Analysis of malpractice claims in breast care for poor cosmetic outcome

Claims for poor cosmetic outcome account for a large proportion of breast care malpractice litigation in the UK. Detailed analysis of such claims has not been conducted. We sought to analyse National Health Service Litigation Authority (NHSLA) data pertaining to breast care over the period September 2005-April 2008, focussing on claims for poor cosmetic outcome. Data from a medical indemnity organisation detailing similar claims in the private sector were also analysed. Comparison of the NHSLA data with previously obtained NHSLA data (May 1995-September 2005) demonstrated an upward trend in claims for poor cosmetic outcome. The majority of claimants for poor cosmesis had benign disease and the vast majority of claimants with breast malignancy had undergone breast reconstruction. The majority of claims for poor cosmetic outcome were against plastic surgeons. This was more marked in the private sector data than in the NHSLA data, reflecting their workload.     

Malpractice litigation in patients in relation to delivery of breast care in the NHS

Malpractice litigation involving patients with carcinoma of the breast has been evaluated in United States of America (USA). The extent of litigation in breast cancer has not been published in UK and malpractice claims in relation to overall breast care have not been published before. We sought to study and evaluate all the litigation claims in relation to breast care with the National Health Service Litigation Authority (NHSLA) from May 1995 to September 2005. We also studied changes in litigation claims and outcomes in incidents reported before and after January 1, 2000.     

Fourteen years of litigation claims in cardiothoracic surgery in the United Kingdom National Health Service

Approximately 36 400 cardiac and 23 100 thoracic operations are carried out in the United Kingdom between 2006 and 2015. National Health Service (NHS) resolution, as known as the NHS litigation authority, is one of the essential bodies of the Department of Health. Its purpose is to provide NHS expertise to resolve concerns fair and square share learning for improvement. We aim to evaluate and increase awareness of medicolegal cases in cardiothoracic surgery. Total numbers and details of claims coded by NHS resolution in cardiothoracic surgery from 2004 to 2017 were requested under the Freedom of Information Act 2000. The data provided in successful claims is further breakdown into damages paid to the claimant, defence cost, claimant cost paid and the sum of the three. In contrast, unsuccessful claims only include the defence cost. Moreover, data provided also includes further analysis of primary causes and primary injuries for Claims Closed/Settled with damages paid. There were 753 claims recorded from 2004 to 2017, of which 415 (55.11%) were successful. The number of claims has been steadily increasing since 2004, with two significant raises from 2009/10 to 2010/11 (37‐55, 48.64% raise) and 2012/13 to 2013/14 (49‐69, 40.82% raise). The mean successful claim ratio was 69.58% (range, 47.56%‐ 83.33%) There is also a steady increase in the successful ratio from 2004 to 2017. In summary, this is the first study published in relation to litigation claims on cardiothoracic surgery in the United Kingdom. The results have provided insight on claims made against cardiothoracic surgery.     

Medical malpractice and cancer of the skin

BACKGROUND: A litigation crisis exists in this country, and it may be better understood through analysis of lawsuits. Verdict summary analysis has been used for this purpose. METHODS: Ninety-nine jury verdict reviews from 1986 to 2001 were obtained from a computerized database. Reviews compiled data on defendants, plaintiffs, allegations of wrongdoing, cancer cell types, sites, outcomes, and case summaries. Data was entered into a spreadsheet for analysis. RESULTS: Failure to diagnose was alleged in 54%; of these, 48% alleged biopsies were inappropriately omitted. Allegations were highest for failure to diagnose in dermatologists and general practice physicians, for misdiagnosis in pathologists, and for complications in surgeons. Young patients and those with poor outcomes received more and larger awards. Trauma appears to have support for a role in causation of skin cancer in some courts. CONCLUSIONS: The study of skin cancer suits may help develop risk management and prevention strategies.     

Urological litigation in the UK National Health Service (NHS): an analysis of 14 years of successful claims

What’s known on the subject? and What does the study add? There are no previous studies for urology in the UK but several studies from physician insurance groups in North America. There is anecdotal evidence of common reasons for litigation, e.g. missed testicular torsion. This is the first analysis of the claims data compiled by the NHS litigation authority for the speciality of urology; it provides realistic insight into the areas and procedures of the speciality most commonly affected by litigation. The article identifies areas of high risk, both clinical and medico‐legal.

OBJECTIVES

? To present a summary of the collected data on urological litigation within the UK National Health Service (NHS). ? Knowledge of the main areas of litigation is essential for maintaining good clinical practice as well as risk management procedures in any specialty.

MATERIALS AND METHODS

? Details of all claims closed with indemnity payment pertaining to the specialty of urology as practiced by urologists, general surgeons and paediatric surgeons was obtained from the NHS Litigation Authority (NHSLA) for the years since its creation in 1995 to 2009. ? The data was then classified and analysed.

RESULTS

? In all, 493 cases were closed with indemnity payment with a total of £20 508 686.18 paid. The average payment per claim was £41 599.77. ? Most of the claims were related to non‐operative events (232), followed by postoperative events (168) and intraoperative events (92). ? The most common reason for non‐operative‐related claims was failure to diagnose/treat cancer (69), perforation/organ injury (38) was the highest intraoperative‐related claim and a forgotten ureteric stent (23) was the most frequent postoperative‐related claim. ? The five most commonly implicated procedures were ureteroscopy/ureteric stenting (45), transurethral resection of the prostate (30), nephrectomy (26), vasectomy (19) and urethral catheterisation (15).

CONCLUSIONS

? The present study once again emphasizes the importance of thorough clinical assessment, record keeping and follow‐up as well as informed consent and good communication with patients. ? Recognising the areas of highest risk and improving practice should limit future claims.     

Patterns of seeking medical care among Egyptian breast cancer patients: relationship to late-stage presentation

Breast cancer is the most common cancer among Egyptian women, accounting for 37.6% of female tumors, and is often diagnosed at later stages. The objective of this study was to investigate breast cancer patient navigation through the health care system in the Nile Delta. Interviews were conducted with 163 newly diagnosed breast cancer patients at the Tanta Cancer Center (TCC), the major cancer center of the region. Patients described their medical care pathway from the initial symptom experienced until their arrival at TCC. Patients whose initial contact was with a general surgeon (OR: 7.6, 95% CI: 2.1, 27.6), primary care provider (OR: 12.2, 95% CI: 2.9, 51.0), or gynecologist (OR: 8.6, 95% CI: 1.4, 53.4) were significantly more likely to experience a delay in reaching the TCC as compared to those visiting a surgical oncologist. Overcoming health care system and patient navigation barriers in developing countries may reduce the time for breast cancer patients to reach a cancer center for early management.     

Trends in breast cancer presentation and care according to age in a single institution

BACKGROUND: This study sought to determine the differences in presentation and treatment of young women (< or =40 years of age) with breast cancer. METHODS: A prospective database was analyzed for differences in presentation and care in breast cancer patients < or =40 and >40 years of age. RESULTS: The study group consisted of 1685 women. Younger women were more likely to present with a palpable mass, have estrogen receptor/progesterone receptor (ER/PR)-negative tumors, and have more advanced disease at presentation. Although there was no difference in breast conservation rates, younger women were more likely to have postmastectomy reconstruction. Younger women were more likely to receive chemotherapy, even with node-negative tumors less than 1 cm in diameter (37% vs. 13%, P = 0.01). CONCLUSIONS: The presentation of younger women with breast cancer differs from that of older women. Although the surgical management is similar, adjuvant therapy differs, with younger women more likely to be treated with chemotherapy.     

Defense of breast cancer malpractice claims

The goal of this study was to determine whether factors associated with the successful defense and cost of malpractice cases involving the failure to diagnose breast cancer could be identified in medical and legal records. Secondary goals were to develop a multidisciplinary clinical algorithm utilizing National Comprehensive Cancer Network (NCCN) practice guidelines with practitioner risk management strategies. Physician deviations from these guidelines were tracked to identify high-risk areas in the diagnosis of breast cancer. A multidisciplinary clinical algorithm was introduced and practitioner risk management issues were addressed. In this study specific medical, legal, and cost factors were retrospectively abstracted and analyzed to identify associations between medical and legal factors and medicolegal outcome. ProMutual handled 156 malpractice cases involving breast cancer between January 22, 1986, and November 20, 1997. Of the total, 124 cases involving 212 defendants were closed. The closed cases were analyzed, using multivariable stepwise logistic and linear regression, to identify associations between clinical factors and case outcome. Women's health practitioners (WHPs), including obstetrician-gynecologists (OB-GYNs), family medicine, and internal medicine clinicians, were the largest group of defendants (97). Others included radiologists (43), surgeons (33), and pathologists (3). OB-GYNs accounted for 31% of these defendants, with a cost of more than $16 million. The greatest number of specialists represented in the open cases were radiologists, with 38% of the total. The defense model predicts that the probability of successful defense is lessened with inadequate record keeping, a patient that has metastasis and is alive, and a delay in diagnosis of 12 months or more. The overall indemnity model predicts a higher indemnity with the spread of disease at the time of evaluation, a patient who has metastasis and is alive, and a date of occurrence closer to the present. Indemnity is less in patients who have had a lymph node dissection, who have died, or who are alive without metastasis. The WHP model predicts an increased overall indemnity with the spread of disease at the time of evaluation and the presence of a mass without pain. Indemnity decreases with a history of pregnancy, absence of presenting symptoms, or presentation with pain with or without a mass, and the performance of a lymph node dissection.     

The perception of support received from breast care nurses by depressed patients following a diagnosis of breast cancer

INTRODUCTION

Due to their specialist training, breast care nurses (BCNs) should be able to detect emotional distress and offer support to breast cancer patients. However, patients who are most distressed after diagnosis generally experience least support from care staff. To test whether BCNs overcome this potential barrier, we compared the support experienced by depressed and non-depressed patients from their BCNs and the other main professionals involved in their care: surgeons and ward nurses.

PATIENTS AND METHODS

Women with primary breast cancer (n = 355) 2–4 days after mastectomy or wide local excision, self-reported perceived professional support and current depression. Analysis of variance compared support ratings of depressed and non-depressed patients across staff types.

RESULTS

There was evidence of depression in 31 (9%) patients. Depressed patients recorded less surgeon and ward nurse support than those who were not depressed but the support received by patients from the BCN was high, whether or not patients were depressed.

CONCLUSIONS

BCNs were able to provide as much support to depressed patients as to non-depressed patients, whereas depressed patients felt less supported by surgeons and ward nurses than did non-depressed patients. Future research should examine the basis of BCNs'' ability to overcome barriers to support in depressed patients. Our findings confirm the importance of maintaining the special role of the BCN.     

Survivorship care after breast cancer treatment--experiences and preferences of Australian women

Follow-up care after breast cancer treatment is becoming more complex as it attempts to address the long-term needs of an increasing number of survivors. Workforce issues in oncology challenge the sustainability of current specialist-based care. This study explores survivors’ experiences with follow-up care and attitudes to alternative models including a tailored survivorship care plan and involvement of primary care physicians and breast care nurses.Twenty women across Australia participated in semi-structured telephone interviews. All continued to attend follow-up visits with a specialist oncologist and reported a high level of satisfaction with care. Participants described a strong reliance on their specialist but were open to an increased role for their primary care physician in a shared model of care. Communication between multidisciplinary team members was perceived as an ongoing problem and there was enthusiasm for a patient-held written survivorship care plan to address this, and to meet information needs.     

The identification and treatment of isolated tumor cells reflect disparities in the delivery of breast cancer care

Background

Disparities in the quality of health care delivered among different socioeconomic strata (SES), race/ethnic groups, and health care systems are well documented; however, relevant quality measures in breast cancer have been debated. The identification of isolated tumor cells (ITCs) in axillary lymph nodes of patients with breast cancer requires diagnosis of early stage disease, appropriate implementation of sentinel lymph node (SLN) dissection, and pathologic analysis of the SLN with serial sectioning and immunohistochemical staining. We hypothesized that ITCs could be interpreted as a quality indicator and sought to determine factors that are associated with the identification and treatment of ITCs.

Methods

We performed a retrospective cohort review of women with N0(i+) breast cancer diagnosed between 2004 and 2006 in the California Cancer Registry. The proportions of patients in SES quintiles (1 = lowest, 5 = highest), race/ethnicity groups, and hospital surgical volume tertiles (low, 1-241 cases/y; medium, 242-491 cases/y; high, ≥492 cases/y) were compared for use of SLN dissection, identification of ITCs, and treatment of ITCs with additional axillary surgery or chemotherapy.

Results

SLN dissections were performed less frequently in women of lower SES, of nonwhite race/ethnicity, and in hospitals with lower surgical volumes (P <.0001). A total of 369 patients had ITCs (.6%). With increasing SES, the proportion of patients with ITCs increased: 7.1% of patients with ITCs were from SES 1; 15.7% were from SES 2; 20.3% were from SES 3; 23.9% were from SES 4; and 33.1% were from SES 5. A total of 69.4% of patients with ITCs were non-Hispanic white, 12.8% were Asian, 11.9% were Hispanic, and 5.2% were non-Hispanic black. A total of 46.9% of ITCs were identified in high-volume hospitals, although high-volume hospitals represented only one third of all surgical cases. There were no differences in the use of additional axillary surgery among different groups with ITCs, but chemotherapy was given more frequently to Hispanic women (P = .002) and those in higher-volume hospitals (P = .01).

Conclusions

Although the identification and chemotherapy treatment of ITCs vary among SES categories, race/ethnic groups, and hospitals, the infrequent occurrence of ITCs precludes its use as a valid quality indicator. Because significant disparities exist in the use of SLN dissection, further research will be required to validate the use of SLN dissection as a quality measure.     

Patient navigation reduces time to care for patients with breast symptoms and abnormal screening mammograms

Introduction

Concern has been raised about delays for patients presenting with breast symptoms in Canada. Our objective was to determine if our Rapid Access Breast Clinic (RABC) improved care for patients presenting with breast symptoms compared to the traditional system (TS).

Supportive care after curative treatment for breast cancer (survivorship care): Resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement

Breast cancer survivors may experience long-term treatment complications, must live with the risk of cancer recurrence, and often experience psychosocial complications that require supportive care services. In low- and middle-income settings, supportive care services are frequently limited, and program development for survivorship care and long-term follow-up has not been well addressed.As part of the 5th Breast Health Global Initiative (BHGI) Global Summit, an expert panel identified nine key resources recommended for appropriate survivorship care, and developed resource-stratified recommendations to illustrate how health systems can provide supportive care services for breast cancer survivors after curative treatment, using available resources.Key recommendations include health professional education that focuses on the management of physical and psychosocial long-term treatment complications. Patient education can help survivors transition from a provider-intense cancer treatment program to a post-treatment provider partnership and self-management program, and should include: education on recognizing disease recurrence or metastases; management of treatment-related sequelae, and psychosocial complications; and the importance of maintaining a healthy lifestyle. Increasing community awareness of survivorship issues was also identified as an important part of supportive care programs. Other recommendations include screening and management of psychosocial distress; management of long-term treatment-related complications including lymphedema, fatigue, insomnia, pain, and women's health issues; and monitoring survivors for recurrences or development of second primary malignancies. Where possible, breast cancer survivors should implement healthy lifestyle modifications, including physical activity, and maintain a healthy weight. Health professionals should provide well-documented patient care records that can follow a patient as they transition from active treatment to follow-up care.     

Quality improvement by implementing an integrated oncological care pathway for breast cancer patients

Background and aimIn cancer care, more and more systemized approaches such as care pathways are used to reduce variation, reduce waiting- and throughput times and to improve quality of care. The aim of this study was to determine whether the implementation of a multidisciplinary breast cancer pathway in three hospitals has improved the care for breast cancer patients.MethodsRetrospectively almost 800 patients with breast cancer were selected from the Netherlands Cancer Registry (NCR). The patients were divided in two groups: before implementation of the pathway in 2006–07 (baseline measurement) and those after implementation in 2009 (post measurement). Fourteen quality indicators were compared before and after the implementation of the care pathway. To estimate the impact of the care pathway relative to evidence based guidelines and profession-based norms, involved project leaders were interviewed.ResultsSeven out of eight indicators with medical information and four out of five indicators with information about waiting- and throughput times improved. With the multidisciplinary meeting as key in the breast cancer care, more compliance to national guidelines was observed. E.g. for more patients a HER2neu test was performed after implementation of the pathway (from 92% to 96%, ⤳ = 0.016) and more patients started with their first chemotherapy (from 33% to 45%) or their first radiotherapy (from 55% to 59%) within 4 weeks after surgery.ConclusionImplementing a multidisciplinary breast cancer pathway leads to better compliance with the national guidelines and can improve breast cancer care.     

Supportive care during treatment for breast cancer: Resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement

Breast cancer patients may have unmet supportive care needs during treatment, including symptom management of treatment-related toxicities, and educational, psychosocial, and spiritual needs. Delivery of supportive care is often a low priority in low- and middle-income settings, and is also dependent on resources available.This consensus statement describes twelve key recommendations for supportive care during treatment in low- and middle-income countries, identified by an expert international panel as part of the 5th Breast Health Global Initiative (BHGI) Global Summit for Supportive Care, which was held in October 2012, in Vienna, Austria. Panel recommendations are presented in a 4-tier resource-stratified table to illustrate how health systems can provide supportive care services during treatment to breast cancer patients, starting at a basic level of resource allocation and incrementally adding program resources as they become available. These recommendations include: health professional and patient and family education; management of treatment related toxicities, management of treatment-related symptoms of fatigue, insomnia and non-specific pain, and management of psychosocial and spiritual issues related to breast cancer treatment.Establishing supportive care during breast cancer treatment will help ensure that breast cancer patients receive comprehensive care that can help 1) improve adherence to treatment recommendations, 2) manage treatment-related toxicities and other treatment related symptoms, and 3) address the psychosocial and spiritual aspects of breast cancer and breast cancer treatments.     

Trends in surgical treatment of breast cancer at Mayo Clinic 1980-2004

The study encompassed the time period January 1980 through December 2004. During this time 9485 women underwent mastectomy, 6847 women underwent breast conserving surgery (BCS) and 2477 women underwent breast radiotherapy (RT) for breast cancer. Linear regression modeling was used to quantify the rate of change in the proportion of women undergoing mastectomy during specific time periods. Chi-square tests were used to compare the proportion of women with a breast cancer less than 3 cm in size undergoing mastectomy the year prior to and the year after a specific event.There was a significant decrease in the number and proportion of mastectomies performed, an increase in the number of BCS procedures performed and an increase in the number of women undergoing breast RT around the times of (1) the employment of a young surgeon trained in BCS, (2) publication of the NIH Consensus Statement and (3) establishment of a multidisciplinary Breast Clinic.     

Completeness of breast cancer operative reports in a community care setting

ObjectivesThe narrative operative report represents the traditional means by which breast cancer surgery has been documented. Previous work has established that omissions occur in narrative operative reports produced in an academic setting. The goal of this study was to determine the completeness of breast cancer narrative operative reports produced in a community care setting and to explore the effect of a surgeon's case volume and years in practice on the completeness of these reports.Materials and methodsA standardized retrospective review of operative reports produced over a consecutive 2 year period was performed using a set of procedure-specific elements identified through a review of the relevant literature and work done locally.Results772 operative reports were reviewed. 45% of all elements were completely documented. A small positive trend was observed between case volume and completeness while a small negative trend was observed between years in practice and completeness.ConclusionThe dictated narrative report inadequately documents breast cancer surgery irrespective of the recording surgeon's volume or experience. An intervention, such as the implementation of synoptic reporting, should be considered in an effort to maximize the utility of the breast cancer operative report.