Declining autopsy rates affect medicine and public health

Lexington, Ky., pathologist Gregory J. Davis, MD, credits autopsies for many of the medical and public health advancements made in the past few decades.

Much of what is known about cardiovascular, kidney and lung disease is due to autopsies, he said. The harms of smoking have been proven through the postmortem procedure. Even the U.S. military's body armor has been improved due to common patterns of injury that pathologists identified during autopsies, Dr. Davis said.

"The autopsy has long been and remains the gold standard for confirming or ruling out diagnoses and plays an integral role in promoting the public health," said Dr. Davis, a forensic pathologist at the University of Kentucky College of Medicine.

But data show the rate of autopsies performed in the U.S. has fallen. Nine percent of all deaths were autopsied in 2007, compared with 19% in 1972, according to the most recent data from the Centers for Disease Control and Prevention.

Even more concerning, health professionals say, is how few autopsies are performed for deaths due to diseases such as cancer and cardiovascular disease. In 2007, the autopsy rate for such deaths was 4%, compared with 17% in 1972.

Among the consequences of the declining autopsy rate is inaccurate mortality statistics, which are used to determine the incidence and prevalence of particular conditions, said Elizabeth C. Burton, MD, pathologist and deputy director of the autopsy service at Johns Hopkins University School of Medicine in Baltimore. Money often is provided by the federal government to research diseases identified as the nation's leading causes of death, she said. "If we've got it wrong from the get-go, we are taking research funding and putting it" in the wrong areas, she said.

The reduction in autopsies also means physicians are missing opportunities to improve care for patients, said Hershey, Pa., pathologist Jennifer Baccon, MD, PhD. She said autopsies help doctors determine the effectiveness of their treatment for a particular condition, and the procedure can identify medical issues the physician might have overlooked.

"We do our absolute best to treat everybody to the highest quality of care, but if we do not learn from our experiences, I think we lose something valuable," said Dr. Baccon, assistant professor of pathology and neurosurgery at Penn State Milton S. Hershey Medical Center.

Reasons for fewer autopsies

Driving the decline is improved imaging that some physicians mistakenly think eliminates the need for an autopsy, health professionals say. There also is a lack of payment for the procedure by health insurers and Medicaid. Another contributing factor was the 1971 decision by the Joint Commission to drop its requirement that hospitals have an autopsy rate of 20% to 25% for deaths that occur there.

About half of autopsies produce medical findings that were unsuspected before the patient died, said a 2005 study in Histopathology.

Among the most common medical problems Dr. Davis identifies during an autopsy is extensive coronary artery disease in young people who were thought to be in good health before they suddenly died. Knowing that information can help prevent early onset cardiac death among the individual's siblings or children who would have an increased risk of developing the condition, Dr. Davis said.

Dr. Davis encourages primary care physicians to talk to their patients who are older or ill about the importance of autopsies. He also recommends that pathologists reach out to physicians and remind them of the medical benefits of the procedure.

Performing an autopsy "is a duty we owe our patients," Dr. Davis said. "You don't abandon patients simply because they die. You still have to do the best job you can in certifying their cause of death for the benefit of the family and the greater community."