Diagnostic errors in three medical eras: a necropsy study

Diagnostic algorithm allows for a scientifically robust and reliable retrospective diagnosis using textual evidence from mid-19th century Basel, Switzerland

OBJECTIVE

Diagnosing disease from the past using historic textual sources can be controversial as to its accuracy. To overcome these objections, an empirical approach to the historical clinical data was developed. The approach follows a standardised, objective, and systematic evaluation, satisfying the requirements of the philosophy of science.

MATERIAL

Physician-managed medical records of mid-19th century patients reported to have suffered from tuberculosis.

METHOD

A diagnostic algorithm, quantifying clinical data into a scoring system, was developed based on criteria recorded in the medical sources. The findings were compared to the autopsy results using the Receiver Operating Characteristics method.

RESULTS

The generated scoring system correctly predicted the diagnosis of tuberculosis in 86% of patients in the study. 6% false negatives and 8% false positives were predicted.

CONCLUSIONS

It is possible to retrospectively diagnose in a reliable and scientifically robust manner under certain conditions. It is important to embed the clinical data into the historical context. A general rejection of retrospective diagnosis is unsubstantiated. Well-designed, disease-specific, and source adapted medical scoring systems are new approaches and overcome criticism raised against retrospective diagnosis.

SIGNIFICANCE

This new approach utilises diverse historic sources and potentially leads to reliable retrospective diagnosis of most common diseases of the past.

LIMITATIONS

Selection bias of the records allocated. Quality of the historic sources utilized. Restricted statistical assessment potential of historic sources.

SUGGESTIONS FOR FURTHER RESEARCH

Development of disease- and epoch-specific medical score systems.

Self-learning of cardiac ultrasound by medical students: can augmented online training improve and maintain manual POCUS skills over time?

BACKGROUND

The use of cardiac point of care ultra-sound is rapidly growing and so is the demand for quality POCUS teaching. POCUS teaching is usually conducted in small groups requiring much space and equipment. This study attempts to test whether providing access to an E-learning module as an adjunct to a cardiac POCUS course can increase students' image acquisition skills. This will show POCUS teaching can improve significantly without having to invest a significant amount of resources.

METHODS

Medical students (N = 125) were divided into two groups and had undergone a hands-on Cardiac POCUS course before their internal clerkship. During the clerkship, members of both groups got to practice their POCUS skills in the internal wards. One group was provided with accounts to a cardiac POCUS teaching E-learning platform (eMedical Academy©). After limited time for self- practice, both groups underwent a pre-validated ultrasound examination. The two groups' test results were then compared for each POCUS view and for the total exam score.

RESULTS

The E-learning group performed significantly better than the course-only group in the 6-min exam total score, and at acquiring the following views: parasternal long axis view, apical four-chamber view, and the inferior vena cava view.

CONCLUSION

E-learning platforms can be an efficient tool for improving cardiac POCUS teaching and maintaining POCUS skills. Using it as a supplement to a hands-on course provides better POCUS skills without the need of extra hands-on teaching.

An audit of autopsy-confirmed diagnostic errors in perinatal deaths: What are the most common major missed diagnoses

Perinatal autopsies are essential to establish the cause of stillbirth or neonatal death and improve clinical practice. Limited studies have provided detailed major missed diagnoses of perinatal deaths in current clinical practice. In this retrospective audit of 177 perinatal autopsies including 99 stillbirths and 78 neonatal deaths with complete pathologic evaluation, 66 cases (21 Class I and 45 Class II diagnostic errors) were revealed as major discrepancies (37.3%), with complete agreements in 80 cases (45.2%). The difference in major discrepancies between stillbirth and neonatal death groups was significant (P < 0.001), with neonatal deaths being more prone to Class I errors. Various respiratory diseases (25/66, 37.9%) and congenital malformations (16/66, 24.2%) accounted for the majority of missed diagnoses (41/66, 62.1%). More importantly, neonatal respiratory distress syndrome (NRDS) was the most common type I missed diagnosis (7/8, 87.5%), markedly higher than the average 11.9% of all Class I errors. Our findings suggest that there are high disparities between clinical diagnoses and autopsy findings in perinatal deaths, and that various respiratory diseases are mostly inclined to cause major diagnostic errors. We first demonstrated that NRDS is the most common type I missed diagnosis in perinatal deaths, which clinicians should pay special attention to in practice.

Discrepancies Between Clinical and Autopsy Diagnoses in Rapid Response Team-Assisted Patients: What Are We Missing?

OBJECTIVES

The rapid response team (RRT) assists hospitalized patients with sudden clinical deterioration. There is scarce evidence of diagnostic accuracy in this scenario, but it is possible that a considerable rate of misdiagnosis exists. Autopsy remains a valuable tool for assessing such question. This study aimed to compare clinical (premortem) and autopsy (postmortem) diagnoses in patients assisted by the RRT and describe major discrepancies.

METHODS

We reviewed 104 clinical data and autopsies from patients assisted by the RRT during a cardiac arrest event in a tertiary care hospital in Brazil. Clinical and autopsy diagnostic discrepancies were classified using the Goldman criteria. Other clinical and pathological data were described, and the group with major diagnostic discrepancies was further analyzed.

RESULTS

We found 39 (37.5%) patients with major diagnostic discrepancies. Most frequent immediate causes of death in this group determined by autopsy were sepsis (36%), pulmonary embolism (23%) and hemorrhagic shock (21%). Pulmonary embolism was the cause of death significantly more frequent in the major discrepancy group than in the minor discrepancy group (23% versus 3%, P = 0.002). We individually described all major diagnostic discrepancies.

CONCLUSIONS

We found a high rate (37.5%) of major misdiagnosis in autopsies from patients assisted by the RRT in a tertiary teaching hospital. Pulmonary embolism was the most inaccurate fatal diagnosis detected by autopsy.

Bedside Clinicians' Perceptions on the Contributing Role of Diagnostic Errors in Acutely Ill Patient Presentation: A Survey of Academic and Community Practice

OBJECTIVES

This study aimed to explore clinicians' perceptions of the occurrence of and factors associated with diagnostic errors in patients evaluated during a rapid response team (RRT) activation or unplanned admission to the intensive care unit (ICU).

METHODS

A multicenter prospective survey study was conducted among multiprofessional clinicians involved in the care of patients with RRT activations and/or unplanned ICU admissions (UIAs) at 2 academic hospitals and 1 community-based hospital between April 2019 and March 2020. A study investigator screened eligible patients every day. Within 24 hours of the event, a research coordinator administered the survey to clinicians, who were asked the following: whether diagnostic errors contributed to the reason for RRT/UIA, whether any new diagnosis was made after RRT/UIA, if there were any failures to communicate the diagnosis, and if involvement of specialists earlier would have benefited that patient. Patient clinical data were extracted from the electronic health record.

RESULTS

A total of 1815 patients experienced RRT activations, and 1024 patients experienced UIA. Clinicians reported that 18.2% (95/522) of patients experienced diagnostic errors, 8.0% (42/522) experienced a failure of communication, and 16.7% (87/522) may have benefitted from earlier involvement of specialists. Compared with academic settings, clinicians in the community hospital were less likely to report diagnostic errors (7.0% versus 22.8%, P = 0.002).

CONCLUSIONS

Clinicians report a high rate of diagnostic errors in patients they evaluate during RRT or UIAs.

How to standardize measurement of global longitudinal strain

Global longitudinal strain (GLS) is a robust and sensitive marker of left-ventricular systolic function, reflecting longitudinal shortening of the ventricle. A growing body of evidence indicates its superiority in identifying subclinical, early alterations in cardiac function compared to traditional markers, such as ejection fraction. Therefore, there is a growing demand to assess GLS in clinical settings, but limited availability on how to obtain GLS accurately and appropriately in the current literature. This review summarizes key aspects of GLS measurement, including image acquisition, post-processing, and training/experience needed to facilitate the clinical implication with standardization.

Diagnostic error in the pediatric hospital: a narrative review

INTRODUCTION

Diagnostic error is a prevalent type of medical error that is associated with considerable patient harm and increased medical costs. The majority of literature guiding the current understanding of diagnostic error in the hospital setting is from adult studies. However, there is research to suggest this type of error is also prevalent in the pediatric specialty.

OBJECTIVES

The primary objective of this study was to define the current understanding of diagnostic error in the pediatric hospital through a structured literature review.

METHODS

We searched PubMed and identified studies focusing on three aspects of diagnostic error in pediatric hospitals: the incidence or prevalence, contributing factors, and related interventions. We used a tiered review, and a standardized electronic form to extract data from included articles.

RESULTS

Fifty-nine abstracts were screened and 23 full-text studies were included in the final review. Seventeen of the 23 studies focused on the incidence or prevalence, with only 3 studies investigating the utility of interventions. Most studies took place in an intensive care unit or emergency department with very few studies including only patients on the general wards. Overall, the prevalence of diagnostic error in pediatric hospitals varied greatly and depended on the measurement technique and specific hospital setting. Both healthcare system factors and individual cognitive factors were found to contribute to diagnostic error, with there being limited evidence to guide how best to mitigate the influence of these factors on the diagnostic process.

CONCLUSION

The general knowledge of diagnostic error in pediatric hospital settings is limited. Future work should incorporate structured frameworks to measure diagnostic errors and examine clinicians' diagnostic processes in real-time to help guide effective hospital-wide interventions.

Discrepancies between clinical diagnosis and hospital autopsy: A comparative retrospective analysis of 1,112 cases

Aims

The aim of this study was to compare discrepancies between diagnosed and autopsied causes of death in 1,112 hospital autopsies and to determine the factors causing this discrepancies.

Methods

1,112 hospital autopsies between 2010 and 2013 were retrospectively studied. Ante-mortem diagnoses were compared to causes of death as determined by autopsy. Clinical diagnoses were extracted from the autopsy request form, and post-mortem diagnoses were assessed from respective autopsy reports. Variables, such as sex, age, Body Mass Index, category of disease, duration of hospital stay and new-borns were studied in comparison to discrepancy. P-values were derived from the Mann-Whitney U test for the constant features and chi-2 test, p-values < 0,05 were considered significant.

Results

73.9% (n = 822) patients showed no discrepancy between autopsy and clinical diagnosis. The duration of hospitalisation (6 vs. 9 days) and diseases of the cardiovascular system (61.7%) had a significant impact on discrepancies.

Conclusion

Age, cardiovascular diseases and duration of hospital stay significantly affect discrepancies in ante- and post-mortem diagnoses.

Comparison of Diagnostic Recommendations from Individual Physicians versus the Collective Intelligence of Multiple Physicians in Ambulatory Cases Referred for Specialist Consultation

BACKGROUND

Studies report higher diagnostic accuracy using the collective intelligence (CI) of multiple clinicians compared with individual clinicians. However, the diagnostic process is iterative, and unexplored is the value of CI in improving clinical recommendations leading to a final diagnosis.

METHODS

To compare the appropriateness of diagnostic recommendations advised by individual physicians versus the CI of physicians, we entered actual consultation requests sent by primary care physicians to specialists onto a web-based CI platform capable of collecting diagnostic recommendations (next steps for care) from multiple physicians. We solicited responses to 35 cases (12 endocrinology, 13 gynecology, 10 neurology) from ≥3 physicians of any specialty through the CI platform, which aggregated responses into a CI output. The primary outcome was the appropriateness of individual physician recommendations versus the CI output recommendations, using recommendations agreed upon by 2 specialists in the same specialty as a gold standard. The secondary outcome was the recommendations' potential for harm.

RESULTS

A total of 177 physicians responded. Cases had a median of 7 respondents (interquartile range: 5-10). Diagnostic recommendations in the CI output achieved higher levels of appropriateness (69%) than recommendations from individual physicians (45%; χ² = 5.95, P = 0.015). Of the CI recommendations, 54% were potentially harmful, as compared with 41% of individuals' recommendations (χ² = 2.49, P = 0.11).

LIMITATIONS

Cases were from a single institution. CI was solicited using a single algorithm/platform.

CONCLUSIONS

When seeking specialist guidance, diagnostic recommendations from the CI of multiple physicians are more appropriate than recommendations from most individual physicians, measured against specialist recommendations. Although CI provides useful recommendations, some have potential for harm. Future research should explore how to use CI to improve diagnosis while limiting harm from inappropriate tests/therapies.

Frequency and Significance of Pathologic Pulmonary Findings in Postmortem Examinations-A Single Center Experience before COVID-19

Coronavirus disease 2019 (COVID-19) has shown the importance of postmortem investigation of deceased patients. For a correct interpretation of the pulmonary findings in this new era, it is, however, crucial to be familiar with pathologic pulmonary conditions observed in postmortem investigations in general. Adequate postmortem histopathological evaluation of the lungs may be affected by suboptimal gross work up, autolysis or poor fixation. Using a standardized preparation approach which consisted in instillation of 4% buffered formaldehyde through the large bronchi for proper fixation and preparing large frontal tissue sections of 1-2 cm thickness after at least 24 h fixation, we comprehensively analyzed postmortem pulmonary findings from consecutive adult autopsies of a two-year period before the occurrence of COVID-19 (2016-2017). In total, significant pathological findings were observed in 97/189 patients (51%), with 28 patients showing more than one pathologic condition. Acute pneumonia was diagnosed 33/128 times (26%), embolism 24 times (19%), primary pulmonary neoplasms 18 times (14%), organizing pneumonia and other fibrosing conditions 14 times (11%), pulmonary metastases 13 times (10%), diffuse alveolar damage 12 times (9%), severe emphysema 9 times (7%) and other pathologies, e.g., amyloidosis 5/128 times (4%). Pulmonary/cardiopulmonary disease was the cause of death in 60 patients (32%). Clinical and pathological diagnoses regarding lung findings correlated completely in 75 patients (40%). Autopsy led to confirmation of a clinically suspected pulmonary diagnosis in 57 patients (39%) and clarification of an unclear clinical lung finding in 16 patients (8%). Major discrepant findings regarding the lungs (N = 31; 16%) comprised cases with clinical suspicions that could not be confirmed or new findings not diagnosed intra vitam. A significant proportion of acute pneumonias (N = 8; 24% of all cases with this diagnosis; p = 0.011) was not diagnosed clinically. We confirmed the frequent occurrence of pulmonary pathologies in autopsies, including inflammatory and neoplastic lesions as the most frequent pathological findings. Acute pneumonia was an important cause for discrepancy between clinical and postmortem diagnostics.

Comparison of antemortem clinical diagnosis and post-mortem findings in intensive care unit patients

Autopsy is an important quality assurance indicator and a tool to advance medical knowledge. This study aims to compare the premortem clinical and postmortem pathology findings in patients who died in the Intensive Care Unit (ICU), to analyze if there are any discrepancies between them, and to compare the results to two similar studies performed in our institution in 2004 and 2007. Between January 1, 2016, and December 31, 2018, 888 patients died in the ICU and 473 underwent post-mortem examination (PME) of whom 437 were included in the present study. Autopsies revealed discrepancies between clinical diagnosis and pathologic findings according to in 101 cases (23.1%) according to Goldman classification. Forty-eight major discrepancies (class I and class II) were identified in 44 cases and the most frequent identified discrepancies were pulmonary embolism (3/12) as class I and malignancies (13/35) as class II. They were more frequent in patients hospitalized for less than 10 days then in the group with more than 10 days of hospitalization (13.8% vs 4.5%; p = 0.002). No statistical difference has been noticed concerning age, gender, and ICU stay. We observed an increase of performed autopsies and a total discrepancy rate similar to the studies performed in the same institution in 2004 (22.5%) and 2007 (21%). In conclusion, discrepancies between clinical and PME diagnoses persist despite the medical progress. Secondly, the autopsy after a short hospital stay may reveal unexpected findings whose diagnosis is challenging even if it may be suspected by the intensivist.

Autopsy and pre-mortem diagnostic discrepancy review in an Irish tertiary PICU

Our study had two objectives: (1) to review ante- and post-mortem diagnoses and assign a Goldman error classification and (2) establish autopsy rates within our centre. We performed a retrospective analysis of autopsies performed on patients who died in our paediatric intensive care unit (PICU) between November 13, 2012, and October 31, 2018. Medical and autopsy data of all patients was reviewed, and Goldman classification of discrepancy between ante- and post-mortem diagnoses was assigned. Our centre is a tertiary PICU, and we included all patients that died in PICU within the designated timeframe. Our results were as follows: 396 deaths occurred in PICU from 8329 (4.75%) admissions. Ninety-nine (25%) had an autopsy, 75 required by the coroner. All were included in the study. Fifty-three were male and 46 females. Fifty-three patients were transferred from external hospitals, 46 from our centre. Forty-one were neonates, 32 were < 1 year of age, and 26 were > 1 year of age. The median length of stay was 3 days. Eighteen were post-cardiac surgery, and three post-cardiac catheter procedure. Major diagnostic errors (class I/II) were identified in 14 (14.1%), 2 (2%) class I, and 12 (12.1%) were class II errors. Class III and IV errors occurred in 28 (28.2%) patients. Complete concordance (class V) occurred in 57 (57.5%) cases.Conclusion: We conclude that the autopsy rate and the diagnostic discrepancy rate within our PICU are comparable to those previously reported. Our findings show the continuing value of autopsy in determining the cause of death and providing greater diagnostic clarity. Given their value, post-mortem examinations, where indicated, should be considered part of a physician's duty of care to families and future patients. What is Known: • Major diagnostic discrepancies (class I/II) in PICU have been reported at 20.2%. ⁽¹⁰⁾ • PICU autopsy rates have varied from 36 to 67% since 1994 with most recently reported rates in 2018 being 36%. ^(6-9) What is New: • We report an Irish PICU major diagnostic discrepancy (class I/II) rates of 14.1% contributing further to reported discrepancy rates in PICU literature to date. • This study contributes the Irish PICU post-mortem rate in a tertiary centre which was 25% over an almost 6-year period.

Quality of care and maternal mortality in a tertiary-level hospital in Mozambique: a retrospective study of clinicopathological discrepancies

BACKGROUND

Although an increasing number of pregnant women in resource-limited areas deliver in health-care facilities, maternal mortality remains high in these settings. Inadequate diagnosis and management of common life-threatening conditions is an important determinant of maternal mortality. We analysed the clinicopathological discrepancies in a series of maternal deaths from Mozambique and assessed changes over 10 years in the diagnostic process. We aimed to provide data on clinical diagnostic accuracy to be used for improving quality of care and reducing maternal mortality.

METHODS

We did a retrospective analysis of clinicopathological discrepancies in 91 maternal deaths occurring from Nov 1, 2013, to March 31, 2015 (17 month-long period), at a tertiary-level hospital in Mozambique, using complete diagnostic autopsies as the gold standard to ascertain cause of death. We estimated the performance of the clinical diagnosis and classified clinicopathological discrepancies as major and minor errors. We compared the findings of this analysis with those of a similar study done in the same setting 10 years earlier.

FINDINGS

We identified a clinicopathological discrepancy in 35 (38%) of 91 women. All diagnostic errors observed were classified as major discrepancies. The sensitivity of the clinical diagnosis for puerperal infections was 17% and the positive predictive value was 50%. The sensitivity for non-obstetric infections was 48%. The sensitivity for eclampsia was 100% but the positive predictive value was 33%. Over the 10-year period, the performance of clinical diagnosis did not improve, and worsened for some diagnoses, such as puerperal infection.

INTERPRETATION

Decreasing maternal mortality requires improvement of the pre-mortem diagnostic process and avoidance of clinical errors by refining clinical skills and increasing the availability and quality of diagnostic tests. Comparison of post-mortem information with clinical diagnosis will help monitor the reduction of clinical errors and thus improve the quality of care.

FUNDING

Bill & Melinda Gates Foundation and Instituto de Salud Carlos III.

Decision analysis and reinforcement learning in surgical decision-making

BACKGROUND

Surgical patients incur preventable harm from cognitive and judgment errors made under time constraints and uncertainty regarding patients' diagnoses and predicted response to treatment. Decision analysis and techniques of reinforcement learning theoretically can mitigate these challenges but are poorly understood and rarely used clinically. This review seeks to promote an understanding of decision analysis and reinforcement learning by describing their use in the context of surgical decision-making.

METHODS

Cochrane, EMBASE, and PubMed databases were searched from their inception to June 2019. Included were 41 articles about cognitive and diagnostic errors, decision-making, decision analysis, and machine-learning. The articles were assimilated into relevant categories according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.

RESULTS

Requirements for time-consuming manual data entry and crude representations of individual patients and clinical context compromise many traditional decision-support tools. Decision analysis methods for calculating probability thresholds can inform population-based recommendations that jointly consider risks, benefits, costs, and patient values but lack precision for individual patient-centered decisions. Reinforcement learning, a machine-learning method that mimics human learning, can use a large set of patient-specific input data to identify actions yielding the greatest probability of achieving a goal. This methodology follows a sequence of events with uncertain conditions, offering potential advantages for personalized, patient-centered decision-making. Clinical application would require secure integration of multiple data sources and attention to ethical considerations regarding liability for errors and individual patient preferences.

CONCLUSION

Traditional decision-support tools are ill-equipped to accommodate time constraints and uncertainty regarding diagnoses and the predicted response to treatment, both of which often impair surgical decision-making. Decision analysis and reinforcement learning have the potential to play complementary roles in delivering high-value surgical care through sound judgment and optimal decision-making.

Rate of diagnostic errors and serious misdiagnosis-related harms for major vascular events, infections, and cancers: toward a national incidence estimate using the “Big Three”

Background

Missed vascular events, infections, and cancers account for ~75% of serious harms from diagnostic errors. Just 15 diseases from these “Big Three” categories account for nearly half of all serious misdiagnosis-related harms in malpractice claims. As part of a larger project estimating total US burden of serious misdiagnosis-related harms, we performed a focused literature review to measure diagnostic error and harm rates for these 15 conditions.

Methods

We searched PubMed, Google, and cited references. For errors, we selected high-quality, modern, US-based studies, if available, and best available evidence otherwise. For harms, we used literature-based estimates of the generic (disease-agnostic) rate of serious harms (morbidity/mortality) per diagnostic error and applied claims-based severity weights to construct disease-specific rates. Results were validated via expert review and comparison to prior literature that used different methods. We used Monte Carlo analysis to construct probabilistic plausible ranges (PPRs) around estimates.

Results

Rates for the 15 diseases were drawn from 28 published studies representing 91,755 patients. Diagnostic error (false negative) rates ranged from 2.2% (myocardial infarction) to 62.1% (spinal abscess), with a median of 13.6% [interquartile range (IQR) 9.2–24.7] and an aggregate mean of 9.7% (PPR 8.2–12.3). Serious misdiagnosis-related harm rates per incident disease case ranged from 1.2% (myocardial infarction) to 35.6% (spinal abscess), with a median of 5.5% (IQR 4.6–13.6) and an aggregate mean of 5.2% (PPR 4.5–6.7). Rates were considered face valid by domain experts and consistent with prior literature reports.

Conclusions

Diagnostic improvement initiatives should focus on dangerous conditions with higher diagnostic error and misdiagnosis-related harm rates.

[Analysis of the major clinical-pathological discrepancies in autopsies of adults in a tertiary referral hospital between 2008-2017]

OBJECTIVE

To compare and contrast clinical diagnoses with autopsy findings in order to identify unexpected, relevant discrepancies.

MATERIAL AND METHOD

A retrospective observational study of the revision of autopsies of adults and their respective medical records in order to classify them according to referral department and Goldman's classification was carried out at the Central University Hospital of Asturias between 2008-2017.

RESULTS

694 (52.6%) of 1320 autopsies were included in the study. Discrepancies were observed in 57.6% of cases, although the majority (39.3%) were minor. Type I discrepancies were identified in 63 autopsies (9.1%); malignant neoplasms being the main pathology observed (57.1%), mainly of gastrointestinal origin (about 28%). The second most common discrepancy was found in cases of infectious diseases (23.8%) followed by pulmonary embolism (15.9%). 64 autopsies were classified as type II discrepancies (9.2%), with myocardial infarct the most common (37.5%), especially acute myocardial infarction (18 cases), followed by bronchoaspirations (18.7%), DIC (15.6%), massive haemorrhages (9.4%) and other conditions. It was considered that both the ICU and the Internal Medicine Service were responsible for the largest number of major discrepancies (type I and II), accounting for about 45% of type I and slightly more than 56% for type II.

CONCLUSION

Autopsies are an essential means of identifying ante-mortem clinical errors. The incidence of major discrepancies in the Central University Hospital of Asturias (18.3%) is comparable to that of leading hospitals worldwide.

A Practical Guide to Assess the Reproducibility of Echocardiographic Measurements

Echocardiography plays an essential role in the diagnosis and assessment of cardiovascular disease. Measurements derived from echocardiography are also used to determine the severity of disease, its progression over time, and to aid in the choice of optimal therapy. It is therefore clinically important that echocardiographic measurements be reproducible, repeatable, and reliable. There are a variety of statistical tests available to assess these parameters, and in this article the authors summarize those available for use by echocardiographers to improve their clinical practice. Correlation coefficients, linear regression, Bland-Altman plots, and the coefficient of variation are explored, along with their limitations. The authors also provide an online tool for the easy calculation of these statistics in the clinical environment (www.birmingham.ac.uk/echo). Quantifying and enhancing the reproducibility of echocardiography has important potential to improve the value of echocardiography as the basis for good clinical decision-making.

Does the medical autopsy still have a place in the current diagnostic process? A 6-year retrospective study in two French University hospitals

Medical autopsies have been in considerable decline for several decades, in France and worldwide. We aimed to determine whether a medical autopsy still currently has a role to play in diagnosis, by analyzing its performance and diagnostic limitations. This dual-centre retrospective descriptive study included all medical autopsies performed in the university hospitals of Lille and Marseille, France, between January 2007 and December 2012. Autopsies of fetuses or stillborn infants, or those related to sudden infant deaths and research protocols were excluded. 412 medical autopsies were included. The male:female ratio was 1.5:1 and mean age was 27.3 years. Half of all autopsies were pediatric. Regarding anatomical region and/or injury mechanism, a clinical diagnosis was suggested in 52.2% of cases, an autopsy diagnosis in 55.6% and a microscopic diagnosis in 81.8%. There was very low agreement between the clinician's suggested diagnosis and the final diagnosis, both for organ specific diseases and cause of death. Agreement was moderate between autopsy diagnoses and microscopic diagnoses for organ specific diseases and low for cause of death. From our findings we concluded that an autopsy associated with microscopic examination was still valuable in diagnosing cause of death. Microscopic examination was indispensable to determine certain causes of death.

Clinico-pathological discrepancies in the diagnosis of causes of death in adults in Mozambique: A retrospective observational study

Background

Clinico-pathological discrepancies are more frequent in settings in which limited diagnostic techniques are available, but there is little information on their actual impact.

Aim

We assessed the accuracy of the clinical diagnoses in a tertiary referral hospital in sub-Saharan Africa by comparison with post-mortem findings. We also identified potential risk factors for misdiagnoses.

Methods

One hundred and twelve complete autopsy procedures were performed at the Maputo Central Hospital (Mozambique), from November 2013 to March 2015. We reviewed the clinical records. Major clinico-pathological discrepancies were assessed using a modified version of the Goldman and Battle classification.

Results

Major diagnostic discrepancies were detected in 65/112 cases (58%) and were particularly frequent in infection-related deaths (56/80 [70%] major discrepancies). The sensitivity of the clinical diagnosis for toxoplasmosis was 0% (95% CI: 0–37), 18% (95% CI: 2–52) for invasive fungal infections, 25% (95% CI: 5–57) for bacterial sepsis, 34% (95% CI: 16–57), for tuberculosis, and 46% (95% CI: 19–75) for bacterial pneumonia. Major discrepancies were more frequent in HIV-positive than in HIV-negative patients (48/73 [66%] vs. 17/39 [44%]; p = 0.0236).

Conclusions

Major clinico-pathological discrepancies are still frequent in resource constrained settings. Increasing the level of suspicion for infectious diseases and expanding the availability of diagnostic tests could significantly improve the recognition of common life-threatening infections, and thereby reduce the mortality associated with these diseases. The high frequency of clinico-pathological discrepancies questions the validity of mortality reports based on clinical data or verbal autopsy.

Reaffirming the Value of the Autopsy

OBJECTIVES

To determine characteristic features of myocardial infarction (MI) diagnosed at autopsy and establish the incidence of discrepancy.

METHODS

Autopsy cases at a tertiary hospital with a pathologic diagnosis of acute MI were evaluated for clinicopathologic features. Modified Goldman's classification was used to classify discrepant cases.

RESULTS

Of 529 autopsy cases, 19 (3.6%) demonstrated acute/subacute MI as a pathologic diagnosis. Thrombosis was identified in a minority of cases (3/19, 15.8%). Major clinicopathologic discrepancies were identified in four (21.1%) cases.

CONCLUSIONS

Although acute MI is an uncommon diagnosis rendered at hospital autopsy, a notable subset of cases demonstrates diagnostic discrepancy between the clinical impression and ultimate pathologic diagnosis. Interestingly, most MI cases in this series are not related to plaque disruption and thus best classified as a type 2 MI, which is associated with imbalance between oxygen demand and supply.

Pearls and Myths in the Evaluation of Patients with Suspected Acute Pulmonary Embolism

Significant improvement has been achieved in diagnostic accuracy, validation of probability scores, and standardized treatment algorithms for patients with suspected acute pulmonary embolism. These developments have provided the tools for a safe and cost-effective management for most of these patients. In our experience, however, the presence of medical myths and ongoing controversies seem to hinder the implementation of these tools in everyday clinical practice. This review provides a selection of such dilemmas and controversies and discusses the published evidence beyond them. By doing so, we try to overcome these dilemmas and suggest pragmatic approaches guided by the available evidence and current guidelines.

Comparative Accuracy of Diagnosis by Collective Intelligence of Multiple Physicians vs Individual Physicians

IMPORTANCE

The traditional approach of diagnosis by individual physicians has a high rate of misdiagnosis. Pooling multiple physicians' diagnoses (collective intelligence) is a promising approach to reducing misdiagnoses, but its accuracy in clinical cases is unknown to date.

OBJECTIVE

To assess how the diagnostic accuracy of groups of physicians and trainees compares with the diagnostic accuracy of individual physicians.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study using data from the Human Diagnosis Project (Human Dx), a multicountry data set of ranked differential diagnoses by individual physicians, graduate trainees, and medical students (users) solving user-submitted, structured clinical cases. From May 7, 2014, to October 5, 2016, groups of 2 to 9 randomly selected physicians solved individual cases. Data analysis was performed from March 16, 2017, to July 30, 2018.

MAIN OUTCOMES AND MEASURES

The primary outcome was diagnostic accuracy, assessed as a correct diagnosis in the top 3 ranked diagnoses for an individual; for groups, the top 3 diagnoses were a collective differential generated using a weighted combination of user diagnoses with a variety of approaches. A version of the McNemar test was used to account for clustering across repeated solvers to compare diagnostic accuracy.

RESULTS

Of the 2069 users solving 1572 cases from the Human Dx data set, 1228 (59.4%) were residents or fellows, 431 (20.8%) were attending physicians, and 410 (19.8%) were medical students. Collective intelligence was associated with increasing diagnostic accuracy, from 62.5% (95% CI, 60.1%-64.9%) for individual physicians up to 85.6% (95% CI, 83.9%-87.4%) for groups of 9 (23.0% difference; 95% CI, 14.9%-31.2%; P < .001). The range of improvement varied by the specifications used for combining groups' diagnoses, but groups consistently outperformed individuals regardless of approach. Absolute improvement in accuracy from individuals to groups of 9 varied by presenting symptom from an increase of 17.3% (95% CI, 6.4%-28.2%; P = .002) for abdominal pain to 29.8% (95% CI, 3.7%-55.8%; P = .02) for fever. Groups from 2 users (77.7% accuracy; 95% CI, 70.1%-84.6%) to 9 users (85.5% accuracy; 95% CI, 75.1%-95.9%) outperformed individual specialists in their subspecialty (66.3% accuracy; 95% CI, 59.1%-73.5%; P < .001 vs groups of 2 and 9).

CONCLUSIONS AND RELEVANCE

A collective intelligence approach was associated with higher diagnostic accuracy compared with individuals, including individual specialists whose expertise matched the case diagnosis, across a range of medical cases. Given the few proven strategies to address misdiagnosis, this technique merits further study in clinical settings.

Cause of death coding in Switzerland: evaluation based on a nationwide individual linkage of mortality and hospital in-patient records

BACKGROUND

Cause of death statistics are an important tool for quality control of the health care system. Their reliability, however, is controversial. Comparing death certificates with their corresponding medical records is implemented only occasionally but may point to quality problems. We aimed at exploring the agreement between information in the cause of death statistics and hospital discharge diagnoses at death.

METHODS

Selection of disease categories was based on ICD-10 Tabulation List for Morbidity and ICD-10 Mortality Tabulation List 2. Index cases were defined as deaths having occurred among Swiss residents 2010-2012 in a hospital and successfully linked to the Swiss National Cohort. Rare, external and ill-defined causes were excluded from comparison, leaving 53,605 deaths from vital statistics and 47,311 deaths from hospital discharge statistics. For 95% of individuals, respective information from the 2000 census could be retrieved and used for multiple logistic regression.

RESULTS

For 83% of individuals the underlying cause of death could be traced among hospital diagnoses and for 77% the principal hospital diagnosis among the cause of death information. Mirroring different evaluation of complex situations by individual physicians, rates of agreement varied widely depending on disease/cause of death, but were generally in line with similar studies. Multiple logistic regression revealed however significant variation in reporting that could not entirely be explained by age or cause of death of the deceased suggesting differential exploitation of available diagnosis information.

CONCLUSION

Substantial regional variation and lower agreement rates among socially disadvantaged groups like single, less educated, or culturally less integrated persons suggest potential for improving reporting of diagnoses and causes of death by physicians in Switzerland. Studies of this kind should be regularly conducted as a quality monitoring.

Diagnostic errors in fatal medical malpractice cases in Shanghai, China: 1990-2015

Background

Medical disputes remain unabated in China. Previous studies have shown the changes of diagnostic discrepancy over time in developed countries, but diagnostic discrepancy remains understudied in China, especially in the setting of medical disputes. We sought to describe the year-based changes of diagnostic discrepancies in medical disputes, and to identify factors associated with classes of diagnostic discrepancy.

Methods

We conducted a retrospective cohort study of all medically disputed cases from 1990 through 2015 in Shanghai, China, with use of necropsy as the gold standard for diagnosis. Cases were grouped based on national legislative eras. Diagnostic discrepancy was classified as major errors (class I and II), minor errors (class III and IV), no discrepancy (class V) and undetermined (class VI) based on discrepancy severity.

Results

There were 482 medical disputes. Cases were predominantly males (male: female = 1.6:1) and concentrated in patients less than 10 years old or between 50 and 70 years. Major and minor discrepancy accounted for 51.7 and 34.8%, respectively. Fifty-five cases (11.2%) were non-discrepant (Class V). The dispute rate remained high before the first round of legislation (mean 0.31 per 1 million patients) but declined dramatically afterwards (R² = − 0.82, p < 0.001 for time trends). Over the national legislative eras, the annual number of cases with diagnostic errors declined steadily. Incidence rates of discrepancy decreased significantly for class I (R² = − 0.73, p = 0.024), II (R² = − 0.48, p = 0.013), III (R² = − 0.69, p < 0.0001), IV (R² = − 0.69, p < 0.0001) and V discrepancy (R² = − 0.58, p = 0.0018). Diseases from the respiratory system had significantly lower risks of any diagnostic errors (OR = 0.48, 95% 0.24–0.95, p = 0.036). A neoplasm carrier increased by 92% the risk of any diagnostic error (OR = 1.92; 95%CI 1.18–3.14; p = 0.009) and hypertension reduced by 78% the risk of minor errors (OR = 0.22, 95%CI 0.06–0.91, p = 0.036). Severity of discrepancy relieved over years and associated with ageing in patients with cardiovascular diseases (p = 0.01).

Conclusions

The rate of fatal medical disputes and diagnostic discrepancy declined after stepwise legislations in China. Respiratory diseases, neoplasm carrier and hypertension could be independent predictors for assessing diagnostic errors.

Autopsy Standardized Mortality Review: A Pilot Study Offering a Methodology for Improved Patient Outcomes

A standardized mortality review of hospital autopsies identified discrepancies between clinical diagnoses and autopsy findings, unexpected deaths, adequacy of diagnostic workup, presence of adverse event, and type of a quality issue if present. The standardized review elements were chosen based on a review of quality metrics commonly used by hospitals. The review was completed by the pathologist based on their initial autopsy findings. The final autopsy report was later reviewed to confirm the initial review findings. Major discrepancies in diagnosis were categorized as class I or II based on the modified Goldman criteria. Ninety-six hospital autopsy cases from January 2015 to February 2018 were included in the study. The overall major discrepancy rate was 27%. Class I discrepancies, where a diagnosis found at autopsy might have improved survival had it been made premortem, were identified in 16% of cases. Categories associated with increased discrepancy rates included unexpected deaths, inadequate workup, abnormal labs or imaging not addressed, and certain quality issues. Deaths not expected at admission but expected at the time of death, those with adverse events, those within 48 hours of a procedure, those within 48 hours of admission, those with physician-specific quality issues, and those with system or process issues were not significantly related to diagnostic accuracy.

The value of autopsy to determine the cause of maternal deaths in Turkey

Objective:

To analyze the value of autopsy reports for determining the cause of maternal deaths in Turkey.

Material and Methods:

In this descriptive retrospective study, the case files of 992 maternal deaths, except for accidental causes, that occurred in Turkey between 2012 and 2016 were reviewed. An autopsy examination was performed in 177 (17.8%) of the cohort. When the files were reviewed, maternal descriptive data and the cause of maternal mortality according to the autopsy reports were recorded.

Results:

The mean age at death was 31.5±6.6 years. No exact cause of maternal death was identified after autopsy in 44 (24.9%) of the 177 cases. An exact cause of death could be determined in 133 (75.1%); 34.5% (n=61) were due to direct causes, and 40.7% (n=72) were due to indirect causes. The leading direct causes of maternal deaths were obstetric hemorrhage (13.0%) and obstetric (pulmonary and amniotic fluid) embolism (12.4%). The main cause among the indirect causes was ruptured aortic aneurysm and/or dissection of aorta (8.5%). Among the subjects with no clinical diagnosis based on the clinical course before death (n=96), the exact cause of death could not be determined at autopsy in 19 (19.8%) cases. The exact or possible cause of death was identified at autopsy in 80.3% (n=77) cases with no clinical diagnosis. Among the cases who had antemortem diagnoses based on the clinical course (n=81), the final diagnosis at autopsy was compatible with the clinical diagnosis in 48 (59.3%) subjects.

Conclusion:

Maternal autopsy examination provides an exact cause of death in most cases and is still a valuable tool for understanding the cause of maternal mortality.

Implementation of modern tools in autopsy practice-the way towards contemporary postmortal diagnostics

Medical, legal, and socioeconomic issues have contributed to the decline of autopsy rates. Pathology-related factors, however, with changing clinical duties on the one hand and decreasing interest and lack of substantial technical developments in this field on the other, may have contributed to this condition as well. We present our experience of a restructuring project that culminated in the introduction of a modernized postmortal diagnostic (PMD) unit: Workflows of PMD procedures and space organization were restructured according to LEAN management principles method. Classical autopsy suites were transformed into postmortal operating rooms. A PMD pathologist staff was designated to perform postmortal operative diagnostics (i.e., using laparotomy and thoracotomy approaches) with the intention of gradually replacing classical autopsy procedures. Postmortal minimal invasive diagnostics (PMID) using laparoscopy and thoracoscopy were successfully implemented with the expertise of clinical colleagues. Reorganization of workflow reduced turn-around times for PMD reports from a median of 33 days to 15 days. Short-term analysis revealed that this combined effort leads to a slight increase in the number of adult postmortal examinations 1 year after the introduction of this project. A change of culture in postmortal diagnostics may contribute to a better reputation of postmortal examinations from the perspective of clinicians, the general public, and affected relatives of the deceased. It may also serve to demonstrate that the pathology community is keen not only to preserve but also to further develop this valuable tool for medical quality control and education.

Focused Ethnography of Diagnosis in Academic Medical Centers

BACKGROUND

Approaches of trainees to diagnosis in teaching hospitals are poorly understood. Identifying cognitive and system-based barriers and facilitators to diagnosis may improve diagnosis in these settings.

METHODS

We conducted a focused ethnography of trainees at 2 academic medical centers to understand the barriers and facilitators to diagnosis. Field notes regarding the diagnostic process (eg, information gathering, integration and interpretation, working diagnosis) and the work system (eg, team members, organization, technology and tools, physical environment, tasks) were recorded. Following observations, focus groups and interviews were conducted to understand the viewpoints, problems, and solutions to improve diagnosis.

RESULTS

Between January 2016 and May 2016, 4 teaching teams (4 attendings, 4 senior residents, 9 interns, and 12 medical students) were observed for 168 h. Observations of diagnosis during care led to identification of the following 4 key themes: (a) diagnosis is a social phenomenon; (b) data necessary to make diagnoses are fragmented; (c) distractions interfere with the diagnostic process; and (d) time pressures impede diagnostic decision-making. These themes suggest that specific interventions tailored to the academic setting such as team-based discussions of diagnostic workups, scheduling diagnostic time-outs during the day, and strategies to "protect" learners from interruptions might prove to be useful in improving the process of diagnosis. Future studies that implement these ideas (either alone or within a multimodal intervention) appear to be necessary.

CONCLUSIONS

Diagnosis in teaching hospitals is a unique process that requires improvement. Contextual insights gained from this ethnography may be used to inform future interventions.

Cognitive and visual diagnostic errors in dermatology: part 1

Sir William Osler famously, and ironically, stated that 'Medicine is a science of uncertainty and an art of probability'. The processes by which each physician metes out diagnostic uncertainty and navigates probabilities in dermatology is far from uniform. While certain ubiquitous cognitive and visual heuristics can enhance diagnostic speed, they also create pitfalls and thinking traps that introduce significant variation in the diagnostic process. Discussed in this part of a two-part article are various cognitive and visual heuristics as they pertain to skin disease, with an introduction and special attention paid to the heuristic methods classically applied by dermatologists. How to best address error and improve our thought processes will be addressed in part 2.

Cancer of unknown primary-Epidemiological trends and relevance of comprehensive genomic profiling

Background

Cancer of unknown primary (CUP) is a distinct clinicopathological entity with poor prognosis, frequently resistant to chemotherapy. Comprehensive genomic profiling (CGP) by next‐generation sequencing potentially identifies novel treatment options for CUP patients. The objective of this study was to determine incidence and survival trends and to discuss the value of CGP in CUP patients.

Methods

Age‐standardized incidence rates (ASR) per 100 000 were calculated for 2935 CUP patients from 1981 to 2014 using cancer registry data of the canton of Zurich, Switzerland. Kaplan–Meier survival curves were estimated for sex, age, and histological groups. Cox proportional hazards regression models were used to estimate adjusted hazard ratios (HR). A literature review was conducted to assess the current use of CGP in CUP patients.

Results

ASR of CUP increased from 10.3 to 17.6 between 1981 and 1997 and decreased to 5.8/100 000 in 2014. Mean overall survival remained stable. Mortality was significantly lower for patients with squamous cell carcinoma (HR 0.48 [95% CI, 0.41‐0.57]) and neuroendocrine carcinoma (0.75 [0.63‐0.88]) and higher for unclassified neoplasms (1.25 [1.13‐1.66]) compared to adenocarcinomas. The literature review identified 10 studies using CGP of CUP tissue. Clinically relevant mutations were identified in up to 85% of CUP patients, of which 13%‐64% may benefit from currently available drugs.

Conclusions

CUP incidence decreased probably due to improved diagnostics, but mortality did not improve over the last 34 years. CGP testing may help to identify molecular signatures in CUP patients and enable targeted treatment.

The impact of speed and bias on the cognitive processes of experts and novices in medical image decision-making

Training individuals to make accurate decisions from medical images is a critical component of education in diagnostic pathology. We describe a joint experimental and computational modeling approach to examine the similarities and differences in the cognitive processes of novice participants and experienced participants (pathology residents and pathology faculty) in cancer cell image identification. For this study we collected a bank of hundreds of digital images that were identified by cell type and classified by difficulty by a panel of expert hematopathologists. The key manipulations in our study included examining the speed-accuracy tradeoff as well as the impact of prior expectations on decisions. In addition, our study examined individual differences in decision-making by comparing task performance to domain general visual ability (as measured using the Novel Object Memory Test (NOMT) (Richler et al. Cognition 166:42–55, 2017). Using signal detection theory and the diffusion decision model (DDM), we found many similarities between experts and novices in our task. While experts tended to have better discriminability, the two groups responded similarly to time pressure (i.e., reduced caution under speed instructions in the DDM) and to the introduction of a probabilistic cue (i.e., increased response bias in the DDM). These results have important implications for training in this area as well as using novice participants in research on medical image perception and decision-making.

A method to identify pediatric high-risk diagnoses missed in the emergency department

BACKGROUND

Diagnostic error can lead to increased morbidity, mortality, healthcare utilization and cost. The 2015 National Academy of Medicine report "Improving Diagnosis in Healthcare" called for improving diagnostic accuracy by developing innovative electronic approaches to reduce medical errors, including missed or delayed diagnosis. The objective of this article was to develop a process to detect potential diagnostic discrepancy between pediatric emergency and inpatient discharge diagnosis using a computer-based tool facilitating expert review.

METHODS

Using a literature search and expert opinion, we identified 10 pediatric diagnoses with potential for serious consequences if missed or delayed. We then developed and applied a computerized tool to identify linked emergency department (ED) encounters and hospitalizations with these discharge diagnoses. The tool identified discordance between ED and hospital discharge diagnoses. Cases identified as discordant were manually reviewed by pediatric emergency medicine experts to confirm discordance.

RESULTS

Our computerized tool identified 55,233 ED encounters for hospitalized children over a 5-year period, of which 2161 (3.9%) had one of the 10 selected high-risk diagnoses. After expert record review, we identified 67 (3.1%) cases with discordance between ED and hospital discharge diagnoses. The most common discordant diagnoses were Kawasaki disease and pancreatitis.

CONCLUSIONS

We successfully developed and applied a semi-automated process to screen a large volume of hospital encounters to identify discordant diagnoses for selected pediatric medical conditions. This process may be valuable for informing and improving ED diagnostic accuracy.

Autopsy-detected diagnostic errors over time in the intensive care unit

We evaluate the evolution over time of discrepancies between clinical diagnoses and postmortem findings in critically ill patients and assess the factors associated with these discrepancies. We conducted a prospective study of all consecutive patients who underwent autopsy in a medical-surgical intensive care unit (ICU) between January 2008 and December 2015. Among 7655 patients admitted to our ICU, 671 (8.8%) died. Clinical autopsy was performed in 215 (32%) patients. Major missed diagnoses were noted in 38 patients (17.7%). Eighteen patients (8.4%) had class I discrepancies, and 20 patients (9.3%) had class II discrepancies. The most frequently missed diagnoses were invasive aspergillosis, intestinal ischemia, myocardial infarction, cancer, and intra-abdominal abscesses. We did not find a statistically significant correlation between any premortem factor, including age, sex, severity of illness, length of hospital stay before ICU admission, length of ICU stay before death, duration of mechanical ventilation, or admitting unit, and the level of agreement between clinical and pathological diagnosis. In the last decades, the discrepancies between clinical and autopsy diagnoses persisted despite advances in medical skills and technology. Specific clinical entities such as invasive aspergillosis, mesenteric ischemia, myocardial infarction, intra-abdominal abscesses, and neoplastic diseases remain a diagnostic challenge in critically ill patients. Clinical level of diagnostic certainty does not increase with specific premortem characteristics.

Preventable diagnostic errors in fatal cervical spine injuries: a nationwide register-based study from 1987 to 2010

BACKGROUND

Fall-induced injuries in patients are increasing in number, and they often lead to serious consequences, such as cervical spine injuries (CSI). CSI diagnostics remain a challenge despite improved radiological services.

PURPOSE

Our aim is to define the incidence and risk factors for diagnostic errors among patients who died following a CSI.

STUDY DESIGN/SETTING

A retrospective death certificate-based study of the whole population of Finland was carried out.

PATIENT SAMPLE

We identified 2,041 patients whose death was, according to the death certificate, either directly or indirectly caused by a CSI.

OUTCOME MEASURES

Demographics, injury- and death-related data, and adverse event (AE)-related data were the outcome measures.

METHODS

All death certificates between the years 1987 and 2010 from Statistics Finland that identified a CSI as a cause death were reviewed to identify preventable AEs with the emphasis on diagnostic errors.

RESULTS

Of the 2,041 patients with CSI-related deaths, 36.5% (n=744) survived at least until the next day. Errors in CSI diagnostics were found in 13.8% (n=103) of those who died later than the day of injury. Those with diagnostic errors were significantly older (median age 79.4 years, 95% confidence interval 75.9-80.1 vs. 74.9, 95% confidence interval 70.2-72.9, p<.001) and the mechanism of injury was significantly more often a fall (86.4%, n=89 vs. 69.7%, n=447, p=.002) compared with those who did not have a diagnostic error. The incidence of diagnostic errors increased slightly during the 24-year study period.

CONCLUSIONS

Cervical spine injury diagnostics remain difficult despite improved radiological services. The majority of the patients subjected to diagnostic errors are fragile elderly people with reduced physical capacity. In our analysis, preventable AEs and diagnostic errors were most commonly associated with ground-level falls.

Autopsy interrogation of emergency medicine dispute cases: how often are clinical diagnoses incorrect?

AIMS

Emergency medicine is a 'high risk' specialty. Some diseases develop suddenly and progress rapidly, and sudden unexpected deaths in the emergency department (ED) may cause medical disputes. We aimed to assess discrepancies between antemortem clinical diagnoses and postmortem autopsy findings concerning emergency medicine dispute cases and to figure out the most common major missed diagnoses.

METHODS

Clinical files and autopsy reports were retrospectively analysed and interpreted. Discrepancies between clinical diagnoses and autopsy diagnoses were evaluated using modified Goldman classification as major and minor discrepancy. The difference between diagnosis groups was compared with Pearson χ² test.

RESULTS

Of the 117 cases included in this study, 71 of cases (58 class I and 13 class II diagnostic errors) were revealed as major discrepancies (60.7%). The most common major diagnoses were cardiovascular diseases (54 cases), followed by pulmonary diseases, infectious diseases and so on. The difference of major discrepancy between the diagnoses groups was significant (p<0.001). Aortic dissection and myocardial infarction were the most common cause of death (15 cases for each disease) and the most common missed class I diagnoses (80% and 66.7% for each), higher than the average 49.6% of all class I errors of the study patients.

CONCLUSIONS

High major disparities between clinical diagnoses and postmortem examinations exist in emergency medical disputes cases; acute aortic dissection and myocardial infarction are the most frequently major missed diagnoses that ED clinicians should pay special attention to in practice. This study reaffirmed the necessity and usefulness of autopsy in auditing death in EDs.

The feasibility and efficacy of implementing a focused cardiac ultrasound course into a medical school curriculum

BACKGROUND

Teaching cardiac ultrasound to medical students in a brief course is a challenge. We aimed to evaluate the feasibility of teaching large groups of medical students the acquisition and interpretation of cardiac ultrasound images using a pocket ultrasound device (PUD) in a short, specially designed course.

METHODS

Thirty-one medical students in their first clinical year participated in the study. All were novices in the use of cardiac ultrasound. The training consisted of 4 hours of frontal lectures and 4 hours of hands-on training. Students were encouraged to use PUD for individual practice. Finally, the students' proficiency in the acquisition of ultrasound images and their ability to recognize normal and pathological states were evaluated.

RESULTS

Sixteen of 27 (59%) students were able to demonstrate all main ultrasound views (parasternal, apical, and subcostal views) in a six-minute test. The most obtainable view was the parasternal long-axis view (89%) and the least obtainable was the subcostal view (58%). Ninety-seven percent of students correctly differentiated normal from severely reduced left ventricular function, 100% correctly differentiated a normal right ventricle from a severely hypokinetic one, 100% correctly differentiated a normal mitral valve from a rheumatic one, and 88% correctly differentiated a normal aortic valve from a calcified one, while 95% of them correctly identified the presence of pericardial effusion.

CONCLUSIONS

Training of medical students in cardiac ultrasound during the first clinical year using a short, focused course is feasible and enables students with modest ability to acquire the main transthoracic ultrasound views and gain proficiency in the diagnosis of a limited number of cardiac pathologies.

Comparison of Clinical and Pathological Diagnoses in Cats and Dogs

The comparison of clinical ante-mortem and pathological post-mortem diagnoses is a prerequisite for quality control, but is rarely done in veterinary medicine. This study reports the occurrence and concurrence of clinical and pathological diagnoses linked to death in 1,000 cats and 1,000 dogs examined and subjected to necropsy examination at the University of Zurich, Switzerland. Potential factors influencing the correlation between diagnoses were examined retrospectively. In 5.8% of cats and 5.2% of dogs no diagnosis was made; in 2.6% and 3.8% of cases only a clinical, and in 17.8% and 11.2%, respectively, only a pathological diagnosis was available. Of the 73.8% of cats and 79.8% of dogs with both diagnoses present, 38.3% and 36.2% were in agreement, while there was disagreement in 17.9% and 16.0%, respectively. The remaining cases (43.8% and 47.8%) had different levels of further diagnostic procedures following necropsy examination. In both species, the manner of death, the clinical discipline submitting the animal for necropsy examination and the quality of the necropsy submission request, as well as the timespan between death and necropsy examination in dogs, proved to influence the concurrence between diagnoses. In contrast, the organ system affected and the type of disease entity were, for both species, the most influential factors in the concurrence of diagnoses. Therefore, in veterinary medicine, even in times of improving diagnostic abilities, necropsy examination still reveals important information for quality control and education.

Diagnostic discrepancies in clinical practice: An autopsy study in patients with heart failure

Autopsies are the gold standard for diagnostic accuracy; however, no recent study has analyzed autopsies in heart failure (HF).We reviewed 1241 autopsies (January 2000-May 2005) and selected 232 patients with HF. Clinical and autopsy diagnoses were analyzed and discrepancies categorized according to their importance regarding therapy and prognosis.Mean age was 63.3 ± 15.9 years; 154 (66.4%) patients were male. The causes of death at autopsy were end-stage HF (40.9%), acute myocardial infarction (17.2%), infection (15.9), and pulmonary embolism 36 (15.5). Diagnostic discrepancies occurred in 191 (82.3%) cases; in 56 (24.1%), discrepancies were related to major diagnoses with potential influence on survival or treatment; pulmonary embolism was the cause of death for 24 (42.9%) of these patients. In 35 (15.1%), discrepancies were related to a major diagnosis with equivocal influence on survival or treatment; in 100 (43.1%), discrepancies did not influence survival or treatment. In multivariate analysis, age (OR: 1.03, 95% CI: 1.008-1.052, P = 0.007) and presence of diabetes mellitus (OR: 0.359, 95% CI: 0.168-0.767, P = 0.008) influenced the occurrence discrepancies.Diagnostic discrepancies with a potential impact on prognosis are frequent in HF. These findings warrant reconsideration in diagnostic and therapeutic practices with HF patients.

Acute kidney injury as a risk factor for diagnostic discrepancy among geriatric patients: a pilot study

Diagnostic discrepancy, defined as different admission and discharge diagnoses, could be a potential source of diagnostic error. We evaluated whether acute kidney injury (AKI) in the elderly affected their risk for diagnostic discrepancy. Patients aged ≥60 years from the general medical wards were prospectively enrolled and divided according to AKI status upon admission, using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. We compared their discharge and admission diagnoses and identified patients with a diagnostic discrepancy, using multiple logistic regression analysis to evaluate the relationship between initial AKI and the presence of a diagnostic discrepancy. A total of 188 participants (mean age, 77.9 years) were recruited. Regression analysis showed that initial AKI on admission was associated with a higher risk of diagnostic discrepancy upon discharge (odds ratio [OR] 3.3; p < 0.01). In contrast, higher AKI severity was also associated with an increased risk of diagnostic discrepancy (for KDIGO grade 1, 2, and 3; OR 2.92, 3.91, and 4.32; p = 0.04, 0.03, and 0.02, respectively), suggesting that initial AKI upon admission could be an important risk factor for diagnostic discrepancy. Consequently, reducing geriatric AKI might have the potential to reduce diagnostic discrepancy among these patients.

Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015

BACKGROUND

Improving survival and extending the longevity of life for all populations requires timely, robust evidence on local mortality levels and trends. The Global Burden of Disease 2015 Study (GBD 2015) provides a comprehensive assessment of all-cause and cause-specific mortality for 249 causes in 195 countries and territories from 1980 to 2015. These results informed an in-depth investigation of observed and expected mortality patterns based on sociodemographic measures.

METHODS

We estimated all-cause mortality by age, sex, geography, and year using an improved analytical approach originally developed for GBD 2013 and GBD 2010. Improvements included refinements to the estimation of child and adult mortality and corresponding uncertainty, parameter selection for under-5 mortality synthesis by spatiotemporal Gaussian process regression, and sibling history data processing. We also expanded the database of vital registration, survey, and census data to 14 294 geography-year datapoints. For GBD 2015, eight causes, including Ebola virus disease, were added to the previous GBD cause list for mortality. We used six modelling approaches to assess cause-specific mortality, with the Cause of Death Ensemble Model (CODEm) generating estimates for most causes. We used a series of novel analyses to systematically quantify the drivers of trends in mortality across geographies. First, we assessed observed and expected levels and trends of cause-specific mortality as they relate to the Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. Second, we examined factors affecting total mortality patterns through a series of counterfactual scenarios, testing the magnitude by which population growth, population age structures, and epidemiological changes contributed to shifts in mortality. Finally, we attributed changes in life expectancy to changes in cause of death. We documented each step of the GBD 2015 estimation processes, as well as data sources, in accordance with Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).

FINDINGS

Globally, life expectancy from birth increased from 61·7 years (95% uncertainty interval 61·4-61·9) in 1980 to 71·8 years (71·5-72·2) in 2015. Several countries in sub-Saharan Africa had very large gains in life expectancy from 2005 to 2015, rebounding from an era of exceedingly high loss of life due to HIV/AIDS. At the same time, many geographies saw life expectancy stagnate or decline, particularly for men and in countries with rising mortality from war or interpersonal violence. From 2005 to 2015, male life expectancy in Syria dropped by 11·3 years (3·7-17·4), to 62·6 years (56·5-70·2). Total deaths increased by 4·1% (2·6-5·6) from 2005 to 2015, rising to 55·8 million (54·9 million to 56·6 million) in 2015, but age-standardised death rates fell by 17·0% (15·8-18·1) during this time, underscoring changes in population growth and shifts in global age structures. The result was similar for non-communicable diseases (NCDs), with total deaths from these causes increasing by 14·1% (12·6-16·0) to 39·8 million (39·2 million to 40·5 million) in 2015, whereas age-standardised rates decreased by 13·1% (11·9-14·3). Globally, this mortality pattern emerged for several NCDs, including several types of cancer, ischaemic heart disease, cirrhosis, and Alzheimer's disease and other dementias. By contrast, both total deaths and age-standardised death rates due to communicable, maternal, neonatal, and nutritional conditions significantly declined from 2005 to 2015, gains largely attributable to decreases in mortality rates due to HIV/AIDS (42·1%, 39·1-44·6), malaria (43·1%, 34·7-51·8), neonatal preterm birth complications (29·8%, 24·8-34·9), and maternal disorders (29·1%, 19·3-37·1). Progress was slower for several causes, such as lower respiratory infections and nutritional deficiencies, whereas deaths increased for others, including dengue and drug use disorders. Age-standardised death rates due to injuries significantly declined from 2005 to 2015, yet interpersonal violence and war claimed increasingly more lives in some regions, particularly in the Middle East. In 2015, rotaviral enteritis (rotavirus) was the leading cause of under-5 deaths due to diarrhoea (146 000 deaths, 118 000-183 000) and pneumococcal pneumonia was the leading cause of under-5 deaths due to lower respiratory infections (393 000 deaths, 228 000-532 000), although pathogen-specific mortality varied by region. Globally, the effects of population growth, ageing, and changes in age-standardised death rates substantially differed by cause. Our analyses on the expected associations between cause-specific mortality and SDI show the regular shifts in cause of death composition and population age structure with rising SDI. Country patterns of premature mortality (measured as years of life lost [YLLs]) and how they differ from the level expected on the basis of SDI alone revealed distinct but highly heterogeneous patterns by region and country or territory. Ischaemic heart disease, stroke, and diabetes were among the leading causes of YLLs in most regions, but in many cases, intraregional results sharply diverged for ratios of observed and expected YLLs based on SDI. Communicable, maternal, neonatal, and nutritional diseases caused the most YLLs throughout sub-Saharan Africa, with observed YLLs far exceeding expected YLLs for countries in which malaria or HIV/AIDS remained the leading causes of early death.

INTERPRETATION

At the global scale, age-specific mortality has steadily improved over the past 35 years; this pattern of general progress continued in the past decade. Progress has been faster in most countries than expected on the basis of development measured by the SDI. Against this background of progress, some countries have seen falls in life expectancy, and age-standardised death rates for some causes are increasing. Despite progress in reducing age-standardised death rates, population growth and ageing mean that the number of deaths from most non-communicable causes are increasing in most countries, putting increased demands on health systems.

FUNDING

Bill & Melinda Gates Foundation.

Retrospective analysis of population-based causes of death and life expectancy in urban Western China from 2003 to 2012

BACKGROUND

Hitherto, a population-based analysis of the cause of death in urban areas of Western China has not been undertaken over an extended period. The aims of this study were to calculate the overall and annual cause-specific mortality rates by age and sex in urban areas of Western China from 2003 to 2012 and to evaluate the quality of the data.

METHODS

We used Excel software, cause-of-death registrations, and International Classification of Diseases, 10th revision, codes to calculate the overall and yearly cause-specific crude mortality rates by age and sex, the Chinese age-standardized mortality rate, and life expectancies.

RESULTS

In the Jiulongpo District from 2003 to 2012, there was an increase in the number of death case reports in the census-registered population, a decrease in the number of omitted deaths, and rise in the crude mortality rate. Except for 2003, the Chinese age-standardized mortality rate was the lowest in 2012 (330.83/100,000) and highest in 2005 (390.08/100,000). Life expectancy increased from 78.36 years in 2005 to 81.67 years in 2012.

CONCLUSIONS

With the development of its social economy, the Chinese government and public attach greater importance to cause-of-death surveillance. The quality of cause-of-death registrations has gradually increased, crude mortality rates have risen, the Chinese age-standardized mortality rate has fallen, and life expectancies have increased.

Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine

OBJECTIVES

Diagnostic errors are common in the emergency department (ED), but few studies have comprehensively evaluated their types and origins. We analysed incidents reported by ED physicians to determine disease conditions, contributory factors and patient harm associated with ED-related diagnostic errors.

METHODS

Between 1 March 2009 and 31 December 2013, ED physicians reported 509 incidents using a department-specific voluntary incident-reporting system that we implemented at two large academic hospital-affiliated EDs. For this study, we analysed 209 incidents related to diagnosis. A quality assurance team led by an ED physician champion reviewed each incident and interviewed physicians when necessary to confirm the presence/absence of diagnostic error and to determine the contributory factors. We generated descriptive statistics quantifying disease conditions involved, contributory factors and patient harm from errors.

RESULTS

Among the 209 incidents, we identified 214 diagnostic errors associated with 65 unique diseases/conditions, including sepsis (9.6%), acute coronary syndrome (9.1%), fractures (8.6%) and vascular injuries (8.6%). Contributory factors included cognitive (n=317), system related (n=192) and non-remedial (n=106). Cognitive factors included faulty information verification (41.3%) and faulty information processing (30.6%) whereas system factors included high workload (34.4%) and inefficient ED processes (40.1%). Non-remediable factors included atypical presentation (31.3%) and the patients' inability to provide a history (31.3%). Most errors (75%) involved multiple factors. Major harm was associated with 34/209 (16.3%) of reported incidents.

CONCLUSIONS

Most diagnostic errors in ED appeared to relate to common disease conditions. While sustaining diagnostic error reporting programmes might be challenging, our analysis reveals the potential value of such systems in identifying targets for improving patient safety in the ED.

Medical Malpractice in Wuhan, China: A 10-Year Autopsy-Based Single-Center Study

Medical disputes in China are historically poorly documented. In particular, autopsy-based evaluation and its impact on medical malpractice claims remain largely unstudied. This study aims to document autopsy findings and medical malpractice in one of the largest cities of China, Wuhan, located in Hubei Province. A total of 519 autopsies were performed by the Department of Forensic Medicine, Wuhan University School of Medicine, Wuhan, China, over a 10-year period between 2004 and 2013. Of these cases, 190 (36.6%) were associated with medical malpractice claims. Joint evaluation by forensic pathologists and clinicians confirmed that 97 (51.1%) of the 190 claims were approved medical malpractice cases. The percentage of approved malpractice cases increased with patient age and varied according to medical setting, physician specialty, and organ system. The clinico-pathological diagnostic discrepancy was significantly different among various physician specialties (P = 0.031) and organ systems (P = 0.000). Of those cases involved in malpractice claims, aortic dissection, coronary heart disease, and acute respiratory infection were most common. Association between incorrect diagnosis and malpractice was significant (P = 0.001). This is the first report on China's medical malpractice and findings at autopsy which reflects the current state of health care services in one of the biggest cities in China.

Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

Up-to-date evidence on levels and trends for age-sex-specific all-cause and cause-specific mortality is essential for the formation of global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013) we estimated yearly deaths for 188 countries between 1990, and 2013. We used the results to assess whether there is epidemiological convergence across countries.

METHODS

We estimated age-sex-specific all-cause mortality using the GBD 2010 methods with some refinements to improve accuracy applied to an updated database of vital registration, survey, and census data. We generally estimated cause of death as in the GBD 2010. Key improvements included the addition of more recent vital registration data for 72 countries, an updated verbal autopsy literature review, two new and detailed data systems for China, and more detail for Mexico, UK, Turkey, and Russia. We improved statistical models for garbage code redistribution. We used six different modelling strategies across the 240 causes; cause of death ensemble modelling (CODEm) was the dominant strategy for causes with sufficient information. Trends for Alzheimer's disease and other dementias were informed by meta-regression of prevalence studies. For pathogen-specific causes of diarrhoea and lower respiratory infections we used a counterfactual approach. We computed two measures of convergence (inequality) across countries: the average relative difference across all pairs of countries (Gini coefficient) and the average absolute difference across countries. To summarise broad findings, we used multiple decrement life-tables to decompose probabilities of death from birth to exact age 15 years, from exact age 15 years to exact age 50 years, and from exact age 50 years to exact age 75 years, and life expectancy at birth into major causes. For all quantities reported, we computed 95% uncertainty intervals (UIs). We constrained cause-specific fractions within each age-sex-country-year group to sum to all-cause mortality based on draws from the uncertainty distributions.

FINDINGS

Global life expectancy for both sexes increased from 65.3 years (UI 65.0-65.6) in 1990, to 71.5 years (UI 71.0-71.9) in 2013, while the number of deaths increased from 47.5 million (UI 46.8-48.2) to 54.9 million (UI 53.6-56.3) over the same interval. Global progress masked variation by age and sex: for children, average absolute differences between countries decreased but relative differences increased. For women aged 25-39 years and older than 75 years and for men aged 20-49 years and 65 years and older, both absolute and relative differences increased. Decomposition of global and regional life expectancy showed the prominent role of reductions in age-standardised death rates for cardiovascular diseases and cancers in high-income regions, and reductions in child deaths from diarrhoea, lower respiratory infections, and neonatal causes in low-income regions. HIV/AIDS reduced life expectancy in southern sub-Saharan Africa. For most communicable causes of death both numbers of deaths and age-standardised death rates fell whereas for most non-communicable causes, demographic shifts have increased numbers of deaths but decreased age-standardised death rates. Global deaths from injury increased by 10.7%, from 4.3 million deaths in 1990 to 4.8 million in 2013; but age-standardised rates declined over the same period by 21%. For some causes of more than 100,000 deaths per year in 2013, age-standardised death rates increased between 1990 and 2013, including HIV/AIDS, pancreatic cancer, atrial fibrillation and flutter, drug use disorders, diabetes, chronic kidney disease, and sickle-cell anaemias. Diarrhoeal diseases, lower respiratory infections, neonatal causes, and malaria are still in the top five causes of death in children younger than 5 years. The most important pathogens are rotavirus for diarrhoea and pneumococcus for lower respiratory infections. Country-specific probabilities of death over three phases of life were substantially varied between and within regions.

INTERPRETATION

For most countries, the general pattern of reductions in age-sex specific mortality has been associated with a progressive shift towards a larger share of the remaining deaths caused by non-communicable disease and injuries. Assessing epidemiological convergence across countries depends on whether an absolute or relative measure of inequality is used. Nevertheless, age-standardised death rates for seven substantial causes are increasing, suggesting the potential for reversals in some countries. Important gaps exist in the empirical data for cause of death estimates for some countries; for example, no national data for India are available for the past decade.

FUNDING

Bill & Melinda Gates Foundation.