HOSPITAL autopsies are the “ultimate medical audit” and their decline could have long-term consequences for student education, research, treatment validation and quality assurance, according to a leading pathology expert.
Professor Roger Byard, senior specialist forensic pathologist with Forensic Science SA and professor of pathology at the University of Adelaide, told MJA InSight that hospital autopsies were “the only way to verify that new diagnostic and imaging tools are working”.
Professor Byard was commenting on a study published last week in the Journal of Clinical Pathology
that found the practice of hospital autopsy in the UK was “on the verge of extinction”. (1)
The research was based on data from 184 National Health Service (NHS) trusts across England, Scotland, Wales and Northern Ireland on the number of autopsies performed in 2013 as a percentage of the total inpatient deaths.
As previous research indicated that autopsy rates were higher in stillbirths, neonates and young children, the researchers excluded data from these categories. They found a mean autopsy rate of 0.69% of all UK hospital deaths.
The authors wrote that their results confirmed the continued decline of hospital autopsy, with 23% of all UK NHS trusts reporting that they had not performed any autopsies during 2013, saying future research was needed to focus on the impact of this decline on patient safety, audit, research and teaching.
“While debate continues over the value of hospital autopsy in medical practice, if action is not taken imminently, the practice may disappear”, the authors wrote.
Professor Jane Dahlstrom, professor of anatomical pathology at the Australian National University and staff specialist at Canberra Hospital, told MJA InSight that the declining autopsy rate identified in the UK study was applicable to both Australia and the rest of the developed world.
“One reason is that doctors might think that with current imaging technology, they already know why the patient has died and don’t need an autopsy to confirm that.”
However, Professor Dahlstrom said that despite improvements in technology, “some doctors do get it wrong”.
Professor Ibrahim Zardawi, conjoint professor at the University of Newcastle’s school of medicine and public health and senior pathologist at Douglass Hanly Moir Pathology, agreed, telling MJA InSight that hospital autopsies were crucial in determining the clinical appropriateness of the treatment the patient received.
“Sometimes we just don’t know whether a certain management system we applied to a patient was effective, and without a final examination after death, there is no absolute arbiter.”
Professor Dahlstrom said that from the perspective of the patient’s family, the “bad wrap” autopsies received in the mainstream media and popular culture and the delay in being able to arrange a funeral also contributed to the decline in autopsy rates.
However, she said Australia had a much higher frequency of perinatal autopsy than the UK, with the ACT reporting a rate of 53.5% for the period 2006‒2010. (2)
Professor Dahlstrom said there were two driving factors for performing a perinatal autopsy — the desire of the family and treating doctor to understand why the child died, and the need for guidance in planning for future pregnancies.
She said that apart from determining cause of death, autopsies could also provide national data, identify adverse drug reactions and serve as an education tool. “A hospital autopsy is often the first time a medical student will see a person who is dead, and they get a systemic view of all the organs in a body as a whole.”
Much of the medical community’s breakthroughs in understanding diseases such as HIV, legionellosis and mesothelioma had come from performing autopsies, Professor Dahlstrom said.
Associate Professor David Ranson, deputy director of the Victorian Institute of Forensic Medicine, told MJA InSight that hospital autopsy offered an important “quality assurance measure” for clinical practice.
However, he acknowledged that the move away from routine hospital autopsy was a “vicious cycle that is hard to break”.
“With a reduction in the number of hospital autopsies being performed, there’s a lesser need for pathologists-in-training to learn how to do it”, Professor Ranson said.
Professor Roger Byard agreed, saying that improving hospital autopsy rates had to be a combined effort.
While doctors should be requesting autopsies more regularly, “pathologists also need to stop putting all the blame on clinicians”, Professor Byard said.
“Doctors and pathologists both need to work together more closely and realise the true value of performing hospital autopsies.”
(Photo: Mauro Fermariello / Science Photo Library)