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

Discussion

In the past half century, concern has been raised about the declining number of autopsies performed on patients dying within hospitals. Three studies have reported historical data suggesting autopsy rates in some hospitals in the 1950s and 1960s to be in the 50% to 85% range.[2,3,10] A number of reasons for this decline have been postulated, including:[18] improvements in diagnostic technology, fear of litigation, removal of defined minimum autopsy rate standards, a lack of direct reimbursement, as well as the lack of standardization of the autopsy as a medical procedure with resultant lack of credibility as a valid outcome or performance measure. Although there is little evidence to support any of these stated reasons for the decline in autopsies, some researchers have sought to explore determinants of autopsy.[17] Most of the emphasis has been on patient-related characteristics, with only a few studies including institutional factors related to autopsy performance.

In this study, we have re-examined the complex issue of declining autopsy rates, their cause, and possible remedial measures. We have specifically focused our analysis on the hospital administrator as an important locus of decision-making in the ongoing debate over the value of autopsies. Our finding that the median inpatient autopsy rate in a sample of hospitals was 2.4% (mean 6.1%) for 1999 contrasts with the findings of an earlier survey of autopsy rates among 410 hospitals in the United States and Canada during the 1990s, which found an aggregate autopsy rate of 12.4% and a median rate of 8.3%.[19] The difference between the results of these 2 studies is most likely a reflection of the secular decline in autopsy rates in the United States.

Although we asked individual institutions to report both the direct and indirect costs of performing autopsies, most could not provide these data. Our estimate of the average variable cost of autopsies in 1999 of between $1062 and $1123 (median $853) contrasts with the findings of one other survey of autopsy costs,[20] which surveyed 188 medico-legal offices throughout the United States and found that the average fee paid to pathologists per autopsy was $518 in 1993. Detailed autopsy cost data from our own institutions suggest that personnel costs per autopsy are approximately 93.5% of total variable costs. After adjusting for inflation within the healthcare sector, our results suggest an average labor cost of $798 to $844 (1993 dollars). This is considerably higher than the estimates generated by Jason and colleagues,[20] although this difference may be due to the fact that they gathered cost data on medico-legal autopsies only. The authors speculate that the main reason why their cost estimates were considerably lower than published estimates of autopsy costs may have been due, in part, to the willingness of residents and forensic pathology fellows to perform autopsies at a loss for reasons of medical education or community service.

Our data support the general conclusion that explanations for autopsy rates are multifactorial and are conditional, at least in part, on individual hospital characteristics. Three institutional characteristics, in particular, seem to be associated with higher autopsy rates: large hospital size, teaching status, and federal ownership. It is possible to hypothesize that 3 underlying factors may explain these associations: resources, mission, and case mix. Larger hospitals and the federal government may, on balance, be expected to control greater resources and, therefore, have the ability to fund a higher autopsy rate. Teaching and federal hospitals may have missions that indirectly encourage higher autopsy rates. Most obvious among these are teaching hospitals whose educational mandate is advanced by the information yield of autopsies. In addition, among federal hospitals, higher autopsy rates may be the consequence of an explicit or implicit mandate to ultimately address the medical and public health needs of a broader national community. Among larger hospitals, the greater volume and complexity of case loads may lead to more medical questions whose resolution may be facilitated by autopsy-generated information. One additional factor that may affect the autopsy rate but is not explored here is whether families in any of these states must incur out-of-pocket expenses if they desire an autopsy for their deceased relative.

Of the 10 hypothesized reasons for the decline in autopsy rates, 7 were deemed to be important by over 50% of our sample of hospital administrators, although the most important is clearly improved diagnostic technology. Despite this perception, several recent research studies have suggested that new diagnostic technology does not obviate the need for autopsies for detection of clinical errors as well as verification of diagnostic procedures and data interpretation.[21,22,23,24,25,26] Any effort to increase the autopsy rate must confront this lack of congruence between perception and empirical evidence.

With respect to the appropriate level of autopsy rates, only 25% of our sample felt that rates should be higher. All 7 of the postulated incentives for increasing these rates received more than 50% support, but the most important (the direct reimbursement of pathologists for their services) and 3 other possible initiatives are financial in nature. This finding supports the conclusion that an important force in declining autopsy rates is the changing economic landscape, with its increased focus on cost control within both the public and private healthcare sectors. At the root of this issue is the contrast between: (1) the immediate, tangible, and usually nonreimbursed costs of the autopsy; and (2) its medium- to long-term, diffuse, and intangible social benefits, which are difficult to price. Within the discipline of economics, this falls squarely into the category of "market failure."[9] Only a monetization of such benefits can resolve this particular facet of the problem. Until then, any conclusion about the appropriate level of the autopsy and whether the benefits of the autopsy are worth its cost is premature.

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