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Table.  
Primary Presenting Nonalarm Symptoms for Claims Alleging Delay in Diagnosis of Esophageal Malignancy in 2002-2012
Primary Presenting Nonalarm Symptoms for Claims Alleging Delay in Diagnosis of Esophageal Malignancy in 2002-2012
1.
Shaheen  NJ, Weinberg  DS, Denberg  TD, Chou  R, Qaseem  A, Shekelle  P; Clinical Guidelines Committee of the American College of Physicians.  Upper endoscopy for gastroesophageal reflux disease: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med. 2012;157(11):808-816.
PubMedArticle
2.
Spechler  SJ, Sharma  P, Souza  RF, Inadomi  JM, Shaheen  NJ; American Gastroenterological Association.  American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. Gastroenterology. 2011;140(3):1084-1091.
PubMedArticle
3.
Wang  KK, Sampliner  RE; Practice Parameters Committee of the American College of Gastroenterology.  Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J Gastroenterol. 2008;103(3):788-797.
PubMedArticle
4.
Rubenstein  JH, Saini  SD, Kuhn  L,  et al.  Influence of malpractice history on the practice of screening and surveillance for Barrett’s esophagus. Am J Gastroenterol. 2008;103(4):842-849.
PubMedArticle
5.
Ben-Menachem  T, Decker  GA, Early  DS,  et al; ASGE Standards of Practice Committee.  Adverse events of upper GI endoscopy. Gastrointest Endosc. 2012;76(4):707-718.
PubMedArticle
6.
Peery  AF, Dellon  ES, Lund  J,  et al Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology2012;143(5):1179-1187, e1-e3.
PubMedArticle
Research Letter
October 1, 2014

Medical Professional Liability Claims Related to Esophageal Cancer Screening

Author Affiliations
  • 1Division of Gastroenterology, University of Michigan Medical School, Ann Arbor
  • 2PIAA, Rockville, Maryland
  • 3Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan
JAMA. 2014;312(13):1348-1349. doi:10.1001/jama.2014.7960

Endoscopic screening for esophageal adenocarcinoma has been recommended for patients with chronic symptoms of gastroesophageal reflux disease, but only if they have additional risk factors.13 Surveys of gastroenterologists indicate that concern about litigation for missing a cancer may drive endoscopy use in patients at low risk for esophageal adenocarcinoma.4 However, the perception of medical professional liability may not accurately reflect the true incidence of liability claims.

Although the rate of serious adverse events arising from esophagogastroduodenoscopies is small,5 6.9 million esophagogastroduodenoscopies were performed in the United States in 2009.6 We hypothesized that the incidence of medical professional liability claims alleging failure to screen for esophageal cancer is less than the incidence of claims alleging complications from esophagogastroduodenoscopy performed with inadequate indication.

Methods

This study was determined exempt by the Ann Arbor VA human studies committee. PIAA (formerly, Physician Insurers Association of America) is an insurance trade association, representing medical professional liability insurance companies that collectively insure more than two-thirds of private practice physicians. In 2012, approximately 50% of member insurers contributed claims data to PIAA’s Data Sharing Project, the largest US medical professional liability claims database. Data accuracy is enhanced through specific protocols for coding and validating data and training abstractors; however, data accuracy has not been formally evaluated.

We performed 2 queries using International Classification of Diseases, Ninth Revision, codes. First, we identified all claims relating to a diagnostic esophagogastroduodenoscopy (1985-2012), and then restricted to claims alleging inadequate indication for esophagogastroduodenoscopy. Second, we identified claims related to esophageal cancer restricted to those alleging delay in diagnosis. We then excluded claims in which the presenting condition was an alarm symptom or sign (defined as weight loss, dysphagia, or iron deficiency anemia), and those in which the presenting condition was an esophageal or cardia malignancy or an abnormal radiographic finding. Data on the presenting symptom were only available for 2002-2012.

Results

The database contained 278 220 claims filed against physicians in 1985-2012, and 103 381 in 2002-2012. A total of 761 claims in 1985-2012 were related to esophagogastroduodenoscopy (193 paid, 25.4%; average indemnity, $242 414). The leading types of misadventure alleged were improper performance (n = 267), errors in diagnosis (n = 186), and no medical misadventure (ie, claims that did not involve a purely medical error, such as abandonment, breach of confidentiality, or consent issues) (n = 147). Seventeen claims (2.2%) alleged inadequate indication for esophagogastroduodenoscopy (8 paid, 47.1%; average indemnity, $174 634). Due to the small number of cases, database policies restricted access to information regarding presenting condition.

A total of 268 claims in 1985-2012 involved esophageal malignancies, including 122 in 2002-2012 (30 paid, 24.6%; average indemnity, $354 175). Of these 122 claims, 62 (50.8%) alleged delay in diagnosis. Nineteen claims reported nonalarm presenting symptoms (4 paid, 21.1%; average indemnity, $475 000) (Table).

Discussion

We sought to contextualize the incidence of reported medical professional liability claims in acts of omission (failure to screen) by comparing it with the incidence of reported liability claims in acts of commission (arising from complications of esophagogastroduodenoscopy in which the indication was insufficient). We found a low incidence of reported medical professional liability claims against physicians for failure to screen for esophageal cancer in patients without alarm features (19 claims in 11 years, 4 paid). In contrast, in 28 years, there were 17 claims for complications from esophagogastroduodenoscopies with questionable indication (8 paid). This suggests that the risks of medical professional liability claims arising from acts of commission as well as acts of omission in endoscopic screening are similarly low.

Limitations include an inability to distinguish squamous cell carcinoma from adenocarcinoma, potential for misclassification of alarm symptoms, and the lack of data on presenting medical symptom for claims alleging inadequate indication for esophagogastroduodenoscopy or how many occurred in 2002-2012.

There may be legitimate reasons to screen for esophageal cancer in some patients, but our findings suggest that the risk of a medical professional liability claim for failing to screen is not one of them. Physicians need to balance the risk of complications from diagnostic procedures, even if those complications are rare.

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Article Information
Section Editor: Jody W. Zylke, MD, Senior Editor.

Corresponding Author: Megan A. Adams, MD, JD, Division of Gastroenterology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (meganada@med.umich.edu).

Author Contributions: Dr Rubenstein had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Adams, Rubenstein.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Adams.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Adams.

Administrative, technical, or material support: Parikh, Miller.

Study supervision: Rubenstein.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

References
1.
Shaheen  NJ, Weinberg  DS, Denberg  TD, Chou  R, Qaseem  A, Shekelle  P; Clinical Guidelines Committee of the American College of Physicians.  Upper endoscopy for gastroesophageal reflux disease: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med. 2012;157(11):808-816.
PubMedArticle
2.
Spechler  SJ, Sharma  P, Souza  RF, Inadomi  JM, Shaheen  NJ; American Gastroenterological Association.  American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. Gastroenterology. 2011;140(3):1084-1091.
PubMedArticle
3.
Wang  KK, Sampliner  RE; Practice Parameters Committee of the American College of Gastroenterology.  Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J Gastroenterol. 2008;103(3):788-797.
PubMedArticle
4.
Rubenstein  JH, Saini  SD, Kuhn  L,  et al.  Influence of malpractice history on the practice of screening and surveillance for Barrett’s esophagus. Am J Gastroenterol. 2008;103(4):842-849.
PubMedArticle
5.
Ben-Menachem  T, Decker  GA, Early  DS,  et al; ASGE Standards of Practice Committee.  Adverse events of upper GI endoscopy. Gastrointest Endosc. 2012;76(4):707-718.
PubMedArticle
6.
Peery  AF, Dellon  ES, Lund  J,  et al Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology2012;143(5):1179-1187, e1-e3.
PubMedArticle
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