CEO SUMMARY: On the surface, the “exposé” published by The Oregonian newspaper on February 12 seemed designed to sensationalize an effort by local obstetricians, hospitals, and pathologists to do a better job of evaluating placentas taken from patients who had experienced a difficult birth as an arrangement intended to provide a defense in malpractice cases. But deeper investigation uncovers a more benign story.
ON FEBRUARY 12, 2006, The Oregonian newspaper in Portland, Oregon published a story about how, from 1996 to 2003, the placentas from as many as 700 women who had difficult births were sent to a laboratory in Portland, Oregon. The placentas were examined, and the women were not told, according to The Oregonian.
This story directly implied that the existence of the Cascadia Placenta Registry, as this specialized laboratory was called, was exclusively an arrangement organized around malpractice concerns related to difficult births. The newspaper pointed out that some of the women learned about the registry only after filing a malpractice lawsuit.
Hospitals In Three States
The Oregonian also published information that the original funding to launch the Portland, Oregon-based Cascadia Placenta Registry in 1996 had come from malpractice insurers, a number of hospitals, and a malpractice attorney in the area. During the years it operated the registry accepted placentas for study from hospitals in Oregon, Washington, and California.
For pathologists and ob-gyns in the Northwest, however, the Cascadia Placenta Registry was not news. The registry was established to collect medical information that could be used to help protect doctors and hospitals if needed against a malpractice lawsuit. While it was in operation, it provided a useful and needed service not available elsewhere, according to an ob-gyn and a pathologist interviewed by THE DARK REPORT.
“Sometimes, there’s a lot to be a learned from the placental material,” said Robert D. Dyson, M.D., an ob-gyn with Gateway Women’s Clinic in Portland, Oregon. “Many of the questions we have regarding births get answered with pathology reports, and the local pathologists are perfectly able to answer most of them. But if it’s a difficult birth, there are sometimes subtleties involved in the pathology that we need to know about. The idea behind the registry was to have a pathologist with specialized expertise examine placentas from patients who had experienced difficult results. Unfortunately, the registry failed for lack of funding.
“The article in the newspaper made it look like we sneak around behind people’s backs and steal placentas in order to keep lawyers from making a lot of money,” Dr. Dyson explained. “That’s not true. There’s a whole other side to the story. Ob-gyns knew about the registry because those who started it made an effort to publicize it so that it would be financially viable. But, because it didn’t get used enough to be financially self-sustaining, it was closed in 2003.
Payers Are Reluctant
“Frankly, it’s hard to get third-party payers to pay for something like that,” Dyson continued. “Most insurers use their in-plan institutions and this effort involved a pathologist who did not hold contracts with key payers. So, the problem was with payment. About the only way for the pathologists to get paid was to have the hospital pay them. When the hospital paid for it, it did so for risk management reasons—if there was a bad outcome, for instance.
“Even when the registry was running, the vast majority of the placentas that we referred for analysis were examined by the in-house pathologist,” Dyson said. “When there was a big question about a particular case, then the hospitals might send it out and pay for the registry to do the exam. For instance, when the in-house pathologists couldn’t answer the questions that we asked of them, or if there was a baby that had a problem, such as cerebral palsy, the placenta might be sent to the registry. When the registry did the exam, it was a far more thorough exam than was available from the in-house pathologists.
“In a typical case, results would come back to the obstetrician and would be shared with the patient, the same as with other tests,” he added. “Of course, if the patient initiated legal action before that could happen, communication with the patient would not occur and indeed they might find out about the registry only from their lawyer.
Cascadia Placenta Registry Not the First Attempt to Identify Problems, Improve Care
PORTLAND,OREGON’S CASCADIA PLACENTA REGISTRY was not the first effort to use a placenta registry as a way to better diagnose problems and improve obstetric care.
There has been growing recognition for the need to develop more advanced knowledge of placental pathology. That’s because of increased knowledge about how different diseases and conditions affect the placenta.
In recent years, the College of American Pathologists (CAP) has encouraged initiatives designed to advance pathologists’ skills in evaluating and diagnosing placentas. These efforts have had some notable successes.
For example, one initiative was the Arizona Placental Project. During the time it was active and reviewing placentas, pathologists participating in this project have said that no obstetrician was successfully sued for delivery-related malpractice, in a case where placental pathology had been performed and a lesion had been found.
This is a noteworthy outcome. It reflects how better use of pathology services can help both clinicians and patients understand the true factors which contributed to the outcomes of unusual cases. It is also an example of how pathology can add value to clinicians, patients, and the healthcare system.
“Examining placentas is not a popular pastime for pathologists. They’re difficult to handle, can be messy, and most pathologists have had minimal formal training in placental pathology.”
“When it went to the registry, it was primarily because it involved defensive medicine,” Dyson explained. “But that’s not the primary reason we do a pathology exam of a placenta. For example, if we have someone who runs a fever during labor, we might want to know if the placenta showed signs of infection. If so, then the baby might be at risk and it would receive different treatment than if the placenta showed no signs of infection.”
Medically Useful Service
Alfred Lui, M.D., President and CEO of Pathology Inc., in Torrance, California, was familiar with the Cascadia Placenta Registry. “It was always my impression that they were truly trying to provide a medically useful service that would help decrease malpractice liability,” he said. “By documenting true placental pathology, often the attending obstetrician could defend the delivery- related care of a patient, even if there was a bad outcome.
“Placental pathology has an increasingly important role in risk management and in learning about the various possible problems of newborns,” Dr. Lui continued. “Examining placentas is not a popular pastime for pathologists. They’re difficult to handle, can be messy, and most pathologists have had minimal formal training in placental pathology. In many hospitals, placental examination defaults to obstetricians. Their examination is almost always cursory at best. We believe that more thorough placental exams are a significant advance in pathology and in patient care.”
Prominent Local Hospitals
The Oregonian’s February 12 story said several hospitals and their parent corporations in Oregon helped finance Cascadia and sent placental materials there, including Providence Health System, Legacy Health System, Adventist Health, PeaceHealth, and Kaiser Permanente Northwest. Many of the women involved were unaware of the practice, the article said.
The Oregonian considered it significant that some women interviewed did not learn that a detailed pathology examination had been conducted on their placenta until they had initiated a malpractice action. In response, hospitals interviewed in the story noted that appropriate consent forms had been signed by the patient at the time they were admitted.
THE DARK REPORT observes that the lesson for pathologists and ob-gyns is to ensure that patients are told specifically through the informed consent process whenever placental material will be collected and examined and stored for use later. Doing so might require adding a sentence to the current consent forms used at the hospital and carefully explaining the implications to patients.