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Current Trends Autopsy Frequency -- United States, 1980-1985

In approximately 14% of the 2,089,378 deaths reported in the United States in 1985, an autopsy was performed. Recent reports indicate that the frequency of autopsy has been declining and that the decline may have adversely affected the accuracy of determining the underlying cause of death (1). To assess the recent variation in autopsy frequency, mortality data collected by the National Center for Health Statistics, CDC, for the period 1980-1985 were analyzed. During that time, the proportion of deaths involving an autopsy gradually declined from 17% to 14%. Within each year, however, autopsy frequency varied substantially by cause of death.

For this analysis, cause of death was grouped into six general categories: natural causes, unintentional injuries and poisonings,* suicide, homicide, external causes with undetermined intent, and unknown or unspecified causes. These groups correspond to the codes in the International Classification of Diseases, Ninth Revision (ICD-9) (Table 1).

The proportion of autopsies performed ranged from 12% among natural deaths to 97% among homicide deaths (Table 1). Deaths with unknown autopsy status were enumerated separately and excluded from the calculations. Although 12% of all records lacked autopsy data, the proportion of records without autopsy data varied from 2% among homicide deaths to 13% among natural deaths. In general, larger autopsy percentages are associated with smaller percentages of missing data.

Autopsies for natural deaths declined at least 0.5% every year during the period 1980-1985, from 13% in 1980 to 10% in 1985 (Figure 1). In contrast, the frequency of autopsies for deaths caused by unintentional injuries and poisoning increased from 46% to 51%, and the frequency among suicide deaths increased from 48% to 52%. Similarly, autopsies among deaths due to external causes of undetermined intent increased from 79% to 84%. The frequency of autopsy among homicide deaths was consistently high over this period (between 96% and 97%). The number of autopsies for deaths of unknown or unspecified cause fluctuated between 28% and 32%.

The distribution of cause of death for all autopsies has changed. In 1980, natural deaths accounted for 70% of all autopsies. By 1985, natural deaths accounted for 66% of all autopsies.

Autopsies for natural deaths or deaths occurring among patients under the care of a physician are usually performed at the hospital where the death occurred and with the permission of the decedent's next of kin. If the death is sudden, unexpected, or due to external causes, local statutes may require an autopsy. This autopsy is either requested by a coroner or performed by a medical examiner, depending upon the local medicolegal system. Since deaths due to other than natural causes require medicolegal investigation in most states, the number of autopsies performed was examined by type of medicolegal jurisdiction in the state.

In 1980, 15 states had coroner systems; 18 states and the District of Columbia had medical examiner systems, and 17 states had both medical examiner systems and coroner systems (2). Approximately 44% of all deaths during the period 1980-1985 occurred in states with both medical examiners and coroners (a mixed medicolegal system); 29% of deaths occurred in states with a medical examiner system; the remaining 27% occurred in states with a coroner system. The percentage of deaths in which an autopsy was performed during this 6-year period was greatest among states with a mixed medicolegal system, 16% (Table 2). States with a medical examiner system had autopsies performed in 15% of deaths and states with coroners, 14%. States with a coroner system had the highest proportion of death records that did not indicate whether an autopsy was performed (16%), and states with mixed systems had the smallest (10%).

When autopsy frequency was examined by medicolegal system and cause of death, states with a medical examiner system had the highest autopsy frequency for deaths due to unintentional injuries and poisoning , homicide, suicide, undetermined intent, and unknown causes (Figure 2). States with mixed systems had higher autopsy frequencies for deaths due to unintentional injuries and poisoning, suicide, and undetermined intent than did states with coroners. The same pattern of annual trends was observed for each medicolegal system (Figure 1). Reported by: Surveillance and Programs Br, Div of Environmental Hazards and Health Effects, Center for Environmental Health and Injury Control. Editorial Note: Death certificates are the principal source of mortality statistics for the United States. Several studies, however, have raised questions concerning the accuracy of the recorded cause of death (3,4), and some investigators have advocated improving these statistics by performing more autopsies. Current data show a decline in the proportion of autopsy for natural causes of death (1) and an increase in autopsy proportions for medicolegal deaths (homicides, suicides, and deaths caused by unintentional injuries and poisoning). As a result, 34% of autopsies performed in 1985 involved deaths due to other than natural causes, compared to 30% of autopsies performed in 1980.

State and local laws vary, but medical examiners and coroners typically have the legal authority to order autopsies for traumatic, sudden, or unexpected deaths. A more accurate picture of the frequency of autopsy among deaths outside of the medicolegal system would require separating the sudden or unexpected deaths from other natural

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