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PubMed1992

A decade of acceptable autopsy rates. Does concordance of clinician and pathologist views explain relative success?

In an attempt to better understand the basis and significance of an annual autopsy rate consistently over 45% for the past decade, we recently investigated the attitudes and practices of 36 pathologists and 176 clinicians in our institution with respect to the function of the autopsy service and the utility of the autopsy. The autopsy report was "not used in a consistent manner" by 57% of clinical respondents. Several clinicians thought that autopsy reports were too long (20%) and too slow (38%), but not with the frequency that pathologists did, 73% and 58%, respectively. Significantly more pathologists than clinicians believed autopsy rates have fallen over the past 20 years because (1) people think that everything about the deceased is already known, (2) medical students are poorly educated about the autopsy, (3) pathologists have diminished interest, (4) physicians fear litigation, (5) physicians fear "being wrong," (6) pathologists lack financial incentives, and (7) Joint Commission on Accreditation of Healthcare Organizations requirement is not in place. Perceptions regarding the frequency of major discrepancies between clinical and autopsy findings were comparable, 17% and 13%, for pathologists and clinicians, respectively. Our "high" institutional autopsy rate does not reflect concordance of perceptions expressed by clinicians and pathologists and, thus, other factors may be important in the maintenance of an acceptable rate.

Attitude of Health Personnel↗
PubMed1990

Who asks permission for an autopsy?

A survey was undertaken of all hospitals with more than 400 beds in North East Thames Region to ascertain the way in which permission for an autopsy was obtained, in an attempt to explore reasons for declining autopsy rates. We found that there was a considerable variation in autopsy rates, and in the systems within hospitals whereby permission for autopsy is sought. The responsibility for requesting an autopsy is often delegated to younger doctors who have not received any training in how it should be done. A sensitive lay person can achieve high rates of permission for autopsy. Most consultants interviewed stated that they requested less autopsies now than 5 or 10 years ago. They seldom attended autopsies, and one-third of pathologists have given up contacting the clinician before an autopsy.

Autopsy↗
PubMed1985

Descriptive epidemiology of the autopsy in Connecticut, 1979-1980.

Knowledge of the differences between deaths for which autopsies are performed and all deaths is pertinent to epidemiologic investigation in such areas as disease trends, chronic disease incidence, and occupationally related disease. A population-based study was undertaken to evaluate these differences for deaths in Connecticut in 1979 and 1980. Analyses for 1979 and 1980 were comparable. Of 28,440 deaths in 1980, 14% underwent autopsy. Differences by sex, race, marital status, age, underlying cause of death, and place of occurrence of death were demonstrated when decedents who underwent an autopsy were compared with all decedents. Non-white men who died at 20 to 29 years of age were the most likely group to undergo an autopsy. Proportions of autopsies, by major category of underlying cause, did not parallel the leading causes of death. Deaths due to trauma accounted for a larger proportion of all autopsies (25%) than of all deaths (6%). If a death certificate indicated a circulatory disorder or neoplasm as the cause of death, an autopsy was less likely to be performed. A disproportionately high number of autopsies were performed for deaths occurring in hospitals; the converse was true for deaths occurring in nursing-convalescent homes. We conclude that knowledge of the ways in which autopsies are biased will permit broader use of the sensitive and specific information that can be obtained from them.

Adolescent↗
PubMed1966

Autopsy in California.

From information complied from death certificates registered in 1952 and 1962 an examination was made of California's autopsy performance and the characteristics of deaths in which autopsy was done. The data indicated that California had an overall autopsy rate of 37 per cent of total deaths in 1962, probably higher than any other state. In the decade reviewed, there was a 62 per cent absolute increase in autopsies and a 7 per cent increase relative to total deaths. Substantial increases in the proportion of deaths in which autopsy was done were found for physician-certified deaths in both metropolitan and nonmetropolitan counties and for coroner-certified deaths in nonmetropolitan counties. For all but two of forty-five selected natural causes of death there were increases in the proportion of deaths in which autopsy was done. Seventy per cent of deaths occurred in some type of facility. About one-half of all deaths occurred in general hospitals, and autopsy was done in 42 per cent of such cases. The dual factors of a high autopsy rate and overrepresentation of deaths brought to autopsy in white males, ages 35-64, support the validity of a reported decline in California's death rate for arteriosclerotic heart disease.

Autopsy↗
PubMed1994

In perspective of the declining autopsy rate. Attitudes of the public.

The autopsy rate is declining, probably due to attitude changes. However, attitudes toward the autopsy have been sparsely studied, public opinion evidently not at all. The present study has, therefore, investigated the attitudes and reactions of the public toward autopsy as a basis for a new autopsy act in Sweden. An age-stratified, random sample of 1950 individuals in Sweden was surveyed. Eighty-four percent reported acceptance of an autopsy for themselves and 80% for next of kin. However, 70% felt discomfort at the thought of autopsy. Irrespective of the attitudes, the most common source of discomfort was the thought of the dead body being cut up, followed by fear of being disrespectful of the dead person. Sociodemographic factors were only weakly correlated to attitudes. The most impressive finding was that older women were the most hesitant or negative group concerning the autopsy, both for themselves and for relatives. The low autopsy rate is evidently not connected with the public's negative attitudes. Even if discomfort reactions are general, rational factors dominate. Thus, it is up to the medical community to use this positive opinion to let the autopsy regain its role of quality guarantee.

Adult↗
PubMed1993

Physicians' attitudes to the autopsy.

The overall autopsy rate (excluding coroner's autopsies) at a large teaching district general hospital over a four year period was 16.5%, but individual rates for ten general physicians varied from 5% to 35%. During this period, the mean autopsy rate for general medicine (14%) was significantly lower than rates for cardiology (21%), geriatrics (23%) and paediatrics (36%), but similar to general surgery (13%). Autopsies were widely perceived as being of benefit to education and research, but physicians were often unaware of their value for confirming the diagnosis and for clinical audit, and over-estimated their actual autopsy rates on average by 50%. High rates (18-30%) were associated with consultants who had a definite policy regarding autopsies and had made this clear to their junior staff. Low rates (6-10%) obtained where there was no consultant policy on autopsies, and were frequently attributed by the consultant physicians to failure by their junior staff. Physicians should be more aware of the value of autopsies, and should take responsibility for increasing and monitoring autopsy requests to improve clinical audit, quality assurance and medical education.

Attitude of Health Personnel↗
PubMed1996

Misdiagnosis of lung cancer in a 2000 consecutive autopsy study in Budapest.

OBJECTIVE: To determine the accuracy of lung cancer mortality data based on clinical observations in the absence of autopsy and to identify factors affecting the accuracy of diagnosis. METHODS: Admission, pre-autopsy and post-autopsy diagnoses were recorded for 1000 consecutive autopsies in each of two University departments in Budapest with high autopsy rates for persons dying in hospital. In those 87 cases where one or more diagnosis included primary lung cancer, additional data were collected concerning clinical investigations relevant to the diagnosis and the histological type lung cancer, and on smoking habits. RESULTS: 59% (36/61) of lung cancers seen at autopsy were not detected pre-autopsy, while 50% (25/50) of those diagnosed pre-autopsy were not confirmed at autopsy. Many misdiagnoses arose because patients were too ill to be properly investigated and/or died before investigations could be completed. Accuracy of diagnosis increased with the number of diagnostic techniques applied, but was still far from perfect in the absence of necropsy. Underdiagnosis was commoner in non-smokers and overdiagnosis commoner in smokers. CONCLUSIONS: Without necropsy, lung cancer misdiagnosis is common, especially when modern diagnostic procedures cannot be fully employed. Knowledge of smoking habits may affect diagnostic accuracy.

Adult↗
PubMed1996

Percutaneous needle autopsy sampling.

Despite the recognized advantages of a complete postmortem examination, autopsy rates continued to decline in recent decades. This study compares postmortem needle sampling to the complete, conventional autopsy to determine whether needle sampling is a viable alternative when consent for a complete autopsy is denied. A prospective study where postmortem percutaneous biopsies were obtained from the heart, the lungs, the liver, the kidney, and any other clinically relevant tissue or body fluid before the complete autopsy in 20 consecutive patients is presented. Cultures of the lungs, the spleen, and any other suspicious body fluid were also obtained. Liver and heart were recovered from all 20 of the patients, lung from 18 (90%), and kidney from 16 cases (80%). The cause of death was confirmed in 67% of the patients. Needle sampling correlated with the complete autopsy in 87% of the additional major diagnoses and with equally pertinent negative results. Postmortem needle lung cultures correlated with the complete autopsy in 17 (85%) of 20 patients and 16 (80%) of 20 spleen cultures. Cultures of the brain (one patient), cerebrospinal fluid (two patients), peritoneum (two patients), and serum (one patient) correlated 100% when compared to the complete autopsy. A complete autopsy is the goal of every postmortem examination. Postmortem "biopsies" can be an alternative option in certain situations and may be more acceptable to relatives of the deceased when consent for a complete autopsy is declined.

Adolescent↗
PubMedDate not supplied

[Errors in autopsy in Germany. Results of a multicenter study (II)].

In the result of a workshop held in Münster on 1st May 1993, 23 institutes of legal medicine in Germany reported death cases where the primary supposition was natural death or a death without legal relevance, but where the autopsies by chance revealed an unnatural death or a death with legal relevance. In the institutes participating in the study 13,000 autopsies were performed during the period of the reports, i.e. 75% of all legal autopsies performed in one year in Germany. A total of 92 "discoveries by chance" were reported where a natural death was given on the death certificate after the external examination of the corpse among them 49 accidents, 10 homicides, and 19 deaths by medical implications. In 717 deaths the manner of death was certified as "unclear" on the death certificate, but the autopsy revealed an unnatural manner of death. Some of these cases are also "discoveries by chance" after serious medical errors during the examination of corpses. Among these 717 cases were 35 homicides. It seems remarkable, that the prosecutors did not order a toxicological examination in several cases of fatal intoxications. Furthermore the results show that doctors often overlooked signs of carbon monoxide poisoning during the external examination of corpses. From errors made during the external examination another group of cases resulted which were initial classified as unnatural death without legal relevance, but the autopsy surprisingly revealed relevant facts. Finally in 29 autopsies carried out after exhumation evidence of homicide was found in 3 cases. On the basis of this multicentre study it can be estimated that there are at least 1200 homicide cases or 11,000 cases of unnatural death per year which do not appear in the official statistics and have been classified as natural death. The considerable grey area of fatal cases in connection with medical intervention resulting from the study (n > 2000) is also alarming. In addition at least 100 undiscovered homicides are certainly included in the group of death cases certified as unclear during the external examination and where no autopsy was performed. Sources of the grey area are essentially errors made during the external examination of corpses and to a lesser degree incorrect decisions to release the corpse, mistakes were seldom made also by doctors performing the autopsy. The study shows a considerable grey area of unnatural death cases, which exists within the modern society of Germany. In face of this emphasis must placed on the historical demands of criminologists and forensic pathologists: reinforced education and further education of medical students and doctors in the field of the external examination of corpses. Introduction of a specialized medical external examination of corpses Adherence to the 3 classical classifications of the manner of death: natural, unnatural and unclear on the death certificate. Increased number of autopsies.

Accidents↗
PubMed1998

The value of autopsy from a clinical point of view. A survey of 250 general practitioners and hospital clinicians in the county of Sør-Trøndelag, Norway.

An enquiry into clinicians' attitudes to autopsies was conducted by questionnaire sent to 166 general practitioners in the county of Sør-Trøndelag in Norway and to 186 clinicians working at the University Hospital of Trondheim. It was considered especially important for us to include general practitioners. As the result of a government decision taken at the end of 1994, autopsies requested by general practitioners on patients dying outside hospitals have from January 1995 been covered by national health insurance. Answers were obtained from 250 doctors: 110 general practitioners and 140 hospital physicians. One hundred and seventy-nine (73.1%, n=245) felt that the possibility of having autopsies performed was of great importance in their daily work. Autopsy was considered to be a very important means of quality assurance in the health care system by 158 (66.4%, n=238). One hundred and two (41.2%, n=247) answered that improvements in medicine and technology during the last decades had not reduced the importance of autopsy. One hundred and twenty-two (81.3%, n=150) felt that especially computer tomography (CT) had reduced the value of autopsy. Among the general practitioners, 73 (68.9%, n=106) welcomed the opportunity to have non-forensic autopsies performed on patients who died outside hospitals. Our study showed differences in the attitudes of clinicians towards autopsies, but our results still indicate that the value of autopsy for furthering clinical knowledge is acknowledged by most clinicians.

Attitude of Health Personnel↗
PubMed2004

Comorbidity in dementia: an autopsy study.

CONTEXT: There is a paucity of accurate postmortem data pertinent to comorbid medical conditions in patients with dementia, including Alzheimer disease. OBJECTIVES: The purposes of this study were (a) to examine general autopsy findings in patients with a dementia syndrome and (b) to establish patterns of central nervous system comorbidity in these patients. DESIGN: Review of autopsy reports and selected case material from 202 demented patients who had "brain-only" autopsies during a 17-year period (1984-2000) and from 52 demented patients who had general autopsies during a 6-year period (1995-2000). SETTING: Large academic medical center performing approximately 200 autopsies per year. RESULTS: Among the 52 patients who underwent complete autopsy, the most common cause of death was bronchopneumonia, which was found in 24 cases (46.1%). Other respiratory problems included emphysema, found in 19 (36.5%) of 52 patients, and pulmonary thromboembolism, found in 9 (17.3%) of 52 patients. In 6 cases, pulmonary thromboembolism was the proximate cause of death. Twenty-one (40.3%) of the 52 patients had evidence of a myocardial infarct (varying ages) and 38 (73.1%) had atherosclerotic cardiovascular disease, 27 of a moderate to severe degree. Four clinically unsuspected malignancies were found: 1 each of glioblastoma multiforme, diffusely infiltrative central nervous system lymphoma, pancreatic adenocarcinoma, and adenocarcinoma of the lung. One patient with frontotemporal dementia and amyotrophic lateral sclerosis died of severe meningoencephalitis/ventriculitis, probably secondary to seeding of the central nervous system by an infected cardiac valve. Of the 202 demented patients who underwent brain-only autopsies, the following types of dementia were found: 129 (63.8%) cases showed changes of severe Alzheimer disease, 21 (10.4%) showed combined neuropathologic abnormalities (Alzheimer disease plus another type of lesion, such as significant ischemic infarcts or diffuse Lewy body disease), 12 (5.9%) cases of relatively pure ischemic vascular dementia, 13 (6.4%) cases of diffuse Lewy body disease, and 8 (4.0%) cases of frontotemporal dementia. The remaining 19 (9.4%) patients showed miscellaneous neuropathologic diagnoses, including normal pressure hydrocephalus and progressive supranuclear palsy. Among the demented patients, 92 (45.5%) had cerebral atherosclerosis, which was moderate to severe in 65 patients (32.2%). CONCLUSIONS: Some of the conditions found at autopsy, had they been known antemortem, would likely have affected clinical management of the patients. Autopsy findings may be used as a quality-of-care measure in patients who have been hospitalized in chronic care facilities for a neurodegenerative disorder.

Adult↗
PubMed2004

The decline of the hospital autopsy: a safety and quality issue for healthcare in Australia.

Even with new diagnostic modalities, autopsy remains an important tool for quality and safety assurance. A systematic review of reports from 1996 to 2002 found autopsies detected, on average, 23.5% of clinically missed diagnoses involving the principal or underlying cause of death, and 9% of errors that would or could have affected the patient's outcome. We surveyed pathology laboratories and hospital administrators across Australia, and found a decline in the hospital autopsy rate from 21% (210/1000 deaths) in 1992-93 to 12% (118/1000 deaths) in 2002-03. This decrease is in adult autopsies (66% of all autopsies in 1992-93; 39% in 2002-03). Perinatal autopsies increased from 29% to 58% of all autopsies in this period, mainly due to more examinations of fetuses less than 20 weeks' gestation. Factors contributing to this decline may include community attitudes, clinicians' reluctance to request autopsy (partly because of administrative burdens in making the request), hospital concern about legal action if a misdiagnosis is detected, and funding priorities. Reversing this decline will require cooperative action at several levels of the healthcare system, and from government bodies.

Attitude of Health Personnel↗
PubMed1982

Factors influencing neonatal autopsy rate.

To determine if common clinical factors are associated with the neonatal autopsy rate, we conducted a retrospective analysis of 117 deaths in a neonatal intensive care unit. The autopsy rate of neonatal deaths was significantly greater than the autopsy rate of adult and non-neonatal pediatric deaths. In the newborn period, the autopsy rate of transported patients was significantly less than that of inborn patients. Among those transported, autopsies were significantly less common in patients of low birth weight or low gestational age. Furthermore, among all newborns dying within two days of admission, transported patients were less likely to undergo autopsies than inborn patients. Other factors, including maternal age, race, and marital status, did not affect the autopsy rate of newborn deaths. These data suggest that early separation of the mother from her infant and the medical team caring for the infant adversely affect the process of autopsy request and consent.

Autopsy↗
PubMed1982

Validation of autopsy method for evaluating trauma care.

A previous study on the simplified autopsy method evaluated autopsies from a series of motor vehicle deaths. The results were not generally accepted by the medical and political community because of reservations concerning the validity of the autopsy data. In response, I undertook a second study evaluating a similar series, using data from hospital records as well as autopsies. Results were evaluated by the autopsy method and compared with the results obtained by the hospital records method. Seventy-one percent of the deaths were judged preventable by the autopsy method as compared with 85% by the hospital records method. All deaths judged preventable by the autopsy method were also judged preventable by the method using hospital records. This confirms that the autopsy method accurately identifies and understates the problem it exposes.

Accidents, Traffic↗
PubMed1998

Autopsy diagnoses of malignant neoplasms: how often are clinical diagnoses incorrect?

CONTEXT: Autopsy often reveals new diagnoses of malignant neoplasms, but as technological advances to improve diagnosis during life have improved, autopsy rates have declined dramatically. OBJECTIVE: To determine if there is still a high discordance rate between clinical and autopsy diagnoses of malignant neoplasms despite increasing technological advances in diagnostic methods. DESIGN AND SETTING: A 10-year retrospective study (1986-1995) of all autopsies performed at the Medical Center of Louisiana at New Orleans. PARTICIPANTS: All patients autopsied, excluding preterm fetuses, at the Medical Center of Louisiana at New Orleans, by both Tulane and Louisiana State University Schools of Medicine in which consent was obtained or authorization given from the Orleans Parish Coroner's Office. MAIN OUTCOME MEASURES: Discordance between clinical and autopsy diagnoses of malignant neoplasms. RESULTS: A total of 1625 cases were reviewed of which 520 preterm fetuses were excluded. Of the remaining 1105 cases, 654 were male and 451 were female. The mean age was 48.3 years (range, 1-98 years). A total of 433 neoplasms were diagnosed, 250 of which were malignant. One hundred eleven malignant neoplasms in 100 patients had been either undiagnosed or misdiagnosed, and in 57 patients, the immediate cause of death could be attributed to the malignant neoplasm. The discordance between clinical and autopsy diagnoses of malignant neoplasms in this study is 44%, which is similar to previously reported studies. CONCLUSION: The discordance rate between clinical and autopsy diagnoses of malignant neoplasms is large and confirms the importance of the postmortem examination.

Adolescent↗
PubMed2001

Postmortem whole-body magnetic resonance imaging as an adjunct to autopsy: preliminary clinical experience.

The purpose of this study was to evaluate whole-body magnetic resonance imaging (MRI) of cadavers as an adjunct to autopsy. Eight consecutive patients underwent both whole-body MRI and autopsy [either conventional (six), limited (one), or percutaneous (one)] within 24 hours of death. Comparison was made of major and minor abnormalities and predicted cause of death recorded by independent readers at both MRI and autopsy. Major discrepancies between the recorded primary cause of death at imaging and autopsy occurred in five (5) patients. These included a myocardial infarction found at autopsy alone, bowel infarction and portal venous gas found at MRI alone, and aortic dissection and occipital infarct found at MRI alone in a patient on whom only limited autopsy was performed. Postmortem MRI may represent a useful adjunct to autopsy, particularly in patients in whom autopsy is limited due to patient/family consent, inoculation risks, and ethnic doctrines.

Aged↗
PubMed1991

The value of autopsies in neurosurgery.

Many previous studies have reported the value of autopsy in assessing clinical diagnostic accuracy. None of them however, assessed the value of autopsies in a specific clinical speciality. The authors reviewed the findings of 123 consecutive neurosurgical autopsies with reference to the premortem clinical diagnoses. The study showed that 7% of cases had a wrong clinical diagnosis and in 9% of cases the clinical diagnosis was incomplete. Only in 5% of all cases knowledge of the autopsy findings would have led to a change in management and outcome. The autopsies also confirmed that 11% of cases died following a surgical complication and in 3% of cases the primary cause of death was non-neurosurgical. The latter was a previously unrecognised finding in 8% of autopsies. The autopsy will remain a valuable means of clinical audit and the increasing financial pressures to reduce the number of autopsies should be resisted.

Adolescent↗
PubMed2007

Clinical utility of autopsy after hematopoietic stem cell transplantation.

Autopsy is the gold standard for establishing the cause of death. We present results of the largest retrospective review of complete autopsies of subjects after hematopoietic stem cell transplantation to better define the role of the autopsy in discovering a missed diagnosis. We reviewed the medical chart and autopsy records of 111 patients who had undergone hematopoietic stem cell transplantation from July 1986 to June 2003 from a single center. We compared the cause of death as charted by the clinical team with data obtained from postmortem chart review and autopsy reports. Of 29 (26%) cases when the premortem and postmortem major diagnoses did not agree, only 4 (4%) autopsy records provided data that might have led to the initiation of new treatments, and none of these diagnoses would be missed today with more sensitive and specific diagnostics and improved supportive care. Although autopsies after transplantation can be important educational, research, and epidemiologic tools and provide an emotional benefit to patient's families, in our series they rarely provided missed diagnoses that would alter the management of subsequent patients. Improvements in noninvasive tests for relapse or occult infections may further erode the role of autopsies in discovering missed diagnoses.

Adolescent↗