Certifying diabetes-related cause-of-death: a comparison of inappropriate certification statements in Sweden, Taiwan and the USA

The aim of this study was to assess differences in the certification practices of physicians in Sweden, Taiwan and the USA with regard to diabetes-related cause-of-death (COD) statements. Multiple-cause-of-death data from Sweden (2000), Taiwan (2001) and the USA (2001) were used for this study. All deaths with mention of diabetes anywhere on the death certificate were extracted for analysis. Two types of inappropriate COD statements were: (1) reporting two or more diagnoses per line; and (2) entering an incorrect causal sequence among reported diagnoses. Of those deaths in which diabetes was reported in Part I of the death certificate, American physicians (19%) were less likely to report two or more diagnoses per line than physicians in Sweden (46%) and Taiwan (56%). On the other hand, Swedish physicians (5%) were less likely to report incorrect causal sequences than were their counterparts in Taiwan (21%) and the USA (28%). These findings reveal substantial differences in diabetes-related COD statements among physicians in Sweden, Taiwan and the USA, implying that caution should be used when interpreting differences in mortality statistics between these countries.