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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. - PowerPoint PPT Presentation
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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.
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.
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.
Methods
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%.
0200400600800
1000
2005 2006 2007 2008
CHUV AUTOPSY RATENumber of patient deceaded inthe CHUV
Number of medical autopsies
Number of forensic autopsies
Autopsy rate
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:Old age home
intensive care unit (ICU) CHUVCHUV (other than ICU)
Other hospital
OTHER (home, publicspace,…)
32.3 %
31.4 %
22.7%
9.9 % 3.6 %
Study population
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
Results
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)
Autopsy for cause of death
Results
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
major discrepancy
minor discrepancy
concordant
other
Distribution of major, minor discrepancies and concording autopsy diagnoses in the amount of autopsies with specific question (69.3 %)
Autopsy with specific questions
60.4 %21.9 %
15.9 %
Clinical diagnoses Autopsy diagnosesMyocardial infarction MyocarditisSeptic choc Hemophagocytic syndrome
secondary to lymphoproliferative diseaseHemorhagic /Hypovolemic choc (2)
Acute pulmonary oedema Broncho- pneumoniaPulmonary fat embolism Pulmonary thrombo-embolismInfectious pneumonia Adenocarcinoma of the lung (2)
Pulmonary thrombo-embolism (1)Tuberculosis (2)
Hepatic insufficiency Hepatic tuberculosis
Clinical diagnoses Autopsy diagnosesHigh risk coronary syndrome Mesenteric ischemia and necrosis
Stroke Metabolic gliomatosis, Post epileptic oedema
Interstitial pneumopathy Bacterial pneumoniaIntra- abdominal hemorhage Peritoneal carcinosis
Intra- abdominal lipomatosis Peritoneal carcinosis
Abscess secondary to diverticulitis
Invasive adenocarcinoma
Peptic ulcer Ulcerated gastric metastasis
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 complication 4 Hemochromatosis, prothetic valve thrombus, cardiac biventricular thrombosis, chronic hydrocephalus with acute issue, central nervous system vasculitis, Horton disease,…
Major missed diagnoses without clinical diagnoses
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
Minor missed diagnoses: examples
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 to function 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.
Discussion
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/
Conclusions