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

Bob Swerlick rswerli at GMAIL.COM
Mon Apr 10 00:52:05 UTC 2017


If there is a disagreement, how does one adjudicate the differences? Does
one assume the second one is right or do you need to get a third opinion?

Bob

On Sun, Apr 9, 2017 at 7:38 PM, Bruno, Michael <
mbruno at pennstatehealth.psu.edu> wrote:

> The only method I can think of is to perform blinded
> second-opinion/second-look autopsies.  Sort of an “autopsy peer review.”
>
>
>
> MAB
>
>
>
>
>
> *From:* Bob Swerlick [mailto:rswerli at gmail.com]
> *Sent:* Sunday, April 09, 2017 7:20 PM
> *To:* Society to Improve Diagnosis in Medicine <IMPROVEDX at list.
> improvediagnosis.org>; Bruno, Michael <mbruno at pennstatehealth.psu.edu>
> *Subject:* Re: [IMPROVEDX] Autopsies (in connection with thread about The
> Value of a Second Opinion at the Mayo Clinic)
>
>
>
> 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
> Futm-5Fterm-3D.11d4a1346899&d=DQIFaQ&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY
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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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> <Payne et al - 2014 - Patient-initiated second opinions -  Systematic
> reivew of characteristics and impact on diagnosis, treatment, and
> satisfaction.pdf>
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> >> ources_faq.asp-234A&d=DQIFaQ&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLU
> >> QRxhA&r=-7e4riqIt55t2dJrgCurSOAaZ9YfqnMopB2FIHXKJzY&m=SfdVEuqtJnQTI9F
> >> 56tW2vYSsx863VpoqEHsQWBArk50&s=JI3bZw6KtUgMdBsZOvIAjN9QQOaWRnnMVED5Cq
> >> ot-BY&e=
> https://urldefense.proofpoint.com/v2/url?u=http-3A__LIST.
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> >> 9mXYXEGfSnM3bY53YSKuLUQRxhA&r=-7e4riqIt55t2dJrgCurSOAaZ9YfqnMopB2FIHX
> >> KJzY&m=SfdVEuqtJnQTI9F56tW2vYSsx863VpoqEHsQWBArk50&s=no4lKPH7DTgaz6sl
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> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
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> >> d=DQIFaQ&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=-7e4riqIt55t
> >> 2dJrgCurSOAaZ9YfqnMopB2FIHXKJzY&m=SfdVEuqtJnQTI9F56tW2vYSsx863VpoqEHs
> >> QWBArk50&s=vQJq9jzUvRJP3NyDxDSKUsoR6QYIjHM06Qdv7t0j_14&e=
> "
> >> target="_blank">https://urldefense.proofpoint.com/v2/url?u=http-3A__l
> >> ist.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVED
> >> X-26A-3D1&d=DQIFaQ&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=-7
> >> e4riqIt55t2dJrgCurSOAaZ9YfqnMopB2FIHXKJzY&m=SfdVEuqtJnQTI9F56tW2vYSsx
> >> 863VpoqEHsQWBArk50&s=vQJq9jzUvRJP3NyDxDSKUsoR6QYIjHM06Qdv7t0j_14&e=
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> https://urldefense.proofpoint.com/v2/url?u=http-3A__LIST.
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> opB2FIHXKJzY&m=SfdVEuqtJnQTI9F56tW2vYSsx863VpoqEHsQWBArk50&s=9-
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> >  (with your password)
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> > Y&m=SfdVEuqtJnQTI9F56tW2vYSsx863VpoqEHsQWBArk50&s=no4lKPH7DTgaz6slVV7E
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> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
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> 3FSUBED1-3DIMPROVEDX-26A-3D1&d=DQIFaQ&c=4sF48jRmVAe_CH-
> k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=-7e4riqIt55t2dJrgCurSOAaZ9YfqnM
> opB2FIHXKJzY&m=SfdVEuqtJnQTI9F56tW2vYSsx863VpoqEHsQWBArk50&s=
> vQJq9jzUvRJP3NyDxDSKUsoR6QYIjHM06Qdv7t0j_14&e=
> "
> > target="_blank">https://urldefense.proofpoint.com/v2/url?u=http-3A__li
> > st.improvediagnosis.org_scripts_wa-2DIMPDIAG.exe-3FSUBED1-3DIMPROVEDX-
> > 26A-3D1&d=DQIFaQ&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=-7e4r
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> > poqEHsQWBArk50&s=vQJq9jzUvRJP3NyDxDSKUsoR6QYIjHM06Qdv7t0j_14&e=
> </a>
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> wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
> </p>
>
>
>
>
>
>
>
>
> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
> Medicine
>
> To unsubscribe from the IMPROVEDX list, click the following link:<br> <a
> href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=
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> wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
> </p>
>
>
>
>
>
>
> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
> Medicine
>
> To unsubscribe from the IMPROVEDX list, click the following link:<br>
> <a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=
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> wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
> </p>
>
>
>
>
> --
>
> Bob Swerlick
>



-- 
Bob Swerlick






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


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