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

Results

Opinions of Hospital Administrators

Of the 1017 surveys mailed, 44 were returned by the post office with no forwarding address and 20 hospitals acknowledged receipt but chose not to participate and returned the survey unanswered. We received 407 surveys from 953 eligible participants, yielding a response rate of 43%. Hospitals excluded from eligibility included those determined not to be medical facilities, those that had closed or whose letters were unclaimed, and hospitals whose mandate was detoxification and rehabilitation. Table 2 compares the distribution of hospital types, nationally, within our 8-state sample area, and for our survey respondents. There is no statistically significant difference among these distributions (chi-square P < .000) although, in contrast to the national data, both our 8-state sample and the survey response group have a larger percentage of nonfederal government-controlled hospitals and a lower percentage of private, for-profit institutions.

Forty percent of hospitals provided adequate supplemental data about autopsy performance (n = 385) for analysis. The mean number of reported inpatient deaths for 1999 was 143 ± 188, and the median autopsy rate was 2.4% (mean = 6.1%). Of those hospitals that reported inpatient deaths, 48% also reported that no autopsies were performed at their facility or were referred out to a different facility for autopsy. Sixty percent of hospitals reported that they had no on-site autopsy facility. However, more than half of those hospitals that reported no on-site autopsy facility referred cases to an outside facility for autopsy (excluding forensic cases). Of the 40% of hospitals that were reported to have an on-site autopsy facility, no autopsies were performed in 5% of those institutions.

Autopsy rates tended to vary by hospital characteristic. Table 3 reports autopsy rates for the 4 major categories of hospitals, including only those hospitals that provided the number of deaths as well as autopsy numbers and rates (n = 327). Table 4 presents pair-wise t-tests for the differences of means. Larger hospitals were associated with higher autopsy rates than smaller hospitals. Hospitals with 200 beds or more were much more likely to have a teaching program than hospitals with less than 50 beds (odds ratio [OR] = 22.1, 95% confidence interval [CI] 10.0-48.9), and teaching hospitals had a significantly higher autopsy rate than nonteaching institutions. Autopsy rates also varied by type of hospital control. The only significant differences were between federal government and investor-owned for-profit and nonfederal government hospitals, with federal government hospitals having the highest autopsy rate.

Forty-two percent of the sample (n = 399) completed the opinion portion of the questionnaire. When asked whether autopsy rates in their hospital were appropriate, 66% of all respondents agreed either mildly, strongly, or very strongly that current autopsy rates were adequate. Of the 34% who felt that current rates were not adequate, however, 97% agreed that rates should be higher, while 99% disagreed that rates should be lower.

The survey responses to the question concerning perceived reasons for the decline in autopsy rates can be divided into 2 general categories: 1 reason with strong support (improved diagnostics -- 86% agreement), and 9 reasons for which there was substantial disagreement and/or for which there was no strong opinion either way (Figure 2). Of this latter group of reasons for autopsy rate decline, hospital administrators' agreement about their contribution ranged from a high of 64% for the shift in care from acute care hospitals to nursing homes and hospice care, to a low of 35% for exposure to infectious pathogens.

Figure 2.

Hospital administrators' opinions about declining autopsy rates.

Hospital characteristics appeared to influence administrators' opinions about why autopsy rates have declined. Administrators were less likely to agree that the increase in the average life span has led to the decline in autopsy rates if their hospital resides in an SMSA (OR = 0.65, 95% CI 0.42-0.99), if their hospital is accredited by the JCAHO (OR = 0.51, 95% CI 0.32-0.82), or autopsies had been performed on patients who had died within their hospital (OR = 0.41, 95% CI 0.26-0.65).

Administrators whose hospitals were designated as teaching hospitals were less likely to agree that increased budgetary constraints have led to a decline in autopsy rates (OR = 0.40, 95% CI 0.24-0.68). Administrators were twice as likely to agree that the threat of litigation has led to the decline in hospital autopsies if their hospital resides in an SMSA (OR = 1.9, 95% CI 1.3-2.97) or if autopsies were performed on patients who had died within their facility (OR = 2.1, 95% CI 1.34-3.44).

When questioned about incentives that might result in increasing hospital autopsy rates, the 2 policies that received the highest level of agreement from hospital administrators were direct payment to pathologists for autopsies under the physician fee schedule (78%) and enactment of legislation by Congress to protect the confidentiality of healthcare error reporting (71%) (Figure 3). The 5 other possible policy options ranged from a high of 67% agreement for reinstating the Medicare autopsy rate mandate to a low of 55% for financial penalties for hospitals not meeting a target autopsy rate.

Figure 3.

Hospital administrators' opinions about raising autopsy rates.

Hospital characteristics also influenced administrators' opinions about which policies were likely to raise hospital autopsy rates. Administrators whose hospitals reside within an SMSA were more likely to agree that reinstitution of a minimum autopsy rate mandate by the JCAHO would increase rates (OR = 1.5, 95% CI 0.96-2.4), and administrators of teaching hospitals were more than twice as likely to agree that bonus payments for hospitals achieving targeted autopsy rates would lead to increased rates (OR = 2.2, 95% CI 1.2-4.0).

Hospital Autopsy Patterns and Costs

Only 11% (105/953) of the hospitals responded with autopsy cost information. Three specific questions were asked with respect to autopsy cost: the total per-case cost of performing autopsies, the total per-case cost of referral autopsies, and the total variable costs (eg, personnel and materials) exclusive of overhead (fixed costs). The total per-case costs averaged $1275 and ranged from $100 to $7500 [median value = $853]. The principal problem with using these cost estimates is that they include prorated fixed costs and will clearly vary according to the number of autopsies performed at each facility. The ideal economic estimate is marginal cost; but failing the availability of this cost estimate, one can utilize 2 possible surrogate variables: the cost per referral case or the average variable cost of in-house autopsies. From our sample, these values were calculated at $1062 and $1123, respectively (in 1999 dollars). [Updating to April 2006 using the medical care component of the US Consumer Price Index yields a range of $1418-$1450 per autopsy.]

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