Comparison of Clinical Diagnoses and Autopsy Findings: Six-Year Retrospective Study.
Hospital autopsy rates in the United States declined from 30% to 40% in the 1960s (1) to 8% in the early 2000s. (2) Multiple factors, such as the elimination of the hospital autopsy rate requirement in 1972, lack of reimbursement, cultural and religious objections by families, and increasing workload for house staff, account for the decrease. (3) Even as sophisticated medical technologic tools have been developed and made available, the role of the autopsy for confirming clinical diagnoses and identifying unsuspected findings should be reevaluated regularly. Herein, we report our findings of the importance of the autopsy by comparing the clinical diagnosis with the anatomic findings in a single large academic institution between the years of 2009 and 2014.MATERIALS AND METHODS
Clinical information of all adult (18 years or older) autopsy cases performed in Jackson Memorial Hospital (Miami, Florida) for 6 years (from January 2009 to December 2014) was retrospectively evaluated. Only cases with a stay longer than 24 hours in Jackson Memorial Hospital were included in the study in order to ensure enough time for initial clinical evaluation and management. Exclusion criteria were: (1) a hospital stay of less than 24 hours, (2) restrictions to single-organ or body cavity dissections, and (3) cases referred from other facilities. Cases from the University of Miami Hospital (Miami, Florida), which shares attending physicians and residents in the adjacent campus and whose full medical records were available, were considered in-house cases.
All cases had consent for autopsy from the legal next of kin, and each autopsy was performed by pathology residents who observed restrictions, if there were any. Attending pathologists directly supervised each case. For each eligible autopsy the autopsy report, including clinical history, was reviewed by 2 pathologists (H.M. and C.M.). Medical records were reviewed if the clinical information provided in the autopsy report was unclear or inadequate. Each case was classified using the Goldman Classification (Table 1).4 When a case could be classified with more than one discrepancy, the higher class (smaller number) was regarded as the final classification. The pathologists reviewed the cases independently, compared their assessments, and came to consensus by discussion if there was discordance.
The study design was reviewed by the Institutional Review Board of the University of Miami and approved to be conducted as nonhuman research.
RESULTS
Of 923 autopsies performed in Jackson Memorial Hospital for the 6 years (2009-2014), 512 cases (55.5%) were performed on adults (age >18 years). A total of 334 of 512 cases (65.2%) were subject to review after excluding those with a short (<1 day) hospital stay, restriction to a single-organ or body cavity dissection, and those referred from other facilities (Table 2). The demographics of the patients included are presented in Table 3.
A total of 33 of 334 cases (9.9%) were identified as a class I discrepancy, where the autopsy revealed a discrepant diagnosis with a potential impact on survival or treatment (Table 4). Various critical findings, such as untreated infection (15 of 33 cases; 45.5%), pulmonary embolism (8 of 33 cases; 24.2%), and undiagnosed malignancy (6 of 33 cases; 18.2%) were identified in cases of this class (Table 5). For the cases with class I discrepancies, the clinical history or impression and critical laboratory or imaging results are listed in Table 6. Major significant findings that had not been clinically detected, whether they might or might not have clinical impact, were found in a total of 65 of 334 cases (class I and II; 19.5%).
DISCUSSION
This study is a retrospective review of the adult autopsy reports for recent years in the third largest public hospital (1550 beds) in the United States. It excluded cases from outside institutions, patients with short hospital stays, and those in which the autopsy was restricted to a single organ or body cavity, in order to optimize the clinical and pathologic correlation. Even though the exclusion made the size of the study smaller, the entire set of included cases was comprehensively reviewed, unlike in some previous studies which only reviewed randomly sampled cases. (5)
There was a limitation to calculate the exact autopsy rate because: (1) some cases were declared to be under the jurisdiction of the medical examiner, and therefore dropped from the initial data set, and (2) Jackson Memorial Hospital has many branches and affiliated hospitals from which autopsies are requested, and the total number of deaths in each hospital was not available.
Despite intensive modern clinical investigations, autopsies have continued to reveal major antemortem diagnostic errors in as many as 30% of cases. (6-8) Follow-up or meta-analysis studies show that the rate of clinically significant discrepancy is decreasing over decades; however, 4% to 7% of cases still have class I discrepancies. (1,5) This study shows a comparable result of 9.9% of clinically significant findings to the previous studies.
Undiagnosed infections, especially pneumonia, and pulmonary embolism were the 2 most common significant unexpected findings. These are common complications of hospitalization and subsequent immobilization. The character of the study, which excluded the short hospital stay, may make the frequency of those complications more notable by a possible exclusion of sudden cardiovascular accidents, which might have a significant portion in autopsies but have a short time period between the initial clinical presentation and the patient's demise. Because early suspicion and detection may make for a significantly better prognosis in those potentially fatal complications, vigilant management for preventing these conditions is suggested.
Beyond the direct clinical or administrative advantages, autopsies have other virtues, such as educational and epidemiologic values. (9) The autopsy should continue to be the gold standard for quality control in clinical management, including radiologic evaluation, (10-15) in spite of declining requests. (16) The most crucial factors influencing attitudes toward the autopsy have been shown to be the clinician's level of experience with autopsy in training and practice. Therefore, the importance of the autopsy should be emphasized in medical education and postgraduate training so the number of significant diagnostic discrepancies can be reduced and patient care can be optimized.
Please Note: Illustration(s) are not available due to copyright restrictions.
References
(1.) Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003; 289(21):2849-2856.
(2.) National Center for Health Statistics. Autopsy Patterns in 2003: Data on Mortality. Hyattsville, MD: US Dept of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2007.
(3.) Scordi-Bello IA, Kalb TH, Lento PA. Clinical setting and extent of premortem evaluation do not predict autopsy discrepancy rates. Mod Pathol. 2010; 23(9):1225-1230.
(4.) Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg M. The value of the autopsy in three medical eras. N Engl J Med. 1983; 308(17):1000-1005.
(5.) Schwanda-Burger S, Moch H, Muntwyler J, Salomon F. Diagnostic errors in the new millennium: a follow-up autopsy study. Mod Pathol. 2012; 25(6):777-783.
(6.) Spiliopoulou C, Papadodima S, Kotakidis N, Koutselinis A. Clinical diagnoses and autopsy findings: a retrospective analysis of 252 cases in Greece. Arch Pathol Lab Med. 2005; 129(2):210-214.
(7.) Tavora F, Crowder CD, Sun CC, Burke AP. Discrepancies between clinical and autopsy diagnoses: a comparison of university, community, and private autopsy practices. Am J Clin Pathol. 2008; 129(1):102-109.
(8.) Gonzalez-Franco MV, Ponce-Camacho MA, Barboza-Quintana O, Ancer-Rodriguez J, Cecenas-Falcon LA. Discrepancies between clinical and autopsy diagnosis: a study of 331 autopsies performed over a 7 years period. Medicina Universitaria. 2012; 14(54):16-22.
(9.) Burton JL, Underwood J. Clinical, educational, and epidemiological value of autopsy. Lancet. 2007; 369(9571):1471-1480.
(10.) Bauer TM, Potratz D, Goller T, Wagner A, Schafer R. Quality control by autopsy: how often do the postmortem examination findings correct the clinical diagnosis [in German]? Dtsch Med Wochenschr. 1991; 116(21):801-807.
(11.) Grundmann E. Autopsy as clinical quality control: a study of 15, 143 autopsy cases. In Vivo. 1994; 8(5):945-952.
(12.) Hasan M, Woodhouse K. Autopsy: its role in clinicalquality controlin the elderly in the 1990s. Arch Gerontol Geriatr. 1995; 21(2):199-203.
(13.) Murken DR, Ding M, Branstetter BF 4th, Nichols L. Autopsy as a quality control measure for radiology, and vice versa. AJRAm J Roentgenol. 2012; 199(2): 394-401.
(14.) Sebok J, Magyar E, Csanadi C, Csaky A, Schonfeld T. The importance of the autopsy in quality control of medicine (possibilities in the Hungarian conditions). Orv Hetil. 2005; 146(33):1711-1720.
(15.) Solheim K. Quality control in the last round: autopsy is still necessary [in Norwegian]! Tidsskr Nor Laegeforen. 1993; 113(20):2553.
(16.) Hooper JE, Geller SA. Relevance of the autopsy as a medical tool: a large database of physician attitudes. Arch Pathol Lab Med. 2007; 131(2):268-274.
Hyejong Song Marshall, MD; Clara Milikowski, MD
Accepted for publication December 29, 2016.
Published as an Early Online Release June 28, 2017.
From the Department of Pathology and Laboratory Medicine, Jackson Memorial Hospital/University of Miami, Miami, Florida.
The authors have no relevant financial interest in the products or companies described in this article.
The data and abstract were presented at the annual meeting of the United States and Canadian Academy of Pathology (USCAP); March 14, 2016; Seattle, Washington.
Reprints: Clara Milikowski, MD, Pathology and Laboratory Medicine, Jackson Memorial Hospital/University of Miami, 1611 NW 12th Ave, Holtz Children's Hospital, 2nd Floor, Suite 2042, Miami, FL 33136 (email: CMilikowski@med.miami.edu).
Table 1. Criteria of Goldman Classification
Type of
Class Discrepancy Definition Example: Death Due
to:
I Major Directly related to Unsuspected
death; if myocardial
recognized, may have infarction
altered treatment or presenting with
survival chest pain
II Major Directly related to Unsuspected
death; if recognized, myocardial
would not have infarction
altered treatment or presenting with
survival cardiac arrest
III Minor Incidental autopsy Known myocardial
finding not directly infarction with
related to death but unsuspected left
related to terminal ventricular mural
disease process thrombus
IV Minor Incidental autopsy Known myocardial
finding unrelated to infarction with
cause of death unsuspected lung
cancer
V No error Clinical and autopsy
diagnoses in
complete agreement
Table 2. Numbers of Cases Included and Excluded by Year
Year 2009 2010 2011 2012
Total number of autopsies (A) 204 151 140 154
Cases of age older than 18 y (B) 107 66 76 105
Outside case (C) 6 2 4 6
Short (<1 d) stay (D) 21 14 8 23
Single organ or single cavity only (E) 6 4 8 9
Cases subject to review (B-[C + D + E]) 74 46 56 67
Year 2013 2014 Total
Total number of autopsies (A) 137 137 923
Cases of age older than 18 y (B) 74 84 512
Outside case (C) 6 5 29
Short (<1 d) stay (D) 13 17 96
Single organ or single cavity only (E) 13 13 53
Cases subject to review (B-[C + D + E]) 42 49 334
Table 3. Patient Demographics
Item No. (%)
Sex
Male 189 (56.6)
Female 145 (43.4)
Total 334 (100)
Age, y
18-30 38 (11.4)
31-40 22 (6.6)
41-50 43 (12.9)
51-60 89 (26.6)
61-70 85 (25.4)
71-80 42 (12.6)
>80 15 (4.5)
Total 334 (100)
Table 4. Result of Case Classification
Class No. (%) of Cases
I 33 (9.9)
II 32 (9.6)
III 12 (3.6)
IV 110 (32.9)
V 147 (44.0)
334 (100)
Table 5. Findings With Potential Impact on Survival
or Treatment (Class I Discrepancy)
Item and Findings No. (%)
Infection 15 (45.5)
Fungal pneumonia (1 case with coexisting 6
fungal myocarditis)
Viral pneumonia 2
Bacterial pneumonia 2
Miliary tuberculosis and bacterial 1
meningitis
Meningitis of unknown etiology 1
Toxoplasmosis involving lung, liver, and 1
brain
Candidemia confirmed by postmortem 1
blood culture
Renal abscess 1
Pulmonary embolism 8 (24.2)
Malignancy 6 (18.2)
Lymphoma involving multiple organs 3
Diffuse large B-cell lymphoma
Follicular lymphoma
Peripheral T-cell lymphoma
Pulmonary carcinoma 2
Small cell carcinoma
Squamous cell carcinoma
Gastric adenocarcinoma 1
Cardiovascular 3 (9.1)
Retroperitoneal and/or intraabdominal 2
hemorrhage
Cartilaginous emboli 1
Immunologic 1 (3.0)
Anaphylactic laryngeal edema 1
Total 33 (100)
Table 6. Clinical History or Impression and Critical Labs or
Imaging Compared With Class I Autopsy Findings
Serial Age, y/Sex Clinical History or Impression
1 34/M History of stroke, shortness of
breath, flulike symptoms,
possible pneumonia
2 81/M DM, valvular heart disease, fever
and chills after procedure for
benign prostatic hyperplasia
3 68/F DM, HTN, ischemic
cardiomyopathy
4 83/F Myasthenia gravis, pneumonia
5 64/F COPD aggravation
6 56/M DM, HTN, nausea, vomiting,
chest pain
7 68/M Pneumonia
8 48/F Mixed connective tissue disease,
sepsis by multiple organisms
9 65/F Leukemia, s/p bone marrow
transplant
10 65/F s/p liver transplant, transfusion of
red blood cells to correct anemia
11 55/M Admitted for schizophrenia,
COPD
12 58/M Adrenal mass, steroid therapy for
numbness
13 54/M s/p kidney transplant, hematuria
and abdominal pain, chest pain
14 43/F HIV, HTN, hypertensive crisis
15 77/M Dementia, HTN, normal pressure
hydrocephalus, hematemesis
16 59/M POEMS syndrome, vomiting
17 39/M Neck pain, complicated hospital
course including pulmonary
embolism
18 57/M DM, s/p kidney and pancreas
transplant, nausea and
abdominal pain
19 69/M Lymphoma, s/p chemotherapy,
rash, fever
20 23/F 36-wk pregnancy, pulmonary
infiltrates, emergency cesarean
delivery
21 58/M Inguinal hernia, persistent HTN
after surgery
22 30/F Anti-NMDA receptor autoimmune/
paraneoplastic encephalitis
23 54/M HTN, DM, s/p kidney transplant,
pulmonary edema, acute renal failure
24 58/F DM, HTN, weight loss,
lymphadenopathy, shortness of
breath
25 50/F Bronchiectasis, cirrhosis due to
probable autoimmune hepatitis,
hemoptysis
26 41/M HTN, sickle cell trait, after elective
lumbar disk surgery, abdominal
pain and respiratory failure,
renal injury, disseminated
intravascular coagulation,
possible septicemia
27 62/F HTN, autoimmune hepatitis
overlap with primary biliary
cirrhosis, varices, hepatorenal
syndrome, acute respiratory
distress syndrome
28 74/F Cirrhosis, pleural effusion,
aspiration pneumonia
29 54/F Asthma, cough, chest pain,
antibiotic treatment, diarrhea,
biopsy was planned but not
done
30 20/M Cerebral palsy, hydrocephalus s/p
shunt, hip dislocation s/p
replacement. Septic shock.
Treated with antibiotics
31 42/M HIV, DM, congestive heart failure,
atrial fibrillation
32 58/M Gout, asthma, HTN, atrial
fibrillation, extremity weakness,
and altered speech
33 76/F Bladder and upper urinary tract
cancer, DM, coronary artery
disease, sudden collapse in
hospital stay for urinary tract
infection
Serial Critical Lab or Imaging
1 Diffuse nodularity on chest
radiograph, MSSA in blood
2 Blood and urine culture negative
3 Atrial fibrillation
4 Pneumonia and pulmonary
edema, Proteus bacteremia
5 Hilar lymphadenopathy on
imaging, BAL with Candida
6 Hepatitis C virus positive with
elevated liver enzymes, cardiac
enzyme negative
7 Blood culture negative, pleural
effusion, consolidation of lung
8 Rhabdomyolysis, CMV, Klebsiella,
Acinetobacter, Enterococcus
9 Elevated liver enzymes, negative
blood culture and BAL
10 Bibasilar opacity and pleural
effusion on chest radiograph
11
12 Adrenal mass, pleural effusion on
imaging, hypercalcemia
13 Nonsignificant electrocardiogram
and troponin
14 Pulmonary edema and enlarged
cardiac silhouette, positive for
cocaine
15
16 Hepatomegaly, spontaneous
bacterial peritonitis
17 Edema of spinal cord
18 Leukocytosis
19 Pulmonary interstitial edema on
chest radiography, gram-
negative rods in bone marrow
culture
20 Pulmonary embolism workup with
negative results
21 Lung consolidation with mild
pleural effusion
22 Infection workup with negative
results
23 Leukopenia
24 Pulmonary embolism workup with
negative result
25 Soft tissue mass encasing the
celiac vessels and pericardium,
mild elevation of aspergillosis
glucomannan level
26 Decreasing hemoglobin and
hematocrit
27 Chronic cholestatic hepatitis on
liver biopsy, Klebsiella
bacteremia
28 MSSA bacteremia, blood culture
positive for Klebsiella, aspiration
pneumonia on chest radiograph
29 Lung opacity concerning for
infection, multiple enlarged
lymph nodes
30 Hypernatremia, coagulopathy
31 Hyponatremia, marked and
diffuse cerebral edema, MSSA
bacteremia, pulmonary opacity;
consolidation versus atelectasis
32 Brain CT with no intracranial
hemorrhage
33 Mild interstitial pulmonary edema
on chest radiograph
Serial Significant Autopsy Findings
1 Pulmonary embolism
2 Pulmonary embolism
3 Pulmonary embolism
4 CMV pneumonia and colitis,
not bacterial
5 Small cell carcinoma of lung
with metastasis to lymph
nodes and bone
6 Acute retroperitoneal
hemorrhage extending into
abdominal cavity
7 HSV pneumonia, not bacterial
or fungal
8 Fungal pneumonia, not just
viral and bacterial
9 Toxoplasmosis involving lung,
liver, and brain
10 Laryngeal edema
11 Squamous cell carcinoma of
lung
12 Diffuse large B-cell
lymphoma, meningeal
malignant lymphomatosis
13 Pulmonary embolism
14 Chronic meningitis of
undetermined etiology
15 Bacterial pneumonia
16 Follicular lymphoma
17 Cartilaginous emboli to cervical
spinal cord, recent hematoma
of thalamus
18 Intra-abdominal and
retroperitoneal hemorrhage
19 Fungal pneumonia
20 Pulmonary embolism
21 Pulmonary embolism
22 Pulmonary embolism
23 Abscesses of transplanted
kidney
24 Poorly differentiated
adenocarcinoma of stomach
with metastasis to vertebral
bone marrow
25 Fungal pneumonia and
myocarditis
26 Fungal pneumonia
27 Fungal pneumonia
28 Fungal pneumonia
29 Peripheral T-cell lymphoma
30 Candidemia confirmed by
postmortem blood culture
31 Miliary tuberculosis. Acute
meningitis suggestive of
bacterial etiology
32 Pulmonary embolism
33 Bacterial pneumonia
Abbreviations: BAL, bronchoalveolar lavage; CMV, cytomegalovirus;
COPD, chronic obstructive pulmonary disease; CT, computed
tomography; DM, diabetes mellitus; HIV, human immunodeficiency
virus; HSV, herpes simplex virus; HTN, hypertension; MSSA,
methicillin/sensitive Staphylococcus aureus; NMDA,
N/methyl/D/aspartate; POEMS, polyneuropathy, organomegaly,
endocrinopathy, monoclonal gammopathy and skin changes; s/p, status
post.
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| Title Annotation: | Original Article |
|---|---|
| Author: | Marshall, Hyejong Song; Milikowski, Clara |
| Publication: | Archives of Pathology & Laboratory Medicine |
| Article Type: | Report |
| Date: | Sep 1, 2017 |
| Words: | 2901 |
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