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      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

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          Abstract

          Background

          Autopsy 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 Findings

          Of 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.

          Conclusions

          This 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.

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          Most cited references51

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          Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.

          E Burton, Lee Goldman, Kristin K. McDonald … (2003)
          Substantial discrepanies exist between clinical diagnoses and findings at autopsy. Autopsy may be used as a tool for quality management to analyze diagnostic discrepanies. To determine the rate at which autopsies detect important, clinically missed diagnoses, and the extent to which this rate has changed over time. A systematic literature search for English-language articles available on MEDLINE from 1966 to April 2002, using the search terms autopsy, postmortem changes, post-mortem, postmortem, necropsy, and posthumous, identified 45 studies reporting 53 distinct autopsy series meeting prospectively defined criteria. Reference lists were reviewed to identify additional studies, and the final bibliography was distributed to experts in the field to identify missing or unpublished studies. Included studies reported clinically missed diagnoses involving a primary cause of death (major errors), with the most serious being those likely to have affected patient outcome (class I errors). Logistic regression was performed using data from 53 distinct autopsy series over a 40-year period and adjusting for the effects of changes in autopsy rates, country, case mix (general autopsies; adult medical; adult intensive care; adult or pediatric surgery; general pediatrics or pediatric inpatients; neonatal or pediatric intensive care; and other autopsy), and important methodological features of the primary studies. Of 53 autopsy series identified, 42 reported major errors and 37 reported class I errors. Twenty-six autopsy series reported both major and class I error rates. The median error rate was 23.5% (range, 4.1%-49.8%) for major errors and 9.0% (range, 0%-20.7%) for class I errors. Analyses of diagnostic error rates adjusting for the effects of case mix, country, and autopsy rate yielded relative decreases per decade of 19.4% (95% confidence interval [CI], 1.8%-33.8%) for major errors and 33.4% (95% [CI], 8.4%-51.6%) for class I errors. Despite these decreases, we estimated that a contemporary US institution (based on autopsy rates ranging from 100% [the extrapolated extreme at which clinical selection is eliminated] to 5% [roughly the national average]), could observe a major error rate from 8.4% to 24.4% and a class I error rate from 4.1% to 6.7%. The possibility that a given autopsy will reveal important unsuspected diagnoses has decreased over time, but remains sufficiently high that encouraging ongoing use of the autopsy appears warranted.
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            The value of the autopsy in three medical eras.

            L Cohn, Harlan S Robbins, M Weisberg … (1983)
            To determine whether advances in diagnostic procedures have reduced the value of autopsies, we analyzed 100 randomly selected autopsies from each of the academic years 1960, 1970, and 1980 at one university teaching hospital. In all three eras about 10 per cent of the autopsies revealed a major diagnosis that, if known before death, might have led to a change in therapy and prolonged survival; another 12 per cent showed a clinically missed major diagnosis for which treatment would not have been changed. Among 1980 autopsies, renal disease and pulmonary embolus were less common causes of death than before, but systemic bacterial, viral, and fungal infections increased significantly and were missed clinically 24 per cent of the time. The introduction of radionuclide scans, ultrasound, and computerized tomography as diagnostic procedures did not reduce the use of conventional tests in patients who subsequently died and were studied by autopsy. Over-reliance on these new procedures occasionally contributed directly to missed major diagnoses. We conclude that advances in diagnostic technology have not reduced the value of the autopsy, and that a goal-directed autopsy remains a vital component in the assurance of good medical care.
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              Factors influencing discrepancies between premortem and postmortem diagnoses.

              Ajay D. Pathak, Kyle Hill, Blair Anderson … (1987)
              A study of 2067 autopsies collected from 32 university and community hospitals of various sizes located throughout the United States showed the rate of discrepancies between premortem and postmortem diagnoses to be influenced by the type and size of hospital, the age and sex of the patient, and the disease responsible for the patient's death. Of equivocal or no influence were the length of the terminal hospitalization, the degree of clinical involvement in the case of the person responsible for establishing the discrepancy level, and the autopsy rate, at least as it applies to community hospitals.
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                Author and article information

                Contributors
                : Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2012
                Publication date (Electronic): 22 May 2012
                Volume: 7
                Issue: 5
                Electronic Location Identifier: e37460
                Affiliations
                [1 ]Institute of Pathology, Charité University Hospital, Berlin, Germany
                [2 ]Institute of Legal Medicine, University Hospital Münster, Münster, Germany
                [3 ]Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
                [4 ]Institute of Pathology, University Hospital Rostock, Rostock, Germany
                [5 ]Department of General, Visceral and Transplantation Surgery, Charité University Hospital, Berlin, Germany
                University of Barcelona, Spain
                Author notes

                Conceived and designed the experiments: DW JB AS. Performed the experiments: DW ACK AS. Analyzed the data: DW AS FK ACK MvW CK HJS AE CD WW JB. Contributed reagents/materials/analysis tools: JB CK. Designed the study and wrote the first draft of the manuscript: DW AS. Contributed to writing of the manuscript: DW AS JB FK AE HP CD MD WW.

                Article
                Publisher ID: PONE-D-11-23881
                DOI: 10.1371/journal.pone.0037460
                PMC ID: 3358345
                PubMed ID: 22629399
                SO-VID: 79f83e5c-c6f9-40ac-9d53-4c2fe35e865d
                Copyright © Wittschieber et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                Date received : 21 November 2011
                Date accepted : 20 April 2012
                Page count
                Pages: 10
                Categories
                Subject: Research Article
                Subject: Biology
                Subject: Population Biology
                Subject: Epidemiology
                Subject: Medicine
                Subject: Clinical Research Design
                Subject: Epidemiology
                Subject: Longitudinal Studies
                Subject: Retrospective Studies
                Subject: Statistical Methods
                Subject: Diagnostic Medicine
                Subject: Pathology
                Subject: Clinical Pathology
                Subject: General Pathology
                Subject: Epidemiology
                Subject: Clinical Epidemiology

                ScienceOpen disciplines: Uncategorized
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                ScienceOpen disciplines: Uncategorized

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