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Sensitivity and Specificity of Death Certificates for Diabetes: As Good as it Gets?

Sensitivity and Specificity of Death Certificates for Diabetes: As Good as it Gets?. Deborah Wingard, W. Susan Cheng, Donna Kritz-Silverstein, Elizabeth Barrett-Connor. Insulin Hexamer. Introduction. Diabetes sixth major cause of death in US

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Sensitivity and Specificity of Death Certificates for Diabetes: As Good as it Gets?

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  1. Sensitivity and Specificity of Death Certificates for Diabetes:As Good as it Gets? Deborah Wingard, W. Susan Cheng, Donna Kritz-Silverstein, Elizabeth Barrett-Connor Insulin Hexamer

  2. Introduction • Diabetes sixth major cause of death in US • Among diabetic population, diabetes listed 20%-50% anywhere on death certificates • Mortality data used for policy decisions • Disease reporting • Burden of disease • Funding

  3. Introduction • Death Certificates for Disease Reporting • No standard form • No standard training • Inadequate fields • Not regular physician

  4. Purpose • Examine change in accurate reporting of diabetes on death certificate • Potential factors improving reporting: • Sex • Age, year, place, & cause of death • Diabetes medication use

  5. Methods • Rancho Bernardo cohort • Age 30+ at enrollment (1972-74) • Mortality data through 2003 • follow-up: 1-30 years • mean = 15.2 + 7.6 yrs • Death certificates for 3209 decedents

  6. Methods • Diagnosed Diabetes • Periodic clinic visits • 1972-74, 1984-86, 1992-96, 1997-99 • Blood work & self-report • Mailed questionnaires • 1982, 1988, 1993, 1996, 1998 • Diabetes Listed on Death Certificate • Anywhere • Cause of Death

  7. Death Certificates • Underlying cause of death • Consequence leading to death • Significant conditions . . . . . . . . . . . .

  8. 3209 w/Death Certificate And ICD9 Codes Diabetes Reported During Study Diabetes (n=322) No Diabetes (n=2887) Diabetes Listed On Death Certificates Diabetes (n=56) No Diabetes (n=2831) No Diabetes (n=210) Diabetes (n=112)

  9. Methods • Sensitivity and specificity • Unadjusted and Stratified • Sex • Age at death • Year of death • Place of death • Cause of death • Diabetes medication use

  10. Accuracy of Reporting:Sensitivity and Specificity Diabetes on Death Certificate Yes No Diabetes Status Ever Reported (Yes) A B A+B Never Reported (No) C DC+D Sensitivity: A/(A+B) Specificity: D/(C+D)

  11. Logistic Regression Sample: 378 diabetic decedents Outcome: Death certificate reporting diabetes Predictors of Better Reporting: • Sex • Age, year, place, cause of death • Diabetes medication use

  12. 3209 w/Death Certificate And ICD9 Codes Diabetes Reported During Study Diabetes (n=322) No Diabetes (n=2887) Diabetes Listed On Death Certificates Diabetes (n=56) No Diabetes (n=2831) No Diabetes (n=210) Diabetes (n=112)

  13. Mean age (yrs) At Visit 1: 65 At Death: 82 Sex (%) Men: 51 Women: 49 Descriptives of Decedents

  14. Place of Death (%) Hospital: 67 Home: 22 Other: 11 Year of Death (%) 1972-81: 22 1982-91: 41 1992-03: 37 Cause of Death (%) CVD: 41 Diabetes: 1 Cancer: 23 Other: 35 Descriptives of Decedents

  15. DiabetesNo Diabetes Age at Enrollment (yrs): 64.2 65.4 Men (%): 61 50 CVD deaths (%): 44 41 No difference: age at death, place & year of death Descriptives of Decedents

  16. Results: Accuracy of Reporting • 322 decedents with reported diabetes • 168 listed diabetes anywhere on death certificates • 56 did not report diabetes • Sensitivity of diabetes reporting • Anywhere: 34.7% • Cause of Death: 6.2% • Specificity of diabetes reporting • Anywhere: 98.1% • Cause of Death: 99.8%

  17. Stratified Sensitivity Characteristic N Sensitivity (%) Sex Men 1641 32 Women 1568 39 Age at Death (yrs) <76 (ref) 863 37 77-82 719 32 83-88 856 40 89+ 771 29 Year of Death 1972-81 (ref) 714 37 1982-91 1324 34 1992-03 1171 35

  18. Stratified Sensitivity (cont) Characteristic N Sensitivity(%) Cause of Death All Other 1862 23 CVD 1324 39 Place of Death Other (ref) 366 26 Hospital 2136 36 Home 689 37 Diagnosis MD only 139 17 MD + medication use 183 49

  19. Summary of Results • Higher sensitivity for diabetes reporting: • Deaths in hospitals, home • CVD as underlying cause • Diabetes medication use • Sensitivity did not vary by: • Sex • Age of death • Year of death

  20. Logistic Regression Among Diabetic Decedents (n=378) Characteristic OR 95%CI Age 1.0 0.9, 1.0 Men vs. women 1.5 1.0, 2.2 Year of Death 1.0 0.9, 1.0

  21. Logistic Regression Among Diabetic Decedents (n=378) Characteristic OR 95%CI Cause of Death CVD v. all other 1.4 0.9, 2.2 Place of Death Hospital v. other 1.0 0.5, 2.2 Home v. other 1.0 0.6, 1.9 Diagnosis Db med. use v. Dx only 4.8 2.8, 8.1

  22. CVD v. all other cause of death by decade of death Sensitivity (%)

  23. Summary: US Population-Based Author (year) N Years Ages Sensitivity (%) Minnesota Palumbo (1976) 1470 1945-70 6-70+ 32 Ochi (1985) 428 1964-74 30-80+ 38 Spratka (1993) 274 1978-88 m=74 54 North Dakota Brousseau (1987) 552 1985 m=77 45 Washington Anderson (1993) 282 1989-90 m=69 41 Rancho Bernardo Present study 3209 1972-2003 m=82 35 m=mean

  24. Summary: US National Author (year) N Years Ages Sensitivity (%) Diabetic Eye Disease MMWR (1991) 569 1985-90 18+ 48 Mortality Follow-Back Bild (1992) 2766 1986 25+ 38 NHANES Gu (1998) 14,374 1975-93 25-75+ 36 (Men) 47 (Women) Will (2001) 16,567 1986 25-75+ 38 16,593 1993 25-75+ 36

  25. Summary: Studies Abroad Author (year) N Years Ages Sensitivity (%) Scotland Waugh (1985) 1827 1985-88 15-75 70 Jamaica Alleyene (1989) 8799 1970-79 All 67 Portugal Coeli (2002) 2974 1994 60-80+ 52

  26. Limitations Generalizability White, middle class, good access to medical care Results similar to other US based studies Strengths Direct access to individuals Lengthy follow-up period Recent data Strengths & Limitations

  27. Conclusions • No overall improvement in diabetes reporting on death certificates • Better reporting observed in recent years (1992-2003) for CVD listed as cause of death • Persistent under-reporting of diabetes on death certificates leads to an underestimate of the burden of disease in the population

  28. Questions? Rancho Bernardo, CA

  29. Table 1: Descriptives of Sample

  30. Place of Death (%) Hospital: 67 Home: 22 Other: 11 Year of Death (%) 1972-81: 22 1982-91: 41 1992-03: 37 Mean age (yrs) At Visit 1: 65 At Death: 82 Sex (%) Men: 51 Women: 49 Cause of Death (%) CVD: 41 Diabetes: 1 Cancer: 23 Other: 35 Descriptives of Decedents

  31. Logistic Regression Among Diabetic Decedents (n=378) Characteristic OR 95%CI Age 1.0 0.9, 1.0 Men vs. women 1.5 1.0, 2.2 Year of Death 1.0 0.9, 1.0 Cause of Death CVD v. all other 1.4 0.9, 2.2 Place of Death Hospital v. other 1.0 0.5, 2.2 Home v. other 1.0 0.6, 1.9 Diagnosis Db med. use v. Dx only 4.8 2.8, 8.1

  32. Summary: US Based Studies Author (year) N Years Ages Sensitivity (%) Palumbo (1976) 1470 1945-70 6-70+ 32 Ochi (1985) 428 1964-74 30-80+ 38 Spratka (1993) 274 1978-88 m=74 54 Brousseau (1987) 552 1985 m=77 45 Anderson (1993) 282 1989-90 m=69 41 National Studies MMWR (1991) 569 1985-90 18+ 48 Bild (1992) 2766 1986 25+ 38 Gu (1998) 14,374 1975-93 25-75+ 36 (Men) 47 (Women) Will (2001) 16,567 1986 25-75+ 38 16,593 1993 25-75+ 36 m=mean

  33. Local Studies Minnesota Prospective (32%) Pop based (38%) Pop based (54%) North Dakota Pop based (45%) Washington Pop based (41%) National Studies Diabetic Eye Disease (48%) Mortality Follow-back (38%) NHANES 36% Men, 47% Women US Based Studies (Sensitivity %)

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