Lee P N
P. N. Lee Statistics and Computing Ltd., Sutton, Surrey, UK.
APMIS Suppl. 1994;45:1-42.
Some clinicians and some epidemiologists appear to be under the illusion that techniques available for the diagnosis of internal diseases such as lung cancer have improved so much that autopsies are not necessary on the bodies of most people who die. Partly for this reason, partly for economic reasons and partly because clinicians fear litigation if autopsy shows that they treated patients for the wrong disease, autopsy rates have been falling in most developed countries. The object of the present review was to ascertain how much reliance can reasonably be put on clinical diagnoses made and death certificates completed in the absence of autopsy data. In the case of lung cancer, high rates of false positive and false negative diagnoses are universally prevalent, with biases influencing these rates, so that smokers are more likely to be appropriately investigated for lung cancer, and false negatives are commoner in non-smokers. All investigators who have compared clinical-based and autopsy-based death certificates have concluded that higher autopsy rates are necessary and the results of one study suggest that a high autopsy rate in a hospital leads to improvements in the accuracy of clinical diagnoses. The extent to which diagnoses on death certificates that are dependent solely on clinical data are seriously inaccurate for internal diseases such as lung cancer should engender caution in all who use mortality data to guide public health policies and to identify and quantify environmental risks to healths.
一些临床医生和流行病学家似乎误以为，诸如肺癌等内科疾病的诊断技术已经有了很大改进，以至于对大多数死亡者的尸体进行尸检已无必要。部分出于这个原因，部分出于经济原因，部分还因为临床医生担心尸检显示他们误诊了病人而引发诉讼，在大多数发达国家，尸检率一直在下降。本综述的目的是确定在没有尸检数据的情况下，临床诊断和填写的死亡证明能在多大程度上得到合理信赖。就肺癌而言，假阳性和假阴性诊断的高发生率普遍存在，且存在影响这些发生率的偏差，因此吸烟者更有可能接受适当的肺癌检查，而非吸烟者的假阴性更为常见。所有比较基于临床的死亡证明和基于尸检的死亡证明的研究者都得出结论，有必要提高尸检率，一项研究结果表明，医院的高尸检率会提高临床诊断的准确性。对于诸如肺癌等内科疾病，仅依赖临床数据的死亡证明诊断严重不准确的程度，应让所有利用死亡率数据来指导公共卫生政策以及识别和量化健康环境风险的人保持谨慎。
