In the News

Malpractice claim numbers similar for inpatient, outpatient settings

More than half of all malpractice claims involve outpatient care, although inpatient claims are more expensive on average, a study found.

To report and compare the number, magnitude, and type of paid malpractice claims for each setting, researchers conducted a retrospective analysis of malpractice claims recorded by the National Practitioner Data Bank from 2005 through 2009. Results appeared in the June 15 Journal of the American Medical Association.

Researchers evaluated claims paid by setting, characteristics of paid claims, and factors associated with payment amount. In 2009, 10,739 malpractice claims were paid. Of these payments, 4,910 (47.6%) were for inpatient events and 4,448 (43.1%) were for outpatient events. Another 966 (9.4%) involved events in both settings.

While the overall number of malpractice claims decreased significantly from 2005 to 2009 in all three categories, inpatient claims declined the most. Inpatient claims declined from 6,515 in 2005 to 4,910 in 2009 while outpatient claims declined from 5,511 in 2005 to 4,448 in 2009 (P<0.001). The proportion of payments that were made for events in the outpatient setting increased a small but significant amount, from 41.7% in 2005 to 43.1% in 2009 (P<0.001).

For inpatient care, the events that led to the claims were most commonly surgical (34.1%), diagnostic (21.1%) and treatment-related (20.3%). In the outpatient setting, the most common were diagnostic (45.9%), treatment-related (29.5%) and surgical (14.4%). Major injury was the most common outcome in the inpatient (37.8%) and outpatient (36.1%) settings. Death was the second most common outcome in the inpatient (36.1%) and outpatient (30.6%) settings. The mean payment amount of $362,965 for inpatient events was significantly higher than the $290,111 for outpatient events (P<0.001). An editorial noted that malpractice claims are decreasing overall, but current ambulatory risk management is insufficient. “It is likely that with the continued shift to care delivery in ambulatory settings, the medical home, and the growth of hospital-based ambulatory networks, the risk of malpractice in the ambulatory setting will continue to increase,” it said.

Hospitalization rates for sepsis, septicemia up in U.S., CDC reports

Rates of hospitalization for sepsis and septicemia more than doubled from 2000 through 2008, according to a recent data brief from the Centers for Disease Control and Prevention's National Center for Health Statistics. Researchers analyzed data from the 2008 National Hospital Discharge Survey to examine trends in care for hospitalized patients with sepsis and septicemia. They found that the rate of a principal diagnosis of these conditions increased from 11.6 per 10,000 population in 2000 to 24.0 per 10,000 population in 2008, and that the rate of a principal or secondary diagnosis increased 70%, from 22.1 to 37.7 per 10,000 population. Patients age 65 and older were much more likely to be hospitalized for septicemia or sepsis than those younger than 65 (122.2 per 10,000 population vs. 9.5 per 10,000 population). Hospitalizations for septicemia and sepsis were associated with longer hospital stays than other conditions (8.4 days vs. 4.8 days), as well as higher in-hospital mortality rates (17% vs. 2%). The costs of treating sepsis and septicemia have also risen, to an estimated $14.6 billion in 2008, but mortality rates remained high even with increased spending. Only 2% of hospitalizations in 2008 were for sepsis or septicemia, but they accounted for 17% of inpatient deaths.

The authors hypothesized that the increases in sepsis and septicemia hospitalization rates may be due to an aging, chronically ill population; increased use of invasive procedures, chemotherapy, immunosuppressive drugs, and transplantation; and increased antibiotic resistance. Clinicians may also have been more likely to code for these conditions due to enhanced awareness during the study period, they noted. The complete data brief is available online.

Tool helps estimate heart failure patients' risk for low quality of life

Researchers have designed a simple tool to help recognize heart failure patients who, at the time of hospital discharge, are at high risk for death or an unfavorable quality of life.

Current prognostic models for heart failure patients focus only on death or readmissions, but quality-of-life (QoL) prognosis can help with shared decision making between physicians and patients, noted the authors of the study, published in the July Circulation: Cardiovascular Quality and Outcomes. Researchers analyzed data from 1,458 heart failure patients in the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial. Baseline data, including formal health status measures, were taken for these patients within 48 hours of hospital admission as well as one week and 24 weeks after hospital discharge. Health status was measured via the Kansas City Cardiomyopathy Questionnaire (KCCQ), a 23-item self-administered questionnaire for heart failure patients with scores ranging from 0 to 100, with higher scores reflecting better health status. The primary end point of the analysis was a composite of all-cause death or unfavorable QoL (defined by KCCQ <45 at weeks one and 24 after discharge).

There were 478 deaths (32.8%) and another 192 patients (13.2%) who had persistently unfavorable QoL throughout follow-up. After adjustment for 23 covariates, independent predictors of the composite end point were:

  • low baseline KCCQ score (per 10-U increase in baseline QoL: risk ratio [RR], 0.82; 95% CI, 0.78 to 0.87),
  • high B-type natriuretic peptide (500 to 999 pg/mL: RR, 1.27 [95% CI, 1.05 to 1.53]; ≥1000 pg/mL: RR, 1.41 [95% CI, 1.14 to 1.73], both compared with <500 pg/mL),
  • hyponatremia (sodium <135 mEq/L: RR, 1.30 [95% CI, 1.04 to 1.62] compared with sodium 135 to 145 mEq/L),
  • increased heart rate at discharge (per 10 bpm increase: RR, 1.08 [95% CI, 1.01 to 1.15]),
  • decreased systolic blood pressure at discharge (per 10 mm Hg increase: RR, 0.92 [95% CI, 0.88 to 0.97]),
  • absence of beta-blocker therapy at discharge (beta-blocker prescribed: RR, 0.80 [95% CI, 0.64 to 0.99]),
  • history of diabetes (HR, 1.18 [95% CI, 1.01 to 1.39]), and
  • history of arrhythmia (RR, 1.32 [95% CI, 1.08 to 1.60]).

A simplified predischarge heart failure score for later death or unfavorable QoL using nine clinical characteristics had moderate discrimination (c-statistic 0.72), the authors noted. The results should help physicians adhere to clinical practice guidelines that recommend discussing risk with heart failure inpatients. Providing a prognosis of QoL and death, rather than readmissions and death, gives information “that most directly relates to patients' concerns and experiences,” they wrote.

July change in physician trainees increases deaths, lowers efficiency

Year-end changeovers of physician trainees at teaching hospitals are associated with increased mortality and lower efficiency of care during July, a recent review of studies found.

Researchers reviewed 39 studies to determine the effect of the annual changeovers on patient outcomes including mortality, morbidity, medical errors and efficiency. Thirteen (33%) of the 39 studies, most of which were conducted in the U.S., were of higher quality. Studies with higher-quality designs and larger sample sizes more often showed higher mortality and lower efficiency at changeover, while studies examining morbidity and medical error outcomes were of lower quality and had inconsistent results. The review was published in the Sept. 6 Annals of Internal Medicine.

Overall, six (22%) of the studies showed increased mortality during trainee turnover compared with nonturnover months or nonteaching hospitals; most (five, or 83%) of these studies were of higher methodologic quality. For the higher-quality studies that showed an association, the effect size ranged from a relative risk increase of 4.3% to 12%, or an adjusted odds ratio of 1.08 to 1.34. For morbidity outcomes such as intraoperative complications or anesthesia-related events, only four of the 23 studies (17%) reported an increase, and only one of the four was of higher quality. Three of the six studies that reported medical error outcomes suggested changeovers were associated with worse outcomes; all six of the studies were of lower quality. Seven (37%) of the 19 studies that examined efficiency measures were higher quality and seven (37%) showed lower efficiency. The proportion of studies with a statistically significant reduction in efficiency was positively associated with study quality (4 of 7, or 57%) and higher sample size.

An editorialist called the review “superb,” saying it added evidence to a long-held suspicion that quality of care in academic hospitals declines at the beginning of the academic year. Many of the interventions to improve the so-called “July effect”—such as enhanced supervision, graduated clinical responsibilities, simulation and team training—are standard approaches in the Accreditation Council for Graduate Medical Education's accreditation standards, but “require political will and financial support for implementation,” he wrote.

12% of PCIs for nonacute indications are inappropriate

Twelve percent of the percutaneous coronary interventions (PCIs) done on patients with nonacute indications are inappropriate, a study found.

Researchers evaluated the appropriateness of 602,781 PCIs submitted to the National Cardiovascular Data Registry (NCDR) between July 1, 2009 and September 30, 2010. Acute indications for PCI were defined as those performed in the setting of acute coronary syndrome, including all myocardial infarctions, and unstable angina with high-risk features per the appropriate use criteria for coronary revascularization. All other PCIs were assumed to have been performed for nonacute indications. Researchers were able to classify 500,154 PCIs from 1,091 hospitals to an appropriate use criteria indication, and these comprised the study cohort. Results were stratified by whether the procedure was performed for an acute (71.1%) or nonacute (28.9%) indication, and were published in the July 6 Journal of the American Medical Association.

For acute indications, 98.6% of PCIs were classified as appropriate, 0.3% as uncertain and 1.1% as inappropriate. For nonacute indications, 50.4% were classified as appropriate, 38.0% as uncertain, and 11.6% as inappropriate. The majority of inappropriate PCIs for nonacute indications were in patients without angina (53.8%), those with low-risk ischemia on noninvasive stress testing (71.6%), or those who were on suboptimal antianginal therapy with only one or no medications (95.8%). There was large variation between hospitals in terms of appropriateness of nonacute procedures (median hospital rate for inappropriate PCI, 10.8%; interquartile range, 6.0% to 16.7%), and minimal variation in appropriateness for acute procedures.

These findings reflect contemporary practice and provide benchmarks for future assessment of PCI appropriateness, the authors said. Most of the inappropriate nonacute procedures were done in settings in which the benefit of PCI hasn't been shown, such as with mildly symptomatic angina or low-risk ischemia, they wrote. While some of the inappropriate procedures can be explained by patient preference or extenuating circumstances, “it is likely that clinician factors are responsible for many of these procedures,” suggesting a need for physician education on appropriateness, they said.