The National Practitioner Data Bank (NPDB) is an electronic repository of payments made on behalf of practitioners for malpractice settlements or judgments. This mandatory reporting system was established to execute the Health Care Quality Improvement Act of November 14, 1986, that sought to limit the possibility that practitioners might be moving between hospitals to avoid issues related to malpractice lawsuits and disciplinary actions taken against them (1). The NPDB, under the authority and direction of the Department of Health and Human Services, contains data starting from September 1990 (2,3).
Insurance companies and state funds provide approximately 70% of the information in the NPDB when they make settlement or judgment malpractice payments on behalf of a practitioner. Approximately 30% of the information in the NPDB is reported by agencies, such as state medical or dentistry boards or the Drug Enforcement Agency and Medicare, when they take “adverse actions” against individual practitioners.
The purpose of this brief report is to review the current anesthesia-related malpractice payment data at the NPDB.
The “Public Use” SPSS database was downloaded from the NPDB website (www.npdb-hipdb.com) on October 27, 2005. Although data regarding adverse actions against practitioners are available in the NPDB, and these data were not within the scope of this report. We should also note that recently, the NPDB data regarding adverse actions against practitioners were criticized as being incomplete (4). In contrast, data regarding malpractice payments are complete, and the reporting of such data by the insurance carriers to the NPDB is mandatory.
The downloaded NPDB database consisted of 375,364 individual reports that were dated between 1991 and 2004. After excluding data regarding adverse actions taken by organizations, such as state boards against individual practitioners, our Malpractice-NPDB database included 276,274 malpractice payments reports (9190 judgments, 230,559 settlements, and 36,515 other). For the purpose of this brief report, we will use only data from two time periods: 1991–1994 and 2001–2004.
Currently, these reports include basic demographics of the practitioner and patient and data regarding the payment amount. Clinical data are limited to variables such as “Malpractice Allegation Group” (e.g., anesthesia related, surgery related, medication related, etc.), “Specific Malpractice Allegation” (e.g., failure to monitor, intubation, delay in diagnosis, etc.), and “Severity of Alleged Malpractice Injury” (e.g., death, temporary, emotional, etc.). Data regarding age of the patient and severity of injury are available only since January 31, 2004. Interested readers are referred to the NPDB website for more information (http://www.npdb-hipdb.com/).
To take into consideration the population growth in the United States (US) during the study period, we adjusted the annual number of malpractice payments per 100,000 members of population (5). Thus, the adjusted malpractice payment number is the number of payments in a specific year divided by the US population in that year (in 100,000 U). We have used the same technique when we report data regarding the incidence of malpractice payment in the various states.
To analyze changes over time, we report the incidence of malpractice payments as well as the size of these payments during 2001–2004 as compared to the period a decade earlier of 1991–1994. Differences between groups were analyzed using one-way analysis of variance or Student’s t-test for continuous variables and χ2 for categorical variables. Skewed data are presented as median (25%–75%) and analyzed using nonparametric tests such as Friedman’s test. Significance was accepted at P = 0.05. Data were analyzed using SPSS 11.0 (SPSS Inc, Chicago, IL).
As can be seen in Figure 1, the overall number of malpractice payments made on behalf of practitioners did not differ between the time periods of 1991–1994 and 2001–2004. Furthermore, when adjusted for population growth, the number of malpractice payments per 100,000 indeed decreased by 12.5% from the time period of 1991–1994 to 2001–2004 (7.52 versus 6.58).
Over the 14 yr of NPDB existence, 8297 anesthesia-related malpractice payments were made on behalf of physicians (82%), nurses (12.2%), and dentists (5%). No data were available at the NPDB regarding the actual involvement of these providers in the anesthetic management of the cases involved. There were 7219 cases of settlements, 235 judgments, and 843 other. Overall, the frequency of anesthesia malpractice payments has decreased from 1991–1994 to 2001–2004. Indeed, when adjusted for US population growth, there was a 27.7% decrease in the number of anesthesia malpractice payments per 100,000 people during 2001–2004 as compared with 1991–1994 (0.26 versus 0.19).
Next, we adjusted median payment amounts in the NPDB to 2005 dollars using the US Consumer Price Index (6). As can be seen from Figure 2, median payment increased significantly from the time periods of 1991–1994 to 2001–2004, both among all practitioners’ payments ($54,730 versus $131,500) and anesthesia practitioners’ malpractice payments ($69,330 versus $205,222). We also found significant variability, based on geographical location in both median pay and incidence of malpractice payments (Tables 1 and 2).
Data regarding severity of injury and age group of the patients are available in the NPDB only since January 31, 2004, and thus, our report in this area is limited to this time period. Most common anesthesia malpractice payments included death (35%), quadriplegic, brain damage, lifelong care (13%), minor permanent injury (10%), significant permanent injury (9.7%), and minor temporary injury (9.4%). The median anesthesia payment in 2004 differed significantly based on the severity of injury ($40,000, emotional injury; $32,500, temporary injury; $235,000, permanent injury; $745,000.00, quadriplegic, brain damage, or lifelong care; and $245,000.00, death). Anesthesia malpractice payments were significantly higher for children. The median payment for cases involving children younger than 1 yr of age was $465,000 ($195,000–$835,000) as compared with the median payment for cases involving children 1 to 9 yr old ($270,000 [$97,500–$572,500]) and median payment to cases involving adults older than 20 yr ($195,000 [$47500–$595,000]).
We also found that in the NPDB database, “monitoring” issues were the leading cause for anesthesia malpractice payments (1183), followed by “improper technique” (845), “intubation” (803), “agent use or selection” (390), and “positioning” (425).
Anesthesia-related malpractice payments accounted for 3% of all malpractice payments made in the US between 1991 and 2004. During the time period of the study, when adjusted to US population growth, the number of anesthesia malpractice payments decreased with time. Anesthesia payments are characterized as being higher in dollar amount as compared with all other malpractice payments. One should note, however, that the median anesthesia malpractice payment should ideally be compared with that of other high-risk specialties, such as obstetrics and neurosurgery. Finally, significant geographical variability was found both in median payment and incidence.
It is important to contrast the NPDB with the American Society of Anesthesiologists (ASA) closed claim study. The ASA Closed Claims Project, launched in 1985, was intended to “Identify major areas of loss in anesthesia, patterns of injury and strategies for prevention” (7). The closed claim study has made significant contributions to increased safety in the discipline of anesthesiology. The NPDB, in contrast, contains no clinical data and was intended to provide patients’ and various agencies’ information regarding involvement of individual clinicians in malpractice payments. One should note, however, that the closed claim study is limited in that it “has successfully recruited companies insuring approximately 14,500 of the 23,000 or so practicing anesthesiologists in the United States” (6). Thus, whereas the closed claim study does not contain all anesthesia-related data, the NPDB, a mandatory reporting system, contains a complete database of malpractice payments in the US.
Several methodological limitations related to this brief report have to be reviewed. First, the frequency of petitions submitted to courts that ask to dismiss malpractice claims before settlement of court proceedings is not known. As such, some under-reporting of payments may occur in the data available in the NPDB. Second, it is unclear how valid the “anesthesia related” categorization is in the NPDB. It is possible that some errors may have occurred by NPDB administrative personnel. Third, I was unable to identify predictable internal validation of the size and frequency of payments data. For example, whereas California is among those with the lowest per capita malpractice payment, it is not among the states with the lowest numbers of malpractice payments. I submit that there are other confounding known and unknown variables. That is, California may have a large concentration of tertiary care centers, and thus, the number of malpractice payments may be more frequent than in more rural states such as Idaho. The reader should also note that the NPDB does not provide information about the actual involvement of various anesthesia-providing personnel in the malpractice event. For example, it may be that a proportion of the malpractice payments made on behalf of anesthesiologists were actually related to the actions of certified registered nurse anesthetists working with these anesthesiologists. Thus, no conclusions should be made from this report regarding relative malpractice risk when comparing various anesthesia providers. Finally, a detailed discussion regarding the impact of the data described in this report on clinical practice and malpractice risk for anesthesiologists cannot be provided because of significant limitations of the NPDB data regarding the “reason” for the malpractice event (e.g., monitoring). That is, the reason listed in the NPDB is based on a brief report that originates from the administrative personnel of the entity that paid on behalf of the anesthesia practitioner. Once the report is received by the NPDB personnel, they categorize the cause of the event based on their own understanding. No anesthesiologist or any other physician is involved in the preparation of the initial report, nor in the NPDB classification. Thus, this process calls into serious question the validity of the listed “causes” of the payments. Hence the author’s apprehension to develop a discussion of the risk factors for malpractice payments based on data provided in this report.
In conclusion, anesthesia malpractice payments, as recorded by the NPDB, are larger than the median payments to other types of practitioners. Payments for cases involving young children are higher than those for injuries to adults. Although the number of payments relative to the population has decreased since 1991, this has been more than offset by an increase in the magnitude of the payments.