December 2011, Week 3


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Sat, 17 Dec 2011 01:39:27 -0500
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Without Autopsies, Hospitals Bury Their Mistakes

by Marshall Allen
Dec. 15, 2011, 12:36 p.m.
ProPublica, in collaboration with the Investigative Reporting Program at the UC Berkeley Graduate School of Journalism

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

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

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 to learn about the effectiveness of medical
treatments and the progression of diseases. Inaccurate
information winds up on death certificates, undermining
the reliability 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 the tumors, 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, 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. When deaths
are unexplained, unobserved or within 24 hours of
admission, hospitals may 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 to explore 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 considered self-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 or didn'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

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

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 and
private 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, said
Dr. John Sinard, director of autopsy service for the
Yale University School of Medicine.

"The hospital is going to get the money whether they do
the autopsy or not, so the autopsy just becomes an
expense," Sinard said.

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 and 25 percent for teaching
facilities, but dropped the requirement. Many hospitals
were performing autopsies "simply to meet the numbers"
and not to improve quality, said Dr. Paul Schyve, the
commission's senior adviser of health-care improvement.

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

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

A 2002 review of academic studies by the federal Agency
for Healthcare Research and Quality found 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.

"Clinicians have compelling reasons to request autopsies
far more often than currently occurs," the agency

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

But Sinard said so few autopsies are being conducted -
one survey found that 63 percent of hospitals in
Louisiana performed none in a given year - that doctors
and hospitals can't say for certain how patients are
dying. "They've never checked," the Yale pathologist

Pathologists interviewed 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

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

Dr. Elizabeth Burton, deputy director of the pathology
department at Johns Hopkins University School of
Medicine, said performing autopsies on patients who have
died of hospital-acquired infections helps save others.
Infection clusters "go in waves" in hospitals, she said.
Physicians have used her findings to change antibiotic
regimens, snuffing out the bacterium.

Dr. Renu Virmani, president and medical director of the
nonprofit CVPath Institute, has used postmortem
examinations to help reform the treatment of heart
disease. Virmani and her team have collected about 250
specimens of metal stents removed at autopsy from
patients who had procedures to clear blockages from
their arteries.

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

Sitting in her lab in Gaithersburg, Md., Virmani peers
through a microscope at a specimen slide taken from a
61-year-old man who died suddenly in 2004, about four
months after receiving a clot-resistant stent. She
points out signs of inflammation in the 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 that the stent had led to the
patient's fatal blood clot.

Autopsies should be used to evaluate the effectiveness
of other therapies, Virmani said, from chemotherapy to
heart-valve replacements. "The only way to learn is
through autopsies."

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

Without autopsies to confirm patients' precise causes of
death, public health officials say, the health-care
system overall suffers. Erroneous information sometimes
ends up on death certificates. Broad categories of
disease such as cancer are probably 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

"These data are used to set public health priorities, to
develop public health programs and allocate resources,"
Anderson said. "We do the best that we can given the
information we have, but if you put bad information into
the system, you're going to get bad information out."

In 1999, the Medicare Payment Advisory Commission, or
MedPAC, which advises Congress about Medicare, issued a
report stating that increasing the rate of clinical
autopsies could improve health care and reduce errors.

The report recommended paying pathologists directly for
autopsies and giving hospitals bonuses or penalties for
hitting or missing target autopsy rates. The advisory
group also suggested that Medicare change its hospital
regulations to encourage more autopsies and use them as
a standard of performance.

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

Other organizations that advocate for better medicine,
such as the Institute for Healthcare Improvement,
National Quality Forum and The Joint Commission, have
not pushed for higher levels of autopsies, either,
despite the widely held belief  that this could produce
improved care.

Raising the rate "is not one of our priorities by any
means," The Joint Commission's Schyve said.

Dr. George Lundberg, a pathologist and one of the
country's most vocal advocates for increasing the
autopsy rate, shakes his head when discussing the
medical industry's apathy about low autopsy rates.
Lundberg, the editor of the journal MedPage Today, said
The Joint Commission should re-establish mandatory
autopsy rates "like they used to have back in the good
old days of quality when we weren't running away from
trying to find the truth [about] our sickest patients."

One way to shake the complacency, various experts told
ProPublica, would be for insurance companies and the
government to pay for autopsies. But an official from
UnitedHealth Group, the largest health-insurance company
in the country, said the autopsy is not reimbursed
because it "isn't a procedure that would prevent or
treat a sickness or injury" in a patient.

Virmani called this shortsighted. The cost of an autopsy
is small relative to the money spent on drugs, treatment
and diagnostic imaging, she said, and the payoff could
save lives and money.

"We are letting go of something which we could really
use tomorrow to improve the health care of patients,"
she said.


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