Histopathology at autopsy: why bother?

AIMS

The frequency of histopathological sampling at autopsy varies, even though inadequate sampling may limit the value of autopsy reports. This study aims to investigate the contribution of histopathology at autopsy in a major teaching hospital.

METHODS AND RESULTS

A total of 532 coronial autopsy reports from Manchester Royal Infirmary were analysed retrospectively. Gross and microscopic diagnoses were compared and classified as concordant, discordant, histology needed (i.e. indeterminate or unremarkable gross findings) or autolysed. Revisions made to the cause of death following histopathology were categorised as: altered direct cause of death, altered indirect cause of death, concordant with supportive information, irrelevant or inconclusive. The study was limited to brain, heart, kidney, liver, lung and spleen. Histopathology had been requested in 141 cases (27%), which were further analysed. The greatest discordance between gross and microscopic findings was observed in the lung (11.6%). The organs most frequently requiring histopathology to provide a diagnosis were the kidney and lung, at 52.8 and 28.2%, respectively. Alterations were made to the direct cause of death in 45% of cases where histopathology was taken; it provided additional or supportive information in a further 38%. Diagnoses of primary malignancy had a sensitivity of 74% [confidence interval (CI) = 0.59-0.86] and bronchopneumonia had a sensitivity of 45% (CI = 0.29-0.62).

CONCLUSION

Histopathology has a major impact on the interpretation of organ pathology and determining a cause of death at autopsy.

Dissecting and Streamlining the Medical Record Acquisition Process in Death Investigation Systems

Though medicolegal death investigation (MDI) systems are generally associated with criminal justice, they serve an integral role in the realm of public health and safety. Medicolegal death investigation offices collect information, including medical records, from a variety of outside sources. For data to travel efficiently, transmission should be fully integrated between the MDI office and external organizations. This is often not the case. Delays in the transmission of medical records in particular lead to subsequent delays in autopsy report completion and death certification or to resource waste in cases where a timely record would have let the pathologist know an autopsy was not required. Almost no peer-reviewed literature currently exists regarding the problem of record acquisition by MDI systems. To develop a better understanding of how electronic medical records have impacted MDI systems, we conducted a mixed methods survey through the National Association of Medical Examiners (NAME) e-mail listserv. We inquired about the medical records acquisition processes at MDI systems around the nation to gauge opinions about the use of electronic health data and the integration of MDI data in public health. Concurrently, we piloted a quality improvement project at the Alameda County Sheriff-Coroner's Office (ACSCO) in Oakland, California, in which we worked with various hospitals to get ACSCO employees direct access to decedents' electronic health records. With data from the survey and pilot project, we were able to document the barriers encountered when attempting to reform medical record acquisition and to suggest systemic changes to reduce delays and wasted resources.

The utility of medico-legal databases for public health research: a systematic review of peer-reviewed publications using the National Coronial Information System

BACKGROUND

Medico-legal death investigations are a recognised data source for public health endeavours and its accessibility has increased following the development of electronic data systems. Despite time and cost savings, the strengths and limitations of this method and impact on research findings remain untested. This study examines this issue using the National Coronial Information System (NCIS).

METHODS

PubMed, ProQuest and Informit were searched to identify publications where the NCIS was used as a data source for research published during the period 2000-2014. A descriptive analysis was performed to describe the frequency and characteristics of the publications identified. A content analysis was performed to identify the nature and impact of strengths and limitations of the NCIS as reported by researchers.

RESULTS

Of the 106 publications included, 30 reported strengths and limitations, 37 reported limitations only, seven reported strengths only and 32 reported neither. The impact of the reported strengths of the NCIS was described in 14 publications, whilst 46 publications discussed the impacts of limitations. The NCIS was reported to be a reliable source of quality, detailed information with comprehensive coverage of deaths of interest, making it a powerful injury surveillance tool. Despite these strengths, researchers reported that open cases and missing information created the potential for selection and reporting biases and may preclude the identification and control of confounders.

CONCLUSIONS

To ensure research results are valid and inform health policy, it is essential to consider and seek to overcome the limitations of data sources that may have an impact on results.

Death investigation systems and disease surveillance

Medico-legal death investigation systems have the potential to play an important role in disease surveillance. While these systems are in place to serve a public function, the degree to which they are independent of central government can vary depending on jurisdiction. How these systems use this independence may present problems for public health initiatives, as it allows death investigators to decline to participate in government-led surveillance regardless of how critical the studies may be to public health and safety. A recent illustration of this problem in the UK is examined, as well as general lessons for removing impediments to death investigation systems participating in public health research.