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Does Litigation Increase or Decrease Health Care Quality?: A National Study of Negligence Claims Against Nursing Homes

Stevenson, David G. PhD*; Spittal, Matthew J. PhD; Studdert, David M. LLB, ScD†,‡

doi: 10.1097/MLR.0b013e3182881ccc
Original Articles

Background: The tort system is supposed to help improve the quality and safety of health care, but whether it actually does so is controversial. Most previous studies modeling the effect of negligence litigation on quality of care are ecologic.

Objective: To assess whether the experience of being sued and incurring litigation costs affects the quality of care subsequently delivered in nursing homes.

Research Design, Subjects, Measures: We linked information on 6471 negligence claims brought against 1514 nursing homes between 1998 and 2010 to indicators of nursing home quality drawn from 2 US national datasets (Online Survey, Certification, and Reporting system; Minimum Data Set Quality Measure/Indicator Reports). At the facility level, we tested for associations between 9 quality measures and 3 variables indicating the nursing homeslitigation experience in the preceding 12–18 months (total indemnity payments; total indemnity payments plus administrative costs; ≥1 paid claims vs. none). The analyses adjusted for quality at baseline, case-mix, ownership, occupancy, year, and facility and state random effects.

Results: Nearly all combinations of the 3 litigation exposure measures and 9 quality measures—27 models in all—showed an inverse relationship between litigation costs and quality. However, only a few of these associations were statistically significant, and the effect sizes were very small. For example, a doubling of indemnity payments was associated with a 1.1% increase in the number of deficiencies and a 2.2% increase in pressure ulcer rates.

Conclusions: Tort litigation does not increase the quality performance of nursing homes, and may decrease it slightly.

Supplemental Digital Content is available in the text.

*Department of Health Care Policy, Harvard Medical School, Boston, MA

Melbourne School of Population and Global Health

Melbourne Law School, University of Melbourne, Vic., Australia

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Funding from the Harvard Interfaculty Program for Health Systems Improvement. D.G.S. was supported by a training grant from the National Institute on Aging (K01 AG038481). D.M.S. was supported by a Laureate Fellowship from the Australian Research Council.

The authors declare no conflict of interest.

Reprints: David G. Stevenson, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115. E-mail:

© 2013 Lippincott Williams & Wilkins, Inc.