wrongdoctors

Introduction

The term "autopsy" is derived from the Greek word autopsia, which means seeing with one's own eyes (the prefix aut means "self"; the prefix opsis, "site/appearance"). The term is synonymous with "necropsy" and "postmortem examination," although "autopsy" is the preferred term in the United States. Autopsies are classified as either clinical (eg, hospital, academic), in which permission for autopsy is granted by the next of kin of the deceased, or forensic (eg, medicolegal), in which a medical examiner, coroner, or justice of the peace has jurisdiction and may order the autopsy to be performed (see Autopsy Request Process). Autopsies are considered a medical procedure and are performed by a pathologist.

Rates of Autopsy

Autopsy rates have decreased substantially over the past decades, both within the United States and abroad. Exact rates are difficult to delineate, owing to differences in the reporting of data and to the fact that no single institution systematically collects autopsy data. Autopsy rate reporting may vary between institutions, depending on whether forensic, other outpatient cases, stillbirth cases, and cases referred from outside the hospital are included; many of the rates are reported from individual hospitals and appear in published studies.

The highest autopsy rates have been reported from a small proportion of hospitals (mainly academic hospitals); in general, it is likely that hospitals in which autopsies are not performed outnumber those in which autopsies are performed. It has been estimated that in the United States before 1970, autopsies were performed in 40% to 60% of all cases involving hospital deaths; in recent years, that number has decreased to approximately 5%.¹ Data from the United States National Center for Health Statistics have shown that the autopsy rate has decreased from 19.1% of all deaths in 1972 to 8.3% in 2003.²

Autopsy rates in countries other than the United States have also decreased substantially. In Australia, the rate decreased approximately 50% between 1992 and 2003.³ Data from the Danish National Institute of Health showed that in Denmark, the autopsy rate decreased from 45% in 1970 to 16% in 1990.⁴ Data from Halifax, Nova Scotia, showed that the rate of clinical (ie, hospital) autopsies decreased from 30% in 1987 to 20% in 1999.⁵

Benefits of Autopsy

Despite the downward trend of autopsy rates, the benefits of performing autopsies are widely documented.⁶ In both clinical and forensic cases, the autopsy is instrumental in accurately establishing the cause and manner of death. Autopsies also allow confirmation, clarification, and correction of antemortem diagnoses, as well as the identification of new and reemerging diseases, and thus they are important in both protecting the public health and improving the accuracy of vital statistics.⁷

The list of new diseases or the better understanding of diseases discovered and elucidated from autopsy studies are many and have advanced medical science considerably. Autopsy studies have improved and refined our understanding of such diseases as myocardial infarction and heart disease,⁸ human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS),⁹ and Alzheimer's and other dementias.^10,11

From a public health standpoint, autopsies have proven particularly important as an epidemiologic tool for establishing risk factors and identifying potential disease outbreaks. Recent examples include the 1999 outbreak of encephalitis that occurred in New York City, in which the etiologic agent was found to be West Nile virus¹² ; severe acute respiratory syndrome (SARS) caused by a coronavirus that was first reported in Asia in 2003, with 204 people infected and 26 deaths that quickly spread to infect over 8,000 people in 4 continents with nearly 800 deaths¹³ ; and the 2001 bioterrorism-related outbreak of inhalational anthrax.^14,15

Autopsies remain a powerful tool for education and quality control, although these benefits may be difficult to quantify (see Quality Control Metrics). Autopsy studies have documented significant discrepancies between clinical diagnoses and autopsy diagnoses that have important implications in terms of clinical care. Moreover, major diagnostic errors detected by autopsies indicate substantial inaccuracies in death certificates and hospital discharge data that have important roles in epidemiologic research and healthcare policy decisions.¹⁶

Reasons for the Decline in Autopsy Rates

There are many reasons for the decline in autopsy rates. One reason is that there has been a shift in care -- older and sicker patients are dying in long-term facilities and in the hospice care setting.¹⁷ Cost constraints and a lack of defined industry standards for a specified autopsy rate have had an impact on autopsy rates. Before 1970, the Joint Commission on Accreditation of Healthcare Organizations (now called the Joint Commission) mandated a 25% autopsy rate for teaching institutions and a 20% rate for nonteaching institutions; this mandate has been discontinued, in part because hospitals were unselectively using autopsies to meet target rates without utilizing the information derived as intended to assess quality and improve hospital care. Additionally, with the changes in healthcare coverage and reimbursement, autopsies were essentially no longer funded.

Few data exist as to the true cost of an autopsy (including both fixed and variable costs), although from the small number studies that attempted to capture both fixed and variable costs, there is great variability. The most recent published mean cost estimate per autopsy case was $1,275.00 (range: $100.00 - $7500.00).² The actual cost of an autopsy depends on many variables, including the case load and cost for personnel, space, materials, processing, and ancillary testing.

In addition, the cost of an autopsy is generally not covered by managed care organizations or by third-party insurers as part of an individual's healthcare coverage. As a result, costs may be passed on to the next of kin of the deceased at the discretion of the hospital or individual pathologist performing the procedure. Although the costs of some components of hospital autopsies are reimbursable through Medicare Part A, there is no specific reimbursement figure for autopsies under the Medicare resource–based relative value scale (RBRVS) fee schedule.¹⁸ Costs of forensic (medicolegal) autopsies are covered under local and state governments as part of their annual operating budgets.

Physician Attitudes Toward Autopsy

Physician attitudes have a major effect on autopsy rates. In hospital cases, permission to perform an autopsy is granted by the next of kin of the deceased; the clinician who cared for the patient is usually the person who requests permission from the next of kin. However, several studies have shown that permission for autopsy is often not requested by the clinician.² Clinicians may not seek permission to perform an autopsy because of overreliance on the technology used to make the diagnosis and because a substantial amount of information was known about the patient before death.

Despite this overreliance, considerable discrepancies have been found between premortem and postmortem diagnoses. Although clinicians generally attribute such results to selection bias arising from the fact that the cases in which autopsy was performed were those in which there was the greatest diagnostic uncertainty, clinicians have demonstrated little ability to predict the occurrence of such discrepancies.¹⁶

Although many clinicians report a perceived value in obtaining autopsies, this interest may be offset by concerns over litigation,¹⁹ inadequate information about autopsy procedures, and discomfort in approaching the next of kin about obtaining permission.

In terms of malpractice litigation, some clinicians involved in the care of patients fear that autopsies may increase their risk of being sued, and some pathologists fear that their autopsy may lead to unnecessary malpractice lawsuits.¹⁹ Autopsies, in and of themselves, simply provide facts that may support or refute expert opinions; they do not prove or disprove that patient care was substandard.²⁰ In proving medical malpractice, negligence must be shown. In such cases, it must be demonstrated that the healthcare provider incurred a duty by undertaking care; that the healthcare provider failed to meet the relevant standard of care; and that an injury resulted and damages were incurred.

Often, clinicians are unsure of the logistics involved in obtaining an autopsy. They may lack adequate knowledge about the actual autopsy procedure itself, as well as its cost. These factors may increase the clinician's discomfort in approaching the patient's next of kin to request permission to perform an autopsy. Some studies have shown that clinicians do not request permission to perform an autopsy, because in their experience, autopsy results were not reported in a timely fashion or the quality of the autopsy was unsatisfactory.^21,22

Poor communication between the treating clinician and the pathologist has contributed to a decrease in the number of autopsies performed. A lack of direct contact between the treating clinician and the pathologist before the autopsy, the fact that questions of clinical interest were not addressed, and lengthy reports that catalogue anatomic diagnoses without interpretation are some of the problems that have been cited.⁶ (Autopsy communication will be discussed in another article.)

From the pathologists' point of view, autopsies are time consuming, costly, and do not generate revenue. Few hospitals have pathologists that solely provide autopsy services within the group or department. Many pathologists, particularly at academic institutions, describe that research, teaching, and surgical and clinical pathology take precedence over autopsies, which often prolong their workday.

The lack of funding for autopsies is well known by pathologists. Although the American Medical Association (AMA) has assigned procedural codes (under the AMA's Current Procedural Terminology [CPT]), there is no assigned relative value for autopsies. The pathologist or pathology group is unable to bill for either the technical or professional component of an autopsy in the same manner that they can bill for other laboratory services.

Clinicians and physicians, including pathologists, recognize that the decreasing number of autopsies now being performed has an effect on the expertise needed to competently perform an adequate autopsy.

Pathologists who choose autopsy as their major career focus tend to subspecialize in forensic pathology rather than hospital-based autopsy pathology. In community hospitals, the number of treating clinicians consistently requesting autopsies for their patients is low, as is the number of pathologists willing and able to competently perform an adequate autopsy. The highest autopsy rates are seen primarily in academic institutions where pathology residents are trained. Autopsy education remains a requirement for accreditation in pathology training programs and for board certification of pathologists, but it is not a requirement for completion of medical school or residency training and certification in other specialties of medicine.

Although the rate of autopsy performance continues to decline, it is unlikely that autopsies will ever completely cease to exist. There will continue to be a need for autopsies, particularly in the field of forensics and in specific fields of research in which focused autopsies (ie, those limited to answering a particular question) are becoming more widely used.²³ New technologies, including full-body 3-dimensional (3-D) imaging, are also currently being used as an adjunct to traditional autopsies to enhance forensic autopsy examination (see Postmortem Radiology and Imaging).^24,25