Abstract
Background: Clinico-pathological discrepancies are more frequent in settings in which limited diagnostic techniques are available, but there is little information on their actual impact. We assessed the accuracy of the clinical diagnoses in a tertiary referral hospital in sub-Saharan Africa by comparison with post-mortem findings. We also identified potential risk factors for misdiagnoses. Methods: Retrospective observational study performed from November 2013 to March 2015 in the Maputo Central Hospital (Mozambique), including 112 adult deaths, which underwent complete autopsy. We reviewed the clinical records. Major clinico-pathological discrepancies were assessed using a modified version of the Goldman and Battle classification. Findings: Major diagnostic discrepancies were detected in 65/112 cases (58%) and were particularly frequent in infection-related deaths (56/80 [70%] major discrepancies). The sensitivity of the clinical diagnosis for toxoplasmosis was 0% (95% CI: 0-37), 18% (95% CI: 2-52) for invasive fungal infections, 25% (95% CI: 5-57) for bacterial sepsis, 34% (95% CI: 16-57), for tuberculosis, and 46% (95% CI: 19-75) for bacterial pneumonia. Major discrepancies were more frequent in HIV-positive than in HIV-negative patients (48/73 [66%] vs. 17/39 [44%]; p=0*0236). Interpretation: Major clinico-pathological discrepancies are frequent in resource constrained settings. Increasing clinical awareness of the frequency of infectious diseases and expanding the availability of diagnostic tests could significantly improve the recognition of common life-threatening infections, and thereby reduce the mortality associated with these diseases. The high frequency of clinico-pathological discrepancies questions the validity of mortality reports based on clinical data or verbal autopsy. Funding: Bill & Melinda Gates Foundation (Grants OPP2068633 and OPP2239002). Declaration of Interest: The authors have declared that no competing interests exist. Ethical Approval: The study was approved by the Clinical Research Ethics Committee of the Hospital Clinic of Barcelona (Spain; File 2013/8677) and the National Bioethics Committee of Mozambique (Mozambique; Ref. 342/CNBS/13).
Highlights
Healthcare systems worldwide face the challenge of improving the quality of care they deliver in order to improve health outcomes
The sensitivity of the clinical diagnosis for toxoplasmosis was 0%, 18% for invasive fungal infections, 25% for bacterial sepsis, 34%, for tuberculosis, and 46% for bacterial pneumonia
Major discrepancies were more frequent in human immunodeficiency virus (HIV)-positive than in HIV-negative patients (48/73 [66%] vs. 17/39 [44%]; p = 0.0236)
Summary
Healthcare systems worldwide face the challenge of improving the quality of care they deliver in order to improve health outcomes. Complete diagnostic autopsy is an important tool for quality control of clinical practice [6,7]. Autopsy rates have been declining over the past decades [3,4,5,8,9]. The reasons for this decline have been discussed previously in literature [3,4,6] and include, among others, introduction of modern diagnostic tools in clinical practice. Clinico-pathological discrepancies are more frequent in settings in which limited diagnostic techniques are available, but there is little information on their actual impact
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