UNLABELLED:New techniques have influenced the attitude to the autopsy and contribute to a de-emphasis on the importance of post-mortem examination. Since 1990, new Danish legislation has provoked a dramatic fall in the autopsy rate, which had already declined from 45% in 1970 to 35% in 1980. In the first half of 1990 the rate was 24% in the second half of that same year it had fallen to 16% (SOURCE:The Danish National Institute of Health, 1992). The clinicians now seem to manage without the autopsy to confirm or correct their daily diagnostics. They also seem to be of the opinion that they do well without this "final checklist". The autopsy, however, is still an important tool in understanding, correcting and improving future diagnosis. Therefore, post-mortems should again be carried out as a matter of course and common practice. The following proposals are all aimed at obtaining a higher autopsy rate: The 1990 legislation on autopsy should be changed so that permission to perform a post-mortem can be given in due time, before the supposed death, preferably by the patient himself and obviously with the right to a subsequent change of mind. It is of great importance that the Public Health Service informs both the public and health workers in general about the nature and importance of the autopsy. Likewise, doctors and health workers in general should be educated in how best to give information to patients. Pathologists should, through a more uniform and exact practice, encourage the clinicians to a renewal of the close collaboration concerning the facts revealed by the autopsy, both in their everyday practice and in scientific projects in general.
Four randomized Swedish studies on the usefulness of mammography in screening for breast cancer have been published. The results have shown a variable but positive effect of screening in women more than 50 years of age but the effect is questionable before this age. The protocol and end points however differ between the studies and in order to summarize the results of the present studies, an unbiased, blinded end-point committee was created. The results of this study have been published recently. The present communication only concerns the role of autopsy in this study. The deaths of 1367 patients with a diagnosis of breast cancer have been studied. The percentage of autopsy varied from 21 to 74% between the four studies. When autopsy was performed, 58% were found to have died from breast cancer, 13% from other malignancies and the rest from other diseases. In cases with no autopsy, 73% were considered to have died of breast cancer and 9% of other malignancies. Deaths due to other cancers included a surprising number of cancers of the stomach, gallbladder and pancreas, two to three times higher than expected.
A retrospective study of post-mortem examinations of abortions and perinatal deaths (104 cases) were undertaken in order to evaluate the clinical importance of the findings. The major disease and the cause of death were clinically diagnosed in about 50% of cases (usually medical abortions and liveborn infants). Only one clinical mis-diagnosis was revealed by autopsy. In an additional 25% of cases (usually spontaneous abortions and intra-uterine deaths) were the major disease and cause of death disclosed by autopsy, leaving about 25% of cases undiagnosed even after post-mortem examination. In considerably more than half the cases, important new information was gained through the autopsy. The study shows that the pathologist can make a considerable contribution to the medical personnel and the family who are dealing with the loss of a young life.
The autopsy rate has declined in the last 20 years in Sweden and is now approximately 30%. Clinical autopsies constitute about 18% and medico-legal autopsies somewhat more than 10%. There is an obvious geographical variation in clinical autopsy rate, whereas the variation in medico-legal autopsy rate is narrower. The difference in autopsy frequency between males and females seemed to be mainly dependent on the higher number of medico-legal autopsies among males. In order to explore the reasons behind the decline in autopsy rate we accomplished a study of the autopsy rate in 1986 and 1991 in three Swedish hospitals of various types and sizes. The hospitals studied were one university hospital and two community hospitals of different sizes. The autopsy rate varied between 0 and 100% among the different departments within these hospitals and also varied considerably between wards within the same department. The number of clinical autopsies declined between 1986 and 1991 in all three hospitals. The fall was greatest in the university hospital and in the larger of the two community hospitals. However, in these two hospitals departments with active research of clinico-pathological relevance maintained or even increased their autopsy rate during this period. The decline in autopsy rate in general and the difference in rate between hospitals, departments and wards could be explained neither by the Autopsy Act of 1976, or by the reluctance of relatives to give consent to the autopsy of a relative. A change in attitude toward and interest in the autopsy activity of clinicians seemed to be the major explanation for the decline of the autopsy.
A retrospective analysis of 3042 autopsies was carried out to determine and compare the discrepancy rates between clinical and autopsy diagnoses as well as the sensitivity and specificity of clinical diagnostics in 10 diseases in 1977/78 and 1987/88. The autopsy rate decreased from 80% to 39%, which might explain the increased discrepancy rate from 22% to 27% regarding the diagnoses of major, principal diseases. The accuracy of clinical diagnostics seemed to improve during the period for some of the diseases (pulmonary embolism, peptic ulcer, infectious carditis, peritonitis), while it worsened for others (acute myocardial infarction, thrombosis of the mesenteric artery, ruptured aortic aneurysm, tuberculosis) or remained unchanged (cirrhosis of the liver, malignant tumours regarded as a whole group). The findings underline the importance of autopsies and their cumulative studies in assessing the accuracy and providing data for the determination of necessary fallibility of clinical diagnostics.
The factors which could influence the selection of cases for post-mortem examination were analysed during a 6-month period. The variables studied included the age and sex of the patients, the length of terminal hospitalization, the principal disease, the certainty of the clinical diagnostics and the extent of the clinical investigation. Both clinical and autopsy records were reviewed. Seventy-four patients died at the Department of Surgery during this period of whom 50 (68% autopsy rate) were autopsied. The autopsy rate was influenced by (a) the length of the terminal hospitalization, (b) the diagnosis of the principal disease and, to a certain degree, (c) the extent of the clinical investigation. Thus, patients who were hospitalized for a shorter period, had no clinically diagnosed malignant tumours and were not investigated with more sophisticated methods were more frequently autopsied. The discrepancy rate between principal clinical and post-mortem diagnoses was 28% and was not influenced by the use of modern investigative methods.
In many treatment trials the aim is to prevent deaths from one type of disease. The cause of death evaluation is therefore of the utmost importance. A high autopsy rate is required, even as regards sudden deaths that cannot routinely be referred to as ischemic heart disease. Autopsies are also necessary for studying non-lethal and lethal side effects of the involved drug. Even in the best of cases the post-mortem rate is far from 100% and correctness of the cause of death evaluation is not ensured. If the treatment has prevented deaths from the cause studied, this gain must not be outweighed by increases of other causes of death, for the result to be considered reliably positive.
Previous audit at the Homerton Hospital had revealed a poor level of compliance with established antenatal protocols mandated by risk factors detected at the booking visit. Medical staff were questioned as to their awareness of five of the most important protocols and their response was analysed by a new scoring system. The scores were generally low though consultants scored more highly than junior staff. Scores were related to the length of obstetric experience and duration of work in the obstetric unit but were not related to frequency of the use of the protocol manual nor to the last time that reference was made to the manual. To improve compliance within the unit, the following recommendations were made: (1) regular revision of protocols to incorporate the current views of senior clinicians and (2) improved dissemination of information. The scoring system described here should prove to be a simple and effective method for the assessment of protocols within any unit.
Autopsy findings from a representative sample of deaths in a clinic provide an opportunity for regular and systematic revision of medical diagnostics and treatment. A standardized analysis of the collected results can furnish useful figures for comparisons and follow-up. On this basis, new strategies for future improvement of medical care should be outlined. Autopsy results can also be used for medical audit concerning more limited items like the certification of death.
Autopsy can represent a key instrument in auditing clinical diagnosis performance, on which in turn the accuracy of diagnoses, as used in a variety of epidemiological investigations, depend. This audit can be implemented through clinico-pathological surveys which require both accurate pathological examinations and validity of study design and analysis. To this end, estimates of sensitivity and specificity of the clinical diagnosis, using the autopsy diagnosis as a yardstick, should be obtained, which can however be severely distorted by factors such as nonrandom selection of cases for autopsy or by unrecognized errors in post-mortem diagnosis. Such distortion may be minimized by (a) estimating the likely magnitude of errors in postmortem diagnosis, (b) specifying standard conditions for performing autopsies and (c) ensuring an unbiased sample of moderate size rather than a large biased sample. Considerable improvement in the validity of clinico-pathological surveys as carried out up until now is possible, and there is room for research to provide the necessary information (e.g. on necropsy diagnosis variability and feasible sampling schemes).
The aim of the study was to analyse the agreement between pathologists regarding macroscopic autopsy diagnostics. Four pathologists examined 35 autopsies and determined the principal disease and its complications, the immediate cause of death, other major diseases and their complications, and minor diseases. The participants were paired and their diagnoses were analysed by using kappa statistics for interobserver variation. The agreement on the principal disease was almost perfect between the participants (kappa values between 0.83 and 0.97), whereas that on the immediate cause of death was moderate/substantial (kappa values between 0.43-0.75). The list of all other major diseases and their complications was almost complete for each observer, but that of the minor diseases showed a more considerable variation. In spite of the high level of agreement it is recommended that the autopsy findings be discussed among pathologists if the clinical picture cannot be explained satisfactorily, and that the cause of death be determined by the clinicians after the demonstration of the autopsy.
The study assessed the quality of care in 410 geriatric patients admitted for rehabilitation following a hip fracture (53%) or stroke (47%) to two types of inpatient setting: geriatric departments in general hospitals (GDs) and free-standing geriatric hospitals (GHs), 45% and 55% of patients, respectively. The assessment of care was based on two outcome criteria, change in functional status (Barthel Index) and patient destination on discharge. Findings suggest that rehabilitation performed in GHs had some advantage over that in GDs although the cost of stay in GHs is half of that in GDs, and GHs seem to be also more cost-efficient. The finding indicates one way in which assessment of quality contributes to health policy and planning.
UNLABELLED:To develop an instrument to measure the quality of acute respiratory infection (ARI) case management among Egyptian children.METHODS:A baseline survey of all health facilities in a single district, using a multi-data source instrument. Data sources included providers, caretakers, patient records and observation of patient care.MAIN RESULTS:Physicians did not count the respiratory rate and check for subcostal retraction. Eighty-seven per cent of children who did not require antibiotics received them. Of five children who required antibiotics, four (80%) were prescribed an oral regimen. Three of these should have been admitted to a hospital but were not. Antibiotics were available at the facilities an estimated 7.9 months per year. Oxygen for inpatient treatment was available in one of two hospitals.CONCLUSIONS:This instrument was useful for comprehensively evaluating facility capability to provide quality case management. Deficiencies were identified but were not unexpected in a baseline survey. The Egypt ARI program has the potential to have a substantial impact on how children with ARI are diagnosed and treated in health facilities.
Journal Article Quality in Alternative Care Get access Josef Bohm Josef Bohm Anglo-European College of ChiropracticBournemouth, UK Search for other works by this author on: Oxford Academic PubMed Google Scholar International Journal for Quality in Health Care, Volume 5, Issue 2, 1 June 1993, Pages 175–176, https://doi.org/10.1093/intqhc/5.2.175 Published: 01 June 1993 Article history Received: 27 December 1992 Accepted: 29 December 1992 Published: 01 June 1993
Journal Article Effect of Total Hip Replacement on Quality of Life Get access IAN GOLDIE IAN GOLDIE Orthopaedic Department, Karolinska InstituteStockholm, Sweden Search for other works by this author on: Oxford Academic PubMed Google Scholar International Journal for Quality in Health Care, Volume 5, Issue 1, 1 March 1993, Pages 9–12, https://doi.org/10.1093/intqhc/5.1.9 Published: 01 March 1993 Article history Received: 08 September 1992 Accepted: 22 October 1992 Published: 01 March 1993
In a quality nursing care survey conducted in Israel, 1988-1990, the four nursing process components were examined. The survey covered 13 hospitals with 119 medical and surgical wards, in which the nursing care quality for a sample of 2065 patients was assessed. Instruments used were (a) the Patient Classification Form, to assess patient dependency level, and (b) Monitor--an index of the quality of nursing care for acute medical and surgical wards [Goldstone et al., Polytechnic Products, Newcastle upon Tyne, 1982], a British adaptation of the Rush Medicus methodology [Jelinek et al., US Dept of Health, Education and Welfare, 1974]. The survey process involved orientation of the hospitals' senior staff, and training of participants in the administration of patient classification and of Monitor. The highest quality nursing care was found in "Meeting the patient's physical needs"; the lowest in "Assessment and planning of patient care". Factors chosen for possible influence on quality of nursing care were: patient dependency category, type of ward (medical, surgical), ward size and hospital size. The most influential factor was found to be the patient dependency category.
The development of quality assurance programmes for psychiatric care has increased the interest in quality of care and accountability from the patient's perspective. The aims of this study were threefold. First, to map descriptive characteristics of ideal outpatient psychiatric care through open-ended patient interviews, using a sample of 94 psychiatric outpatients, second, to have another sample of 84 outpatients rank the importance of 57 treatment characteristics extracted from the qualitative analysis of the interviews, and third to make comparisons with a previously performed investigation on quality of care of psychiatric inpatients. Results of the content analysis showed that characteristics of ideal outpatient treatment could be classified in eight content categories: accessibility of care, treatment content, staff-patient relationship, continuity of care, staff's professionalism, patient information/co-influence, treatment environment and cost of care. Results from the patients' rating of the importance of treatment characteristics showed that patients put the highest emphasis on staff's empathetic qualities in being interested, understanding, listening and respecting patients. Comparisons with the previously studied inpatient sample, showed great similarities in what was considered important to reach a satisfactory care situation. It is concluded that in order to secure content validity of investigations of the quality of psychiatric care from the patient's perspective, effort should be put into including the areas of staff-patient relationship and patient information and co-influence.
The authors present the findings of a study in three stages (1989-1991) on the appropriateness of human albumin use at the hospital of Padova, Italy. In the first stage, guidelines for appropriate use were defined and a monitoring system was set up. In the second stage, compliance of the hospital departments with the new guidelines was assessed in a sample of human albumin prescription charts and related medical records. This revealed a reduction in consumption of 25%. Sixty-eight per cent of all albumin was given for indications that are only occasionally appropriate. The information given in the prescription chart agreed with the diagnosis contained in the medical records in 78% of cases. At the end of this stage new regulating mechanisms were introduced. The third stage consisted of a medium-term assessment and produced basically the same results as the previous stage. Crucial steps in the implementation of effective actions in quality improvement processes have been discussed.
A consensus panel approach was used in Israel to develop a list of clinical indications for which there was agreement that cholecystectomy should be performed. Nine physicians from different disciplines were asked to score a list of 266 clinical indications for cholecystectomy. Each indication was scored on a scale of 1 (inappropriate, i.e. health risks exceed health benefits) to 9 (appropriate, i.e. benefits exceed risks). Each indication also included one of four comorbidity levels (none to high). Agreement and disagreement were defined and panelists met to discuss, modify and rescore the list. The composition of the panel and definitions of agreement had a considerable impact on the preparation of a list of agreed, appropriate indications for cholecystectomy. Gastroenterologists in the panel were less likely to recommend surgery than either surgeons or general internists both before and after the panel discussion. Following the discussion the level of agreement (defined as after discarding the highest and lowest score all of the remaining seven panelists were in a 3-point range) increased from 39% to 46% (p < 0.08) and disagreement decreased from 27% to 18% (p < 0.01). Fifty-nine of the 266 indications were considered appropriate with agreement.
