Annals of Clinical & Laboratory Science 35:387-390 (2005)
© 2005 Association of Clinical Scientists
The Autopsy in a Tertiary Teaching Hospital in Brazil
Luiz Cesar Peres and
Alfredo Ribeiro-Silva
Department of Pathology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil
Address correspondence to Alfredo Ribeiro-Silva, M.D., Ph.D., Departamento de Patologia, Faculdade de Medicina de Ribeirão Preto - USP, Avenida Bandeirantes 3900, Campus Universitário Monte Alegre, 14049-900, Ribeirão Preto, São Paulo, Brasil; tel 55 16 602 3244; fax 55 16 633 1068; e-mail arsilva{at}fmrp.usp.br.
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Abstract
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A high autopsy rate allows accurate epidemiological studies and quality control of medical care. This study aims to analyze all autopsies performed in a university teaching hospital in Brazil during 52 consecutive wk. The following data were retrieved from individual autopsy records: gender, age, time of death (hr, day, and month), and the main cause of death. There were 1419 autopsies (79% adults and 21% pediatrics, 60% male and 40% female). Those performed during working days summed up to 67.5%, the remaining 32.5% were performed during weekends or holidays. Autopsies were more frequent during the nocturnal than diurnal period (52.6% vs 47.4%, respectively). The causes of death distributed among the ICD-10 categories were: cardiovascular diseases 21.3%, infectious diseases 19.2%, neoplasms 12.8%, perinatal conditions 10.8%, respiratory diseases 6.6%, gastrointestinal diseases 6.0%, congenital anomalies 4.7%, CNS diseases 3.8%, genitourinary diseases 1.8%, and others 13.0%. There was coexistence of the diseases typical of both industrialized and developing countries, indicating the epidemiological transition in our country. Our data indicate that staff supervision of undergraduate medical students and residents is adequate. Along with a brief discussion of the historical, cultural, and legal factors that allow a high autopsy rate, this study reinforces the importance of the autopsy in a tertiary teaching hospital.
Keywords: autopsy, epidemiology, pathology teaching
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Introduction
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Autopsy is an invaluable diagnostic tool in medical practice since postmortem studies provide relevant information in patients with complex pathologies [1]. In academic hospitals, the autopsy contributes to research and teaching by supplying material for these purposes [2–4]. Clearly, society needs to know what people are dying of to do anything about it. The findings in a large autopsy series allow epidemiological studies. In our institution, autopsy is performed in 85% of inpatients that die (75% of adult deaths and 90% of fetal and pediatric deaths). In a teaching hospital, it is important to know if the deaths of patients vary in respect to the year, day, and month to see if the deaths are influenced by medical factors such as the activity of less trained residents and medical students. The present study analyzed autopsies performed at the University Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo (HCFMRP-USP) during 52 weeks (December 1997-January 1999).
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Materials and Methods
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The following data were retrieved from individual autopsy records: gender, age, hr of death, hr of autopsy, day of the wk, diurnal or nocturnal period, working days or weekends and holidays, month, and the autopsy diagnosis of the main cause of death. The autopsies were separated in two categories: adult and pediatric (from fetal period to 16 yr). The autopsies were also separated according to the period of the day in which they were performed: diurnal (from 7 am – 7 pm), nocturnal (from 7 pm – 7 am), working days (Monday to Friday) and weekend/holidays. The diagnoses were compiled according to the International Classification of Diseases (ICD-10) in the following groups: infectious diseases, neoplasms, CNS diseases, cardiovascular diseases, respiratory diseases, gastrointestinal diseases, genitourinary diseases, congenital anomalies, perinatal conditions, and others. Statistical analysis was performed by the Chi-square test with a level of significance of p <0.05.
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Results
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The total number of autopsies was 1419, of which 1121 were adult and 298 pediatric, (79% and 21%, respectively). Regarding gender, 60% were men and 40% women. Autopsies performed during working days were 67.5%, the remaining 32.5% were performed during weekends or holidays. There were more autopsies during the nocturnal than diurnal periods (52.6% vs 47.4%, respectively). The autopsy findings distributed among the ICD-10 categories are specified in Table 1
. Cases of AIDS were included in the infectious diseases ICD-10 category, and these AIDS cases amounted to 10.2% of all autopsies. The autopsies were distributed uniformly during 1998, and statistical analyses showed no significant differences in the timing of deaths in respect to mo of the yr, day of the wk, day of the mo, or hr of the day (Figs. 1 to 4).
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Discussion
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At least part of our success in reaching a high autopsy rate at the HCFMRP-USP is related to a historical aspect, followed by procedure adaptations and financial support. Ever since the foundation of our Faculty of Medicine and the establishment of the Department of Pathology in 1954, all inpatient deaths have been submitted to post-mortem examination. This was in large part due to a study of Chagas’ disease that was conducted at this institution in the decades of 1950 and 1960 [5]. Thereafter with the increasing number, complexity, and variety of cases, autopsies were performed round the clock on every day of the week. This schedule was imposed in an attempt to shorten the time between death and autopsy, which is currently about 4 hr in our Department. The hurry to perform autopsies was determined in part by cultural and sanitary factors, since in Brazil the body is buried within 24 hr of death. The autopsy team is composed of an experienced pathologist, a pathology resident, and a mortuary assistant. A macroscopic report with clinical-pathological correlation is released soon after completion of the autopsy, providing prompt and valuable information to doctors and families. Additionally, it is the pathologist in these cases who issues the death certificate, without which burial is not allowed. The availability of the staff and the prompt reporting of results has been fundamental in maintaining our high autopsy rate and sustaining the credibility of autopsies among our clinicians [6].
In our hospital, formal autopsy consent only became necessary in recent years for autopsies performed on patients who died of natural causes. With few exceptions, inpatients who died underwent an autopsy, which explains our high autopsy rate. Actually, autopsy is performed only if consent is signed during admission to the hospital by the patient. This is a valid document unless the family makes a formal statement that an autopsy will not be allowed.
In industrialized countries, the mean autopsy rate at teaching general hospitals is 16.5% [7]. The high autopsy rate at our hospital allows an accurate study of impatient deaths and represents about 20% of all deaths occurring in our city. These do not include (i) medicolegal cases, which are sent to a forensic autopsy service in charge of the police, or (ii) cases in which the patient died outside the hospital or shortly after arrival, and whose autopsy is performed by another service. Altogether, ~40% of deaths in our city have an autopsy examination.
There is no consensus in Brazil regarding the autopsy of patients who die while admitted to community or university hospitals; in most hospitals no autopsies are performed at all. The particular situation at our hospital has historical and cultural aspects that have not changed over time, the round the clock performance of autopsies is an important reason for maintaining our high rate. All autopsies are complete, including the central nervous system, and organs are returned to the body unless they are needed for further examinations or are suitable for teaching or investigation. In university hospitals, part of some organs, or even entire organs, may be retained for academic purposes (teaching, research, publication), and this is set forth in the autopsy report.
In Brazil, there are no objections to performing an autopsy related to ethical, religious, legal, or financial considerations. The National Health Service, the governmental agency responsible for public health, pays a specified amount per patient and not per procedure. This means that the cost of the autopsy is not paid directly to the autopsy service but rather to the central administration of the hospital, which, in turn, allocates the money as necessary. The hospital provides the salaries of the staff and the supplies and equipment required to run the autopsy service, no matter how many autopsies are performed. In Brazil, no financial incentive or embalming allowance is provided to the decedent’s family.
Since our university hospital is used for teaching undergraduate and postgraduate medical students and for resident training, there is always concern about the occurrence of deaths in relation to the levels of medical training and the quality of supervision that students and residents receive. The distribution of deaths in the weeks and months of the year might show significant variation if less trained students and residents are involved, or if they are inadequately supervised by hospital and university staff. In our institution, the residency program starts each February when the less experienced residents and undergraduate students begin their training, while the most experienced ones depart from the hospital. If the transition were to occur with inadequate supervision, the deaths would vary during the year, probably being greatest during the transition period. Our results showed that such variations did not occur, affording reassurance that the levels of medical training did not affect the patients’ clinical outcomes.
In Brazil, the leading cause of death in 1976, irrespective of age and gender, was cardiovascular disease, accounting for 25% of deaths, followed by infectious diseases (10%), external causes (9%), and neoplasms (8%) (www.datasus.gov.br). Using the same criteria, in 2002 the leading cause of death remained cardiovascular disease, rising to 27%, which is in accordance with a worldwide tendency (WHO, 1998). A radical change occurred, however, in the second position, with neoplasms ranking second (13%) and infectious diseases falling to sixth place (5%) (www.datasus.gov.br).
In the present autopsy series (December 1997 to January 1999), cardiovascular disease ranked first, but infectious disease came in second. The high prevalence of infectious diseases probably reflects the low socio-economic conditions of the patients that receive care at our hospital and also because of a high number of HIV-positive patients, who accounted for 10.2% of all deaths. This is in part explained by the prevalence of this disease in our region but mostly to the convergence of these patients to our hospital, which has a specialized unit devoted to AIDS care.
In our autopsy series, the third cause of death was cancer (12.8%). This reflects the changing pattern of disease in our country according to the epidemiological transition theory, as proposed by Omran [8], in which there is coexistence of the health problems typical of industrialized countries, such as cardiovascular diseases and neoplasms, with others typical of developing nations, such as infectious diseases.
The high prevalence of perinatal conditions (10.8%) in our autopsy series is worrisome because it may be a manifestation of inadequate prenatal care. Most of the perinatal deaths are related to prematurity or maternal conditions such as hypertension. The number of congenital anomalies (4.7%) is understandable in a tertiary hospital to which cases of high complexity are referred. Moreover, interruption of pregnancy is illegal in Brazil and gestation is maintained despite prenatal diagnosis of various malformations [9].
Despite the manifold benefits of autopsies, several articles in the past decade have chronicled falling autopsy rates, coupled with apparent decline in clinical interest in the autopsy [10–13]. In many cases, this decrease is due to financial pressures and the difficulty of obtaining permission for autopsies. The present study attests to the importance of a high autopsy rate in a tertiary teaching hospital.
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References
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Abstract
Introduction
