From the Departments of *Pathology and †General Medicine, Government Medical College & Hospital, Chandigarh, India.
Manuscript received March 22, 2010; accepted April 27, 2010.
Dr Bansal participated in the procedure, literature search, and preparation of the final manuscript. Drs Punia and Sachdev conceptualized the study and participated in the interpretation and preparation of the manuscript draft.
No funds were received for this study.
The authors report no conflicts of interest.
Reprints: Rajpal S. Punia, MD, Department of Pathology, Government Medical College & Hospital, Sector 32, Chandigarh 160030, India. E-mail: email@example.com.
Autopsy has become the scientific foundation of medicine today. The autopsy and particularly autopsy histology are the most accurate method of determining the cause of death and auditing accuracy of clinical diagnosis, diagnostic tests, and death certification.1
Clinical autopsy remains a pivotal instrument for quality management; student teaching; and continuous education, epidemiology, and research, and a high rate of autopsy is required if medical progress is to continue.2 Despite these benefits, autopsy rates have fallen worldwide during the past few decades.3,4 The time-consuming task of autopsies for pathology departments and reluctance of families to give permission for the procedure are some of the main reasons for this decrease in autopsy rates.5,6 To reduce the amount of dissection and to save time, needle autopsies have been suggested in recent years as being a useful alternative for conventional autopsies.7–11
Various studies have reported rates of major discrepancies between clinical and conventional autopsy diagnoses ranging between 16% and 39%.1,12–17 However, to date, no prospective study has examined the discrepancy between clinical and needle autopsy diagnoses. We prospectively analyzed 50 needle autopsies on patients who died in the medical emergency department of our tertiary care teaching hospital. Consent for conventional autopsy could not be obtained in these 50 patients. Our objective was to assess the accuracy of clinical diagnoses and efficacy of needle autopsy.
PATIENTS AND METHODS
This prospective study was conducted during a period of 1 year in a 16-bed medical emergency department in a large 630-bed tertiary care teaching hospital. The protocol was in accordance with the ethical standards of the committee for the protection of human subjects at the hospital. Written valid consent from the closest relative available was taken in each subject.
Medical record file of each deceased patient was thoroughly studied, and complete clinical history, physical examination, laboratory investigations, and clinical diagnosis were noted. Needle autopsy was carried out taking universal precautions to prevent dissemination of infection through any fluid or secretions of the deceased patient.
Tissue cores were taken by performing multiple biopsies using spring-loaded automated biopsy gun (Bard Max Core, Bard Biopsy Systems, Tempe, Ariz). The samples were obtained percutaneously from the liver, lungs, kidneys, spleen, pancreas, heart, or any other palpable swelling on the body. Sections were stained with hematoxylin-eosin using standard procedure. Special histochemical stains such as periodic acid–Schiff stain, reticulin, Ziehl-Neelsen stain, phosphotungstic acid–hematoxylin stain, orcein, and Masson’s trichrome stain were used wherever required.
Correlation of Clinical and Autopsy Diagnoses
Tabular analysis was done to compare clinical and autopsy diagnoses. Results of these correlations were classified as follows: clinical diagnosis confirmed by the autopsy, clinical diagnosis refuted by the autopsy, clinical diagnosis impossible to confirm because of an incomplete autopsy, clinical diagnosis impossible to confirm by the autopsy, and autopsy diagnosis missed by physicians. Furthermore, discrepancies between clinical and autopsy diagnoses were classified according to the criteria of Goldman et al18: class I, missed major diagnosis that, had it been made, would have changed patient management and might have resulted in cure or prolonged survival; class II, missed major diagnosis that would not have modified ongoing patient care; class III, missed minor diagnosis associated with the terminal disease but not directly responsible for death; and class IV, other missed minor diagnoses. Discrepancies were classified based on consensus by physicians and pathologists. In the case of discordance between them, the pathologists’ diagnosis was retained.
During the study period, 6523 patients were admitted to the medical emergency department in our hospital, of whom 728 (11.16%) died during their stay and 50 (6.86%) were autopsied. The other 678 patients were not autopsied for the following reasons: family refusal (536 patients [79.05%]), inability to contact family members (24 patients [3.54%]), and family desire for a rapid funeral for personal or religious reasons (118 patients [17.40%]).
The 50 deceased patients who were autopsied were in the age range of 12 to 80 years (mean [SD], 50.48 [18.41] years). Thirty-three (66%) of these 50 patients were males, and 17 (34%) were females. The tissues yielded from various organs were as follows: lungs, 90%; liver, 82%; kidney, 48%; heart, 28%; spleen, 22%; and pancreas, 18%.
Comparison of Clinical and Autopsy Diagnoses
Comparison of the clinical characteristics between patients with major (classes I and II) diagnostic discrepancies and other autopsied patients revealed a higher percentage of elderly patients in the class I and class II groups. Of 16 patients with major diagnostic errors (classes I and II), 11 were older than 55 years. The mean (SD) age of these 11 patients came out to be 65 (6.77) years.
For the 50 autopsied patients, 86 clinical diagnoses before death (mean [SD], 1.72 [0.53] diagnoses per patient) were recorded. Among them, 21 (24.41%) were impossible to verify by the postmortem examination (eg, diabetic ketoacidosis, metabolic encephalopathy, or cardiac arrhythmia). Of the 65 remaining diagnoses, 15 (23.08%) were confirmed, 27 (41.53%) were refuted (Table 1), and 23 (35.38%) were not assessed because of an incomplete autopsy examination. Physicians most frequently erroneously diagnosed septic shock (11 patients, 40.74%), pneumonitis (4 patients, 14.81%), and myocardial infarction (4 patients, 14.81%; Table 1). A total of 48 new diagnoses, missed by physicians, were revealed by needle autopsy. The most frequently missed diagnoses were liver fatty change (19 patients) and pneumonitis (11 patients). Other frequently missed diagnoses were chronic hepatitis (3 patients) and cancer (2 patients: 1 lung squamous cell carcinoma and 1 lung adenocarcinoma).
Classification of 48 discordant clinical and autopsy diagnoses according to the criteria of Goldman et al18 identified 8 class I errors in 6 (12%) of 50 patients, 11 class II errors in 10 patients (20%), 3 class III errors in 3 patients (6%), and 26 class IV errors in 24 patients (48%). There were no discrepancies between the clinical and autopsy diagnoses in 15 (30%) of 50 patients. Major diagnostic errors (classes I and II) were noted in 16 (32%) of 50 patients. Table 2 summarizes the class I discrepancies between clinical and autopsy diagnoses.
Limited autopsies have been advocated as means of cutting both cost and the delay to the authorization of the final report. The aims of this study were to evaluate the accuracy of clinical diagnoses and to determine how many patients reaching the emergency department might have received modified care if the autopsy diagnosis could have been made before death. The autopsy rate was 6.86% in our study, and the major diagnostic errors were identified for 32% of the autopsied patients. The correct diagnosis would have changed the management and possibly resulted in decreased morbidity and mortality for approximately 14% of patients.
To the best of our knowledge, this study is the first to date to prospectively evaluate the potential contribution of needle autopsy to the management of future patients reporting to the medical emergency department. Our autopsy rate of 6.86% is a little lesser than that reported in international studies,19 but this is very well explained by the ignorance toward the cause of death and lower literacy rates in developing countries such as India.
Various retrospective studies1,12,20–22 comparing clinical and autopsy diagnoses reported major (classes I and II) discrepancy rates ranging from 19.8% to 27%. Shojania et al21 conducted a systematic literature search from 1966 to 2002 and identified 45 studies reporting 53 distinct autopsy series meeting prospectively defined criteria. The median discrepancy rates were 23.5% (range, 4.1%–49.8%) for major errors and 9.0% (range, 0%–20.7%) for class I errors. All these studies performed complete clinical autopsies to establish autopsy diagnoses. In our study, needle autopsy was done in place of complete autopsy, and the discrepancy for major errors was noted in 32% of patients. This is very much in concordance with the results of other published studies.
Our study has certain limitations. First, the tissue yielded by needle autopsy is always lesser as compared with conventional autopsy, leading to many diagnoses going unnoticed. Moreover, entities such as pulmonary embolism cannot be diagnosed on needle autopsy. Second, in our study, a biopsy of the brain tissue was not performed. As a result, some common causes of death such as meningitis, encephalitis, and cerebrovascular accidents went undiagnosed. Third, being a developing country, there is lack of 24-hour services of special laboratories and high-end diagnostic modalities in the medical emergency department, thereby leading to lack of definitive clinical diagnoses. All these factors may account for the high rate of major diagnostic discrepancies.
In conclusion, needle autopsies can play a major role in assuring and improving the quality of patient care by monitoring diagnostic accuracy and treatment in the medical emergency department.
The authors thank Amit Bansal, MD, senior resident at the Department of Pulmonary Medicine, Government Medical College & Hospital, Chandigarh, for providing intellectual support in the preparation of the manuscript.
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