Black patients had clinical autopsies more frequently than white patients, CDC data showed.
In nearly 24 million deaths between 2008 and 2017, non-forensic autopsy rates were 12.7% among Black decedents and 7.3% among white decedents (P<0.01), reported Fumiko Chino, MD, of Memorial Sloan Kettering Cancer Center in New York City, and co-authors in JAMA Internal Medicine. Consistent with trends since the 1950s, overall clinical autopsy rates continued to decline over time.
"We hypothesize that the higher rate of autopsies in black decedents may reflect health disparities," the researchers wrote. "Less aggressive diagnostic workups in black patients may translate into less established diagnoses before death, possibly associated with the rates of autopsies."
"Across all evaluated causes of death, Black patients had nearly twice the rate of autopsy than white patients," Chino noted.
"This may reflect additional financial burdens on patient families who are searching for answers after death," she told MedPage Today. "Alternatively, it may reflect increased altruism; the current COVID-19 pandemic has shown that Black families seem more willing to contribute to medical knowledge."
The idea of altruism and helping others understand diseases "definitely is present," observed Sharon Fox, MD, a pathologist at Louisiana State University in New Orleans, who wasn't involved with the study.
"There's a lot of thanks from the community when we do autopsies," said Fox, who recently co-authored an autopsy series in African-American patients with COVID-19.
Autopsy is one of the oldest methods to help doctors understand diseases and make treatment advances, Fox pointed out. "The higher rate of autopsy among Black patients likely reflects questions about why these individuals died, and it is important not only to answer those questions for families, but to incorporate the knowledge gained into the medical literature," she told MedPage Today.
Overall, autopsies are performed less frequently: from 1972 through 2007, autopsy rates fell from 19.3% to 8.5% of deaths.
"An array of systems- and individual-level changes has seen autopsy increasingly relegated to relic status," wrote James Salazar, MD, MAS, and Zian Tseng, MD, MAS, both of the University of California San Francisco, in an editor's note.
On a systems level, financial incentives to perform clinical autopsies have fallen in the past 30 years; the Centers for Medicare & Medicaid Services' decision to eliminate the autopsy program requirement for hospitals to qualify for reimbursement is one example, Salazar and Tseng noted.
"At the individual level, increasing confidence in advanced diagnostic tests has weakened the perceived value of autopsy and negatively biased autopsy discussions that are already uncomfortable for many clinicians," the editorialists added.
In their analysis, Chino and colleagues looked at 23,670,006 adult deaths from 2008 to 2017 in the CDC Wide-Ranging Online Data for Epidemiologic Research database, excluding deaths from homicides, suicides, and accidents. Mortality and autopsy data were obtained from death certificates. Most decedents (73.9%) were older than 65, 49.6% were women, and 85.7% were white.
The overall autopsy rate was 7.9%. It was higher in deaths attributed to cardiovascular disease (7.6%) and cirrhosis (6.7%) than cancer (0.9%) and kidney diseases (1.5%). With the exception of diabetes-related death, autopsy rates among other causes of death declined over the study period (P<0.01).
Difference in autopsy rates between Black and white patients was 5.4%. Across all conditions, Black patients had a significantly higher rate of autopsies than white patients. In cancer, for example, the difference between races was 0.9%; in cardiovascular disease, it was 5.6%.
Autopsy costs often are not reimbursed and are absorbed by the institution or passed to family members, Chino and co-authors noted. But who pays for an autopsy may vary. "An autopsy performed at an academic hospital or major center, or one performed at a coroner or medical examiner's office, is at no cost," Fox said. "It is only a cost if those autopsies are sent for private evaluation. We make a point to tell our patient families that they won't be billed for it."
The study had limitations, Chino and colleagues acknowledged. They couldn't determine whether autopsy was offered, nor motivations for autopsy. The team also couldn't exclude confounding by cases incorrectly classified as nonforensic death. "Despite these limitations, these data suggest differences in rates of autopsies by race and deserve further study," the researchers wrote.