Cost–consequence analysis of cause of death investigation in Finland and in Denmark

Abstract

The 1990s 12-16% total autopsy rate in Denmark has until now declined to 4%, while in Finland, it has remained between 25 and 30%. The decision to proceed with a forensic autopsy is based on national legislation, but it can be assumed that the financing of autopsies influences the decision process. Only little is known about the possible differences between health economics of Finnish and Danish cause of death investigation systems. The aims of this article were to analyse costs and consequences of Finnish and Danish cause of death investigations, and to develop an alternative autopsy practice in Denmark with another cost profile. Data on cause of death investigation systems and costs were derived from Departments of Forensic Medicine, Departments of Pathology, and the National Police. Finnish and Danish autopsy rates were calculated in unnatural (accident, suicide, homicide and undetermined intent) and natural (disease) deaths, and used to develop an alternative autopsy practice in Denmark. Consequences for society were analysed. The estimated unit cost (€) for one forensic autopsy is 3.2 times lower in Finland than in Denmark (€1400 versus €4420), but in Finland the salaries for forensic pathologists working at the National Institute for Health and Welfare are not included in the unit cost. The unit cost for one medical autopsy is also lower in Finland than in Denmark; €700 versus €1070. In our alternative practice in Denmark, the forensic autopsy rate was increased from 2.2% to 8.5%, and the medical autopsy rate from 2.4% to 5.8%. Costs per 10,000 deaths were estimated to be 50% (±25%) higher than now; i.e. €3,678,724 (2,759,112-4,598,336), but would result in a lower unit cost for forensic autopsies €3,094 (2,320-3,868) and for medical autopsies €749 (562-936). This practice would produce a higher accuracy of national mortality statistics, which, consequently, would entail higher quality in public health, an accurate basis for decision-making in health politics, and better legislative safety in society. The implementation of this alternative practice in Denmark requires that legislation demands that forensic autopsy be performed if causality between unnatural death and cause of death cannot be clarified or if cause of death remains unknown. The Danish Health and Medicines Authority should provide guidelines that request a medical autopsy in natural deaths where more information about disease as a cause of death is needed. Our study results warrant similar health economic analyses of different cause of death investigations in other countries.

Autopsy rates in the Netherlands: 35 years of decline

“…Data on the exact costs per autopsy are not available; cost estimates per autopsy vary according to the number of autopsies being performed [31] and the extensiveness of the procedure [32]. At the same time gained benefits per autopsy are difficult to quantify, and, as a consequence, cost-benefits of autopsy cannot easily be determined.…”

“…For example, in Denmark forensic autopsies are paid from the police budget and thus compete with other cost [32], whereas in Finland the forensic autopsies are all payed for by the government. Even in recent years, the overall Finnish autopsy rates have been around 30%, which is explained by increasing medicolegal autopsy rates at the time when clinical autopsy rates started to decrease.…”

“…In some countries, however, forensic autopsy may also be performed on cases that are not of interest to the police, such as deceased whose cause of death is classified as natural, but remains unclear [32]. …”

Post-mortem levels and tissue distribution of codeine, codeine-6-glucuronide, norcodeine, morphine and morphine glucuronides in a series of codeine-related deaths

“…Thus, the potential benefit of sustaining adequate autopsy practices for public health and preventive medicine does not seem to be less relevant in rural areas. Since the publication of paper I, some interesting studies investigating various aspects of the differences in autopsy rates between Denmark and Finland have also been published [161][162][163].…”

“…These studies documented systematically lower autopsy rates in Denmark than in Finland, particularly for suicides [161], and linked this to a much higher frequency of ill-defined and unknown cause of death codes in the Danish death statistics compared to the Finnish [162]. However, in a costconsequence analysis of the cause of death investigations in the two countries, the same group of researchers stated that the implementation of an alternative practice increasing the autopsy rates in Denmark comes at a price, with costs per 10,000 deaths estimated to increase by about 50% compared to current practice [163].…”