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Prevalence and Characteristics of Physicians Prone to Malpractice Claims
The Journal of Emergency Medicine, Vol. 50, No. 6, pp. 930–938, 2016 0736-4679/$ - see front matter
Abstracts , PREVALENCE AND CHARACTERISTICS OF PHYSICIANS PRONE TO MALPRACTICE CLAIMS. Studdert DM, Bismark MM, Mello MM, et al. N Engl J Med 2016;374:354–362 The current medical malpractice system has been described as a ‘‘reactive enterprise’’ in which wrongful physicians are identified after the fact. Even so, studies since the 1970s have continued to demonstrate a maldistribution of claims amongst the physician population where claim- and complaint-prone physicians account for an overwhelming proportion of malpractice claims. Analyses of previous claim patterns have indeed identified characteristic differences between those physicians with multiple claims against them and their colleagues with few or no claims. Ideally, the ability to identify and help socalled problem physicians before they amass multiple complaints and wrongdoing would be valuable to the medical profession, to patient care, and to the medicolegal system. Nonetheless, previous attempts to predict malpractice claims have had mixed results. The objectives of this study were threefold: first, to analyze the maldistribution of malpractice claims nationwide; second, to depict physician characteristics related to incurring multiple paid claims; and third, combine these and previous data to prospectively identify physician factors associated with incurring recurrent claims. Payment data from the January 2005 through December 2014 were obtained from the national practitioner data bank (NPDB), a confidential data repository created by Congress that tracks all claim payments against physicians. The total number of practicing physicians, broken down by specialty, was obtained from the American Medical Association (AMA) Physician Masterfile. Additional physician data obtained included sex, specialty, salary, and payment month and year from the Health Resources and Service Administration (HRSA). All paid claims were included with the exception of paid claims to physicians >65 years of age because retirement may have contributed to reduced payment or was a possible explanation of the absence of additional claims. The authors then calculated the distribution of paid claims in 2 pools: physicians with $1 claim incurred during the study period and all physicians during the study period. Analysis was carried out at the claim level. The outcome variable was a second paid claim, therefore conditional upon having a previous paid claim during the study period. Covariates included the number of previous paid claims during the study period, payment year, degree (MD vs. DO), specialty, sex, age, trainee status (resident vs. nonresident), practice location (state and rurality), and medical school location (United States vs. other). Covariates were timevarying throughout the study, meaning individual physician
characteristics could change (i.e., age, training status, and location). Specialty-specific risk of a claim was taken into account and adjusted for with a variable indicating the incidence of paid claims per 1000 physicians per year per specialty. There were 915,564 active physicians from 2005 to 2014, with 66,426 claims against 54,099 physicians. Of all physicians, only 6% had a paid claim, but approximately 1% of physicians had $2 paid claims during the study, which accounted for 32% of paid claims. When compared to the physician population as a whole, this subset of physicians represents an extreme concentration of claims. However, when the analysis of physician claims was restricted to those physicians with $1 paid claim against them, the distribution slightly normalized. Of all physicians with claims against them, 84% had only 1 paid claim and accounted for 68% of claims during the study period. However, of physicians with $1 claim, 16% had $2 claims and accounted for 32% of all claims. In multivariate analysis, paid claims increased with the number of previously paid claims. Comparing amongst physicians with 1 paid claim, physicians with another paid claim were twice as likely (hazard ratio [HR] 1.97 [95% confidence interval {CI} 1.86–2.07]) to have an additional claim. Risk of recurrence increased to 12 times that of physicians with 1 paid claim when physicians had $6 paid claims during the study period (HR 12.39 [95% CI 8.69– 17.65]). Recurrence risk produced similar estimates when compared within specialties, but when compared across specialties, procedural specialties (i.e., neurosurgery, orthopedic surgery, general surgery, plastic surgery, and obstetrics/gynecology) experienced approximately twice the recurrence risk of their internal medicine colleagues. Recurrence risk was lowest amongst psychiatrists (HR 0.60 [95% CI 0.43–0.82]). Male physicians accounted for 82% of total claims, and recurrence risk in male sex providers was 38% greater than female physicians (HR 1.38 [95% CI 1.30–1.46]). With regard to time, recurrence risk was highest immediately and for the year after a claim, and then gradually decreased thereafter. This study demonstrated an extreme clustering of physician claims to a small subset of physicians, and that the recurrence risk of additional claims increased monotonically with the number of claims. This study used a 10-year period for claim accumulation, and in comparison to previous data from shorter study windows, claim concentration by physicians was larger than what was previously reported. The authors propose that claim concentration is a function of 2 important but difficult to separate factors: first, the individual physician’s penchant for attracting claims; and second, the baseline incidence of claims in the population. Specialty was a clear determinant of risk recurrence, of which personality factors and baseline factors both apply. The temporal risk of recurrence needs additional research to better 930
The Journal of Emergency Medicine characterize the nature of recurrent claims over time. The authors identified several limitations that affected the results. Claim numbers were underestimated to the extent to which claims are unreported to the NPDB through ‘‘shielding’’ of physicians names from claims with the use of institutional codefendants (i.e., hospitals, integrated practice groups, or insurance companies). Second, physician head counts were used to assess risk rather than the more representative but difficult to quantify measures of claim risk (i.e., hours worked, patient volume, and patient case mix). Finally, the authors substantiated their focus on paid claims, but it is not necessarily the case that paid claims are full of merit and unpaid claims are not—rather, paid claims are more likely to involve substandard care. In conclusion, the authors suggest feasibility of reliable prediction of those physicians at risk for recurrent claims and further propose using malpractice claim patterns to revolutionize and individualize the liability and risk-management systems to improve quality of care. [Kathryn Eastley, MD Denver Health Medical Center, Denver, CO] Comments: This study strengthened previous literature describing claims clustering, and showed the extreme concentration of claims to a small subset of physicians and their monotonically increasing recurrence risk. Although the study had many limitations, these limitations were thoroughly addressed in the author’s discussion section. Most pertinent to emergency medicine was the use of the more basic head counts to describe overall risk. In a field where hours, patient volume, patient type, and patient case mix vary enormously, these factors are more than pertinent to describing the inherent and variable risks relevant to emergency medicine–specific complaints, error, and malpractice. Additional factors include physician wellness and workplace safety, and as these factors are being investigated with regard to residency training education and patient care quality, these factors should be studied with regards to complaints, error, and malpractice. , EFFECT OF GENDER ON OUTCOME OF OUT OF HOSPITAL CARDIAC ARREST IN THE RESUSCITATION OUTCOMES CONSORTIUM. Morrison LJ, Schmicker RH, Weisfeldt ML, et al. Resuscitation 2016;100:76–81 It is well documented in the literature that certain conditions have gender-based predominance because of specific hormonal regulation. Female reproductive hormones are believed to protect against cardiovascular disease. Previous research on the relationship between age- and sex-based out of hospital cardiac arrest (OHCA) has led to contradictory findings. Overall, women suffer less OHCA than men. The majority of previous studies have found that women suffer significantly lower unadjusted survival rates than men, but 1 European study found the opposite. Given these contradictory findings, the epidemiology of OHCA warrants further investigation. This was a retrospective analysis of all consecutive nontraumatic OHCA patients enrolled in the Resuscitation Outcomes Consortium (ROC) Epistry-Cardiac Arrest registry between
931 December 2005 and May 2007, before the start of the ROC intervention trials. The ROC is a North American network of 10 United States and Canadian sites investigating OHCA and serving >23.7 million people. All included patients received prehospital chest compressions, defibrillation, or a combination of the two. The primary outcome was survival to hospital discharge, and secondary outcomes included death in the field, return of spontaneous circulation (ROSC), and sustained ROSC on arrival to the hospital. Subjects were compared across age and sex groups, and were further stratified into 2 age cohorts to reflect pre- and postmenopausal reproductive hormone status: women of childbearing age (i.e., 15–45 years of age) and postmenopausal women >55 years of age. Over the study period, 14,690 consecutive patients were treated by emergency medical services (EMS) in the ROC network. Women comprised 36.4% of the cohort with a mean age of 68.3 years. The mean age of the male cohort was 64.2 years. Women were significantly more likely to suffer an unwitnessed arrest, an arrest in private, and were less likely to have bystander cardiopulmonary resuscitation (CPR) or defibrillation. In addition, women were significantly less likely to have a shockable rhythm. Notably, the median EMS response was the same between men and women, and there were no significant differences in CPR process measures. In terms of primary outcome, women were significantly less likely to survive to hospital discharge (p < 0.001). Women were also more likely to have resuscitation terminated in the field. With regard to the primary and secondary outcomes, after adjusting for all Utstein predictors, the difference between men and women’s survival to hospital discharge was not statistically significant (odds ratio [OR] 1.16 [95% CI 0.98–1.36]). However, women survived to hospital discharge at a significantly higher rate in the cohort aged 15–45 years (OR 1.66 [95% CI 1.04–2.64]). No difference was found in the women >55 years of age. This study showed that women are less likely to have favorable Utstein characteristics associated with positive OHCA outcomes, and that after adjusting for this difference in Utstein characteristics, there is no difference in survival to hospital discharge between men and women overall. In a subset of patients, however, the authors concluded that childbearing age women between the ages of 15 and 45 years experienced better adjusted survival rates than their male counterparts, suggesting a protective effect of female reproductive hormones. The authors cite previous experimental and clinical data supporting the hypothesis that female sex hormones may improve clinical outcomes after hypoxic-ischemic insults to kidney and brain, and that estrogen may affect inflammatory cascades and apoptotic signaling pathways. The authors call for future research to elucidate the underlying mechanisms inherent to this survival benefit that may lead to improved OHCA treatment strategies and other ischemia-related disease treatment. [Kathryn Eastley, MD Denver Health Medical Center, Denver, CO] Comments: This retrospective study adds interesting findings to the epidemiologic knowledge surrounding OHCA, clarifying that women’s overall adjusted OHCA survival is
Abstracts , PREVALENCE AND CHARACTERISTICS OF PHYSICIANS PRONE TO MALPRACTICE CLAIMS. Studdert DM, Bismark MM, Mello MM, et al. N Engl J Med 2016;374:354–362 The current medical malpractice system has been described as a ‘‘reactive enterprise’’ in which wrongful physicians are identified after the fact. Even so, studies since the 1970s have continued to demonstrate a maldistribution of claims amongst the physician population where claim- and complaint-prone physicians account for an overwhelming proportion of malpractice claims. Analyses of previous claim patterns have indeed identified characteristic differences between those physicians with multiple claims against them and their colleagues with few or no claims. Ideally, the ability to identify and help socalled problem physicians before they amass multiple complaints and wrongdoing would be valuable to the medical profession, to patient care, and to the medicolegal system. Nonetheless, previous attempts to predict malpractice claims have had mixed results. The objectives of this study were threefold: first, to analyze the maldistribution of malpractice claims nationwide; second, to depict physician characteristics related to incurring multiple paid claims; and third, combine these and previous data to prospectively identify physician factors associated with incurring recurrent claims. Payment data from the January 2005 through December 2014 were obtained from the national practitioner data bank (NPDB), a confidential data repository created by Congress that tracks all claim payments against physicians. The total number of practicing physicians, broken down by specialty, was obtained from the American Medical Association (AMA) Physician Masterfile. Additional physician data obtained included sex, specialty, salary, and payment month and year from the Health Resources and Service Administration (HRSA). All paid claims were included with the exception of paid claims to physicians >65 years of age because retirement may have contributed to reduced payment or was a possible explanation of the absence of additional claims. The authors then calculated the distribution of paid claims in 2 pools: physicians with $1 claim incurred during the study period and all physicians during the study period. Analysis was carried out at the claim level. The outcome variable was a second paid claim, therefore conditional upon having a previous paid claim during the study period. Covariates included the number of previous paid claims during the study period, payment year, degree (MD vs. DO), specialty, sex, age, trainee status (resident vs. nonresident), practice location (state and rurality), and medical school location (United States vs. other). Covariates were timevarying throughout the study, meaning individual physician
characteristics could change (i.e., age, training status, and location). Specialty-specific risk of a claim was taken into account and adjusted for with a variable indicating the incidence of paid claims per 1000 physicians per year per specialty. There were 915,564 active physicians from 2005 to 2014, with 66,426 claims against 54,099 physicians. Of all physicians, only 6% had a paid claim, but approximately 1% of physicians had $2 paid claims during the study, which accounted for 32% of paid claims. When compared to the physician population as a whole, this subset of physicians represents an extreme concentration of claims. However, when the analysis of physician claims was restricted to those physicians with $1 paid claim against them, the distribution slightly normalized. Of all physicians with claims against them, 84% had only 1 paid claim and accounted for 68% of claims during the study period. However, of physicians with $1 claim, 16% had $2 claims and accounted for 32% of all claims. In multivariate analysis, paid claims increased with the number of previously paid claims. Comparing amongst physicians with 1 paid claim, physicians with another paid claim were twice as likely (hazard ratio [HR] 1.97 [95% confidence interval {CI} 1.86–2.07]) to have an additional claim. Risk of recurrence increased to 12 times that of physicians with 1 paid claim when physicians had $6 paid claims during the study period (HR 12.39 [95% CI 8.69– 17.65]). Recurrence risk produced similar estimates when compared within specialties, but when compared across specialties, procedural specialties (i.e., neurosurgery, orthopedic surgery, general surgery, plastic surgery, and obstetrics/gynecology) experienced approximately twice the recurrence risk of their internal medicine colleagues. Recurrence risk was lowest amongst psychiatrists (HR 0.60 [95% CI 0.43–0.82]). Male physicians accounted for 82% of total claims, and recurrence risk in male sex providers was 38% greater than female physicians (HR 1.38 [95% CI 1.30–1.46]). With regard to time, recurrence risk was highest immediately and for the year after a claim, and then gradually decreased thereafter. This study demonstrated an extreme clustering of physician claims to a small subset of physicians, and that the recurrence risk of additional claims increased monotonically with the number of claims. This study used a 10-year period for claim accumulation, and in comparison to previous data from shorter study windows, claim concentration by physicians was larger than what was previously reported. The authors propose that claim concentration is a function of 2 important but difficult to separate factors: first, the individual physician’s penchant for attracting claims; and second, the baseline incidence of claims in the population. Specialty was a clear determinant of risk recurrence, of which personality factors and baseline factors both apply. The temporal risk of recurrence needs additional research to better 930
The Journal of Emergency Medicine characterize the nature of recurrent claims over time. The authors identified several limitations that affected the results. Claim numbers were underestimated to the extent to which claims are unreported to the NPDB through ‘‘shielding’’ of physicians names from claims with the use of institutional codefendants (i.e., hospitals, integrated practice groups, or insurance companies). Second, physician head counts were used to assess risk rather than the more representative but difficult to quantify measures of claim risk (i.e., hours worked, patient volume, and patient case mix). Finally, the authors substantiated their focus on paid claims, but it is not necessarily the case that paid claims are full of merit and unpaid claims are not—rather, paid claims are more likely to involve substandard care. In conclusion, the authors suggest feasibility of reliable prediction of those physicians at risk for recurrent claims and further propose using malpractice claim patterns to revolutionize and individualize the liability and risk-management systems to improve quality of care. [Kathryn Eastley, MD Denver Health Medical Center, Denver, CO] Comments: This study strengthened previous literature describing claims clustering, and showed the extreme concentration of claims to a small subset of physicians and their monotonically increasing recurrence risk. Although the study had many limitations, these limitations were thoroughly addressed in the author’s discussion section. Most pertinent to emergency medicine was the use of the more basic head counts to describe overall risk. In a field where hours, patient volume, patient type, and patient case mix vary enormously, these factors are more than pertinent to describing the inherent and variable risks relevant to emergency medicine–specific complaints, error, and malpractice. Additional factors include physician wellness and workplace safety, and as these factors are being investigated with regard to residency training education and patient care quality, these factors should be studied with regards to complaints, error, and malpractice. , EFFECT OF GENDER ON OUTCOME OF OUT OF HOSPITAL CARDIAC ARREST IN THE RESUSCITATION OUTCOMES CONSORTIUM. Morrison LJ, Schmicker RH, Weisfeldt ML, et al. Resuscitation 2016;100:76–81 It is well documented in the literature that certain conditions have gender-based predominance because of specific hormonal regulation. Female reproductive hormones are believed to protect against cardiovascular disease. Previous research on the relationship between age- and sex-based out of hospital cardiac arrest (OHCA) has led to contradictory findings. Overall, women suffer less OHCA than men. The majority of previous studies have found that women suffer significantly lower unadjusted survival rates than men, but 1 European study found the opposite. Given these contradictory findings, the epidemiology of OHCA warrants further investigation. This was a retrospective analysis of all consecutive nontraumatic OHCA patients enrolled in the Resuscitation Outcomes Consortium (ROC) Epistry-Cardiac Arrest registry between
931 December 2005 and May 2007, before the start of the ROC intervention trials. The ROC is a North American network of 10 United States and Canadian sites investigating OHCA and serving >23.7 million people. All included patients received prehospital chest compressions, defibrillation, or a combination of the two. The primary outcome was survival to hospital discharge, and secondary outcomes included death in the field, return of spontaneous circulation (ROSC), and sustained ROSC on arrival to the hospital. Subjects were compared across age and sex groups, and were further stratified into 2 age cohorts to reflect pre- and postmenopausal reproductive hormone status: women of childbearing age (i.e., 15–45 years of age) and postmenopausal women >55 years of age. Over the study period, 14,690 consecutive patients were treated by emergency medical services (EMS) in the ROC network. Women comprised 36.4% of the cohort with a mean age of 68.3 years. The mean age of the male cohort was 64.2 years. Women were significantly more likely to suffer an unwitnessed arrest, an arrest in private, and were less likely to have bystander cardiopulmonary resuscitation (CPR) or defibrillation. In addition, women were significantly less likely to have a shockable rhythm. Notably, the median EMS response was the same between men and women, and there were no significant differences in CPR process measures. In terms of primary outcome, women were significantly less likely to survive to hospital discharge (p < 0.001). Women were also more likely to have resuscitation terminated in the field. With regard to the primary and secondary outcomes, after adjusting for all Utstein predictors, the difference between men and women’s survival to hospital discharge was not statistically significant (odds ratio [OR] 1.16 [95% CI 0.98–1.36]). However, women survived to hospital discharge at a significantly higher rate in the cohort aged 15–45 years (OR 1.66 [95% CI 1.04–2.64]). No difference was found in the women >55 years of age. This study showed that women are less likely to have favorable Utstein characteristics associated with positive OHCA outcomes, and that after adjusting for this difference in Utstein characteristics, there is no difference in survival to hospital discharge between men and women overall. In a subset of patients, however, the authors concluded that childbearing age women between the ages of 15 and 45 years experienced better adjusted survival rates than their male counterparts, suggesting a protective effect of female reproductive hormones. The authors cite previous experimental and clinical data supporting the hypothesis that female sex hormones may improve clinical outcomes after hypoxic-ischemic insults to kidney and brain, and that estrogen may affect inflammatory cascades and apoptotic signaling pathways. The authors call for future research to elucidate the underlying mechanisms inherent to this survival benefit that may lead to improved OHCA treatment strategies and other ischemia-related disease treatment. [Kathryn Eastley, MD Denver Health Medical Center, Denver, CO] Comments: This retrospective study adds interesting findings to the epidemiologic knowledge surrounding OHCA, clarifying that women’s overall adjusted OHCA survival is