Can patient injury claims be utilised as a quality indicator?
Introduction
The purpose of quality and performance indicators is to provide information on the functioning of the health care system. The need for this information is constantly growing in many countries as cost containment pressures and the growing share of elderly in the population compel health authorities to monitor and improve the equity and efficiency of health services.
A performance indicator should fulfil several requirements. These range from distinct technical features, such as validity and reliability, to acceptability by health professionals [1]. In practice, many indicators do not meet these requirements, or meet them only in part. Even if an indicator meets all the requirements, it often only measures some aspects of performance. Likewise, a specific indicator may contribute to the information needs of some but not all parties involved in health care. In consequence, there is a great need for the development of additional and improved indicators. As new ones are being developed, some existing ones may become redundant.
In Finland, the frequency of claims filed by patients for compensation for a health-care related injury as well as the rate of compensation for those claims varies greatly between hospitals. The reasons for these variations are not known. Neither is it known whether the claims frequency correlates with the total rate of adverse events or with the overall quality of care.
According to previous research, the total rate of malpractice claims is very low in comparison to the total rate of adverse events within health care, which has led researchers to conclude that malpractice claims cannot be used in quality measurement [2], [3], [4], [5]. This conclusion, however, has been made by simply comparing the rate of claims to the total rate of adverse events without any further analyses, such as accurately evaluating claims against quality markers.
The aim of this study was to examine whether there is an association between the rate of patient injury claims, both filed and compensated, and well-known quality indicators. If an association exists and claims otherwise fulfil the prerequisites of a performance indicator, they could be used in quality and performance measurement. To our knowledge, this study is the first to investigate the relationship between malpractice claims and quality in more depth.
In Finland, the processing of patients’ health-care-related claims for damages takes place at the Patient Insurance Centre, a consortium of private insurance companies that is nevertheless regulated largely as a public authority. The centre receives from 7 000 to 8 000 claims annually, which contrasts with the approximately 20 health-care-related cases handled annually by the courts [6].
The Finnish patient injury insurance scheme is a no-fault scheme, as the Patient Insurance Centre does not need proof of negligence in its decisions on compensability. Instead, the centre bases its decisions on the Patient Injury Act (came into force in 1987 and amended in 1999) that defines seven criteria, each of which justifies compensation [6]. These are treatment injury, infection injury, equipment-related injury, accidental injury, injury from damage to health care facilities, injury due to delivery of pharmaceuticals, and unreasonable injury. In addition, in its decision-making the Patient Insurance Centre utilizes various documents, such as medical expert opinion and statements by providers.
In practice, the vast majority of patients who have obtained compensation have done so because of a treatment injury. A treatment injury is, according to the Patient Injury Act, compensable if an experienced health professional would have acted differently and consequently would have prevented the injury. An infection is compensable if the patient did not have to tolerate it, meaning that it was unexpected from the view of the patient's health status, the treatment given and other factors defined by the Patient Injury Act in more detail. The remaining five criteria are only seldom a justification for compensation.
The amendment of the Patient Injury Act on 1 May 1999 concerned most importantly the definition of an infection injury. It was previously compensable on similar grounds to treatment injury with preventability as the main aspect. However, preventability turned out to be difficult to assess in cases involving an infection so that the amendment of the Patient Injury Act introduced a new definition for an infection injury with the main aspect being tolerability [6].
Section snippets
Compilation of patient-level data
We selected hip and knee replacements for this study, since the performance of these medical procedures is measurable with well-known quality and outcome markers [7], [8], [9], [10], [11]. Some of these are already in regular use in Finland [12]. Moreover, in this country, hip and knee replacement are among the most common surgical procedures for which patients claim for damages.
We compiled the data from the Finnish Hospital Discharge Register and from selected information from other registers
Hospital-level analyses
The correlation between claims (both filed and compensated) and the revision indicator as well as between claims and the infection indicator was statistically significant. These correlations were even stronger with 6-year indicator values and remained statistically significant with the indicators unadjusted (except for the correlation between unadjusted filed claims and revisions with the six years combined in the case of hip surgery). In addition, statistical significance emerged between the
Discussion
Based on previous research, only 1–3% of adverse events that might in theory qualify for compensation will result in a claim [2], [3], [4], [19]. At the same time, a large number of the filed claims do not involve an adverse event at all. This discrepancy obviously raises doubts about the feasibility of using malpractice claims in quality measurement. However, the results of this more thorough analysis indicate the opposite: claims actually seem to be associated with some quality aspects. These
Conclusions
An indicator measuring the rate of claims can potentially be applied as a quality indicator. It might also have an application in countries other than Finland, since many health care systems aim at improving the quality and cost-effectiveness of services. Various aspects, however, need to be considered in implementing the indicator, such as the features of the injury compensation scheme. Moreover, a claims indicator should be employed simultaneously with other indicators or actions to improve
Conflicts of interest
None.
Acknowledgement
JJ was supported by a grant from the Yrjö Jahnsson Foundation, a private independent foundation.
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