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

[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.

[Proposals for standardization of autopsy reports]

The decline in the number of autopsies not only in Germany has been attributed to several reasons. Complaints of clinicians about a non-uniform layout of autopsy reports may be one important reason. The lack of initiatives concerning standardization of autopsy reports contributes to a poor comparability of autopsy reports from different institutions and even within one institution. In order to promote harmonization of a protocol for autopsy results proposals for a standardization of autopsy protocols are given. These proposals are based on using modules for different parts of the autopsy protocols, thus giving different institutions the possibility to modify these modules.

[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.

[Autopsy as a tool for quality assurance: Leipzig]

Autopsy rates have declined throughout the world although autopsy serves as an important tool in quality management. Working together with the Department of Heart Surgery of the Heart Centre in Leipzig clinical and autopsy diagnoses were compared. Between 2000 and 2003 an autopsy was performed in 468 patients. Data from clinical and postmortem examinations were prospectively analysed regarding causes of death, concomitant diseases and postoperative complications. Discrepancies between clinical and postmortem cause of death were identified in 23.1% of these patients. In 99.1% of the patients concomitant diseases (e.g. myocardial hypertrophy, pulmonary embolism, former stroke) could be identified, 57.6% were unknown pre-mortem and 19.2% were considered to be of relevance for surgical therapy. Autopsy is the final and most comprehensive physical examination. Autopsy is also the basis of training for pathologists in interpreting interrelated diagnoses. Therefore the task of pathologists is to enhance the appreciation of autopsy among clinical colleagues by working closely side by side. By communication an autopsy can deliver an effective achievement in terms of being relevant for praxis.

[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.