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disadvantaged children will continue to pay a price in terms of fants: results through age 5 from the Infant Health and Development Program.
JAMA. 1994;272:1257-1262.
educational underachievement, vulnerability to substance 4. McCarton CM, Brooks-Gunn J, Wallace IF, et al, for the Infant Health and Devel-
abuse, and the many negative consequences of antisocial and opment Research Group. Results at age 8 years of early intervention for low-birth-weight premature infants. JAMA. 1997;277:126-132.
5. Olds DL, Eckenrode J, Henderson CR, et al. Long-term effects of home visitation
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6. Kitzman H, Olds DL, Henderson CR, et al. Effect of prenatal and infancy home
1. Olds D, Henderson CR, Cole R, et al. Long-term effects of nurse home visitation on
visitation by nurses on pregnancy outcomes, childhood injuries, and repeated child children’s criminal and antisocial behavior: 15-year follow-up of a randomized con- rearing: a randomized controlled trial. JAMA. 1997;278:644-652.
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7. Liu D, Diorio J, Tannerbaum B, et al. Maternal care, hippocampal glucocorticoid
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3. Brooks-Gunn J, McCarton CM, Casey PH, et al, for Phase II of the Infant Health
8. National Center for Poverty in Children. Annual Report, 1997. New York, NY:
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Low-Tech Autopsies in the Eraof High-Tech Medicine Continued Value for Quality Assurance and Patient Safety It’s back. The autopsy question, that is. It will not go away that reasons for the dramatic decline in autopsy rates are many quietly. In 1983, in a theme issue on autopsy, JAMA announced and complex.4 Many thousands of words have been written that it was “declaring war on the nonautopsy.”1 We have, in about the impending “death” of the autopsy in the past 30 truth, based on outcomes, lost most of the battles since then.
years. Various calls to arms have been issued. The autopsy is But we have not lost the war. Today marks a new offensive.
not dead, but it slumbers deeply, apparently the victim of a Autopsies have traditionally been performed to: vast cultural delusion of denial. It is not exactly a conspiracy of silence or necessarily a massive intentional cover-up, but it 2. assist in determining the manner of death (ie, homicide, is a movement with millions of players, all in complicity for widely varying reasons with the final result of “do not bother 3. compare the premortem and postmortem findings, me with the truth” on the sickest patients—the ones who die.1 In fact, there is still a giant gap between what high-tech diagnostic medicine can do in theory in ideal circumstances 6. assess the quality of medical practice, (very much, very well) and what high-tech diagnostic medi- 7. instruct medical students and physicians, cine does do in practice in real-life circumstances (not nearly so well), when human beings have to decide what, where, when, 9. evaluate the effectiveness of therapies such as drugs, how, and why to use it. This gap becomes especially obvious when one looks at patients sick unto death.
Two 1998 reports validate the continued truth that there is 11. protect against false liability claims and settle valid an approximately 40% discordance between what clinical phy- sicians diagnose as causes of death antemortem and what the Preservation of the autopsy has been said to be a “funda- postmortem diagnoses are. In one recent study with such re- mental principle of all clinical research.”7 sults (44.9% discordance) at the University of Pittsburgh, Pa, But the autopsy has come on hard times since the 1960s.8 The Institute of Medicine of Chicago, Ill, has kept autopsy datafor Chicago area hospitals (a reasonable sample for urban ar- Chicago, Ill, Area Hospital Autopsy Rates
eas) since 1923 (Figure). The autopsy rates for hospital deaths at nonteaching hospitals nationally now average below 9%; many hospitals have autopsy rates at or near 0% despite manydeaths. No one seems to know what proportion of nursing home deaths are autopsied, but it appears to be between 1/100 See also p 1245.
Everywhere I go to speak on quality of care and point out these chilling autopsy figures, physicians, policymakers, andthe public ask me what happened. I tell them I do not know and 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 Reprints: George D. Lundberg, MD, JAMA, 515 N State St, Chicago, IL 60610 (e-mail: [email protected]).
two thirds of the undiagnosed conditions were considered effort at amelioration must have an equally broad focus.” The treatable.10 This diagnostic discordance rate compares with authors analyzed 46 different potential interventions targeted 35% in 1938,11 39% in 1959,12 43% in 1974,13 and 47% in 1983.14 at the general public, the medical community, nonmedical sup- No improvement! In this issue of JAMA, Burton and col- port personnel and organizations, and other organizations in leagues15 at the Medical Center of Louisiana, New Orleans, respect to cost, benefits, difficulty, magnitude, and time until document a 44% discordance between clinical and autopsy di- effect. These articles are worth serious consideration.
agnoses, specifically of malignant neoplasms between 1986 But, as a practical matter, the 2 clearest actions most likely to and 1995.15 Their findings compare with rates of 36% disagree- be effective quickly would be these. Approximately 75% of all ment on cancer diagnosis in 192316 and 41% in 1965.17 Again, no US deaths affect Medicare beneficiary patients. Of the remain- improvement! Low-tech autopsy trumps high-tech medicine ing 25% of deaths about 50% are coroner or medical examiner in getting the right answer again and again, even during the cases (another subject). HCFA proclaims quality of care to be 1990s and even at academic medical centers.
important. Since the payment for autopsies performed on hos- In response to these obvious problems, the American Medical pital inpatients is built into the diagnosis-related groups system2 Association (AMA) House of Delegates (HOD) has adopted nu- and since average hospital profits on Medicare inpatients in 1998 merous excellent policies on autopsy between 1986 and 1997.
stand at 15.9%,19 HCFA could simply mandate that a minimum These many policies include such phrases as “autopsy percentage (say 30%) of hospital deaths must be autopsied as a rates . . . be monitored periodically,” “request of an autopsy in condition of participation in Medicare. There would be no in- all deaths,” “increase the rate of autopsy attendance,” “affirms creased costs to HCFA, since the autopsy for the Medicare pa- the importance of autopsies,” “the necessity of autopsy for tient is prepaid.2 The family of the Medicare decedent has a right pathological correlation,” “fully integrate autopsy into the cur- to an autopsy and to have its results. Also, the Joint Commission riculum,” “necessary medical procedure,” “fundamental impor- always states that quality of care matters. Thus, it could declare tance of the autopsy in any effective quality assurance pro- its recent autopsy policies the failures that they are and return gram,” “initiate a program for the appropriate reimbursement to a system that works—a mandatory (say 25%) autopsy rate on of autopsies,” “call on all third-party payers including the Health hospital deaths as a condition to achieve Joint Commission on Care Financing Administration (HCFA) to pay directly for au- Accreditation of Healthcare Organizations accreditation.
topsies” (AMA policies H-85.964, H-85.969, H-85.973, H-85.977, Certainly these are bold moves and many will object. But if H-85.978, H-85.980, H-85.985, H-85.989, and H-85.993).
important steps like these were taken, we would see a rapid In adopting these important policies through the years, the return to a hospital culture that values medical truth rather HOD has called on numerous other organizations to act or assist in the autopsy rejuvenation effort. These include HCFA, National Committee for Quality Assurance, Liaison Commit- 1. Lundberg GD. Medical students, truth, and autopsies. JAMA. 1983;250:1199-1200.
tee on Medical Education, Joint Commission on Accreditation 2. Lundberg GD. The Archives of Pathology and Laboratory Medicine and the
autopsy. JAMA. 1984;252:390-392.
of Healthcare Organizations, Institute of Medicine, National 3. Council on Scientific Affairs. Autopsy: a comprehensive review of current issues.
Institute of Aging of the National Institutes of Health, other 4. Hill RB, Anderson RE. The Autopsy: Medical Practice and Public Policy. Newton,
accrediting bodies, pathology associations, and risk manage- ment and quality assurance programs in hospitals. But, un- Seckinger DL. Our two-day exploration of the autopsy. Arch Pathol Lab Med.
fortunately, no substantial progress has yet been made.
6. Lundberg GD. Now is the time to emphasize the autopsy in quality assurance.
JAMA. 1988;260:3488.
However, there may be reason for fresh hope. Democrats 7. Landefeld CS, Chren M-M, Myers A, et al. Diagnostic yield of the autopsy in a uni-
and Republicans alike and many health care organizations versity hospital and a community hospital. N Engl J Med. 1988;318:1249-1254.
8. Nemetz PN, Ballard DG, Beard CN, et al. An anatomy of the autopsy, Olsmstead
state a new commitment to quality of care. HCFA has yet County, 1935 through 1985. Mayo Clin Proc. 1989;64:1055-1064.
another intelligent new leader. The National Patient Safety 9. Mitka M. Unacceptable nursing home deaths unautopsied. JAMA. 1998;280:1038-
1039.
Foundation at the AMA has been formed to prevent medical 10. Nichols L, Aronica P, Babe C. Are autopsies obsolete? Am J Clin Pathol.
error and to create a culture dedicated to finding and disclos- 11. Bean WB. Infarction of the heart. Ann Intern Med. 1938;11:2086-2108.
ing truth. And, not least, the AMA, largely populated by new 12. Johnson WJ, Achor RWP, Burcell NB, et al. Unrecognized myocardial infarction.
Arch Intern Med. 1959;103:253-261.
high-level staff and emboldened by a newly approved Vision, 13. Britton M. Diagnostic errors discovered at autopsy. Acta Med Scand. 1974;196:
is freshly energized toward high-quality medical care and is 14. Zarling EG, Sexton H, Milnor P Jr. Failure to diagnose acute myocardial infarc-
showing signs of seriously trying again to implement the ex- tion. JAMA. 1983;250:1177-1181.
isting AMA HOD policies. Repeated past failures in this whole 15. Burton EC, Troxclair DA, Newman WP III. Autopsy diagnoses and malignant
neoplasms: how often are clinical diagnoses incorrect? JAMA. 1998;280:1245-1248.
field mute exuberance, but the winds of change do blow and 16. Wells HC. Relation of clinical to necropsy diagnosis in cancer and value of exist-
seem to be doing more than rustling the autumn leaves.
ing cancer statistics. JAMA. 1923;80:737-740.
17. Bauer FW, Robbins SL. An autopsy study of cancer patients, I: accuracy of the
Among the best articles in print on correcting the autopsy clinical diagnoses (1955 to 1965) Boston City Hospital. JAMA. 1972;221:1471-1474.
18. Nemetz PN, Beard CN, Ballard DG, et al. Resurrecting the autopsy: benefits and
problems were 2 from the Mayo Clinic in 1989.8,18 The 10 authors recommendations. Mayo Clin Proc. 1989;64:1065-1076.
wrote that since “a wide range of medical, legal, social, and 19. Medicare Payment Advisory Commission. Health Care Spending and the Medi-
care Program: A Data Book. Washington, DC: Medicare Payment Advisory Commis-
economic causes underlie the decline in autopsy rates . . . any The human suffering related to the 17 deaths, nearly 6000 hos- coping skills learned in the group allowed him to withstand pitalizations, and more than 330 000 ED visits a year and the as- tobacco cravings and avoid relapse. The medication was con- sociated economic impacts justify further efforts to prevent dog tinued for a total of 10 weeks, and the patient had no diffi- culties and did not experience any withdrawal symptoms (eg, Kyran P. Quinlan, MD, MPH
irritability, anxiety, headaches, dizziness) after its discontinu- Jeffrey J. Sacks, MD, MPH
ation. The patient was followed up at 1, 3, and 6 months and Centers for Disease Control and Prevention
Atlanta, Ga
Comment. Recent research suggests a 2-pronged ap-
1. Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries treated in emer-
proach to tobacco cessation with use of both pharmacologic gency departments. JAMA. 1998;279:51-53.
treatment and behavior modification provides maximum ef- 2. Centers for Disease Control and Prevention. Dog bite-related fatalities—
United States, 1995-1996.
ficacy for tobacco cessation.4 Bupropion is considered a first- MMWR Morb Mortal Wkly Rep. 1997;46:463-467.
3. Rice DP, MacKenzie EJ, Jones AS, et al. Cost of Injury in the United States: A
line therapy for smoking cessation.5 However, to our knowl- Report to Congress. San Francisco: Institute for Health and Aging, University of edge, use of bupropion for treatment in smokeless tobacco California, and Injury Prevention Center, The Johns Hopkins University; 1989.
4. MacKenzie EJ, Shapiro S, Siegel JH. The economic impact of traumatic injuries:
addiction has not been reported previously. The behavior modi- one-year treatment-related expenditures. JAMA. 1988;260:3290-3296.
fication used a psychoeducational format to develop effective This letter was shown to Mr Weiss, who declined to reply.—ED.
coping strategies for tobacco cessation. These classes have beenshown to significantly increase rates of tobacco cessation.4 Fur- Treatment of Smokeless Tobacco Addiction
ther studies are needed with a larger population to quantify With Bupropion and Behavior Modification
the efficacy of bupropion hydrochloride and behavior modi-fication in the treatment of nicotine addiction caused by smoke- To the Editor: An estimated 6.9 million people in the United
States use smokeless tobacco, such as chewing tobacco or snuff.
Timothy R. Berigan, DDS, MD
The health risks associated with smokeless tobacco use include Edwin A. Deagle III
increased rates of oropharyngeal cancer and increased subse- 82D Airborne Division
Fort Bragg, NC
quent cigarette smoking.1 Despite the widespread use of smoke-less tobacco, relatively few data have appeared in the literature Disclaimer: Conclusions and opinions expressed are those of the authors and do
not necessarily reflect the position or policy of the US government, Department
regarding treatment of addiction to it.2,3 We describe a case of of Defense, Department of the Army, US Army Medical Command, or the 82D successful treatment of smokeless tobacco use with an approach that combined pharmacotherapy and behavior modification.
1. Kaplan HI, Sadock BJ. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral
Report of a Case. A 31-year-old man had an 11-year his-
Sciences/Clinical Psychiatry. 8th ed. Baltimore, Md: Williams & Wilkins; 1998:433.
tory of using 1 can per day of smokeless tobacco and denied 2. DelGrippo G. Smokeless tobacco cessation: report of a preliminary trial using
any history of smoking. The patient previously had made sev- nicotine chewing gum. J Fam Pract. 1994;38:14.
eral attempts to stop use of smokeless tobacco with nicotine 3. Sinusas K, Coroso JG. Smokeless tobacco cessation: report of a preliminary trial
using nicotine chewing gum. J Fam Pract. 1993;37:264-267.
patches and abrupt cessation but had only limited success for 4. Fiore M, Bailey W, Cohen C, et al. Smoking Cessation: Clinical Practice Guide-
a short time. He agreed to a trial of bupropion hydrochloride line No. 18. Rockville, Md: Agency for Health Care Policy and Research, US Deptof Health and Human Services, Public Health Service; 1996.
and a 4-week course of behavior modification. These ses- 5. Gastfriend DK, Elman I, Solhkhah K. Pharmacotherapy of substance abuse and
sions covered effective withdrawal strategies, coping skills for dependence. In: Dunner DL, Rosenbaum JF, eds. The Psychiatric Clinics of America:Annual of Drug Therapy. Philadelphia, Pa: WB Saunders; 1998:216.
cravings, initial tobacco cessation, and extended mainte-nance skills. During the first session the patient was asked toset a quit date that would occur while he was in the group.
CORRECTIONS
The patient started treatment with bupropion hydrochloride(150 mg twice daily) 1 week prior to group treatment. After Incorrect Web Site Address: In the Consensus Statement entitled “The Urgent
Need to Reform Health Care Quality: Institute of Medicine National Roundtable
approximately 1 week of taking medication, the patient noted on Health Care Quality,” published in the September 16, 1998, issue of THE JOURNAL a reduction in cravings for smokeless tobacco, and at 5 weeks (1998;280:1000-1005), there was an incorrect Web site address. On page 1000,in the last sentence of the first paragraph of text, the Web site address should he was tobacco free. He noted few adverse effects associated have read “http://www2.nas.edu/hcs/.” with the medication but reported a change in the taste of the Incorrect Reference: In the Editorial entitled “Low-Tech Autopsies in the Era of
smokeless tobacco as the most prominent effect. After taking High-Tech Medicine: Continued Value for Quality Assurance and Patient Safety,” bupropion for approximately 3 days, the patient described the published in the October 14, 1998, issue of THE JOURNAL (1998;280:1273-1274), smokeless tobacco as “tasting terrible,” and he felt the poor there was an incorrect reference. On page 1274, reference 10 should have read“Nichols L, Aronica P, Babe C. Are autopsies obsolete? Am J Clin Pathol. 1998; taste was 1 factor in becoming tobacco free. He also felt the 1999 American Medical Association. All rights reserved.
JAMA, January 20, 1999—Vol 281, No. 3 233

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