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- Penny Greenberg, MS, RN
- Sandeep Krishnan, MD
- Gene Quinn, MD, MS, MPH
Malpractice cases in the U.S. that involve cardiology appear to be on the rise and getting more expensive, despite general malpractice trends that show significantly fewer cases relative to the physician population. Most of the errors in outpatient cardiac cases involve diagnosis failures, which bedeviled providers in the inpatient setting as well.
These conclusions come from two recent studies in the American Journal of Cardiology and in the Joint Commission Journal on Quality and Patient Safety. The researchers used a national database, developed at Harvard, of more than 400,000 coded malpractice cases, using similar time-frames.
“We analyzed malpractice claims between 2006 and 2015 in cardiology and noted that the total number of claims and the annual indemnity payments in cardiology has seen an overall increase in the past decade.”
Dr. Sandeep Krishnan is an interventional and structural cardiologist in Tulsa, Oklahoma at the St. John’s Clinic. His research shows that the number of cardiac claims rose 91 percent during that 10-year period, and the associated dollars rose 142 percent. The defendants in Dr. Krishnan’s study were from the cardiology service. Most claims arose from the inpatient setting, but more than 40 percent were outpatient. A plurality of the cases involved improper medical treatment, yet a quarter of the cardiology defendants faced allegations of diagnostic failure. Dr. Krishnan emphasizes that the data do not necessarily show that the quality of care is getting worse.
“Certain outcomes within cardiology or any field are destined to happen regardless of how hard we work as clinicians or how great we are or how smart we are. The good news is that most of these cases never even really get settled. About 60 percent are dropped, denied, or dismissed. I don’t think we’re offering worse care. I think overall, with increased focus on improving communication and transparency, both at the hospital administration level and at the individual provider level, as a whole in health care, I would say we’re probably providing better care, because we also now have more and more patient safety programs. But at the same time I think patients are expecting more from us, which they should. And we need to continue to improve our level of care and the delivery of health care in this county, and it’s lofty goal to strive for.”
Dr. Krishnan doesn’t speculate on the reasons his study shows rising incidence and cost of claims in cardiology and that managing rising patient expectations has become increasingly vital.
What about when the defendant in a cardiac claim is a general practitioner in the outpatient setting? Dr. Gene Quinn used a subset of the same national malpractice data to look at cardiac diagnosis errors in ambulatory settings involving internal or family medicine physicians as the primary responsible clinician. The study’s main conclusion was that most of these cardiac cases in primary care involved patients with conventional risk factors for coronary artery disease.
“A lot of the patients that were misdiagnosed with diagnoses codes like GERD or reflux disease, or even just a diagnosis of nonspecific chest pain that ended up having MI’s, actually had a lot of comorbidities and risk factors for coronary artery disease. So 37 percent of them were smokers. Actually almost a quarter of them already had previous cardiovascular disease. So they maybe had already had a heart attack in the past, which raises your suspicion for them having another heart attack. In fact, 68 percent of patients that were diagnosed with something other than cardiac disease, but ended up actually having a heart attack, had one of these risk factors for coronary artery disease. The majority of these patients are actually patients with at least intermediate or high pretest probability of having cardiovascular disease.”
Dr. Quinn says that analysis of these cardiac malpractice claims also revealed something that could independently predict a higher chance of having to pay that claim, as well as higher case costs: and that’s when a patient went home with a nonspecific diagnosis that mimics classic cardiovascular pain, such as reflux disease or nonspecific chest pain. According to Dr. Quinn, their results suggest that patient safety interventions could hold some promise. At the same time their findings might bust some common myths.
“Traditionally and anecdotally, we think of oh, the patients that you’re going to miss are women with no risk factors that have very atypical symptoms. They are having shortness of breath; they are having a little bit of jaw pain or something like that, and what this suggests is that we’re not missing those difficult ones. We’re actually missing the easy ones, the patients that come in with chest pain or with symptoms that sound like GERD but have a lot of risk factors for having heart attacks. And those are the ones that we’re missing, and those are the ones that are leading to most of the malpractice risk.”
With a clearer view of the characteristics of these kinds of cardiac errors, practices can turn to interventions to reduce them. Penny Greenberg was involved in the cardiac malpractice research. Greenberg is a senior program director at CRICO, Harvard’s malpractice insurance and patient safety program. CRICO sponsors the national database, known as the Comparative Benchmarking System, or CBS.
“When we participate in these research projects, the goal is to look at the data, analyze the data specifically around contributing factors. What’s driving the cases? But also what interventions could be put into place based on the contributing factors that are driving the cases? So, for example, with cardiology cases, one of the things that they found helpful in the inpatient setting was with the electronic health record decision support systems. The provider gets an alert, or the decision support helps them look at the algorithm, based on the symptoms the patient is having.”
Greenberg says that the top contributing factors in these coded claims involving diagnosis are cognitive: assessing the patient, ordering the right diagnostic test, following up on the results and developing a treatment plan.
“Probably the second most common contributing factor we see in these cases is communication. Healthcare is very complex. People are living longer with numerous comorbidities so they see numerous providers, but communication between those providers has to be pristine in order to keep the patient on the right track and make sure you keep them healthy. An example is communication between a surgeon and a cardiologist when the patient is going for surgery if they are on anticoagulation therapy. So those are the two things: the clinical judgment (the cognitive piece, the assessment, ordering a consult as needed or ordering the right tests), and communication between providers.”
Dr. Krishnan says that doing everything right is important, but it isn’t everything. Patients can understand that their providers are human and they make mistakes. He says that preventing bad feelings is also all about setting expectations. He emphasizes a shared decision-making model and a robust informed consent process with the patients he sees, to maximize satisfaction. But according to Dr. Krishnan, working with patients after an adverse event must also be a priority.
“I think that what happens after a diagnostic error is noticed is the most important thing. And what research has shown is that being transparent and open with the family and the patient is the best, in terms of protecting oneself from a future malpractice suit. And that’s something that I think, just editorializing here, that we should all strive to do and be more comfortable with. Because it is difficult for us to say ‘hey, we did make an error and we missed this,’ especially if it caused some harm. But I think it’s important to be forthright with the family and the patient and to let them know that ‘I did my best and this is unfortunately what happened but we’re not going to abandon you. I am your physician. We’re going to figure this out and I’m going to try to make everything better. I’m going to try to help you regardless of what happened in the past, because we’re going to have to move forward and deal with the situation as it stands.’ And that applies to any specialty.”
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