Physician malpractice: Does the past predict the future?

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<ul><li><p>JGIM </p><p>LETTERS TO THE EDITOR </p><p>Physician Malpractice: Does the Past Predict the Future? </p><p>To the Editor.--Dr. Taragin and colleagues 1 would use mal- practice claims data to make direct conclusions about malprac- </p><p>tice. They further suggest that claims data may help in disciplin- </p><p>ing "problem doctors." We respect the value of malpractice </p><p>information to students of the malpractice process but have three </p><p>concerns about the profession using this information to discipline </p><p>physicians. The first is that the medical experts 2 whose activities </p><p>determine malpractice claim outcomes are accredited by the </p><p>court for the purpose of providing guidance to the court, and not </p><p>by medical disciplinary bodies for the purpose of providing medi- </p><p>cal discipline. The second is that the outcome of legal cases may </p><p>depend on issues unrelated to the physician's clinical responsi- </p><p>bil[ties, for example, when a physician believes he acted properly </p><p>but agrees to a settlement to avoid the risk of a large t'mancial </p><p>loss. The third is that the court and professional disciplinary </p><p>board have different goals, and tiros need different types of infor- </p><p>mation to make proper decisions. Therefore, although claims data </p><p>may help to identify problem doctors for malpractice insurers, </p><p>these data should not identify "problem doctors" for disciplining </p><p>by the profession.--~IDl~y FI I~, MD, and T, K. CIIAUDI-rORI, MD, Veterans Affairs Medical Center. Hampton, VA </p><p>REFERENCES </p><p>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. </p><p>2. Fink S, Chaudhuri TK. Serve as a medical expert. Am J Gastroen- terol. 1991;86:1689. </p><p>e </p><p>Cost of Hypertension Treatment </p><p>To the Editor.--The article "Cost of Hypertension Treatment "1 and the accompanying editorial 2 address the important question, </p><p>What proportion of the cost of hypertensive care is attributable to </p><p>antihypertensive drugs? However, the results reported may be </p><p>misleading. Table 1, indicating the average annual laboratory, </p><p>physician visit, and drug costs for 244 patients seen in an aca- </p><p>demic practice of five general internists, gives no information on </p><p>which antihypertensive medications were prescribed. Patients av- </p><p>eraged 7.3 physician visits for the first year, and 54% were taking </p><p>multiple antih~pertensive drugs, suggesting considerable comor- </p><p>bidity. Comorbid illness could have led to the choice of agents </p><p>other than [~-blockers or diuretics and could explain the use of </p><p>multiple agents. In addition, the small study group is not repre- </p><p>sentative of the United States hypertensive population, as 20% of </p><p>the study population had stage 3 or 4 hypertension, and 96% </p><p>were Caucasian, quite different from 5% and 80% in the third Na- </p><p>tional Health and Nutrition Survey (NHANES III), respectively. 3 In </p><p>the editorial, Table 1 lists the percentage of total cost of hyperten- sive care for individual drugs based on the average charges re- </p><p>252 </p><p>ported by Odell. Since laboratory and physician visit charges vary </p><p>with the antihypertensive medication chosen, 4 not considering </p><p>the medication used may result in inaccuracies. Prescribing agents other than diuretics and ~-blockers 5 will </p><p>clearly increase the cost of hypertensive care attributable to anti- </p><p>hypertensive drugs, however, tile effect on the overall cost of hy- </p><p>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 </p><p>REFERENCES </p><p>1. Odetl TW, Gregory MC. Cost of hypertension treatment. J Gen In- tern Med. 1995;10:686-8. </p><p>2. Katzman DA, Littenberg B. Choosing antihypertensive therapy. J Gen Intern Med. 1995;10:700-2- </p><p>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. </p><p>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. </p><p>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. </p><p>fn RepIy:--We appreciate the comments of Drs. Ahluwalia and Doyle. The effect of prescribing agents other than diuretics </p><p>and G-blockers on the overall cost of hypertensive (HTN) care is </p><p>supported by independent evidence. The cost of HTN care from </p><p>the time of initiation of therapy to the time when target blood </p><p>pressure (DBP &lt; 90) is achieved was evaluated by Hilleman et al. 1 </p><p>Total cost for each were: </p><p>diuretics: $1043 </p><p>G-blockers: $895 alpha blockers: $1288 </p><p>central alpha2 agonists: $1165 </p><p>ACE inhibitors: $1243 </p><p>calcium channel blockers: $1425 </p><p>(average: $1176) </p><p>These costs were comparable to the 8947 we calculated for </p><p>the first year of intervention in our patients. However, patients may be on therapy for decades. Tile criti- </p><p>cal economic issue about HTN care is the cost once the patient is </p><p>stabilized. We found that the cost of medications was the major </p><p>factor in determining overall cost. Cost of medications was re- </p><p>markably constant over the next three years, comprising 80% of </p><p>the total cost of care. Even though our patients might have been </p><p>more complex or might have had more "co-morbidity" than the </p><p>United States hypertensive population, once stability of blood </p><p>pressure was achieved, we had to see them only twice yearly for </p><p>HTN, and laboratory charges were minimal. In the absence of conditions requiring specific classes of drugs, thiazide diuretics </p></li></ul>