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Only a minority of malpractice cases related to interventional cardiology end with judgments favoring plaintiffs, according to a review of US cardiac cath litigation published online September 6, 2013, ahead of print in the American Journal of Cardiology. Moreover, payment size seems proportional to injury severity.
Candice Kim, MD, of Cedars-Sinai Medical Center (Los Angeles, CA), and Mladen I. Vidovich, MD, of the University of Illinois (Chicago, IL), obtained data on 1,441 claims processed between 1985 and 2009 from the Physician Insurers Association of American (PIAA) registry, of which 116 were also described in detail on the LexisNexis Academic database.
Most Claims Do Not End in Payment
Overall, 22% of 1,361 closed claims in the PIAA registry resulted in payments to the plaintiff (average of $230,987). The most common alleged error was improper performance, and failure to perform an indicated procedure had the highest percentage of paid claims (table 1).
Table 1. PIAA Registry: Closed Claims 1985-2009
Percentage of Total Claims
Percentage Resulting in Payment
No Medical Misadventure
Errors in Diagnosis
Failure to Supervise or Monitor
Failure to Recognize Complication of Treatment
Performed When Not Indicated or Contraindicated
Delay in Performance
Indicated Procedure Not Performed
Surgical Foreign Body Left in Patient
Failure or Delay in Referral or Consultation
Grave injury accounted for only 2.1% of claims, but 43% of those claims resulted in payment (average $555,625). Death was the cited reason for 44.1% of claims, with 28% resulting in payment (average $268,259). In comparison, minor temporary injury, at 9.8% of the total, resulted in payments 15% of the time (average $53,094), and emotional injury, at 1.7%, favored the plaintiff 9% of the time (average payment $15,500).
Of the 116 LexisNexis cases, 90.5% involved the physician being sued and 29.5% of judgments favored the plaintiff. In the 31% of cases related to death, physicians were sued 97% of the time and plaintiffs won 44% of cases. The top 2 causes of death were MI (36.1%) and bleeding (13.9%).
Broad Picture Does Not Speak to Individual Cases
In a telephone interview, Dr. Vidovich told TCTMD that, importantly for clinicians, “the severity of injury seems to determine how badly things go.” Yet “not that many suits end up getting paid,” he noted. The situation is complicated, Dr. Vidovich explained, with both “errors of omission” and “errors of commission” leading to litigation.
Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), however, expressed some reservations. “It’s nice to give a summary of these claims, but in terms of practical advice for the physician, [it’s lacking] because every case is individualized. . . . It’s very hard for me to provide useful commentary on this,” he told TCTMD in a telephone interview, noting that it is unclear whether the study paints the entire picture.
Dr. Vidovich acknowledged that the sample may not fully represent cardiac cath-related lawsuits but said, “this is probably the best we can do. . . . Any settlements that happen out of court, we can’t see. That is an unknown.” Moreover, the PIAA terms, such as “grave,” are not specific, he said, adding, “The cases are written by non-medical persons, so the quality may not be great. It is an imperfect system of reporting. It is not structured.”
‘Communication Key to Prevention’
In an e-mail communication with TCTMD, Ian C. Gilchrist, MD, of Hershey Medical Center (Hershey, PA), outlined numerous take home messages for clinicians. “The paper suggests that malpractice suits in the cardiovascular field are probably significantly less of a problem than the rumor on the street. It also suggests that claims are usually related to an adverse event or complication and don't materialize out of nowhere,” he commented.
Dr. Gilchrist said that, on a daily basis, physicians can take steps to reduce the risk of facing malpractice claims. “Communication is the key to prevention. If the patient understands the risks and [then a problem] occurs then it is a known risk and probably defendable. On the other hand, if the [claimant] was not informed of a risk, then the claim of lack of consent can be made and legal action may proceed,” he explained, noting that frivolous lawsuits for insignificant injuries are uncommon. “But if something unexpected or expected happens that is bad, good communication and understanding up front and during the hospitalization will mitigate the long-term chance of litigation.”
Dr. Gilchrist confirmed that, based on his 20 years of experience, the study results seem plausible. “Most situations I have been aware of typically involve not only a bad result or complication, but also some other issue usually revolving around a breakdown or corruption in communication between the patient and provider,” he noted.
“Many of us trained and grew professionally during an era when there was a lot of discussion about malpractice. Cardiovascular specialists in general have been affected less than most specialists, yet the fear remains,” Dr. Gilchrist continued.
Interventionalists “have a much greater control over their risk than many believe. These things don't usually appear spontaneously but rather are fairly predictable,” he stressed, adding, “If you have a problem during a procedure, take responsibility for being there and work with the patient and family to help see them through it. They will continue to respect you not only as a doctor but also as a human being who did the best at the time.”
Dr. Kirtane advised: “What we tell trainees is that, if you practice in the United States, litigation is something you have to be educated about. But in the end, if you do your best to try to take care of the patient and communicate what you’re doing to the patient and their family, that’s the best way to proceed. . . . There’s no substitution for face time.”
The PIAA registry recorded more than 200,000 closed claims within that period. Cardiology-related cases represented 18% of the total, tying with gastroenterology for the lowest percentage of paid to closed claims (18%) among 28 specialties. Of the cardiovascular claims, diagnostic catheterization accounted for 12% and angioplasty for 7%.