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PubMed2005

Management of the difficult airway: a closed claims analysis.

BACKGROUND: The purpose of this study was to identify the patterns of liability associated with malpractice claims arising from management of the difficult airway. METHODS: Using the American Society of Anesthesiologists Closed Claims database, the authors examined 179 claims for difficult airway management between 1985 and 1999 where a supplemental data collection tool was used and focused on airway management, outcomes, and the role of the 1993 Difficult Airway Guidelines in litigation. Chi-square tests and multiple logistic regression analysis compared risk factors for death or brain damage (death/BD) from two time periods: 1985-1992 and 1993-1999. RESULTS: Difficult airway claims arose throughout the perioperative period: 67% upon induction, 15% during surgery, 12% at extubation, and 5% during recovery. Death/BD with induction of anesthesia decreased in 1993-1999 (35%) compared with 1985-1992 (62%; P < 0.05; odds ratio, 0.26; 95% confidence interval, 0.11-0.63; P = 0.003). In contrast, death/BD associated with other phases of anesthesia did not significantly change over the time periods. The odds of death/BD were increased by the development of an airway emergency (odds ratio, 14.98; 95% confidence interval, 6.37-35.27; P < 0.001). During airway emergencies, persistent intubation attempts were associated with death/BD (P < 0.05). Since 1993, the Airway Guidelines were used to defend care (8%) and criticize care (3%). CONCLUSIONS: Death/BD in claims from difficult airway management associated with induction of anesthesia but not other phases of anesthesia decreased in 1993-1999 compared with 1985-1992. Development of additional management strategies for difficult airways encountered during maintenance, emergence, or recovery from anesthesia may improve patient safety.

Adult↗
PubMed2006

Trends in anesthesia-related death and brain damage: A closed claims analysis.

BACKGROUND: The authors used the American Society of Anesthesiologists Closed Claims Project database to determine changes in the proportion of claims for death or permanent brain damage over a 26-yr period and to identify factors associated with the observed changes. METHODS: The Closed Claims Project is a structured evaluation of adverse outcomes from 6,894 closed anesthesia malpractice claims. Trends in the proportion of claims for death or permanent brain damage between 1975 and 2000 were analyzed. RESULTS: Claims for death or brain damage decreased between 1975 and 2000 (odds ratio, 0.95 per year; 95% confidence interval, 0.94-0.96; P < 0.01). The overall downward trend did not seem to be affected by the use of pulse oximetry and end-tidal carbon dioxide monitoring, which began in 1986. The use of these monitors increased from 6% in 1985 to 70% in 1989, and thereafter varied from 63% to 83% through the year 2000. During 1986-2000, respiratory damaging events decreased while cardiovascular damaging events increased, so that by 1992, respiratory and cardiovascular damaging events occurred in approximately the same proportion (28%), a trend that continued through 2000. CONCLUSION: The significant decrease in the proportion of claims for death or permanent brain damage from 1975 through 2000 seems to be unrelated to a marked increase in the proportion of claims where pulse oximetry and end-tidal carbon dioxide monitoring were used. After the introduction and use of these monitors, there was a significant reduction in the proportion of respiratory and an increase in the proportion of cardiovascular damaging events responsible for death or permanent brain damage.

Anesthesia↗
PubMed2002

Clinical application of the DEC variables in assessing maximality of muscular effort: report of 34 patients.

OBJECTIVE: To examine maximality of muscular effort in patients with expected muscle strength deficiency using acceptance-rejection cutoff values derived from isokinetic testing of maximal and feigned effort in normal subjects. DESIGN: A retrospective study of 34 patients with orthopedic, rheumatic, or neurologic disorders for which financial compensation was sought. RESULTS: The relevant scores in all patients save one were less than the respective cutoff values that in normal subjects differentiate maximal effort (below cutoff) from feigned weakness (above cutoff) at a 95% level of confidence. CONCLUSIONS: If normal subjects-based cutoff values are accepted as benchmarks for validation of muscle strength deficiency claims, this study indicates that subject to a given protocol, patients performed at a maximal level of effort.

Adolescent↗
PubMed2003

Avoiding denials due to ICD-9-CM coding.

Regional Home Health Intermediaries (RHHIs) continually report a high incidence of PPS denials due to incorrect diagnosis. These down-coded claims result in a lower payment to agencies for services already provided. This article helps clinicians and clinical managers address processes in their agency to assure denials are diminished and, hopefully, eliminated.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1996

Monitoring and analysis of outcome studies.

Monitoring technology appears to be advancing at a rare that exceeds our ability to assess its effectiveness. RCTs are often poorly designed and lacks statistical power. Even high-quality RCTs may not provide inferences that can be generalized across all patient populations. Alternative methods of technology assessment, such as closed claims analysis, meta-analysis, and statistical process control, also have limitations. PORTs using a standard model of combined techniques are beginning to solve some of the more common methodological problems. The future of technology assessment relies on the ability to conduct large-scale cohort studies from routine practice settings. In terms of intraoperative monitors, this may require production of a complete and valid database of all monitored variables that can compared to a complete and valid database of all monitored variables that can be compared to a complete and valid database of appropriate outcome indicators. National standard for collection of data need to be developed. At this time, professional societies should focus more on developing guidelines for technology assessment than on guidelines for technology utilization.

Cohort Studies↗
PubMed1995

Factors influencing mode of claims settlement in workers' compensation cases.

This paper examines the variables that influence the means by which 10,192 injured workers settled their compensation claims during 1990. The data on which this study is based come from a state in Australia where there are three means by which workers' compensation claims can be settled by lump sum payment: settlement following a specific injury payment, early settlement payment and settlement following a common law payment. This paper is specifically concerned with identifying the variables that determine whether the claim will be settled by a lump sum payment and whether different modes of claims settlement by lump sum are unique and predictable from a range of variables that include injury characteristics and demographics. The results of logistic regression modelling revealed that those who received a lump sum settlement could be reliably distinguished from those who did not receive such a payment. Each mode of settlement varied in the extent to which it could be predicted. Contrary to expectations, the most difficult form of settlement mode to predict was that of specific injury payments (4% accurate) with the most predictive being early settlement payments (81% accurate). Common law payments were also highly predictable (48% accurate). The form of lump sum payment received by injured workers was found to depend on a range of injury characteristics, indices of severity and for common law payments, gender and potential income loss. It is argued that although injury characteristics play a part in the process of claims settlement, personal circumstances and insurance company policies are influential in dictating the form by which workers compensation cases are finalized.

Age Factors↗
PubMed2001

Health claims data as a strategy and tool in disease management.

A comprehensive definition of disease management provides an opportunity to track a population of patients across the entire continuum of a condition, from wellness through disease and disability, so that improvements in health status and quality of life and efficiencies in the application of health care resources can be demonstrated. The need is great for information systems that can computerize clinical encounter, summarize, and apply the information to help identify opportunities for improvement in the performance of quality and cost control, monitor processes of care, and report outcomes that are meaningful to the organization. By tracking health care charges as a proxy for the application of health care resources, health claim data analyses can identify conditions for disease management, facilitate provider buy-in, develop the disease management program, monitor interventions, and report outcomes.

Continuity of Patient Care↗
PubMed1993

Medicare beneficiaries: adverse outcomes after hospitalization for eight procedures.

Rehospitalization following surgery is widely recognized as an important outcome measure. The purpose of this study was to identify rehospitalizations for adverse events following 8 procedures, using diagnosis and procedure codes contained in Medicare claims files. Adverse events were broadly defined as: 1) complications; 2) failure of the procedure to achieve its therapeutic goal; and 3) untoward events associated with the natural history of the disease being treated with the procedure. Expert panels identified specific diagnosis and procedure codes that might indicate an adverse event if they appeared on the Medicare record of a rehospitalization. Among patients undergoing percutaneous transluminal coronary angioplasty, almost 36% were rehospitalized for an adverse event within a year of surgery; among patients undergoing coronary artery bypass graft surgery, 20% were rehospitalized for an adverse event. Following the other 6 procedures (cholecystectomy, partial excision of the large intestine, total knee replacement, total hip replacement, replacement of the head of the femur, and reduction of fracture of the femur) between 4% and 9% of patients were rehospitalized for an adverse event. Findings from this exploratory study indicate that rehospitalizations for adverse events appear to be a useful outcome measure for the cardiac procedures; they appear to be less useful for the other procedures, at least at the individual hospital or small area level, because of their relative rarity. Future studies should investigate procedures associated with more frequent rehospitalizations, and medical admissions, which often tend to be associated with higher rehospitalization levels.

Aged↗
PubMed1994

Does physician performance explain interspecialty differences in malpractice claim rates?

Physician specialty has been consistently associated with different malpractice claim rates, with neurosurgery, orthopedics, and obstetrics and gynecology having the highest rates. Whether these differences reflect physician performance or other aspects of patient care that are unique for each specialty is unclear. A retrospective cohort study was performed including 12,829 physicians involved in 8,221 closed cases from 1977 to 1991. For each case an assessment was made whether the plaintiff received an award and whether the physician care of the patient was indefensible. An award was made to the plaintiff in 42% of cases. Physician care was considered indefensible in 23% of the cases. The specialties with the highest award rates were anesthesiology (58.3%), obstetrics and gynecology (47.5%), and radiology (43.0%). Neurosurgery had the lowest rate of award (30.2%). The specialties with the highest indefensibility rates were radiology (36%), obstetrics and gynecology (27%), and anesthesiology (27%). Neurosurgery had the lowest indefensibility rate (10%). These results were unchanged after controlling for physician age, degree, site of training, certification status, and severity of patient injury. In conclusion, differences in award rate and indefensibility are present, but not large enough to explain the large variation in specialty claim rates. This suggests that the variation in malpractice rates results from factors other than a meaningful difference in physician performance.

Clinical Competence↗
PubMed1996

The impact of practicing in multiple hospitals on physician profiles.

Although physicians are all too familiar with the psychologic impact of having multiple responsibilities, the associated impact on practice styles has not been examined systematically. To provide some data on the effects of "work dispersion," we examined the hypothesis that the inpatient resource use of physicians would rise with the number of hospitals in which they work. Data for 1991 from Medicare's National Claims History File were used to profile a sample of attending physicians (n = 33,756) in seven states. The attending physician "profile" was the case mix-adjusted relative value of all physician services (regardless of who delivered them) that were delivered during each patient's hospital stay. Relative value was measured in relative value units, used by Medicare in determining physician payments. The authors then categorized physicians in terms of the number of hospitals to which they admitted patients. Physician profiles were adjusted further to control for geography, physician specialty, and characteristics of the physician's primary (ie, most used) hospital. One third of the physicians in the sample had admissions to more than one hospital. Physicians working in one hospital had inpatient practice profiles 2.1% below the sample mean. Additional hospital affiliations were associated with progressively higher profiles: two hospitals, 2.3% above the mean; three hospitals, 4.5% above; four hospitals, 8.2% above; and five or more hospitals, 11.5% above (all P < 0.01). The practice of medicine in more than one hospital is associated with higher inpatient profiles and shows a dose-response relationship. Physicians and policy makers will need to consider carefully whether there are any associated benefits to justify the increased cost.

Adult↗
PubMed1996

Systemwide provider performance in a Medicaid program. Profiling the care of patients with chronic illnesses.

OBJECTIVES: This study illustrates how claims data can be applied to examine cost and clinical performance of providers in the Medicaid program. METHODS: The authors conducted a cross-sectional analysis of Medicaid beneficiaries in Maryland with diabetes mellitus, hypertension, and asthma treated on an ambulatory basis by hospital-based outpatient departments, physician office-based providers, and community health centers. The study year was July 1987 to June 1988. The authors defined the cost performance (high, medium, or low) of providers in the management of each of the three chronic illnesses, both before and after casemix adjustment, using a classification system based on ambulatory diagnoses (ambulatory care groups). The authors constructed claims-based clinical performance indicators for each of the three conditions. These included the number of patients admitted to acute-care hospitals for any and specific (diabetes mellitus, hypertension, and asthma) causes, the number of patients without a follow-up visit within 30 days of being discharged from the hospital, and the number of patients with consecutive emergency room visits during the study period. RESULTS: The ambulatory care group casemix classification system explained 23%, 33%, and 36% of the variation in total payments for patients with hypertension, diabetes, and asthma, respectively. Without adjustment for casemix, 35% to 50% of providers would be misclassified regarding their cost performance. Forty-one (19.4%) of 211 providers who treated all three illnesses were in the same cost group for all three illnesses and 95 (43%) of 223 providers who treated two of the three illnesses were in the same cost group for both illnesses. Among office-based physicians, for all three chronic illnesses, high-cost providers had more admissions (P < 0.01) for ambulatory care-sensitive conditions than low-cost providers. Among hospital outpatient departments, only high-cost providers of asthma had more admissions (P < 0.05) for asthma than low-cost providers. There was no statistically significant (P > 0.05) difference in the clinical performance indicators between high-cost and low-cost hospital outpatient department providers of primary care for hypertensive and diabetic Medicaid beneficiaries. For the other clinical performance indicators, the results were not consistent across the three illnesses or across the different types of providers. CONCLUSIONS: Without adjustments for casemix, a large number of providers are misclassified regarding to cost performance. In addition, most providers are not equally efficient in managing different chronic illnesses. Provider cost performance is not associated consistently with clinical performance, although severity differences not captured by the casemix adjustment may account for these observations. These measurement methods and relationships between provider performance measures may be useful to state Medicaid programs that seek to contain costs, enhance coordination of care, and improve health.

Aged↗
PubMed1996

Poststroke rehabilitation in older Americans. The Medicare experience.

OBJECTIVES: This study examines the poststroke rehabilitation experience for a 20% sample of Medicare patients age 65 years and older admitted to an acute-care hospital with a stroke diagnosis during the 6-month interval, January 1, 1991 to June 30, 1991. Their Medicare claims data are used for two purposes: to identify current poststroke rehabilitation practice in the US population age 65 years and older, and to evaluate the importance of practice variation within this population. METHODS: Regarding the first objective, the authors develop estimates for many poststroke rehabilitation use and cost parameters that formerly were unmeasured. With respect to the second objective, the authors construct and compare average service use rates across all stroke patients in a census division and across all stroke patients residing in the 30 largest metropolitan statistical areas. RESULTS: The authors' Medicare claims analysis indicates that 73% of stroke survivors received either postacute institutional or ambulatory rehabilitation care during the first 6 months poststroke. The published stroke literature, on the other hand, focuses on the minority of stroke survivors, 16.5% in the Medicare data, who were admitted to an inpatient rehabilitation hospital. Regarding the second study objective, the Medicare analysis provides graphic evidence that poststroke rehabilitation practice varies substantially from one geographic area to another and that practice differences translate into large geographic-related differences in the cost of poststroke rehabilitation. CONCLUSIONS: The authors believe the findings demonstrate a problem with inconsistent poststroke rehabilitation practice.

Aged↗