Evaluative reports on medical malpractice policies in obstetrics: a rapid scoping review

Patient characteristics of, and remedial interventions for, complaints and medico-legal claims against doctors: a rapid review of the literature

BACKGROUND

It is uncertain if patient's characteristics are associated with complaints and claims against doctors. Additionally, evidence for the effectiveness of remedial interventions on rates of complaints and claims against doctors has not been synthesised.

METHODS

We conducted a rapid review of recent literature to answer: Question 1 "What are the common characteristics and circumstances of patients who are most likely to complain or bring a claim about the care they have received from a doctor?" and Question 2 "What initiatives or interventions have been shown to be effective at reducing complaints and claims about the care patients have received from a doctor?". We used a systematic search (most recently in July 2023) of PubMed, Scopus, Web of Science and grey literature. Studies were screened against inclusion criteria and critically appraised in duplicate using standard tools. Results were summarised using narrative synthesis.

RESULTS

From 8079 search results, we reviewed the full text of 250 studies. We included 25 studies: seven for Question 1 (6 comparative studies with controls and one systematic review) and 18 studies for Question 2 (14 uncontrolled pre-post studies, 2 comparative studies with controls and 2 systematic reviews). Most studies were set in hospitals across a mix of medical specialties. Other than for patients with mental health conditions (two studies), no other patient characteristics demonstrated either a strong or consistent effect on the rate of complaints or claims against their treating doctors. Risk management programs (6 studies), and communication and resolution programs (5 studies) were the most studied of 6 intervention types. Evidence for reducing complaints and medico-legal claims, costs or premiums and more timely management was apparent for both types of programs. Only 1 to 3 studies were included for peer programs, medical remediation, shared decision-making, simulation training and continuing professional development, with few generalisable results.

CONCLUSION

Few patient characteristics can be reliably related to the likelihood of medico-legal complaints or claims. There is some evidence that interventions can reduce the number and costs of claims, the number of complaints, and the timeliness of claims. However, across both questions, the strength of the evidence is very weak and is based on only a few studies or study designs that are highly prone to bias.

An alternative model of maternity care for low-risk birth: Maternal and neonatal outcomes utilizing the midwifery-based birth center model

OBJECTIVE

To assess key birth outcomes in an alternative maternity care model, midwifery-based birth center care.

DATA SOURCES

The American Association of Birth Centers Perinatal Data Registry and birth certificate files, using national data collected from 2009 to 2019.

STUDY DESIGN

This observational cohort study compared key clinical birth outcomes of women at low risk for perinatal complications, comparing those who received care in the midwifery-based birth center model versus hospital-based usual care. Linear regression analysis was used to assess key clinical outcomes in the midwifery-based group as compared with hospital-based usual care. The hospital-based group was selected using nearest neighbor matching, and the primary linear regressions were weighted using propensity score weights (PSWs). The key clinical outcomes considered were cesarean delivery, low birth weight, neonatal intensive care unit admission, breastfeeding, and neonatal death. We performed sensitivity analyses using inverse probability weights and entropy balancing weights. We also assessed the remaining role of omitted variable bias using a bounding methodology.

DATA COLLECTION

Women aged 16-45 with low-risk pregnancies, defined as a singleton fetus and no record of hypertension or cesarean section, were included. The sample was selected for records that overlapped in each year and state. Counties were included if there were at least 50 midwifery-based birth center births and 300 total births. After matching, the sample size of the birth center cohort was 85,842 and the hospital-based cohort was 261,439.

PRINCIPAL FINDINGS

Women receiving midwifery-based birth center care experienced lower rates of cesarean section (-12.2 percentage points, p < 0.001), low birth weight (-3.2 percentage points, p < 0.001), NICU admission (-5.5 percentage points, p < 0.001), neonatal death (-0.1 percentage points, p < 0.001), and higher rates of breastfeeding (9.3 percentage points, p < 0.001).

CONCLUSIONS

This analysis supports midwifery-based birth center care as a high-quality model that delivers optimal outcomes for low-risk maternal/newborn dyads.

The Government as Plaintiff: An Analysis of Medical Litigation Against Healthcare Providers in the Eastern Province of the Kingdom of Saudi Arabia

OBJECTIVES

The Saudi healthcare and medicolegal systems have seen several developments to improve quality of services and ensure patient safety. However, violation claims have seen an upward trend in the past few years. Several studies have analyzed medical litigation to better understand violations within healthcare sectors and address them accordingly. Such studies have focused extensively on medical litigations filed by patients against healthcare providers, overlooking other plaintiffs, such as governments. In this study, we examined violation claims filed by governmental entities against healthcare providers in the Eastern Province of the Kingdom of Saudi Arabia.

METHODS

From 2016 to 2019, 718 healthcare providers were involved in violation claims that were referred to the Medical Offenses Committee. Two logistic regression analyses were performed to identify significant predictors of receiving a guilty verdict and the verdict type (for guilty verdicts), given defendant-related factors.

RESULTS

Eighty-two percent of healthcare providers received a guilty verdict. Guilty verdicts were prevalent among non-Saudis and healthcare providers in the private sector. Healthcare providers working in the private sector were significantly more likely to receive a guilty verdict than healthcare providers working in the public sector. Nurses were significantly less likely to receive a guilty verdict than physicians. Being involved in violation claims with 5 or more codefendants decreased the likelihood of receiving a guilty verdict. In addition, non-Saudis being involved in violation claims with multiple defendants, working in the private sector, and working in pharmacies and medical complexes were significant predictors of the verdict type.

CONCLUSIONS

Results of the study extend the extant literature by analyzing medical litigation including plaintiffs other than patients. In addition, the study introduces implications for the government and policymakers as well as areas for future research The study's findings emphasized the importance of employment sector and number of defendants as significant predictors of violation claims' verdicts. Policymakers should take into consideration significant predictors to ensure healthcare providers' compliance with respective rules and regulations. Tailored attention toward these predictors could minimize the prevalence of medical violation claims, ensure patient safety, and avoid associated negative consequences.

Caesarean birth in public maternities in Argentina: a formative research study on the views of obstetricians, midwives and trainees

OBJECTIVES

To explore obstetricians', midwives' and trainees' perceptions of caesarean section (CS) determinants in the context of public obstetric care services provision in Argentina. Our hypothesis is that known determinants of CS use may differ in settings with limited access to essential obstetric services.

SETTING

We conducted a formative research study in 19 public maternity hospitals in Argentina. An institutional survey assessed the availability of essential obstetric services. Subsequently, we conducted online surveys and semistructured interviews to assess the opinions of providers on known CS determinants.

RESULTS

Obstetric services showed an adequate provision of emergency obstetric care but limited services to support women during birth. Midwives, with some exceptions, are not involved during labour. We received 680 surveys from obstetricians, residents and midwives (response rate of 63%) and interviewed 26 key informants. Six out of 10 providers (411, 61%) indicated that the use of CS is associated with the complexities of our caseload. Limited pain management access was deemed a potential contributing factor for CS in adolescents and first-time mothers. Providers have conflicting views on the adequacy of training to deal with complex or prolonged labour. Obstetricians with more than 10 years of clinical experience indicated that fear of litigation was also associated with CS. Overall, there is consensus on the need to implement interventions to reduce unnecessary CS.

CONCLUSIONS

Public maternity hospitals in Argentina have made significant improvements in the provision of emergency services. The environment of service provision does not seem to facilitate the physiological process of vaginal birth. Providers acknowledged some of these challenges.

Paper 3: Selecting rapid review methods for complex questions related to health policy and system issues

Approaches for rapid reviews that focus on streamlining systematic review methods are not always suitable for exploring complex policy questions, as developing and testing theories to explain these complexities requires configuring diverse qualitative, quantitative, and mixed methods studies. Our objective was therefore to provide a guide to selecting approaches for rapidly (i.e., within days to months) addressing complex questions related to health policy and system issues.We provide a two-stage, transdisciplinary collaborative process to select a rapid review approach to address complex policy questions, which consists of scoping the breadth and depth of the literature and then selecting an optimal approach to synthesis. The first stage (scoping the literature) begins with a discussion with the stakeholders requesting evidence to identify and refine the question for the review, which is then used to conduct preliminary searches and conceptually map the documents identified. In the second stage (selection of an optimal approach), further stakeholder consultation is required to refine and tailor the question and approach to identifying relevant documents to include. The approach to synthesizing the included documents is then guided by the final question, the breadth and depth of the literature, and the time available and can include a static or evolving conceptual framework to code and analyze a range of evidence. For areas already covered extensively by existing systematic reviews, the focus can be on summarizing and integrating the review findings, resynthesizing the primary studies, or updating the search and reanalyzing one or more of the systematic reviews.The choice of approaches for conducting rapid reviews is intertwined with decisions about how to manage projects, the amount of work to be done, and the knowledge already available, and our guide offers support to help make these strategic decisions.

Defensive medicine and cesarean sections in Brazil

Brazil has a high rate of cesarean sections (CS) that cannot be solely justified by women's clinical conditions; thus, other causes, for example, CS on maternal request and physicians' fear of litigation as possible influencing factors, cannot be overlooked.This study aimed to identify through a survey whether Brazilian gynecologists and obstetricians (GOs) perform defensive CS.In this cross-sectional, descriptive study, a questionnaire was administered. The target population comprised of GOs who were members of premier Brazilian professional associations of gynecology and obstetrics. A total of 403 GOs participated in the survey using an obstetrics questionnaire about litigation and defensive medicine (DM). Statistical analyses were performed on pairs of variables to determine the risk factors of performing CS due to concerns of complications during vaginal delivery and to avoid lawsuits.The mean age of the GOs was 47.7 years who were mostly female (58.3%) and having worked professionally in both public and private sectors (71.7%). Of all participants, 80.6% had been sued or knew an obstetrician who had been sued. The obstetricians who had been sued or who knew a colleague that had been sued exhibited a significantly higher likelihood of performing defensive CS than physicians who had not been sued or did not know physicians who had been sued. The perception of a higher risk of lawsuits against obstetricians influenced the practice of DM and led to a more than six-fold increase in CSs in specialists with this perception compared to specialists who did not believe the presence of an increased risk of litigation in obstetrics existed.The majority of Brazilian GOs perform defensive CS. It is important to consider DM as one of the causes of high CS rates in Brazil and include it in the development of public policies to reduce these CS rates.

PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation

Scoping reviews, a type of knowledge synthesis, follow a systematic approach to map evidence on a topic and identify main concepts, theories, sources, and knowledge gaps. Although more scoping reviews are being done, their methodological and reporting quality need improvement. This document presents the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist and explanation. The checklist was developed by a 24-member expert panel and 2 research leads following published guidance from the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network. The final checklist contains 20 essential reporting items and 2 optional items. The authors provide a rationale and an example of good reporting for each item. The intent of the PRISMA-ScR is to help readers (including researchers, publishers, commissioners, policymakers, health care providers, guideline developers, and patients or consumers) develop a greater understanding of relevant terminology, core concepts, and key items to report for scoping reviews.

Patient safety initiatives in obstetrics: a rapid review

OBJECTIVES

This review was commissioned by WHO, South Africa-Country office because of an exponential increase in medical litigation claims related to patient safety in obstetrical care in the country. A rapid review was conducted to examine the effectiveness of quality improvement (QI) strategies on maternal and newborn patient safety outcomes, risk of litigation and burden of associated costs.

DESIGN

A rapid review of the literature was conducted to provide decision-makers with timely evidence. Medical and legal databases (eg, MEDLINE, Embase, LexisNexis Academic, etc) and reference lists of relevant studies were searched. Two reviewers independently performed study selection, abstracted data and appraised risk of bias. Results were summarised narratively.

INTERVENTIONS

We included randomised clinical trials (RCTs) of QI strategies targeting health systems (eg, team changes) and healthcare providers (eg, clinician education) to improve the safety of women and their newborns. Eligible studies were limited to trials published in English between 2004 and 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

RCTs reporting on patient safety outcomes (eg, stillbirths, mortality and caesarean sections), litigation claims and associated costs were included.

RESULTS

The search yielded 4793 citations, of which 10 RCTs met our eligibility criteria and provided information on over 500 000 participants. The results are presented by QI strategy, which varied from one study to another. Studies including provider education alone (one RCT), provider education in combination with audit and feedback (two RCTs) or clinician reminders (one RCT), as well as provider education with patient education and audit and feedback (one RCT), reported some improvements to patient safety outcomes. None of the studies reported on litigation claims or the associated costs.

CONCLUSIONS

Our results suggest that provider education and other QI strategy combinations targeting healthcare providers may improve the safety of women and their newborns during childbirth.

Paediatric gastrostomy stoma complications and treatments: A rapid scoping review

AIMS AND OBJECTIVES

To provide a scoping review of the types of treatments used to address paediatric skin-related stoma complications specific to infection, hypergranulation and gastric leakage, and explore their effectiveness and indications for use.

BACKGROUND

Stoma-related complications can be a common occurrence for children with gastrostomy (G) and gastrojejunostomy (GJ) tubes. Nurses require guidance to inform decision-making of the broad spectrum of treatments used in clinical practice.

DESIGN

A scoping review using a rapid review approach.

METHODS

Working with a multidisciplinary health professional team, search terms were generated. A systematic search of CINAHL, MEDLINE and EMBASE databases was completed, coupled with an Internet search to identify relevant clinical practice guidelines and hand searching of citation lists. Eligible articles were peer-reviewed English publications, focused on paediatric populations aged 18 years and under, dating from 2002-2016 and described complications and treatment approaches related to G- and GJ-tube stomas. Pertinent information was extracted using a standardised template, and a narrative synthesis approach was used to analyse the data.

RESULTS

Twenty-five articles were included in this review. Study designs varied, and complication management was often a secondary focus. A broad spectrum of treatments was used to manage each complication type. There was a lack of consensus on lines of therapy; however, a stepwise approach was often used for complication management, particularly for infections.

CONCLUSIONS

The evidence on the comparative effectiveness of different treatment strategies of skin-related gastrostomy stoma complications in paediatric practice is sparse. Current evidence is generally limited to expert opinions. Future studies examining efficacy of treatments and their indications for use with children are warranted.

RELEVANCE TO CLINICAL PRACTICE

Effective management of skin-related stoma complications is important to maintain health and wellness among children who rely on G- and GJ-tubes for nutrition support.