Pathology and Laboratory Medicine

Open journal

ISSN 2996-5942

Autopsy Data to Refine Healthcare Quality: A Fresh Perspective

Jawahar (Jay) Kalra*, Zoher Rafid-Hamed and Patrick Seitzinger

Jawahar (Jay) Kalra, MD, PhD, FRCPC, FCAHS, CCPE

Professor, Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan and Royal University Hospital, Saskatchewan, Canada; Tel. (306) 655-2152; Fax. (306) 655-2223; E-mail: jay.kalra@usask.ca

The medical autopsy is an established quality assurance tool that has laid the foundation for modern quality assurance and improvement strategies.1 Previous studies have predominantly utilized autopsy data to determine discordance rates among pre- and post-mortem diagnoses and to identify pathologies at highest risk of misdiagnosis. Examples of such work that has provided valuable data to guide healthcare policy from around the world include pre- and post-mortem discordance rates of 9.3% in India,2 12.3% in Canada,3 17.2% in the USA,4 18.1% in the Netherlands,5 19.0% in Greece,6 25.6% in Spain,7 28% in Brazil,8 and 48.4% in Jamaica.9 Although this area of work has contributed considerably to the practice of diagnostic medicine, it is only beginning to scratch the surface of the potential applications of autopsy data. New and innovative strategies to apply autopsy data represent timely opportunities to strengthen modern diagnostic processes. The purpose of expanded applications of autopsy data is to inform targeted strategies to recalibrate diagnostic methods and to mitigate factors that contribute to diagnostic error in the evolving landscape of modern healthcare.10

The medical autopsy plays an important role in medical research.1 Advances in science and technology continue to expand the available resources that can be leveraged to inform diagnostic decision-making processes. However, an abundance of diagnostic resources available has added complexity to the interpretation of test results. Unwarranted utilization of laboratory tests results in data pollution, over-diagnosis, and harm to patients.11 By providing a gold standard of diagnostic accuracy, autopsy data has guided research in the development and utilization of diagnostic technologies including imaging modalities. In this way, autopsy data provides insights into the contributions of various diagnostic technologies and allows us to optimize indications for future implementation. Our previous results have shown that 54.8% of computerized tomography (CT) scans and 57.9% of magnetic resonance imaging (MRI) studies yielded a previously unsuspected diagnosis.3 This is in keeping with previous reports that between 20-50% of CT scans and MRI studies do not contribute to patient care.12 Examples such as these highlight the importance of autopsy data in guiding research and optimizing the use of diagnostic testing.

Previous efforts to understand diagnostic error have focused on overall rates of concordance and discordance between pre- and post-mortem diagnoses. It has been proposed that specificity and sensitivity would serve as more appropriate measures of current clinical diagnostic accuracy.13 Traditionally, studies of diagnostic sensitivity and specificity have been conducted on a diseasespecific basis.14,15,16,17 While this approach provides insights into the identification of particular pathologies, it does not allow for the assessment of common underlying factors that are shared in diagnostic processes across different organ systems and disease pathologies. In order to quantify the overall accuracy of clinical diagnostic methods, sensitivity analyses should be done on a per-case rather than on a per-disease basis. Obtaining measures of overall diagnostic specificity presents additional challenges as it not possible to accurately determine the number of conditions not diagnosed and not present in a patient.18 Applying this approach to autopsy data collected over a 5-year period, our preliminary results suggest that the overall sensitivity of clinical diagnoses, calculated across all available pathologies and organ systems involved, is 53.5%. This is in keeping with previous studies that have reported sensitivities ranging from 47% to 74%.14,18 This approach is unique in that it approaches clinical diagnostic accuracy as a parameter that can be quantified across various clinical situations, thereby providing an objective measure of overall diagnostic accuracy. The advantages of such an approach include the capacity to assess systematic factors that contribute to medical error.

As an educational tool autopsy findings play a critical role in refining diagnostic skills at all levels of clinical training.19 It has long been recognized that approximately 80% of physicians do not believe that probabilities of diagnostic error apply to their patients.19 Clinician certainty in a diagnosis and perceived need for autopsy have shown minimal influence on the rate of discrepancies between clinical and autopsy diagnoses.20 This has led to a nearly 50% decrease in autopsy rates in the past six decades.3 It has been reported that for every 10% increase in autopsy rates, there is a 12.4% decrease in major medical errors.9 Some experts have suggested that if medical autopsy rates were performed on every patient that died in hospital, the rate of major medical errors could be decreased to as low as 4%,21 illustrating the importance of autopsy in medical education.

We advocate for increased autopsy rates and expanded utilization of autopsy data to optimize healthcare delivery systems. In-depth analyses of the clinical context in which medical errors occur allow for the recognition of systemic factors that contribute to medical error. By examining the circumstances surrounding cases of diagnostic error, key systemic factors can be recognized and addressed before such misdiagnoses result in a loss of life. Factors including patient demographics, clinical scenarios, workplace circumstances, and healthcare utilization can be assessed to identify clinical scenarios at highest risk of medical error. Subsequently, autopsy data can inform the implementation of additional quality checks in a specific and targeted manner.

Acknowledging shortcomings in our healthcare systems is the first step in mitigating their consequences. The autopsy has been established as a feedback mechanism to measure diagnostic error and improve diagnostic accuracy. The current state of healthcare presents timely opportunities to apply autopsy data to strengthen diagnostic processes. Critical reflection of the accuracy and relevance of lab results, imaging studies, and healthcare policy is a vital component of healthcare quality assurance and improvement. New and innovative ways to implement autopsy data will inform targeted strategies to mitigate systemic factors that contribute to diagnostic error. These represent the first of many steps in realizing the vast potential applications of autopsy data in creating actionable strategies to recalibrate diagnostic methods. The harnessing of autopsy data in innovative ways represents a critical next frontier in strengthening modern diagnostic processes.

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest.

1. Seitzinger P, Rafid-Hamed Z, Kalra J (Jay). The Value of the Medical Autopsy as a Quality Improvement Tool in Modern Diagnostic Medicine. New York, USA: Springer, Cham; 2020: 77-82. doi: 10.1007/978-3-030-50838-8_11

2. Moorchung N, Singh V, Mishra A, Patrikar S, Kakkar S, Dutta V. Is necropsy obsolete – An audit of the clinical autopsy over six decades: A study from Indian sub continent. Indian J Pathol Microbiol. 2014; 56(4): 372-377. doi: 10.4103/0377-4929.125294

3. Kalra J, Markewich D, Seitzinger P. Quality assessment and management: An overview of concordance and discordance rates between clinical and autopsy diagnoses. In: Advances in Intelligent Systems and Computing. NY, USA: Springer Verlag; 2020: 45-54. doi: 10.1007/978-3-030-20451-8_5

4. Tavora F, Crowder CD, Sun C-C, Burke AP. Discrepancies between clinical and autopsy diagnoses. Am J Clin Pathol. 2008; 129(1): 102-109. doi: 10.1309/9M7DFE62RTDKHH4D

5. Kuijpers CC, Fronczek J, Van De Goot FRW, Niessen HWM, Van Diest PJ, Jiwa M. The value of autopsies in the era of hightech medicine: Discrepant findings persist. J Clin Pathol. 2014; 67(6): 512-519. doi: 10.1136/jclinpath-2013-202122

6. Spiliopoulou C, Papadodima S, Kotakidis N, Koutselinis A. Clinical diagnoses and autopsy findings: A retrospective analysis of 252 cases in Greece. Arch Pathol Lab Med. 2005; 129(2): 210-214. doi: 10.1043/1543-2165(2005)129<_x0032_10:CDAAFA>2.0.CO;2

7. Val-Bernal JF. El papel de la autopsia en la práctica clínica actual. Med Clin (Barc). 2015; 145(7): 313-316. doi: 10.1016/j.medcli.2015.02.015

8. Zerbini T, Singer JM, Leyton V. Evaluation of the discrepancy between clinical diagnostic hypotheses and anatomopathological diagnoses resulting from autopsies. Clinics (São Paulo, Brazil). 2019; 74(6): e1197. doi: 10.6061/clinics/2019/e1197

9. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time. JAMA. 2003; 289(21): 2849-2856. doi: 10.1001/jama.289.21.2849

10. Kalra J, Adams S. Medical error and patient safety: Fostering a patient safety culture. Austin J Clin Pathol Open. 2016; 3(1): 1-3.

11. Kalra J, Rafid-Hamed Z, Seitzinger P. The future of diagnostic laboratory testing in healthcare. Am J Biomed Sci Res. 2019; 5(2): 89-91. doi: 10.34297/AJBSR.2019.05.000883

12. Hendee WR, Becker GJ, Borgstede JP, Bosma J, Casarella WJ, Erickson BA, et al. Addressing overutilization in medical imaging. Radiology. 2010; 257(1): 240-245. doi: 10.1148/radiol.10100063

13. Saracci R. Is necropsy a valid monitor of clinical diagnosis performance? Br Med J. 1991; 303(6807): 898-900. doi: 10.1136/bmj.303.6807.898

14. Sington JD, Cottrell BJ. Analysis of the sensitivity of death certificates in 440 hospital deaths: A comparison with necropsy findings. J Clin Pathol. 2002; 55(7): 499-502. doi: 10.1136/jcp.55.7.499

15. Pinto Carvalho FL, Cordeiro JA, Cury PM. Clinical and pathological disagreement upon the cause of death in a teaching hospital: Analysis of 100 autopsy cases in a prospective study. Pathol Int. 2008; 58(9): 568-571. doi: 10.1111/j.1440-1827.2008.02272.x

16. De Vlieger G, Mahieu E, Meersseman W. Clinical review: What is the role for autopsy in the ICU? Crit Care. 2010; 14(2): 221. doi: 10.1186/cc8925

17. Schwanda-Burger S, Moch H, Rg Muntwyler J, Salomon F. Diagnostic errors in the new millennium: A follow-up autopsy study. Mod Pathol. 2012; 25: 777-783. doi: 10.1038/modpathol.2011.199

18. Heriot GS, Pitman AG, Gonzales M, McKelvie P. The four horsemen: Clinicopathological correlation in 407 hospital autopsies. Intern Med J. 2010; 40(9): 626-632. doi: 10.1111/j.1445-5994.2009.01985.x

19. Redelmeier DA, Tversky A. Discrepancy between medical decisions for individual patients and for groups. N Engl J Med. 1990; 322(16): 1162-1164. doi: 10.1056/NEJM199004193221620

20. Clark BW, Derakhshan A, Desai S V. Diagnostic errors and the bedside clinical examination. Med Clin North Am. 2018; 102(3): 453-464. doi: 10.1016/j.mcna.2017.12.007

21. Goldman L. Autopsy 2018: Still necessary, even if occasionally not sufficient. Circulation. 2018; 137(25): 2686-2688. doi: 10.1161/CIRCULATIONAHA.118.033236

LATEST ARTICLES

An Unusual Presentation of Encephalitis in a Patient with Lyme Neuroborreliosis

Maithily Patel*, Jazmin Jatana, Ramya Ramesh and Milind Awale

doi.

Practical Pointers for Drug Development and Medical Affairs

Gerald L. Klein*, Roger E. Morgan, Shabnam Vaezzadeh, Burak Pakkal and Pavle Vukojevic

doi.

10.17140/CTPOJ-7-125

Prevalence and Risk Factors of Subclinical Mastitis of Goats in Banadir Region, Somalia

Omar M. Salah*, Yasin H. Sh-Hassan, Moktar O. S. Mohamed, Mohamed A. Yusuf and Abas S. A. Jimale

doi.10.17140/VMOJ-9-184

Use of Black Soldier Fly (Hermetia illucens) Prepupae Reared on Organic Waste

Maggot Debridement Therapy: A Natural Solution for Wound Healing

Isayas A. Kebede*, Haben F. Gebremeskel and Gelan D. Dahesa,

doi.10.17140/VMOJ-9-183

Figure 11. Risk Map for the Introduction of Ruminant Diseases at Borders

Ovine Network in Morocco: Epizootics Spread Prevention and Identification of the At-Risk Areas for “Peste des Petits Ruminants” and “Foot and Mouth Disease”

Yassir Lezaar*, Mehdi Boumalik, Youssef Lhor, Moha El-Ayachi, Abelilah Araba and Mohammed Bouslikhane

doi.

10.17140/EPOJ-8-131

The Impact of Family Dynamics on Palliative Care at the End-of-Life

Neil A. Nijhawan*, Rasha Mustafa and Aqeela Sheikh

doi.10.17140/PMHCOJ-10-154

LATEST ARTICLES

Case Report

2024 Apr

Maithily Patel*, Jazmin Jatana, Ramya Ramesh and Milind Awale
Pie Chart Showing Overall Proportions of Diagnostic Category of FNAC, JUMC

Retrospective Study

2024 Apr

Abel Tefera*, Lemlem Terefe and Kitesa Biresa
Prevalence (%) of Types of Anthropometric Failure among Previous and Present Studied Tribal Children

Original Research, peer reviewed

2024 Apr

Biswajit Mahapatra and Kaushik Bose*