ORIGINAL ARTICLE

Characteristics of Orthopaedic Malpractice Claims of Pediatric and Adult Patients in Private Practice Matthew E. Oetgen, MD* and P. Divya Parikh, MPHw

Background: Medical liability exposure varies based on scope of practice, patient demographics, and location of practice. There is a generally held belief that treatment of pediatric patients increases one’s medicolegal risk. We examined a large national database of orthopaedic malpractice claims to determine if pediatric malpractice claims were associated with a less favorable medicolegal outcome compared with adults. Methods: Physician Insurers Association of America is an association of medical liability insurance carriers providing liability coverage for 60% of private practice physicians in the United States. The Physician Insurers Association of America data registry of closed medical liability claims was examined, including all orthopaedic claims between 1985 and 2012 in this review. Claims were categorized based on the age of the claimant (pediatric: less than 21 y, adult: 21 y or older). These groups were compared based on percentage of claims resulting in payment, indemnity paid, and years between occurrence of incident and filing of claim. In addition, the top 10 most prevalent claims were identified and compared between groups. Results: A total of 25,702 closed orthopaedic claims were included. Pediatric claims accounted for 13% of the data. The average time from incident to claim filing was 1.92 years for pediatrics and 1.59 years for adults. Pediatric claims resulted in a higher percent of payment (33% vs. 30%) and average indemnity paid ($189,732 vs. $180,171) compared with adults. Five of the top 10 conditions resulting in a claim in each group were the same. Comparing these 5 conditions, in general there were minimal differences in the average time to claim filing between the groups, but larger average indemnity paid in the pediatric group. Conclusions: There appear to be moderate differences in outcomes of orthopaedic malpractice claims between adult and pediatric patients. The longer statute of limitations associated with pediatric claims does not appear to portend a less favorable medicolegal outcome or excessively longer time to claims filing for pediatric patients. From the *Department of Orthopaedics and Sports Medicine, Children’s National Medical Center, Washington, DC; and wResearch and Risk Management, Physician Insurers Association of America, Rockville, MD. P.D.P. is an employee of the Physician Insurers Association of America (PIAA). M.E.O. declares no conflicts of interest. Reprints: Matthew E. Oetgen, MD, Department of Orthopaedics and Sports Medicine, Children’s National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010. E-mail: [email protected] national.org. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.

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Level of Evidence: Level II—prognostic study. Key Words: malpractice, liability claims, pediatric orthopaedics (J Pediatr Orthop 2016;36:213–217)

T

he cost of health care has received much attention in the past few years with all aspects of this issue being reviewed. Recent political activity has led to sweeping changes in the economics and delivery of health care and the much publicized Institute of Medicine report “To Err Is Human: Building a Safer Health System” led to significant changes in medicine to address patient safety issues. Medical liability, in many ways, lies at the crossroads of health care change. It has influence on health care participants, from physicians, to insurance companies, to patients. Efforts to limit medical liability risk exposure have improved patient safety, leading to such things as surgical time-outs, surgical sight marking, and resident work-hour restrictions. Financially, medical liability affects both patients, with its role in the overall cost of health care, and physicians, through insurance rates and indemnity awards. Because of its ubiquitous role in modern health care, evaluation of the system of medical liability is critical to the continued overhaul of the health care system. Previous work has examined medical liability in terms of scope and location of practice.1–3 Gould et al4 looked at orthopaedic medical liability in the acute care setting and found both technical errors in patient management, and poor physician-patient communication frequently led to malpractice claims independent of the severity of injury. This is similar to information found in other medical subspecialties. Oetgen et al5 examined medical professional liability claims in cardiology and found that problems with diagnostic errors and communication led to the majority of malpractice claims. Shea and colleagues studied the statutes of limitations for medical liability between different states in the United States and found a wide range of variability, with higher average and maximum times to bring medical liability claims for younger patients. They felt that this increased the liability risk for physicians treating pediatric patients.6 Recent surveys have shown that medical liability and liability risk does appear to be considered by both medical students and residents when choosing specialties, and avoidance of high-risk specialties may play a significant www.pedorthopaedics.com |

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role in physician shortages in some fields and in turn may significantly influence patient access to care.6,7 Although there does appear to be some differences in medical liability exposure for physicians treating pediatric patients as compared with adult patients, the actual effect of age of patient on medical liability is still unknown. Within orthopaedics there is a generally held belief that treatment of pediatric patients increases ones medicolegal liability risk.7 We examined a large national database of orthopaedic malpractice claims to determine if pediatric malpractice claims were associated with a less favorable outcome compared with adults.

METHODS The Physician Insurers Association of America (PIAA) is an association of 50 medical professional liability insurance carriers which provide liability insurance coverage for approximately 60% of physicians in practice in the United States. PIAA maintains a data registry, the Data Sharing Project, of medical professional liability claim information voluntarily submitted by 21 of the 50 member organizations on twice-yearly basis and available to physician/health researchers for scientific study at http:// www.piaa.us. This database contains information on closed claims in the form of patient diagnoses, cause of the claim, timing of the claim in relation to the incident, severity of the incident, as well as indemnity payments. The PIAA provides initial and ongoing training and standard coding instruction to provide the consistency of how loss causation information is provided. Claims data is reported to the PIAA database manager and director of research and risk management twice a year during submission cycles from PIAA member insurers. Claims professionals and risk managers code and submit the data from claims reported from their insured physician policies. As for retrieving and analytics of the data within PIAA for the purpose of this particular project, the research database manager and the director of research were involved. Within the PIAA data sharing registry a claim is defined as a written demand for compensation in the form of money or services, as such a claim is independent of the filing of a formal lawsuit. Closed claims are defined as those claims that have been resolved, either with or without payment to the claimant, through private agreement or court action. We included in our study all orthopaedic liability claims between 1985 (the start of the PIAA Data Sharing



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Project) and 2012 (last year available with complete data) for review. Claims were grouped based on the age of the claimant in the following groups: pediatric: less than 21 years old and adult: 21 years and older. The data from the 2 groups were then compared with examined percentage of claims resulting in a payment, average indemnity payment, and average years between occurrence of an incident and filing of a claim. In addition, the most prevalent malpractice claims categories in each group were identified, with the top 5 similar claims categories being compared. The data registry contained a total of 25,702 closed orthopaedic claims, of which 1826 claims (7.1%) were excluded from analysis due to missing data regarding age of the claimant. This left a total of 23,876 claims which were analyzed. Data management and statistical analysis was performed using Microsoft Excel (Microsoft Cooperation, Redmond, WA). Continuous data were compared using 2-tailed Student t tests and categorical data were compared using w2 analysis. Statistical significance was defined as a P < 0.05.

RESULTS Of the 23,876 total claims analyzed, 3159 (13%) were included in the pediatric group and 20,717 (87%) were included in the adult group. The comparison of these 2 groups is shown in Table 1. As can be seen from the data the pediatric group had a slightly longer time between incident occurrence and claim filing (16 wk) which was statistically significant. The range of from incident to filing of claim was 1 month to 15.7 years in the pediatric group, and 1 month to 19.3 years in the adult group. In addition, the pediatric group had a higher percentage of paid claims which was statistically significant and average indemnity paid, which did not reach statistical significance. The top 10 most prevalent claim categories for each group are listed in Table 2. In comparing the most frequent claims in each group the first 5 categories which were the same between groups were as follows: application of cast (pediatric #2, adult #9), arthroscopy of the knee (pediatric #3, adult #1), open reduction and internal fixation (ORIF) of the tibia (pediatric #9, adult #4), ORIF of the femur (pediatric #4, adult #8), and closed reduction of the radius and ulna (pediatric #1, adult #11).

TABLE 1. Comparison of Total Claims Between Pediatric and Adult Groups Average time between incident occurrence and claim filing (y) Percentage of claims resulting in payment (%) Average indemnity paid ($)

Pediatric Group

Adult Group

P

1.92 (0.04) 33 189,732 (7850)

1.59 (0.02) 30 180,171 (3246)

< 0.0001 < 0.0001 0.26

All data expressed as mean (SD).

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Characteristics of Orthopaedic Malpractice Claims

TABLE 2. Top 10 Most Frequent Claim Categories in the Pediatric and Adult Groups Pediatric Group

Adult Group

Categories

N

Database (%)

Categories

N

Database (%)

CR radius/ulna Application of cast Arthroscopy of knee ORIF femur fracture CR of tibia fracture CR humerus fracture Interview and evaluation ORIF radius/ulna fracture ORIF tibia fracture Removal of external fixator

52 49 45 34 26 21 21 20 20 20

5 4.7 4.3 3.2 2.3 2 2 1.9 1.9 1.9

Arthroscopy of knee Total hip replacement Total knee replacement ORIF tibia fracture Decompression of spinal canal Excision of intervertebral disk Release carpal tunnel ORIF femur fracture Application of cast Prescription of medication

253 247 223 202 193 191 190 163 121 111

4.1 4 3.6 3.3 3.1 3.1 3.1 2.7 2 1.8

CR indicates closed reduction; ORIF, open reduction and internal fixation.

Comparisons of these claim types between the groups are shown in Table 3.

DISCUSSION Medical liability is an important element in modern day health care. It contributes a substantial amount to the overall cost of health care in the United States through indemnity payments, lost wages as a result of patient injury, and the practice of defensive medicine, which appears to be a common practice overall and specifically within orthopaedics.1,2,8–12 The risk of facing a malpractice claim appears to differ based on medical subspecialty, with surgical subspecialties having the most risk.13 Previous work examining the structure of the liability system has found

variability in risk exposure of physicians based on scope of practice, location of practice, with speculation that patient demographics, specifically the age of the patient also effects risk variability.1–6,12,14 The previously exposed legal possibility of increased medical liability risk when treating pediatric patients has led to the perception that physicians treating pediatric patients are faced with less favorable medicolegal outcomes in medical liability cases.6 This perception has been expressed by physicians in training as a reason why pediatric specialties are avoided and in turn this has been suggested as a cause of physician shortage in some pediatric subspecialties.6,7 Despite this widely held perception, little data regarding actual medicolegal outcomes between adult and pediatric patient populations exist.

TABLE 3. Comparison of Claims Between Pediatric and Adult Groups Based on Most Frequent Claim Type ORIF femur fracture Time (y) Percentage Indemnity ($) ORIF tibia fracture Time (y) Percentage Indemnity ($) CR radius/ulna fracture Time (y) Percentage Indemnity ($) Application of cast Time (y) Percentage Indemnity ($) Arthroscopy of knee Time (y) Percentage Indemnity ($)

Pediatric Group

Adult Group

P

2.57 (0.26) 35 234,691 (36,162)

1.85 (0.12) 36 157,653 (16,516)

0.011 0.89 0.054

1.68 (0.22) 36 339,010 (56,630)

1.78 (0.70) 36 196,441 (17,819)

0.66 0.94 0.017

2.21 (0.16) 46 202,577 (34,205)

1.82 (0.11) 34 77,114 (24,071)

0.046 0.028 0.003

1.80 35 101,568 (25,828)

1.65 26 114,243 (16,436)

0.53 0.035 0.68

0.95 (0.15) 38 78,710 (26,077)

0.97 (0.07) 31 115,604 (10,998)

0.92 0.11 0.19

All data expressed as mean (SD). Time: average time between incident occurrence and claim filing (years); percentage: percentage of claims resulting in payment; indemnity: average indemnity paid ($). CR indicates closed reduction; ORIF, open reduction and internal fixation.

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In comparing adult and pediatric patient populations, we found very little clinical difference in outcomes of medical liability claims. The average time between the occurrence of an incidence and the filing of a malpractice claim was longer in the pediatric patient population and this difference in time to filing was found to be statistically significant; however, the absolute difference in time to filing between these groups was only 16 weeks. Thus, although there was a statistical difference between pediatric and adult populations in this regard, this difference is a small clinically significant difference. This trend held true for percentage of claims which resulted in payment and average indemnity paid between pediatric and adult populations. We found both a slightly higher percentage of paid claims and a higher average indemnity for pediatric claims; however, only the percentage of paid claims was statistically significant. The top 10 most prevalent categories of claims of medical malpractice between the groups is shown in Table 2. As can be seen, in the pediatric group, most malpractice claims were found to involve fractures and fracture management, whereas the adult group had a wider distribution of claims categories of fracture management and common adult orthopaedic procedures. These lists likely show the influence of the PIAA claims database representing primarily private practice physicians. This likely skews the representation of mostly common fracture management in the pediatric group, as most complex reconstructions and complex or known high-risk (supracondylar humerus fractures) fracture patterns are likely transferred to tertiary pediatric care hospitals, which are not represented in this database. When we looked at the liability risk between adult and pediatric populations in frequent clinic conditions resulting in malpractice claims we found some significant differences between these 2 groups; however, no pattern of liability risk emerged. ORIF of the femur showed a longer average time to claim filing for the pediatric group, but no statistical difference in percentage of claims resulting in payment or average indemnity paid. ORIF of the tibia showed a difference only in a significantly higher average indemnity paid in the pediatric group, whereas application of cast showed only a statistical difference in a higher percentage of paid claims for the pediatric group. Closed reduction of a radius and ulna fracture resulted in worse claims outcomes for time to claim, percentage of paid claims, and average indemnity paid in the pediatric group, whereas no difference in any of these factors were found in the knee arthroscopy category between the groups. Although it is difficult to make specific recommendations regarding clinical practice based on these data, it is reasonable to suggest that cases of pediatric radius/ulna, femur, and tibia fractures should be approached with greater care and communication between patient and physician should be emphasized from the start in these cases due to the apparent increased liability risk. Although this study benefits from an extremely large dataset, this also has the possibility to lead to some limitations. As the result of the number of claims which

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were available to be analyzed, small, clinically irrelevant differences in the data have the risk of becoming statistically significant differences. In addition, regional variations exist in medical liability laws, but we were unable to separate the data based on geographic region. As such, the applicability of these results may differ based on these region variations. The applicability to practice is another limitation of these data. The PIAA data sharing project gathers data from physicians in private practice, as such; extremely high acuity pediatric injuries or complex pediatric reconstructive procedures which may be referred by routine to tertiary care pediatric hospitals are likely underrepresented by these data. While this is a limitation, the database supports the fact that many pediatric injuries are treated by private practice physicians making this analysis useful. In addition, pediatric tertiary care facilities treat many of the conditions represented in the PIAA database in addition to higher acuity injuries, making much of these data applicable to these facilities as well. In the future, a study of malpractice claims from pediatric tertiary care hospitals as compared with the PIAA data may be useful to assess these differences. Overall, despite small differences between pediatric and adult patient populations, we found few clinically significant differences between these groups in their medical liability outcomes. The longer statute of limitations associated with pediatric malpractice claims does not appear to portend a less favorable medicolegal outcome or excessively longer time to claim filing for pediatric patients. These data may be useful for pediatric practitioners when negotiating malpractice insurance rates. In addition, we believe these data suggest that pediatric orthopaedic cases done in private practice settings have only a moderate increased risk compared with adult cases in the categories of average time to claim filing, percent payment, and indemnity paid. This information may help orthopaedic trainees when considering choosing pediatrics as a professional subspecialty. REFERENCES 1. Khan IH, Jamil W, Lynn SM, et al. Analysis of NHSLA claims in orthopedic surgery. Orthopedics. 2012;35:e726–e731. 2. Matsen FA III, Stephens L, Jette JL, et al. Lessons regarding the safety of orthopaedic patient care: an analysis of four hundred and sixty-four closed malpractice claims. J Bone Joint Surg Am. 2013;95:e201–e208. 3. Meinberg EG. Medicolegal information for the young traumatologist: better safe than sorry. J Orthop Trauma. 2012;26 (suppl 1): S27–S31. 4. Gould MT, Langworthy MJ, Santore R, et al. An analysis of orthopaedic liability in the acute care setting. Clin Orthop Relat Res. 2003;407:59–66. 5. Oetgen WJ, Parikh PD, Cacchione JG, et al. Characteristics of medical professional liability claims in patients with cardiovascular diseases. Am J Cardiol. 2010;105:745–752. 6. Shea KG, Scanlan KJ, Nilsson KJ, et al. Interstate variability of the statute of limitations for medical liability: a cause for concern? J Pediatr Orthop. 2008;28:370–374. 7. Salsberg ES, Grover A, Simon MA, et al. An AOA critical issue. Future physician workforce requirements: implications for orthopaedic surgery education. J Bone Joint Surg Am. 2008;90: 1143–1159.

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8. Horton JB, Hollier LH Jr. The current state of health care reform: the physicians’ burden. Aesthet Surg J. 2012;32:230–235. 9. Matsen FA III, Stephens L, Jette JL, et al. The quality of upper extremity orthopedic care in liability claims filed and claims paid. J Hand Surg Am. 2014;39:91–99. 10. Miller RA, Sampson NR, Flynn JM. The prevalence of defensive orthopaedic imaging: a prospective practice audit in Pennsylvania. J Bone Joint Surg Am. 2012;94:e18. 11. Pappas ND, Moat D, Lee DH. Medical malpractice in hand surgery. J Hand Surg Am. 2014;39:168–170.

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Characteristics of Orthopaedic Malpractice Claims

12. Sethi MK, Obremskey WT, Natividad H, et al. Incidence and costs of defensive medicine among orthopedic surgeons in the United States: a national survey study. Am J Orthop (Belle Mead, NJ). 2012;41:69–73. 13. Jena AB, Seabury S, Lakdawalla D, et al. Malpractice risk according to physician specialty. N Engl J Med. 2011;365: 629–636. 14. Patel P, Robinson BS, Novicoff WM, et al. The disruptive orthopaedic surgeon: implications for patient safety and malpractice liability. J Bone Joint Surg Am. 2011;93:e1261–e1266.

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Characteristics of Orthopaedic Malpractice Claims of Pediatric and Adult Patients in Private Practice.

Medical liability exposure varies based on scope of practice, patient demographics, and location of practice. There is a generally held belief that tr...
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