Fear Of Malpractice Litigation Research Articles

Overview of the Drivers of Low-Value Care Comment on "Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands".

Verkerk and colleagues explored the key drivers of low-value care from the perspective of 18 policy-makers and researchers who had led and evaluated at least one initiative to reduce low-value care or had been responsible for reducing low-value care in an organisation. They identified several drivers of low-value care presented in the 2017 Lancet Right Care Series (eg, fee for service payment systems, the pharmaceutical and medical device industry, fear of malpractice litigation, issues with research conduct and reporting, a culture of 'more is better' and 'new technology is better') but did not discuss some other important ones. In this commentary, we aim to extend the work of Verkerk and colleagues and provide some additional perspectives on the drivers of low-value care within the following categories: Economic incentives; Money, finance, and organisation; Knowledge beliefs, assumptions, bias and uncertainty; and Power and human relationships.

How defensive medicine is defined in European medical literature: a systematic review

ObjectivesDefensive medicine has originally been defined as motivated by fear of malpractice litigation. However, the term is frequently used in Europe where most countries have a no-fault malpractice system. The...

Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands.

Around the world, policies and interventions are used to encourage clinicians to reduce low-value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries. We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis. The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a 'more is better' culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy. Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care.

Medical Malpractice in Interventional Cardiology: Identifying Patterns and Areas for Improvement

Introduction: The feared possibility of involvement in a medical malpractice lawsuit ultimately becomes reality for many physicians in high-risk specialties including cardiology. In a survey of cardiologists and fellows, 15.9% of those from the United States and 13.5% from China stated they were influenced by the fear of malpractice litigation in at least half of all cases they managed daily. A study of 40,916 physicians covered by a large nationwide professional liability insurer from 1991 to 2005 found that the percentage of cardiologists facing a malpractice claim each year is between 7.5%-10%, above the average across all physicians. This study analyzes interventional cardiology malpractice claims by specific procedure and allegation types. Methods: Seventy-nine cardiology malpractice claims involving procedures were identified in a major nationwide legal database (over 200,000 cases) called VerdictSearch. An exemption was obtained from the Yale University Institutional Review Board. Baseline patient characteristics, reasons for lawsuit, and case outcomes were recorded. Statistical analysis included percentage distributions and Fisher’s exact test. Results: A defendant verdict was reached in 64.6% of cases; plaintiƒ verdict, 21.5% (with average payout $5,212,719.79); and settlement, 13.9%. Death was the injury in 48.1% of cases and did not influence the likelihood of a plaintiƒ verdict. Of the 53.2% of cases involving cardiac catheterization, angioplasty, or stenting, periprocedural injury was alleged in 83.3%, lack of informed consent in 7.1%, failure to perform the correct procedure in a timely manner or at all in 14.3%, and performance of an unnecessary procedure in 7.1% (Figure 1). The most common injury type was arterial (non-coronary), including injury to the catheterization site, followed by coronary artery dissection or tamponade (Figure 2). Electrophysiology procedures were the next most common category, and receiving a defendant verdict was significantly less likely for these cases than any other type. A cardiothoracic or vascular surgeon was named as a co-defendant in 25.3% of cases. In 12.6% of cases, cardiologist failure to obtain timely surgical consultation or ensure backup surgeon availability during procedure performance was alleged. Discussion: Comprehensively reviewing interventional cardiology malpractice claims can elucidate common contributory factors to adverse outcomes and practice improvement opportunities. This study ’ s results suggest, for instance, that securing appropriate cardiothoracic surgical backup prior to a catheterization, angioplasty, or stent procedure would significantly decrease the number of lawsuits. Diligence in the informed consent process should also be prioritized, as this area generated allegations in 7.1% of cases. Though VerdictSearch is a large, nationwide legal database, its content is limited to those attorneys, courts, and states who choose to report cases. However, any selection biases may be bidirectional and ultimately cancel each other out, since the attorney on the prevailing side of every case theoretically has equal incentive to report it to a public database so the verdict can be used as a marketing tool for that attorney. By uniquely stratifying cardiology malpractice claims within a large nationwide database by specific procedure types and allegations, this study points to factors that commonly contribute to adverse patient outcomes and enables cardiologists to reflect upon opportunities for clinical practice improvement.

Potential utility of an independent decision-making board for seriously ill patients lacking decisional capacity

Summary Physicians acknowledge that they are providing unnecessary medical care at the end of life for a variety of reasons, including fear of malpractice litigation, Medicare's fee-for-service reimbursement mechanism, patient and family requests for care, a culture of denial of mortality, and a physician culture which views a patient's death as a professional failure. Recent data suggest that more than one-fifth of medical care provided at the end of life is unnecessary. Although the problem of over-provision of medical care is now well recognized in the legal and medical literatures, private-ordering solutions, such as better communication training for physicians or improved patient decision aids, will have only marginally ameliorating effects. The inherent challenges in making medical decisions during terminal illness become even more complex when patients are unable to make these choices for themselves. Although patient autonomy, implemented via informed consent, is the primary principle that governs medical decision-making, including on behalf of patients who have lost decisional capacity, insufficient evidence of the patient's wishes coupled with uncertainty about prognosis often leaves physicians and family members in a quandary as to whether to implement or to continue providing therapeutic treatment or life-prolonging care. The default operation of the surrogate consent process in the U.S. means that, for patients who do not clearly opt out of life-prolonging treatment before losing decisional capacity, the path of least resistance often will lead to decisions in favour of initiating or continuing life-prolonging care. This state of affairs can lead to substantial stress for all parties concerned, along with the potential for conflict. This paper considers the potential utility and transplantability of a Canadian public decision-support mechanism in this context. In 1996, the provincial government of Ontario implemented a Consent and Capacity Board (CCB), an independent expert body charged, among other things, to mediate and resolve disputes in the context of surrogate decision-making. Two-plus decades of CCB evidence suggest this it provides a better shared, less confrontational and more robust decision-making process than is currently available within the U.S. surrogate decision-making rules. Thus, a CCB type mechanism has the potential to also improve surrogate decision-making at the end of life in the U.S. and this paper discusses the extent to which it is capable of being “transplanted” into the U.S. health system on a state-by-state basis.

Primary Care Providers' Response to the US Preventive Services Task Force Draft Recommendations on Screening for Prostate Cancer

Editorial Comment: Will anyone listen to the recommendation of the task force? These authors queried 123 practitioners in the Johns Hopkins Community Physicians practice, which in 2010 evaluated approximately 40,000 men 40 years or older who were eligible for prostate cancer screening. When asked how they thought the draft recommendations would change their approach, 2% said they would no longer order prostate specific antigen (PSA) testing, 22% said they would be much less likely do so, 39% said they would be somewhat less likely do so and 37% said they would not change their screening practices. However, even among those clinicians who agreed with the draft recommendations fewer than half (41%) stated that they would no longer order routine PSA testing or would be less likely to do so. Reasons that physicians would not change their practice included patient expectation for them to continue screening (75%); lack of time to explain changes (67%); fear of malpractice litigation (54%); and discomfort with uncertainty (42.5%). Finally, the clinicians who were most likely to believe that the draft recommendations would change their practice were also the providers who were least likely to report routinely ordering PSA in the past year. At the same time another article demonstrated that despite the U.S. Preventive Services Task Force recommendations against prostate cancer screening in men 75 years or older, PSA screening rates did not change.

Defenses to Malpractice: What Every Emergency Physician Should Know

Background Emergency medicine is a high-risk specialty that carries a constant risk of malpractice litigation. Fear of malpractice litigation can lead to less-than-optimal patient care as well as impairments in physician quality of life. Although malpractice fear can be ubiquitous among emergency physicians, most receive little to no education on malpractice. Discussion Medical malpractice requires that 1) The physician had a duty, 2) The physician breached the duty, 3) There was harm to the patient, and 4) The harm was caused by the physician’s breach of duty. Even if all four medical malpractice conditions are met, there are still special legal defenses that have been and can be used in court to exonerate the physician. These defenses include assumption of the risk, Good Samaritan, contributory negligence, comparative fault, sudden emergency, respectable minority, two schools of thought, and clinical innovation. Conclusions These legal defenses are illustrated and explained using defining precedent cases as well as hypothetical examples that are directly applicable to emergency medical practice. Knowledge of these special legal defenses can help emergency physicians minimize their risk of litigation when caring for patients.

Medical errors, apologies and apology laws

In everyday life when an error occurs, disclosure, apology and restitution are expected. In health care when a medical error occurs, disclosure and apology are often overridden by the fear of malpractice litigation. Full disclosure to the patient is the ethically and professionally responsible

Do Fears of Malpractice Litigation Influence Teaching Behaviors?

Background : Medical malpractice is prominently positioned in the consciousness of American physicians, and the perceived threat of malpractice litigation may push physicians to practice defensively and alter their teaching behaviors. Purpose : The purposes of this study were to characterize the attitudes of academic medical faculty toward malpractice litigation and to identify teaching behaviors associated with fear of malpractice litigation. Methods : We surveyed 270 full-time clinically active physicians in the Department of Medicine at a large academic medical center. The survey assessed physicians' attitudes toward malpractice issues, fear of malpractice litigation, and self-reported teaching behaviors associated with concerns about litigation. Results: Two hundred and fifteen physicians responded (80%). Faculty scored an average of 25.5 ± 6.9 (range = 6–42, higher scores indicate greater fear) on a reliable malpractice fear scale. Younger age (Spearman's ρ = 0.19, p = .02) and greater time spent in clinical activities (ρ = 0.26, p < .001) were correlated with higher scores on the Malpractice Fear Scale. Faculty reported that because of the perceived prevalence of lawsuits and claims made against physicians, they spend more time writing clinical notes for patients seen by learners (74%), give learners less autonomy in patient care (44%), and limit opportunities for learners to perform clinical procedures (32%) and deliver bad news to patients (33%). Faculty with higher levels of fear on the Malpractice Fear Scale were more likely to report changing their teaching behaviors because of this perceived threat (ρ = 0.38, p < .001). Conclusions: Physicians report changes in teaching behaviors because of concerns about malpractice litigation. Although concerns about malpractice may promote increased supervision and positive role modeling, they may also limit important educational opportunities for learners. These results may serve to heighten awareness to the fact that teaching behaviors and decisions may be influenced by the malpractice climate.

Essential Elements of a Technology and Outcomes Assessment Initiative

THE MISMATCH BETWEEN US HEALTH EXPENDITURES AND the resources devoted to learning which health interventions are most effective is both striking and unwise. Each year US individuals spend more than $2 trillion on health care. More than $100 billion is spent for research and development and for regulatory approval of new technologies. Yet total spending on technology assessment almost certainly falls short of $1 billion per year— 0.05% of all US health care spending. Some of the $2 trillion in health care expenditures buys services of little or no value. This waste has been attributed to misleading advertisements, media hype, misguided state and federal mandates, fear of malpractice litigation, misaligned reimbursement incentives, and generous insurance that encourages patients to ignore the cost of services. Efforts to curb the inappropriate use of medical technologies, however, can have only limited success unless they address the paucity of reliable information about their benefits, cost, and value. For decades, calls for more systematic assessment of medical technologies and outcomes have gone unheeded. Recently, however, federal legislators and officials have recognized that better information is imperative. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 mandated research on “outcomes, comparative clinical effectiveness, and appropriateness of health care.” The former Medicare administrator, Gail Wilensky, has described alternative structures for a technology assessment organization. Representatives, senators, and presidential candidates have supported legislation to fund comparative effectiveness initiatives. Renewed interest in technology and outcomes assessment efforts can be traced to several factors: disillusionment with traditional cost-containment approaches, deepening anxiety about the safety and effectiveness of drugs and medical care, recognition that little is known about the optimal use of existing diagnostic procedures and treatments, and the explosion in health care expenditures anticipated as baby boomers age. By 2015, the number of US individuals in their 60s—a decade of heavy use of medical care— will increase by nearly 50%. Simultaneously, because of scientific advances, many new technologies will enter clinical practice. The combination of new technologies and greater use of older medical interventions are the fundamental drivers of increasing health care costs. Increasing health care costs have induced employers and insurance companies to shift more financial responsibility onto individuals through “consumer-directed” health plans and health savings accounts. In addition, private health plans, Medicare, and Medicaid are likely to urge hospitals and clinicians to become agents of cost control. Essential to these efforts to enhance quality and lower costs is comprehensive, objective information about the absolute and relative costs and benefits of medical interventions. Technology assessment in the United States has been hampered by pressure and limited resources. In the early 1990s, key federal agencies dedicated to technology assessment, such as the Congressional Office of Technology Assessment, were eliminated. Efforts by other federal agencies are fragmented and underfunded. The Department of Veterans Affairs, the National Institutes of Health, and the Centers for Medicare & Medicaid Services have little money for technology assessment. The mission of the Agency for Healthcare Policy and Research (AHCPR) was technology and outcomes evaluation. But, in 1994, when the AHCPR sponsored research showing that there was inadequate evidence to support commonly performed back operations, its funding was almost eliminated at the behest of disgruntled orthopedic and neurosurgeons and congressional critics of the Clinton health plan. While AHCPR survived, it was chastened. Its name was changed to the Agency for Healthcare Research and Quality and it has generally avoided controversial issues. Most importantly, little of its small budget—$320 million—is dedicated to evaluative research. State and private technology evaluation activities supplement federal efforts. In 1985, the Blue Cross and Blue Shield Association established the Technology Evaluation Center “for assessing medical technologies through comprehen-

Physician and public opinions on quality of health care and the problem of medical errors.

The 1999 Institute of Medicine report on medical errors proposed major changes to the health care system and gained widespread media attention, yet there is limited information on physician or public opinion regarding recommendations from that report. Mail survey of 1000 Colorado physicians (n = 594) and 1000 national physicians (n = 304), and telephone survey of 500 Colorado households to assess agreement with several proposals and conclusions from the 1999 Institute of Medicine report. Most physicians believed that reduction of medical errors should be a national priority (69.7% of Colorado physicians). However, physicians were much less likely than the public to believe that quality of care is a problem (29.1% vs 67.6%; P<.001) or that a national agency is needed to address the problem of medical errors (24.1% vs 59.8%; P<.001). Uniformly, physicians believed that fear of medical malpractice is a barrier to reporting of errors and that greater legal safeguards are necessary for a mandatory reporting system to be successful. Nearly all physicians (92.9%) believed that more training in how to handle medical errors is needed, and 60.1% agreed that it is difficult to differentiate errors due to negligence from unintended errors. There appears to be widespread concern among physicians regarding medical errors, but only a minority in this survey believed that the problem is as significant as the Institute of Medicine and the public believe it to be. Our results suggest that physicians see several barriers to successful error reduction including difficulty defining errors, the need for more training in handling errors, and fear of malpractice litigation. Addressing these barriers will be a necessary step to increasing physician support for many of the changes proposed by the Institute of Medicine.

Medical malpractice, mistake prevention, and compensation.

Clinicians' fear of malpractice litigation is the most significant obstacle to the open reporting of medical mistakes. Without open reporting of medical mistakes, however, root cause analysis of mistakes cannot be done, thus undermining efforts to implement safeguards to minimize the occurrence of future mistakes. Efforts to prevent medical mistakes, therefore, must first directly address clinicians' fear of malpractice litigation. In this paper, we explore the relationship between the current malpractice system and clinicians' fear of litigation. Ultimately, we argue that both the prevention of medical mistakes and the goals of malpractice litigation itself will be better served if substantial malpractice reform is undertaken.

Physicians' Attitudes Toward Litigation and Defensive Practice: Development of a Scale

The authors' threefold purpose in this article was to (a) propose a model of the relationship between the emotional aspects of physicians' attitudes to medical errors (eg, fear of litigation) and their functional consequences (eg, tendency to defensive practice); (b) develop a measure of some of these attitudes; and (c) provide empirical support for some of the relationships in the model. Medical students and physicians responded to a questionnaire concerning their attitudes toward uncertainty and medical error. The dependent variables were two dimensions of attitudes to uncertainty (“reluctance to disclose uncertainty” and “stress from uncertainty”) and four dimensions of attitudes to medical error (“fear of litigation,” “support for self-regulation,” “tendency to defensive practice,” and “self-disclosure of errors”). Stress from uncertainty correlated with fear of malpractice litigation and defensive practice. They concluded that interventions that aim to increase physicians' tolerance of uncertainty may also reduce their fear of malpractice litigation and their tendency to defensive practice.

Private health insurance and a healthy personality: new risk factors for obstetric intervention?

In this study 242 nulliparous pregnant women completed standardized psychometric questionnaires and semi-structured interviews in the latter half of pregnancy and again 4-6 weeks postpartum. Discriminant function analysis revealed that the use of operative obstetric interventions was measurably influenced by psychosocial factors. Privately insured women were significantly more likely to experience instrumentally assisted (relative risk = 1.53, 95% CI: 1.05, 2.25) and Caesarean (relative risk = 1.91, 95% CI: 1.05, 3.46) deliveries than those receiving care in the public hospital system. The likelihood of experiencing these procedures was increased further among those who in late pregnancy were thinking clearly, had high self-esteem, mature means of dealing with anxiety, were confident in their knowledge of childbirth procedures and in secure partnerships with highly educated men. There was no evidence that either elevated anxiety or abnormalities of personality contributed to obstetric outcome. These findings indicate that obstetric decision-making is significantly influenced by patient personality and socioeconomic circumstances. In particular, they suggest that fear of malpractice litigation, physician convenience factors and the response of obstetricians to assured, well pregnancy-educated pregnant women may be influencing the use of operative intervention in delivery.

Conflicts of Interest in the Management of Silent Ischemia

Nonclinical factors that may pressure physicians to intervene when a patient presents with so-called silent ischemia, and that may compel a management course not necessarily in the patient's best interest, are explored. These factors include the public's "obsession" with cardiac health, the enormous potential market for pharmaceuticals and medical devices, the funding of ischemia research by drug and medical device companies, the growth of "interventional cardiology" as a subspecialty, the increasingly entrepreneurial approach to medical care on the part of physicians and hospitals, and the fear of malpractice litigation. Given the financial advantage to health facilities and practitioners in recommending an interventionist rather than a conservative approach to silent ischemia, Graboys questions whether studies to determine the optimal management of this condition will ever be undertaken.