COUNTERPOINT Data Bank 1984 And All That
International Journalfor Quality in Health Care, Vol. 9, No. 5. pp. 327-328,1997
© 1997 Ebevier Science Ltd. All righa reserved
Printed in Great Britain
Pergamon
PIL S1353-450S(97)00032-X
I3J3-J5O5/97 $17.00+0.00
COUNTERPOINT
Data Bank — "1984 And All That"
INTERNATIONAL STANDARDS
B. T. COLLOPY
The final few sentences of the paper by Drs Israeli and
Altholz, proposing an international practitioner data
bank, suggest that they have in mind a wider concept for
its content than malpractice information. Nevertheless
the paper and its title are supportive of the national
practitioner data bank, which was established in the
United States of America in 1990, to gather information
on the "litigation" record of medical practitioners as a
quality measure. The concept has Orwellian overtones, is
hardly "peer" review, and its effect on the quality of care
given to patients is as yet unproven. The national
practitioner data bank contains only negative information, includes small "nuisance" claims not reflecting the
quality of care and contains a bias against proceduralists.
For example Sloan et al., found that only 15% of medical
specialists had a claim made against them, whereas
approximately 48% of surgical specialists had a claim
made against them in the same time period [1].
The authors admit a considerable variance in tort costs
from one country to another, for example they are very
high in Ireland and low in France. There are obviously
significant social implications which are not explored by
the authors. Persistence of the variance would provide a
bias against practitioners from highly litigious countries.
A further problem is that a malpractice claim may be
made against a group practice when not all of the
members of the group had any part to play in the event,
thus providing an unfair record against some practitioners.
The four reasons put forward by the authors for
establishing an international data bank, are for the
development of international standards, the provision
of information about professional experience, to overcome professional camaraderie and to enhance quality
assurance.
PROFESSIONAL EXPERIENCE
It should be possible presently for any employer to
obtain information from an applicant concerning his/her
past experience in an appropriately detailed form
together with information on whether or not the
applicant is currently "licensed" to practice.
PROFESSIONAL CAMARADERIE
Whilst it is accepted that there may be some risks in
accepting personalreferences,any employer should (and
does) have the right to request information from a
previous employer regarding the applicant's previous
performance.
An increasing number of professional associations/
colleges have now established a program of recertification for their members and where such programs exist a
future employer should request such information concerning the applicant.
QUALITY ASSURANCE
It is doubtful whether an international data bank as
proposed, that is relying largely on malpractice information, would be a suitable tool for assessment of the
Counterpoint is an occasional feature presenting discussion of a topic that is currently under debate in quality of care circles. We invite readers to write
letten to the Editor adding their opinion on the topic.
327
Downloaded from by guest on April 5, 2016
This is a very appropriate ideal but is "light years"
away from reality. An appropriate starting point would
be the establishment of internationally acceptable terminology, uniform definitions for events and complications
and standardised data gathering processes. It is my
understanding that the International Society for Quality
in Health Care (ISQua) is addressing the feasibility of
these proposals. Establishing uniform standards and
methods for medical education however is a much
larger exercise and at this stage unrealistic for many
developing countries.
ACHS, Level 9, Aitkenhead Centre, 41 Victoria Parade,
Fitzroy, Victoria 3065, Australia
328
performance indicators are now in existence. For example the ACHS indicator on mortality for coronary artery
graft surgery isriskadjusted for seven sub-sets of patients
[6] and if international agreement could be reached at this
level of clinical detail, the development of an international data bank on clinical performance could become a
reality.
REFERENCES
1. Sloan F. A., Mergenhagan P. M., Burfield B. et al,
Medical malpractice experience of physicians: predictable or haphazard? Journal of the American
Medical Association, December 15, 1989, Vol. 262,
No. 232.
2. Bovbjerg R. R. and Petronis K. R., The relationship
between physicians' malpractice claims history and
later claims: does the past predict the future? Journal
of the American Medical Association, November 9,
1994, Vol. 272, No. 18.
3. Rolph J. E. and Kravitz R. L., Malpractice claims
data as a quality improvement tool: is targeting
effective? Journal of the American Medical Association, October 16, 1991, Vol. 266, No. 15.
4. Anzari M. Z., Collopy B. T. and Booth J. L.,
Hospital characteristics associated with unplanned
readmissions. Australian Health Review, 1995, Vol.
18, No. 3.
5. Anzari, M. Z. and Collopy, B. T., The risk of
unplanned return to the operating room in Australian hospitals. Australian and New Zealand Journal
of Surgery 1996; 66: 10-13.
6. Clinical Indicators A Users' Manual: Surgery Indicators. ACHS Care Evaluation Program. Version 1.
January, 1997.
Downloaded from by guest on April 5, 2016
quality of care given by any applicant. Whilst Bovbjcrg
and Petronis have shown that a claims history has some
predictive value of the likelihood of future claims against
a practitioner [2], Rolph and Kravitz suggest that this
predictive power is only modest and that the claims
history is a poor predictor of the quality of care [3]. Sloan
et al. also state that their study of claims experience did
not demonstrate it to be a valid indicator of the quality of
care given by a physician [1].
A preferable approach to the "transferable" assessment of the quality of care given by a practitioner would
be the development of internationally acceptable performance indicators. Some models already exist; for example performance indicators have been developed by the
Joint Commission on Accreditation of Health Care
Organisations (JCAHO), the Maryland Hospitals Association and the Australian Council on Health Care
Standards (ACHS) through its Care Evaluation Program. However, the results from these programs are not
interchangeable at the present time, for although some of
the indicator areas are similar the definitions differ and
therefore their data would not be comparable.
Even with some of the clinical performance measures
developed so far, it has been shown that national data
bases lack sufficient information concerning the case mix
and illness severity of patients to make an accurate
judgement of quality of care. They are of more value as
tools to highlight problems which can be investigated "in
house" where sufficient clinical information exists. This is
certainly so with multidisciplinary performance indicators such as unplanned readmission to hospital and
unplanned return to the operating room [4,5].
However, some disease-specific and procedure-specific
Counterpoint
© 1997 Ebevier Science Ltd. All righa reserved
Printed in Great Britain
Pergamon
PIL S1353-450S(97)00032-X
I3J3-J5O5/97 $17.00+0.00
COUNTERPOINT
Data Bank — "1984 And All That"
INTERNATIONAL STANDARDS
B. T. COLLOPY
The final few sentences of the paper by Drs Israeli and
Altholz, proposing an international practitioner data
bank, suggest that they have in mind a wider concept for
its content than malpractice information. Nevertheless
the paper and its title are supportive of the national
practitioner data bank, which was established in the
United States of America in 1990, to gather information
on the "litigation" record of medical practitioners as a
quality measure. The concept has Orwellian overtones, is
hardly "peer" review, and its effect on the quality of care
given to patients is as yet unproven. The national
practitioner data bank contains only negative information, includes small "nuisance" claims not reflecting the
quality of care and contains a bias against proceduralists.
For example Sloan et al., found that only 15% of medical
specialists had a claim made against them, whereas
approximately 48% of surgical specialists had a claim
made against them in the same time period [1].
The authors admit a considerable variance in tort costs
from one country to another, for example they are very
high in Ireland and low in France. There are obviously
significant social implications which are not explored by
the authors. Persistence of the variance would provide a
bias against practitioners from highly litigious countries.
A further problem is that a malpractice claim may be
made against a group practice when not all of the
members of the group had any part to play in the event,
thus providing an unfair record against some practitioners.
The four reasons put forward by the authors for
establishing an international data bank, are for the
development of international standards, the provision
of information about professional experience, to overcome professional camaraderie and to enhance quality
assurance.
PROFESSIONAL EXPERIENCE
It should be possible presently for any employer to
obtain information from an applicant concerning his/her
past experience in an appropriately detailed form
together with information on whether or not the
applicant is currently "licensed" to practice.
PROFESSIONAL CAMARADERIE
Whilst it is accepted that there may be some risks in
accepting personalreferences,any employer should (and
does) have the right to request information from a
previous employer regarding the applicant's previous
performance.
An increasing number of professional associations/
colleges have now established a program of recertification for their members and where such programs exist a
future employer should request such information concerning the applicant.
QUALITY ASSURANCE
It is doubtful whether an international data bank as
proposed, that is relying largely on malpractice information, would be a suitable tool for assessment of the
Counterpoint is an occasional feature presenting discussion of a topic that is currently under debate in quality of care circles. We invite readers to write
letten to the Editor adding their opinion on the topic.
327
Downloaded from by guest on April 5, 2016
This is a very appropriate ideal but is "light years"
away from reality. An appropriate starting point would
be the establishment of internationally acceptable terminology, uniform definitions for events and complications
and standardised data gathering processes. It is my
understanding that the International Society for Quality
in Health Care (ISQua) is addressing the feasibility of
these proposals. Establishing uniform standards and
methods for medical education however is a much
larger exercise and at this stage unrealistic for many
developing countries.
ACHS, Level 9, Aitkenhead Centre, 41 Victoria Parade,
Fitzroy, Victoria 3065, Australia
328
performance indicators are now in existence. For example the ACHS indicator on mortality for coronary artery
graft surgery isriskadjusted for seven sub-sets of patients
[6] and if international agreement could be reached at this
level of clinical detail, the development of an international data bank on clinical performance could become a
reality.
REFERENCES
1. Sloan F. A., Mergenhagan P. M., Burfield B. et al,
Medical malpractice experience of physicians: predictable or haphazard? Journal of the American
Medical Association, December 15, 1989, Vol. 262,
No. 232.
2. Bovbjerg R. R. and Petronis K. R., The relationship
between physicians' malpractice claims history and
later claims: does the past predict the future? Journal
of the American Medical Association, November 9,
1994, Vol. 272, No. 18.
3. Rolph J. E. and Kravitz R. L., Malpractice claims
data as a quality improvement tool: is targeting
effective? Journal of the American Medical Association, October 16, 1991, Vol. 266, No. 15.
4. Anzari M. Z., Collopy B. T. and Booth J. L.,
Hospital characteristics associated with unplanned
readmissions. Australian Health Review, 1995, Vol.
18, No. 3.
5. Anzari, M. Z. and Collopy, B. T., The risk of
unplanned return to the operating room in Australian hospitals. Australian and New Zealand Journal
of Surgery 1996; 66: 10-13.
6. Clinical Indicators A Users' Manual: Surgery Indicators. ACHS Care Evaluation Program. Version 1.
January, 1997.
Downloaded from by guest on April 5, 2016
quality of care given by any applicant. Whilst Bovbjcrg
and Petronis have shown that a claims history has some
predictive value of the likelihood of future claims against
a practitioner [2], Rolph and Kravitz suggest that this
predictive power is only modest and that the claims
history is a poor predictor of the quality of care [3]. Sloan
et al. also state that their study of claims experience did
not demonstrate it to be a valid indicator of the quality of
care given by a physician [1].
A preferable approach to the "transferable" assessment of the quality of care given by a practitioner would
be the development of internationally acceptable performance indicators. Some models already exist; for example performance indicators have been developed by the
Joint Commission on Accreditation of Health Care
Organisations (JCAHO), the Maryland Hospitals Association and the Australian Council on Health Care
Standards (ACHS) through its Care Evaluation Program. However, the results from these programs are not
interchangeable at the present time, for although some of
the indicator areas are similar the definitions differ and
therefore their data would not be comparable.
Even with some of the clinical performance measures
developed so far, it has been shown that national data
bases lack sufficient information concerning the case mix
and illness severity of patients to make an accurate
judgement of quality of care. They are of more value as
tools to highlight problems which can be investigated "in
house" where sufficient clinical information exists. This is
certainly so with multidisciplinary performance indicators such as unplanned readmission to hospital and
unplanned return to the operating room [4,5].
However, some disease-specific and procedure-specific
Counterpoint