Resuscitating the Dying Autopsy

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Abstract

Clara Menéndez and colleagues consider the importance of conducting autopsies and possible alternative methods for determining cause of death in resource-limited settings.

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Most cited references 30

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A scandal of invisibility: making everyone count by counting everyone.

Philip W Setel, Sarah B. Macfarlane, Simon Szreter … (2007)

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Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.

E Burton, Lee Goldman, Kristin K. McDonald … (2003)

Substantial discrepanies exist between clinical diagnoses and findings at autopsy. Autopsy may be used as a tool for quality management to analyze diagnostic discrepanies. To determine the rate at which autopsies detect important, clinically missed diagnoses, and the extent to which this rate has changed over time. A systematic literature search for English-language articles available on MEDLINE from 1966 to April 2002, using the search terms autopsy, postmortem changes, post-mortem, postmortem, necropsy, and posthumous, identified 45 studies reporting 53 distinct autopsy series meeting prospectively defined criteria. Reference lists were reviewed to identify additional studies, and the final bibliography was distributed to experts in the field to identify missing or unpublished studies. Included studies reported clinically missed diagnoses involving a primary cause of death (major errors), with the most serious being those likely to have affected patient outcome (class I errors). Logistic regression was performed using data from 53 distinct autopsy series over a 40-year period and adjusting for the effects of changes in autopsy rates, country, case mix (general autopsies; adult medical; adult intensive care; adult or pediatric surgery; general pediatrics or pediatric inpatients; neonatal or pediatric intensive care; and other autopsy), and important methodological features of the primary studies. Of 53 autopsy series identified, 42 reported major errors and 37 reported class I errors. Twenty-six autopsy series reported both major and class I error rates. The median error rate was 23.5% (range, 4.1%-49.8%) for major errors and 9.0% (range, 0%-20.7%) for class I errors. Analyses of diagnostic error rates adjusting for the effects of case mix, country, and autopsy rate yielded relative decreases per decade of 19.4% (95% confidence interval [CI], 1.8%-33.8%) for major errors and 33.4% (95% [CI], 8.4%-51.6%) for class I errors. Despite these decreases, we estimated that a contemporary US institution (based on autopsy rates ranging from 100% [the extrapolated extreme at which clinical selection is eliminated] to 5% [roughly the national average]), could observe a major error rate from 8.4% to 24.4% and a class I error rate from 4.1% to 6.7%. The possibility that a given autopsy will reveal important unsuspected diagnoses has decreased over time, but remains sufficiently high that encouraging ongoing use of the autopsy appears warranted.

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Clinical, educational, and epidemiological value of autopsy.

Christine Burton, James Underwood (2007)

The autopsy is now often regarded as of marginal use in modern clinical practice. In this Review we contend that the autopsy remains an important procedure with substantial, if largely underused, potential to advance medical knowledge and improve clinical practice. Many doctors lack familiarity with autopsy practices, and are insufficiently aware of the benefits for not only bereaved families but also present and future patients. In this Review, which has an international perspective, we consider the ascent and decline of the autopsy, the legal frameworks that govern its use, the value and potential pitfalls of alternatives to the conventional method, and the autopsy's role in undergraduate medical education. We also draw attention to the continuing ability of autopsies to improve the completeness and reliability of death certification, which is important for public-health strategies and for some bereaved families.

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Author and article information

Journal

Journal ID (nlm-ta): PLoS Med

Journal ID (iso-abbrev): PLoS Med

Journal ID (publisher-id): plos

Journal ID (pmc): plosmed

Title: PLoS Medicine

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Print): 1549-1277

ISSN (Electronic): 1549-1676

Publication date (Electronic): 12 January 2016

Publication date Collection: January 2016

Volume: 13

Issue: 1

Electronic Location Identifier: e1001927

Affiliations

[1 ]ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain

[2 ]Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique

[3 ]Department of Pathology, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain

[4 ]Global Malaria Program, World Health Organisation, Geneva, Switzerland

Author notes

I have read the journal's policy and have the following conflicts: CM is a member of the Editorial Board of PLOS Medicine.

All authors agreed upon the content of the manuscript before the first version was written. QB and PC drafted the first version of the manuscript. CM, PA, and JO subsequently reviewed this first draft, and provided comments and suggestions. All authors reviewed and approved the manuscript (and subsequent modifications) submitted to the journal. All authors have read, and confirm that they meet, ICMJE criteria for authorship.

* E-mail: clara.menendez@ 123456isglobal.org

Article

Publisher ID: PMEDICINE-D-15-02146

DOI: 10.1371/journal.pmed.1001927

PMC ID: 4710495

PubMed ID: 26756992

SO-VID: 55bd208f-86d7-451a-b7b3-7ff9bd7553a2

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This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

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Figures: 0, Tables: 0, Pages: 5

Funding

The CaDMIA research project (validation of the minimally invasive autopsy tool for cause of death investigation in developing countries) is funded by the Bill & Melinda Gates Foundation (Global Health grant number OPP1067522) and by Spain’s Instituto de Salud Carlos III (FIS, PI12/00757). PC is hired by means of the BMGF Global health Grant funds. QB, JO and CM are co-principal investigators of the CaDMIA research project. QB has a fellowship from the program Miguel Servet of the ISCIII (Plan Nacional de I+D+I 2008-2011, grant number: CP11/00269). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Resuscitating the Dying Autopsy

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Alternative approaches to Alzheimer's Disease

Most cited references 30

A scandal of invisibility: making everyone count by counting everyone.

Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.

Clinical, educational, and epidemiological value of autopsy.

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