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


September 21, 2006

In This Article



We surveyed all medical institutions within 8 states (Illinois, Iowa, Louisiana, Minnesota, Nebraska, North Dakota, South Dakota, and Wisconsin [N = 1017]) that were identified as hospitals by the American Hospital Association's AHA Guide (1998-1999 Edition) to US hospitals. These states were chosen largely because of author affiliation with major teaching and research institutions in these areas. Names of hospitals, addresses, contact information, and institutional characteristics were available from the AHA Guide. We mailed our survey to the chief administrators of the hospitals and specifically requested that the survey opinion questions not be answered by a pathologist or director of clinical laboratory services. We focus on chief administrators because of their role in influencing institutional decision-making related to autopsies. Participation was voluntary, and we assured all participants that their responses would remain anonymous. Those not responding to the first mailing were approached up to 2 additional times in subsequent mailings. The study was approved by the Institutional Review Boards of Mayo Clinic College of Medicine and Louisiana State University Health Sciences Center.

Survey Instrument

The initial survey was piloted in 207 hospitals in Maryland and Massachusetts. The final questions were then chosen after an iterative pretesting process that involved feedback from survey experts, physicians, and hospital administrators to ensure content and face validity. The final, 1 1/2 page survey took approximately 10 minutes to complete and included 3 questions about the adequacy of autopsy rates in their hospital, 10 questions about their opinions about why autopsy rates have fallen, and 7 questions about whether the implementation of specific policies would increase autopsy rates. All participants were asked to respond to the opinion questions using a 6-point scale corresponding to "very strongly agree," "strongly agree," "mildly agree," "mildly disagree," "strongly disagree," and "very strongly disagree." Participants were also asked to provide numerical data about autopsy counts, total inpatient deaths, autopsy-related costs, autopsy referral patterns, and whether their hospital had an on-site autopsy facility for the 1999 calendar year. Additional institutional data were obtained from the AHA Guide and included: hospital accreditation by the Joint Commission on Accreditation of Healthcare Organization's (JCAHO's) hospital program, teaching status, healthcare system affiliations, type of hospital ownership, and annual inpatient bed occupancy. Standard Metropolitan Statistical Area (SMSA) data were obtained from the US Census Bureau, Statistical Abstract of the United States.

Statistical Analysis

The unit of analysis was the hospital. For statistical comparisons, we condensed "very strongly agree," "strongly agree," and "mildly agree" into a single "agree" category (coded as 1) and condensed "mildly disagree," "strongly disagree," and "very strongly disagree" into a single disagree category (coded as 0). We categorized hospitals according to the number of inpatient beds at the hospital: fewer than 50 beds, 50-99 beds, 100-199 beds, and more than 200 beds. Hospital type was coded as nonfederal government, federal government, nongovernment not-for-profit, and investor-owned for-profit. (Appendix One lists the subtypes of hospitals in each category). For each opinion question, we evaluated the association between hospital administrator agreement for a particular question and certain hospital variables using a chi-square test or chi-square test for trend.

For those hospitals that provided data related to hospital autopsy performance, we determined their autopsy rate as the ratio of the total number of autopsies divided by the total number of deaths. We calculated the mean autopsy rates for each hospital type and compared means using the t-test. We then constructed stepwise logistic regression models for the individual questions and adjusted for covariates, which we have hypothesized influence rates of autopsies within hospitals, including JCAHO accreditation, teaching status, location within an SMSA, type of hospital control, and hospital size.[8,17] Calculations were performed using the Stata statistical package, version 6.0 (Stata Corp., College Station, Texas). Odds ratios were adjusted for all covariates reported above.

With a 10% false address rate and a 50% response rate, our responding sample could provide, with 95% confidence, an estimate of the views of 1017 hospital administrators with a sampling error of less than 4%.


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