The autopsy as a performance measure and teaching tool

R.E. Horowitz, W.Y.NaritokuDept of Pathology and Laboratory Medicine, West Los Angeles Veterans Affairs Medical Center, LA and Dept of Pathology, USC, LA

Human Pathology (2007) 38, 688-695.e2

Objectives are to study....

1.The role of autopsy on education of:– Medical students– Pathology residents– Clinical residents

 2.  Autopsy information regarding:– Reporting– Performance measure– Research tool

Method of study

• Questionnaire sent to academic medical centers in US

• 35 responses (25%)• Training programs in 18 states

Autopsy volume

Average 156 case or 16% (1-70%)

Medical students

• Minimal exposure– 8 cases in elective; 0-1 in other– no final Dx or micro seen– Most attend conference, CPC

• Autopsy valued by faculties as education tool • Problems

– logistics– lack of support

• Some solutions– reverse CPC– late autopsy exposure

Pathology residents

• Minimum number of autopsy cases required, average 53

• Accreditation Council for Graduate Medical Education (ACGME) requirement = 50

• Allowed to share case by The Pathology Resident Review Committee (RCC)

• Competency-based evaluation of autopsy skill• Problem of using forensic cases

Pathology residents (2)

• Autopsy reports review by faculties - All• Clinicopathological correlation in report, attend

CPC, MM - 80%• Dedicated autopsy faculty - 40%• Who teach?

– pathology assistant– senior resident

• Who assess the competence?– no answer

Pathology residents (3)

• Departmental autopsy conference - 60% (too low!)– organ recital– micro review

• Problematic law introduced in Massachusette• Digital photography

        " not the same as being able to touch and feel the gross  organs" - A clinician

Clinical residents

• Regularly attend autopsy – 30%• The program with highest autopsy rate

“ we frequently see multiple members of the clinical team come to see the autopsy, including residents, fellows, nurses, and attendings”

• Ligitation concerns• Offer autopsy conferences for clinicians and

participate in clinical conference – 80%

Autopsy reporting

• Reports of volume, rate and turnaround time – all

• Reports of findings (causes of death, type of malignancy or unusual diseases) - <40%

• Provisional autopsy diagnosis (PAD)– Required to complete death certificate

• Some solutions– Digital pictures via HIS– More clinical relevant report (pathophysiology-based)

Performance measurement

• Have QA or peer review – 65%

No significance quality control of autopsies• Mandated in College of American Pathologists

(CAP) checklist

External performance evaluation

• Report discrepancies – 2/3• Analyze discrepancies - <1/2

– Not collaborate with clinician – most

• Communicate significant discrepancies - >80%– ? Influence patient care

• Yes – 50%• No – 20%• Don’t know – 20%

External performance evaluation (2)

• Not prominent role in hospital QA, performance measurement and improvement programs

• Need coordinate effort between departments• The Agency for Healthcare research and Quality

Evidence Report “The autopsy as an Outcome and Performance measure” in 2002

Research from autopsy

• Articles published – 2.3 /2 yr (0-10)• Collaborated with clinicians – 1.6 • Autopsy underused in research & publication

Discussion

Autopsy• Medical student – minimal education role• Pathology resident

– Lack of support– Not considered autopsy skill valuable

• Clinical resident– Minimal pathology input in conferences

• Measurement tool– ? Impact of autopsy on medical practice

What are the problems?

Lack of

1. Credibility

2. Funding

3. Champions

4. Number

5. Modern technology

Credibility

Autopsy• Lack of standardized structure and process

– Example: CAP cancer protocol

• Lack of studies regarding impact of autopsy on clinical practice– Discrepancies analysis

Funding

Lack of autopsy reimbursement; Why?• Not viewed as viable and potent diagnostic

procedure critical for measuring performance and outcome

Champions

Autopsy • Not viewed as valuable by faculties, both

pathology and clinical

“ If we as a profession are not convinced of the value of autopsy, how can we convince our clinical colleague?”

• Again, credibility needed

Volume

In order to increase: Autopsy • Should become a major component of health

care quality control and improvement programs• Should be incorporated into clinical trial• Authorization should be obtained by Decedent

Affair Office• Should not be hindered by law

Technology/innovation

• Modern diagnostic techniques & information technology

• Role of pathologist assistants (PAs)• Innovative approach

– Rosai’s proposal– System analysis

• Centralization

Research

• After the aforementioned suggestions implemented

• However, the law can get in the way

Conclusion