Attitudes Toward the Autopsy -- An 8-State Survey

Peter N. Nemetz, PhD; Eric Tangalos, MD; Laura P. Sands, PhD; William P. Fisher, Jr., PhD; William P. Newman, III, MD; Elizabeth C. Burton, MD

Disclosures

September 21, 2006

In This Article

Introduction

Once considered the "gold standard" in medical diagnosis, the autopsy has declined in use from 19.1% of all deaths in 1972, when the US National Center for Health Statistics (NCHS) first began its systematic tracking of this procedure, to 9.4% in 1994, when the NCHS ceased collecting and collating national autopsy data.[1] A recent survey of all state autopsy rates by one of the authors [PNN] found a continuing decline in the national rate for the subsequent 9 years, with a national average autopsy rate of 8.3% in 2003 (Figure 1). There is evidence to suggest that autopsy rates were markedly higher than 19.1% prior to 1972, but deficiencies in data availability and quality preclude any further systematic analysis.[2,3,4,5] The rate of autopsies on unnatural deaths (including accidents, homicides, suicides, and other unusual deaths, commonly referred to as "e-code" deaths) remained relatively constant over the period from 1972 to 1994 and, consequently, have represented a higher proportion of all autopsies over time. Time series data provided by three states (Minnesota, Oregon, and Washington) suggest that the increasing dominance of e-code autopsies continues to this date. Virtually all of these are medical examiner or coroner cases by legal mandate.

Figure 1.

US autopsy rates, 1972-2003.
Source: NCHS Vital Statistics

Despite the steady decline in overall autopsy rates, this procedure offers benefits in at least 3 critical areas. First, it is a quality-control and verification mechanism with an ultimately salutary impact on clinical practice. Second, from an epidemiologic perspective, it provides accurate information on cause of death, thus facilitating the processes of hypothesis generation and testing concerning the temporal and spatial prevalence of disease.[6,7,8] And, third, it is a valuable instrument for achieving cost-effective healthcare and the efficient allocation of resources within the public sector by signaling the location of the most productive investments in disease treatment and control. The autopsy has also served traditionally as an important adjunct to the teaching of anatomy in particular and medicine in general, but it has continued to lose favor in this area as well.

The autopsy rate is ultimately influenced, both directly and indirectly, by a range of groups, including physicians, pathologists, coroners and medical examiners, the deceased (through advanced directives) and their relatives, as well as nursing home operators and funeral home directors.[9] While research has been conducted on the attitudes of several of these groups,[10,11,12,13,14,15,16] little is known about the attitudes of hospital administrators -- individuals whose role in hospital matters has increased in concert with the increasing importance of the cost of healthcare delivery. In light of this fact, we surveyed hospital administrators in 8 states where declining autopsy rates have mirrored the national trend ( Table 1 ). Our survey addressed 2 central issues: (1) the contributory causes for the declining rate of autopsy; and (2) which policies and actions might facilitate its revival, if such a course of action were deemed desirable. An additional thrust of this research effort was to examine whether the nature of hospital control (government vs private sector, profit vs nonprofit) might influence attitudes towards autopsy policy and practice.

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