CAP Laboratory Improvement Programs. The Autopsy as a Performance Measurement Tool Diagnostic Discrepancies and Unresolved. clinical questions.

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1 CAP Laboratory Improvement Programs The Autopsy as a Performance Measurement Tool Diagnostic Discrepancies and Unresolved Clinical Questions A College of American Pathologists Q-Probes Study of 2479 Autopsies From 248 Institutions Richard J. Zarbo, MD; Peter B. Baker, MD; Peter J. Howanitz, MD Objective. To develop a multi-institutional reference database for quality improvement purposes using the autopsy to define clinical diagnostic discrepancies and resolve clinical questions. Design. Using the College of American Pathologists Q-Probes format, institutions prospectively assessed a maximum of 15 consecutive autopsies each, excluding forensic cases and stillborn infants, conducted over a 6-month period. They documented answers to clinical questions provided at autopsy and classified unexpected disease diagnoses according to a standardized system. Setting and Participants. Hospital-based autopsies performed at 248 institutions participating in the 1993 College of American Pathologists Q-Probes Quality Improvement Program. Main Outcome Measures. Percentages of clinical questions resolved by the autopsy and percentage of autopsies with unexpected findings of graded clinical impact. Results. In the aggregate database of 6427 questions from 2479 autopsies, overall 93.0% were answered by the autopsy. The 3 most common question categories were (1) identify pathology to account for clinical signs or symptoms (28.0%); (2) establish the cause of death (21.0%); and (3) confirm a clinical diagnosis (19.0%). At least one major unexpected disease finding that contributed to the patient s death was discovered in 39.7% of the total number of autopsies. There were no differences in the percentages of autopsies with these major unexpected findings when the data were stratified by institutional demographics or decedent characteristics. Conclusion. This multi-institutional study underscores the clinical relevance of postmortem examination in current medical practice by consistently providing answers to unresolved clinical questions and frequently revealing major unexpected findings that contributed to the patient s death. It is our strong belief that this postmortem-derived clinicopathologic information is a key indicator of effectiveness of care. Integration of this information into institutional quality improvement programs will improve system processes and clinician performance. (Arch Pathol Lab Med. 1999;123: ) The autopsy is widely recognized for providing important contributions in medical education and quality improvement of care. 1 4 Because of the pathologist s ability through the postmortem examination to provide answers to unresolved clinical questions and to discover previously unknown pathologic conditions that may have impacted premortem care, the autopsy has the potential to be a major driver of quality improvement. When collaborations between pathologists and clinicians effectively translate autopsy data into correlated information useful in a total quality management framework, the autopsy can lead to Accepted for publication October 23, From the Henry Ford Hospital, Detroit, Mich (Dr Zarbo); Ohio State University Medical Center, Columbus (Dr Baker); and University Hospital of Brooklyn, Brooklyn, NY (Dr Howanitz). Reprints: Richard J. Zarbo, MD, Department of Pathology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI improved organizational systems and processes as well as clinician performance. The implicit goal of better patient outcomes underscores the importance of the autopsy as a performance measurement tool. The frequency with which clinical questions are answered by the autopsy is one indicator of the potential contribution that the autopsy can provide to physician education and performance improvement. More effective correlation is obtained, and the pathologist has the best opportunity to answer unresolved clinical questions if they are known prior to beginning the autopsy. 5,6 To this end, direct communication with the clinical physician frequently provides new questions and clarification of issues to be investigated that cannot often be fathomed from a reading of the medical chart. The other chief autopsy-derived indicator is the overall measure of diagnostic error reflected in the discrepancy between premortem and postmortem diagnoses. As early Arch Pathol Lab Med Vol 123, March 1999 Autopsy as a Performance Measurement Tool Zarbo et al 191

2 as 1912, Cabot 7 recognized that a high percentage of autopsies revealed important unexpected findings. Based on previously published studies, at least one unexpected finding that contributed to the patient s death has been documented in 21% to 43% of autopsies since the late 1970s Approximately 10% to 13% of autopsies reveal an unexpected finding that would have changed patient management if the finding has been known prior to the patient s death. Communication of unexpected findings discovered at autopsy can provide significant educational opportunities to individual practitioners. This focus on individual performance is the underlying tenet of quality assurance. As we progress to the improvement of systems in the datadriven continuous improvement cycles of total quality management, a general view of these diagnostic errors is useful in clinical departmental and institutional quality improvement programs. In the United States, the major accrediting bodies, the Joint Commission on Accreditation of Healthcare Organizations and the College of American Pathologists (CAP), both require integration of autopsy findings into quality assessment and improvement activities. 15,16 Armed with the autopsy indicator information discussed above, institutions may design changes in systems and processes intended to minimize the risk of clinical error. To that end, a common comparative database for organizations to gauge performance is needed. Previous Q-Probes autopsy studies have focused on numerous quality control parameters related to the preanalytic, analytic, and postanalytic aspects of postmortem examination The goals of this multi-institutional study were (1) to develop an aggregate reference database related to effectiveness of patient care from a defined internal study conducted by many institutions of prospective postmortem examinations; (2) to provide benchmarks of performance that individual institutions could use to evaluate their own experiences and practices; and (3) to provide interinstitutional comparisons based on reported demographic characteristics. The database included the key indicators of frequency that clinical questions originating from the clinical physician were answered by the autopsy and the frequency of unexpected diagnoses discovered at autopsy, categorized in a 4-part classification of decreasing clinical impact. METHODS Data Collection This study was accomplished through the CAP Q-Probes program, a voluntary subscription quality improvement program since The Q-Probes methods and data collection tools have been described in detail previously. 20 Using standardized worksheets, each institution collected data in the second half of 1993 prospectively for 6 months or until a maximum of 15 consecutive autopsies had been performed. Stillbirths and forensic cases were excluded. The age, sex, and length of hospital stay were recorded on the worksheet for each autopsy. The length of stay was recorded as 0 for patients who died outside the hospital. 21 Prior to beginning each autopsy, the pathologist recorded a list of clinical diagnoses and questions on the worksheet. The diagnoses were obtained by reviewing the decedent s clinical record and by contacting the physician who had primary responsibility for the decedent s medical care. Each physician was also asked to provide questions pertaining to an aspect of the decedent s medical condition that was unknown or incompletely understood. These questions specifically originated from the clinical physician, not the pathologist. Up to 4 questions were recorded on the worksheet. Questions that could not be addressed because of restrictions specified in the autopsy permission document were excluded from the study. Each question was assigned to one of the following categories, adapted from Fowler et al 8 : 1. Identify pathology to account for clinical signs or symptoms. 2. Confirm a clinical diagnosis. 3. Establish the cause of death. 4. Determine the extent of a pathologic process. 5. Determine treatment effectiveness. 6. Determine primary site of tumor. 7. Determine source of bleeding. 8. Determine pathology to account for radiographic, endoscopic, imaging, or other study findings. 9. Determine adverse effects of treatment, diagnostic procedure, or patient-monitoring procedure. 10. Determine the condition of the operative or wound site. 11. Other. If a clinical physician could not be contacted prior to beginning the autopsy, the list of clinical questions and diagnoses was completed by contacting that individual within 2 days after the autopsy prosection had been performed. After completion of the final report, the pathologist determined if each clinical question had been answered by the autopsy. The pathologist was encouraged to consult with the clinical physician if any doubt remained that a question had not been answered. For the purposes of this study, questions that were not completely resolved but were substantially clarified by the autopsy were considered to be answered. The final autopsy diagnoses were compared with the list of clinical diagnoses. The number of unexpected findings in each of the following categories was recorded on the worksheet. The following wording and explanations categorizing clinically correlated autopsy findings are exactly as they appeared in the participant instructions. I. Major Unexpected Findings Contributing to the Patient s Death. These major findings include any principal underlying disease that contributed to the patient s death. They may or may not have been treated if known prior to the patient s death. II. Major Unexpected Findings That Did t Contribute to the Patient s Death. These are major disease processes that may have eventually required treatment or contributed to the patient s death. Examples include the discovery of a malignant neoplasm, severe coronary artery atherosclerosis, cirrhosis, or atherosclerotic aortic aneurysm that did not contribute to the patient s death. III. Minor Unexpected Findings Contributing to the Death of the Patient. These are secondary findings related to a principal underlying disease, therapeutic intervention, or diagnostic procedure. IV. Other Minor Unexpected Findings That Might Have Eventually Required Treatment. Data Analysis The number of questions asked per autopsy, the percentage of questions answered by the autopsies, and the percentage of autopsies with unexpected findings in categories I, II, III, and IV were calculated. Group (aggregate) medians were defined as the middle value when all intralaboratory percentages or numbers were ranked from lowest to highest. To measure the strength of association between the results and demographic variables 2 tests were performed. Before performing these tests, log-linear models were used to test the interaction between institutions and the response variables. Since no significant interactions were detected, intrainstitutional correlation was disregarded, and all 2 tests were performed on the autopsy level. A P value of less than.05 indicated a significant difference between demographic groups. To minimize the influence of a small number of institutions whose mean performance differed markedly from the majority, median values were used in data analysis. 192 Arch Pathol Lab Med Vol 123, March 1999 Autopsy as a Performance Measurement Tool Zarbo et al

3 Table 1. Demographic Characteristics of Participating Institutions Characteristic (. of Participants) Government affiliation (n 248) Federal nfederal ngovernmental Teaching status (n 248) Teaching* nteaching Pathology residency program (n 248). of occupied beds (n 244) Participants, % * Defined as any hospital that has more than 2 residency programs approved by the Accreditation Council for Graduate Medical Education. Participants that failed to answer were excluded from the database for this demographic grouping. RESULTS Data were collected on 2479 autopsies from 248 institutions. The number of autopsy cases submitted by individual participating institutions ranged from 1 to 15. The institutional demographic characteristics are shown in Table 1, and the decedent demographics are presented in Table 2. Clinical Questions In the aggregate database of 6427 questions, 93.0% were answered by the autopsy. A high percentage of all questions were answered by the autopsy in most institutions, as can be seen by the percentile distribution of percent answered questions from the 248 participants: 83.9% at the 10th percentile; 95.4% at the 50th percentile (median); and.0% at the 90th percentile. Figure 1 shows the distribution of participants individual laboratory percentages of questions answered by the autopsy. In the aggregate autopsy database, the percentage of questions formulated in each question category and the percentage of those questions that were answered by the autopsy are shown in Table 3. Significant differences were noted for the percentage of questions answered by the autopsy when the data were Table 2. Decedent Demographics Characteristic (. of Decedents)* Participants, % Sex (n 2474) Male Female Length of stay, d (n 2448) Age group (n 2326) 0 1 d 1 10 d 10 d 365 d 1 10 y y y y y y y y y 90 y * Autopsies that did not have a demographic characteristic reported were excluded from the database for that characteristic. stratified by institutional and decedent demographic characteristics (Table 4). The percentage of all questions answered for the aggregate autopsy database varied between age group categories (P.01). The lowest percentage of answered questions was 82.2%, observed for autopsied patients in the age group between 101 and 365 days old. For all autopsied age groups beginning with the group older than 20 and up to 30 years, the percentage of answered questions was at least 92.2%. The percentage of questions answered in the category establish the cause of death (n 1330) was higher for males than females (96.8% vs 91.9%; P.001) and was higher in nonteaching than teaching institutions (96.5% vs 93.3%; P.008). The percentage of questions in the category confirm a clinical diagnosis (n 1205) did not show a clear trend but varied among the length-of-stay intervals as follows: 0 to 1 day, 96.7%; more than 1 to 5 days, 90.3%; more than 5 to 14 days, 94.3%; and more than 14 days, 92.6% (P.01). A longer length of stay was associated with a higher percentage of autopsies with 4 clinical questions generated and a lower percentage with but 1 clinical question (P.001). As shown in Table 5, a higher number of occupied Figure 1. Distribution of participants individual laboratory percentages of clinical questions answered by the autopsy. Arch Pathol Lab Med Vol 123, March 1999 Autopsy as a Performance Measurement Tool Zarbo et al 193

4 Table 3. Aggregate Results for Questions Asked (n 6427) Percentage of Questions Answered in Each Category Percentage of All Questions Question Category Asked Identify pathology to account for clinical signs or symptoms Establish the cause of death Confirm a clinical diagnosis Determine the extent of a pathologic process Determine pathology to account for radiographic, endoscopic, imaging, or other findings Determine treatment effectiveness Determine primary source of tumor Determine adverse effects of treatment, diagnostic, or patient-monitoring procedures Determine the condition of the operative or wound site Other beds was associated with a lower percentage of autopsies with 4 clinical questions and a higher percentage with only 1 question (P.001). Unexpected Autopsy Findings In the aggregate database, nearly 40% of the 2497 autopsies revealed at least one major unexpected finding (category I) that contributed to the patient s death. However, a broad percentage distribution of category I unexpected findings was documented by the individual participants (Figure 2 and Table 6), ranging from none (10th percentile) to 71.4% (90th percentile). significant differences were observed in the percentage of autopsies with at least one category I finding when the data were stratified by the institutional and demographic characteristics listed in Tables 1 and 2. Major unexpected findings not contributing to death (category II) were found in 24% of autopsies, minor unexpected findings contributing to death were noted in 17.3% (category III), and other minor unexpected findings that might have eventually required treatment (category IV) were documented in 31.8% of autopsies. The percentile distributions of these unexpected findings obtained by the individual institutions are shown in Table 6. The percentage of autopsies with at least one major unexpected finding not contributing to death (category II) and at least one other minor unexpected finding that might have eventually required treatment (category IV) varied when stratified by decedent age group (P.02 and P.001, respectively) (Figure 3). The percentage of autopsies with at least one category II finding varied with governmental affiliation as follows: federal, 36.5%; nonfederal, 23.5%; and nongovernmental, 22.7% (P.001). The percentage of autopsies with at least one category IV finding also varied with governmental affiliation as follows: federal, 43.4%; nonfederal, 35.1%; and nongovernmental, 29.8% (P.001). Institutions with a pathology residency program, compared with institutions without such a program, had a higher percentage of category II findings (27.9% vs 22.3%; P.003), category III findings (20.1% vs 16.4%; P.02), and category IV findings (35.1% vs 30.7%; P.03). COMMENT The high yield of the 2 autopsy indicators measured in the Q-Probes data derived from 248 institutions underscores the importance of the autopsy as a performance measurement tool. The potential to evaluate the effectiveness of care encompassing the clinical spectrum from diagnosis to treatment by postmortem examination is not new. The present challenge for the pathologist is the clinical collaboration and effective integration of this information into a total quality management approach to improve health care. Clinical Questions In the aggregate database of 6427 clinical questions, 93.3% were answered by the autopsy. These questions Decedent Demographic Characteristic Sex Male Female Length of stay, d Institution type ngovernmental Government, nonfederal Government, federal Teaching status Teaching nteaching Pathology residency program * NS indicates not significant. Table 4. Percentage of Questions Answered by the Autopsy* All Question Categories (n 6427; P.001) (n 6358; NS) (n 6279; NS) (n 6236; P.001) (n 6236; NS) Percentage of Questions Answered Identify Pathology to Account for Clinical Signs or Symptoms (n 1834; NS) (n 1826; P.004) (n 1796; P.019) (n 1791; P.001) (n 1791; P.004) Arch Pathol Lab Med Vol 123, March 1999 Autopsy as a Performance Measurement Tool Zarbo et al

5 Table 5. Decedent Demographic Characteristic Length of stay, d P value. of occupied beds P value * NS indicates not significant. Percentage of Autopsies By Number of Questions Generated*. of Questions Generated NS NS NS NS were elicited from the decedents physicians and should have reflected the most important clinical concerns. Three previous studies have also documented high rates of resolution of clinical questions from postmortem examinations (Table 7). The 3 most common categories, which accounted for 68% of all questions in the present study as well as in the study from which they were adapted, 8 were (1) to identify pathology to account for clinical signs or symptoms, (2) to establish the cause of death, and (3) to confirm a clinical diagnosis. At least 90% of the questions in each of these categories were answered demonstrating the reliability and high clinical yield of autopsy examination. A longer length of hospital stay was associated with a lower percentage of answered questions for the categories identify pathology to account for clinical signs or symptoms and confirm a clinical diagnosis. We postulate that several factors may have contributed to a reduced ability to answer questions from these postmortem examinations. First, pathologic processes initially causing signs or symptoms may be obscured or significantly altered by subsequent and/or superimposed pathologic changes. Second, during hospitalization and treatment, some pathologic processes may resolve or heal. Finally, pathologic processes that are readily diagnosable are more likely to be detected early in the course of clinical evaluation. Questions in the category identify pathology to account for clinical signs or symptoms were answered less frequently in teaching institutions and institutions with a pathology residency program. The reasons for these differences in the teaching setting are not known, but we postulate that this may be related to a higher level of dis- Figure 2. Distribution of participants individual laboratory percentages of autopsies with at least one major unexpected finding that contributed to the patient s death (category I). Table 6. Aggregate and Intralaboratory Percentages of All Autopsies With at Least One Unexpected Finding, According to Classification Percentile Distributions of All Laboratories (%) Category Aggregate 10th 50th 90th I. Major unexpected findings contributing to death II. Major unexpected findings not contributing to death III. Minor unexpected findings contributing to death IV. Other minor unexpected findings that might have eventually required treatment Arch Pathol Lab Med Vol 123, March 1999 Autopsy as a Performance Measurement Tool Zarbo et al 195

6 Figure 3. Percentage of autopsies, by decedent age group, with at least one major unexpected finding not contributing to death (category II; P.02) or at least one minor unexpected finding that may have eventually required treatment (category IV; P.001). Table 7. Clinical Questions Answered by the Autopsy Authors, Year Fowler et al, Schned et al, Veress and Alafuzoff, Present study Mean. of Questions Questions per Answered, % Autopsy 83* * An additional 12% were partially answered. indicates data not reported ease complexity and longer length of hospital stay at these teaching institutions. Previous studies have documented discrepancies between causes of death listed on death certificates and those determined by autopsies in up to 29% of cases The high percentage (95%) of questions answered in the category establish the cause of death documents that the cause of death can be identified in nearly all postmortem examinations. Therefore, we believe that in the case of natural deaths (nonforensic cases), autopsy data, when available, should be used in completing and amending death certificates. Accurate, autopsy-derived cause-of-death information could be extremely important in selected populations. Longer length of hospital stay was associated with a higher percentage of autopsies in which 4 clinical questions were generated compared with the overall mean of 2.6 questions per autopsy in this study. It seems reasonable to assume that as patients fail to improve despite treatment, more questions arise regarding the disease process, effects of treatment, complications, and superimposed pathologic changes. Although an underlying cause of death may be well documented, other questions critical to retrospective evaluation of patient management will no doubt be raised. Institutions with higher numbers of occupied beds had lower percentages of autopsies with 4 clinical questions. Although not statistically significant, there tended to be a lower percentage of autopsies with 4 questions in teaching (25.8%) compared with nonteaching (30.6%) institutions and in institutions with a pathology residency program (25.9%) than without such a program (29.1%). Since clinical responsibility for patients may be assumed by multiple physicians at large teaching institutions, it may have been more difficult for the pathologist to identify the physician who could best provide the clinical questions. We believe that special efforts may be required to routinely elicit clinical questions for autopsy correlation in teaching institutions. 196 Arch Pathol Lab Med Vol 123, March 1999 Autopsy as a Performance Measurement Tool Zarbo et al

7 Table 8. Rate of Autopsies With Major Unexpected Findings That Contributed to the Patient s Death Authors, Year Rate, % Britton, Fowler et al, Sandritter et al, Cameron and McGoogan, Pounder et al, Scottolini and Weinstein, Gough, Schned et al, Sarode et al, Goldman et al, * Landefeld et al, Veress and Alafuzoff, Szende et al, Nichols et al, Present study of Autopsies Studied * Data collected from same institution for 3 separate years, 1960, 1970, and Data collected from 2 institutions. Data collected from same institution for 2 time periods, and Unexpected Findings In this Q-Probes study we calculate an average rate of 40% from the 2479 autopsies in which at least one major unexpected finding that contributed to the patient s death was missed. In this 1990s era of high-technology medicine, data from the 248 institutions show the autopsy to still be a major opportunity for the study of diagnostic error in many health care settings. Table 8 compares 14 previous studies that reported major unexpected findings in 21% to 58% of autopsies. Each used definitions of major unexpected findings that were similar to category I of the present study. From these studies, we calculate a median rate of 34% diagnostic discrepancy and no significant change over the past 20 years. Again, this confirms the diagnostic usefulness of the autopsy in current medical practice. Unexpected autopsy findings can range from incidental findings that may have eventually required treatment to major underlying disease processes that contributed to the patient s death. Several classification systems have been developed to account for the range of clinical significance attributed to autopsy findings. Goldman et al 9 have proposed a dichotomous classification of major unexpected findings into those that would and those that would not have led to change in patient management. Battle et al 11 recognized one class of major unexpected findings ( primary diagnosis ) that had an adverse impact on patient survival and a second class of major unexpected findings that had an equivocal impact on survival. In the present study, category I unexpected autopsy findings included those that would have changed patient management as well as those that would not have changed management. The separation of unexpected autopsy findings that would from those that would not have changed patient management can provide valuable information for quality improvement. However, determining if an unexpected finding would have changed patient management can be difficult and often requires consultation with the decedent s physician. To keep this multi-institutional study relatively simple, decisions regarding whether an unexpected finding would have changed management were purposely not part of the design. The term unexpected findings may be subject to various interpretations. Many of these findings are not completely unexpected but may represent one of several differential diagnostic possibilities or a diagnosis that was suspected but not confirmed. Goldman et al 9 considered missed diagnosis to be a diagnosis that had not been established or was not considered sufficiently likely for specific treatment to be instituted. Until these diagnoses are established at autopsy, significant doubt remains about their presence. One method for determining if an unexpected diagnosis should be considered major is to construct a cause of death sequence as it would appear on a standard death certificate. 25 If the unexpected finding is listed on the cause of death sequence or as a significant factor that contributed to death, then it should be considered a major unexpected finding. This practice should help avoid upgrading to major a category for unexpected findings with equivocal impact on survival. In this Q-Probes study, no statistically significant differences were observed in the rates of major unexpected findings that contributed to death when the data were stratified by the institution s number of occupied beds, teaching status, presence of a pathology residency program, government affiliation, length of hospital stay, and decedent sex and age groups. The autopsy had similar value in the discovery of unexpected diagnoses regardless of the institutional and decedent characteristics examined in this study. However, previous studies have demonstrated variation in the rate of unexpected autopsy findings with different decedent age groups (Table 9). Table 9. Authors, Year Britton, Cameron and McGoogan, McGoogan, Battle et al, Landefeld et al, Mitchell, Present study * indicates data not reported. Influence of Decedent Characteristics on the Rate of Major Unexpected Autopsy Findings* Decedent Characteristic Age Sex Place of Death Length of Stay Probability of Diagnosis Arch Pathol Lab Med Vol 123, March 1999 Autopsy as a Performance Measurement Tool Zarbo et al 197

8 Compared with institutions without a pathology residency program, those with residents had more unexpected findings in categories II, III, and IV. A previous Q- Probes multi-institutional study 18 revealed that institutions with a pathology residency program were also more likely to obtain permission for and to perform complete autopsies. By correlating these 2 databases, we postulate that more extensive autopsy procedures in these institutions may have revealed more unexpected findings. In addition to the powerful contribution to medical, educational, and quality improvement programs, unexpected autopsy findings can provide significant medical information for the decedent s survivors. An incidental malignant tumor and advanced but asymptomatic atherosclerosis are examples of unexpected findings that may have important medical implications for close relatives. The evolving understanding of genetic influences in disease processes and the possibility of genetic testing on archival autopsy tissue further amplify the importance of autopsy findings for the decedent s family. In summary, in this Q-Probes study, we have validated the efficiency of the autopsy in confirming clinical impressions, resolving numerous types of clinical questions, and uncovering unexpected diagnoses. The results indicate that systematic recording and specific investigation of clinical questions elicited prior to beginning the autopsy can consistently provide valuable information for quality improvement purposes. Most of this information would not be available from any other source. The multi-institutionally derived documentation of a high percentage of autopsies with major unexpected findings that would have contributed to death emphasizes the importance of incorporating autopsy information into institutional and departmental quality improvement programs. An ongoing comparative database composed of these indicator measures would reaffirm the autopsy as an effective performance measurement tool and as an experienced driver of quality improvement. References 1. Council on Scientific Affairs. Autopsy: a comprehensive review of current issues. JAMA. 1987;258: ; Arch Pathol Lab Med. 1996;120: Chavigny KH. Autopsy overview. In: Hutchins GM, ed. Autopsy Performance and Reporting. rthfield, Ill: College of American Pathologists; 1990: Hiss RB, Anderson RE. The Autopsy: Medical Practice and Public Policy. Boston, Mass: Butterworths; Lundberg GD. Let s make this autopsy conference matter. Arch Pathol Lab Med. 1996;120: Mergner WJ, Sutherland JC, Tigertt WD, Trump BF. To answer questions: a review of an autopsy service. Arch Pathol Lab Med. 1980;104: Landefield CS, Goldman L. The autopsy in quality assurance: history, current status, and future directions. QRB. 1989;15: Cabot RC. Diagnostic pitfalls identified during a study of three thousand autopsies. JAMA. 1912;59: Fowler EF, Nicol AG, Reid IN. Evaluation of a teaching hospital necropsy service. J Clin Pathol. 1977;30: Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg M. The value of the autopsy in three medical eras. N Engl J Med. 1983;308: Gough J. Correlation between clinical and autopsy diagnoses in a community hospital. Can Med Assoc J. 1985;133: Battle RM, Pathak D, Humble CG, et al. Factors influencing discrepancies between premortem and postmortem diagnoses. JAMA. 1987;258: Landefeld CS, Chren M-M, Myers A, Geller R, Robbins S, Goldman L. Diagnostic yield of the autopsy in a university hospital and a community hospital. N Engl J Med. 1988;318: Sarode VR, Data BN, Banerjee AK, et al. Autopsy findings and clinical diagnoses: a review of cases. Hum Pathol. 1993;24: Veress B, Alafuzoff I. A retrospective analysis of clinical diagnoses and autopsy findings in 3,042 cases during two different time periods. Hum Pathol. 1994;25: Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for Hospitals. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; Commission on Laboratory Accreditation Inspection Checklist: Autopsy Pathology. rthfield, Ill: College of American Pathologists; Baker PB, Zarbo RJ, Howanitz PJ. Quality assurance of autopsy face sheet reporting, final autopsy report turnaround time, and autopsy rates: a College of American Pathologists Q-Probes study of autopsies from 418 institutions. Arch Pathol Lab Med.1996;120: Zarbo RJ, Baker PB, Howanitz PJ: Quality assurance of autopsy permit form information, timeliness of performance and issuance of preliminary report: a College of American Pathologists Q-Probes study of 5434 autopsies from 452 institutions. Arch Pathol Lab Med. 1996;120: Nakhleh RE, Baker PB, Zarbo RJ. Autopsy result utilization: a College of American Pathologists Q-Probes study of 256 laboratories. Arch Pathol Lab Med In press. 20. Schifman RB, Howanitz PJ, Zarbo RJ. Q-Probes: a College of American Pathologists benchmarking program for quality management in pathology and laboratory medicine. In: Weinstein RS, ed. Advances in Pathology and Laboratory Medicine. Chicago, Ill: Mosby-Yearbook; 1996; Baker P, Saladino AJ. Q-Probes 93-06: Autopsy Contributions in Quality Assurance. rthfield, Ill: College of American Pathologists; Kircher T. The autopsy and vital statistics. Hum Pathol.1990;21: McKelvie P. Medical certification of causes of death in an Australian metropolitan hospital: comparison with autopsy findings and a critical review. Med J Aust. 1993;158: Pounder DJ, Horowitz M, Rowland R, Reid DP. The value of autopsy in medical audit: a combined clinical and pathological assessment of cases. Aust N Z J Med. 1983;13: Hanzlick R. The Medical Cause of Death Manual. rthfield, Ill: College of American Pathologists; Schned AR, Mogielnicki RP, Stauffer ME. A comprehensive quality assessment program on the autopsy service. Am J Clin Pathol. 1986;86: Britton M. Diagnostic errors discovered at autopsy. Acta Med Scand. 1974; 196: Sandritter W, Staeudinger M, Drexler H. Autopsy and clinical diagnosis. Pathol Res Pract. 1980;168: Cameron HM, McGoogan E. A prospective study of 1152 hospital autopsies, I: inaccuracies in death certification. J Pathol. 1981;133: Scottolini AG, Weinstein SP. The autopsy in clinical quality control. JAMA. 1983;250: Szende B, Kendrey G, Lapis K, Lee PN, Roe FJC. Accuracy of admission and pre-autopsy clinical diagnoses in the light of autopsy findings: a study conducted in Budapest. Hum Exp Toxicol. 1994;13: Nichols L, Aronica P, Baba C. Are autopsies obsolete? Am J Clin Pathol. 1988;110: McGoogan E. The autopsy and clinical diagnosis. J R Coll Physicians Lond. 1984;18: Mitchell ML. Interdepartmental quality assurance using coded autopsy results. Mod Pathol.1993;6: Arch Pathol Lab Med Vol 123, March 1999 Autopsy as a Performance Measurement Tool Zarbo et al

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