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Unacceptable Nursing Home Deaths Unautopsied

Unacceptable Nursing Home Deaths Unautopsied RECENT INITIATIVES and investigations coming out of Washington, DC, call for improving conditions in nursing homes, but some physicians said regulators are ignoring a valuable component that could help save lives. A US General Accounting Office (GAO) report, California Nursing Homes: Care Problems Persist Despite Federal and State Oversight, presents the results of an investigation of 62 cases involving the death of a nursing home resident in 1993. The retrospective study found that 34 of them received care that was unacceptable. The report also said that about 30% of California's 1400 nursing homes have been cited for serious violations under federal and state guidelines. The report served as the cornerstone of a two-day hearing by the Senate's Special Committee on Aging that began on July 27 and came on the heels of a July 21 presentation by President Clinton of an initiative to improve quality in nursing homes. Pathologists Decry Data Lack While preventing death and improving quality in nursing homes are admirable goals, some pathologists question whether investigators are using all the tools available to get the job done. Specifically they note a lack of autopsies to determine the true cause of death. In raising questions about the 34 deaths that followed unacceptable care, the GAO report noted, "In the absence of autopsy information that establishes the cause of death, we cannot be conclusive about the extent to which this unacceptable care may have contributed directly to individual deaths." The GAO investigators were two registered nurses with advanced degrees in gerontological nursing and expertise in clinical nursing home care and data abstraction. They reviewed the medical records of a sample of the 3113 residents alleged to have died avoidable deaths from malnutrition, dehydration, urinary tract infection, bowel obstruction, or bedsores in 971 nursing homes in 1993, the GAO said. But medical records can tell only part of the story, said Stephen A. Geller, MD, chair of the Department of Pathology and Laboratory Medicine at Cedars-Sinai Medical Center in Los Angeles. "Whether there's an abuse or not, people die in nursing homes," he said. "There's something to learn from an autopsy because people die from a cause, and some causes are treatable." Autopsies, though, have fallen out of favor over the last few decades for a variety of reasons—societal, economic, and professional. Larry Nichols, MD, chief of the autopsy service and assistant professor of pathology and medicine at the University of Pittsburgh Medical School, said the changing patient-physician relationship and the threat of lawsuits are making everyone leery of performing autopsies. "Autopsies used to be routine when families and physicians liked each other," he said. "Now it's much more antagonistic. Now a family member will say, ‘You couldn't save him, and now you want to chop him up?' " Cost, which ranges roughly between $500 and $3000, is another issue. "Under Medicare Part B, each year you get a certain amount of money for autopsies whether you do one or a thousand," Nichols said. "And while autopsies are done automatically if you die in an acute care hospital, they're not covered if you die in a nursing home, your own home, or the street. And since more people are dying outside a hospital, families are going to have to pay for it—if they want it. Families may be curious if Grandma had Alzheimer's, but they're not $2000 curious." And there's the professional issue: Many physicians feel that they already know the cause of death, but they are wrong, according to a new study by Nichols and colleagues (Am J Clin Pathol. 1998;110:210-218). Autopsy Study Revealing The researchers looked at 176 complete or "no head" autopsies performed at a major tertiary care transplantation referral center and found that 79 (44.9%) revealed one or more undiagnosed causes of death and that about two thirds of these causes were treatable conditions. Premortem diagnoses came from those coded for billing purposes in the hospital's medical records department. Of the 123 undiagnosed causes of death from the 79 cases, 13 were sole immediate causes of death, 72 were one of multiple immediate causes, 22 were intervening causes, and 16 were underlying causes, the report said. The largest category of undiagnosed causes was infections, with 34 reported. The researchers noted that their findings are in line with other studies showing high percentages of missed diagnoses of death. They cited a nationwide study in 1994 by the College of American Pathologists showing 39.7% of autopsies revealed major unexpected findings contributing to death and 17.3% disclosed minor unexpected findings contributing to death. Also, an early 1970s study from Sweden showed that 43% of autopsies uncovered an undiagnosed main cause of death. "If more autopsies were performed, we'd save more lives," Nichols said, adding that information gathered after death gives physicians a depth of knowledge that can be used in the care of future patients. Who Keeps Track? National statistics on the use of autopsy are hard to come by. Queries to federal and state agencies, nursing home trade associations, specialty societies, and the National Association of Medical Examiners failed to produce autopsy numbers, although the College of American Pathologists is trying to create a national autopsy data bank. And few nursing home episodes lead to autopsies. According to a 1990 report of nursing home deaths from 1980 to 1984 in New York State, only 0.8% were autopsied (Arch Pathol Lab Med. 1990;114:145-147). Investigations and procedures for certifying nursing home deaths are left to the states, said Carolyn Harris, RN, a nursing home administrator in Vergennes, Vt, and chair of the American Health Care Association's (AHCA) Long-term Care Nurse Council. The AHCA is a federation of 50 affiliated associations representing more than 11000 nonprofit and for-profit nursing homes. John Hagerty, chief of southern field operations with the California Department of Health Services, said his agency typically doesn't order autopsies for deaths in nursing homes. The state investigates suspicious deaths usually after surveying nursing homes and uncovering questionable facts surrounding a death or if notified by a physician, nurse, or family member. California's approach is typical of the way the states handle nursing home problems and death. In Iowa, the process is similar, said David Werning, a public information officer for the state's Department of Inspections and Appeals. "We get complaints from family members, and we review every complaint that comes in," Werning said. "Also, we conduct surveys and look at the medical records." With about 1.6 million people in approximately 16700 nursing homes in the United States and with those numbers growing, the federal government has a need to assure that quality care is delivered. President Clinton wants legislation that calls for improvement in several areas, including improved nutrition and hydration, by allowing more categories of nursing home employees to receive training in these subjects. Senator Chuck Grassley (R, Iowa), who chairs the Senate Special Committee on Aging, is asking for additional studies from the GAO and the Department of Health and Human Services Inspector General to determine whether nursing home neglect is a national problem. No one mentions autopsies. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Unacceptable Nursing Home Deaths Unautopsied

Mitka, Mike
JAMA , Volume 280 (12) – Sep 23, 1998
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Publisher
American Medical Association
Copyright
Copyright © 1998 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.280.12.1038-JMN0923-3-1
Publisher site
See Article on Publisher Site

Abstract

RECENT INITIATIVES and investigations coming out of Washington, DC, call for improving conditions in nursing homes, but some physicians said regulators are ignoring a valuable component that could help save lives. A US General Accounting Office (GAO) report, California Nursing Homes: Care Problems Persist Despite Federal and State Oversight, presents the results of an investigation of 62 cases involving the death of a nursing home resident in 1993. The retrospective study found that 34 of them received care that was unacceptable. The report also said that about 30% of California's 1400 nursing homes have been cited for serious violations under federal and state guidelines. The report served as the cornerstone of a two-day hearing by the Senate's Special Committee on Aging that began on July 27 and came on the heels of a July 21 presentation by President Clinton of an initiative to improve quality in nursing homes. Pathologists Decry Data Lack While preventing death and improving quality in nursing homes are admirable goals, some pathologists question whether investigators are using all the tools available to get the job done. Specifically they note a lack of autopsies to determine the true cause of death. In raising questions about the 34 deaths that followed unacceptable care, the GAO report noted, "In the absence of autopsy information that establishes the cause of death, we cannot be conclusive about the extent to which this unacceptable care may have contributed directly to individual deaths." The GAO investigators were two registered nurses with advanced degrees in gerontological nursing and expertise in clinical nursing home care and data abstraction. They reviewed the medical records of a sample of the 3113 residents alleged to have died avoidable deaths from malnutrition, dehydration, urinary tract infection, bowel obstruction, or bedsores in 971 nursing homes in 1993, the GAO said. But medical records can tell only part of the story, said Stephen A. Geller, MD, chair of the Department of Pathology and Laboratory Medicine at Cedars-Sinai Medical Center in Los Angeles. "Whether there's an abuse or not, people die in nursing homes," he said. "There's something to learn from an autopsy because people die from a cause, and some causes are treatable." Autopsies, though, have fallen out of favor over the last few decades for a variety of reasons—societal, economic, and professional. Larry Nichols, MD, chief of the autopsy service and assistant professor of pathology and medicine at the University of Pittsburgh Medical School, said the changing patient-physician relationship and the threat of lawsuits are making everyone leery of performing autopsies. "Autopsies used to be routine when families and physicians liked each other," he said. "Now it's much more antagonistic. Now a family member will say, ‘You couldn't save him, and now you want to chop him up?' " Cost, which ranges roughly between $500 and $3000, is another issue. "Under Medicare Part B, each year you get a certain amount of money for autopsies whether you do one or a thousand," Nichols said. "And while autopsies are done automatically if you die in an acute care hospital, they're not covered if you die in a nursing home, your own home, or the street. And since more people are dying outside a hospital, families are going to have to pay for it—if they want it. Families may be curious if Grandma had Alzheimer's, but they're not $2000 curious." And there's the professional issue: Many physicians feel that they already know the cause of death, but they are wrong, according to a new study by Nichols and colleagues (Am J Clin Pathol. 1998;110:210-218). Autopsy Study Revealing The researchers looked at 176 complete or "no head" autopsies performed at a major tertiary care transplantation referral center and found that 79 (44.9%) revealed one or more undiagnosed causes of death and that about two thirds of these causes were treatable conditions. Premortem diagnoses came from those coded for billing purposes in the hospital's medical records department. Of the 123 undiagnosed causes of death from the 79 cases, 13 were sole immediate causes of death, 72 were one of multiple immediate causes, 22 were intervening causes, and 16 were underlying causes, the report said. The largest category of undiagnosed causes was infections, with 34 reported. The researchers noted that their findings are in line with other studies showing high percentages of missed diagnoses of death. They cited a nationwide study in 1994 by the College of American Pathologists showing 39.7% of autopsies revealed major unexpected findings contributing to death and 17.3% disclosed minor unexpected findings contributing to death. Also, an early 1970s study from Sweden showed that 43% of autopsies uncovered an undiagnosed main cause of death. "If more autopsies were performed, we'd save more lives," Nichols said, adding that information gathered after death gives physicians a depth of knowledge that can be used in the care of future patients. Who Keeps Track? National statistics on the use of autopsy are hard to come by. Queries to federal and state agencies, nursing home trade associations, specialty societies, and the National Association of Medical Examiners failed to produce autopsy numbers, although the College of American Pathologists is trying to create a national autopsy data bank. And few nursing home episodes lead to autopsies. According to a 1990 report of nursing home deaths from 1980 to 1984 in New York State, only 0.8% were autopsied (Arch Pathol Lab Med. 1990;114:145-147). Investigations and procedures for certifying nursing home deaths are left to the states, said Carolyn Harris, RN, a nursing home administrator in Vergennes, Vt, and chair of the American Health Care Association's (AHCA) Long-term Care Nurse Council. The AHCA is a federation of 50 affiliated associations representing more than 11000 nonprofit and for-profit nursing homes. John Hagerty, chief of southern field operations with the California Department of Health Services, said his agency typically doesn't order autopsies for deaths in nursing homes. The state investigates suspicious deaths usually after surveying nursing homes and uncovering questionable facts surrounding a death or if notified by a physician, nurse, or family member. California's approach is typical of the way the states handle nursing home problems and death. In Iowa, the process is similar, said David Werning, a public information officer for the state's Department of Inspections and Appeals. "We get complaints from family members, and we review every complaint that comes in," Werning said. "Also, we conduct surveys and look at the medical records." With about 1.6 million people in approximately 16700 nursing homes in the United States and with those numbers growing, the federal government has a need to assure that quality care is delivered. President Clinton wants legislation that calls for improvement in several areas, including improved nutrition and hydration, by allowing more categories of nursing home employees to receive training in these subjects. Senator Chuck Grassley (R, Iowa), who chairs the Senate Special Committee on Aging, is asking for additional studies from the GAO and the Department of Health and Human Services Inspector General to determine whether nursing home neglect is a national problem. No one mentions autopsies.

Journal

JAMA – American Medical Association

Published: Sep 23, 1998

Keywords: nursing homes,autopsy

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