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

Bob Swerlick rswerli at GMAIL.COM
Sun Apr 9 23:20:18 UTC 2017


How might one structure such a study? I am at a loss to conceive this. What
would be the controls? Obviously if there some gross anatomic finding
(ruptured aorta, large thrombosis in a key structure), this could be viewed
as definitive, But what of more subtle findings? One would need to know the
frequency of such findings in different clinical contexts.

I am reminded of the perception of anatomic pathology as an invariant gold
standard and how this has tended to break down. What do you do when the
gold standard is not so golden?

Bob Swerlick

On Sun, Apr 9, 2017 at 6:43 PM, Bruno, Michael <
mbruno at pennstatehealth.psu.edu> wrote:

> It would be very desirable to know that!  I did a lit search on the topic
> not too long ago, and could not find a single published study which
> reported on the error rate of autopsies.  All of the studies I found used
> the autopsy as the "gold standard" to find other types of errors.
>
> Surely autopsies are also subject to error, no?
>
> MAB
>
>
> -----Original Message-----
> From: Traian Mihaescu [mailto:traian at MIHAESCU.EU]
> Sent: Sunday, April 09, 2017 4:18 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] Autopsies (in connection with thread about The
> Value of a Second Opinion at the Mayo Clinic)
>
>
> 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-aut
> > opsy-detected-diagnostic-errors-over-time-a-systematic-review?q=autops
> > y
> )   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=DQI
> > FaQ&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=-7e4riqIt55t2dJrgC
> > urSOAaZ9YfqnMopB2FIHXKJzY&m=SfdVEuqtJnQTI9F56tW2vYSsx863VpoqEHsQWBArk5
> > 0&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.washington
> >>> p
> 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
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> 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> Address
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> "
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> "
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>
>
>
>
>
>
>
> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
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>
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> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
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>
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> </p>
>



-- 
Bob Swerlick






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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