R. Hwang, H. Y. Park, W. Sheppard, N. M. Bernthal, Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
Clin Orthop Relat Res. 2020 Oct;478(10):2239-2253. doi: 10.1097/CORR.0000000000001340.
Sarcoma care is highly litigated in medical malpractice claims. Understanding the reasons for litigation and legal outcomes in sarcoma care may help physicians deliver more effective and satisfying care to patients while limiting their legal exposure. However, few studies have described malpractice litigation in sarcoma care.
QUESTIONS/PURPOSES: (1) What percentage of sarcoma malpractice cases result in a defendant verdict? (2) What is the median indemnity payment for cases that result in a plaintiff verdict or settlement? (3) What are the most common reasons for litigation, injuries sustained, and medical specialties of the defendant physicians? (4) What are the factors associated with plaintiff verdicts or settlements and higher indemnity payments?
The national medicolegal database Westlaw was queried for medical malpractice cases pertaining to sarcomas that reached verdicts or settlements. Cases from 1982 to 2018 in the United States were included in the study to evaluate for trends in sarcoma litigation. Demographic and clinical data, tumor characteristics, reasons for litigation, injuries, and legal outcomes were recorded for each case. A univariate analysis was performed to identify factors associated with plaintiff verdicts or settlements and higher indemnity payments, such as tumor characteristics, defendant's medical or surgical specialty, reason for litigation, and injuries sustained. A total of 92 cases related to sarcomas were included in the study, of which 40 were related to bone sarcomas and 52 were related to soft-tissue sarcomas. Eighty-five percent (78 of 92) of cases involved adult patients (mean age ± SD: 40 ± 15 years) while 15% (14 of 92) of cases involved pediatric patients (mean age ± SD: 12.5 ± 5 years).
Thirty-eight percent (35 of 92) of the included cases resulted in a defendant verdict, 30% (28 of 92) resulted in a plaintiff verdict, and 32% (29 of 92) resulted in a settlement. The median (interquartile range [IQR]) indemnity payment for plaintiff verdicts and settlements was USD 1.9 million (USD 0.5 to USD 3.5 million). Median (IQR) indemnity payments were higher for cases resulting in a plaintiff verdict than for cases that resulted in a settlement (USD 3.3 million [1.1 to 5.7 million] versus USD 1.2 million [0.4 to 2.4 million]; difference of medians = USD 2.2 million; p = 0.008). The most common reason for litigation was delayed diagnosis of sarcoma (91%; 84 of 92) while the most common injuries cited were progression to metastatic disease (51%; 47 of 92) and wrongful death (41%; 38 of 92). Malpractice claims were most commonly filed against primary care physicians (26%; 28 of 109 defendants), nononcology-trained orthopaedic surgeons (23%; 25 of 109), and radiologists (15%; 16 of 109). Cases were more likely to result in a ruling in favor of the plaintiff or settlement if a delay in diagnosis occurred despite suspicious findings on imaging or pathologic findings (80% versus 51%; odds ratio 3.84 [95% CI 1.34 to 11.03]; p = 0.02). There were no differences in indemnity payments with the numbers available in terms of tumor type, tumor location, defendant specialty, reason for litigation, and resulting injuries.
Many lawsuits were made against primary care physicians, nononcology-trained orthopaedic surgeons, or radiologists for a delayed diagnosis of sarcoma despite the presence of imaging or histologic findings suspicious for malignancy. Although previous studies of bone and soft-tissue sarcomas have not shown a consistent association between time to diagnosis and decreased survival, our study suggests that physicians are still likely to lose these lawsuits because of the perceived benefits of an early diagnosis.
Physicians can mitigate their malpractice risk while reducing delays in diagnosis of sarcomas by carefully reviewing all existing diagnostic studies, establishing closed-loop communication protocols to communicate critical findings from diagnostic studies, and developing policies to facilitate second-opinion consultation, particularly for imaging studies, with an experienced sarcoma specialist. Musculoskeletal oncologists may be able to help further reduce the rates of malpractice litigation in sarcoma care by helping patients understand that delays in diagnosis do not necessarily constitute medical malpractice.
肉瘤治疗在医疗事故索赔中争议很大。了解肉瘤治疗中诉讼的原因和法律结果可能有助于医生为患者提供更有效和更满意的治疗，同时限制他们的法律风险。然而，很少有研究描述过肉瘤治疗中的医疗事故诉讼。
问题/目的：（1）肉瘤医疗事故案件中有多少被判为被告败诉？（2）导致原告胜诉或和解的案件的中位数赔偿额是多少？（3）诉讼的最常见原因、受伤情况以及被告医生的医疗专业是什么？（4）哪些因素与原告胜诉或和解以及更高的赔偿额相关？
在 Westlaw 国家医学法律数据库中查询了已作出判决或和解的肉瘤医疗事故案件。该研究纳入了 1982 年至 2018 年在美国发生的案件，以评估肉瘤诉讼的趋势。记录了每个案件的人口统计学和临床数据、肿瘤特征、诉讼原因、受伤情况和法律结果。进行了单变量分析，以确定与原告胜诉或和解以及更高赔偿额相关的因素，如肿瘤特征、被告的医疗或外科专业、诉讼原因和受伤情况。研究共纳入 92 例与肉瘤相关的病例，其中 40 例与骨肉瘤相关，52 例与软组织肉瘤相关。85%（78/92）的病例涉及成年患者（平均年龄±标准差：40±15 岁），15%（14/92）的病例涉及儿科患者（平均年龄±标准差：12.5±5 岁）。
38%（35/92）的纳入病例被判为被告败诉，30%（28/92）被判为原告胜诉，32%（29/92）被判为和解。原告胜诉和和解的中位数（四分位距 [IQR]）赔偿额为 190 万美元（100 万美元至 350 万美元）。与和解相比，导致原告胜诉的案件的中位数赔偿额更高（3300 万美元[1100 万美元至 5700 万美元]与 120 万美元[400 万美元至 240 万美元]；中位数差值为 2200 万美元；p=0.008）。诉讼的最常见原因是肉瘤的延迟诊断（91%；92 例中有 84 例），最常见的受伤情况是进展为转移性疾病（51%；92 例中有 47 例）和死亡（41%；92 例中有 38 例）。医疗事故索赔最常针对初级保健医生（26%；109 名被告中有 28 名）、非肿瘤专业的骨科医生（23%；109 名被告中有 25 名）和放射科医生（15%；109 名被告中有 16 名）。如果在存在影像学或组织学可疑恶性肿瘤的情况下出现诊断延迟，那么案件更有可能判决有利于原告或和解（80%与 51%；比值比 3.84[95%CI 1.34 至 11.03]；p=0.02）。根据肿瘤类型、肿瘤位置、被告专业、诉讼原因和受伤情况，可用的赔偿金没有差异。
尽管先前的骨和软组织肉瘤研究并未显示诊断时间与生存率降低之间存在一致的关联，但我们的研究表明，由于早期诊断的好处，医生仍可能因对肉瘤的延迟诊断而输掉这些诉讼。
医生可以通过仔细审查所有现有的诊断研究、建立闭环沟通协议以传达诊断研究的关键发现以及制定政策来促进与经验丰富的肉瘤专家的二次咨询，特别是对于影像学研究，从而减少肉瘤诊断延迟的风险，从而减轻医疗事故诉讼的风险。肌肉骨骼肿瘤学家可以通过帮助患者理解诊断延迟并不一定构成医疗事故，进一步降低肉瘤治疗中的医疗事故诉讼率。
