A critique of the use of generic screening in quality assessment

Article Abstract:

Twenty years ago, quality assessment of medical care was a relatively haphazard procedure, but systematic assessment of care by hospital medical staffs is now widespread. Both Medicare and the Joint Commission on Accreditation of Hospitals first required that hospitals conduct medical care evaluations based on objective criteria, but this system was soon found to be ineffective. Each hospital was then asked to develop its own method of quality assurance. In addition to this, the impetus to develop quality control procedures was strengthened by the increase in malpractice lawsuits. Risk management acquired greater importance. Adverse patient outcomes are referred for peer review to assess quality of care and identify potential malpractice claims. In spite of this, the usefulness of these procedures has never been systematically evaluated. The California Medical Insurance Feasibility Study (CMIFS) developed generic screening criteria to measure the frequency and severity of adverse outcomes, to test the feasibility of a non-fault-based insurance plan to replace the current system of malpractice lawsuits. A more efficient version of the system is now in widespread use. The effectiveness of generic screening depends on the validity of peer review, which varies greatly. Many physicians, fearful of malpractice suits, do not record their conclusions explicitly, or state in all cases that the standard of care was met. Generic screening is too vague, and it also fails to identify key elements such as diagnostic accuracy, adequate patient evaluation, appropriate drug therapy, and indications for surgery. Risk management and quality assessment are better served by identification of adverse patient outcomes and other performance measures relating to quality. (Consumer Summary produced by Reliance Medical Information, Inc.)

Laws, regulations and rules, Medicare, Joint Commission on Accreditation of Healthcare Organizations

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Effect of outcome on physician judgments of appropriateness of care

Article Abstract:

When injury results from medical care, peer review is used to determine whether the medical care was appropriate. Peer review is also used in malpractice proceedings and insurance investigations, and by disciplinary boards. The question that all of these groups need to answer is whether or not the patient received appropriate care. However, judgments of the appropriateness of care seem to depend on the severity of the outcome. Care resulting in nondisabling injuries was more often deemed appropriate, but if it resulted in disability or death, care was rated less than appropriate. This trend has important implications for all involved. To find out whether judgment was affected by the severity of the outcome, 21 actual cases were selected, and each was supplied with two outcomes, one involving permanent injury and the other, temporary injury. One hundred twelve practicing anesthesiologists with experience in case review were asked to judge whether care was appropriate or less than appropriate, or if it was impossible to judge. There was only a fair amount of agreement among reviewers. In 15 of the 21 cases, care was judged as less appropriate when the outcome was the one involving more severe injury. Unlike the implicit (personal) judgments in this study, explicit judgments are based on specific, predetermined criteria, requiring sophisticated techniques for their construction. The results of this study support the development of explicit criteria for determining appropriateness of care, since knowledge of the severity of outcome influenced the reviewers' opinions of the appropriateness of care. (Consumer Summary produced by Reliance Medical Information, Inc.)

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Standard of care and anesthesia liability

Article Abstract:

The Committee on Professional Liability of the American Society of Anesthesiologists conducted a national study of malpractice claims related to anesthesia care. Over 1,000 lawsuits were examined to define the impact of the "standard of care." The long-term goal of the study was to identify causes of anesthesia-related injury and the role of substandard care for those injuries. The study found that filing of a lawsuit alleging malpractice does not necessarily imply that substandard care was delivered as judged by peers (i.e., other anesthesiologists). The analysis of lawsuits showed that use of anesthesia has the potential for causing severe injury. In more than 50 percent of all cases, the anesthesia-related injury was severe and disabling or resulted in death. Furthermore, of the 243 cases of disabling injury, 119 (49 percent) were cases of permanent brain damage. This is in keeping with the National Association of Insurance Commissioners' finding that anesthesia-related claims were "high- cost claims" that reflect a high severity of injury. Analysis of the incidence of payment data by quality of care indicates that the current system of payment for anesthesia-related injuries favors the patient when a lawsuit is filed. The study found that if care was substandard, the likelihood of payment was 82 percent; if care met accepted standards, there was payment in 42 percent of cases. It was found that the current system of care favors payment to the injured patient, but that inequities in the payment system exist for both patient and physician.

Cases, Complications and side effects, Statistics, Surveys, Anesthesia, Medical malpractice insurance, American Society of Anesthesiologists

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