The frequency of autopsies has declined in most developed countries beginning in the latter half of the 20th century. During this time period the technology of medicine made significant advances; however, it is important to regularly reevaluate the role of the autopsy to confirm suspected diagnoses and identify unsuspected findings.
To determine what portion of autopsies reveal clinically meaningful unexpected findings.
Reports that included clinical histories of autopsies performed at Jackson Memorial Hospital during the 6 years between 2009 and 2014 were reviewed by 2 pathologists. Each case was classified using the Goldman Classification.
In the given time period, 923 autopsies were performed; 512 patients (55.5%) were adults. A total of 334 cases were subject to review after excluding those with a short (<1 day) hospital stay, restriction to a single organ or body cavity, and cases referred from other facilities. A total of 33 of 334 cases (9.9%) were identified as class I discrepancy, where the autopsy revealed a discrepant diagnosis with a potential impact on survival or treatment. Critical findings, such as untreated infection (15 of 33 cases; 45.5%), pulmonary embolism (8 of 33 cases; 24.2%), and undiagnosed malignancy (6 of 33 cases; 18.2%), were found in these cases. Major significant findings that had not been clinically detected, whether clinically manageable or not (class I and II), were found in 65 of 334 cases (19.5%).
Despite intensive modern clinical investigations, autopsies continue to reveal major antemortem diagnostic errors in a significant number of cases.
Hospital autopsy rates in the United States declined from 30% to 40% in the 1960s1 to 8% in the early 2000s.2 Multiple factors, such as the elimination of the hospital autopsy rate requirement in 1972, lack of reimbursement, cultural and religious objections by families, and increasing workload for house staff, account for the decrease.3 Even as sophisticated medical technologic tools have been developed and made available, the role of the autopsy for confirming clinical diagnoses and identifying unsuspected findings should be reevaluated regularly. Herein, we report our findings of the importance of the autopsy by comparing the clinical diagnosis with the anatomic findings in a single large academic institution between the years of 2009 and 2014.
MATERIALS AND METHODS
Clinical information of all adult (18 years or older) autopsy cases performed in Jackson Memorial Hospital (Miami, Florida) for 6 years (from January 2009 to December 2014) was retrospectively evaluated. Only cases with a stay longer than 24 hours in Jackson Memorial Hospital were included in the study in order to ensure enough time for initial clinical evaluation and management. Exclusion criteria were: (1) a hospital stay of less than 24 hours, (2) restrictions to single-organ or body cavity dissections, and (3) cases referred from other facilities. Cases from the University of Miami Hospital (Miami, Florida), which shares attending physicians and residents in the adjacent campus and whose full medical records were available, were considered in-house cases.
All cases had consent for autopsy from the legal next of kin, and each autopsy was performed by pathology residents who observed restrictions, if there were any. Attending pathologists directly supervised each case. For each eligible autopsy the autopsy report, including clinical history, was reviewed by 2 pathologists (H.M. and C.M.). Medical records were reviewed if the clinical information provided in the autopsy report was unclear or inadequate. Each case was classified using the Goldman Classification (Table 1).4 When a case could be classified with more than one discrepancy, the higher class (smaller number) was regarded as the final classification. The pathologists reviewed the cases independently, compared their assessments, and came to consensus by discussion if there was discordance.
The study design was reviewed by the Institutional Review Board of the University of Miami and approved to be conducted as nonhuman research.
RESULTS
Of 923 autopsies performed in Jackson Memorial Hospital for the 6 years (2009–2014), 512 cases (55.5%) were performed on adults (age >18 years). A total of 334 of 512 cases (65.2%) were subject to review after excluding those with a short (<1 day) hospital stay, restriction to a single-organ or body cavity dissection, and those referred from other facilities (Table 2). The demographics of the patients included are presented in Table 3.
A total of 33 of 334 cases (9.9%) were identified as a class I discrepancy, where the autopsy revealed a discrepant diagnosis with a potential impact on survival or treatment (Table 4). Various critical findings, such as untreated infection (15 of 33 cases; 45.5%), pulmonary embolism (8 of 33 cases; 24.2%), and undiagnosed malignancy (6 of 33 cases; 18.2%) were identified in cases of this class (Table 5). For the cases with class I discrepancies, the clinical history or impression and critical laboratory or imaging results are listed in Table 6. Major significant findings that had not been clinically detected, whether they might or might not have clinical impact, were found in a total of 65 of 334 cases (class I and II; 19.5%).
DISCUSSION
This study is a retrospective review of the adult autopsy reports for recent years in the third largest public hospital (1550 beds) in the United States. It excluded cases from outside institutions, patients with short hospital stays, and those in which the autopsy was restricted to a single organ or body cavity, in order to optimize the clinical and pathologic correlation. Even though the exclusion made the size of the study smaller, the entire set of included cases was comprehensively reviewed, unlike in some previous studies which only reviewed randomly sampled cases.5
There was a limitation to calculate the exact autopsy rate because: (1) some cases were declared to be under the jurisdiction of the medical examiner, and therefore dropped from the initial data set, and (2) Jackson Memorial Hospital has many branches and affiliated hospitals from which autopsies are requested, and the total number of deaths in each hospital was not available.
Despite intensive modern clinical investigations, autopsies have continued to reveal major antemortem diagnostic errors in as many as 30% of cases.6–8 Follow-up or meta-analysis studies show that the rate of clinically significant discrepancy is decreasing over decades; however, 4% to 7% of cases still have class I discrepancies.1,5 This study shows a comparable result of 9.9% of clinically significant findings to the previous studies.
Undiagnosed infections, especially pneumonia, and pulmonary embolism were the 2 most common significant unexpected findings. These are common complications of hospitalization and subsequent immobilization. The character of the study, which excluded the short hospital stay, may make the frequency of those complications more notable by a possible exclusion of sudden cardiovascular accidents, which might have a significant portion in autopsies but have a short time period between the initial clinical presentation and the patient's demise. Because early suspicion and detection may make for a significantly better prognosis in those potentially fatal complications, vigilant management for preventing these conditions is suggested.
Beyond the direct clinical or administrative advantages, autopsies have other virtues, such as educational and epidemiologic values.9 The autopsy should continue to be the gold standard for quality control in clinical management, including radiologic evaluation,10–15 in spite of declining requests.16 The most crucial factors influencing attitudes toward the autopsy have been shown to be the clinician's level of experience with autopsy in training and practice. Therefore, the importance of the autopsy should be emphasized in medical education and postgraduate training so the number of significant diagnostic discrepancies can be reduced and patient care can be optimized.