An Effective Program to Reduce Malpractice Claims and Payments in a Large Orthopaedic Practice.

BACKGROUND: High reliability in health care requires a balance between intentionally designed systems and individual professional accountability. One element of accountability includes a process for addressing clinicians whose practices are associated with a disproportionate share of patient complaints. This study aimed to evaluate the impact of the Patient Advocacy Reporting System (PARS), a tiered intervention model to reduce patient complaints about clinicians. METHODS: A retrospective cohort study was conducted involving a southeastern U.S. orthopaedic group practice. The study assessed the implementation of the PARS program and subsequent malpractice claims from 2004 to 2020. RESULTS: The implementation of PARS was associated with an 83% reduction in malpractice claims cost per high-risk clinician after intervention (p = 0.05; Wilcoxon rank sum test). The overall practice group experienced an 87% reduction in mean annual claims cost per clinician (p = 0.007; segmented regression). The successful adoption required essential elements such as PARS champions, peer messengers, an Office of Patient Affairs, and a clear statement of practice values and professionalism expectations at the time of onboarding. CONCLUSIONS: The PARS program was successfully adopted within a surgical specialty group as a part of ongoing risk prevention and management efforts. The period following PARS was associated with a retrospectively measured reduction in malpractice claim costs. The PARS program can be effectively implemented in a large, single-specialty orthopaedic practice setting and, although not necessarily causal, was, in our case, associated with a period of reduced malpractice claim costs. CLINICAL RELEVANCE: We have learned in previous research that there are clear links between professionalism and patient outcomes (e.g., surgical complications), but agree that the focus here on medical malpractice is not directly clinical.

Coworker Reports about Unprofessional Behavior in Plastic Surgery.

BACKGROUND: Patient reports of unprofessional conduct by surgeons have been linked to postprocedure complications and increased risk for malpractice claims. Coworkers are also positioned to observe and report unprofessional behaviors, including concerns related to delivery of competent medical care, clear and respectful communication, integrity, and responsibility. This study compared rates of coworker concerns between plastic surgeons and other physicians (other surgical specialists and nonsurgeons), and characterized whether plastic surgery subspecialties differed in their rates of complaints. METHODS: Coworker concern data from January 1, 2014, to December 31, 2019, were retrieved from the Vanderbilt Center for Patient and Professional Advocacy's Coworker Observation Reporting System database. Specialty was classified as plastic surgery, non-plastic surgical, and nonsurgical. The plastic surgery cohort was further characterized by sex, medical school graduation year, predominant practice type (reconstructive only, aesthetic only, or hybrid), and postresidency training (ie, completion of a fellowship). RESULTS: The study cohort included 34,170 physicians (302 plastic surgeons, 7593 non-plastic surgeons, and 26,275 nonsurgeons). A greater proportion of plastic surgeons (13.6%) had one or more coworker concerns compared with nonsurgeons (10.8%) and non-plastic surgeons (6.1%) ( P < 0.001). The most prevalent concern category reported for plastic surgeons was clear and respectful communication. Among plastic surgeons who had no concerns versus those who had at least one concern, there was no significant difference when comparing sex, medical school graduation year, predominant practice type, or postresidency training. CONCLUSIONS: Plastic surgeons in this cohort study received more coworker reports than other surgeons and nonsurgical physicians. These data may be used by institutions to identify plastic surgeons at risk for preventable postprocedure complications and intervene with peer feedback intended to promote self-regulation.

Patient Complaints in Orthopedic Surgery: An Analysis Utilizing a Large National Database.

INTRODUCTION: Unsolicited patient complaints (UPCs) about surgeons correlate with surgical complications and malpractice claims. Analysis of UPCs in orthopedics is limited. METHODS: Patient complaint reports recorded at 36 medical centers between January 1, 2015 and December 31, 2018 were coded using a previously validated coding algorithm Patient Advocacy Reporting System. RESULTS: A total of 33,174 physicians had 4 consecutive years of data across the 36 participating medical centers and met other inclusion criteria. CONCLUSIONS: Orthopedists with high numbers of UPCs may benefit from being made aware of their elevated risk status in ways that invite reflection on underlying causes.

Professionalism of Admitting and Consulting Services and Trauma Patient Outcomes.

OBJECTIVE: To determine whether trauma patients managed by an admitting or consulting service with a high proportion of physicians exhibiting patterns of unprofessional behaviors are at greater risk of complications or death. SUMMARY BACKGROUND DATA: Trauma care requires high-functioning interdisciplinary teams where professionalism, particularly modeling respect and communicating effectively, is essential. METHODS: This retrospective cohort study used data from 9 level I trauma centers that participated in a national trauma registry linked with data from a national database of unsolicited patient complaints. The cohort included trauma patients admitted January 1, 2012 through December 31, 2017. The exposure of interest was care by 1 or more high-risk services, defined as teams with a greater proportion of physicians with high numbers of patient complaints. The study outcome was death or complications within 30 days. RESULTS: Among the 71,046 patients in the cohort, 9553 (13.4%) experienced the primary outcome of complications or death, including 1875 of 16,107 patients (11.6%) with 0 high-risk services, 3788 of 28,085 patients (13.5%) with 1 high-risk service, and 3890 of 26,854 patients (14.5%) with 2+ highrisk services (P < 0.001). In logistic regression models adjusting for relevant patient, injury, and site characteristics, patients who received care from 1 or more high-risk services were at 24.1% (95% confidence interval 17.2% to 31.3%; P < 0.001) greater risk of experiencing the primary study outcome. CONCLUSIONS: Trauma patients who received care from at least 1 service with a high proportion of physicians modeling unprofessional behavior were at an increased risk of death or complications.

Unsolicited patient complaints among radiation, medical, and surgical oncologists.

BACKGROUND: Unsolicited patient complaints (UPCs) about physician practices are nonrandomly associated with malpractice claims and clinical quality. The authors evaluated the distributions and types of UPCs associated with oncologists by specialty and assessed oncologist characteristics associated with UPCs. METHODS: This retrospective study reviewed UPCs associated with US radiation oncologists (ROs), medical oncologists (MOs), and surgical oncologists (SOs) from 35 health care systems from 2015 to 2018. Average total UPCs were compared by specialty in addition to sex, medical school graduation year, degree, medical school location, residency location, practice setting, and practice region. For continuous variables, linear regression was used to test for an association with total complaints. RESULTS: The study included 1576 physicians: 318 ROs, 1020 MOs, and 238 SOs. The average number of UPCs per physician was different and depended on the oncologic specialty: ROs had significantly fewer complaints (1.28; 95% confidence interval [CI], 1.02-1.54) than MOs (3.81; 95% CI, 3.52-4.10) and SOs (6.89; 95% CI, 5.99-7.79; P < .0001). In a multivariable analysis, oncologic specialty, recency of graduation, and academic practice were predictive of higher total UPCs (P < .05). UPCs described concerns with care and treatment (42.8%), communication (26.4%), accessibility (17.5%), concern for patient (10.3%), and billing (2.9%). CONCLUSIONS: ROs had significantly fewer complaints than MOs and SOs and may have a lower risk of malpractice claims as a group. In addition to oncologic specialty, a more recent year of medical school graduation and working at an academic center were independent risk factors for UPCs. Further research is needed to clarify the reasons underlying these associations and to identify interventions that decrease UPCs and associated risks. LAY SUMMARY: This study of 1576 oncologists found that radiation oncologists had significantly fewer complaints than medical oncologists, who in turn had significantly fewer complaints than surgical oncologists. Other characteristics associated with more patient complaints included recency of medical school graduation and practice in an academic setting. Oncologists' patient complaints provide information that may have practical applications for patient safety and risk management. Understanding and addressing the characteristics that increase the risk for complaints could improve patients' experiences and outcomes.

Development and Validation of a Model to Predict Neonatal Abstinence Syndrome.

OBJECTIVES: To develop and validate clinical risk prediction tools for neonatal abstinence syndrome (NAS). STUDY DESIGN: We developed prediction models for NAS based on a set of 30 demographic and antenatal exposure covariates collected during pregnancy. Data (outpatient prescription, vital, and administrative records), were obtained from enrollees in the Tennessee Medicaid Program from 2009 to 2014. Models were created using logistic regression and backward selection based on improvement in the Akaike information criterion, and internally validated using bootstrap cross-validation. RESULTS: A total of 218 020 maternal and infant dyads met inclusion criteria, of whom 3208 infants were diagnosed with NAS. The general population model included age, hepatitis C virus infection, days of opioid used by type, number of cigarettes used daily, and the following medications used in the last 30 day of pregnancy: bupropion, antinausea medicines, benzodiazepines, antipsychotics, and gabapentin. Infant characteristics included birthweight, small for gestational age, and infant sex. A high-risk model used a smaller number of predictive variables. Both models discriminated well with an area under the curve of 0.89 and were well-calibrated for low-risk infants. CONCLUSIONS: We developed 2 predictive models for NAS based on demographics and antenatal exposure during the last 30 days of pregnancy that were able to risk stratify infants at risk of developing the syndrome.

Do neurosurgeons receive more patient complaints than other physicians? Describing who is most at risk and how we can improve.

OBJECTIVE: The number of unsolicited patient complaints (UPCs) about surgeons correlates with surgical complications and malpractice claims. Using a large, national patient complaint database, the authors sought to do the following: 1) compare the rates of UPCs for neurosurgeons to those for other physicians, 2) analyze the risk of UPCs with individual neurosurgeon characteristics, and 3) describe the types of UPCs made about neurosurgeons. METHODS: Patient and family complaint reports among 36,265 physicians, including 423 neurosurgeons, 8292 other surgeons, and 27,550 nonsurgeons who practiced at 33 medical centers (22 academic and 11 regional) from January 1, 2014, to December 31, 2017, were coded with a previously validated Patient Advocacy Reporting System (PARS) algorithm. RESULTS: Among 423 neurosurgeons, 93% were male, and most (71%) practiced in academic medical centers. Neurosurgical subspecialties included general practice (25%), spine (25%), tumor (16%), vascular (13%), functional (10%), and pediatrics (10%). Neurosurgeons had more average total UPCs per physician (8.68; 95% CI 7.68-9.67) than nonsurgeons (3.40; 95% CI 3.33-3.47) and other surgeons (5.01; 95% CI 4.85-5.17; p < 0.001). In addition, a significantly higher percentage of neurosurgeons received at least one UPC (71.6%; 95% CI 67.3%-75.9%) than did nonsurgeons (50.2%; 95% CI 49.6%-50.8%) and other surgeons (58.2%; 95% CI 57.1%-59.3%; p < 0.001). Factors most associated with increased average UPCs were younger age, measured as median medical school graduation year (1990.5 in the 0-UPC group vs 1993 in the 14+-UPC group, p = 0.009) and spine subspecialty (13.4 mean UPCs in spine vs 7.9 mean UPCs in other specialties, 95% CI 2.3-8.5, p < 0.001). No difference in complaints was seen in those who graduated from non-US versus US medical schools (p = 0.605). The most common complaint types were related to issues surrounding care and treatment, communication, and accessibility, each of which was significantly more common for neurosurgeons than other surgical specialties (p < 0.001). CONCLUSIONS: Neurosurgeons were more likely to generate UPCs than other surgical specialties, and almost 3 out of 4 neurosurgeons (71.6%) had at least one UPC during the study period. Prior studies have shown that feedback to physicians about behavior can result in fewer UPCs. These results suggest that neurosurgeons have opportunities to reduce complaints and potentially improve the overall quality of care delivered.

Hepatitis C Testing Among Perinatally Exposed Infants.

BACKGROUND: Hepatitis C virus (HCV) prevalence doubled among pregnant women from 2009 to 2014, reaching 3.4 per 1000 births nationwide. Infants exposed to HCV may acquire HCV by vertical transmission. National guidelines recommend that infants exposed to HCV be tested; however, it is unclear if these recommendations are being followed. Our objectives were to determine if infants exposed to HCV were tested and to determine hospital- and patient-level factors associated with differences in testing. METHODS: In this retrospective cohort study of infants exposed to HCV who were enrolled in the Tennessee Medicaid program, we used vital statistics-linked administrative data for infants born between January 1, 2005, and December 31, 2014. Infants were followed until 2 years old. Multilevel logistic regression was used to assess the association of HCV testing and hospital- and patient-level characteristics. RESULTS: Only 23% of 4072 infants exposed to HCV were tested. Infants whose mothers were white versus African American (96.6% vs 3.1%; P <.001), used tobacco (78% vs 70%; P <.001), and had HIV (1.3% vs 0.4%; P = .002) were more likely to be tested. Infants exposed to HCV who had a higher median of well-child visits (7 vs 6; P <.001) were more likely to be tested. After accounting for maternal and infant characteristics and health care use patterns, African American infants were less likely to undergo general testing (adjusted odds ratio 0.32; 95% confidence interval, 0.13-0.78). CONCLUSIONS: Testing occurred in <1 in 4 infants exposed to HCV and less frequently among African American infants. Public health systems need to be bolstered to ensure that infants exposed to HCV are tested for seroconversion.

Individual short-acting opioids and the risk of opioid-related adverse events in adolescents.

PURPOSE: Hydrocodone, codeine, oxycodone, and tramadol are frequently prescribed to adolescents for moderate pain related to minor trauma or dental, surgical, or medical procedures. Pharmacokinetic and pharmacodynamic differences between these opioids could affect their relative safety. We aimed to compare occurrence of opioid-related adverse events in adolescents without cancer or other severe conditions taking hydrocodone, codeine, oxycodone, and tramadol. METHODS: Retrospective cohort study of 201 940 Tennessee Medicaid enrollees 12 to 17 years of age without cancer, other severe conditions, or evidence of substance abuse with 529 731 filled prescriptions for study opioids. Adverse events were defined as an emergency department visit, hospital admission, or death related to opioid use, confirmed by medical record review. Serious events had opioid-related escalation of care, hospitalization, or death. Propensity-score adjusted hazard ratios (HRs) were calculated with hydrocodone as the reference category. RESULTS: The incidence of opioid-related adverse events per 10 000 person-years of opioid exposure was 97.5 for hydrocodone (127 events/13 026 person-years), 91.2 for codeine (58/6,359), 229.7 for oxycodone (43/1,872), and 317.7 for tramadol (47/1479). The HRs for tramadol in comparison with hydrocodone for all and serious events were 2.98 (2.03-4.39) and 2.94 (1.81-4.75), respectively. Increased risk for tramadol was consistently present when the adverse events were restricted to those with neurologic-respiratory depression/other symptoms of possible overdose. CONCLUSION: In adolescents without cancer or other severe conditions prescribed short-acting opioids, the incidence of both all opioid-related adverse events and more serious events with opioid-related escalation of care, hospitalization, or death was consistently greater for tramadol than for hydrocodone.

Increased Severity of Neonatal Abstinence Syndrome Associated With Concomitant Antenatal Opioid and Benzodiazepine Exposure.

BACKGROUND: Polysubstance use is common among opioid-using women, yet its association with pharmacotherapy for neonatal abstinence syndrome (NAS) remains unclear. We hypothesized that benzodiazepine exposure would increase risk of an infant developing pharmacologically treated NAS. METHODS: We conducted a retrospective cohort study of maternal-infant dyads enrolled in Tennessee Medicaid, using individual-level data linkage of vital records and administrative (ie, outpatient, inpatient, and prescription) data from 2009 to 2011. These data underwent chart review from 2013 to 2016 to obtain clinically relevant exposure data (eg, toxicology testing). The association of antenatal exposures with pharmacologically treated NAS was evaluated by using multivariable logistic regression, controlling for maternal and infant factors and clustered by hospital. RESULTS: Among 112 029 maternal-infant dyads, we confirmed 822 cases of NAS, of which 598 (72.7%) were cases of pharmacologically treated NAS. Infants who developed pharmacologically treated NAS were more likely to have been exposed to antenatal benzodiazepines compared with infants with confirmed NAS not treated pharmacologically (40.9% vs 30.8%; P = .008). In adjusted analyses, benzodiazepine exposure was associated with greater risk of developing pharmacologically treated NAS (odds ratio: 1.51; 95% confidence interval: 1.04-2.21). Alternatively, exposure to tobacco, marijuana, cocaine, gabapentin, and selective serotonin reuptake inhibitors were not associated with increased risk of developing pharmacologically treated NAS. CONCLUSIONS: Among a population of infants with intrauterine polysubstance exposure, benzodiazepine exposure was an independent predictor of an infant developing pharmacologically treated NAS. Obtaining history of antenatal benzodiazepine exposure among opioid-exposed infants may allow for risk stratification and development of personalized care plans.

Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients.

Importance: For surgical teams, high reliability and optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviors may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications. Objective: To test the hypothesis that patients of surgeons with higher numbers of reports from coworkers about unprofessional behaviors are at greater risk for postoperative complications than patients whose surgeons generate fewer coworker reports. Design, Setting, and Participants: This retrospective cohort study assessed data from 2 geographically diverse academic medical centers that participated in the National Surgical Quality Improvement Program (NSQIP) and recorded and acted on electronic reports of safety events from coworkers describing unprofessional behavior by surgeons. Patients included in the NSQIP database who underwent inpatient or outpatient operations at 1 of the 2 participating sites from January 1, 2012, through December 31, 2016, were eligible. Patients were excluded if they were younger than 18 years on the date of the operation or if the attending surgeon had less than 36 months of monitoring for coworker reports preceding the date of the operation. Data were analyzed from August 8, 2018, through April 9, 2019. Exposures: Coworker reports about unprofessional behavior by the surgeon in the 36 months preceding the date of the operation. Main Outcomes and Measures: Postoperative surgical or medical complications, as defined by the NSQIP, within 30 days of the operation. Results: Among 13 653 patients in the cohort (54.0% [7368 ] female; mean [SD] age, 57 [16] years) who underwent operations performed by 202 surgeons (70.8% [143] male), 1583 (11.6%) experienced a complication, including 825 surgical (6.0%) and 1070 medical (7.8%) complications. Patients whose surgeons had more coworker reports were significantly more likely to experience any complication (0 reports, 954 of 8916 [10.7%]; ≥4 reports, 294 of 2087 [14.1%]; P < .001), any surgical complication (0 reports, 516 of 8916 [5.8%]; ≥4 reports, 159 of 2087 [7.6%]; P < .01), or any medical complication (0 reports, 634 of 8916 [7.1%]; ≥4 reports, 196 of 2087 [9.4%]; P < .001). The adjusted complication rate was 14.3% higher for patients whose surgeons had 1 to 3 reports and 11.9% higher for patients whose surgeons had 4 or more reports compared with patients whose surgeons had no coworker reports (P = .05). Conclusions and Relevance: Patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient's operation appeared to be at increased risk of surgical and medical complications. These findings suggest that organizations interested in ensuring optimal patient outcomes should focus on addressing surgeons whose behavior toward other medical professionals may increase patients' risk for adverse outcomes.

Unsolicited Patient Complaints among Otolaryngologists.

OBJECTIVES: To analyze unsolicited patient complaints (UPCs) among otolaryngologists, identify risk factors for UPCs, and determine the impact of physician feedback on subsequent UPCs. METHODS: This retrospective study reviewed UPCs associated with US otolaryngologists from 140 medical practices from 2014 to 2017. A subset of otolaryngologists with high UPCs received peer-comparative feedback and was monitored for changes. RESULTS: The study included 29,778 physicians, of whom 548 were otolaryngologists. UPCs described concerns with treatment (45%), communication (19%), accessibility (18%), concern for patients and families (10%), and billing (8%). Twenty-nine (5.3%) otolaryngologists were associated with 848 of 3659 (23.2%) total UPCs. Male sex and graduation from a US medical school were statistically significantly associated with an increased number of UPCs ( P = .0070 and P = .0036, respectively). Twenty-nine otolaryngologists with UPCs at or above the 95th percentile received peer-comparative feedback. The intervention led to an overall decrease in the number of UPCs following intervention ( P = .049). Twenty otolaryngologists (69%) categorized as "responders" reduced the number of complaints an average of 45% in the first 2 years following intervention. DISCUSSION: Physician demographic data can be used to identify otolaryngologists with a greater number of UPCs. Most commonly, UPCs expressed concern regarding treatment. Peer-delivered, comparative feedback can be effective in reducing UPCs in high-risk otolaryngologists. IMPLICATIONS FOR PRACTICE: Systematic monitoring and respectful sharing of peer-comparative patient complaint data offers an intervention associated with UPCs and concomitant malpractice risk reduction. Collegial feedback over time increases the response rate, but a small proportion of physicians will require directive interventions.

Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events.

BACKGROUND AND OBJECTIVES: Little is known about opioid prescribing for children without severe conditions. We studied the prevalence of and indications for outpatient opioid prescriptions and the incidence of opioid-related adverse events in this population. METHODS: This retrospective cohort study between 1999 and 2014 included Tennessee Medicaid children and adolescents aged 2 to 17 without major chronic diseases, prolonged hospitalization, institutional residence, or evidence of a substance use disorder. We estimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid-related adverse events, defined as an emergency department visit, hospitalization, or death related to an opioid adverse effect. RESULTS: There were 1 362 503 outpatient opioid prescriptions; the annual mean prevalence of opioid prescriptions was 15.0%. The most common opioid indications were dental procedures (31.1% prescriptions), outpatient procedure and/or surgery (25.1%), trauma (18.1%), and infections (16.5%). There were 437 cases of opioid-related adverse events confirmed by medical record review; 88.6% were related to the child's prescription and 71.2% had no recorded evidence of deviation from the prescribed regimen. The cumulative incidence of opioid-related adverse events was 38.3 of 100 000 prescriptions. Adverse events increased with age (incidence rate ratio = 2.22; 95% confidence interval, 1.67-2.96; 12-17 vs 2-5 years of age) and higher opioid doses (incidence rate ratio = 1.86 [1.45-2.39]; upper versus lower dose tertiles). CONCLUSIONS: Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute, self-limited conditions. One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (71.2% of which were related to therapeutic use of the prescribed opioid).

Male Sex Associated With Increased Risk of Neonatal Abstinence Syndrome.

BACKGROUND: Neonatal abstinence syndrome (NAS) is a postnatal opioid withdrawal syndrome. Factors associated with development of the syndrome are poorly understood; however, infant sex may influence the risk of NAS. Our objective was to determine if infant sex was associated with the development or severity of the syndrome in a large population-based cohort. METHODS: This retrospective cohort study used vital statistics and prescription, outpatient, and inpatient administrative data for mothers and infants enrolled in the Tennessee Medicaid program between 2009 and 2011. Multivariable logistic regression models were used to evaluate the association between male sex and diagnosis of NAS, accounting for potential demographic and clinical confounders. NAS severity, as evidenced by hospital length of stay, was modeled by using negative binomial regression. RESULTS: Of 102 695 infants, 927 infants were diagnosed with NAS (484 male subjects and 443 female subjects). Adjustments were made for the following: maternal age, race, and education; maternal hepatitis C infection, anxiety, or depression; in utero exposure to selective serotonin reuptake inhibitors and cigarettes; infant birth weight, small for gestational age, and year; and the interaction between opioid type and opioid amount. Male infants were more likely than female infants to be diagnosed with NAS (adjusted odds ratio, 1.18 [95% confidence interval, 1.05-1.33]) and NAS requiring treatment (adjusted odds ratio, 1.24 [95% confidence interval, 1.04-1.47]). However, there was no sex-based difference in severity for those diagnosed with NAS. CONCLUSIONS: Treatment of NAS should be tailored to an infant's individual risk for the syndrome. Clinicians should be mindful that male sex is an important risk factor in the diagnosis of NAS.

Use of Unsolicited Patient Observations to Identify Surgeons With Increased Risk for Postoperative Complications.

Importance: Unsolicited patient observations are associated with risk of medical malpractice claims. Because lawsuits may be triggered by an unexpected adverse outcome superimposed on a strained patient-physician relationship, a question remains as to whether behaviors that generate patient dissatisfaction might also contribute to the genesis of adverse outcomes themselves. Objective: To examine whether patients of surgeons with a history of higher numbers of unsolicited patient observations are at greater risk for postoperative complications than patients whose surgeons generate fewer such unsolicited patient observations. Design, Setting, and Participants: This retrospective cohort study used data from 7 academic medical centers participating in the National Surgical Quality Improvement Program and the Vanderbilt Patient Advocacy Reporting System from January 1, 2011, to December 31, 2013. Patients older than 18 years included in the National Surgical Quality Improvement Program who underwent inpatient or outpatient operations at 1 of the participating sites during the study period were included. Patients were excluded if the attending surgeon had less than 24 months of data in the Vanderbilt Patient Advocacy Reporting System preceding the date of the operation. Data analysis was conducted from June 1, 2015, to October 20, 2016. Exposures: Unsolicited patient observations for the patient's surgeon in the 24 months preceding the date of the operation. Main Outcomes and Measures: Postoperative surgical or medical complications as defined by the National Surgical Quality Improvement Program within 30 days of the operation of interest. Results: Among the 32 125 patients in the cohort (13 230 men, 18 895 women; mean [SD] age, 55.8 [15.8] years), 3501 (10.9%) experienced a complication, including 1754 (5.5%) surgical and 2422 (7.5%) medical complications. Prior unsolicited patient observations for a surgeon were significantly associated with the risk of a patient having any complication (odds ratio, 1.0063; 95% CI, 1.0004-1.0123; P = .03), any surgical complication (odds ratio, 1.0104; 95% CI, 1.0022-1.0186; P = .01), any medical complication (odds ratio, 1.0079; 95% CI, 1.0009-1.0148; P = .03), and being readmitted (odds ratio, 1.0088, 95% CI, 1.0024-1.0151; P = .007). The adjusted rate of complications was 13.9% higher for patients whose surgeon was in the highest quartile of unsolicited patient observations compared with patients whose surgeon was in the lowest quartile. Conclusions and Relevance: Patients whose surgeons have large numbers of unsolicited patient observations in the 24 months prior to the patient's operation are at increased risk of surgical and medical complications. Efforts to promote patient safety and address risk of malpractice claims should continue to focus on surgeons' ability to communicate respectfully and effectively with patients and other medical professionals.

Unsolicited Patient Complaints in Ophthalmology: An Empirical Analysis from a Large National Database.

PURPOSE: The number of unsolicited patient complaints about a physician has been shown to correlate with increased malpractice risk. Using a large national patient complaint database, we evaluated the number and content of unsolicited patient complaints about ophthalmologists to identify significant risk factors for receiving a complaint. DESIGN: Retrospective cohort study. PARTICIPANTS: Ophthalmologists, nonophthalmic surgeons, nonophthalmic nonsurgeons. METHODS: We analyzed 2087 unsolicited or spontaneous complaints reported about 815 ophthalmologists practicing in 24 academic and nonacademic organizations using the Patient Advocacy Reporting System (PARS). Complaints against 5273 nonophthalmic surgeons and 19487 nonophthalmic nonsurgeons during the same period were used for comparison. Complaint type profiles were assigned using a previously validated standardized coding system. We (1) described the distribution of complaints against ophthalmologists; (2) compared the distribution and rates of patient complaints about ophthalmologists with those of nonophthalmic surgeons and nonophthalmic nonsurgeons in the database; (3) analyzed differences in complaint type profiles and quantity of complaints by ophthalmic subspecialty, practice setting, physician gender, medical school type, and graduation date; and (4) identified significant risk factors for high numbers of unsolicited patient complaints after adjusting for other covariates. MAIN OUTCOME MEASURES: Unsolicited patient complaints. RESULTS: Ophthalmologists had significantly fewer complaints per physician than other nonophthalmic surgeons and nonsurgeons. Sixty-three percent of ophthalmologists had 0 complaints, whereas 10% of ophthalmologists accounted for 61% of all complaints. Ophthalmologists from academic centers, female ophthalmologists, and younger ophthalmologists had significantly more complaints (P < 0.01), and general ophthalmologists had significantly fewer complaints than subspecialists (P < 0.05). After adjusting for covariates using multivariable analysis, working at an academic center was a statistically significant risk factor (adjusted relative risk, 1.82; 95% confidence interval, 1.36-2.43; P < 0.001). CONCLUSIONS: Ophthalmologists had significantly fewer complaints than nonophthalmic surgeons and nonophthalmic nonsurgeons, and by implication may have a lower malpractice risk as a group. Nevertheless, a small number of ophthalmologists generated a disproportionate number of complaints. Working at an academic center was a significant independent risk factor for having more patient complaints. Further research is needed to clarify the underlying reasons for this association and to identify interventions that may decrease this risk.

Patient Complaints and Adverse Surgical Outcomes.

One factor that affects surgical team performance is unprofessional behavior exhibited by the surgeon, which may be observed by patients and families and reported to health care organizations in the form of spontaneous complaints. The objective of this study was to assess the relationship between patient complaints and adverse surgical outcomes. A retrospective cohort study used American College of Surgeons National Surgical Quality Improvement Program data from an academic medical center and included 10 536 patients with surgical procedures performed by 66 general and vascular surgeons. The number of complaints for a surgeon was correlated with surgical occurrences (P < .01). Surgeons with more patient complaints had a greater rate of surgical occurrences if the surgeon's aggregate preoperative risk was higher (ß = .25, P < .05), whereas there was no statistically significant relationship between patient complaints and surgical occurrences for surgeons with lower aggregate perioperative risk (ß = -.20, P = .77).

Maternal Folic Acid Supplementation During Pregnancy and Early Childhood Asthma.

BACKGROUND: Asthma is one of the most common chronic childhood diseases. While folic acid supplementation around conception helps prevent neural tube defects, an animal model suggests that it may be a risk factor for respiratory diseases, although epidemiologic studies have had conflicting results. We investigated the timing of folic acid-containing prescription filling during pregnancy and child asthma. METHODS: In a retrospective cohort study of 104,428 children, born 1996-2005, and their mothers enrolled in Tennessee Medicaid, we investigated the association of filling folic acid-containing prescriptions during pregnancy and childhood asthma at ages 4.5-6 years. We categorized women into exposure groups based on prescription filling centered around the first trimester: no folic acid prescription exposure, exposure in first trimester only, exposure after first trimester, and exposure in first trimester and beyond. We defined asthma using asthma-specific healthcare visits and medication fills. Using logistic regression models, we investigated the relationship adjusting for potential confounders. RESULTS: Overall 15% of children had asthma. Compared with children born to women with no folic acid prescription exposure, children born to women with exposures in the first trimester only or first trimester and later had increased relative odds of asthma (adjusted odds ratios = 1.2, 95% confidence interval = 1.1, 1.3, and 1.2, 95% confidence interval = 1.2, 1.3); no association was seen in children born to women exposed after the first trimester. CONCLUSION: Timing of folic acid-containing prescription filling during pregnancy was associated with childhood asthma. Our findings contribute to understanding of the role of prenatal nutritional supplements on child respiratory health.