Diagnostic performance in a primary referral hospital assessed by autopsy: Evolution over a ten-year period
ABSTRACT Despite remarkable progress in modern laboratory testing and imaging technology in recent years, diagnostic errors still occur. To assess whether diagnostic performance in a primary referral hospital improves with new diagnostic tools and algorithms, autopsy reports were analyzed over a ten-year period to monitor diagnostic errors.
Medical reports from 1997 to 2006 were compared retrospectively with autopsy reports. A diagnostic error was assumed when the main clinical diagnosis was missed, independently of whether this influenced the patient's survival or whether this error led to incorrect treatment without effect on survival. Two cardiovascular markers with high sensitivity, namely cardiac troponin T and D-dimer testing and two algorithms for thoracic pain and thromboembolic disease were introduced during the study period.
970 cases were included; the autopsy rate was 50.1%. Cardiovascular diseases were misdiagnosed in 18.7%, followed by infectious diseases in 12.9%, oncological 3.6% and neurological diseases in 1.8%. The most commonly missed diagnoses were myocardial infarction, pulmonary embolism and aortic dissection; however, the rate of errors for cardiovascular diseases decreased over the 10 years (p<0.002). Overall diagnostic sensitivity and specificity rose from 67% to 87% and from 94% to 99%, respectively.
Autopsy remains a valuable tool to measure diagnostic performance. Errors occur most frequently in cardiovascular events, whereas in malignant and neurological diseases they are rare. The significant improvement of diagnostic accuracy for cardiovascular diseases is associated with the introduction of new sensitive laboratory tests and algorithms for thoracic pain and thromboembolic diseases.
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ABSTRACT: Although the autopsy is still the gold standard for quality assessment of clinical diagnoses, autopsy rates have been declining over the last decades to <10%. The aim of this study was to investigate the value of autopsies in the high-tech medicine era by determining the frequency of discrepancies between clinical and autopsy diagnoses. We classified all adult autopsy cases (n=460), performed at Symbiant, Pathology Expert Centre, in 2007 and 2012/2013, as having major, or minor discrepancy or total concordance. The roles of possible contributory factors were analysed. Finally, we assessed the role of microscopic examination in identifying cause of death. Major and minor discrepancies were found in 23.5% and 32.6% of the classifiable autopsies, respectively. Most commonly observed major discrepancies were myocardial infarction, pulmonary embolism and pneumonia. Improper imaging and discontinuation of active treatment were significantly associated with a higher and a lower frequency of major discrepancies, respectively. Comparing 2007 and 2012/2013, the frequency of minor discrepancies significantly increased from 26.8% to 39.3%. Final admission length of >2 days was significantly associated with a lower frequency of class III minor discrepancies. Microscopic examination contributed to establishing cause of death in 19.6% of the cases. Discrepant findings persist at autopsy, even in the era of high-tech medicine. Therefore, autopsies still should serve as a very important part of quality control in clinical diagnosis and treatment. Learning from individual and system-related diagnostic errors can aid in improving patient safety.Journal of clinical pathology 03/2014; DOI:10.1136/jclinpath-2013-202122 · 2.55 Impact Factor
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ABSTRACT: Die Gründe für die Abnahme der Autopsierate in den meisten Krankenhäusern sind vielfältig. Häufig wird der Nachweis von Diagnoseirrtümern als Argument für eine hohe Autopsierate benutzt, jedoch ist die diagnostische Qualität in einem Krankenhaus weitgehend unabhängig von der Autopsierate. In Zürich wurde in einer Langzeitstudie gezeigt, dass mithilfe einer detaillierten Auswertung der Autopsieberichte zusammen mit den internistischen Krankenakten eine hohe diagnostische Qualität dokumentiert werden kann. So ging die Häufigkeit der diagnostischen Fehler der KlasseI in der inneren Medizin von 16% (1972), 9% (1982), 7% (1992) auf 2% (2002) zurück. Wesentliche Ursache dafür sind in erster Linie die verbesserten diagnostischen Möglichkeiten der Kliniker (Computertomographie, „magnetic resonance imaging“ etc.). Im Jahr 2010 betrug am gesamten Klinikum die Zahl der Klasse-I-Fehler nur 1%. Diese ausgesprochen niedrige Zahl von Klasse-I-Diagnosediskrepanzen wurde im jährlichen Qualitätsbericht des UniversitätsSpitals Zürich publiziert. Die Autoren hoffen, dass durch die Berücksichtigung von Autopsiedaten in den jährlichen Qualitätsberichten in positiver Weise die diagnostische Qualität des ärztlichen Handelns dokumentiert wird und somit Spitaladministration sowie Gesundheitspolitik besser überzeugt werden können, sich für eine angemessene Autopsierate einzusetzen. Multiple factors have affected the decline in autopsy rates. Discrepancies between clinical diagnoses and findings at autopsy are frequently used as an argument for a high autopsy rate. However, the quality of the diagnosis is independent of the autopsy rate. A long-term study covering the years 1972–2002 in the University Hospital Zurich has documented a significant reduction of diagnostic errors in internal medicine. Major diagnostic errors (class1) declined from 16% (1972), to 9% (1982), to 7% (1992) to 2% (2002). The main reason is the availability of new diagnostic procedures. In 2010 the analysis of class 1 diagnostic errors throughout the hospital documented class 1 discrepancies in only 1%. This low number of diagnostic errors has been published in the annual quality report of the University Hospital Zurich. The documentation of this improvement in the quality report of the hospital provides the opportunity to convince clinicians, health politicians and the hospital administration to support autopsies in teaching as well as non-teaching hospitals. SchlüsselwörterAutopsie–Diagnostische Fehler–Innere Medizin–Qualitätsindikatoren–Qualitätssteigerung KeywordsAutopsy–Diagnostic errors–Internal medicine–Quality indicators–Quality improvementDer Pathologe 11/2011; 32:282-286. DOI:10.1007/s00292-011-1521-4 · 0.64 Impact Factor
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ABSTRACT: OBJECTIVES: A follow-up, retrospective study to determine whether the proportion of discrepancies between clinical and pathological diagnoses made during 2009, 1999 and 1989 and the proportion of dogs necropsied have changed. METHODS: Medical records of 148 hospitalised dogs that died or were euthanased in a veterinary medical teaching hospital during 2009 were reviewed. Clinical and pathological diagnoses were recorded, categorised and compared to historical controls using a data set of 623 dogs from a previous study. RESULTS: The proportion of discrepancies was significantly (P<0·001) lower in 2009 (14·9%), compared to both 1999 (37%) and 1989 (39·8%). There was also a significant (P<0·001) decrease in the number of necropsies performed during 2009 (21·4%) compared to both 1999 (48·4%) and 1989 (58·9%). CLINICAL SIGNIFICANCE: There was a marked improvement in the ante-mortem diagnosis of patients in 2009 compared with both 1989 and 1999 as evidenced by the decrease in the proportion of discrepancies between the clinical and pathological diagnoses. Necropsies should still be regarded as a vital tool for teaching, determining the pathological basis of disease, identification of new and emerging diseases, and for an individual animal determining the cause of death.Journal of Small Animal Practice 10/2012; DOI:10.1111/j.1748-5827.2012.01296.x · 0.91 Impact Factor