The four horsemen: Clinicopathological correlation in 407 hospital autopsies

Background: Few previous papers comparing clinical diagnoses with autopsy findings present sensitivities and positive predictive values for individual conditions. The aim of this study is to determine the sensitivity and positive predictive value of current clinical diagnosis both overall and for individual conditions. Methods: Retrospective review of hospital records of a consecutive series of patients undergoing hospital autopsy at two metropolitan teaching hospitals over a 7-year period (407 patients). Comparison was made with autopsy reports to allocate one of three outcome measures (true-positive, false-positive, false-negative) to each condition. Results: The overall sensitivity and positive predictive value of clinical diagnosis were 0.74 and 0.93 respectively. Pneumonia, acute myocardial infarction, bowel ischaemia and pulmonary embolism were each present in greater than 10% of patients and had sensitivities below 0.70 and positive predictive values below 0.90. Conclusion: There exists a large burden of clinically undiagnosed and incorrectly diagnosed disease in hospital. Pneumonia, acute myocardial infarction, bowel ischaemia and pulmonary embolism represent important and difficult diagnostic challenges.