Background: With the recent consolidation of hospital systems and the increasing complexity of inpatient care, receiving inter-hospital transfers (IHT) has become more common for large academic medical centers. Notably, studies have shown IHT to be associated with increased length of hospital stay (1,2), increased cost of care (2,3), as well as delays in care and treatment, including procedures (4, 5, 6). One may expect that a number of these cases end with a medical malpractice suit filed for the care related to the IHT. While the characteristic of medical malpractice claims as a whole have been evaluated in several studies (7,8,9), no one study has specifically characterized such claims for cases involving IHT.
Methods: We did a retrospective observational cohort study of all closed medical malpractice claims at a large academic-medical center from 1/1/2010 – 12/31/2019. Of the total 326 cases during this period, we excluded (248) cases with any source of admission other than ER or inter-hospital transfer, open cases and cases where no pay out was awarded. The dataset included the year claim was paid, payment amount, severity of injury, type of error alleged, and an encrypted physician identifier(specialty). Severity of injury, ranging from emotional injury to death, was categorized based on the National Association of Insurance Commissioners’ (NAIC) Severity of Injury Scale. The types of errors categorized as diagnosis related, medication related, treatment related, surgery related, monitoring related and other. We performed descriptive analysis of the available malpractice database to further find the prevalence of the interhospital transfer, the major allegation type, severity of injury and payment amount in the IHT compared with the group of patients with medical malpractice claims admitted through the ED.
Results: Overall, severity of illness was higher in patients from the ED with average Charlson score of 6.5 in ED group, 3.7 in IHT (p=0.1) and average Elixhauser score of 7.9 in ED group and 6.4 in IHT (p=0.35). Average payout for IHT was $1,227,133 and $320,732 for ED cases (p < 0.05). Median payments for the IHT and ED were $440,000 and $100,000 respectively. Severity of injury was death or “high” in 11 (73% of IHT cases) and 25 (39% of ED cases) compared to “medium” or “low” in 4 (27% of IHT cases) and 38 (60% of ED cases) (p < 0.05). Major Allegation was medical treatment related in 5 (33%), 19 (30%); diagnosis related in 5 (30%), 13 (21%); medication related in 3 (20%), 7 (11%); monitoring in 2 (13%), 18(29%) and surgical related in 0, 6 (9%) of IHT and ED cases respectively (p=0.48).
Conclusions: We found that, despite having lower indicators of SOI, malpractice claims involving IHT have higher severity of injury with a higher rate of death than claims involving ED admissions. Diagnosis related allegations are higher in IHT while monitoring related allegations are higher in ED cases. These IHT claims resulted in much higher payments, with mean and median settlements being almost four times the claims from patients admitted through the ED. Our study evaluated all the malpractice claims with payout at a single medical center, therefore generalizability to other systems needs to be confirmed; however, such data is sensitive and not readily available. Based on these results, improving care following IHT should be a high priority for hospitals, with a particular focus on diagnostic issues.