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Re: lung cancers, primary vs secondary - response to Maury
Maury,
I am somewhat hesitant to respond to your question. Weren't you critical of
me posting just a few days ago?
There are numerous ways to establish the reliability of primary lung cancer dx
other than an autopsy, but in response to your question some hospitals such as
Stanford performed them for years at no costs, while private firms may cost as
much as $5,000 depending on whether or not specific tox screens are requested.
Perhaps this Medscape article may be of help.
---------------------------
Letter
Institutional and Economic Influences on Autopsy Performance - In Reply
July 7, 2000
from Medscape General Medicine [TM]
Elizabeth C. Burton, MD
Louisiana State University Health Sciences Center
New Orleans, Louisiana
Peter N. Nemetz, PhD
University of British Columbia
Vancouver, BC, Canada
We agree that there is definite value in collecting autopsy data and recognize
the need for a centralized autopsy data repository for the public good. We are
alarmed by a national autopsy rate of 9.4% and the fact that hospital autopsy
rates have fallen to below 6% and continue to decline. Morris's letter
highlights several interesting and complicated issues regarding autopsies,
including the fact that autopsies are not discussed or offered as a service to
the decedent's family by many healthcare professionals and the issue of who
will pay for autopsies.
Many healthcare professionals believe that the public's attitudes toward
autopsies are generally negative; however, several studies have shown this not
to be true.[1-3] This false perception may more accurately reflect the
attitudes of healthcare professionals toward autopsies. In a recent secondary
data analysis from a multi-institutional study conducted 10 years ago, one of
us found that when family members or surrogates of terminally ill patients
were asked specific questions about autopsies prior to the patient's death,
68% said that they had no personal objections to autopsies. Fifty-six percent
of surrogates stated a willingness to permit an autopsy in the event of the
patient's death if requested by the physician (unpublished data). In fact,
this analysis also revealed that at the time of death, autopsy consent was not
requested in almost half of all cases, a number similar to that found by
McPhee and colleagues in a previous 1986 study.[1] The decline in autopsy
rates can be partially attributed to the fact that autopsy permission is often
not sought by healthcare professionals, a phenomenon that is likely to
continue as medical care continues to shift from acute inpatient hospitals to
long-term care facilities (ie, nursing homes and hospices).
Central to the problem of declining autopsy rates is the issue of cost and
payment for autopsies. Autopsy cost estimates range from approximately $500-
$3500, dependent on whether a complete or partial (restricted) autopsy is
performed, and it appears that hardly anyone is interested in paying for them.
In 1983, Carolyne Davis of the Health Care Financing Administration (HCFA)
stated that "Autopsies as a specific service are not covered under Medicare,
although Medicare does recognize hospital overhead costs related to autopsies,
including space, equipment, and personnel as well as physician services under
Part A as administrative and quality control activities. These costs will be
included in the hospital's base under prospective payment."[4] In a 1995
statement by Charles Booth from the HCFA's Office of Hospital Policy, he
claimed that although payment is through the hospital, HCFA does pay for
autopsies, but this payment is based on whether autopsies were performed
within a particular hospital in 1981.[5] In 1995, Trelstad and colleagues
surveyed the Medical Directors of 12 insurance or healthcare plans about their
policies concerning autopsies. Of the 5 organizations that responded, 4 had no
policy for autopsy claims coverage and 1 organization stated that "coverage of
autopsies are [sic] included in all of our hospital contracts."[6]
In an effort to verify and update this information, we attempted to contact
HCFA's Administrator and the chief executive officers, the chief operations
officers, or the medical directors of 15 of the largest United States
healthcare insurers about specific policy coverage for autopsies (Table). We
received no response from HCFA. Prior to June 30, 2000, 6 of the 15 healthcare
insurers responded to our questions as follows:
Does your organization pay claims for autopsies? If yes, how are the claims
paid, what is the maximum dollar amount allowable, and to whom are the claims
paid? All 6 responded with "No."
Does your organization have an official policy concerning autopsies? If yes,
describe or attach a copy of the policy.
Three responded with "No." Two responded with "Yes." One did not give a
description of their policy, and 1 stated that "autopsies are not a covered
benefit according to EOCs." One did not respond to this question.
Does your organization contract with a managed care organization? If yes, is
there a stated policy with the managed care organization that includes
specific language about performing autopsies?
One responded with "No" and stated that they are a managed care organization.
Three responded with "Yes," that they do contract with a managed care
organization but do not have a stated policy with that organization about
autopsies. Two did not respond to this question.
Additional comments:
Autopsies are not health benefits and are not medically necessary to the
insured who has expired.
Although we have no specific autopsy policy, we also do not have a policy that
specifically excludes autopsies.
Health insurance benefits cease upon the death of the insured.
This procedure is considered to be included in the hospital's charges for care
provided to the patient when alive.
Professional charges for performing autopsies are also not covered.
Although the general consensus is that autopsy coverage does not occur by most
healthcare insurers, it appears that HCFA does cover autopsy costs as part of
Medicare Part A.[4] This payment is built into the diagnosis-related groups
system for autopsies performed on inpatient deaths as part of the hospital's
operating expenses. However, because this coverage is nonspecific, there is no
guarantee that this money is actually used to cover the cost of autopsies. As
a result, some hospitals do not offer autopsies as a medical service, and
those that do provide this service may bill the decedent's family directly on
a fee-for-service basis.
It is not surprising that when families are not informed about autopsies as an
option, when they are told that autopsies are not possible, or they are told
that they will have to pay for the autopsy, feelings of mistrust may occur. In
some cases, an autopsy may be sought outside of the hospital. But in most
cases, the autopsy will not be done and many questions remain unanswered. When
a death occurs, it is usually an emotional time for families. Autopsies can
provide answers about the cause of death, information about heritable
diseases, and confirmation of the appropriateness of medical care, which can
help families through the bereavement process and provide closure. In
addition, as we have stressed in our original article, autopsies provide an
extraordinary opportunity to help address the issue of quality and cost of
care, which loom so large in current medical practice and health policy. It
would be a shame if this opportunity were to be forgone because of ignorance,
apathy, or government accounting practices that do not tie autopsy
reimbursement directly to the delivery of this service.
Medscape General Medicine 2(3), 2000. © 2000 Medscape Portals, Inc
------------------------------------------------>
Dr. Field, do you happen to have any approximation of the cost to have an
> autopsy
> done on. say, a deceased relative? I vaguely recall around $500 many years ago,
> but
> really have no idea.
> Thanks in advance,
> Maury Siskel maury@webtexas.com
> =============================
> epirad@mchsi.com wrote:
>
> > The accuracy of death certificate information regarding primary versus
> > secondary lung cancer is always suspect unless additional information is
> > available to confirm the information on the death certificate. The greatest
> > inaccuracy likely occurs in misdiagnosed primary lung cancer in non smoking
> > females. The lung cancer may often be a secondary cancer from a hidden cancer
> > from elsewhere else in the body such as the breast.
> >
> > More to the point, we have conclusively shown that the mortality data used by
> > Dr. Cohen is temporally incorrect in relation to the latency period for
> cancers
> > and radon testing periods in Dr. Cohen's data. Actual incidence lung cancer
> > data from a National Cancer Institute Cancer Registry is in very poor
> agreement
> > with Dr. Cohen's surrogate data for the time period of interest.
> >
> > See also -
> >
> > Am J Ind Med. 1992;22(4):469-80.
> >
> > Use of death certificates in epidemiological studies, including occupational
> > hazards: discordance with clinical and autopsy findings.
> >
> > Selikoff IJ.
> >
> > Mount Sinai School of Medicine, City University of New York, New York 10029.
> >
> > There has long been evidence of frequent inaccuracy of death certificates,
> with
> > significant discordance between such designations and clinical and autopsy
> > data. This exists for occupational diseases as well. The use of statistical
> > rates based on death certificates has been seriously questioned despite their
> > utility for total mortality. Programs to supplement death certificate data,
> > particularly in occupational disease studies, may be helpful, and are
> reviewed.
> > ------------------------------
> >
> > APMIS Suppl. 1994;45:1-42.
> >
> > Comparison of autopsy, clinical and death certificate diagnosis with
> particular
> > reference to lung cancer. A review of the published data.
> >
> > Lee PN.
> >
> > P. N. Lee Statistics and Computing Ltd., Sutton, Surrey, UK.
> >
> > Some clinicians and some epidemiologists appear to be under the illusion that
> > techniques available for the diagnosis of internal diseases such as lung
> cancer
> > have improved so much that autopsies are not necessary on the bodies of most
> > people who die. Partly for this reason, partly for economic reasons and partly
> > because clinicians fear litigation if autopsy shows that they treated patients
> > for the wrong disease, autopsy rates have been falling in most developed
> > countries. The object of the present review was to ascertain how much reliance
> > can reasonably be put on clinical diagnoses made and death certificates
> > completed in the absence of autopsy data. In the case of lung cancer, high
> > rates of false positive and false negative diagnoses are universally
> prevalent,
> > with biases influencing these rates, so that smokers are more likely to be
> > appropriately investigated for lung cancer, and false negatives are commoner
> in
> > non-smokers. All investigators who have compared clinical-based and autopsy-
> > based death certificates have concluded that higher autopsy rates are
> necessary
> > and the results of one study suggest that a high autopsy rate in a hospital
> > leads to improvements in the accuracy of clinical diagnoses. The extent to
> > which diagnoses on death certificates that are dependent solely on clinical
> > data are seriously inaccurate for internal diseases such as lung cancer should
> > engender caution in all who use mortality data to guide public health policies
> > and to identify and quantify environmental risks to healths.
> > -------------------
> > > A few days ago, someone said that my lung cancer data were no good
> > > because many of the deaths included were from cases where lung cancer was
> > > secondary, a metathesis from other cancers. I sent a query about this to
> > > NCHS and received the reply below.
> > >
> > > Bernard L. Cohen
> > > Physics Dept.
> > > University of Pittsburgh
> > > Pittsburgh, PA 15260
> > > Tel: (412)624-9245
> > > Fax: (412)624-9163
> > > e-mail: blc@pitt.edu
> > > web site: http://www.phyast.pitt.edu/~blc
> > >
> > > ---------- Forwarded message ----------
> > > Date: Mon, 23 Jun 2003 10:00:41 -0400
> > > From: "Kochanek, Kenneth D." <kdk2@cdc.gov>
> > > To: "'blc+@pitt.edu'" <blc@pitt.edu>
> > > Cc: "Kochanek, Kenneth D." <kdk2@cdc.gov>, "Ingram, Deborah D."
> <ddi1@cdc.gov>
> > > Subject: query
> > >
> > > In 2000, there were 155,521 lung cancer underlying cause deaths in the
> > > United States. The information about the cause of these deaths is coded
> > > from the death certificate. If the certifier reported "primary lung cancer"
> > > or "lung cancer," the death is coded as primary lung cancer and this is what
> >
> > > constitutes the number of deaths listed above.
> > >
> > > Lung cancer deaths that are coded as secondary lung cancer are not included
> > > in the number of lung cancer underlying cause deaths above. These deaths
> > > are included in a separate code called "Secondary malignant neoplasm of
> > > lung." In 2000, there were 224 underlying cause deaths coded to this cause.
> > >
> > > If you have any further questions, please let me know.
> > >
> > > Ken Kochanek
> > > --------------------------------------------------------------
> > > Kenneth D. Kochanek
> > > Statistician
> > > Mortality Statistics Branch
> > > Division of Vital Statistics
> > > National Center for Health Statistics
> > > 3311 Toledo Road, Room 7318
> > > Hyattsville, Maryland 20782
> > > Tel: 301-458-4319
> > > Fax: 301-458-4034
> > > E-mail: kdk2@cdc.gov
> > > Mortality Web Page:
> > > http://www.cdc.gov/nchs/about/major/dvs/mortdata.htm
> > >
> > > -----Original Message-----
> > > From: BERNARD L COHEN [mailto:blc+@pitt.edu]
> > > Sent: Thursday, June 19, 2003 1:23 PM
> > > To: CDC Wonder Customer Support
> > > Subject: RE: query
> > >
> > >
> > > Yes, I mean mortality data.
> >
> > >
> > > Bernard L. Cohen
> > > Physics Dept.
> > > University of Pittsburgh
> > > Pittsburgh, PA 15260
> > > Tel: (412)624-9245
> > > Fax: (412)624-9163
> > > e-mail: blc@pitt.edu
> > > web site: http://www.phyast.pitt.edu/~blc
> > >
> > > On Tue, 17 Jun 2003, CDC Wonder Customer Support wrote:
> > >
> > > > Are you referring to the Mortality dataset?
> > > >
> > > > -----Original Message-----
> > > > From: Bernard Cohen [mailto:blc+@pitt.edu]
> > > > Sent: Monday, June 16, 2003 10:41 AM
> > > > To: cwus@cdc.gov
> > > > Subject: query
> > > >
> > > >
> > > > In your data on lung cancer, in what fraction of the cases reported is
> > > > cancer of the lung primary, and in what fraction may it be secondary?
> > > >
> > >
> > >
> > >
> > > ************************************************************************
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> >
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> --
> It is the soldier, who salutes the flag, who serves under the flag,
> and whose coffin is draped by the flag, who allows the protester to
> burn the flag. Charles M. Province
>
>
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