Statistical models of outcome in malpractice lawsuits involving death or neurologically impaired infants.

The objective was to determine whether factors could be identified in medical and legal records that are associated with the successful defense of obstetrical malpractice cases involving the death or neurological impairment of infants. Obstetrical claims (169) closed by PROMUTUAL between January 1, 1990, and December 31, 1994, were retrospectively abstracted and analyzed to identify associations between medical and legal factors, and the medicolegal outcome. Multivariable analysis identifies that the use of pitocin, diagnosis of asphyxia, a delay in delivery, and the use of multiple defense expert witnesses decreased the chances of a successful defense. Two statistical models explaining indemnity payment were developed. The first, based on medical outcome, showed an increased indemnity payment when a case involved major neurological deficits, diagnosis of asphyxia, newborn seizures, later year of delivery, and participation of a particular defense firm. Perinatal or childhood death and the use of pitocin were indicators of a decrease in payment. The second model was based on long-term care requirements. In this model, indicators of increased indemnity payment were: nonreassuring intrapartum fetal heart rate tracing, later year of delivery, intensity of long-term care required, and participation of a particular defense law firm. Perinatal or childhood death, the use of pitocin, and settlement date increasingly removed from the occurrence date were the determinants of decreased payments in this model. Finally, the presence of major neurological deficits, the prolongation of a case, and the involvement of multiple law firms and defense witnesses increased the expense charged to and paid by the insurance company. Using the medical, legal, and financial data relevant to 169 obstetrical cases closed by one malpractice insurance carrier between 1990 and 1994, statistical models with potential predictive values for future malpractice claims involving neurologically impaired infants were constructed. These models may help determine in advance the chance a future case has for successful defense and the likely amount of expense and indemnity dollars that will be paid out to settle and defend it.

A statistical model for predicting the outcome in breast cancer malpractice lawsuits.

OBJECTIVE: To analyze specific medical, legal, and cost factors that predict the probability of successfully defending lawsuits filed because of failure to diagnose breast cancer. METHODS: Seventy-six malpractice cases handled by the Massachusetts Medical Professional Insurance Association between June 29, 1983 and December 30, 1993 were abstracted and analyzed using univariate analysis, multivariate stepwise logistic and least-square regression analysis, and the Cox proportional hazards model to identify statistically significant associations between clinical factors and medicolegal outcomes. RESULTS: Obstetrician-gynecologists were defendants in the largest number of cases (38) and incurred the highest total indemnity ($7,629,570). The probability of defending a suit successfully increased with smaller tumor size and younger patients (less than 40 years of age). The failure to perform a biopsy was associated with a decreased probability of successful defense. Variables predicting high case cost included younger patient age, an increased length of delay in diagnosis, and the failure to perform a biopsy. The presence of metastasis at diagnosis was associated with an increased interval from diagnosis to the initiation of a suit. CONCLUSION: Statistical models that use medicolegal and cost factors can predict both the probability of a successful defense and the total cost of a breast cancer malpractice case.

Relationship between cyclic variation of fetal heart rate patterns and cord pH in preterm gestations.

The presence or absence of cyclic variation (cyclicity) of fetal heart rate patterns was prospectively investigated in fetuses between 25 and 32 weeks' gestation. All fetuses were delivered by cesarean section before the onset of labor. The relationship between the presence or absence of fetal heart rate cyclicity and fetal acidosis, as determined by cord pH measurements, was investigated. The sensitivity, specificity, positive predictive value, and negative predictive value of this method in predicting fetal acidosis were: 100, 90, 50, and 100%, respectively. All fetuses with reactive nonstress tests also had fetal heart rate cyclicity present and none were acidotic at birth. The majority of fetuses (68.8%) with nonreactive nonstress tests had fetal heart rate cyclicity present and none were acidotic; fetuses with nonreactive nonstress tests and absence of fetal heart rate cyclicity were acidotic in 50% of the cases. These preliminary data suggest that the presence or absence of fetal heart rate cyclicity may help to select the healthy preterm fetuses with nonreactive nonstress testing who are in good condition and therefore in no need for further testing.

Antenatal sonographic findings in a case of intra-abdominal pulmonary sequestration.

This report describes the antenatal sonographic identification of a hyperechoic intra-abdominal mass in a 30-week fetus. The mass was proved by autopsy to be an extralobar pulmonary sequestration. Although a rare type of congenital malformation, pulmonary sequestration should be included in the differential diagnosis of an echodense intra-abdominal mass seen during antenatal ultrasound examination.

Use of the fetal biophysical profile in severe oligohydramnios after preterm premature rupture of the membranes.

A protocol of expectant management using daily fetal biophysical assessment was applied to 23 consecutive women with severe oligohydramnios after preterm premature rupture of the membranes. A persistently low biophysical score (less than or equal to 6 on two examinations two hours apart) in the presence of a nonreactive nonstress test and absence of fetal breathing was used as an indication for delivery. The pregnancy outcome in this group was compared to that in a historic control group managed similarly except that an abnormal biophysical assessment was not an indication for delivery. The results suggest that the management of women with severe oligohydramnios after preterm premature rupture of the membranes with daily fetal biophysical profiles decreases the incidence of low five-minute Apgar scores as well as that of maternal and neonatal infection.

The use of fetal biophysical profile improves pregnancy outcome in premature rupture of the membranes.

A protocol using daily fetal biophysical assessment was applied in 73 consecutive patients with premature rupture of the membranes and no clinical signs of infection or labor. A persistently low biophysical score (7 or less on two examinations 2 hours apart) in the presence of a nonreactive nonstress test and absence of fetal breathing was used as an indication for delivery. Measures of pregnancy outcome included the presence of amnionitis or neonatal infection. The outcome of pregnancy in this group of patients was compared with the outcomes of two historic groups: one managed conservatively (control group) and the other managed with amniocentesis on admission to the hospital (amniocentesis group). Infection outcome, maternal as well as neonatal, and low 5-minute Apgar scores were significantly less in the study than in the control group. The frequency of neonatal sepsis was significantly less in the study than in the amniocentesis group. These data suggest that management of premature rupture of the membranes with daily fetal biophysical profiles improves pregnancy outcome by reducing the incidence of maternal and neonatal infection.

Fetal weight estimation formulas with head, abdominal, femur, and thigh circumference measurements.

Most current sonographic techniques for estimating fetal weight involve measurements of the head, abdomen, and femur length both alone and in combination. The value of the fetal thigh circumference measurement in addition to the head, abdominal, and femur length measurements has not been investigated previously. Eighty-nine patients were scanned within 72 hours of delivery, and the following ultrasonic fetal parameters were obtained in all fetuses: biparietal diameter, head circumference, abdominal circumference, femur length, and thigh circumference. With multiple stepwise regression analysis, the best-fit formulas were developed with one, two, three, four, and five parameters, respectively. The best results were obtained by combining measurements of all five parameters: biparietal diameter, head circumference, abdominal circumference, femur length, and thigh circumference. The mean error of this formula was 6%, the mean deviation 0.3%, and the SD 7.8%. These data suggest that the addition of thigh circumference to measurements of the head, abdomen, and femur length improves the accuracy of fetal weight estimates.