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Comment & Response
February 27, 2019

In Search of Denominators—Reply

Author Affiliations
  • 1Division of Trauma and Surgical Critical Care, Ryder Trauma Center, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
  • 2Public Health Education, Florida Public Health Institute, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami
JAMA Surg. 2019;154(5):470. doi:10.1001/jamasurg.2018.5845

In Reply We thank Spaulding et al for their feedback and interest in our first description of the incidence of surgical related deaths in an inmate population.1 We agree that accurate denominators are difficult to ascertain. There are multiple challenges in making inferences about the death rate in prisons. First, mortality data collected by the Bureau of Justice Statistics relies on prison-level and jail-level voluntary self-reporting.2 The authors’ admitted inability to obtain online death statistics between 2008 and 2012 itself highlights the incomplete availability of this voluntarily reported data. Second, the US Centers for Disease Control and Prevention notes that states have different requirements for which deaths require investigation or autopsy,3 and these requirements can vary even based on type of incarceration facility. For example, in the state of Florida, reporting is mandatory for deaths occurring in jail but not in state facilities.4 Third, the circumstances mandating autopsy to determine the true cause of death are left to the discretion of the medical examiner.5 The intention of our article, in light of these apparent epidemiological challenges, was not to quantify a population-based prevalence of all surgical disease-related deaths in inmates but merely to highlight an apparent high incidence amongst available autopsy data, which may or may not represent an underrepresentation of the true prevalence. The verbiage of the Florida state legislature also suggests that many of these common surgical problems do not fall under “suspicious” or “violent” categories that would otherwise mandate autopsy.5 Regardless of denominator, we feel that any death from an incarcerated inguinal hernia, small-bowel obstruction, hemorrhage, or other treatable surgical illness or injury is a violation of human rights that requires comprehensive, transparent tracking and prevention on a national level.

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