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. Author manuscript; available in PMC: 2024 Feb 1.
Published in final edited form as: Res Autism Spectr Disord. 2022 Dec 1;100:102077. doi: 10.1016/j.rasd.2022.102077

Mortality rate and age of death among Medicare-enrolled autistic older adults

Morgan Krantz 1, Djhenne Dalmacy 1, Lauren Bishop 2, J Madison Hyer 1, Brittany N Hand 1
PMCID: PMC9851177  NIHMSID: NIHMS1854511  PMID: 36685335

Abstract

Background:

An emerging body of evidence suggests that autistic people are at greater risk for mortality than non-autistic people. Yet, relatively little is known about mortality rates among autistic people during older adulthood (i.e., age 65 or older).

Methods:

We examined 5-year mortality among a national US sample of Medicare-enrolled autistic (n=3,308) and non-autistic (n=33,080) adults aged 65 or older.

Results:

Autistic older adults had 2.87 times greater rate of mortality (95% CI=2.61–3.07) than non-autistic older adults. Among decedents (39.6% of autistic and 15.1% of non-autistic older adults), the median age of death was 72 years (IQR=69–78) for autistic and 75 years (IQR=70–83) for non-autistic older adults. Among autistic older adults, those with intellectual disability had 1.57 times greater rate of mortality (95% CI=1.41–1.76) than those without, and males had 1.27 times greater rate of mortality (95% CI=1.12–1.43) than females.

Conclusions:

Many trends regarding mortality observed in younger samples of autistic people were also observed in our study. However, we found only a three-year difference in median age at death between autistic and non-autistic decedents, which is a much smaller disparity than reported in some other studies. This potentially suggests that when autistic people live to the age of 65, they may live to a more similar age as non-autistic peers.

Keywords: Autism, older adulthood, survival, mortality

Introduction

Public health efforts and advances in medical care have lengthened life expectancy for all Americans over the past century. This includes efforts that have led to reductions in vaccine-preventable diseases, improvements in state and local infrastructure to control infectious diseases, enhanced tobacco regulations, and cardiovascular disease prevention initiatives (Centers for Disease Control and Prevention, 2011). However, an emerging body of evidence suggests that autistic people are at greater risk for mortality compared to non-autistic peers. Multiple studies have shown that autistic children and adults have over a 2-fold increased odds of mortality compared to same-aged peers who are not autistic (Hirvikoski et al., 2016; Hwang et al., 2019; Schendel et al., 2016). Possible drivers of disparities in mortality may include that autistic people experience higher rates of co-occurring health conditions (Croen et al., 2015; Hand et al., 2020; Roestorf et al., 2019; Vivanti et al., 2021), unintentional injury (Guan & Li, 2017), and intentional self-injury (Jokiranta-Olkoniemi et al., 2021) than non-autistic people. Additionally, autistic people are more likely than non-autistic people to experience social factors that may contribute to higher rates of mortality and reduce quality of life, such as barriers to accessing healthcare (Raymaker et al., 2017), chronic stress (Bishop-Fitzpatrick, Minshew, et al., 2017; Courtemanche et al., 2021; Hirvikoski & Blomqvist, 2015), discrimination (Dickter et al., 2020; Nicolaidis et al., 2015), social isolation (Bishop-Fitzpatrick, Smith DaWalt, et al., 2017; Bishop-Fitzpatrick, Mazefsky, et al., 2018) and economic insecurity (Burgess & Cimera, 2014).

Since existing literature mainly focuses on mortality rates in autistic children and younger adults, relatively little is known about mortality rates among autistic older adults. However, by the year 2050, there will be about 1.16 million autistic adults aged 65 years or older in the United States, necessitating a better understanding of this populations’ health needs and outcomes (Dietz et al., 2020). Some studies of mortality rates among autistic adults include people over age 65 years combined with younger age groups, making it hard to differentiate mortality rates among autistic older adults specifically. For instance, a recent study that included a sample of autistic adults mostly ≤ age 65 years identified high mortality among autistic people in their early 20s and mid-50s (Bishop-Fitzpatrick, Movaghar, et al., 2018). In contrast, adults in the general population typically had high mortality in their mid-70s. In part, the low representation of autistic older adults in previous mortality studies may be an archetype of historical disparities that leave a “lost generation” of autistic older adults who never receive a formal autism diagnosis (Lai & Baron-Cohen, 2015). However, the inclusion of primarily young to middle-aged autistic adults in mortality rate studies may overestimate disparities in life expectancy among autistic people.

Data about mortality rates in older autistic adults are needed to inform initiatives by healthcare systems, providers, and policy makers to maximize life expectancy among autistic older adults. We examined mortality rates among a full national United States sample of Medicare-enrolled autistic and non-autistic older adults. We compared mortality rates among older adults as a function of autism diagnosis, sex, and intellectual disability status, as these factors have been linked with mortality rates in previous studies with younger samples of autistic people (Hirvikoski et al., 2016; Jokiranta-Olkoniemi et al., 2021; Schendel et al., 2016).

Methods

Data Source

Data were derived from 2016 through 2020 Medicare Standard Analytical Files (SAF), which included Limited Data Set (LDS) information on 100% of Medicare beneficiaries for these years. Medicare is a nationally administered program that provides publicly funded, health insurance for people aged 65 and older, younger people with a formal disability determination that makes them eligible for Social Security Disability Insurance, and people of any age with end-stage renal disease or amyotrophic lateral sclerosis in the United States. Medicare differs from private health insurance in the United States, which is typically provided through employment, and Medicaid, which varies by state and is available to people with low income.1 Of note, because Medicare provides nearly universal healthcare coverage to Americans aged 65 and older (including autistic and non-autistic older adults), disparities in care access are greatly reduced once individuals are eligible to enroll in Medicare at age 65 (Wallace et al., 2021). Therefore, our study population likely experiences fewer disparities in access to care compared to other populations of autistic adults in the United States.

De-identified beneficiary-level healthcare claims data from LDS SAF inpatient and outpatient files were used in this analysis. We also used the LDS SAF denominator files for demographic and enrollment related information. We did not examine home health, skilled nursing facility, or hospice records for this study. Because LDS SAF are at the beneficiary-level, we were able to track beneficiaries from year to year. The baseline period, from which the study population was identified, was 2016–2017. Our total observational period, from which outcomes were extracted, was 2016–2020.

Study Population

Autistic beneficiaries were included if they: (1) were age 65 and older; (2) were enrolled in Medicare Fee for Service for at least 6 months in 2016 or 2017 to ensure enough follow up time; and (3) had at least one inpatient or two outpatient claims with an autism diagnosis during January 1, 2016 through December 31, 2017. Autism diagnoses were identified using International Classification of Diseases, 10th revision, clinical modification (ICD-10-CM)2 codes F84.0, F84.1, F84.5, or F84.9.

A population comparison (PC) group of beneficiaries who met all the same inclusion criteria, but without autism diagnoses, was selected at a 10:1 ratio to autistic beneficiaries using group frequency matching (Feng, 2010) for 5-year age category and sex. Group frequency matching involves category matching on a group basis, rather than individual matching; thus, PC beneficiaries were selected with relative frequency of sex and age category equal to that of autistic beneficiaries, resulting in these groups having equivalent distributions for sex and age category. Additional information about the sample is available in Hand et al., 2020.

While recent expert opinions suggest that age 50 years should indicate older adulthood among autistic individuals (Roestorf et al., 2019), we used the traditional cut-off of 65 years of age due to Medicare eligibility criteria. Most Medicare beneficiaries are entitled to coverage based on their age (i.e., any United States citizen or permanent resident over the age of 65 years). In contrast, individuals younger than 65 years can only qualify for Medicare with a formal disability ruling by the Social Security Administration. Medicare beneficiaries under the age of 65 years may differ in meaningful ways from individuals who qualify for Medicare on the basis of age; for example, Medicare beneficiaries under age 65 years demonstrate distinct patterns of healthcare utilization, have more difficulty with access to services, and experience more financial barriers to care (Colligan et al., 2016; Cubanski et al., 2016; Cubanski & Neuman, 2010). As a result, we made the methodologic choice that would result in the most homogeneous study sample.

Variable Definitions

The primary outcome of this study was the number of years from age 65 to the beneficiary’s death. Medicare obtains beneficiary dates of death from the United States Social Security Administration nightly. Therefore, the date of death in the denominator file of the LDS SAF is current based on Social Security Administration records as of the day the files were generated and includes only dates of death that have been independently validated using standard procedures in the LDS SAF. We assumed beneficiaries with no date of death during January 1, 2016 through December 31, 2020 were still alive at the end of the observational period and used the number of years between turning age 65 years and their last observed claim to calculate their survival time (right censoring).

The independent variables of interest were autism diagnosis status, sex, and intellectual disability. Intellectual disability was identified based on at least one claim with ICD-10-CM codes F70-F79. Additional variables included age, race, geographical region, metropolitan statistical classification (rural vs. urban), and estimated household income measured in thousands of United States dollars. Household incomes were estimated at the county level for each beneficiary using the median per capita household income during 2017 for individuals over age 65 years. We generated these estimates by merging the Federal Information Processing Standard Publication (FIPS) county codes provided in the LDS SAF denominator files with the median household income for each FIPS county code among people over the age of 65 years, which we obtained from the United States Census Bureau’s American Community Survey data tables.

Statistical Analysis

Demographic characteristics were summarized using descriptive statistics. We performed a survival analysis using age 65 as the reference point instead of the date of birth. Kaplan Meier estimates were used to obtain and visually display differences in the probability of survival between: (1) autistic and PC beneficiaries, with and without stratifying by sex; (2) autistic beneficiaries with and without intellectual disability; and (3) autistic males and autistic females. Cox proportional hazard regression models were used to compare overall survival between autistic and PC beneficiaries while controlling for sex, race, rurality, geographical region, and estimated income. The possible differential effect of sex on overall survival was evaluated by repeating this model with an interaction between sex and group membership (i.e., autism vs. PC). Among autistic beneficiaries, separate Cox proportional hazard models were used to compare overall survival as a function of sex and intellectual disability status, while controlling for race, rurality, geographical region, and estimated income. We also performed a sensitivity analysis to determine the extent to which our results were influenced by our inclusion criteria, requiring only a single inpatient or outpatient claim with a diagnosis of autism. We replicated our analyses with only the subset of beneficiaries who met a more stringent inclusion criterion of at least one inpatient or two outpatient claims with a diagnosis code for autism. All statistical analyses were performed using SAS statistical software version 9.4.

Ethical Approval

The Institutional Review Board of The Ohio State University reviewed this study and determined it to be exempt due to the use of limited datasets.

Results

Our analysis included 3,308 autistic Medicare beneficiaries and 33,080 PC beneficiaries (Table 1). Most beneficiaries were male, aged 65–69 years old, and white. Nearly half of autistic beneficiaries (46.9%) and 0.2% of PC beneficiaries had an intellectual disability. More autistic beneficiaries died during the study period (39.6%) than PC beneficiaries (15.1%). Autistic decedents were a median age of 72 years (interquartile range [IQR]=69, 78) while the corresponding figure for PC decedents was 75 years (IQR=70, 83). The distribution of age of death for both groups is displayed in Figure 1, which suggests that the age of autistic decedents was similarly distributed to that of PC decedents.

Table 1:

Demographic characteristics

Autistic Beneficiaries Population Comparison Group
Variable Died N=1,309 Living N=1,999 Total N=3,308 Died N=5,000 Living N=28,080 Total N=33,080
Female, n (%) 382 (29.2) 596 (29.8) 978 (29.6) 1,279 (25.6) 8,501 (30.3) 9,780 (29.6)
Years of Age, n (%)
   65–69 552 (42.2) 1,210 (60.5) 1,762 (53.3) 1,637 (32.7) 15,983 (56.9) 17,620 (53.3)
   70–74 339 (25.9) 488 (24.4) 827 (25.0) 1,113 (22.3) 7,157 (25.5) 8,270 (25.0)
   75–79 184 (14.1) 191 (9.6) 375 (11.3) 793 (15.9) 2,957 (10.5) 3,750 (11.3)
   80–84 122 (9.3) 78 (3.9) 200 (6.0) 630 (12.6) 1370 (4.9) 2,000 (6.0)
   >84 112 (8.6) 32 (1.6) 144 (4.4) 827 (16.5) 613 (2.2) 1,440 (4.4)
Race and Ethnicity, n (%)
   White 1,180 (90.1) 1771 (88.6) 2,951 (89.2) 4,256 (85.1) 23,337 (83.1) 27,593 (83.4)
   Black 77 (5.9) 149 (7.5) 226 (6.8) 448 (9.0) 2,068 (7.4) 2,516 (7.6)
   Hispanic, 52 (4.0) 79 (4.0) 131 (4.0) 296 (5.9) 2,675 (9.5) 2,971 (9.0)
Other, or Unknown
Intellectual Disability, n (%) 625 (47.7) 928 (46.4) 1,553 (46.9) 18 (0.4) 35 (0.1) 53 (0.2)
Rurala, n (%) 243 (18.6) 358 (17.9) 601 (18.2) 1,163 (23.3) 5,916 (21.1) 7,079 (21.4)
   U.S. Region, n (%)
   South 419 (32.0) 646 (32.3) 1,065 (32.2) 1,796 (35.9) 10,249 (36.5) 12,045 (36.4)
   Northeast 333 (25.4) 553 (27.7) 886 (26.8) 1,239 (24.8) 6,515 (23.2) 7,754 (23.4)
   West 138 (10.5) 213 (10.7) 351 (10.6) 643 (12.9) 3,595 (12.8) 4,238 (12.8)
   Midwest 287 (21.9) 374 (18.7) 661 (20.0) 818 (16.4) 4,858 (17.3) 5,676 (17.2)
   Unknown 132 (10.1) 213 (10.7) 345 (10.4) 504 (10.1) 2,863 (10.2) 3,367 (10.2)
Estimated Incomeb, Median (IQR) 30 (11, 77) 30 (11, 78) 30 (11, 78) 24 (7, 73) 28 (8, 74) 27 (8, 74)
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a

Rural residence was defined as living in a non-metropolitan statistical area

b

Estimated Household Income Reported in thousands of 2017 US dollars IQR = Interquartile range

Figure 1:

Figure 1:

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Kaplan-Meier estimates of survival probabilities

Compared to PC beneficiaries, autistic beneficiaries had a greater reduction in the probability of survival with increasing age that was evident before (Figure 2A) and after (Figure 2B) stratifying by sex. There was not a differential effect of sex on the probability of survival (Figure 2B). The Cox proportional hazard regression models revealed the hazard rate of death for autistic beneficiaries was 2.83 times higher than that of PC beneficiaries (Adjusted Hazard Ratio [95% Confidence Interval]: 2.83 [2.61–3.07]). When stratified by sex, autistic females had 2.85 times higher hazard rate of death than PC females (2.85 [2.52–3.23]). Autistic males had 2.33 times higher hazard rate of death than PC males (2.33 [2.13–2.56]).

Figure 2.

Figure 2.

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Distribution of age of death among autistic (n=1,309) and PC (n=5,000) decedents

Among autistic beneficiaries, those with intellectual disability had lower probability of survival (Figure 2C) and a 1.57 times higher hazard rate of death than those without intellectual disability (1.57 [1.41–1.76]). Also, among autistic beneficiaries, males had lower probability of survival (Figure 2D) and 1.27 times higher hazard rates of death than autistic females (1.27 [1.12–1.43]).

Discussion

This study adds to a growing body of literature on mortality rates among autistic people. This study is the first, to our knowledge, to examine mortality rates among a national Untied States sample of autistic older adults. Our findings underscore the need for increased attention to research on the individual, system, and population-level factors that may reduce the length and quality of autistic adults’ lives and lay the foundation for future initiatives to mitigate high mortality rates among autistic older adults.

When interpreting our results, it is important to recognize the unique characteristics of the autistic older adults in this study. All of the autistic adults in this study were born before 1950 and many were born before the concept of autism was introduced by Kanner in 1943 (Kanner, 1943). All beneficiaries in this study were born before autism was an official diagnosis (1980) in the Diagnostic and Statistical Manual III (DSM-III); revisions were made to the diagnostic criteria for autism in the DSM-IV (1994) and DSM-5 (2013); the concept of “Asperger Syndrome” became known to the English-speaking world (Wing & Gould, 1979); and behavioral therapies were available for autistic individuals (Lovaas, 1987). It is likely, therefore, that many beneficiaries included in this analysis were identified with autism in adulthood and may not have received empirically supported therapies and supports. It is also possible that our sample of autistic older adults is reflective of those with more substantial support needs, as evidenced by a higher prevalence of co-occurring intellectual disability observed in our sample (46.9%) relative to younger samples of autistic adults (19.3%) (Croen et al., 2015). These beneficiaries were also raised in a time before the Americans with Disabilities Act (1990) and the Individuals with Disabilities Education Act (1975), which afford important rights to individuals with disabilities that may have shaped their developmental trajectory. Thus, this may be a sample of autistic individuals with different health-related needs as compared to subsequent generations. As such, results of this study may not be reflective of outcomes for children currently diagnosed, who may have more nuanced symptom presentation and may benefit from evidence-based services and supports throughout their lives. Finally, while our sample is reflective of the current population of US Medicare-enrolled autistic older adults and thus represents a population within a service system (key for policy implications), the extent to which this population is representative of the entire population of autistic older adults in the US is unknown. There are likely a small number of autistic older adults who did not work and pay Medicare tax for at least 10 years, making them ineligible for premium-free Medicare; some of those individuals may be unable to afford Medicare premiums, leaving them uninsured. Importantly, uninsured autistic older adults likely have less access to healthcare and therefore may have greater mortality rates than the present sample. However, recent data suggest only 0.7% of older adults in the US are uninsured (Cha & Cohen, 2022), indicating this is a small minority.

Another unique attribute of this study and sample is that approximately nine months of our follow-up period (March through December 2020) extended into the start of the the COVID-19 pandemic in the United States. The recent global coronavirus pandemic (COVID-19) has led to a decline in life expectancy in the United States by 2.7 years, most of which occurred during the first year of the COVID-19 pandemic (Arias et al., 2022). Data from the Centers for Disease Control and Prevention indicate the pandemic catalyzed an exacerbation of health disparities, leading to greater declines in life expectancy among some groups of people (Arias et al., 2022). This may have had an impact on our findings. However, it is important to note that a majority of both groups (60.4% of autistic beneficiaries and 84.9% of PC beneficiaries) were still alive at the end of the study period. Further, most decedents died prior to 2020 in both groups (78% of autistic decedents and 76% of PC decedents), indicating that the nine months of follow-up into the COVID-19 pandemic did not disproportionately influence or skew our findings. However, the potential differential effect of COVID-19 on mortality rates among autistic older adutls is an important consideration for future studies, which should be conducted with follow-up data that extends further into the pandemic.

Some of our findings were consistent with prior literature, indicating that trends observed in younger samples may extend into older adulthood. For example, our finding that autistic older adults had 2.83 times greater rate of mortality than PC older adults is consistent with prior studies reporting 2–3 times greater rate of mortality among younger samples (Hirvikoski et al., 2016; Jokiranta-Olkoniemi et al., 2021; Schendel et al., 2016). We also found an increased rate of mortality among autistic older adults with co-occurring intellectual disability, which is consistent with other studies (Hirvikoski et al., 2016). However, prior studies (Jokiranta-Olkoniemi et al., 2021; Schendel et al., 2016) found a differential effect of sex on the relative rate of mortality, while we did not (Figure 2B), suggesting sex may have less of a differential effect on relative rate of mortality for autistic people during older adulthood.

While a minority of autistic and non-autistic beneficiaries died during the observation period, we found that the median age of death was relatively similar between autistic (age 72 years) and PC decedents (age 75 years); this finding is consistent with some studies but differs from others. For example, one study of predominately middle-aged and older autistic adults reported a mean age of death among autistic decedents of 67.3 years vs. 68.7 years among non-autistic decedents (Bishop-Fitzpatrick, Movaghar, et al., 2018). Other studies, focused specifically on autistic children and young adults, reported mean age of autistic decedents around 18–19 years compared to 16–17 years among non-autistic decedents (Jokiranta-Olkoniemi et al., 2021; Schendel et al., 2016). In contrast, some studies have found much larger disparities, where the average age of death of autistic decedents was 2–3 decades younger than non-autistic decedents (Guan & Li, 2017; Hirvikoski et al., 2016). We posit this may, in part, be because these studies examined autistic older adults together with younger age groups and averages are sensitive to skewed data. Although preliminary, our findings may indicate that autistic people who survive into older adulthood live to a more similar, though somewhat reduced, age as their non-autistic peers. This finding has important implications for mortality rate estimation and may reduce biases against autistic people in programs that financially penalize people who belong to groups with reduced life expectancy, such as commercially purchased health and life insurance.

Limitations

This study focused exclusively on Medicare beneficiaries with diagnostic codes for autism in their Medicare claims within a two-year period and may not be representative of the entire population of autistic older adults. For example, autistic older adults who did not have an ICD-10-CM code for an autism spectrum disorder associated with a Medicare claim during this period were not included in this study. Our sample of autistic older adults also does not include those without a formal diagnosis (e.g., those who are self-diagnosed or those who do not know that they might qualify for a diagnosis). We also did not have any way to externally validate diagnoses of autism or intellectual disability. Further, our analysis only included people that lived to age 65 years, so our findings may not generalize to autistic people who do not. Autism diagnoses are also more common in younger age groups so this factor may affect the comparisons between autistic children and autistic older adults. Another limitation is that medical billing data do not contain social variables that may be linked with mortality such as educational attainment, social support, and the extent to which someone’s healthcare needs are being met. We also recognize that the race and ethnicity information in Medicare data is less accurate than self-reported race and ethnicity, particularly among some groups. However, the race and ethnicity information in Medicare data has been shown to have excellent accuracy (k > 0.81) and high positive predictive value (>94%) for both Black and white beneficiaries (Jarrín et al., 2020). To our knowledge, there is no published data on the accuracy of the sex variable in Medicare data. Our estimation of household income was based on county-level information, which has been shown to result in systematic underestimation of the role of socioeconomic status in mortality (Moss et al., 2021) and may not reflect disparities in income between autistic and non-autistic older adults. We did not analyze cause of death, as this information is not available in Medicare LDS SAF files, nor did we examine trends in mortality over time, but these are important directions for future work. Last, a minority of both groups (39.6% of autistic older adults and 15.1% of PC older adults) died during the observational period. In part, this may be because the observational period was short (five calendar years). As a result, we can report the median age of death of decedents but cannot draw conclusions about the age of death for the entire sample.

Conclusions and Implications

To our knowledge, our study is the first to use United States national data to examine mortality rates among autistic older adults. Many trends regarding mortality observed in younger samples of autistic people were also observed in our study. Specifically, rates of mortality were greater among autistic than PC older adults and higher among autistic older adults with co-occurring intellectual disability than those without. However, there were two key differences in our findings with that of prior studies. First, we did not find a differential effect of sex on mortality, suggesting that the differential effect of sex on mortality observed among younger samples is attenuated during older adulthood. Second, we found a three-year difference in median age at death between autistic and PC decedents, which is a much smaller disparity than reported in some other studies. Although preliminary, our findings may indicate that autistic people who survive into older adulthood live to a more similar, though somewhat reduced, age as their non-autistic peers.

Disparities in mortality among autistic adults represent a social justice issue that must be urgently addressed by the research community. Findings of this study have several implications for policy and for future research. First, increased mortality rates among autistic older adult Medicare beneficiaries may have implications for Medicare costs and cost projections, particularly as the population of idenfitied older autistic adults increases over the coming decades (Rubenstein & Bishop, 2019). Second, it is perhaps time to begin to consider autistic people as a group that experiences health disparities, given that the literature consistently suggests that life expectancy is reduced and co-occurring conditions are more prevalent in autistic people. Including considerations for the population of autistic people in legislation that seeks to address and ameliorate health disparities would have implications for increasing funding for research and medical care for autistic people. Finally, increased mortality among autistic older adult Medicare beneficiaries suggests the need for effective strategies to expand access to and enrollment in high-quality healthcare earlier in life, which could be partially accomplished via expansions of state Medicaid programs that specifically target autistic people. Future research should seek to identify tools that are able to accurately predict life expectancy among older adults. In addition, future research should seek to idenfiy factors that increase or reduce life expectancy for autistic older adults that are actionable for individuals, communities, families, providers, and policymakers.

Highlights.

  • We examined mortality rate among autistic and non-autistic older adults

  • Autistic older adults had 2.87 times greater rate of mortality

  • 39.6% of autistic and 15.1% of non-autistic people died during the study period

  • Median age of death was similar for autistic and non-autistic decedents

  • When autistic people live to age 65, they may live to a similar age as non-autistic peers

Funding Support:

Eunice Kennedy Shriver National Institute of Child Health and Human Development (Grant number: U54HD090256)

Footnotes

Credit author statement

Morgan Krantz: Conceptualization, Writing – Original Draft. Djhenne Dalmacy: Methodology, Formal analysis, Visualization. Lauren Bishop: Conceptualization, Writing – Review & Editing. J. Madison Hyer: Validation, Methodology, Formal analysis, Visualization, Writing – Review & Editing. Brittany N. Hand: Conceptualization, Methodology, Supervision, Data curation, Writing – Review & Editing.

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

1

A more detailed description of the different types of health insurance coverage in the US and what they cover is beyond the scope of this paper.

2

The ICD-10-CM is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms, and procedures relevant for healthcare in the United States.

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