Four delays of child mortality in Rwanda: a mixed methods analysis of verbal social autopsies.

OBJECTIVES: We sought to understand healthcare-seeking patterns and delays in obtaining effective treatment for rural Rwandan children aged 1-5 years by analysing verbal and social autopsies (VSA). Factors in the home, related to transport and to quality of care in the formal health sector (FHS) were thought to contribute to delays. DESIGN: We collected quantitative and qualitative cross-sectional data using the validated 2012 WHO VSA tool. Descriptive statistics were performed. We inductively and deductively coded narratives using the three delays model, conducted thematic content analysis and used convergent mixed methods to synthesise findings. SETTING: The study took place in the catchment areas of two rural district hospitals in Rwanda-Kirehe and Southern Kayonza. Participants were caregivers of children aged 1-5 years who died in our study area between March 2013 and February 2014. RESULTS: We analysed 77 VSAs. Although 74% of children (n=57) had contact with the FHS before dying, most (59%, n=45) died at home. Many caregivers (44%, n=34) considered using traditional medicine and 23 (33%) actually did. Qualitative themes reflected difficulty recognising the need for care, the importance of traditional medicine, especially for 'poisoning' and poor perceived quality of care. We identified an additional delay-phase IV-which occurred after leaving formal healthcare facilities. These delays were associated with caregiver dissatisfaction or inability to adhere to care plans. CONCLUSION: Delays in deciding to seek care (phase I) and receiving quality care in FHS (phase III) dominated these narratives; delays in reaching a facility (phase II) were rarely discussed. An unwillingness or inability toadhere to treatment plans after leaving facilities (phase IV) were an important additional delay. Improving quality of care, especially provider capacity to communicate danger signs/treatment plans and promote adherence in the presence of alternative explanatory models informed by traditional medicine, could help prevent childhood deaths.

Discrepancias entre el diagnóstico Clínico y Anatomo-Patológico en el Hospital Escuela Universitario De Honduras / Discrepancies between the Clinical and Anatomy-Pathological diagnosis at the Hospital Escuela Universitario in Honduras

La calidad diagnóstica es el resultado de integrar el conocimiento médico y reconocimiento de los errores clínicos, se alcanza únicamente con la identificación de las causas de muerte; es la correlación clínico patológica la herramienta principal para dicha acción. El objetivo general de la investigación fue determinar la discrepancia clínico-patológica y su relación con otras variables en las autopsias realizadas en la institución. Se revisaron 159 protocolos de autopsia del período comprendido entre enero 2012 y junio 2016, elaborados por el Servicio de Patología del Hospital Escuela Universitario de Tegucigalpa, Honduras. Se excluyeron 36 por no cumplir los criterios de inclusión. Se utilizaron la CIE-10 y la clasificación de Goldman et al. para clasificar las patologías y establecer las discrepancias diagnósticas, respectivamente. El sexo predominante fue el femenino (2,96:1), la edad media fue de 38 años; prevalecieron los diagnósticos de embarazo/parto/puerperio y enfermedades infecciosas y parasitarias. Concluimos que en 46% de los casos existe discrepancia diagnóstica y la glomerulonefritis fue la principal causa de error, seguida de bronconeumonía. Se recomienda estandarizar el protocolo de autopsias y promover sesiones clínico-patológicas periódicas e integrales.

Diagnostic quality is the result of the integration of medical knowledge and recognition of clinical error, achieved only by identifying the cause of death; clinical pathological correlation is the primary tool for this action. The overall objective of this research was to determine clinical pathological discrepancy and its relationship with other variables within the autopsies performed at the institution. 159 autopsy protocols, elaborated by the Department of Pathology of Hospital Escuela Universitario in Tegucigalpa, Honduras, from January 2012 to June 2016, were reviewed. 36 were excluded for not meeting the inclusion criteria. ICD-10 and Goldman et al. modified by Battle criteria were used to classify diseases and establish diagnostic discrepancies, respectively. The majority of patients were female (2.96:1), the mean age was 38 years old; diagnoses of pregnancy/birth/puerperium and infectious and parasitic diseases prevailed. We conclude that diagnostic discrepancies exist in 46% of all cases and glomerulonephritis was the leading cause of error, followed by bronchopneumonia. It is recommended that autopsy protocols be standardized, and integrative clinical pathological sessions are promoted and integral.

El papel de la autopsia en la práctica clínica actual / The current role of autopsy in current clinical practice

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[Autopsy-a procedure of medical history?]. / Die Obduktion - ein Verfahren der Medizingeschichte?

An autopsy is an important tool of quality assurance in clinical medicine. It serves to determine the exact cause of death, unravel unexpected complications of disease processes including adverse or any other effects of treatment as well as to validate the official mortality statistics. An autopsy also makes an important contribution to training medical students and physicians; however, the rate of clinical autopsies has been declining drastically for decades, the causes being manifold. Lack of interest among clinicians, mainly due to inadequate knowledge of the advantages of autopsy seems to play a special role. The lack of reasonable reimbursement has also been discussed as another possible cause. In order to counteract this negative trend, efforts should be made to work on the awareness of medical students and young clinicians so that an autopsy is perceived as a general measure of quality assurance and physician self-control. Furthermore, a realistic reimbursement of financial and personnel expense is necessary.

The epidemiology of 'bewitchment' as a lay-reported cause of death in rural South Africa.

BACKGROUND: Cases of premature death in Africa may be attributed to witchcraft. In such settings, medical registration of causes of death is rare. To fill this gap, verbal autopsy (VA) methods record signs and symptoms of the deceased before death as well as lay opinion regarding the cause of death; this information is then interpreted to derive a medical cause of death. In the Agincourt Health and Demographic Surveillance Site, South Africa, around 6% of deaths are believed to be due to 'bewitchment' by VA respondents. METHODS: Using 6874 deaths from the Agincourt Health and Socio-Demographic Surveillance System, the epidemiology of deaths reported as bewitchment was explored, and using medical causes of death derived from VA, the association between perceptions of witchcraft and biomedical causes of death was investigated. RESULTS: The odds of having one's death reported as being due to bewitchment is significantly higher in children and reproductive-aged women (but not in men) than in older adults. Similarly, sudden deaths or those following an acute illness, deaths occurring before 2001 and those where traditional healthcare was sought are more likely to be reported as being due to bewitchment. Compared with all other deaths, deaths due to external causes are significantly less likely to be attributed to bewitchment, while maternal deaths are significantly more likely to be. CONCLUSIONS: Understanding how societies interpret the essential factors that affect their health and how health seeking is influenced by local notions and perceived aetiologies of illness and death could better inform sustainable interventions and health promotion efforts.

Estudo sobre a contribuição da autópsia como método diagnóstico / Study on the contribution of the autopsy as a diagnostic tool

INTRODUÇÃO: As taxas hospitalares de autópsias vêm diminuindo mundialmente, atingindo níveis críticos no Hospital das Clínicas da Universidade Federal de Minas Gerais (HC-UFMG) no que concerne a autópsias não-perinatais. OBJETIVO: Verificar se houve diminuição da relevância da autópsia no HC-UFMG. METODOLOGIA: Realizou-se estudo comparativo entre diagnósticos clínicos e post mortem, estabelecendo taxas de discordância com impacto terapêutico ou prognóstico em duas amostras aleatórias de 80 autópsias realizadas no HC-UFMG nos anos 1970 e outras 80 nos anos 1990, incluindo procedimentos perinatais e não-perinatais. RESULTADOS: Autópsias não-perinatais (adultos e crianças) predominaram na década de 1970. As perinatais (natimortos e neomortos) predominaram na década de 1990, com discordâncias em 56 por cento dos casos. Discordâncias parciais, com correta classificação de malformações congênitas pela autópsia, foram as mais frequentes. Não houve discordâncias na maioria das autópsias de crianças na década de 1970; entretanto, a maioria destas na amostra da década de 1990 revelou discordâncias. Em relação aos adultos, a frequência de erros diagnósticos não apresentou alterações significativas entre as décadas de 1970 (68 por cento) e 1990 (57 por cento). Infecções bacterianas e tromboembolismo pulmonar constituíram frequentes condições não diagnosticadas clinicamente na década de 1970; nos anos 90, os diagnósticos não formulados em vida formaram grupo heterogêneo de doenças. CONCLUSÃO: A autópsia permanece útil como método diagnóstico, apesar de restritamente utilizada na atualidade. É necessária elevação das taxas de autópsias não-perinatas para evitar os efeitos deletérios de sua ausência no ensino, na pesquisa e no controle de qualidade da assistência médica.

BACKGROUND: Hospital autopsy rates have declined worldwide and non-perinatal autopsies have reached extremely low numbers at the University Hospital of Federal University of Minas Gerais (HC-UFMG). OBJECTIVES: To determine if there has been a decrease in the relevance of autopsy at HC-UFMG. METHODS: A comparative study between clinical diagnoses and autopsy findings was conducted, establishing discrepancy rates with therapeutic or prognostic impact on two random samples from 80 autopsies performed at HC-UFMG in the mid 1970's and 80 autopsies in the 1990's, both including perinatal and non-perinatal procedures. RESULTS: Non-perinatal (adult and pediatric) autopsies predominated in the 1970's. Perinatal autopsies (stillbirth and neonatal mortality) predominated in the 1990's, with a discrepancy rate of 56 percent. Partial discrepancies, with correct classification of congenital malformations by autopsy, were the most frequent. There were no discrepancies in most pediatric autopsies from the 1970's. However, most pediatric autopsies from the 1990's revealed discrepancies. As to the adults, the frequency of diagnostic errors did not change significantly from 1970's (68 percent) to 1990's (57 percent). Bacterial infections and pulmonary embolism were common conditions that were not clinically diagnosed in the 1970's; in the 1990s, the post mortem diagnoses comprised a heterogeneous group of diseases. CONCLUSION: Autopsies remain as a useful diagnostic tool in spite of its restricted use currently. The rates of non-perinatal autopsies need urgent improving in order to avoid deleterious effects on medical education, research and quality control of medical care.

Discrepancias entre el diagnóstico clínico y el anatomopatológico en un Servicio de Cuidados Intensivos Polivalente / Discrepancies between clinical and pathological diagnosis in a Polyvalent Intensive Care Service

Objetivos. Analizar la frecuencia y espectro de las patologías más relevantes encontradas en el estudio necrópsico. Valorar la asociación entre estancia en la Unidad de Cuidados Intensivos (UCI) inferior a 24 horas y la tasa de errores diagnósticos. Material y métodos. Estudio retrospectivo observacional durante un período de 46 meses en una UCI polivalente. Las diferencias entre el diagnóstico clínico y anatomopatológico se establecieron en función de la clasificación de Goldman. Resultados. Se realizaron 85 autopsias de un total de 520 exitus (16,3%). Cinco pacientes fueron excluidos por información incompleta. De los 80 casos, encontramos 30 pacientes con errores mayores, 21 con repercusión terapéutica y pronóstica, y 9 en los que la estrategia terapéutica no se hubiera modificado. El diagnóstico más frecuentemente encontrado en el error tipo I fue la infección bacteriana seguida de la patología cardiovascular. La tasa de errores mayores con repercusión terapéutica fue superior en los pacientes con una estancia en UCI inferior a 24 horas (40% frente a 21%; p < 0,05). Conclusiones. La autopsia continúa siendo una herramienta útil para evaluar la calidad del diagnóstico clínico. Los errores diagnósticos con repercusión terapéutica son las infecciones bacterianas y la patología cardiovascular. Los pacientes con una estancia en la UCI inferior a 24 horas presentan una tasa mayor de errores diagnósticos tipo I

Objectives. Analyze the frequency and spectrum of the most relevant diseases found in the necropsic study. Assess the association between stay in Intensive Care Unit (ICU) less than 24 hours and rate of diagnostic errors. Material and methods. Retrospective, observational study during a 46 month period in a polyvalent ICU. The differences between the clinical and pathological diagnoses were established based on Goldman's classification. Results. A total of 85 autopsies out of 520 exitus (16.3%) were done. Five patients were excluded due to incomplete information. Of the 80 cases, we found 30 patients with major errors, 21 with therapeutic and prognostic repercussion, 9 in which the therapeutic strategy had not been modified. The most frequently found diagnosis in type I error was bacterial infection followed by cardiovascular disease. Major error rate with therapeutic repercussion was superior in patients with a stay in the ICU less than 24 hours (40% vs 21%; p < 0.05). Conclusions. Autopsy continues to be a useful tool to assess quality of clinical diagnosis. The diagnostic errors with therapeutic repercussion are bacterial infections and cardiovascular disease. Patients with a stay less than 24 hours have a higher rate of type I diagnostic errors

Concordancia entre el diagnóstico clínico y el patológico por necropsias / Clinico-pathological concoradance at autopsies

Objetivo. Determinar la concordancia entre diagnósticos clínicos y patológicos con base en los resultados de necropsia. Material y métodos. Se revisaron 67 protocolos de necropsia y expedientes clínicos de niños y adultos del servicio de patología del Centro de Especialidades Médicas del Estado de Veracruz Doctor Rafael Lucio, durante 1995 y 1996. Se obtuvieron las frecuencias simples de las variables de estudio, y la concordancia se calculó con el estadístico kappa simple. Resultados. En general la cifra de necropsias fue de 10.5 por ciento. Correspondió a la población infantil la mayor frecuencia (17.5 por ciento). El 59 por ciento de diagnósticos clínicos en niños y el 57 por ciento en adultos presentaron algún tipo de error. La concordancia del diagnóstico principal ante y postmortem fue de 26 por ciento (infantes) y 41 por ciento (adultos); Conclusiones. La alta cifra de errores diagnósticos y la consecuente baja concordancia clínico-patológica apoyan el hecho de que, a pesar del avance tecnológico en los procedimientos diagnósticos, es necesario realizar necropsias con el fin de documentar de manera más definitiva el control de calidad del ejercicio de la medicina

[The workload in Pathological Anatomy measured on the basis of categories of services]. / I carichi di lavoro in Anatomia Patologica misurati sulla base del nomenclatore di prestazioni.

Workload measurement is one of the most reliable tools in perspective payment systems, to evaluate clerk and technical personnel needs in a Surgical Pathology Department. In 1992 Italian Government began a full-comprehensive modification of financial support in National Health Care System, and during the last four years Public Hospitals and Local Health Units modified their financial organization with the introduction of workload measurement for the personnel needs. We propose a synthetic method for the workload measurement in Surgical Pathology Departments, similar to that proposed for perspective payment of surgical pathology services. The method is reliable and simple representing the full performance to obtain pathological report.

Discrepancia diagnóstica clínico patológica. Revisión de 1000 casos de autopsia del Hospital General de México / Clinico pathological diagnostic discrepancy. Review of 1000 autopsies in the Hospital General de México

Con el objetivo de conocer la frecuecia de discrepancia entre los diagnósticos clínicos y los anatómicos en casos autopsiados y de conocer el grado de discrepancia de los mismos, se examinaron los protocolos de 1,000 autopsias consecutivas realizadas en el HGM. De cada caso se recabaron los siguientes datos: edad, sexo, servicio, días de estancia, análisis de laboratorio y gabinete, diagnósticos clínicos (DC) y diagnósticos anatómicos (DA). Se compararon los DA, las discrepancias entre ellos se clasificaron como leves (L) cuando la diferencia no influyó en la evolución del caso y como importantes (l) cuando ésta repercutió importantemente en la evolución del mismo. La frecuencia de discrepancia fue de 28.6 por ciento. De los casos discrepantes el 61.2 por ciento tuvieron l y el 38.8 por ciento fue L. La única variable que resultó estadísticamente significativa en la presencia o no de discrepancia fue la duración de la hospitalización. Los servicios en los que hubo mayor proporción de casos discrepantes fueron: Terapia Intensiva, Urgencias, Cirugía General, Neumología y Medicina Interna