Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Case of the Month: Institutional Autopsy Rates

Case of the Month: Institutional Autopsy Rates A 35-YEAR-OLD man with end-stage acquired immune deficiency syndrome was admitted to the hospital for severe abdominal pain, abdominal tenderness, and fever. A computed tomographic scan showed colonic distension, thickening of the colonic wall, and a possible rectal mass. Death occurred within 24 hours of admission to the hospital, and permission to perform an autopsy was requested to evaluate the gastrointestinal tract. Recently, he had been given clindamycin for empirically suspected central nervous system toxoplasmosis. Autopsy findings The results of the autopsy showed pneumonia due to cytomegalovirus infection and massive dilatation of the entire colon, which had a diameter approximately 3 times the normal size. The colonic wall was thickened and edematous, the mucosa of the distal colon was necrotic, and the remaining mucosa showed numerous ulcerative lesions and a thick fibropurulent pseudomembrane. Microscopically, the colon showed morphologic changes typical of pseudomembranous colitis, normally distributed ganglia (ie, no evidence of congenital megacolon), and no features suggestive of ulcerative colitis, regional enteritis, ischemic bowel disease, or other infectious bowel disease. The brain showed organizing abscesses consistent with recently treated toxoplasmosis. Based on the autopsy findings, a cause of death statement could be prepared as follows: Part 1 A. Toxic megacolon Due to or as a consequence of: B. Pseudomembranous colitis Due to or as a consequence of: C. Clindamycin therapy for cerebral toxoplasmosis Due to or as a consequence of: D. Acquired immune deficiency syndrome Part 2. OTHER SIGNIFICANT CONDITIONS: Pneumonia due to cytomegalovirus Comment Although clindamycin-associated pseudomembranous colitis due to Clostridium difficile is a well-known entity,1 it is not commonly associated with toxic megacolon. The findings in this case prompted the pathologist to consider a retrospective review of autopsy cases at the institution in a search for similar cases among patients with acquired immune deficiency syndrome who had been treated with clindamycin. Unfortunately, the number of autopsies performed in such cases was too small to enable such an analysis. This problem prompted the pathologist to review the overall autopsy rates in the institution. A review of annual institutional mortality and autopsy data showed that the annual deaths of inpatients remained relatively constant between 1986 and 1995 but the number of autopsies performed had progressively declined from 250 in 1986 to 105 in 1995, resulting in an autopsy rate that declined from 17% to 7% of in-hospital deaths. A review of the literature2 showed that similar trends have occurred nationally and that nationwide autopsy rates gradually declined from 41% in 1964 to about 15% in 1983. A 1994 survey of 244 hospitals conducted by the College of American Pathologists3 showed that half of hospitals had autopsy rates at or below 8.5% and 75.0% had autopsy rates below 13.5%. Interestingly, accreditation programs4 in internal medicine recommend an autopsy rate of at least 15%. Why have autopsy rates fallen so dramatically? This question and other issues have been discussed extensively for 35 years at various symposia in the United States.5-8 In brief, the following are the most commonly mentioned reasons: Lack of reimbursement. In general, hospitals do not charge families for autopsy services, insurers do not usually pay for autopsy costs, and the Health Care Financing Administration's Medicare reimbursements do not provide payments (Part B) for specific autopsy services. Part A reimbursements, according to the Health Care Financing Administration, include non–line-item money to support autopsy services, but the payment is not based on autopsy rate, autopsy use, outcomes assessment, or actual autopsy costs. In essence, the lack of reimbursement makes the autopsy a "loss leader," which hospital financial managers and pathology departments must manage. Lack of incentive. The autopsy is a labor-intensive and expensive procedure. In most hospital settings, pathologists are not paid on a fee-per-case basis. Managed care has resulted in fewer pathologists who have to work longer and harder, and the autopsy poses workforce burdens with little incentive. Decreased emphasis in medical school. Medical schools have moved toward clinical problem-solving curricula and away from basic sciences. Time allocated to pathology curricula has dwindled. Many medical students now graduate with no training in autopsy procedure, no instruction on how to request permission for an autopsy, and no opportunity to view an autopsy in progress or the inside of a cadaver. Perhaps as a result of decreased emphasis, it has been shown that clinicians frequently do not ask for permission to have an autopsy performed. Technological advances. The dramatic and rapid advancements in diagnostic modalities such as computed tomography and magnetic resonance imaging have improved the ability to view images of internal bodily aspects, resulting in the perception among clinicians that the autopsy may be replaced by imaging and other methods. Changing nature of disease patterns. Changing disease patterns affect the autopsy in 2 ways. First, some pathologists have become concerned about the increased risk of occupational exposure to potentially fatal and/or drug-resistant, blood-borne, respiratory, and other pathogens, causing them to take a closer look at the risk-benefit ratio of autopsy performance. Second, the increase in deaths involving human immunodeficiency virus infection and survival among patients with terminal diseases of many types have changed the mortality patterns in some institutions. More patients have lengthy illnesses and prolonged hospitalization during which many of their disease processes may be elucidated. Negative feedback. Many pathologists are not interested in the autopsy and have attitudes of indifference, avoidance, and in some cases, antagonism resulting in half-hearted autopsy performance. These attitudes and practices may negatively affect the attitudes and practices of clinicians in the institution who are the suppliers of autopsy authorizations and users of autopsy information. Despite the use of sophisticated imaging technologies and other new diagnostic tools, recent studies9-11 demonstrate that 32% to 42% of autopsies reveal at least 1 major unexpected or clinically unconfirmed finding that contributed to the patient's death. In addition, approximately 93% of clinical questions made known to the pathologist prior to autopsy are answered in the results of the autopsy.11,12 These studies indicate that the autopsy continues to be a valuable resource for education and quality assurance. The positive contributions of the autopsy have also been recognized by the American Medical Association.2 One of us (R.H.) has educated physician housestaff about these data, and the institution's autopsy rate rose nearly 30% in 1997 compared with 1996. Several reasons cited herein for declining autopsy rates could be addressed by regionalization of hospital autopsies to medical centers with interest in performing autopsies, experience in performing autopsies involving infectious and complex conditions, and adequate facilities for recommended and regulated infection control practices.8 A list of the members of the Autopsy Committee of the College of American Pathologists appears in the August 1997 issue of the ARCHIVES (1997;157:1645). References 1. Cotran RSKumar VRobbins SL Robbins Pathologic Basis of Disease. 4th ed. Philadelphia, Pa WB Saunders Co1989;360- 361 2. AMA Council on Scientific Affairs, Autopsy: a comprehensive review of current issues. JAMA. 1987;258364- 369Google ScholarCrossref 3. Baker PBZarbo RJHowanitz PJ Quality assurance of autopsy permit form information, timelines of performance, and issuance of preliminary report: a College of American Pathologists Q-Probes study of 5434 autopsies from 452 institutions. Arch Pathol Lab Med. 1996;120346- 352Google Scholar 4. Not Available, Program requirements for residency education in internal medicine. Accreditation Council for Graduate Medical Education Web site. Available at: http://www.acgme.org/RRC/Int_Req2.asp. Accessed March 27, 1998. 5. Angrist A What remedies for the failing autopsy? In: Symposium on the autopsy. JAMA. 1965;193805- 814Google ScholarCrossref 6. Williams MJPeery TM The autopsy, a beginning, not an end. Am J Clin Pathol. 1978;69(suppl 2)215- 216Google Scholar 7. College of American Pathologists Foundation Conference on the Autopsy, Revitalizing the ultimate medical consultation. Arch Pathol Lab Med. 1984;108437- 512Google Scholar 8. College of American Pathologists Conference XXIX, Restructuring autopsy practice for health care reform. Arch Pathol Lab Med. 1996;120700- 785Google Scholar 9. Sarode VRDatta BNBanergee AK et al. Autopsy findings and clinical diagnoses: a review of 1000 cases. Hum Pathol. 1993;24194- 198Google ScholarCrossref 10. Veress BAlafuzoff I A retrospective analysis of clinical diagnoses and autopsy findings in 3,042 cases during two different time periods. Hum Pathol. 1994;25140- 145Google ScholarCrossref 11. Baker PBSaladino AJ Autopsy Contributions to Quality Assurance: Data Analysis and Critique. Northfield, Ill College of American Pathologists1993;Q-Probes series No. 93-06. 12. Fowler EFNicol AGReid IN Evaluation of a teaching hospital necropsy service. J Clin Pathol. 1977;30575- 578Google ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Case of the Month: Institutional Autopsy Rates

Hanzlick, Randy; Baker, Peter
Archives of Internal Medicine , Volume 158 (11) – Jun 8, 1998
Download PDF
2 pages

Loading next page...
 
/lp/american-medical-association/case-of-the-month-institutional-autopsy-rates-BMcmGm8sFR

References (12)

Publisher
American Medical Association
Copyright
Copyright © 1998 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.158.11.1171
Publisher site
See Article on Publisher Site

Abstract

A 35-YEAR-OLD man with end-stage acquired immune deficiency syndrome was admitted to the hospital for severe abdominal pain, abdominal tenderness, and fever. A computed tomographic scan showed colonic distension, thickening of the colonic wall, and a possible rectal mass. Death occurred within 24 hours of admission to the hospital, and permission to perform an autopsy was requested to evaluate the gastrointestinal tract. Recently, he had been given clindamycin for empirically suspected central nervous system toxoplasmosis. Autopsy findings The results of the autopsy showed pneumonia due to cytomegalovirus infection and massive dilatation of the entire colon, which had a diameter approximately 3 times the normal size. The colonic wall was thickened and edematous, the mucosa of the distal colon was necrotic, and the remaining mucosa showed numerous ulcerative lesions and a thick fibropurulent pseudomembrane. Microscopically, the colon showed morphologic changes typical of pseudomembranous colitis, normally distributed ganglia (ie, no evidence of congenital megacolon), and no features suggestive of ulcerative colitis, regional enteritis, ischemic bowel disease, or other infectious bowel disease. The brain showed organizing abscesses consistent with recently treated toxoplasmosis. Based on the autopsy findings, a cause of death statement could be prepared as follows: Part 1 A. Toxic megacolon Due to or as a consequence of: B. Pseudomembranous colitis Due to or as a consequence of: C. Clindamycin therapy for cerebral toxoplasmosis Due to or as a consequence of: D. Acquired immune deficiency syndrome Part 2. OTHER SIGNIFICANT CONDITIONS: Pneumonia due to cytomegalovirus Comment Although clindamycin-associated pseudomembranous colitis due to Clostridium difficile is a well-known entity,1 it is not commonly associated with toxic megacolon. The findings in this case prompted the pathologist to consider a retrospective review of autopsy cases at the institution in a search for similar cases among patients with acquired immune deficiency syndrome who had been treated with clindamycin. Unfortunately, the number of autopsies performed in such cases was too small to enable such an analysis. This problem prompted the pathologist to review the overall autopsy rates in the institution. A review of annual institutional mortality and autopsy data showed that the annual deaths of inpatients remained relatively constant between 1986 and 1995 but the number of autopsies performed had progressively declined from 250 in 1986 to 105 in 1995, resulting in an autopsy rate that declined from 17% to 7% of in-hospital deaths. A review of the literature2 showed that similar trends have occurred nationally and that nationwide autopsy rates gradually declined from 41% in 1964 to about 15% in 1983. A 1994 survey of 244 hospitals conducted by the College of American Pathologists3 showed that half of hospitals had autopsy rates at or below 8.5% and 75.0% had autopsy rates below 13.5%. Interestingly, accreditation programs4 in internal medicine recommend an autopsy rate of at least 15%. Why have autopsy rates fallen so dramatically? This question and other issues have been discussed extensively for 35 years at various symposia in the United States.5-8 In brief, the following are the most commonly mentioned reasons: Lack of reimbursement. In general, hospitals do not charge families for autopsy services, insurers do not usually pay for autopsy costs, and the Health Care Financing Administration's Medicare reimbursements do not provide payments (Part B) for specific autopsy services. Part A reimbursements, according to the Health Care Financing Administration, include non–line-item money to support autopsy services, but the payment is not based on autopsy rate, autopsy use, outcomes assessment, or actual autopsy costs. In essence, the lack of reimbursement makes the autopsy a "loss leader," which hospital financial managers and pathology departments must manage. Lack of incentive. The autopsy is a labor-intensive and expensive procedure. In most hospital settings, pathologists are not paid on a fee-per-case basis. Managed care has resulted in fewer pathologists who have to work longer and harder, and the autopsy poses workforce burdens with little incentive. Decreased emphasis in medical school. Medical schools have moved toward clinical problem-solving curricula and away from basic sciences. Time allocated to pathology curricula has dwindled. Many medical students now graduate with no training in autopsy procedure, no instruction on how to request permission for an autopsy, and no opportunity to view an autopsy in progress or the inside of a cadaver. Perhaps as a result of decreased emphasis, it has been shown that clinicians frequently do not ask for permission to have an autopsy performed. Technological advances. The dramatic and rapid advancements in diagnostic modalities such as computed tomography and magnetic resonance imaging have improved the ability to view images of internal bodily aspects, resulting in the perception among clinicians that the autopsy may be replaced by imaging and other methods. Changing nature of disease patterns. Changing disease patterns affect the autopsy in 2 ways. First, some pathologists have become concerned about the increased risk of occupational exposure to potentially fatal and/or drug-resistant, blood-borne, respiratory, and other pathogens, causing them to take a closer look at the risk-benefit ratio of autopsy performance. Second, the increase in deaths involving human immunodeficiency virus infection and survival among patients with terminal diseases of many types have changed the mortality patterns in some institutions. More patients have lengthy illnesses and prolonged hospitalization during which many of their disease processes may be elucidated. Negative feedback. Many pathologists are not interested in the autopsy and have attitudes of indifference, avoidance, and in some cases, antagonism resulting in half-hearted autopsy performance. These attitudes and practices may negatively affect the attitudes and practices of clinicians in the institution who are the suppliers of autopsy authorizations and users of autopsy information. Despite the use of sophisticated imaging technologies and other new diagnostic tools, recent studies9-11 demonstrate that 32% to 42% of autopsies reveal at least 1 major unexpected or clinically unconfirmed finding that contributed to the patient's death. In addition, approximately 93% of clinical questions made known to the pathologist prior to autopsy are answered in the results of the autopsy.11,12 These studies indicate that the autopsy continues to be a valuable resource for education and quality assurance. The positive contributions of the autopsy have also been recognized by the American Medical Association.2 One of us (R.H.) has educated physician housestaff about these data, and the institution's autopsy rate rose nearly 30% in 1997 compared with 1996. Several reasons cited herein for declining autopsy rates could be addressed by regionalization of hospital autopsies to medical centers with interest in performing autopsies, experience in performing autopsies involving infectious and complex conditions, and adequate facilities for recommended and regulated infection control practices.8 A list of the members of the Autopsy Committee of the College of American Pathologists appears in the August 1997 issue of the ARCHIVES (1997;157:1645). References 1. Cotran RSKumar VRobbins SL Robbins Pathologic Basis of Disease. 4th ed. Philadelphia, Pa WB Saunders Co1989;360- 361 2. AMA Council on Scientific Affairs, Autopsy: a comprehensive review of current issues. JAMA. 1987;258364- 369Google ScholarCrossref 3. Baker PBZarbo RJHowanitz PJ Quality assurance of autopsy permit form information, timelines of performance, and issuance of preliminary report: a College of American Pathologists Q-Probes study of 5434 autopsies from 452 institutions. Arch Pathol Lab Med. 1996;120346- 352Google Scholar 4. Not Available, Program requirements for residency education in internal medicine. Accreditation Council for Graduate Medical Education Web site. Available at: http://www.acgme.org/RRC/Int_Req2.asp. Accessed March 27, 1998. 5. Angrist A What remedies for the failing autopsy? In: Symposium on the autopsy. JAMA. 1965;193805- 814Google ScholarCrossref 6. Williams MJPeery TM The autopsy, a beginning, not an end. Am J Clin Pathol. 1978;69(suppl 2)215- 216Google Scholar 7. College of American Pathologists Foundation Conference on the Autopsy, Revitalizing the ultimate medical consultation. Arch Pathol Lab Med. 1984;108437- 512Google Scholar 8. College of American Pathologists Conference XXIX, Restructuring autopsy practice for health care reform. Arch Pathol Lab Med. 1996;120700- 785Google Scholar 9. Sarode VRDatta BNBanergee AK et al. Autopsy findings and clinical diagnoses: a review of 1000 cases. Hum Pathol. 1993;24194- 198Google ScholarCrossref 10. Veress BAlafuzoff I A retrospective analysis of clinical diagnoses and autopsy findings in 3,042 cases during two different time periods. Hum Pathol. 1994;25140- 145Google ScholarCrossref 11. Baker PBSaladino AJ Autopsy Contributions to Quality Assurance: Data Analysis and Critique. Northfield, Ill College of American Pathologists1993;Q-Probes series No. 93-06. 12. Fowler EFNicol AGReid IN Evaluation of a teaching hospital necropsy service. J Clin Pathol. 1977;30575- 578Google ScholarCrossref

Journal

Archives of Internal Medicine – American Medical Association

Published: Jun 8, 1998

Keywords: autopsy

There are no references for this article.