Pathologists Request Autopsy Revival

JAMA — Thursday, 1 June 1995

To look at the data, the practice of autopsy is a dying procedure. Thirty years ago around 50% of hospital deaths were autopsied. Since then there has been a steady decline, so that today in teaching hospitals only 10% to 20% of deaths are autopsied. In community hospitals, the rate is probably below 5%-and the trend and continues downward. “American health care policymakers have relegated the role of autopsy to the back burner of health care reform,” said Paul Raslavicus, MD, secretary-treasurer of the College of American Pathologists. The situation worries those who think the autopsy is a valuable tool for the improvement of medical care. “Medicine needs the autopsy. It is the one place where truth can be sought, found, and told without conflicts of interest,” said George D. Lundberg, MD, editor-in-chief of the Journal of the American Medical Association. Raslavicus and Lundberg were among the speakers at a 2-day conference in Washington, DC, sponsored by the College of American Pathologists, American Society of Clinical Pathologists, and Association of Pathology Chairs. The conference, “Restructuring Autopsy Practice for Health Care Reform, was called to discuss the reasons for the decline in autopsies and determine what can be done to reverse the trend.

Change Offers Opportunity

By the end of the meeting, the participants were in general agreement that in the state of flux the nation's health care system is currently experiencing there is an opportunity to demonstrate the value of the autopsy to society in general, to third-party payers, and to skeptics within the medical profession who remain unconvinced of its usefulness. In airing reasons why autopsies have declined and why they should continue to be performed, conference participants went over familiar ground. Many speakers cited reasons for the decline: Nobody likes doing them; physicians are afraid an autopsy will reveal mistakes in their clinical diagnosis, which in turn could lead to litigation; hospital administrators see no need for autopsies as long as licensing and accreditation agencies do not request them; and third-party payers do not want to pay for them, preferring to expend limited resources on the living rather than the dead. There is also much to be said of the value of doing autopsies. Lundberg summarized some of them: An autopsy unequivocally establishes the cause of death; it provides accurate vital statistics; it is useful for comparing premortem and postmortem findings; it is a valuable monitor of the public health, for example, in spotting contagious diseases; it plays an important role in medical education; and it helps assure the high quality of medical practice.

Truth Matters

“Truth Matters,” said Lundberg. who chaired the meeting, “It's fundamental in the science and practice of medicine.” During the past decade there has been much publicity about the declining interest in autopsies, but, he said, “The sound and the fury have signified nothing. We want to see whether we may be able to change this.” Participants in general, not all of them pathologists, agreed that autopsies provide useful information. Dennis S. O'Leary, MD, president of the Joint Commission on Accreditation of Healthcare Organizations, for example, said that his agency had always supported autopsies. However, in 1970 the Joint Commission dropped the accreditation requirement that hospitals perform a set percentage of autopsies. Critics of this step have maintained that the move contributed to at leas part of the decline in the performance of autopsies. O'Leary said that while this may be partly true, the decline had in fact begun before the Joint Commission's action. He defended his agency's action as emphasizing quality, not quantity, and performance, not employ fulfilling a preset series of numbers. Rather than concentrating on percentages, concentrate on quality, he recommended. Along with other speakers, O'Leary also called for standardizing autopsy procedures and recommended that the date be turned into useful information. “Provide solid evidence that improvement in care results. Show that it makes a difference, that it alters or improves behavior, and that is had led to reduced costs,” he said. In response to a questions, O'Leary admitted that the Joint Commission inspectors don't even ask about hospital autopsy rate anymore.

“The decline in the autopsy rate is a serious disease. We should be doing more than we are doing now, three or four times higher than the current national average,” said another speaker, Sidney Wolfe, MD, director of the Public Citizen Health Research Group, Washington, DC. No one doubts the value of the autopsy, he said, and cited several instances in which autopsies were instrumental in detecting problems in hospital procedure that might otherwise have gone uncorrected. One involved three patients who died of encephalopathy after undergoing open heart surgery. The clinical diagnoses before autopsy were thrombotic or air emoboli to the brain during surgery. During autopsy, areas of necrotic hemorrhage foci with aspergillus were found in the brains of all three patients. Investigating the source of the organism, the hospital found aspergillus present in the operating room ventilating system. Once this problem was corrected, there were no more deaths from aspergillus in those undergoing open heart surgery. Wolfe called for public disclosure of autopsy rates in hospitals. “How can a hospital be accountable to the population it serves unless it is performing a sufficient number of autopsies to make sure that it is doing as good a job of delivering care as possible?” he asked. Conference participants agreed that there were a number of instances where they needed to put their own house in order by simplifying autopsy reporting procedures, obtaining consent from families, and shortening reporting time. But the central issue was payment for the procedure.

Payment Is Primary Issue

Speaking from the floor, Nancy Young, MD, of Fox Chase Cancer Center, Philadelphia, Pa, said “All this talk about increasing the number of autopsies, improving the turnaround time, demonstrating its significance, is all well and good, but unless we get paid for that autopsy, then nothing will happen. ”We are told we are essential. Well, we ought to be paid for our work. Other services provided by hospitals, such as surgery, are just as essential, but we don't expect surgeons to operate and not get paid for their work. If you get paid, it's an incentive, you become a more valuable member of the hospital staff. If we got paid, all these other problems could be resolved.“ Another speaker, Marcella F. Fierro, MD, Richmond, Va, chief medical examiner of Virginia, echoed these thoughts. She said her office is continually receiving requests to do autopsies. ”There's no lack of demand for autopsies. What there is a demand for the free autopsy.

“We need friends, and one way to get friends is to show what life is like without our service. In the hospital setting, we say to the surgeons, �You want to know the outcome of this case; to health insurers. 'You need to know the outcome' of particular case. Very well, we ought not to be persuading them of the need for our information, they ought to be on their knees begging us for it and be prepared to pay the price.”

Some Will Pay Price

It seems that a sizable number are indeed prepared to pay the price, however, and Vidal Herrera, who runs an operation called Autopsy/Post Services Inc. in Los Angeles, Calif, provides the information. “Families come to us because many hospitals don't have autopsy suites and don't provide the service. Many hospitals do not have autopsy technicians because there are not schools that teach how to do autopsies,” Herrera said, speaking from the floor at the conference. “We go to the mortuaries, procure the brains, tissues for research, organs for transplants. We also provide autopsy support services, such as photography. We also do DNA analysis.” Herrera noted that autopsies are often requested by relatives of the deceased for detection of such conditions as Alzheimer's disease. (Speakers had earlier made the point that relatives often wanted to know the final diagnosis particularly in patients with dementia.) “If the family wants an autopsy done badly enough, they come to us.” The business is mushrooming,” he said. “There's a huge demand for autopsies. Last year we did 900. We have become known all over the country for our services. We are now looking into the feasibility of opening a franchising arrangement, planning to open 24 offices around the country.”

The Health Care Financing Administration (HCFA) has been charged with railing to reimburse for autopsies. This omission was denied by another speaker at the conference, HCFA's Charles R. Booth, director of the Office of Hospital Policy. The agency does pay for autopsies, he said. Payment is based on whether a hospital performed autopsies in 1981. If it did, the coverage is there, Booth said, but he indicated that payment is through the hospital and not to the physician. Therein lies the problem, according to one speaker during a discussion period. “HCFA pays, all right. It's just that the hospital takes the money and doesn't pay us. We should ask HCFA to pay for autopsies under the CPT (current procedural terminology) codes and stop advancing the money to the hospitals,” he said to a round of applause.

Booth did offer a possible olive branch. “We are looking at the conditions of participation (in Medicare),” he said, “perhaps toward making them less process oriented and more outcome oriented. So we would be pleased to have your views on what should be included in these conditions regarding autopsies.” “Here's your opportunity,” Lundberg told his audience. He pointed out that 75% of deaths in the United States today occur in Medicare patients, “What's our message to HDFA? Very briefly, establish resource-based relative value scales or current procedural terminology codes, and thus establish autopsy as a legitimate professional service.”

- by Charles Marwick