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Biomedical subjects

D W Shapiro

Publications and source records attributed to D W Shapiro.

12 recordsLinked to original sources
PubMed1996

Medical practice guidelines in malpractice litigation: an early retrospective.

The role of practice guidelines in malpractice litigation has been discussed in some theoretical detail. Little information is available, however, on how courts use guidelines or on the effort of state legislatures to explicitly link guideline compliance with malpractice defenses. We review all relevant case law and legislative enactments to shed light on the influence of medical malpractice on guidelines. We also use data from a nationwide survey of malpractice attorneys to supplement our legal analysis. Although guidelines are being used for both inculpatory and exculpatory purposes in common-law litigation (a two-way street), legislatures are interested in applying them only for exculpatory purposes (a one-way street).

Expert Testimony↗
PubMed1995

Practice guidelines and malpractice litigation: a two-way street.

OBJECTIVE: To understand how practice guidelines are used in malpractice litigation. DESIGN: Review of the open and closed malpractice claims of two medical malpractice insurance companies, and a mailed survey of attorneys who litigate malpractice claims. SETTING: United States. PARTICIPANTS: Two insurance companies and 960 randomly selected malpractice attorneys. MEASUREMENTS: Frequency and nature of the use of practice guidelines in litigation; understanding and frequency of the use of practice guidelines by attorneys in malpractice cases. RESULTS: 259 claims opened in 1990-1992 at two insurance companies, including all obstetrics and anesthesia claims and a random sample of other claims, were reviewed. Seventeen of these claims involved practice guidelines, which were used as exculpatory evidence (exonerating the defendant physician) in 4 cases and as inculpatory evidence (implicating the defendant physician) in 12 cases. The only physician or patient factors associated with use of a guideline was a longer physician-patient relationship (P = 0.021). Nine hundred and sixty surveys were mailed and 578 were returned (response rate, 60.1%). Attorneys reported that once a suit is initiated, practice guidelines are likely to be used for inculpatory purposes (inculpatory in 54% of cases; exculpatory in 22.7% of cases). However, guidelines that seem to offer exculpatory value induce attorneys not to bring suits. The only attorney factor associated with increased use of guidelines was a practice in which more than 50% of business was in medical malpractice. CONCLUSIONS: Guidelines are used both by plaintiffs' and defendants' attorneys in malpractice cases. The emphasis in health reform proposals on guidelines as exculpatory evidence should be carefully considered.

Humans↗
PubMed1994

The contributions of authors to multiauthored biomedical research papers.

OBJECTIVE: To determine the contributions of each author to multiauthored biomedical research papers. DESIGN: Mailed, self-administered survey. PARTICIPANTS: A total of 184 first authors from a consecutive sample of 200 papers with four or more authors published in 10 leading biomedical journals. MAIN OUTCOME MEASURES: First authors' ratings of which authors had made substantial contributions to the following: initial conception of the study, design of the study, provision of needed resources, collection of data, analysis and interpretation of data, and writing the first draft of the paper or revising drafts for important intellectual content. RESULTS: The contributions of nonfirst authors varied greatly within and among papers. Even second and last authors--though they generally contributed more than other nonfirst authors--were markedly inconsistent in the extent and pattern of their contributions. Time spent on the research differed among authors by orders of magnitude. An appreciable number of authors made few or no substantial contributions to the research. CONCLUSIONS: The nature and extent of contributions of nonfirst authors to biomedical research reported in multiauthored papers cannot reliably be discerned (or discounted) by authorship or order of authors. The two core purposes of scientific authorship--to confer credit and denote responsibility for research--are not adequately being met by these authorship practices.

Authorship↗
PubMed1994

Key issues in managed competition.

All managed competition proposals for health system reform must confront several key issues. The premiums paid to health care purchasing cooperatives will need to be subsidized for those who cannot pay full fare; the amount and sources of the subsidies are controversial political issues. The payments passed on by purchasing cooperatives to health plans must be risk adjusted to account for differences in the health care needs of their enrolled populations. This is essential to create a level playing field for competition and to eliminate incentives for plans to use risk assessment for attracting enrollees. The data and methods needed for risk adjustment, however, are not adequate at present. The Clinton Administration's plan to limit expenditure increases raises a host of thorny issues. Maintaining quality of care will require health plan quality report cards to be supplemented by external quality assurance systems. Assuring quality will be particularly problematic for traditional indemnity plans. The structure and governance of the system, administration simplification, and other issues need to be addressed. The size and voluntariness of the purchasing cooperatives greatly influence all of these considerations. Physicians should inform their political representatives on how these issues should be resolved as compromise bills are drafted by the United States Congress this year.

Competitive Medical Plans↗
PubMed1993

Effect of an educational program on medical students' conversations with patients about advance directives: a randomized trial.

Advance directives, such as the durable power of attorney for health care (DPAHC), help patients and physicians make end-of-life health care decisions. Medical education should prepare student physicians to be knowledgeable about and comfortable with discussing advance directives. The authors developed an educational module for the third-year medical school curriculum and conducted a randomized trial to evaluate in students its effect on various outcome measures regarding the DPAHC. Over a six-week period, students who received written material about the DPAHC and a two-hour seminar significantly increased knowledge about and reported increased skill, comfort, and experience with the DPAHC.

Adult↗
PubMed1992

Realizing the potential of practice pattern profiling.

In January 1992, the Physician Payment Review Commission held a conference to learn about the appropriateness of present uses of profiling of practice patterns, and to identify what will be required to realize the full potential of this technique in the future. The conference addressed the data needs of profiling, the development of valid and relevant profiles, the impact of profiles on medical practice, and controversies surrounding public access to profiling information and the uses to which profiling has been put. This paper, based in part on that conference, reviews the basic concepts that underlie profiling and describes the roles that profiling can play in quality improvement, assessment of provider performance, and utilization review. It uses case studies to illustrate the types of problems that have arisen in actual usage and discusses what will be required to resolve them. The final section describes the roles that profiling can play in achieving the goals of health care reform, and concludes with what is needed in data and infrastructure development to improve the quality and usefulness of profiling.

Data Collection↗