"We carried out a meta-analysis of discrepancies between clinical and autopsy diagnoses and the contribution of autopsy histology. There has been little improvement in the overall rate of discrepancies between the 1960s and the present. At least a third of death certificates are likely to be incorrect and 50% of autopsies produce findings unsuspected before death. In addition, the cases which give rise to discrepancies cannot be identified prior to autopsy.
...In some diseases retention of organs or tissues is essential for diagnosis, but there is apocryphal evidence that many pathologists are now reluctant, with the advent of the Human Tissue Act, to seek consent from relatives to examine histological sections in autopsy cases. In many cases coroners will not permit such retention of tissue.
...In 1993 the Royal College of Pathologists published The Autopsy and Audit, giving a discrepancy rate of 75% for significant clinical discrepancies, and 10% for discrepancies where the patient would have been expected to live had the clinical diagnosis been correct.
...The discrepancies between clinical and post mortem diagnoses ranged from 15%15 to 41%24 with a discrepant major diagnosis, with a rate of 30%8 to 63%16 for the cause of death. Between 45%14 and 76.5%13 of all post mortems revealed at least one clinically unsuspected finding, with most studies giving a figure of around 50%.
...In a study including adult medical and surgical patients, Cameron and McGoogan15 increased the autopsy rate to 65% during the period of their study to reduce a possible bias due to only difficult cases being autopsied. The clinicians were asked to complete a dummy death certificate indicating the cause of death, the main admitting diagnosis, the confidence of their diagnosis and whether they would normally have asked for an autopsy. The discrepancy rate for the main diagnosis was 12% when the clinicians described themselves as ‘certain’ or ‘fairly certain’, compared with a rate of 15% for all levels of certainty. In cases where the clinicians said they would have requested an autopsy, the discrepancy rate for the main diagnosis was 15%. In cases where they would not usually have requested one, it was similar, at 14%. In a study including medical patients the discrepancy rate for the main diagnosis was 6% when the diagnosis was ‘certain’, 28% when the diagnosis was ‘probable’ and 60% when it was ‘uncertain’.24 In this study the clinicians could give several main diagnoses, in the study by Cameron and McGoogan only one main diagnosis could be given.
...Four studies noted that some patients had a discrepant diagnosis due to a misleading result from a diagnostic test. This occurred in 3% of 68 vascular surgery patients,22 4% of 312 general and vascular surgery patients,21 4.4% of 428 patients12 and 6% of 77 surgical patients with gastrointestinal tract disorders.11 These discrepancies occurred even though tests were judged to have been appropriately requested and performed. Goldman et al.26 studied discrepancies due to diagnostic tests between 1960 and 1980. They classified tests into three categories and found that 1% of 209 endoscopies ⁄ biopsies ⁄ surgical explorations led to a discrepant diagnosis, as did 0.7% of 541 standard radiology procedures and 3% of 157 computed tomography (CT) ⁄ ultrasound ⁄ isotope scans.
...These studies indicate the cause of death is likely to be wrong on at least a third of death certificates. ...Ten to thirteen percent of deaths are potentially avoidable if the patient is correctly diagnosed and treated. The rate among perioperative patients was as high as 20.6%13 in one study, although the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report published in 200227 gives a figure of 6% for potentially avoidable deaths.
...It is important to note that these discrepancy rates apply only to those patients who die and have an autopsy. The rate of diagnostic errors may be lower now, but since the majority of patients survive their hospital stay, they are not included in our figures and the discrepancy rate appears to remain the same. Patients who died after being discharged from hospital were included in only one study,13 so most do not appear in our figures, either."
See also http://www.overcomingbias.com/2011/05/what-killed-autopsies.html (but note that the meta-analytic results directly contradict many of the comments there).
+Robin Hanson
...In some diseases retention of organs or tissues is essential for diagnosis, but there is apocryphal evidence that many pathologists are now reluctant, with the advent of the Human Tissue Act, to seek consent from relatives to examine histological sections in autopsy cases. In many cases coroners will not permit such retention of tissue.
...In 1993 the Royal College of Pathologists published The Autopsy and Audit, giving a discrepancy rate of 75% for significant clinical discrepancies, and 10% for discrepancies where the patient would have been expected to live had the clinical diagnosis been correct.
...The discrepancies between clinical and post mortem diagnoses ranged from 15%15 to 41%24 with a discrepant major diagnosis, with a rate of 30%8 to 63%16 for the cause of death. Between 45%14 and 76.5%13 of all post mortems revealed at least one clinically unsuspected finding, with most studies giving a figure of around 50%.
...In a study including adult medical and surgical patients, Cameron and McGoogan15 increased the autopsy rate to 65% during the period of their study to reduce a possible bias due to only difficult cases being autopsied. The clinicians were asked to complete a dummy death certificate indicating the cause of death, the main admitting diagnosis, the confidence of their diagnosis and whether they would normally have asked for an autopsy. The discrepancy rate for the main diagnosis was 12% when the clinicians described themselves as ‘certain’ or ‘fairly certain’, compared with a rate of 15% for all levels of certainty. In cases where the clinicians said they would have requested an autopsy, the discrepancy rate for the main diagnosis was 15%. In cases where they would not usually have requested one, it was similar, at 14%. In a study including medical patients the discrepancy rate for the main diagnosis was 6% when the diagnosis was ‘certain’, 28% when the diagnosis was ‘probable’ and 60% when it was ‘uncertain’.24 In this study the clinicians could give several main diagnoses, in the study by Cameron and McGoogan only one main diagnosis could be given.
...Four studies noted that some patients had a discrepant diagnosis due to a misleading result from a diagnostic test. This occurred in 3% of 68 vascular surgery patients,22 4% of 312 general and vascular surgery patients,21 4.4% of 428 patients12 and 6% of 77 surgical patients with gastrointestinal tract disorders.11 These discrepancies occurred even though tests were judged to have been appropriately requested and performed. Goldman et al.26 studied discrepancies due to diagnostic tests between 1960 and 1980. They classified tests into three categories and found that 1% of 209 endoscopies ⁄ biopsies ⁄ surgical explorations led to a discrepant diagnosis, as did 0.7% of 541 standard radiology procedures and 3% of 157 computed tomography (CT) ⁄ ultrasound ⁄ isotope scans.
...These studies indicate the cause of death is likely to be wrong on at least a third of death certificates. ...Ten to thirteen percent of deaths are potentially avoidable if the patient is correctly diagnosed and treated. The rate among perioperative patients was as high as 20.6%13 in one study, although the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report published in 200227 gives a figure of 6% for potentially avoidable deaths.
...It is important to note that these discrepancy rates apply only to those patients who die and have an autopsy. The rate of diagnostic errors may be lower now, but since the majority of patients survive their hospital stay, they are not included in our figures and the discrepancy rate appears to remain the same. Patients who died after being discharged from hospital were included in only one study,13 so most do not appear in our figures, either."
See also http://www.overcomingbias.com/2011/05/what-killed-autopsies.html (but note that the meta-analytic results directly contradict many of the comments there).
+Robin Hanson