Associate Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI

Dr. Allen reports she is a Nexplanon trainer for Merck, and has served as a consultant for Bayer and Pharmanest.

SYNOPSIS: In this review of medicolegal claims data from 2005-2014, obstetric and gynecologic surgery had the second highest average indemnity payment compared to other specialties, topped only by neurosurgery. Of the 10,915 claims identified, the majority (60%) were dropped, withdrawn, or dismissed; 31.1% of claims were paid by the defendant (90% before trial); and 7.5% were successfully defended by the physician.

SOURCE: Glaser LM, Alvi FA, Milad MP. Trends in malpractice claims for obstetrics and gynecologic procedures, 2005 through 2014. Am J Obstet Gynecol 2017;217:340.e1-340.e6.

This is a retrospective study from January 1, 2005, to December 31, 2014, of medical liability claims using the Physician Insurers’ Association of America (PIAA) data-sharing project. The PIAA is an insurance trade association representing multiple medical professional liability insurance companies and other entities. This de-identified medical liability database was created to identify medical professional liability trends across specialties using claims from 20 private insurance carriers. A “claim” was defined as any written or oral demand for compensation. “Closed claims” were defined as resolved either with or without payment, and “paid claims” as those resolved with any payment to the plaintiff. Claims data from general obstetrics and gynecology were examined and included all types of deliveries and gynecologic surgical procedures, both in the hospital and in the office. Claims factors examined included average indemnity payments, single largest indemnity payments, and the paid-to-closed ratios of all claims for each specialty.

During the study period, 10,915 claims were identified. Although the majority (60%) of claims were dropped, withdrawn, or dismissed, 31.1% of claims were paid by the defendant (90% before trial), and 7.5% were successfully defended by the physician. The average indemnity for all paid claims was $423,250; indemnity was $417,518 for claims settled prior to trial and $750,791 for claims given a verdict in favor of the plaintiff. Over time, average indemnity decreased 10% when comparing 2005-2009 and 2010-2014. When compared with other medical specialties, the average indemnity for obstetrics and gynecology procedures ($423,250) was 27% higher than the average indemnity for all medical specialties combined ($330,940). When ranked by medical specialty, obstetrics and gynecology procedures had the second highest average indemnity payment of 28 specialties after neurosurgery. The most common procedure associated with claims was operative procedures on the uterus. (See Table 1.)

COMMENTARY

The authors of this study sought to report on trends in obstetrics and gynecology medicolegal claims, a subject of interest to every OB/GYN physician. The paper would have been improved with more analysis on trends over time (e.g., number of claims). In addition, using ICD-9 codes and unique PIAA codes hampered a greater understanding of which procedures most commonly were involved in claims. For example, the following procedures were not included in Table 1 because the description was not informative: prescription of medication; general physical examination; diagnostic interview, evaluation, or consultation; and miscellaneous manual examinations and nonoperative procedures. Nevertheless, the comparison with other specialties provides interesting information. I suppose it is not surprising that obstetrics and gynecologic surgery was the second highest specialty in average indemnity paid for medical claims given the stakes involved. Similarly, pediatrics was also one of the top 5, which also included nonsurgical neurology and anesthesiology.

In 2015, the American College of Obstetricians and Gynecologists reported on its survey of its members regarding professional liability issues.¹ A total of 4,294 OB/GYN physicians responded to the survey out of 32,425 fellows and junior fellows (13% response rate). Most respondents (74%) reported that at least one liability claim was filed against them during their professional career. The average number of claims per physician was 2.6. The most common obstetric claim was neurologically impaired infant (27.4%) followed by stillbirth or neonatal death (15%). The most common gynecologic claim was major patient injury (27.9%), followed by minor patient injury (23.4%) and “delay in or failure to diagnose” (21.5%). Of the “delay in or failure to diagnose” claims, the most frequent claims involved failure to diagnose cancer, with breast cancer being the most common type. Respondents reported that because of fear of litigation, 23.8% decreased the number of high-risk obstetric patients they saw, 13.4% stopped performing vaginal birth after cesarean delivery, 19.7% decreased the number of gynecologic surgeries, and 7.7% stopped performing major gynecologic surgery.

The authors speculated that one reason gynecologic surgery had higher numbers of claims was because of volume issues. They maintained that OB/GYN physicians have to stay competent in so many different types of procedures that it is difficult to maintain adequate procedural volume and technical competence. That is an issue, but the paid-to-closed claim ratio for obstetric and gynecologic surgery was 31.2, compared to 29.4 in general surgery. This is not very different, and general surgeons also perform a number of varied procedures. Overall, our field is known to have high liability costs not because of gynecologic surgery but rather because of obstetric procedures. Vacuum delivery was highlighted by the authors because it represented 8.3% of all delivery-related claims, but it only occurs during 2.8% of births. Maintaining operative vaginal delivery skills is a weakness in our field but, by definition, a delivery that requires forceps or vacuum already is higher risk and may be more likely to result in litigation. Unfortunately, there is no easy answer to adequately training our residents in vacuum and forceps delivery given decreasing volume of these procedures.

REFERENCE

1. Carpentieri AM, Lumalcuri J, Shaw J, Joseph G. American College of Obstetricians and Gynecologists survey on professional liability. Washington, DC: American College of Obstetricians and Gynecologists; 2015.