Pathologists point out that autopsies consistently reveal doctors make a high rate of diagnostic errors—even with increasingly sophisticated imaging equipment

Pathologists and public health officials say the downward trend in autopsy rates is having far-reaching consequences for healthcare in the United States. The decline in the number of autopsies performed annually comes in spite of extensive literature documenting multiple benefits of the autopsy procedure.

No less an authority than the American Medical Association is calling attention to this situation. The AMA just published a story titled, “Declining Autopsy Rates Affect Medicine and Public Health,” to call attention to the fact that the rate of autopsies has fallen significantly.

Of course, most older pathologists know that the rate of autopsies has dropped dramatically, compared to past years. Recent data from the Centers for Disease Control and Prevention (CDC), demonstrates that, in 1972 the number of deaths autopsied was 19%. By 2007, that number had plummeted to just 9%.

On its web page, Public Broadcasting System (PBS) is using this photo to illustrate its feature story titled “Without Autopsies, Hospitals Bury Their Mistakes.” Although pathologists and clinical laboratory managers know that the number of autopsies performed annually in the United States has declined substantially over the years, the public is unaware of this trend—nor the fact that autopsies play a valuable role in advancing medical knowledge and improving the ability of physicians to more accurately diagnose disease. (Photo by PBS.org.)

Experts are concerned about this continuing trend. That’s because autopsies have historically played a crucial role in three ways:

• medical education;
• characterization of new diseases; and,
• advancing the understanding of disease pathogenesis. 

“Much of what we know about medicine comes from the autopsy,” observed Stephen J. Cina, M.D., P.C., Chairman of the Forensic Pathology Committee for the College of American Pathologists (CAP).

Autopsy Statistics Consistently Show Declining Rates

The significance of autopsies as important to advancing medical science has been the subject of several television shows aired on PBS. The information was based on investigations conducted by ProPublica.org  in conjunction with PBS. On its website, PBS.org posted an article about autopsies that was titled: “Without Autopsies, Hospitals Bury Their Mistakes.” PBS reported the following data:

• Patients Who Died in Hospitals. Fifty years ago, autopsies were performed about 50% of the time. Today, according to CDC, that number is about 5%.
• Patients Who Died of Diseases Such as Cancer and Cardiovascular Disease. In 1972, the autopsy rate for such deaths was 17%. In 2007, the number was 4%.
• Teaching, Private and Community Hospitals. Teaching hospitals perform autopsies around 20% of the time, private and community hospitals’ autopsy rate is close to zero.
• Older Patients Who Died in Hospitals. CDC data show that, in 2008, 684,000 patients over the age of 60 died in hospitals. Although that represented more than 25% of all deaths in the country that year, just 2.3 % were autopsied. Experts note the lost opportunity to learn about age-related diseases.
• Some Hospitals Performing Zero Autopsies. One survey found that in a given year, 63% of hospitals in the state of Louisiana performed no autopsies.

According to John H Sinard, M.D., Ph.D., Director of Autopsy Service for the Yale University School of Medicine, without an autopsy, doctors and hospitals can’t say for certain how patients are dying. CAP’s Cina added, “You really can’t say for sure what went on or didn’t go on without the autopsy as a quality assurance tool.”

Experts agree that autopsies can be a crucial tool for evaluating and improving medical care. For example, physicians used the findings of Elizabeth Burton, M.D., Deputy Director, Pathology Department, Johns Hopkins University School of Medicine to change antibiotic regimens to snuff out the bacterium that was causing hospital-acquired infections. That example was reported by PBS.org.

Another example came from the autopsies performed by Renu Virmani, M.D., F.A.C.C., President and Medical Director of the nonprofit CVPath Institute, and her team. In certain patients, they determined that a metal stent intended to clear artery blockages was actually causing potentially fatal reactions.

Autopsies Detect Clinically Unsuspected and Erroneous Diagnoses

About 50% of autopsies produce medical findings that were unsuspected before the autopsy, reported the AMA. A 2002 report by the Agency for Healthcare Research and Quality found that autopsies revealed major errors related to the principle diagnosis or underlying cause of death 25% of the time. In 10% of the cases, the error appeared severe enough to have led to the patient’s death.

In 1999, the Medicare Payment Advisory Commission (MedPAC) issued a report stating that increasing the rate of clinical autopsies could improve healthcare and reduce errors. However, despite the data, industry organizations, such as Institute for Healthcare Improvement, National Quality Forum, and The Joint Commission have not pushed to increase the use of autopsies.

According to the PBS piece, hospitals have powerful financial incentives to avoid autopsies. Medicare bundles payments for autopsies into overall payments to hospitals for quality assurance, Yale’s Sinard explained. “The hospital is going to get the money whether they do the autopsy or not, so the autopsy just becomes an expense,” he stated.

Two other factors have helped drive down the frequency of autopsies. In 1971, the Joint Commission dropped its requirement that hospitals conduct a certain percentage of autopsies in order to maintain their accreditation.

Also, growing confidence in modern diagnostic tools, such as CT scans and MRIs, has induced doctors to rely on new technology as a substitute for autopsies. However, pathologists interviewed for the PBS piece said they often find diagnostic errors. “We often identify things that the imaging study could not,” said Debra L. Kearney, M.D., Director of Autopsy Pathology at Texas Children’s Hospital.

The United States is not alone in losing the full range benefits that result from performing an adequate number of autopsies. In 2011, pathologists in Russia conducted a press conference to bemoan the drop in the rate of autopsies performed in their country. (See Dark Daily, “‘Death’ of Pathology in Russia Lamented by Nation’s Leading Pathologists, April 29, 2011.)

The precipitous fall in the rate of autopsies performed in the United States has yet to catch the attention of the public. Even the recent news coverage of the trend of a sustained decline in the number of autopsies by such news outlets as PBS and the AMA has gone unremarked by the media.

That does not surprise pathologists and clinical laboratory managers. It is one more example of how the healthcare system in this country fails to benefit from the high value that results from effective use of autopsies, as well as clinical lab testing and anatomic pathology services.

—Pamela Scherer McLeod

Related Information:

Declining autopsy rates affect medicine and public health

Without Autopsies, Hospitals Bury Their Mistakes, as Reported by ProPublica

Without Autopsies, Hospitals Bury Their Mistakes, as Reported by NPR

Addressing health care errors under Medicare

“Death” of Pathology in Russia Lamented by Nation’s Leading Pathologists