[The clinical autopsy in the perspective of public health policy]

[Autopsy-a procedure of medical history?]

An autopsy is an important tool of quality assurance in clinical medicine. It serves to determine the exact cause of death, unravel unexpected complications of disease processes including adverse or any other effects of treatment as well as to validate the official mortality statistics. An autopsy also makes an important contribution to training medical students and physicians; however, the rate of clinical autopsies has been declining drastically for decades, the causes being manifold. Lack of interest among clinicians, mainly due to inadequate knowledge of the advantages of autopsy seems to play a special role. The lack of reasonable reimbursement has also been discussed as another possible cause. In order to counteract this negative trend, efforts should be made to work on the awareness of medical students and young clinicians so that an autopsy is perceived as a general measure of quality assurance and physician self-control. Furthermore, a realistic reimbursement of financial and personnel expense is necessary.

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

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.