Hospitals Performing Fewer Autopsies

Doctors fear loss of key learning too

By Marla Puente 

The number of autopsies performed in American hospitals has fallen dramatically since the 1960s, raising alarm among doctors who fear the trend threatens the quality of care and the country’s store of medical knowledge. About half the people who died in hospitals in the 1960s were autopsied. But by the 1990s, the average autopsy rate for health-care facilities had dropped to less than 13% according to medical research records in Chicago that are believed to reflect the national picture. An autopsy-from the ancient Greek for "seeing with one’s own eyes"-is performed to determine cause of death, to teach medical students, to track changing disease patterns, to provide families with genetic information and to gauge the effect of medical treatment before death. If a patient is diagnosed and treated for one disease, but in fact has another disease, no one will know unless an autopsy is performed. The next patient with the same symptoms may suffer the same fate.

Researchers say few autopsies are being performed because insurance companies don’t cover them and families don’t demand them. And doctors and hospitals are fearful that autopsy results could be used against them in malpractice suits. And many doctors say they can get more information from modern diagnostic equipment than from time-consuming, expensive autopsies. An autopsy can cost up to $3000. "The autopsy is a basic medical technique intended to ascertain truth. . .and it’s just as important in 1996 as it was in 1956," says George Lundberg, editor of the Journal of the American Medical Association. Lundberg has been trying to raise awareness about the negative consequences of the declining autopsy rate.

By contrast, forensic autopsies are on the rise. These autopsies are performed by coroners or medical examiners when someone has died by violence, accident or questionable circumstances. "If you have only $10 to spend and you can pick something that gives you more bank for your buck, then autopsies are going to have a tough time competing," says Dennis O’Leary, president of the Joint Commission on Accreditation of Health Care Organizations. The agency no longer requires hospitals to maintain a minimum autopsy rate. Pathologists, physicians who study disease, say the decline in autopsies could have serious consequences. "If you don’t know your mistakes, you’re going to repeat them," says Carl Becker, pathology chief at Medical College of Wisconsin in Milwaukee. Gregory Davis, professor at Bowman Grey School of Medicine in Wake Forest, N.D., says that 20% to 40% of autopsies reveal information previously unknown.

"Every person who is a patient or has a loved one who is a patient should care about this because the gold standard of quality assurance has always been and always will be the autopsy," Davis says. There a few national statistics on autopsy rates. In 1988, the Centers for Disease Control and Prevention in Atlanta conducted a small study that showed the national autopsy rate of natural deaths in 1980 was 13%, but by 1985 it had dropped to 10%, But the Institute of Medicine of Chicago, a medical research think tank, has kept records since the 1920s on average autopsy rates in Chicago.

These numbers are believed to give an accurate portrayal of the situation on a national scale. In 1965, the average autopsy rate for Chicago-area hospitals was about 51%. In 1994, the average autopsy rate was 12.6%. Margaret Hastings, vice president of the institute, says the actual 1994 rate is probably much lower. Many of the 102 area hospitals no longer report statistics to the institute, and about half of those that do are connected to medical schools. Teaching hospitals generally have high autopsy rates because autopsies are used to train students.

"If the autopsy once was one of the very best teaching tools, then we have to assume this low rate is going to have a major impact on medical education," Hastings says. One thing is certain: Insurance companies aren’t going to start paying for autopsies anytime soon. "Medical insurance by definition provides reimbursement for the cost of getting well, " Says Richard Coorsh, spokesman for the Health Insurance Association of America, which represents many of the nation’s insurance carriers. "Death, by definition, has little to do with getting well."

Demand soaring for pathologist 

Vidal Herrera zips around southern California in a white van emblazoned with his business phone - 1-800-AUTOPSY. And hundreds of Californians are calling. Fewer autopsies are being done in hospitals, so business is booming for Herrera, a former investigator for the Los Angeles medical examiner. People who call him are relatives of someone who died in a health-care facility. They want an autopsy performed, but the hospital won’t do it because it’s too expensive or doesn’t think it’s necessary.

Herrera employs 19 part-time pathologists who perform about 900 autopsies a year - up form 40 a year in 1988. Herrera charges families $2,000 for an autopsy, compared with $2,850 charge by the medial examiner for private autopsies. Demand is so strong his business may turn into the McDonald’s of autopsies. He plans to sell 72 franchises around the country and 16 in foreign countries. He says he now has 2,300 franchise applicants. Last year, someone offered me $7.2 million to buy my business," Herrera says. "Because of the baby boomers, there’s going to be a large number of deaths in future years. People know the need is there."