Sonderegger-Iseli K, Burger S, Muntwyler J, Salomon F
Medical Clinic B, Department of Internal Medicine, University Hospital, University of Zurich, Switzerland.
Lancet. 2000 Jun 10;355(9220):2027-31. doi: 10.1016/s0140-6736(00)02349-7.
Studies comparing the accuracy of clinical diagnosis in unselected patients who died in hospital in different medical eras have shown no decline of errors in the main diagnosis. We assessed changes in diagnostic accuracy over 20 years.
We analysed retrospectively diagnostic errors, with use of necropsy as the gold standard for diagnosis. We randomly selected 300 patients who died at a tertiary-care teaching hospital in Switzerland--100 in each of 1972, 1982, and 1992. We classified discrepancies between clinical diagnosis and necropsy findings as major and minor errors.
The overall necropsy rate at the hospital stayed at around 90% for the whole period. During the study, the frequency of major discrepancies declined significantly (1972, 30%; 1982, 18%; 1992, 14%; p=0.007). The rate of minor diagnostic errors increased significantly from 23% in 1972 to 46% in 1992 (p<0.001). The increase in overall diagnostic accuracy occurred mainly because of a significant improvement in specificity for cardiovascular diseases (1972, 85%; 1982, 82%; 1992, 97%; p=0.034) and non-significantly improved sensitivity (1972, 69%; 1982, 82%; 1992, 86%; p=0.061). Sensitivity also improved for infectious diseases (1972, 25%; 1982, 67%; 1992, 86%; p=0.036). Sensitivity and specificity for neoplastic diseases were high originally and did not change. The total number of diagnostic procedures per year increased from 191 in 1972 to 259 in 1992, mainly because of non-invasive techniques, such as ultrasonography, and endoscopies.
The frequency of major diagnostic errors in unselected patients who died in hospital was halved over 20 years, probably because of improved clinical skills and new diagnostic procedures.
对不同医学时代在医院死亡的未经挑选的患者的临床诊断准确性进行比较的研究表明，主要诊断中的错误并未减少。我们评估了20年间诊断准确性的变化。
我们以尸检作为诊断的金标准，对诊断错误进行回顾性分析。我们随机选择了瑞士一家三级护理教学医院的300名死亡患者——1972年、1982年和1992年各100名。我们将临床诊断与尸检结果之间的差异分为重大错误和微小错误。
该医院的总体尸检率在整个期间保持在90%左右。在研究期间，重大差异的频率显著下降（1972年为30%；1982年为18%；1992年为14%；p=0.007）。微小诊断错误的发生率从1972年的23%显著增加到1992年的46%（p<0.001）。总体诊断准确性的提高主要是因为心血管疾病的特异性有显著改善（1972年为85%；1982年为82%；1992年为97%；p=0.034），敏感性虽有提高但不显著（1972年为69%；1982年为82%；1992年为86%；p=0.061）。传染病的敏感性也有所提高（1972年为25%；1982年为67%；1992年为86%；p=0.036）。肿瘤疾病的敏感性和特异性最初较高，没有变化。每年诊断程序的总数从1972年的191次增加到1992年的259次，主要是因为超声检查和内镜检查等非侵入性技术。
在医院死亡的未经挑选的患者中，重大诊断错误的频率在20年内减半，可能是因为临床技能的提高和新的诊断程序。
