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AUDIT AND NECROPSY 1 Gobbato
SIR,-Audit is a prominent feature of several recent proposals on
postgraduate training and clinical practice in the UK. The
Government’s white-paper on the National Health Service
encourages it. In 1988 a Royal College of Physicians working-party
stated that a post for training might not be approved "if adequate
clinical review meetings are not held", and the National
Confidential Enquiry into Perioperative Deaths (NCEPOD) has
instigated the formal audit of deaths within 30 days of surgery. The
low necropsy rate in the UK invalidates any form of clinical audit
where death is possible outcome.
Clinical diagnoses, often made with confidence, are frequently
not verified at necropsy. 1,2 Patients die from treatable conditions
because of diagnostic errors revealed only at necropsy. In one
survey, covering a period during which the necropsy rate had been
increased to 65%, 42% of causes of death were unconfirmed and
15% of errors were conceded to be significant by the requesting
clinicians.3 Such errors will usually remain undiscovered unless a
necropsy is asked for. Undoubtedly, the necropsy rate for deaths in
UK hospitals has fallen from over 60% to 25% or less in the past
thirty years.4 The rate is especially low for deaths in geriatric units.s
Elderly patients are assumed to have irreversible disease processes
which are themselves a function of senility. Yet one necropsy study
in patients over 65 revealed that in 31 % of cases a potentially
treatable contributory factor to death had not been diagnosed
during life.’7
Low necropsy rates may be attributable to a variety of
factors-the pressures of more immediate clinical commitments;
the view that imaging, biopsy, and biochemical techniques applied
during life render necropsy superfluous; the reluctance of relatives
to give consent because the deceased has "suffered enough"; the low
priority given to necropsies by pathologists burdened with a heavy
biopsy and cytology workload; the reluctance of some clinicians to
have diagnostic errors revealed; the fear of litigation for diagnostic
errors; and the lack of interest that results if pathologists do not
communicate their findings rapidly and clearly to the clinicians who
ask for a necropsy.
In the USA, the importance of necropsy has been drawn to the
public’s attention through the columns of the New York Times
(cited by Hill and Anderson8). The Joint Commission on
Accreditation of Health Organisations has recommended the use of
necropsies for quality assurance. A senior administrator of the
Health Care Financing Administraton has expressed concern about
the falling necropsy rate. The reliability of death certificate data,
unverified by necropsy, has also been questioned in the USA
because of the implications for national health policy.
In the UK, there should be greater professional, managerial, and
public awareness of the importance of necropsy as the "ultimate
audit" of clinical outcome. The task of seeking consent from
relatives should not be left to the most inexperienced, and often
exhausted, member of the clinical team. Adequate funding should
be provided for the maintenance of a necropsy rate of at least 75%
for deaths in hospital. The importance of the necropsy must be
sustained in the new training programmes and examinations in
histopathology for membership of the Royal College of
Pathologists. Necropsy data should be collected systematically to
provide a reliable demographic database of morbidity and
mortality.
All hospitals, NHS and private, should be obliged to audit and
report internally their necropsy rates and the rates attributable to
individual consultants. Staffing levels should be increased where
necessary so that necropsies are done thoroughly and the results
communicated rapidly to the clinician. The Royal Colleges should
monitor necropsy rates and the procedures for disseminating
information from them, accreditation for training being conditional
on an adequate local necropsy rate that permits valid audit of
diagnoses and treatments.
Department of Pathology,
J. C. E. UNDERWOOD
University of Sheffield Medical School, D. W. K. COTTON
Sheffield S10 2RX T. J. STEPHENSON
F, Vecchiet F, Barbierato D, Melato A, Manconi R. Inaccuracy of death
certificate diagnoses in malignancy an analysis of 1405 autopsied cases. Hum Pathol
1982; 13: 1036-38.
2. Stevanovic G, Tucakovic G, Dotlic R, Kanjish V. Correlation of clinical diagnoses
with autopsy findings. Hum Pathol 1986, 17: 1225-30.
3. Cameron HM, McGoogan E, Watson H. Necropsy as a yardstick for clinical
diagnoses. Br MedJ 1980; 281: 985-88.
4. Cameron HM. Future of the hospital autopsy. BrJ Hosp Med 1988; 40: 335
5. Kohn RR. Causes of death in very old people. JAMA 1982; 247: 2793-97.
6. Editorial. Death in old age. Lancet 1982, ii: 477.
7. Puxty JA, Horan MA, Fox RA. Necropsies in the elderly. Lancet 1983; i: 1262-64
8. Hill RB, Anderson RE Is a valid quality assurance program possible without the
autopsy? Hum Pathol 1988; 19: 1125-26.
MEDICAL RESEARCH FUNDING
SIR,-A Lancet editorial of Oct 29 on funding for medical
research in the UK (Wellcome Steps into the Breach Once More)
accused the Medical Research Council of being "lacklustre ...
clearly unable to inspire any important changes in official policy".
The MRC’s "modest stillness and humility" (Henry V) should not
have misled you; we can "disguise fair nature with hard-favour’d
rage" and have long argued the case for an increase in public
funding (as have many others) with conviction and with force. The
extra allocation of 14-5 million over 3 years for AIDS research,
additional to our grant-in-aid, is one recent (1987) example of
successful persuasion. It is rewarding to be able to report that the
allocation of the science vote for 1989-90 (announced on Feb 7 by
the Secretary of State for Education Science) provides the MRC
with an additional C20 4 million. The Council can now look
forward, over the next three years, to an overall grant-in-aid
averaging some ;C180 million annually. Can we now expect to see
another lead article from you-perhaps under the heading "say not
the struggle naught availeth" (A. H. Clough)?
Medical Research Council,
20 Park Crescent, D. A. REES,
London WIN 4AL Secretary
BROTHER-TO-SISTER TRANSMISSION OF
MEASLES AFTER MMR IMMUNISATION
SIR,-Dr Millson (Feb 4, p 271) claims that the timing of a
measles-like illness in two siblings indicates "the probable
transmission" of measles from the live attenuated Schwartz strain
contained in measles-mumps-rubella (MMR) vaccine. He suggests
that caution should be exercised when vaccinating normal children
with immunocompromised siblings and complains that the
Department of Health publication Immunisation Against Infectious
Disease offers no specific advice on this problem.
Extensive testing and experience with measles vaccine and MMR
vaccine has not shown evidence of vaccine virus transmission to
susceptible contacts. It would be wrong to modify current advice
that "children with post vaccination symptoms are not infectious"
on the basis of a clinical report unsubstantiated by laboratory
evidence. Furthermore, Immunisation Against Infectious Disease
(page 3) contains specific advice about immunocompromised
children. "Siblings and close contacts of such children must be
immunised against measles. Oral poliomyelitis vaccine (OPV)
should not be given to these children, their siblings or other
household contacts; inactivated poliomyelitis vaccine (IPV) should
be used in its place. There is no risk of virus transmission following
measles, mumps or rubella vaccines."
Department of Child Health, A. G. M. CAMPBELL,
University of Aberdeen, Chairman-elect, Joint Committee
Aberdeen AB9 2ZD on Vaccination and Immunisation
BALDNESS AND MINOXIDIL ADVERTISING
SIR,-In my local pharmacy recently I was regaled by a
promotional wall-video which pointed out that male-pattern
alopecia is bad for the image and is hereditary. It showed a miserable
and worried-looking bald father and an equally worried young son
who was anxiously examining his hair in the mirror. The message to
the son was that something could now be done to prevent this awful
fate, if only preventive measures were taken early enough. The firm