Thursday, December 29, 2011

A Matter of Life and Death

Happy Holidays, readers!  Let's talk dead bodies...

The above article is a part of the ongoing ProPublica/NPR/PBS Frontline investigation into American coroner and medical examiner offices (very cool information; see here).  In it, journalist Marshall Allen describes the decline of autopsies in the modern healthcare system. 

Whereas autopsies used to be routine procedures in the case of all hospital deaths, the autopsy rate has now plummeted to 5% of all hospital deaths. Among private and community hospitals--which account for 80% of hospitals--that rate hovers around 0%. While autopsy is crucial in determining disease progression, pathogen dissemination, medical mis-diagnosis, and faulty treatment, most hospitals have simply chosen not to perform them.

The reasons for the decline are logical, though misguided.  At a price tag of $1,275, which is rarely compensated by insurers or Medicare, autopsies are considered financially extraneous. And with the recent proliferation of malpractice suits, healthcare professionals are unlikely to fight for a procedure which could leave them potentially liable for damages.

Normally, I am a proponent of cutting unnecessary medical procedures that drive up healthcare costs. However, as Allen reveals, the consequences of eliminating autopsy are severe.  Without autopsy, “opportunities are lost to learn about the effectiveness of medical treatments and the progression of disease.” Physicians operate with a “false sense of security” as they allow their practices to go unexamined. Inaccurate cause-of-death information undermines national health statistics. Worst of all, potentially-fatal diagnostic errors go undiscovered. Allen details the magnitude of this particular consequence:

...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.

Absent post-mortem investigation, healthcare professionals never even know if they are treating the right conditions!   With more autopsies, however, there would be a vast data pool on the efficacy of diagnostic tools and treatments.  From this information, healthcare professionals could learn from their mistakes, improve their practices, and advance public health.

In the long run, this would actually save money by eliminating medically unnecessary procedures. Take, for example, the current obsession with medical imaging. Imaging procedures have become increasingly popular over recent years, even though numerous studies have confirmed that “doctors make a high rate of diagnostic errors even with increasingly sophisticated imaging equipment.” Despite this, hospitals continue to order countless CT scans, x-rays, and MRIs, concealing the fact that they are usually ordered because they generate a huge income stream for cash-strapped hospitals (see here, for example).

Yet without any oversight into its efficacy for particular cases, medical imaging continues to be routinely ordered and praised as a diagnostic miracle. And as insurance companies and Medicare increase premiums to cover the steep costs of these technologies, the cost is quickly passed to the unknowing healthcare consumer. If more autopsies confirmed the over-utilization of imaging techniques and exposed the insidious uses for such technology, we would actually eliminate much waste in the system. (Note: this is not to say that medical imaging is not useful in certain cases, but that it is vastly over-utilized).

Instead, as we have seen, the use of medical imagery has exploded over the years, while autopsy rates have declined. These trends exemplify how out-of-whack our financial priorities are in the American healthcare system. We will perform profitable procedures at the drop of a hat, without considering the financial burden on the system. At the same time, procedures that could provide a wealth of medical data, improve overall health outcomes, and actually save money in the system are brushed aside.

Unfortunately, this is a common theme in our health care system:  medical procedures are more about money-- either making it or saving it-- than health outcomes. There is an irony in this, of course-- healthier Americans would be less of a financial burden on the system.  Consequently, if we are to even think about rescuing our healthcare system, we need to acknowledge health as the end goal and act accordingly.  

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