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Patterns and predictors of settlement amounts from surgical malpractice claims in the United States, 1990-2006
Vol. 213, No. 3S, September 2011
tions, they may identify a quality gap, which could influence important outcomes.
Man or machine: Multi-institutional evaluation of automated chart review Christopher M Dodgion MD, MSPH, Thien M Nguyen BS, Anita Karcz MD, MBA, Yue-Yung Hu MD, MPH, Wei Jiang MS, Katherine A Corso MPH, Stuart R Lipsitz SCD, Leonard W D’Avolio PhD, Caprice C Greenberg MD, MPH, FACS Brigham and Women’s Hospital, Boston, MA, Massachusetts Veterans Epidemiology Research and Information Center, Boston, MA and Institute for Health Metrics, Burlington, MA INTRODUCTION: Obtaining valuable clinical information from the free text of medical records currently requires labor-intensive manual abstraction. With electronic medical records (EMR), variables in free text are accessible with automated retrieval, increasing the data available for research. We aimed to evaluate the feasibility of automated isolation and categorization of breast cancer patients’ pathology and operative reports in a multi-institutional cohort. METHODS: 6,037 patients underwent an operation for breast cancer at 66 hospitals from 2007-2008. 103,106 free text reports were isolated from these patients’ EMRs. Two surgical abstractors classified 1597 randomly selected documents as breast cancer operative notes, pathology reports and not relevant. This reference set was used to train and test the automated retrieval console (ARC). The ARC model was chosen to maximize sensitivity. Agreement between two chart categorizations (manual vs. manual or manual vs. ARC) was assessed using Cohen’s kappa. RESULTS: Overall, operative note, and pathology report manual abstractor agreement (kappa) was 0.92 (95% CI 0.89-0.95), 0.91 (95% CI 0.87-0.95) and 0.96 (95% CI 0.91-1) respectively. 152/1597 (9.5%) disagreements required adjudication by a surgical oncologist. ARC agreement with the adjudicated abstraction (kappa) was 0.88 (95% CI 0.84-0.92) overall and 0.86 (95% CI 0.82-0.91) for operative notes and 0.93 (95% CI 0.87-0.99) for pathology reports. CONCLUSIONS: ARC is nearly as reliable as manual chart review. This open source software can be used to categorize disease-specific free text reports across multiple EMR platforms. Utilizing ARC can facilitate rapid multi-institutional chart review for health services and clinical research.
A predictive model for readmission within 30 days after coronary artery bypass grafting Kelly Bettina Currie MD, Robert Lancey MD Bassett Healthcare, Cooperstown, NY INTRODUCTION: The literature suggests readmission rates within 30 days of discharge after coronary artery bypass grafting (CABG) are high (10.8-20.9%). As part of value-based purchasing, within the next two years Medicare is expected to begin using clinical outcomes, like readmission, as metrics for determining reimbursement. Although prior studies examined factors associated with readmission after CABG, none have developed a predictive model that iden-
Surgical Forum Abstracts S107
tifies individuals at risk. Such a model would be instrumental in appropriately focusing resources to prevent readmission. METHODS: A univariate analysis of institutional data (demographic/preoperative/intraoperative/postoperative specifics) from all patients undergoing cardiac surgery between March 2003 and September 2010 was performed to determine factors related to 30-day readmission. Chi-squared and independent t-test were used for categorical and continuous variables, respectively. A logistic regression was performed with variables having tests with p-value ⱕ 0.02. RESULTS: Independent predictors of readmission were the presence preoperatively of congestive heart failure, chronic lung disease, body mass index ⱖ 40, and time on cardiopulmonary bypass. A strong correlation between predicted and actual length of stay was uncovered, enhancing the ability to identify those at increased risk. From the data, a mathematical model was developed to serve as a function for predicting probability of readmission. CONCLUSIONS: By using patient-specific parameters for individual risk assessment for early readmission, a predictive model will provide the advantage of foresight when arranging postoperative services and determining follow up. The ultimate goal is quality improvement by reducing the readmission rate from preventable processes. The model will help in achieving this and consequently allow for maximum Medicare reimbursement.
Patterns and predictors of settlement amounts from surgical malpractice claims in the United States, 1990-2006 Ryan K Orosco MD, Jonathan Talamini JD, David C Chang PhD, MPH, Mark A Talamini MD, FACS University of California-San Diego, San Diego, CA INTRODUCTION: Medical malpractice litigation continues to be hotly debated, particularly given recent healthcare reform legislation. In this study the National Practitioner Data Bank (NPDB) data was scrutinized to evaluate predictors of malpractice claims ending in large payments. METHODS: Retrospective analysis of the NPDB from 1990-2006 involving physicians and/or residents. Payments were adjusted to 2006 dollars. Large payments defined as those exceeding one million dollars. Multivariate regression evaluated predictors of large payments. Statutory law in the states demonstrating significant predictive values was analyzed. RESULTS: A total of 58,518 claims were included. Patients were predominantly female (62%) and inpatient (63%) with mean age of 42 years. Claims per year decreased and payment sums increased over the study period. Median payment was $132,915 (95th percentile $983,263). Claims most frequently cited improper performance (42%). Adjusted analysis explored predictors of large settlements. Patient outcomes of quadriplegia/brain damage/life-long care (OR 142), major permanent injury (OR 66), and death (OR 28) increased the likelihood of large settlements. Compared to 20-69 year-olds, claims
S108
Surgical Forum Abstracts
involving children less than 10 years-old were 1.7 times more likely to receive large payments (p⫽0.005); and patients over 70 years were 80% less likely (p⬍0.0005). Other positive predictors included claims in Illinois, Connecticut, Wisconsin, Rhode Island, New York, Massachusetts, and Georgia. CONCLUSIONS: Nationwide, surgical malpractice claims are decreasing in number with rising payment amounts. Patient outcome is the strongest predictor of payment size although significant variation in payments between states exists. Heterogeneity of payment sizes among states suggests a profound impact from the local legal environments.
Impact of resident participation on perioperative outcomes in index laparoscopic general surgical cases: An analysis using the American College of Surgeons/ National Surgical Quality Improvement Program (ACS/ NSQIP) Participant Use File (PUF) S Scott Davis Jr MD, FACS, Farah A Husain MD, FACS, Kalyana C Nandipati MD, Edward Lin MD, FACS, Sebastian F Perez MSPH, John F Sweeney MD, FACS Emory University, Atlanta, GA INTRODUCTION: The current study was undertaken using the ACS/ NSQIP PUF file, to evaluate the impact of resident participation on perioperative outcomes for index laparoscopic surgeries. METHODS: Six index laparoscopic procedures were selected (appendectomy, cholecystectomy, gastric bypass, fundoplication, colectomy, inguinal hernia). A retrospective review of the ACS/NSQIP PUF file yielded 79,720 cases. Demographics, preoperative comorbidities, and ASA class, operative time, hospital length of stay, mortality, morbidity, and return to OR were assessed. An initial analysis comparing case outcomes with/without resident participation was undertaken. A subset analysis was undertaken by dividing the data set into junior (PGY 1-2), senior (PGY 3-5), or fellow (PGY ⬎5) groups. A p-value of ⬍0.05 was considered significant. RESULTS: The demographics, preoperative comorbidities, and ASA classes were clinically similar between groups. Operative times were 20-47% longer with resident participation, with basic procedures having greater differences (e.g.: laparoscopic cholecystectomy and laparoscopic appendectomy). Mortality and return to the OR were not clinically different. Morbidity rates were similar, although advanced procedures had rates that were higher with resident participation (15.5% vs 12.4% for colectomy and 5.2% vs 4.0% for gastric bypass). On subset analysis, participation of senior residents was associated with longer operative times. CONCLUSIONS: Operative times for laparoscopic procedures significantly increase with resident participation. Operative times are longer for senior residents implying greater resident involvement in the procedure. Outcomes are largely equivalent, although there are slightly higher morbidity rates with advanced procedures. This study supports resident participation but stresses the need to develop training techniques that occur outside the OR.
J Am Coll Surg
Prospective randomized controlled trial comparing two methods of securing skin grafts using negative pressure wound therapy: VAC and GSUC Justine C Lee MD, PhD, Mieczyslawa Franczyk PhD, MPH, Trang Q Nguyen MD, Matthew R Greives MD, Francisca Maertens, Amir H Dorafshar MB BCh, Lawrence J Gottlieb MD, FACS University of Chicago Medical Center, Chicago, IL INTRODUCTION: Negative pressure wound therapy (NPWT) revolutionized complicated wound management and contributed a new modality for securing skin grafts. However, the industry standard in NPWT, the VAC device, has limited accessibility due to the cost of utilization. In the past decade, we accumulated experience using gauze sealed with an occlusive dressing and wall suction (GSUC) as our primary method for NPWT. We now report a randomized controlled trial comparing the efficacy of GSUC versus VAC in securing skin grafts. METHODS: 81 wounds requiring split thickness skin grafts were prospectively enrolled from August 2009 to February 2011 and randomized to VAC or GSUC. Wounds were assessed 4 to 5 days postoperatively for adherence and re-evaluated 7-18 days postoperatively for graft take. Study failures and reoperative rates were reviewed. RESULTS: 42 wounds and 39 wounds were randomized to the GSUC and VAC study arms, respectively. Patient demographics were similar between groups. Wound size averaged 238 cm2 and received 4.39 days of NPWT. Skin graft take averaged 97.8% (p⫽0.03) for GSUC and 97.3% (p⫽0.04) for VAC. Reoperation was required for one wound in the VAC arm and three wounds in the GSUC arm. Two wounds were study failures due to loss of suction by the VAC system. Both wounds were salvaged by conversion to wall suction. CONCLUSIONS: NPWT is a useful method for promoting adherence and healing of skin grafts. We demonstrate that a low cost, readily accessible system utilizing standard gauze dressings and wall suction (GSUC) results in comparable skin graft take to the VAC device.
Single-incision surgery has higher cost with equivalent pain and quality of life scores compared to multiple-incision laparoscopic cholecystectomy: A prospective randomized blinded comparison Dennis Leung MS, Joan Carbray BS, Yumiko Hoeger BS, Woody Denham MD, FACS, Michael B Ujiki MD NorthShore University Health System, Evanston, IL and University of Chicago/Pritzker School of Medicine, Chicago, IL INTRODUCTION: Since the development of single-incision surgery, several retrospective studies have demonstrated its feasibility; however, randomized prospective trials are still lacking. We report a prospective randomized single-blinded trial with a cost analysis of single-incision to multiple-incision laparoscopic cholecystectomy. METHODS: After obtaining Institutional Review Board approval, patients with chronic cholecystitis, acute cholecystitis, or biliary dyskinesia were offered participation in this multi-hospital, multisurgeon trial. Consenting patients were computer randomized into
tions, they may identify a quality gap, which could influence important outcomes.
Man or machine: Multi-institutional evaluation of automated chart review Christopher M Dodgion MD, MSPH, Thien M Nguyen BS, Anita Karcz MD, MBA, Yue-Yung Hu MD, MPH, Wei Jiang MS, Katherine A Corso MPH, Stuart R Lipsitz SCD, Leonard W D’Avolio PhD, Caprice C Greenberg MD, MPH, FACS Brigham and Women’s Hospital, Boston, MA, Massachusetts Veterans Epidemiology Research and Information Center, Boston, MA and Institute for Health Metrics, Burlington, MA INTRODUCTION: Obtaining valuable clinical information from the free text of medical records currently requires labor-intensive manual abstraction. With electronic medical records (EMR), variables in free text are accessible with automated retrieval, increasing the data available for research. We aimed to evaluate the feasibility of automated isolation and categorization of breast cancer patients’ pathology and operative reports in a multi-institutional cohort. METHODS: 6,037 patients underwent an operation for breast cancer at 66 hospitals from 2007-2008. 103,106 free text reports were isolated from these patients’ EMRs. Two surgical abstractors classified 1597 randomly selected documents as breast cancer operative notes, pathology reports and not relevant. This reference set was used to train and test the automated retrieval console (ARC). The ARC model was chosen to maximize sensitivity. Agreement between two chart categorizations (manual vs. manual or manual vs. ARC) was assessed using Cohen’s kappa. RESULTS: Overall, operative note, and pathology report manual abstractor agreement (kappa) was 0.92 (95% CI 0.89-0.95), 0.91 (95% CI 0.87-0.95) and 0.96 (95% CI 0.91-1) respectively. 152/1597 (9.5%) disagreements required adjudication by a surgical oncologist. ARC agreement with the adjudicated abstraction (kappa) was 0.88 (95% CI 0.84-0.92) overall and 0.86 (95% CI 0.82-0.91) for operative notes and 0.93 (95% CI 0.87-0.99) for pathology reports. CONCLUSIONS: ARC is nearly as reliable as manual chart review. This open source software can be used to categorize disease-specific free text reports across multiple EMR platforms. Utilizing ARC can facilitate rapid multi-institutional chart review for health services and clinical research.
A predictive model for readmission within 30 days after coronary artery bypass grafting Kelly Bettina Currie MD, Robert Lancey MD Bassett Healthcare, Cooperstown, NY INTRODUCTION: The literature suggests readmission rates within 30 days of discharge after coronary artery bypass grafting (CABG) are high (10.8-20.9%). As part of value-based purchasing, within the next two years Medicare is expected to begin using clinical outcomes, like readmission, as metrics for determining reimbursement. Although prior studies examined factors associated with readmission after CABG, none have developed a predictive model that iden-
Surgical Forum Abstracts S107
tifies individuals at risk. Such a model would be instrumental in appropriately focusing resources to prevent readmission. METHODS: A univariate analysis of institutional data (demographic/preoperative/intraoperative/postoperative specifics) from all patients undergoing cardiac surgery between March 2003 and September 2010 was performed to determine factors related to 30-day readmission. Chi-squared and independent t-test were used for categorical and continuous variables, respectively. A logistic regression was performed with variables having tests with p-value ⱕ 0.02. RESULTS: Independent predictors of readmission were the presence preoperatively of congestive heart failure, chronic lung disease, body mass index ⱖ 40, and time on cardiopulmonary bypass. A strong correlation between predicted and actual length of stay was uncovered, enhancing the ability to identify those at increased risk. From the data, a mathematical model was developed to serve as a function for predicting probability of readmission. CONCLUSIONS: By using patient-specific parameters for individual risk assessment for early readmission, a predictive model will provide the advantage of foresight when arranging postoperative services and determining follow up. The ultimate goal is quality improvement by reducing the readmission rate from preventable processes. The model will help in achieving this and consequently allow for maximum Medicare reimbursement.
Patterns and predictors of settlement amounts from surgical malpractice claims in the United States, 1990-2006 Ryan K Orosco MD, Jonathan Talamini JD, David C Chang PhD, MPH, Mark A Talamini MD, FACS University of California-San Diego, San Diego, CA INTRODUCTION: Medical malpractice litigation continues to be hotly debated, particularly given recent healthcare reform legislation. In this study the National Practitioner Data Bank (NPDB) data was scrutinized to evaluate predictors of malpractice claims ending in large payments. METHODS: Retrospective analysis of the NPDB from 1990-2006 involving physicians and/or residents. Payments were adjusted to 2006 dollars. Large payments defined as those exceeding one million dollars. Multivariate regression evaluated predictors of large payments. Statutory law in the states demonstrating significant predictive values was analyzed. RESULTS: A total of 58,518 claims were included. Patients were predominantly female (62%) and inpatient (63%) with mean age of 42 years. Claims per year decreased and payment sums increased over the study period. Median payment was $132,915 (95th percentile $983,263). Claims most frequently cited improper performance (42%). Adjusted analysis explored predictors of large settlements. Patient outcomes of quadriplegia/brain damage/life-long care (OR 142), major permanent injury (OR 66), and death (OR 28) increased the likelihood of large settlements. Compared to 20-69 year-olds, claims
S108
Surgical Forum Abstracts
involving children less than 10 years-old were 1.7 times more likely to receive large payments (p⫽0.005); and patients over 70 years were 80% less likely (p⬍0.0005). Other positive predictors included claims in Illinois, Connecticut, Wisconsin, Rhode Island, New York, Massachusetts, and Georgia. CONCLUSIONS: Nationwide, surgical malpractice claims are decreasing in number with rising payment amounts. Patient outcome is the strongest predictor of payment size although significant variation in payments between states exists. Heterogeneity of payment sizes among states suggests a profound impact from the local legal environments.
Impact of resident participation on perioperative outcomes in index laparoscopic general surgical cases: An analysis using the American College of Surgeons/ National Surgical Quality Improvement Program (ACS/ NSQIP) Participant Use File (PUF) S Scott Davis Jr MD, FACS, Farah A Husain MD, FACS, Kalyana C Nandipati MD, Edward Lin MD, FACS, Sebastian F Perez MSPH, John F Sweeney MD, FACS Emory University, Atlanta, GA INTRODUCTION: The current study was undertaken using the ACS/ NSQIP PUF file, to evaluate the impact of resident participation on perioperative outcomes for index laparoscopic surgeries. METHODS: Six index laparoscopic procedures were selected (appendectomy, cholecystectomy, gastric bypass, fundoplication, colectomy, inguinal hernia). A retrospective review of the ACS/NSQIP PUF file yielded 79,720 cases. Demographics, preoperative comorbidities, and ASA class, operative time, hospital length of stay, mortality, morbidity, and return to OR were assessed. An initial analysis comparing case outcomes with/without resident participation was undertaken. A subset analysis was undertaken by dividing the data set into junior (PGY 1-2), senior (PGY 3-5), or fellow (PGY ⬎5) groups. A p-value of ⬍0.05 was considered significant. RESULTS: The demographics, preoperative comorbidities, and ASA classes were clinically similar between groups. Operative times were 20-47% longer with resident participation, with basic procedures having greater differences (e.g.: laparoscopic cholecystectomy and laparoscopic appendectomy). Mortality and return to the OR were not clinically different. Morbidity rates were similar, although advanced procedures had rates that were higher with resident participation (15.5% vs 12.4% for colectomy and 5.2% vs 4.0% for gastric bypass). On subset analysis, participation of senior residents was associated with longer operative times. CONCLUSIONS: Operative times for laparoscopic procedures significantly increase with resident participation. Operative times are longer for senior residents implying greater resident involvement in the procedure. Outcomes are largely equivalent, although there are slightly higher morbidity rates with advanced procedures. This study supports resident participation but stresses the need to develop training techniques that occur outside the OR.
J Am Coll Surg
Prospective randomized controlled trial comparing two methods of securing skin grafts using negative pressure wound therapy: VAC and GSUC Justine C Lee MD, PhD, Mieczyslawa Franczyk PhD, MPH, Trang Q Nguyen MD, Matthew R Greives MD, Francisca Maertens, Amir H Dorafshar MB BCh, Lawrence J Gottlieb MD, FACS University of Chicago Medical Center, Chicago, IL INTRODUCTION: Negative pressure wound therapy (NPWT) revolutionized complicated wound management and contributed a new modality for securing skin grafts. However, the industry standard in NPWT, the VAC device, has limited accessibility due to the cost of utilization. In the past decade, we accumulated experience using gauze sealed with an occlusive dressing and wall suction (GSUC) as our primary method for NPWT. We now report a randomized controlled trial comparing the efficacy of GSUC versus VAC in securing skin grafts. METHODS: 81 wounds requiring split thickness skin grafts were prospectively enrolled from August 2009 to February 2011 and randomized to VAC or GSUC. Wounds were assessed 4 to 5 days postoperatively for adherence and re-evaluated 7-18 days postoperatively for graft take. Study failures and reoperative rates were reviewed. RESULTS: 42 wounds and 39 wounds were randomized to the GSUC and VAC study arms, respectively. Patient demographics were similar between groups. Wound size averaged 238 cm2 and received 4.39 days of NPWT. Skin graft take averaged 97.8% (p⫽0.03) for GSUC and 97.3% (p⫽0.04) for VAC. Reoperation was required for one wound in the VAC arm and three wounds in the GSUC arm. Two wounds were study failures due to loss of suction by the VAC system. Both wounds were salvaged by conversion to wall suction. CONCLUSIONS: NPWT is a useful method for promoting adherence and healing of skin grafts. We demonstrate that a low cost, readily accessible system utilizing standard gauze dressings and wall suction (GSUC) results in comparable skin graft take to the VAC device.
Single-incision surgery has higher cost with equivalent pain and quality of life scores compared to multiple-incision laparoscopic cholecystectomy: A prospective randomized blinded comparison Dennis Leung MS, Joan Carbray BS, Yumiko Hoeger BS, Woody Denham MD, FACS, Michael B Ujiki MD NorthShore University Health System, Evanston, IL and University of Chicago/Pritzker School of Medicine, Chicago, IL INTRODUCTION: Since the development of single-incision surgery, several retrospective studies have demonstrated its feasibility; however, randomized prospective trials are still lacking. We report a prospective randomized single-blinded trial with a cost analysis of single-incision to multiple-incision laparoscopic cholecystectomy. METHODS: After obtaining Institutional Review Board approval, patients with chronic cholecystitis, acute cholecystitis, or biliary dyskinesia were offered participation in this multi-hospital, multisurgeon trial. Consenting patients were computer randomized into