ORIGINAL ARTICLE
Year : 2013 | Volume
: 56 | Issue : 4 | Page : 372--377
Is necropsy obsolete - An audit of the clinical autopsy over six decades: A study from Indian sub continent
Nikhil Moorchung, Vikram Singh, Ankit Mishra, Seema Patrikar, Sunita Kakkar, Vibha Dutta
Department of Pathology, Armed Forces Medical College, Pune, Maharashtra, India
Correspondence Address:
Nikhil Moorchung
Department of Pathology, Armed Forces Medical College, Sholapur Road, Pune, Maharashtra
India
Abstract
Introduction: Several studies have documented a decrease in the autopsy rate. This study was taken up to analyse the cause of mortality, the discrepancies between the ante mortem and post mortem diagnosis and the discrepancies between diagnoses according to the type of the disease over a period of six decades. Materials and Methods: Autopsy reports and medical records were retrospectively analyzed over a 63 year period from 1947 to 2010. Results: In our study, there was a steady increase in the percentage of neoplastic cases from 1947 to 1994 after which there has been a significant drop. The cases dying due to infection has also shown a steady decline over the years until 1994. After 1994, there has been a significant increase in the deaths until 2010 (p < 0.05). Death due to cardiac causes has shown an increase until 1962 which has been followed by a steady decline. There has been a sudden rise in the number of cases dying due to renal causes between 1994 and 2000 (p < 0.05). There has been a statistically significant decrease in the discrepancies between the ante mortem and the post mortem diagnosis over the years. Discussion: This study shows that therapeutic and preventive measures correctly instituted have significantly reduce the mortality, particularly with reference to cardiac and infectious causes. The discrepancy between antemortem and post-mortem diagnosis in 2010 is still very high at 9.30 percent. The autopsy will continue to remain relevant especially in elucidating the molecular cause of disease.
How to cite this article:
Moorchung N, Singh V, Mishra A, Patrikar S, Kakkar S, Dutta V. Is necropsy obsolete - An audit of the clinical autopsy over six decades: A study from Indian sub continent.Indian J Pathol Microbiol 2013;56:372-377
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Moorchung N, Singh V, Mishra A, Patrikar S, Kakkar S, Dutta V. Is necropsy obsolete - An audit of the clinical autopsy over six decades: A study from Indian sub continent. Indian J Pathol Microbiol [serial online] 2013 [cited 2023 Dec 1 ];56:372-377
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Full Text
Introduction
Hospital-based medical autopsies are a well-established tool for education and quality assurance. [1],[2],[3] However, several studies have documented a decrease in the autopsy rate and in the importance given to autopsy by clinicians. [4] The causes for the decreasing autopsy rate are diverse and include technological advances in clinical testing and imaging, fear of potential medico legal problems that could result from discrepant findings and a declining interest in autopsies among Pathologists. [5] Despite this declining interest in autopsies, however, clinicopathological discrepancy rates remain high. [6]
A meta-analysis based on a College of American Pathologists survey of 248 institutions in the United States noted that nearly 40% of autopsies yield at least one unexpected finding that contributed to the patient's death. [7] This indicates that the autopsy still has a significant role to play in medical education. Most studies have analyzed the autopsy data over a period of a year to a decade. [8],[9],[10]
No studies have analyzed the clinical autopsy over a period of decades. A study over several decades would be informative because of the following reasons. Firstly, it would tell us the relative causes for hospital deaths over the six decades. It would then be possible to analyze if there has been a definite trend in mortality due to disease etiology like neoplastic or inflammatory causes. Secondly, it would tell us about the rate of discrepancies between the antemortem and postmortem diagnosis and if there has been a significant change in the discrepancies over the decades. This would help us in evaluating the value of the autopsy as a clinical tool. Finally, it would also give us some demographic data like the change in the age of hospital deaths. Most of the published autopsy studies are from the western countries, only few Indian studies has been published so far. [11],[12]
This study was taken up to answer the questions noted above. The following aspects of the autopsy were evaluated. Firstly, the cause for mortality over the years was analyzed. Secondly, the discrepancies between the antemortem and postmortem diagnosis were studied. The discrepancies between antemortem and postmortem diagnoses according to the type of the disease were also studied. Finally, demographic factors were also analyzed. We could not analyze the unautopsied cases since the data for the last 63 years was not available.
Materials and Methods
Autopsy reports and medical records were retrospectively analyzed over a 63 year period from 1947 to 2010 in a teaching hospital. The number of autopsies performed during this period is approximately 6500; however, complete data was available for approximately 1500 cases. Complete data included the case history where the physician in charge of the case had recorded a day-by-day record of the case from admission to death. Complete data also included the complete postmortem findings including histopathology and ancillary techniques. We have randomly selected 1 or 2 years autopsy data from each decade from 1947 to 2010 using non-probability, convenient random sampling method and finally 591 autopsy cases were selected for data analysis. We analyzed only autopsies in which the complete clinical details and an antemortem diagnosis were available. We also ensured that only complete autopsies were analyzed and partial autopsies, neonatal autopsies and medico legal autopsies were excluded. It was also ensured that all the autopsies were performed according to standard protocols.
For determination of discrepant diagnoses, clinical and autopsy records all the 591 cases were reviewed separately. The clinical records were reviewed independently and retrospectively without knowledge of autopsy findings. Clinical diagnoses, suspected and confirmed, were interpreted based on the hospital charts, autopsy request forms and death certificates. Autopsy diagnoses were annotated based on the final autopsy reports. Autopsy diagnosis was taken as the gold standard. All cases were divided into two categories like discrepant and non-discrepant cases based on disagreement and agreement between clinical antemortem and autopsy diagnosis. Discrepancies were defined as major when it was directly related to cause of death and minor when was not directly related to cause of death. In our study, we have only analyzed the major discrepancies.
In addition to discrepancies, we also noted the major categories of disease, which were responsible for causing death in these discrepant cases. We categorized diseases as neoplastic, infective, traumatic, cardiac, neurological, hepatic, toxic, congenital and renal. Examples of these categories are presented in [Table 1].{Table 1}
Time of death after admission
Patients were also categorized into two categories; the first included patients where death occurred within 24 h of admission and the second when death occurred after 24 h after admission. This was done to evaluate if there has been a significant change in the survival of patients over six decades after admission in a tertiary care center.
Statistical analysis was performed using SPSS for Windows version 14.0 . P < 0.05 was considered significant. Quantitative variables were expressed as mean ± standard deviation. The reliability co-efficient in terms of 95% of confidence interval was calculated for the percentage of discrepant cases. The trend in the percentage of discrepant cases from 1947 to 2010 was analyzed using a simple regression model with the equation along with the R2 value.
Results
A total of 591 autopsies were analyzed. The breakup of the autopsy cases analyzed per year is as shown in [Table 2].{Table 2}
Mean age of the patients
In our study, the mean age of the patients was 34.63 ± 3.11. The year wise mean age is also shown in [Table 3]. We found that there been no significant change in the mean age of the patients who were autopsied. In our study, male to female ratio was 10.3:1.{Table 3}
Time of death after admission
An analysis of the data showed that there had been a statistically declining trend in the number of cases who have died within 24 h of admission with R2 value (0.706) [Figure 1].{Figure 1}
The figure was 17% in 1947. The percentage remained almost constant until 1970 when there has been a sudden significant fall in the percentage. This trend has been maintained over the next four decades until 2010.
Characteristics of the autopsy cases
The autopsy cases were classified based on the broad etiological head as neoplastic, infective, traumatic, cardiac, neurological, hepatic, toxic and congenital. Majority of the cases were due to neoplastic (30.62%), infective (29.44%) and cardiac (14.72%) cases. Year wise data was analyzed and also expressed in the form of a percentage of the total number of cases. The data presented in [Table 4], showed In 1940s, neoplastic and infection related deaths formed the majority of the cases who were autopsied. However, in recent past 2000-2010, it was formed by the infection related deaths along with cardiac, hepatic and renal cases.{Table 4}
Major discrepancies seen between the ante-mortem and post-mortem diagnosis
Year wise percentage of the major discrepancies noted between the antemortem and postmortem diagnosis is shown in [Table 5]. In our study, 137 cases out of 591 had major discrepancy and overall discrepancy rate was 23.18%. Major discrepancy was seen in neoplastic (20.9%), infective (21.26%) and cardiac (27.58%) cases.{Table 5}
Reliability coefficient in terms of 95% confidence interval calculated for percentage of discrepant cases. Trend in percentage of discrepant cases from 1947 to 2010 analyzed using simple regression model with R2 value. An analysis of the data showed that there had been a statistically significant decrease in the percentage of the discrepant cases over the last six decades. The percentage of discrepant cases had dropped from almost 40% in 1940-9.39% in 2010 [Figure 2].{Figure 2}
Major discrepant diagnoses in autopsy cases with specific diagnoses by type
In all cases where there was a discrepancy between the clinical and autopsy diagnosis, an analysis by the specific type of disease was done. Since there has been a decrease in the discrepancies between the clinical and autopsy diagnosis over the entire period, showing the data in the form of a percentage may not appear representative as in [Table 5]. Therefore, the details of the cases from 1990 have been elaborated in detail since the numbers of cases were few.
In 1990, there was a case of a mesothelioma misdiagnosed as a carcinoma lung. In the second discrepant case, a case of viral hepatitis was treated symptomatically. However, he also had marked coronary atherosclerosis and gradually developing heart failure. He died due to the progressive heart failure. In 1994, there were two cases of carcinoma of the head of pancreas which were diagnosed as hepatocellular carcinoma based on clinical and imaging techniques.
In 2000, there were three cases where there was a discrepancy between the clinical and postmortem diagnosis. In the first case, a young male was diagnosed as a case of cerebral malaria. Postmortem offered a diagnosis of DIC (Disseminated Intravascular Coagulation) as a sequel of Japanese encephalitis. In the second case, the antemortem diagnosis was massive thromboembolism in the pulmonary vessels based on the imaging findings. The postmortem showed a large intra cerebral blood clot and septicemia without any evidence of a pulmonary thromboembolism. The last case was of colonic amoebiasis, in which the presenting symptoms and radiological findings closely resembled an obstructing right-sided colonic carcinoma, with liver metastases. Patient underwent extensive surgery and later died due to septicemia.
In 2005, there were three cases where there was discordance between the antemortem and the postmortem diagnosis. One patient was a 31-year-old male who was diagnosed as a case of tuberculosis and put on anti-tubercular therapy. However, he went into fulminant hepatic failure as a result of therapy and died. After postmortem, the diagnosis was revised to Kikuchi's disease. In the second case, an immunocompromised patient, diagnosis of systemic fungal infection (mucormycosis) was missed in antemortem work-up. In the third case, the patient was diagnosed as a case of septicemia with exertional heat stroke because he died while undergoing severe physical exertion. The autopsy showed the hemorrhagic stage of leptospirosis.
In 2010, five cases showed a discrepancy between the antemortem and postmortem diagnosis. The first was a case of a young postpartum female who went into cardiac arrest. On autopsy, the diagnosis offered was arrhythmogenic right ventricular dysplasia. The second case was that of a 72-year-old male who was diagnosed as a case of septicemia. An autopsy showed a T-cell lymphoma. A third case was diagnosed as toxic inflammatory myopathy, which did not show any features on postmortem. In the fourth case, an 80-year-old diabetic patient, diagnosis of systemic fungal infection was missed during antemortem work-up. The last case was a case of acute respiratory distress syndrome, which showed lymphocytic myocarditis on postmortem.
Discussion
In our study, there was no significant change in the mean age of hospital related deaths. Other studies have shown wide discrepancies in the age of autopsied patients with an age range from 15 to 94 years. [2],[7]
We feel that this data is of limited value especially since the cases included a wide variety of diagnosis including medical and surgical cases.
Time of death after admission
In our study, there was a significant decrease in the number of cases who died within 24 h of admission. We attribute this to improvements in emergency care. Lu et al. [13] analyzed a series of patients with early mortality. Early mortality was defined as the deaths occurring within 24 h of admission. They concluded that the major causes contributing to early mortality were (i) misdiagnosis (ii) delayed diagnosis, which included a delay in making the correct diagnosis and providing timely medical-care and (iii) inappropriate medical management, which included other actions or missed actions that would result in the unexpected death of the patient. In our study, we noticed that there were a large number of cases in the 1940's, 1950's and 1960's where the diagnosis was not clear antemortem. In such cases, the autopsy provided the final diagnosis. The quality of antemortem diagnosis has improved over the 70's and 80's. In the 90's and during the first decade of this century, diagnostics have improved to such an extent that the discrepancies between the antemortem and postmortem diagnosis is relatively uncommon.
In relation to inappropriate medical management, we believe that medicine has been changing over the years. In agreement with the opinions of McDonald et al. and Honig et al., [14],[15] we believe that medicine is an ever changing art and that deaths because of wrong treatment or wrong judgment may not necessarily indicate errors in some circumstances. For example, in the pre antibiotic era, when diagnostics were limited, clinicians had to rely on their clinical judgment to a large extent. The study indicates that newer diagnostic and therapeutic measures instituted over six decades have significantly decreased the early mortality.
Characteristics of autopsy cases
When we analyzed the characteristics of the autopsy cases, we found that there was a significant year-to-year difference in the neoplastic, infective, cardiac, neurological and hepatic related deaths in which autopsies were carried out [Table 4].
Neoplastic causes
We found a steady increase in the percentage of discrepant cases due to neoplastic causes from 1947 to 1994, after which there has been a significant drop. Marked improvement in the newer diagnostic measures instituted over the decades, enabled clinicians to get an early and correct antemortem diagnosis. Since most of the cases are diagnosed antemortem, the deaths due to neoplastic diseases are not subjected to autopsy.
Infectious causes
In our study, we found the majority of the cases were caused by bacterial, protozoal, mycobacterial infections (predominantly involving the gastrointestinal tract) along with viral, spirochetal, fungal and rickettsial infections. While analyzing the trend in the discrepancy rate due to infection related deaths, we found a steady decline in the discrepancy rate in the infection related deaths till 1994. This is perhaps due to better and more effective antibiotics, which are now available and newer diagnostic measures instituted over the decades. Studies over the years have shown that effective antibiotic therapy has significantly reduced mortality in infectious disease. [16],[17]
In fact, Arkwright and David have documented a 98% reduction in the mortality rate in children in England and Wales after the introduction of antibiotics. [17]
After 1994, there has been a significant increase in the number of discrepant cases due to the infection related deaths until 2010 (P < 0.05) [Figure 3]. This is more complex and difficult to understand. We attribute this phenomenon to two possible causes; the first is an increase in antibiotic resistance, which is an accepted fact. [18],[19]{Figure 3}
The second possible cause is because of the acquired immune deficiency syndrome epidemic in India, which has led to an increase in the number of deaths due to secondary infection. [20]
Cardiac causes
In our study, we also found that death due to cardiac causes has shown an increase until 1962, which has been followed by a steady decline. The Framingham study was a pioneering study in defining the risk factors for coronary artery disease. [21],[22]
The ramifications of this study were felt all over the world including India. Changes in life-style were instituted based on this study and the mortality rate from cardiac disease subsequently decreased. We attribute this to better preventive measures being instituted over the years.
Discrepancies between antemortem and postmortem diagnosis
There has been a statistically significant decrease in the discrepancies between the antemortem and the postmortem diagnosis over the years. This is in direct contrast to other studies [6] who have said that the overall major discrepancy rate seems to have remained the same since 1960. In our study, we found over all discrepancy rate of 23.18%, comparison with other studies is shown here in [Table 6]. [6],[11],[12],[23],[24] Goldman found a shift in discrepancies from Class 2 (a discrepant major diagnosis but with equivocal or no impact on survival) to Class 1 (a discrepant diagnosis with a potential impact on survival) between the 1960s and 1980s but with no change in the overall discrepancy rate.{Table 6}
Several studies have noted a declining autopsy rate and some considered the potential effect of a low autopsy rate to raise the apparent discrepancy rate as the cases, which are thought to be least likely to show discrepancies do not undergo autopsy. There are studies showing this effect [10] and one study of 300 patients in a center with an autopsy rate of around 90% found a declining major discrepancy rate from 30% in 1972 to 14% in 1992. [25]
This finding correlates well with our present study. The study by Cameron et al. [26] designed to reduce this potential bias, with an autopsy rate of 65%, found little difference between cases where the clinicians were confident of their diagnosis and those where they were not; there was also a similar discrepancy rate in cases where the clinicians would have requested an autopsy to those where they would not. In our center, being a teaching hospital, autopsies are mandatory even when the clinicians are sure of their diagnosis. The decrease in discrepancies in our study would be explained by better diagnostics and imaging studies, which has dramatically reduced the discrepancy rate.
This study has several important conclusions. It has shown that there has been a significant decrease in the discrepancy rate between antemortem and postmortem diagnosis in the last seven decades. However, the discrepancy in 2010 is still very high at 9.09%. We can conclude that the autopsy may have declined in value, but it is still a very important tool for the clinician for providing the final diagnosis.
In recent years, research into the etiopathogenesis of disease includes evaluation of ribonucleic acid and protein expression. Usually, such studies are performed on biopsy if site are accessible. However, autopsies are useful to obtain tissues from sites which are inaccessible to biopsy techniques. One of the examples may be brain tissue where autopsies are a great source for studying neurodegenerative diseases. Therefore, the autopsy will continue to remain relevant for research purposes, especially in elucidating the molecular cause of disease, but it remains limited to site accession rather than amount of material.
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