Effects of the threat of medical malpractice litigation and other factors on birth outcomes.

Most major health reform proposals include reform of medical malpractice. A major objective of the current medical malpractice system is to improve quality of care. The authors examine the effect of variations in the threat of medical malpractice, measured by claims frequency and payments per exposure year, on various indicators of birth outcomes, fetal deaths, low Apgar score, death within 5 days of birth, infant death, and death or permanent impairment at 5 years of age. Data came from 2 sources: a Survey of Obstetrical Care of 963 women in Florida in 1992 who delivered 5 years previously; and a fetal death and a linked birth-death file obtained from Florida Vital Statistics for 1987. Among the outcomes considered, only fetal deaths decreased in response to an increased threat of being sued, and this relationship was only obtained from one of the data sets. Overall, no systematic improvement in birth outcomes in response to an increased threat of medical malpractice litigation was obtained.

Obstetricians' prior malpractice experience and patients' satisfaction with care.

OBJECTIVE: To examine the relationship between prior physician malpractice experience and patients' satisfaction with care. DESIGN: Women were interviewed using a questionnaire that contained structured and open-ended questions. PARTICIPANTS: Mothers of all stillborn infants, infant deaths, and a random sampling of viable infants drawn from 1987 Florida Vital Statistics were sorted into four groups based on the malpractice claims experience of their obstetricians between 1983 and 1986. Interviews were completed with 963 of 1536 women, most by telephone, 53 by in-person interview. MAIN OUTCOME MEASURES: Mothers' responses to closed-ended and open-ended questions about their perceptions of the care they received during their pregnancy, labor, and delivery. RESULTS: Even though none of the women actually filed a claim, a consistent pattern of differences emerged when comparing women's perceptions of care received. Patients seeing physicians with the most frequent numbers of claims but without high payments were significantly more likely to complain that they felt rushed, never received explanations for tests, and were ignored. In response to the open-ended question, "What part of your care were you least satisfied with?" women seeing physicians in the High Frequency malpractice risk group offered twice as many complaints as those seeing physicians who had never been sued. Problems with physician-patient communication were the most commonly offered complaints. CONCLUSION: Physicians who have been sued frequently are more often the objects of complaints about the interpersonal care they provide even by their patients who do not sue.

The relationship between malpractice claims history and subsequent obstetric care.

OBJECTIVE: To determine the relationship between prior malpractice claims experience and the quality of clinical obstetric care. DESIGN: Historical cohort study of obstetricians, classified by their prior malpractice claims experience, with blinded review of medical records from their practices 5 to 10 years later. SETTING: Florida obstetricians who lost, settled, or defended malpractice claims between 1977 and 1983 and who were still practicing obstetrics in 1987. MAIN OUTCOME MEASURES: Objective and subjective assessment of quality of clinical care of patients attended by obstetricians with different histories of malpractice claims. RESULTS: No differences were found in any of the objective or subjective measures of the quality of clinical care provided to patients of obstetricians who were classified into one of four groups according to their prior claims history. CONCLUSIONS: No relationship was found between prior malpractice claims experience and the technical quality of practice by Florida obstetricians. Strategies that attempt to identify physicians at risk for future clinical errors by using data on prior malpractice claims (such as the National Practitioner Data Bank) may be misjudging the likelihood that substandard clinical care will be provided by physicians with prior claims.

Maternal recall and medical records: an examination of events during pregnancy, childbirth, and early infancy.

It is not currently known whether sufficiently precise data on a previous pregnancy, labor and delivery, and early infancy can be obtained retrospectively. We conducted a telephone survey in 1991 of women who delivered babies between 1984 and 1986 at two teaching hospitals in Nashville, Tennessee, to assess how well mothers recall information on factors predictive of an adverse birth outcome. The survey yielded 102 usable responses that were compared with hospital records for mothers and infants. Overall, 89 percent agreement was found between women's responses and their charts. Respondents were not reluctant to answer potentially sensitive questions, and their technical knowledge was typically better for their own health than about some prenatal diagnostic procedures and their infants' health. We found no difference in recall accuracy according to whether mothers experienced some adversity with the index pregnancy. Accurate perinatal information can generally be obtained with a recall period as high as four to six years.

Factors that prompted families to file medical malpractice claims following perinatal injuries.

OBJECTIVE: To identify self-reported reasons that prompt families to file malpractice claims following perinatal injuries. DESIGN: Families were interviewed by telephone using a questionnaire that contained structured and open-ended questions. PARTICIPANTS: Mothers of infants who had experienced permanent injuries or deaths and had closed malpractice claims in Florida between 1986 and August 1989 were interviewed. Questionnaires were completed by 127 (35%) of a total of 368 such families. OUTCOME MEASURES: Reasons prompting families to file and families' descriptions of medical events, advice from acquaintances, and the quality of physician-family communication. RESULTS: Families volunteered numerous reasons for filing: advised by knowledgeable acquaintances (33% of respondents), recognized cover-up (24%), needed money (24%), recognized that their child would have no future (23%), needed information (20%), and decided to seek revenge or protect others from harm (19%). Over one third of all families indicated that they were told by medical personnel prior to filing that the care provided had caused their children's injuries. Families expressed dissatisfaction with physician-patient communication. Families believed that physicians would not listen (13% of sample), would not talk openly (32%), attempted to mislead them (48%), or did not warn about long-term neurodevelopmental problems (70%). CONCLUSION: Families give many reasons for filing a claim. Obtaining money may not be the only goal for some families who file suit.

Acute prolapsed lumbar intervertebral disc. An epidemiologic study with special reference to driving automobiles and cigarette smoking.

An epidemiologic case-control study to identify risk factors for acute prolapsed lumbar intervertebral disc was undertaken in Connecticut during 1979-1981. This paper focuses on nonoccupational factors of possible etiologic significance. Persons in their 30s were affected most frequently. Among surgical cases, the ratio of men to women was 1.5 to 1, while among probable and possible cases not undergoing surgery, the male to female ratio was about 1 to 1. Cigarette smoking in the past year was associated with an increased risk for prolapsed disc. The greater the number of hours spent in a motor vehicle, the higher the risk. Use of Swedish and Japanese cars was associated with a lower-than-average risk, while use of other cars was associated with a higher-than-average risk. For each type of car, older cars were associated with higher risks than newer cars. Variables that did not affect the risk for prolapsed lumbar disc in this study included height, weight, number of pregnancies, number of children, frequency of wearing shoes with high heels, smoking cigars or pipes, and participation in baseball or softball, golf, bowling, swimming, diving from a board, tennis, bicycling or jogging.

An epidemiological study of acute prolapsed cervical intervertebral disc.

In this epidemiological study of acute prolapsed cervical intervertebral disc, we found that people in the fourth decade of life were affected somewhat more frequently than individuals in other age groups, and men with a prolapsed cervical disc outnumbered women by a ratio of 1.4 to one. Factors that were associated relatively strongly with this diagnosis were frequent lifting of heavy objects on the job that was held around the time of the onset of symptoms, cigarette-smoking, and frequent diving from a board. Positive associations that were of borderline statistical significance or were not statistically significant were found with operating or driving vibrating equipment and time spent in motor vehicles. Variables that did not appear to affect the risk for a prolapsed cervical disc included participation in certain sports other than diving, frequent wearing of shoes with high heels, the number of pregnancies or live births, frequent twisting of the neck on the job, time spent sitting on the job, and smoking cigars or a pipe.

An epidemiologic study of lifting and twisting on the job and risk for acute prolapsed lumbar intervertebral disc.

An epidemiologic case-control study undertaken in Connecticut during 1979-1981 indicated that persons with jobs requiring lifting objects of more than 11.3 kg (25 lb) an average of more than 25 times per day had over three times the risk for acute prolapsed lumbar intervertebral disc as people whose jobs did not involve lifting objects of this weight. If the body was usually twisted while the lifting was done, this elevation in risk was apparent with less frequent lifting. An especially high risk for prolapsed lumbar disc was associated with jobs involving lifting objects of more than 11.3 kg with the body usually twisted and the knees not bent while the lifting was done. Neither lifting objects of less than 11.3 kg nor twisting without lifting was associated with an increase in risk.