Caroline Helwick

October 16, 2014

NEW ORLEANS — The number of malpractice claims related to chronic pain management is increasing, and many involve permanent disabling injury or death, according to a closed-claims analysis presented here at Anesthesiology 2014.

"Malpractice claims associated with chronic pain have increased in number and severity over the past three decades, and they have increased out of proportion to the increase in pain anesthesiologists," said Kelly Pollak, MD, from the University of Washington and the Seattle Cancer Care Alliance, who presented the findings.

Anesthesiologists prescribing opioid medications and those performing cervical neuraxial injections need to be particularly aware of the increase in severe adverse outcomes, investigators warn.

Not only have malpractice claims associated with chronic pain management increased, so has the number of pain specialists, who are using more potent analgesics and interventions, said Dr Pollak.

In the past, many claims involved epidural steroid injections, but those injuries tended to be minor and temporary. However, recent closed-claims analyses have identified an increase in major adverse outcomes, including death related to medication overdoses and major neurologic injury associated with pain treatment.

Dr Pollak and colleagues analyzed overall trends, type of care, and complications in chronic pain management malpractice claims from 1980 to 2012.

The investigators evaluated 10,367 anesthesia malpractice claims from the Anesthesia Closed Claims Project Database. They also examined the number of pain anesthesiologists, determined from surveys conducted by the American Medical Association, and the number of pain procedures performed, according to the National Anesthesia Clinical Outcomes Registry (NACOR).

During the study period, there were 1037 claims related to chronic pain management and 8545 related to surgical, obstetric, and acute pain. As a proportion of anesthesia malpractice claims, litigation for chronic pain management increased from 3% in 1980 to 18% in 2012 (P < .001), Dr Pollak reported.

Overdose Deaths, Major Neurologic Injury

The increase in claims related to chronic pain management could not be explained merely by the increase in pain specialists. "We found that pain claims increased by 6.3% for every 10 years, whereas the number of pain anesthesiologists increased by only 2.0% per 10 years," Dr Pollak said.

There was also a change in the type of pain management in malpractice claims. Medication management, as a proportion of claims, increased from 2% to 17% (P < .001); cervical neuraxial injections increased from 16% to 27% (P < .001); implantation, removal, and maintenance of devices increased from 3% to 16% (P < .001); and lumbar injections decreased from 37% to 17% (P < .001).

Importantly, complications associated with chronic pain claims rose considerably over the 30-year period, and some interventions were shown to be riskier than others, Dr Pollack reported.

In the 1980s, death was the cited reason for 6% of chronic pain malpractice claims, and severe nerve injury for another 6%; after 2000, there was a concerning increase in these rates, to 19% and 28%, respectively (P < .001).

"Deaths and severe nerve injury increased significantly, whereas temporary minor injuries actually decreased," she noted.

 
This is indirect evidence that cervical injections may be riskier than lumbar injections.
 

The most common outcome for lumbar and cervical injections was severe permanent disabling injury, often of the spinal cord. The most common adverse outcome for medication-related claims was death. Adverse outcomes related to implanted devices, however, tended to be temporary and not disabling.

In the NACOR database, which has collected data on 303,267 procedures from self-identified pain specialists, lumbar injections accounted for 61% of pain management procedures, cervical injections for 23%, and device implantations for 16%. In contrast, 44% of malpractice claims involved cervical injections, 29% involved lumbar injections, and 27% involved devices.

"This is indirect evidence that cervical injections may be riskier than lumbar injections," she suggested.

The investigators were not able to identify factors associated with the shift in frequency or severity of adverse outcomes appearing in chronic pain malpractice claims. They suspected that the increase in claims against anesthesiologists might be related to an overall increase in chronic pain care provided by anesthesiologists; however, the number of practicing pain specialists does not mirror this rise. It is possible that complications are actually increasing, she said, or the increase could be the result of changes in the type of treatment being offered.

Previous closed-claims analyses have been "very informative to the specialty, identifying areas where anesthesiologists can improve patient care and outcomes, said Michael Avram, PhD, from the Northwestern University Feinberg School of Medicine in Chicago, and executive editor of Anesthesiology, who comoderated the Best of the Clinical Abstracts session during which these results were presented.

This study "ranks up there with those," and provides "exciting data," he told Medscape Medical News.

He suggested that there is a need to better understand the physicians targeted by these claims. "We need to look hard at the data and at who is providing the care that's leading to the adverse outcomes. Are these all board-certified pain specialists? Are they other physicians? That's a very important factor that should be examined," he said.

Dr Avram added that some of the information could be used for prevention. "We heard that deaths were the most common adverse outcome associated with medications, and it was from a combination of opioids and sedatives. That's an alarm bell."

Dr Pollack and Dr Avram have disclosed no relevant financial relationships.

Anesthesiology 2014 from the American Society of Anesthesiologists (ASA): Abstract BOC02. Presented October 14, 2014.

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