The autopsy: its decline and a suggestion for its revival

The hospital autopsy rate in the United States dropped from 41 per cent in 1964 to 22 per cent in 1975. This reduction is attributable to a declining interest for many reasons by clinicians, surgeons, pathologists, families of the deceased and hospital administrators and hospital accreditors. Various advances in medicine and surgery in recent years have not replaced the value of the autopsy; indeed they have increased the potential information to be gained from it. For interest in autopsies to be revived among physicians and surgeons, pathologists must provide more expert information from the autopsy. To provide the type of information sought from autopsies by physicians and surgeons, the training of pathologists must be altered so that there can be more specialization in anatomic pathology and more subspecialization in the various organ systems, as in internal medicine. In addition, the means of communication between anatomic pathologists and clinicians needs altering so that important clinical questions are recognized by pathologists, and the answers sought and promptly, understandably and diplomatically communicated to physicians and surgeons. Moreover, the large body of information obtained in recent years from autopsies alone needs to be better recognized by clinicians so that they may better understand the value of these examinations.     

Attitudes of senior pathologists towards the autopsy

The attitudes of 205 consultant British pathologists in four regions were assessed by a postal questionnaire in which they were asked to indicate their level of agreement with 15 statements relating to autopsies. A total of 144 pathologists completed the questionnaire (response rate 70 per cent). Senior pathologists strongly agreed with statements relating to the importance of autopsies within pathology workloads, medical audit, and accreditation for training posts. There was strong support for the attendance of clinicians at autopsy demonstrations and for the suggestion that material from medico-legal autopsies should be made available for teaching and research. There was strong disagreement with the suggestions that advances in diagnostic techniques have diminished the role of autopsies, that performing autopsies does not further pathologists' education, that the cost of autopsies may not be justifiable within a limited budget, and that the autopsy should no longer be part of the MRCPath examination. These results are discussed in the context of the current status of the autopsy in general.     

The autopsy as a performance measure and teaching tool

A survey of pathology training programs about current operations and attitudes revealed that the autopsy is underused in medical student and pathology resident teaching, is inadequately reported, often does not have a dedicated faculty, is not championed by pathologists or clinicians, is not valued as a performance measure, and is barely used as a resource for medical research. The autopsy can be reestablished as a teaching tool and performance measure, but this will require that the autopsy be recognized as a credible and valuable medical procedure. The autopsy must then be funded; and new sources of both volume and funding, such as incorporating autopsies into payment schedules, into clinical trials, and in pay-for-performance initiatives, must be solicited. Once there is reimbursement for autopsies, pathologists, clinicians, and health care administrators will embrace the autopsy as a new source of revenue and as a valid measure of physician, hospital, and health system performance. Pathologists and the pathology specialty societies must take the lead in the reestablishment of the autopsy and must, at the same time, encourage innovations such as centralization, greater use of Pathology Assistants, and application of molecular techniques. New tools for using the autopsy in medical student teaching should be embraced, and the role of the autopsy in pathology residency programs must be reevaluated.     

Improve your hospital autopsy rate to 40-50 per cent, a tale of two towns.

In the light of medical audit, all pathology departments are scrutinizing their hospital autopsy rate. In most countries, the rate has fallen over the last few decades to between 10 and 20 per cent. However, it is still possible to achieve a much higher rate. We compare two neighbouring District General Hospitals (DGHs): Northampton, with the more usual autopsy rate of 11 per cent, and Kettering, with a higher rate of 40-50 per cent. These hospitals are comparable in almost every way except for the system used to request permission for an autopsy. These differences were evaluated and the following factors were found to be of importance in achieving a high rate: (1) centralization of death certificates within the mortuary and personal contact between the certifying doctor and the relatives within the bereavement room; (2) mortuary pathology technicians are designated as bereavement officers and act as coordinators between relatives, clinicians, and pathologists; and (3) regular clinico-pathological meetings and a positive attitude to autopsies by clinicians.     

The autopsy: A useful tool or an old relic?

In a combined retrospective and prospective study, clinical and autopsy data were collected to assess the changes in autopsy rate in recent years, the attitudes of clinicians and pathologists to the autopsy, and the accuracy of ante-mortem diagnosis when compared with autopsy findings. Between 1962 and 1986, the total autopsy rate for hospital patients remained relatively constant, with an increase in Coroner's and a decrease in the hospital autopsy rate. Analysis of 5064 deaths over a 6-year period showed a significantly greater number of males than females coming to autopsy and a decrease in autopsy rate with age for both sexes. Attitudes to the autopsy were assessed using a questionnaire. The majority of clinicians considered the autopsy to be an important investigation despite new diagnostic techniques and confirmed its value in teaching and research. Seventy-seven per cent agreed that autopsy findings occasionally led to modification of the treatment of subsequent patients with the same condition. Pathologists disagreed that the autopsy is outdated in its present form and considered that not enough hospital autopsies are being requested. They also upheld its use and value in education. The cause of death as given by clinicians for a group of 60 patients was inaccurate in 12 cases.     

A decade of acceptable autopsy rates. Does concordance of clinician and pathologist views explain relative success?

In an attempt to better understand the basis and significance of an annual autopsy rate consistently over 45% for the past decade, we recently investigated the attitudes and practices of 36 pathologists and 176 clinicians in our institution with respect to the function of the autopsy service and the utility of the autopsy. The autopsy report was "not used in a consistent manner" by 57% of clinical respondents. Several clinicians thought that autopsy reports were too long (20%) and too slow (38%), but not with the frequency that pathologists did, 73% and 58%, respectively. Significantly more pathologists than clinicians believed autopsy rates have fallen over the past 20 years because (1) people think that everything about the deceased is already known, (2) medical students are poorly educated about the autopsy, (3) pathologists have diminished interest, (4) physicians fear litigation, (5) physicians fear "being wrong," (6) pathologists lack financial incentives, and (7) Joint Commission on Accreditation of Healthcare Organizations requirement is not in place. Perceptions regarding the frequency of major discrepancies between clinical and autopsy findings were comparable, 17% and 13%, for pathologists and clinicians, respectively. Our "high" institutional autopsy rate does not reflect concordance of perceptions expressed by clinicians and pathologists and, thus, other factors may be important in the maintenance of an acceptable rate.     

Correlation of clinical diagnoses with autopsy findings: A retrospective study of 2,145 consecutive autopsies

The protocols of 2,145 autopsies were retrospectively reviewed and the findings compared with the clinical diagnoses. A sudden decline in the autopsy rate that occurred during the period studied was followed by a highly statistically significant difference in clinical accuracy (P less than 0.01), in favor of the predecline period. The overall rate of major discrepancies was 29 per cent. The most frequently missed diagnoses were infections, which were found in 26 per cent of all autopsies and had not been diagnosed clinically in 63 per cent of these cases. Malignancies occupied second place among overlooked diagnoses in the selected disease categories; in 99 per cent of the cases the malignancy was the principal diagnosis, and it had been misdiagnosed clinically in 42 per cent of these cases. Cerebrovascular disorders were correctly diagnosed in most cases (87 per cent of the patients in this group). Among autopsy diagnoses labeled as the immediate causes of death, the most frequently overlooked were pulmonary embolism and gastrointestinal hemorrhage, which were not recognized in 84 and 78 per cent, respectively. In cases in which clinicians were not entirely confident in their impressions, their diagnoses were usually confirmed at autopsy. In these cases 15 per cent of the patients died soon after admission to the hospital, with accurate diagnoses in 71 per cent. The discrepancies disclosed should be regarded as sufficiently large to mandate continued emphasis on autopsy evaluation as the basis for the control of the quality of patient care.     

Autopsy result utilization: a College of American Pathologists Q-probes study of 256 laboratories.

OBJECTIVES: To document the level of involvement and communication with nonpathology clinical personnel regarding autopsies and to document the destination of autopsy reports. DESIGN: The College of American Pathologists Q-Probes format was used to collect information on 15 consecutively performed autopsies per institution or for 6 months, whichever occurred first. The following information was recorded for each autopsy: decedent's age, hospital service, length of hospital stay, whether organs were donated, who was present at autopsy, methods of communicating preliminary and final autopsy results, special techniques used to arrive at a preliminary diagnosis, activities for which the autopsy was used, and destination of final report. PARTICIPANTS: Two hundred fifty-six laboratories collected information on 2755 autopsies. RESULTS: The aggregate autopsy rate was 12.4% (median 8.5%). Nonpathology clinical personnel attended 35.8% of all autopsies. A clinical physician was more likely to attend an autopsy if the patient was from a surgical service. Three primary methods were used to communicate preliminary autopsy results, namely, written reports (82.5%), telephone calls (50.6%), and meetings (11.5%). The primary care physician was sent the autopsy report in 91.1% of cases. Approximately half of the autopsy cases were used in both pathology departmental and extradepartmental activities. Aggregate autopsy data were distributed in the majority of cases to various departmental chairpersons and institutional quality assurance committees. CONCLUSIONS: This study provides a comparative multiinstitutional database for the utilization of autopsy results by clinicians and clinical departments. Although autopsy rates are low, autopsy results are routinely being used for hospital quality assurance activities and for educational purposes.     

The role of the autopsy in medical malpractice cases,II: controversy related to autopsy performance and reporting

CONTEXT: We studied 99 appellate court records in cases of alleged medical malpractice and found no relationship between discrepant clinical and autopsy findings and outcome of litigation. Standard-of-care issues and not diagnostic accuracy were at the heart of every case. OBJECTIVE: To characterize and discuss issues related to the autopsy and/or pathologist behavior that were raised in court records of medical malpractice litigation. DESIGN: In 18 appellate court records, issues were raised about quality of autopsy performance and reporting or about death certification. The details of these controversies are succinctly reported here in a manner intended to be instructive to pathologists who perform autopsies in a hospital setting or on a private fee-for-service basis. CONCLUSION: Autopsy reports are intended to provide objective medical information in a coherent format to the patient's medical record, to the attending physician and other concerned staff physicians, to other health care professionals, and to the families of the deceased. Inevitably, occasions arise that require legal counsel to be added to this list of parties with a legitimate interest. Our findings emphasize that incomplete, incoherent, obfuscated, or delayed reporting of autopsy findings do not meet professional standards, are unethical if intentional, and may be counterproductive.     

Limited autopsies. Defined benefits, limited costs

Discussions of the autopsy in conferences and the medical literature commonly depict it as a complex, time-consuming, difficult, and expensive procedure that requires sophisticated research techniques and should be performed only in large medical centers in coordination with organized research and teaching programs by teams of pathologists specially trained in this esoteric discipline. Many patients are cared for (and die) in community hospitals where pathologists perform "limited" autopsies that answer questions about the cause of death and the complications of the disease and its treatment and that provide sound data for mortality statistics and quality control. In view of anticipated funding problems, it appears to be desirable to seek such limited information at minimum expense.     

Declining autopsy rate in a French hospital: physician's attitudes to the autopsy and use of autopsy material in research publications

CONTEXT: Autopsy rates have been declining throughout the world, although preservation of the autopsy is considered a fundamental principle of medical care. In France, the 1994 bioethics law requires physicians to inform relatives before performing an autopsy. OBJECTIVE: To analyze the following factors that potentially influence hospital autopsy rates: legal constraints, autopsy reporting times, opinions of physicians requesting autopsies and pathologists regarding the usefulness of autopsy in patient care, and use of autopsy material in research publications. DESIGN: Record of the annual numbers of deaths and autopsies during a 10-year period (1988-1997). Record of the delays for transmission of final autopsy report to the requesting physician. Questionnaire analyzing the possible factors influencing autopsy rate. Categorization of articles published by pathologists according to the use of autopsy material. SETTING: A 1000-bed, university teaching hospital in the Paris, France, area. PARTICIPANTS: Questionnaire addressed to physicians, head nurses, and mortuary staff. RESULTS: A total of 1454 autopsies were reviewed. The autopsy rate declined from 15.4% in 1988 to 3.7% in 1997. This decline was marked after 1994 and tended to be slower for neurologic indications than for other indications. The final report had not been communicated within 180 days in 620 (42.6%) of 1454 autopsies. Fifty-five of 105 respondents considered that the bioethics law was one cause of the recent decrease of autopsy rate. Considering the contribution of autopsy to medical research, 94 (81%) of 116 articles dealing with central nervous system but only 28 (6%) of 464 articles dealing with other organs used autopsy-derived material. CONCLUSIONS: The 1994 bioethics law seems to contribute to the decline of autopsy. Inadequate delays for communicating autopsy results are frequent. Except for neuropathologists, autopsy is a minor source of research material.     

Views of pathologists and clinicians on autopsy

The study was performed using questionnaires which were filled in by 114 pathologists and 210 clinicians. The pathologists considered the major attractive professional motivations to be the elucidation of clinical aspects and possibility to be engaged in biopsy diagnosis, the most unattractive thing was a small salary. The clinicians supported the view that an autopsy was obligatory, the ratio of supporters to ++nonsupporters among clinicians and pathologists being 2.5:1 and 1:1, respectively. The average expected autopsy cost is 50 levs, but its real one is 84 levs. The overload of dissectors decreases the quality of autopsies and requires the revision of their performance rates. Pathologists's specialization, contact with clinicians, and labour safety are also discussed in the paper. It is only one half of the clinicians who are able to determine which disease is the major one. The death certificates that are filled in by a physician are insignificant (20% of errors are due to improper diagnosis of the major disease). The authors believe that it is high time to set up a national pathoanatomical record office equipped with computers.     

Comparing the case materials available from a teaching hospital's autopsies in 1968 and 20 years later

The Accreditation Committee on Graduate Medical Education requires both sufficient volume and variety of necropsy material for training in anatomic pathology. Since the number of autopsies has declined markedly in the last 20 years, the author sought to determine whether the variety of case material available from the autopsies performed at his teaching hospital had changed during that time span. Major diagnoses were abstracted from the reports of 200 autopsies of adults performed in 1968 and from a period 20 years later (1987, 1988, and part of 1989). Comparison between the two eras' diagnoses revealed very few changes in the incidences of various diseases. This was true even though the racial mix of patients had changed markedly. While declining autopsy rates are of concern, this study suggests that medical educators may not need to be concerned over the variety of autopsy case material. The author makes several suggestions for maximizing the teaching impact of each autopsy.     

Diagnostic yield of the autopsy in a university hospital and a community hospital

To determine the extent to which autopsies yield unexpected findings that are relevant to the patient's death and whether cases with a high yield of such findings can be identified selectively, we studied a total of 233 autopsies at a university hospital and at a community hospital. The rates at which autopsies detected major unexpected findings whose premortem diagnosis would probably have improved survival were 11 percent at the university hospital and 12 percent at the community hospital. Major unexpected findings whose premortem diagnosis would not have prolonged survival were found in another 12 and 21 percent of cases, respectively. Pulmonary embolism and fungal infections in immuno-compromised hosts were the most common major unexpected findings. Neither we nor the patients' physicians were able to identify from the clinical data the autopsies likely to have high yields. Furthermore, the physicians' estimates of an autopsy's expected yield were similar for patients evaluated by autopsy and for matched patients who were not. We conclude that the autopsy continues to yield clinically relevant findings at a high level and that it is not currently possible to predict which cases will have high yields. Autopsies are vital to ensure the quality of medical care, and autopsy rates must be increased substantially if this role is to be fully realized.     

The autopsy as a measure of accuracy of the death certificate

To determine the extent of agreement on underlying cause of death between death certificates and autopsy reports, we analyzed 272 randomly selected autopsy reports and corresponding death certificates from among all such data on autopsies performed in Connecticut in 1980. In 29 per cent of the deaths, a major disagreement on the underlying cause of death led to reclassification of the death in a different International Classification of Diseases major disease category. In an additional 26 per cent, the death certificate and autopsy report agreed on the major disease category but attributed the death to a different specific disease. Deaths due to neoplasms were most accurately diagnosed, with a sensitivity of 87 per cent and a positive predictive value of 85 per cent. Deaths resulting from diseases of the respiratory or digestive system were associated with the highest rates of disagreement. Diseases most commonly overdiagnosed were circulatory disorders, ill-defined conditions, and respiratory diseases. Diseases most commonly underdiagnosed as the cause of death on the death certificate were specific traumatic conditions and gastrointestinal disorders. The autopsy remains an important method for ensuring the quality of mortality statistics.     

Professional attitudes toward the autopsy. A survey of clinicians and pathologists

One hundred six clinicians and 20 pathologists at a pediatric hospital and an adult general hospital in Halifax, Nova Scotia, were surveyed by way of a mailed questionnaire on their attitudes toward the autopsy. Approximately two-thirds of both groups rated the overall usefulness of the autopsy as high, but most limited its benefits to ascertaining the cause of death and as a tool for medical education. The autopsy was rated more highly by pathologists; those who worked in the pediatric hospital; medical rather than surgical specialists; and medical staff rather than housestaff. Personal attitudes toward authorization of an autopsy on a member of the respondent's family or on his or her own body did not differ from declared professional attitudes. It is unclear whether clinicians' and pathologists' negative attitudes toward the autopsy are related to lack of knowledge, lack of hospital and community support of the autopsy, or barriers to the practice of autopsy pathology.     

Clinical and post-mortem assessment of the cause of death

Analysis of the clinical and post-mortem assessment of the underlying cause of death in 742 autopsies showed that over- and underdiagnosis cancelled each other out in the majority of the main diagnostic groups, so there was little difference in the total number of cases recorded in the different groups after clinical and post-mortem investigation. However, in the individual case the reliability of the clinical diagnosis varied greatly with the nature of the diagnosis and its degree of certainty. Reliability was for example high with clinically certain arteriosclerotic heart disease and low with cerebrovascular disease. Underdiagnosis of lung cancer is still a problem. Lack of interest in autopsy investigation may be reflection of lack of clinical involvement or therapeutic frustration rather than the use of sophisticated diagnostic procedures, as has been assumed by previous authors. It is suggested that the idea of selection of cases for autopsy should be replaced by selection of autopsies for microscopic investigation on the basis of the macroscopic post-mortem findings. It is suggested also that clinicians might profitably attend autopsies on patients in their sphere of interest that were not admitted under their care.     

Resident physician opinions on autopsy importance and procurement

The national decline in hospital autopsy cases negatively impacts physician education and medical quality control to an unknown degree. The current non-medicolegal autopsy rate is less than 5% of hospital deaths. This study compares internal medicine and pathology resident physician perceptions of the autopsy, including the importance, procurement, technique, and the pathologist-internist interaction. An 84-item survey based on autopsy literature was designed, piloted, and distributed to 214 residents at a single 800+ bed tertiary care academic teaching hospital (Massachusetts General Hospital, Boston) to accomplish this goal. Completed surveys were obtained from 72% of medicine (n = 118) and 84% of pathology (n = 42) residents. Residents strongly agree on the importance of autopsies for education, answering clinical questions, public health, and research. Autopsy rates are deemed inadequate. Internists are comfortable requesting autopsies, but report insufficient guidance and difficulty with answering technical questions. Although not requested on all hospital deaths, internists are more likely to initiate an autopsy request than a decedent's family, and worry significantly less about institutional costs and malpractice litigation than pathologists believe. Internists expressed interest in having an instructional brochure to give families, observing an autopsy, and having increased communication and support with autopsies from pathology residents. The main reasons why autopsy consent is not requested (it is unpleasant, cause of death is known, family is upset or seems unwilling) and why families refuse (patient has suffered enough, body may be handled disrespectfully, religious/moral objections, lack information) were similar for both resident groups. Despite their decline, autopsies still remain important to medicine as indicated by internal medicine and pathology residents at a large academic center. Improving autopsy education, enhancing availability of resources, and strengthening the pathologist-internist collaboration may serve to heighten awareness and ultimately procurement.     

Immunohistochemistry utilization in autopsy pathology: a Canadian experience

Immunohistochemistry (IHC) is an important part of the diagnostic work-up in surgical pathology, but the use of IHC in autopsy pathology is poorly defined. We measured IHC utilization by pathologists performing 609 consecutive non-medicolegal, hospital-based, adult autopsies over a three-year period. IHC requests on non-neurologic and neurologic material were analyzed separately. Total stains, number of tissue blocks, specific antibody requests, resident trainee involvement, and ordering pathologist were recorded. For all autopsies on which IHC was requested, the final autopsy report was reviewed. IHC was requested on 345 cases (57%), and a total of 4612 stains were performed (mean 13.5 per autopsy). For non-neurologic autopsy tissues, IHC was used most commonly for the accurate diagnosis of malignancy. For neuropathologic autopsy examinations, IHC was employed most commonly to exclude neurodegenerative conditions and correlate ante-mortem clinical neurologic findings. Resident involvement did not significantly impact utilization. Individual pathologists demonstrated a wide variation in IHC utilization. We conclude that IHC is used extensively in Canadian non-medicolegal autopsy pathology reflecting the complexity, extent, and severity of disease in patients dying in a tertiary-care, academic hospital setting. Utilization is strongly influenced by the neuropathology component of these autopsies. The results provide a point of reference for IHC utilization in autopsy pathology.     

Problems of agreement of clinical and autopsy diagnoses

Results obtained from autopsy are parameters of importance to efficacy of diagnosis and therapy. To enable better overseeability of higher numbers of cases, the necessary congruence between clinical and postmortem diagnoses should be consistently settled on the basis of identical criteria used by clinicians and pathologists. Aspects relating to the problem are discussed in some detail, and suggestions are made on how to formulate final evaluations in postmortem reports.