Clinical vs. autopsy diagnostic discrepancies in the intensive care unit: a systematic review and meta-analysis of autopsy series,Intensive Care Medicine

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Clinical vs. autopsy diagnostic discrepancies in the intensive care unit: a systematic review and meta-analysis of autopsy series
Intensive Care Medicine ( IF 27.1 ) Pub Date : 2024-09-17 , DOI: 10.1007/s00134-024-07641-y
Britt Marcoen ₁ , Koenraad H Blot ₂ , Dirk Vogelaers _{1,

3} , Stijn Blot _{1,

4}

Affiliation

Purpose

The aim of this study was to assess whether there is a discrepancy between clinical and autopsy-based diagnoses in adult intensive care unit (ICU) patients.

Methods

We conducted a systematic review of cohort studies reporting on conventional autopsy-confirmed missed diagnoses. The discrepancy rate was per study calculated by dividing the number of patients with a missed diagnosis by the number of autopsies. Missed diagnoses were classified according to the Goldman classification as ‘major’ and ‘minor’ with major missed diagnoses further differentiated into Class I missed diagnoses (i.e., diagnoses that may have altered therapy or survival) and Class II missed diagnoses (i.e., diagnoses that would not have altered therapy or survival). Class I missed diagnoses constitute the primary outcome of interest. Pooled estimates for discrepancy rates (95% confidence intervals) were calculated using a mixed-effects logistic regression model with ‘study’ as random effect. Meta-regression was used to assess relationships between major discrepancy rates and autopsy rates, start year of study, and ICU type.

Results

Forty-two studies were identified totaling 6305 analyzed autopsies and 1759 patients with missed diagnoses. The pooled discrepancy rates for Class I and major missed diagnoses were 6.5% (5–8.5) and 19.3% (15.3–24), respectively. Meta-regression analysis revealed that autopsy rate was inversely associated with discrepancy rate. Class I discrepancy rates did not change over time. Burn and trauma ICUs had lower discrepancy rates as compared to medical ICUs, possibly because of higher autopsy rates.

Conclusions

Missed diagnoses remain common in ICUs. A higher autopsy rate does not reveal more major diagnostic errors. These data support a clinically driven autopsy policy rather than a systematic autopsy policy.

中文翻译：

重症监护病房的临床与尸检诊断差异：尸检系列的系统评价和荟萃分析

目的

本研究的目的是评估成人重症监护病房（ICU）患者的临床诊断和基于尸检的诊断之间是否存在差异。

方法

我们对报告常规尸检证实漏诊的队列研究进行了系统评价。每项研究的差异率是通过将漏诊患者人数除以尸检次数计算得出的。漏诊根据 Goldman 分类分为“主要”和“轻微”，主要漏诊进一步分为 I 类漏诊（即可能改变治疗或生存的诊断）和 II 类漏诊（即不会改变治疗或生存的诊断）。I 类漏诊构成了感兴趣的主要结局。使用混合效应 logistic 回归模型计算差异率（95% 置信区间）的合并估计值，其中 “研究” 作为随机效应。Meta 回归用于评估主要差异率与尸检率、研究开始年份和 ICU 类型之间的关系。

结果

确定了 42 项研究，共 6305 例分析了尸检和 1759 例漏诊患者。I 类和主要漏诊的合并差异率分别为 6.5% （5-8.5）和 19.3% （15.3-24）。Meta 回归分析显示，尸检率与差异率呈负相关。I 类差异率不随时间变化。与内科 ICU 相比，烧伤和创伤 ICU 的差异率较低，可能是因为尸检率较高。