0855-713X102/56-60$03.00/0 AMERICAN JOURNAL OF MEPICAL QUALITY Copyright 0 2002 by American College of Medical Quality .,t.
Voll7, No 2 Mar/Apr 2002
The 'Autopsy: A Professional Responsibility in Assuring Quality of Care
Elizabeth C. Burton, MD
Forly years ago, the value of autopsies was widely reoognized as new diseases were discovered or clarified andscientific technology advanced greatly. Despite the autopsy's strong foundation, its value is not currently being properly conveyed to physicians or patients. Although autopsy-related policy exists, these policies have had little effect on. increasing or even maintaining adequate autopsy rates, More recently, the autopsy has fallen on hard times, with US hospital rates now below 5%,The reasons for the decline in rates are multffaceted and include a lack of direct reimbursement for the procedure, lack of defined minimum rate standards, overconfidence in diagnostic ' technology, and the fear of litigation. Regardless of the reasons for the declining rates, the ethical and professional reasons for increasing the number of autopsies are far more important. Key words: Autopsy, autopsy rates, ethics, health care policy, health care quality assessment, health care quality assurance, quality of health care, '.'
that technological advances have replaced the need for autopsies. Regardless of the reasons for the decline in autopsy rates, the ethical and professional reasons for increasing the number of autopsies are.far more important. The American Medical Association (AMA) has adopted and reaffirmed a policy that states "performance of autopsies constitutes the practice of medicine" (2). That being said, there are 5 (of the 7) principles of medical ethics of the AMA (3) that are directly applicable to autopsies: 'I. A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity. II. A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or"competence, or who en. gage in 'fraud 'Ordeception. III. A physician~hall respect the law and recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. V. A physician shall continue to study, apply, and advance scientific knowledge, make relevant information available to patients; colleagues, and the public, obtain consultation, and use the talent of other health professionals when indicated. VII. A physician shall recognize a responsibility to . participate in activities contributing to an improved community. . Like most of health care, economic constraints have had a huge effect on the autopsy. Many pathologists do not want to do autopsies because they are time-consuming, underappreciated, and not specifically paid for. Most clinicians do not request autopsies because . they believe that everything about the patient's' illness .was already known', the autopsy findings might contradict their clinical findings, and tHey are generally' . uncomfortable: talking with the family about the au.,
US autopsy rates have decreased ckamatically from approximately 50% in the 1960s to a low of about 5% of all patients who die in oUI hospitals under our care. Because no institution currently syste¥1.at,icallycollects autopsy rates for OUInation's hospitals, this 5% rate is an extrapolation 'based on 1995 numbers from the National Center for Health Statistics (1). It is an undisputed fact that the autopsy lias' served us well in the past by advancing medical knowledge, monitoring the quality of care, and establishing the truth. However, for the past 40 years, autopsy rates have continued to decline and autopsies are now near extinction. Reversing this problem deserves serious attention. There 'ire 4 primary reasons for the decrease in autopSies: lack .of direct reimbursemen t, lack of defined minim urn ra te standards, fear 01 malpractice litigation, and the belief
Dr Burton was with the Louisiana State University Health Sciences Center, Department ofPatbology, New Orleans, LA She is now with the Baylor Health Care System, Dallas, Tex. I , Corresponding author: Elizabeth C. Burton, MD, Clinical Scholar, Pathology and Laboraooty Medicine, Baylor Health Care System, Baylor University Medical Center, Department of Pathology, 350Q Gaston Ave, Dallas, TX 75246.
this shift in payment structuring has led to a definite underutilization of the autopsy. of care. set rate. Moreover.. . H-85.. Despite the fact that the autopsy is the ultimate care and are encouraging care below minimum profesoutcome measure and the "gold standard" for quality sional standards... in the plan may provide to their patients. When managed care plans place restrictions on the care that physicians Sles.. H-~5. Hospital administrators do not want autopsies done because they cost money. Further fueling:·. Additionally. autopsies fort. H~85.' hoes. in the past. may pose financial risk
. Physicians should not. In fact. health mainte(ACGME). dethe new focus is supposed to be in assessing and imvelops and uses criteria that identify deaths in which proving quality within all health care delivery systems. tutions such a~ the Joint Commission on Accreditation of Health Care Organizations (JCAHO). the AMA has adopted and pense under Medicare Part A..to the hospital. most benefits cease upon 'the patient's death. an autopsy should be performed . .I interests of patients firat. fee schedule (RBRV8) for direct compensation to patholothey are denied this service or told that they will have to pay -for the autopsy. when the Medicare resource-based relative value scale. '. and primary care rather than to invest in auminimum number of autopsies to . the medical staff. Although these institutions have no hospitals have been converted into space for other acnew requirements for performing autopsies at a. . attempts to secure How does a hospital with no facilities or provisions for autopsies in all deaths that met the criteria. In the Medical Staff Cha pter of the Hospi tal Manautopsy facilities.. they do have some standards that address autoptivities and many new hospitals are now built without sies.977. they have in fact restricted care.989. the health care lowing principles apply. surprising that physicians are reluctant to talk. H-S5. ·. And. ties (as part of the hospital's general operating exH-S5. . c I eian's ability to practice ethical medicine will be ad. Some administrators see autopsies as nonrevpitals. find. H-85.. misuse. nent for autopsies is covered asa:·.. veloped to provide physicians with general guide. "The medical staff should attempt to secure autopsies in all cases of The expansion of managed care has brought a verieunusual deaths and of medical-legal and educational ty of changes to: medicine. it is not assurance. assessment and improvement" activities" (8).. what may have resulted is the unWhen a hospital (managed care or not) makes no derutilization of medical services.be performed in hostopsies. and the Aceconomic pressures to tighten the bottom line and inereditation Council on Graduate Medical Education vest revenue up-front for prevention. Instead. . there exist strong Care Financing Administration (HCFA). . Instiare not recognized as a coverable benefit (6). .. . the folOne reason for the restructuring of.. in quality do not look at why their patients die? The Code of Ethics (E8.8I!ddifferr
topsy. .9S5.969.964. to families about the benefits of autopsies. H-85. Overuse.980.973. . This is especially alarming because ual. when there are no facilities or provisions for autopsy performance.. in the event there is no specific reimbursement figure provided in that the f~y requests that an autopsy be done.. the autopsy suites in many_ decline in rates. had defined standards for a nance. Some. and this action has certainly added to the high cost of health cafe and are therefore viewed as dispensable .13) of the AMA 'states.. are nonrevenue producj~g! and ~ost versely affected by the modification of the syswould rather. including new . Currently. many hospitals choose not 85.. invest money up-front for prev. The numerical targets for autopsies were later enue producing and believe that they contribute to the eliminated. industry and accrediting agencies-no Ion:'. they become distrustful and gists for the professional c01I!po~nt of ~utopsy performay believe that the physician and/or hospital has mance (4).. As a result. and primary care. Although coverage is reaffirmed a number of excelIentpolicies pertaining to "built into Medicare Part A for autopsy-related activiautopsies (AMA policies H~85. autopsies assess the quality of care they provide if they ings from autopsies are used as a source. H~ penses in providing care). and underuse all potentially threaten the quality of provisions for autopsies. the Health Within health care organizations.993) and the House of Delegates has asked that to use this money for autopsiesIfi). "..' . Physicians must continue to place the ' ger hold hospitals accountable for performing autop.978.tem. the following points were dehealth maintenance. the decline. of these changes have ra:i:_sedoncerns that a physi-: . " . participate 'in al1:Y plan that enceurages or requires payment system from fee-far-service to prospective care at or below minimum professional standards. paymany organizations act to rejuvenate the autopsy efers do not have specific autopsy policies and because. HCFA states in its current hospital regulations. but to date. In response. the JCAHO states. payment was to decrease the cost and ·overutilization (!:!).. Whether this has been accomplished is questionable. only the nonprofe'!lsional composomething to hide.ent~on.AMERIGAN JOURNAL OF MEDICAL QUALITY
Autopsy: Assuring Quality of Care
ent reimbursement .reimbursable exFrom a policy standpoint. .. little progress has occurred (7).s¥!!temafor physicians.
and posed. perhaps a different strategy is in order. autopsy report in some instances is not. the motithat error reporting for improving systems of care will vation for doing autopsies could be publicly scrutinot likely occur until confidentiality and reporting pronized. and histological. (17) we provide is at stake. 1.. as physicians. a report shall be filed with the-Medireimplement payment for autopsies.f:
. economically based. There has been a push to incompetence... or medical excould have some negative consequences. This Podiatric Medicine.. plaintiffs 'malpractice attorney could not only allege Ir~espective "fthese economic and legal concerna about . . Education. the CAP BOiUd of Govgood. . Also. nor any sqns should not override the professionaljand ethical authorized agent.. stated. Although the peer-redards continue to be ineffective in maintaining or inview process is generally protected from discovery. The fact that 'an autopsy was not of patients who received care by residents must be reoffered or performed could be detrimental. physician and surgeon. nor any autPorized agent. that the patient's death was a iresult of an en-or or autopsies.58
AMERICAN JOURNAL OF MEDICAL QUALITY
interest . the autopsy has been a part of and should remain an essential component of the peer-rerelated standards. shall be liable for autopsies have traditionally been viewed as a means the damages in any ~vil action as a result of his or for advancing scientific knowledge. replaces conjecture with facts and hard evidence in deresidents should review .he . Because there has been no progress in achieving tections are in place (18). the creasing autopsy rates.'of these bills could likely impact autopsy performance. Autopsy reInterestingly. in quality assessment but have not supported policy California is the only state with a statute currently in changes for minimum rate standards as a condition of place that specifically addresses protection from legal participation fQT' Medicare or by the JCAHO for hosliability when disclosing gross negligence for the public pital accreditation. . aminer. No . assessing the qualher acting in compliance with this section. Currently. howWhen a coroner receives infonnation that is based ever. and approved by a board-certified or board-eligible pathologist indjcating th~t a death may be a result Unfortunately. ''Numerical standards or minimum autopon findings that were reached by. The Residency Review Committee of negligence but could also allege that the death might the ACGME for Internal Medicine states. The report shall be confidential. the latter position seems overwhelmof a . In this regard. The autopsy viewed and autopsies performed whenever possible . our profeseional. there are 2 Senate bills (8. The 8. In the event of a patient's death. gross . '1 ernor's affirmed its position that autopsies are important in quality assessment and improvement but. soon after autopsies are performed on their patients and should review the autopsy reports" (10). not much effort is expended "tion acts' unless an exception applies (13). Passage gal standpoint. Economic reaboard-certified or board-eligible pathologist.. rate standards (Medicare . and establishing the truth. these current stanview process within hospitals. line-item reimbursement on a per-case basis but should be broad-and autopsy specific. without a defined minimum rate. Although organized pathology recognizes the value of autopsies. and accountability. or documented sy rates for hospital deaths are inappropriate" (11). on a fee-for-service cal Board of California or the California Board of basis or as abillable procedure under the RBRVS.physician's or podiatrist's gross negligence or ingly.2743) that have been referred to the Senate Health.and ethical
. " (9). termining the cause of death and could allow for . monitoring. . Recently.. shall be liable for damages in any 'reasons for doing autopsies when the qu~ity of care civil action as a result of his or her providing information.2738 and JcAHO) would not only force the autopsy numbers up but' could force monetary support for this service. pathologists are firmly divided on the ports generated by coroners or medical examiners can be publicly accessed under state freedom-of-informaautopsy issue. Some juristo change/autopsy policy. patient safety and health care quality have been proRedefining minimum. Recommendations to enact direct line-item reimbursement for autopsy perfor. and Pensions Committee regarding monetary support does not necessarily have to be a reduction in medical errors and creation of a national. No coroner. ity of care. Labor. For decades. "All deaths have been hastened or caused by economic incentives to undertreat (12). legislation extending peer-review protections related to mance to date. if reimbursement on an autopsy-specific per-case basis were to occur with a Experts in the field of quality of care have proposed concomitant increase in autopsy numbers. Alprompt dismissal of the case or a quick and fair settlethough these institutions continue to include autopsyment. ical errors and improve'patient safety (19 20). voluntary reporting systerp to continually reduce medAutopsy issues present a real conundrum from a le. Both the American Society of dictions recognize the exception that autopsy reports Clinical Pathologists (ASCP) and the College of Amerare considered medical records and thus can be exican Pathologists (CAP) support the use of the autopsy cluded under the freedom-of-information acts (14-16).
despite this overconfi-.. C4P 7bday. 10.surrogate in such cases where the physician has erred and death has occurred as a result. 7. 533 NE2d 1359. Situations occasionally occur in improve the~quality of health care surrounds us. 14'.l advances that we will act in his or her best interest. Medical error and outcomes measures: where have all the autopsies gone? Medscape Gen Med. Healthcare Finance Administration. 5.. Concern regarding legal liability which might result following truthful disclosure should not affect the physician's honesty with the 'patient'! (3) :. tions that may have resulted ffum the physician's and making health care safe. Lundberg GD. 2000. the physician is ethically required to inforrri-the patient of all autopsy. Burton EC. 172. 524 NYS2d 94·9:App Div. Lundberg GO.8:150. Accreditation Council 00 Graduate Medical Education. and to apply this sense of failure. Ifwe which a patient suffers significant medical complicaare truly serious about narrowing the quality chasm. 16. do autopsies? In my opinion. 1988.252:390-392. Accrediuuion. TheArchives ot Pathology and Laboratory Medicine 'and the autopsy. Furthermore. it is our ethical and professional responsibility and th~ mis'conception that autopsies no longer reveal to deal openly and honestly with our patients. "Disclosing the death of a patient to the patient's' family is a duty which goes to the very heart of the physician-patient relationship . 1112. Modified: Res. then this is morally reprehensible. 2001. A·90. arid critically assess the porting the fact that clinical diagnosis' is not an exact 'care that we provide. includes the ability to recognize.. 2000.22 (d). Condition of Participation: Medical Staff. Scientific and the potential for inciting malpractice litigation. most physicians dislike medical uncertainty sick. our patients (and their families) with the necessary indeuce. F. American Medical Association. 28: E51. This leads to a through research and publication. Being J. provide anything new. Carey K. these reason's are inappropriate for not performing autopsies. and each patient trusts
. 17.. if the physician suspects thl:\t_ a death is a result of his/her mistake or judgment and chooses to avoid discovery by not requesting an autopsy. . 'Institutional and economic influences on autopsy performance. Vol §802. Cal Bus & Prof Code. Knowledge also occurs through self-discovery It is a fundamental ethical requirement that a phyand self-c1ticism and. Burton EC. 2. Vol. JAMA 1998. The emotional needs of the family and the integrity of the physician-patient relationship must at all times be given foremost consideratioh" (3). but knowledge does not The Code of Ethics (EB. THe demand to with patients . In these sttl. 15. NY County §677.
Autopsy: Assuring Quality of Care
obligations should prevail! Technologica. Kohn L. Globe Newspaper'Co. 1~. advance. also have an obligation to society in exchange for the if the premortem diagnosis had been correct.14:5. Nonetheless. the interests of the individual physician or health care organization (eg. H-85. December 1994.orgll'eq/140pr700. 524 NYS2d 949. inquiry leads to knowledge. Residency Review Committee.·in 10-15% of the cases. AB physihave contributed to the illusion of clinical omniscience cians. and validate our knowledge and perceive errors as unacceptable. ' Physicians are first bound by ethics(moral culpability) . knowledge in the treatment and care of our patients error~ equate to negligence and the fear that autopsies (31). to expand. HeraJil Co v Murray. Powers J. Nemetz PN. . Without it. of which the most fundamental obligation is trust. as physicians. 1996. Herald Co. Jul 7:E51. Chicago: American Medical Association. Code of Medical Ethics Current Opinions and Annotaticns. Ill: Joint Cbmmission on Accreditation o(Healthcare Organizations: 1995.120:759-762. Low-tech autopsies in the era of high-tech medicine: continued value for quality assurance and patient safety. provide compasin -approximately 40% of all patients autopsied. personal fear of the consequences.
has occurred.18) states.' 11. This code does not exclude full disclosure to the patient's family or . 8. JAMA 1984. Unforcians to use our skills and knowledge to benefit the tunately. How can we fulfill these obligations if we do not might uncover mistakes. Internal Medicine. Furthermore. 1b Err Is Human: Building a
and the AMA Code (EB. Corrigan J. Sub. ~e"must bring back the mistake or judgment. fallibility is an inevitable of autopsies because of concerns of personal discredit and necessary feature of intellectual growth. Arch PallwI Lab Med. we science (21-27). we have no idea about the magthe facts necessary to ensure understanding of what nitude of our 'undertaking.acgme. negligence/malpractice litigation) should not override our moral and ethical principles. This may result in avoidance . And. Donaldson M. documented premortem diagnostic errors occur I formation for shared decision making. 6.978. 19911. occur solely through the accumulation of objective evidence. First and foremost. 18. Although the cited reasons for the decline in autopsy rates are true. followed by the internalized belief that: . 2001. Res. Section TV. 512. we have a fiduciary duty to our patients. Med Cien Med. sician should at aU times deal honestly and openly admit. Nemetz PN.5j 1990. and\ learn from our mistakes. A-OO.
References I. and then by law. 42 CFR Cb.!ations. Manual lor Hospitals.504. : .asp#edu. sup-:' sionate and competent care. C4P Trxlay. A potpourri of legal issues relating to the autopsy. 3.12) of the AMA states. Fla Stat §415.. 4.280:1273-1274. Board takes stance on autopsy service pay. Oakbrook Terrace. Additionally. Q & A. the treatpublic investment incurred for' our training as physiment and outcome could have changed (2B-30). IV at section 482.AMERICAN JOURNAL OF MEDICAL QUALITY
. Available at: http:// www. 9.
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24. et al. Robbins SL. 20. Arch Pallwl Lab Med. Babe C. Nichols L. Autopsy diagnoses of malignant neoplasms: how often are clinical diagnoses incorrect? -". Muntwyler J. et a1. Burton EO. 1988. Are autopsies obsolete? Am J CUn Pathol.Safer Health System. Schafii C. JAMA 1998.
.75:29-40. Mangione CM. 23. 30. 28. A bill to amend the Public Health Service Act to reduce medical mistakes and medication-related errors. I. 1996. Pellegrino ED. 2000. 1998.265:885-887. Accuracy of the clinical diagnoses (1955 to 1965) Boston City Hospital. 25.gov!cgi-binJbdquerylD?d106:338:. families. Bauer FW. Ermenc B. Aronica P. Burger B. 29. Diagnostic yield cif the autopsy in a university hospital and a community hospital.308:1000-1005. Diagnostic errors in three medical eras: a necropsy study.114:117-119. Washington.355: 2027-2031. 1991. 21. Lancet. The value of the autopsy in three medical eras. Some ethical reflections on the obligations of pathologists.htmll.196:203-210. et al. 2000. 2000. DC: Nationai'Academy Press. Myers A. Papadakis MA.Itemp/-bdTrL T::V bssldl06query.2. Kirch W. . hospitals. 1983.110:210--2i8.
. Available at: http:// thomas. Troxclair DA.loc. Sonderegger-Iseli K. Bayson R. 2. A bill to amend the Public Heath Service Act to develop an infrastructure for creating a national voluntary reporting system to continually reduce medical errors and improve patient safety to ensure that individuals receive high quality health care.loc. Available at: http://thomas. Newman WP Ill. Miediagnoais at a university hospital in 4 medical eras. JAMA. and society. Goldman L. The autopsy. 2000.htmll. N Engl J Med.. Forensic Sci Int. An autopsy study of cancer patients. et al. JAMA. Lee KK. Chren MM. 1972.60
. LAndefeld CS. Comparison of the clinical and post mortem diagnoses of the causes of death. Diagnostic errors discovered at autopsy. Medicine (Baltimore). 27. N Eng/ J Med. Robbins S.280:1245-1248. 19. 1996. Acta Med Scand.Itemp/ -bdTrLT::l!bssldl06query.221:1471-1474.318:1249-1254. Treatable abdominal pathologic conditions and unsuspected malignant neoplasms at autopsy in veterans who received mechanical ventilation.govlcgi-binlbdquerylD?dI06:337 :. • 31.120:739-742. 2000. Britton M. 1974.