Does Experience Rating Improve Obstetric Practices? Evidence from Italy

Virtual reality evidence on the impact of physicians' open versus defensive communication on patients

Using virtual reality (VR) in an experimental setting, we analyse how communicating more openly about a medical incident influences patients' feelings and behavioural intentions. Using VR headsets, participants were immersed in an actual hospital room where they were told by a physician that a medical incident had occurred. In a given scenario, half of the participants were confronted by a physician who communicated openly about the medical incident, while the other half were confronted with the exact same scenario except that the physician employed a very defensive communication strategy. The employed technology allowed us to keep everything else in the environment constant. Participants exposed to open disclosure were significantly more likely to take further steps (such as contacting a lawyer to discuss options and filing a complaint against the hospital) and express more feelings of blame against the physician. At the same time, these participants rated the physician's communication skills and general impression more highly than those who were confronted with a defensive physician. Nevertheless, communicating openly about the medical incident does not affect trust in the physician and his competence, perceived incident severity and likelihood of changing physician and filing suit.

Does patient behaviour drive physicians to practice defensive medicine? Evidence from a video experiment

OBJECTIVE

By manipulating patients' critical attitude in a video experiment, we examined whether physicians are more intended to perform defensive acts because of a higher perceived liability risk in Belgium.

METHODS

We assigned 85 practicing gynaecologists/obstetricians and orthopaedists randomly to four hypothetical video consultations, in which the patients show either a critical attitude (i.e., getting ahead of the facts, showing distrust) or a non-critical attitude (i.e., displaying more neutral questions and expressions). We asked the physicians about the care they would administer in the presented cases and the expected likelihood that the patient would sue the physician in case of a medical incident.

RESULTS

By manipulating patients' verbal critical attitude (which indicates patients' intention to take further steps), while keeping constant physician's communication, patients' clinical situation, preferences, and non-verbal behaviour in the videos, we were able to discover differential treatment styles driven by physicians' perceived liability risk among patients with a different critical attitude. We found that physicians perform 17 percentage points more defensive acts (e.g., surgeries and diagnostic tests that are not medically necessary) when experiencing a high liability risk.

CONCLUSIONS

Our results show that patients' critical attitude drives physicians' perceived liability risk and consequent defensive behaviour among obstetricians/gynaecologists and orthopaedists.

Fee equalization and appropriate health care

Fee equalization in health care brings under a unique tariff several medical treatments, coded under different Diagnosis Related Groups (DRGs). The aim is to improve healthcare quality and efficiency by discouraging unnecessary, but better-paid, treatments. We evaluate its effectiveness on childbirth procedures to reduce overuse of c-sections by equalizing the DRGs for vaginal and cesarean deliveries. Using data from Italy and a difference-in-differences approach, we show that setting an equal fee decreased c-sections by 2.6%. This improved the appropriateness of medical decisions, with more low-risk mothers delivering naturally and no significant changes in the incidence of complications for vaginal deliveries. Our analysis supports the effectiveness of fee equalization in avoiding c-sections, but highlights the marginal role of financial incentives in driving c-section overuse. The observed drop was only temporary and in about a year the use of c-sections went back to the initial level. We found a greater reduction in lower quality, more capacity-constrained hospitals. Moreover, the effect is driven by districts where the availability of Ob-Gyn specialists is higher and where women are predominant in the gender composition of Ob-Gyn specialists.

Perspectives of Italian pregnant women on pregnancy examinations and pregnancy care: is the caregiver more important than the care?

AIM

Assessing awareness of Italian low-risk pregnant patients on low-risk pregnancy care and what do they feel about their own pregnancy.

METHODS

A questionnaire was administered to 382 low-risk pregnant women. This questionnaire assessed general knowledge of low-risk pregnancy, low-risk pregnancy care, and how much patients rated ten topics of low-risk pregnancy care. It would be expected that the knowledge of each topic would associates with the patient's perceived importance of that topic.

RESULTS

Poor knowledge of pregnancy care was proven. Patients seem to incorrectly overrate vaginal examinations and obstetric and gynecologist-led care, while they attribute appropriate importance to midwife-led care. The more examinations performed (vaginal examinations, sonographic checks, cardiotocographies), the higher their rating.

CONCLUSIONS

In Italy, expectations of pregnant women about their own pregnancy are incorrectly trusted in the obstetrics and gynecologists. Both poor knowledge of pregnancy care and cultural perspectives on the birth process amongst Italian people explain the finding. Referring low-risk pregnant women to midwives would help them to rate more the care than the caregiver.

New Rules on Patient's Safety and Professional Liability for the Italian Health Service

BACKGROUND

The phenomenon of clinical negligence claims has rapidly spread to United States, Canada and Europe assuming the dimensions and the severity of a pandemia. Consequently, the issues related to medical malpractice need to be studied from a transnational perspective since they raise similar problems in different legal systems.

METHODS

Over the last two decades, medical liability has become a prominent issue in healthcare policy and a major concern for healthcare economics in Italy. The failures of the liability system and the high cost of healthcare have led to considerable legislative activity concerning medical malpractice liability, and a law was enacted in 2012 (Law no. 189/2012), known as the "Balduzzi Law".

RESULTS

The law tackles the mounting concern over litigation related to medical malpractice and calls for Italian physicians to follow guidelines. Briefly, the law provided for the decriminalisation of simple negligence of a physician on condition that he/she followed the guidelines and "good medical practice" while carrying out his/her duties, whilst the obligation for compensation, as defined by the Italian Civil Code, remained. Judges had to consider that the physician followed the provisions of the guidelines but nevertheless caused injury to the patient.

CONCLUSION

However, since the emission of the law, thorny questions remain which have attracted renewed interest and criticism both in the Italian courts and legal literature. Since then, several bills have been presented on the topic and these have been merged into a single text entitled "Regulations for healthcare and patient safety and for the professional responsibility of healthcare providers".

The resolution process and the timing of settlement of medical malpractice claims

We draw on uniquely detailed micro-level data from a Belgian professional medical liability insurer to examine how different procedural and legal events that take place during the unfolding of a medical malpractice claim influence the timing of its settlement. Utilizing the competing risks regression framework, we find that settlement hazard is all else equal statistically significantly positively associated with the completion of those procedural and legal events that most effectively reveal factual information about the underlying medical malpractice case. Consistent with theory, settlement hazard is either unassociated or even negatively associated with the completion of other procedural and legal events. Our analysis, therefore, provides policy insights into which aspects of the resolution process could be emphasized, and which de-emphasized, in order to reduce the often excessive duration of medical malpractice claims and its adverse effects on the healthcare system.

Now trending: Coping with non-parallel trends in difference-in-differences analysis

Difference-in-differences (DID) analysis is used widely to estimate the causal effects of health policies and interventions. A critical assumption in DID is "parallel trends": that pre-intervention trends in outcomes are the same between treated and comparison groups. To date, little guidance has been available to researchers who wish to use DID when the parallel trends assumption is violated. Using a Monte Carlo simulation experiment, we tested the performance of several estimators (standard DID; DID with propensity score matching; single-group interrupted time-series analysis; and multi-group interrupted time-series analysis) when the parallel trends assumption is violated. Using nationwide data from US hospitals (n = 3737) for seven data periods (four pre-interventions and three post-interventions), we used alternative estimators to evaluate the effect of a placebo intervention on common outcomes in health policy (clinical process quality and 30-day risk-standardized mortality for acute myocardial infarction, heart failure, and pneumonia). Estimator performance was assessed using mean-squared error and estimator coverage. We found that mean-squared error values were considerably lower for the DID estimator with matching than for the standard DID or interrupted time-series analysis models. The DID estimator with matching also had superior performance for estimator coverage. Our findings were robust across all outcomes evaluated.

Public and social environment changes and caesarean section delivery choice in Japan

Objective

As in many other countries, the ratio of caesarean section (c-section) delivery to total births in Japan is rising steadily, while the total number of deliveries is decreasing. Although c-sections can effectively prevent maternal and perinatal mortality and morbidity when medically justified, it is uncertain how medically unnecessary c-sections affect the short-, middle-, and long-term postnatal effects on the mother and child. As there are no empirical studies on c-section choice for Japan, this study uses individual medical facility panel data from 1999 to 2014 to comprehensively examine the effects of recent public and social environment changes on c-section delivery choice.

Results

The empirical results from our fixed effect model show that c-section delivery and its ratio are higher in public hospitals, in relatively large clinics, and in clinics opening on holidays. In addition, increases in the lump-sum birth allowance and the number of medical malpractice lawsuits also increase the number of c-section delivery.