Can Postmortem CT Scans Effectively Replace Full Autopsies?

Study examines the impact of CT scans on workflow and tallies the cost savings of postmortem CT in lieu of full autopsy.

There are about 500 practicing forensic pathologists in the United States—only about half the actual number that is needed. That shortage, coupled with a significant increase in drug intoxication, homicide, and motor vehicle deaths in 2019 and 2020, has caused a serious strain on medical investigation offices. Methods that can streamline postmortem examinations without compromising accuracy can help meet that demand, potentially at reduced cost.

One such method is postmortem computed tomography (or CT) scanning. Postmortem CT scans can be used in advance of a physical examination to decide whether to perform a full autopsy, partial autopsy, or other testing. They are routinely employed in Europe, Australia, and Japan, but their use in the United States is limited.

NIJ-funded researchers from the New Mexico Office of the Medical Investigator sought to investigate the cost-effectiveness of postmortem CT scans compared to traditional postmortem exams. The forensic pathologists had observed that, although the total number of cases they were receiving was increasing, the number of full autopsies they were performing was decreasing (presumably due to their use of postmortem CT). They wanted to quantify just how much the technology had increased their efficiency, decreased their need for full autopsy, and affected their budgetary needs.

The researchers from that office sought to investigate:

• The impact of postmortem CT scans on workflow, costs, and staffing as compared to traditional postmortem examinations.
• The effectiveness of integrating postmortem CT scans into routine investigation.

Case management, workflow positively impacted

The researchers created a 15-question postmortem assessment questionnaire that was completed by case forensic pathologists at the New Mexico Office of the Medical Investigator. Researchers collected data for 2,037 consecutive cases over a nine-month period, 94% of which used postmortem CT scans. They observed that postmortem CT scans had a significant effect on case management, impacting:

• The choice of exam type (full autopsy, partial autopsy, or external examination only) in 31% of the cases.
• The final determination of cause and manner of death in 20% of cases.
• The determination of a significant finding that would not have been seen at autopsy in 2.6% of the cases.
• The number of full autopsies needed: the number of full autopsies decreased, reducing the need to hire two additional forensic pathologists.

Over the course of five years (2013-2018), the New Mexico Office of the Medical Investigator has been able to decrease the number of full autopsies by 10%, even as the total number of cases arriving in their office rose by more than 15%. This is largely because postmortem CT nearly doubled the proportion of cases that were investigated by external examination rather than full autopsy.

Integrating postmortem CT into routine investigation

Researchers retrospectively audited 10% (200) of the cases from their questionnaire phase to determine whether findings visible to a radiologist on CT scans were identified and incorporated into the death investigation report by a forensic pathologist. The researchers found:

• Thirteen errors (6.5% of cases); in all cases where errors were identified, the manner of death was certified as either accident or natural.
• Ninety-five percent of cases had minor findings that were not previously noted.
• In none of the 200 cases reviewed did a postmortem CT finding that was missed definitively change the manner of death.

Significant cost savings

The researchers found that postmortem CT provided them significant cost savings because they are a high-volume office that already has the equipment available for time-saving CT scan use. But for a smaller medical examiner or coroner office, they predicted that the use of postmortem CT scans could at least be cost neutral. Should forensic pathologists become even more scarce, then their salaries might increase faster than the cost of using postmortem CT, likely making postmortem CT even more cost effective.

By disseminating the research results to other medical examiner and coroner offices nationwide, the researchers hope to help medical investigators make informed decisions about the use of postmortem CT in their practices.