Autopsies (in connection with thread about The Value of a Second Opinion at the Mayo Clinic)

Traian Mihaescu traian at MIHAESCU.EU
Sun Apr 9 20:17:40 UTC 2017


1.A local study from Romania (attached to this mail) found that "the
pathology of the respiratory system is the main source of diagnostic
discrepancies" and

2.taking into account that frequent discrepancies of tracheobronchial
content findings occurres in postmortem CT versus forensic autopsy
(https://www.ncbi.nlm.nih.gov/pubmed/26400026)

3.in the context of my anectodical experiences in some local autopsy
misdiagnosis (eg TB)

my question was:

"what is the error rate in autopsies diagnosis itself"?

Traian Mihaescu MD
Clinic of Pulmonary Diseases
Iasi, Romania
ispro.ro
@tmihaescu


> As an FYI in connection with the autopsy comments in this thread, there
are indeed data on the value of autopsies.
> The systematic review below (from JAMA in early 2000s and indexed here
in
> the AHRQ website PSNet
> https://psnet.ahrq.gov/resources/resource/1511/changes-in-rates-of-autopsy-detected-diagnostic-errors-over-time-a-systematic-review?q=autopsy
)   included some studies in 'modern era' and also took into account the
idea that clinicians might only ask for autopsy when they are already
worried about a diagnostic error. Interestingly that turns out to be not
very true. What we did in the analysis in the systematic review was look
at error rates as a function of autopsy rates. If clinicians were great at
> selecting cases for autopsy ( i.e., they asked for autopsy mostly when
they suspected they had missed the correct diagnosis), then studies with
high autopsy rates (most deceased patients sent for autopsy) would have
low error rates, because all these extra deaths with no concerns about
errors would be added. But, in fact, studies from places with high autopsy
> rates showed fairly high error rates. In other words, all the patients
with no autopsy include a fair number with errors.
> For anyone who is interested, what is meant by error here (ie in the
very
> large literature on autopsy detected errors in clinical diagnosis)
usually
> amounts to the following (based on a classic study by Lee Goldman, the
senior author on the review below from UCSF, but then at the Brigham, now
> Dean at Columbia, I believe) from the early 80s in NEJM and a second
study
> in the late 80s from same group but with Seth Landefeld as 1st author):
>  Class I errors: knowing the right diagnosis (ie the one detected at
> autopsy) would for sure have changed treatment and probably/possibly
would have altered outcome (ie, patient more likely to have left
hospital
> alive).
> Major Errors: includes Class I plus Class II, where the latter amounts
to
> saying the diagnosis was really very different than the clinicians
thought
> but it’s not clear that treatment would have been any different. So, for
instance, if a patient with chest pain in the ED is diagnosed as an acute
MI but in fact has aortic dissection, that’s a Class I error. Not
> only is the treatment for acute MI not the same as for aortic
dissection,
> it would actually make death more likely.
> A less dramatic Class I error might be (bacterial) pneumonia as the
clinical diagnosis, but the correct diagnosis is TB.
> For an example of a major error, pneumonia but the real diagnosis is
post-obstructive pneumonia from metastatic lung cancer. The idea behind
calling this a “major error” (but not a Class I error) is that no one
could say that missing metastatic lung cancer is unimportant (the way one
> might say about many ‘incidentalomas’ found at autopsy). But, the fact
is
> that treatment probably would not have been any different if the lung
cancer were already  metastatic.  Yes,  I know that some metastatic
cancers are stil treatable, but example just meant to convey the general
idea that sometimes, even with a major missed diagnosis, there is no
impact on treatment. Plus, the point of this classification system was to
> convince clinicians using a conservative framework that would not appear
to ‘overcall’ diagnostic errors
> Anyway, there continue to be studies of autosy detected errors,
espiecally
> in settings like ICUs, where autopsy rates remain high (Winters B et al.
Diagnostic errors in the intensive care unit: a systematic review of
autopsy studies. BMJ Qual Saf. 2012 Nov;21(11):894-902.
> https://www.ncbi.nlm.nih.gov/pubmed/22822241) this systematic review,
similar to the older JAMA review below, showed that clinically important
missed diagnoses stil occur at a substantial rate.
> Keep in mind that these error classifications are particularly
> conservative in that they count the clinicians as having made the
diagnosis if they made it any point while the patient was still alive (ie
> even if they made it too late to save the patient. For instance,
recognizing that  a patient was dying of TB or an acute dissection even if
> that recognition came too late to save the patient – as long as someone
said that’s the likely diagnosis before the patient actually died, it
didn’t get counted as an error.)
> In terms of the point recently made in this thread about not all
diagnostic errors leading to death. That’s of course true in many ways –
instead of death, missed diagnoses may ‘just’ lead to years of untreated
symptoms, disability and anxiety over no answer. But, the point of these
sorts of autopsy studies, especially when undertaken by clinicians rather
> than pathologists, was to draw attention to clinicians that, despite the
may incredibly advanced in imaging, serologic testing etc, we stil miss
important diagnoses at a not insignificant rate. And, importantly these
error rates are not simply an artefact of selection bias.
> In terms of why autopsies are so seldom performed, a viewpoint in NEJM
from 2008 provides an overview of the various problems. [Shojania KG,
Burton EC. The vanishing nonforensic autopsy. The New England journal of
medicine 2008;358:873-5.
> http://www.nejm.org/doi/full/10.1056/NEJMp0707996
> Kaveh
> Kaveh G. Shojania, MD
> Professor and Vice Chair, Quality & Innovation
> Department of Medicine
> Director, University of Toronto
> Centre for Quality Improvement and Patient Safety (www.cquips.ca)
Sunnybrook Health Sciences Centre
> Room H468, 2075 Bayview Avenue
> Toronto, Ontario M4N 3M5
> Editor-in-chief, BMJ Quality & Safety
> Shojania KG1, Burton EC, McDonald KM, Goldman L.Changes in rates of
autopsy-detected diagnostic errors over time: a systematic review. JAMA.
2003 Jun 4;289(21):2849-56.
> CONTEXT: Substantial discrepancies exist between clinical diagnoses and
findings at autopsy. Autopsy may be used as a tool for quality
management
> to analyze diagnostic discrepancies.
> OBJECTIVE:To determine the rate at which autopsies detect important,
clinically missed diagnoses, and the extent to which this rate has changed
> over time.
> DATA SOURCES: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. STUDY
SELECTION: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). DATA
EXTRACTION: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.
> DATA SYNTHESIS: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%.
> CONCLUSION: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.
________________________________________
> From: Goldman, Bruce I [Bruce_Goldman at URMC.ROCHESTER.EDU]
> Sent: April-09-17 11:34 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] The Value of a Second Opinion at the Mayo
Clinic
> Lab accreditation is supposed to assure autopsy quality, but diagnostic
accuracy is not a directly evaluated parameter-it is a really important
question, especially since the primary responsibility for an autopsy is
often given to a trainee.
> -----Original Message-----
> From: Traian Mihaescu [mailto:traian at MIHAESCU.EU]
> Sent: Friday, April 07, 2017 3:08 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] The Value of a Second Opinion at the Mayo
Clinic
> "An autopsy can reveal clinically significant diagnoses missed before
death"..but, are there any data about diagnostic errors in autopsy studies?
> Traian Mihaescu, MD
> Clinic of Pulmonary Diseases
> Iasi, Romania
> https://urldefense.proofpoint.com/v2/url?u=http-3A__www.ispro.ro&d=DQIFaQ&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=-7e4riqIt55t2dJrgCurSOAaZ9YfqnMopB2FIHXKJzY&m=SfdVEuqtJnQTI9F56tW2vYSsx863VpoqEHsQWBArk50&s=JH19pC8Ck33mexsqm9i2BBQPVIguU2vYL2CuhXd2xqY&e=
>> The gold standard used to be autopsy. Unfortunately, the rate too low
to be of much use today.
>> Harry B. Burke, MD, PhD
>> Chief, Section of Safety and Quality
>> Associate Professor of Medicine
>> Department of Medicine
>> F. Edward Hébert School of Medicine
>> Uniformed Services University of the Health Sciences
>>> On Apr 5, 2017, at 12:45 PM, Mark Graber
>>> <Mark.Graber at IMPROVEDIAGNOSIS.ORG> wrote:
>>> Thanks Bridget for this KEY question.  There are indeed a few studies
that have done longer-term follow up of patients to determine whether the
second opinion was correct (referenced in the attached review
article) and you won’t be surprised to know that in a fraction of these
cases (around 10%) the original diagnosis was correct, or even something
not yet considered.  These long-term follow-up studies are difficult to
conduct but very valuable.
>>> Your comments also touch on another big problem in our field – what is
the gold standard?  There is a great deal of uncertainty even at this
level, given that biopsy and autopsy results are not always
definitive.
>>> Mark
>>> Mark L Graber MD FACP
>>> President, SIDM
>>> Senior Fellow, RTI International
>>> Professor Emeritus, Stony Brook University
>>> From: Bridget Kane <kaneb at tcd.ie <mailto:kaneb at tcd.ie>>
>>> Date: Wednesday, April 5, 2017 at 12:49 AM
>>> To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>,
>>> "mark.graber at improvediagnosis.org
>>> <mailto:mark.graber at improvediagnosis.org>"
>>> <Mark.Graber at Improvediagnosis.org>>
>>> <mailto:Mark.Graber at Improvediagnosis.org>>
>>> Subject: Re: [IMPROVEDX] The Value of a Second Opinion at the Mayo
Clinic
>>> One of the questions for me is “are we assuming that the second
opinion is the gold standard?”
>>> Or how can we identify the truth, i.e. the correct diagnosis?
>>> Is there a stronger placebo effect following a second opinion, I
wonder?
>>> Does anyone have any research on this, by chance?
>>> Thanks
>>> Bridget
>>> On 4 Apr 2017, at 16:02, Mark Graber
>>> <Mark.Graber at IMPROVEDIAGNOSIS.ORG>>
>>> <mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG>> wrote:
>>> Just coming out – this study from the Mayo Clinic
>>> <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.washingtonp
ost.com_national_health-2Dscience_20-2Dpercent-2Dof-2Dpatients-2Dwith
-2Dserious-2Dconditions-2Dare-2Dfirst-2Dmisdiagnosed-2Dstudy-2Dsays_2
017_04_03_e386982a-2D189f-2D11e7-2D9887-2D1a5314b56a08-5Fstory.html-3
Futm-5Fterm-3D.11d4a1346899&d=DQIFaQ&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY
53YSKuLUQRxhA&r=-7e4riqIt55t2dJrgCurSOAaZ9YfqnMopB2FIHXKJzY&m=SfdVEuq
tJnQTI9F56tW2vYSsx863VpoqEHsQWBArk50&s=A37cxdq81T3k3BLLvzRBM2uveYtXpG
ll56AjR0LJ4Ns&e= > finds that 20% of referred patients end up with a very
different diagnosis.  The findings are very similar to the
results
>>> from the second opinion program at Best Doctors, as referenced in the
Mayo Clinic article.  In both cases, however, these are not randomly
selected patients being studied – they are patients who were concerned
enough about their initial diagnosis (or lack thereof) to seek out the
second opinion.
>>> Mark
>>> Mark L Graber MD FACP
>>> President, SIDM
>>> Senior Fellow, RTI International
>>> Professor Emeritus, Stony Brook University <image001.png>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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