CRICO Corner – Pilot Project: Orthopedics and Neurosurgery
The MIEC/CRICO Strategies partnership began with a pilot project in which MIEC submitted claims data for orthopedic surgeons and neurosurgeons, report dates from 2006 to 2011, to CRICO Strategies for coding and analysis. One hundred sixteen (116) orthopedic and 42 neurosurgical medical incidents were deep coded and benchmarked against 152 orthopedic and 38 neurosurgical comparable CRICO peer group cases.
Orthopedic claims review
CRICO Strategies’ analysts found that MIEC’s rate of orthopedic claims has remained steady and comparable to peers since 2006. MIEC faces a higher percentage of surgical treatment allegations versus peers (78% vs. 61% respectively). Significantly more of MIEC’s cases (frequency) originate in the outpatient setting; however, inpatient OR claims result in greater indemnity dollars paid to patients. When compared to the peer group, fewer of MIEC’s orthopedic cases result in indemnity payments and the average indemnity payment is lower. Thirteen percent (13%) resulted in indemnity payments which averaged $171,566 per claim as compared to the peer claims, of which 35% resulted in payments averaging $273,955 per case.
Orthopedic Claims: Post-operative medical issues Type of medical issue Number of cases Percent Pain (continuous or new) 33 28% Infection (wound, skin necrosis, bone, prosthesis, pin site) 15 13% Non-union or mal-union 15 13% Hardware issue (removal, loosening, infection, or revision) 14 12% Foot drop 12 10% Reported nerve damage 10 8% Embolism (pulmonary, fossa, saddle) 7 6% Hematoma/hemorrhage 5 4% Retained foreign body 4 3% Necrosis 4 3%
CRICO Strategies’ analysis found that communication and patient behavior-related contributing factors significantly impacted the patients’ experiences. Communication problems between the providers and patients and their families, miscommunication of follow-up instructions, and issues with communication between co-treaters affected the outcome of these claims. Patient dissatisfaction with procedure outcomes, mismanaged expectations, and financial complaints proved to be prevalent factors in these cases as well.
Devices used intra-operatively or post-operatively were involved in 11% of the cases such as pedicle screws, polar ice packs, interspinous process decompression implants, allograft plugs, ceramic femoral heads, prosthetic discs, interlocking screws and suture anchors. Five percent of the cases included a post-operative fall in the hospital or the patients’ homes; 16% percent of the cases experienced record-keeping issues; 3% of the claims were impacted by nursing miscommunication; and 3% involved pain medication mismanagement.
CRICO Strategies’ recommendations included:
1. Educate insured providers on key surgical risk areas;
2. Enhance physician-patient communication;
3. Explore options for team training curriculum; and,
4. Investigate intra-operative technical challenges.
For additional reading about malpractice in orthopedics, review the study published by Frederick A. Matsen III, MD, Linda Stephens, PhD, et al., in the Journal of Bone and Joint Surgery titled, “The Orthopaedic Forum – Lessons Regarding the Safety of Orthopaedic Patient Care: An Analysis of Four Hundred and Sixty-Four Closed Malpractice Claims” [J Bone Joint Surg Am. 2013:95:320(1-8)].
Neurosurgical claims review
CRICO Strategies’ analysts found that MIEC’s rate of neurosurgical cases have remained consistently above comparable peers since 2006. As with orthopedic cases, MIEC’s neurosurgery cases experience a higher percentage of surgical treatment allegations versus peers (79% vs. 65% respectively). MIEC’s distribution of inpatient versus outpatient neurosurgical claims are on par with peers.
Fewer of MIEC’s neurosurgical cases result in indemnity payments than the peer group; however, MIEC’s average indemnity payment was much higher. Twenty-five percent (25%) of MIEC’s neurosurgery cases resulted in indemnity payments averaging $545,682 per claim as compared to the CRICO peer claims, of which 37% resulted in payments averaging $286,823 per case.
Neurosurgery Claims: Post-operative medical issues Type of medical issue Number of cases Percent Pain (continuous or new) 15 36% Hematoma/hemorrhage 11 26% Infection (wound, skin necrosis, bone, prosthesis, pin site) 11 26% Hardware issue (removal, loosening, infection, or revision) 7 17% Leg weakness/diminished function 6 14%
By comparison to peers, technical skill factors were more prevalent for MIEC neurosurgeons (76% of MIEC cases vs. 50% for peers). Clinical judgment issues affected 62% of the cases vs. 50% for peers while documentation issues affected 17% of the MIEC neurosurgical cases vs. 26% in peer cases.
CRICO Strategies’ findings and/or recommendations after analyzing the 42 neurosurgical medical events:
- When compared with peers, MIEC faces a higher frequency of neurosurgical claims, but claims are driven by a similar distribution of clinical factors.
- MIEC neurosurgeons experience was dominated by unrecognized intra-operative technical errors, manifesting as post-operative complications.
- Providers’ “disconnectedness” from the inpatient care team is a notable root cause of many surgical misadventures.
- There appears to be a connection between Items 2 and 3. If providers wish to avoid malpractice claims while improving their relationships with patients, sharpening providers’ ability to detect and respond to intra-operative complications is critical to improving post-op outcomes.
Overall, the top drivers of risk across both specialties upon which interventions should focus include technical skills, clinical judgment, communication, and behavior-related issues.