Medical professional liability risk among US cardiologists.

BACKGROUND: Medical professional liability (MPL) remains a significant burden for physicians, in general, and cardiologists, in particular, as recent research has shown that average MPL defense costs are higher in cardiology than other specialties. Knowledge of the clinical characteristics and outcomes of lawsuits against cardiologists may improve quality of care and risk management. METHODS: We analyzed closed MPL claims of 40,916 physicians and 781 cardiologists insured by a large nationwide insurer for ≥1 policy year between 1991 and 2005. RESULTS: The annual percentage of cardiologists facing an MPL claim was 8.6%, compared with 7.4% among physicians overall (P < .01). Among 530 claims, 72 (13.6%) resulted in an indemnity payment, with a median size of $164,988. Mean defense costs for claims resulting in payment were $83,593 (standard deviation (s.d.) $72,901). The time required to close MPL claims was longer for claims with indemnity payment than claims without (29.6 versus 18.9 months; P < .001). More than half of all claims involved a patient's death (304; 57.4%), were based on inpatient care (379; 71.5%), or involved a primary cardiovascular condition (416; 78.4%). Acute coronary syndrome was the most frequent condition (234; 44.2%). Medical professional liability claims involving noncardiovascular conditions were common (66; 12.5%) and included falls or mechanical injuries had while under a cardiologist's care and a failure to diagnose cancer. CONCLUSIONS: Rates of malpractice lawsuits are higher among cardiologists than physicians overall. A substantial portion of claims are noncardiovascular in nature.

The incremental value of lipids and inflammatory biomarkers in determining residual cardiovascular risk.

With the increasing use of drug therapy and lifestyle modification for primary and secondary prevention of cardiovascular disease, there remain questions on how to quantify residual risk, particular in patients with diabetes mellitus or obesity. Clinicians have turned to other screening modalities to identify individuals who would benefit from even more intensive therapy or to identify those with difficult-to-assess risk factors. Once a patient has been identified for aggressive risk factor modification, lipid biomarkers such as Apo B, LDL-P, and Lp (a) can potentially have clinical utility, and inflammatory markers such as hs-CRP may be useful for evaluating residual risk.

South Asians and risk of cardiovascular disease: current insights and trends.

Patients from the Indian subcontinent have a distinct cardiovascular risk profile with profound health consequences. South Asians tend to develop more severe coronary artery disease at a younger age, and may also suffer from earlier myocardial infarction and heart failure. The genesis of this risk is multi-factorial. One important culprit is increased insulin resistance, possibly due to recently identified genetic polymorphisms. Another possible explanation is subclinical inflammation and a prothrombotic environment, as evidenced by increased levels of homocysteine, plasminogen activator inhibitor-1, and fibrinogen. The lipid profile of South Asians may play a role, as this population is known to have elevated levels of lipoprotein (a), as well as lower levels of HDL. In addition, this HDL may be dysfunctional, as this population may have a higher prevalence of low levels of HDL2b, as well as an increased preponderance of smaller HDL. Current guidelines for primary and secondary prevention have not reflected our growing insight into the unique characteristics of the South Asian population, and may need to evolve to reflect our knowledge.

Characterization of Medical Professional Liability Risks Associated With Transesophageal Echocardiography.

BACKGROUND: Medical claim data offer the possibility to improve patient care and mitigate liability. Although published analyses exist in cardiology, no information is available for transesophageal echocardiography (TEE). In this study, the authors reviewed medical claims involving TEE to identify potential risk management concerns so that these lessons could be used to improve the safety and quality of transesophageal echocardiographic practice. METHODS: The authors reviewed anonymized clinical and claims data from all closed claims from 2008 to 2013 for a single national physician liability insurer. RESULTS: There were no claims involving transthoracic echocardiography and eight involving TEE. Three claims involved esophageal perforation, a known risk of TEE. Two claims involved quadriplegia allegedly due to neck manipulation in the setting of a cervical spinal abscess that should have been suspected. Three claims involved the cardiologist's failure to diagnose endocarditis, with allegations that the cardiologist did not perform TEE in an appropriate time frame to avoid major morbidity and mortality from endocarditis. CONCLUSIONS: Liability claims associated with TEE involve failure to order and perform TEE in an appropriate clinical scenario and in a timely manner; failure to properly document medical decision making; failure to inform patients regarding risks of TEE; failure to properly monitor the patient before, during, and after TEE; and technical difficulties in performing the procedure. Cardiologists should recognize guideline-based indications when TEE is needed and be mindful of the complication rates of this procedure. When screening a patient for TEE, consider expert input that may reduce the risks of TEE (e.g., a spine specialist for a neck injury, a gastroenterologist for esophageal comorbidity). Informed consent and medical record documentation should be practiced as a vehicle to inform patients of these risks and chronicle decision-making processes.

Risks associated with statin therapy: a systematic overview of randomized clinical trials.

BACKGROUND: Although statins reduce the risk of cardiovascular events, concerns about adverse effects may deter physicians from prescribing these agents. We performed a systematic overview of randomized statin trials to quantify the risks of musculoskeletal, renal, and hepatic complications associated with therapy. METHODS AND RESULTS: Major statin trials were identified by electronic search of the MEDLINE database from 1966 to December 2005. We included English language reports of adults with documented hyperlipidemia; double-blind, random allocation of > or = 100 patients to statin monotherapy versus placebo; and reports of myalgia, creatine kinase elevations, rhabdomyolysis, transaminase elevations, and discontinuation due to adverse events. Among 74,102 subjects enrolled in 35 trials (follow-up range, 1 to 65 months), statin therapy (excluding cerivastatin) did not result in significant absolute increases in risks of myalgias (risk difference/1000 patients [RD], 2.7; 95% CI, -3.2 to 8.7), creatine kinase elevations (RD, 0.2; 95% CI, -0.6 to 0.9), rhabdomyolysis (RD, 0.4; 95% CI, -0.1 to 0.9), or discontinuation due to any adverse event (RD, -0.5; 95% CI, -4.3 to 3.3). The absolute risk of transaminase elevations was significantly higher with statin therapy (RD, 4.2; 95% CI, 1.5 to 6.9). CONCLUSIONS: On the basis of data available from published clinical trials, statin therapy is associated with a small excess risk of transaminase elevations, but not of myalgias, creatine kinase elevations, rhabdomyolysis, or withdrawal of therapy compared with placebo. Further study is necessary to determine whether the results from these published clinical trials are similar to what occurs in routine practice, particularly among patients who are older, have more severe comorbid conditions, or receive higher statin doses than most patients in these clinical trials.