Lack of autopsies = missed medical errors: a Pro Publica investigation

This story notes that “when patients were autopsied, major errors related to the principle diagnosis or underlying cause of death were found in one of four cases. In one of 10 cases, the error appeared severe enough to have led to the patient’s death.”

So, it is bad news that all of the New England states report low autopsy rates in cases of unexpected deaths. Personally, it’s sad that NC also reports a low rate.  The Raleigh News & Observer  did a similar same story in 1995.

Without Autopsies, Hospitals Bury Their Mistakes

by Marshall Allen ProPublica, Dec. 15, 2011, 12:36 p.m.by Marshall Allen, ProPublica, Dec. 15

When Renee Royak-Schaler unexpectedly collapsed and died on May 22, no one ordered anautopsy.

Not the doctors at Howard County General Hospital in Columbia, Md., where the 64-year-old professor and cancer researcher was pronounced dead.

Not the Maryland Office of the Chief Medical Examiner, which passed on the case because no foul play was involved.

And not Royak-Schaler’s physicians at Johns Hopkins University School of Medicine who had diagnosed cancer in her hip two days beforehand but acknowledged they didn’t know what had caused her unforeseen death.

A half-century ago, an autopsy would have been routine. Autopsies, sometimes called the ultimate medical audit, were an integral part of American health care, performed on roughly half of all patients who died in hospitals. Today, data from the Centers for Disease Control and Prevention show, they are conducted on about 5 percent of such patients.

As Royak-Schaler’s husband, Jeffrey Schaler, discovered, even sudden unexpected deaths do not trigger postmortem reviews. Hospitals are not required to offer or perform autopsies. Insurers don’t pay for them. Some facilities and doctors shy away from them, fearing they may reveal malpractice. The downward trend is well-known — it’s been studied for years.

What has not been appreciated, pathologists and public health officials say, are the far-reaching consequences for U.S. health care of minuscule autopsy rates.

Diagnostic errors,which studies show are common, go undiscovered, allowing physicians to practice on other patients with a false sense of security. Opportunities are lost tolearn about the effectiveness of medical treatments and the progression ofdiseases. Inaccurate information winds up on death certificates, undermining thereliability of crucial health statistics.

It was only because of Royak-Schaler’s connections that her case ended differently. Her colleagues at the University of Maryland School of Medicine urged her husband to authorize an autopsy and volunteered to conduct it for free.

In her case, as in so many, the autopsy revealed a surprise: Royak-Schaler, the renowned cancer researcher, had cancer ravaging her body — in her lungs, kidneys ,abdomen and the marrow of her bones. A blood clot, likely related to thetumors, caused her sudden death.

Jeffrey Schaler has wrestled with anger that his wife wasn’t diagnosed sooner but said knowing how she died was better than not.

“There’s a sense of peace that accompanies that knowledge,” he said.

For the last year, ProPublica, PBS “Frontline” and NPR have probed America’s deeply flawed system of death investigation [1], focusing primarily on forensic autopsies, which are conducted by coroners’ offices and medical examiners when there is suspicion of an unnatural death. State laws vary, but the preponderance of deaths that occur in hospitals are considered natural. Whendeaths are unexplained, unobserved or within 24 hours of admission, hospitalsmay be required to report them to local coroners or medical examiners, but such  agencies rarely take hospital cases.

Hospital physicians,with consent from patients’ next of kin, may order a clinical autopsy toexplore the disease process in the body and determine the cause of death. That was the norm 50 years ago, when the value of the autopsy was consideredself-evident.

“Much of what we know about medicine comes from the autopsy,” said Dr. Stephen Cina, chairman of the forensic pathology committee for the College of American Pathologists. “You really can’t say for sure what went on ordidn’t go on without the autopsy as a quality assurance tool.”

Yet, autopsy rates at teaching hospitals, which are typically run on a nonprofit basis and have an educational mission, hover around 20 percent today. At private and community hospitals, which constitute 80 percent of facilities nationwide,rates can be close to zero.

“I know new hospitals are being built these days without a place to do an autopsy,” saidDr. Dean Havlik, the Mesa County, Colo., coroner, who estimated that theoverall hospital autopsy rate in his area is less than 1 percent.

Hospitals have powerful financial incentives to avoid autopsies. An autopsy costs about$1,275, according to a survey of hospitals in eight states. But Medicare andprivate insurers don’t pay for them directly, typically limiting reimbursement to procedures used to diagnose and treat the living. Medicare bundles payments for autopsies into overall payments to hospitals for quality assurance, increasing the incentive to skip them, saidDr. John Sinard, director of autopsy service for the Yale University School ofMedicine.

“The hospital is going to get the money whetherthey do the autopsy or not, so the autopsy just becomes an expense,” Sinardsaid.

Since a 1971 decision by The Joint Commission, which accredits health-care facilities ,hospitals haven’t had to conduct autopsies to remain in good standing. The commission had mandated autopsy rates of 20 percent for community hospitals and25 percent for teaching facilities, but dropped the requirement. Many hospitalswere performing autopsies “simply to meet the numbers” and not to improvequality, said Dr. Paul Schyve, the commission’s senior adviser of health-careimprovement.

Doctors,too, have gravitated away from autopsies because of growing confidence inmodern diagnostic tools such as CT scans and MRIs, which can identify ailmentswhile patients are still alive.

Still, instudy after study, autopsies have revealed that doctors make a high rate ofdiagnostic errors even with increasingly sophisticated imaging equipment.

A 2002review of academic studies by the federal Agency for Healthcare Research andQuality found [2] that when patients were autopsied, major errors related to theprinciple diagnosis or underlying cause of death were found in one of fourcases. In one of 10 cases, the error appeared severe enough to have led to thepatient’s death.

“Clinicianshave compelling reasons to request autopsies far more often than currentlyoccurs,” the agency concluded.

Schyvecalled the findings of such studies flawed because cases in which autopsies areperformed are typically the most complex, making diagnostic errors more likely.The overall error rate is far lower, he said.

But Sinardsaid so few autopsies are being conducted — one survey found that 63percent of hospitals in Louisiana performed none in a given year — thatdoctors and hospitals can’t say for certain how patients are dying. “They’venever checked,” the Yale pathologist said.

Pathologistsinterviewed by ProPublica said they often find diagnostic errors. “We often identify things that the imaging study could not,” said Dr.Debra Kearney, director of autopsy pathology at Texas Children’s Hospital.

Autopsiescan also be a crucial tool for evaluating and improving medical care.

Dr. Elizabeth Burton, deputy director of the pathology department at Johns Hopkins UniversitySchool of Medicine, said performing autopsies on patients who havedied of hospital-acquired infections helps save others. Infection clusters “go in waves” inhospitals, she said. Physicians have used her findings to change antibioticregimens, snuffing out the bacterium.

Dr. RenuVirmani, president and medical director of the nonprofit CVPath Institute, hasused postmortem examinations to help reform the treatment of heart disease.Virmani and her team have collected about 250 specimens of metal stents removedat autopsy from patients who had procedures to clear blockages from theirarteries.

Their workshowed that, in certain patients, a type of stent designed to reduce the riskof blood clots was causing delayed healing, inflammation and reactions thatcould be fatal. As a result, patients who receive these stents are now requiredto take blood-thinning medication for a year after the procedure.

Sitting inher lab in Gaithersburg, Md., Virmani peers through a microscope at a specimenslide taken from a 61-year-old man who died suddenly in 2004, about four monthsafter receiving a clot-resistant stent. She points out signs of inflammation inthe cross-section of his stented artery, describing the swirls and grains,stained pink and purple so they stand out on the slide. The autopsy showed thatthe stent had led to the patient’s fatal blood clot.

Autopsiesshould be used to evaluate the effectiveness of other therapies, Virmani said,from chemotherapy to heart-valve replacements. “The only way to learn isthrough autopsies.”

Hospitalautopsies are even rarer when patients older than 60 die in hospitals,representing a lost opportunity to learn about age-related diseases, Burtonsaid. More than 684,000 such patients died in hospitals in 2008 — morethan one-quarter of the total deaths in the country — and just 2.3percent were autopsied, CDC data show.

Withoutautopsies to confirm patients’ precise causes of death, public health officialssay, the health-care system overall suffers. Erroneous information sometimesends up on death certificates. Broad categories of disease such as cancer areprobably accurate, but specifics such as the type of cancer may not be, said Robert Anderson, chief of the mortality statistics branch of the CDC’s National Center for Health Statistics.

“These dataare used to set public health priorities, to develop public health programs andallocate resources,” Anderson said. “We do the best that we can given theinformation we have, but if you put bad information into the system, you’regoing to get bad information out.”

In 1999, theMedicare Payment AdvisoryCommission, or MedPAC, which advises Congress about Medicare, issued a reportstating that increasing the rate of clinical autopsies could improve healthcare and reduce errors.

The reportrecommended paying pathologists directly for autopsies and giving hospitalsbonuses or penalties for hitting or missing target autopsy rates. The advisorygroup also suggested that Medicare change its hospital regulations to encouragemore autopsies and use them as a standard of performance.

But Medicare has notacted upon these recommendations. An official from the Centers for Medicare& Medicaid Services declined ProPublica’s request for an interview, sayingthe use of autopsies in hospitals“is not within[Medicare’s] bailiwick at all.”

Otherorganizations that advocate for better medicine, such as the Institute for Healthcare Improvement,National Quality Forum and The Joint Commission, have not pushed for higherlevels of autopsies, either, despite the widely held belief  that this could produce improvedcare.

Raising the rate “is not one of our priorities by anymeans,” The Joint Commission’s Schyvesaid.

Dr. GeorgeLundberg, a pathologist and one of the country’s most vocal advocates forincreasing the autopsy rate, shakes his head when discussing the medicalindustry’s apathy about low autopsy rates. Lundberg, the editor of the journal MedPage Today, said The JointCommission should re-establish mandatory autopsy rates “like they used to haveback in the good old days of quality when we weren’t running away from tryingto find the truth [about] our sickest patients.”

One way toshake the complacency, various experts told ProPublica, would be for insurancecompanies and the government to pay for autopsies. But an official fromUnitedHealth Group, the largest health-insurance company in the country, saidthe autopsy is not reimbursed because it “isn’t a procedure that would preventor treat a sickness or injury” in a patient.

Virmanicalled this shortsighted. The cost of an autopsy is small relative to the moneyspent on drugs, treatment and diagnostic imaging, she said, and the payoffcould save lives and money.

“We ar eletting go of something which we could really use tomorrow to improve thehealth care of patients,” she said.

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