Records of medical malpractice litigation: a potential indicator of health-care quality in China.

Introduction The quality of health care can be difficult to measure, (1) but many potentially relevant indicators have been investigated. In high--income countries, case report cards are frequently and widely used to record health outcomes--including adverse outcomes that may sometimes be attributable to poor health care--and health providers may also employ quality assurance systems such as error--reporting mechanisms. In many low--and middle--income countries, however, the lack of such records and systems is a major obstacle to measuring the quality of health care. (2) In theory, patients should be protected from some aspects of poor health care by the litigation relating to medical malpractice. Such litigation can lead to financial compensation for patients who have suffered as the result of medical negligence and can encourage physicians to maintain at least basic standards of health care.1 In high-income countries, such as the United States of America (USA), researchers have examined the quality of health care from the perspective of medical errors and have concluded that--even though "to err is human"--most errors in the provision of health care could be prevented. (3) However, as an effective approach to prevent medical errors in particular and to increase the quality of health care in general, the operation of the medical malpractice system in the USA is far from ideal. (4) Litigation records have rarely been used as an external data source for studies on medical malpractice. (5-8) However, in the investigation of health-care quality, a potential strength of using such records is that health providers may lack the incentive to report comprehensively and honestly unless they are in court and being accused of negligence. Litigation records may also allow the quality of care to be assessed from the perspective of both patient and provider. Although such records may cover only a very small proportion of all adverse outcomes, (9, 10) they can still be useful indicators of the general quality of health care in a country. When, for example, patient injury claims from Finnish hospital registries for 1998-2003 were investigated, some more traditional indicators of poor hospital care--such as high prevalences of infection--were found to be significantly associated with the incidence of claims and compensation. (11) We need a better understanding of the relationship between adverse health outcomes, medical malpractice claims and poor health care. Donabedian divided the measurement of health-care quality into three categories: (i) outcomes, that is the health status of patients after they had received care; (ii) process, i.e. the procedures involved in diagnosis and treatment; and (iii) structure, i.e. the human and material resources available and the infrastructure of the health system. (12) The relationship between the structural components of quality and patient outcomes has been investigated. (13, 14) Not all adverse health outcomes can be attributed to health care of poor quality. In addition, attempts to improve the quality of health-care services may not always result in improved health outcomes. (15) For example, if litigation is increased to reduce medical negligence, physicians may become so fearful of being sued that they turn towards so-called defensive medicine (4) which may well be suboptimal in terms of the health outcomes of the physicians' patients. It should be possible to use litigation records, from a fault-based legal system, to identify the court cases where adverse outcomes were not attributed to the poor quality of care, i.e. where there was litigation but no consequent compensation. Such records are unlikely to reveal any medical negligence that did not adversely affect the health outcomes of the patients involved. They also give no indication of the numbers of patients who, although they have suffered adverse consequences of medical negligence, chose not to seek any compensation in a court of law. …