Section 1 -

The Autopsy as a Performance Measure and Teaching Tool Richard E. Horowitz

Average Annual Number Of Autopsies Per Program Number 155 Range (10 To 479 ) Average Autopsy Rate Per Program Rate 15% Range ( 1 To 70 ) Do Medical Students Attend Autopsies? Yes 34% Yes, But Only If On Autopsy Elective 20% No 23% How Many? If On Autopsy Elective, Average 8 (Range 2 To 35) If Not On Autopsy Elective, Average 1 (Range 0 To 5) Does The Pathology Course Utilize Autopsy Materials? Yes 59% No 18% No Ans 23% Does Autopsy Have Value For Medical Students? Yes 88% No Ans 12% The Medical Students' Predicament Logistics Lack Of Time Lack Of Support From Clinical Faculty Lack Of Pathology Faculty Enthusiasm Is There Exclusive Autopsy Faculty For Residents? Yes 41% No 56% Should Residents Be Required To Perform Specific Numbers Of Autopsies? Yes 74% No 21% How Many Should Each Resident Do? Average 53 (Range 25 To 100) Are Residents Required To Demonstrate Competence? Yes 82% No 15% Is The Residents Work Reviewed By Faculty? Yes 97% Are Autopsies Presented In Departmental Conferences? Yes 59% No 38% Do Residents Participate In Cpc's And M & M Conferences? Yes 71% No 12% Pathology Residents' Problems Lack Of Faculty Involvement Lack Of Faculty And 4th Year Enthusiasm Inadequate Supervision Limited Conferences Do Clinical Residents Rotate On The Autopsy Service? Yes 20% No 74% Do Clinical Residents Or Staff Attend Autopsies? Yes 29% Rarely 6% No 56% Are There Autopsy Conferences For Clinicians? Yes 71% No 18% No Ans 12% Clinical Residents' Obstacles No Support From Chief Of Service Logistics Again - No Time No Recognition Of Benefit Change In M&M Conference Format Does The Service Issue Periodic Reports Of Autopsy Rate? Yes 91% No 6% Does The Service Issue Reports Of Autopsy Findings? Yes 35% No 56% Autopsy Reporting Problems Lack Of Pre-Autopsy Consultation Lack Of Immediate Reporting Of Pad Inaccuracy In Death Certification Prolonged Turnaround Time For Final Report No Public Relations VA Monthly Report (VA Form 10-0424) Number Of Inpatient Deaths Number Of Autopsies Autopsy Rate Number Of Coroner Cases Number Of Autopsies That Validated Clinical Cod Number Where Autopsy Established The Cod Number Of Autopsies That Failed To Identify Cod Quarterly Report To The Chief Of Staff Number Of Deaths (Current And Last Year) Number Of Autopsies (Current And Last Year) Autopsy Rate (Current And Last Year) Number Of Cases Referred To Coroner Turnaround Time To Pad Turnaround Time To Fad Proximate Causes Of Death Conditions Contributing To Death Categorization Of Discrepancies Peer Review Are Discrepancies Categorized? Yes 62% No 32% Are Discrepancies Analyzed? Yes 47% No 50% Do Clinicians Collaborate In The Analysis? Yes 38% No 56% Are There Inter-Rater Reproducibility Studies? Yes 6% No 88% Discrepancy Categories Patient Demographics Autopsy And Clinical Diagnoses Variance Categorization Clinical Factors Contributing To Variance Diagnosis Suspected, But Not Confirmed Diagnosis Equally Considered Unremitting Course Of Disease Error In Judgment Or Treatment Plan Result Of Complication Or Therapeutic Procedure Unrecognized Diagnosis With Pre-Mortem Evidence By: Physical Exam Patient Complaint Or Symptom Clinical Course Inattention Or Misinterpretation Of Diagnostic Tests Other Summary And Comment Are Discrepancies Communicated To Clinicians? Yes 62% No 32% Are Discrepancies Part Of The Hospital Qa Program? Yes 85% No 15% Have Discrepancy Analyses Influenced Patient Care? Yes 62% No 18% Don't Know 15% Are Autopsies Peer Reviewed? Yes 62% No 32% Autopsy Peer Review Correlation Of Pad With Fad Agree With Fad, Death Certification And Cpc Assess Communication With Clinician And Next Of Kin Adequacy Of Tissue Sampling, Slides, Special Stains Adequacy Of Gross And Microscopic Description Adequacy Of Photographs Discussion And Action Prn Obstacles To Use Of Autopsy As A Performance Measure Inadequate Number Of Autopsies Inadequate Number Of Random Autopsies No Internal Quality Assurance Standards No Peer Review No Data Re Discrepancies And Patient Care No Clinician Involvement In Outcome Analysis Papers From The Autopsy Service In Past Two Years Average 2.3 Range 0 To 10 Paper In Collaboration With Clinicians Average 1.6 Range ( O To 10) Research Projects Currently In Progress Average 2.0 Range (0 To 6) Why So Little Research? Lack Of Dedicated Faculty Rapid Resident Rotations Obsolete Technology Irb Restrictions What Is Needed? Establish Credibility - Which Will Justify Funding - Which Will Encourage Champions - Which Will Increase Volume - Which Will Demand Innovation - Which Will Show Results And Which Will Confirm Credibility Establish Credibility Define Autopsy As A Standard Diagnostic Test Or Medical Procedure Define Standards For Discrepancy Categorization And Analysis Establish Impact Of Error Detection On Clinical Performance Establish Autopsy As Standard For Vital Statistics Funding Market The Autopsy As A Medical Procedure Cpt And Rbrvs Outcome Tool For Clinical Trials Performance Measurement Tool Pay For Performance Tool Champions Pathology Chairs & Faculty Clinical Chairs Hospital & Health Care Administrators Volume Random And Problem Cases Clinical Trials Decedent Affairs Office Innovation In Autopsy Technology Pathology Assistant Centralization Focused Autopsy Virtual Autopsy Acknowledgement I am grateful to the many directors of pathology training programs who responded to this survey and added their pertinent and pithy comments! They are the true authors of this report