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PubMed2003

Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.

CONTEXT: Substantial discrepanies exist between clinical diagnoses and findings at autopsy. Autopsy may be used as a tool for quality management to analyze diagnostic discrepanies. OBJECTIVE: To determine the rate at which autopsies detect important, clinically missed diagnoses, and the extent to which this rate has changed over time. DATA SOURCES: A systematic literature search for English-language articles available on MEDLINE from 1966 to April 2002, using the search terms autopsy, postmortem changes, post-mortem, postmortem, necropsy, and posthumous, identified 45 studies reporting 53 distinct autopsy series meeting prospectively defined criteria. Reference lists were reviewed to identify additional studies, and the final bibliography was distributed to experts in the field to identify missing or unpublished studies. STUDY SELECTION: Included studies reported clinically missed diagnoses involving a primary cause of death (major errors), with the most serious being those likely to have affected patient outcome (class I errors). DATA EXTRACTION: Logistic regression was performed using data from 53 distinct autopsy series over a 40-year period and adjusting for the effects of changes in autopsy rates, country, case mix (general autopsies; adult medical; adult intensive care; adult or pediatric surgery; general pediatrics or pediatric inpatients; neonatal or pediatric intensive care; and other autopsy), and important methodological features of the primary studies. DATA SYNTHESIS: Of 53 autopsy series identified, 42 reported major errors and 37 reported class I errors. Twenty-six autopsy series reported both major and class I error rates. The median error rate was 23.5% (range, 4.1%-49.8%) for major errors and 9.0% (range, 0%-20.7%) for class I errors. Analyses of diagnostic error rates adjusting for the effects of case mix, country, and autopsy rate yielded relative decreases per decade of 19.4% (95% confidence interval [CI], 1.8%-33.8%) for major errors and 33.4% (95% [CI], 8.4%-51.6%) for class I errors. Despite these decreases, we estimated that a contemporary US institution (based on autopsy rates ranging from 100% [the extrapolated extreme at which clinical selection is eliminated] to 5% [roughly the national average]), could observe a major error rate from 8.4% to 24.4% and a class I error rate from 4.1% to 6.7%. CONCLUSION: The possibility that a given autopsy will reveal important unsuspected diagnoses has decreased over time, but remains sufficiently high that encouraging ongoing use of the autopsy appears warranted.

Autopsy↗

PubMed2001

Referral to autopsy: effect of antemortem cardiovascular disease: a population-based study in Olmsted County, Minnesota.

PURPOSE: Autopsy studies can provide insight into disease trends and their determinants, including data on the prevalence of atherosclerosis. However, such studies are subject to autopsy bias, which limits their generalizability to the source population. The impact of this bias on autopsy based estimates of time trends in heart disease prevalence is unknown. To report on the trends over time in autopsy rates in Olmsted County, MN, to examine the association between clinical diagnoses of cardiovascular diseases (CVDs) and referral to autopsy and how this association may have changed over time. METHODS: We examined the trends in autopsy rates between 1979 and 1994 in Olmsted County, and the association between antemortem characteristics including cardiovascular diagnoses and autopsy referral. RESULTS: From 1979 to 1994, a total of 9110 residents died in Olmsted County. The average annual autopsy rate was 30%. Autopsy rates declined from 36% in 1979 to 23% in 1994, corresponding to an average decline of 0.6%/year (p < 0.01). Referral to autopsy was positively associated with younger age, male sex, in-hospital place of death, antemortem diagnoses of myocardial infarction (MI) or peripheral vascular disease (PVD), and earlier calendar period. There was no evidence of an interaction between calendar period and any of these predictor variables. Antemortem diagnosis of heart failure was associated with a decrease in the odds of referral to autopsy over time as compared to persons without such diagnosis. CONCLUSIONS: In Olmsted County, autopsy rates, although declining over time, have remained on average approximately 30%. Antemortem diagnoses of MI or PVD are associated with autopsy referral but this association did not change over time. While the greater decline overtime in the use of autopsy observed among decedents with an antemortem diagnosis of congestive heart failure (CHF) deserves further studies, the present findings reduce the concern for bias of time trends in the prevalence of atherosclerosis by changes in the clinical characteristics of decedents referred to autopsy.

Adult↗

PubMedDate not supplied

Temporal and geographic trends in the autopsy frequency of blunt and penetrating trauma deaths in the United States.

OBJECTIVE: To examine national trends in the percentage of blunt and penetrating trauma deaths autopsied. DESIGN, SETTING, AND PARTICIPANTS: For each year from 1980 through 1989, we used national mortality data files to determine the autopsy frequency (percentage of deaths autopsied) of all deaths in the United States. We analyzed variation in the autopsy frequency of blunt and penetrating trauma deaths by cause of injury and place of occurrence of death. RESULTS: The autopsy frequency of blunt and penetrating trauma deaths in the United States increased by 14.3% during the 1980s to 58.9% in 1989 (62,004 of 105,309 deaths autopsied), while the autopsy frequency of all deaths decreased by 23.6% during the same period to 11.5% in 1989 (248,272 of 2,153,859 deaths autopsied). Among trauma deaths, homicides remained far more likely to be autopsied than nonhomicides (deaths due to unintentional injuries, suicides, and injuries of undetermined intentionality). The autopsy frequency of homicidal trauma deaths in 1989 was 90.0% or higher in 44 states and ranged from 79.6% in Mississippi to 100.0% in six states. The autopsy frequency of nonhomicidal trauma deaths in 1989 was 90.0% or higher in two states and ranged from 10.3% in Oklahoma to 94.5% in Hawaii. Nationwide, we found significant differences in the autopsy frequency of trauma deaths in 1989 between metropolitan and nonmetropolitan counties, both for homicides (97.7% vs 89.3%; P < .001) and nonhomicides (58.2% vs 29.9%; P < .001). CONCLUSIONS: The percentage of blunt and penetrating trauma deaths autopsied has increased recently in the United States, but extensive geographic variation in autopsy frequency suggests that the benefits of autopsy findings for trauma care quality improvement and public health surveillance of injuries are distributed unevenly throughout the nation.

Autopsy↗

PubMed1992

Improving the autopsy rate at a university hospital.

PURPOSE: Although the autopsy is widely recognized as an invaluable tool for medical education, as well as the gold standard by which the accuracy of diagnoses are measured, there has been a steady decline in the autopsy rate over the last 20 years. At Westchester County Medical Center, a university hospital of New York Medical College, we observed an alarming drop in our autopsy rate. We realized that the methods used to obtain consent from the family of the deceased were haphazard and often left to the junior houseofficer available. We hypothesized that we could increase the autopsy rate by explicitly involving senior housestaff in the task of obtaining autopsy consent after giving them formal instruction in the technique of asking for consent and by having them record information regarding their encounters with families. PATIENTS AND METHODS: Data concerning the frequency of autopsies at Westchester County Medical Center were collected for a 3-month period in 1990. A corresponding period in 1991 was designated the study period during which our intervention was initiated. All medical examiner's cases were excluded for both periods since autopsy consent for these patients is not at the discretion of the family. At the start of the study period and each month thereafter, formal instruction regarding obtaining permission for autopsy was given to all senior residents assigned to direct patient care duty. The senior resident was required to complete a data form regarding autopsy request on each patient who died. RESULTS: Nine autopsies among 89 deaths (10%) were obtained during the study period in 1990, compared with 31 autopsies among 116 deaths (27%) in 1991 (p less than 0.01). In 1991, autopsies were more likely to be obtained when death was unexpected (p less than 0.05). CONCLUSION: The institution of a formal program to educate and involve the senior resident staff in obtaining autopsy consent can significantly improve the autopsy rate at a university hospital.

Autopsy↗

PubMed1998

A regional audit of perinatal and infant autopsies in Northern Ireland.

OBJECTIVE: To investigate the rate and quality of perinatal/infant autopsies and their contribution to the final diagnosis. METHODS: The anonymised reports of autopsies performed on 174 of the 367 cases reported to the Northern Ireland Regional Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) coordinator in 1993 were reviewed. They were scored using a modification of the CESDI Pathology Audit Form 93 and, based on the score obtained, ascrined to one of three groups: good, adequate or inadequate. Based on the information obtained, they were also assessed as providing diagnostic, confirmatory, additional or no diagnostic data. The pre-autopsy clinical extended Wigglesworth classification was compared with that based on autopsy findings. RESULTS: The autopsy rate was 47.4% and included 18 late fetal losses, 70 stillbirths, 57 neonatal deaths and 29 post neonatal deaths. The Regional Paediatric Pathology Centre performed 34.5% of the autopsies. Of the total number of autopsies, 46.6% failed to reach an adequate standard. Only 4.9% of the inadequate autopsies were performed in the Regional Centre. The Wigglesworth classification was altered in 20.7% of cases following autopsy. The autopsy findings of 49 cases were diagnostic, 75 confirmatory, 23 yielded additional information and 27 were useful in only a negative sense. CONCLUSION: The autopsy rate for this region is well below the recommended level of 75%. With the exception of the Regional Centre, the quality of the perinatal/infant autopsy did not reach the standard suggested in the CESDI Pathology Audit form 93. Despite this the autopsy yielded valuable diagnostic, confirmatory or additional findings in 84.5% and resulted in alteration to the pre-autopsy Wigglesworth classification in 20.7%.

Autopsy↗

PubMed2002

Ten years of neonatal autopsies in tertiary referral centre: retrospective study.

OBJECTIVES: To measure the neonatal autopsy rate at a tertiary referral centre and identify trends over the past decade. To identify factors that may influence the likelihood of consent being given for autopsy. To examine any discordance between diagnoses before death and at autopsy. DESIGN: Retrospective review of patients' records. SETTING: Tertiary neonatal referral centre affiliated to university. OUTCOME MEASURES: Sex, gestational age, birth weight, type of delivery, and length of stay in neonatal unit for baby. Maternal age, marital status, history of previous pregnancies, and details of who requested permission for autopsy. Concordance between diagnoses before death and at autopsy. RESULTS: An autopsy was performed in 209/314 (67%) cases. New information was obtained in 50 (26%) autopsies. In six (3%) cases this information was crucial for future counselling. In 145 (74%) there was complete concordance between the clinical cause of death and the findings at autopsy. From 1994 onwards the autopsy rate in the neonatal unit fell. The only significant factor associated with consent for autopsy was increased gestational age. CONCLUSIONS: Important extra information can be gained at neonatal autopsies. This should help parents to make an informed decision when they are asked to give permission for their baby to have an autopsy. These findings are of particular relevance in view of the recent negative publicity surrounding neonatal autopsies and the general decline in the neonatal autopsy rate over the decade studied.

Autopsy↗

PubMedDate not supplied

The autopsy in pediatrics and pediatric oncology: a single-institution experience.

Autopsy rates and clinicopathologic correlations for pediatric autopsies and the subgroup of pediatric oncology autopsies in a large teaching hospital were studied to evaluate the utility of autopsy in these populations. Autopsy records of the University of North Carolina hospitals from 1982 to 2001 were reviewed for all patients less than 18 years of age. Autopsies performed during 1982 to 1991 (decade 1) were compared to those from 1992 to 2001 (decade 2) with respect to absolute numbers of autopsy and rates of unexpected postmortem diagnoses. Postmortem diagnostic discrepancies were subclassified into major and minor categories. The mean number of autopsies per year for decade 1 was 110+/-24.5, compared with 77.5+/-40.9 for decade 2 (P<0.001), a change largely due to a decline in fetal/perinatal (patients<7 days of age) autopsies. Of 533 pediatric autopsies, 43 were in patients with a primary diagnosis of a neoplasia. At least one antemortem misdiagnosis and/or clinically occult process was identified in 20.5% of all pediatric autopsy cases, and in 25.6% of pediatric oncology cases. These rates did not change significantly over time. In 10 of 43 pediatric oncology cases (23.3%), autopsies provided diagnostic information that was previously unknown to the clinicians. Three of these patients died shortly after presentation. Although autopsy rates for fetal/perinatal cases have declined, those for non-perinatal and pediatric oncology patients remain stable. Autopsy continues to provide diagnostic information that is unknown during the antemortem period, and remains a valuable tool for pediatricians and pediatric oncologists.

Adolescent↗

PubMed2002

Pathologists in a teaching institution assess the value of the autopsy.

CONTEXT: With the advent of modern diagnostic technology, use of the autopsy as a means of assessing diagnostic accuracy has declined precipitously. Interestingly, during the same period, the rate of misdiagnosis found at autopsy has not changed. OBJECTIVES: To ascertain why an autopsy was requested, whether or not questions asked by clinicians were specifically addressed, and what types of misdiagnoses were found. DESIGN: One hundred forty-two consecutive autopsy records from the University of Arkansas for Medical Sciences Hospital were reviewed. In the same period, 715 deaths occurred, giving an overall autopsy rate of 20.14%. RESULTS: Of the 125 autopsies in which the problem-oriented autopsy request was available for review, a reason for the autopsy was given in only 69 cases (55%). One hundred three clinical questions were asked, and of these, 81 were specifically addressed in the final anatomic diagnosis, 10 were addressed in some part of the autopsy report but not in the final anatomic diagnosis, 10 were not addressed at all, and 2 could not be answered by the autopsy. Sixty-one autopsies revealed 81 misdiagnoses: 47 class I (missed major diagnosis that, if detected before death, could have led to a change in management that might have resulted in cure or prolonged survival) and 34 class II misdiagnoses (missed major diagnosis in which antemortem detection would have not led to a change in management). CONCLUSIONS: The autopsy continues to be a vital part of medical education and quality assurance. It is important for the clinician to provide a clinical summary and specific clinical questions to be addressed or to speak directly with the pathologist and for the pathologist to provide answers that are easily accessible within the autopsy report. In this way, a problem-oriented autopsy can be performed based on questions raised by the clinician and the pathologist as a result of the gross dissection and microscopic evaluation.

Adolescent↗

PubMed1991

[Changes in autopsies in cancer in Navarra from 1980 to 1988].

BACKGROUND: Autopsies may be used to know the causes of death in population. In Navarra, the number of patients who died by cancer and were autopsied has increased. A similar pattern appeared in other communities. METHODS: We reviewed 2,643 autopsies performed in the main hospitals of Navarra. In each autopsy, age, sex, existence of primary malignant tumor, and its histologic type and localization were analyzed. The results were compared to the statistics of mortality of the Tumoral Register of Navarra. The modifications from 1980 to 1988 were studied. RESULTS: There is a significant increase of autopsy and mortality by cancer in Navarra. In autopsy cases, there is a high incidence of colon carcinoma and hepato-biliary carcinoma. The incidence in all cancer dead patients is similar being greater in hepato-biliary carcinoma and pancreas carcinoma. The percentage of autopsies in patients over 60 years of age is decreased, but it has increased in all cancer dead patients of the same group of age in the community of Navarra. In the autopsies of patients over 60 years of age there has been a rise in breast carcinoma, while there has been a general increase in all dead patients. In all deaths of people under 60 years of age, there has been a decrease, but in autopsy cases there has been an increase of colon carcinoma. CONCLUSIONS: In autopsy series from 1980 to 1988, cancer deaths increased significantly. There is not relationship between cancer dead patients and autopsy cases in the studied data. In hepato-biliary carcinoma, there is an increase in autopsy cases and cancer dead patients. Discrepancies between the number of deaths of cancer patients and autopsy patients revealed that the performance of autopsy depends of multiple causes.

Age Factors↗

PubMed2000

The educational value of autopsy in a residency training program.

BACKGROUND: Historically, the autopsy has been an indispensable educational tool. Over the past several decades, however, the national autopsy rate has declined and the educational role of autopsy in modern medicine is being questioned. OBJECTIVE: To assess the educational value of autopsy attendance in an internal medicine residency program. METHODS: We performed a retrospective review of all autopsies performed on the general internal medicine teaching service between October 1996 and September 1998. Premortem and postmortem diagnoses were determined and compared and attending physician surveys were reviewed. RESULTS: Eighty-eight deaths occurred during the study period. Twenty-nine (33%) patients underwent autopsy. All autopsies were observed by the primary team and the attending physician completed an autopsy survey on each patient. An unexpected pathological diagnosis directly contributing to death was detected in 10 (34%) patients at autopsy. Additional unexpected pathological diagnoses were discovered in 23 (79%) cases. Attending physician surveys revealed that all 10 unexpected diagnoses contributing to death were observed by the primary team at the time of autopsy. Autopsy attendance was rated as a valuable educational experience in 27 cases (93%). CONCLUSION: Autopsy is a valuable educational tool and autopsy attendance should remain an integral part of internal medicine residency training.

Autopsy↗

PubMed1995

The clinical utility of the perinatal autopsy.

OBJECTIVE: To evaluate the clinical utility of the perinatal autopsy in determining the cause of a perinatal death. DESIGN: Retrospective observational survey. SETTING: University-affiliated, private, tertiary care hospital, limited to obstetrics, gynecology, and neonatology. SUBJECTS: All fetal deaths and neonatal deaths from 1990 and 1991 at Women and Infants Hospital, Providence, RI, were reviewed. Fetal deaths with a gestational age of less than 20 weeks and neonatal deaths occurring more than 48 hours after birth were excluded. MAIN OUTCOME MEASURES: A clinical medical record review assessed the clinical diagnosis. Pathology records were reviewed independently. The clinical and autopsy diagnoses were compared and categorized as follows: (1) confirm (clinical and autopsy diagnoses concordant); (2) change (clinical and autopsy diagnoses discordant); (3) add (significant unexpected findings noted on the autopsy although the clinical diagnosis was not altered); (4) autopsy inconclusive; (5) autopsy not done or not available. RESULTS: Of 168 perinatal deaths, an autopsy was not obtained in 26.2% and was inconclusive in 24.2% of cases with an autopsy. Of 94 patients with conclusive autopsies, in 55.3%, the pathologic diagnosis confirmed the clinical diagnosis, and in 44.7%, it changed or significantly added to the clinical diagnosis. CONCLUSIONS: These findings support the clinical relevance of the perinatal autopsy. As few published reports directly address the specific yield of the autopsy among fetal and neonatal deaths, these results may be useful in counseling patients who are considering a perinatal autopsy.

Autopsy↗

PubMed1988

The autopsy: a useful tool or an old relic?

In a combined retrospective and prospective study, clinical and autopsy data were collected to assess the changes in autopsy rate in recent years, the attitudes of clinicians and pathologists to the autopsy, and the accuracy of ante-mortem diagnosis when compared with autopsy findings. Between 1962 and 1986, the total autopsy rate for hospital patients remained relatively constant, with an increase in Coroner's and a decrease in the hospital autopsy rate. Analysis of 5064 deaths over a 6-year period showed a significantly greater number of males than females coming to autopsy and a decrease in autopsy rate with age for both sexes. Attitudes to the autopsy were assessed using a questionnaire. The majority of clinicians considered the autopsy to be an important investigation despite new diagnostic techniques and confirmed its value in teaching and research. Seventy-seven per cent agreed that autopsy findings occasionally led to modification of the treatment of subsequent patients with the same condition. Pathologists disagreed that the autopsy is outdated in its present form and considered that not enough hospital autopsies are being requested. They also upheld its use and value in education. The cause of death as given by clinicians for a group of 60 patients was inaccurate in 12 cases.

Adult↗

PubMed2006

Resident physician opinions on autopsy importance and procurement.

The national decline in hospital autopsy cases negatively impacts physician education and medical quality control to an unknown degree. The current non-medicolegal autopsy rate is less than 5% of hospital deaths. This study compares internal medicine and pathology resident physician perceptions of the autopsy, including the importance, procurement, technique, and the pathologist-internist interaction. An 84-item survey based on autopsy literature was designed, piloted, and distributed to 214 residents at a single 800+ bed tertiary care academic teaching hospital (Massachusetts General Hospital, Boston) to accomplish this goal. Completed surveys were obtained from 72% of medicine (n = 118) and 84% of pathology (n = 42) residents. Residents strongly agree on the importance of autopsies for education, answering clinical questions, public health, and research. Autopsy rates are deemed inadequate. Internists are comfortable requesting autopsies, but report insufficient guidance and difficulty with answering technical questions. Although not requested on all hospital deaths, internists are more likely to initiate an autopsy request than a decedent's family, and worry significantly less about institutional costs and malpractice litigation than pathologists believe. Internists expressed interest in having an instructional brochure to give families, observing an autopsy, and having increased communication and support with autopsies from pathology residents. The main reasons why autopsy consent is not requested (it is unpleasant, cause of death is known, family is upset or seems unwilling) and why families refuse (patient has suffered enough, body may be handled disrespectfully, religious/moral objections, lack information) were similar for both resident groups. Despite their decline, autopsies still remain important to medicine as indicated by internal medicine and pathology residents at a large academic center. Improving autopsy education, enhancing availability of resources, and strengthening the pathologist-internist collaboration may serve to heighten awareness and ultimately procurement.

Attitude of Health Personnel↗

PubMed2002

The autopsy: experience of a regional neonatal intensive care unit.

Autopsy rates have declined steadily throughout the 1970s and 1980s. This trend, if not reversed, could negatively affect information provided to families as well as the training of physicians. In the 1980s, low autopsy rates among neonatal deaths, 50-72%, were attributed to limited parental understanding and to physicians' attitudes. In the early 1990s, alternatives to the routine autopsy, such as limited endoscopic/needle autopsies, were widely popularised, and the physician's education about autopsy vigorously addressed. The effects of these efforts on autopsy rates in the latter part of the 1990s have not been well studied. The study population consisted of 643 infants who died at an Ohio, USA, neonatal intensive care unit (NICU) between 1 January 1986 and 31 December 1998. Neonatologists obtained consent for autopsy. Information obtained from the computer database included birth hospital, gestational age, age at death, birth and death weight, race, sex, death year and maternal age, religion, gravidity and parity. The overall autopsy rate during the 13-year study period was 54% [95% CI 44.1%, 63.1%]. There was a trend towards progressive decrease in autopsy rates, 59% in 1986-89, 52% in 1990-94 and 47% in 1995-98 (P = 0.078). Autopsy was associated with increasing gestational age (P < 0.001) and decreasing parity [OR = 0.53 for >2 compared with <or=2, 95% CI 0.36, 0.99], but not with other variables. Autopsy rates remain suboptimum and may be declining despite efforts at educating the medical and general community about its benefits. Among infants who die in the NICU, autopsy is more likely the more mature the infant at birth and the fewer children the mother has. Physicians need to seek autopsy more conscientiously, with consideration for the emotional well-being of the family, and for its potential diagnostic and research value to science.

Age Distribution↗

PubMed2001

Family members' experiences of autopsy.

BACKGROUND: The experiences of family members will teach us how to handle an autopsy, the ultimate quality assessment tool. OBJECTIVE: The aim of this study was to determine surviving family members' experience of autopsy. METHOD: Seven GPs were asked to approach surviving family members of autopsied patients to ask for their co-operation with an interview about their experiences. The interview took place at the residences of the individual families, 6 months to a year after the autopsy. A partially structured set of interview questions was used by the interviewer (not a GP) who had experience with the grieving process and with grief counselling. RESULTS: Twelve family members of autopsied patients were interviewed: six partners, three mothers, one offspring and two sisters. In the case of one 35-year-old man, the autopsy was performed as a judicially required post-mortem. The GP initiated the autopsy request in eight cases. It appears that there is definite room for improvement in how the GP handles the topic of autopsy. The best way to explain it is to compare an autopsy with an operation. Several family members had specific concerns about the appearance of their relative after the autopsy. Several of the family members indicated that they were reassured by the autopsy results. Clarity about the cause of death was important, and reassurance that they had not overlooked important symptomatology helped the family members in their grieving process. CONCLUSION: A request for autopsy is one of the most difficult questions which has to be asked at a very difficult time. Three main considerations were important for the relatives: they wanted an answer to the questions "Is there something I overlooked", "How could this have happened" and "Are there hereditary factors which could have consequences for the rest of the family?" The GP is the optimal professional to discuss the autopsy report with the surviving family members. The best approach for the GP includes an open attitude, paying attention to informing the family and supporting their grieving process.

Adaptation, Psychological↗

PubMed1992

Autopsy rate and a clinicopathological audit in an Australian metropolitan hospital--cause for concern?

OBJECTIVES: To determine the annual autopsy rates at five major Melbourne teaching hospitals between 1979 and 1989; to investigate the cause(s) of the decline in autopsy rates during that period; and to assess the importance of autopsies at the index hospital by a clinicopathological audit. DESIGN: Retrospective data for annual autopsy rates (i.e. all patients undergoing autopsy as a ratio of the total number of deaths) were obtained for five hospitals and, for the index and one other hospital, demographic data for autopsy rates within certain ethnic and religious groups for 1988. For the clinicopathological audit, clinical diagnoses from hospital charts and death certificate diagnoses were compared with the major findings for all autopsies in 1988. SETTING: The index and the other four hospitals are major Melbourne metropolitan teaching hospitals. PATIENTS: For the index hospital in 1988, demographic data for age, sex, death in a surgical or medical unit were obtained for 643 deceased patients, of whom 124 underwent a hospital autopsy. Data of ethnic background and religion were available for 557 of 643 deceased patients. At another hospital, religious affiliation was obtained for all patients who died in hospital (543) for 1989. RESULTS: Between 1979 and 1989, the autopsy rate declined from 47% to 19% at the index hospital, by relative levels of 50% at three hospitals, and showed a smaller decline at the fourth. At the index hospital in 1988, permission for autopsy was sought in 84% of deceased patients, but was granted in only 22%. The audit showed that major misdiagnoses occurred in 18 of 124 cases (14.5%), with relevance to patient management in eight cases (6%). CONCLUSIONS: The falling autopsy rate at five major teaching hospitals could be attributed to the relatively low status of the autopsy among clinicians and pathologists and the high refusal rates by relatives of the deceased since the introduction in 1983 of the Human Tissue Act 1982 (Vic.). The audit corroborated the importance of autopsies as a diagnostic tool.

Attitude↗

PubMed1995

Are perinatal autopsy rates satisfactory?

OBJECTIVE: To determine perinatal autopsy rates and whether any maternal or obstetric factors affect consent for autopsy. DESIGN: Ascertainment of perinatal autopsy rates between 1990 and 1993 for three categories of perinatal deaths: termination of pregnancy for antenatally diagnosed anomalies; fetal deaths and still-births; and neonatal and post-neonatal deaths. A case-control study matched deaths for which consent for autopsy was refused with the next death in the same category for which consent was given. SETTING: A tertiary maternity hospital in South Australia. RESULTS: The autopsy rate for pregnancies terminated for fetal abnormalities was 92.4% (171/185) and for intrauterine death was 87.7% (264/301); the rates in these two groups were higher for registrable births (gestation > 20 weeks) than non-registrable births. The overall autopsy rate in liveborn babies was 58.8% (80/136), the neonatal autopsy rate being 59.6% (68/114). No significant differences were found with regard to gestational age at birth, maternal gravidity and parity, employment, health insurance or marital status, or, among liveborn babies, postnatal age, between the autopsy and non-autopsy groups. CONCLUSIONS: Perinatal autopsy rates are higher than rates in adults but are lower in registrable births than the recommended 75%. Consent for autopsy is the limiting factor. There is a need for a clearer definition of perinatal autopsies, and perinatal autopsy rates, to take into account non-registrable deliveries.

Abortion, Eugenic↗

PubMedDate not supplied

[Reasons, circumstances and results of repeat forensic medicine autopsy].

There are only scant literature data on reasons and circumstances of medico-legal second autopsies. The present study includes 12 second autopsies from the period 1992-1997; the first post-mortem examination took place either in the home country (institutes of pathology) or abroad. 7 of the 12 cases of death investigated happened in Germany (exclusively in hospitals) and 5 of them abroad (Netherlands, Romania, Portugal, Libya). Repeat autopsies were ordered by criminal courts (n = 9), private persons (n = 2) and social insurances (n = 1). The main indication was possible medical malpractice (n = 6); acts of violence (n = 3), insurance questions (n = 2) and accidents (n = 1) followed. The time lapse between death and second autopsy was 2-35 days. It was striking, that German institutes of pathology had partially performed autopsies despite the certification of a non-natural death. Clinical autopsies were stopped twice, when evidence of a possible non-natural death occurred. It could be fundamentally stated, that first autopsies in German institutes of pathology had been carefully performed and sufficiently documented. In these cases the second autopsy presented no or only little additional information, as far as the broader taking of (toxicological) samples is not considered. The final medico-legal expertise was then mainly based on the findings of the clinical first autopsy. However, the concurrence of the forensic expert (instead of the clinical pathologist) is undoubtedly essential for the evaluation of these issues involving frequently questions of malpractice. By contrast, the quality of postmortems performed abroad varies widely. 4 of the 5 first autopsies done abroad were regarded as completely or partly insufficient with superficial or almost absent preparation of organs or contradictions in the medical reports, respectively. A repeat autopsy is absolutely necessary in such cases. On the whole, the initial question could be answered in all second autopsies at least in part. This emphasizes the high value of second autopsies and expertises, especially in non-natural cases of death (10 of 12 deaths were finally judged as non-natural).

Adult↗