Time trends of assessments for medical dispute cases in Taiwan: a 20-year nationwide study.

BACKGROUND: In Taiwan, nearly all medical dispute cases were reviewed by an official Medical Review Committee (MRC). AIMS: The aim of this study was to investigate the time trends of assessment reports by the MRC to estimate the changing trends of medical malpractice litigation. METHODS: All assessment reports of the MRC from a nationwide database were reviewed. The assessment reports were analysed according to the year of completion. We further analysed the time trends by adjusting numbers for the size of the general population and numbers of physicians. Stratified analyses were also conducted by region and commission authority. RESULTS: Between 1987 and 2006, the MRC completed a total of 5324 assessment reports, with 4949 reports involving a medical dispute and the remaining 375 reports not involving a medical dispute. The numbers of assessment reports increased from 139 in 1987 to 221 in 1996 and 361 in 2006. The assessment increased from 0.70 per 100 000 people in 1987 to 1.03 and 1.58 per 100 000 people in 1996 and 2006 respectively. There was a stable trend of 8.5-10.0 assessments per 1000 physicians annually during the study period. Rising trends were consistent for all regions of Taiwan and for all criminal cases, but increases were more significant for civil cases. CONCLUSIONS: The numbers of medical dispute cases have increased significantly over the past 20 years. More studies to investigate the reasons of the rising trends and to find resolving methods to decrease the numbers of medical dispute will be helpful in the future.

The effect of pre-emptive use of minimal dose fentanyl on fentanyl-induced coughing.

We performed a randomised, double-blind study to evaluate the effect of the pre-emptive use of minimal dose intravenous fentanyl (25 microg) on the incidence of cough caused by a larger bolus of intravenous fentanyl. Six hundred patients were randomly assigned to one of three groups to receive either 0.5 ml saline 0.9% 1 min before administration of fentanyl 150 microg (3 ml), or pre-emptive fentanyl 25 microg (0.5 ml) 1 min before administration of fentanyl 125 microg or 150 microg. The incidence of fentanyl-induced cough was significantly lower in both pre-emptive groups (7 (3.5%) for 125 microgfentanyl and 15 (7.5%) for 150 microg fentanyl) than in the saline group (37 (18.5%); p = 0.001). We conclude that pre-emptive use of fentanyl 25 microg, administered 1 min before bolus injection of fentanyl (125 or 150 microg), can effectively suppress fentanyl-induced cough.

Modeling the costs and outcomes of cardiovascular surgery.

Coronary artery bypass graft (CABG) operations consume more health care resources than any other single procedure. The objective of this study was to develop a computer simulation model that can be used to predict costs and patient outcomes of CABG surgery. The analysis is based on a systems dynamic model developed using STELLA software. Two sets of data from Medicare patients who underwent CABG operations at Methodist Hospital of Indiana were used to construct and validate the model. The model predictions of length of hospital stay, use of specialists in caring for patients, costs and postoperative functional status are reasonably close to actual data on patients who underwent CABG surgery. The analysis indicates the most important factors affecting costs and outcomes are gender, age, whether or not the surgery is a reoperation and whether the patient experiences postoperative complications. The model can be used to predict costs and outcomes for a patient population from a small set of preoperative characteristics (i.e., age, gender, DRG, whether the surgery is a reoperation, and the patient's operative status). A second potential use of the model is to answer clinical questions such as do the costs and risks of CABG operations outweigh the benefits for patients with certain risk factors.

Computers in the consulting room: a case study of clinician and patient perspectives.

Few clinicians in the United States use computers during patient encounters and many still worry that computers will depersonalize their interactions with patients. This case study describes patient and clinician reactions to a computer-based health appraisal system. Findings showed no difference in any aspect of patient satisfaction between computer and non-computer groups. Use of a computer in the consulting room neither depersonalized nor enhanced patient satisfaction. Clinicians (in this case, nurse practitioners and physician assistants) were willing to use the system, which they perceived as having benefits for patient care, but were concerned about the increased time required for exams, effort required to learn the system while still interacting appropriately with the patient, increased monitoring of their performance, and other organizational issues. Clinicians who used the system showed a higher tolerance for uncertainty and communicated more frequently with each other and with others throughout the department. Implementation was slowed by the need to demonstrate the monetary value of the system.

Studying the effect of clinical uncertainty on physicians' decision-making using ILIAD.

The influence of uncertainty on physicians' practice behavior is not well understood. In this research, ILIAD, a diagnostic expert system, has been used to study physicians' responses to uncertainty and how their responses affected clinical performance. The simulation mode of ILIAD was used to standardize the presentation and scoring of two cases to 46 residents in emergency medicine, internal medicine, family practice and transitional medicine at Methodist Hospital of Indiana. A questionnaire was used to collect additional data on how physicians respond to clinical uncertainty. A structural equation model was developed, estimated, and tested. The results indicate that stress that physicians experience in dealing with clinical uncertainty has a negative effect on their clinical performance. Moreover, the way that physicians respond to uncertainty has positive and negative effects on their performance. Open discussions with patients about clinical decisions and the use of practice guidelines improves performance. However, when the physician's clinical decisions are influenced by patient demands or their peers, their performance scores decline.