International Journal for Quality in Health Care Advance Access originally published online on March 14, 2006
International Journal for Quality in Health Care 2006 18(3):220-223; doi:10.1093/intqhc/mzl004
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Epidemiology of medical complaints in Mexico: identifying a general profile
1 National Institute of Public Health, Tuberculosis Unit, Cuernavaca, Morelos, 2 National Institute of Medical Sciences and Nutrition, Salvador Zubiran, Subdirection of Hospital Epidemiology and Quality of Medical Care, 3 Mexican Institute of Social Security, IMSS and 4 National Institute of Cancerology, General Direction, D.F., Mexico City, Mexico
Objective. To determine the problems that were the sources of the complaints most frequently received at the National Commission of Medical Arbitration (CONAMED) in Mexico, as well as the diagnoses most frequently related, the institutions involved, and the populations affected.
Design. From all complaints received from 1 January 1998 to 31 December 2000, we chose a random sample of 639 complaints and carried out our study using a cross-sectional design.
Setting. CONAMED receives complaints from Mexico City and the surrounding areas.
Participants. Patients attending public and private health institutions from the three levels of medical attention who submitted a complaint to the CONAMED in Mexico.
Main outcome measures. Assessment of health care quality (good practice or malpractice). Type of malpractice (negligence, lack of skill, or deceit). Main motives of complaint.
Results. We analyzed 639 complaints; 57.6% were submitted by women, average age 41.0 years. Surgical treatment was the main cause of complaint. Most frequent diagnoses were diseases of the digestive system. Evaluation of medical practice revealed 36.5% of malpractice. Lack of skill accounted for 67.4% of those cases.
Conclusions. Malpractice was identified in a third of the complaints, and lack of skill was the main reason for malpractice. Surgical patients were the most frequently affected. The other two-thirds of the complaints were related to lack of communication between patients and physicians. These results suggest potential points of intervention to decrease the risk and the conflict.
Keywords: malpractice, negligence, patient complaint
Address reprint requests to Maria-Eugenia Jimenez-Corona, Instituto Nacional de Salud Publica, Av. Universidad No. 655, Col. Sta. Maria Ahuacatitlan, C.P. 62508, Cuernavaca, Morelos, Mexico. E-mail: ejimenez{at}correo.insp.mx
Accepted for publication February 16, 2006.
Currently, there is an increasing international concern regarding medical errors and adverse events and their negative effect on morbidity, mortality, disability, and excess time in hospitals [1,2]. Medical error can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve a goal in clinical care. If the error harms the patient, it is known as an adverse event [3]. A medical complaint is an allegation made by patients or their relatives about presumed irregularities in the medical attention [4].
The National Commission of Medical Arbitration (CONAMED) was created in Mexico in 1996 to identify and solve problems related to medical care. It works as an independent agency of the Health Ministry. Its activities include solving complaints submitted by patients or by users of public and private health services through the use of alternative methods of dispute resolution, conciliation, and arbitration. CONAMED aims to establish a bridge between patients and physicians when conflict is present and to contribute to the improvement of medical care quality [5,6].
This study analyzes the problems that cause the most frequent complaints submitted to CONAMED, diagnoses involved, the health care institution, and care level where they occur. We evaluated the quality of medical practice and its impact on the affected population.
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Methods |
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Complaints received at CONAMED from 1 January 1998 to 31 December 2000 were analyzed using a cross-sectional design. From 5061 complaints, a random sample of 639 patients (considering alpha 0.05, power 0.80, and over-sample 10%) was calculated. The complaints were selected through stratified random sampling based on the type of medical institution attending: social security, public, and private services. Social security institutions provide medical services to an insured population that pays a monthly fee. Public institutions offer medical services to low-income, uninsured population. Private institutions provide medical services to patients who can afford them directly or through private insurance systems [7].
The sources of information were the System for the Attention of Medical Complaints (SAQMED), which consists of a dataset comprising all medical complaints received, and the Integral Medical Evaluation (IME) developed by the commission. The information included age, gender, diagnoses, type of health care institution, health care attention level (primary care, general hospitals, and specialty institutes), medical specialty, and practice quality (good practice or malpractice) analyzed through the IME.
Malpractice was classified into three categories: negligence, lack of skill, and deceit. Negligence means carelessness or omission; it can be legally equalled to lack of due haste or care in executing an act. Lack of skill is related to ignorance; a fault can be committed because of ignorance, lack of experience, or practice. Deceit is defined by intent and illegality, and the intent that is a component of deceit involves two aspects: willingness and knowledge. Thus, a person who is responsible for deceit must be aware of the wrongdoing or omission incurred, as well as its consequences, and decides to perform the fault anyway [8]. Diagnoses were classified in accordance with the 10th International Classification of Diseases [9].
Statistical analysis
Qualitative analysis was used to determine the cause of complaint, the specific problems related to the medical care, and the physician–patient relationship. Frequencies and percentages were calculated. Comparisons of categorical and continuous variables by medical practice (good medical practice and medical malpractice) were carried out using chi-squared and t-test when appropriate. To estimate the odds ratio (OR) between the studied variables and malpractice, logistic regression was used. The confounders were tested by comparing the coefficients with and without them in the models. To evaluate the fit of the model, we used Hosmer-Lemeshow test. The analysis was conducted using Stata 7.0. (Statistical software for data analysis, College Station, Texas 77845, USA)
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Results |
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The sample included 639 cases; 368 of them were women (57.6%). Average age was 41.0 years [standard deviation (SD), 21.0]. Comparisons between people included in the sample and people not included were done. We did not observe any significant difference by age, sex, health care institution, or health care attention level.
The most common reasons of complaint were related to surgical treatment (34.9%). The medical specialties most frequently involved in complaints were Obstetrics and Gynaecology (OBGYN) (15.6%), and Traumatology and Orthopaedics (12.7%); the remaining 72.7% corresponded to other specialties. The most frequent diagnoses were diseases of the digestive system (15.8%), followed by trauma (14.6%) and cancer (8.1%).
The outcome was (i) ‘patient improvement’ in 62.9% (n = 392); (ii) ‘temporary disability’ in 8.8% (n = 55); (iii) ‘permanent disability’ in 15.6% (n = 97); and (iv) ‘death’ in 12.7% (n = 79). Additionally, a qualitative analysis showed that in over 80% of complaints there were communication problems between physician and patient, such as lack of information or misunderstanding, the latter being most frequent.
The analysis to qualify medical practice revealed 60.7% (n = 388) of cases as good practice, 36.5% (n = 233) as malpractice, and 2.8% (n = 18) of cases in which there was not enough information to have a qualification. Lack of skill accounted for 67.4% of malpractice cases, negligence 30.0%, and deceit just 2.6%. No differences regarding gender, age, health care institution, or health care attention level according to type of medical practice were found (Table 1).
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Malpractice
In malpractice complaints, the most frequently involved medical areas were OBGYN (19.7%), emergency medicine (14.2%), and Trauma and Orthopaedics (9.0%). Malpractice complaints were most frequently associated with surgical treatment in 33.5% of cases (78/233) (Table 2).
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The distribution of diagnoses related to malpractice (n = 233) was similar to the distribution in the whole sample. The outcome in cases of medical malpractice was cure (66.5%), death (12.9%), permanent disability (11.6%), and temporary disability (9.0%).
In a bivariate analysis, no significant association was observed between health care institution, primary health care, surgery, emergency attention, and medical malpractice (Table 3). In a multivariate analysis, the variables associated with malpractice were medical care at the primary care level [OR, 2.09; confidence interval (CI) 95%, 1.09–4.01], surgery (OR, 1.81; CI 95%, 1.16–2.84), and emergency care (OR, 1.59; CI 95%, 0.93–2.70), after adjustment for other variables (Table 3).
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Discussion |
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In this study, we noticed a predominance of medical complaints from female patients. This trend could be associated with a higher demand of medical services on the part of women [10]. Most complaints came from social security institutions, which may be conditioned by several factors. For example, these institutions attend a higher number of users than do other institutions [11]. In the year 2000, 65.2% of hospital admissions in Mexico occurred in social security institutions [12]. On the other hand, less than 6% of the complaints originated in public institutions, which could be associated with a lower cultural and educational level on the part of users that may explain limited capabilities to make a complaint.
Whether there was medical malpractice or not, most complaints involved communication problems between patients and physicians. According to some studies, one of the most common problems between patients and the physician staff is lack of information and miscommunication [13].
Surgical emergencies such as appendicitis and cholecystitis were most frequently associated with malpractice and the consequent morbidity. Lack of skill was the most frequent problem in malpractice cases (67.4%). The high percentage of lack of skill points to a lack of supervision in training physicians, particularly in surgery, as well as to knowledge deficiencies. Those factors should be identified in a timely manner and corrected. It is noteworthy that all cases of deceit occurred in private institutions. On the other hand, the proportion of negligence cases identified in the complaints is similar to other studies [14].
Malpractice did not show significant differences by type of medical care institution, specifically private versus public or social security institutions. These results are in contrast to the general belief that medical care given in private health care centres is better than that given by social security health systems [15]. This is an important finding of our study, considering the high cost of medical attention in private institutions. Finally, in terms of the level of medical care, malpractice was more common in primary care institutions, which leads us to assume that the higher the level of attention, the better training and education the physician staff has.
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Conclusions |
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The main cause of complaint was associated with surgical treatment. Behind the main reason for a complaint was a lack of communication between the physician and the patient.
Patients who received medical attention at the primary care level, and those who underwent a surgery, had a higher risk of suffering an adverse event because of medical malpractice. Considering the main type of malpractice (lack of experience) involved, we think that adverse events and medical errors are likely to decrease through improved supervision.
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Acknowledgements |
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The authors thank CONAMED, particularly Dr Carlos Tena, Lic. Agustin Ramirez, and Dr Gabriel R. Manuell for their support of this study.
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References |
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