Autopsy in older medical patients: concordance in ante- and post-mortem findings and changing trends

Retrospective cohort study of breast cancer incidence, health service use and outcomes in Europe: a study of feasibility

Background

Comparisons of outcomes of health care in different systems can be used to inform health policy. The EuroHOPE (European Healthcare Outcomes, Performance and Efficiency) project investigated the feasibility of comparing routine data on selected conditions including breast cancer across participating European countries.

Methods

Routine data on incidence, treatment and mortality by age and clinical characteristics for breast cancer in women over 24 years of age were obtained (for a calendar year) from linked hospital discharge records, cancer and death registers from Finland, the Turin metropolitan area, Scotland and Sweden (all 2005), Hungary (2006) and Norway (2009). Age-adjusted breast cancer incidence and 1-year survival were estimated for each country/region.

Results

In total, 24 576 invasive breast cancer cases were identified from cancer registries from over 13 million women. Age-adjusted incidence ranged from 151.1 (95%CI 147.2-155.0) in Hungary to 234.7 (95%CI 227.4-242.0)/100 000 in Scotland. One-year survival ranged from 94.1% (95%CI 93.5-94.7%) in Scotland to 97.1% (95%CI 96.2-98.1%) in Italy. Scotland had the highest proportions of poor prognostic factors in terms of tumour size, nodal status and metastases. Significant variations in data completeness for prognostic factors prevented adjustment for case mix.

Conclusion

Incidence of and survival from breast cancer showed large differences between countries. Substantial improvements in the use of internationally recognised common terminology, standardised data coding and data completeness for prognostic indicators are required before international comparisons of routine data can be used to inform health policy.

Risk of hospitalization and death following prostate biopsy in Scotland

OBJECTIVE

To investigate the risk of hospitalization and death following prostate biopsy.

STUDY DESIGN

Retrospective cohort study.

METHODS

Our study population comprised 10,285 patients with a record of first ever prostate biopsy between 2009 and 2013 on computerized acute hospital discharge or outpatient records covering Scotland. Using the general population as a comparison group, expected numbers of admissions/deaths were derived by applying age-, sex-, deprivation category-, and calendar year-specific rates of hospital admissions/deaths to the study population. Indirectly standardized hospital admission ratios (SHRs) and mortality ratios (SMRs) were calculated by dividing the observed numbers of admissions/deaths by expected numbers.

RESULTS

Compared with background rates, patients were more likely to be admitted to hospital within 30 days (SHR 2.7; 95% confidence interval 2.4, 2.9) and 120 days (SHR 4.0; 3.8, 4.1) of biopsy. Patients with prior co-morbidity had higher SHRs. The risk of death within 30 days of biopsy was not increased significantly (SMR 1.6; 0.9, 2.7), but within 120 days, the risk of death was significantly higher than expected (SMR 1.9; 1.5, 2.4). The risk of death increased with age and tended to be higher among patients with prior co-morbidity. Overall risks of hospitalization and of death up to 120 days were increased both in men diagnosed and those not diagnosed with prostate cancer.

CONCLUSIONS

Higher rates of adverse events in older patients and patients with prior co-morbidity emphasizes the need for careful patient selection for prostate biopsy and justifies ongoing efforts to minimize the risk of complications.

Survival Benefits of Statins for Primary Prevention: A Cohort Study

OBJECTIVES

Estimate the effect of statin prescription on mortality in the population of England and Wales with no previous history of cardiovascular disease.

METHODS

Primary care records from The Health Improvement Network 1987-2011 were used. Four cohorts of participants aged 60, 65, 70, or 75 years at baseline included 118,700, 199,574, 247,149, and 194,085 participants; and 1.4, 1.9, 1.8, and 1.1 million person-years of data, respectively. The exposure was any statin prescription at any time before the participant reached the baseline age (60, 65, 70 or 75) and the outcome was all-cause mortality at any age above the baseline age. The hazard of mortality associated with statin prescription was calculated by Cox's proportional hazard regressions, adjusted for sex, year of birth, socioeconomic status, diabetes, antihypertensive medication, hypercholesterolaemia, body mass index, smoking status, and general practice. Participants were grouped by QRISK2 baseline risk of a first cardiovascular event in the next ten years of <10%, 10-19%, or ≥20%.

RESULTS

There was no reduction in all-cause mortality for statin prescription initiated in participants with a QRISK2 score <10% at any baseline age, or in participants aged 60 at baseline in any risk group. Mortality was lower in participants with a QRISK2 score ≥20% if statin prescription had been initiated by age 65 (adjusted hazard ratio (HR) 0.86 (0.79-0.94)), 70 (HR 0.83 (0.79-0.88)), or 75 (HR 0.82 (0.79-0.86)). Mortality reduction was uncertain with a QRISK2 score of 10-19%: the HR was 1.00 (0.91-1.11) for statin prescription by age 65, 0.89 (0.81-0.99) by age 70, or 0.79 (0.52-1.19) by age 75.

CONCLUSIONS

The current internationally recommended thresholds for statin therapy for primary prevention of cardiovascular disease in routine practice may be too low and may lead to overtreatment of younger people and those at low risk.

Cause-specific mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites

BACKGROUND

Because most deaths in Africa and Asia are not well documented, estimates of mortality are often made using scanty data. The INDEPTH Network works to alleviate this problem by collating detailed individual data from defined Health and Demographic Surveillance sites. By registering all deaths over time and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available.

OBJECTIVE

To build a large standardised mortality database from African and Asian sites, detailing the relevant methods, and use it to describe cause-specific mortality patterns.

DESIGN

Individual demographic and verbal autopsy (VA) data from 22 INDEPTH sites were collated into a standardised database. The INDEPTH 2013 population was used for standardisation. The WHO 2012 VA standard and the InterVA-4 model were used for assigning cause of death.

RESULTS

A total of 111,910 deaths occurring over 12,204,043 person-years (accumulated between 1992 and 2012) were registered across the 22 sites, and for 98,429 of these deaths (88.0%) verbal autopsies were successfully completed. There was considerable variation in all-cause mortality between sites, with most of the differences being accounted for by variations in infectious causes as a proportion of all deaths.

CONCLUSIONS

This dataset documents individual deaths across Africa and Asia in a standardised way, and on an unprecedented scale. While INDEPTH sites are not constructed to constitute a representative sample, and VA may not be the ideal method of determining cause of death, nevertheless these findings represent detailed mortality patterns for parts of the world that are severely under-served in terms of measuring mortality. Further papers explore details of mortality patterns among children and specifically for NCDs, external causes, pregnancy-related mortality, malaria, and HIV/AIDS. Comparisons will also be made where possible with other findings on mortality in the same regions. Findings presented here and in accompanying papers support the need for continued work towards much wider implementation of universal civil registration of deaths by cause on a worldwide basis.

Coding ill-defined and unknown cause of death is 13 times more frequent in Denmark than in Finland

Exact cause and manner of death determination improves legislative safety for the individual and for society and guides aspects of national public health. In the International Classification of Diseases, codes R00-R99 are used for "symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified" designated as "ill-defined" or "with unknown etiology". The World Health Organisation recommends avoiding the use of ill-defined and unknown causes of death in the death certificate as this terminology does not give any information concerning the possible conditions that led to the death. Thus, the aim of the study was, firstly, to analyse the frequencies of R00-R99-coded deaths in mortality statistics in Finland and in Denmark and, secondly, to compare these and the methods used to investigate the cause of death. To do so, we extracted a random 90% sample of the Finnish death certificates and 100% of the Danish certificates from the national mortality registries for 2000, 2005 and 2010. Subsequently, we analysed the frequencies of forensic and medical autopsies and external clinical examinations of the bodies in R00-R99-coded deaths. The use of R00-R99 codes was significantly higher in Denmark than in Finland; OR 18.6 (95% CI 15.3-22.4; p<0.001) for 2000, OR 9.5 (95% CI 8.0-11.3; p<0.001) for 2005 and OR 13.2 (95% CI 11.1-15.7; p<0.001) for 2010. More than 80% of Danish deaths with R00-R99 codes were over 70 years of age at the time of death. Forensic autopsy was performed in 88.3% of Finnish R00-R99-coded deaths, whereas only 3.5% of Danish R00-R99-coded deaths were investigated with forensic or medical autopsy. The codes that were most used in both countries were R96-R99, meaning "unknown cause of death". In Finland, all of these deaths were investigated with a forensic autopsy. Our study suggests that if all deaths in all age groups with unclear cause of death were systematically investigated with a forensic autopsy, only 2-3/1000 deaths per year would be coded as an ill-defined and unknown cause of death in national mortality statistics. At the same time the risk to overlook unnatural deaths is decreased to a minimum. To achieve this in Denmark requires that the existing legislation on cause of death investigation would need to be changed to ensure that all deaths with unknown cause of death are investigated with a forensic autopsy.

Quality of coroner's post-mortems in a UK hospital

PURPOSE

The aim of this paper was, principally, to look at the coroner's post-mortem report quality regarding adult medical patients admitted to an English hospital; and to compare results with Royal College of Pathologists guidelines.

DESIGN/METHODOLOGY/APPROACH

Hospital clinical notes of adult medical patients dying in 2011 and who were referred to the coroner's office to determine the cause of death were scrutinised. Their clinical care was also reviewed.

FINDINGS

There needs to be a comprehensive approach to coroner's post-mortems such as routinely taking histological and microbiological specimens. Acute adult medical patient care needs to improve.

RESEARCH LIMITATIONS/IMPLICATIONS

Steps should be taken to ensure that comprehensive coroner's post-mortems are performed throughout the UK, including with routine histological and microbiological specimens examination. Additionally, closer collaboration between clinicians and pathologists needs to occur to improve emergency adult medical patient clinical care.

ORIGINALITY/VALUE

The study highlights inadequacies in coroner's pathology services.

Can the science of communication inform the art of the medical humanities?

CONTEXT

There is increasing interest in establishing the medical humanities as core integrated provision in undergraduate medicine curricula, but sceptics point to the lack of evidence for their impact upon patient care. Further, the medical humanities culture has often failed to provide a convincing theoretical rationale for the inclusion of the arts and humanities in medical education.

DISCUSSION

Poor communication with colleagues and patients is the main factor in creating the conditions for medical error; this is grounded in a historically determined refusal of democracy within medical work. The medical humanities may play a critical role in educating for democracy in medical culture generally, and in improving communication in medical students specifically, as both demand high levels of empathy. Studies in the science of communication can provide a valuable evidence base justifying the inclusion of the medical humanities in the core curriculum. A case is made for the potential of the medical humanities--as a form of 'adult play'--to educate for collaboration and tolerance of ambiguity or uncertainty, providing a key element of the longer-term democratising force necessary to change medical culture and promote safer practice.

CONCLUSION

The arts and humanities can provide important contextual media through which the lessons learned from the science of communication in medicine can be translated and promoted as forms of medical education.