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Sensitivity of Death Certificate Data for Monitoring Diabetes Mortality -- Diabetic Eye Disease Follow-Up Study, 1985 - 1990

Although death certificates are a primary source of data for characterizing mortality patterns in the United States, the underreporting of diabetes as a cause of death limit the use of death certificates for monitoring diabetes mortality (1). To determine whether diabetes was underreported on the death certificates of patients with known diabetic eye disease, CDC analyzed data from death certificates for persons identified as deceased by the Diabetic Eye Disease Follow-Up Study (DEDFUS).*

DEDFUS was designed to determine adherence to recommended eye-treatment protocols and to measure changes in visual acuity among participants who were first evaluated from 1985 through 1987 in diabetes-control programs (DCPs). A stratified probability sample (n=569) was selected from persons with diabetes who had been

  1. identified at high risk âdaggeră for blindness and 2) screened for or diagnosed with eye disease by DCPs in Colorado, Florida, Maryland, and Minnesota.

For this analysis, during September 1989-December 1990, DCP staff attempted to interview and obtain medical record information for the 569 persons in the sample from the four states; vital records in the four states were searched for those patients who had died or were lost to follow-up. CDC's National Center for Health Statistics coded the death certificates by the underlying causes of death according to the International Classification of Diseases, Ninth Revision.

Of the 569 persons, 74 (13%) had died during 1985-1990 (Table 1). Of these, CDC was able to obtain death certificates for 59 (80%) patients (15 death certificates were unavailable at the time of the analysis). Overall, cardiovascular disease, particularly heart disease, was the most common underlying cause of death (28 (48%) deaths). Diabetes was mentioned as either the underlying or contributory cause on 28 (48%) of the 59 death certificates and listed as the underlying cause on 10 (36%) of these 28. The proportion of death certificates listing diabetes as a contributory cause of death was statistically greater (p less than 0.01; 1-sided Fisher exact test) if cardiovascular disease was given as the underlying cause of death than if other causes were given (50% versus 19%, respectively). The frequency of any mention of diabetes was 53% for whites, 50% for Hispanics, and 33% for blacks. Reported by: S Michael, Colorado Dept of Health. S Gard, Florida Dept of Health and Rehabilitative Svcs. E Schurman, Maryland Dept of Health and Mental Hygiene. D Kurth, Weiner Memorial Medical Center, Marshall, Minnesota. Div of Data Processing, Div of Epidemiology and Health Promotion, National Center for Health Statistics; Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: When compared with studies of diabetes-related mortality in the general population, diabetes appears to be recorded more often on the death certificates of persons from the DEDFUS sample (48% versus 40%) (2-4). Nonetheless, the findings in this report indicate that even though DEDFUS patients were known to have diabetes, diabetes was substantially underreported in the DEDFUS sample. This underreporting limits the use of death certificates for monitoring diabetes mortality, even for persons with a recognized complication of diabetes. Factors associated with underreporting of diabetes-related mortality include the specific underlying cause of death (2,5) and the duration of the disease (6).

To plan and implement public health programs for control of diabetes, national and state health officials need to be able to measure accurately the magnitude of the disease burden. Therefore, physicians and other medical personnel are urged to record diabetes on death certificates, when appropriate, to assist in public health surveillance for and efforts to better characterize this disease. Additional efforts will be necessary to determine factors affecting the recording of diabetes on death certificates.


  1. CDC. Diabetes surveillance, 1980-1987. Atlanta: US Department of Health and Human Services, Public Health Service, 1990.

  2. Ochi JW, Melton LJ, Palumbo PJ, Chu CP. A population-based study of diabetes mortality. Diabetes Care 1985;8:224-9.

  3. Palumbo PJ, Elveback LR, Chu C, Connolly DC, Kurland LT. Diabetes mellitus: incidence, prevalence, survivorship, and causes of death in Rochester, Minnesota, 1945-1970. Diabetes 1976;25:566-73.

  4. Brousseau JD. Occurrence of diabetes among decedents in North Dakota. Diabetes Care 1987;10:542-3.

  5. Fuller JH, Elford J, Goldblatt P, Adelstein AM. Diabetes mortality: new light on an underestimated public health problem. Diabetologia 1983;24:336-41.

  6. O'Sullivan JB, Mahan CM. Mortality related to diabetes and blood glucose levels in a community study. Am J Epidemiol 1982;116:678-84.

âdaggerăConsidered at high risk were postpubertal persons who had not received an eye examination in the past 12 months and who had either type II diabetes or type I diabetes for 5 or more years.

*The risk for LEA among persons with diabetes appears greatest for those aged less than 45 years because few persons without diabetes account for nontraumatic LEA in that age group. When the risk is calculated only for persons with diabetes, the risk increases with age.

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