C. Minami1, J. Chung1, J. Holl1, M. Mello2, K. Bilimoria1 1Northwestern University,Surgery,Chicago, IL, USA 2Stanford University,Law School,Palo Alto, CA, USA
Introduction: The current US malpractice system rests on the assumption that the constant threat of lawsuit will deter negligence and improve the quality of care. However, the system may fail to function in its intended manner and result in unintended consequences, such as encouraging “defensive” medical practices including over-testing and over-treatment that, in turn, may lead to potential patient harm. The objective of this study was to assess whether state malpractice environment is associated with hospital performance on national quality indicators.
Methods: From HospitalCompare (October 2011 public release), short-term, acute-care, general hospitals in the U.S. that publicly reported process-of-care, imaging efficiency, outcomes, and/or Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures were identified. Hierarchical regression models were developed to estimate the associations between state malpractice environment and hospital performance on quality indicators. State-level indicators of malpractice environment included rates of paid claims/physician, state average Medicare Malpractice Geographic Practice Cost Index (MGPCI; a reflection of premiums), 8 malpractice laws, and a composite measure that combines claims, premiums, and the laws. The hospital quality indicators included publicly reported processes of care, outcomes, and patient experience (HCAHPS).
Results: Overall, there were few associations between measures of malpractice environment and quality indicators. There were no significant associations between process-of-care measures and the number of paid claims, MGPCI, state malpractice laws, or malpractice environment composite measures. Higher state malpractice costs/premiums were associated with increased use of certain diagnostic tests (e.g., brain CTs and cardiac stress tests). Hospitals in high malpractice risk environments were, by some measures, associated with lower 30-day risk-adjusted mortality rates but had significantly higher 30-day readmission rates (p<0.05). Higher malpractice cost/premium environments were associated with lower HCAHPS performance (effect size range:-2.06 to -4.92 percentage points, Bonferroni-corrected p<0.01).
Conclusion: We found little evidence that state malpractice environments with greater levels of malpractice risk were associated with better hospital quality. They were, however, associated with lower levels of patient satisfaction and potential increases in “defensive” medicine practices (e.g., imaging, readmissions). These findings do not support the assumption that the current malpractice system deters poorer quality of care.