Education, Ethics, and History: The Peer Review Process in the US.

Despite the near-universal acceptance of the benefits of a sound peer review process (PRP), the topic of peer review remains a source of controversy among surgeons. The current PRP is plagued by heterogeneity across different hospital and institutional systems. These inconsistencies, combined with a perceived lack of fairness inherent to the PRP in some institutions, led to concerns among practicing surgeons. In this review of the relevant literature on the PRP, we attempted to provide some context and insight into the history of the PRP, its role, its shortcomings, its potential abuses, and some key requirements for its successful execution.

Associations Over Time Between Paid Medical Malpractice Claims and Imaging Utilization in the United States.

PURPOSE: The aim of this study was to explore state-level relationships between the incidence and payout amounts for medical malpractice claims and Medicare imaging utilization and spending across the United States. METHODS: Using claims data from a 5% sample of Medicare beneficiaries for 2004 to 2016, annual state population-adjusted rates of imaging utilization and spending were calculated. Using National Practitioner Data Bank files, all paid physician malpractice claims were identified, and lagged state population-adjusted rolling averages of paid claim frequencies and payout amounts were calculated. Controlling for secular trends and state fixed effects with robust standard errors clustered at the state level to account for serial autocorrelation, associations between imaging utilization and lagged paid malpractice claims were assessed using multivariate regression models. Log-log model specification was used to obtain elasticity measures. RESULTS: Between 2004 and 2016, national Medicare diagnostic imaging utilization and spending declined by 31.4% and 47.2%, respectively (from 355,057 to 243,517 examinations and from $28,591,146 to $15,099,291 per 100,000 beneficiaries). Overall national paid malpractice claims and payout amounts declined by 46.4% and 39.6%, respectively (from 4.83 to 2.59 claims and from $1,803,565 to $1,089,112 per 100,000 population). After controlling for secular trends and state fixed effects, advanced imaging utilization was positively associated with the lagged number of per capita paid malpractice claims. Each 1% increase in average paid malpractice claims was associated with a subsequent 0.20% increase in advanced imaging utilization (P = .001). CONCLUSIONS: Positive associations between paid malpractice claims and advanced Medicare imaging utilization support the contention that US physicians use medical imaging as a defensive medicine strategy.

An Analysis of Otolaryngology Medical Malpractice Payments From the National Practitioner Data Bank.

OBJECTIVE: To describe malpractice payments made on behalf of otolaryngologists, analyze trends over time, and test the association of payment amount with severity of alleged malpractice and patient age. STUDY DESIGN: Retrospective cross-sectional analysis. SETTING: National Practitioner Data Bank. SUBJECTS AND METHODS: This study comprised all payments made on behalf of otolaryngologists from 1991 to 2018 that were reported to the National Practitioner Data Bank. Descriptive statistics were calculated within and across years. Trends in payments were analyzed with the Mann-Kendall test. Generalized linear regression was utilized to test for association of payment amount with severity of the alleged injury and patient age. RESULTS: From 1991 to 2018, there was a significant decrease in the number of payments (272 to 81) and number of otolaryngologists on whose behalf payments were made (250 to 77). Mean and median payments increased significantly from $248,848 to $420,386 and from $96,813 to $275,000, respectively. By severity of alleged injury, mean payments ranged from $39,755 (95% CI, $20,957-$75,412) for insignificant injury to $754,349 (95% CI, $624,847-$910,692) for patients who were left quadriplegic, sustained brain damage, or required lifelong care. By patient age, mean payments for patients ≥60 years old were $191,465 (95% CI, $159,880-$229,292) versus $247,878 (95% CI, $209,416-$293,402) for patients aged 20 to 39 years and $232,225 (95% CI, $197,691-$272,793) for patients aged 40 to 59 years. CONCLUSION: The annual number and total value of malpractice payments decreased, while the annual mean and median payments increased. Payment amount was associated with severity of alleged malpractice and patient age.

Using Big Data Analytics to Identify Dentists with Frequent Future Malpractice Claims.

Healthcare spending has been growing at an increasing rate in the US, due in part to medical malpractice costs. Dental malpractice is an area that has not been studied in depth. Using National Practitioner Data Bank (NPDB), we explored the extent of dental malpractice claims and sought to construct a predictive model that can help us identify dental practitioners at risk of performing medical malpractice. Over 1,500 dental malpractice claims were reported annually, and over $1.7 billion being paid out by medical malpractice insurers over the past 15 years. Majority of claims resulted in minor injuries, and the number of major injury claims increased over years. In prediction, we randomly split the data into train (75%) and test (25%) datasets. We trained and tuned models using 5-fold cross validation on the training set. Then, we fitted the model on the test data for performance measures. We used Logistic Regression, Random Forest (RF) and XGBoost and tuned the hypermeters of models accordingly through grid search and cross validation. XGBoost was the best machine learning model to predict the risk of dentists having several malpractice reports. The best performing model had an accuracy of 72.8% with 30.6% F1 score. The NPDB database is a valuable dataset to study dental malpractice claims. Further analysis of information extracted from this dataset is warranted.

The Detection, Analysis, and Significance of Physician Clustering in Medical Malpractice Lawsuit Payouts.

OBJECTIVES: There is evidence that most adverse events result from individual errors and that most malpractice suits with payouts reflect both patient injury and error. HYPOTHESIS: There are outlier physicians with regard to the frequency and total amount of malpractice payouts. METHODS: Using the public use file of the National Practitioner Data Bank (NPDB), we sought the percentage of physicians who lay above several cutoff points with regard to total amounts of payments and number of payments. We looked at the frequency with which outliers were likely to have additional paid claims and to be disciplined by their hospitals and state boards. RESULTS: Approximately 1.8% of physicians were responsible for half of the $83,368,588,200 reported to the NPDB over 25 years. Within that group, 12.6% had an adverse licensure action reported to the NPDB, and 6.3% had a clinical privileges action reported. Physicians who were in the high dollar payout category and had one malpractice claim payout had a 74.5% chance of another payout, more than twice the rate for all physicians who had a single payout (chi-square, P < 0.0001). The likelihood that that physician would have additional payments increased as the number of previous payments increased. Total dollar payouts per physician better predicted future payouts than numbers of payouts. (For 1, 2, and 3 payouts, the P value was less than 0.0001 for each category.) Limitations: Neither a prospective nor a randomized study was feasible. Sorting by specialty was not done. Malpractice cases are an indirect measure of adverse events. CONCLUSIONS: There is a clustering of payments in medical malpractice cases among a small group of physicians. These findings point up the need to oppose the negative impact of such outlier physicians on the safety of patients.

Time to End Physician Sexual Abuse of Patients: Calling the U.S. Medical Community to Action.

Despite the strict prohibition against all forms of sexual relations between physicians and their patients, some physicians cross this bright line and abuse their patients sexually. The true extent of sexual abuse of patients by physicians in the U.S. health care system is unknown. An analysis of National Practitioner Data Bank reports of adverse disciplinary actions taken by state medical boards, peer-review sanctions by institutions, and malpractice payments shows that a very small number of physicians have faced "reportable" consequences for this unethical behavior. However, physician self-reported data suggest that the problem occurs at a higher rate. We discuss the factors that can explain why such sexual abuse of patients is a persistent problem in the U.S. health care system. We implore the medical community to begin a candid discussion of this problem and call for an explicit zero-tolerance standard against sexual abuse of patients by physicians. This standard must be coupled with regulatory, institutional, and cultural changes to realize its promise. We propose initial recommendations toward that end.

Crossing the line: Sexual misconduct by nurses reported to the National Practitioner Data Bank.

OBJECTIVE: The objective of this study was to examine nurse sexual-misconduct-related reports in the National Practitioner Data Bank (NPDB) and to compare them with reports for other types of offenses. DESIGN AND POPULATION: We analyzed NPDB's reports of adverse state nursing board licensure actions and malpractice payments for all nurses from January 1, 2003, to June 30, 2016. RESULTS: Overall, 882 nurses had sexual-misconduct-related reports. Most were aged 35-54 (63.2%), male (63.2%), and registered or advanced practice nurses (61.5%). The disciplinary actions noted in the 988 nurse sexual-misconduct-related licensure reports were more frequently serious than those noted in the 207,023 reports for other offenses committed by nurses (90.8% vs. 74.8%, respectively; p < 0.001). Of the 33 nurses with sexual-misconduct-related malpractice-payment reports, 48.5% were not disciplined by any state board of nursing for these offenses. Three-quarters of the victims in the 47 sexual-misconduct-related malpractice-payment reports were female, with "emotional injury only" reported as the severity of injury in 91.5% of these reports. CONCLUSIONS: Very few nurses have been reported to the NPDB due to sexual misconduct. We welcome a zero-tolerance standard against sexual misconduct involving patients by all types of health care professionals, including nurses.

Nurse practitioner malpractice data: Informing nursing education.

BACKGROUND: Nurse practitioners (NPs) are often identified in medical malpractice claims. However, the use of malpractice data to inform the development of nursing curriculum is limited. The purpose of this study is to examine medical errors committed by NPs. METHODS: Using National Practitioner Data Bank public use data, years 1990 to 2014, NP malpractice claims were classified by event type, patient outcome, setting, and number of practitioners involved. RESULTS: The greatest proportion of malpractice claims involving nurse practitioners were diagnosis related (41.46%) and treatment related (30.79%). Severe patient outcomes most often occurred in the outpatient setting. Nurse practitioners were independently responsible for the event in the majority of the analyzed claims. CONCLUSION: Moving forward, nurse practitioner malpractice data should be continuously analyzed and used to inform the development of nurse practitioner education standards and graduate program curriculum to address areas of clinical weakness and improve quality of care and patient safety.

Under Investigation?

Revisions to the National Practitioner Data Bank's NPDB Guidebook concern health law attorneys who are warning physicians to protect themselves if they plan to step away from their practices.

Trends in US malpractice payments in dentistry compared to other health professions - dentistry payments increase, others fall.

Background Little is known about trends in the number of malpractice payments made against dentists and other health professionals. Knowledge of these trends will inform the work of our professional organisations.Methods The National Practitioner Data Bank (NPDB) in the United States was utilised. Data about malpractice payments against dentists, hygienists, nurses, optometrists, pharmacists, physicians (DO and MD), physicians' assistants, podiatrists, psychologists, therapists and counsellors during 2004-14 were studied. Variables include type of healthcare provider, year malpractice payment was made and range of payment amount.Results In 2004 there were 17,532 malpractice payments against the studied health professions. In 2014 there were 11,650. In 2004, the number of malpractice payments against dentists represented 10.3% of all payments and in 2014 it represented 13.4%. Number of malpractice payments against dentists in 2012-2014 increased from 1,388 to 1,555.Conclusions There is an upward pressure on the number of dental malpractice payments over the last 3 years. Concurrently, there is a downward pressure on the number of combined non-dentist healthcare professional malpractice payments.

Physician Assistant and Nurse Practitioner Malpractice Trends.

Trends in malpractice awards and adverse actions (e.g., revocation of provider license) following an act or omission constituting medical error or negligence were examined. The National Practitioner Data Bank was used to compare rates of malpractice reports and adverse actions for physicians, physician assistants (PAs), and nurse practitioners (NPs). During 2005 through 2014, there ranged from 11.2 to 19.0 malpractice payment reports per 1,000 physicians, 1.4 to 2.4 per 1,000 PAs, and 1.1 to 1.4 per 1,000 NPs. Physician median payments ranged from 1.3 to 2.3 times higher than PAs or NPs. Diagnosis-related malpractice allegations varied by provider type, with physicians having significantly fewer reports (31.9%) than PAs (52.8%) or NPs (40.6%) over the observation period. Trends in malpractice payment reports may reflect policy enactments to decrease liability.

Medical Malpractice in Dermatology-Part II: What To Do Once You Have Been Served with a Lawsuit.

Facing a malpractice lawsuit can be a daunting and traumatic experience for healthcare practitioners, with most clinicians naïve to the legal landscape. It is crucial for physicians to know and understand the malpractice system and his or her role once challenged with litigation. We present part II of a two-part series addressing the most common medicolegal questions that cause a great deal of anxiety. Part I focused upon risk-management strategies and prevention of malpractice lawsuits, whereas part II provides helpful suggestions and guidance for the physician who has been served with a lawsuit complaint. Herein, we address the best approach concerning what to do and what not to do after receipt of a legal claim, during the deposition, and during the trial phases. We also discuss routine concerns that may arise during the development of the case, including the personal, financial, and career implications of a malpractice lawsuit and how these can be best managed. The defense strategies discussed in this paper are not a guide separate from legal representation to winning a lawsuit, but may help physicians prepare for and cope with a medical malpractice lawsuit. This article is written from a US perspective, and therefore not all of the statements made herein will be applicable in other countries. Within the USA, medical practitioners must be familiar with their own state and local laws and should consult with their own legal counsel to obtain advice about specific questions.

Cross-Sectional Analysis of the 1039 U.S. Physicians Reported to the National Practitioner Data Bank for Sexual Misconduct, 2003-2013.

BACKGROUND: Little information exists on U.S. physicians who have been disciplined with licensure or restriction-of-clinical-privileges actions or have had malpractice payments because of sexual misconduct. Our objectives were to: (1) determine the number of these physicians and compare their age groups' distribution with that of the general U.S. physician population; (2) compare the type of disciplinary actions taken against these physicians with actions taken against physicians disciplined for other offenses; (3) compare the characteristics and type of injury among victims of these physicians with those of victims in reports for physicians with other offenses in malpractice-payment reports; and (4) determine the percentages of physicians with clinical-privileges or malpractice-payment reports due to sexual misconduct who were not disciplined by medical boards. METHODS AND RESULTS: We conducted a cross-sectional analysis of physician reports submitted to the National Practitioner Data Bank (NPDB) from January 1, 2003, through September 30, 2013. A total of 1039 physicians had ≥ 1 sexual-misconduct-related reports. The majority (75.6%) had only licensure reports, and 90.1% were 40 or older. For victims in malpractice-payment reports, 87.4% were female, and "emotional injury only" was the predominant type of injury. We found a higher percentage of serious licensure actions and clinical-privileges revocations in sexual-misconduct-related reports than in reports for other offenses (89.0% vs 68.1%, P = < .001, and 29.3% vs 18.8%, P = .002, respectively). Seventy percent of the physicians with a clinical-privileges or malpractice-payment report due to sexual misconduct were not disciplined by medical boards for this problem. CONCLUSIONS: A small number of physicians were reported to the NPDB because of sexual misconduct. It is concerning that a majority of the physicians with a clinical-privileges action or malpractice-payment report due to sexual misconduct were not disciplined by medical boards for this unethical behavior.

Reputation management.

Patients with a computer and access to social media can now easily and effortlessly comment on your practice and your services. Most comments about physicians are positive. However, a negative one may be posted by a disgruntled patient and can severely impact your practice with a mere mouse click. A physician's most valuable asset is his or her reputation. This article will discuss how to manage and protect your online reputation.

An empirical data comparison of regulatory agency and malpractice legal problems for psychiatrists.

BACKGROUND: Our objective is to compare legal difficulties that psychiatrists encounter in regulatory agency and malpractice (insurance) settings. METHODS: Data sources included a literature search of malpractice and medical board discipline from 1990 to 2009 (rates and types of discipline); publicly available insurance data (malpractice frequency and type); and data from the National Practitioner Data Bank (NPDB) (required reports of malpractice settlements and hospital discipline). RESULTS: Medical board discipline findings indicate that psychiatrists are at increased risk of disciplinary action compared with other specialties. NPDB data indicated relatively infrequent problems for psychiatrists. In malpractice, psychiatry accounted for a small percentage of overall claims and settlements. Overall, more years in practice and a lack of board certification increased the risk of legal difficulties. CONCLUSIONS: There are shared and separate risk factors in the malpractice and regulatory agency areas, but there is evidence that these 2 legal areas are distinct from each other.

Surgical malpractice claims in the United States.

Despite ongoing reform, there is still significant physician concern regarding the impact of medical claims on their practices. It is important that physicians and healthcare risk management professionals have a good understanding of the outcomes of medical malpractice to participate in its restructuring as needed and to prevent potentially harmful practices. In our study, we reviewed National Practitioner Data Bank (NPDB) paid malpractice claim reports from September 1, 1990, through July 30, 2011, and identified the 10 most common surgery-related allegations against physicians, excluding those listed as unspecified. Data were collected on the number of claims, the cost of the claims, and physician and patient characteristics.

How policy makers can smooth the way for communication-and- resolution programs.

Communication-and-resolution programs (CRPs) in health care organizations seek to identify medical injuries promptly; ensure that they are disclosed to patients compassionately; pursue timely resolution through patient engagement, explanation, and, where appropriate, apology and compensation; and use lessons learned to improve patient safety. CRPs have existed for years, but they are being tested in new settings and primed for broad implementation through grants from the Agency for Healthcare Research and Quality. These projects do not require changing laws. However, grantees' experiences suggest that the path to successful dissemination of CRPs would be smoother if the legal environment supported them. State and federal policy makers should try to allay potential defendants' fears of litigation (for example, by protecting apologies from use in court), facilitate patient participation (for example, by ensuring access to legal representation), and address the reputational and economic concerns of health care providers (for example, by clarifying practices governing National Practitioner Data Bank reporting and payers' financial recourse following medical error).