LOS ANGELES - It’s a good thing for Vidal Herrera that autopsy has seven letters.

Herrera, a one-time technician at the L.A. County coroner’s office, has parlayed a clever phone number and a clear need into a thriving trade in private autopsies for families, hospitals, and lawyers. Called Autopsy/Post Services, it uses nine pathologists who do some 900 postmortems a year, for about $2,000 each. DNA testing is extra.

He has ambitions of franchising 1-800 AUTOPSY to 92 cities. 

REVIVING POSTMORTEMS

Would regional centers and payment to pathologists breathe new life into autopsies? 

WASHINGTON - Pathologists aren’t giving autopsies up for dead.

Once one of medicine’s most illustrious clinical-research tools, the post-mortem exam has been squelched by noninvasive imaging, overconfident clinicians, tight hospital budgets, fear of litigious relatives - and zero reimbursement for most pathologists. Aside from mandatory forensic autopsies, definitive causes of death are determined for only about 5% of those who die in the U.S. That’s down from a 50% autopsy rate in 1950, and one pathologist calls this an "unspoken conspiracy about the dead." Though pathologists are among the highest paid of specialists, many complain that autopsies-traditionally an educational duty-can’t be billed. They prefer biopsies, which can be, says Dr. Peter Baker of Ohio State. Also, some pathologists worry about HIV and hepatitis risks. But mainstream pathology accepts the view of Dr. Thomas Starzl, the University of Pittsburgh transplant surgeon, "Losing autopsies is like a submarine losing a periscope," he says, "You can’t tell where you’ve been or where you’re going."

Mickey Mantel’s death is an example of an autopsy not done that might have told a tale, says pathologist Robert Treistad of the Robert Wood Johnson Medical School. He says it can’t be assumed that metastatic liver cancer, on Mantle’s death certificate, was the proximate cause. Did Mantle reject his liver graft or did it fail? Was his chemotherapy too toxic? Did he have pneumonia? No one can trace all the twists and turns of the autopsy’s decline, though the Joint Commission did it no favor in 1970 when it stopped requiring a set percentage of autopsies for accreditation. But at a meeting here sponsored by the College of American Pathologists and two other pathology groups, autopsy proponents batted around ways to give it a rebirth. Dr. Trelstad notes that outcomes research can be undermined by erroneous assumptions about the causes of death. "We need to know why people in the health care system are dying," he says. Yale’s Dr. Alvan Feinstein says that Dr. Alvan Feinstein says that unreliable disease rates and death-certificate data still prevail in scientifically unacceptable "statistical fantasies."

But autopsy findings are rarely in clinical-trial protocols. Dr. Grover Hutchins, a pathologist at Johns Hopkins, thinks they should be the rule. Dr. Bruce Mcmanus of the University of British Columbia finds it contradictory that autopsies are required in animal studies but not inhuman trials with mortality endpoints. In an oft-cited study of 2,500 autopsies, major unexpected findings were uncovered in 40%, and 15% would have changed treatment had they been know premortem. Dr. Baker says he recently found that a radiation-treated lung lesion of a patient with metastases was a non-malignant fibrotic area, and the primary tumor was in the stomach. Often found only during autopsy are pneumonia, pulmonary embolism, acute pancreatitis, vascular aneurysm, mesenteric thrombosis, infectious endocarditis, MI, cirrhosis, and cancer, says Dr. McManus.

"It’s a myth," says Bowman Gray’s Dr. Gregory Davis, "that CTs and MRIs can replace autopsies." Such scans, plus an EG, failed to indicate a possible cause of a middle-age woman’s change in mental status, but the necropsy revealed a primary brain lymphoma, he says.

The pathology chief at the University of Nebraska, Dr. Samuel Cohen, says he had to demand an autopsy when his father died at the University of Wisconsin, and some of the several unexpected findings had genetic implications for his family. "Our technology can’t see inside the body for everything," he says. Dr. Hutchins is among those who would establish regional centers in medical schools or teaching hospitals to do all the autopsies for smaller hospitals, forensic and otherwise. Regional centers are the only reasonable approach, says Dr. Trelstad. Hospital autopsies, he adds, "are to biased, too undersupported, and too parochial." Critics say treating physicians will be less likely to attend out-of-hospital autopsies. But, says Dr. McManus, TV systems or videodiscs can relay the information. The vest way to goose the autopsy rate, says pathologist George Lundberg, the editor of JAMA, would be for Medicare to reimburse legitimate autopsy expenses directly to hospitals and pathologist instead of tucking the costs into DRG’s. But HCFA says Medicare’s introduction in 1966 caused not "even a blip" in an autopsy rate already failing rapidly.

Dr. David Chernof, a senior consultant to Blue Cross of California, suggest that if pathologists want to be paid, they need to provide an "articulate justification" for autopsies. "they should develop a dialogue with managed-care decision-makers to re-assert the autopsy’s value. Yet a few pathologists would be reluctant even if they were paid. At Kaiser Permanente in Santa Clara, Calif., pathologist Seth Haber discourages autopsies on bodies of people who had AIDS, TB, hepatitis, and Creutzfeldt-Jakob. He rarely removes brains from HIV-tainted cadavers and has virtually banned an electric saw in feat of potentially infectious aerosol. One major factor cited for autopsy’s decline is its role in potential malpractice suits. But Aaron Broder, a New York plaintiff attorney, says he views an autopsy report "with fear and trepidation." He says doctors nearly always benefit. Autopsies find "scores of different things that might have caused death or reduced the person’s life expectancy," he says.