Outcomes/Effectiveness Research

Continuing use of autopsy appears warranted to uncover important unsuspected diagnoses

Substantial discrepancies still exist between clinical diagnoses and findings at autopsy. The likelihood that a given autopsy will reveal important unsuspected diagnoses has decreased over the past four decades, yet it remains sufficiently high that encouraging ongoing use of autopsy appears warranted, concludes a study supported by the Agency for Healthcare Research and Quality (contract 290-97-0013).

To examine the usefulness of autopsy as a tool for quality measurement and improvement, investigators at the University of California San Francisco-Stanford Evidence-based Practice Center systematically reviewed the research literature to estimate the frequency with which autopsy reveals important, clinically missed diagnoses. Of 53 autopsy series identified, 42 reported major errors (missed diagnoses involving a principal underlying disease or primary cause of death) and 37 reported class I errors (which, had they been detected during life, would or could have affected patient outcome). Twenty-six autopsy series reported both major and class I error rates. The median error rate was 23.5 percent for major errors and 9 percent 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 percent for major errors and 33.4 percent for class I errors. Despite these decreases, the researchers estimated that a contemporary U.S. institution could observe a major error rate from 8.4 percent to 24.4 percent and a class I error rate from 4.1 to 6.7 percent. This suggests the continuing value of autopsies to uncover such errors.

More details are in "Changes in rates of autopsy-detected diagnostic errors over time," by Kaveh G. Shojania, M.D., Elizabeth C. Burton, M.D., Kathryn M. McDonald, M.M., and Lee Goldman, M.D., M.P.H., in the June 4, 2003, Journal of the American Medical Association 289(21), pp. 2849-2856.

Copies of Evidence Report/Technology Assessment No. 58, The Autopsy as an Outcomes and Performance Measure (AHRQ Publication No. 03-E002, full report; 03-E001, summary) are available from the AHRQ Publications Clearinghouse.

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