Autopsy rates differ by race, age, sex, education

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A first-of-its-kind study has found that younger, well-educated and wealthy people are more likely to be autopsied when they die.

More men than women are autopsied. And blacks, Hispanics, Asians and Native Americans are more likely to be autopsied than whites.

The disparity has a profound effect on how people understand the diseases that run in their families and how medical research is conducted.

The findings from Scripps Howard News Service's seven-month review of the 4.9 million deaths in the United States in 2005 and 2006 surprised medical experts.

"Wow," said veteran coroner Michael Doberson of Colorado, the state with the nation's highest rate of autopsies. "This could have something to do with a greater educational level among these families, families that may want to have more information about the death. Less-educated people may not be aware of the benefits of an autopsy."

There are few laws that dictate when an autopsy must be conducted, and it depends largely on the age of the deceased and on the preference of local authorities.

For example, excluding cases of homicide and suicide that are routinely autopsied, the study found that nearly 10 percent of people who died between ages 45 and 54 received an autopsy, compared to less than 4 percent of people 65 to 74. The rate drops to less than 2 percent for older Americans.

"The population is aging and we're not researching how different diseases affect people," said Dr. Elizabeth Burton of Baylor Medical Center in Dallas. "When you get a 113-year-old woman into the pathology lab, the question shouldn't be so much why did she die, but how did she manage to live so long? What was different about her?"

The study found that racial and ethnic minorities were more likely to be autopsied than whites. When looking at all 4.9 million deaths, whites were autopsied less than 6 percent of the time compared to 11 percent for blacks, 14 percent for Hispanics, 8 percent for Asians and 13 percent for American Indians.

Blacks and Hispanics are much more likely than whites to die before reaching 60 years of age, and therefore would be expected to receive more autopsies. These groups are also more likely to be the victims of homicides and therefore be autopsied as part of a criminal investigation.

But even looking at only deceased persons who are 60 or older and who were not victims of homicide or suicide, the autopsy rate for blacks and Hispanics was about twice as high as that for whites.

"This may have something to do with higher rates of unattended death," said Robert Anderson, chief of mortality statistics for the National Center for Health Statistics. "People who have less access to health care can have conditions like hypertension that can lead to sudden death," which are more likely to trigger an autopsy.

Black families also may be more likely than whites to question the official cause of death for a family member.

Scripps Howard in February conducted a national survey with Ohio University of 946 adult residents of the United States. The poll found that 26 percent doubt the accuracy of the official cause of death listed on the death certificate of someone they know personally.

Nearly half of the blacks in the poll said they mistrust the death diagnosis of someone they know. One-fifth of Hispanic respondents said they have similar doubts, a rate of mistrust similar to that of non-Hispanic whites. Women were significantly more likely to have doubts about death diagnoses of people they know than were men.

"Yes, we do get families who call us wanting to know exactly what happened and whether they are at risk" from genetic diseases like sickle-cell anemia, said Dr. Doberson, coroner for Arapahoe County in Colorado.

The study found that men are more than twice as likely as women to receive an autopsy. Even when looking only at autopsies given to people over the age of 60 who did not die violently, about 60 percent were given to men and 40 percent to women.

There was a similar pattern according to how much education, closely related to wealth, each American received.

Among deceased people over the age of 60 who did not die violently, the autopsy rate was only 1 percent among whites who did not graduate from high school, was 2 percent among high-school graduates and was 3 percent among college graduates.

The patterns were similar for blacks, Hispanics, Asians and American Indians.

"That's very interesting. I've not heard that before," said Anderson. "Maybe the more educated you are, the more curious you are about why a member of your family died."

But increased autopsy rates for men and better-educated, more affluent people may have other explanations.

"A lot of that has to do with (life and auto) insurance policies," said Doberson. "Often, insurance companies will request autopsies before they make payouts. Also, in cases of vehicular deaths, a lot more information is required for government statistics for vehicular safety."

Historically, men are much more likely to die in traffic accidents than women since they do most of the driving. Men and prosperous people also are much more likely to have insurance policies.

Health experts agree that autopsies are a critical tool in learning the truth about death. For example, the Scripps study found that autopsies reduce claims of fatal heart disease by about 20 percent nationwide and by nearly 50 percent in New York City.

Fatalities are much more likely to be attributed to vague causes like coronary disease when no autopsies are conducted. But when they are, autopsies uncover often-treatable conditions like hypertension, peptic ulcers and circulatory diseases.

"The bottom line is that you don't really know the cause of death unless you do an autopsy," said Doberson. "Usually, an autopsy is done when the cause of death is not clear and because we need to sign off on the cause of death."

Historically, autopsies have revealed that the original diagnosis of the cause of death was wrong about 30 percent of the time for major diseases like heart attack, breast cancer, pneumonia and stroke, according to an analysis done for the federal Agency for Healthcare Research and Quality. Some recent studies have found the error rate is more than 50 percent.

"That's pretty terrifying for patients. If it's like that when we're dead, what about when we are living?" asked Dr. Eric Mitchell, chief coroner for Topeka, Kan. "Autopsies give information that definitely lead to our understanding. It is only by looking that we can find it."

But autopsies have become increasingly rare.

Fifty years ago, most people who died in a hospital underwent autopsy, but today less than 5 percent of hospital deaths are autopsied.

Lack of money, lack of standards, worry over legal liability and even a declining pool of trained pathologists are all cited for the decline in the use of autopsy. Perhaps the biggest reason, though, is that doctors aren't familiar with the exams -- most pass through medical school without seeing one.

The Scripps study found that the rate at which coroners conduct autopsies varies significantly. 10 states conduct autopsies at least 10 percent of the time (Arizona, California, Colorado, Florida, Hawaii, Maryland, Texas, Utah, Vermont and Washington), while four states conduct them less than 5 percent of the time (Arkansas, Maine, Oregon and Pennsylvania). These rates vary even more among counties, with some conducting autopsies at a rate three times more than others within the same state.

E-mail Thomas Hargrove at hargrovet@shns.com and Lee Bowman at bowmanl@shns.com.

(Distributed by Scripps Howard News Service, http://www.scrippsnews.com)