Institutional and economic influences on autopsy performance.
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Autopsy↗
Biomedical subjects
P N Nemetz
Publications and source records attributed to P N Nemetz.
Medical error and outcomes measures: where have all the autopsies gone?
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Autopsy↗
Traumatic brain injury and time to onset of Alzheimer's disease: a population-based study.
Controversy continues as to whether traumatic brain injury is a risk factor for Alzheimer's disease. The authors examined a related hypothesis that among persons with traumatic brain injury who develop Alzheimer's disease, time to onset of the disease is reduced. They used data on all documented episodes of traumatic brain injury that occurred from 1935 to 1984 among Olmsted County, Minnesota, residents. Community-based medical records were used to follow traumatic brain injury cases who were aged 40 years or older at last contact prior to June 1, 1988, for Alzheimer's disease until last contact, death, or June 1, 1988. The test of the hypothesis was restricted to those cases who developed Alzheimer's disease. The expected time to onset of Alzheimer's disease was derived from a life table constructed by using age-of-onset distributions within sex groups for a previously identified cohort of Rochester, Minnesota, Alzheimer's disease incidence cases without a history of head trauma. The authors found that of the 1,283 traumatic brain injury cases followed, 31 developed Alzheimer's disease, a number similar to that expected (standardized incidence ratio = 1.2, 95% confidence interval 0.8-1.7). However, the observed time from traumatic brain injury to Alzheimer's disease was less than the expected time to onset of Alzheimer's disease (median = 10 vs. 18 years, p = 0.015). The results suggest that traumatic brain injury reduces the time to onset of Alzheimer's disease among persons at risk of developing the disease.
Adult↗
Determinants of the autopsy decision: a statistical analysis.
Our goal was to use cross-sectional national mortality data to provide a multivariable statistical analysis of the factors that contribute to the decision of whether an autopsy will be performed. The identification of determinants of the autopsy is an important prerequisite for finding cost-effective alternatives for arresting or reversing the decline of autopsy rates in the circumstances in which the autopsy can continue to make a crucial contribution to clinical medicine and public health. The source of the data was 1986 National Center for Health Statistics (Washington, DC) mortality data tapes for Kentucky, Maryland, Minnesota, and Washington for the 1986 calendar year. Separate multiple logistic regressions were conducted on these data on a state-by-state basis, with a total of 139,063 individual mortality records as the unit of analysis. The dependent variable in all models was autopsy (yes/no). Odds ratios for selected explanatory variables were estimated for all four states, and the relative contribution of each explanatory variable was studied in a detailed analysis of one state. In general, the following independent variables had a statistically significant positive relationship with whether an autopsy will be performed: male sex; nonwhite ethnicity; death due to ill-defined or unknown cause; death due to accident, suicide, or homicide; presence of a nationally recognized medical center in the county of death; and death occurring in a standard metropolitan statistical area. In general, the following independent variables had a statistically significant negative relationship with whether an autopsy will be performed: older age at death; higher income level of the decedent; death in a nursing home; death at home; and residency in the county of death. The two most important variables influencing the autopsy decision were age at death (especially old age) and death due to accident, homicide, or suicide.
Adolescent↗
Mechanical trauma as a risk factor in classic amyotrophic lateral sclerosis: lack of epidemiologic evidence.
We have examined the relationship between mechanical injuries and the subsequent development of classic amyotrophic lateral sclerosis (ALS) through a critical review of the literature. Only prospective evaluation of a large cohort of trauma victims can provide an unbiased answer to this controversy. However, such an evaluation would be prohibitively expensive, and the results would not be available in our lifetime. The results of retrospective case-control studies are conflicting in part because of biases in the selection of patients and controls, poor definition of the nature and extent of the trauma and its chronological relationship to the onset of ALS, and a non-uniform approach to the collection of antecedent information. More rigorously designed studies show no association of ALS to antecedent trauma. The existing data thus do not suggest that mechanical trauma is a risk factor for ALS. Future case-control studies should conform to a standardized methodology. The critical analysis presented here of the research on the purported connection between mechanical injury and ALS may serve as a model for the evaluation of the role of trauma in other chronic diseases. Application of these methodological principles may bring increased scientific rigor to assessing the frequently litigated question of what constitutes a true trauma sequela.
Adult↗
Contributions of autopsy to population-based cancer epidemiology: targetted intervention to improve ascertainment.
The importance of autopsy data in cancer epidemiological investigation is well appreciated by researchers at the Mayo Clinic. The Rochester Epidemiology Program Project is a complete population-based collection of morbidity and mortality data in Olmsted County, Minnesota (population, 100,000), funded by the National Institutes of Health since 1964. Comprehensive ascertainment of cancer in this community cohort has been augmented by initial diagnosis at autopsy for 12% of colorectal cancers, 35% of intracranial neoplasms, 45% of phaeochromocytomas and 37% of renal-cell carcinomas. These rates are in stark contrast to autopsy diagnoses in our cancer registry--usually less than 1%. The difference is attributable to the denominator in these comparisons, a concept of vital importance to the epidemiological interpretation of autopsy findings. Despite the enormous value of the autopsy in our research, social and economic factors diminished autoptic rates in Olmsted County from 63% in 1970 to 39% in 1984. These rates are well above that for the USA as a whole but parallel our national decline in frequency of autopsy. The major factors responsible for this reduction appear to be the increasing proportion of deaths in nursing homes and the advent of declining reimbursement in US health care.
Autopsy↗
The autopsy and epidemiology--Olmsted County, Minnesota and Malmo, Sweden.
The existence of high quality, population-based, medical data facilitates the practice of modern epidemiology with its concomitant benefits for clinical practice and public health policy. Two exceptional examples of such databases are provided by Malmo, Sweden, and Olmsted County, Minnesota. This paper outlines briefly the similarities between these two geographic entities, and focuses, in particular, on the central role of the autopsy in Olmsted County. Changing temporal and spatial patterns of autopsy are reviewed as well as two important related issues: the role of consent and the medico-legal autopsy. The paper concludes with a summary of some of the more noteworthy contributions of autopsy-based epidemiological research in Olmsted County, and offers several recommendations for the establishment of a select network of special population-based study areas. These epidemiological "laboratories", through the interchange of data and tissue specimens, could make significant contributions to the study of diseases both nationally and internationally. Their interactive efforts and high quality data bases would help to increase the efficiency of the expenditure of scarce societal resources in epidemiology and health care.
Autopsy↗
Passive smoking results: new risk for active smokers.
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Humans↗
An anatomy of the autopsy, Olmsted County, 1935 through 1985.
In this study, we examined in detail the patterns of autopsy rates for a half century (1935 through 1985) among residents of Olmsted County, Minnesota. The time trend of the autopsy in this community represents, in many respects, a microcosm of national trends. In the process of this analysis, we identified several medical and socioeconomic variables that may influence the rate of autopsy, including the age at death, physical location of death, gender, surgical procedures preceding death, immediate cause of death, and direct and indirect costs of the autopsy. In particular, the advancing mean age at death and the increase of the nursing home as a social phenomenon seem to have had a profound effect on autopsy rates both in Olmsted County and throughout the United States.
Adult↗
Resurrecting the autopsy: benefits and recommendations.
Maintenance of high autopsy rates is associated with specific benefits, especially for clinical practice and for clinical and epidemiologic research. We have compiled and evaluated (on the basis of related costs and benefits) a comprehensive list of recommendations to resurrect the autopsy and reestablish it as a central contributor to medical practice, teaching, and research.
Autopsy↗
Assessing the autopsy.
This study outlines the role of autopsies in medical practice and health policy, details the nature and reason for declining rates, including those in Rochester, Minnesota, and suggests possible remedial measures to halt or reverse this trend. It is concluded that one of the principal impediments to reversing the declining rate of autopsies is what is referred to in Economics as "market failure." In particular, the nature of the spatial and temporal distribution of costs and benefits has precluded the existence of an incentive structure which can lead to a realization of the major net social benefits from the autopsy. Ultimately, it is only the explicit recognition by the medical profession, government agencies, corporate insurers, and the general public of the nature and significance of this market failure and foregone benefits which can lead to remediation.
Age Factors↗
Toxic chemical regulation in Canada: preliminary estimates of costs and benefits.
This paper makes an assessment of the impact of toxic chemical regulation in Canada. Ranges of costs and benefits, supplemented by survey information, analogous American data, interviews and case studies have been used to demonstrate the general usefulness of a cost-benefit framework for public sector decision-making even where information availability is constrained and complete analysis is not feasible. It is concluded that, with few exceptions, the impact of environmental regulation on chemical producers in Canada is neither excessive nor unduly onerous.
Air Pollution↗