Chest
Volume 119, Issue 2, February 2001, Pages 530-536
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Clinical Investigations in Critical Care
A Study of Consecutive Autopsies in a Medical ICU: A Comparison of Clinical Cause of Death and Autopsy Diagnosis

https://doi.org/10.1378/chest.119.2.530Get rights and content

Objective

To determine the degree of concordancebetween clinical cause of death and autopsy diagnosis in a medical ICU(MICU) setting.

Design

Retrospective medical chartand autopsy report review.

Setting

MICU in a tertiaryreferral hospital.

Patients

Consecutive admissions toan MICU over a 2-year period from January 1, 1994, to December 31,1995.

Interventions

None.

Measurements andmain results

One thousand eight hundred patients were admittedto the MICU during the study period. There were 401 in-ICU deaths(22.3%). The autopsy rate was 22.7% (91 of 401). The mean ± SD ageof the autopsied patients (55.1 ± 13.5 years) was lower thanthose without autopsy (62.4 ± 15.2 years; p < 0.001). The twogroups were otherwise similar with regard to sex, race, APACHE (acutephysiology and chronic health evaluation) III scores, and lengths ofstay in the MICU and hospital. The discordance between clinical andpostmortem diagnoses was 19.8% (95% confidence interval, 12 to 29%). There were no differences in age, sex, APACHE III scores, predictedmortality, and lengths of stay in MICU hospital between patients withconcordant and discordant diagnoses. In 44.4% (8 of 18) of thediscordant cases, management would have been modified had the autopsieddiagnosis been made premortem. Seven of the autopsied patients hadorgan transplantation. Three of the patients who had organtransplantation had discordant diagnoses, including two patients withdisseminated fungal infection that was not diagnosed clinically. Although the observed discordance in transplant patients (43%) washigher than in those without transplant (19%), the difference was notstatistically significant (p = 0.15).

Conclusion

Younger patients tended to have a higher autopsy rate than olderpatients. The discordance between the clinical cause of death andpostmortem diagnosis was 19.8%. In 44.4% of the discordant cases, knowledge of the correct diagnosis would have alteredtherapy.

Section snippets

Study Patients

Consecutive patients admitted to the MICU at the Cleveland Clinic Foundation over a 2-year period from January 1, 1994, to, December 31, 1995, were studied retrospectively. The MICU is staffed by, Residents from the Internal Medicine Residency Program, Fellows fromthe Pulmonary and Critical Care Department, and Attendings for the, Pulmonary Department, board certified in internal medicine, pulmonarymedicine, and critical care medicine. The medical staff makes roundsevery day, and every medical

Results

During the study period, there were 1,800 admissions to the MICU. The in-ICU mortality was 22.3% (401 of 1,800 patients). Theautopsy rate was 22.7% (91 of 401 deaths). The patientswho had an autopsy were younger than those without autopsy(p < 0.001; Table 1). There were no significant differences in sex, race, APACHE IIIscores, and lengths of stay in the MICU and hospital between thesetwo groups (Table 1).

Discussion

The 22.7% autopsy rate in our study is higher than the overallnational hospital autopsy rates in the United States (12%) andsome studies in the United Kingdom (11 to 24%),22 and arecomparable to the autopsy rates in two postmortem studies inadult ICUs (31% and 29%, respectively).1718 The largestcomparison of clinical and autopsy diagnoses was made by, Britton,13 from 1970 to 1971. In his analysis of 400consecutive deaths in the medical department with an autopsy rate of96%, the main cause of

Conclusion

Advances in diagnostic technology have not diminished the value ofautopsy. The discordance between the clinical cause of death andpostmortem diagnosis was 19.8%. In 44.4% of the discordant cases, knowledge of the correct diagnosis would have altered therapy. Postmortem study can serve as a valuable monitor of quality control indiagnostic accuracy of MICU patients.

References (35)

  • CS Landefeld et al.

    Diagnostic yield of the autopsy in a university hospital and a community hospital

    N Engl J Med

    (1988)
  • L Goldman et al.

    The value of the autopsy in the three medical eras

    N Engl J Med

    (1983)
  • P Fernandez-Segoviano et al.

    Autopsy as quality assurance in the intensive care unit

    Crit Care Med

    (1988)
  • JF Gwynne

    Death certification in Dunedin Hospitals

    NZ Med J

    (1977)
  • DW King

    Potential of the autopsy

    Arch Pathol Lab Med

    (1984)
  • M Britton

    Diagnostic errors discovered at autopsy

    Acta Med Scand

    (1974)
  • RC Cabot

    Diagnostic pitfalls identified during a study of 3000 autopsies

    JAMA

    (1912)
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