Notes

Outline

Death as Data:  Autopsy and the Death Certificate Two basic goals  value of the autopsy  proper use of the death certificate

Web sites and references page 1 Greetings all: I am informed that the links provided for the lecture on AUTOPSY and DEATH CERTIFICATE are dead, and have found some alternatives: 1.  The National Association of Medical Examiners has revised their site and taken down the tutorial, while they rebuild:  they say: 11/22/02 UNDER REPAIR-EXPECT BROKEN LINKS (the site is http://www.thename.org/ ) Specific to Texas, you could take a look at http://www.perfectfit.org/CME/ .   CENTERS FOR DISEASE CONTROL have a page of links at http://www.cdc.gov/nchs/about/major/dvs/handbk.htm to documents on the correct filing of the death certificate (unfortunately their first one is the same one I gave you!).

Web sites and references page 2 CMAJ has also moved!  They are now at http://www.cmaj.ca/ with the search page for articles at http://www.cmaj.ca/search.dtl. In addition they no longer provide html links, only PDF copies of actual articles.  The article in question is available at http://www.cmaj.ca/cgi/reprint/158/10/1317.pdf .  You need the Adobe Acrobat Reader 5 free from Adobe (download direct by clicking http://ardownload.adobe.com/pub/adobe/acrobatreader/win/5.x/5.1/AcroReader51_ENU_full.exe or go to text page http://www.adobe.com/products/acrobat/alternate.html or http://www.adobe.com/products/acrobat/readstep2.html .

Outline Autopsy: history in three periods; The fall of the autopsy: 1960 onward Evidence of continuing relevance Some attempts to explain the problem Effects of falling rates An example of the effect Death certificate:  what it is, how it should be approached

The autopsy in history Classical period: “test authority” Pre-modern period (17-18C) : emphasis on anatomy Modern period; 19C on… Rokitansky (gross autopsy) Virchow (added the microscope) Osler – a modern example Ultimate recognition as prime goal a contribution to medical knowledge

Falling Autopsy Rates From 50% in the 1960’s to Much lower than 10% today, despite (for example) of three U.S. studies, an incorrect diagnosis of malignant tumors was shown in 36.5% of cases (1923) 41% of cases (1972) 44% of cases (1998, Louisiana)

Falling Autopsy Rates: RVH

JAMA 1998:  Louisiana study All autopsies 1986-95 Outcome measure:  discordance in clinical vs. autopsy for cancer 1105 cases; mean age 48 years (very atypical) 443 “neoplasms” at autopsy; 250 “malignant” 111 wrong CLINICAL diagnoses of “malignancy” including 57 which caused death

Extremely low birth-weight infant deaths 111 infants 300-1000 g with autopsies 1990-93 INFECTION caused death: 56/111 Respiratory distress syndrome (BPD) 21; congenital defect 15 “immaturity” usually a wrong (or incomplete) diagnosis, especially over 500 g. Most deaths by infection were misdiagnosed

So what is wrong?  1.  Why do the rates keep falling in the face of continuing evidence of error? Increasing reliance on imaging Fear of lawsuits?  May explain USA but not elsewhere

So what is wrong?  2. Changing patterns in pathology and pathologists A new but worrying factor:  regard for autopsy practices as “violating civil rights” (lawsuit in UK over pediatric autopsies); reflects a constant fight over “values” over the years coupled with some abuses such as “Burking”…

So what is wrong?  3. Suggestions of poor communication between pathologists and clinicians: Wherever a special effort is made to “educate” rates increase, although this may be transitory.  Rates can reach 100% in some centres!

So what is wrong?  4. Suggestions of poor communication between pathologists and clinicians: Poor pay, lack of curiosity, lack of professional attitude to reporting can lead to “vicious circle” of late reporting; Clinical “mortality rounds” seem to result in higher rates when pathologists attend

Is anything right? In academic centres cases with unknown cause still invoke requests for autopsy; This means that almost every increasingly “rare autopsy” has become more “interesting” both for the pathologist, for teaching, and for publication, BUT... This applies only to academic centres

Effects of falling rates Similar to effects of bad death certificate reporting National health statistics wrong; Lack of Quality Control; Problems for analytical epidemiology (garbage in, garbage out)

Autopsy trends and their effect on disease ascertainment: an example.

Special Procedures in Pathology:  Trends for 228 women with mesothelioma 1970-90 Trends among 142 and 98 female cases diagnosed 1970-1984 and 1985-1991, respectively.

Slide 18

"1." 1. “Improving the accuracy of death certification” Eight case scenarios are presented Kathryn A. Myers, MD, EdM; Donald R.E. Farquhar, MD, SM CMAJ 1998;158:1317-23

2.  WRITING CAUSE-OF-DEATH STATEMENTS (Why learn this now)? Often, a physician's first encounter with the death certificate occurs upon the physician's first patient death when he/she is handed the death certificate form and asked to complete it. This usually occurs during the first year of residency. Many, perhaps most, are not told “how” – and never learn!

The cause-of- death statement contains two parts: A) Due to, or as a result of    B) Due to, or as a result of    C)

The cause-of- death statement contains two parts: Part II. OTHER SIGNIFICANT CONDITIONS: Conditions contributing to death but not resulting in the underlying cause of death in Part I

PART I:  ONE CONDITION per line, starting with the most recent condition on the top line and going backward in time

Slide 24

Variants; problems Single Line Part I Format (missing data) e.g. no autopsy, patient dies at home, known to have prostate carcinoma uncertainty or presumption:  use “probable” ALWAYS REPORT CANCER! Can “cheat” on part two to record risk factor (smoking, asbestos exposure)

Variants Usually a space to record TIME since onset of event Always indicate whether (a) an autopsy has been asked for and (b) whether the DC includes autopsy information In some places, can record occupation – “retired” is NOT an occupation!!! Mandatory reporting:  violent death, certain infections; varies with state

Slide 27

Multiple coding All data to date are based on a SINGLE cause of death but Modern national statistics programs record ALL information on the death certificate and can derive “multiple cause-of-death” data