Without autopsies, hospitals bury their mistakes

Today we talked about what a post-medical error investigation should look like, and (I think it was Dave) mentioned the importance of autopsies (great article PDF here), but autopsies aren’t covered by insurance. This was news to me, so I did some research.

Previously I had only learned about the early history of autopsies. Roman Law forbade the dissection of human cadavers in the 3rd Century BC. Although Galen‘s anatomical teachings were based only on animal dissections, and thus hopelessly flawed, his teachings on human anatomy survived essentially unchallenged from the 2nd through 14th Centuries AD. In the 14th Century the dissection of human cadavers resumed, and the field of anatomy experienced centuries of discoveries that both rocked the foundation of medicine and boosted the healing potential its practitioners (e.g. the discoveries of the circulatory and lymphatic systems). This summer I read a biography of John Hunter, a mid-1700s London resurrectionist, anatomist and surgeon who was among the pioneers in human and comparative anatomy. He personally performed tens of thousands of autopsies and cadaver dissections. He allowed his experimental observations to lead him to the truth. This was a man who truly understood the teaching potential of the autopsy. Interesting aside: Hunter’s commitment to experimental medicine was passed on to many of his medical students including one Edward Jenner, who later as a country doctor discovered the ability of cowpox to prevent smallpox infection.

Long story short: John Hunter encouraged his medical students to get autopsies on every patient who died. Autopsy rates remained high for centuries. Then, only in the last five decades, autopsy rates began to decline dramatically (see graph here), perhaps due to hospitals’ reluctance to provide fodder for lawsuits. Some interesting ideas/facts about autopsies from a 2011 article on the blog ProPublica called “Without Autopsies, Hospitals Bury Their Mistakes“:

  • avg. autopsy rate at teaching hospitals (which account for 80% of U.S. hospitals): 20%
  • avg. autopsy rate at private/community hospitals: often close to 0%
  • avg. cost of an autopsy: $1,275
  • autopsies are not a covered procedure for Medicaid or private insurance, and Medicare pays for autopsies as part of a bundled package that discourages hospitals from performing autopsies
  • prior to 1971, a U.S. hospital’s accreditation was subject to maintaining a 20-25% autopsy rate, but the Joint Commission removed this requirement in 1971
  • a 2002 review of autopsies found diagnostic errors in 25% of patients, and errors that affected outcomes in 10% of patients
  • 63% of Louisiana hospitals performed zero autopsies in one year

Are autopsies fodder for lawsuits? Well, not if your hospital has a CandOR approach to addressing medical errors. Are they a great way to avoid being condemned to repeat past failures? Absolutely. Should private insurance pay for autopsies, even if an autopsy can’t help the patient who already died? Yes. As Evan pointed out today, it is important for hospitals and insurance companies to have long-term vision.

I would love to hear your thoughts. I will read any tomorrow morning, bright and early.