Forensic Science International, 13 (1979) 239 - 251 in the Netherlands 0 Elsevier Sequoia S.A., Lausanne -Printed
THE EPIDEMIOLOGY OF AUTOPSIES OF MIDDLE-AGED MEN IN FINLAND
A. PENTTILA
239
IN CARDIOVASCULAR IN 1973*
DEATHS
and A. AHONEN
Department of Forensic Medicine, University of Tampere (Finland)
University
of Helsinki,
and Institute
of Clinical Sciences,
Summary There were 414 certified deaths from cardiovascular diseases (CVD) in men aged 35 - 44, and 1372 at ages 45 - 54, in Finland during 1973. A detailed analysis of the examination of the cause of death in these cases was made by paying specific attention to the autopsy epidemiology. In men aged 35 44 years 68.6% of all cardiovascular deaths and 55.2% at ages 45 - 54 was verified by autopsy. The autopsy rate of cardiovascular deaths in these two populations of deceased males (1) was in 1973 about three times higher than it had been 10 years earlier, (2) decreased significantly with the age of the deceased population, (3) was higher in urban than in rural areas, (4) was markedly higher in Helsinki than anywhere else in Finland (at ages 35 - 44 the rate in Helsinki was 94.9% and at 45 - 54 76.2% in 1973), (5) was dependent on the actual place of death, (6) was higher than the mean rate recorded for all natural deaths in these two groups of male deceased, (7) was higher in the category of cerebrovascular deaths and lower in deaths from ischaemic heart diseases than the mean rate recorded for all cardiovascular deaths, and (8) was composed mainly of medicolegal autopsies, when the cause of death was some ischaemic or functional heart disease; mostly a clinical autopsy was made when the death was due to some other category of CVD. In addition, 76% of the deceased 35 - 54year-old males who died from CVD were either autopsied and/or treated in a hospital before death. This result and the quite high national autopsy rates among the deceased young and middle-aged populations give support to the reliability of the national mortality statistics at these ages.
Introduction A large-scale survey by Heasman and Lipworth [l] demonstrated the difficulty of establishing accurate diagnoses of causes of death without postmortem examinations. This and several other reports [ 2 - 71 have suggested that in the countries with well-developed diagnostic services, and in those where few certificates are based upon autopsy data, there may be considerable inaccuracy in the cause-of-death statistics. This apparently seriously impairs the value of international comparisons. It has been recommended that data from death certificates on autopsied cases should be tabulated separately from the non-autopsied cases [ 81 . However, it is quite difficult to find infor*Paper Unexpected
presented at the Second Meeting of the International Study Death (ISNUD), Wichita, Kansas, U.S.A., May 23, 1978.
Group
of Natural
240
mation on the incidence and prevalence of autopsies either locally, nationally or internationally ]5] . International statistics of causes of death have been compiled by the WHO for decades, but these data have never included data pertaining, for example, to the national autopsy frequencies. The results in the accompanying report indicate that mortality rates in middle-aged men from cardiovascular diseases (CVD) were markedly higher in Finland than in any other country in the world [9]. The natural question following this unique result is, how have the deaths from cardiovascular causes been investigated in Finland? In this report we have examined this question and especially the epidemiology of autopsies in cardiovascular deaths.
Material
and methods
A magnetic tape containing all data drawn from the official death certificates of 43 410 Finnish persons who died in 1973 was obtained for this study from the Central Statistical Office of Finland. The tape contained information of 39 variables which have been described in detail previously [lo] . Specific attention in this study was paid to the underlying cause of death and the frequency of various types of ante-mortem and post-mortem examinations used to determine the cause of death and its certification. The various categories of the ante-mortem and post-mortem examinations which have been coded by the Central Statistical Office from death certificates for more than 15 years are mentioned in Table 1, and have been given in detail previously [lo] . Certification and coding practices in Finland in 1973 were based on the 8th revision of the International Classification of Diseases (ICD), which has been in use in this country since the beginning of 1969. Various categories of deaths are defined and abbreviated in the text with the respective ICD main (ICD,_xv,,) and intermediate rubrics (ICD* classification) of diseases. The frequency of the cause-of-death examinations is presented as a percentage. A Burroughs 6700 computer at the Computing Centre of the University of Helsinki was used.
Results Examination of the cause of death The medicolegal autopsy was the most frequently used examination on the basis of which certification of death in middle-aged men from CVD was made in Finland in 1973 (Table 1). In about half of the deceased middleaged men who died from CVD the cause of death was verified by medicolegal autopsy in 1973, whereas the clinical autopsy rate was about two to four times lower than the medicolegal rate. The relative proportion of medicolegal autopsies decreased clearly with the age of the deceased population, and with this trend the death certificate was given more often on the basis of the case history and the clinical examination including one or several labora-
241 TABLE
1
The percentage of various types of examination on which certification cardiovascular diseases was based in middle-aged men in Finland in 1973 Examination
All cardiovascular diseases
-.
Clinical
autopsy
45 - 54 Lschaemic heart diseases
All cardiovascular diseases
Ischaemic heart diseases
46.1
52.4
35.7
38.6
autopsy
22.5
12.8
19.5
13.9
Case history and clinical examination and specific laboratory examination
14.5
17.4
22.2
24.0
Case history examination
12.6
12.1
17.5
17.7
3.6
4.5
4.1
4.8
0.2
0.2
0.1
0.0
0.7
0.8
and clinical
Case history alone or case history and clinical inspection of the corpse -the physician had seen the corpse Case history and/or police investigation -the physician not seen the corpse Medicolegal corpse Certification Total
from
Age of males in years 35 - 44
Medicolegal
of death
inspection abroad
had
-
-
of the 0.1 100.0
0.8 100.0
100.0
100.0
tory, roentgen, etc., examinations (Table 1). Medicolegal inspection of the corpse, which is made by the request of the police in Finland, was the principal examination only in very few cases.
Autopsy
rate for various categories of diseases
The autopsy rate in cardiovascular deaths of middle-aged men was quite high in Finland in comparison to the rates in most other main ICD categories of deaths ( Table 2 ). Also the number of autopsied to non-autopsied deaths was higher for cardiovascular deaths than that recorded for all natural deaths. Surprisingly low autopsy rates were recorded for deaths from neoplasms and infectious and parasitic diseases, whereas the rates were quite high when the cause of death had been some disease of the nervous or digestive system. Almost all deceased who had died from violent causes, such as accident, suicide, and homicide, were autopsied in Finland in 1973 (Table 2). It is logical that in most categories of death from natural causes the clinical autopsy rate was higher than the medicolegal rate, but this did not apply to the cardiovascular
Diseases system
Congenital Ill-defined Accidents,
All causes
All natural
XIII
XIV XVI XVII
- XVII
- XVI
I
I
causes
of death
etc. and violence
of death
anomalies symptoms, poisoning
of the musculoskeletal
Infectious, etc., diseases Neoplasms Endocrine, etc., diseases Diseases of blood, etc. Mental disorders Diseases of the nervous system Cardiovascular diseases Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system
I II III IV V VI VII VIII IX X
main ICD categories
Diseases
rate in various
Autopsy
ICD rubric
2
TABLE in Finland
in 1973
697
1179
9 3 482
35
72
33 92
22
0
6
17 3
17 1 21 50 40 46 50 31
6 118 19 0 14 20 414 22 52
Forensic Total
67
28
11
0 1
44
63
83
66 33 93
67
65
79 60 69 86 79
29 20 23 36 48 59
50 32 53
33 31 32 -
Clinical
rate (%)
2116
2612
6 5 496
2
13
38 449 32 1 17 16 1372 98 67
No. of cases
Autopsy
No. of cases
- 54
45
35 -44
Age of males in years
of deaths
27
39
33 20 88
0
0
21 3 22 0 53 50 36 26 22
Autopsy ~ Forensic
24
20
33 0 0
100
85
21 32 31 0 29 6 20 27 51
Clinical
rate (%)
51
59
661 20 88
100
85
42 35 53 0 82 56 56 53 73
Total
243
diseases. Also in the case of accidents, a medicolegal autopsy was performed.
suicides,
and homicides
almost always
Autopsy rate for various categories of cardiovascular diseases In general, the autopsy rate for deaths from ischaemic heart diseases was slightly lower, whereas that for cerebrovascular deaths was clearly higher, than the mean rate recorded for all cardiovascular deaths (Table 3). Otherwise, no clear systematic differences were found in the autopsy rate between various categories of cardiovascular deaths. Regional autopsy rates for cardiovascular deaths The relative proportion of autopsied to non-autopsied deaths from cardiovascular diseases varied greatly between different parts of the country (Table 4). The highest autopsy rates were found in Helsinki. About 95% of all 35 - 44-year-old deceased men who died from CVD were autopsied in Helsinki in 1973, whereas in the older male age group (45 - 54 years) the autopsy frequency was 77%. The lowest rates were found in the eastern and northern provinces of the country, i.e. in Kuopio, Pohjois-Karjala and Lappi. In these provinces the autopsy frequency was about 40 - 45% in the younger and about 25 - 30% in the older male age group analysed in this study. The regional rates of the autopsied to non-autopsied deaths from ischaemic heart diseases largely resembled the results recorded for all cardiovascular deaths in different parts of Finland. However, more often a forensic than a clinical autopsy was performed when the cause of death had been some ischaemic heart disease (ICDA8s) th an any other cardiovascular disease (these data are not shown). Autopsy rates according to place of death About 60% of all cardiovascular deaths and 54% of all deaths in middleaged men from ischaemic heart diseases in Helsinki in 1973 occurred in various hospitals of the city. The respective figure for all natural deaths other than cardiovascular was about 73% (Table 5). This trend was also found in all provinces of Finland. However, in general the number of deaths that occurred outside the hospitals was clearly lower in all provinces of the country than in Helsinki. In many provinces only about one-third of all deaths, for example, from ischaemic heart diseases, occured in various hospitals. The results presented in Table 5 indicate that in Helsinki the autopsy frequency was high, about 80 - lOO%, in spite of the fact that cardiovascular death had taken place either in a hospital, at home, or elsewhere. However, in all parts of Finland the autopsy praxis was quite different in 1973, and mostly only a minor part of all cardiovascular deaths that occurred in the hospitals were autopsied. However, when the cardiovascular death had taken place somewhere else than in a hospital relatively more autopsies were performed than in hospital cases. On the other hand, those who died at home from CVD were hardly ever autopsied in all other parts of the country, except in Helsinki (Table 5). Also the autopsy activity in all other types of
414
All cardiovascular
A86 - 88
-480-88
A84
A80.81
A82
diseases
265 79 27 10 18 15
No. of cases
35 -44
Ischaemic heart diseases Cerebrovascular diseases Other forms of heart diseases Hypertensive diseases Rheumatic heart diseases All other cardiovascular diseases
A85
deaths
in Finland
46
53 28 73 10 11 55
Forensic
Autopsy
in 1973
23
13 43 5 70 50 40
Clinical
rate (W)
Age of males in years
of cardiovascular
A83
ICD subgroups
Diseases
rate in various
Autopsy
ICD rubric
3
TABLE
69
66 71 78 80 61 95
Total
- 54
1372
1032 195 54 19 44 28
No. of cases
45
36
39 22 44 5 36 33
Forensic
Autopsy
20
14 43 12 32 34 39
Clinical
rate (%)
56
53 65 56 37 70 72
Total
245 TABLE Regional
4 autopsy
Province
rates for all cardiovascular
diseases (ICD,,)
in Finland
in 1973
Age of males in years 45-54
35 -44 No. of cases
Autopsy
rate (%)
Forensic
Clinical
Total 90 74 100 72 50 67 45 71 69 63 41 68
No. of cases
Autopsy
rate (%)
Forensic
Clinical
Total
240 164 6 183 114 78 95 114 171 61 75 71
49 37 17 35 37 37 17 34 39 23 25 31
22 26 6 31 15 18 8 11 22 8 9 16
71 63 84 66 52 55 25 45 61 31 34 47
Uusimaa Turku and Pori Ahvenanmaa Hame Kymi Mikkeli Kuopio Vaasa Oulu Lappi Pohjois-Karjala Keski-Suomi
87 49 1 32 30 18 29 41 48 19 32 28
68 51 50 33 56 24 42 42 42 28 36
22 23 100 22 17 11 21 29 27 21 13 32
Helsinki
39
67
28
95
130
52
25
77
414
46
23
69
1372
36
20
56
Whole country
natural deaths was dependent on the actual place of death and the trend was quite similar to that found in cardiovascular deaths (Table 5). The results in Table 6 report the relative proportion of the cardiovascular deaths that occurred in various hospitals but in which no autopsy was performed. In general, the number of these deaths was low in Helsinki; this was due to the high autopsy rate in the capital area. On the other hand, the situation was quite different in most provinces of Finland where the number of unautopsied hospital deaths from cardiovascular causes was mostly about 20 - 30% of all cases. A comparison of the results in Table 6 with the autopsy data in Table 4 for middle-aged men indicate that in all parts of Finland in at least three of four cardiovascular deaths either an autopsy was performed or the death took place in a hospital, i.e. in controlled circumstances, but no autopsy was made.
Discussion As reported in various connections [ll - 141 earlier and in the accompanying study [9] , mortality in middle-aged men from CVD has been high in Finland during the past decades in comparison to the rates in other countries. The assessment of the high cardiovascular mortality problem in men in Finland must necessarily take into consideration the quality of the data on
5
56 47 43 53 49 47 50 50 48 43 39 45
60
49
Heisin ki
Whole country
52
83
76 65 100 56 35 41 23 33 52 23 29 42
In hospital
1
diseases
7 0 10 8 17 31 0 0 0
78 0
3
29
3 100
4 2 3 2 4 4 3 3 2 3 3
.At home
All cardiovascular
(ICDvn
Uusimaa Turku and Pori Ahvenanmaa Hame Kymi Mikkeli Kuopio Vaasa Oulu Lappi Pohjois-Karjala Keski-Suomi
Province
48
37
40 51 57 44 49 49 46 47 49 55 58 52
52
80
72 53 75 60 44 51 24 47 56 44 31 47
Elsewhere
40
54
46 35 50 44 41 40 45 39 37 37 29 37
50
83
77 63 100 57 37 45 18 24 54 19 22 38
In hospital
(I’=~83
Ischaemic )
diseases
3
3
5 2 2 2 4 3 3 3 2 2 3
34
100
10 0 14 25 11 40 0 0 0
80 0
At home
heart
57
43
49 63 50 54 57 56 52 58 60 61 69 60
51
81
71 54 75 59 42 50 22 48 56 44 27 42
Elsewhere
All other
natural
63
73
71 62 63 64 61 60 60 63 61 60 52 60
46
76
68 53 73 3 30 40 20 33 48 25 25 32
In hospital 64 4 0 46 7 5 21 13 21 0 0 6
3
20
2 100
3 3 4 3 2 5 4 4 3 2 5 4
At home
causes
79 51
34
71 51 75 59 44 49 25 44 56 43 31 50 25
26 35 33 33 37 35 36 33 36 38 43 36
Elsewhere
of death
in 1973. The first number in each at home or elsewhere in each prorate in per cent.
(ICJ%-VI,VIII-XVI)
deceased males in Finland The place of death and the respective autopsy rate of the 35 - 54-year-old column indicates the percentage number of deaths (100% is the total number of deaths in a hospital, vince and each category of diseases). The second number in each column shows the respective autopsy
TABLE z a,
247 TABLE
6
The relative proportion of deaths among 35 - 54-year-old males who died in various hospitals but for which no autopsy was performed, as a percentage of total deaths in three categories of diseases in Finland in 1973 All cardiovascular diseases (ICDyn)
Ischaemic heart diseases (ICDAa3)
All other
Uusimaa Turku and Pori Ahvenanmaa Hame Kymi Mikkeli Kuopio Vaasa Oulu Lappi Pohjois-Karjala Keski-Suomi Helsinki
14 16 0 24 32 25 38 34 23 33 38 26 10
11 13 0 19 26 22 36 30 17 30 31 23 9
23 29 17 35 42 36 48 42 31 45 39 41 18
Whole country
24
20
34
Province
natural
causes of
death WQ-VI,VII-XVI)
which such an assessment is based. The data for international comparisons by the WHO are drawn from national cause-of-death statistics which, in their turn, are drawn from official death certificates in various countries. Several investigations have indicated that the value of information on death certificates varies [2 - 4, 6, 71 which apparently causes false deviations in mortality rates between different countries. Because an autopsied individual is likely to have the cause(s) of death more accurately determined and recorded than one who is not autopsied [2,4,6,11,15,16] the accuracy of national cause-of-death statistics is apparently greatly dependent on the national autopsy activity. Therefore, the international mortality statistics should be supplied with the respective national autopsy rates by sex, age, category of diseases, etc., corresponding to the presentation of national mortality rates. Previous studies by us have shown that the over-all national autopsy rate in Finland was 17.4% in 1963, 28.3% in 1968 and 38.2% in 1973 [17]. In ten years the autopsy activity has then more than doubled and in 1973 about 20.6% of all autopsies were clinical and 17.6% forensic autopsies. These national figures are somewhat lower than those reported, for example, for the end of the 1960s from Sweden [ 18,191, many areas of the United States [ 201 and England [21, 221, but clearly higher than, for example, those reported from Ireland [ 151 and New Zealand [ 231. Several observations made in the present study indicate that the deaths from cardiovascular diseases in middle-aged men were investigated in a more proper way than the mean practice had been in this field in Finland. In the 35 - 44 age group more than two-thirds, and at ages 45 - 54 clearly more than
248
half, of all males who died from CVD were autopsied. The national autopsy rate for all cardiovascular deaths (ICD,,,) in that year was only 33.4%, and that for all deaths from natural causes (ICDi.xVI) 33.2% [17]. This corresponds to the general trend also found elsewhere that with the age of the deceased the autopsy rate tends to decrease in practically all categories of deaths [3, 5,10,18,24]. Kunitz and Edland (1973) reported from Monroe County, New York, that when they compared autopsied to non-autopsied deaths by distribution of the underlying causes of death the rates were approximately the same, with only a few exceptions [ 51 . In this respect we have found great differences in the autopsy rate for various categories of deaths in Finland [17] . For example, in 1973 about 85.4% of all deaths from unnatural causes (ICDxvn) were autopsied, whereas the respective rate for all natural deaths (ICDr -xvi) was only 33.2%. In addition, marked differences between various categories of diseases (ICDi -xvi) were found [ 171. The present results showed that a slightly larger relative proportion of deaths in middle-aged men from CVD than of all natural deaths was verified by autopsy in Finland in 1973. However, the difference was not very large, and it seems that cardiovascular deaths were not over-autopsied. The high autopsy rate recorded for of the regulations deaths from unnatural causes (ICD xvII) is the consequence governing post-mortem examinations in Finland, whereas the data in Table 2 show that the deaths from neoplasms (ICDn), for example, were clearly under-autopsied and those from diseases of the digestive system (ICDrx) over-autopsied in middle-aged men in Finland. The present results showed that in middle-aged men the autopsy rates according to various ICD subcategories of cardiovascular deaths varied only slightly. The major proportion of all cardiovascular deaths in the present two age groups of males was due to the ischaemic heart diseases and in this category of deaths the autopsy rate remained slightly below the average national rate recorded for all cardiovascular deaths. For cerebrovascular and functional heart diseases, which were the next largest subcategories of cardiovascular deaths, the autopsy rates were in general slightly higher than the respective mean national rates. The data in Table 5 show that in the capital Helsinki about 60% of all cardiovascular deaths occurred in various hospitals, whereas in many areas of Finland the respective frequency was only about 40 - 50%. For this reason and because the deaths from cardiovascular causes often occur suddenly and unexpectedly, and because the cause of death is not directly established, a medicolegal autopsy was already made on the basis of the regulations governing forensic post-mortems in Finland. Therefore, in the present material the medicolegal autopsy rates are much higher than the respective clinical autopsy rates. Many observations made in this survey indicate that the autopsy frequency was greatly dependent on the actual place of death. In men aged 35 - 44 years about 95% of all cardiovascular deaths were verified by autopsy in Helsinki in 1973, which corresponds to the figures reported from larger
249
cities in Sweden [ 181. However, in many provinces of Finland the respective rate was only about half of that. Surprisingly low autopsy rates were recorded in many areas of Finland for cardiovascular deaths that occurred in a hospital in comparison to the much higher clinical autopsy activity reported, for example, from Sweden [ 11,181, England [ 131 and the United States [ 5,161 for hospital cases. On the other hand, the medicolegal autopsy rates of cardiovascular deaths that occurred outside a hospital were fairly high in Finland, as seen in Table 5. We were not assessing in this study the validity of clinical diagnoses or other ante-mortem findings by comparing them to post-mortem diagnoses because these are other further major areas to be investigated. Rather we were concerned with accounting for the distribution of autopsies in the highrisk male population in their prime who died from cardiovascular diseases. It is appropriate to ask what findings made in this study may reveal about the validity of vital statistics of Finland in general and especially in the case of cardiovascular diseases. The most important finding made in this study is apparently the quite high national autopsy rate of deceased middle-aged men who died either from cardiovascular or other causes, as was discussed above. This result supports the validity of the Finnish vital statistics for international comparisons of mortality rates at younger and middle ages [9]. In this connection we have not investigated the validity of autopsy diagnoses and interpretation of the cause of death on the basis of autopsy findings, which are also other scopes of study. However, it should be mentioned that practically all autopsies that were made in Finland in 1973 were so-called complete autopsies [ 171 . The other main observation in this study was the high relative proportion of cardiovascular deaths which occurred in hospitals but for which no autopsy was performed. The proportion of these deaths was quite high in many remote provinces of Finland where the autopsy activity was also low. About 52% of all 35 - 54-year-old men who died from CVD in Finland in 1973 were autopsied. In about 24% of all cases the death certificate was given on the basis of hospital treatment without autopsy. So the number of deaths in which the death certificate was given in “controlled circumstances”, i.e. following autopsy and/or hospital treatment, was about 76% of all cases. It must be pointed out in this connection that the number of autopsies for most categories of diseases has more than doubled in Finland in the ten years from 1963 to 1973 [ 171. This has occurred at the expense of the anamnesis and clinical examination (see Material and methods) on the basis of which deaths were certified more frequently in the beginning of the 1960s than at the beginning of the 1970s. However, in ten years only slight alterations were found in mortality rates of middle-aged men from all CVD or ischaemic heart diseases [ 171, which corresponds to the findings reported from some other industrialized countries [ 11,12,16]. So, the marked increase in autopsy activity in Finland has not markedly changed the cardiovascular mortality figures. The above results suggest that the anamnesis and hospital treatment often supplied in Finland with specific diagnostic investigations,
250
such as ECG, roentgen, etc., have apparently been quite valid for making the diagnosis of cardiovascular death, because a major proportion of all deaths in middle-aged men occurred in hospitals. Therefore, the national rate of 76%, presented above which indicates the number of all autopsied and/or hospitaltreated cardiovascular deaths in middle-aged men, gives support to the overall validity of the Finnish mortality statistics at younger ages. Of course these statistics cannot be regarded as precise measures, but rather as a reliable source of leads to be elaborated by other study approaches, as stressed by Moriyama [ 251.
Acknowledgements This work was supported tion, Helsinki, Finland.
by a grant from the Sigrid Jusehus
Founda-
References 1 M. A. Heasman and L. K. Lipworth, Accuracy of certification of cause of death. General Register Office, Studies on Medical and Population Subjects, No. 20. H. M. Stationery Office, London, 1966. 2 F. W. Bauer and S. L. Robbins, An autopsy study of cancer patients. I. Accuracy of the clinical diagnoses (1955 to 1965). J. Amer. Med. Ass., 221 (1972) 1471. 3 W. G. Beadenkopf, M. Abrams, A. Dauod and R. U. Marks, An assessment of certain medical aspects of death certificate data for epidemiologic study of arteriosclerotic heart diseases. J. Chronic Dis., 16 (1963) 249. 4 G. James, R. E. Patton and A. S. Heslin, Accuracy of cause-of-death statements on death certificates, Publ. Health Rep., 70 (1955) 38. 5 S. J. Kunitz and J. E. Edland, The epidemiology of autopsies in Monroe County, New York. J. Forensic Sci., 18 (1973) 370 - 379. 6 B. C. Paton, The accuracy of diagnosis of myocardial infarction: a clinico-pathologic study. Amer. J. Med., 23 (1957) 761. 7 H. 0. Swartout and R. G. Webster, To what degree are mortality statistics dependable? Amer. J. Pub. Health, 30 (1940) 811. 8 T. M. Peery, The new and old diseases. A study of mortality trends in the United States, 1900 - 1969. Amer. J. Clin. Pathol., 63 (1975) 453. 9 A. Penttila and A. Ahonen, An international comparison of mortality in middle-aged Sci., 13 (I 979) 221. men from cardiovascular diseases during 1970 - 1974. Forensic 10 A. Penttili, Mortality from arteriosclerotic and other degenerative heart diseases in Finland in 1968. Health Serv. Res. Nat. Board Health Finland, 12 (1975) 1. 11 G. Biiirk, Epidemiological studies on cardiovascular diseases in Sweden. J. Chronic Dis., 18 (1965) 519. 12 J. H. DeHaas, Changing Mortality Patterns and Cardiovascular Diseases. DeErven F. Bohn N.V., Haarlem, 1964, p. 1. 13 A. H. T. Robb-Smith, The Enigma of Coronary Heart Disease. Lloyd-Luke, London, 1967, p. 1. 14 World Health Organization, World Health Statistics Report, 22 (1969) 430. 15 G. Dean, The need for accurate certification of the cause of death and for more autopsies. J. Irish Med. Ass., 62 (1969) 273.
251 16 17 18
19 20 21 22 23 24 25
F. H. Epstein, The epidemiology of coronary heart disease. J. Chronic Dis., 18 (1965) 735. A. Penttila and A. Ahonen, Mortality patterns and examination of cause of death in Finland in 1955 1973. A death certificate study. In preparation. A.-M. Bolander, A comparative study of mortality by cause in four Nordic countries, 1966 1968, with special reference to male excess mortality. Statist. Rep., 9 (1971) 29. M. Britton, The consequences of informing relatives of intended autopsy in conjuction with death in hospital. Acta Sociomed. Stand., 1 (1972) 37. J. B. Arthaud, Autopsies in the United States - frequency by states. J. Amer. Med. Ass., 213 (1970) 1195. J. D. J. Havard, The Detection of Secret Homicide. The Need for Post-Mortem Examination. Macmillan, London, 1960, p. 151. R. D. Teare, The Scotland Yard autopsy. Bull. N.Y. Acad. Med., 44 (1968) 843. J. F. Gwynne, The unreliability of death certificates. N.Z. Med. J., 80 (1974) 336. L. Munan, A. Kelly and R. Cote, Do the right children have necropsies? Arch. Dis. Childhood, 50 (1975) 620. I. M. Moriyama, Factors in diagnosis and classification of deaths from cardiovascular diseases. Pub. Health Rep., 75 (1960) 189.
THE EPIDEMIOLOGY OF AUTOPSIES OF MIDDLE-AGED MEN IN FINLAND
A. PENTTILA
239
IN CARDIOVASCULAR IN 1973*
DEATHS
and A. AHONEN
Department of Forensic Medicine, University of Tampere (Finland)
University
of Helsinki,
and Institute
of Clinical Sciences,
Summary There were 414 certified deaths from cardiovascular diseases (CVD) in men aged 35 - 44, and 1372 at ages 45 - 54, in Finland during 1973. A detailed analysis of the examination of the cause of death in these cases was made by paying specific attention to the autopsy epidemiology. In men aged 35 44 years 68.6% of all cardiovascular deaths and 55.2% at ages 45 - 54 was verified by autopsy. The autopsy rate of cardiovascular deaths in these two populations of deceased males (1) was in 1973 about three times higher than it had been 10 years earlier, (2) decreased significantly with the age of the deceased population, (3) was higher in urban than in rural areas, (4) was markedly higher in Helsinki than anywhere else in Finland (at ages 35 - 44 the rate in Helsinki was 94.9% and at 45 - 54 76.2% in 1973), (5) was dependent on the actual place of death, (6) was higher than the mean rate recorded for all natural deaths in these two groups of male deceased, (7) was higher in the category of cerebrovascular deaths and lower in deaths from ischaemic heart diseases than the mean rate recorded for all cardiovascular deaths, and (8) was composed mainly of medicolegal autopsies, when the cause of death was some ischaemic or functional heart disease; mostly a clinical autopsy was made when the death was due to some other category of CVD. In addition, 76% of the deceased 35 - 54year-old males who died from CVD were either autopsied and/or treated in a hospital before death. This result and the quite high national autopsy rates among the deceased young and middle-aged populations give support to the reliability of the national mortality statistics at these ages.
Introduction A large-scale survey by Heasman and Lipworth [l] demonstrated the difficulty of establishing accurate diagnoses of causes of death without postmortem examinations. This and several other reports [ 2 - 71 have suggested that in the countries with well-developed diagnostic services, and in those where few certificates are based upon autopsy data, there may be considerable inaccuracy in the cause-of-death statistics. This apparently seriously impairs the value of international comparisons. It has been recommended that data from death certificates on autopsied cases should be tabulated separately from the non-autopsied cases [ 81 . However, it is quite difficult to find infor*Paper Unexpected
presented at the Second Meeting of the International Study Death (ISNUD), Wichita, Kansas, U.S.A., May 23, 1978.
Group
of Natural
240
mation on the incidence and prevalence of autopsies either locally, nationally or internationally ]5] . International statistics of causes of death have been compiled by the WHO for decades, but these data have never included data pertaining, for example, to the national autopsy frequencies. The results in the accompanying report indicate that mortality rates in middle-aged men from cardiovascular diseases (CVD) were markedly higher in Finland than in any other country in the world [9]. The natural question following this unique result is, how have the deaths from cardiovascular causes been investigated in Finland? In this report we have examined this question and especially the epidemiology of autopsies in cardiovascular deaths.
Material
and methods
A magnetic tape containing all data drawn from the official death certificates of 43 410 Finnish persons who died in 1973 was obtained for this study from the Central Statistical Office of Finland. The tape contained information of 39 variables which have been described in detail previously [lo] . Specific attention in this study was paid to the underlying cause of death and the frequency of various types of ante-mortem and post-mortem examinations used to determine the cause of death and its certification. The various categories of the ante-mortem and post-mortem examinations which have been coded by the Central Statistical Office from death certificates for more than 15 years are mentioned in Table 1, and have been given in detail previously [lo] . Certification and coding practices in Finland in 1973 were based on the 8th revision of the International Classification of Diseases (ICD), which has been in use in this country since the beginning of 1969. Various categories of deaths are defined and abbreviated in the text with the respective ICD main (ICD,_xv,,) and intermediate rubrics (ICD* classification) of diseases. The frequency of the cause-of-death examinations is presented as a percentage. A Burroughs 6700 computer at the Computing Centre of the University of Helsinki was used.
Results Examination of the cause of death The medicolegal autopsy was the most frequently used examination on the basis of which certification of death in middle-aged men from CVD was made in Finland in 1973 (Table 1). In about half of the deceased middleaged men who died from CVD the cause of death was verified by medicolegal autopsy in 1973, whereas the clinical autopsy rate was about two to four times lower than the medicolegal rate. The relative proportion of medicolegal autopsies decreased clearly with the age of the deceased population, and with this trend the death certificate was given more often on the basis of the case history and the clinical examination including one or several labora-
241 TABLE
1
The percentage of various types of examination on which certification cardiovascular diseases was based in middle-aged men in Finland in 1973 Examination
All cardiovascular diseases
-.
Clinical
autopsy
45 - 54 Lschaemic heart diseases
All cardiovascular diseases
Ischaemic heart diseases
46.1
52.4
35.7
38.6
autopsy
22.5
12.8
19.5
13.9
Case history and clinical examination and specific laboratory examination
14.5
17.4
22.2
24.0
Case history examination
12.6
12.1
17.5
17.7
3.6
4.5
4.1
4.8
0.2
0.2
0.1
0.0
0.7
0.8
and clinical
Case history alone or case history and clinical inspection of the corpse -the physician had seen the corpse Case history and/or police investigation -the physician not seen the corpse Medicolegal corpse Certification Total
from
Age of males in years 35 - 44
Medicolegal
of death
inspection abroad
had
-
-
of the 0.1 100.0
0.8 100.0
100.0
100.0
tory, roentgen, etc., examinations (Table 1). Medicolegal inspection of the corpse, which is made by the request of the police in Finland, was the principal examination only in very few cases.
Autopsy
rate for various categories of diseases
The autopsy rate in cardiovascular deaths of middle-aged men was quite high in Finland in comparison to the rates in most other main ICD categories of deaths ( Table 2 ). Also the number of autopsied to non-autopsied deaths was higher for cardiovascular deaths than that recorded for all natural deaths. Surprisingly low autopsy rates were recorded for deaths from neoplasms and infectious and parasitic diseases, whereas the rates were quite high when the cause of death had been some disease of the nervous or digestive system. Almost all deceased who had died from violent causes, such as accident, suicide, and homicide, were autopsied in Finland in 1973 (Table 2). It is logical that in most categories of death from natural causes the clinical autopsy rate was higher than the medicolegal rate, but this did not apply to the cardiovascular
Diseases system
Congenital Ill-defined Accidents,
All causes
All natural
XIII
XIV XVI XVII
- XVII
- XVI
I
I
causes
of death
etc. and violence
of death
anomalies symptoms, poisoning
of the musculoskeletal
Infectious, etc., diseases Neoplasms Endocrine, etc., diseases Diseases of blood, etc. Mental disorders Diseases of the nervous system Cardiovascular diseases Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system
I II III IV V VI VII VIII IX X
main ICD categories
Diseases
rate in various
Autopsy
ICD rubric
2
TABLE in Finland
in 1973
697
1179
9 3 482
35
72
33 92
22
0
6
17 3
17 1 21 50 40 46 50 31
6 118 19 0 14 20 414 22 52
Forensic Total
67
28
11
0 1
44
63
83
66 33 93
67
65
79 60 69 86 79
29 20 23 36 48 59
50 32 53
33 31 32 -
Clinical
rate (%)
2116
2612
6 5 496
2
13
38 449 32 1 17 16 1372 98 67
No. of cases
Autopsy
No. of cases
- 54
45
35 -44
Age of males in years
of deaths
27
39
33 20 88
0
0
21 3 22 0 53 50 36 26 22
Autopsy ~ Forensic
24
20
33 0 0
100
85
21 32 31 0 29 6 20 27 51
Clinical
rate (%)
51
59
661 20 88
100
85
42 35 53 0 82 56 56 53 73
Total
243
diseases. Also in the case of accidents, a medicolegal autopsy was performed.
suicides,
and homicides
almost always
Autopsy rate for various categories of cardiovascular diseases In general, the autopsy rate for deaths from ischaemic heart diseases was slightly lower, whereas that for cerebrovascular deaths was clearly higher, than the mean rate recorded for all cardiovascular deaths (Table 3). Otherwise, no clear systematic differences were found in the autopsy rate between various categories of cardiovascular deaths. Regional autopsy rates for cardiovascular deaths The relative proportion of autopsied to non-autopsied deaths from cardiovascular diseases varied greatly between different parts of the country (Table 4). The highest autopsy rates were found in Helsinki. About 95% of all 35 - 44-year-old deceased men who died from CVD were autopsied in Helsinki in 1973, whereas in the older male age group (45 - 54 years) the autopsy frequency was 77%. The lowest rates were found in the eastern and northern provinces of the country, i.e. in Kuopio, Pohjois-Karjala and Lappi. In these provinces the autopsy frequency was about 40 - 45% in the younger and about 25 - 30% in the older male age group analysed in this study. The regional rates of the autopsied to non-autopsied deaths from ischaemic heart diseases largely resembled the results recorded for all cardiovascular deaths in different parts of Finland. However, more often a forensic than a clinical autopsy was performed when the cause of death had been some ischaemic heart disease (ICDA8s) th an any other cardiovascular disease (these data are not shown). Autopsy rates according to place of death About 60% of all cardiovascular deaths and 54% of all deaths in middleaged men from ischaemic heart diseases in Helsinki in 1973 occurred in various hospitals of the city. The respective figure for all natural deaths other than cardiovascular was about 73% (Table 5). This trend was also found in all provinces of Finland. However, in general the number of deaths that occurred outside the hospitals was clearly lower in all provinces of the country than in Helsinki. In many provinces only about one-third of all deaths, for example, from ischaemic heart diseases, occured in various hospitals. The results presented in Table 5 indicate that in Helsinki the autopsy frequency was high, about 80 - lOO%, in spite of the fact that cardiovascular death had taken place either in a hospital, at home, or elsewhere. However, in all parts of Finland the autopsy praxis was quite different in 1973, and mostly only a minor part of all cardiovascular deaths that occurred in the hospitals were autopsied. However, when the cardiovascular death had taken place somewhere else than in a hospital relatively more autopsies were performed than in hospital cases. On the other hand, those who died at home from CVD were hardly ever autopsied in all other parts of the country, except in Helsinki (Table 5). Also the autopsy activity in all other types of
414
All cardiovascular
A86 - 88
-480-88
A84
A80.81
A82
diseases
265 79 27 10 18 15
No. of cases
35 -44
Ischaemic heart diseases Cerebrovascular diseases Other forms of heart diseases Hypertensive diseases Rheumatic heart diseases All other cardiovascular diseases
A85
deaths
in Finland
46
53 28 73 10 11 55
Forensic
Autopsy
in 1973
23
13 43 5 70 50 40
Clinical
rate (W)
Age of males in years
of cardiovascular
A83
ICD subgroups
Diseases
rate in various
Autopsy
ICD rubric
3
TABLE
69
66 71 78 80 61 95
Total
- 54
1372
1032 195 54 19 44 28
No. of cases
45
36
39 22 44 5 36 33
Forensic
Autopsy
20
14 43 12 32 34 39
Clinical
rate (%)
56
53 65 56 37 70 72
Total
245 TABLE Regional
4 autopsy
Province
rates for all cardiovascular
diseases (ICD,,)
in Finland
in 1973
Age of males in years 45-54
35 -44 No. of cases
Autopsy
rate (%)
Forensic
Clinical
Total 90 74 100 72 50 67 45 71 69 63 41 68
No. of cases
Autopsy
rate (%)
Forensic
Clinical
Total
240 164 6 183 114 78 95 114 171 61 75 71
49 37 17 35 37 37 17 34 39 23 25 31
22 26 6 31 15 18 8 11 22 8 9 16
71 63 84 66 52 55 25 45 61 31 34 47
Uusimaa Turku and Pori Ahvenanmaa Hame Kymi Mikkeli Kuopio Vaasa Oulu Lappi Pohjois-Karjala Keski-Suomi
87 49 1 32 30 18 29 41 48 19 32 28
68 51 50 33 56 24 42 42 42 28 36
22 23 100 22 17 11 21 29 27 21 13 32
Helsinki
39
67
28
95
130
52
25
77
414
46
23
69
1372
36
20
56
Whole country
natural deaths was dependent on the actual place of death and the trend was quite similar to that found in cardiovascular deaths (Table 5). The results in Table 6 report the relative proportion of the cardiovascular deaths that occurred in various hospitals but in which no autopsy was performed. In general, the number of these deaths was low in Helsinki; this was due to the high autopsy rate in the capital area. On the other hand, the situation was quite different in most provinces of Finland where the number of unautopsied hospital deaths from cardiovascular causes was mostly about 20 - 30% of all cases. A comparison of the results in Table 6 with the autopsy data in Table 4 for middle-aged men indicate that in all parts of Finland in at least three of four cardiovascular deaths either an autopsy was performed or the death took place in a hospital, i.e. in controlled circumstances, but no autopsy was made.
Discussion As reported in various connections [ll - 141 earlier and in the accompanying study [9] , mortality in middle-aged men from CVD has been high in Finland during the past decades in comparison to the rates in other countries. The assessment of the high cardiovascular mortality problem in men in Finland must necessarily take into consideration the quality of the data on
5
56 47 43 53 49 47 50 50 48 43 39 45
60
49
Heisin ki
Whole country
52
83
76 65 100 56 35 41 23 33 52 23 29 42
In hospital
1
diseases
7 0 10 8 17 31 0 0 0
78 0
3
29
3 100
4 2 3 2 4 4 3 3 2 3 3
.At home
All cardiovascular
(ICDvn
Uusimaa Turku and Pori Ahvenanmaa Hame Kymi Mikkeli Kuopio Vaasa Oulu Lappi Pohjois-Karjala Keski-Suomi
Province
48
37
40 51 57 44 49 49 46 47 49 55 58 52
52
80
72 53 75 60 44 51 24 47 56 44 31 47
Elsewhere
40
54
46 35 50 44 41 40 45 39 37 37 29 37
50
83
77 63 100 57 37 45 18 24 54 19 22 38
In hospital
(I’=~83
Ischaemic )
diseases
3
3
5 2 2 2 4 3 3 3 2 2 3
34
100
10 0 14 25 11 40 0 0 0
80 0
At home
heart
57
43
49 63 50 54 57 56 52 58 60 61 69 60
51
81
71 54 75 59 42 50 22 48 56 44 27 42
Elsewhere
All other
natural
63
73
71 62 63 64 61 60 60 63 61 60 52 60
46
76
68 53 73 3 30 40 20 33 48 25 25 32
In hospital 64 4 0 46 7 5 21 13 21 0 0 6
3
20
2 100
3 3 4 3 2 5 4 4 3 2 5 4
At home
causes
79 51
34
71 51 75 59 44 49 25 44 56 43 31 50 25
26 35 33 33 37 35 36 33 36 38 43 36
Elsewhere
of death
in 1973. The first number in each at home or elsewhere in each prorate in per cent.
(ICJ%-VI,VIII-XVI)
deceased males in Finland The place of death and the respective autopsy rate of the 35 - 54-year-old column indicates the percentage number of deaths (100% is the total number of deaths in a hospital, vince and each category of diseases). The second number in each column shows the respective autopsy
TABLE z a,
247 TABLE
6
The relative proportion of deaths among 35 - 54-year-old males who died in various hospitals but for which no autopsy was performed, as a percentage of total deaths in three categories of diseases in Finland in 1973 All cardiovascular diseases (ICDyn)
Ischaemic heart diseases (ICDAa3)
All other
Uusimaa Turku and Pori Ahvenanmaa Hame Kymi Mikkeli Kuopio Vaasa Oulu Lappi Pohjois-Karjala Keski-Suomi Helsinki
14 16 0 24 32 25 38 34 23 33 38 26 10
11 13 0 19 26 22 36 30 17 30 31 23 9
23 29 17 35 42 36 48 42 31 45 39 41 18
Whole country
24
20
34
Province
natural
causes of
death WQ-VI,VII-XVI)
which such an assessment is based. The data for international comparisons by the WHO are drawn from national cause-of-death statistics which, in their turn, are drawn from official death certificates in various countries. Several investigations have indicated that the value of information on death certificates varies [2 - 4, 6, 71 which apparently causes false deviations in mortality rates between different countries. Because an autopsied individual is likely to have the cause(s) of death more accurately determined and recorded than one who is not autopsied [2,4,6,11,15,16] the accuracy of national cause-of-death statistics is apparently greatly dependent on the national autopsy activity. Therefore, the international mortality statistics should be supplied with the respective national autopsy rates by sex, age, category of diseases, etc., corresponding to the presentation of national mortality rates. Previous studies by us have shown that the over-all national autopsy rate in Finland was 17.4% in 1963, 28.3% in 1968 and 38.2% in 1973 [17]. In ten years the autopsy activity has then more than doubled and in 1973 about 20.6% of all autopsies were clinical and 17.6% forensic autopsies. These national figures are somewhat lower than those reported, for example, for the end of the 1960s from Sweden [ 18,191, many areas of the United States [ 201 and England [21, 221, but clearly higher than, for example, those reported from Ireland [ 151 and New Zealand [ 231. Several observations made in the present study indicate that the deaths from cardiovascular diseases in middle-aged men were investigated in a more proper way than the mean practice had been in this field in Finland. In the 35 - 44 age group more than two-thirds, and at ages 45 - 54 clearly more than
248
half, of all males who died from CVD were autopsied. The national autopsy rate for all cardiovascular deaths (ICD,,,) in that year was only 33.4%, and that for all deaths from natural causes (ICDi.xVI) 33.2% [17]. This corresponds to the general trend also found elsewhere that with the age of the deceased the autopsy rate tends to decrease in practically all categories of deaths [3, 5,10,18,24]. Kunitz and Edland (1973) reported from Monroe County, New York, that when they compared autopsied to non-autopsied deaths by distribution of the underlying causes of death the rates were approximately the same, with only a few exceptions [ 51 . In this respect we have found great differences in the autopsy rate for various categories of deaths in Finland [17] . For example, in 1973 about 85.4% of all deaths from unnatural causes (ICDxvn) were autopsied, whereas the respective rate for all natural deaths (ICDr -xvi) was only 33.2%. In addition, marked differences between various categories of diseases (ICDi -xvi) were found [ 171. The present results showed that a slightly larger relative proportion of deaths in middle-aged men from CVD than of all natural deaths was verified by autopsy in Finland in 1973. However, the difference was not very large, and it seems that cardiovascular deaths were not over-autopsied. The high autopsy rate recorded for of the regulations deaths from unnatural causes (ICD xvII) is the consequence governing post-mortem examinations in Finland, whereas the data in Table 2 show that the deaths from neoplasms (ICDn), for example, were clearly under-autopsied and those from diseases of the digestive system (ICDrx) over-autopsied in middle-aged men in Finland. The present results showed that in middle-aged men the autopsy rates according to various ICD subcategories of cardiovascular deaths varied only slightly. The major proportion of all cardiovascular deaths in the present two age groups of males was due to the ischaemic heart diseases and in this category of deaths the autopsy rate remained slightly below the average national rate recorded for all cardiovascular deaths. For cerebrovascular and functional heart diseases, which were the next largest subcategories of cardiovascular deaths, the autopsy rates were in general slightly higher than the respective mean national rates. The data in Table 5 show that in the capital Helsinki about 60% of all cardiovascular deaths occurred in various hospitals, whereas in many areas of Finland the respective frequency was only about 40 - 50%. For this reason and because the deaths from cardiovascular causes often occur suddenly and unexpectedly, and because the cause of death is not directly established, a medicolegal autopsy was already made on the basis of the regulations governing forensic post-mortems in Finland. Therefore, in the present material the medicolegal autopsy rates are much higher than the respective clinical autopsy rates. Many observations made in this survey indicate that the autopsy frequency was greatly dependent on the actual place of death. In men aged 35 - 44 years about 95% of all cardiovascular deaths were verified by autopsy in Helsinki in 1973, which corresponds to the figures reported from larger
249
cities in Sweden [ 181. However, in many provinces of Finland the respective rate was only about half of that. Surprisingly low autopsy rates were recorded in many areas of Finland for cardiovascular deaths that occurred in a hospital in comparison to the much higher clinical autopsy activity reported, for example, from Sweden [ 11,181, England [ 131 and the United States [ 5,161 for hospital cases. On the other hand, the medicolegal autopsy rates of cardiovascular deaths that occurred outside a hospital were fairly high in Finland, as seen in Table 5. We were not assessing in this study the validity of clinical diagnoses or other ante-mortem findings by comparing them to post-mortem diagnoses because these are other further major areas to be investigated. Rather we were concerned with accounting for the distribution of autopsies in the highrisk male population in their prime who died from cardiovascular diseases. It is appropriate to ask what findings made in this study may reveal about the validity of vital statistics of Finland in general and especially in the case of cardiovascular diseases. The most important finding made in this study is apparently the quite high national autopsy rate of deceased middle-aged men who died either from cardiovascular or other causes, as was discussed above. This result supports the validity of the Finnish vital statistics for international comparisons of mortality rates at younger and middle ages [9]. In this connection we have not investigated the validity of autopsy diagnoses and interpretation of the cause of death on the basis of autopsy findings, which are also other scopes of study. However, it should be mentioned that practically all autopsies that were made in Finland in 1973 were so-called complete autopsies [ 171 . The other main observation in this study was the high relative proportion of cardiovascular deaths which occurred in hospitals but for which no autopsy was performed. The proportion of these deaths was quite high in many remote provinces of Finland where the autopsy activity was also low. About 52% of all 35 - 54-year-old men who died from CVD in Finland in 1973 were autopsied. In about 24% of all cases the death certificate was given on the basis of hospital treatment without autopsy. So the number of deaths in which the death certificate was given in “controlled circumstances”, i.e. following autopsy and/or hospital treatment, was about 76% of all cases. It must be pointed out in this connection that the number of autopsies for most categories of diseases has more than doubled in Finland in the ten years from 1963 to 1973 [ 171. This has occurred at the expense of the anamnesis and clinical examination (see Material and methods) on the basis of which deaths were certified more frequently in the beginning of the 1960s than at the beginning of the 1970s. However, in ten years only slight alterations were found in mortality rates of middle-aged men from all CVD or ischaemic heart diseases [ 171, which corresponds to the findings reported from some other industrialized countries [ 11,12,16]. So, the marked increase in autopsy activity in Finland has not markedly changed the cardiovascular mortality figures. The above results suggest that the anamnesis and hospital treatment often supplied in Finland with specific diagnostic investigations,
250
such as ECG, roentgen, etc., have apparently been quite valid for making the diagnosis of cardiovascular death, because a major proportion of all deaths in middle-aged men occurred in hospitals. Therefore, the national rate of 76%, presented above which indicates the number of all autopsied and/or hospitaltreated cardiovascular deaths in middle-aged men, gives support to the overall validity of the Finnish mortality statistics at younger ages. Of course these statistics cannot be regarded as precise measures, but rather as a reliable source of leads to be elaborated by other study approaches, as stressed by Moriyama [ 251.
Acknowledgements This work was supported tion, Helsinki, Finland.
by a grant from the Sigrid Jusehus
Founda-
References 1 M. A. Heasman and L. K. Lipworth, Accuracy of certification of cause of death. General Register Office, Studies on Medical and Population Subjects, No. 20. H. M. Stationery Office, London, 1966. 2 F. W. Bauer and S. L. Robbins, An autopsy study of cancer patients. I. Accuracy of the clinical diagnoses (1955 to 1965). J. Amer. Med. Ass., 221 (1972) 1471. 3 W. G. Beadenkopf, M. Abrams, A. Dauod and R. U. Marks, An assessment of certain medical aspects of death certificate data for epidemiologic study of arteriosclerotic heart diseases. J. Chronic Dis., 16 (1963) 249. 4 G. James, R. E. Patton and A. S. Heslin, Accuracy of cause-of-death statements on death certificates, Publ. Health Rep., 70 (1955) 38. 5 S. J. Kunitz and J. E. Edland, The epidemiology of autopsies in Monroe County, New York. J. Forensic Sci., 18 (1973) 370 - 379. 6 B. C. Paton, The accuracy of diagnosis of myocardial infarction: a clinico-pathologic study. Amer. J. Med., 23 (1957) 761. 7 H. 0. Swartout and R. G. Webster, To what degree are mortality statistics dependable? Amer. J. Pub. Health, 30 (1940) 811. 8 T. M. Peery, The new and old diseases. A study of mortality trends in the United States, 1900 - 1969. Amer. J. Clin. Pathol., 63 (1975) 453. 9 A. Penttila and A. Ahonen, An international comparison of mortality in middle-aged Sci., 13 (I 979) 221. men from cardiovascular diseases during 1970 - 1974. Forensic 10 A. Penttili, Mortality from arteriosclerotic and other degenerative heart diseases in Finland in 1968. Health Serv. Res. Nat. Board Health Finland, 12 (1975) 1. 11 G. Biiirk, Epidemiological studies on cardiovascular diseases in Sweden. J. Chronic Dis., 18 (1965) 519. 12 J. H. DeHaas, Changing Mortality Patterns and Cardiovascular Diseases. DeErven F. Bohn N.V., Haarlem, 1964, p. 1. 13 A. H. T. Robb-Smith, The Enigma of Coronary Heart Disease. Lloyd-Luke, London, 1967, p. 1. 14 World Health Organization, World Health Statistics Report, 22 (1969) 430. 15 G. Dean, The need for accurate certification of the cause of death and for more autopsies. J. Irish Med. Ass., 62 (1969) 273.
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F. H. Epstein, The epidemiology of coronary heart disease. J. Chronic Dis., 18 (1965) 735. A. Penttila and A. Ahonen, Mortality patterns and examination of cause of death in Finland in 1955 1973. A death certificate study. In preparation. A.-M. Bolander, A comparative study of mortality by cause in four Nordic countries, 1966 1968, with special reference to male excess mortality. Statist. Rep., 9 (1971) 29. M. Britton, The consequences of informing relatives of intended autopsy in conjuction with death in hospital. Acta Sociomed. Stand., 1 (1972) 37. J. B. Arthaud, Autopsies in the United States - frequency by states. J. Amer. Med. Ass., 213 (1970) 1195. J. D. J. Havard, The Detection of Secret Homicide. The Need for Post-Mortem Examination. Macmillan, London, 1960, p. 151. R. D. Teare, The Scotland Yard autopsy. Bull. N.Y. Acad. Med., 44 (1968) 843. J. F. Gwynne, The unreliability of death certificates. N.Z. Med. J., 80 (1974) 336. L. Munan, A. Kelly and R. Cote, Do the right children have necropsies? Arch. Dis. Childhood, 50 (1975) 620. I. M. Moriyama, Factors in diagnosis and classification of deaths from cardiovascular diseases. Pub. Health Rep., 75 (1960) 189.
