Primary Care Malpractice Cases 'More Difficult to Defend'

September 30, 2013

Primary care practices account for fewer than 1 in 10 malpractice cases, but those cases are far more likely to be either settled or lost in a jury trial compared with non–general medical claims, according to a new study published online today in JAMA Internal Medicine.

In short, such cases in the primary care realm "seem more difficult to defend," write study author Gordon Schiff, MD, the associate director of the Center for Patient Safety Research and Practice at Harvard Medical School, Boston, Massachusetts, and coauthors.

Allegations of malpractice in claims involving primary care practices usually center on the failure to diagnose or on a delayed diagnosis. Dr. Schiff and coauthors blame the slip-ups generally on breakdowns in humdrum office processes such as updating patient and family histories, ordering tests, managing referrals, and following up with patients. Fortunately, they write, practices can implement safeguards to cure office dysfunction.

Dr. Schiff and his team looked at 7224 closed malpractice claims of 2 medical liability insurers in Massachusetts between 2005 and 2009 and identified 551, or 7.7%, arising from primary care practices. Of these cases, 72.1% were related to diagnosis, with medications (12.3%), other medical treatment (7.4%), communication (2.7%), patient rights (2.0%), and patient safety or security (1.5%) accounting for the others.

Cancer (35%), heart disease (8%), blood vessel diseases (5%), and infections (4%) topped the list of diagnoses.

The prime role of diagnosis in primary-care malpractice cases comes as no surprise. A study in the British Medical Journal Open published in July arrived at the same finding. More piquant was the finding that malpractice cases ended more badly in primary care than they did outside that broad specialty. The study by Dr. Schiff and coauthors reported that 1.6% of primary-care cases were lost in jury trials compared with 0.9% of all other cases. The difference in settlement rates for these 2 categories of cases — 35.2% versus 20.5%, respectively — also was substantial.

"Usually, what it means, when the malpractice insurers look at the case, they say 'This will be a hard case to win,' so they settle," said Dr. Schiff. "This is where you find an X-ray that was misread or not followed up on.

"They may not have monumental consequences such as taking off the wrong leg. But I think that in some ways they are also harder to defend."

"Not Talking About People in the Hinterland"

The study by Dr. Schiff and colleagues raised the caveat that what they discovered in Massachusetts may not be representative of the rest of the nation because their state abounds in academic institutions and affiliated medical practices.

However, in an interview with Medscape Medical News, Dr. Schiff said these practice differences do not pose a major limitation. The incidence of malpractice settlements and jury awards arising from botched diagnoses could be higher in other states, given the higher proportion of Massachusetts physicians affiliated with academic medical centers.

"We're not talking about people in the hinterland with no access to diagnostic technology or specialists," said Dr. Schiff.

Improved office processes such as ensuring patients keep appointments with specialists or obtain recommended tests will go a long way in reducing malpractice, according to Dr. Schiff. Well-designed electronic health record systems will further that cause. However, the merger and acquisition craze in healthcare that is shuffling physicians around may lead to more "ball dropping," he said.

Dr. Schiff described how several physician practices became aligned with a larger organization only to find that the specialists they normally referred to "were no longer on the approved list."

In the rush to get bigger and better, "I hope...we are creating accountability for these small day-to-day processes that really need improvement and help," he said.

The authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online September 30, 2013. Abstract


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