Rising number of claims filed by obese patients
In a recent multi-specialty review of claims, The Doctors Company, a Napa, CA- based medical malpractice insurer, noted an increase in the number of 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 decided to perform 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.
Additionally, the use of opioids in these patients greatly increased the risk of harm in these patients. Diamond says these risk-reducing practices were identified from the claims analysis:
• Include a focused history and calculation of Body Mass Index (BMI) and neck circumference in the pre-operative evaluation.
• Consider a sleep apnea study prior to surgery.
• Use continuous oxygen monitoring 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 accompanying anesthesia, notes Diamond. A 2007 study reported a higher incidence of postoperative complications in obese patients with meningiomas (53%), including deep vein thrombosis (DVT) and pulmonary embolus, than in nonobese patients (18%).1
3 tips to reduce your risks
Physicians treat obese patients for a variety of 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.” Diamond suggests physicians consider these approaches to reduce legal risks:
• Physicians should address any negative attitudes or discomfort that they or their staff members have 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.
• When the physician performs the history and physical, the patient’s obesity must be identified as a problem.
“A plan then should be established to deal with it,” says Diamond.
• Physicians should 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. (For more information on caring for obese patients, see “Are you prepared for high BMI patients or just focused on their gown sizes?” Same-Day Surgery, January 2012.)
1. Aghi MK, Eskandar EN, Carter BS. Increased prevalence of obesity and obesity-related postoperative complications in male patients with meningiomas. Neurosurgery 2007; 61(4):754-760.