Subscribe Now Subscribe Today
Review Article
 

Medical Specialties at High Risk of Litigation in Iran, 1991-2011: A Systematic Review of 24 Studies



Farhad Kalantari, Saeid Saeidimehr and Fakher Rahim
 
Facebook Twitter Digg Reddit Linkedin StumbleUpon E-mail
ABSTRACT

We attempt to review all databases from which data on medical malpractices and complaints on Iranian health system were presented. We systematically searched PubMed, Medline, four national databases and hand-searched three relevant journals from 1991 to 2011. After quality appraisal, data was extracted from the literature and analyzed using qualitative synthesis approach. Twenty-four reports on the medical malpractice in various medical specialties, dentistry and pharmacy were reviewed. A total of 8394 complaints out of 16584 cases were found related to medical malpractice in Iran from 1991-2011. The highest number of medical malpractice reported, were from the capital city following by eastern north part and central part of Iran. The highest risk of medical liability lawsuits were observed in obstetrics and gynecology, orthopedy, general surgery and ophthalmology. Studies only focused on some elements of the problem and rarely on process-related or systematic causes of malpractice and medical errors. There is substantial variation in the likelihood of malpractice suits across specialties. Despite considerable financial impacts of healthcare fraud and malpractice, this aspect of the problem had received even less attention.

Services
Related Articles in ASCI
Search in Google Scholar
View Citation
Report Citation

 
  How to cite this article:

Farhad Kalantari, Saeid Saeidimehr and Fakher Rahim, 2012. Medical Specialties at High Risk of Litigation in Iran, 1991-2011: A Systematic Review of 24 Studies. Journal of Medical Sciences, 12: 248-255.

DOI: 10.3923/jms.2012.248.255

URL: https://scialert.net/abstract/?doi=jms.2012.248.255
 
Received: January 06, 2013; Accepted: March 18, 2013; Published: May 03, 2013



INTRODUCTION

Medical malpractices lawsuits may increase the health care expenditure, resulting in many doctors attempt to protect themselves from the increasing threat of liability suits by changing their methods of practicing medicine. In particular, this type of claims may divert health care professional’s resources and time away from their foremost purposes, which is providing the patient care (Zuckerman, 1984).

When a claim occurs, health care professionals are forced to devote some time and effort to the legal issues and, in many cases, obtain a legal consultant. These elements contribute in raising the cost of medical practice and, as with premiums, can translate into higher charges of healthcare services. Over the past decade, health care professional and researchers have claimed that defensive medicine is the most destructive consequence of the medical malpractices lawsuits. Numerous researchers have committed or observed a relationship between concerns about the risk and costs of medical negligence, overall malpractice effect on health care environment and defensive performance (Dubay et al., 1999; Localio et al., 1993; Vimercati et al., 2000a, b). Hence, others reported that medical malpractices lawsuits would not significantly influence medical and health care decision-making (Sloan and Shadle, 2009).

Although health care professionals may implement defensive medicine due to fear of litigation, but this may also cause health care professionals to accomplish medically unnecessary tests and treatment in their best professional judgments. As health care costs are increasing and insurance coverage remains to shrink, many people worldwide have begun to surprise where the health system went wrong.

Two significant contributing factors in rising health care costs include medical malpractice and defensive medicine.

To the best of our knowledge, though there are many scientific attempts to assess the malpractice in Iran, but no one observed the medical specialties at high risk of litigation in Iran. So, the aim of this review was to assess the medical specialties at high risk of litigation in Iran, with clinically malpractice issues. All the available published data on the subject matter were pooled together in a systematic review.

MATERIALS AND METHODS

Search strategy: We searched PubMed and Medline using MeSH terms including “defensive medicine”, “Malpractice”, “legislation and jurisprudence”, “Medical complaints”, “Medical claims” and “Iran”, in following sequential form: ((("Defensive Medicine"[Mesh]) OR "Malpractice"[Mesh]) AND "legislation and jurisprudence" [Subheading]) AND "Iran"[Mesh]. Besides, we searches four local databases include IranMedex, IranDoc, SID (Scientific Information Database) and Magiran using same search terms in both English and Persian languages. The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guideline was followed (Moher et al., 2009).

Inclusion criteria: All the studies about medical malpractice in the medical fields including general practice, specialties, dentistry, pharmacy and other were collected.

Data extraction: The extracted data included study characteristics such as medical specialty, number of claims that stratified to different specialties and geographical region.

Outcome measures: The primary endpoint variable for this systematic review was malpractice in the physician groups. Outcome data on medical negligence, the cost of malpractice and type of high-risk medical fields were retrieved.

Statistical analysis: The frequencies of different lawsuits were presented and the results were expressed as number and percentage. All data were analyzed using Microsoft Excel 2010 and STATA 11.0.

RESULTS

Twenty-four reports on the medical malpractice in various medical specialties were reviewed (Fig. 1) (Akhlaghei et al., 2004; Badakhsh, 2003; Bazrafkan et al., 2008; Daneshparvar and Javadian, 2008; Ghashlaghei et al., 2009; Haghghi et al., 2005, 2006; Haghshenas et al., 2012; Hedayati et al., 2012; Hejazi et al., 2009; Jafarian et al., 2009; Kiani and Sheikhazadi 2009; Mahfouzi and Zamani, 2007; Manouchehri Moghadam et al., 2010; Mirza Aghaei et al., 2011; Moin et al., 2011; Naghibi et al., 2011; Parhizgar and Fayaz, 2005; Zavareh et al., 2007; Saberi et al., 2009; Sadr et al., 2006; Shahsavari et al., 2010; Siabani et al., 2009). A total of 8394 complaints out of 16584 cases were found related to medical malpractice in Iran that the details are given in Table 1. Total malpractice cases appear to have jumped markedly, from 74 cases in 1991 to 822 and 724 cases in 2003 and 2007, respectively (Fig. 2).

Image for - Medical Specialties at High Risk of Litigation in Iran, 1991-2011: A Systematic Review of 24 Studies
Fig. 1: Flowchart of eligible studies

Image for - Medical Specialties at High Risk of Litigation in Iran, 1991-2011: A Systematic Review of 24 Studies
Fig. 2: The trend of aggregated number of medical malpractice complaints in different year based on the available literature

The highest number of medical malpractice reported cases account for 13412/16584 (80.89%), were from Tehran (the capital city), following by Mashhad (eastern north part) and Isfahan (central part) of Iran with the values of 1148/16584 (6.9%) and 965/16584 (5.8%), respectively (Fig. 3). The stratification of malpractice cases by the medical fields, revealed that the majority of cases were about various medical specialties 5922 (69.1%), followed by 1049 (12.49%) and 1003 (11.94%), for dentists and general practitioners, respectively (Table 2). Of 8394 cases of complaints related to general practitioners, medical specialties, dentists and pharmacists, 8065 cases from 17 studies were about ten different specialties exposed to lawsuits. Consequentially, the highest risk of medical liability lawsuits s were observed in obstetrics and gynecology, orthopedy, general surgery and ophthalmology account for of 10.43% (841), 8.98% (724), 5.69% (459) and 4.84% (390), respectively (Fig. 4).

DISCUSSION

This is the first comprehensive review regarding the medical malpractice presented among board certified expert physicians from ten different medical disciplines and other medical field experts such as general practitioners, dentists and pharmacists, from Iran. In the current review, we included three major disciplines of medicine and ten specialties that are at greater risk of litigation in a time period of 20-year, from 1991 to 2010. Our study was not limited to a certain area or a single specialty, nor was it limited to high risk or low risk specialists alone.

Creating solutions to reduce the medical malpractice is a challenging duty, mainly because reliable empirical evidence on the subject remains limited. One of the suggested solutions is defensive medicine, which may reduce access to care and even risk of physical suffering or harm (Cohen and Eisenberg, 2002; Michota and Donnelly, 2009; Tippett, 2010; Weisman et al., 1988). Among high-risk specialist physicians in our study, the highest risk of medical liability lawsuits were observed in obstetrics and gynecology, orthopedy, general surgery and ophthalmology, while Studdert et al. (2005) studied the prevalence and characteristics of defensive medicine among six specialties at high risk of litigation including emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology and radiology (Studdert et al., 2005).

Image for - Medical Specialties at High Risk of Litigation in Iran, 1991-2011: A Systematic Review of 24 Studies
Fig. 3: In each box; Top, The aggregated number of medical malpractice complaints in different cities of Iran based on the available literature; Down, The number of studies from each city in Iran

Image for - Medical Specialties at High Risk of Litigation in Iran, 1991-2011: A Systematic Review of 24 Studies
Fig. 4(a-b): (a) Percentage of board certified physicians (n = 8065) exposed to lawsuits in each of the ten studied specialties, (b) Stratification of certified physicians (n = 8065) exposed to lawsuits in each of the ten studied specialties based on each single study

Moreover, other recent study reported that the most specialty at high risk of litigation was obstetrics/gynecology following by neurosurgery, general surgery, orthopedics and family medicine (Asher et al., 2012).

The care experience survey data and available literature might be useful for managing individual physician malpractice risk, but available evidence is limited. Rodriguez et al. (2008) assessed whether patients’ experiences with individual physicians, as measured by a validated survey, are associated with patient complaints and malpractice lawsuits.

Table 1: The available Literature about medical malpractice
Image for - Medical Specialties at High Risk of Litigation in Iran, 1991-2011: A Systematic Review of 24 Studies

The showed the challenges that face when attempting to use patient survey data to manage individual physician medical malpractice risk. Besides due to infrequent nature of lawsuits, calibrating these validated patient survey measures to malpractice lawsuit risk will require large physician samples from diverse practices (Rodriguez et al., 2008).

Bratland and Hunskår assessed the predictability in the processing of complaints from patients against general practitioners and identified medical issues and situations prone to elicit complaints and possible reactions (Bratland and Hunskar, 2006). They claimed that the assessments of complaints made against physician are coherent and predictable and may be a source of learning from mistakes.

Table 2: No. of complaints in different group of physicians
Image for - Medical Specialties at High Risk of Litigation in Iran, 1991-2011: A Systematic Review of 24 Studies

B-Lynch et al. (1996) evaluated the common causes of medico-legal dispute and assessed the potential benefit of early alternative dispute resolution and recommended recruiting independent, experienced and unbiased consultants in active practice within the appropriate specialty to review such cases at the level of hospital complaints management as an in house review procedure, particularly for small and moderate-sized claims.

Many malpractice reviews offer an opportunity for the study of the properties of different practice patterns, thus in the field of obstetrics/gynecology, the usefulness of such approach has been verified repeatedly. Consequently, in a review that published by Iffy and McArdle, they assessed the role of medico-legal reviews in medical research. They claimed that there is reason to anticipate that objective evaluation of the background of other prenatal birth injuries can provide more useful clinical information than traditional randomized prospective studies (Iffy and McArdle 1996). Jena et al. (2011) analyzed malpractice data from 1991 through 2005 for all physicians who were covered by a large professional liability insurer with a nationwide client base from USA and reported the proportion of physicians facing a claim each year ranged from 19.1% in neurosurgery, 18.9% in thoracic–cardiovascular surgery and 15.3% in general surgery to 5.2% in family medicine, 3.1% in pediatrics and 2.6% in psychiatry.

Recently, Brasme et al. (2012) systematically reviewed the distribution, determinants and consequences of time to diagnosis of pediatric malignancies and compared these findings with those of court-appointed expert witnesses in malpractice claims, which showed the relations between delay in diagnosis and outcome are complex and probably depend more on tumor biology than on parental or medical factors (Brasme et al., 2012).

Pegalis and Bal (2012) investigated whether physician groups have examined the data about closed claims related to medical negligence identify error patterns and to then institute specific patient treatment protocols. They showed that safety guidelines derived from analyzing past medical malpractice litigation can achieve the same goals while also promoting patient safety.

CONCLUSION

Studies only focused on some elements of the problem and rarely on process-related or systematic causes of malpractice and medical errors. Studies that focused on medical criminal offences did not discuss potential legal limitations. Despite considerable financial impacts of healthcare fraud and abuse, this aspect of the problem had received even less attention.

REFERENCES

1:  Akhlaghei, M., H.T. Zavareh and F. Samadi, 2004. Complaints of malpractice in the field of obstetrics and gynecology referred to legal medicine organization medical commission during 2001 and 2002: Causes and methods of prevention. Scient. J. Forensic Med., 10: 70-74.

2:  Asher, E., S. Greenberg-Dotan, J. Halevy, S. Glick and H. Reuveni, 2012. Defensive medicine in Israel: A nationwide survey. PLoS ONE, Vol. 7.
CrossRef  |  Direct Link  |  

3:  Badakhsh, M.H., 2003. Malpractice claims of gynecologists received by medical council, Tehran, 1992-96. Feyz, 6: 76-81.
Direct Link  |  

4:  Bazrafkan, L., N. Shokrpour and S.Z. Tabeie, 2008. A survey of patients complaints against physicians in a five year period in Fars province: Implication for medical education. J. Med. Educ., 12: 23-28.
Direct Link  |  

5:  Brasme, J.F., M. Morfouace, J. Grill, A. Martinot and R. Amalberti et al., 2012. Delays in diagnosis of paediatric cancers: A systematic review and comparison with expert testimony in lawsuits. Lancet Oncol., 13: e445-e459.
CrossRef  |  Direct Link  |  

6:  Bratland, S.Z. and S. Hunskar, 2006. Medico-legal assessments of complaints against general practitioners. Tidsskr Nor Laegeforen, 126: 166-169.
PubMed  |  Direct Link  |  

7:  B-Lynch, C., A. Coker and J.A. Dua, 1996. A clinical analysis of 500 medico-legal claims evaluating the causes and assessing the potential benefit of alternative dispute resolution. BJOG: Int. J. Obstetrics Gynaecol., 103: 1236-1242.
CrossRef  |  PubMed  |  

8:  Cohen, M.H. and D.M. Eisenberg, 2002. Potential physician malpractice liability associated with complementary and integrative medical therapies. Ann. Internal Med., 136: 596-603.
Direct Link  |  

9:  Daneshparvar, H.R. and A. Javadian, 2008. Malpractice complaints against ophthalmologists referred to the state of legal medicine organization in Iran. Iran. J. Ophthalmol., 20: 4-8.
Direct Link  |  

10:  Dubay, L., R. Kaestner and T. Waidmann, 1999. The impact of malpractice fears on cesarean section rates. J. Health Econ., 18: 491-522.
CrossRef  |  PubMed  |  

11:  Haghghi, Z., H. Esmaeeli and H. Attaran, 2005. Analysis of 100 malpractice claims against surgical team judged at Mashad medical council. Iran. J. Surg., 13: 18-26.

12:  Haghghi, Z., H. Esmaeeli and H. Attaran, 2006. Factors in malpractice claims and condemnation of the surgical team to investigate the claims of the Medical Council of Mashhad. Scient. J. Forensic Med., 11: 137-141.

13:  Haghshenas, M., K. Vahidshahi, A. Ahmadzadeh Amiri, M. Shyck Rezaee and N. Rahmani et al., 2012. Study the frequency of malpractice lawsuits referred to forensic medicine department and medical council, Sari, 2006-2011. J. Mazandaran Univ. Med. Sci., 22: 224-251.

14:  Hedayati, M., M. Nejadnik and M. Setareh, 2012. The factors affecting the final verdict in medical errors complaints. J. Isfahan Med. School, 29: 1497-1509.
Direct Link  |  

15:  Hejazi, S., M. Zainali and H.R. Faroukh Eslamlou, 2009. Medical malpractice cases in the field of pediatrics referred to the Medical Council of Urmia in 1996 to 2006. J. Urmia Univ. Med. Sci., 20: 123-130.

16:  Iffy, L. and J.J. McArdle, 1996. The role of medico-legal reviews in medical research. Med. Law, 15: 399-406.
PubMed  |  Direct Link  |  

17:  Jafarian, A., A. Parsapour, A. Haj-Tarkhani, F. Asghari, S.H.E. Razavi and A. Yalda, 2009. A survey of the complaints entering the medical council organization of Tehran in three time periods: The years ending on 20 March 1992, 20 March 1997 and 20 March 2002. J. Med. Ethics History Med., Vol. 2.
Direct Link  |  

18:  Jena, A.B., S. Seabury, D. Lakdawalla and A. Chandra, 2011. Malpractice risk according to physician specialty. N. Engl. J. Med., 365: 629-636.
CrossRef  |  Direct Link  |  

19:  Kiani, M. and A. Sheikhazadi, 2009. A five-year survey for dental malpractice claims in Tehran, Iran. J. Forensic Legal Med., 16: 76-82.
CrossRef  |  

20:  Localio, A.R., A.G. Lawthers, J.M. Bengtson, L.E. Hebert, S.L. Weaver, T.A. Brennan and J.R. Landis, 1993. Relationship between malpractice claims and cesarean delivery. J. Am. Med. Assoc., 269: 366-373.
CrossRef  |  

21:  Mahfouzi, A. and R. Zamani, 2007. Causes of complaint against anesthesiologists reffered to Medical Council of Tehran from 1993 to 2003. Scient. J. Forensic Med., 13: 98-101.

22:  Manouchehri Moghadam, J., H. Ibrahimipour, A. Sari Akbari, M. Farahbakhsh and Z. Khoshgoftar, 2010. Study of patient complaints reported over 30 months at a large heart centre in Tehran. Qual. Saf. Health Care, Vol. 19.
CrossRef  |  Direct Link  |  

23:  Michota, F.A. and M.J. Donnelly, 2009. Medicolegal issues in perioperative medicine: Lessons from real cases. Cleveland Clin. J. Med., 76: S119-S125.
CrossRef  |  Direct Link  |  

24:  Mirza Aghaei, F., Z. Moein Far, S. Eftekhari and A. Rashidian, 2011. Complaints recorded at three hospitals affiliated to Tehran university and its influencing factors from 2007 to 2009. Hospital, 10: 19-28.

25:  Moher, D., A. Liberati, J. Tetzlaff and D.G. Altman, 2009. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Br. Med. J., Vol. 339.
CrossRef  |  Direct Link  |  

26:  Moin, A., M.O.A. Makhmalba and A. Davati, 2011. Study of medical malpractice complaints in the field of dermatology and cosmetic, in the coroner's office of forensic medicine, Province of Tehran, during 2002 to 2010. Dermatol. Cosmet., 2: 17-29.
Direct Link  |  

27:  Naghibi, K., K. Montazari and S.S. Khalifeh Soltani, 2011. Review of medical complaints files in the medical council of Isfahan in 2007-2009. J. Isfahan Med. School, 29: 1542-1553.

28:  Parhizgar, S. and A.F. Fayaz, 2005. Complaints against opthtalmologists referred to Legal Medicine Organization in 2000 to 2003. Scient. J. Forensic Med., 11: 68-70.

29:  Pegalis, S.E. and B.S. Bal, 2012. Closed medical negligence claims can drive patient safety and reduce litigation. Clin. Orthopaedics Related Res., 470: 1398-1404.
CrossRef  |  

30:  Zavareh, S.R.T., R. Haj Manouchehri and M.N. Zavareh, 2007. Prevalence of medical malpractice complaints referred to the Committee on Legal Medicine Center in Tehran from 2003 to 2005. Scient. J. Forensic Med., 13: 152-157.

31:  Rodriguez, H.P., A.M.C. Rodday, R.E. Marshall, K.L. Nelson, W.H. Rogers and D.G. Safran, 2008. Relation of patients experiences with individual physicians to malpractice risk. Int. J. Qual. Health Care, 20: 5-12.
CrossRef  |  

32:  Saberi, S.M., A. Sheikhazadi, H. Joghataei, V. Mohammadi and M. Fallahian, 2009. A survey of sued physicians self-reported reactions to malpractice litigation in Iran. J. Forensic Legal Med., 16: 301-306.
CrossRef  |  

33:  Sadr, S., A.D. Abedi, M.H. Ghdyani and M. Abedi, 2006. A survey on permits of therapeutic abortion in iran by legal medicine organization within one year from Jan. to Dec. 2003. Scient. J. Forensic Med., 11: 198-200.
Direct Link  |  

34:  Shahsavari, F., D. Sadri, M. Mohammad and A. Siddiqui, 2010. Frequency of complaints against dentists in Tehran between 2001 and 2008. Med. Rights, 4: 121-132.

35:  Siabani, S., A.A. Alipour, H. Siabani, M. Rezaee and S. Daniali, 2009. Complaints against doctors in medical council of Kermanshah (2001-2005). J. Kermanshah Univ. Med. Sci., 13: 74-83.

36:  Sloan, F.A. and J.H. Shadle, 2009. Is there empirical evidence for defensive medicine? A reassessment. J. Health Econ., 28: 481-491.
CrossRef  |  

37:  Studdert, D.M., M.M. Mello, W.M. Sage, C.M. DesRoches, J. Peugh, K. Zapert and T.A. Brennan, 2005. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. J. Am. Med. Assoc., 293: 2609-2617.
CrossRef  |  

38:  Tippett, T.M., 2010. Health care reform 2009-2010: A neurosurgeon's perspective. J. Neurosurg., 113: 1127-1132.
CrossRef  |  PubMed  |  

39:  Vimercati, A., P. Greco, A. Kardashi, C. Rossi, V. Loizzi, M. Scioscia and G. Loverro, 2000. Choice of cesarean section and perception of legal pressure. J. Perinatal Med., 28: 111-117.
CrossRef  |  Direct Link  |  

40:  Vimercati, A., P. Greco, V. Loizzi, G. Loverro and L. Selvaggi, 2000. Defensive medicine in the choice of cesarean section. Acta Biomed. Ateneo. Parmense., 71: 717-721.
PubMed  |  Direct Link  |  

41:  Weisman, C.S., M.A. Teitelbaum and L.L. Morlock, 1988. Malpractice claims experience associated with fertility-control services among young obstetrician-gynecologists. Med. Care, 26: 298-306.
Direct Link  |  

42:  Zuckerman, S., 1984. Medical malpractice: Claims, legal costs and the practice of defensive medicine. Health Affairs, 3: 128-133.
CrossRef  |  Direct Link  |  

43:  Ghashlaghei, F., K. Montazeri and G. Montazeri, 2009. Five years investigation of complaints made against anesthesiologist at the center of legal medicine and medical council. J. Soc. Anesthesiol. Critical Care, 30: 49-56, (Article in Persian).

©  2021 Science Alert. All Rights Reserved