Decline in the Use of Medical Autopsy
Despite its potential contribution to medical knowledge, autopsy has been in decline in all developed countries for approximately 50 years.[5] Since 1960, US autopsy rates have steadily declined from approximately 50% of all hospital deaths to less than 10%.[5] The causes of the decline of autopsy are multiple and complex and include (1) lack of direct reimbursement, (2) lack of minimum autopsy rate requirements, (3) fear of malpractice litigation, and (4) the belief that advances in diagnostic technology have replaced the need for autopsy.
Reimbursement for autopsy by Medicare and other payers is very limited. According to Elizabeth C. Burton, MD, Director of Autopsy Pathology at Baylor Medical Center in Dallas, Texas (references indicated and personal communication, October 2007), Medicare Part A has a "built-in" payment for autopsy-related activities in its diagnostic-related reimbursement groups.[4,5] However, this payment to hospitals does not include reimbursement for the physician and other professional components of autopsy services. As a result, there is little incentive for hospitals to increase autopsy rates, especially as hospital administrators increasingly focus on the financial bottom line. Despite this lack of financial incentive for hospitals, most will conduct autopsies if a physician requests it and the family consents. Also, families of patients who die in the hospital are likely to be able to request and obtain an autopsy without incurring expenses for themselves.
The scenario for patients who die outside a hospital is different. Medicare Part B and other insurers do not provide coverage for autopsy. When requested by the family to help resolve unanswered questions, autopsy can cost anywhere from $500 (for a partial autopsy) to over $3000.[4,5] These costs don't include transporting the body to the facility where the autopsy will take place. Family members who are interested in autopsy often will not pursue it once the financial aspects become clear.
If a hospice provider has questions about the adequacy of care or diagnoses and requests an autopsy for the purposes of clarification, then the family generally is not responsible for the cost. If the hospice is part of a teaching hospital or a hospital system, then the cost may be absorbed there (personal communication, Elizabeth C. Burton, MD, October 2007). However, if a hospice is not part of a hospital system, costs of doing autopsy could be prohibitive. This may be especially true for smaller hospice organizations. Thus, limitations in payment for autopsy are an important barrier to access to autopsy services in hospice.
Autopsy rate decline is also partly due to the removal of minimum rate requirements by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and by the CMS. Although these organizations removed the rate requirements several decades ago, they set standards that stipulate under what circumstances institutions should pursue autopsies and that results from autopsies should be used for quality improvement activities. However, these standards are not defined in a manner that is enforceable, and are therefore ineffective in stopping the decline in autopsy rate.[4]
Fear of litigation and the lack of confidentiality and reporting protections also have contributed to the decline in autopsy rates. Despite research findings that autopsy does not increase the likelihood of litigation, even when the autopsy finds something previously unknown, the pervasive litigious environment and lack of trust between physician and family have continued to drive down the autopsy rate.[1]
Finally, research indicates that some of the decline in autopsy rates may be due to the belief of providers that advanced diagnostic technologies are making autopsy unnecessary. However, there is still a gap between what high-tech diagnostic medicine can achieve in theory vs what it actually achieves in practice.[8] This is echoed by Shojania and colleagues, who have shown that despite the use of advanced diagnostic tools, diagnostic discrepancies between pre- and postmortem diagnoses persist at relatively unchanged rates.[1]
Research concerning the use of autopsy to improve diagnostic accuracy is almost entirely limited to the hospital setting. A single published article discusses the use of autopsy in an inpatient hospice program. Abdel-Karim and colleagues sought to identify causes of death of hospice patients via autopsy.[9] The results showed that in no case did autopsy findings refute the primary diagnosis for which the patient received palliative care. Autopsies usually confirmed the suspected mechanism of death and that the cause of death was related to the primary diagnosis.
The medicolegal autopsy has not suffered the same decline in rates as medical autopsy.[2] Medicolegal autopsy occurs when specific legal requirements, rather than family or healthcare provider requests, trigger the autopsy. Medicolegal autopsy laws vary by state, and are related to coroner and medical examiner functions. When death is of a suspicious "nonnatural" cause, most states require the death to be reported to the coroner or medical examiner. At that point, the death is investigated through evaluation of the death scene and examination of the medical records and the deceased's remains. If the examiner determines cause for concern, an autopsy is required. Funding for medicolegal investigation comes from county governments with variable appropriations.
Arkansas is the only state that mandates a coroner's examination of all out-of-hospital death scenes, including deaths that occur in nursing homes, hospices, and private homes. Investigations of deaths in hospitals are also mandated for patients who die within 3 days of transfer to the hospital. This law was passed in 1999 in an effort to address quality-of-care concerns in nursing homes after Mark Malcolm, County Coroner for Pulaski County, Arkansas, grew concerned about several suspicious deaths that appeared to be the result of neglect rather than natural causes. As a result of the law, all nursing home deaths are required to be reported to the coroner. The coroner examines the scene of the death, and if anything about the death seems suspicious, the coroner alerts the medical examiner who will then conduct further investigation and autopsy if indicated. In the case of a death in the home, with or without hospice care, the death is reported to law enforcement and the coroner.
According to Mark Malcolm, barriers to implementing similar medicolegal approaches in other states include lack of funding, lack of coroner personnel and infrastructure to handle the increased volume of investigations, and opposition from the nursing home industry. Also, interfacing with other agencies is very complex (references cited and personal communication, Mark Malcolm, October 2007).[2,10] No systematic evaluation of the impact of this approach to quality improvement in the nursing homes has been conducted. However, Mark Malcolm reports that there has been a sharp decrease in the number of deceased nursing home residents who show signs of neglect or substandard care.
Medscape J Med. 2008;10(12):289 © 2008
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