The autopsy as an outcome and performance measure

Shojania K, Burton E, McDonald K
Record ID 32003000421
Authors' objectives:

This report reviews the literature addressing the extent to which the autopsy reveals important errors in clinical diagnosis and the roles these data have in measuring and improving clinical performance.

Authors' results and conclusions: Multiple regression analysis incorporating study period, autopsy rate, country (U.S. vs. non-U.S.) and case mix as predictors showed that diagnostic errors that may have affected patient outcome ("Class I errors") are detected in 10.2% (95% CI: 6.7-15.3%) of autopsies performed in the base time (1980) and country (U.S.), and with the reference case mix (general autopsies) and mean autopsy rate. The prevalence of other "major errors" related to the principal diagnosis or underlying cause of death was 25.2% (95% CI: 20.8-31.2%). When changes in autopsy rates are taken into account, these error rates showed modest decreases with time. Specifically, Class I errors exhibited a relative decrease of 26.2% per decade (p=0.10), and major errors decreased at a rate of 28.0% per decade (p=0.006). Nonetheless, Class I errors still occur in 3.8-7.9% of cases and major errors in 8.0-22.8%, with these ranges reflecting the impact of variations in autopsy rates. Studies specifically addressing the issue of clinical selection indicate that clinicians cannot reliably predict which autopsies will be of high diagnostic yield. No intervention study has directly addressed the impact of autopsy findings on clinical practice or performance improvement. However, the existing evidence strongly suggests substantial inaccuracies in death certificates and hospital discharge data, both of which play important roles in epidemiologic research and healthcare policy decisions.
Authors' recommendations: At the level of the individual clinician, the chance that autopsy will reveal important unsuspected diagnoses in a given case remains significant. Moreover, clinicians do not seem able to predict the cases in which such findings are likely to occur. There is no evidence to determine whether findings from autopsy improve subsequent clinical performance. The existing literature does demonstrate that clinical diagnoses, whether obtained from death certificates or hospital discharge data, contain major inaccuracies compared with autopsy diagnoses. The health care system as a whole can thus benefit enormously from autopsy data, by substantially enhancing the accuracy of vital statistics, which play important roles in research, funding, and other policy decisions. Future research opportunities include characterizing the factors leading to errors in clinical diagnosis, establishing optimal means of using autopsy data in performance improvement strategies, and exploring different mechanisms for encouraging autopsies.
Authors' methods: Systematic review
Project Status: Completed
Year Published: 2002
English language abstract: An English language summary is available
Publication Type: Not Assigned
Country: United States
MeSH Terms
  • Autopsy
  • Cause of Death
  • Quality Assurance, Health Care
  • Quality of Health Care
Organisation Name: Agency for Healthcare Research and Quality
Contact Address: Center for Outcomes and Evidence Technology Assessment Program, 540 Gaither Road, Rockville, MD 20850, USA. Tel: +1 301 427 1610; Fax: +1 301 427 1639;
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Copyright: Agency for Healthcare Research and Quality (AHRQ)
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