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Autopsies continue to detect clinically important diagnostic discrepancies, according to a new evidence report from the Agency for Healthcare Research and Quality. The report was prepared for AHRQ by researchers at the University of California at San Francisco-Stanford University Evidence-based Practice Center.
Based on an analysis of more than 50 studies spanning 40 years, the EPC researchers estimate that, in U.S. hospitals in the year 2000, the correct cause of death escaped clinical detection in between 8 percent and 23 percent of cases, with as many as 4 percent to 8 percent of all deaths having a diagnostic discrepancy that may have harmed the patient. In addition to clinically missed diagnoses, up to 5 percent of autopsies disclosed clinically unsuspected complications of care.
These diagnostic discrepancy rates do not simply reflect selection by clinicians of diagnostically challenging cases, according to the researchers. In fact, considerable evidence suggests that clinicians have trouble predicting which autopsies are likely to yield important new information. The researchers note that, although often referred to as "diagnostic errors," these findings refer to discrepancies between clinical diagnoses and autopsy diagnoses and not necessarily to medical mistakes. Although diagnostic discrepancies can result from a clinician's failure to consider an appropriately broad listing of alternative diagnoses or misinterpretation of test results, there are also situations with atypical symptoms or limited diagnostic test information. These discrepancies, regardless of source, create inaccuracies in death certificates and hospital discharge data, both of which play important roles in epidemiologic research and health care policy decisions, according to the researchers.
For the evidence report, they examined the benefits of the autopsy as a tool in health care performance measurement and improvement. However, they did not attempt to address other roles of the autopsy in medical education, furthering medical research, quality control within the medical specialty of pathology, verification of second opinion consultations, legal documentation of findings, and the bereavement process for surviving family members. The focus of the report on the autopsy's role in detecting quality problems reflected an objectively quantifiable area to evaluate the potential negative effects of the trend toward fewer autopsies during the past 40 years.
In 1994, the last year for which national data exist, the autopsy rate for all non-forensic deaths fell below 6 percent, from a high of 50 percent in the 1960s. This decline is probably due to lack of reimbursement for autopsies, the attitudes of clinicians regarding the utility of autopsies in light of other diagnostic advances, and general unfamiliarity with the autopsy and techniques for requesting one, especially among physicians in medical training.
Select for the online summary of Evidence Report/Technology Assessment No. 58, The Autopsy as an Outcome and Performance Measure.
Select National Guideline Clearinghouse™ (NGC) for information on NGC Resources.
Print copies of the summary (AHRQ Publication No. 03-E001) are available from the AHRQ Publications Clearinghouse.
Copies of the full report (AHRQ Publication No. 03-E002) are also available from the AHRQ Publications Clearinghouse.
Other recently published evidence reports and summaries are now available from AHRQ. They include:
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