A retrospective analysis of clinical diagnoses and autopsy findings in 3,042 cases during two different time periods

doi:10.1016/0046-8177(94)90269-0

Human Pathology

Volume 25, Issue 2, February 1994, Pages 140-145

https://doi.org/10.1016/0046-8177(94)90269-0 Get rights and content

Abstract

The accuracy of clinical diagnoses was determined and compared between the two periods of time 1977 to 1978 and 1987 to 1988 based on the analysis of 3,042 autopsies at Huddinge University Hospital. The discrepancy rates were calculated by counting the number of missed or incompletely diagnosed major diseases and their complications. Moreover, sensitivity, specificity, and clinical accuracy for positive and negative diagnoses also were calculated for all cases of acute myocardial infarction and malignant tumors. The autopsy rate decreased from 80% to 39%. The autopsy successfully addressed the clinical questions in 97% of the cases. The selection of the cases possibly could explain the significant 5% increase in the proportion of clinically undetected major underlying diseases. The discrepancy rate was higher among the older patients. There were no significant changes in the diagnosis of cardiovascular diseases apart from thrombosis of the mesenteric artery, which more than doubled. The proportion of infectious diseases increased significantly from 27% to 32%. The number of cases with clinically missed tuberculosis was twice as high in the 1987 to 1988 period as in the 1977 to 1978 period and there was a marked increase in fungal and viral infections. There was no significant change in the clinical diagnosis of malignant tumors between the two periods. Approximately 15% of all major cancers were not diagnosed before autopsy; half of these tumors were lethal. We conclude that the role of the autopsy has not diminished in spite of advanced diagnostic methods and it remains an effective tool in the assessment of medical care.

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Analizar el diagnóstico clínico ante mortem y el resultado de la autopsia clínica para identificar hallazgos inesperados de alta relevancia clínica.
Estudio retrospectivo observacional realizado en el Hospital Universitario Central de Asturias en el que se examinaron las autopsias de adulto y sus respectivas historias clínicas en la década 2008-2017 y se clasificaron siguiendo la Clasificación de Goldman y por servicios de procedencia.
De las 1320 autopsias se incluyeron finalmente 694 (52,6%). De ellas, hasta en un 57,6% se observaron discrepancias, la mayoría menores (39,3%). En 63 autopsias se identificaron discrepancias de tipo I (9,1%) siendo las neoplasias malignas la principal patología observada (57,1%), especialmente de origen gastrointestinal con cerca del 28% de los casos. Tras el cáncer, fueron las enfermedades infecciosas (23,8%) y después el embolismo pulmonar (15,9%). Por otra parte, 64 autopsias fueron clasificadas como discrepancias tipo II (9,2%) identificando mayoritariamente al infarto como principal causante (37,5%), sobre todo el infarto agudo de miocardio (18 casos), seguido de broncoaspiraciones (18,7%), CID (15,6%), hemorragias masivas (9,4%) y otros procesos. Se observó que tanto la UVI como el Servicio de Medicina Interna fueron los responsables del mayor número de discrepancias mayores (tipo I y II), representando cerca del 45% para discrepancias tipo I y algo más del 56% para discrepancias tipo II.
Las autopsias son una herramienta esencial de calidad hospitalaria para vislumbrar errores ante mortem significativos. El Hospital Universitario Central de Asturias muestra una proporción de discrepancias mayores (18,3%) en rangos similares a los mejores hospitales de referencia mundial.
To compare and contrast clinical diagnoses with autopsy findings in order to identify unexpected, relevant discrepancies.
A retrospective observational study of the revision of autopsies of adults and their respective medical records in order to classify them according to referral department and Goldman's classification was carried out at the Central University Hospital of Asturias between 2008-2017.
694 (52.6%) of 1320 autopsies were included in the study. Discrepancies were observed in 57.6% of cases, although the majority (39.3%) were minor. Type I discrepancies were identified in 63 autopsies (9.1%); malignant neoplasms being the main pathology observed (57.1%), mainly of gastrointestinal origin (about 28%). The second most common discrepancy was found in cases of infectious diseases (23.8%) followed by pulmonary embolism (15.9%). 64 autopsies were classified as type II discrepancies (9.2%), with myocardial infarct the most common (37.5%), especially acute myocardial infarction (18 cases), followed by bronchoaspirations (18.7%), DIC (15.6%), massive haemorrhages (9.4%) and other conditions. It was considered that both the ICU and the Internal Medicine Service were responsible for the largest number of major discrepancies (type I and II), accounting for about 45% of type I and slightly more than 56% for type II.
Autopsies are an essential means of identifying ante-mortem clinical errors. The incidence of major discrepancies in the Central University Hospital of Asturias (18.3%) is comparable to that of leading hospitals worldwide.
Autopsies are essential for a better knowledge and prevention of sudden cardiac death
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En France, la mort subite cardiaque (MSC) représente environ 30 000 à 50 000 décès par an. La MSC, tous âges et sexes confondus, est due à une maladie coronaire athéroscléreuse dans plus de 80 % des cas. En revanche, chez le sujet jeune (< 35 ans), les causes de MSC sont variées : génétiques, malformatives, infectieuses, toxiques, immunologiques… Dans cette population, il est donc important d’établir précisément la cause du décès afin de prévenir d’autres MSC chez les apparentés. La détermination de la cause du décès chez le cas index doit reposer sur une approche pluridisciplinaire. Cet article examine les différents aspects des autopsies et des investigations complémentaires : histologie, toxicologie, génétique, virologie, biochimie. Six observations illustrent l’importance de cette démarche pluridisciplinaire. Il existe deux catégories d’autopsies : judiciaire et médicale. Leur point commun est la recherche de la cause du décès. En revanche, plusieurs aspects les distinguent. Une autopsie judiciaire est ordonnée par un magistrat dans le cadre d’une enquête judiciaire à la suite d’un « obstacle médico-légal » mentionné dans le certificat de décès. Au cours des autopsies, des prélèvements sont effectués et placés sous scellés, mais c’est le magistrat qui décide si des analyses complémentaires doivent être ordonnées. Le médecin légiste intervient en tant qu’auxiliaire de la justice, mais il est donc confronté à la difficulté de faire valoir son rôle en matière de santé publique, pourtant essentiel. Les autopsies médicales, pratiquées par des pathologistes, sont demandées par des médecins cliniciens. Ces autopsies doivent respecter les exigences de recherche du consentement. Toutes les analyses utiles sont effectuées, ce qui permet un diagnostic précis par une approche pluridisciplinaire. L’histologie est indispensable, complétée parfois par immunohistochimie pour préciser des infiltrats inflammatoires (CD3, CD68). Les myocardites virales sont parmi les causes les plus fréquentes de MSC chez le sujet jeune. Des analyses virologiques sont pratiquées à partir de prélèvements congelés, par biologie moléculaire. Des analyses toxicologiques et biochimiques peuvent s’avérer utiles. Le concept d’« autopsie moléculaire » souligne l’importance des analyses génétiques chez le cas index jeune. La cardiomyopathie hypertrophique et la cardiomyopathie ventriculaire droite arythmogène sont les causes génétiques les plus fréquentes chez le sujet jeune. Cette approche pluridisciplinaire est donc indispensable pour une meilleure connaissance et la prévention des MSC.
In France, the incidence of sudden cardiac deaths (SCD) is approximately 30,000–50,000 per year. In the whole population, their cause is an atherosclerotic coronary disease in more than 80 % of cases, but in the young (< 35 years old), causes are various, including genetic, infectious, toxic, congenital anomalies, immune…Therefore a multidisciplinary approach is required for a better knowledge and prevention of SCD. In this article, we examine different aspects of autopsies and complementary investigations: histopathology, toxicology, biochemistry, genetics and virology. Six cases illustrate the importance of a multidisciplinary approach. There are two categories of autopsies: medicolegal or medical. Medicolegal autopsies are requested by a judicial authority when a death is considered suspicious. These autopsies are performed by forensic doctors. Most of them are not pathologists. During the autopsies, blood and tissue samples are taken, but analyses are done only at the request of the judicial authority if the analyses are useful for the truth. Consequently, the cause of death can remain uncertain. Medical autopsies are performed by a pathologist at the request of a clinician. The family consent is required. Useful analyses are performed, which is essential for the determination of a precise cause of death. In the young, “molecular autopsy”, in addition to histology and other analyses, is essential in preventing genetic causes of SCD.
Autopsy-detected diagnostic errors over time in the intensive care unit
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We evaluate the evolution over time of discrepancies between clinical diagnoses and postmortem findings in critically ill patients and assess the factors associated with these discrepancies. We conducted a prospective study of all consecutive patients who underwent autopsy in a medical-surgical intensive care unit (ICU) between January 2008 and December 2015. Among 7655 patients admitted to our ICU, 671 (8.8%) died. Clinical autopsy was performed in 215 (32%) patients. Major missed diagnoses were noted in 38 patients (17.7%). Eighteen patients (8.4%) had class I discrepancies, and 20 patients (9.3%) had class II discrepancies. The most frequently missed diagnoses were invasive aspergillosis, intestinal ischemia, myocardial infarction, cancer, and intra-abdominal abscesses. We did not find a statistically significant correlation between any premortem factor, including age, sex, severity of illness, length of hospital stay before ICU admission, length of ICU stay before death, duration of mechanical ventilation, or admitting unit, and the level of agreement between clinical and pathological diagnosis. In the last decades, the discrepancies between clinical and autopsy diagnoses persisted despite advances in medical skills and technology. Specific clinical entities such as invasive aspergillosis, mesenteric ischemia, myocardial infarction, intra-abdominal abscesses, and neoplastic diseases remain a diagnostic challenge in critically ill patients. Clinical level of diagnostic certainty does not increase with specific premortem characteristics.
Diagnostic Errors and the Bedside Clinical Examination
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Citation Excerpt :
Advanced medical technology appears to make only a marginal impact on diagnostic accuracy. Studies comparing the frequency of missed diagnoses before and after the advent of modern diagnostic imaging found little improvement in diagnostic accuracy.7,8 A more recent analysis9 argues that this lack of improvement is likely an artifact of clinical selection bias.
Undiagnosed fatal malignancy in adult autopsies: A 10-year retrospective study
2016, Human Pathology
Autopsies reveal undiagnosed malignancies even in this era of modern diagnostic imaging and ancillary laboratory studies. The incidence of clinically undiagnosed malignancies related to primary cause of death in a university hospital setting has rarely been studied. Our objective was to determine the incidence of clinically undiagnosed fatal malignancies in an urban teaching hospital and to assess whether this incidence was influenced by the duration of hospital stay. We performed a retrospective analysis of consecutive adult hospital autopsies in which the primary cause of death was related to undiagnosed malignancy. The detailed autopsy report, clinical records, and relevant laboratory results from laboratory and hospital databases were reviewed. Eight hundred twenty-one adult autopsies were performed over 10 years. Sixty-nine clinically undiagnosed malignant neoplasms were found in 66 cases (8%). In 26 of these 66 cases, the undiagnosed malignant neoplasm was related to the primary cause of death (3.1%). The duration of hospital stay was less than 24 hours in 8 cases (30.7%), 2 to 7 days in 9 cases (34.6%), and greater than 7 days in 9 cases (34.6%). In 10 of these 26 cases (1.2%), there was suspicion of malignancy without definitive tissue diagnosis, and the average hospital stay was 4.9 days. In 16 (1.9%) of these 26 cases, malignancy was not clinically suspected, and the average hospital stay was 9.9 days. We conclude that despite the recent advances in diagnostic imaging and laboratory techniques, a subset of adult autopsies (3.1%) performed in an urban university hospital have clinically undiagnosed malignancy related to the primary cause of death. Malignancy was not clinically suspected in 1.9% of these cases. There is a need to conduct comprehensive “root cause” analysis in these cases for improvement of clinical care.
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^☆: Presented in part at the “State of the Art Conference: The Autopsy in Clinical Practice and Research. Problems and Possibilities,” Medical Research Council, Sweden, Sigtuna, November 16–17, 1992.

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Original contributionA retrospective analysis of clinical diagnoses and autopsy findings in 3,042 cases during two different time periods☆

Abstract

Am J Med

Hum Pathol

Is necropsy a valid monitor of clinical diagnosis performance?

BMJ

The value of autopsy in three medical eras

N Engl J Med

The sensitivity and specificity of clinical diagnostics during five decades. Toward an understanding of necessary fallibility

JAMA

The autopsy

JAMA

The postmortem examination. Scientific necessity or folly?

JAMA

Diagnostic errors discovered at autopsy

Acta Med Scand

Diagnostic yield of the autopsy in a university hospital and a community hospital

N Engl J Med

The necropsy as a tool in medical progress

Bull NY Acad Sci

Autopsy: Clinicopathological concordance and imaging techniques

International Classification of Disease, 1965 (revision)

Original contribution
A retrospective analysis of clinical diagnoses and autopsy findings in 3,042 cases during two different time periods☆