Original research
Reduced medicolegal risk by compliance with obstetric clinical pathways: a case–control study

https://doi.org/10.1016/S0029-7844(02)03129-0Get rights and content

Abstract

Objective

To estimate whether guideline compliance affected medicolegal risk in obstetrics and whether malpractice claims data can provide useful information on guideline noncompliance by focusing on the claims experience of a large health system delivering approximately 12,000 infants annually.

Methods

We retrospectively identified 290 delivery-related (diagnosis-related groups 370–374) malpractice claims and 262 control deliveries at the health system during the period from 1988 to 1998. Clinical pathways for vaginal and cesarean delivery implemented in 1998 were used as a “standard of care.” We compared rates of noncompliance with the pathways in the claims and control groups, calculated an odds ratio for increased risk of being sued given departure from the guideline standards, and calculated the elevated risk of litigation introduced by noncompliance. We also compared the frequencies of different types of departures across claims and control groups.

Results

Claims closely resembled controls on several descriptive measures (mother’s age, location of delivery, type of delivery, and complication rates), but noncompliance with the clinical pathway was significantly more common among claims than controls (43.2% versus 11.7%, P < .001; odds ratio = 5.76, 95% confidence interval 3.59, 9.2). In 81 (79.4%) of the claims involving noncompliance with the pathway, the main allegation in the claim related directly to the departure from the pathway. The excess malpractice risk attributable to noncompliance explained approximately one third (104 of 290) of the claims filed (attributable risk = 82.6%). There were no significant differences in the types of deviation from the guidelines across claims and control groups.

Conclusion

In addition to reducing clinical variation and improving clinical quality of care, adherence to clinical pathways might protect clinicians and institutions against malpractice litigation. Malpractice data might also be a useful resource in understanding breakdowns in processes of care.

Section snippets

Materials and methods

This research was approved by the institutional review board at Wayne State University.

In 1998, the management team of a $1.8 billion health system, responsible for the delivery of approximately 12,000 infants annually, encouraged the implementation of a clinical pathway for normal vaginal delivery and cesarean delivery. The goal of the pathway project was to develop a clinically efficient and effective care plan to boost the system’s competitiveness through improved clinical quality and

Results

We retrospectively identified 290 delivery-related malpractice claims and 262 controls from among the 118,434 vaginal and cesarean deliveries in the three hospitals during the study period. We completed medical record review for 236 claims (81%) and 240 controls (92%). Some of the medical records were not reviewed owing to the inability to locate or obtain the medical records, which caused a slight difference in the numbers of cases and controls.

There were no significant differences between

Discussion

Clinical pathways are a useful metric for exploring the relationship between health care quality and malpractice because, conceptually, they approximate both the clinical and the legal standards of care. We found empirical support for our first study hypothesis—that quality improvement interventions may have a substantive impact on malpractice risk. Departures from the obstetric pathway were nearly four times more frequent among claims than controls in our retrospective analysis, and

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Cited by (0)

This study was made possible through a generous grant from the Richard J. Barber Fund for Interdisciplinary Legal Research. DMS was supported in part by grant no. KO2HS11285 from the Agency for Healthcare Research and Quality.

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