JAMA: Ambulatory, inpatient malpractice rates are similar
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Tara F. Bishop, MD, MPH, and colleagues from Weill Cornell Medical College, in New York City, conducted a study to compare the number, magnitude and type of paid malpractice claims for events in inpatient and outpatient settings. The study included an analysis of malpractice claims paid on behalf of physicians in outpatient and inpatient settings using data from the National Practitioner Data Bank (NPDB) from 2005 through 2009. The researchers evaluated trends in claims paid by setting, characteristics of paid claims and factors associated with payment amount.
In 2009, 10,739 malpractice payments were made on behalf of physicians. Of these payments, 4,910 (47.6 percent) were for events in the inpatient setting, 4,448 (43.1 percent) were for events in the outpatient setting and 966 (9.4 percent) involved events in both settings.
From 2005 to 2009, the number of claims decreased significantly in all three settings, but the rate of decline was greater for the inpatient setting compared with the outpatient setting. The proportion of payments for events in the outpatient setting increased a small but significant amount from 41.7 percent in 2005 to 43.1 percent in 2009. The average payment amount (in 2009 U.S. dollars) did not increase significantly in any of the settings.
The researchers found that in the inpatient setting, the most common types of adverse events were classified as surgical (34.1 percent), diagnostic (21.1 percent) and treatment (20.3 percent). "In the outpatient setting, the most common types of adverse events were classified as diagnostic (45.9 percent), treatment (29.5 percent) and surgical (14.4 percent)," the authors wrote.
Major injury was the most common outcome in both the inpatient (37.8 percent) and outpatient (36.1 percent) settings. Death was the next most common outcome in both the inpatient (36.1 percent) and outpatient (30.6 percent) settings, they reported.
In the inpatient setting, the average payment amount for events was significantly higher than that in the outpatient setting ($362,965 vs. $290,111), as was the median payment amount ($195,000 vs. $145,000).
"Our findings provide empirical support for suggestions that patient safety initiatives should focus on the outpatient setting, not just on inpatient care. The findings also support suggestions that more attention should be paid to adverse events related to diagnostic errors," Bishop and colleagues concluded, adding that improving patient safety will likely be even more difficult in the outpatient setting than in the inpatient setting.
"There are many more sites of outpatient care than inpatient care, and many outpatient sites may be too small to have well-trained staff who devote significant attention to improving patient safety."
There is good and bad news regarding the Bishop study, according to an accompanying editorial, "Malpractice Risk in Ambulatory Settings - An Increasing and Under-recognized Problem."
“I truly believe that the pattern of risk the study authors describe is what’s happening out there in terms of malpractice, and it’s very under-recognized,” said Gianna Zuccotti, MD, MPH, of the Risk Management Foundation of the Harvard Medical Institutions in Boston and contributing editor at JAMA, during an interview.
Zuccotti, along with Risk Management Foundation colleague Luke Sato, MD, wrote the editorial. “About half of malpractices events occur in an ambulatory setting and a lot of those are in general medicine and medical subspecialties. People don’t anticipate that,” said Zuccotti.
"It is good that malpractice claims, as reflected in the NPDB, apparently are decreasing overall. It is possible that this is the result of successful inpatient interventions such as physician team training, simulation, computerized order entry systems and a general increase in the awareness of safety and risk management.
"Highlighting ambulatory risk at this particular point in time is also good news. Nationally, hospitals and physicians are moving toward optimizing the implementation of health IT under the HITECH Act, which is establishing a definition of 'meaningful use' of HIT and is creating financial incentives for achieving meaningful use,” Zuccotti and Sato wrote in the editorial.
The bad news is that rigorous, effective ambulatory risk management programs currently do not exist, Zuccotti and Sato continued. “We need to understand at a granular level where the gaps in care are so we can develop intervention, either IT-based or not, but targeted at specific patterns and gaps,” Zuccotti said.
“There are no defined best practices or benchmarks. A few forward-looking institutions are considering and piloting such programs, but the need for additional research and testing of interventions is essential,” Zuccotti and Sato wrote. “Moreover, the other bad news is that more information is needed about the details of ambulatory risk, but it may not be forthcoming. A more granular understanding of gaps in ambulatory care is essential to developing programs to mitigate risk."
Zuccotti also mentioned that malpractice evaluations for programmatic development have some limitations. “They are a very small portion of the total number of events,” she explained. “They usually represent a confluence of different bad things like doctor-patient relationship issues or communications issues. It’s usually multiple consequential gaps that lead to an adverse event so that has to be kept in mind.”
Malpractice evaluations also represent a snapshot in time. “In other words, you can’t use malpractice as a measure for success for programmatic intervention because you’re not going to see it until long after the program is put in place,” Zuccotti concluded.