The Value of Necropsy in Quality Control of Medical Diagnosis – The Gold Standard for Years to Come

Despite the well-known valuable role of necropsies in pathology training and their indisputable importance for quality assurance in medical practice, the number of necropsies performed worldwide has decreased over the last few years. This has been ascribed, in part, to the idea that, at the time of death, most diagnoses have already been made using new diagnostic technologies, including clinical, morphological, and molecular pathology and imaging methods. In CLINICS 2008;63(5):581-8, Kotovicz et al. 1 compared necropsy and clinical diagnosis at our large teaching hospital, where, although still performed, the number of necropsies has also declined. Unexpectedly, major missed diagnoses, which could have led to a change in management with increased survival or cure, were detected in 16.3% of cases. Minor diagnoses not directly related to the cause of death were detected in an additional 28.1% of cases. In a similar study at the Heart Institute of the same hospital, Saad et al. 2 also found major disagreements regarding the cause of death in 30.0% of cases in a sequential series of 406 necropsies, mostly involving cardiovascular and respiratory diseases. In both articles, the authors quoted other studies from different hospitals and countries, and found that, although new technological tools had indeed diminished the differences between clinical and necropsy findings, major diagnostic discrepancies were found in 14 – 39% of cases, even in recent series from developed countries 3-6. These papers highlight the occurrence of remarkable diagnostic failures, with important consequences for patient management. One reason for the decline in autopsy rates seems to be family concern about the procedure. In the United Kingdom, this concern arose mainly after the revelation of unauthorized organ retention 7. In Brazil, and possibly in other countries, there is a cultural desire that burials occur promptly, and families will not often consent to necropsies because of the delay caused by the procedure. Given this, pathology departments should try to decrease such delays as much as possible. However, at the Heart Institute, where for several years families were asked to consent to an autopsy upon hospital admission, the percent of family authorization (~60%) was much higher than the actual necropsy rate (~25%), indicating that, in many cases, even when consent is granted, physicians did not request a necropsy. Thus, it seems reasonable to question what has caused this lack of physician interest. Some reasons might include: a desire to avoid ethical or legal problems that might …