Rising number of claims filed by obese patients

In a recent multi-specialty review of claims over four years, The Doctors Company, a Napa-CA based medical malpractice insurer, noted an increase in claims filed by patients who were overweight or obese, reports chief patient safety officer Robin Diamond, JD, RN.

Based on the findings, The Doctors Company performed an in-depth analysis of some of the claims related to postsurgical risks of obese patients. “The analysis found several claims in which patients with either a suspected or known diagnosis of obstructive sleep apnea suffered severe respiratory depression during the post-op period,” says Diamond. Also, using opioids for these patients greatly increased the risk of harm. These risk-reducing practices were identified from the claims analysis:

• Include a focused history and calculation of BMI and neck circumference in the preoperative evaluation.

• Consider a sleep apnea study prior to surgery.

• Use continuous oxygen and carbon dioxide monitoring.

• Prescribe opioids only with the greatest care, and consider the use of non-opioids.

• Do not assume that the obese patient needs higher levels of medication to control pain.

“It may be just the opposite in obese patients, who may be unable to metabolize these medications as effectively as a patient of average weight,” says Diamond.

There is an increased risk associated with an obese patient who undergoes a procedure with anesthesia, she notes.

Physicians treat obese patients for chronic conditions that co-exist with obesity, such as diabetes and heart disease, notes Diamond. “With the rate of obesity increasing, physicians have to address more complex issues with this population,” she says.

Obese patients have an increased risk of developing pulmonary emboli post-surgery, an increased risk associated with establishing and maintaining an airway, and those who have diabetes will have a higher probability of prolonged healing time, says Diamond.

Patients don’t generally mention obesity as a factor when the complaint is filed. They might instead allege negligent technical performance of a procedure or failure to manage the patient post-surgery, she explains. “As we prepare to respond to the complaint, we learn about the patient’s medical history, including obesity,” says Diamond. “Then we dive into the ‘causation,’ and whether the patient’s obesity and other co-morbidities could have been a causative factor of the alleged injury.” Consider these approaches:

• Address negative attitudes or discomfort about obese patients.

Physicians need to speak openly to patients about a characteristic such as obesity that places them at higher risk for an adverse event, she explains.

“This is a difficult issue for anyone to acknowledge. However, everyone has preconceived feelings or impressions about a certain characteristic or stereotype,” says Diamond.

• In the history and physical, obesity must be identified as a problem.

“A plan then should be established to deal with it,” says Diamond.

Fully inform the patient of the risks of obesity related to the current diagnosis, as well as the potential health problems that are more likely to arise. Document these discussions.

The defense attorney then can show through documentation that the physician addressed any health conditions or habits that could increase the patient’s risk, says Diamond.

“Even when the patient alleges harm, the defense attorney can more easily demonstrate that the patient was not compliant with the health education provided by the physician, and therefore that the patient’s noncompliance mitigated or neutralized the patient’s allegations,” she explains.