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Autopsies: still a gold standard ?. Sarro R.; Bosman F.; Rotman S. IUP, Bugnon 25, CH-1011 Lausanne. Background. Pathology in Switzerland is confronted with a declining number of medical autopsies.

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autopsies still a gold standard

Autopsies: still a gold standard ?

Sarro R.; Bosman F.; Rotman S.IUP, Bugnon 25, CH-1011 Lausanne

background
Background
  • Pathology in Switzerland is confronted with a declining number of medical autopsies.
  • This can be explained by advances in medical imaging which offers clinicians a high level of certainty in diagnosis. For this reason, clinicians often assume that autopsies have no added value.
  • In this study, we compared clinical with autopsy pathology diagnoses in order to evaluate the contribution of autopsies to the control of the quality of health care.
  • Between January 2004 and December 2008, we reviewed all adult autopsy cases in our Institute. A retrospective analysis of 717 consecutive autopsy reports was performed.
methods
Methods
  • We excluded incomplete autopsy cases and also pediatric autopsies (< 16 years old).
  • We confronted the clinical diagnoses listed on the autopsy request form with pathological diagnoses in the autopsy report.
  • Clinically important discrepancies were defined as:

-major :missed diagnoses for which detection and treatment before death might have resulted in cure or prolongation of survival or for which detection before death would probably have led to a change in management.

-minor: missed diagnoses without clinical implication.

  • Sudden death was defined as death occurring less than 12 hours after the first symptoms.
slide4

Autopsy rate

  • Mean medical autopsy rate for adult patients (>16 years) death was 10.7 % (2005-2008) and mean total autopsy rate (medical autopsies and forensic autopsies of patients deceaded in the hospital) was 15.8 %. Data from 2004 are not avalaible.
  • For paediatric patients deceaded during the same period (2005-2008) the mean autopsy rate in our hospital was 48%.
slide5

Study population

  • Among 717 autopsy cases:
    • 35.6% (255) were qualified as sudden death
    • 59.8 % (429) concerned men
  • Provenance (place of death) of the 717 cases of autopsy:

9.9 %

3.6 %

22.7%

32.3 %

31.4 %

slide6

Results

  • Reasons for requesting an autopsy
  • 63.6 %: cause of death without a specific medical problem
  • 69.3 %: specific questions:
      • confirmation of diagnosis
      • elucidation of complications of medical interventions
      • elucidation of etiology or pathogenesis
slide7

Results

Autopsy for cause of death

  • Cause of death was established in 526 cases (73.3%):
    • In 164 of 255 sudden death cases (64.3 %)a cause of death was established
    • In 362 of 462 non sudden death cases (78.3%) a cause of death was established
    • In 456 of 717 (63,6%) with specific question of the cause of death, a cause was established in 66.2% (302 cases)
slide8

Autopsy with specific questions

  • 103 (14.4%) clinically important diagnoses (major) were established that were missed by the attending clinicians
  • 166 (23.2%) missed diagnoses without important clinical implications (minor) were encountered

Distribution of major, minor discrepancies and concording autopsy diagnoses in the amount of autopsies with specific question (69.3 %)

15.9 %

21.9 %

60.4 %

slide11

Major missed diagnoses without clinical diagnoses

  • Invasif tumor or lymphoma discovered 24
  • CT, XR, US, coronarography, biopsies, endoscopy normal 12 disclosing diagnoses of:
    • Pulmonary embolism
    • Coronary stenosis,
    • Invasive carcinoma,
    • Hemorhagic infarctus of hypophysis
  • Infectious 8
  • Post-operatory complication4
  • Hemochromatosis, prothetic valve thrombus, cardiac biventricular thrombosis, chronic hydrocephalus with acute issue, central nervous system vasculitis, Horton disease,…
slide12

Minor missed diagnoses: examples

  • Meningiomas 12
  • Gastro-intestinal adenomas 23
  • Other tumors 25
  • Renal angiomyolipoma 8
  • Cirrhosis 17
  • Auricular myxoma 2
  • Floppy cardiac valve 1
  • Ovary mature teratoma 1
  • Adrenal ganglioneuroma 2
  • Parathyroid adenomas 2
  • Schistosomiasis 2
  • Vascular amyloidosis 5
  • Sarcoidosis 1
slide13

Discussion

  • We have a low autopsy rate in our university teaching hospital. Often clinicians do not request an autopsy and when requested frequently family members do not accept the request . We have no data on the autopsy request rate.
  • For autopsies tofunction as a valid tool in monitoring of clinical diagnostic performance, a high autopsy rate is needed in order to avoid selection bias
  • The important number of minor missed diagnoses might be partly caused by the high number of incompletely documented autopsy request forms.
slide14

Conclusions

  • In a high % of cases the autopsy allowed to establish the cause of death. In sudden death cases this is lower, which can be explained by acute pathologies not resulting in a perceptible anatomical substrate
  • Missed diagnoses with important clinical implications continue to be found in spite of progress in medical imaging.
  • autopsies should be reconsidered as essential for quality control of health care

Web link :http://www.chuv.ch/iup/

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