A new study by The Physician Insurers Assoc. reported a study on heart attack diagnosis-related malpractice claims shows that family practitioners and general internists have the highest number of malpractice claims and the highest average indemnity payments, respectively, of any physician group. The results suggest that heart attack is difficult to diagnose and easily confused with a plethora of other conditions.

According to the study, heart attack (acute myocardial infarction) is the third most expensive medical condition leading to claims against physicians, after those involving brain-damaged infants and breast cancer. The study evaluated medical malpractice information on paid claims related to heart attacks with an accident date since January 1985. Twenty-seven member insurance companies participated in the study, reporting a total of 349 paid cases related to heart attack. The total indemnity value for the claims reported is more than $91 million.
Family physicians were the target of the highest number of claims (160 of 423 defendants). Internal medicine physicians, the group with the second highest number of claims filed against it, had the highest average indemnity payment for any specialty group, at $252,100.

The study revealed some surprising patient demographics. Of the claimants who had suffered acute myocardial infarctions, nearly 70 percent reported no prior history of coronary artery disease; 83 percent reported no previous heart attacks; 47 percent were under the age of 50, with 76 percent of those reporting no previous history of a heart attack; and nearly 16 percent were under the age of 40, accounting for almost one-quarter of total payments.

Heart attack symptoms closely resembled those of other diseases, making claims due to diagnostic errors the most prevalent. A total of 304 providers were sued for allegations involving diagnostic misadventures related to acute myocardial infarctions. The most common initial diagnosis made in error by the provider was that of a gastrointestinal complaint, followed by musculoskeletal pain; angina; a respiratory ailment, such as bronchitis, pneumonia or asthma; and anxiety.

For those cases involving diagnostic errors, the provider ordered an electrocardiogram (EKG) in 59 percent of the cases. However, in 28 percent of the cases, no diagnostic studies of any kind were performed,
In the majority of the cases in which an EKG was performed but the provider failed to make the diagnosis, the EKG was either misinterpreted or the results were not conveyed to the provider in a timely fashion. Surprisingly, 277 of the 304 providers who were sued for diagnostic errors did not correctly diagnose the heart attack at all. Of these, 220 did not refer the patient to another provider.
Claimants filed allegations of treatment errors in 154 cases. Significantly, 109 cases in this study involved an allegation related to both diagnostic and treatment issues. In 22 of the 154 cases, patients received no treatment at all. The treatment error alleged most frequently was a delay in hospitalization, which occurred 46 percent of the time. Delay in performing a follow-up procedure was the second most common treatment error. Other errors included not seeking a consultation or referral; prematurely discharging a patient from the emergency room; or treating for another diagnosis.

Allegedly, 77 percent of patients died as a result of the diagnostic and treatment errors.
Family practice physicians had the highest number of medical malpractice claims but comparatively low average payments for problems involved with diagnosing and treating heart attacks. Internists, who had the second highest number of claims filed, had the highest average indemnity payment of any specialty group ($252,100). This is 35 percent higher than the overall average indemnity payment for all physicians in the study. Emergency medicine physicians received the third largest number of claims in the study, with an average of $180,800 per claim.

Heart Attack Warnings

The Physician Insurers Association of America has issued these risk-management recommendations for health care practitioners involved in diagnosing and treating heart attacks:

Document the results of previous cardiac studies, and compare them with the results of present studies.
Document all patient complaints relative to pain/pressure and its location.
Document a thorough personal history as well as a family history of heart disease for each patient, including complete risk factor profiles.
Do not rule out the diagnosis of a heart attack in younger patients.
Follow any patient presenting with any symptoms indicative of a heart condition until the diagnosis is ruled out, even if the diagnostic testing is inconclusive.
If clinical suspicion is present, despite unchanged or negative electrocardiogram results, recommend an exercise tolerance test.
Have the same index of suspicion for the patient who presents in the office as for those who present in the emergency room.
Promptly report any positive test findings to the referring physician, and follow up with other physician consultants.

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