In an examination of trends of malpractice claims, there has been a greater decline in the rate of paid claims for inpatient settings than outpatient settings, and in 2009, the number of malpractice claims for events resulting in paid malpractice claims in outpatient and inpatient settings were similar, according to a study in the June 15 issue of JAMA .
Much attention has been given to patient safety, but most initiatives have centered around inpatient care. “For example, in the past 5 years, the number of studies funded by the Agency for Healthcare Research and Quality on inpatient safety has been almost 10-fold that of outpatient studies,” according to background information in the article. “There are, however, almost 30 times more outpatient visits than hospital discharges annually, and invasive and high-technology diagnostic and therapeutic procedures are increasingly being performed in the outpatient setting.” The authors write that the number and dollar amount of malpractice cases that conclude with an award for the plaintiff may be taken as a crude indicator of the prevalence and seriousness of adverse medical events.
Tara F. Bishop, M.D., M.P.H., and colleagues from Weill Cornell Medical College, New York, conducted a study to compare the number, magnitude, and type of paid malpractice claims for events in inpatient and outpatient settings. The study included an analysis of malpractice claims paid on behalf of physicians in outpatient and inpatient settings using data from the National Practitioner Data Bank (NPDB) from 2005 through 2009. The researchers evaluated trends in claims paid by setting, characteristics of paid claims and factors associated with payment amount.
In 2009, 10,739 malpractice payments were made on behalf of physicians. Of these payments, 4,910 (47.6 percent) were for events in the inpatient setting, 4,448 (43.1 percent) were for events in the outpatient setting, and 966 (9.4 percent) involved events in both settings. From 2005 to 2009, the number of claims decreased significantly in all 3 settings, but the rate of decline was greater for the inpatient setting compared with the outpatient setting. The proportion of payments for events in the outpatient setting increased a small but significant amount from 41.7 percent in 2005 to 43.1 percent in 2009. The average payment amount (in 2009 U.S. dollars) did not increase significantly in any of the settings.
The researchers found that in the inpatient setting, the most common types of adverse events were classified as surgical (34.1 percent), diagnostic (21.1 percent), and treatment (20.3 percent). “In the outpatient setting, the most common types of adverse events were classified as diagnostic (45.9 percent), treatment (29.5 percent), and surgical (14.4 percent). Major injury was the most common outcome in both the inpatient (37.8 percent) and outpatient (36.1 percent) settings. Death was the next most common outcome in both the inpatient (36.1 percent) and outpatient (30.6 percent) settings.”
In the inpatient setting, the average payment amount for events was significantly higher than that in the outpatient setting ($362,965 vs. $290,111), as was the median (midpoint) payment amount ($195,000 vs. $145,000).
“Our findings provide empirical support for suggestions that patient safety initiatives should focus on the outpatient setting, not just on inpatient care. The findings also support suggestions that more attention should be paid to adverse events related to diagnostic errors,” the authors write. They add that improving patient safety will likely be even more difficult in the outpatient setting than in the inpatient setting. “There are many more sites of outpatient care than inpatient care, and many outpatient sites may be too small to have well-trained staff who devote significant attention to improving patient safety.”
“Given the longitudinal and often fragmented nature of outpatient care, future research should seek to develop a better understanding of the epidemiology of serious adverse medical events in the outpatient setting, including events that initially may not be obvious to patients; to better understand ways to reduce the frequency and severity of diagnostic errors; and to conduct root cause analysis of detected adverse events to help determine where, when, and how failures occur. These goals may be achievable through analysis of administrative data, malpractice claims, and patient records, particularly as the prevalence of electronic health records increases. This information will help inform the design of programs aimed at increasing the safety of outpatient care.”
Malpractice Risk in Ambulatory Settings – An Increasing and Underrecognized Problem
In an accompanying editorial, Gianna Zuccotti, M.D., M.P.H., and Luke Sato, M.D., of the Risk Management Foundation of the Harvard Medical Institutions Inc., Boston, (Dr. Zuccotti is also Contributing Editor, JAMA), write that there is both good and bad news regarding the findings of this study.
“It is good that malpractice claims, as reflected in the NPDB, apparently are decreasing overall. It is possible that this is the result of successful inpatient interventions such as physician team training, simulation, computerized order entry systems, and a general increase in the awareness of safety and risk management. Highlighting ambulatory risk at this particular point in time is also good news. Nationally, hospitals and physicians are moving toward optimizing the implementation of health information technology (HIT) under the Health Information Technology for Economic and Clinical Health (HITECH) Act, which is establishing a definition of ‘meaningful use’ of HIT and is creating financial incentives for achieving meaningful use.”
“The bad news is that rigorous, effective ambulatory risk management programs currently do not exist. There are no defined best practices or benchmarks. A few forward-looking institutions are considering and piloting such programs, but the need for additional research and testing of interventions is essential. Moreover, the other bad news is that more information is needed about the details of ambulatory risk, but it may not be forthcoming. A more granular understanding of gaps in ambulatory care is essential to developing programs to mitigate risk.”
Material adapted from JAMA.
 JAMA. 2011;3052427-2431.
 JAMA. 2011;3052464-2465.