Background:
While medical professional liability (MPL) claims involving pediatric cases (ages 0-17 years) represent a small fraction of overall MPL claim activity nationally, they differ substantially from adult cases, both in the clinical conditions that result in claims as well as possible indemnity payments. In a recent analysis of MPL claim and lawsuit data in the journal, Pediatric Emergency Care, the authors highlight how changes in childhood immunizations, medical practice patterns, and the pediatric acute care (emergency and urgent care) marketspace have shifted both the clinical conditions that typically result in MPL claims as well as the type of facility of involved.
What We Knew:
In 2005, Selbst and colleagues published a study analyzing the MPL trends in pediatric acute care. They analyzed pediatric claims data from the Physicians Insurers Association of America (PIAA) during a 16-year period encompassing 1985-2000. In the resulting 2283 cases, 96% arose from care delivered in emergency departments while 4% from urgent care centers. Emergency physicians, pediatricians, family medicine physicians, orthopedic surgeons, and general surgeons were most often involved. Overall, payments were issued to plaintiffs in approximately one-third of the MLP claims filed.
Most cases involved children under the age of 2 years (47%). The most common diagnoses involved were fractures, meningitis, and appendicitis. In cases where the child died (46 claims), meningitis was most frequently cited diagnosis, followed closely by pneumonia. In older children (12-17 years) the most common claims involved fractures, appendicitis, and testicular torsion. The four most cited medical factors were: diagnostic error, no medical error, improper performance of a procedure and failure to supervise staff. Interestingly, “no medical error” appeared in 18% of cases that resulted in payment to the plaintiff.
The average indemnity payment for all claims during this period was approximately $160,000. However, indemnity payment amounts increased 300% between 1985-2000, far outstripping inflation. Only 32% of closed cases resulted in payments to the plaintiff. Average payments were significantly higher for the youngest (0-2 years) patients, likely because the conditions resulting in MLP (meningitis, pneumonia, and neonatal impairment) are more likely to occur in this age group than older children and confer a higher risk for permanent harm.
What This New Article Tells Us:
In July 2021, Glerum and colleagues published a study updating the Selbst 2005 study. They analyzed the PIAA database from 2001-2015 from a total of 8281 pediatric cases. They found the share of urgent care cases increased slightly to 9%. While the mix of physicians was very similar, radiologists now represent a larger portion of defendants, likely due to the proliferation of advanced imaging (CT, ultrasound, MRI) compared to the previous study period. For example, CT utilization has increased by at least 3-fold in the past 20 years in emergency medicine.
The diagnostic pattern also shifted between 1985 and 2015. In the youngest patients, cardiopulmonary arrest is now the leading cause for MLP claims, followed by pulmonary disease and meningitis. The decreasing incidence of meningitis MLP claims is likely due a large decrease in neonatal and infant meningitis in the United States stemming from new vaccines and improved diagnostic pathways. In the school-age group (3-11 years), cardiopulmonary arrest is still the leading cause of MLP, followed by appendicitis and fracture. Meningitis now only represents 3.2% of paid claims. In the oldest group (12-17 years), testicular torsion accounts for the majority of MPL claims. Clinical factors in MLP claims remains mostly unchanged. Errors in diagnosis were the leading reason for MPL claims, followed by improper performance, no medical error, and failure to supervise. The category “no medical error” now represents only 2.7% of paid claims.
Payments to plaintiffs averaged $319,000 during this study period and roughly 30% of claims resulted in payment – similar to the 1985-2000 study. Again, MPL indemnities are higher for children due to their need for longer term care due to their lengthier lifespans. Death was the leading outcome in 29% of paid claims with an average payment of $249,000 while the largest claims were in children with grave or major, permanent injuries ($923K and $551K, respectively).
Takeaways
Over the past thirty years, advances in immunizations, practice pathways, utilization of advanced imaging, and the proliferation of urgent care centers have resulted in changes to the MPL claims landscape. Urgent care centers now account for nearly 10% of MPL claims in the pediatric population, a share that is likely to continue to grow as these facilities proliferate in the United States.
Advances in radiographic imaging techniques and teleradiology have allowed for the near real-time interpretation of radiographic studies by radiologists – often resulting in final radiographic interpretations of studies while the patient is still in the acute care setting. While this has likely contributed to the lower incidence of fracture MPL claims, it may also be responsible for the increase in claims against radiologists.
Rather than meningitis, the leading cause of an MPL claim in the pediatric population is now cardiopulmonary arrest (0-11 years). Cardiopulmonary arrest is a multifactorial, highly complex clinical entity. It is not a diagnosis in and of itself, but rather a result of a myriad of disease states, such as sepsis, trauma, neurologic disorders, and toxicologic exposures, to name a few.
Analyzing breach, causation, and harm in any claim is the key to understanding potential liability, and such an analysis often requires experts from more than one specialty. For example, pediatric cardiopulmonary arrest in an emergency department due to seizures in a cerebral palsy patient may require experts in Emergency Medicine, Developmental and Behavioral Pediatrics, and Pediatric Neurology.
Elite Medical Experts specializes in matching medical expertise coupled with longitudinal case strategy to assist trial attorneys with complex medical professional liability cases. Call today to speak with a Case Strategist on our team.
2000-2015 Study: Glerum KM, Selbst SM, Parikh PD, Zonfrillo MR. Pediatric Malpractice Claims in the Emergency Department and Urgent Care Settings From 2001 to 2015. Pediatr Emerg Care. 2021 Jul 1;37(7):e376-e379. doi: 10.1097/PEC.0000000000001602. PMID: 30211835.
https://pubmed.ncbi.nlm.nih.gov/30211835/
1985-2000 Study: Selbst SM, Friedman MJ, Singh SB. Epidemiology and etiology of malpractice lawsuits involving children in US emergency departments and urgent care centers. Pediatr Emerg Care. 2005 Mar;21(3):165-9. PMID: 15744194.
