Jutta Järvelin

Factors predisposing to claims and compensations for patient injuries following total hip and knee arthroplasty

Background and purpose Factors associated with malpractice claims are poorly understood. Knowledge of these factors could help to improve patient safety. We investigated whether patient characteristics and hospital volume affect claims and compensations following total hip arthroplasty (THA) and knee arthroplasty (TKA) in a no-fault scheme. Methods A retrospective registry-based study was done on 16,646 THAs and 17,535 TKAs performed in Finland from 1998 through 2003. First, the association between patient characteristics—e.g., age, sex, comorbidity, prosthesis type—and annual hospital volume with filing of a claim was analyzed by logistic regression. Then, multinomial logistic regression was applied to analyze the association between these same factors and receipt of compensation. Results For THA and TKA, patients over 65 years of age were less likely to file a claim than patients under 65 (OR = 0.57, 95% CI: 0.46–0.72 and OR = 0.65, CI: 0.53–0.80, respectively), while patients with increased comorbidity were more likely to file a claim (OR = 1.17, CI: 1.04–1.31 and OR = 1.14, CI: 1.03-1.26, respectively). Following THA, male sex and cemented prosthesis reduced the odds of a claim (OR = 0.74, CI: 0.60–0.91 and OR = 0.77, CI: 0.60–0.99, respectively) and volume of between 200 and 300 operations increased the odds of a claim (OR = 1.29, CI: 1.01–1.64). Following TKA, a volume of over 300 operations reduced the probability of compensation for certain injury types (RRR = 0.24, CI: 0.08–0.72). Interpretation Centralization of TKA to hospitals with higher volume may reduce the rate of compensable patient injuries. Furthermore, more attention should be paid to equal opportunities for patients to file a claim and obtain compensation.

Developing the formula for state subsidies for health care in Finland

Aim: The aim was to generate a research-based proposal for a new subsidy formula for municipal healthcare services in Finland. Methods: Small-area data on potential need variables, supply of and access to services, and age-, sex- and case-mix-standardised service utilisation per capita were used. Utilisation was regressed in order to identify need variables and the cost weights for the selected need variables were subsequently derived using various multilevel models and structural equation methods. Results: The variables selected for the subsidy formula were as follows: age- and sex-standardised mortality (age under 65 years) and income for outpatient primary health services; age- and sex-standardised mortality (all ages) and index of overcrowded housing for elderly care and long-term inpatient care; index of disability pensions for those aged 15 - 55 years and migration for specialised non-psychiatric care; and index of living alone and income for psychiatric care. Conclusion: Decisions on the amount of state subsidies can be divided into three stages, of which the first two are mainly political and the third is based on the results of this study.

Morbidity and Health Care Costs After Early Term Birth

BACKGROUND Early term birth is associated with increased need for hospital care during the early postnatal period. The objective of this study was to assess the morbidity and health care-related costs during the first 3 years of life in children born early term. METHODS Data come from a population-based birth cohort study in the municipalities of Helsinki, Espoo, and Vantaa, Finland using data from the national medical birth register and outpatient, inpatient, and primary care registers. All surviving infants born in 2006-08 (n = 29 970) were included. The main outcome measures were morbidities, based on ICD-10 codes recorded during inpatient and outpatient hospital visits, and health care costs, based on all care received, including well child visits (specialised care, primary care, private care, and medications). RESULTS 7.0% of children born full term had at least one of the studied morbidities by 3 years of age. This percentage was significantly higher in children born early term: 8.6% (adjusted odds ratio 1.2, 95% confidence interval (CI) 1.1, 1.4). The increased morbidity of children born early term was attributed to obstructive airway diseases and ophthalmological and motor problems. Health care-related costs during the first 3 years of life were 4813€ (95% CI 4385, 5241) per child in the early term group, higher than for full term children 4047€ (95% CI 3884, 4210). CONCLUSIONS Infants born early term have increased morbidity and higher health care-related costs during early childhood than full term infants. Early term birth seems to be associated with a health disadvantage.

Association between household income and the outcome of arthroplasty: a register-based study of total hip and knee replacements

IntroductionPrevious research findings regarding the association between the outcomes of total hip and knee arthroplasty and patients’ socioeconomic status have been contradictory. Consequently, we wanted to analyse whether individual-level household income was associated with the risk of revision arthroplasty and whether the time span in days from the primary arthroplasty to the revision operation varied according to income quintile.Materials and methodsAll first total hip and knee arthroplasties performed due to primary osteoarthritis in Finland from 1998 to 2007 were included in the study. Cox proportional hazard regression modelling was applied in the analysis regarding the risk of revision after the primary operation, while Poisson regression modelling was applied in the analysis regarding differences in the time from the primary to the revision operation between income quintiles.ResultsThe relationship between household income and the risk of revision arthroplasty was not statistically significant. The relationship remained insignificant, even when age, sex, and other confounding factors were adjusted for or analyses concerned revision in short or long term. In both the total hip arthroplasty and knee arthroplasty populations, patients in the lowest income quintiles underwent revision surgery earlier than patients in the highest income groups, but this difference was not statistically significant.ConclusionThe quality of arthroplasty as measured by the risk of revision does not seem to depend on patients’ income quintile.

Can patient injury claims be utilised as a quality indicator

OBJECTIVES To examine the association between patient injury claims and well-known quality indicators and to assess whether claims can be utilised in performance measurement. METHODS Data were derived from administrative registers and comprised hip and knee replacement patients (n=34181) in Finland from 1998 to 2003. Hospital-level correlations were calculated between claims and quality indicators (5-year revision rate, 1-year deep infection rate, and 14-day readmission rate), while logistic regression analysis was used to analyze patient-level data for an association between claims and quality indicators. RESULTS Correlations between claims and revisions as well as claims and infections were statistically significant, with correlation coefficients ranging from 0.21 to 0.62. In the regression analysis, both the revision and the infection indicator had a positive and statistically significant association with filing a claim (OR 1.002; 95% CI 1.001-1.003 and 1.001; 1.00005-1.001, respectively) and obtaining compensation (1.003; 1.001-1.005 and 1.001; 1.0003-1.002, respectively). CONCLUSIONS A claims indicator has the potential to be applied as a quality indicator. It should be complemented, however, with other indicators or actions to improve its acceptability by health professionals and to mitigate its possible undesirable effects.

Patient and hospital characteristics associated with claims and compensations for patient injuries in coronary artery bypass grafting in Finland

Objectives To analyse the association between individual patients’ risk factors and rates of claims and compensations for patient injuries in an insurance scheme in which proof of negligence is not required. And to explore whether either hospital productivity or volume of procedures is related to claims and compensation rates. Methods A two-step sequential logistic regression was applied on data collected from administrative registers. It included 17,834 patients who had undergone coronary artery bypass grafting at public hospitals in Finland between 1998 and 2002. The main outcome measure was the odds of claiming and receiving compensation. Results Men were less likely to claim compensation (odds ratio [OR] 0.66; 95% confidence interval 0.54-0.81), but among those having claimed were more likely to receive compensation (OR 2.08; 1.15-3.75) than women. Patients with a co-morbidity were more likely to claim (OR 1.29; 1.06-1.57), but among those having claimed were less likely to receive compensation (OR 0.52; 0.31-0.86) than those without a co-morbidity. Advanced age reduced the probability of claiming (OR 0.71; 0.52-0.96). Conclusions Although high-risk patients file a claim more frequently than low-risk patients, the latter have a higher probability of getting their claims accepted and receiving compensation. This risk pattern is probably a reflection of compensation practices related to patient injuries involving an infection.

The development of differences in hospital costs accross income groups in Finland from 1998 to 2010

OBJECTIVE To quantify differences in hospital costs between socioeconomic groups and the development over time. METHODS Register data on somatic specialised hospital admissions for patients aged between 25 and 84 in Finland in 1998-2010 were used with income data individually linked to them. The cost of an admission was calculated by multiplying the number of a patients inpatient days by the inpatient day cost of the patients DRG. We calculated age-standardised admission costs per resident and per user as well as costs per inpatient day and concentration indices separately for men and women. RESULTS Hospital admission costs reduced with increasing income. The difference between the extreme income quintiles was more than 50% throughout the study period, and this difference widened. However, the cost per inpatient day was more than 20% higher in the highest income group. The differences between income groups were the most prominent in disease categories involving surgery. CONCLUSIONS The growth between socioeconomic groups in hospital costs is presumably mainly due to increasing differences in morbidity. More attention needs to be paid to prevention of health inequalities and access to and content of primary care among low-income groups in order to decrease the need for hospitalisations.

Comparison of Health Care Costs Between Claimants and Nonclaimants in the No-Fault Compensation System of Finland.

Objectives If patients experience health care–related adverse events, they may claim for compensation. Adverse events of claimants are generally more severe and presumably involve higher health care costs than those of nonclaimants. The aim of this study was to estimate the cost differential between claimants and nonclaimants in the no-fault system in Finland. Methods We compiled register data on patients having had coronary artery bypass grafting (CABG, n = 20,500), total hip arthroplasty (n = 17,506), or knee arthroplasty (TKA, n = 18,512) and calculated risk-adjusted cost differentials by using a gamma distributed, log-linked generalized linear model. The explained variable comprised costs, whereas the main explanatory variables were whether the patient filed a claim and whether he or she received compensation. Results Uncompensated claimants had higher admission costs (CABG, €3660, 29%; total hip arthroplasty, €418, 5%; TKA, €359, 4%) compared with nonclaimants, whereas the differential between compensated claimants and uncompensated claimants was statistically insignificant. Significant associations emerged concerning CABG 1-year costs: uncompensated claimants had €12,990 (71%) higher costs than nonclaimants, whereas compensated claimants had €6388 (20%) higher costs than uncompensated claimants. Conclusions Although the precise cost differentials may be specific to Finland, the implications may apply also to other countries. (1) Excess costs of claimants should motivate efforts to reduce adverse events. (2) Analyses of claims to improve patient safety should not be restricted to compensated claims only but should equally concern uncompensated claims. A further implication regarding Finland is that additional approaches to identify and report adverse events are necessary.