Learning from claims and complaints: an epidemiological approach to medical regulation

Abstract

This collection of works examines patterns in medico-legal claims and complaints to help improve decision-making by regulatory agencies. The contribution to medical knowledge is threefold: first, we provide new evidence on patient harm as seen through the eyes of medico-legal agencies in Australia and New Zealand; second, we demonstrate new ways to apply epidemiological methods to medico-legal data; and third, we inform the development of evidence-based regulatory policies to better protect the public from harm. Over the centuries, as medicine has evolved, so too have the risks it entails. In the wake of serious preventable patient harm, calls for stronger regulation by medico-legal agencies are common. By 2012, both Australia and New Zealand had established a medico-legal system that rested on three core pillars: national health practitioner regulation boards with strong lay representation, independent health complaints commissioners, and a commitment to compensating patients who are seriously injured by medical care. The approach of these agencies is at the forefront of medical regulation internationally. Yet, both patients and practitioners express dissatisfaction with current processes. A review of the literature suggests that the case-by-case, reactive, process-driven nature of medico-legal agencies is dulling their ability to hear the voices of patients and practitioners and to see broader patterns of concern. We applied methods drawn from epidemiology to data collected from insurers, health complaints commissioners, and health practitioner regulation boards. We sought to understand: Who takes medico-legal action and what remedies do they seek? Where do hot-spots of medico-legal risk occur? How can we identify high-risk practitioners earlier? Our findings show that most patients who are injured by medical care do not claim or complain. Worryingly, the odds of complaining are significantly lower for patients who are elderly, of Māori ethnicity, or live in the most deprived areas. Those who do complain have a complex array of needs that are only partially met by current medico-legal processes. It seems that certain factors ‘supercharge’ a healthcare interaction for a medico-legal complaint. While medical practitioners may feel that they all practice under a medico-legal cloud, we found that just three percent of all doctors accounted for nearly half of all complaints. The number of prior complaints a doctor had experienced was a strong predictor of subsequent events: doctors named in a third complaint had a nearly 60% probability of being named in a further complaint within two years. Mandatory reporting offers one potential way to identify high-risk practitioners. However, early data from Australia’s new mandatory reporting regime suggests that some groups of practitioners remain reluctant (or unsure of their obligations) to report concerns regarding the health, conduct or performance of another health practitioner. Medico-legal agencies find themselves at the confluence of several growing ideas: patient safety, responsive regulation, empirical legal studies, and ‘big data’ analyses of consumer information. Our findings should encourage medico-legal agencies to use epidemiological methods as a way of ‘sharpening their senses’: to hear the voices of patients and practitioners in new ways and to see patterns that might help prevent future harm.