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Association Between State Medical Malpractice Environment and Surgical Quality and Cost in the United States

Bilimoria, Karl Y. MD, MS; Sohn, Min-Woong PhD; Chung, Jeanette W. PhD; Minami, Christina A. MD; Oh, Elissa H. MA; Pavey, Emily S. MA; Holl, Jane L. MD, MPH; Black, Bernard S.; Mello, Michelle M. JD, PhD; Bentrem, David J. MD, MS

doi: 10.1097/SLA.0000000000001538

Context: The US medical malpractice system is designed to deter negligence and encourage quality of care through threat of liability.

Objective: To examine whether state-level malpractice environment is associated with outcomes and costs of colorectal surgery.

Design, Setting, and Patients: Observational study of 116,977 Medicare fee-for-service beneficiaries who underwent colorectal surgery using administrative claims data. State-level malpractice risk was measured using mean general surgery malpractice insurance premiums; paid claims per surgeon; state tort reforms; and a composite measure. Associations between malpractice environment and postoperative outcomes and price-standardized Medicare payments were estimated using hierarchical logistic regression and generalized linear models.

Main Outcome Measures: thirty-day postoperative mortality; complications (pneumonia, myocardial infarction, venous thromboembolism, acute renal failure, surgical site infection, postoperative sepsis, any complication); readmission; total price-standardized Medicare payments for index hospitalization and 30-day postdischarge episode-of-care.

Results: Few associations between measures of state malpractice risk environment and outcomes were identified. However, analyses using the composite measure showed that patients treated in states with greatest malpractice risk were more likely than those in lowest risk states to experience any complication (OR: 1.31; 95% CI: 1.22–1.41), pneumonia (OR: 1.36; 95%: CI, 1.16–1.60), myocardial infarction (OR: 1.44; 95% CI: 1.22–1.70), venous thromboembolism (OR:2.11; 95% CI: 1.70–2.61), acute renal failure (OR: 1.34; 95% CI; 1.22–1.47), and sepsis (OR: 1.38; 95% CI: 1.24–1.53; all P < 0.001). There were no consistent associations between malpractice environment and Medicare payments.

Conclusions: There were no consistent associations between state-level malpractice risk and higher quality of care or Medicare payments for colorectal surgery.

*Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC)

Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL

Department of Public Health Sciences, University of Virginia School of Medicine, University of Virginia, Charlottesville, VA

§Northwestern University Law School and Kellogg School of Management, Northwestern University, Chicago, IL

Stanford Law School and Stanford School of Medicine, Stanford University, Stanford, CA

||Jesse Brown Veteran's Administration Hospital, Chicago, IL.

Reprints: Karl Y. Bilimoria, MD, MS, Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Northwestern Memorial Hospital, 676 St. Clair Street, Arkes Pavilion Suite 6-650, Chicago, 60611 IL. E-mail:

This study was supported by AHRQ R21HS021857 and a Center Development Award from Northwestern University and Northwestern Memorial Hospital to Dr. Bilimoria.

The authors declare no conflicts of interest to disclose.

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