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23 Autopsy rates in the Netherlands: 35 years of decline 2 than non-academic autopsy rates, even when divided in the three time periods (Table 2). Compared to non-academic hospitals, the odds of an autopsy being performed in an academic hospital were 1.374 (95%CI 1.356,1.392). DISCUSSION Main findings From 1977 to 2011 overall deaths increased, especially those among women and the age group of 80 years and older. The fraction of in-hospital deceased patients declined and there was a small decline of deaths due to external causes. Each year the majority of both the in-hospital deceased patients and deaths due to external causes were male. Also, more autopsies were performed on men. Both clinical and forensic autopsy rates were higher among men, and among patients who died at a young age (18 to 59 years). Over the 35-year time period there was a decline of performed clinical autopsies, and a decline in clinical autopsy rates for both sexes, all age groups, and for both hospital categories. Academic hospitals performed fewer autopsies, but had higher autopsy rates than non-academic hospitals. Strengths and limitations of this study We present primary results on 35 years of Dutch population-based data containing more than 4.5 million people overall, including over 1.5 million in-hospital deceased patients, and over 180 thousand deaths due to external causes. We assume that there are no missing cases, apart from those that were not officially registered with death certificates. Of 264,450 of these cases we know that an autopsy was performed. However, it is unknown how many autopsies were performed on out-of-hospital deceased adults with a supposed natural cause of death. We assume that the number is negligible, based on publications in Dutch medical journals concerning the difference in autopsy rates between intramural and extramural diseased cases. 64 Also, from our experience we know that general practitioners or geriatricians rarely send in out-of-hospital deceased for clinical autopsy. To support this, we retrieved the numbers of autopsies performed in our own university medical centre from 2010 to 2015. We found that only 6.7% of all adult autopsies were performed on extramural cases, which correlates with the 6% reported in 1986. 65 Overall, the autopsy rates among all extramural deaths in the Netherlands are reported to be less than 1%. 65,66