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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. Pathology in Switzerland is confronted with a declining number of medical autopsies.

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Autopsies: still a gold standard ?

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  1. Autopsies: still a gold standard ? Sarro R.; Bosman F.; Rotman S.IUP, Bugnon 25, CH-1011 Lausanne

  2. 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.

  3. 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.

  4. 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%.

  5. 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 %

  6. 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

  7. 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)

  8. 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 %

  9. 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,…

  10. 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

  11. 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.

  12. 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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