Autopsy and the internal medicine department.

The accuracy of major clinical diagnoses and causes of death was estimated from the analysis of clinical diagnoses and autopsy findings of patients deceased at the internal medicine department of a large university hospital in two different periods (1965-1967 and 1985-1987). The autopsy cases from the second period were subdivided in two groups i.e. less and more than seven days of hospital stay prior death. From 100 randomly selected autopsy cases in each period there was no statistically significant variability in clinico-pathological concordance. In three groups studied (1965-1967, 1985-1987 < seven days and 1985-1987 < seven days hospital stay) the major clinical diagnosis was confirmed in 85, 94 and 86% respectively. A decrease of nearly 27% in the number of autopsies performed is shown between analysed periods. Clinico-pathological conferences are regularly held weekly, this being one of the reasons for a stable and extremely high clinico-pathological concordance.     

Correlation of clinical diagnoses with autopsy findings: A retrospective study of 2,145 consecutive autopsies

The protocols of 2,145 autopsies were retrospectively reviewed and the findings compared with the clinical diagnoses. A sudden decline in the autopsy rate that occurred during the period studied was followed by a highly statistically significant difference in clinical accuracy (P less than 0.01), in favor of the predecline period. The overall rate of major discrepancies was 29 per cent. The most frequently missed diagnoses were infections, which were found in 26 per cent of all autopsies and had not been diagnosed clinically in 63 per cent of these cases. Malignancies occupied second place among overlooked diagnoses in the selected disease categories; in 99 per cent of the cases the malignancy was the principal diagnosis, and it had been misdiagnosed clinically in 42 per cent of these cases. Cerebrovascular disorders were correctly diagnosed in most cases (87 per cent of the patients in this group). Among autopsy diagnoses labeled as the immediate causes of death, the most frequently overlooked were pulmonary embolism and gastrointestinal hemorrhage, which were not recognized in 84 and 78 per cent, respectively. In cases in which clinicians were not entirely confident in their impressions, their diagnoses were usually confirmed at autopsy. In these cases 15 per cent of the patients died soon after admission to the hospital, with accurate diagnoses in 71 per cent. The discrepancies disclosed should be regarded as sufficiently large to mandate continued emphasis on autopsy evaluation as the basis for the control of the quality of patient care.     

Notwendigkeit der Obduktionssteigerung durch Einführung der DRGs

With the introduction of DRGs (diagnosis related groups) in 2004, a new charging system was initiated in Germany. Changes primarily involve lump sum based charging of inpatient cases regardless of the duration or complexity of diagnostic procedures and therapy, and the equalization of costs for similar services. Calculation of DRGs also includes the costs of autopsy. This has three major consequences for autopsy practice: Quality assurance: continuous monitoring of professional quality under lump sum payment can only be permanently guaranteed and independently and reliably attained by autopsy. This is the only way to overcome the danger of abolishing essential diagnostic procedures because of economic pressure and thus risking incorrect diagnoses. Economy: additional diagnoses revealed by autopsy will, in many cases, raise calculated charges. This could have a significant financial impact. Legal certainty: autopsies increase the accuracy and objectivity of diagnoses. Thus, they protect the attending physician from incorrect charging which may be unintended but could be legally relevant, especially when the cause of death is unclear.For these reasons, autopsy should become more important in clinical routine.     

Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology; a meta-analysis and review

The autopsy is in decline, despite the fact that accurate mortality statistics remain essential for public health and health service planning. The falling autopsy rate combined with the Coroners Review and Human Tissue Act have contributed to this decline, and to a falling use of autopsy histology, with potential impact on clinical audit and mortality statistics. At a time when the need for reform and improvement in the death certification process is so prominent, we felt it important to assess the value of the autopsy and autopsy histology. We carried out a meta-analysis of discrepancies between clinical and autopsy diagnoses and the contribution of autopsy histology. There has been little improvement in the overall rate of discrepancies between the 1960s and the present. At least a third of death certificates are likely to be incorrect and 50% of autopsies produce findings unsuspected before death. In addition, the cases which give rise to discrepancies cannot be identified prior to autopsy. Over 20% of clinically unexpected autopsy findings, including 5% of major findings, can be correctly diagnosed only by histological examination. Although the autopsy and particularly autopsy histology are being undermined, they are still the most accurate method of determining the cause of death and auditing accuracy of clinical diagnosis, diagnostic tests and death certification.     

The importance of autopsy for quality assurance in medical care

For all persons who died in the city of Dresden and 7 surrounding counties from 1967 to 1978, documents relating to the clinical and pathologic diagnosis were examined and findings compared. The study covered nearly two thirds of all deaths which occurred in the district of Dresden during this time period. The autopsy rate overall was found to be 22.8%. In 57.3% the clinical diagnoses were found to have been correct, in 19.7% they corresponded in part, but in 23% there was no concordance whatsoever between the clinical and autopsy diagnoses. The influence of age, place of death and disease group on the agreement between clinical and underlying pathoanatomic diagnosis was also examined. The analysis highlighted the degree to which death statistics based on the death certificate are misleading. In up to 28.8% of cases there were formal errors in the underlying disease diagnosis listed by the certifying physician on the death certificate. The value of regular comparison between the diagnoses, and its usefulness for training and continuing medical education are emphasized. The results of the study underline the importance of making available more prospectors in the district of Dresden to meet the expanding tasks of the clinically active pathologist in autopsy and biopsy diagnostic efforts.     

Concordance between premortem and postmortem diagnosis in the autopsy: results of a 10-year study in a tertiary care center

We describe the concordance between clinical diagnoses and autopsy findings in a tertiary care center. Clinical autopsy is a useful tool for the evaluation of accuracy of the clinical diagnoses. However, autopsy rates have declined around the world recently. We randomly evaluated 500 of 2,211 autopsies performed in the department of pathology of a tertiary care hospital during a 10-year period. We computed the sensitivity, specificity, predictive values, and concordance scores between premortem and postmortem diagnoses. The autopsy diagnoses were used as the "gold standard." Four-hundred twenty-two (84.4%) of the autopsies met inclusion criteria. Diseases of the respiratory tract were diagnosed in 44.1% (186) of all autopsy reports reviewed. The higher sensitivity for diagnosis was observed in congenital anomalies (87.5%), while the higher specificity was observed in diagnosis of complications of pregnancy, childbirth, and the puerperium (98.98%). The higher concordance between premortem and postmortem diagnosis was observed with the diagnoses of neoplasms (kappa = 0.76), and for the group of complications of pregnancy, childbirth, and the puerperium (kappa = 0.76). A clinical diagnosis successfully addressed the cause of death in 40% of the cases Low values for concordance between autopsy reports and clinical diagnoses were present in most of the autopsies reports reviewed. We encourage physicians to continue considering the autopsy as an important tool that extends our understanding of diseases.     

The autopsy as a performance measurement tool--diagnostic discrepancies and unresolved clinical questions: a College of American Pathologists Q-Probes study of 2479 autopsies from 248 institutions

OBJECTIVE: To develop a multi-institutional reference database for quality improvement purposes using the autopsy to define clinical diagnostic discrepancies and resolve clinical questions. DESIGN: Using the College of American Pathologists Q-Probes format, institutions prospectively assessed a maximum of 15 consecutive autopsies each, excluding forensic cases and stillborn infants, conducted over a 6-month period. They documented answers to clinical questions provided at autopsy and classified unexpected disease diagnoses according to a standardized system. SETTING AND PARTICIPANTS: Hospital-based autopsies performed at 248 institutions participating in the 1993 College of American Pathologists Q-Probes Quality Improvement Program. MAIN OUTCOME MEASURES: Percentages of clinical questions resolved by the autopsy and percentage of autopsies with unexpected findings of graded clinical impact. RESULTS: In the aggregate database of 6427 questions from 2479 autopsies, overall 93.0% were answered by the autopsy. The 3 most common question categories were (1) identify pathology to account for clinical signs or symptoms (28.0%); (2) establish the cause of death (21.0%); and (3) confirm a clinical diagnosis (19.0%). At least one major unexpected disease finding that contributed to the patient's death was discovered in 39.7% of the total number of autopsies. There were no differences in the percentages of autopsies with these major unexpected findings when the data were stratified by institutional demographics or decedent characteristics. CONCLUSION: This multi-institutional study underscores the clinical relevance of postmortem examination in current medical practice by consistently providing answers to unresolved clinical questions and frequently revealing major unexpected findings that contributed to the patient's death. It is our strong belief that this postmortem-derived clinicopathologic information is a key indicator of effectiveness of care. Integration of this information into institutional quality improvement programs will improve system processes and clinician performance.     

Virtual CT autopsy in clinical pathology: feasibility in clinical autopsies

For the past century, autopsy techniques in clinical pathology have not changed significantly, while autopsy rates are declining. Modern imaging techniques offer interesting prospects of supportive post-mortem diagnostic investigation. In a prospective study of 29 autopsy cases, complimentary virtual autopsy using unenhanced post-mortem computed tomography (pmCT) was performed. We analysed in a prospective cohort study 29 unenhanced pmCT scans, generated prior to autopsy. Clinical information regarding clinical history and circumstances of death were provided. The objective of the study was to find consistency and/or discrepancy between virtual autopsy and conventional autopsy findings regarding cause of death and death-related diagnoses, reconstruction of the pathogenetic mechanisms involved, side diagnoses and CPR (cardiopulmonary resuscitation)- or death-related post-mortem changes. Accuracy of pmCT for cause of death was 68?% and the positive predictive value (PPV) was 75?%. Regarding the pathogenetic mechanisms, accuracy of pmCT was 21?% and PPV was 29?%. The combined diagnostic yield of autopsy and pmCT was 133?% compared to autopsy only. Modern imaging techniques give an opportunity for post-mortem diagnostics to complete but not yet replace traditional autopsy. We could show that in two out of three cases, the cause of death found by pmCT matched the diagnosis from classical autopsy. While both disciplines, pathology and radiology, will profit from the mutual exchange of data, it seems a realistic aim to strive for virtual autopsy possibly further supported by biopsies and contrast-enhanced pmCT as an alternative to the classical clinical autopsy. A combination of both methods enhances diagnostic quality and completeness of the autopsy report.     

Clinical and pathological disagreement upon the cause of death in a teaching hospital: analysis of 100 autopsy cases in a prospective study

The aim of the present study was to analyze the concordance between clinical and autopsy diagnoses. For this purpose, 100 patients submitted to autopsy from July 2000 to April 2001 were studied prospectively. In all cases, clinicians gave the immediate and the underlying causes of death for patients dying under their care. The diagnoses were compared to the macroscopic autopsy diagnoses. Cohen's kappa coefficient of agreement was estimated. Sixty-four men and 36 women were submitted to autopsy. The most frequent pathological diagnosis of underlying cause of death were diseases of the circulatory system (35%), infections and parasitic diseases (20%) and diseases of the digestive system (11%). The kappa coefficient for immediate cause of death was 0.40 (95% confidence interval (CI): 0.29–0.50); for underlying cause it was 0.38 (95%CI: 0.18–0.44), and for basic cause codified by group according to ICD-10 it was 0.55 (95%CI: 0.44–0.67). Major disagreement occurred in 10 cases involving pathological causes of death as circulatory diseases, in which the clinicians diagnosed a digestive system disease as the cause of death ( n  = 5), or infectious and parasitic diseases ( n  = 5). The present study shows that agreement between clinical and pathological causes of death are moderate, proving that the autopsy is still a very important procedure.     

Utility of autopsy in uncovering unexpected neuropathology

Autopsy rates have declined in the last several decades for a variety of reasons. The purpose of this study is to compare autopsy neuropathologic findings from 2 periods to assess the prevalence of unexpected neuropathologic findings and unexpected neuropathologic diagnoses determined to be the major cause of death. Retrospective review of autopsies with examination of the central nervous system was performed in 2007 to 2008 (n = 289) and 1984 to 1985 (n = 328). Unexpected neuropathologic diagnoses were found at autopsy in 42.4% of cases from 1984 to 1985 vs 38.8% of cases from 2007 to 2008. The neuropathology was felt to contribute to the cause of death in 22% of cases from 1984 to 1985 vs 19.7% of cases from 2007 to 2008. Unexpected neuropathologic findings were the cause of death in 5.2% of cases from 1984 to 1985 vs 3.1% of cases from 2007 to 2008. These findings underscore the continued use of brain and spinal cord examination at autopsy despite advances in "modern" medicine.     

The role of the autopsy in medical malpractice cases,I: a review of 99 appeals court decisions

CONTEXT: Fear that damaging information from autopsy may be introduced as evidence in lawsuits alleging medical malpractice is often cited as one factor contributing to the decline in autopsy rates. OBJECTIVE: To determine how autopsy information influences the outcome of medical malpractice litigation. DESIGN: We studied state court records in 99 cases of medical malpractice adjudicated from 1970 to the present to assess the role of information from autopsies in the outcomes. RESULTS: The 3 largest groups defined by cause of death at autopsy were acute pulmonary embolism, acute cardiovascular disease, and drug overdose/interaction. Findings for defendant physicians outnumbered medical negligence in the original trial proceedings by a 3:1 margin. The appellate courts affirmed 51 acquittals and 19 findings of negligence, and reversed the original trial court decision in 29 cases for technical reasons. We found no significant relationship between accuracy of clinical diagnosis (using the autopsy standard) and outcome of a suit charging medical negligence. Even when a major discrepancy existed between the autopsy diagnosis and the clinical diagnosis, and the unrecognized condition was deemed treatable, defendant physicians were usually exonerated. Moreover, major diagnostic discrepancies were relatively uncommon in suits in which a physician was found to be negligent. Conversely, in about 20% of cases, autopsy findings were helpful to defendant physicians. CONCLUSIONS: Our study confirms that a finding of medical negligence is based on standard-of-care issues rather than accuracy of clinical diagnosis. Autopsy findings may appear to be neutral or favorable to either the plaintiff or the defendant, but are typically not the crux of a successful legal argument for either side in a malpractice action. We conclude that fear of autopsy findings has no rational basis and is an important obstacle to uninhibited outcomes analysis.     

Clinical utility of autopsy after hematopoietic stem cell transplantation.

Autopsy is the gold standard for establishing the cause of death. We present results of the largest retrospective review of complete autopsies of subjects after hematopoietic stem cell transplantation to better define the role of the autopsy in discovering a missed diagnosis. We reviewed the medical chart and autopsy records of 111 patients who had undergone hematopoietic stem cell transplantation from July 1986 to June 2003 from a single center. We compared the cause of death as charted by the clinical team with data obtained from postmortem chart review and autopsy reports. Of 29 (26%) cases when the premortem and postmortem major diagnoses did not agree, only 4 (4%) autopsy records provided data that might have led to the initiation of new treatments, and none of these diagnoses would be missed today with more sensitive and specific diagnostics and improved supportive care. Although autopsies after transplantation can be important educational, research, and epidemiologic tools and provide an emotional benefit to patient's families, in our series they rarely provided missed diagnoses that would alter the management of subsequent patients. Improvements in noninvasive tests for relapse or occult infections may further erode the role of autopsies in discovering missed diagnoses.     

Medical autopsy: whose gain is it? An audit

Medical audit is essential in assessing the efficacy of health care delivery system. Though autopsy services are generally looked upon indifferently and with sceptism by the clinicians, it can form an important part of the medical audit system. The aims of this study were to audit autopsies of deaths within 24 hours of hospital admission by: 1) Comparing premortem and postmortem diagnosis; 2) Comparing postmortem gross diagnosis with postmortem histopathologic diagnosis; 3) Whether deaths could be certified based on clinical judgement and autopsies avoided. The study sample was 99 autopsies. In 45% autopsies, clinical impression did not match the final cause of death. In 14.2% autopsies, final cause of death could have been given by the clinician based on his clinical judgement. In 54.5% autopsies, there was agreement between premortem and postmortem diagnosis. In 67.6% autopsies, gross findings matched with the histopathologic findings.     

Yorkshire Regional Lymphoma Histopathology panel: analysis of five years' experience

Five years' experience of operating a Regional Lymphoma Histopathology Panel is described. During this period, approximately 1400 cases were registered of which nearly 1200 were confirmed as malignant lymphoma. Complete concordance of diagnosis was achieved between submitting pathologists and the Panel in two-thirds of cases of Hodgkin's disease and just over half of non-Hodgkin's lymphoma. Most discrepancies in diagnosis were found to be of clinical importance in terms of prognosis and/or therapeutic management of patients. In approximately two-thirds of such instances disagreement arose because of wrong assignment of tumour grade within the main lymphoma class but in one-third of cases the main class of lymphoma was wrongly designated. Panel members experienced similar diagnostic problems as submitting pathologists although to a lesser extent. The existence of the panel has not reduced the proportion of cases causing diagnostic difficulty for submitting pathologists or panel members during the 5 year study period. The principal cause of death was ascertained from death certificates and autopsy findings in nearly half the cases dying during the study period. In approximately half of these infection (largely pulmonary) played a major role while most of the remainder died of various cardiovascular, pulmonary or renal disorders. There was no specific pattern relating to the main lymphoma class. It is concluded that whilst the panel fulfils a useful function in resolving diagnostic difficulties and standardizing lymphoma diagnosis its role is restricted somewhat by the limitations imposed by conventional morphological assessments.     

Clinical diagnosis of mycobacterial diseases versus autopsy findings in 350 patients with AIDS

Three-hundred fifty consecutively autopsied AIDS patients in Milan, Italy, were studied to determine the frequencies of clinical and postmortem diagnoses of mycobacterial diseases, to evaluate the clinical histories of those patients with mycobacterial diseases, and to investigate the reasons for nondiagnosis of mycobacterial diseases during life. Seventy-eight patients (22.3%) had mycobacterial diseases. In 64 cases (18.3%) the diagnosis was made antemortem and in 50 (14.2%) at autopsy; there were 36 cases of concordant clinical and postmortem diagnoses. Nontuberculous mycobacterioses (NTM) were diagnosed in 41 patients (20 clinical/postmortem diagnoses, 11 clinical diagnoses, and 10 postmortem diagnoses), extrapulmonary tuberculosis (TB) in 19 patients (7 clinical/postmortem, 8 clinical, 4 postmortem), and pulmonary TB in 18 patients (9 clinical/postmortem, 9 clinical). Patients with a clinical diagnosis of mycobacteriosis but with no pathological evidence of disease at autopsy were considered to have recovered on the basis of negative culture findings and prolonged antimycobacterial treatment. In Italian patients with AIDS, NTM occurs less frequently and TB more frequently than in American AIDS patients. At least some of the patients reported in this study seemed to have recovered from mycobacterial disease after prolonged treatment. The lack of diagnosis during life can be attributed to aspecific symptoms, a rapidly terminal course, and the presence of concomitant opportunistic diseases.     

The value of postmortem examination in cases of metastasis of unknown origin-20-year retrospective data from a tertiary care center

BACKGROUND: Metastasis of unknown origin (MUO) is a diagnostic challenge in clinical practice even with the state of current advanced diagnostic technology. To evaluate the value of autopsy in determining the primary site of MUO, this study reviewed the Hamilton experience-over the last 20 years-with patients autopsied with clinical diagnosis of MUO. METHODS: All autopsy diagnoses from cases performed at the Hamilton Health Sciences Center and St Joseph's Healthcare from 1980 to 2000 were reviewed. Fifty-three cases of MUO were identified (MUO was defined as a patient with pathological and/or radiological diagnosis of a metastatic tumor for which the primary site of malignancy was unknown). The clinical history and gross and microscopic diagnoses for these cases were reviewed. RESULTS: There were 31 men (58.5%) and 22 women (41.5%) in the study. Their mean age was 66 years. Pathological diagnoses at autopsy were adenocarcinoma (n = 37), small cell carcinoma (n = 6), anaplastic carcinoma (n = 3), and undifferentiated carcinoma (n = 3). Primary tumors were identified in 27 patients (51%), most commonly in the lung (n = 8), large bowel (n = 6), and pancreas (n = 4). Histochemical and immunohistochemical stains were helpful in reaching the diagnosis of a primary tumor in 4 of 27 cases. CONCLUSIONS: The following were observed: (1) in this series, autopsy was helpful in establishing the diagnosis of a primary tumor in 51% of the cases, reaffirming the value of postmortem examination in these instances; (2) adenocarcinoma was the most frequent tumor presenting as MUO; (3) the lung and the large bowel were the most frequent sites for primary tumors; and (4) careful gross and histological examinations remain the most important tools in identifying the primary site.     

Why couldn’t an accurate diagnosis be made? An analysis of 1044 consecutive autopsy cases

The protocols of 1044 consecutive patients autopsied between 1983 and 1997 at Sumitomo Hospital (Osaka, Japan) were retrospectively analyzed and the findings were compared with clinical diagnoses. In 73 cases, the clinical diagnosis apparently differed from the autopsy findings, and in six cases the origin of a malignant neoplasm remained unsolved even at autopsy. Of the 73 discrepant cases, 24 were a result of clinician misjudgment and a neglect to conduct further examinations. Missed diagnosis due to an erroneous pathological report, technical error of endoscopy, and misleading results obtained by new non-invasive technologies accounted for seven, nine, and 11 cases, respectively. Twenty-two cases were missed because the clinician could not carry out precise examination. It is concluded that advances in diagnostic technology and medical knowledge have not reduced the value of an autopsy.     

Postmortem findings after fatal anaphylactic reactions

AIMS: To determine the frequency at which classic manifestations of anaphylaxis are present at necropsy after fatal anaphylactic reactions. METHODS: A register has been established of fatal anaphylactic reactions in the UK since 1992, traced from the certified cause of death and other sources. Details of the previous medical history and the reaction suggest anaphylaxis as the cause of death for 130 cases; a postmortem report was available for 56. RESULTS: The 56 deaths studied included 19 reactions to bee or wasp venom, 16 to foods, and 21 to drugs or contrast media. Death occurred within one hour of anaphylaxis in 39 cases. Macroscopic findings included signs of asthma (mucous plugging and/or hyper-inflated lungs) (15 of 56), petechial haemorrhages (10 of 56), pharyngeal/laryngeal oedema (23 of 56), but for 23 of 56 there was nothing indicative of an allergic death. Mast cell tryptase was raised in 14 of 16 cases tested; three of three tested had detectable IgE specific for the suspected allergen. CONCLUSIONS: In many cases of fatal anaphylaxis no specific macroscopic findings are present at postmortem examination. This reflects the rapidity and mode of death, which is often the result of shock rather than asphyxia. Investigations that might help determine whether anaphylaxis was the cause of death had rarely been performed. In the presence of a typical clinical history, absence of postmortem findings does not exclude the diagnosis of anaphylaxis.     

Infectious diseases detected at autopsy at an urban public hospital, 1996-2001

Previous studies have demonstrated significant discrepancy rates between clinical and autopsy diagnoses. However, infectious diseases have not received emphasis in these studies. We conducted a study to determine whether the clinical and autopsy diagnoses of infectious diseases are concordant or discrepant and to determine discrepancy rates. Retrospective reviews of the records of 276 patients (adults, 182; fetuses and neonates, 94) who underwent autopsy during the years 1996 through 2001 were performed. Comparison of clinical and autopsy diagnoses was performed using the Goldman classification scheme. Of 182 adult patients, 137 (75.3%) had an infectious disease at autopsy. In 59 (43.1%) of 137 patients, the infectious disease diagnoses were unknown clinically. Of 94 fetuses and neonates, 45 (48%) had an infectious disease at autopsy. In 26 (58%) of 45 patients, the infectious disease diagnoses were unknown before death. There are substantial discrepancies between clinical and autopsy diagnoses of infectious diseases. In adults, acute bronchopneumonia is the infectious disease most often missed clinically; in fetuses and neonates, it is acute chorioamnionitis.     

Discrepancies between clinical and autopsy diagnoses: a comparison of university, community, and private autopsy practices

Although it is known that autopsies often disclose unexpected findings, few studies have been published that address the effect of institutional setting, selection bias, and length of hospitalization. Records of medical autopsies from 3 institutional settings were studied for discrepancies between clinical and autopsy findings. The settings were university hospital (n = 85); community hospital (n = 146); and private autopsy (n = 60), which were referred from various community hospitals and paid for by family members. The same prosector performed the autopsies in the community and private settings. The overall rate of major discrepancy that involved the cause of death was 17.2%. Factors that increased the likelihood of missed diagnoses were private setting (P = .0005), community setting (P = .02), and short hospital stay before death (P = .02). Additional major findings were present in 28.5% of autopsies. Length of hospital stay before death, institution, and selection bias all affect the rate of major unexpected findings in hospital-based autopsies.