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Chances are, you’ll be sued

September 2011

Published in the September 2011 issue of Today’s Hospitalist

Physicians: high probability of being sued during career

AN ANALYSIS OF MALPRACTICE CLAIMS and payments finds that the vast majority of physicians face at least one malpractice claim over the course of their career. The good news is that more than three-quarters of all malpractice claims (78%) are resolved without any payment.

The analysis, which appeared in the Aug. 18 New England Journal of Medicine, looked at 1991-2005 data from a large national insurer for 24 specialties. (Hospital medicine wasn’t broken out separately.)

In the highest-risk specialties, the probability of facing a claim each year was 19.1% for neurosurgery, 18.9% for cardiothoracic surgery and 15.3% for general surgery. Among the lowest-risk specialties, that annual probability fell to 5.2% for family practice, 3.1% for pediatrics and 2.6% for psychiatry. Internal medicine physicians faced about an 8% annual probability of facing a claim, about the same as emergency physicians.

The likelihood of being sued over the course of a career ranged from 75% for doctors in low-risk specialties to 99% for physicians in high-risk specialties. The research found that the mean payment is just under $275,000.

Moving to CPOE? Watch out for duplicate orders

RESEARCHERS TRACKING the number of duplicate medication orders that occurred before and after the implementation of a CPOE system found a dramatic jump in the number of those errors in two ICUs.

The study, which was posted online in July by the Journal of the American Medical Informatics Association, looked at duplicate orders after CPOE and electronic clinical decision-support were introduced in a 400-bed tertiary teaching hospital. The authors found that the number of duplicate orders for the same drug and the same patient jumped from 2.6% of all orders before CPOE was introduced to 8.1% after.

The authors identified several reasons why more duplicate orders were being made in the wake of CPOE implementation. Those included different doctors placing the same order during rounds; miscommunication during handoffs at shift changes; design problems with both clinical decision-support and CPOE data display, which made it tougher to review existing orders; and confusing alerts, as well as a high false-positive alert rate.

Rivaroxaban goes head-to-head with warfarin

A RANDOMIZED TRIAL that looked at the use of newly approved rivaroxaban vs. warfarin in patients with nonvalvular AFib found that rivaroxaban was not inferior to warfarin in terms of preventing stroke or systemic embolism.

The trial was sponsored by the makers of rivaroxaban, with results posted online by the New England Journal of Medicine. Patients included in the re- search were at moderate or high risk for stroke.

Previous trials have shown rivaroxaban to be noninferior to enoxaparin. In this trial, researchers compared the use of daily 20 mg of rivaroxaban to dose-adjusted warfarin and found no significant differences in the number of incidents of major bleeding. Among patients randomized to warfarin, those patients’ INR values were within therapeutic range 55% of the time.

Patients randomized to rivaroxaban, however, did post fewer episodes of intracranial and fatal bleeding. At the same time, researchers noted that patients in the rivaroxaban cohort experienced more GI bleeding, as well as more bleeding that resulted in a drop in hemoglobin and bleeding that required a transfusion.

Anemia linked to excessive blood draws

RESEARCH INTO HOSPITAL-ACQUIRED ANEMIA found that as many as 20% of myocardial infarction patients developed the condition, which researchers linked to excessive blood draws for lab tests.

The trial analyzed data for nearly 17,700 patients in 57 U.S. hospitals from 2000-08. While patients were admitted with no anemia, one in five developed moderate to severe anemia. Those patients had hemoglobin levels of less than 11 g/dL.

The authors found that the mean phlebotomy volume for patients who developed hospital-acquired anemia was 173.8 mL vs. 83.5 mL for other MI patients. According to the study, which was posted online by the Archives of Internal Medicine, every 50 mL of blood drawn was associated with an 18% increase in patients’ risk for moderate to severe hospital-acquired anemia. A great deal of variation in blood-draw volume was also seen across hospitals.

The authors conclude that many cases of hospital-acquired anemia are preventable and that hospitals should introduce tactics to decrease the number of diagnostic blood draws.

A look at pediatric hospitalizations

A PRACTICE BRIEF from the Agency for Healthcare Research and Quality looking at 2009 hospitalizations found that children made up one out of every six hospital discharges that year. The total cost of pediatric hospitalizations in 2009 was $33.6 billion, which represented 9% of the country’s total hospital costs.

Among hospitalized children, 72% were either newborns or infants under age 1. The average length of stay for children was shorter than for adults (3.8 days vs. 4.6 days), and average costs per pediatric hospitalization ran $5,200 vs. $9,200 for adult patients. The leading pediatric admission diagnoses were pneumonia, asthma and acute bronchitis, followed by depression and bipolar disorder.

The analysis also found a significant shift in payers for pediatric hospitalizations. In 2000, the brief stated, 55% of pediatric admissions were paid for by private insurers, while 37% were paid by Medicaid. In 2009, however, those figures had changed to 45% of pediatric hospitalizations being billed to private payers vs. 47% to Medicaid.

Who works the longest hours?

A SNAPSHOT of work hours for more than 40 physician specialties indicates that physicians who treat acutely ill patients in hospitals tend to work much longer hours than doctors in outpatient practices. However, neither hospitalists nor ED doctors were found to be among the inpatient specialties working the longest.

That was due, study authors wrote, to the fact that both hospitalists and ED physicians typically work shifts. The analysis, which appeared in the July 11 Archives of Internal Medicine, found that vascular surgeons pull the most hours per week, followed by intensivists, internal medicine subspecialists, and neonatal and perinatal specialists.

Among the specialties working many fewer hours per week were pediatric emergency physicians, doctors in occupational medicine and dermatologists. The analysis also found an inverse relationship between hours worked and career satisfaction, with doctors putting in longer hours reporting lower satisfaction levels. The exceptions were neonatologists and perinatologists.

The most significant mismatch between fewer hours worked and more income were for neurosurgeons and dermatologists.