Return of the Autopsy

Cheryl Clark, for HealthLeaders Media , May 1, 2014

The autopsy, long out of favor in non-forensic cases, is enjoying new life in some hospitals as a tool for uncovering cause of death and improving quality of care.

This article appears in the April 2014 issue of HealthLeaders magazine.

For years, the hospital autopsy has been dying.

In fact, experts say most hospital policies regard the autopsy as already dead—at best a calcified relic—since the mid-1970s, when The Joint Commission lifted its requirement that hospitals perform autopsies on 20% of inpatient deaths to gain accreditation. Even teaching hospitals have reduced the number they do for training medical students.

Rare is the hospital where the autopsy rate is greater than 5% of nonforensic deaths. At most it's usually only 1%, several pathology experts say.

A big deterrent is the autopsy's cost, $1,000–$3,500 or more, which the hospital usually has to absorb as part of its quality assurance requirements. Medicare embeds this in the episode payment for its beneficiaries without a line item, per se, which means that hospitals can't bill separately for the procedure, although every beneficiary has the right to one if requested.

Revealing information on misdiagnosis

But against all this, a few hospital leaders are resisting the trend, trying to keep the autopsy alive, and even revive it as they campaign for their doctors and families to allow much wider usage. The autopsy can answer questions about contributing causes of death and thus improve quality of care, they say.

"We thought you had x but you ended up dying of y, and that means somewhere between 60,000–80,000 people a year die in the intensive care unit because of misdiagnosis," says Peter J. Pronovost, MD, senior vice president for patient safety and quality at 1,059-bed Johns Hopkins Hospital in Baltimore, Md. Pronovost also is director of the Armstrong Institute for Patient Safety and Quality, also in Baltimore.

A staunch autopsy advocate whose research discovered those statistics, Pronovost says missed infections and unrecognized vascular complications are the most common diagnostic errors resulting in death, and yet many of these complications are preventable.

Recognizing such risks can prompt ultrasound testing to find deep vein thrombosis, which puts patients at risk of potentially lethal pulmonary embolism, he says. The autopsy "is a valuable tool to help us learn how to prevent misdiagnoses in the future," Pronovost says.

Hospitals with good autopsy track records might consider showcasing that as evidence that they are committed to transparency and aren't afraid to learn from their mistakes.

The caveat, however, is that the autopsy must be part of a feedback loop that gets that diagnostic information back to the clinical team, he says. "Where we go wrong, and where people question the autopsy's value, is if the result just sits in pathology and doesn't get back to the team to show ways to improve."

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1 comments on "Return of the Autopsy"

Dr. John Carter (5/12/2014 at 2:09 PM)
This is a great article with much important information. For 20+ years our hospital-based pathologist group has covered the autopsy service for the Lexington County (SC) Coroner. We have worked up natural cause of death cases as thoroughly as forensic cases and have found a 5% rate of unexpected findings involving patients of the Medical Center and its medical staff. The increased number of autopsies (120 vs. 8) for study, and the out-of-hospital death settings provide an important difference in perspective. We correlate findings of these cases with clinical impressions, send a copy of the autopsy report to all physicians involved in the patient's care, and present an annual summary of findings to the medical staff as a form of amplified learning. Over the years findings that have been presented to the medical staff have significantly decreased in occurrence[INVALID]a remarkable result of this unique use of a coroner autopsy system in a Medical Center QA program. A review of specific findings and results of QA discussions is in preparation for a national meeting presentation.




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