Medico-Legal Cases Involving Cardiologists and Cardiac Test Underuse or Overuse

doi:10.1016/j.cjco.2020.11.018

. 2020 Dec 1;3(4):434-441.

doi: 10.1016/j.cjco.2020.11.018. eCollection 2021 Apr.

Medico-Legal Cases Involving Cardiologists and Cardiac Test Underuse or Overuse

Lisa A Calder^{1

2}, Heather K Neilson¹, Eileen M Whyte¹, Jun Ji¹, R Sacha Bhatia³

Affiliations

¹ Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ontario, Canada.
² Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
³ Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

PMID: 34027346
PMCID: PMC8129482
DOI: 10.1016/j.cjco.2020.11.018

Medico-Legal Cases Involving Cardiologists and Cardiac Test Underuse or Overuse

Lisa A Calder et al. CJC Open. 2020.

. 2020 Dec 1;3(4):434-441.

doi: 10.1016/j.cjco.2020.11.018. eCollection 2021 Apr.

Authors

Lisa A Calder^{1

2}, Heather K Neilson¹, Eileen M Whyte¹, Jun Ji¹, R Sacha Bhatia³

Affiliations

¹ Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ontario, Canada.
² Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
³ Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

PMID: 34027346
PMCID: PMC8129482
DOI: 10.1016/j.cjco.2020.11.018

Abstract
in English, French

Background: Evidence-based campaigns are available to support appropriate diagnostic testing in cardiology, but medico-legal concerns can impede implementation.

Methods: We conducted a retrospective descriptive analysis of medico-legal cases (civil legal, regulatory authority, hospital matters) involving cardiologists in Canada. For eligibility, cases must have closed at the Canadian Medical Protective Association between January 1, 2009 and December 31, 2018. We defined test underuse and overuse using criticisms in the medico-legal record from peer experts, regulatory authorities, or hospitals. We used a contributing factors framework and descriptive statistics for analysis.

Results: From 2009 to 2018, the Canadian Medical Protective Association closed 60,598 cases with 368 (0.6%) involving a cardiologist. Within those cases, there was no criticism of cardiac diagnostic test overuse and 15 cases (4.1%) with criticism of underuse (tests not ordered, not expedited, delayed). In 12 of 15 cases of underuse (80.0%), the patient experienced severe harm or death. Of 8 civil legal cases, 6 were decided in favour of the plaintiff (75.0%) and 2 were dismissed by consent before proceeding to trial (25.0%). Decisions on regulatory authority matters did not favour the cardiologist (7 of 7 cases). In all cases of underuse, there was need for focused testing to investigate new or worsening symptoms. The most common contributing factors included clinical decision-making, situational awareness, and communication with teams and patients.

Conclusions: Medico-legal cases involving cardiologists and the overuse or underuse of cardiac diagnostic tests were extremely rare in Canada, despite the potential for harm. The criticisms of cardiac diagnostic test underuse related to issues with diagnosing symptomatic patients.

Contexte: Même s’il existe des campagnes fondées sur des données probantes visant à promouvoir le recours aux tests diagnostiques appropriés en cardiologie, il arrive que des préoccupations d’ordre médico-légal nuisent à la réalisation de ces tests.

Méthodologie: Nous avons réalisé une analyse descriptive rétrospective des affaires médico-légales (poursuites au civil et plaintes déposées auprès d’organismes de réglementation et d’hôpitaux) touchant des cardiologues au Canada. Ont été retenus pour l’analyse les dossiers clos à l’Association canadienne de protection médicale entre le 1^er janvier 2009 et le 31 décembre 2018. La sous-utilisation et la surutilisation de tests ont été définies à partir des critiques formulées dans les dossiers médico-légaux par des pairs spécialistes, des organismes de réglementation ou des hôpitaux. L’analyse reposait sur un cadre décrivant les facteurs contributifs et sur un modèle de statistique descriptive.

Résultats: De 2009 à 2018, l’Association canadienne de protection médicale a clos 60 598 dossiers; de ce nombre, 368 (0,6 %) dossiers visaient un cardiologue. Parmi ces dossiers, aucun ne concernait la surutilisation de tests visant à diagnostiquer un trouble cardiaque, et 15 (4,1 %) concernaient la sous-utilisation de tels tests (test non demandé, non accéléré ou reporté). Dans 12 (80 %) des 15 cas de sous-utilisation, le patient a subi un tort grave ou est décédé. Sur les huit poursuites au civil, six (75 %) ont été jugées en faveur du demandeur, et deux (25 %) ont été rejetées d’un commun accord entre les parties avant le début du procès. Toutes les décisions relatives à des questions relevant des organismes de réglementation, au nombre de sept, ont été en défaveur du cardiologue. Dans tous les cas de sous-utilisation, le patient avait besoin de subir des tests ciblés afin d’évaluer l’apparition ou l’aggravation de symptômes. Les facteurs contributifs les plus fréquents comprenaient la prise de décisions cliniques, la connaissance de la situation et la communication avec les équipes et les patients.

Conclusions: Les affaires médico-légales touchant des cardiologues et la surutilisation ou la sous-utilisation de tests de diagnostic cardiaque étaient extrêmement rares au Canada, malgré les préjudices qui peuvent en découler. Les critiques relatives à la sous-utilisation des tests de diagnostic cardiaque concernaient toutes des problèmes liés à l’investigation diagnostique chez des patients présentant des symptômes.

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Figures

**Figure 1**
(A) Common criticisms associated with cardiac diagnostic test underuse by cardiologists, according to peer experts or colleges in 15 medico-legal cases; Canadian Medical Protective Association (CMPA) closed cases, 2009-2018. Dots represent the presence of criticism in the medico-legal case. Infrequent criticisms (not shown) concerned a patient transfer and a procedure violation, respectively (physician factors). All cases involved a patient safety incident defined in Supplemental Table S2. (B) Specific factors in (A) that might have contributed to cardiac diagnostic test underuse by cardiologists, according to peer experts or colleges in 15 medico-legal cases; CMPA closed cases, 2009-2018. CT, computed tomography imaging.

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[1] Chassin M.R., Galvin R.W. The urgent need to improve health care quality: Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998;280:1000–1006. - PubMed

[2] Chassin M.R., Galvin R.W. The urgent need to improve health care quality: Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998;280:1000–1006. - PubMed

[3] Born K.B., Levinson W. Choosing Wisely campaigns globally: a shared approach to tackling the problem of overuse in healthcare. J Gen Fam Med. 2019;20:9–12. - PMC - PubMed

[4] Born K.B., Levinson W. Choosing Wisely campaigns globally: a shared approach to tackling the problem of overuse in healthcare. J Gen Fam Med. 2019;20:9–12. - PMC - PubMed

[5] Cohen D., Manuel D.G., Sanmartin C. Do rural patients in Canada underutilize preventive care for myocardial infarction? J Rural Health. 2016;32:345–352. - PubMed

[6] Cohen D., Manuel D.G., Sanmartin C. Do rural patients in Canada underutilize preventive care for myocardial infarction? J Rural Health. 2016;32:345–352. - PubMed

[7] Edwards J.D., Kapral M.K., Fang J. Underutilization of ambulatory ECG monitoring after stroke and transient ischemic attack: missed opportunities for atrial fibrillation detection. Stroke. 2016;47:1982–1989. - PubMed

[8] Edwards J.D., Kapral M.K., Fang J. Underutilization of ambulatory ECG monitoring after stroke and transient ischemic attack: missed opportunities for atrial fibrillation detection. Stroke. 2016;47:1982–1989. - PubMed

[9] O’Neill D.E., Southern D.A., Norris C.M. Acute coronary syndrome patients admitted to a cardiology vs non-cardiology service: variations in treatment and outcome. BMC Health Serv Res. 2017;17:354. - PMC - PubMed

[10] O’Neill D.E., Southern D.A., Norris C.M. Acute coronary syndrome patients admitted to a cardiology vs non-cardiology service: variations in treatment and outcome. BMC Health Serv Res. 2017;17:354. - PMC - PubMed

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Medico-Legal Cases Involving Cardiologists and Cardiac Test Underuse or Overuse

Affiliations

Medico-Legal Cases Involving Cardiologists and Cardiac Test Underuse or Overuse

Authors

Affiliations

Abstract
in English, French

Figures

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Cited by

References

LinkOut - more resources

Full Text Sources

Abstract in English, French

Figures

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Cited by

References

LinkOut - more resources

Full Text Sources

Abstract
in English, French