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ACP HospitalistWeekly

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In the News for the Week of 8-24-11

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Highlights

Most doctors sued for malpractice never pay a claim

While most physicians are sued for malpractice at least once during their careers, the vast majority will never have to make an indemnity payment, a new study found. More...

Venous thromboembolism

New model predicts future risk of VTE

Researchers have devised a new algorithm to predict a patient's risk of developing venous thromboembolism (VTE) in the next five years, based on simple clinical variables. More...

Perioperative care

Central catheters play big role in postoperative DVT

Efforts to prevent postoperative deep vein thrombosis (DVT) should focus on limiting the use and duration of use of central catheters, and possibly increasing the use of anticoagulation with the catheters, authors of a new study concluded. More...

Critical care

Weaning after longer extubation period carries higher risk of death

Patients who are weaned more than seven days after the first attempt at extubation have a higher risk of death than those weaned after shorter periods, a study found. More...

Cartoon caption contest

And the winner is …

ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. More...

Physician editor: James S. Newman, FACP

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Highlights

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Most doctors sued for malpractice never pay a claim

While most physicians are sued for malpractice at least once during their careers, the vast majority will never have to make an indemnity payment, a new study found.

Researchers analyzed malpractice data from 1991 through 2005 for all physicians covered by a single large professional liability insurer with a nationwide client base. The study covered nearly 41,000 physicians and nearly 234,000 physician-years. Because the study relied on one insurer's results, researchers compared their data to similar figures in the National Practitioner Data Bank. Results appeared in the Aug. 18 issue of the New England Journal of Medicine.

By the age of 65 years, 75% of physicians in low-risk specialties had faced a malpractice claim, compared with 99% of physicians in high-risk specialties. Roughly 55% of physicians in internal medicine and its subspecialties were projected to face a malpractice claim by the age of 45 years. This contrasts with projections of 80% of physicians in surgical specialties, including general surgery, and 74% of physicians in obstetrics and gynecology. Among physicians in internal medicine, 89% were projected to face a malpractice claim by the age of 65 years.

Each year, an average of 7.4% of physicians had a malpractice claim filed against them. But only 1.6% of the physicians had to make an indemnity payment, so 78% of all claims did not result in payments. Annual rates of malpractices claims ranged from the top three specialties (19.1% in neurosurgery, 18.9% in thoracic-cardiovascular surgery, and 15.3% in general surgery) to the bottom three (5.2% in family medicine, 3.1% in pediatrics, and 2.6% in psychiatry). Internal medicine was only slightly higher than the average among physician specialties for frequency of claims made and claims resulting in payment.

The authors wrote that, "Our projections suggest that nearly all physicians in high-risk specialties will face at least one claim during their career; however, a substantial minority will not have to make an indemnity payment."

Overall, the mean indemnity payment was $274,887, and the median was $111,749. Mean payments ranged from $117,832 for dermatology to $520,923 for pediatrics, which was by far the largest mean payment among all specialties. Pediatrics' mean payment was more than $100,000 more than the second-highest specialty of pathology, which was $383,509. There was little correlation between mean payments and rates of being sued. For example, the average payment for neurosurgeons was $344,811, but neurosurgeons were the most likely to face a claim in a year.

Authors used their conclusions to interpret physicians' concerns about malpractice risk. "Although the frequency and average size of paid claims may not fully explain perceptions among physicians, one may speculate that the large number of claims that do not lead to payment may shape perceived malpractice risk. Physicians can insure against indemnity payments through malpractice insurance, but they cannot insure against the indirect costs of litigation, such as time, stress, added work, and reputational damage," they wrote.

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Venous thromboembolism

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New model predicts future risk of VTE

Researchers have devised a new algorithm to predict a patient's risk of developing venous thromboembolism (VTE) in the next five years, based on simple clinical variables.

Researchers in England and Wales conducted a prospective open cohort study of primary care patients in 564 general practices, using data that is routinely collected in practice. Participants were aged 25 to 84 years, had no record of pregnancy in the last year or of any VTE, and were not taking oral anticoagulation. There were 2,314,701 patients in the derivation cohort and 1,240,602 in the validation cohort. The main outcome was incident cases of VTE (either deep vein thrombosis [DVT] or pulmonary embolism [PE]) as recorded in primary care records or cause-of-death records. Cox proportional hazards models were used in the derivation cohort to create risk equations at one and five years from baseline. Researchers examined 21 prediction variables based on established risk factors for VTE, specifically those that are recorded in a patient's record and that patients are likely to know. The study was published online Aug. 16 in BMJ.

The VTE rate was 14.6 per 10,000 person years in the derivation cohort and 14.9 per 10,000 person years in the validation cohort. The predictor variables in the final simplified models for both sexes included: smoking status (smoker or non-smoker, and heavy/moderate/light smoker); history of varicose veins, heart failure and chronic kidney disease, any cancer, chronic obstructive pulmonary disease, inflammatory bowel disease, and hospital admission in the past six months; and current use of antipsychotics. For women, current use of tamoxifen, oral contraceptives and hormone replacement therapy were also included in the final model. Variables that didn't change risk, and weren't included in the models, were: current antiplatelet therapy, asthma, cardiovascular disease, atrial fibrillation, and family history of VTE.

The algorithm, embedded in a clinical risk calculator, could be useful in several clinical situations, such as to identify increased VTE risk on or before hospital admission, or before long flights, the authors said. In such cases, prophylaxis could be considered. The algorithm could also be used when considering whether to prescribe medications, such as oral contraceptives, that might increase VTE risk, as well as to identify high risk groups of patients who might need more testing, monitoring or preventive treatment, the authors noted. They cautioned, however, that the model is meant to identify patients at risk of VTE who might require prophylaxis before a medical procedure or other event, not to diagnose symptomatic patients or estimate changing risk during a hospital episode.

A guideline on the issue, "Venous Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice Guideline from the American College of Physicians," will appear in an upcoming issue of Annals of Internal Medicine.

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Perioperative care

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Central catheters play big role in postoperative DVT

Efforts to prevent postoperative deep vein thrombosis (DVT) should focus on limiting the use and duration of use of central catheters, and possibly increasing the use of anticoagulation with the catheters, authors of a new study concluded.

Researchers at an academic hospital analyzed data on 2,189 general surgery operations in 2008 and 2009. The review of medical records focused on perioperative complications, including DVT, which occurred within 30 days of an index hospitalization for surgery. DVT was defined as the presence of documented venous thrombosis within deep veins that required anticoagulation therapy or placement of a vena cava filter. Main outcomes included location of DVT, time of DVT diagnosis from index operation, presence of a concomitant central catheter, presence of an associated pulmonary embolism (PE), and 30-day mortality. Results were published online Aug. 15 in Archives of Surgery.

Thirty-five patients, or 1.6%, were identified with DVT in the perioperative period. Upper extremity DVT accounted for 40% of cases, lower extremity DVT accounted for 45.7% of cases, and the remaining 14.3% had combined upper and lower extremity DVT. The mean time between diagnosis of DVT and the index operation was 8.6 days; 83% of cases were diagnosed when patients were still in the hospital. Sixty percent of diagnosed patients had an indwelling central or peripherally inserted central catheter, 54% had an upper extremity catheter, and 6% had a femoral catheter. Concomitant PE occurred in 11.4% of patients with DVT, and 30-day mortality of DVT patients was 14.2%. Almost 63% of DVT patients had other complications like ventilator dependence, sepsis, infection, renal failure and pneumonia. Compliance with DVT prophylaxis according to Surgical Care Improvement Program criteria averaged 93% over the study period.

While DVT incidence after general surgery is low when prophylaxis is used, more than half of cases that do occur are caused by central catheters, the authors noted. As such, DVT prevention efforts should include closer scrutiny of the need for central catheters, including limiting the duration of catheter use, they said. Physicians should also consider adding—or increasing the dosage of—anticoagulation when central catheters are used, the authors concluded.

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Critical care

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Weaning after longer extubation period carries higher risk of death

Patients who are weaned more than seven days after the first attempt at extubation have a higher risk of death than those weaned after shorter periods, a study found.

To analyze outcomes based on a new weaning classification, researchers conducted a secondary analysis of patients who were weaned and underwent scheduled extubation from a cohort of almost 5,000 adult patients mechanically ventilated for more than 12 hours. The new weaning classification was based on expert consensus developed at an international conference, which proposed definitions based on the difficulty and length of the weaning process. Definitions included:

• simple weaning group: patients who were extubated on the same day as their first attempt of withdrawal from mechanical ventilation;
• difficult weaning group: patients who required up to 7 days to be extubated from the first attempt of withdrawal from mechanical ventilation;
• prolonged weaning group: patients who required more than 7 days of weaning after the first attempt of withdrawal from mechanical ventilation.

The prospective study enrolled patients from 349 participating intensive care units (ICU) in 23 participating countries beginning March 1, 2004. The study enrolled patients over a 1-month period at each center and followed each patient for the duration of mechanical ventilation, up to 28 days. There were 2,714 patients in the secondary cohort. The simple weaning group included 1,502 patients (55%); the difficult weaning group, 1,058 patients (39%); and the prolonged weaning group, 154 patients (6%). Results appeared in the Aug. 15 issue of the American Journal of Respiratory and Critical Care Medicine.

A spontaneous breathing trial with a T-piece was more commonly used in the simple weaning group than in other groups. A gradual reduction of pressure support was the preferred method for weaning in the difficult and prolonged weaning groups. There were significant differences (P<0.001) in the median days of weaning between the three groups: simple, 1 median day; difficult, 3 median days; and prolonged, 9 median days.

Overall ICU mortality was 7.1% (193 patients). After adjusting for other variables, only the prolonged weaning group had a significantly (P=0.01) higher mortality compared with the simple weaning group (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.17 to 3.31). Mortality for the difficult weaning group was similar to the simple weaning group (OR, 0.89; 95% CI, 0.65 to 1.22). Adjusted probability of death remained constant for any duration of weaning up to day seven, after which point the risk of death increased to 12.1%.

Patients with prolonged weaning represent a small proportion of ventilated patients reaching the weaning period, the authors wrote. Also, duration of mechanical ventilation before the start of weaning was associated with weaning outcome. Patients with chronic pulmonary disease, but not COPD, with neuromuscular disease or patients with pneumonia as the reason for initiating mechanical ventilation were more likely to have difficult or prolonged weaning, they wrote. Finally, the level of positive end expiratory pressure needed during ventilatory support was statistically associated with prolonged weaning.

Editorialists commented that weaning isn't needed because the majority of patients successfully complete their first spontaneous breathing trial. No evidence exists for gradual reduction of respiratory support. Instead, ventilator discontinuation should focus on aggressive treatment of the underlying disease. But too often, excessive sedation gets in the way, they wrote. "It is time to stop weaning from the ventilator and to start weaning old-fashioned ideas," they concluded.

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Cartoon caption contest

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And the winner is …

ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

"You say niacin gives you a flushing problem?"

This issue's winning cartoon caption was submitted by David S Borislow, ACP Member. Readers cast 88 ballots online to choose the winning entry. Thanks to all who voted! The winning entry captured 63.6% of the votes.

The runners-up were:

"I'm not sure there's a CPT code for this, but here goes ...."

"Of course, the informed consent form is a little longer if you want me to use this one ...."

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