Who Is at Risk for Diagnostic Discrepancies? Comparison of Pre- and Postmortal Diagnoses in 1800 Patients of 3 Medical Decades in East and West Berlin

Abstract

BackgroundAutopsy rates in Western countries consistently decline to an average of <5%, although clinical autopsies represent a reasonable tool for quality control in hospitals, medically and economically. Comparing pre- and postmortal diagnoses, diagnostic discrepancies as uncovered by clinical autopsies supply crucial information on how to improve clinical treatment. The study aimed at analyzing current diagnostic discrepancy rates, investigating their influencing factors and identifying risk profiles of patients that could be affected by a diagnostic discrepancy.Methods and FindingsOf all adult autopsy cases of the Charité Institute of Pathology from the years 1988, 1993, 1998, 2003 and 2008, the pre- and postmortal diagnoses and all demographic data were analyzed retrospectively. Based on power analysis, 1,800 cases were randomly selected to perform discrepancy classification (class I-VI) according to modified Goldman criteria. The rate of discrepancies in major diagnoses (class I) was 10.7% (95% CI: 7.7%–14.7%) in 2008 representing a reduction by 15.1%. Subgroup analysis revealed several influencing factors to significantly correlate with the discrepancy rate. Cardiovascular diseases had the highest frequency among class-I-discrepancies. Comparing the 1988-data of East- and West-Berlin, no significant differences were found in diagnostic discrepancies despite an autopsy rate differing by nearly 50%. A risk profile analysis visualized by intuitive heatmaps revealed a significantly high discrepancy rate in patients treated in low or intermediate care units at community hospitals. In this collective, patients with genitourinary/renal or infectious diseases were at particularly high risk.ConclusionsThis is the current largest and most comprehensive study on diagnostic discrepancies worldwide. Our well-powered analysis revealed a significant rate of class-I-discrepancies indicating that autopsies are still of value. The identified risk profiles may aid both pathologists and clinicians to identify patients at increased risk for a discrepant diagnosis and possibly suboptimal treatment intra vitam.

The value of autopsies in the era of high-tech medicine: discrepant findings persist

“…This is in line with recent literature, in which major discrepancy rates ranged from 7% to 50%, mainly depending on patient populations studied 3 10 12–18. The 23.5% major discrepancy rate is identical to that presented in a review by Shojania et al 2 using the results from 42 studies.…”

“…This is evident from previous studies comparing clinical diagnoses and autopsy findings, which revealed major discrepancies in approximately 25% of the deceased patients that underwent postmortem examination 2 3…”

Are Autopsy Findings Still Relevant to the Management of Critically Ill Patients in the Modern Era?

“…Given that over 80% of class I misdiagnoses previously reported were due to unrecognized vascular and infective complications, any improvement in radiological imaging and microbiological surveillance is likely to result in a lower class I error rate than previously reported. Second, the wide variation in reported discrepancy rates is unlikely to be explained solely by differences in the quality of clinical practice and may relate, in part, to differences in the application and interpretation of the various definitions used to classify misdiagnoses (15,19,31,32). The criteria used to assign discrepancies are necessarily quite vague, leaving room for differing interpretation between authors; an outcome that is more likely in multimorbid critically ill patients (15,26).…”

“…Some investigators classified the clinical diagnosis as that which was stated on the autopsy request form; an approach that relies heavily on the requesting doctor to represent all important details and diagnoses (32). Additionally, significant variation may have existed in the conduct of the postmortem-for example, the cranium was not examined in all reported series (19).…”

Post-mortem MRI as an alternative to non-forensic autopsy in foetuses and children: from research into clinical practice

“…[5][6][7][8][9] This figure may be higher in paediatric rather than perinatal cases. 1 Several studies have also shown a significant discrepancy rate between what clinicians think is the cause of death and full traditional autopsy findings, 3,10 and error rates can be as high as 50% on medical certificates in stillbirths. 11 The clinical information gained from performing a full post-mortem examination forms the basis of National Health Service autopsy service provision following foetal and childhood deaths in the UK, and despite its inherent limitations is the key part in developing appropriate preventative measures.…”