physician malpractice: does the past predict the future?

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    Physician Malpractice: Does the Past Predict the Future?

    To the Editor.--Dr. Taragin and colleagues 1 would use mal- practice claims data to make direct conclusions about malprac-

    tice. They further suggest that claims data may help in disciplin-

    ing "problem doctors." We respect the value of malpractice

    information to students of the malpractice process but have three

    concerns about the profession using this information to discipline

    physicians. The first is that the medical experts 2 whose activities

    determine malpractice claim outcomes are accredited by the

    court for the purpose of providing guidance to the court, and not

    by medical disciplinary bodies for the purpose of providing medi-

    cal discipline. The second is that the outcome of legal cases may

    depend on issues unrelated to the physician's clinical responsi-

    bil[ties, for example, when a physician believes he acted properly

    but agrees to a settlement to avoid the risk of a large t'mancial

    loss. The third is that the court and professional disciplinary

    board have different goals, and tiros need different types of infor-

    mation to make proper decisions. Therefore, although claims data

    may help to identify problem doctors for malpractice insurers,

    these data should not identify "problem doctors" for disciplining

    by the profession.--~IDl~y FI I~, MD, and T, K. CIIAUDI-rORI, MD, Veterans Affairs Medical Center. Hampton, VA


    1. Taragin MI, Martin K, Shapiro S~ Trout R, Carson JL. Physician malpractice: does the past predict the future? J Gen Intern Med. 1995; 10:550-6.

    2. Fink S, Chaudhuri TK. Serve as a medical expert. Am J Gastroen- terol. 1991;86:1689.


    Cost of Hypertension Treatment

    To the Editor.--The article "Cost of Hypertension Treatment "1 and the accompanying editorial 2 address the important question,

    What proportion of the cost of hypertensive care is attributable to

    antihypertensive drugs? However, the results reported may be

    misleading. Table 1, indicating the average annual laboratory,

    physician visit, and drug costs for 244 patients seen in an aca-

    demic practice of five general internists, gives no information on

    which antihypertensive medications were prescribed. Patients av-

    eraged 7.3 physician visits for the first year, and 54% were taking

    multiple antih~pertensive drugs, suggesting considerable comor-

    bidity. Comorbid illness could have led to the choice of agents

    other than [~-blockers or diuretics and could explain the use of

    multiple agents. In addition, the small study group is not repre-

    sentative of the United States hypertensive population, as 20% of

    the study population had stage 3 or 4 hypertension, and 96%

    were Caucasian, quite different from 5% and 80% in the third Na-

    tional Health and Nutrition Survey (NHANES III), respectively. 3 In

    the editorial, Table 1 lists the percentage of total cost of hyperten- sive care for individual drugs based on the average charges re-


    ported by Odell. Since laboratory and physician visit charges vary

    with the antihypertensive medication chosen, 4 not considering

    the medication used may result in inaccuracies. Prescribing agents other than diuretics and ~-blockers 5 will

    clearly increase the cost of hypertensive care attributable to anti-

    hypertensive drugs, however, tile effect on the overall cost of hy-

    pertensive care including laboratory and physician visit charges, remains unc lear~A~l lT S. AIILUWALIA, MD, MPIt, MS, Assistant Professor of Medicine arid Health Policy, and JOIrCE P. DOYLE, MID, Assistant Professor of Medicine, Division of General Medicine, Em- ory University School of Medicine, Atlanta. GA


    1. Odetl TW, Gregory MC. Cost of hypertension treatment. J Gen In- tern Med. 1995;10:686-8.

    2. Katzman DA, Littenberg B. Choosing antihypertensive therapy. J Gen Intern Med. 1995;10:700-2-

    3. Burt VL, Whelton P, Roccella EJ, Brown C, Cutler JA, Higgins MJ. Prevalence of hypertension in the US adult population, Results from the third National Health and Nutrition Examination Survey, 1988-1991. Hypertension. 1995;25:305--13.

    4, Joint National Committee on Detection, Evaluation, and Treat- ment of High Blood Pressure. The Fifth Report of the Joint Na- tional Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med. 1993; 153:154-83.

    5. Manolio TA, Cutler JA, Furberg CD, Psaty BM, Whelton PK, Apple- gate WB. Trends in pharmacologic management of hypertension in the United States. Arch Intern Med. 1995;155:829-37.

    fn RepIy:--We appreciate the comments of Drs. Ahluwalia and Doyle. The effect of prescribing agents other than diuretics

    and G-blockers on the overall cost of hypertensive (HTN) care is

    supported by independent evidence. The cost of HTN care from

    the time of initiation of therapy to the time when target blood

    pressure (DBP < 90) is achieved was evaluated by Hilleman et al. 1

    Total cost for each were:

    diuretics: $1043

    G-blockers: $895 alpha blockers: $1288

    central alpha2 agonists: $1165

    ACE inhibitors: $1243

    calcium channel blockers: $1425

    (average: $1176)

    These costs were comparable to the 8947 we calculated for

    the first year of intervention in our patients. However, patients may be on therapy for decades. Tile criti-

    cal economic issue about HTN care is the cost once the patient is

    stabilized. We found that the cost of medications was the major

    factor in determining overall cost. Cost of medications was re-

    markably constant over the next three years, comprising 80% of

    the total cost of care. Even though our patients might have been

    more complex or might have had more "co-morbidity" than the

    United States hypertensive population, once stability of blood

    pressure was achieved, we had to see them only twice yearly for

    HTN, and laboratory charges were minimal. In the absence of conditions requiring specific classes of drugs, thiazide diuretics


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