Hospital autopsy audit: discordant primary clinical diagnoses are found in 20% of cases in a reducing autopsy case load. Selection bias or significant findings?
Hospital autopsy audit: discordant primary clinical diagnoses are found in 20% of cases in a reducing autopsy case load. Selection bias or significant findings?
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医院%20尸检%20审核：%20不一致%20primary%20clinical%20diagnoses%20are%20found%20in%2020%%20of%20cases%20in%20a%20reducing%20尸检%20case%20load.%20Selection%20bias%20or%20significant%20findings
DOI：
10.1097/pat.0000000000000297
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发表时间：
2015
期刊：
影响因子：
4.5
通讯作者：
C. Mclean
中科院分区：
文献类型：
--
作者：
L. Jackett;C. Mclean
尸检是一种有效的工具，可以深入了解患者的医疗护理，并有助于审计临床决策。因此，验尸有可能提高护理质量，教育医学界，确保准确的流行病学健康统计数据，并帮助失去亲人的亲属接受生命结束的问题。验尸，也被称为解剖或尸检，成为中世纪一种有影响力的医疗程序，大大提高了我们对人类疾病的理解。在魏尔啸的标准化指导下，"解剖尸体，通过直接观察来确定死因或疾病的性质“是很常见的，直到世纪中期都是医学课程的组成部分。然而，近几十年来，澳大利亚和国际医院的尸检率有所下降，部分原因是诊断技术的进步，以及可能很少接触尸检的医生对其价值的不熟悉。澳大利亚2000年代中期的综合数据显示，该国的医院尸检率在10年内从21%下降到12%。其他地方也有类似的观察结果，包括美国、英国、欧洲、香港和中国。尽管这种下降，在过去15年中发表的有限的研究中继续发现临床和尸检诊断之间的差异。Roulson等人对尸检研究进行的荟萃分析发现，主要诊断和潜在可治疗疾病的差异率分别为15-41%和10- 44%。因此，许多作者认为，尸检仍然是一个相关和有价值的工具，有可能告知和教育医学界。可以理解，诊断技术的进步是导致这种下降的一个因素。其他原因包括公众态度不利、对近亲检查范围的限制、缺乏资源、医务人员在同意解剖方面的培训不足、同意过程耗时以及医学界不熟悉解剖的价值。据作者所知，澳大利亚的医院尸检数据已经有十年没有公布了。因此，我们在2011年8月至2013年8月期间对澳大利亚一家主要的创伤和心肺移植三级中心的非冠状动脉尸检进行了审计，以检查临床和尸检结果的一致性。使用来自死亡证明、医院记录和尸检报告的回顾性数据，将临床死亡原因（COD）和主要共病诊断与2年期间（2011年8月至2013年8月）进行的所有医院尸检结果进行比较。提交给验尸官的案件被排除在研究之外。在每一个案例中，临床小组在进行尸检之前都填写了死亡证明。记录每个病例的尸检类型（部分或全部），并在知情同意的范围内尽可能进行全面的显微镜检查。根据尸检结果，死亡证明和临床诊断被评估为正确或不一致。还注意到可能影响临床护理的重大漏诊。从最终结果中排除了被认为不会影响患者急性护理事件的微小差异。因此，不一致的尸检是指与死亡证明和主要的死前诊断相比，尸检结果被认为是导致死亡的实质性不同的病理过程。这些发现与过去的研究结果雅阁。在2011年8月至2013年8月期间的1298例医院死亡病例中，有86例患者被转诊进行尸检（尸检率为6.6%）。全尸检占70%（60/86），部分尸检占30%（26/86）。年龄范围为14至91岁（平均年龄61岁）。男性占52%（45/86），器官移植受者占29%（25/86）。除一次部分尸检外，所有尸检均可评估死亡原因。在后一种情况下，无法充分评价COD（多发性骨髓瘤），因为近亲仅同意检查心脏，其中诊断为心肌血管淀粉样蛋白。在尸检中，正确诊断率为80%（68/85），不一致诊断率为20%（17/85）。最常见的正确死亡原因为感染（20%（17/85））、呼吸道病因（20%（17/85））和心血管疾病（16%（14/85））（表1）。最常见的漏诊COD是9%的病例（8/85）中发生的感染性病因（通常是真菌），其中一半是移植患者。呼吸系统和心血管疾病各占4%（3/85）。在12%（10/85）中，不一致是从一个身体系统到另一个身体系统的重大变化（表2）。不一致诊断的例子如图1-4所示。病理学（2015年10月）47（6），pp. 499–502
The post-mortem examination is an effective tool that provides insight into a patient’s medical care and assists in auditing clinical decision making. Thus, post-mortems have the potential to improve quality of care, educate the medical community, ensure accurate epidemiological health statistics and assist bereft relatives in coming to terms with end of life issues. The post-mortem examination, also known as autopsy or necropsy, became an influential medical procedure in the Middle Ages that significantly advanced our understanding of human disease. Standardised by Virchow, ‘the dissection of the dead body to determine, through direct observation, the cause of death or the nature of the disease’ was common place and an integral part of medical curricula until the mid-twentieth century. However, Australian and international hospital autopsy rates have declined in recent decades, due in part to advances in diagnostic technologies and possibly an unfamiliarity of their value among doctors with little exposure to autopsies. Comprehensive Australian data from the mid-2000s reported that the nation’s hospital autopsy rate declined from 21% to 12% over a 10 year period. Similar observations have been made elsewhere, including in the USA, UK, Europe, Hong Kong and China. Despite this decline, discrepancies between clinical and autopsy diagnoses continue to be found in limited studies published over the last 15 years. A meta-analysis of autopsy studies by Roulson et al. found that discrepancies in major diagnoses and potentially treatable conditions occurred at rates of 15–41% and 10–44%, respectively. Therefore, many authors contend that the autopsy remains a relevant and valuable tool with the potential to inform and educate the medical community. Advances in diagnostic technologies are understandably a factor that has contributed to the decline. Other reasons include unfavourable public attitudes, restrictions placed on the extent of examination by next-of-kin, lack of resources, poor training of medical staff in autopsy consent, time-consuming consent processes and unfamiliarity among the medical community of the value of autopsy. As far as the authors are aware, hospital autopsy data have not been published from Australian sources for a decade. Therefore, we undertook an audit of non-coronial autopsies between August 2011 and August 2013 at a major Australian tertiary centre for trauma and heart-lung transplantation to examine concordance of clinical and autopsy findings. Using retrospective data from death certificates, hospital records and autopsy reports, the clinical cause of death (COD) and major co-morbid diagnoses were compared with autopsy findings for all hospital post-mortems performed across a 2 year period (August 2011–August 2013). Cases referred to the coroner were excluded from the study. In every case a death certificate was completed by the clinical team prior to the autopsy being conducted. The type of autopsy (partial or full) was recorded for each case and a comprehensive microscopic examination was carried out where possible within the limitations of consent. Based on the autopsy findings, the death certificate and clinical diagnoses were assessed as either correct or discordant. Significant missed diagnoses that may have impacted clinical care were also noted. Minor discrepancies that were considered not to have impacted on the patient’s acute episode of care were excluded from the final results. Thus, a discordant autopsy was one where the autopsy findings were considered a substantially different pathological process contributing to death when compared to the death certificate and major ante-mortem diagnoses. The findings were then rated in accord with past studies. Of 1298 hospital deaths between August 2011 and August 2013, 86 patients were referred for autopsies (autopsy rate 6.6%). Full autopsies accounted for 70% (60/86) and partial for 30% (26/86). Ages ranged from 14 to 91 (mean age 61). Male cases accounted for 52% (45/86) and organ transplant recipients for 29% (25/86). Cause of death was assessable at post-mortem in all but one partial autopsy. In the latter case the COD (multiple myeloma) was unable to be fully evaluated since the next-of-kin consented only to examination of the heart, in which amyloid of the myocardial vessels was diagnosed. Of conclusive autopsies, correct diagnoses were made in 80% (68/85) while discordant diagnoses accounted for 20% (17/85). The most common correct causes of death were infections in 20% (17/85), respiratory aetiologies in 20% (17/85) and cardiovascular conditions in 16% (14/85) (Table 1). The most common missed COD was an infective aetiology (frequently fungal) occurring in 9% of cases (8/85), of which half were transplant patients. Respiratory and cardiovascular causes each accounted for 4% of cases (3/85). In 12% (10/85) the discordance was a major change from one body system to another (Table 2). Examples of discordant diagnoses are shown in Fig. 1–4. Pathology (October 2015) 47(6), pp. 499–502