Nonforensic Autopsies More Common in Blacks Than Whites

Troy Brown, RN

June 29, 2020

Autopsies are required by law for certain types of death, for example, those that result from violence or are intentional. For other deaths, a clinician usually decides whether to offer an autopsy of the deceased to the individual's caregivers or next-of-kin. In these types of situations, black individuals are significantly more likely to undergo autopsies compared with white individuals, national data show.

Clinicians need to know these disparities exist, lead author Arun Gupta, MD, told Medscape Medical News. "There may be additional financial burden on black families due to this...we must dig deeper to understand why that is, how it influences them, and how this reflects our care to black patients before (antemortem) and after death (postmortem)," he continued.

Gupta, from the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland, and colleagues report their findings in a research letter published online today in JAMA Internal Medicine.

"Autopsy provides crucial insight into both established and emerging diseases, rigorous means for quality assurance and outcomes research, and an important check on our collective premortem diagnostic hubris. However, an array of systems- and individual-level changes has seen autopsy increasingly relegated to relic status," write James W. Salazar, MD, and Zian H. Tseng, MD, in an accompanying editorial.

Salazar and Tseng are from the University of California, San Francisco, and Salazar is also an editorial fellow at JAMA Internal Medicine.

The researchers analyzed data on more than 25 million decedents older than 18 years from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database from 2008 to 2017. They excluded homicides, suicides, and accidental deaths, and extracted mortality and autopsy data from death certificates.

After excluding deaths occurring from external causes and those with unknown autopsy status, the study included 23,670,006 decedents (73.9% older than 65 years; 49.6% women; 85.7% white).

"We excluded medicolegal autopsies the best we could for this analysis since autopsies are mandated in those cases. For ''natural'' deaths, it is really up to the physician to offer it (but there is no standard criteria) and the caregivers to accept it," Gupta said. A "major limitation" of the study was that the researchers could not account for whether clinicians offered autopsy to decedents' caregivers, why it may have been offered, and what kind of discussion, if any, occurred as a result, he explained.

The researchers compared autopsy rates by race for all deaths and deaths caused by "cancer, cardiovascular disease, cerebrovascular disease, diabetes, kidney disease, liver disease, and respiratory disease."

The overall autopsy rate was 7.9%, and was higher in those who were black (12.7%) compared with those who were white (7.3%) (P < .01), for a difference of 5.4% between black and white decedents.

Overall, autopsy rates were higher for deaths from cardiovascular disease (7.6%) and cirrhosis (6.7%), compared with those from cancer (0.9%) and kidney diseases (1.5%).

"Given the current state of health care policy and financial incentives, autopsy is likely to become an even scarcer resource; therefore, it is critical that we understand and monitor the determinants of autopsy," Salazar and Tseng write.

The researchers hypothesized that higher autopsy rates in black decedents may demonstrate health care disparities, lack of trust in the health care system, and less-extensive premortem testing in minority populations, the editorialists continue. "However, it is easy to envision a near future where autopsy availability, restricted to academic hospitals or affluent populations, reflects health care privilege," they add.

"Black families may feel pressured to say yes when offered — but this is all conjecture. We do not have this info," Gupta told Medscape Medical News.

When asked whether he and his colleagues believe any particular hypothesis may play more of a role than others, he said that is unclear. "This is exploratory work evaluating this disparity — we really do not want to be making too many assumptions."

A secondary finding is the study's confirmation of the decline of autopsy rates during the last 10 to 15 years, Gupta said. With the exception of deaths related to diabetes, autopsy rates among deaths related to other causes such as cancer and cirrhosis fell during the study period (P < .01).

Gupta said the reasons for the decline are unclear but are likely the result of multiple factors. The Joint Commission no longer requires a minimum number, there is no reimbursement for autopsies, conducting an autopsy risks finding another diagnosis or diagnoses that call into question the clinician's medical care, and "perceived/real improvements in diagnosis" lead to an incorrect assumption that "we don't need autopsies anymore," he said.

Study author Brawley has reported receiving grants from the National Cancer Institute and the Maryland Cigarette Restitution Fund during the conduct of the study. Gupta and the remaining authors have disclosed no relevant financial relationships. Editorialist Tseng has reported receiving grants from the National Institutes of Health and Centers for Disease Control and Prevention during the conduct of the study. Salazar has disclosed no relevant financial relationships.

JAMA Int Med. Published online June 29, 2020. Research letter, Editorial

Troy Brown is an award-winning Medscape contributor with a special interest in infectious diseases, women's health, and pediatrics.

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