clinico-pathological discrepancies in the diagnosis of ... · - 1 - clinico-pathological...
TRANSCRIPT
- 1 -
Clinico-pathological discrepancies
in the diagnosis of causes of death
in adults in Mozambique
Natalia Rakislova
Departments of Pathology, Hospital Clínic and IsGlobal,
Barcelona
- 2 -
Background
Complete Diagnostic Autopsy:
Determination of cause of death (gold standard
diagnosis)
Tool for clinical quality control to analyze diagnostic
discrepanies
Observation of disease and treatment effects
Training residents and physicians
Information & closure for families
Tissue banking/research
- 3 -
Background
Complete Diagnostic Autopsy:
Determination of cause of death (gold standard
diagnosis)
Tool for clinical quality control to analyze diagnostic
discrepanies
Observation of disease and treatment effects
Training residents and physicians
Information & closure for families
Tissue banking/research
- 4 -
Background
• Medical errors persist over time despite all the progress..
- 5 -
Background
• Medical errors persist over time despite all the progress..
• Hospitals with limited resources: medical errors are likely to
be more frequent
- 6 -
Background
• Medical errors persist over time despite all the progress..
• Hospitals with limited resources and diagnostic tools:
clinical errors are likely to be more frequent
• Very few studies on clinico-pathological discrepancies at
these settings
- 7 -
Aims
1. Analyze the concordance clinical vs autopsy main
diagnosis in a tertiary hospital in sub-Saharan Africa
- 8 -
Aims
1. Analyze the concordance clinical vs autopsy main
diagnosis in a tertiary hospital in sub-Saharan Africa:
Complete Diagnostic Autopsy: Gold Standard Diagnosis
- 9 -
Aims
1. Analyze clinical vs autopsy diagnoses concordance in a
tertiary hospital in sub-Saharan Africa:
Complete Diagnostic Autopsy: Gold Standard Diagnosis
Major discrepancies
(clinically missed diagnosis involving primary cause of
death)
- 10 -
Aims
1. Analyze the accuracy of Clinical main diagnoses in a
tertiary hospital in sub-Saharan Africa:
Complete Diagnostic Autopsy: Gold Standard Diagnosis
Major discrepancies
(missed diagnosis involving primary cause of death)
2. Identify potential risk factors for Major discrepancies
Risk Factors vs Major error
Demographics Clinical signs Symptoms Analytics Other
age at death dehydration fever hemoglobin alcoholism
sex (M vs F ) hepatomegaly, splenomegaly cough leucocytes smoking
time admission-
death
pallor, jaundice, petechia,
exantema
headache GGT, GPT
nutritional
status
ethnic group oliguria, dysuria, hematuria abdominal pain diabetes
origin (urban vs
rural)
edema dyspnea hypertension
coma diarrhea antiretrovirals
axillar t vomit HIV status
- 12 -
Study design
A series of 112 autopsies*:
Maputo Central Hospital, Mozambique
Nov 2013-March 2015
Clinical records
Autopsy findings
>15 years
57 males/55 females
median age: 37 years (range 15-76)
- 13 -
Study design
Inclusion criteria:
autopsy requested by clinician
autopsy consented by relatives
Exclusion criteria:
maternal deaths
traumatic deaths
- 14 -
Autopsy procedure
Histology/Microbiology:
Liver, lungs, CNS, kidneys, spleen, intestine, bone marrow, any
grossly visible lesions
Microbiology:
Blood
Cerebrospinal fluid
- 15 -
Histology
H&E all the samples
Special and/or IHC stains if suspicion
- 16 -
Microbiology analysis
All the samples:
PCR for Plasmodium falciparum
(HIV)-1/2 antibodies; viral load
HIV+ cases:
real time PCR in CSF, Brain and Lung: Toxoplasma gondii,
Mycobarcterium tuberculosis, Cryptococcus spp
real time PCR in Lung: Pneumocystis jirovecii
Blood and CSF:
bacterial/fungal culture
- 17 -
Autopsy results
Gross examination
Histological report
Microbiological results
Clinical records
ICD-10
Final cause of death
Clinical error analysis
Autopsy: final cause of death
n=112
Autopsy: final cause of death
n=112
Clinical diagnosis accuracy
n=112
Clinical vs Autopsy diagnosis
n=112
Clinical diagnostic errors
56% of all the cases
Clinical diagnostic errors
Knowledge of correct diagnosis before death would
have led to survival or cure!
56% (n=63) of all the cases
Diagnostic category vs Major
error
Type of error
No- or
minor
Major error Odds ratio p
Cause of death
Infectious
Malignant tumors
Other diseases
24 (51%)
11 (23%)
12 (26%)
56 (86%)
5 (8%)
4 (6%)
1
0.21 (0.07, 0.64)
0.16 (0.05, 0.51)
0.0007
n=112
Diagnostic category vs Major
error
Type of error
No- or
minor
Major error Odds ratio p
Cause of death
Infectious
Malignant tumors
Other diseases
24 (51%)
11 (23%)
12 (26%)
56 (86%)
5 (8%)
4 (6%)
1
0.21 (0.07, 0.64)
0.16 (0.05, 0.51)
0.0007
n=112
Major discrepancy in 56/80 (70%) of infection-related cause of death
Clinico-pathological discrepanciesInfections
Cause of death
Autopsy
diagnosis
Clinical error (Major
error)
n n %
Tuberculosis 23 15 65%
Bacterial pneumonia 13 7 54%
Sepsis 12 9 75%
Invasive fungal infections 11 9 82%
Toxoplasmosis 8 8 100%
Bacterial meningitis 4 3 75%
Viral pneumonia 2 2 100%
Viral meningoencephalitis 3 2 67%
Cause of death Autopsy diagnosis Clinical error (Major error)
n n %
Tuberculosis 23 15 65%
Bacterial pneumonia 13 7 54%
Sepsis 12 9 75%
Invasive fungal infections 11 9 82%
Toxoplasmosis 8 8 100%
Bacterial meningitis 4 3 75%
Viral pneumonia 2 2 100%
Viral meningoencephalitis 3 2 67%
Clinico-pathological discrepanciesInfections
Cause of death Autopsy diagnosis Missed diagnosis (Major error)
n n %
Tuberculosis 23 15 65%
Bacterial pneumonia 13 7 54%
Sepsis 12 9 75%
Invasive fungal infections 11 9 82%
Toxoplasmosis 8 8 100%
Bacterial meningitis 4 3 75%
Viral pneumonia 2 2 100%
Viral meningoencephalitis 3 2 67%
Clinico-pathological discrepanciesInfections
Cause of death
Autopsy
diagnosis
Missed diagnosis (Major
error)
n n %
Tuberculosis 23 15 65%
Bacterial pneumonia 13 7 54%
Sepsis 12 9 75%
Invasive fungal infections 11 9 82%
Toxoplasmosis 8 8 100%
Bacterial meningitis 4 3 75%
Viral pneumonia 2 2 100%
Clinico-pathological discrepanciesInfections
Autopsy diagnosis Primary clinical diagnoses (n)
Meningoencephalitis (4)Tuberculosis Hypertensive encephalopathy (1)
Cryptococcal meningitis (1)Bacterial pneumonia (2)
Pulmonary pneumocystosis (1)Gastroenteritis (1)Severe anemia (1)
Renal failure (1)
Abdominal tumor (1)Pericarditis (1)
Invasive fungal infection Meningoencephalitis (4)Cerebral malaria (1)
Hypertensive encephalitis (1)Sepsis (1)
Gastroenteritis (1)Appendicitis (1)
Toxoplasmosis Meningoencephalitis (4)Cryptococcus meningitis (2)Pulmonary pneumocystis (1)
Hemorrhagic stroke (1)
Sepsis Meningoencephalitis (3)Severe anemia (2)
Stevens Johnson syndrome (1)Uremic coma (1)Gastroenteritis (1)
Malignant tumor (1)
Bacterial pneumonia Meningoencephalitis (2)Renal failure (1)
Submandibular abscess (1)
Severe anemia (1)AIDS (1)
Disseminated Kaposi’s sarcoma (1)
Cause of death AutopsyMissed diagnosis
(Major error)
n n %
Liver carcinoma 5 0 0%
Cervical
carcinoma3 0 0%
Lymhoma 3 1 33%
Kaposi sarcoma 2 1 50%
Myeloid leukemia 11 100%
Brain tumor 1 1 100%
Undifferentiated
tumor1 1 100%
Clinico-pathological discrepanciesMalignant tumors and other diseases
5/16 (30%) missed dx
Cause of death Autopsy Missed diagnosis
(Major error)
n n %
Cardiovascular
disease11 1 9%
Renal disease 1 1 100%
Pulmonary
disease2 1 33%
Gastrointestinal
disease2 1 50%
Demographics Clinical signs Symptoms Analytics Other
age at death dehydration fever hemoglobin alcoholism
sex (M vs F ) hepatomegaly, splenomegaly cough leucocytes smoking
time admission-
death
pallor, jaundice, petechia,
exantema
headache* GGT, GPT
nutritional
status
ethnic group oliguria, dysuria, hematuria abdominal pain diabetes
origin (urban vs
rural)
edema dyspnea hypertension
coma diarrhea antiretrovirals*
axillar t vomit HIV status*
Major error vs risk factors
* p<0.05
Conclusions
• Major clinico-pathological dicrepancies have a
significant impact on mortality in health facilities in sub-
Saharan Africa
• The high frequency of major clinico-pathological
dicrepancies infectious diseases
• The validity of mortality reports based on clinical data and
verbal autopsies?
• Next Steps:
Increasing clinical awareness of the impact of infectious
diseases
Introduction of easy-to-perform tests for most common
and life-threatening infections
Thank you for your attention