Autopsy Rate and Physician Attitudes Toward Autopsy

Many people not associated with health care form their impressions of pathology based on television and movie portrayals, with the belief that pathologists spend their time performing autopsies. This is a fallacy. Before 1970, approximately 40% to 60% of all hospital deaths in the United States ended in autopsy; in more recent years that number has decreased to below 5%. ^{[1, 2]}  Worldwide autopsy rates have declined steadily since the 1950s—and there is no evidence to suggest that the trend will change. ^{[3, 4]}

Fictional pathologists are often medical examiners (MEs), frequently caricatured as eccentric, tortured geniuses who work in dramatically lit morgues and draw astonishing conclusions from autopsies. The majority of US pathologists typically work in community hospitals attending to surgical specimens and cytology studies, and taking care of administrative obligations; performing autopsies is an increasingly rare occurrence. Indeed, many community pathologists regard the autopsy, once an important part of the educational, patient care, and quality assurance missions of a hospital pathology department, as an unexpected and irritating interruption from their busy routine.

The medical and lay press have debated the significance of the decline in hospital autopsy rates and offered a wide variety of explanations. At one end of the spectrum, some authors have characterized the autopsy as a vestige of a bygone medical era that has largely been supplanted by noninvasive techniques. At the other end are those who have insisted on the continued clinical relevance of the autopsy and warned of the dire consequences of underutilizing it.

This article will discuss the current state of the autopsy with respect to autopsy rates, several explanations for the current decline in autopsy rates, the current benefits of autopsy, physician attitudes toward autopsy, and suggestions for improving autopsy rates.

Medicolegal autopsies are performed by forensic pathologists or coroners as mandated by local statutes, typically in cases of suspected homicide, suicide, or accident, ^[5] and (unlike hospital autopsies) they do not require permission from the next of kin. Most jurisdictions collect reliable data on their medicolegal autopsies, and statistical data suggest that rates of medicolegal autopsies have increased over time.

Exact hospital autopsy rates are more difficult to delineate owing in part to a lack of standards regarding definitions and data reporting. Autopsy rate reporting may vary between institutions depending on whether forensic cases, stillbirth cases, and cases referred from outside the hospital are included. There is general agreement, however, that autopsy rates have decreased substantially over the past decades in the United States. Data from the United States National Center for Health Statistics (NCHS) have shown that the overall autopsy rates (ie, medicolegal plus forensic cases) decreased from 19.1% of all deaths in 1972 to 8.5% in 2007. ^[2] These figures become even more striking when one separates the statistics for hospital and medicolegal autopsies. Although the medicolegal autopsy rate for the 35-year period rose from 43.6% to 55.4%, the hospital autopsy rate fell from 16.9% to 4.3%. ^[2]

Even the 4.3% figure, an average for all US hospitals, does not provide an accurate picture. There are 5,564 registered hospitals in the United States, ^[6] of which only about 6% are teaching hospitals. ^[7] Autopsy rates at teaching hospitals with pathology residency programs tend to be significantly higher than those seen at community hospitals. It is, in fact, likely that hospitals in which autopsies are not performed outnumber those in which autopsies are performed. Therefore, it seems reasonable to assume that the median figure for the hospital autopsy rate in the United States is substantially lower than 4.3%.

Autopsy rates outside the United States have also decreased precipitously. In Australia, the rate decreased by approximately 50% between 1992 and 2003. ^[8]  data from the Danish National Institute of Health showed a decrease in autopsy rates from 45% in 1970 to 16% in 1990, ^[9] and data from Halifax, Nova Scotia, showed a reduction of clinical autopsies from 30% in 1987 to 20% in 1999. ^[10] In the United Kingdom, clinical autopsy rates plummeted from 25.8% in 1979 to an abysmal 0.69% of all hospital deaths in 2013. ^{[11, 12]}

The decline in autopsy rates represents the intersection of several changes that have taken place in the field of medicine. One such change is the shift in care toward treating older and sicker patients who are dying in long-term facilities and in hospice care settings. ^[13] However, the most important changes to affect autopsy rates have occurred in the realms of healthcare economics, professional standards, and medical technology.

Financial considerations

Few data exist as to the true cost of an autopsy (including both fixed and variable costs), although the small number of studies that have attempted to capture this information suggest a wide range of potential price tags. The most recent published mean cost estimate per autopsy case was $1,275.00 (range: $100.00 - $7,500.00). ^{[4, 14]} The total charge for an autopsy depends on many variables, including the case load and cost for personnel, space, materials, processing, and ancillary testing.

No financial incentives currently exist for either the hospital or the pathologist to perform autopsies because reforms in healthcare coverage and reimbursement have essentially eliminated direct funding for autopsies altogether. The cost of an autopsy is not included by managed care organizations or by third-party insurers as part of an individual's healthcare coverage. Although the American Medical Association (AMA) has assigned procedural codes (under the AMA's Current Procedural Terminology [CPT]), there is no assigned relative value for autopsies. As a result, the pathologist or pathology group cannot bill for either the technical or professional component of an autopsy in the same manner that they can bill for other laboratory services. Some hospitals—especially teaching hospitals—will absorb the expense. In other situations, the resulting costs may be passed on to the next of kin of the deceased at the discretion of the hospital or individual pathologist performing the procedure.

No specific reimbursement figure exists for autopsies under the Medicare resource–based relative value scale (RBRVS) fee schedule. ^[15] The federal government technically funds autopsies as part of a fixed annual payment made to hospitals to cover a variety of services. This system implicitly incentivizes hospitals not to perform autopsies and instead retain the leftover revenue for other overhead costs they determine to be more valuable.

Professional standards

Support for the hospital autopsy can be found in professional medical societies and in the medical literature, but no formal benchmark exists for an acceptable hospital autopsy rate. ^[16] For decades, none was necessary. After Abraham Flexner’s scathing indictment of medical education in 1910, ^[17] American medical schools adopted the German model of medical education, in which clinical pathological correlation and the autopsy were central elements. Academic physicians (clinicians and pathologists alike) promoted the autopsy as a research and teaching tool. Community hospitals largely followed suit. For a time a hospital’s autopsy rate became a marker of its commitment to quality medical care. By the end of the Second World War, nearly half of the people who died in American hospitals underwent autopsy, and the rate in teaching hospitals was often much higher.

The subsequent decline probably began in the 1950s with the truly dramatic rise in federal funding for medical research. ^[18] As academic success became defined by the ability to secure federal grants for laboratory research, interest in autopsies waned. As early as 1956 an academic cardiologist commenting on this trend said, “What wonder that the new professor of pathology…has washed his hands of the…routine autopsy.” ^[19]

The often mentioned Joint Commission on Accreditation of Healthcare Organizations (JCAHO; now called the Joint Commission) accreditation requirement of a 25% autopsy rate for teaching institutions and a 20% rate for nonteaching institutions was not implemented until 1965 and was only in place for about 6 years. Following the advent of Medicare and Medicaid, and the downfall of the doctrine of charitable immunity for hospitals, the JCAHO completely overhauled its standards in 1971 and abolished many of its numerical benchmarks in the process—including the autopsy rate requirement. ^{[3, 4]} It was felt that hospitals were unselectively using autopsies to meet arbitrary target rates without utilizing the information derived as intended to assess quality and improve hospital care. The JCAHO reached this decision after extensive study and with the input of hospital administrators, clinicians, and pathologists. ^[20] They believed that hospitals and physicians themselves could be relied upon to decide on an appropriate autopsy rate. The precipitous change in the slope of the already-declining hospital autopsy rate after 1971 suggests that this confidence was misplaced.

Technical advancements

There is a narrative in the literature that suggests that the decline in the hospital autopsy rate is part of an evolutionary process, the natural result of improvements in less-invasive medical technology. The idea is that better laboratory testing and improved medical imaging has improved diagnostic accuracy to the point that postmortem confirmation is no longer necessary in the vast majority of cases. ^{[3, 4]}

A couple of things should be noted. First, the medical literature has consistently shown that hospital autopsies uncover clinically important and unsuspected diagnoses in a significant fraction of cases (see below, under Benefits of Autopsy) even in patients who have received an extensive diagnostic evaluation. Second, the autopsy rate began to decline in the 1950s, decades before the widespread availability of the computerized imaging modalities that are credited with replacing it.

Despite the downward trend of autopsy rates, the benefits of performing autopsies are widely documented. ^[21] In both clinical and forensic cases, the autopsy is instrumental in accurately establishing the cause and manner of death. Autopsies also allow confirmation, clarification, and correction of antemortem diagnoses as well as the identification of new and reemerging diseases. Thus, they prove instrumental in both protecting the public health and improving the accuracy of vital statistics. ^[22]

Autopsy studies have proven invaluable for the discovery of many diseases and the elucidation of a multitude of pathologic processes. ^[3] For example, such studies have improved and refined our understanding of such diseases as myocardial infarction and heart disease, ^[23]  human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), ^[24] and Alzheimer disease and other dementias. ^{[25, 26]}

From a public health standpoint, autopsies have proven particularly important for establishing risk factors and identifying potential disease outbreaks. Examples include the 1999 outbreak of encephalitis that occurred in New York City, in which the etiologic agent was found to be West Nile virus ^[27] ; severe acute respiratory syndrome (SARS) caused by a coronavirus that was first reported in Asia in 2003, with 204 people infected and 26 deaths that quickly spread to infect over 8,000 people in four continents with nearly 800 deaths ^[28] ; the 2001 bioterrorism-related outbreak of inhalational anthrax ^{[29, 30]} ; and most recently, the 2015 Zika virus epidemic and its association with microcephaly. ^[31]

Autopsies remain a powerful tool for education and quality control, although quantifying these benefits prove challenging (see Autopsy Quality Metrics). Autopsy studies have documented significant discrepancies between clinical antemortem diagnoses and postmortem diagnoses that have important implications in terms of clinical care. ^{[3, 4, 32, 33, 34, 35]}  Moreover, major diagnostic errors detected by autopsies indicate substantial inaccuracies in death certificates and hospital discharge data that have important roles in epidemiologic research and healthcare policy decisions. ^{[32, 36]}

Evolving physician attitudes exert tremendous influence over autopsy rates. In hospital cases, permission to perform an autopsy is granted by the next of kin of the deceased. The clinician who cared for the patient is often the healthcare professional who requests permission from the next of kin. However, several studies have shown that permission for autopsy is often not requested by the physician. ^[14] As mentioned earlier, clinicians may not seek permission to perform an autopsy because of overreliance on the technology used to make the diagnosis and because a substantial amount of information was known about the patient before death. ^[37]

Despite this overreliance, considerable discrepancies have been found between premortem and postmortem diagnoses. Clinicians generally attribute such results to selection bias arising from the fact that the cases in which autopsy was performed were those in which there was the greatest diagnostic uncertainty. Nevertheless, clinicians demonstrate little ability to predict the occurrence of such discrepancies. ^[32]

Many clinicians report a perceived value in obtaining autopsies, but this interest may be offset by concerns over litigation, ^[38] inadequate information about autopsy procedures, and discomfort in approaching the next of kin about obtaining permission. ^{[3, 4]}

In terms of malpractice litigation, some clinicians involved in the care of patients fear that autopsies may increase their risk of being sued, whereas some pathologists believe that their autopsy may lead to unnecessary malpractice lawsuits. ^[38]  Autopsies, in and of themselves, simply provide facts that may support or refute expert opinions. They do not prove or disprove that patient care was substandard. ^[39] In proving medical malpractice, negligence must be shown. In such cases, it must be demonstrated that the healthcare provider incurred a duty by undertaking care; that the healthcare provider failed to meet the relevant standard of care; and that an injury resulted and damages were incurred.

Oftentimes, clinicians are unsure of the logistics involved in obtaining an autopsy. They may lack adequate knowledge about the actual autopsy procedure itself, its cost, or other technical details. These factors may increase the clinician's discomfort in approaching the patient's next of kin to request permission to perform an autopsy. Much of this knowledge gap stems from the fact that few internal medicine residencies provide any curriculum time to the discussion of autopsy. ^{[40, 41, 42]} Numerous studies have shown that autopsy rates increase substantially once physicians are exposed to formal training in autopsy consent. ^{[43, 44]} Interventions targeting education of junior physicians suggest that the greatest and most sustained increases in autopsy rates occur when employing consistent periodic encouragement by senior house staff, including senior residents and department heads. ^{[44, 45]}

Some studies have also shown that clinicians do not request permission to perform an autopsy because, in their experience, autopsy results were not reported in a timely fashion or the quality of the autopsy was unsatisfactory. ^{[46, 47]} Other problems cited by physicians include a lack of direct contact between the treating clinician and the pathologist before the autopsy, the fact that questions of clinical interest were not addressed, and lengthy reports that catalogue anatomic diagnoses without adequate interpretation. ^[21] (Autopsy communication will be discussed in another article.)

From the pathologists' point of view, autopsies are time-consuming, costly, and do not generate revenue. Few hospitals recruit pathologists who solely provide autopsy services within the group or department. Many pathologists, particularly at academic institutions, describe that research, teaching, and surgical and clinical pathology take precedence over autopsies, which often prolong their workday.

Clinicians and pathologists recognize that the decreasing number of autopsies now being performed negatively impacts the ability for budding pathologists to gain the expertise needed to competently perform an adequate autopsy. Pathologists who choose autopsy as their major career focus tend to subspecialize in forensic pathology rather than hospital-based autopsy pathology. The number of treating clinicians consistently requesting autopsies for their patients in the community hospital setting is low, as is the number of pathologists willing and able to competently perform an adequate autopsy. The highest autopsy rates cluster in academic institutions where pathology residents are trained. Autopsy education remains a requirement for accreditation in pathology training programs and for pathology board certification, but it is not a requirement for completion of medical school or residency training and certification in other specialties of medicine.

Although the rate of autopsy performance continues to decline, it is unlikely that autopsies will completely cease to exist. The need for autopsies persists, particularly in the field of forensics and in specific fields of research in which focused autopsies (ie, those limited to answering a particular question) are becoming more widely used. ^[48] New technologies, including full-body three-dimensional (3-D) imaging, currently lack the sophistication to outperform autopsies, ^[49] but they are employed both as an adjunct to traditional autopsies and to enhance forensic autopsy examination (see Postmortem Radiology and Imaging). ^{[50, 51]}