Malpractice and syncope, heart failure and fracking

Research summaries from ACP Hospitalist Weekly.

Local rate of malpractice claims linked to admissions of low-risk patients with syncope

A recent study found that when states have higher malpractice claims rates, there's a substantial increase in the hospital admission rate of lower-risk patients with syncope who are generally discharged from the ED.

Researchers used de-identified data from the Clinformatics Data Mart database to assess whether hospital admission rates after ED visits among patients with lower-risk syncope are associated with state-level variations in malpractice claims rates. They defined lower-risk syncope visits as those with a primary diagnosis of syncope and collapse based on ICD-9 and ICD-10 codes that did not include another major diagnostic code for a condition requiring hospital admission (e.g., heart disease, stroke, cancer, medical shock) or an inpatient hospital stay of more than three days. These data were linked to publicly available data from the National Practitioner Data Bank pertaining to physician malpractice claims from 2008 through 2017 at the state-year level. The main outcome was the association between the rate of hospital admission after ED visits among patients with lower-risk syncope and the rate of physician malpractice claims at the state-year level. Costs were adjusted for inflation and expressed in 2017 U.S. dollars. Results were published Dec. 15, 2020, by JAMA Network Open.

Of more than 40 million ED visits from 2008 through 2017, 519,724 visits (1.3%) were associated with syncope. Of those, 234,750 visits (45.2%) met the criteria for lower-risk syncope. In the lower-risk cohort, the mean age of patients was 71.8 years, about 60% were women, and 18.8% were admitted to the hospital, representing an extra cost of $6,542 per admission. The mean rate of physician malpractice claims varied from 0.27 to 8.63 claims per 100,000 people across states and across years within states. The state-level fixed-effects model indicated that for every 1 in 100,000-person increase in the physician malpractice claims rate, there was an absolute increase of 6.70% (95% CI, 4.65% to 8.75%) or a relative increase of 35.6% in the hospital admission rate, which the authors calculated would add $102 million in costs from the lower-risk cohort.

Limitations include that the study population was patients with commercial or Medicare Advantage insurance, not those who are uninsured or have Medicaid coverage, the study authors said. In addition, some factors about treating clinicians (e.g., years of training, board certification) that may have been associated with physician decision making were unavailable, they said.

The findings “indicate an association between malpractice claims rates or liability risks and unnecessary hospital admissions because of the practice of defensive medicine. . . . Physicians' risk-averse behaviors may be associated with many factors, but such behaviors come with substantial costs, as indicated by the findings of this study,” the authors wrote.

Unconventional natural gas development associated with heart failure exacerbations

Patients with heart failure who were exposed to more unconventional natural gas development (UNGD) activity were more likely to be hospitalized for the condition than those with the least exposure, a recent study found.

Researchers evaluated associations between UNGD activity metrics by phase of development (e.g., preparation of well pads, drilling, stimulation [i.e., hydraulic fracturing, also known as “fracking”], and production) and hospitalization among patients with heart failure. Using electronic health records, they evaluated the odds of hospitalization among heart failure patients seen at an integrated health system in Pennsylvania from Jan. 1, 2008, to July 31, 2015, coinciding with active UNGD in the region. They stratified patients by both ejection fraction (reduced, preserved, and not classifiable) and heart failure severity. Results were published online on Dec. 7, 2020, by the Journal of the American College of Cardiology.

Image by Getty Images
Image by Getty Images

Overall, 9,054 patients (mean age, 71.1 years; 47.7% women) with heart failure were included in the study. Of these, 5,839 were hospitalized at the health system for heart failure during the study period. In addition, 3,215 patients with heart failure who did not have a hospitalization for heart failure at the health system served as controls. When the highest to lowest quartile of UNGD activity were compared, adjusted odds ratios for hospitalization were 1.70 (95% CI, 1.35 to 2.13), 0.97 (95% CI, 0.75 to 1.27), 1.80 (95% CI, 1.35 to 2.40), and 1.62 (95% CI, 1.07 to 2.45) for pad preparation, drilling, stimulation, and production metrics, respectively. While these associations did not differ by ejection fraction status, associations of most UNGD metrics with hospitalization were stronger among patients with more severe heart failure at baseline.

Among other limitations, the study used ICD-9 codes to identify heart failure cases, which is less specific than other methods of case ascertainment, the authors noted. They added that they did not have information on dietary intake and physical activity, and information on alcohol use was too often incomplete to use.

“These associations are plausible given environmental (e.g., air pollution, water contamination, noise, traffic) and community impacts of UNGD,” they concluded. “Understanding how people living with heart failure are susceptible to environmental exposures is especially important given the growing prevalence of heart failure and the possibility that environmental factors play a role in clinical heart failure outcomes.”

The study may be the first epidemiological investigation regarding the impacts of UNGD on heart failure outcomes, but more research is needed, an accompanying editorial noted. “Moving forward, we need to better understand the mediating effects by air and water pollutants, as well as particle radioactivity, and the existence of racial disparities in the fracking impacts,” the editorialists wrote.