[Necessity of increasing autopsy frequency following the introduction of DRGs]

[Autopsy rates in Germany]

BACKGROUND

In 2015 the German professional Association of Pathologists conducted a survey to establish a baseline for an autopsy rate in Germany and to collect data from 2005-2014, as hospitals must meet a fixed autopsy quota to receive the supplementary payment for autopsies as stated in the law for hospital structure (KHSG 10.12.2015).

MATERIAL AND METHODS

The survey comprised 12 questions and was sent to 450 institutes of pathology. The overall return rate was 38%. The data of the different institutional types was grouped and statistically analyzed.

RESULTS

Of 86.416 reported autopsies on deceased adults in Germany from 2005-2014, 47% took place in university hospitals, 36% in local hospitals and 17% in privately run practices. Out of 4320 autopsies on deceased children and adolescents, the majority (83%) were performed at university hospitals, 8%, and 9%, respectively, at the other two entity types. Of the 14.047 fetal autopsies, 55% were done at university hospitals, 25% at other hospitals and 20% at private practices. From 2005 to 2014 the overall number of autopsies decreased by 30%, independently of the institute type. Within each group of institution types there was a wide range in numbers and rate of autopsies done per year: university hospitals total 0‑428, quota of 3,4-19,4%; local hospitals 0‑324, quota of 1,1-30,8%; private practices 0‑268, quota 0,4-5,2%.

CONCLUSION

To this day, there is no universal system to document and register hospital autopsy rates in Germany. Due to the high range of yearly autopsy rates even within the different groups of institute types, the threshold for the autopsy rate that must be met to obtain the supplementary payment should be low in the beginning.

[Adult autopsies during the past decade in Germany : Data from two university hospitals]

BACKGROUND

The clinical autopsy is the ultimate medical service for a patient and plays a crucial role in the education of physicians and other medical personnel, as well as in the context of quality control. Nevertheless, the number of autopsies is constantly decreasing. Numerous factors, such as the personal attitude of relatives and also clarification of relatives, as well as the increasing application of imaging methods while the patient is still alive, play a central role in this decline.

OBJECTIVE

This study aimed to demonstrate the development of autopsy services over the past decade in two university hospitals in Germany and therefore to underline the importance of this investigation procedure in pathology.

MATERIAL AND METHODS

Autopsy reports between the years 2005 and 2014 from 2 university institutes of pathology were analyzed regarding a diverse dataset, including age and sex of the deceased as well as the clinical and pathological causes of death.

RESULTS

The data showed that the number of autopsies has continuously decreased over the past decade; however, the distribution of characteristics of the deceased remained relatively stable. In this cohort the clinically assumed cause of death differed from the pathological cause of death in 6% of the autopsies. Frequently occurring discrepant diagnoses were cardiac tamponade, aortic dissection and endocarditis/myocarditis.

DISCUSSION

Our results show that, despite significant improvements in imaging methods, findings do not yield more accurate results than does autopsy. This underscores once again the need to encourage the performance of this final medical act on patients.

[Autopsy-a procedure of medical history?]

An autopsy is an important tool of quality assurance in clinical medicine. It serves to determine the exact cause of death, unravel unexpected complications of disease processes including adverse or any other effects of treatment as well as to validate the official mortality statistics. An autopsy also makes an important contribution to training medical students and physicians; however, the rate of clinical autopsies has been declining drastically for decades, the causes being manifold. Lack of interest among clinicians, mainly due to inadequate knowledge of the advantages of autopsy seems to play a special role. The lack of reasonable reimbursement has also been discussed as another possible cause. In order to counteract this negative trend, efforts should be made to work on the awareness of medical students and young clinicians so that an autopsy is perceived as a general measure of quality assurance and physician self-control. Furthermore, a realistic reimbursement of financial and personnel expense is necessary.

Virtual CT autopsy in clinical pathology: feasibility in clinical autopsies

For the past century, autopsy techniques in clinical pathology have not changed significantly, while autopsy rates are declining. Modern imaging techniques offer interesting prospects of supportive post-mortem diagnostic investigation. In a prospective study of 29 autopsy cases, complimentary virtual autopsy using unenhanced post-mortem computed tomography (pmCT) was performed. We analysed in a prospective cohort study 29 unenhanced pmCT scans, generated prior to autopsy. Clinical information regarding clinical history and circumstances of death were provided. The objective of the study was to find consistency and/or discrepancy between virtual autopsy and conventional autopsy findings regarding cause of death and death-related diagnoses, reconstruction of the pathogenetic mechanisms involved, side diagnoses and CPR (cardiopulmonary resuscitation)- or death-related post-mortem changes. Accuracy of pmCT for cause of death was 68 % and the positive predictive value (PPV) was 75 %. Regarding the pathogenetic mechanisms, accuracy of pmCT was 21 % and PPV was 29 %. The combined diagnostic yield of autopsy and pmCT was 133 % compared to autopsy only. Modern imaging techniques give an opportunity for post-mortem diagnostics to complete but not yet replace traditional autopsy. We could show that in two out of three cases, the cause of death found by pmCT matched the diagnosis from classical autopsy. While both disciplines, pathology and radiology, will profit from the mutual exchange of data, it seems a realistic aim to strive for virtual autopsy possibly further supported by biopsies and contrast-enhanced pmCT as an alternative to the classical clinical autopsy. A combination of both methods enhances diagnostic quality and completeness of the autopsy report.

Who is at risk for diagnostic discrepancies? Comparison of pre- and postmortal diagnoses in 1800 patients of 3 medical decades in East and West Berlin

BACKGROUND

Autopsy rates in Western countries consistently decline to an average of <5%, although clinical autopsies represent a reasonable tool for quality control in hospitals, medically and economically. Comparing pre- and postmortal diagnoses, diagnostic discrepancies as uncovered by clinical autopsies supply crucial information on how to improve clinical treatment. The study aimed at analyzing current diagnostic discrepancy rates, investigating their influencing factors and identifying risk profiles of patients that could be affected by a diagnostic discrepancy.

METHODS AND FINDINGS

Of all adult autopsy cases of the Charité Institute of Pathology from the years 1988, 1993, 1998, 2003 and 2008, the pre- and postmortal diagnoses and all demographic data were analyzed retrospectively. Based on power analysis, 1,800 cases were randomly selected to perform discrepancy classification (class I-VI) according to modified Goldman criteria. The rate of discrepancies in major diagnoses (class I) was 10.7% (95% CI: 7.7%-14.7%) in 2008 representing a reduction by 15.1%. Subgroup analysis revealed several influencing factors to significantly correlate with the discrepancy rate. Cardiovascular diseases had the highest frequency among class-I-discrepancies. Comparing the 1988-data of East- and West-Berlin, no significant differences were found in diagnostic discrepancies despite an autopsy rate differing by nearly 50%. A risk profile analysis visualized by intuitive heatmaps revealed a significantly high discrepancy rate in patients treated in low or intermediate care units at community hospitals. In this collective, patients with genitourinary/renal or infectious diseases were at particularly high risk.

CONCLUSIONS

This is the current largest and most comprehensive study on diagnostic discrepancies worldwide. Our well-powered analysis revealed a significant rate of class-I-discrepancies indicating that autopsies are still of value. The identified risk profiles may aid both pathologists and clinicians to identify patients at increased risk for a discrepant diagnosis and possibly suboptimal treatment intra vitam.

[Autopsies 2010. Is death still teaching the living?]

Autopsy rates have been declining for decades all over the world; however, the causes of this decline have not been clearly elucidated. This negative trend could cause wider problems as yet unthought of. Autopsies serve medical training and specialist medical training, quality management, patient care systems as well as cause of death statistics, thereby ensuring good medical practice and a balanced allocation of funds. The aim of this article is to present autopsies and their impact on teaching, patient care and epidemiology in an objective manner. Heeding the crucial points could have a positive effect on the entire health system with a minimum of effort, while ignoring them could have adverse consequences for physicians, patients and their relatives, as well as society as a whole.

[Clinical autopsies. Practical approach, legal foundations and ethical considerations]

Only an autopsy can demonstrate topographical and morphological circumstances in detail and correlate the clinical and autopsy findings based on the examination of all organs. The practical approach in a fatality is described based on the example of the Lüdenscheid Hospital. A uniform legal regulation for dealing with corpses does not exist in Germany. There are two approaches to the question under which circumstances a clinical autopsy is allowed: the extended permission solution and the objection solution. Whether a clinical autopsy can be carried out is decided by the medical specialist selected on application. Autopsies can be necessary from insurance or administrative legal grounds or in the case of an anatomical autopsy is decided by the persons themselves. In order to guarantee the quality of an autopsy it is necessary to use a standardized approach with evaluation and assessment of the results, for example using a quality assurance protocol and the production of an autopsy report. Using this approach important information can be gained not only on the accuracy of the main diagnosis and cause of death but also on additional diseases, response to therapy and the course of the disease and under circumstances can lead to modifications in the approach.

[Evaluation of the clinical utility of autopsy: an investigation at the Institute of Pathology, University Hospital of Leipzig]

BACKGROUND

The aim of this study of autopsies performed in our institute was to investigate whether clinical requirements had been met and specific clinical questions answered.

METHOD

With each autopsy report, a questionnaire was sent to the clinic where the patient had died. The clinicians evaluated how often additional diagnoses were made and whether these were clinically relevant.

RESULTS

Seventy-two percent of all autopsies resulted in further diagnoses. Clinicians estimated that these could have influenced their clinical management in 36% of cases. Weaknesses in interdisciplinary cooperation were uncovered and solved.

CONCLUSION

The great benefit of the autopsies conducted in our institute was demonstrated. The results emphasise once again the importance of autopsy for quality assurance in clinical medicine.

[Post-mortems with organ and tissue retention]

Autopsies have always been the basis of new scientific developments, of quality control in hospitals, epidemiology-based health policy decisions and medical education. The socially relevant reasons for conducting an autopsy easily outweigh the feelings and fears of relatives in their decision for or against a post-mortem. The many reservations expressed by patients and their relatives and the competing interests of information, consent, common welfare, and individual autonomy call for regulations which clearly define the legal framework towards post-mortem in accordance with modern medicine. In addition, a public discussion is needed as to whether every citizen should contribute to fulfil this task in terms of an obligatory autopsy. This implies that performing an autopsy is taken for granted and not considered as extraordinary or appalling; see the comment "Autopsie" of the German Medical Association (Bundesärztekammer) in 2006. Furthermore, the urgent necessity of a self-critical approach to medicine shall be emphasized, i.e., of medicine subjecting itself to rigid quality control as the adequate basis of a humane healthcare system. The most reliable and convenient way to achieve this goal will be the ubiquitous establishment of clinical autopsies.

[How often is bronchopneumonia overlooked as the cause of death in intensive care unit patients?]

BACKGROUND

This study addresses the issue of analyzing the relationship between pre-mortem diagnoses and post-mortem findings in an intensive care unit (ICU).

MATERIALS AND METHODS

Investigating a total of 1,205 autopsy cases, pre-mortem and post-mortem diagnoses were retrospectively evaluated and compared statistically by means of established categories (i.e."complete, partial, or lacking concordance" and"clinically suspected diagnosis").

RESULTS

When comparing clinical diagnoses and autopsy findings in terms of bronchopneumonia, concordance was recorded in only 21.15% of the cases investigated.

CONCLUSION

In multimorbid ICU patients, bronchopneumonia frequently fails to be clinically recognized since clinical parameters commonly used for monitoring appear to be modified due to therapeutical interventions, and thus are inappropriate to reflect the complete histomorphological equivalent of the disease. This study also emphasizes the importance of autopsy which represents a sensitive means for professional medical quality assurance, and again establishes the necessity for strengthening the request for autopsy, which is currently characterized by an unfavourable decline.