Autopsy 2018
2018; Lippincott Williams & Wilkins; Volume: 137; Issue: 25 Linguagem: Inglês
10.1161/circulationaha.118.033236
ISSN1524-4539
Autores Tópico(s)Public Health Policies and Education
ResumoHomeCirculationVol. 137, No. 25Autopsy 2018 Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBAutopsy 2018Still Necessary, Even if Occasionally Not Sufficient Lee Goldman, MD, MPH Lee GoldmanLee Goldman Vagelos College of Physicians and Surgeons, Columbia University, New York, NY. Originally published19 Jun 2018https://doi.org/10.1161/CIRCULATIONAHA.118.033236Circulation. 2018;137:2686–2688The average autopsy rate in US hospitals was ≈50% in the 1940s and 41% in 1970, just before the Joint Commission on the Accreditation of Hospitals eliminated the requirement for a 20% autopsy rate. Since that time, autopsy rates have been in free fall, with estimated rates currently ≈8% overall, including forensic cases, but only 4% among in-hospital deaths. About 700 000 Americans die in acute-care hospitals each year, so these percentages translate into ≈28 000 hospital autopsies annually.Three explanations are commonly proposed for these falling rates: the lack of reimbursement for autopsies, the fear of disclosing mistakes that would lead to malpractice suits, and the belief that advances in medical technology, including but not limited to computed tomographic scans and magnetic resonance imaging, have made autopsies obsolete.The first 2 rationales could easily be resolved by effective legislation, such as Medicare reimbursement for autopsies, or regulation, such as reinstatement of a minimum required autopsy rate. From a scientific perspective, however, the key issue is whether autopsies remain as critical for measuring the quality of care and advancing medicine as they were 80 or even 50 years ago.AUTOPSY AS A DIAGNOSTIC TESTThe autopsy is the ultimate diagnostic test, typically the gold standard, with an assumed 100% sensitivity for finding causes of death and 100% specificity for excluding them. Of course, no test is perfect; any gold standard is simply the current best.Diagnosis in isolation, although interesting, is not sufficient to justify the expense and inconvenience of a test. Diagnostic tests are most useful when they result in a change in treatment. For example, my colleagues and I showed that cardiac nuclear medicine scans in 1980 and echocardiograms in 1994 provided information that led to an appropriate change in treatment, which would not have been clear without the test's result, after ≈10% of examinations. Since then, however, the landscape has changed dramatically. Cardiac nuclear medicine circa 1980 was of 3 types: gated radionuclide scans to assess ventricular function, technetium pyrophosphate scans to diagnose acute myocardial infarction, and thallium scintigraphy to diagnose transient ischemia or prior myocardial infarction. Gated radionuclide scans were made obsolete by 2-dimensional echocardiography. Pyrophosphate scans, which at best probably confirmed large enough infarcts to be found by enzymatic or other criteria anyway, are rarely used today except for the occasional diagnosis of amyloidosis. By comparison, more sophisticated versions of myocardial ischemia scanning still remain useful, despite new technologies such as coronary calcium scoring by computed tomography.So the question is fairly simple: has the autopsy, like gated radionuclide scans, become totally irrelevant? Has it become a small-niche test, like pyrophosphate scanning? Or does it remain important despite other newer technologies, like ischemia scintigraphy?WHAT AUTOPSIES FINDIn widely cited studies in 1960, 1970, 1980,1 1985,2 and 2010,3 autopsies found class 1 errors, defined as principal causes of death that were missed by clinicians and for which treatment likely would have impacted survival, in ≈10% of cases. On the one hand, premortem diagnosis has improved for many conditions, such as myocardial infarction and pulmonary emboli. On the other hand, however, the yield of autopsies for class 1 missed diagnoses has remained relatively constant because infections, especially in patients who are immunosuppressed or have received multiple antibiotics, are an increasing cause of in-hospital deaths that are correctly diagnosed microbiologically and sometimes anatomically only at autopsy.All reports of the percent yield of autopsies are biased, however, because they report only on autopsied patients, who progressively represent a smaller and smaller proportion of patients who die. Although common sense would suggest that the likelihood of misdiagnosis is lower in nonautopsied patients, the ability of physicians to estimate the yield of an autopsy is remarkably poor. In our work, the probability of a major unexpected autopsy finding is really ≈30% when physicians think it is >50%, but still ≈20% when they think it is 10-fold increase in comparison with current practices. Our collective inability to address the financial and medicolegal disincentives to higher autopsy rates is a societal shortcoming, undoubtedly reinforced by overconfidence in modern diagnostic technology.However, the history lesson is clear. Autopsies drive improvements in technology that then diminish the rate of current autopsy-detected misdiagnoses, only to have medical care advance so that patients stay alive longer to develop other conditions (eg, infections and oftentimes previously obscure infections that are now more common because of the use of broad-spectrum antibiotics) that then reinforce the continued need for autopsies. The persistent value of autopsies does not mean medicine has failed to advance, but rather that every advance brings new challenges and new unknowns.The goal of reducing human imperfection requires that the search for truth always must trump hubris, bias, complacency, and the fear of new knowledge. In medicine, autopsies remain a critical weapon in that fight.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.http://circ.ahajournals.orgLee Goldman, MD, MPH, Harold and Margaret Hatch Professor, Dean of the Faculties of Health Sciences and Medicine, Columbia University Irving Medical Center, Vagelos College of Physicians and Surgeons, 630 W 168th St, Ste 2-401, New York, NY 10032. E-mail [email protected]References1. Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg M. The value of the autopsy in three medical eras.N Engl J Med. 1983; 308:1000–1005. doi: 10.1056/NEJM198304283081704.CrossrefMedlineGoogle Scholar2. Landefeld CS, Chren MM, Myers A, Geller R, Robbins S, Goldman L. Diagnostic yield of the autopsy in a university hospital and a community hospital.N Engl J Med. 1988; 318:1249–1254. doi: 10.1056/NEJM198805123181906.CrossrefMedlineGoogle Scholar3. Marshall HS, Milikowski C. Comparison of clinical diagnoses and autopsy findings: six-year retrospective study.Arch Pathol Lab Med. 2017; 141:1262–1266. doi: 10.5858/arpa.2016-0488-OA.CrossrefMedlineGoogle Scholar4. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.JAMA. 2003; 289:2849–2856. doi: 10.1001/jama.289.21.2849.CrossrefMedlineGoogle Scholar5. Shojania KG, Burton EC, McDonald KM, Goldman L. Overestimation of clinical diagnostic performance caused by low necropsy rates.Qual Saf Health Care. 2005; 14:408–413. doi: 10.1136/qshc.2004.011973.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Fine D, Dickins K, Adams L, De Las Nueces D, Weinstock K, Wright J, Gaeta J and Baggett T (2022) Drug Overdose Mortality Among People Experiencing Homelessness, 2003 to 2018, JAMA Network Open, 10.1001/jamanetworkopen.2021.42676, 5:1, (e2142676) Kaur G, Williams N, Vidhun R, Stroever S and Dodge J (2021) The Gallbladder and Vermiform Appendix as Quality Assurance Indicators in Autopsy Pathology, American Journal of Clinical Pathology, 10.1093/ajcp/aqab199, 157:6, (858-862), Online publication date: 7-Jun-2022. 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