To See or Not to See

THIS issue of ANESTHESIOLOGY contains two fascinating outcome studies. Cheney et al. provide a trend analysis of the proportion of closed malpractice claims involving death or permanent brain damage reported to the American Society of Anesthesiologists Closed Claims Project. Lienhart et al. present an innovative approach to identifying specific causes of anesthesia-related deaths in France. Both authors describe their unique sampling methodologies and peer review processes, along with some limitations, but do not fully acknowledge the effect that these limitations could have on their conclusions. Shakespeare’s Hamlet pondered the question “to be or not to be,” but for the readers of this issue of ANESTHESIOLOGY, to see or not to see—that is the question. Cheney et al. use the American Society of Anesthesiologists Closed Claims database to determine changes in the proportion of claims for death or permanent brain damage over a 26-yr period and to identify factors associated with the observed changes. Their methodology includes a structured evaluation of adverse outcomes from 6,894 closed anesthesia malpractice claims that shows that the proportion of claims for death or brain damage decreased between 1975 and 2000. The authors conclude that the significant decrease in the proportion of claims for death or permanent brain damage from 1975 through 2000 seems to be unrelated to a marked increase in the proportion of claims where pulse oximetry and end-tidal carbon dioxide monitoring were used. That is, they could not find an association between the increase in monitoring and decrease in death or permanent damage. This should not come as a surprise, because malpractice claims, in general, may be unrelated to the quality of patient care. In fact, one study, specific to anesthesia care, found absolutely no relation between human errors by anesthesiologists that resulted in disabling patient injuries and subsequent risk of malpractice litigation. In that study, the investigators identified 13 cases in which human error by an anesthesia provider, as determined by peer review, resulted in patient injury over a 3-yr period. None of those 13 incidents resulted in a closed malpractice claim or even a letter of intent. During that same time period, 18 cases involving legal action directed at the anesthesiologists were judged by peer review to be devoid of human error with regard to the anesthetic management. Still, the proponents of closed claims analyses argue that the use of such data circumvents the problem of gaining access to low-frequency adverse events, despite inherent limitations that must be considered when interpreting the data. Among these limitations is the lack of any real denominator data. Specifically, the authors do not know how many anesthetics resulted in the number of closed claims present in their database. Instead, the authors use the total number of closed claims reported to the database annually as a denominator, and report their outcome measures as a proportion of all annual claims. The authors admit that the number of annual claims reported by a select group of insurance companies is not a random sample, but have they acknowledged the impact of changing the insurance companies over time? The current study reports that the Closed Claims Project has 18 insurance organizations in its active panel, but as many as 35 insurance companies have contributed to the database over the study period. It seems likely that changing insurance companies might produce a change in the number and type of annual claims. For example, the authors excluded claims from 1970 through 1974 and 2001 because there were “insufficient” numbers (n 21 and n 15, respectively) per year for meaningful analysis. With so much variability in the denominator data, the readers must be cautious when interpreting trends. Readers must also give consideration to the numerator data used by the Closed Claims Project. As noted previously, not all patient injury due to anesthesia provider error results in a claim. Also, closed claims can occur in the absence of human error. For example, in the current study, overall standard of care was judged as less than appropriate in only 28% of the cardiovascular-related damaging events. Therefore, closed claims occurrences may not be a valid indicator of patient safety or quality of care. If the frequency of closed claims were a valid indicator of patient safety, one might conclude that 2001 was a very “safe” year for anesthetized patients. The proportion of claims for death and brain damage is as likely to be affected by legal practice as it is by medical practice. Malpractice attorneys operating under a contingency-based system are becoming more inclined to pursue litigation involving disabling injury leading to lost wages in younger clients than to pursue cases involving death or permanent brain damage in older patients beThis Editorial View accompanies the following two articles: Cheney FW, Posner KL, Lee LA, Caplan RA, Domino KB: Trends in anesthesia-related death and brain damage: A closed claims analysis. ANESTHESIOLOGY 2006; 105:1081–6; Lienhart A, Auroy Y, Péquignot F, Benhamou D, Warszawski J, Bovet M, Jougla E: Survey of anesthesia-related mortality in France. ANESTHESIOLOGY 2006; 105:1087–97.