This report presents data describing a large cohort of closed cardiovascular medical professional liability (MPL) claims. The Physician Insurers Association of America established a registry of closed MPL claims in 1985. This registry contains data describing 230,624 closed claims for 28 medical specialties through 2007. The registry is maintained to support educational programs designed to improve the quality of care and to reduce patient injury and MPL claims. In this report, descriptive techniques are used to present summary information for the medical cardiovascular claims in the registry. Of 230,624 closed claims, 4,248 (1.8%) involved cardiovascular medical physicians. Of the 4,248 closed cardiovascular medical claims, 770 (18%) resulted in indemnity payments, and the average indemnity payment was $248,291. In the entire database, 30% of closed claims were paid, and the average indemnity payment was $204,268. The most common allegation among cardiovascular closed claims was diagnostic error, and the most prevalent diagnosis was coronary atherosclerosis. Claims involving cardiac catheterization and coronary angioplasty represented 12% and 7% of the cardiovascular closed claims. Aortic aneurysms and dissections, although relatively infrequent as clinical events, represent a substantial MPL risk because of the high percentage of paid claims (30%) and the very high average indemnity payment of $417,298. In conclusion, MPL issues are common and are important to all practicing cardiologists. Detailed knowledge of risks associated with liability claims should assist practicing cardiologists in improving the quality of care, reducing patient injury, and reducing the incidence of claims.
The risk for medical professional liability (MPL) claims is a daily consideration in cardiovascular (CV) medicine. The minimization of liability risk is a worthy goal for all practitioners, and evidence from other specialties suggests that educational efforts and other strategies aimed at increasing practitioners’ understanding of their liability risks may reduce those risks. The purpose of this report is to present a summary of the CV physician professional liability claims experience of a consortium of MPL insurance companies to increase CV physicians’ awareness of the details of the problem of MPL. The data presented in this report were collected by the Physician Insurers Association of America (PIAA), an association of 50 MPL insurance carriers that are owned and operated by physicians and dentists. PIAA-affiliated companies provide MPL insurance coverage for approximately 60% of physicians in private practice in the United States.
Methods
The PIAA maintains a data registry, the Data Sharing Project (DSP), of MPL claim information voluntarily submitted by its member organizations on a twice-yearly basis. (A claim is defined as a written demand for compensation in the form of money or services, with no legal papers having been filed in court.) Currently, 21 of 50 member organizations report claims data to the PIAA-DSP. The data are submitted to the PIAA in a codified format. The PIAA provides the reporting companies with explicit definitions of the data elements requested for inclusion in the registry. Diagnostic information is submitted using the International Classification of Diseases, Ninth Revision, Clinical Modification . To simplify reporting, the PIAA aggregates data within broad diagnostic categories. For example, all cases of acute myocardial infarction, codes 410.00 to 410.92, are classified together for the purposes of reporting and analysis. Original detailed classification data are maintained in the registry. Procedures are reported to the PIAA using the International Classification of Diseases coding system as well as PIAA-designated procedure codes.
With respect to the PIAA-DSP data, information is available on closed claims, those that have been resolved, either with or without payment to the claimant, through private agreement between the parties or by court action. Data are also collected describing the number of PIAA-DSP closed claims per 28 specifically identified physician specialties. Specialty-specific data are available that quantify the proportion of closed claims that ended in payments, the total indemnity payments, and the average, median, and largest payments made. (Indemnity payments are defined as moneys paid to plaintiffs for damages incurred. An indemnity payment includes an amount equal to the economic recovery for expenses already incurred or expected to be incurred and may also include noneconomic damages.)
Claims are further characterized as involving 1 of 19 “medical misadventures.” Medical misadventures are alleged principal departures from the standard of medical care. They are errors or omissions of diagnosis, treatment, procedure performance, supervision, and timeliness that result in putative injury to patients. The PIAA-DSP also codifies “no medical misadventure” for cases in which claims are brought against physicians who had little or no contact with the patients.
Patient diagnoses are recorded for the claims in the PIAA-DSP, and claims are further classified by the most common CV procedures implicated in the alleged professional liability. Data are also available in the PIAA-DSP regarding the severity of a claimant’s injury. Severity of injury is assigned to 1 of 9 categories as established by the National Association of Insurance Commissioners severity index: emotional injury only, insignificant injury, minor temporary injury, major temporary injury, minor permanent injury, significant permanent injury, major permanent injury, grave injury, and death.
The PIAA-DSP registry contains data describing allegations specifying associated medical and legal issues, such as consent or communications issues. Twenty-nine such associated medical and legal issues are identified in the registry. The PIAA-DSP registry also contains data describing the area of expertise of any associated professional who may be named in the claim in question.
Results
At the end of 2008, the PIAA-DSP registry contained information on 230,624 closed claims. These claims were closed between 1985 and 2007. Of these closed claims, 4,248 (1.8%) involved medical CV cases.
Table 1 lists the claim payment analysis by 28 specialties for the PIAA-DSP registry of 230,624 closed claims. There were 4,248 closed claims involving CV medical specialists between 1985 and 2007. In total closed claims, CV medicine ranked 14th among the 28 medical specialties studied. Obstetrics and gynecology ranked first, with 31,486 closed claims, and oral surgery ranked 28th, with 62 closed claims.
| Specialty | Closed Claims | Paid Claims | % Paid to Closed | Total Indemnity | Average Indemnity | Median Indemnity | Largest Payment |
|---|---|---|---|---|---|---|---|
| Anesthesiology | 8,866 | 2,875 | 32% | $636,193,819 | $221,285 | $75,000 | $5,048,678 |
| Cardiovascular and thoracic surgery | 6,960 | 1,642 | 24% | $356,739,943 | $217,259 | $100,000 | $4,247,423 |
| Cardiology | 4,248 | 770 | 18% | $191,183,963 | $248,291 | $150,000 | $1,950,000 |
| Dentistry | 838 | 365 | 44% | $14,869,780 | $40,739 | $15,000 | $1,000,000 |
| Dermatology | 2,620 | 757 | 29% | $101,440,748 | $134,004 | $32,500 | $3,000,000 |
| Emergency medicine | 3,991 | 1,049 | 26% | $202,049,937 | $192,612 | $75,000 | $2,000,000 |
| Gastroenterology | 2,354 | 425 | 18% | $88,121,039 | $207,344 | $95,000 | $2,900,000 |
| General and family practice | 26,658 | 8,535 | 32% | $1,365,943,314 | $160,040 | $75,000 | $4,089,414 |
| General surgery | 24,177 | 8,299 | 34% | $1,488,680,092 | $179,381 | $84,645 | $3,116,180 |
| Gynecology | 2,723 | 832 | 31% | $128,846,958 | $154,864 | $53,750 | $2,000,000 |
| Internal medicine | 31,299 | 7,902 | 25% | $1,644,739,599 | $208,142 | $100,000 | $9,780,000 |
| Neurology | 3,656 | 775 | 21% | $245,989,868 | $317,406 | $150,000 | $5,000,000 |
| Neurosurgery | 5,431 | 1,530 | 28% | $477,770,521 | $312,268 | $165,000 | $5,600,000 |
| Obstetrics and gynecology | 31,486 | 11,118 | 35% | $3,086,138,311 | $277,580 | $125,000 | $5,330,000 |
| Ophthalmology | 6,703 | 1,925 | 29% | $347,735,112 | $180,642 | $95,000 | $3,550,000 |
| Oral surgery | 62 | 20 | 32% | $538,583 | $26,929 | $13,000 | $133,500 |
| Orthopedics | 21,848 | 6,375 | 29% | $1,042,180,835 | $163,479 | $78,000 | $3,000,000 |
| Nonsurgical specialties | 2,234 | 513 | 23% | $96,717,958 | $188,534 | $50,000 | $8,749,980 |
| Otorhinolaryngology | 3,819 | 1,200 | 31% | $241,644,424 | $201,370 | $95,000 | $4,000,000 |
| Paraprofessional | 376 | 87 | 23% | $18,194,867 | $209,136 | $90,000 | $1,322,290 |
| Pathology | 1,633 | 461 | 28% | $112,847,595 | $244,789 | $116,000 | $2,700,000 |
| Pediatrics | 6,794 | 1,897 | 28% | $505,084,556 | $266,254 | $115,000 | $4,418,041 |
| Plastic surgery | 8,683 | 2,281 | 26% | $262,301,626 | $114,994 | $45,000 | $1,650,000 |
| Psychiatry | 2,276 | 458 | 20% | $74,568,108 | $162,812 | $55,000 | $2,375,000 |
| Radiation therapy | 2,212 | 620 | 28% | $172,036,688 | $277,479 | $130,625 | $2,700,000 |
| Radiology | 12,970 | 3,787 | 29% | $736,138,969 | $194,386 | $85,000 | $3,125,000 |
| Resident | 130 | 42 | 32% | $2,515,932 | $59,903 | $62,500 | $200,000 |
| Urology | 5,577 | 1,640 | 29% | $285,762,192 | $174,245 | $87,500 | $3,200,000 |
| Total | 230,624 | 68,180 | 30% | $13,926,975,337 | $204,268 | $90,000 | $9,780,000 |
Seven hundred seventy of the 4,248 CV medicine closed claims resulted in payments to the plaintiffs (18%). CV medicine and gastroenterology closed claims represented the lowest percentage of paid claims (those that have been resolved with indemnity payments to the plaintiffs) to closed claims for the 28 specialties studied, with 18% of claims paid. Claims against dentists resulted in payments in 44% of cases, and those against obstetricians and gynecologists resulted in payments in 35% of cases. The average ratio of paid claims to closed cases was 30% for all 28 specialties.
The average indemnity paid per claim for all specialty groups was $204,268, and the median indemnity payment was $90,000. The highest specialty average indemnity paid per claim was $317,406, for neurology, and the lowest specialty average indemnity paid per claim was $26,929, for oral surgery. The highest median indemnity paid was $165,000, for neurosurgery, and the lowest median indemnity paid was $13,000, for oral surgery. The average indemnity paid per claim for CV medicine was $248,291 and was the sixth highest among 28 specialties studied. The median indemnity paid for CV medicine claims was $150,000 and, with neurology, was (after neurosurgery) the second highest median indemnity paid for 28 specialties.
The total indemnity paid between 1985 and 2007 was $13.9 billion. The highest total indemnity for specialists was for obstetrics and gynecology, at $3.1 billion; the lowest total indemnity for specialists was for oral surgery, at $538,583. The total indemnity paid for CV medical specialists was $191 million. CV medicine ranked 17th among 28 specialties in total indemnity paid.
The largest single payment in the PIAA-DSP registry ($9,780,000) was for an internal medicine claim. On the opposite end of this spectrum, the largest payment for an oral surgery case was $133,500. CV medicine ranked 23rd, with the single largest CV medicine payment of $1,950,000.
Figure 1 shows the trends of closed CV medical claims and the percentage of paid closed CV claims from 1985 to 2007. The number of closed CV claims per year has varied from 97 in 1991 to 373 in 2004 in this time period. Peaks in closed claims occurrences are noted from 1995 to 1997 and again in 2004 and 2005. The percentage of paid closed CV claims has varied from 11% in 1991 to 24% in 1999. In general, there appears to be an inverse relation between the number of closed claims and the percentage of closed claims with payments in a given year.
The 10 most common medical misadventures encountered in the PIAA registry for CV closed claims are listed in Table 2 . These are the primary causes for claims filings for 4,248 CV claims. No specific medical misadventure is present in 892 closed CV medical claims. Table 2 also lists the percentage of paid claims and the average indemnity paid for paid claims for each of the 10 most frequent medical misadventures. For claims in which no identifiable medical misadventures were present, the percentage of paid to closed claims is lowest, at 5%. The average indemnity payment for these claims is significant, however. At $208,205, the average payment for these claims is higher than the average payments for cases involving delays in the performance of procedures ($177,413), cases involving procedures performed with no indications or with contraindications ($194,698), and cases involving medication errors ($194,560).
| Medical Misadventure | Closed Claims | Paid Claims | % Paid to Closed | Average Indemnity |
|---|---|---|---|---|
| None noted | 892 | 46 | 5% | $208,205 |
| Diagnostic error | 878 | 190 | 22% | $305,797 |
| Improper performance | 647 | 129 | 20% | $241,378 |
| Failure to supervise case | 550 | 95 | 17% | $222,194 |
| Medication errors | 337 | 61 | 18% | $194,560 |
| Failure to recognize complication | 185 | 48 | 26% | $259,686 |
| No indication or contraindication | 152 | 34 | 22% | $194,698 |
| Failure to perform | 142 | 36 | 25% | $377,193 |
| Delay in performance | 90 | 24 | 27% | $177,413 |
| Failure or delay in referral or consultation | 78 | 28 | 36% | $260,163 |
| Other | 297 | 79 | 27% | $289,911 |
| Total | 4,248 | 770 | 18% | $248,291 |
Diagnostic error represented the most prevalent identified medical misadventure, and the improper performance of a procedure was the next most prevalent medical misadventure. Failure or delay in referral or consultation represented the least prevalent medical misadventure among the 10 most prevalent. For failure or delay in referral or consultation cases, however, the proportion of paid to closed claims was highest of all medical misadventures (36%). Failure to supervise a case was the medical misadventure with the lowest proportion of paid to closed claims (17%). The highest average indemnity was $377,193 for failure to perform a procedure, and the lowest average indemnity was $177,413 for delay in performance of a procedure.
Of the 878 closed claims that were brought for errors in diagnosis, 24% of claims involved errors in the diagnosis of acute myocardial infarction, coronary atherosclerosis, or chest pain not further specified. Six percent involved errors in the diagnosis of aortic aneurysm, and 3% represented errors in the diagnosis of pulmonary embolism. The percentage of paid to closed claims for myocardial infarction, coronary atherosclerosis, or chest pain was 23%, and the percentage of paid to closed claims for aortic aneurysm was 35%. The percentage of paid to closed claims for pulmonary embolism was 21%.
Of 647 closed claims brought for improper performance of a procedure, 26% involved diagnostic cardiac catheterization, and 16% involved coronary interventional procedures. The percentage of paid to closed claims in diagnostic catheterization and interventional procedures was 24%. The average indemnity for diagnostic procedures was $183,634, and for interventional procedures, the average indemnity paid was $302,832. The percentage of paid to closed claims for improper performance of pacemaker insertion or removal resulted in payment was 18% of claims, with an average indemnity of $63,857.
Medical misadventures involving medication errors represent a relatively small proportion of closed CV claims (8%), and most of these closed claims (27%) were related to disorders of lipid metabolism. Of note, none of these closed claims raised for medication errors for lipid metabolism resulted in payments to the plaintiffs. Other diagnoses related to medication errors included atrial arrhythmias (8%), acute myocardial infarction (7%), other cardiac arrhythmias (4%), and heart failure (4%). Claims for medication errors for heart failure resulted in payment in 33% of cases.
Table 3 lists the 10 most prevalent CV diagnoses in the PIAA registry. Coronary atherosclerosis (12% of claims) was the most prevalent patient condition, and the next most prevalent condition was acute myocardial infarction (10% of claims). The least prevalent of the 10 common diagnostic conditions was aortic aneurysm, representing 2% of claims; however, this diagnosis resulted in the highest percentage of paid to closed claims (30%). Excluding disorders of lipid metabolism, the diagnostic condition with the lowest ratio of paid to total closed claims (12%) was nonatrial cardiac dysrhythmia, a condition that represented only 3% of closed claims. The diagnosis with the lowest average paid indemnity was heart failure ($175,474), and the diagnosis with the highest average paid indemnity was aortic aneurysm ($417,298).
| Diagnosis | Closed Claims | Paid Claims | % Paid to Closed | Average Indemnity |
|---|---|---|---|---|
| Coronary atherosclerosis | 493 | 82 | 17% | $262,701 |
| Acute myocardial infarction | 435 | 85 | 20% | $299,596 |
| Chest pain not further defined | 244 | 52 | 21% | $277,990 |
| Chronic ischemic heart disease | 154 | 20 | 13% | $241,162 |
| Cardiac dysrhythmia | 127 | 15 | 12% | $276,774 |
| Heart disease not further defined | 121 | 26 | 21% | $230,587 |
| Heart failure | 100 | 14 | 14% | $175,474 |
| Atrial fibrillation and flutter | 99 | 15 | 15% | $362,833 |
| Disorders of lipid metabolism | 98 | 0 | 0% | $0 |
| Aortic aneurysm | 90 | 27 | 30% | $417,298 |
| Other | 2,287 | 434 | 19% | $186,786 |
| Total | 4,248 | 770 | 18% | $248,291 |
The most prevalent procedure performed among closed CV claims was the diagnostic interview, evaluation, or consultation, accounting for 28% of closed claims, and the next most common procedure was the prescription of medication (12%). Cardiac catheterizations were involved in 12% of closed claims, and coronary angioplasty was involved in 7% of CV closed claims. The least prevalent of common procedures in this series of claims against cardiologists was coronary artery bypass grafting (2%). The ratio of paid to total closed claims was lowest (13%) for patients who had only physical examinations, and the highest ratio (30%) was for coronary artery bypass grafting.
Table 4 lists information on the severity of patients’ injuries for CV cases in the PIAA-DSP registry. The degree of injury is measured on the severity index of the National Association of Insurance Commissioners. Slightly more than half (53%) of all claims are associated with the death of the patient. Approximately 10% of patients had major temporary injuries. The ratio of paid to total closed claims is lowest (2%) in patients who had emotional injuries only, and it is highest (30%) in patients with grave injuries. There is a decrement in the payment ratio to 21% for patients who died. Figure 2 presents a graphic display of the relation between the ratio of paid to total closed CV claims and the degree of injury for CV claims in the PIAA-DSP registry.
| Severity of Injury | Closed Claims | Paid Claims | % Paid to Closed | Average Indemnity |
|---|---|---|---|---|
| Emotional injury only | 222 | 4 | 2% | $198,250 |
| Insignificant injury | 68 | 5 | 7% | $59,080 |
| Minor temporary injury | 323 | 42 | 13% | $49,346 |
| Major temporary injury | 453 | 57 | 13% | $179,157 |
| Minor permanent injury | 287 | 45 | 16% | $117,080 |
| Significant permanent injury | 303 | 56 | 18% | $209,416 |
| Major permanent injury | 237 | 53 | 22% | $367,236 |
| Grave injury | 106 | 32 | 30% | $522,614 |
| Death | 2,249 | 476 | 21% | $266,186 |
| Total | 4,248 | 770 | 18% | $248,291 |
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