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Context: A small number of physicians experience a disproportionate share of malpractice claims and expenses. If malpractice risk is related in large measure to factors such as patient dissatisfaction with interpersonal behaviors, care and treatment, and access, it might be possible to monitor physicians' risk of being sued., Objective: To examine the association between physicians' patient complaint records and their risk management experiences., Design, Setting, and Participants: Retrospective longitudinal cohort study of 645 general and specialist physicians in a large US medical group between January 1992 and March 1998, accounting for 2546 physician-years of care., Main Outcome Measures: Computerized records of all unsolicited patient complaints were recorded by the medical center's patient affairs office, coded to characterize the nature of the problem and alleged offender, and compared with each physician's risk management records for the same period., Results: Both patient complaints and risk management events were higher for surgeons than nonsurgeons. Specifically, 137 (32%) of the 426 nonsurgeons had at least 1 risk management file compared with nearly two thirds (137 [63%] of 219) of all surgeons (chi2(1)= 54.7, P<.001). Both complaint and risk management data were positively correlated with physicians' volume of clinical activity. Logistic regression revealed that risk management file openings, file openings with expenditures, and lawsuits were significantly related to total numbers of patient complaints, even when data were adjusted for clinical activity. Predictive concordance of specialty group, complaint count, clinical activity, and sex for risk management file openings was 84%; file openings with expenditures, 83%; lawsuits, 81%; and multiple lawsuits, 87%., Conclusions: Unsolicited patient complaints captured and recorded by a medical group are positively associated with physicians' risk management experiences.

Context: The abrupt initiation of capitated Medicaid care in Tennessee (TennCare) in 1994 prompted many questions about changes in quality of care., Objective: To evaluate the effect on perinatal outcomes of the transition to TennCare in 1994., Design: Before and after retrospective cohort analysis., Setting and Population: Births to women residing in Tennessee between 1990 and 1995 with complete demographic information on birth certificates, with a focus on women enrolled in Medicaid giving birth in 1993 (before TennCare) and 1995 (after TennCare)., Outcome Measures: Late prenatal care (after the fourth month of pregnancy) or inadequate prenatal visits, low and very low birth weight, and death in the first 60 days of life., Results: Tennessee residents had 72014 study births in 1993 and 72278 in 1995, of which 37543 (52.1%) and 35707 (49.4%) were to women enrolled in Medicaid at delivery. For these Medicaid births, there were no changes after TennCare in the proportions with late prenatal care (16.2% in 1993 vs 15.8% in 1995), inadequate prenatal visits (5.9% vs 5.6%), low birth weight (9.4% vs 9.0%), very low birth weight (1.6% vs 1.5%), and death in the first 60 days (0.6% both years). These findings were unchanged in multivariate analysis, in analysis of high-risk subgroups, and in analysis of women with demographics characteristic of Medicaid women., Conclusion: Study perinatal outcomes did not change among Medicaid births following the transition to TennCare.

Objective: To examine the relationship between prior physician malpractice experience and patients' satisfaction with care., Design: Women were interviewed using a questionnaire that contained structured and open-ended questions., Participants: Mothers of all stillborn infants, infant deaths, and a random sampling of viable infants drawn from 1987 Florida Vital Statistics were sorted into four groups based on the malpractice claims experience of their obstetricians between 1983 and 1986. Interviews were completed with 963 of 1536 women, most by telephone, 53 by in-person interview., Main Outcome Measures: Mothers' responses to closed-ended and open-ended questions about their perceptions of the care they received during their pregnancy, labor, and delivery., Results: Even though none of the women actually filed a claim, a consistent pattern of differences emerged when comparing women's perceptions of care received. Patients seeing physicians with the most frequent numbers of claims but without high payments were significantly more likely to complain that they felt rushed, never received explanations for tests, and were ignored. In response to the open-ended question, "What part of your care were you least satisfied with?" women seeing physicians in the High Frequency malpractice risk group offered twice as many complaints as those seeing physicians who had never been sued. Problems with physician-patient communication were the most commonly offered complaints., Conclusion: Physicians who have been sued frequently are more often the objects of complaints about the interpersonal care they provide even by their patients who do not sue.

Objective: To determine the relationship between prior malpractice claims experience and the quality of clinical obstetric care., Design: Historical cohort study of obstetricians, classified by their prior malpractice claims experience, with blinded review of medical records from their practices 5 to 10 years later., Setting: Florida obstetricians who lost, settled, or defended malpractice claims between 1977 and 1983 and who were still practicing obstetrics in 1987., Main Outcome Measures: Objective and subjective assessment of quality of clinical care of patients attended by obstetricians with different histories of malpractice claims., Results: No differences were found in any of the objective or subjective measures of the quality of clinical care provided to patients of obstetricians who were classified into one of four groups according to their prior claims history., Conclusions: No relationship was found between prior malpractice claims experience and the technical quality of practice by Florida obstetricians. Strategies that attempt to identify physicians at risk for future clinical errors by using data on prior malpractice claims (such as the National Practitioner Data Bank) may be misjudging the likelihood that substandard clinical care will be provided by physicians with prior claims.

Objective: To identify self-reported reasons that prompt families to file malpractice claims following perinatal injuries., Design: Families were interviewed by telephone using a questionnaire that contained structured and open-ended questions., Participants: Mothers of infants who had experienced permanent injuries or deaths and had closed malpractice claims in Florida between 1986 and August 1989 were interviewed. Questionnaires were completed by 127 (35%) of a total of 368 such families., Outcome Measures: Reasons prompting families to file and families' descriptions of medical events, advice from acquaintances, and the quality of physician-family communication., Results: Families volunteered numerous reasons for filing: advised by knowledgeable acquaintances (33% of respondents), recognized cover-up (24%), needed money (24%), recognized that their child would have no future (23%), needed information (20%), and decided to seek revenge or protect others from harm (19%). Over one third of all families indicated that they were told by medical personnel prior to filing that the care provided had caused their children's injuries. Families expressed dissatisfaction with physician-patient communication. Families believed that physicians would not listen (13% of sample), would not talk openly (32%), attempted to mislead them (48%), or did not warn about long-term neurodevelopmental problems (70%)., Conclusion: Families give many reasons for filing a claim. Obtaining money may not be the only goal for some families who file suit.