Corinne L Fligner

D Butler

Drucilla J Roberts

E Fottrell

IA Scordi-Bello

J Murray

J Ordi

JA Cox

Jill Murray

KG Shojania

L Goldman

M Dgedge

N Soleman

T Ayoub

English

PubMed

Crossref

COMMENTARY Open AccessSynergism of verbal autopsy and diagnosticpathology autopsy for improvedaccuracy of mortality dataCorinne L Fligner1*, Jill Murray2 and Drucilla J Roberts3CommentaryThis series provides an important opportunity to con-sider how diagnostic pathology autopsy could be used inconjunction with verbal autopsy to provide more accu-rate cause of death and mortality data in all countries,and specifically in those countries with inadequate ornonexistent death registrations systems. For the pur-poses of this commentary, the term “autopsy” willdenote the medical-pathology diagnostic procedure, incontrast to “verbal autopsy.”The term “autopsy” means “to see or observe for one-self,” but traditional use has been reserved for the post-mortem examination of a (dead) body by a physician/pathologist, in order to identify diseases and injuries anddetermine the cause(s) of death. This medical-diagnosticpathology procedure integrates trained observation ofthe external and internal body with dissection or otherinvasive procedures, in order to obtain tissue samples,which are evaluated by microscopy and other specializedlaboratory modalities, including chemical, toxicologic,genetic, and molecular biologic analyses. Used morebroadly, the term “autopsy” reflects the aggregate of pro-cedures used for postmortem medical diagnosis or deathinvestigation, including investigative procedures thatidentify information about the deceased’s medical his-tory and the circumstances and scene of his/her death.To most pathologists and physicians, the term “verbalautopsy” seems a contradiction in terms. However, it isa clearly defined procedure, which allows classificationof cause of death and cause-specific mortality by theanalysis of data derived from structured interviews offamily, friends, and caretakers, as well as review of anyavailable medical records [1]. As more than two-thirdsof the world’s population lives and dies in countries thatlack functional vital registration systems, and in whichmost deaths occur outside of medical facilities and areneither enumerated nor classified by cause, verbalautopsy has become the primary methodology for deter-mining population-based cause-specific mortality [2,3].The development of computerized algorithmic systemsfor determination of cause of death by analysis of verbalautopsy data is a major focus of health metrics research,and emphasis is currently focused on using the recently-completed dataset from the Population Health MetricsResearch Consortium (PHMRC) project that will allowanalysis of verbal autopsy data collected from more than12,000 hospitalized patients with causes of death estab-lished by rigorous clinical criteria.The accuracy of verbal autopsy depends in large parton the quality of the diagnostic criteria, as well as onthe age of the deceased and the type of diseases that areinvolved. Deaths associated with nonspecific signs andsymptoms are especially problematic. The recent contro-versy about malaria mortality in India was a newsworthyexample of the difficulty of differentiating malaria-caused deaths from those due to other febrile illnesses,such as septicemia, meningitis, encephalitis, and pneu-monia [4]. Other areas of poor diagnostic specificityinclude maternal deaths, perinatal deaths, and stillbirths.Verbal autopsy has not been validated using deaths inwhich diagnostic pathology autopsies have been per-formed to determine the cause of death.Diagnostic pathology autopsies have long been consid-ered the “gold standard” for cause of death determina-tion. Although autopsy rates are generally low in manydeveloped countries, estimated at less than 5% in UShospital deaths, studies have continued to demonstratesubstantial discordance between clinically- and autopsy-determined causes of death despite technologic advancesin diagnostic modalities. These discrepancies arereflected in both clinical records and death certificates.Major diagnostic error rates involving the primary cause* Correspondence: fligner@u.washington.edu1Departments of Pathology and Laboratory Medicine, University ofWashington School of Medicine, Box 356100, Seattle, WA, 98195, USAFull list of author information is available at the end of the articleFligner et al. Population Health Metrics 2011, 9:25http://www.pophealthmetrics.com/content/9/1/25© 2011 Fligner et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.of death have ranged from 10% to more than 30%, evenin a recent study that suggested a decline in the autopsydetection of unsuspected diagnoses [5]. The extent ofantemortem diagnostic workup did not predict autopsydiscrepancy rates. It is still widely accepted that a prop-erly performed autopsy and death review or investiga-tion can provide the most accurate determination ofcause of death. The contributions of autopsy to afamily’s understanding of a death, to the clinician’sunderstanding of a death, to discovery of new diseaseprocesses or effects of therapy, and to medical educationare well established [6-8].Autopsy-based studies of cause of death in Africa havealso confirmed a high rate of diagnostic discrepancy. In apopulation-based autopsy study of HIV-1 infected goldminers, discrepancies between clinical and autopsy diag-noses were high, with 51% of infections and 55% of pul-monary tuberculosis diagnosed at autopsy having beenmissed clinically [9]. A study in Maputo, Mozambiquenoted that autopsies identified more specific diagnosesthan death registries, resulting in a different distributionof leading causes of death [10]. A review of the autopsyseries in sub-Saharan Africa from 1992 to 2010 showedonly a weak correlation between clinical diagnosis andpathologic findings in HIV-positive individuals [11]. In aunique autopsy-based study of maternal deaths, a 40%discrepancy rate between clinical and autopsy diagnoseswas identified in a tertiary referral hospital in Mozambi-que from 2002 to 2004 [12]. Given that verbal autopsydatasets frequently do not have any medical sources ofinformation, it is even more likely that there are substan-tial discrepancies between diagnostic autopsy- and verbalautopsy-determined causes of death.A major advantage of a diagnostic autopsy is that itcan identify a cause or causes of death based on patho-logic tissue diagnosis. Even in deaths in which patholo-gic examination does not identify a definite cause ofdeath, that information can be integrated into the deathinvestigation process to guide the performance of addi-tional studies and the formulation of the most likelycause of death based on all available diagnostic informa-tion. Autopsy also identifies chronic and infectious dis-ease processes that may not be the direct cause ofdeath, permitting assessment of prevalence for theseprocesses. Another advantage is that the creation of tis-sue repositories by preservation of tissue for histologicstudies may facilitate later disease discovery and charac-terization, allowing modification of mortality data basedon medical scientific advancement.A major impediment to the performance of diagnosticpathology autopsies is the requirement for trainedpathologists and assistants and histologic laboratoryinfrastructure for processing tissues for microscopy andpreserving tissues, not currently available in many low-and middle-resource countries, particularly in nonurbansettings. However, compared with many diagnostic mod-alities, such as those required for radiologic imaging,autopsy is a relatively low-tech and inexpensive proce-dure, which utilizes the same clinical and anatomicpathology laboratory resources needed for the provisionof quality medical care in these settings. Another con-cern is the impact of cultural and religious attitudesabout death and the handling of dead bodies. As thisvaries by country, culture and religion, this issue willneed to be addressed on a case-by-case basis. Education,discussion, respectful communication and practice, andmodification and limitation of invasive procedures forcommunity acceptance could contribute to acceptanceof this postmortem diagnostic procedure.Verbal autopsy is a valuable indirect system for estab-lishing cause of death and cause-specific mortality, butlike any clinical and historical investigation, it will mis-classify a substantial number of deaths when comparedto the true “gold standard” for death classification, diag-nostic pathology autopsy. Too many natural disease pro-cesses have similar presentations, symptoms, and signs,and the same assumptions that result in inaccuratecause of death determination in up to 40% of physician-certified deaths will be present in verbal autopsy data.What is now needed in low- and middle-resource coun-tries are robust studies of the concordance of verbal anddiagnostic pathology autopsy to assess the contributionthat diagnostic pathology autopsy can make to the qual-ity of verbal autopsy and other mortality data. Similarstudies would also be valuable in developed countrieswith reportedly high-quality cause of death data. Contin-uous evaluation of a proportion of deaths by diagnosticpathology autopsy in conjunction with verbal autopsycould promote continuous quality assessment andimprovement of mortality data, and at the same timefacilitate the identification of new or emerging diseaseprocesses.Author details1Departments of Pathology and Laboratory Medicine, University ofWashington School of Medicine, Box 356100, Seattle, WA, 98195, USA.2National Institute for Occupational Health, National Health LaboratoryService and School of Public Health, Faculty of Health Sciences, University ofthe Witwatersrand, PO Box 4788, Johannesburg 2000, South Africa.3Massachusetts General Hospital (MGH)-Pathology, 55 Fruit Street WRN 219,Boston, MA, 02114, USA.Authors’ contributionsCLF, JM, and DJR participated in the discussion of the concepts. CLF draftedthe manuscript. All authors read, revised, edited, and approved themanuscript.Competing interestsCLF has received grant funding from the Washington Global Health Alliance(formerly Puget Sound Partners in Global Health) for the development of aminimally-invasive autopsy for low-resource settings.Fligner et al. Population Health Metrics 2011, 9:25http://www.pophealthmetrics.com/content/9/1/25Page 2 of 3CLF, JM, and DJR received funding from the INDEPTH Network to attend the2011 Global Congress on Verbal Autopsy: State of the Science and a post-meeting session focused on research opportunities related to diagnosticpathology autopsies and verbal autopsies in Bali, Indonesia, in February2011.Received: 15 April 2011 Accepted: 1 August 2011Published: 1 August 2011References1. World Health Organization: Verbal Autopsy Standards: Ascertaining andattributing causes of death [http://www.who.int/whosis/mort/verbalautopsystandards/en/].2. Soleman N, Chandramohan D, Shibuya K: Verbal autopsy: Currentpractices and challenges. Bulletin of the World Health Organization 2006,84:239-245.3. Fottrell E, Byass P: Verbal autopsy: Methods in transition. Epidemiol Rev2010, 32:38-55.4. Butler D: Verbal autopsy methods questioned: Controversy flares overmalaria mortality levels in India. Nature 2010, 467:1015.5. Shojania KG, Burton EC, McDonald KM, Goldman L: Changes in rates ofautopsy-detected diagnostic errors over time–A systematic review. JAMA2003, 289:2849-2856.6. Goldman L, Sayson R, Robbins ZAZ, Cohn LH, Bettman M, Weisberg M: Thevalue of the autopsy in three medical eras. N Engl J Med 1983,308:1000-1005.7. Scordi-Bello IA, Kalb TH, Lento PA: Clinical setting and extent ofpremortem evaluation do not predict autopsy discrepancy rates. ModernPathology 2010, 23:1225-1230.8. Ayoub T, Chow J: The conventional autopsy in modern medicine. J R SocMed 2008, 101:177-181.9. Murray J, Sonnenberg P, Nelson G, Bester A, Shearer S, Glynn JR: Cause ofdeath and presence of respiratory disease at autopsy in an HIV-1seroconversion cohort of southern African gold miners. AIDS 2007,21(supple 6):S97-104.10. Dgedge M, Novoa A, Macassa G, Sacarlal J, Black J, Michaud C, Cliff J: Theburden of disease in Maputo City, Mozambique: Registered andautopsied deaths in 1994. Bulletin of the World Health Organization 2001,79:546-552.11. Cox JA, Lukande RL, Lucas S, Nelson AM, Van Marck E, Colebunders R:Autopsy causes of death in HIV positive individuals in sub-SaharanAfrica and correlation with clinical diagnoses. AIDS Rev 2010, 12:183-194.12. Ordi J, Ismail MR, Carrilho C, Romagosa C, Osman N, Machungo F,Bombí JA, Balasch J, Alonso PL, Menéndez C: Clinico-pathologicaldiscrepancies in the diagnosis of causes of maternal death in sub-Sahara Africa: retrospective analysis. PLOS Med 2009, 6(2):e100036.doi:10.1186/1478-7954-9-25Cite this article as: Fligner et al.: Synergism of verbal autopsy anddiagnostic pathology autopsy for improved accuracy of mortality data.Population Health Metrics 2011 9:25.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitFligner et al. Population Health Metrics 2011, 9:25http://www.pophealthmetrics.com/content/9/1/25Page 3 of 3

Population Health Metrics

Synergism of verbal autopsy and diagnostic pathology autopsy for improved accuracy of mortality data

Murray Jill

Fligner Corinne L

Roberts Drucilla J

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COMMENTARY Open Access
Synergism of verbal autopsy and diagnostic
pathology autopsy for improved
accuracy of mortality data
Corinne L Fligner1*, Jill Murray2 and Drucilla J Roberts3
Commentary
This series provides an important opportunity to con-
sider how diagnostic pathology autopsy could be used in
conjunction with verbal autopsy to provide more accu-
rate cause of death and mortality data in all countries,
and specifically in those countries with inadequate or
nonexistent death registrations systems. For the pur-
poses of this commentary, the term “autopsy” will
denote the medical-pathology diagnostic procedure, in
contrast to “verbal autopsy.”
The term “autopsy” means “to see or observe for one-
self,” but traditional use has been reserved for the post-
mortem examination of a (dead) body by a physician/
pathologist, in order to identify diseases and injuries and
determine the cause(s) of death. This medical-diagnostic
pathology procedure integrates trained observation of
the external and internal body with dissection or other
invasive procedures, in order to obtain tissue samples,
which are evaluated by microscopy and other specialized
laboratory modalities, including chemical, toxicologic,
genetic, and molecular biologic analyses. Used more
broadly, the term “autopsy” reflects the aggregate of pro-
cedures used for postmortem medical diagnosis or death
investigation, including investigative procedures that
identify information about the deceased’s medical his-
tory and the circumstances and scene of his/her death.
To most pathologists and physicians, the term “verbal
autopsy” seems a contradiction in terms. However, it is
a clearly defined procedure, which allows classification
of cause of death and cause-specific mortality by the
analysis of data derived from structured interviews of
family, friends, and caretakers, as well as review of any
available medical records [1]. As more than two-thirds
of the world’s population lives and dies in countries that
lack functional vital registration systems, and in which
most deaths occur outside of medical facilities and are
neither enumerated nor classified by cause, verbal
autopsy has become the primary methodology for deter-
mining population-based cause-specific mortality [2,3].
The development of computerized algorithmic systems
for determination of cause of death by analysis of verbal
autopsy data is a major focus of health metrics research,
and emphasis is currently focused on using the recently-
completed dataset from the Population Health Metrics
Research Consortium (PHMRC) project that will allow
analysis of verbal autopsy data collected from more than
12,000 hospitalized patients with causes of death estab-
lished by rigorous clinical criteria.
The accuracy of verbal autopsy depends in large part
on the quality of the diagnostic criteria, as well as on
the age of the deceased and the type of diseases that are
involved. Deaths associated with nonspecific signs and
symptoms are especially problematic. The recent contro-
versy about malaria mortality in India was a newsworthy
example of the difficulty of differentiating malaria-
caused deaths from those due to other febrile illnesses,
such as septicemia, meningitis, encephalitis, and pneu-
monia [4]. Other areas of poor diagnostic specificity
include maternal deaths, perinatal deaths, and stillbirths.
Verbal autopsy has not been validated using deaths in
which diagnostic pathology autopsies have been per-
formed to determine the cause of death.
Diagnostic pathology autopsies have long been consid-
ered the “gold standard” for cause of death determina-
tion. Although autopsy rates are generally low in many
developed countries, estimated at less than 5% in US
hospital deaths, studies have continued to demonstrate
substantial discordance between clinically- and autopsy-
determined causes of death despite technologic advances
in diagnostic modalities. These discrepancies are
reflected in both clinical records and death certificates.
Major diagnostic error rates involving the primary cause
* Correspondence: fligner@u.washington.edu
1Departments of Pathology and Laboratory Medicine, University of
Washington School of Medicine, Box 356100, Seattle, WA, 98195, USA
Full list of author information is available at the end of the article
Fligner et al. Population Health Metrics 2011, 9:25
http://www.pophealthmetrics.com/content/9/1/25
© 2011 Fligner et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
of death have ranged from 10% to more than 30%, even
in a recent study that suggested a decline in the autopsy
detection of unsuspected diagnoses [5]. The extent of
antemortem diagnostic workup did not predict autopsy
discrepancy rates. It is still widely accepted that a prop-
erly performed autopsy and death review or investiga-
tion can provide the most accurate determination of
cause of death. The contributions of autopsy to a
family’s understanding of a death, to the clinician’s
understanding of a death, to discovery of new disease
processes or effects of therapy, and to medical education
are well established [6-8].
Autopsy-based studies of cause of death in Africa have
also confirmed a high rate of diagnostic discrepancy. In a
population-based autopsy study of HIV-1 infected gold
miners, discrepancies between clinical and autopsy diag-
noses were high, with 51% of infections and 55% of pul-
monary tuberculosis diagnosed at autopsy having been
missed clinically [9]. A study in Maputo, Mozambique
noted that autopsies identified more specific diagnoses
than death registries, resulting in a different distribution
of leading causes of death [10]. A review of the autopsy
series in sub-Saharan Africa from 1992 to 2010 showed
only a weak correlation between clinical diagnosis and
pathologic findings in HIV-positive individuals [11]. In a
unique autopsy-based study of maternal deaths, a 40%
discrepancy rate between clinical and autopsy diagnoses
was identified in a tertiary referral hospital in Mozambi-
que from 2002 to 2004 [12]. Given that verbal autopsy
datasets frequently do not have any medical sources of
information, it is even more likely that there are substan-
tial discrepancies between diagnostic autopsy- and verbal
autopsy-determined causes of death.
A major advantage of a diagnostic autopsy is that it
can identify a cause or causes of death based on patho-
logic tissue diagnosis. Even in deaths in which patholo-
gic examination does not identify a definite cause of
death, that information can be integrated into the death
investigation process to guide the performance of addi-
tional studies and the formulation of the most likely
cause of death based on all available diagnostic informa-
tion. Autopsy also identifies chronic and infectious dis-
ease processes that may not be the direct cause of
death, permitting assessment of prevalence for these
processes. Another advantage is that the creation of tis-
sue repositories by preservation of tissue for histologic
studies may facilitate later disease discovery and charac-
terization, allowing modification of mortality data based
on medical scientific advancement.
A major impediment to the performance of diagnostic
pathology autopsies is the requirement for trained
pathologists and assistants and histologic laboratory
infrastructure for processing tissues for microscopy and
preserving tissues, not currently available in many low-
and middle-resource countries, particularly in nonurban
settings. However, compared with many diagnostic mod-
alities, such as those required for radiologic imaging,
autopsy is a relatively low-tech and inexpensive proce-
dure, which utilizes the same clinical and anatomic
pathology laboratory resources needed for the provision
of quality medical care in these settings. Another con-
cern is the impact of cultural and religious attitudes
about death and the handling of dead bodies. As this
varies by country, culture and religion, this issue will
need to be addressed on a case-by-case basis. Education,
discussion, respectful communication and practice, and
modification and limitation of invasive procedures for
community acceptance could contribute to acceptance
of this postmortem diagnostic procedure.
Verbal autopsy is a valuable indirect system for estab-
lishing cause of death and cause-specific mortality, but
like any clinical and historical investigation, it will mis-
classify a substantial number of deaths when compared
to the true “gold standard” for death classification, diag-
nostic pathology autopsy. Too many natural disease pro-
cesses have similar presentations, symptoms, and signs,
and the same assumptions that result in inaccurate
cause of death determination in up to 40% of physician-
certified deaths will be present in verbal autopsy data.
What is now needed in low- and middle-resource coun-
tries are robust studies of the concordance of verbal and
diagnostic pathology autopsy to assess the contribution
that diagnostic pathology autopsy can make to the qual-
ity of verbal autopsy and other mortality data. Similar
studies would also be valuable in developed countries
with reportedly high-quality cause of death data. Contin-
uous evaluation of a proportion of deaths by diagnostic
pathology autopsy in conjunction with verbal autopsy
could promote continuous quality assessment and
improvement of mortality data, and at the same time
facilitate the identification of new or emerging disease
processes.
Author details
1Departments of Pathology and Laboratory Medicine, University of
Washington School of Medicine, Box 356100, Seattle, WA, 98195, USA.
2National Institute for Occupational Health, National Health Laboratory
Service and School of Public Health, Faculty of Health Sciences, University of
the Witwatersrand, PO Box 4788, Johannesburg 2000, South Africa.
3Massachusetts General Hospital (MGH)-Pathology, 55 Fruit Street WRN 219,
Boston, MA, 02114, USA.
Authors’ contributions
CLF, JM, and DJR participated in the discussion of the concepts. CLF drafted
the manuscript. All authors read, revised, edited, and approved the
manuscript.
Competing interests
CLF has received grant funding from the Washington Global Health Alliance
(formerly Puget Sound Partners in Global Health) for the development of a
minimally-invasive autopsy for low-resource settings.
Fligner et al. Population Health Metrics 2011, 9:25
http://www.pophealthmetrics.com/content/9/1/25
Page 2 of 3
CLF, JM, and DJR received funding from the INDEPTH Network to attend the
2011 Global Congress on Verbal Autopsy: State of the Science and a post-
meeting session focused on research opportunities related to diagnostic
pathology autopsies and verbal autopsies in Bali, Indonesia, in February
2011.
Received: 15 April 2011 Accepted: 1 August 2011
Published: 1 August 2011
References
1. World Health Organization: Verbal Autopsy Standards: Ascertaining and
attributing causes of death [http://www.who.int/whosis/mort/
verbalautopsystandards/en/].
2. Soleman N, Chandramohan D, Shibuya K: Verbal autopsy: Current
practices and challenges. Bulletin of the World Health Organization 2006,
84:239-245.
3. Fottrell E, Byass P: Verbal autopsy: Methods in transition. Epidemiol Rev
2010, 32:38-55.
4. Butler D: Verbal autopsy methods questioned: Controversy flares over
malaria mortality levels in India. Nature 2010, 467:1015.
5. Shojania KG, Burton EC, McDonald KM, Goldman L: Changes in rates of
autopsy-detected diagnostic errors over time–A systematic review. JAMA
2003, 289:2849-2856.
6. Goldman L, Sayson R, Robbins ZAZ, Cohn LH, Bettman M, Weisberg M: The
value of the autopsy in three medical eras. N Engl J Med 1983,
308:1000-1005.
7. Scordi-Bello IA, Kalb TH, Lento PA: Clinical setting and extent of
premortem evaluation do not predict autopsy discrepancy rates. Modern
Pathology 2010, 23:1225-1230.
8. Ayoub T, Chow J: The conventional autopsy in modern medicine. J R Soc
Med 2008, 101:177-181.
9. Murray J, Sonnenberg P, Nelson G, Bester A, Shearer S, Glynn JR: Cause of
death and presence of respiratory disease at autopsy in an HIV-1
seroconversion cohort of southern African gold miners. AIDS 2007,
21(supple 6):S97-104.
10. Dgedge M, Novoa A, Macassa G, Sacarlal J, Black J, Michaud C, Cliff J: The
burden of disease in Maputo City, Mozambique: Registered and
autopsied deaths in 1994. Bulletin of the World Health Organization 2001,
79:546-552.
11. Cox JA, Lukande RL, Lucas S, Nelson AM, Van Marck E, Colebunders R:
Autopsy causes of death in HIV positive individuals in sub-Saharan
Africa and correlation with clinical diagnoses. AIDS Rev 2010, 12:183-194.
12. Ordi J, Ismail MR, Carrilho C, Romagosa C, Osman N, Machungo F,
Bombí JA, Balasch J, Alonso PL, Menéndez C: Clinico-pathological
discrepancies in the diagnosis of causes of maternal death in sub-
Sahara Africa: retrospective analysis. PLOS Med 2009, 6(2):e100036.
doi:10.1186/1478-7954-9-25
Cite this article as: Fligner et al.: Synergism of verbal autopsy and
diagnostic pathology autopsy for improved accuracy of mortality data.
Population Health Metrics 2011 9:25.
Submit your next manuscript to BioMed Central
and take full advantage of: 
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at 
www.biomedcentral.com/submit
Fligner et al. Population Health Metrics 2011, 9:25
http://www.pophealthmetrics.com/content/9/1/25
Page 3 of 3


Byass P: Verbal autopsy: Methods in transition. Epidemiol Rev

Cause of death and presence of respiratory disease at autopsy in an HIV-1 seroconversion cohort of southern African gold miners. AIDS

Changes in rates of autopsy-detected diagnostic errors over time–A systematic review. JAMA

Clinical setting and extent of premortem evaluation do not predict autopsy discrepancy rates. Modern Pathology

Colebunders R: Autopsy causes of death in HIV positive individuals in sub-Saharan Africa and correlation with clinical diagnoses. AIDS Rev

Organization: Verbal Autopsy Standards: Ascertaining and attributing causes of death [http://www.who.int/whosis/mort/ verbalautopsystandards/en/].

The burden of disease in Maputo City, Mozambique: Registered and autopsied deaths in 1994. Bulletin of the World Health Organization

The conventional autopsy in modern medicine.

The value of the autopsy in three medical eras.

Verbal autopsy methods questioned: Controversy flares over malaria mortality levels in India. Nature

Verbal autopsy: Current practices and challenges. Bulletin of the World Health Organization

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Synergism of verbal autopsy and diagnostic pathology autopsy for improved accuracy of mortality data

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