Death as Data: Autopsy and the Death Certificate

Two basic goals value of the autopsy proper use of the death certificate

Essential websites and URLS

Bruce.case@mcgill.ca

National Association of Medical Examiners Death Certificate Tutorials: http://www.thename.org/CauseDeath/main.htm

A Canadian angle: 1998 article from the Canadian Medical Association Journal: http://www.cma.ca/cmaj/vol-158/issue-10/1317.htm

Outline

Autopsy: history in three periods; The fall of the autopsy: 1960 onward Evidence of continuing relevance Some attempts to explain the problem

Effects of falling rates

An example of the effect

Death certificate: what it is, how it should be approached

The autopsy in history

1. Classical period: test authority

2. Pre-modern period (17-18C) : emphasis

on anatomy 3. Modern period; 19C on

a.
b. c.

Rokitansky (gross autopsy)

Virchow (added the microscope) Osler a modern example

d.

Ultimate recognition as prime goal a contribution to medical knowledge

Falling Autopsy Rates

1. From 50% in the 1960s to 2. Much lower than 10% today, despite 3. (for example) of three U.S. studies, an incorrect diagnosis of malignant tumors was shown in
a. 36.5% of cases (1923) b. 41% of cases (1972) c. 44% of cases (1998, Louisiana)

Falling Autopsy Rates: RVH 1998

(figures from 1998)

DEATHS 721 43 19

AUTOPSIES 92 3 12

RATE (%)

ADULT INPATIENTS EMERGENCY INFANTS (OVER 500g)

12.8% 7% 63%

JAMA 1998: Louisiana study

1. All autopsies 1986-95 2. Outcome measure: discordance

in clinical vs. autopsy for cancer 3. 1105 cases; mean age 48 years (very atypical) 4. 443 neoplasms at autopsy; 250 malignant 5. 111 wrong CLINICAL diagnoses of malignancy including 57 which caused death

So what is wrong? 1. Why do the rates keep falling in the face of continuing evidence of error?
1. Increasing reliance on imaging
2. Fear of lawsuits? May explain USA but

not elsewhere

So what is wrong? 2. Changing patterns in pathology

1. Changing patterns in pathology and

pathologists
2. A new but worrying factor: regard for

autopsy practices as violating civil rights (lawsuit in UK over pediatric autopsies); reflects a constant fight over values over the years coupled with some abuses such as Burking

So what is wrong? 3. Poor communication

5. Suggestions of poor communication

between pathologists and clinicians:

a. Wherever a special effort is made to

educate rates increase, although this

may be transitory. Rates can reach 100% in some centres!

So what is wrong? 4.
5. Suggestions of poor communication

between pathologists and clinicians:

b. Poor pay, lack of curiosity, lack of

professional attitude to reporting can lead to vicious circle of late reporting;

c. Clinical mortality rounds seem to result

in higher rates when pathologists attend

Is anything right?
1. In academic centres cases with

unknown cause still invoke requests for autopsy;

2. This means that almost every

increasingly rare autopsy has become more interesting both for the pathologist, for teaching, and for publication, BUT...
3. This applies only to academic centres

Effects of falling rates

1. Similar to effects of bad death

certificate reporting
2. National health statistics wrong; 3. Lack of Quality Control; 4. Problems for analytical

epidemiology (garbage in, garbage out)

Autopsy trends and their effect on disease ascertainment: an example.

1. 1. What is this lesion?
2. 2. How rare is it? 3. 3. Difficulties in Diagnosis: 4. 1. Result in UNCERTAINTY (or guessing This could be X or possibly Y or) 1. 2. Result in outright error (mainly lung ca)

Special Procedures in Pathology: Trends for 228 women with mesothelioma 1970-90
60%

Prior to 1985 1985 and Later

50%

40%

30%

20%

10%

Trends among 142 and 98 female cases diagnosed 1970-1984 and 19851991, respectively.

0%
Immunopath Electron Micr. Histochem Autopsy Rate

Effect of Autopsy Rate on Reliability and Accuracy in Two Diagnostic Eras

Number of cases
Autopsy done, 19701984 Autopsy not done, 19701984 Autopsy done, 19851991 Autopsy not done, 19851991

Uncertain of Diagnosis 26%

Accuracy (10 = perfect) 5.8 +/- 2.1

59

83
20

52%
20%

4.7 +/- 2.9

6.9 +/- 1.2

78

42%

5.8 +/- 2.4

CMAJ ARTICLE
1. Improving the accuracy of death certification
Eight case scenarios are presented
Kathryn A. Myers, MD, EdM; Donald R.E. Farquhar, MD, SM CMAJ 1998;158:1317-23

Ontario Death Certificate

2. WRITING CAUSE-OF-DEATH
STATEMENTS

An On-Line Tutorial http://www.thename.org/CauseDea th/main.htm

Why learn this now?

Often, a physician's first encounter with the death certificate occurs upon the physician's first patient death when he/she is handed the death certificate form and asked to complete it. This usually occurs during the first year of residency. Many, perhaps most, are not told how and never learn!

The cause-of- death statement contains two parts: Part I

I. A)
Due to, or as a result of B) Due to, or as a result of C)

PART I is designed so that a sequence of conditions leading to death may be reported

The cause-of- death statement contains two parts: Part II

II. Part II. OTHER SIGNIFICANT CONDITIONS: Conditions contributing to death but not resulting in the underlying cause of death in Part I

EXAMPLES: hypertension, diabetes, chronic obstructive lung disease, renal diseasediseases pre-existing or co-existing with the MAIN UNDERLYING DISEASE but NOT related to it

PART I: ONE CONDITION per line, starting with the most recent condition on the top line and going backward in time
PART I: A. Most recent condition (e.g., Cardiac tamponade) Due to, or as a consequence of: B. Next oldest condition (e.g., Ruptured myocardial infarction) Due to, or as a consequence of: C. Oldest (original, initiating) condition (e.g., Atherosclerotic coronary artery)

Part I A. Cerebral infarction Due to, or as a consequence of:

An example

B. Thrombo-embolism to right internal carotid artery Due to, or as a consequence of:

C. Thrombo-embolism from bacterial endocarditis of mitral valve Due to, or as a consequence of: D. Floppy mitral valve syndrome (underlying cause of death-- the specific condition (disease or injury) that started the downhill course of events that led to death.)

Variants; problems

Single Line Part I Format (missing data) e.g. no autopsy, patient dies at home, known to have prostate carcinoma uncertainty or presumption: use probable

ALWAYS REPORT CANCER! Can cheat on part two to record risk factor (smoking, asbestos exposure)

Additional Information on the Death Certificate

1. Usually a space to record TIME since onset of event 2. Always indicate whether (a) an autopsy has been asked for and (b) whether the DC includes autopsy information 3. In some places, can record occupation retired is NOT an occupation!!! 4. Mandatory reporting: violent death, certain infections; varies with state

Multiple cause-of-death coding

1. All data to date are based on a SINGLE cause of death but 2. Modern national statistics programs record ALL information on the death certificate and can derive 3. multiple cause-of-death data

http://www.thename.org/CauseDea th/main.htm
(This is the web address for the tutorial on death certificates)