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Kentucky and Death Certificates

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					Diabetes Reporting on Death
  Certificates in Kentucky,
          2002-2003
     Melonie Heron, Ph.D.
  & Robert N. Anderson, Ph.D.
       Mortality Statistics Branch
       Division of Vital Statistics
    Centers for Disease Control and Prevention
    National Center for Health Statistics
                  Outline

• Background: Death certificate layout and
 cause of death coding issues
• Diabetes reporting on death certificates
• Kentucky diabetes checkboxes
  • Pros and cons
  • Descriptive results and effects on
    diabetes reporting
• Alternative methodology
US Standard Death Certificate
US Standard Death Certificate
US Standard Death Certificate



 Acute renal failure
 Hyperosmolar nonketotic coma

 Diabetes mellitus, non insulin dependent
US Standard Death Certificate



 Acute renal failure
 Hyperosmolar nonketotic coma

 Diabetes mellitus, non insulin dependent
                  US Standard Death Certificate



                     Acute renal failure
                     Hyperosmolar nonketotic coma

                     Diabetes mellitus, non insulin dependent




Hypertension, Previous myocardial infarction
  Cause of Death Coding and Statistics

• All information reported in Parts I and II is
  coded (up to 20 conditions)
  • Conversely, cause of death information
    not recorded in Parts I or II does not get
    coded or entered into mortality database
• Underlying cause of death is selected
  from among the conditions reported
• Mortality statistics usually based on
  underlying cause of death
Issues in the reporting of diabetes on the
             death certificate

• Certifier may not know about a diagnosis
  of diabetes or its relation to other co-
  morbid conditions
• Causal sequence not always obvious in
  the presence of other co-morbid
  conditions
• Diabetes most often reported in Part II
Kentucky Death Certificate
      Diabetes Checkbox Questions

Implemented in July of 2002 in Kentucky
1. Did the deceased have Diabetes?
2. Was Diabetes an immediate, underlying,
   contributing cause of or condition leading
   to death?
         Upside of checkbox questions

•   1st question - Ability to identify diabetic
    decedents
•   2nd question indicates whether diabetes should
    have been reported in Part I or II
    • May help assess underreporting of diabetes
      in the cause of death section of the death
      certificate
•   Reminder to certifier to report diabetes
       Downside of checkbox questions

•   Could result in underreporting in cause of death
    (COD) section of the death certificate
•   Cause of death coding standards and rules
    • Causes not reported in COD section are not
      coded
    • Causes not coded do not make it into official
      statistics or data release
•   Loss of detail – no info about type of diabetes
Results: 12,320 KY death certificates with “yes” to
           at least one of the questions

 Q1: Did the Q2: Was diabetes an immediate,
 deceased underlying or contrib cause of death?
    have
 diabetes?      Yes         No        Unknown
    Yes        5789        6380         62
   (N=12,231)
                (47.3%)    (52.2%)      (0.5%)

   No (N=84)      84           0           0

  Unknown         5            0           0
     (N=5)
  Results: Responses in Checkbox 1 vs.
        Reported Cause of Death

               Q1: Did the deceased have       North
                       diabetes?           Dakota: Was
                                             deceased
                 Yes           No          diabetic? Yes
Percent with
diabetes
reported as
                  15             5              15
UCD
Percent with
any mention
of diabetes
                  34             6              43
as COD
  Results: Responses in Checkbox 2 vs.
        Reported Cause of Death

                   Q2: Was diabetes an immediate,
                   underlying or contributing cause of
                   death?
                         Yes                  No
Percent with
diabetes                  27                   3
reported as UCD
Percent with any
mention of                52                   17
diabetes as COD
       What does Checkbox 2 tell us?

• Diabetes is not reported in the cause of death
 section in about 40% of cases in which
 diabetes is identified as an immediate,
 underlying or contributing cause
• But…is this checkbox question an indicator or
 a cause of underreporting?
Do the Checkboxes Have an Effect
     on the Trend in Diabetes
            Reporting?
          Diabetes Deaths: US, 1990-2003
250,000


200,000


150,000


100,000


 50,000


     0
        90

        91

        92

        93

        94

        95

        96

        97

        98

        99

        00

        01

        02

        03
     19

     19

     19

     19

     19

     19

     19

     19

     19

     19

     20

     20

     20

     20
                 Any mention   Underlying cause
        Diabetes Deaths: Kentucky, 1990-2003
3,500

3,000

2,500

2,000

1,500

1,000

 500

   0
      90

      91

      92

      93

      94

      95

      96

      97

      98

      99

      00

      01

      02

      03
   19

   19

   19

   19

   19

   19

   19

   19

   19

   19

   20

   20

   20

   20
                 Any mention   Underlying cause
          Diabetes Deaths: US, 1990-2003
160,000

140,000

120,000

100,000

 80,000

 60,000

 40,000

 20,000

     0
        90

        91

        92

        93

        94

        95

        96

        97

        98

        99

        00

        01

        02

        03
     19

     19

     19

     19

     19

     19

     19

     19

     19

     19

     20

     20

     20

     20
                      Part I   Part II
        Diabetes Deaths: Kentucky, 1990-2003
2,000



1,500



1,000



 500



   0
      90

      91

      92

      93

      94

      95

      96

      97

      98

      99

      00

      01

      02

      03
   19

   19

   19

   19

   19

   19

   19

   19

   19

   19

   20

   20

   20

   20
                      Part I   Part II
                  Conclusions

• The diabetes checkboxes clearly have a
 marked effect on where (Part I or II) diabetes is
 reported
  • Increases in Part I and decreases in Part II
• Slight increase in diabetes as the underlying
 cause of death
• Decrease in overall reporting of diabetes
        Alternative Methodology

• Can use national health surveys linked to
 mortality data to:
  • Explore the extent to which diabetes is
    reported as a cause of death for those
    who self-reported diabetes.
  • Analyze the impact of diabetes on risk
    of mortality, generally and by cause of
    death
              NHIS-NDI Linked Data
•   National Health Interview Survey (NHIS)
    • National survey conducted annually by NCHS
      since 1957
    • Monitors the health of the U.S. population
•   National Death Index (NDI)
    • National file of death record information
      compiled by NCHS from state registries
    • Deaths added annually, 1979-present
    • Helps researchers determine the mortality
      status of study participants
                 Study Approach

•   Linked NHIS and NDI files for 1997 to 2000
    • Includes mortality follow up of NHIS
      participants until 2002
•   Restricted analyses to survey participants who
    were eligible for follow up and determined to be
    dead
•   Compared self-reports of diabetes on the survey
    to subsequent recording of diabetes as a cause
    of death on the death certificate
     Percent of deceased diabetics for whom diabetes was
      reported as a cause of death, NHIS-NDI Linked Data,
                           1997-2002
45       42.8                                     41.1
                   39.1                                     39.7
40                           37.7
                                                                      33.8
35                                      31.6
30
25
20
                13.3                           13.5      14.1      14.5
15    10.5                11.1
                                    8.7
10
5
0
       1997      1998      1999     2000        2001      2002     KY 2002-
                                                                    2003
                           Underlying     Any mention
          Future Linked Data Research
•   Trends in self-reports of diabetes vs. death
    certificate recording of diabetes
    • Extend analyses past 2002
    • Any changes in the Kentucky trends?
      (assuming sufficient number of observed
      deaths)
•   Trends in mortality from other causes of death
    for diabetic decedents
•   Analyze risk of death from diabetes and other
    causes using multivariate modeling
               THE END

Contacts: mheron@cdc.gov, RNAnderson@cdc.gov




Centers for Disease Control and Prevention

				
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