Tuesday, 18 September 2012

Aspergillosis and the Role of Misdiagnosis in Morbidity and Mortality

A recent US study systematically surveyed 31 reports giving a total of nearly 6000 autopsies. Of these cases anything from 6 - 100% showed evidence of misdiagnosis - indicating that the doctors diagnosed and treated incorrectly, presumably often contributing to death (mortality).
28% of all autopsies revealed evidence of at least one missed diagnosis and 8% evidence of a Class I (Goldman criteria) error which means that the misdiagnosis could have contributed to or directly caused death (the most common of which were heart attack, pulmonary embolism, artery blockage in the lungs, pneumonia and aspergillosis).

About two thirds of all missed diagnoses are thought to have not contributed to death

This is clearly a serious issue and as a result of this study an estimate for the United States is that 40 500 deaths occur in intensive care units every year as a result of misdiagnosis. Given that aspergillosis is one of the most common of these (up to 30% of Class I misdiagnoses - though the paper isn't clear on this) this could account for up to 13 000 deaths a year. For a rare infection such as aspergillosis that represents a substantial increase in the number of recorded fatal infections per year.

Why so many? What can we do about it?

The report mentions several factors involved and many are mentioned in this slide presentation by the author (Winters suggested hospitals consider employing intensivists to monitor their ICUs, as well as improving nurse-to-patient ratios) but a major factor is the lack of autopsies now carried out to discover the true cause of death. In the US and throughout the EU the rate of autopsies has been falling for years, consequently doctors can no longer learn from comparing what they diagnosed with what actually killed a patient - or at least they can do far less than they used to. Under-representation of aspergillosis as a cause of death is one consequence.

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