Jeffrey G. Nicholson's Dissertation

CHAPTER IV
RESULTS OF DATA ANALYSIS

Introduction
Chapter IV consists of study analyses in written, table, and figure format. The reader is encouraged to examine the data tables and figures and to draw his/her own conclusions from the table and figure presentation of results. In interpreting the analysis, the reader is cautioned to bear in mind that the liability and risk of the three provider groups is different because each group provides care that varies in complexity and risk of poor outcome. Discussion of results, unexpected findings, further limitations, conclusions and recommendations will be reserved and presented in Chapter V.

Results of Analysis
Spanning January 1, 1991 - December 31, 2007, the NPDB recorded 324,285 total entries of malpractice payments and adverse actions for PAs, APNs and physicians. Of these, 249,097 were malpractice payments and 75,188 were adverse actions (Table 6). Global results demonstrated that statistically significant associations existed between provider groups for total entries, malpractice payments and most adverse actions. Therefore, the null hypotheses that no significant associations existed between these groups are rejected. The number of physician reports was 320,034 while the number of PA reports was 1,535 and APN reports 2,715. Broken down into malpractice
payments versus adverse actions, the number of malpractice payments and adverse actions were respectively 245,267, and 74,767 for physicians, 1,222 and 314 for PAs, 2,608 and 107 for APNs.

Table 6. National Practitioner Data Bank Entries by Provider Type (1/01/1991 - 12/31/2007)
Type of Provider	Total Entries	Malpractice Payments	Adverse Actions
Physician	320,034	245,267	74,767
PA	1,536	1,222	314
APN	2,715	2,608	107
TOTAL	324,285	249,097	75,188
______________________________________________________________________________
Note: Total entries: ?2 = 576.67; df =2; p< 0.0001; effective sample size n= 324,285. Malpractice Payment field RECTYPE M & P: ?2 = 181.36; df =2; p< 0.0001. Adverse action field RECTYPE A & C: ?2 = 565.66; df =2; p< 0.0001.

Table 7 displays the number of payment reports, providers involved, and ratio of providers per report. The number of providers involved is higher than the number of malpractice payments because multiple providers may be involved in some payments. For example, a physician and PA or physician and APN could be involved in the same payment. Physicians had 1.10 reports per provider, PAs had 1.24 reports per provider and APNs had 1.26 providers than reports. This means that 10%, 24% and 26% of each provider group respectively had another provider involved in the malpractice payment.

Table 7. Number of Payment Reports, Providers, and Average Number of Providers per Report
Provider	Number of Payment Reports	Average Number of Providers per Report	Number of Providers Involved
Physician	245,267	1.10	268,919
PA	1,222	1.24	1,509
APN	2,608	1.26	3,265
Note: ?2 = 1395.82; df =6; p< 0.0001; effective sample size n=326,671. Number of Providers Involved field = NUMBPRSN. There maybe more than one provider type involved with some malpractice payments.

Table 8 displays the average age of the provider at time of event leading to the report. For malpractice payments, the average age of physicians, PAs, and APNs were 43 (±11), 37 (±9), and 41 (±11) years, respectively. Scheffe’s method of one-way ANOVA for mean comparisons among three types of health care providers revealed statistically significant differences in mean age at the time of the event leading to report between physicians and PAs, physicians and APNs, as well as PAs and APNs (F=280.19 and p<0.0001, df=2).

For adverse action reports, the average age of physicians, PAs, and APNs at the time of adverse action leading to report was 48 (±11), 41(±9), and 43 (±9) years, respectively. By using the Scheffe’s method of one-way ANOVA for mean comparisons among three types of health care providers, statistically significant differences were found in mean age at the time of the adverse action leading to report between physicians and PAs, physicians and APNs (F=65.44 and p<0.0001, df=2), but no significant difference was found between PAs and APNs at p-value <0.05. PAs and APNs were statistically significantly younger than physicians for malpractice reports but not between themselves.

Table 8. Average Age (in years) of Provider at the Time of the Event Leading to the Report

Provider	Adverse Action*	Malpractice‡
Physician	48 (±11)	43 (±11)
PA	41 (± 9)	37 (± 9)
APN	43 (± 9)	41 (± 9)
___________________________________________________________________________________
Note: For physician to PA and physician to APN: Adverse action: F= 65.44; p<0.0001; df=2; Number of observations used n= 74,862; Malpractice: F= 280.19; p<0.0001; df=2; n= 247,924. For PA to APN: p<0.05 for both adverse actions and malpractice. ± = Standard Deviation.

Table 9 displays medical practice payment by type of provider and average year in practice. This was determined by subtracting the year of graduation from the year of the malpractice payment. The average number of years in practice at the time the malpractice payment report was 25.2 (± 13.1) for physicians, 15.1 (± 8.5) for PAs, and 18.7 (± 10.5) for APNs. Scheffe’s method of one-way ANOVA revealed statistically significant differences in mean age at the time of the event leading to report between physicians and PAs, physicians and APNs, and PAs and APNs (F=678.28 and p<0.0001). On average PAs and APNs made malpractice payments earlier in their careers than physicians.

Table 9. Medical Malpractice Payment by Type of Provider and Average Year of Practice
(1991-2007)

______________________________________________________________________________
Provider	Year of Practice (± SD)
______________________________________________________________________________
Physician		25.2 (±13.1)
PA		15.1 (± 8.5)
APN		18.7 (±10.5)
______________________________________________________________________________
Note: ANOVA (Scheffe) F= 678.28; p<0.0001; df=2; n= 248,246. SD = Standard Deviation.

Table 10 reports malpractice claims for the period 1/31/2004 - 12/31/2007 by patient’s age and gender stratified by health care providers. Data for other years was not available. There were 47,457 patients involved in malpractice payments by physicians, including 26,483 females (55.8%) and 20,974 males (44.2%). Physician assistants and advanced practice nurses were involved with less than 2% of patients relating to malpractice payments. For PAs, 203 (47.7%) female patients and 223 (52.3%) male patients were involved in malpractice payment reports.
For APNs. 536 (59.2%) female patients and 369 (40.8%) male patients involved in malpractice payment reports. The chi-square test revealed a significant association between patient’s age and gender with the type of care providers (p<0.0001 for each provider). For all provider types the total number of females involved was 27,322 or 56% of the total.

Table 10. Malpractice Claims (2004-2007) by Patients’ Age and Gender

______________________________________________________________________________
Age Group Physician PA APN Total
______________________________________________________________________________
Fetus
Male	609	1	25	635
Female	438	1	25	464
Under 1 Year
Male	1,868	2	92	1962
Female	1,264	5	71	1340
1-9 Years
Male	745	4	25	774
Female	619	12	15	646
10-19 Years
Male	1,062	14	18	1094
Female	993	14	26	1033
20-29 Years
Male	1,294	16	21	1331
Female	2,829	23	71	2923
30-39 Years
Male	2,616	29	24	2669
Female	5,180	32	105	5317
40-49 Years
Male	3,831	55	46	3932
Female	5,365	49	67	5481
50-59 Years
Male	3,985	45	48	4078
Female	4,357	28	69	4454
60-69 Years
Male	2,834	36	37	2907
Female	2,842	15	41	2898
70-79 Years
Male	1,688	18	23	1729
Female	1,865	11	28	1904
80 and Over
Male	442	3	10	455
Female	731	13	18	762
TOTAL	47,457	426	907	48788
Total Male	20,974	223	369	21,566
Total Female	26,483	203	536	27,222
_____________________________________________________________________________________
Note: For Physicians: ?2 = 1309.10; df =11; p< 0.0001; effective sample size n=47,457. For Physician Assistants: ?2 = 26.85; df =11; p< 0.0048; effective sample size n=426. For APN: ?2 = 67.29; df =11; p< 0.0001; effective sample size n=905.

Table 11 reports medical malpractice payments by reason for payment and provider type. This table is useful in demonstrating the main reasons for malpractice payments. The top five reasons for malpractice payments among physicians were diagnosis (33.9%), surgery (27.1%), treatment (18.0%), obstetrics (8.6%), and medication related (5.5%). The top five reasons among PAs were diagnosis (55.5%), treatment (24.6%), medication related (8.5%), surgery (4.6%), and miscellaneous (3.1%). For APNs, the top five reasons for payments were anesthesia (38.7%), obstetrics (22.2%), diagnosis (14.8%), treatment (10.5%), and medication related (4.8%). The
chi-square test indicated a significant association between reasons for malpractice payment and type of health care provider (?2 =11525.38 and p<0.0001). Table 12 displays a ranking of the eight major reasons for payment by provider type.

Table 11. Medical Malpractice Payments by Reason for Payment and Provider Type (2004- 2007)

Reason for Payment	Total	Physician	PA	APN
Diagnosis	84,193	83,130	678	385
Surgery	66,605	66,451	56	98
Treatment	44,603	44,028	301	274
Obstetrics	21,700	21,114	8	578
Medication	13,676	13,446	104	126
Anesthesia	8,611	7,592	10	1,009
Monitoring	3,859	3,757	22	80
Miscellaneous	3,663	3,600	38	25
Equipment/Product	980	966	2	12
IV and Blood Products	858	839	3	16
Behavioral Health	235	230	0	5
TOTAL	248,983	245,153	1,222	2,608
________________________________________________________________________
Note: ?2 = 11,525.38; df =20; p< 0.0001; effective sample size n=248,983.

Table 12. Top Medical Malpractice Reasons for Payment by Provider Type

Rank	Physicians	PAs		APNs
1	Diagnosis		Diagnosis	Anesthesia
2	Surgery		Treatment	Obstetrics
3	Treatment		Medication	Diagnosis
4	Obstetrics		Surgery	Treatment
5	Medication		Miscellaneous	Medication
6	Anesthesia		Monitoring	Surgery
7	Monitoring		Anesthesia	Monitoring
8	Miscellaneous		Obstetrics	Miscellaneous

Table 13 reveals medication-related medical malpractice payments by reason for payment for the data dates available, January 1, 2004 – December 31, 2007. The most common type of medication errors were the same for all three provider types. In order of frequency these were: a) improper management of medication regimen, and b) improper technique. Other common errors were failure to order appropriate medication, wrong medication ordered, wrong dosage of the correct medication and consent issues. Administration of medication errors was proportionately
higher for PAs and APNs.

Table 13. Medication-Related Medical Malpractice Payments by Reason for Payment and
Provider Type (2004-2007)

______________________________________________________________________________
Malpractice Type	Physician	PA	APN
______________________________________________________________________________
Improper management of medication regimen 18,687 58 203
Improper technique	8,060	55	139
Consent issues	3,133	6	15
Failure to order appropriate medication	1,394	7	9
Wrong medication ordered	1,047	14	11
Wrong dosage ordered of correct medication	1,014	12	15
Failure to instruct on medication	848	10	13
Wrong medication administered	611	17	23
Wrong dosage administered	555	3	14
Failure to medicate	440	6	4
Wrong route	72	0	1
Wrong patient	29	0	0
TOTAL	35,890	188	447
Note: ?2 = 7,097.77; df =178 ; p< 0.0001; effective sample size n=248,983.

Table 14 displays the average duration between litigation and payment for medical malpractice payments between January 1, 1991 and December 31, 2006. Table 14 revealed an average duration between these events of 4.1 years for physicians, 3.6 years for PAs and 3.8 years for APNs. The average duration for all three provider types was 3.9 years.

Table 14. Duration from Litigation to Payment

Provider Type	Average Duration in Years (SD)
Physicians	4.1 (2.2)
PAs	3.6 (1.9)
APNs	3.8 (2.1)
______________________________________________________________________________
Note: ANOVA (Scheffe) F= 61.69; p<0.0001; df=2; n= 181,128. SD=Standard deviation

Table 15 displays the mean and median payment for malpractice reports by gender for thefull 17 year study period in 2008 dollars. These data were provided separately by the NPDB staff and is not part of the public use data file. The data demonstrated that female providers, regardless of type of provider, had larger malpractice payments on average than male providers. Female providers also had higher median malpractice payments for physicians and APNs. Median malpractice payment was slightly lower for PAs. Both the average and median payments for
female practitioners was higher than that for males when provider types are combined.

Table 15. Mean and Median Malpractice Payment by Gender for 1999-2007*

	Mean			Median
	Male	Female	Male			Female
Physicians	302,659	365,146		160,553	183,489
PAs	204,373	218,701		104,250	97,479
APNs	336,404	383,707		143,351	182,342
AVERAGE	281,146	322,184		136,055	154,437
*Note. Data provided by Robert E. Oshel, Ph.D., Associate Director for Research and Disputes, Division of Practitioner Data Banks, U.S. Health Resources and Services Administration; April 1, 2008, adjusted for  inflation to 2008 dollars using the CPI provided by the U.S. BLS. Statistical values are not available.

*Note. Data provided by Robert E. Oshel, Ph.D., Associate Director for Research and Disputes, Division of Practitioner Data Banks, U.S. Health Resources and Services Administration; April 1, 2008, adjusted for inflation to 2008 dollars using the CPI provided by the U.S. BLS. Statistical values are not available. Table 16 and Figures 4-15 display malpractice reports and adverse action reports by year for all three provider groups as well as the percent change in reports by year from 1991-2007.

While percent change is useful, given the small numbers of PA and APN reports compared to physicians, both percent and absolute number changes were reported. The year with the largest number of physician malpractice reports was 2001. Physician malpractice reports remained fairly consistent between 1991 and 2005 and then saw a decrease in 2006 and 2007. The physician malpractice reports were also noted to be on a steady downward sloping from 2003-2007. The number of PA malpractice reports saw a continual increase peaking at 135 in 2004 with a jump
from 81 in 2001 to 123 in 2002. PA reports have decreased from 2004 to 2007. The number of APN malpractice reports was fairly consistent from 1991 to 2000 hovering between 90 and 140 but then saw a large increase from 111 in 2000 to 183 in 2001 and increases again in 2004, 2005, and 2006 (from 168 in 2003 to 264 in 2006). The largest percent change in malpractice reports for physicians was a decrease in 1995 of 11.4%, for PAs was an increase in 2002 of 51.1% and for APNs an increase in 2001 of 61.3%. The comparison in physician malpractice reports between 1991 and 2007 was a decrease of 1900 reports or 14.2%. The average number of reports for the 17 year period was 14,512. The comparison of PA malpractice reports between 1991 and 2007 was an increase of 80 and the average number of reports over the period was 72. The comparison in APN reports between 1991 and 2007 was an increase of 137 and the average number of reports for the period was 153.

The year with the largest number of physician adverse action reports was 1998 with 4971 reports. Physician adverse action reports were fairly consistent between 1991 and 2007 with an overall flat slope. The number of PA adverse action reports was fairy inconsistent but did show an overall upward slope peaking in 2003 with an overall decrease from 2003 to 2007. The number of APN adverse action reports saw low numbers of one to seven reports from 1991 to 2002 but then a large increase in 2003 and 2004 with a peak of 21 in 2004. The APN reports increased from 5 in 2002 to 21 in 2004. The number decreased in 2005, 2006 and 2007. The largest percent change in adverse action reports for physicians was a decrease in 2006 of 10.8%, for PAs was an increase in 1997 of 175% and for APNs an increase in 2001 of 133% followed by increases in 2003 of 120% and 2004 of 90%. The total change in physician adverse action reports from 1991 to 2007 was an increase of 235 reports or 6.7% and the average number of reports was 4,315. The total change in PA adverse action reports from 1991 to 2007 was an
increase from 6 to 14 or 133% and the average number of reports for the period was 18. The total change in APN reports from 1991 to 2007 was an increase of 1 to 8 or 700% and the average number of reports was 106.

Table 16. Number of Malpractice Payments and Adverse Actions Total and by Year, 1991-1999

Report Year	Provider	Malpractice Payment Reports*	Change %	Adverse Action Reports†	Change %
1991	Total	13522	0	3487	0
	Physicians	13399	0	3480	0
	PAs	14	0	6	0
	APNs	109	0	1	0
1992	Total	14839	9.7	3570	2.4
	Physicians	14692	9.6	3549	2.0
	PAs	30	114.3	16	166.7
	APNs	117	7.3	5	400.0
1993	Total	14771	-0.5	3910	9.5
	Physicians	14629	-0.4	3896	9.8
	PAs	33	10.0	11	-31.3
	APNs	109	-6.8	3	-40.0
1994	Total	15258	3.3	4293	9.8
	Physicians	15124	3.4	4266	9.5
	PAs	44	33.3	24	118.2
	APNs	90	-17.4	3	0.0
1995	Total	14120	-8.1-	4692	9.3
	Physicians	13988	-7.5	4676	9.6
	PAs	39	-11.4	12	5.0
	APNs	93	3.3	4	33.3
1996	Total	15336	8.6	4882	4.0
	Physicians	15186	8.6	4873	4.2
	PAs	44	12.8	8	-33.3
	APNs	106	14.0	1	-75
1997	Total	14696	-4.2	4920	0.8
	Physicians	14531	-4.3	4892	0.4
	PAs	46	4.5	22	175
	APNs	119	12.3	6	500
1998	Total	14103	-4.0	4998	1.6
	Physicians	13944	-4.0	4971	1.6
	PAs	49	6.5	22	0.0
	APNs	110	-7.6	5	-16.7
1999	Total	15151	7.4	4742	-5.1
	Physicians	14945	7.2	4720	-5.0
	PAs	75	53.1	20	-9.1
	APNs	131	19.1	2	-60

Table 16. (continued)

Report Year	Provider	Malpractice Payment Reports*	Change  %	Adverse Action Reports†	Change  %
2000	Total	15631	3.2	4300	-9.3
	Physicians	15447	3.4	4274	-10.0
	PAs	73	-2.7	23	15.0
	APNs	111	-15.3	3	50.0
2001	Total	16831	7.7	4504	4.7
	Physicians	16571	7.3	4471	4.6
	PAs	81	11.0	26	13.0
	APNs	179	61.3	7	133.3
2002	Total	15506	-7.9	4278	-5.0
	Physicians	15200	-8.3	4251	-4.9
	PAs	123	51.1	22	-15.4
	APNs	183	2.2	5	-28.6
2003	Total	15520	0.9	4376	2.2
	Physicians	15233	0.2	4338	2.0
	PAs	119	-3.3	27	22.7
	APNs	168	-8.2	11	120.0
2004	Total	14722	-5.1	4484	2.5
	Physicians	14373	-5.6	4440	2.4
	PAs	135	13.4	23	-14.8
	APNs	214	27.4	21	90.1
2005	Total	14380	-8.4	4342	-3.2
	Physicians	14011	-2.5	4319	-2.7
	PAs	110	-18.5	12	-47.8
	APNs	259	21.0	11	-47.6
2006	Total	12872	-10.0	4240	-2.3
	Physicians	12495	-10.8	4210	-2.5
	PAs	113	2.7	20	66.7
	APNs	264	1.9	10	-9.1
2007	Total	11,839	-8.0	3744	-11.7
	Physicians	11,499	-8.0	3722	-11.6
	PAs	94	-16.8	14	-30.0
	APNs	246	-6.8	8	-20.0
_________________________________________________________________________
Note: * For Malpractice: ?2 = 899.76; df =32; p< 0.0001; effective sample size n=249,097. † For Adverse Action: ?2 = 97.85; df =32; p= 0.0002; effective sample size n=74,117.

Figure 4. Physician Malpractice Payment Reports 1991-2007


Figure 5. PA Malpractice Payment Reports 1991-2007



Figure 6. APN Malpractice Payment Reports 1991-2007


Figure 7. Total Malpractice Payment Reports 1991-2007


Figure 8. Total Malpractice Payments By Provider Type 1991-2007


Figure 9. Average Annual Malpractice Payments by Provider Type 1991-2007


Figure 10. Physician Adverse Action Reports 1991-2007



Figure 11. PA Adverse Action Reports 1991-2007


Figure 12. APN Adverse Action Reports 1991-2007


Figure 13. Total Adverse Action Reports 1991-2007


Figure 14. Total Adverse Action Reports by Provider Type 1991-2007


Figure 15. Average Annual Adverse Action Reports by Provider Type 1991-2007


Table 17 displays the number of malpractice payments and adverse actions by state of practice (work state) for the period 1991-2007. The table is sorted by physician malpractice payment rank. The states with the highest number of malpractice reports for physicians were those with the largest populations and number of physicians: New York, California, Pennsylvania, Florida and Texas. The number of adverse action reports however, was not as connected to population. The states with the highest number of adverse actions in order of frequency were California, Texas, Ohio, Florida, and New York. Pennsylvania ranked much lower in its number of adverse actions even though it had the third highest number of malpractice payments.

The states with the highest number of malpractice payments for PAs were New York, Florida, Texas, California, Michigan and North Carolina while for APNs those states were Florida, Texas, New York, Pennsylvania and California. The states with the highest number of adverse action reports against PAs were New York and North Carolina while for APNs were Texas and Florida.

Table 17. Number of Malpractice Payments and Adverse Actions by Work State, 1991-2007


Table 17. (continued)


Table 18 provides the ratio of malpractice payments to adverse action reports by state and the percent of adverse actions to malpractice payments over the 17 year study period. This table compares the number of adverse actions taken against providers’ ability to practice to the number of malpractice payments over the same period. The table is displayed in rank order from highest percentage of adverse actions to malpractice payments to lowest. The average ratio was 4.4 malpractice payments to one adverse action report. In percent, the occurrence of adverse actions
reports was 23% of malpractice payments on average. Some smaller jurisdictions and military jurisdictions had more adverse actions than malpractice payments, and two had no adverse actions at all. The majority of states and jurisdictions had greater than the 23% average adverse action reports to malpractice payments.

Table 18. Ratio of Adverse Actions per Malpractice Payments by State, 1991-2007


Table 18. (continued)

Table 19 displays adjusted mean, median and total malpractice payments forthe three providers types over the 17 year study period in 2008 dollars. The total malpractice payments for the 17 years for all providers exceeded 74 billion dollars. Physician assistant payments comprised just 0.003% of the total and APN payments comprised only 0.007% of the total (see Figure 20). The average and median APN payments were the highest at $350,540 and $190,898. The average and median physician payments were $301,150 and $150,821while the average and
mean PA payments were $173,128 and $80,003. The physician adjusted mean payment was 1.74 times higher than PAs but only 0.86 that of APNs. The physician adjusted median payments were 1.89 times that of PAs but only 0.79 that of APNs. The APN adjusted mean payments were 2.02 times that of PAs and median payments were 2.40 times that of PAs.

Table 19. Malpractice Payment (Adjusted) Amount for the Period Jan. 1. 1991-Dec. 31, 2007

Note: ANOVA (Scheffe) was used with F=35.58; df=2; and p<0.0001. Mean and median are reported in dollars;
total is reported in millions of dollars, adjusted for inflation to 2008 dollars using the CPI as reported by the U.S.
BLS.

Table 20 displays the adjusted mean, median and total malpractice payments by year for the study period for all three provider types. In combination with Figures 16-26, these data presentation examined trends in malpractice payments over the study period. These data were also reported in Table 21 adjusted to 1991dollars in order to make comparisons with earlier research.

Table 20. Malpractice Payment (Adjusted) Amount by Year from 1991 to 2007*


Table 20. (continued)*

Table 20. (continued)*

*Note: ANOVA (Scheffe) F=35.58; df=2; and p<0.0001. Mean and median reported in dollars; total payments
reported in millions of dollars, adjusted for inflation to 2008 dollars based on the CPI as reported by the U.S. BLS.

Figures 16 -26 demonstrate the trends in average, median and total malpractice payment amounts for the 17 year study period adjusted for inflation to 2008 dollars. Total, average and median payment amounts increased throughout the study period for all three provider groups. As previously noted the average and median payment amounts of APNs were higher than that of physicians and PAs. Physician payments comprised 98.9% of total payments for the three provider groups during the study period. Physician total payment amount peaked in 2001 and 2003 and then declined each year since. PA total payment amount also peaked in 2003 and in 2006 but declined in 2007. APN total payments amount saw its first peak in 2003 but then continued an overall upward slope peaking again in 2005 and 2007. There were spikes in median payment for APNs in 2002 and PAs in 2003. Median payments for PAs and APNs have been decreasing overall since 2003. Trends in average and median payments are discussed in Chapter V.

Figure 16. Physician, PA and APN Average Malpractice Payments by Year 1991-2007


Figure 17. Physician, PA and APN Median Malpractice Payments by Year 1991-2007


Figure 18. Average Malpractice Payment 1991-2007


Figure 19. Average of Median Malpractice Payments 1991-2007


Figure 20. Total Malpractice Payments in Millions 1991-200


Figure 21. Physician Total Malpractice Payments by Year 1991-2007 (in millions)


Figure 22. Physician Median Malpractice Payments by Year 1991-2007


Figure 23. PA Total Malpractice Payments by Year 1991-2007 (in millions)


Figure 24. PA Median Malpractice Payments by Year 1991-2007


Figure 25. APN Total Malpractice Payments by Year 1991-2007 (in millions)


Figure 26. APN Median Malpractice Payments by Year 1991-2007


Table 21 displays mean and median malpractice payments adjusted to 1991 dollars for the full 17 year study period. Dollar amounts for 1991 were chosen to make similar comparisons to the 1998 studies of Brock and Cawley discussed in Chapters II and V. Physician adjusted mean payments are 1.75 times higher than PAs but only 0.86 that of APNs. Physician adjusted median payments are 1.90 times that of PAs but only 0.80 that of APNs. This table will be discussed in Chapter V.


_____________________________________________________________________________________
*Note: ANOVA (Scheffe) F=35.58; df=2; and p<0.0001; effective sample size n=249,072. Total is reported in
millions of dollars.

Table 22 displays the adjusted mean, median and total malpractice payments by year for the study period, adjusted to 1991 dollars. The Consumer Price Indexes (CPI) from the U.S. Department of Labor, Bureau of Labor Statistics was used to estimate the amount of mean and median (in dollars) and total amount (in millions of dollars) by year adjusted to 1991 dollar values (www.bls.gov/cpi). Graphs are not presented for the adjusted amounts because trends may be determined as validly from the unadjusted amounts. The 1991adjustment is discussed in Chapter V.

Table 22. Malpractice Payment (Adjusted to 1991 Dollars) Amount by Year from 1991 to 2007*


Table 22. (continued)*


Table 22. (continued)*

______________________________________________________________________________
*Note: ANOVA (Scheffe) F=35.58; df=2; and p<0.0001; effective sample size n=249,072. Mean and median is
reported in dollars; total is reported in millions of dollars.

Table 23 displays the ratio of malpractice payments per total number of providers in 2006 for each provider type. The most recent available surveys for the provider groups were in 2006. There were 12,495 payments for 774,883 active physicians, 113 payments for 63,609 active PAs and 264 payments for 268,293 both active and non-active APNs. The ratios were 1:62, 1:563 and 1:1016 respectively. This table allows calculation of the probability of
malpractice payment by provider type in 2006. See Chapter V for an interpretation of this analysis and precautions about conclusions.

Table 23. Ratio of Payment Entries per Active Provider in 2006*

*Note: ANOVA (Scheffe) F=35.58; DF=2;, and p<0.0001; effective sample size n=249,072.
Data for active physicians is from the Physician Characteristics and Distribution in the US, 2008 edition, American
Medical Association received from Judy Torres, Data Coordinator, Survey & Data Resources, American Medical
Association, personal communication, May 14, 2008.
Data for active physician assistants from the American Academy of Physician Assistants Information Update posted
at http://www.aapa.org/research/06number-clinpractice06.pdf retrieved May 13, 2008.
Data for APNs from the National Nursing Survey Report of the U.S. Health Resources and Services Administration
posted at http://bhpr.hrsa.gov/healthworkforce/nursing.htm retrieved July 12, 2008. NNSR data includes both active and non-active APNs.

Table 24 provides the number of malpractice payments over the 17 year period per average number of active providers within the 17 year study period. This provided an estimate of the probability of malpractice payment by provider type in the 17 study period. The average number of active providers was calculated by averaging the number of active providers in each year of the study period. The estimated number of providers for years in which a survey was not taken was calculated by determining the annual difference between known years. There was one
payment report for every 2.7 active physicians, one for every 32.5 active PAs and one for every 65.8 active and non-active APNs. In percent, 37% of physicians, 3.08% of PAs and at least 1.52% of APNs would have made a malpractice payment over the 17 year period. The analysis assumed one malpractice payment per provider.

Table 24. Ratio of Malpractice Payments per Provider Type 1991-2007


Figure 27. Probability of Malpractice Payment 1991-2007


Table 25 displays the most common bases for adverse action reports since reporting began for this category (11/22/1999 to 12/31/2007). The most common basis for action by reporting entities by far was a licensing action by federal, state or local licensing authorities for physicians and PAs. This was followed by unprofessional conduct, alcohol and other substance abuse, criminal conviction and narcotic violation. The most common basis for action against APNs was unprofessional conduct.

Table 25. Most Common Bases for Action by Reporting Entities from Nov. 22. 1999 – Dec. 31,


Five adverse action types are reported to the NPDB: state and medical board licensing actions; clinical privileges actions; professional society membership actions; practitioner exclusions from Medicare and Medicaid programs; and U.S. D.E.A. actions. Please note that of these five adverse actions, state and medical board licensing actions, clinical privileges actions, and professional society membership actions were not required reporting elements for PAs and APNs. Therefore PA and APN data for those three voluntary reporting actions have been omitted from their respective tables. Table 26 displays state and medical board licensing actions for the 17 year study period. Of the five adverse action types taken against three providers, state and medical board actions represented the largest proportion (67%) of all actions taken. Using the 2006 active provider census data, 5.7% or 1 of 17.5 physicians had state and medical licensing board actions taken against them in the 17 year study period.


Table 26. State and Medical Board Licensing Actions for the Period January 1, 1991-December 31, 2007*


*Note: 67.0% of all AA Classes (n=66,173) recorded in the NPDB from 1/1/91-12/31/07. NA=Not applicable as
data was voluntarily reported. Data fields AACLASS1={1110-1296}. Chi-square and p-value are not relevant due to
absence of data for PAs and APNs.

Table 27 displays state and medical board licensing actions by year of action. Physicians
had actions recorded in all study years.

Table 27. State and Medical Board Licensing Actions by Year 1991-2007

Note: NA=Not applicable as data was voluntarily reported. Chi-square and p-value are not relevant due to absence
of data for PAs and APNs.

Table 28 displays state and medical licensing board actions by state for the 17 year study period. The states with the largest number of actions taken against physicians were California, Texas, Ohio, Florida and Arizona. However, the states with the most adverse actions against physicians were not necessarily those with the most malpractice payments. New York had the highest number of malpractice payments, but ranked fifth in state and medical board licensing actions. Likewise Pennsylvania ranked third in malpractice payments but 20th in state and medical licensing actions. Table 29 compares the rank by state of the top twenty physician malpractice payments and medical licensing board actions.

Table 28. State and Medical Licensing Board Actions by State, 1991-2007


Table 28. (continued)

Note: NA=Not applicable as data was voluntarily reported. Data fields WORKSTAT & AACLASS1 (1110-1296) with 1991<=AAYEAR<=2007. Only 33,284 records were available in the NPDB for this descriptive analysis (missing 21,531). Chi-square and p-value are not relevant due to absence of data for PAs and APNs.

Table 29. State Rank of Physician Malpractice Payments and State and Medical Board Licensing Actions


Table 30 displays clinical privileges actions for the 17 year study period. Clinical privilege actions were the second most common type of adverse action taken against providers constituting 22.3% of all adverse actions in the dataset. There were 14,547 actions reported against physicians which are 1.9% of the number of all active physicians of 2006.

Table 30. Clinical Privilege Actions for the Period January 1, 1991-December 31, 2007*

*Note: 22.3% of all AA Classes (n=66,173) recorded in the NPDB from 1/1/91-12/31/07 includes voluntary
submissions for PAs and APNs. NA=Not Applicable as data was voluntarily reported for PAs and APNs
Data fields for Clinical Privileges Actions (AACLASS1={1610-1699}). Chi-square and p-value are not relevant due
to absence of data for PAs and APNs.

Table 31 displays clinical privilege actions by year for each year of the study period for physicians. The number of physician actions displayed a mild downward trend from 1991 to 1998, a mild upward trend from 1998 to 2004, and then a more moderate downward trend from 2004 to 2007. PA and APN data was not included because their voluntary reporting status would make comparisons meaningless.
Clinical Privilege Actions 14,547 NA NA 15,739 (22.3%)*

Table 31. Clinical Privilege Actions by Year 1991- 2007

Note: Chi-square and p-value are not relevant due to absence of data for PAs and APNs

Figure 28. Physician Clinical Privileges Actions 1991-2007


Table 32 displays clinical privilege actions by state for the study period. It is ranked by
physician clinical privileges actions. California had the most clinical privilege actions for
physicians. It also had 74% more actions than the next highest ranking state of New York and
81% more than Texas. PA and APN actions were omitted in the table due to their voluntary
reporting status.

Table 32. Clinical Privilege Actions by State 1991-2007


Table 32. (continued)

Note: Data using WORKSTAT & AACLASS1 (1610-1699) with 1991<=AAYEAR<=2007). Only 15,585 records
were available in the NPDB for this descriptive analysis. Chi-square and p-value are not relevant due to absence of
data for PAs and APNs.

Table 33 displays professional society membership actions for the study period. The number of professional society actions against physicians was 574 for the study period which constituted less than 1% of all adverse actions in the dataset. Actions against PAs and APNs were omitted from the table as reporting was not required for PAs and APNs.

Table 33. Professional Society Membership Actions for the Period January 1, 1991-December 31, 2007*


*Note: 0.9% of all AA Classes (n=66,173) recorded in the NPDB from 1/1/91-12/31/07. Data fields (AACLASS1={1710-1799}). Chi-square and p-value are not relevant due to absence of data for PAs and APNs.

Table 34 displays professional society membership actions for physicians for the full study period by year. The number of actions sloped downward from 1991until a low in 1999 and has been sloping upward on average from 1999 to 2007.

Table 34. Professional Society Membership Actions by Year 1991- 2007

Note: Chi-square and p-value are not relevant due to absence of data for PAs and APNs

Table 35 displays professional society membership actions by state for the full study period. The table is ranked by states with the most actions. Oklahoma stood out as the state with third highest professional society membership actions when compared with states that have the highest number of adverse actions overall. There was no reporting requirement for PAs and APNs.

Table 35. Professional Society Membership Actions by State 1991-2007


Table 35. (continued)

Note: Data fields WORKSTAT & AACLASS1 (1710-1799) with 1991<=AAYEAR<=2007). Only 656 records were available in the NPDB for this descriptive analysis. Chi-square and p-value are not relevant due to absence of data for PAs and APNs.

Table 36 displays practitioner exclusions from Medicare and Medicaid programs. Exclusions from Medicare and Medicaid programs constituted 9.9% of all adverse actions reported in the database. There were 6,311 physicians excluded from Medicare and Medicaid Programs in the study period, or 0.81% of the active physician population of 2006. There were 219 PA exclusions or 0.34% of the active PA population of 2006. There were no APN
exclusions. This category was required reporting for all three practitioner groups.

Table 36. Practitioner Exclusion from Medicare and Medicaid Programs for the period January 1, 1991-December 31, 2007*

*Note: 9.9% of all AA Classes (n=66,173) recorded in the NPDB from 1/1/91-12/31/07. Data fields
(AACLASS1={1500-1516}). Chi-square=1,748.63, df= 6; effective sample size=67,518, and p<0.0001.

Table 37 and Figures 29 and 30 display practitioner exclusions from Medicare and Medicaid programs by year for the full study period. For both physicians and PAs, the number of exclusions had an overall average increase till 2001 and 2002. In 2001 the number of physician exclusions from Medicare and Medicaid programs began to decline dramatically through 2007. PA exclusions declined dramatically in 2003 from 23 to an average of less than ten for the subsequent four years.

Table 37. Practitioner Exclusion from Medicare and Medicaid Programs by Year 1991-2007


Figure 29. Physician Exclusions from Medicare and Medicaid Programs 1991-2007


Figure 30. PA Exclusions from Medicare and Medicaid Programs 1991-2007


Table 38 displays U.S. D.E.A. actions for the 17 year study period. The 1,355 total D.E.A. actions were 2.1% of all adverse actions for the period. There were 1,352 D.E.A. actions against physicians in the period which constituted 0.17% of active physicians of 2006. There were two PA and one APN actions in the 17 year period. The results are not statistically significant due to the small proportion of adverse actions.

Table 38. U.S. D.E.A. Actions for the Period January 1, 1991-December 31, 2007


Table 39 and Figure 31 display D.E.A. actions by year for the full 17 year study period. The analysis revealed two peaks with the largest number of actions occurring in 1994 and 2004. The actions decreased to a low in 1998 and the again from 2004 to an all time low in 2007. There were two actions against PAs, one in 1999 and one in 2004. There was one action against an APN in 2004.

Table 39. U.S. D.E.A. Actions by Year 1991- 2007


Figure 31. Physician D.E.A. Actions 1991-2007


Table 40 displays D.E.A. actions ranked by state for the 17 year study period. The state with the largest number of D.E.A. actions was California, with more than double or 131% more than the state with the second most actions, Texas.

Table 40. U.S. D.E.A. Actions by State, 1991-2007


Table 40. (continued)


Table 41 summarizes the adverse action reports by provider type for the study period. For physicians, the largest number of adverse actions were state and medical board licensing actions, followed by clinical privileges actions, and practitioner exclusions from Medicare and Medicaid programs. For PAs Medicare and Medicaid program exclusions were reported most. For APNs, only one DEA action was reported. A discussion of this table and all tables follows in Chapter V.

Table 41. Adverse Actions Report Summary 1991-2007

Note: NA= Not applicable as reporting was voluntary for PAs and APNs. M/M = Medicare and Medicaid.

Table 42 displays the number of actions for each provider group as a percentage of the total number of providers in that group in 2006. Table 42 indicated that 5.72% of the number of physicians of 2006 had state and medical board licensing actions in the 17 year study period. For PAs the highest proportion of adverse actions per provider was exclusions form Medicare and Medicaid programs. No program exclusions were reported for APNs. The adverse action affecting the greatest proportion APNs in the 17 year period was clinical privileges.

Table 42. Adverse Actions 1991-2007 as a Percent of Providers of 2006

Note: NA=Not applicable as reporting was voluntary for PAs and APNs. M/M = Medicare and Medicaid.

Summary
Chapter IV presented a statistical analysis of data pertinent to the study available from theNational Practitioner Data Bank in the Spring of 2008. Most data were available and analyzed for complete calendar years 1991-2007. The majority of the data for analysis came from the NPDB public use file, some of it was provided by the NPDB staff. For those tables that required demographic data, the best available demographic data was utilized, with disclaimers or precautions noted where appropriate. The analyses using chi-square and ANOVA (Sheffe) showed statistically significant associations and differences in malpractice payments and adverse actions between physicians, PAs and APNs. Analyses also revealed statistically significant differences between states on the number of malpractice payments and adverse actions and differences between states of adverse actions as a proportion of the number of malpractice payments. The analyses also revealed differences in the amount of malpractice payment by gender. Possible reasons for these statistically significant differences will be discussed in the next chapter. The reader is again cautioned to bear in mind the role, autonomy and malpractice risk differences between the three provider types when formulating opinions.