Sociocultural Determinants of Clinical Autopsy Refusal and Their Medicolegal Impact on Diagnostic Accuracy in Indonesian Tertiary Hospitals: A Retrospective Cohort Study

Abstract

Background. Clinical autopsy is the only procedure that verifies antemortem diagnosis against pathological truth, yet in Indonesian tertiary hospitals refusal is the norm and neither its determinants nor its medicolegal consequences are quantified.

Methods. This STROBE-reported retrospective cohort study analysed 324 consecutive adult in-hospital deaths across three tertiary referral hospitals in Palembang, South Sumatra, from 2019 to 2023. The primary outcome was next-of-kin refusal of autopsy consent; secondary outcomes were Goldman-class diagnostic discrepancy and time to correct diagnosis, censored at day 90. Proportions carry Wilson intervals; tests were checked against Monte-Carlo exact methods, ordinal exposures against trend tests and multiplicity against Benjamini-Hochberg.

Results. Refusal was 84.0% (272/324; 95% CI 79.6-87.5) and did not differ across hospitals (p = 0.330). Javanese ethnicity carried the strongest association (94.3% versus 77.7%; OR 4.71, 95% CI 2.05-10.82), with monotonic gradients across education (trend z = -3.87, p < 0.001) and income (z = -2.84, p = 0.005) and refusal concentrated among the disadvantaged (Wagstaff index -0.312). Religious affiliation showed no association (p = 0.290; Cramér's V = 0.108). Any diagnostic discrepancy was commoner after refusal (61.4% versus 36.5%; OR 2.76, 95% CI 1.49-5.11), whereas the major-discrepancy contrast did not reach significance (26.1% versus 13.5%; OR 2.27, 95% CI 0.98-5.27; fragility index 1). Median time to correct diagnosis was 19 versus 5 days (p < 0.001).

Conclusion. Autopsy refusal in Indonesia tracks ethnic mortuary practice and socioeconomic position rather than religious affiliation, redirecting policy towards ritual accommodation and mandatory mortality audit where consent is declined.