Thursday, March 8, 2007
Why Are C-Section Rates Still Going Up?
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As an anesthesiologist I provide anesthesia for cesarean sections quite often. In fact, when I'm on overnight call it's what I spend most of my time doing. Usually, anesthesia for c-section consists of a spinal anesthetic, or using a pre-existing epidural catheter, or (more rarely and usually only in emergencies) a general anesthetic. I am therefore quite interested in the subject of cesarean section rates and what effects how often they are done. I learned some things from this article [free full text]:
Cesarean Delivery and The Risk-Benefit Calculus
1. Parturients are different--they are heavier and older.
2. The number of premature and low birth-weight babies has grown.
3. Vaginal breech deliveries are no longer recommended.
4. Operative deliveries (forceps or vacuum) are less common due to better data describing their risks.
5. More labors are induced (20% in 2003 vs 9.5% in 1990) and induced labors are more likely to result in C-section.
6. Changes in provider behavior
"At least one study found that physicians' malpractice premiums, the number of claims against physicians and hospitals, and the physician's preception of the risk fo being sued were all positively correlated with the likelihood of cesarean delivery. Many in the field defend the rising cesarean rates by citing concern about legal jeopardy, and indeed lawsuits often allege a failure to perform a timely cesarean delivery."
Look at John Edwards' list of law cases (thank you, Google). Notice the medical malpractice cases:
MEDICAL MALPRACTICE CASES
Another specialty Edwards developed was in medical malpractice cases involving problems during births of babies. According to the New York Times, after Edwards won a $6.5M verdict for a baby born with cerbral-palsy, he filed at least 20 similar lawsuits against doctors and hospitals in deliveries gone wrong, winning verdicts and settlements of more than $60M.
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| Case |
Summary of Facts |
Case Type |
Result |
Griffin v. Teague, et al.
(Mecklenburg Co. Superior Ct., NC, 1997) |
Application of abdominal pressure and delay in performing c-section caused brain damage to infant and resulted in child having cerebral palsy and spastic quadriplegia. Verdict set record for malpractice award. |
Medical Malpractice |
$23.25M
verdict |
Campbell v. Pitt County Memorial Hosp.
(Pitt County, NC, 1985)
|
Infant born with cerebral palsy after breech birth via vaginal delivery, rather than cesarean. Established North Carolina precedent of physician and hospital liability for failing to determine if patient understood risks of particular procedure. |
Medical
Malpractice |
$5.75M
settlement |
| Wiggs v. Glover, et al. |
Plaintiff alleged infant's severe cerebral palsy was caused by negligent administration of pitocin, failure to use fetal monitor, or timely intervening in baby's fetal distress. |
Medical
Malpractice |
2.5M
settlement |
| Cooper v. Craven Regional Med. Ctr., et al. |
Infant suffered severe brain damage after obstetrician failed to moderate use of Picotin after baby displayed clear fetal distress. |
Medical
Malpractice |
$2.5M
settlement |
Dixon v. Pitt County Memorial Hospital
(Pitt County, NC) |
Birth-related injuries including cerebral palsy and mental retardation allegedly caused by obstetrician's failure to diagnose fetal distress, including umbilical cord wrapped around baby's neck prior to delivery. |
Medical
Malpractice |
2.4M
settlement
|
Despite the increase in c-section rates nationwide, we have seen no reduction in the cerebral palsy rate...
Tuesday, February 27, 2007
Even Malpractice Lawyers Need Doctors, Sometimes
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In An Eye For An Eye, Charity Doc describes a close encounter with a malpractice attorney who once sued him. I'm not sure I would have been as, um, gracious....
"Yeah, I'm a personal injury lawyer. I have no problems telling doctors that. I get better care that way, actually. Makes you guys more careful around me."
"Yes, I know you very well, Mr. Cochran. You were the plaintiff attorney accusing me of being a baby killer, remember?!"
Wednesday, May 24, 2006
Pennsylvania's Health Care Crisis has NOT 'turned the corner'
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Our Governor is quoted as saying that Pennsylvania's health care crisis has turned a corner. It has not and as evidence I point you to the following article about a Cardiology group in Philadelphia that will no longer provide coverage at one health center there:
"Frankford Health Care System, which is already getting ready to discontinue maternity services at its Torresdale division, is losing another group of specialists at its Frankford campus in another departure tied in part to Pennsylvania's high medical malpractice insurance costs. --Philadelphia Business Journal"
Imagine you're, say, a plastic surgeon. There used to be fifteen of you on staff at a hospital so you took ER call only two days per months (as a precondition for maintaining staff privileges). Well, because of a malpractice crisis that has NOT turned the corner there are only three of you now. That's ten days of ER call each month. Kinda forces you to ponder whether maintaining staff privileges is worth is, doesn't it? And if you decide it's not, then patients loose access to yet another specialist at the hospital. See where this goes?
Sunday, May 14, 2006
RangelMD on Tort Reform in Texas
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Texas enacted caps on medical malpractice awards in 2003. The debate there on whether these caps are good or have been responsible for the drop in new malpractice cases by 60%-80% continues.
"Obviously the need is to reduce legal costs, increase ease and access to the system, increase efficiency and speed of proceedings so that justified compensation finds its way to the plaintiff with all deliberate speed, and establish much more consistency in finding fault and awarding compensation. One solution is the establishment of special health courts where neutral expert witnesses would be hired by the court, judges or panels would hand down judgments, and guidelines would be in place for the determining of fault and compensation.
It's easy to see why trial lawyers oppose special health courts because their roles would be significantly reduced. A system like this would be far less susceptible to such intangibles as the fickle mood of a jury or the charisma of the lawyer. We've been talking for years about reducing costs and improving access to health care. Maybe it's about time we started doing the same with our tort system. Proposition 12 may have been the first small step in that direction."
[RangelMD]
Tuesday, March 14, 2006
Wisconsin Limits Noneconomic Damages In Malpractice Suits
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Wisconsin Senate Approves Limits On Noneconomic Damages In Malpractice Suits:
"The Wisconsin state Senate on Wednesday voted 25-8 to approve a bill that would place a $750,000 limit on noneconomic damage awards in medical malpractice cases, the Milwaukee Journal Sentinel reports. Six Democrats joined all 19 Republicans in voting for the bill."
[Via UK Medical News Today]
Sunday, February 5, 2006
Pennsylvania Doctor's Advocate
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An organization called Doctor's Advocate is announcing it's first successful effort to stop a 'frivolous' lawsuit in Pennsylvania: Doctor's Advocate Terminates First Frivolous Medical Malpractice Lawsuit; Case Against OB-GYN Dropped in Seven Weeks:
"Dr. Coslett-Charlton's case stemmed from an incident earlier in 2004, when she met with a woman late in pregnancy for the first and only time. After an examination revealed drastic complications, she sent the patient directly to the hospital. The doctors at the hospital took over treatment of the patient. The patient later sued several doctors including Dr. Coslett-Charlton."
Here's the background on the organization: "Doctor's Advocate works to reverse the medical malpractice crisis and keep doctors in Pennsylvania by raising public awareness, lobbying for legislation to produce tort reform, and combating frivolous lawsuits with an inexpensive legal service."
Looks like being a member costs $1200 per year.
Saturday, January 21, 2006
Can damage caps influence premium growth and physician supply?
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The Impact of Caps on Damages: How are Markets for Medical Liability Insurance and Medical Services Affected?
"[This report] provides a summary of research on the impact of caps including those on punitive and total damages in addition to those that apply only to non-economic damages. Our focus is on those papers that employ statistical techniques to control for potentially competing explanations of changes that are observed when simple descriptive statistics are used."
and concludes
"the body of research on the impacts of tort reform shows that caps have resulted in lower growth in medical liability losses in states that passed caps than in states that did not. The more recent literature on premium effects has found that caps result in lower premium growth. And, two very recent papers based on sufficiently many years of the AMAâs Masterfile data have found that non-economic caps and direct tort reforms more generally have a positive effect on the number of physicians per capita in a state."
Insurance Profits Don't Explain Malpractice Crisis
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The American Medical Association has released a new article which takes to task the so-called 'Angoff Report' which claimed that the medical liability insurance crisis is caused by insurance companies booming profits, overcharging physicians for coverage, and ballooning surpluses. It refers to two subsequent analyses which point up the flaws in the approach used by Angoff. Revised analysis shows the growth rate of insurance company surpluses was only 3.9% per year, and they were profitable in only one year (2004) when they made 5%
Thursday, December 22, 2005
More on why anesthesia is (or is not) safer
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Walter Olson responded to my earlier post and I feel I need to clarify what I meant. I thank him for pointing out (gently) the error of my words.
First off, I trained in the early 1990's after the advent of improved monitoring such as pulse oximetry and end tidal gas monitoring. My statement that 'overdose risk is not and was never a cause of patient morbidity and mortality in my field' was overly broad and, as Olson points out, incorrect.
The point I tried to make (though not well) was that overdose is not something we presently worry about and does not explain the apparent increase in awareness under anesthesia. What can explain it (in part) is the use of muscle paralyzing drugs (even when they are not absolutely necessary) often together with medical errors such as empty vaporizers (inhaled anesthetic delivery source), incorrectly installed vaporizers, or other human error.
Though Google turns up many hits on anesthesia and overdose, these tend to be written by non-anesthesiologists for the lay public and should not be taken as evidence that anesthetic overdoses is a cause of malpractice claims (though, admittedly, it is a term that most juries readily understand)
Walter, if you're reading this, I'd love to be able to read more about how the legal system portrays us during trials. Any pointers?
Misconceptions about why anesthesia is safer
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Walter Olson has taught me much about the legal system as it pertains to medicine via the PointOfLaw forum. I have to take exception with a post made today however. In pointing to an article that considers whether the lessons of patient safety in anesthesiology are generalizable to other fields of medicine, he writes:
"Incidentally, because anesthesiologists are now more vigilant than ever not to court an overdose risk by giving patients any more than the minimum they need, there is apparently a rising incidence of the phenomenon of "anesthesia awareness", in which underdosed patients are actually aware of the surgery in progress and perhaps end up undergoing psychological trauma as a result. So what happens next? You guessed it."
Overdose risk is not and was never a cause of patient morbidity and mortality in my field. Second, it is not at all clear whether the 'rising incidence of the phenomenon of anesthesia awareness' is anything but a) better reporting (i.e. you don't find what you don't look for) b) realization among patients that there's something else they can sue for or c) an effort by one medical device company which makes depth of anesthesia monitors to panic hospitals and anesthesia groups into buying their product (a product which, by the way, has not been shown to decrease the incidence of awareness).
The specialty is actively engaged in evaluating this 'problem' with the same approach it has used to improve patient safety in other areas such as airway management and positioning injuries.
Friday, July 1, 2005
Med Mal Costs 2004
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Med Mal Costs 2004:
"Where is the most expensive place to defend oneself against malpractice in 2004? Florida is tops and Wyoming is the least expensive."
Hmmm. From the summary, it looks like my state (Pennsylvania) is 5th for costs incurred...
[Via PointOfLaw Forum]
How to survive a deposition
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"Malpractice: How to survive a deposition"
"Be concise, be cool, be prepared, and don't try to outwit the plaintiff's attorney."
[Via Overlawyered]
Saturday, June 11, 2005
Malpractice Insurance for Bariatric Surgeons Increasing
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Other Perils of Overweight - New York Times:
" But after several years in which the surgery was seen as the last best hope by many obese people, a growing array of scientific data shows that the risks are greater than patients realized. One new study reported that almost one in 5 patients had complications after surgery. For one in 20 patients, the complications were serious, including heart attacks and strokes. Another recent study said the mortality rate for the most common type of bariatric surgery, gastric bypass, was one in 200 - a rate higher than for coronary angioplasty, which opens blocked heart vessels.
For thousands of patients, the weight-loss surgery has eliminated debilitating diseases and improved the quality of life. But the threat of malpractice lawsuits against doctors and hospitals, as well as the reluctance of health plans to cover the surgery costs, is creating difficulties for people now seeking treatment. "
The article points to an Annals of Internal Medicine article titled Meta-Analysis: Surgical Treatment of Obesity (Annals is another one of those nice free full-text journals).
[Via Common Good]
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