Series 20, Number 32 March 2007

Autopsy Patterns in 2003
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Hoyert DL, Kung HC, Xu J. Autopsy patterns in 2003. National Center for

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Autopsy patterns in 2003.

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1. Autopsy—United States—Statistics. 2. United States—Statistics, Medical. I.

National Center for Health Statistics (U.S.) II. Series. III. Series: Vital and health

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Series 20, Number 32

Autopsy Patterns in 2003

Data on Mortality

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Hyattsville, Maryland

March 2007

DHHS Publication No. (PHS) 2007-1851
National Center for Health Statistics

Edward J. Sondik, Ph.D., Director

Jennifer H. Madans, Ph.D., Acting Co-Deputy Director

Michael H. Sadagursky, Acting Co-Deputy Director

Jennifer H. Madans, Ph.D., Associate Director for Science

Jennifer H. Madans, Ph.D., Acting Associate Director for

Planning, Budget, and Legislation

Michael H. Sadagursky, Associate Director for

Management and Operations

Lawrence H. Cox, Ph.D., Associate Director for Research

and Methodology

Margot A. Palmer, Director for Information Technology

Margot A. Palmer, Acting Director for Information Services

Linda T. Bilheimer, Ph.D., Associate Director for Analysis

and Epidemiology

Charles J. Rothwell, M.S., Director for Vital Statistics

Jane E. Sisk, Ph.D., Director for Health Care Statistics

Jane F. Gentleman, Ph.D., Director for Health Interview

Statistics

Clifford L. Johnson, Director for Health and Nutrition

Examination Surveys

Division of Vital Statistics

Charles J. Rothwell, M.S., Director

James A. Weed, Ph.D., Deputy Director

Robert N. Anderson, Ph.D., Chief, Mortality Statistics

Branch
Contents

Abstract ................................................................................................. 1

Introduction .............................................................................................. 1

Background .............................................................................................. 1

Methods ................................................................................................. 2

Results .................................................................................................. 2

Comparison with 1993 ................................................................................... 3

Age and Manner of Death Adjustment....................................................................... 4

Conclusion ............................................................................................... 4

References ............................................................................................... 6

Appendix ................................................................................................ 18

Technical Notes ......................................................................................... 18

Text Figures

1. Percentage of deaths for which autopsies were reported, by race: 47 states and the District of Columbia, 1993 and

2003.............................................................................................. 4

2. Percentage of deaths for which autopsies were reported, by sex: 47 states and the District of Columbia, 1993 and

2003.............................................................................................. 5

3. Percentage of deaths for which autopsies were reported, by age groups: 47 states and the District of Columbia, 1993

and 2003 .......................................................................................... 5

4. Percentage of deaths for which autopsies were reported, by region and adjusting for age and manner: 47 states and

the District of Columbia, 1993 and 2003 ................................................................ 6

Text Tables

A. Percentage of responses on the death certificate item on autopsy in agreement with corresponding National Mortality

Followback item: United States, 1993................................................................... 2

B. Number of deaths and percentage autopsied for selected causes: 47 states and the District of Columbia, 2003 ........ 3

C. Number of infant deaths and percentage autopsied for selected causes: 47 states and the District of Columbia, 2003. . . 4

Detailed Tables

1. Number and percentage of deaths for which autopsies were reported: United States, 1955, 1958, 1972–1994 and

47 states and the District of Columbia, 2003 ............................................................. 7

2. Number and percentage of deaths for which autopsies were reported, by state: United States and each state, 1993 and

2003.............................................................................................. 8

3. Number and percentage of deaths for which autopsies were reported, by 10-year age groups, race, and sex: 47 states

and the District of Columbia, 2003 ..................................................................... 9

4. Number and percentage of deaths for which autopsies were reported, by 10-year age groups, Hispanic origin, and race

for non-Hispanic population, and sex: 47 states and the District of Columbia, 2003.............................. 10

5. Number and percentage autopsied, by place of death: 47 states and the District of Columbia, 2003................. 10

6. Number and percentage of deaths for which autopsies were reported by 113 selected causes and sex: 47 states and

the District of Columbia, 2003......................................................................... 11

iii
7. Number and percentage of infant deaths for which autopsies were reported, by 130 selected causes and sex: 47 states

and the District of Columbia, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

iv
Objectives

This report presents information on

autopsy data in 2003 and compares

data for 1993 and 2003.

Methods

Death certificates are completed by

funeral directors, attending physicians,

medical examiners, and coroners. The

original records are filed in the state

registration offices. Statistical

information is compiled into a national

database through the Vital Statistics

Cooperative Program of the Centers for

Disease Control and Prevention’s

National Center for Health Statistics.

This report focuses on the autopsy item

on the death certificate and presents

descriptive tabulations.

Results

In 2003, autopsies were performed

for 7.7 percent of deaths occurring in 47

states and the District of Columbia. This

was less than in 1994, when the data

was last available in this database.

Decedents with particular

characteristics were more likely to be

autopsied than others. For example,

almost one-third of infant deaths, more

than one-half of decedents aged 15–24

years, and almost none of the

decedents aged 85 years and over

were autopsied.

Keywords: autopsy c vital statistics c

National Mortality Followback Survey

Autopsy Patterns in 2003

by Donna L. Hoyert, Ph.D.; Hsiang-Ching Kung, Ph.D.; and Jiaquan

Xu, M.D., Division of Vital Statistics

Introduction

Autopsy serves a number of

purposes (1–4); however, the

prevalence of its use has varied

over time in the United States (1–6).

Data from the Centers for Disease

Control and Prevention’s National

Center for Health Statistics (NCHS) was

a source of information on the use of

autopsy for 1955, 1958, 1972–94, and

again in 2003. This report presents 2003

information on autopsy trends and

provides some comparison with data for

1993.

Background

The prevalence of autopsies

increased during the first half of

the 20th century (2). According to

the literature, physicians and other

hospital staff valued autopsies, and

hospitals took great pride in having high

autopsy rates around the midcentury

(1–2). Reinforcing the demand for

autopsies among hospitals and

physicians, accreditation standards for

hospitals and state laws about

medico-legal investigations encouraged

the performance of autopsies (2,4).

The Joint Commission on

Accreditation of Hospitals (JCAH)

standards required that hospitals autopsy

20 to 25 percent of deaths (3). Each of

the states and some smaller jurisdictions

had laws and regulations that specified

when a death should be subject to a

medico-legal investigation that may

include autopsy. Although state laws

varied in specific requirements, deaths

that typically required investigation were

those due to unusual or suspicious

circumstances, violence (accident,

suicide, or homicide), those due to

natural disease processes when the death

occurred suddenly and without warning,

when the decedent was not being treated

by a physician, or the death was

unattended (7,8). This resulted in a

relatively substantial percentage of

deaths falling potentially under the

jurisdiction of medical examiners or

coroners who might use autopsy as one

of the tools in their investigation. Of all

the cases referred to a medical examiner

or coroner including those for which the

medical examiner or coroner decides not

to investigate, 26 percent are autopsied,

according to the 1993 National

Mortality Followback Survey (NMFS).

For those cases for which the medical

examiner or coroner accepts jurisdiction

and does further investigation, local

medical examiner or coroner offices

indicate that an autopsy is performed for

more than one-half of the accepted cases

(9,10).

This report was prepared in the Division of Vital Statistics (DVS) under the general direction of

Charles J. Rothwell, Director of DVS and Robert N. Anderson, Chief, Mortality Statistics Branch (MSB).

Hsiang-Ching Kung and Jiaquan Xu of MSB provided content related to autopsy data in the National

Mortality Followback Survey. Registration Methods staff and staff of the Data Acquisition and

Evaluation Branch provided consultation to state vital statistics offices regarding collection of the death

certificate data on which this report is based. Drs. Greg G. Davis and Marcus Nashelsky provided

suggestions. This report was edited by Demarius V. Miller, Office of Information Services, Information

Design and Publishing Staff; typeset by Jacqueline M. Davis and graphics produced by John Jeter, both

of CoCHIS/NCHM/Division of Creative Services.

Page 1
Page 2 [ Series 20, No. 32

During the second half of the 20th

century, autopsies were done less often.

According to the National Vital

Statistics System data (Table 1), the

percentage of deaths autopsied was less

in 1955 (17.8 percent) than in 1958

(19.1 percent), the same in 1958 and

1972, and has since decreased. Other

studies identified decreasing trends

earlier than 1972 (2,3,5). Many factors

have been attributed to the decline in

the autopsy rate (2–6). One of the

notable events was when JCAH dropped

the 20 to 25 percent standard for

accreditation in 1971. The intention was

to eliminate uniform standards for

hospitals in different situations;

however, a more nuanced standard was

not introduced. State laws regarding

investigations of deaths have changed

little over time and thus have not

contributed to declines. Investigation

protocols for sudden and unexplained

infant deaths may have increased the

demand for autopsies among a select

group of deaths.

The capability to track autopsy

trends was hampered by the removal of

the autopsy item from NCHS data in

1995 (11,12). This capacity was restored

with the reinstatement of the autopsy

item in 2003.

Methods

Data presented in this report are

based on information from death

certificates filed in the 50 states

and the District of Columbia that are

subsequently compiled into national data

by NCHS. Physicians, medical

examiners, and coroners are responsible

for completing the medical portion of

the death certificate. Funeral directors

are responsible for completing legal and

demographic information on death

certificates and ensuring that the death

certificates are filed with local or state

governments.

The autopsy data presented in this

report are based on the item on the

death certificate that asks ‘‘Was an

autopsy performed?’’ Certifiers (i.e.,

physicians, medical examiners, and

coroners) are instructed to respond yes

if a partial or complete autopsy was

performed. Otherwise, they are

instructed to answer no. Because the

death certificate often is completed,

signed, and sent forward before an

autopsy is completed, the item measures

expectation of autopsy at the time that

the death certificate is completed in

some cases.

Table 2 shows data by place of

occurrence and for all states to show the

levels of reporting, whereas other tables

are by place of residence. For the other

tables, data for Minnesota, New Mexico,

and Pennsylvania are excluded because

of the lack of information on autopsy

for these states. Autopsy patterns in

2003 were compared with those a

decade earlier (1993). For the purpose

of comparison, the same states were

excluded in the 1993 data as in 2003.

This report presents the number and

percentage of deaths for which autopsies

are reported. Comparisons made in the

text among percentages, unless

otherwise specified, are statistically

significant at the 0.05 level. Lack of

comment in the text about any two

percentages does not mean that the

difference was tested and found not to

be significant at this level. See the

‘‘Technical Notes’’ for further details.

There is some information on the

quality of the autopsy item. Item

nonresponse traditionally is relatively

high. Item completion remained the

same or improved for 16 states and the

District of Columbia comparing 1993

and 2003 data but deteriorated for the

others, substantially for some. Although

it would be much clearer if the certifier

always indicated yes or no, it has been

assumed that leaving the item blank is

equivalent to specifying no. The

substantially higher percentage of deaths

reported to be autopsied in states with

more complete reporting than in states

with more than 20 percent not stated

suggests that the autopsy item is left

blank for some deaths that may have

been autopsied. This challenges the

assumption that no response is

equivalent to a negative response. In

addition, Hanzlick and Parrish (13)

found that a substantial fraction of death

certificates in a small, nonrandom

sample of deaths known to be autopsied

did not state that an autopsy was done.

In contrast, about 7 percent more

autopsies were stated on the death

certificate than in the medical examiner

or coroner reports in the 1993 NMFS

(see ‘‘Technical Notes’’ for further

details) (14). For those cases with

medical examiner or coroner

documentation that an autopsy had been

done, the death certificate also indicated

that an autopsy had been done for 97

percent (Table A). These different results

may indicate that autopsies as indicated

on the death certificate for deaths that

are referred to a medical examiner are

slightly overstated on death certificates,

whereas deaths from natural causes and

not involving medical examiners are

understated. Because records with

characteristics common to the NMFS

subsample represent about one-half of

the deaths now autopsied, overall, the

autopsy item may underestimate the

percentage of deaths that are autopsied

by between 10 to 20 percent.

Results

For 2003, all states requested

information on the death

certificate as to whether autopsies

were performed; 47 states and the

District of Columbia provided NCHS

with data for this field. In 2003,

autopsies were reported as performed on

173,745 decedents, or 7.7 percent of the

deaths that occurred in 2003 in the 47

states and the District of Columbia

(Table 1).

The percentage of deaths autopsied

varied by geography (Table 2), with the

highest levels in the West and lowest

levels in the South. Colorado and the

District of Columbia reported the

highest levels (12.9 and 23.4 percent,

respectively). Of the more than 3,000

Table A. Percentage of responses on the

death certificate item on autopsy in

agreement with corresponding National

Mortality Followback item: United States,

1993

Response about autopsy on

National Mortality Followback Survey Percent

Total ..................... 83.6

Autopsy performed ............ 96.8

Autopsy not performed .......... 82.1

Autopsy performance not stated .... 0.5
Series 20, No. 32 [ Page 3

counties, 20 percent or more of all

deaths occurring in a county were

autopsied in 30 counties.

The percentage autopsied varied by

the decedent’s demographic

characteristics. By race (Table 3), the

percentage autopsied was lower for the

white population (6.8 percent) than for

other groups (Asian or Pacific Islander

(API) 9.6 percent, black 12.8 percent,

and American Indian or Alaska Native

(AIAN) 15.1 percent). By Hispanic

origin (Table 4), Hispanic decedents

were autopsied more often than the

non-Hispanic decedents on the whole

(15.7 versus 7.2). Male decedents were

autopsied more often than female

decedents (10.6 and 4.8, respectively)

(Tables 3 and 4). Autopsy patterns

depended upon age (Tables 3 and 4).

The percentage autopsied was

substantial for younger ages, particularly

among decedents aged 15–24 years,

54.9 percent, and dropped precipitously

with older age.

The percentage of deaths autopsied

was associated with the place where

death was pronounced (Table 5). More

than 20 percent of deaths pronounced in

hospital emergency rooms, dead on

arrival at hospitals, and in other

specified locations (e.g., prison,

physician’s office, highway where traffic

accident occurred, ship, orphanage,

group home, at work) were autopsied.

Decedents pronounced at nursing homes

and hospice facilities were particularly

unlikely to be autopsied (0.6 and

0.8 percent, respectively).

Certain circumstances of death were

associated with the percentage of deaths

autopsied. For all ages, the causes for

which the highest percentage of deaths

were autopsied (Tables B and 6) were:

Assault (homicide) (91.8 percent); Legal

intervention (81.7 percent); Events of

undetermined intent (76.7 percent);

certain unintentional injuries (e.g.,

Accidental poisoning and exposure to

noxious substances at 72.5 percent and

Accidental drowning and submersion

63.7 percent); and Pregnancy, childbirth,

and the puerperium (60.3 percent). The

causes for which the highest percentage

of infant deaths were autopsied

(Tables C and 7) were: Assault

(homicide) (92.3 percent); Sudden infant

death syndrome (92.2 percent); Other

Table B. Number of deaths and percentage autopsied for selected causes:

47 states and the District of Columbia, 2003

[The asterisks (*) preceding the cause-of-death codes indicate that they are not part of the International

Classification of Diseases, Tenth Revision (ICD–10); see ‘‘Technical Notes’’]

Cause of death (based on the International

Classification of Diseases, Tenth Revision, 1992) Number Percent

All causes ......................................... 173,745 7.7

Leading causes

Diseases of heart ..................... (I00–I09,I11,I13,I20–I51) 39,510 6.2

Malignant neoplasms ........................... (C00–C97) 6,543 1.3

Cerebrovascular diseases ..........................(I60–I69) 2,943 2.0

Chronic lower respiratory diseases ................... (J40–J47) 2,337 2.0

Accidents (unintentional injuries) .............. (V01–X59,Y85–Y86) 44,148 43.7

Diabetes mellitus ............................. (E10–E14) 1,868 2.7

Influenza and pneumonia ......................... (J10–J18) 2,548 4.2

Alzheimer’s disease ................................(G30) 443 0.8

Nephritis, nephrotic syndrome and

nephrosis .....................(N00–N07,N17–N19,N25–N27) 654 1.7

Septicemia ................................. (A40–A41) 1,278 4.1

Intentional self-harm (suicide) ............... (*U03,X60–X84,Y87.0) 15,178 51.8

Chronic liver disease and cirrhosis ................(K70,K73–K74) 1,892 7.4

Essential (primary) hypertension and hypertensive

renal disease ................................. (I10,I12) 326 1.6

Parkinson’s disease ............................(G20–G21) 172 1.1

Assault (homicide) ................. (*U01–*U02,X85–Y09,Y87.1) 15,388 91.8

Causes associated with autopsy

Assault (homicide) ................. (*U01–*U02,X85–Y09,Y87.1) 15,388 91.8

Legal intervention .............................(Y35,Y89.0) 330 81.7

Events of undetermined intent ............. (Y10–Y34,Y87.2,Y89.9) 3,740 76.7

Accidental poisoning and exposure to noxioussubstances .... (X40–X49) 12,857 72.5

Accidental drowning and submersion .................(W65–W74) 2,000 63.7

Accidental discharge of firearms ....................(W32–W34) 415 60.7

Pregnancy, childbirth and the puerperium ..............(O00–O99) 311 60.3

Accidental exposure to smoke, fire and flames ........... (X00–X09) 1,859 59.3

Intentional self-harm (suicide) by other andunspecified means and

their sequelae .................(*U03,X60–X71,X75–X84,Y87.0) 7,495 55.2

Water, air and space, and other and unspecified transport accidents

and their sequelae ......................... (V90–V99,Y85) 1,004 54.6

symptoms, signs, and abnormal clinical

and laboratory findings, not elsewhere

classified (85.8 percent); certain

circulatory problems (e.g., Pericarditis,

endocarditis, and myocarditis,

88.5 percent); and Other external causes

and their sequelae (83.1 percent).

Researchers concerned with sudden

infant deaths often group a number of

categories to get a more complete group

of sudden and unexplained infant deaths

and more recent guidelines for

investigations are targeting a broader

range of sudden and unexplained infant

deaths. For the cause-of-death categories

used by Shapiro-Mendoza et al. (ICD-10

R95, R99, W75–W77, W81–W84,

Y06–Y07) (15), the percentage of

sudden and unexplained infant deaths

that were autopsied was 86 percent.

Comparison with 1993

The percentage of deaths autopsied

in the 47 states and the District of

Columbia generally was lower in 2003

than 1993 regardless of geography,

demographic characteristics, or other

associated factors. The percentage of

deaths autopsied was lower in 2003 than

in 1993 in each of the regions and for

most states (Table 2). However, the

percentage was higher for five states

(Mississippi, Rhode Island, Tennessee,

Utah, and Vermont) and not statistically

different for another eight states.

The autopsy levels were generally

less in 2003 than 1993 by demographic

characteristics. The percentage autopsied

decreased by race, sex, and many age

groups (Figures 1–3). The percentage
autopsied increased for age groups

25–34 and 35–44 years of age and was

not statistically different for age groups

1–4 and 45–54 years.

Age and Manner of Death

Adjustment

Changes in the distribution of

deaths by age and manner accounted for

about 15 percent of the overall decrease

in the percentage of deaths autopsied

between 1993 and 2003 (Figure 4). If

the age and manner of death distribution

had been the same for the two time

periods, the percentage autopsied would

still be lower in 2003 than in 1993 for

region, Hispanic origin, and race.

When the age and manner of death

distribution was held constant, the

differential in the percentage autopsied

by region in 2003 was wider than if not

held constant (Figure 4), whereas the

differential for other characteristics were

substantially smaller. Although smaller,

the percentage autopsied still was

different by sex, Hispanic origin, race,

and place of death. However, the

adjusted percentage autopsied for the

AIAN population was about the same as

the white population and less than that

for the black or API populations. If the

persons being pronounced dead at

different locations had the same age and

manner of death profile, those dying on

arrival would still be far more likely to

be autopsied than those in a nursing

home, but the respective percentages

would be 12.5 and 2.9 percent.

Conclusion

I

nformation from death certificates is

a major source of statistical data to

identify public health problems, to

monitor progress in public health, to

allocate research funds, and to conduct

scientific research. For these reasons,

good reporting of the circumstances of

death on death certificates is very

important. Autopsy has long been a tool

that potentially enhances the quality of

cause-of-death information reported on

the death certificate. An autopsy

provides an additional source of

information to take into consideration

when deciding upon the cause of death.

The autopsy results might confirm

clinical findings, provide more complete

information to describe cause of death,

Figure 1. Percentage of deaths for which autopsies were reported, by race: 47 states and

the District of Columbia, 1993 and 2003

Table C. Number of infant deaths and percentage autopsied for selected causes:

47 states and the District of Columbia, 2003

Cause of death (based on the

International Classification of Diseases, Tenth Revision, 1992) Number Percent

All causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,093 30.6

Leading causes

Congenital malformations, deformations and chromosomal

abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Q00–Q99) 1,232 23.3

Disorders related to short gestation and low birth weight, not

elsewhere classified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P07) 372 8.1

Sudden infant death syndrome . . . . . . . . . . . . . . . . . . . . . . . . .(R95) 1,889 92.2

Newborn affected by maternal complications of pregnancy . . . . . . . . (P01) 122 7.7

Newborn affected by complications of placenta, cord and

membranes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P02) 129 12.7

Accidents (unintentional injuries) . . . . . . . . . . . . . . . . . . . . (V01–X59) 701 77.5

Respiratory distress of newborn . . . . . . . . . . . . . . . . . . . . . . . . (P22) 89 11.6

Bacterial sepsis of newborn . . . . . . . . . . . . . . . . . . . . . . . . . . . (P36) 138 18.7

Neonatal hemorrhage . . . . . . . . . . . . . . . . . . . . . . . .(P50–P52,P54) 64 10.4

Diseases of the circulatory system . . . . . . . . . . . . . . . . . . . .(I00–I99) 227 40.0

Causes associated with autopsy

Assault (homicide) . . . . . . . . . . . . . . . . . . . . . . . . . (*U01,X85–Y09) 299 92.3

Sudden infant death syndrome . . . . . . . . . . . . . . . . . . . . . . . . .(R95) 1,889 92.2

Pericarditis, endocarditis and myocarditis . . . . . . . . . . . . . .(I30,I33,I40) 23 88.5

Other accidental suffocation and strangulation . . . . (W76–W77,W81–W84) 114 87.7

Other symptoms, signs and abnormal clinical and laboratory findings,

not elsewhere classified . . . . . . . . . . . . (R00–R53,R55–R94,R96–R99) 957 85.8

Accidental suffocation and strangulation in bed . . . . . . . . . . . . . . (W75) 345 85.0

Other external causes and their sequelae . . . . . . . . (X60–X84,Y10–Y36) 59 83.1

Accidental drowning and submersion . . . . . . . . . . . . . . . . . (W65–W74) 45 80.4

Other and unspecified

accidents . . . . . . .(W20–W31,W35–W64,W85–W99,X10–X39,X50–X59) 40 78.4

Acute bronchitis and acute bronchiolitis . . . . . . . . . . . . . . . .(J20–J21) 40 76.9

Page 4 [ Series 20, No. 32
or uncover conditions that were not

recognized clinically and would not be

reported among the causes of death

without an autopsy (1).

Despite the continuing value of

autopsies, their use has declined

(1–3,5,6). This report provides more

recent data on the prevalence of

autopsies. As suspected (11), the

percentage of deaths expected to be

autopsied was less than when autopsy

data were last available. The decreases

occurred for most characteristics of

decedents but not for all. The use of

autopsies remained level or increased at

some younger ages, and in a few states.

The changing profile of decedents

(e.g., by age and manner of death)

contributed somewhat to the overall

decrease in use of autopsy and

influenced differentials by other

characteristics. A substantial portion of

the differential in the use of autopsy by

sex, Hispanic origin, race, and place of

death reflect differences in the age and

manner of death. For example, the

disparity in the overall percentage

autopsied between the white and AIAN

population was eliminated, with

differences in the age and manner of

death held constant. This generally

reflects that the AIAN population dies at

younger ages and more often from

external causes, especially accidents,

than the white population. Because

autopsies tend to be more common at

younger ages and for homicide, suicide,

accidents, and undetermined manner,

these differences account for some of

the variations in autopsy by race. The

differential by region increased

somewhat when holding age and manner

of death constant. In part, this reflects

that some regions’ percentage of death

autopsied were relatively low despite the

age and manner of death distribution

and vice versa.

Although the levels generally

decreased, patterns remained similar to

that reported in the literature (3–5) as

well as in earlier vital statistics data.

Autopsies were more common for

younger and male decedents, for certain

circumstances of death involving

violence and differed by place of death.

This suggests that autopsies were more

likely to be done for those deaths that

state laws specify should be investigated

further as well as deaths that occur in

hospitals but for which the contact with

the hospital was brief (i.e., those dying

as an outpatient or in an emergency

room and those pronounced dead on

arrival) rather than for a typical death

(e.g., 65 years of age and over and

pronounced dead at nursing home,

residence, or as an inpatient). In

contrast, persons pronounced at hospice

facilities were unlikely to be autopsied.

These deaths were expected and the

cause(s) resulting in death were likely

recognized, so there would be fewer

questions that an autopsy might resolve.

To some extent, deaths pronounced in

nursing home and long-term care

facilities would be similar to the hospice

facility situation.

Figure 2. Percentage of deaths for which autopsies were reported, by sex: 47 states and

the District of Columbia, 1993 and 2003

Figure 3. Percentage of deaths for which autopsies were reported, by age groups: 47

states and the District of Columbia, 1993 and 2003

Series 20, No. 32 [ Page 5
Page 6 [ Series 20, No. 32

Figure 4. Percentage of deaths for which autopsies were reported, by region and adjusting

for age and manner: 47 states and the District of Columbia, 1993 and 2003

References

1. Hanzlick R. Wrapping things up. Arch

Int Med. 160(20): 3029–31. 2000.

Available from: http://www.cdc.gov/

nchs/data/series/sr_03/sr03_032.pdf.

2. Hill RB, Anderson RE. The autopsy

crisis reexamined: The case for a

national autopsy policy. Milbank

Quarterly 69(1): 51–78. 1991.

3. Council on Scientific Affairs. Autopsy:

A comprehensive review of current

issues. JAMA 258(3): 364–9. 1987.

4. McPhee SJ, Bottles K. Autopsy:

moribund art or vital science? Am J

Med 78(1): 107–13. 1985.

5. Roberts WC. The autopsy: Its decline

and a suggestion for its revival. N Engl

J Med 299: 332–8. 1978.

6. Dalen JE. The moribund autopsy: DNR

or CPR? Arch Int Med. 1997.

157:1633. Available from: http://

www.cdc.gov/nchs/data/series/sr_03/

sr03_032.pdf.

7. National Center for Health Statistics.

1995. Model State Vital Statistics Act

and Regulations. Hyattsville, MD.

8. CDC. Death Investigation Systems

Descriptions. Accessed on February 1,

2006. Available from: http://

www.cdc.gov/epo/dphsi/mecisp/

death_investigation.htm.

9. Pierce County Medical Examiner. 2005

Annual Statistics. Accessed on July 24,

2006. Available from: http://

www.co.pierce.wa.us/pc/abtus/ourorg/

me/stats2005.htm.

10. Washtenaw County Medical Examiner.

Washtenaw County Medical Examiner

2005 Annaul Report. Accessed on July

24, 2006. Available from: http://

www.ewashtenaw.org/government/

departments/public_health/phcontent/

2005%20me%20annual%20report.

11. Burton EC, Nemetz PN. Medical error

and outcomes measures: Where have

all the autopsies gone? Med Gen Med

2(2):E8. 2000.

12. Hanzlick R. National autopsy data

dropped from the National Center for

Health Statistics database. JAMA 280:

886. 1998.

13. Hanzlick R, Parrish RG. The failure of

death certificates to record the

performance of autopsies. JAMA

269(1): 47. 1993.

14. National Center for Health Statistics,

Centers for Disease Control and

Prevention. National Mortality

Followback Survey—Provisional Data,

1993. Public-Use Data File

Documentation (Machine readable data

file and documentation). Hyattsville,

MD. 1998.

15. Shapiro-Mendoza CK, Tomashek KM,

Anderson RN, Wingo J. Recent

national trends in sudden, unexpected

infant deaths: More evidence

supporting a change in classification or

reporting. Am J Epidemiol 163:762–9.

2006.

16. Hoyert DL, Heron MP, Murphy SL,

Kung HC. Deaths: Final data for 2003.

National vital statistics reports; vol 54

no 13. Hyattsville, MD: National

Center for Health Statistics. 2006.

17. World Health Organization.

International Statistical Classification of

Diseases and Related Health Problems,

Tenth Revision. Geneva: World Health

Organization. 1992.

18. National Center for Health Statistics.

ICD-10 cause-of-death lists for

tabulating mortality statistics (updated

October 2002). NCHS instruction

manual: part 9. Hyattsville, MD: Public

Health Service. 2002. Available from:

http://www.cdc.gov/nchs/about/major/

dvs/im.htm.

19. Heron MP, Smith BL. Deaths: Leading

causes for 2003. National vital statistics

reports. Hyattsville, MD: National

Center for Health Statistics.

Forthcoming.

20. Kung HC, Hanzlick R, Spitler JF.

Abstracting data from medical

examiner/coroner reports: Concordance

among abstractors and implications for

data reporting. J Forensic Sci

46(5):1126–31. 2001.

21. Chiang CL. Introduction to stochastic

processes in biostatistics. New York:

Wiley. 1968.

22. Brillinger DR. The natural variability of

vital rates and associated statistics.

Biometrics 42: 693–734. 1986.

23. Martin JA, Hamilton BE, Sutton PD, et

al. Births: Final data for 2003. National

vital statistics reports; vol 54 no 2.

Hyattsville, MD: National Center for

Health Statistics. 2005.
Series 20, No. 32 [ Page 7

Table 1. Number and percentage of deaths for which autopsies were reported: United States, 1955, 1958, 1972–1994 and 47 states and the

District of Columbia, 2003

[By residence]

Year Number Percent

2003 ................................. 173,745 7.7

1994 ................................. 213,879 9.4

1993 ................................. 220,620 9.7

1992 ................................. 224,071 10.3

1991 ................................. 233,707 10.8

1990 ................................. 239,591 11.2

1989 ................................. 247,251 11.5

1988 ................................. 251,095 11.6

1987 ................................. 253,023 11.9

1986 ................................. 257,890 12.2

1985 ................................. 258,596 12.4

1984 ................................. 259,187 12.7

1983 ................................. 266,362 13.2

1982 ................................. 272,431 13.8

1981 ................................. 279,656 14.1

1980 ................................. 291,702 14.7

1979 ................................. 294,182 15.4

1978 ................................. 303,134 15.7

1977 ................................. 309,259 16.3

1976 ................................. 318,830 16.7

1975 ................................. 333,068 17.6

1974 ................................. 355,515 18.4

1973 ................................. 369,655 18.7

1972 ................................. 375,820 19.1

1958 ................................. 315,203 19.1

1955 ................................. 271,797 17.8

NOTE: 2003 data based on 47 states and the District of Columbia.
Page 8 [ Series 20, No. 32

Table 2. Number and percentage of deaths for which autopsies were reported, by state: United States and each state, 1993 and 2003

[By occurrence]

1993 2003

Area Number Percent Number Percent

United States1 ............... 220,620 9.7 174,461 7.1

Alabama ................. 3,015 7.4 2,784 6.1

Alaska................... 672 28.4 290 9.4

Arizona .................. 3,490 10.3 4,660 10.6

Arkansas ................. 1,243 4.7 1,295 4.7

California ................. 31,004 14.0 25,034 10.5

Colorado ................. 3,516 14.5 3,843 12.9

Connecticut ............... 2,555 8.8 1,822 6.2

Delaware ................. 671 10.7 557 7.9

District of Columbia .......... 2,018 22.6 1,573 23.4

Florida .................. 16,587 11.3 3,465 2.1

Georgia .................. 5,497 9.7 5,790 8.6

Hawaii................... 1,058 14.3 938 10.3

Idaho ................... 529 6.5 502 4.9

Illinois .................. 10,130 9.7 8,330 8.1

Indiana .................. 4,022 7.6 2,675 4.7

Iowa .................... 1,804 6.5 1,772 6.4

Kansas .................. 1,735 7.6 1,869 7.8

Kentucky ................. 2,456 6.8 2,284 5.7

Louisiana ................. 4,009 10.1 3,533 8.2

Maine ................... 582 5.0 512 4.1

Maryland ................. 4,177 10.5 4,790 10.8

Massachusetts ............. 5,207 9.2 3,153 5.6

Michigan ................. 8,256 10.2 7,766 9.1

Minnesota ................ 3,753 10.3 - - - - - -

Mississippi ................ 1,672 6.5 2,153 7.7

Missouri.................. 3,829 6.9 3,068 5.4

Montana ................. 627 8.5 521 6.2

Nebraska ................. 1,181 7.8 1,080 6.9

Nevada .................. 1,230 10.4 1,963 10.6

New Hampshire............. 564 6.4 561 5.8

New Jersey ............... 5,482 7.7 4,604 6.4

New Mexico ............... 1,577 13.5 - - - - - -

New York ................. 20,553 12.1 14,932 9.7

North Carolina.............. 5,088 8.1 4,804 6.5

North Dakota .............. 480 7.6 419 6.5

Ohio .................... 9,359 9.1 8,724 8.0

Oklahoma ................ 1,690 5.4 1,661 4.8

Oregon .................. 1,934 7.0 1,371 4.4

Pennsylvania .............. 10,112 8.0 12 0.0

Rhode Island .............. 721 7.3 959 9.4

South Carolina ............. 2,602 8.4 3,012 8.1

South Dakota .............. 450 6.5 413 5.6

Tennessee ................ 2,445 4.7 2,985 5.0

Texas ................... 15,963 11.8 17,249 11.0

Utah .................... 1,059 9.8 1,471 10.7

Vermont ................. 495 9.9 614 12.1

Virginia .................. 3,425 6.7 3,309 5.8

Washington ............... 4,453 11.0 4,300 9.4

West Virginia .............. 1,375 6.8 1,217 5.8

Wisconsin ................ 3,977 9.0 3,578 7.8

Wyoming ................. 291 8.7 244 6.1

---Data not available.

1

Percentage for United States in 2003 includes the states that do not report the item. The percent is 7.7 excluding those three states.
Series 20, No. 32 [ Page 9

Table 3. Number and percentage of deaths for which autopsies were reported, by 10-year age groups, race, and sex: 47 states and the

District of Columbia, 2003

Race and sex Total

Under

1 year

1–4

years

5–14

years

15–24

years

25–34

years

35–44

years

45–54

years

55–64

years

65–74

years

75–84

years

85 years

and over

Not

stated

Number

All races...................

Male .....................

Female ...................

173,745

118,026

55,719

8,093

4,776

3,317

2,344

1,340

1,004

2,629

1,617

1,012

17,190

13,244

3,946

19,295

14,357

4,938

30,479

21,209

9,270

35,592

24,875

10,717

23,307

16,022

7,285

15,727

10,135

5,592

13,167

7,643

5,524

5,725

2,648

3,077

197

160

37

White.....................

Male .....................

Female ...................

132,599

90,359

42,240

5,314

3,197

2,117

1,574

902

672

1,786

1,102

684

11,848

8,974

2,874

13,595

10,067

3,528

23,225

16,381

6,844

27,407

19,400

8,007

18,694

12,988

5,706

12,797

8,336

4,461

11,208

6,546

4,662

4,977

2,327

2,650

174

139

35

Black .....................

Male .....................

Female ...................

35,597

24,024

11,573

2,431

1,363

1,068

676

389

287

719

440

279

4,589

3,741

848

4,952

3,776

1,176

6,364

4,209

2,155

7,166

4,763

2,403

4,008

2,650

1,358

2,487

1,535

952

1,596

902

694

590

239

351

19

17

2

American Indian or Alaska Native . . .

Male .....................

Female ...................

1,770

1,186

584

128

77

51

32

16

16

35

24

11

284

200

84

261

182

79

368

243

125

359

252

107

156

100

56

89

59

30

45

26

19

11

5

6

2

2

–

Asian or Pacific Islander .........

Male .....................

Female ...................

3,779

2,457

1,322

220

139

81

62

33

29

89

51

38

469

329

140

487

332

155

522

376

146

660

460

200

449

284

165

354

205

149

318

169

149

147

77

70

2

2

–

Percent

All races...................

Male .....................

Female ...................

7.7

10.6

4.8

30.6

31.8

29.0

50.0

50.4

49.4

40.3

41.6

38.2

54.9

57.7

47.2

49.6

53.3

41.3

36.3

40.0

29.9

21.5

24.0

17.2

9.5

10.9

7.3

4.1

4.7

3.3

2.0

2.4

1.7

0.9

1.3

0.7

61.2

62.0

57.8

White.....................

Male .....................

Female ...................

6.8

9.6

4.3

30.7

32.4

28.4

47.6

48.5

46.4

37.9

39.3

35.8

51.1

53.2

45.6

48.9

51.6

42.5

37.3

40.7

31.1

21.9

24.3

17.5

9.4

10.9

7.2

4.0

4.6

3.2

1.9

2.3

1.6

0.9

1.2

0.7

62.6

63.5

59.3

Black .....................

Male .....................

Female ...................

12.8

17.0

8.5

30.3

30.2

30.4

58.9

58.2

59.8

48.5

49.5

47.0

67.3

72.4

51.3

52.0

59.0

37.7

33.5

38.1

27.2

20.2

22.7

16.7

9.8

11.2

7.9

4.9

5.7

4.0

2.7

3.3

2.2

1.3

1.7

1.1

*

*

*

American Indian or Alaska Native . . .

Male .....................

Female ...................

15.1

18.9

10.8

43.1

43.0

43.2

39.0

*

*

32.4

36.9

*

52.8

52.1

54.5

47.7

48.5

45.9

34.5

36.7

30.9

22.1

26.2

16.1

8.5

9.8

6.9

4.3

5.4

3.1

2.1

2.6

*

*

*

*

*

*

*

Asian or Pacific Islander .........

Male .....................

Female ...................

9.6

11.9

7.1

26.8

30.5

22.1

39.7

38.4

41.4

39.4

40.2

38.4

60.2

62.9

54.7

49.1

52.5

43.2

31.8

37.7

22.8

19.6

23.4

14.3

9.5

10.3

8.3

4.8

5.1

4.4

3.0

3.1

2.9

1.7

2.1

1.5

*

*

*

– Quantity zero.

* Figure does not meet standards of reliability or precision.
Page 10 [ Series 20, No. 32

Table 4. Number and percentage of deaths for which autopsies were reported, by 10-year age groups, Hispanic origin, and race for

non-Hispanic population, and sex: 47 states and the District of Columbia, 2003

Under 1–4 5–14 15–24 25–34 35–44 45–54 55–64 65–74 75–84 85 years Not

Race and sex Total 1 year years years years years years years years years years and over stated

Number

All origins .................. 173,745 8,093 2,344 2,629 17,190 19,295 30,479 35,592 23,307 15,727 13,167 5,725 197

Male ..................... 118,026 4,776 1,340 1,617 13,244 14,357 21,209 24,875 16,022 10,135 7,643 2,648 160

Female ................... 55,719 3,317 1,004 1,012 3,946 4,938 9,270 10,717 7,285 5,592 5,524 3,077 37

Hispanic ................... 18,143 1,445 474 488 3,229 3,272 3,125 2,667 1,502 1,036 657 220 28

Male ..................... 13,529 860 264 306 2,657 2,708 2,415 2,029 1,087 673 399 107 24

Female ................... 4,614 585 210 182 572 564 710 638 415 363 258 113 4

Non-Hispanic ................ 154,617 6,600 1,864 2,134 13,882 15,941 27,190 32,723 21,652 14,613 12,459 5,478 81

Male ..................... 103,748 3,881 1,072 1,306 10,526 11,583 18,672 22,690 14,812 9,402 7,212 2,528 64

Female ................... 50,869 2,719 792 828 3,356 4,358 8,518 10,033 6,840 5,211 5,247 2,950 17

Non-Hispanic white ............ 114,290 3,903 1,114 1,313 8,660 10,355 20,053 24,677 17,137 11,734 10,526 4,750 68

Male ..................... 76,682 2,357 643 806 6,351 7,382 13,929 17,319 11,852 7,638 6,135 2,217 53

Female ................... 37,608 1,546 471 507 2,309 2,973 6,124 7,358 5,285 4,096 4,391 2,533 15

Non-Hispanic black ............ 35,023 2,381 661 707 4,511 4,877 6,282 7,067 3,928 2,447 1,576 576 10

Male ..................... 23,585 1,328 381 433 3,671 3,717 4,149 4,685 2,587 1,507 887 232 8

Female ................... 11,438 1,053 280 274 840 1,160 2,133 2,382 1,341 940 689 344 2

Percent

All origins .................. 7.7 30.6 50.0 40.3 54.9 49.6 36.3 21.5 9.5 4.1 2.0 0.9 61.2

Male ..................... 10.6 31.8 50.4 41.6 57.7 53.3 40.0 24.0 10.9 4.7 2.4 1.3 62.0

Female ................... 4.8 29.0 49.4 38.2 47.2 41.3 29.9 17.2 7.3 3.3 1.7 0.7 57.8

Hispanic ................... 15.7 28.4 49.5 43.5 63.0 55.5 38.5 22.4 10.7 5.3 2.6 1.2 62.2

Male ..................... 21.0 30.4 48.3 45.5 65.8 59.8 43.3 25.6 12.6 6.2 3.3 1.6 63.2

Female ................... 9.0 25.9 51.2 40.4 52.6 41.3 28.0 16.1 7.6 4.2 2.0 0.9 *

Non-Hispanic ................ 7.2 31.2 50.1 39.6 53.3 48.6 36.0 21.4 9.4 4.0 2.0 0.9 59.6

Male ..................... 9.9 32.3 51.0 40.8 56.0 52.0 39.6 23.8 10.8 4.6 2.4 1.2 57.7

Female ................... 4.6 29.9 49.0 37.8 46.3 41.3 30.1 17.3 7.3 3.3 1.6 0.7 *

Non-Hispanic white ............ 6.3 31.7 47.0 36.3 47.8 47.1 37.1 21.8 9.3 3.9 1.9 0.9 60.2

Male ..................... 8.7 33.3 48.7 37.6 49.3 49.2 40.2 24.2 10.8 4.4 2.3 1.2 58.2

Female ................... 4.0 29.6 44.9 34.5 44.2 42.7 31.4 17.6 7.2 3.1 1.6 0.7 *

Non-Hispanic black ............ 12.7 30.5 59.0 48.4 67.3 52.0 33.5 20.2 9.7 4.9 2.7 1.3 *

Male ..................... 16.9 30.3 58.4 49.3 72.5 59.0 38.0 22.6 11.1 5.6 3.3 1.7 *

Female ................... 8.4 30.8 59.7 47.0 51.4 37.7 27.2 16.7 7.8 4.0 2.2 1.1 *

* Figure does not meet standards of reliability or precision.

Table 5. Number and percentage autopsied, by place of death: 47 states and the District of Columbia, 2003

Place Number Percent

Hospital: 85,895 8.0

Inpatient ................. 42,874 4.9

Outpatient or emergency room.... 36,198 21.2

Dead on arrival ............. 6,823 26.6

Nursing home or long-term care

facility .................... 2,787 0.6

Hospice facility ............... 42 0.8

Residence.................. 50,117 9.2

Other..................... 34,185 23.8

Place unknown............... 719 9.5
Series 20, No. 32 [ Page 11

Table 6. Number and percentage of deaths for which autopsies were reported by 113 selected causes and sex: 47 states and the District of

Columbia, 2003

[The asterisks (*) preceding the cause-of-death codes indicate that they are not part of the International Classification of Diseases, Tenth Revision (ICD–10)]

Number Percent

Cause of death (based on the Both Both

International Classification of Diseases, Tenth Revision, 1992) sexes Male Female sexes Male Female

All causes ........................................ 173,745 118,026 55,719 7.7 10.6 4.8

Salmonella infections .......................... (A01–A02) 4 – 4 * * *

Shigellosis and amebiasis ........................(A03,A06) 2 1 1 * * *

Certain other intestinal infections ................ (A04,A07–A09) 104 51 53 3.7 5.1 2.9

Tuberculosis ............................... (A16–A19) 79 54 25 11.7 13.3 9.3

Respiratory tuberculosis .......................... (A16) 63 45 18 11.8 13.6 *

Other tuberculosis .......................... (A17–A19) 16 9 7 * * *

Whooping cough ............................... (A37) 2 – 2 * * *

Scarlet fever and erysipelas .......................(A38,A46) – – – * * *

Meningococcal infection ........................... (A39) 70 35 35 47.3 50.7 44.3

Septicemia ................................ (A40–A41) 1,278 651 627 4.1 4.7 3.6

Syphilis .................................. (A50–A53) 6 6 – * * *

Acute poliomyelitis .............................. (A80) – – – * * *

Arthropod-borne viral encephalitis .............. (A83–A84,A85.2) 2 2 – * * *

Measles ..................................... (B05) – – – * * *

Viral hepatitis ............................... (B15–B19) 273 195 78 5.3 5.9 4.3

Human immunodeficiency virus (HIV) disease .......... (B20–B24) 600 470 130 4.6 4.8 3.9

Malaria .................................. (B50–B54) 1 1 – * * *

Other and unspecified infectious and parasitic diseases and

their sequelae ........... (A00,A05,A20–A36,A42–A44,A48–A49,

A54–A79,A81–A82,A85.0–A85.1,A85.8,A86–B04,B06–B09,

B25–B49,B55–B99) 622 358 264 9.0 9.7 8.2

Malignant neoplasms .......................... (C00–C97) 6,543 4,146 2,397 1.3 1.6 1.0

Malignant neoplasms of lip, oral cavity and pharynx ..... (C00–C14) 104 91 13 1.4 1.8 *

Malignant neoplasm of esophagus ................... (C15) 144 127 17 1.2 1.4 *

Malignant neoplasm of stomach ..................... (C16) 131 95 36 1.2 1.5 0.8

Malignant neoplasms of colon, rectum and anus ....... (C18–C21) 500 301 199 1.0 1.2 0.8

Malignant neoplasms of liver and intrahepatic bile ducts ...... (C22) 247 182 65 1.8 2.1 1.3

Malignant neoplasm of pancreas .................... (C25) 292 174 118 1.0 1.2 0.8

Malignant neoplasm of larynx ...................... (C32) 65 55 10 1.8 2.0 *

Malignant neoplasms of trachea, bronchus and lung ..... (C33–C34) 1,503 1,087 416 1.0 1.3 0.7

Malignant melanoma of skin ....................... (C43) 58 35 23 0.8 0.8 0.9

Malignant neoplasm of breast ...................... (C50) 271 3 268 0.7 * 0.7

Malignant neoplasm of cervix uteri ................... (C53) 36 – 36 1.0 * 1.0

Malignant neoplasms of corpus uteri and uterus, part

unspecified .............................. (C54–C55) 68 – 68 1.1 * 1.1

Malignant neoplasm of ovary ....................... (C56) 125 – 125 0.9 * 0.9

Malignant neoplasm of prostate ..................... (C61) 187 187 – 0.7 0.7 *

Malignant neoplasms of kidney and renal pelvis ........ (C64–C65) 133 102 31 1.2 1.4 0.7

Malignant neoplasm of bladder ..................... (C67) 86 65 21 0.8 0.8 0.6

Malignant neoplasms of meninges, brain and other parts of

central nervous system ...................... (C70–C72) 182 120 62 1.5 1.8 1.2

Malignant neoplasms of lymphoid, hematopoietic and related

tissue ................................. (C81–C96) 1,099 704 395 2.7 3.2 2.1

Hodgkin’s disease ............................ (C81) 61 35 26 5.0 5.3 4.7

Non–Hodgkin’s lymphoma .................... (C82–C85) 434 279 155 2.2 2.7 1.7

Leukemia .............................. (C91–C95) 604 390 214 3.0 3.5 2.5

Multiple myeloma and immunoproliferative neoplasms . . . (C88,C90) 174 109 65 1.7 2.0 1.3

Other and unspecified malignant neoplasms of lymphoid,

hematopoietic and related tissue ................... (C96) 2 1 1 * * *

All other and unspecified malignant

neoplasms ........ (C17,C23–C24,C26–C31,C37–C41,C44–C49,

C51–C52,C57–C60,C62–C63,C66,C68–C69,C73–C80,C97) 1,136 708 428 2.0 2.4 1.5

In situ neoplasms, benign neoplasms and neoplasms of uncertain

or unknown behavior ......................... (D00–D48) 405 200 205 3.3 3.3 3.3

Anemias .................................. (D50–D64) 229 129 100 5.4 7.6 4.0

Diabetes mellitus ............................ (E10–E14) 1,868 1,123 745 2.7 3.4 2.1

Nutritional deficiencies ......................... (E40–E64) 74 44 30 2.3 3.9 1.5

Malnutrition .............................. (E40–E46) 71 43 28 2.4 4.1 1.5

Other nutritional deficiencies .................... (E50–E64) 3 1 2 * * *

See footnotes at end of table.
Page 12 [ Series 20, No. 32

Table 6. Number and percentage of deaths for which autopsies were reported by 113 selected causes and sex: 47 states and the District of

Columbia, 2003—Con.

[The asterisks (*) preceding the cause-of-death codes indicate that they are not part of the International Classification of Diseases, Tenth Revision (ICD–10)]

Number Percent

Cause of death (based on the Both Both

International Classification of Diseases, Tenth Revision, 1992) sexes Male Female sexes Male Female

Meningitis ................................. (G00,G03) 173 104 69 25.4 28.7 21.6

Parkinson’s disease ........................... (G20–G21) 172 105 67 1.1 1.1 0.9

Alzheimer’s disease .............................. (G30) 443 212 231 0.8 1.2 0.6

Major cardiovascular diseases ..................... (I00–I78) 45,064 30,711 14,353 5.4 7.8 3.2

Diseases of heart ...................(I00–I09,I11,I13,I20–I51) 39,510 27,463 12,047 6.2 8.8 3.7

Acute rheumatic fever and chronic rheumatic heart

diseases ............................... (I00–I09) 171 63 108 5.1 5.9 4.8

Hypertensive heart disease ....................... (I11) 4,388 2,835 1,553 16.1 23.5 10.2

Hypertensive heart and renal disease ................. (I13) 175 103 72 5.9 8.1 4.2

Ischemic heart diseases ...................... (I20–I25) 25,654 18,956 6,698 5.7 8.3 3.1

Acute myocardial infarction ................... (I21–I22) 6,987 5,143 1,844 4.4 6.2 2.5

Other acute ischemic heart diseases ................ (I24) 156 110 46 5.2 7.1 3.1

Other forms of chronic ischemic heart disease ........(I20,I25) 18,511 13,703 4,808 6.5 9.5 3.4

Atherosclerotic cardiovascular disease, so described .... (I25.0) 7,628 5,594 2,034 12.3 16.8 7.1

All other forms of chronic ischemic heart

disease .........................(I20,I25.1–I25.9) 10,883 8,109 2,774 4.9 7.3 2.5

Other heart diseases ........................ (I26–I51) 9,122 5,506 3,616 5.9 8.0 4.1

Acute and subacute endocarditis .................. (I33) 109 66 43 9.5 10.5 8.3

Diseases of pericardium and acute myocarditis .... (I30–I31,I40) 327 185 142 40.7 44.4 36.8

Heart failure ............................... (I50) 502 277 225 1.0 1.4 0.7

All other forms of heart disease .... (I26–I28,I34–I38,I42–I49,I51) 8,184 4,978 3,206 8.1 10.6 5.9

Essential (primary) hypertension and hypertensive

renal disease ............................... (I10,I12) 326 187 139 1.6 2.4 1.1

Cerebrovascular diseases ...................... (I60–I69) 2,943 1,566 1,377 2.0 2.7 1.6

Atherosclerosis ................................ (I70) 187 116 71 1.5 2.5 0.9

Other diseases of circulatory system ................ (I71–I78) 2,098 1,379 719 9.3 11.3 6.9

Aortic aneurysm and dissection ..................... (I71) 1,771 1,202 569 13.1 14.6 10.7

Other diseases of arteries, arterioles and capillaries ..... (I72–I78) 327 177 150 3.6 4.5 2.9

Other disorders of circulatory system ................. (I80–I99) 1,019 503 516 23.0 27.4 19.9

Influenza and pneumonia ........................(J10–J18) 2,548 1,531 1,017 4.2 5.7 3.0

Influenza ................................. (J10–J11) 125 68 57 7.5 10.5 5.6

Pneumonia ................................(J12–J18) 2,423 1,463 960 4.1 5.6 2.9

Other acute lower respiratory infections ...............(J20–J22) 97 58 39 25.0 36.9 16.9

Acute bronchitis and bronchiolitis ..................(J20–J21) 94 56 38 33.1 47.5 22.9

Unspecified acute lower respiratory infection ..............(J22) 3 2 1 * * *

Chronic lower respiratory diseases ..................(J40–J47) 2,337 1,376 961 2.0 2.4 1.6

Bronchitis, chronic and unspecified .................(J40–J42) 70 39 31 8.7 11.8 6.6

Emphysema ..................................(J43) 454 283 171 3.2 4.0 2.5

Asthma ..................................(J45–J46) 663 349 314 17.4 25.1 13.0

Other chronic lower respiratory diseases ............. (J44,J47) 1,150 705 445 1.2 1.5 0.9

Pneumoconioses and chemical effects ............. (J60–J66,J68) 61 57 4 6.7 6.6 *

Pneumonitis due to solids and liquids ....................(J69) 192 116 76 1.2 1.5 1.0

Other diseases of respiratory system . . (J00–J06,J30– J39,J67,J70–J98) 1,311 779 532 5.6 6.9 4.4

Peptic ulcer ................................ (K25–K28) 413 260 153 11.2 14.7 8.0

Diseases of appendix .......................... (K35–K38) 99 61 38 24.1 25.1 22.6

Hernia ................................... (K40–K46) 178 94 84 12.0 15.3 9.7

Chronic liver disease and cirrhosis .............. (K70,K73–K74) 1,892 1,332 560 7.4 8.0 6.3

Alcoholic liver disease ........................... (K70) 1,005 725 280 8.6 8.4 9.1

Other chronic liver disease and cirrhosis ............ (K73–K74) 887 607 280 6.3 7.5 4.8

Cholelithiasis and other disorders of gallbladder ......... (K80–K82) 167 83 84 6.1 6.7 5.6

Nephritis, nephrotic syndrome and

nephrosis ................... (N00–N07,N17–N19,N25–N27) 654 362 292 1.7 1.9 1.5

Acute and rapidly progressive nephritic and nephrotic

syndrome (N00–N01,N04) 8 5 3 * * *

Chronic glomerulonephritis, nephritis and nephropathy not

specified as acute or chronic, and renal sclerosis

unspecified ..................... (N02–N03,N05–N07,N26) 29 18 11 5.8 * *

Renal failure .............................. (N17–N19) 616 338 278 1.6 1.9 1.4

Other disorders of kidney ...................... (N25,N27) 1 1 – * * *

See footnotes at end of table.
Series 20, No. 32 [ Page 13

Table 6. Number and percentage of deaths for which autopsies were reported by 113 selected causes and sex: 47 states and the District of

Columbia, 2003—Con.

[The asterisks (*) preceding the cause-of-death codes indicate that they are not part of the International Classification of Diseases, Tenth Revision (ICD–10)]

Number Percent

Cause of death (based on the Both Both

International Classification of Diseases, Tenth Revision, 1992) sexes Male Female sexes Male Female

Infections of kidney ................... (N10–N12,N13.6,N15.1) 105 37 68 13.5 15.7 12.5

Hyperplasia of prostate ........................... (N40) 20 20 – 4.4 4.4 *

Inflammatory diseases of female pelvic organs .......... (N70–N76) 29 ... 29 25.7 ... 25.7

Pregnancy, childbirth and the puerperium ............. (O00–O99) 311 ... 311 60.3 ... 60.3

Pregnancy with abortive outcome ................. (O00–O07) 24 ... 24 63.2 ... 63.2

Other complications of pregnancy, childbirth and the

puerperium ............................. (O10–O99) 287 ... 287 60.0 ... 60.0

Certain conditions originating in the perinatal period ....... (P00–P96) 1,740 1,026 714 12.9 13.3 12.2

Congenital malformations, deformations and chromosomal

abnormalities .............................. (Q00–Q99) 2,047 1,192 855 20.8 23.2 18.1

Symptoms, signs and abnormal clinical and laboratory findings,

not elsewhere classified ....................... (R00–R99) 9,736 6,052 3,684 34.7 45.8 24.8

All other diseases .............................(Residual) 11,514 6,799 4,715 6.2 9.0 4.3

Accidents (unintentional injuries) ............. (V01–X59,Y85–Y86) 44,148 30,823 13,325 43.7 47.1 37.3

Transport accidents ...................... (V01–V99,Y85) 19,546 13,838 5,708 43.4 44.3 41.2

Motor vehicle accidents ....... (V02–V04,V09.0,V09.2,V12–V14,

V19.0–V19.2,V19.4–V19.6,V20–V79,V80.3–V80.5,

V81.0–V81.1,V82.0–V82.1,V83–V86,V87.0–V87.8,

V88.0–V88.8,V89.0,V89.2) 17,876 12,462 5,414 42.6 43.4 40.9

Other land transport accidents .......... (V01,V05–V06,V09.1,

V09.3–V09.9,V10–V11,V15–V18,V19.3,V19.8–V19.9,

V80.0–V80.2,V80.6–V80.9,V81.2–V81.9,

V82.2–V82.9,V87.9,V88.9,V89.1,V89.3,V89.9) 666 520 146 52.5 53.2 50.2

Water, air and space, and other and unspecified transport

accidents and their sequelae .............. (V90–V99,Y85) 1,004 856 148 54.6 57.1 43.7

Nontransport accidents .................... (W00–X59,Y86) 24,602 16,985 7,617 43.9 49.7 34.8

Falls ................................ (W00–W19) 3,314 2,135 1,179 21.2 26.3 15.8

Accidental discharge of firearms ............... (W32–W34) 415 369 46 60.7 60.0 66.7

Accidental drowning and submersion ............ (W65–W74) 2,000 1,566 434 63.7 62.7 67.5

Accidental exposure to smoke, fire and flames ....... (X00–X09) 1,859 1,090 769 59.3 59.8 58.7

Accidental poisoning and exposure to noxious

substances ............................ (X40–X49) 12,857 8,734 4,123 72.5 73.0 71.3

Other and unspecified nontransport accidents and their

sequelae ......... (W20–W31,W35–W64,W75–W99,X10–X39,

X50–X59,Y86) 4,157 3,091 1,066 26.4 33.8 16.2

Intentional self-harm (suicide) ..............(*U03,X60–X84,Y87.0) 15,178 11,780 3,398 51.8 50.3 57.7

Intentional self-harm (suicide) by discharge of firearms .... (X72–X74) 7,683 6,635 1,048 48.9 48.2 53.5

Intentional self-harm (suicide) by other and unspecified means

and their sequelae ............(*U03,X60–X71,X75–X84,Y87.0) 7,495 5,145 2,350 55.2 53.3 59.8

Assault (homicide) ................ (*U01–*U02,X85–Y09,Y87.1) 15,388 12,108 3,280 91.8 92.3 90.0

Assault (homicide) by discharge of firearms ......(*U01.4,X93–X95) 10,383 8,880 1,503 92.0 92.7 87.8

Assault (homicide) by other and unspecified means and their

sequelae ........ (*U01.0–*U01.3,*U01.5–*U01.9,*U02,X85–X92,

X96–Y09,Y87.1) 5,005 3,228 1,777 91.5 91.3 91.9

Legal intervention ........................... (Y35,Y89.0) 330 317 13 81.7 81.5 *

Events of undetermined intent ............ (Y10–Y34,Y87.2,Y89.9) 3,740 2,420 1,320 76.7 76.2 77.5

Discharge of firearms, undetermined intent ........... (Y22–Y24) 165 128 37 76.0 73.6 86.1

Other and unspecified events of undetermined intent and their

sequelae ................. (Y10–Y21,Y25–Y34,Y87.2,Y89.9) 3,575 2,292 1,283 76.7 76.4 77.3

Operations of war and their sequelae ............... (Y36,Y89.1) 1 1 – * * *

Complications of medical and surgical care ......... (Y40–Y84,Y88) 476 241 235 18.7 20.3 17.3

– Quantity zero.

* Figure does not meet standards of reliability or precision.

...Category not applicable.
Table 7. Number and percentage of infant deaths for which autopsies were reported, by 130 selected causes and sex: 47 states and the

District of Columbia, 2003

Cause of death (based on the

International Classification of Diseases, Tenth Revision, 1992)

Number Percent

Both

sexes Male Female

Both

sexes Male Female

All causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,093 4,776 3,317 30.6 31.8 29.0

Certain infectious and parasitic diseases . . . . . . . . . . . . . . . . . (A00–B99) 169 86 83 35.7 34.4 37.2

Certain intestinal infectious diseases . . . . . . . . . . . . . . . . . . (A00–A08) 8 3 5 * * *

Diarrhea and gastroenteritis of infectious origin . . . . . . . . . . . . . . (A09) 1 1 – * * *

Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (A16–A19) – – – * * *

Tetanus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (A33,A35) – – – * * *

Diphtheria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (A36) – – – * * *

Whooping cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (A37) 2 – 2 * * *

Meningococcal infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (A39) 4 4 – * * *

Septicemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (A40–A41) 81 46 35 30.6 30.9 30.2

Congenital syphilis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (A50) – – – * * *

Gonococcal infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (A54) – – – * * *

Viral diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (A80–B34) 60 24 36 53.6 50.0 56.3

Acute poliomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (A80) – – – * * *

Varicella (chickenpox) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (B01) – – – * * *

Measles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (B05) – – – * * *

Human immunodeficiency virus (HIV) disease . . . . . . . . . . . (B20–B24) 1 – 1 * * *

Mumps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (B26) – – – * * *

Other and unspecified viral diseases . . . . . . . . . .(A81–B00,B02–B04,

B06–B19,B25,B27–B34) 59 24 35 55.1 52.2 57.4

Candidiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (B37) 4 2 2 * * *

Malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (B50–B54) – – – * * *

Pneumocystosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (B59) 1 1 – * * *

All other and unspecified infectious and parasitic

diseases . . . . . . (A20–A32,A38,A42–A49,A51–A53,A55–A79,B35–B36,

B38–B49,B55–B58,B60–B99) 8 5 3 * * *

Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (C00–D48) 35 15 20 27.3 * 31.3

Malignant neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . (C00–C97) 17 6 11 * * *

Hodgkin’s disease and non-Hodgkin’s lymphomas . . . . . . . (C81–C85) – – – * * *

Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (C91–C95) 6 1 5 * * *

Other and unspecified malignant neoplasms . . . . . . . . . . . .(C00–C80,

C88–C90,C96–C97) 11 5 6 * * *

In situ neoplasms, benign neoplasms and neoplasms of uncertain

or unknown behavior . . . . . . . . . . . . . . . . . . . . . . . . . . (D00–D48) 18 9 9 * * *

Diseases of the blood and blood-forming organs and certain disorders

involving the immune mechanism . . . . . . . . . . . . . . . . . . . (D50–D89) 33 22 11 35.1 41.5 *

Anemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (D50–D64) 11 7 4 * * *

Hemorrhagic conditions and other diseases of blood and

blood-forming organs . . . . . . . . . . . . . . . . . . . . . . . . . . (D65–D76) 17 12 5 * * *

Certain disorders involving the immune mechanism . . . . . . . . (D80–D89) 5 3 2 * * *

Endocrine, nutritional and metabolic diseases . . . . . . . . . . . . . . (E00–E88) 92 47 45 39.1 34.6 45.5

Short stature, not elsewhere classified . . . . . . . . . . . . . . . . . . . (E34.3) 2 – 2 * * *

Nutritional deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . (E40–E64) 3 2 1 * * *

Cystic fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (E84) 4 3 1 * * *

Volume depletion, disorders of fluid, electrolyte and acid-base

balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (E86–E87) 20 10 10 26.7 * *

All other endocrine, nutritional and metabolic

diseases . . . . . (E00–E32,E34.0–E34.2,E34.4–E34.9,E65–E83,E85,E88) 63 32 31 46.7 42.7 51.7

Diseases of the nervous system . . . . . . . . . . . . . . . . . . . . . (G00–G98) 99 56 43 26.5 26.8 26.1

Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (G00,G03) 24 14 10 32.4 * *

Infantile spinal muscular atrophy, type I (Werdnig-Hoffman) . . . . . .(G12.0) 3 1 2 * * *

Infantile cerebral palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (G80) 1 1 – * * *

Anoxic brain damage, not elsewhere classified . . . . . . . . . . . . .(G93.1) 26 16 10 60.5 * *

Other diseases of nervous system . . . . . . . (G04,G06–G11,G12.1–G12.9,

G20–G72,G81–G92,G93.0,G93.2–G93.9,G95–G98) 45 24 21 19.5 18.6 20.6

Diseases of the ear and mastoid process . . . . . . . . . . . . . . . (H60–H93) 4 3 1 * * *

Diseases of the circulatory system . . . . . . . . . . . . . . . . . . . . . (I00–I99) 227 132 95 40.0 41.4 38.2

Pulmonary heart disease and diseases of pulmonary

circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (I26–I28) 37 22 15 29.4 30.6 *

Pericarditis, endocarditis and myocarditis . . . . . . . . . . . . . . (I30,I33,I40) 23 11 12 88.5 * *

Cardiomyopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (I42) 63 37 26 51.2 54.4 47.3

See footnotes at end of table.

Page 14 [ Series 20, No. 32
Table 7. Number and percentage of infant deaths for which autopsies were reported, by 130 selected causes and sex: 47 states and the

District of Columbia, 2003—Con.

Cause of death (based on the

International Classification of Diseases, Tenth Revision, 1992)

Number Percent

Both

sexes Male Female

Both

sexes Male Female

Cardiac arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (I46) 8 7 1 * * *

Cerebrovascular diseases . . . . . . . . . . . . . . . . . . . . . . . . . (I60–I69) 27 16 11 27.3 * *

All other diseases of circulatory system . . . . . . . . . (I00–I25,I31,I34–I38,

I44–I45,I47–I51,I70–I99) 69 39 30 39.0 38.2 40.0

Diseases of the respiratory system ....................(J00–J98) 407 252 155 60.8 62.5 58.3

Acute upper respiratory infections ....................(J00–J06) 11 6 5 * * *

Influenza and pneumonia .........................(J10–J18) 220 132 88 71.4 72.1 70.4

Influenza ..................................(J10–J11) 15 9 6 * * *

Pneumonia ................................(J12–J18) 205 123 82 73.7 74.1 73.2

Acute bronchitis and acute bronchiolitis ................(J20–J21) 40 27 13 76.9 81.8 *

Bronchitis, chronic and unspecified ...................(J40–J42) 16 12 4 * * *

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (J45–J46) 6 4 2 * * *

Pneumonitis due to solids and liquids ....................(J69) 6 3 3 * * *

Other and unspecified diseases of respiratory

system ............... (J22,J30–J39,J43–J44,J47–J68,J70–J98) 108 68 40 42.0 44.7 38.1

Diseases of the digestive system . . . . . . . . . . . . . . . . . . . . . (K00–K92) 142 89 53 27.3 27.6 26.6

Gastritis, duodenitis, and noninfective enteritis and

colitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (K29,K50–K55) 64 40 24 22.3 22.2 22.4

Hernia of abdominal cavity and intestinal obstruction without

hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (K40–K46,K56) 23 12 11 36.5 * *

All other and unspecified diseases of digestive

system . . . . . . . . . . . . . . . . . . . . . . (K00–K28,K30–K38,K57–K92) 55 37 18 32.2 34.3 *

Diseases of the genitourinary system . . . . . . . . . . . . . . . . . . (N00–N95) 29 18 11 14.8 * *

Renal failure and other disorders of kidney . . . . . . . .(N17–N19,N25,N27) 18 10 8 * * *

Other and unspecified diseases of genitourinary

system . . . . . . . . . . . . . . . . . . . (N00–N15,N20–N23,N26,N28–N95) 11 8 3 * * *

Certain conditions originating in the perinatal period . . . . . . . . . . (P00–P96) 1,705 1,005 700 12.7 13.2 12.1

Newborn affected by maternal factors and by complications of

pregnancy, labor and delivery . . . . . . . . . . . . . . . . . . . . . (P00–P04) 326 180 146 11.2 11.3 11.0

Newborn affected by maternal hypertensive disorders . . . . . . . . (P00.0) 10 7 3 * * *

Newborn affected by other maternal conditions which

may be unrelated to present pregnancy . . . . . . . . . . . (P00.1–P00.9) 20 10 10 25.3 * *

Newborn affected by maternal complications of pregnancy . . . . . . (P01) 122 77 45 7.7 8.8 6.4

Newborn affected by incompetent cervix . . . . . . . . . . . . . . . (P01.0) 21 11 10 5.0 * *

Newborn affected by premature rupture of membranes . . . . . . (P01.1) 52 37 15 7.8 10.3 *

Newborn affected by multiple pregnancy . . . . . . . . . . . . . . . (P01.5) 16 8 8 * * *

Newborn affected by other maternal complications of

pregnancy . . . . . . . . . . . . . . . . . . . . (P01.2–P01.4,P01.6–P01.9) 33 21 12 15.3 15.1 *

Newborn affected by complications of placenta, cord and

membranes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P02) 129 65 64 12.7 11.8 13.8

Newborn affected by complications involving

placenta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P02.0–P02.3) 64 32 32 11.7 10.7 12.8

Newborn affected by complications involving cord . . . . (P02.4–P02.6) 9 2 7 * * *

Newborn affected by chorioamnionitis . . . . . . . . . . . . . . . . (P02.7) 56 31 25 13.1 13.4 12.7

Newborn affected by other and unspecified abnormalities

of membranes . . . . . . . . . . . . . . . . . . . . . . . . . (P02.8–P02.9) – – – * * *

Newborn affected by other complications of labor and

delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P03) 22 7 15 14.9 * *

Newborn affected by noxious influences transmitted via

placenta or breast milk . . . . . . . . . . . . . . . . . . . . . . . . . . . (P04) 23 14 9 59.0 * *

Disorders related to length of gestation and fetal

malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P05–P08) 382 233 149 8.2 8.8 7.4

Slow fetal growth and fetal malnutrition . . . . . . . . . . . . . . . . . . (P05) 10 7 3 * * *

Disorders related to short gestation and low birth weight, not

elsewhere classified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P07) 372 226 146 8.1 8.7 7.3

Extremely low birth weight or extreme immaturity . . . . . (P07.0,P07.2) 264 166 98 7.6 8.4 6.5

Other low birth weight or preterm . . . . . . . . . . . . . . . (P07.1,P07.3) 108 60 48 9.8 9.7 9.8

Disorders related to long gestation and high birth weight . . . . . . . (P08) – – – * * *

Birth trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P10–P15) 9 4 5 * * *

Intrauterine hypoxia and birth asphyxia . . . . . . . . . . . . . . . . (P20–P21) 117 70 47 22.2 24.7 19.3

Intrauterine hypoxia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P20) 33 23 10 32.4 41.1 *

Birth asphyxia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P21) 84 47 37 19.8 20.7 18.8

See footnotes at end of table.

Series 20, No. 32 [ Page 15
Table 7. Number and percentage of infant deaths for which autopsies were reported, by 130 selected causes and sex: 47 states and the

District of Columbia, 2003—Con.

Cause of death (based on the

International Classification of Diseases, Tenth Revision, 1992)

Number Percent

Both

sexes Male Female

Both

sexes Male Female

Respiratory distress of newborn . . . . . . . . . . . . . . . . . . . . . . . . (P22) 89 53 36 11.6 11.7 11.4

Other respiratory conditions originating in the perinatal

period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P23–P28) 230 137 93 19.9 19.5 20.6

Congenital pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P23) 33 23 10 44.6 54.8 *

Neonatal aspiration syndromes . . . . . . . . . . . . . . . . . . . . . . . (P24) 27 10 17 54.0 * *

Interstitial emphysema and related conditions originating in the

perinatal period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P25) 17 10 7 * * *

Pulmonary hemorrhage originating in the perinatal period . . . . . . (P26) 28 14 14 18.2 * *

Chronic respiratory disease originating in the perinatal period . . . . (P27) 49 34 15 19.8 21.4 *

Atelectasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P28.0–P28.1) 66 40 26 15.6 15.4 16.0

All other respiratory conditions originating in the perinatal

period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (P28.2–P28.9) 10 6 4 * * *

Infections specific to the perinatal period . . . . . . . . . . . . . . . (P35–P39) 177 103 74 19.1 19.0 19.4

Bacterial sepsis of newborn . . . . . . . . . . . . . . . . . . . . . . . . . (P36) 138 81 57 18.7 18.5 18.9

Omphalitis of newborn with or without mild hemorrhage . . . . . . . . (P38) 2 1 1 * * *

All other infections specific to the perinatal period . . . . . (P35,P37,P39) 37 21 16 20.2 20.2 *

Hemorrhagic and hematological disorders of newborn . . . . . . . (P50–P61) 86 54 32 12.1 12.7 11.2

Neonatal hemorrhage . . . . . . . . . . . . . . . . . . . . . . . (P50–P52,P54) 64 39 25 10.4 10.8 9.7

Hemorrhagic disease of newborn . . . . . . . . . . . . . . . . . . . . . (P53) – – – * * *

Hemolytic disease of newborn due to isoimmunization and other

perinatal jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . (P55–P59) 3 1 2 * * *

Hematological disorders . . . . . . . . . . . . . . . . . . . . . . . . (P60–P61) 19 14 5 * * *

Syndrome of infant of a diabetic mother and neonatal diabetes

mellitus (P70.0–P70.2) 2 2 – * * *

Necrotizing enterocolitis of newborn . . . . . . . . . . . . . . . . . . . . . (P77) 58 36 22 15.2 16.3 13.7

Hydrops fetalis not due to hemolytic disease . . . . . . . . . . . . . . . (P83.2) 67 42 25 37.0 42.4 30.5

Other perinatal conditions . . . . . . . . . . . . . . .(P29,P70.3–P76,P78–P81,

P83.0–P83.1,P83.3–P83.9,P90–P96) 162 91 71 13.7 13.6 13.9

Congenital malformations, deformations and chromosomal

abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Q00–Q99) 1,232 714 518 23.3 25.1 21.2

Anencephaly and similar malformations . . . . . . . . . . . . . . . . . . . (Q00) 15 5 10 * * *

Congenital hydrocephalus . . . . . . . . . . . . . . . . . . . . . . . . . . . (Q03) 21 10 11 22.1 * *

Spina bifida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Q05) 1 – 1 * * *

Other congenital malformations of nervous system . . . . . (Q01–Q02,Q04,

Q06–Q07) 60 33 27 20.0 20.9 19.0

Congenital malformations of heart . . . . . . . . . . . . . . . . . . (Q20–Q24) 458 266 192 33.9 34.9 32.7

Other congenital malformations of circulatory system . . . . . . . (Q25–Q28) 62 31 31 27.3 25.2 29.8

Congenital malformations of respiratory system . . . . . . . . . . (Q30–Q34) 157 93 64 26.7 27.6 25.4

Congenital malformations of digestive system . . . . . . . . . . . (Q35–Q45) 35 24 11 39.3 44.4 *

Congenital malformations of genitourinary system . . . . . . . . . (Q50–Q64) 80 63 17 25.3 28.3 *

Congenital malformations and deformations of musculoskeletal

system, limbs and integument . . . . . . . . . . . . . . . . . . . . (Q65–Q85) 123 79 44 24.2 27.3 20.1

Down’s syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Q90) 19 9 10 * * *

Edward’s syndrome . . . . . . . . . . . . . . . . . . . . . . . . . (Q91.0–Q91.3) 16 7 9 * * *

Patau’s syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . (Q91.4–Q91.7) 11 5 6 * * *

Other congenital malformations and deformations . . . (Q10–Q18,Q86–Q89) 145 77 68 29.5 30.0 29.1

Other chromosomal abnormalities, not elsewhere classified . . . (Q92–Q99) 29 12 17 15.4 * *

Symptoms, signs and abnormal clinical and laboratory findings,

not elsewhere classified . . . . . . . . . . . . . . . . . . . . . . . . . (R00–R99) 2,846 1,697 1,149 89.9 90.1 89.7

Sudden infant death syndrome . . . . . . . . . . . . . . . . . . . . . . . . (R95) 1,889 1,110 779 92.2 91.9 92.6

Other symptoms, signs and abnormal clinical and laboratory findings,

not elsewhere classified . . . . . . . . . . . . (R00–R53,R55–R94,R96–R99) 957 587 370 85.8 87.0 84.1

All other diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Residual) 4 4 – * * *

External causes of mortality . . . . . . . . . . . . . . . . . . . . . (*U01,V01–Y84) 1,069 636 433 81.4 83.4 78.6

Accidents (unintentional injuries) . . . . . . . . . . . . . . . . . . . . (V01–X59) 701 411 290 77.5 79.8 74.6

Transport accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . (V01–V99) 72 40 32 50.7 52.6 48.5

Motor vehicle accidents . . . . . . . . (V02–V04,V09.0,V09.2,V12–V14,

V19.0–V19.2,V19.4–V19.6,V20–V79,V80.3–V80.5,V81.0–V81.1,

V82.0–V82.1,V83–V86,V87.0–V87.8,V88.0–V88.8,V89.0,V89.2) 70 39 31 50.4 52.0 48.4

See footnotes at end of table.

Page 16 [ Series 20, No. 32
Table 7. Number and percentage of infant deaths for which autopsies were reported, by 130 selected causes and sex: 47 states and the

District of Columbia, 2003—Con.

Cause of death (based on the

International Classification of Diseases, Tenth Revision, 1992)

Number Percent

Both

sexes Male Female

Both

sexes Male Female

Other and unspecified transport accidents . . . . . . . . . . . . . . . (V01,

V05–V06,V09.1,V09.3–V09.9,V10–V11,V15–V18,V19.3,V19.8,

V19.9,V80.0–V80.2,V80.6–V80.9,V81.2–V81.9,V82.2–V82.9,

V87.9,V88.9,V89.1,V89.3,V89.9,V90–V99) 2 1 1 * * *

Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (W00–W19) – – – * * *

Accidental discharge of firearms . . . . . . . . . . . . . . . . . . (W32–W34) 12 7 5 * * *

Accidental drowning and submersion . . . . . . . . . . . . . . . (W65–W74) 45 26 19 80.4 76.5 *

Accidental suffocation and strangulation in bed . . . . . . . . . . . . .(W75) 345 210 135 85.0 85.4 84.4

Other accidental suffocation and strangulation . . (W76–W77,W81–W84) 114 68 46 87.7 87.2 88.5

Accidental inhalation and ingestion of food or other objects causing

obstruction of respiratory tract . . . . . . . . . . . . . . . . . . . (W78–W80) 41 21 20 71.9 72.4 71.4

Accidents caused by exposure to smoke, fire and flames . . . . (X00–X09) 15 6 9 * * *

Accidental poisoning and exposure to noxious substances . . . (X40–X49) 17 7 10 * * *

Other and unspecified accidents . . . . . . . . . . . (W20–W31,W35–W64,

W85–W99,X10–X39,X50–X59) 40 26 14 78.4 92.9 *

Assault (homicide) . . . . . . . . . . . . . . . . . . . . . . . . . (*U01,X85–Y09) 299 181 118 92.3 93.8 90.1

Assault (homicide) by hanging, strangulation and suffocation . . . . (X91) 35 21 14 92.1 100.0 *

Assault (homicide) by discharge of firearms . . . . . . . (*U01.4,X93–X95) 8 7 1 * * *

Neglect, abandonment and other maltreatment syndromes . . . (Y06–Y07) 90 59 31 92.8 92.2 93.9

Assault (homicide) by other and unspecified means . . . (*U01.0–*U01.3,

*U01.5–*U01.9,X85–X90,X92,X96–X99,Y00–Y05,Y08–Y09) 166 94 72 91.7 93.1 90.0

Complications of medical and surgical care . . . . . . . . . . . . . . (Y40–Y84) 10 6 4 * * *

Other external causes and their sequelae . . . . . . . . (X60–X84,Y10–Y36) 59 38 21 83.1 80.9 87.5

– Quantity zero.

* Figure does not meet standards of reliability or precision.

Series 20, No. 32 [ Page 17
Page 18 [ Series 20, No. 32

Appendix

Technical Notes

Nature and sources of data

Data in this report are primarily

based on information from all death

certificates filed in the 50 states and the

District of Columbia and are processed

by the Centers for Disease Control and

Prevention’s National Center for Health

Statistics (NCHS). Mortality statistics

are based on information coded by the

states and provided to NCHS through

the Vital Statistics Cooperative Program

and from copies of the original

certificates received by NCHS from the

state registration offices. In 2003, all

the states and the District of Columbia

participated in this program and

submitted part or all of the mortality

data for 2003 in electronic data files to

NCHS. Additional information on the

data is available (16). See later section

on the National Mortality Followback

Survey for information on the source

data for some of the information on the

quality of autopsy data.

Cause-of-death classification

The mortality statistics presented in

this report were compiled in accordance

with the World Health Organization

(WHO) regulations, which specify that

member nations classify and code

causes of death in accordance with the

current revision of the International

Classification of Diseases (ICD). The

ICD provides the basic guidance used in

virtually all countries to code and

classify causes of death. Effective with

deaths occurring in 1999, the United

States began using the Tenth Revision of

this classification (ICD-10) (16,17).

These guidelines on cause-of-death

classification incorporate circumstances

and manner of death into its structure

and refers to the categories in the

classification as causes of death.

Tabulation lists for ICD-10 are

published in the NCHS Instruction

Manual, Part 9, ICD-10 Cause-of-Death

Lists for Tabulating Mortality Statistics

(Updated October 2002) (18). This

report uses two tabulation lists: the List

of 113 Selected Causes of Death for

deaths of all ages, and the List of 130

Selected Causes of Infant Death for

infants. These lists are also used to rank

leading causes of death for the two

population groups. More detail regarding

ranking procedures can be found in

‘‘Deaths: Leading Causes for 2003’’

(19).

Race and Hispanic origin

In order to provide uniformity and

comparability of race data during the

transition period between single-race

reporting and multiple-race reporting,

before all or most of the data are

available in the new multiple-race

format, it was necessary to ‘‘bridge’’ the

responses of those for whom more than

one race was reported (multiple race) to

one, single race. Additional details on

race reporting and the bridging

procedure are available (16).

Race and Hispanic origin are

reported separately on the death

certificate. Therefore, data shown by

race include persons of Hispanic and

non-Hispanic origin, and data for

Hispanic origin include persons of any

race. In this report, unless otherwise

specified, deaths of Hispanic origin are

included in the totals for each race

group—white, black, American Indian

or Alaska Native (AIAN), and Asian or

Pacific Islander (API)—according to

the decedent’s race as reported on the

death certificate. Data shown for

Hispanic persons include all persons of

Hispanic origin of any race.

Place death pronounced

Beginning with data for 2003, states

are beginning to add a category for

deaths occurring in licensed hospice

facilities. Unknown place of death

includes deaths thought to occur in

hospitals but for which the decedent’s

status was unknown.

National Mortality Followback

Survey

The National Mortality Followback

Survey (NMFS) is a survey conducted

to provide additional information related

to the mortality experience of the United

States beyond that obtained through the

vital registration of deaths. The survey

was composed of a sample of 22,957

death certificates for individuals aged 15

years or over who died in 1993 in 49

states and the District of Columbia. In

the 1993 NMFS, additional information

was collected from medical examiner or

coroner offices if the death was due to

homicide, suicide, accidents, pending

and undetermined causes, a medical

examiner or coroner certified the death,

and the proxy respondent authorized

release of the medical examiner or

coroner records. Thus, additional

information was not collected for deaths

from natural causes. A total of 6,671

records were included in this subsample.

Of these, 4,696 medical examiner or

coroner reports were received (20).

Random variation

Mortality data are not subject to

sampling error. Mortality data, even

based on complete counts, may be

affected by random variation. That is,

the number of deaths that actually

occurred may be considered as one of a

large series of possible results that could

have arisen under the same

circumstances (21,22). When the

number of deaths is small (perhaps less

than 100), random variation tends to be

relatively large. Therefore, considerable

caution must be observed in interpreting

statistics based on small numbers of

deaths.

To quantify the random variation

associated with mortality statistics,

deaths, as infrequent events, can be

viewed as deriving from a Poisson

probability distribution. The Poisson

distribution is simple conceptually and

computationally, and provides

reasonable, conservative variance

estimates for mortality statistics when

the probability of dying is relatively low

(22). Confidence limits for numbers and

percentages can be estimated from the

actual number of vital events.

When the number of vital events is

large, the distribution is assumed to

follow a normal distribution (where the

relative standard error is small). When

the number of events is small and the

probability of the event is small, the

distribution is assumed to follow a
Series 20, No. 32 [ Page 19

Poisson probability distribution.

Considerable caution should be observed

in interpreting the occurrence of

infrequent events. An asterisk (*) will be

shown for any percentage that is based

on fewer than 20 deaths in the

numerator.

Computing 95 percent confidence

intervals for percentages—A 95-percent

confidence interval can be computed for

a percentage when the following

conditions are met (23):

D x p ≥ 5 and D x q ≥ 5

where

D = number of deaths in the denominator

p = percent divided by 100

q =1– p

For mortality data, these conditions

will be met except for very rare events

in small subgroups. If the conditions are

not met, the variation in the percentage

will be so large as to render the

confidence intervals meaningless. When

these conditions are met the 95 percent

confidence interval can be computed

using the normal approximation of the

binomial. The 95 percent confidence

intervals are computed by the following

formulas:

Lower limit = p – [1.96 x (√pxq/D)]

Upper limit = p + [1.96 x (√pxq/D)]

where

p = percent divided by 100

q =1– p

D = number of deaths in the

denominator

Example—Suppose that the

percentage of deaths among females

aged 15–24 in Arizona that were

autopsied was 49.7 percent. This was

based on 14,751 deaths in the numerator

and 29,682 deaths in the denominator.

First we test to make sure we can use

the normal approximation of the

binomial:

29,682 x 0.497 = 14,752

29,682 x (1 – 0.497) = 29,682 x 0.503 = 14,930

Both 14,752 and 14,930 are greater

than 5 so we can proceed. The 95

percent confidence interval would be:

Lower limit = 0.497 – [1.96 x

(√0.497 x 0.503 / 29,682)]

= 0.497 – 0.006

= 0.491 or 49.1 percent

Upper limit = 0.497 + [1.96 x

(√0.497 x 0.503 / 29,682)]

= 0.497 + 0.006

= 0.503 or 50.3 percent

This means that the chances are 95

out of 100 that the actual percentage of

deaths of females aged 15–24 years that

were autopsied in Arizona would be

between 49.1 and 50.3 percent.

Testing differences between two

percentages—When testing the

difference between two percentages,

both percentages must meet the

following conditions:

D x p ≥ 5 and D x q ≥ 5

where

D = number of deaths in the denominator

p = percent divided by 100

q =1– p

When both percentages meet these

conditions, then the difference between

the two percentages is considered

statistically significant if it is greater

than the statistic in the formula below.

This statistic equals 1.96 times the

standard error for the difference between

two percentages.

1

1.96 x Œ[p x (1 – p) x S 1 + D] D1 D2

where

D1 = number of deaths in the denominator of

the first percentage

D2 = number of deahts in the denominator of

the second percentage

[(D1 x p1

) + (D2 x p2)]

p = (D1 + D2

)

p1 = the first percentage

p 2 = the second percentage

Example—Is the percentage of

deaths to females aged 15–24 years that

were autopsied higher in New Mexico

(50.2) than in Arizona (49.7)? Suppose

that the number in the denominator was

13,714 in New Mexico and 29,682 in

Arizona. The necessary conditions are

met for both percentages (calculations

not shown). The difference between the

two percentages is 0.502 – 0.497 =

0.005. The statistic is then calculated as

follows:

1.96 x √ ( 0.499 x 0.501) x (0.000106609)

= 1.96 x √0.000026652

= 1.96 x 0.005162563

= 0.010

The difference between the

percentages (0.005) is less than this

statistic (0.010). Therefore, the

difference is not statistically significant

at the 95 percent confidence level.
Vital and Health Statistics

series descriptions

SERIES 1. Programs and Collection Procedures—These reports

describe the data collection programs of the National Center

for Health Statistics. They include descriptions of the methods

used to collect and process the data, definitions, and other

material necessary for understanding the data.

SERIES 2. Data Evaluation and Methods Research—These reports

are studies of new statistical methods and include analytical

techniques, objective evaluations of reliability of collected

data, and contributions to statistical theory. These studies

also include experimental tests of new survey methods and

comparisons of U.S. methodology with those of other

countries.

SERIES 3. Analytical and Epidemiological Studies—These reports

present analytical or interpretive studies based on vital and

health statistics. These reports carry the analyses further than

the expository types of reports in the other series.

SERIES 4. Documents and Committee Reports—These are final

reports of major committees concerned with vital and health

statistics and documents such as recommended model vital

registration laws and revised birth and death certificates.

SERIES 5. International Vital and Health Statistics Reports—These

reports are analytical or descriptive reports that compare U.S.

vital and health statistics with those of other countries or

present other international data of relevance to the health

statistics system of the United States.

SERIES 6. Cognition and Survey Measurement—These reports are

from the National Laboratory for Collaborative Research in

Cognition and Survey Measurement. They use methods of

cognitive science to design, evaluate, and test survey

instruments.

SERIES 10. Data From the National Health Interview Survey—These

reports contain statistics on illness; unintentional injuries;

disability; use of hospital, medical, and other health services;

and a wide range of special current health topics covering

many aspects of health behaviors, health status, and health

care utilization. They are based on data collected in a

continuing national household interview survey.

SERIES 11. Data From the National Health Examination Survey, the

National Health and Nutrition Examination Surveys, and

the Hispanic Health and Nutrition Examination Survey—

Data from direct examination, testing, and measurement on

representative samples of the civilian noninstitutionalized

population provide the basis for (1) medically defined total

prevalence of specific diseases or conditions in the United

States and the distributions of the population with respect to

physical, physiological, and psychological characteristics, and

(2) analyses of trends and relationships among various

measurements and between survey periods.

SERIES 12. Data From the Institutionalized Population Surveys—

Discontinued in 1975. Reports from these surveys are

included in Series 13.

SERIES 13. Data From the National Health Care Survey—These

reports contain statistics on health resources and the public’s

use of health care resources including ambulatory, hospital,

and long-term care services based on data collected directly

from health care providers and provider records.

SERIES 14. Data on Health Resources: Manpower and Facilities—

Discontinued in 1990. Reports on the numbers, geographic

distribution, and characteristics of health resources are now

included in Series 13.

SERIES 15. Data From Special Surveys—These reports contain

statistics on health and health-related topics collected in

special surveys that are not part of the continuing data

systems of the National Center for Health Statistics.

SERIES 16. Compilations of Advance Data From Vital and Health

Statistics—Advance Data Reports provide early release of

information from the National Center for Health Statistics’

health and demographic surveys. They are compiled in the

order in which they are published. Some of these releases

may be followed by detailed reports in Series 10–13.

SERIES 20. Data on Mortality—These reports contain statistics on

mortality that are not included in regular, annual, or monthly

reports. Special analyses by cause of death, age, other

demographic variables, and geographic and trend analyses

are included.

SERIES 21. Data on Natality, Marriage, and Divorce—These reports

contain statistics on natality, marriage, and divorce that are

not included in regular, annual, or monthly reports. Special

analyses by health and demographic variables and

geographic and trend analyses are included.

SERIES 22. Data From the National Mortality and Natality Surveys—

Discontinued in 1975. Reports from these sample surveys,

based on vital records, are now published in Series 20 or 21.

SERIES 23. Data From the National Survey of Family Growth—These

reports contain statistics on factors that affect birth rates,

including contraception, infertility, cohabitation, marriage,

divorce, and remarriage; adoption; use of medical care for

family planning and infertility; and related maternal and infant

health topics. These statistics are based on national surveys

of women of childbearing age.

SERIES 24. Compilations of Data on Natality, Mortality, Marriage, and

Divorce—These include advance reports of births, deaths,

marriages, and divorces based on final data from the National

Vital Statistics System that were published as National Vital

Statistics Reports (NVSR), formerly Monthly Vital Statistics

Report. These reports provide highlights and summaries of

detailed data subsequently published in Vital Statistics of the

United States. Other special reports published here provide

selected findings based on final data from the National Vital

Statistics System and may be followed by detailed reports in

Series 20 or 21.

For answers to questions about this report or for a list of reports published

in these series, contact:

Information Dissemination Staff

National Center for Health Statistics

Centers for Disease Control and Prevention

3311 Toledo Road, Room 5412

Hyattsville, MD 20782

1-866-441-6247

E-mail: nchsquery@cdc.gov

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OFFICIAL BUSINESS

PENALTY FOR PRIVATE USE, $300

07-0008 (3/2007)

CS108449

T27347

DHHS Publication No. (PHS) 2007-1851, Series 20, No. 32