract/Free Full Text]
  5. Tierney EF, Geiss LS, Engelgau MM, Thompson TJ, Schaubert D, Shireley LA, Vukelic PJ, McDonough SL: Population-based estimates of mortality associated with diabetes: use of a death certificate check box in North Dakota. Am J Public Health 91:84–92, 2001[Abstract]
  6. Will JC, Vinicor F, Stevenson J: Recording of diabetes on death certificates: has it improved? J Clin Epidemiol 54:239–244, 2001[Medline]
  7. Chen F, Florkowski CM, Dever M, Beaven DW: Death certification and New Zealand Health Information Service (NZHIS) statistics for diabetes mellitus: an under-recognised health problem. Diabetes Res Clin Pract 63:113–118, 2004[Medline]
  8. Thomason MJ, Biddulph JP, Cull CA, Holman RR: Reporting of diabetes on death certificates using data from the UK Prospective Study. Diabet Med 22:1031–1036, 2005[Medline]
  9. Centers for Disease Control: Sensitivity of death certificate data for monitoring diabetes mortality–Diabetic Eye Disease Follow-Up Study, 1985–1990. JAMA 266:2812, 1991[Medline]
  10. The TRIAD Study Group: The Translating Research Into Action for Diabetes (TRIAD) study: a multicenter study of diabetes in managed care. Diabetes Care 25:386–389, 2002[Free Full Text]
  11. RootsWeb: Social Security Death Index Interactive Search [online search engine]. Available from http://ssdi.rootsweb.com/cgi-bin/ssdi.cgi. Accessed 30 March 2007
  12. Charlson ME, Pompei P, Ales KL, MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383, 1987[Medline]
  13. Coppell K, McBride K, Williams S: Under-reporting of diabetes on death certificates among a population in Otago Province, New Zealand. N Z Med J 117:U1217, 2004[Medline]
  14. Fuller JH: Causes of death in diabetes mellitus. Horm Metab Res Suppl 15:3–9, 1985[Medline]
  15. Jarrett RJ, Colwell L: Pathologists not told about diabetes. Lancet 1:863–864, 1982[Medline]

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This Article
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