Supriya Raman, BE, MS

The hospitalist model of care is becoming an increasingly prominent part of the inpatient clinical landscape. The percentage of hospitals in which hospitalists provide care has risen every year since 2003, and this trend is anticipated to continue.[1] In 2010, 59.8% of hospitals reported utilizing hospitalists to provide care, with a prevalence as high as 84.9% in New England.[1] Though the model started within internal medicine,[2] hospitalists can now be found in multiple medical disciplines including pediatrics, neurology, obstetrics‐gynecology, and orthopedics.[3] This model has many strengths, which include an improved provider presence in the hospital for acute issues, as well as a better understanding of hospital operations and knowledge of inpatient care. However, concerns have been raised that the hospitalist model, which does not usually involve longitudinal relationships with patients and introduces discontinuities in care, could carry a higher risk of malpractice claims.[4, 5, 6]

However, little is known about whether the hospitalist model actually leads to greater liability. Theoretical analyses suggest that failure to provide adequate follow up care, especially with regard to tests pending at discharge, may be a source of greater medical liability risk for hospitalists.[7] Coordination of care with consulting specialists and supervision of trainees may also be areas of increased liability risk.[7, 8] Prior research evaluating the difference in malpractice payments between the inpatient and outpatient settings found that the mean payment amounts were significantly higher in the inpatient setting.[9] Another study examined the rates of malpractice claims against physicians and determined that internal medicine physicians were at average risk of claims compared to other specialties.[10] However, none of the available data have provided direct information on liability risks specific to the hospitalist model.

METHODS

RESULTS

We identified 272 medical malpractice claims against hospitalists. The mean age of the claimants was 56 years (standard deviation, 22 years). Claimants were 51.8% female and 44.5% male (gender not available for 3.7%).

The rate of claims against hospitalists (0.52 claims per 100 PCYs; 95% CI: 0.30‐0.85) was significantly lower than the rate of claims against nonhospitalist internal medicine physicians (1.91 claims per 100 PCYs; 95% CI: 1.73‐2.11), as well as the other physician types studied (P<0.001 for all claims rate comparisons) (Table 1). The rate of claims against nonhospitalist internal medicine physicians and emergency medicine physicians were approximately 3.5 times and 7 times, respectively, the rate of claims against hospitalists.

The most common types of allegations against hospitalists were for issues related to medical treatment (41.5%; 95% CI: 35.6%‐47.6%) and diagnosis‐related claims (36.0%; 95% CI: 30.3%‐42.0) (Table 2). The most common steps in the diagnostic process implicated in the diagnosis‐related allegations were errors in the ordering of diagnostic or lab tests (16.2%; 95% CI: 12.0%‐21.1%) and the performance of the history and physical (12.1%; 95% CI: 8.5%‐16.6%).

The most common categories of contributing factors were errors in clinical judgment (54.4%; 95% CI: 48.3%‐60.4%) and lapses in communication (encompassing communication among clinicians and between the clinician and patient) (36.4%; 95% CI: 30.7%‐42.4%) (Table 3). Issues involving transitions of care were a factor in 37.9% of cases (95% CI: 32.1%‐43.9%). Supervision of housestaff was a factor in 1.5% of cases (95% CI: 0.4%‐3.7%).

The percentage of claims involving a patient death was significantly higher among hospitalist cases (50.4%; 95% CI: 44.3%‐56.5%) compared to all other inpatient cases (29.1%; 95% CI: 28.4%‐29.8%) or outpatient cases (18.2%; 95% CI: 17.6%‐18.9%) (P<0.001 for both comparisons), but lower than nonhospitalist inpatient internal medicine cases (57.6%; 95% CI: 54.6%‐60.5%) (P=0.035) (Table 4).

There were no significant differences in the percentage of hospitalist cases in which payment was made (32.0%; 95% CI: 26.5%‐37.9%) compared to any of the other 3 groups studied (Table 5). The median payment in hospitalist cases, $240,000 (interquartile range [IQR]: $100,000$524,245), was significantly higher than that in all other inpatient cases ($156,714; IQR: $39,188$488,996) (P=0.040) and in outpatient cases ($92,671; IQR: $20,895$325,461) (P<0.001), though not significantly different than the median payment in all other inpatient internal medicine cases ($206,314; IQR: $57,382$488,996).

DISCUSSION

In our analysis of closed medical malpractice claims, we found that hospitalists have a significantly lower rate of claims compared to the other types of physicians studied, including other internal medicine physicians and emergency medicine physicians. Although hospitalists had a relatively low rate of claims, the severity of injury involved in those claims was high.

Prior research has found that the proportion of internal medicine physicians who face a malpractice claim each year is between 7% and 8%.[10] The rate of claims against internal medicine physicians in this prior study was similar to that of emergency medicine physicians, who, like hospitalists, are defined by their site of practice. In addition, both frequently work with acutely ill patients with whom they do not have a longitudinal relationship. However, this prior analysis did not assess for any difference in malpractice risk based on whether internal medicine physicians were practicing primarily as outpatient physicians or as hospitalists, and so the liability risk of hospitalists (as opposed to internal medicine physicians generally) remains undefined. Our analysis sought to determine whether there is a difference in claims rates when adopting a hospitalist model.

Notably, two factors have been raised as potentially increasing the risk that hospitalists will be subject to malpractice claims. The first is that hospitalists have only a brief relationship with their patients, thus limiting their ability to form the strong physician‐patient relationships that decrease the likelihood of a malpractice claim.[14, 15, 16, 17] Second, hospitalists face the challenge of transitions of care as patients move from the outpatient to the inpatient setting, and vice versa.[4, 7, 18, 19] Despite these theoretical concerns, we found that hospitalists face a relatively low rate of claims compared to other physicians. The reasons for this low liability risk remain uncertain.

One possible explanation for this relatively low rate of claims against hospitalists is that hospitalists are actually at lower risk of missing a diagnosis, the most common reason for a malpractice claim in the ambulatory setting.[20, 21, 22] In contrast to how patients may present in the clinic or the emergency department, when patients are admitted to the hospital, it is likely that they present to the hospitalist with a known problem, rather than a clinical symptom without an etiology. For example, when a patient is admitted to the hospital for chest pain, other physicians may have already been concerned enough to raise clinical suspicion of a myocardial infarction and order basic testing, making the diagnosis less likely to be missed when the hospitalist assumes care of that patient. Indeed, we found that, among the claims made against hospitalists, the leading type of allegation was an error in treatment rather than an error in diagnosis.

It is also possible that the lower rate of claims against hospitalists reflects the high quality of care provided by hospitalists, resulting from their clinical expertise and knowledge of hospital systems. High clinical volume is associated with better outcomes for multiple surgical procedures,[23] and, to a lesser degree, for certain medical conditions.[24] Because hospitalists are likely to see a high volume of those medical conditions that regularly require admission to an inpatient medical service, this high volume could translate into higher quality of care, both because of medical expertise in managing these conditions and because of proficiency in dealing with hospital systems. However, this theory must be tempered by the conclusion from earlier work that did not show a large difference in outcomes among patients cared for by hospitalists.[25]

Another reason for the lower claims rate could be a direct result of how hospitalist jobs are structured. In prior research, an inadequate physician‐patient relationship has been found to be a factor in patients deciding to file a malpractice claim.[14, 15, 16, 17] Although hospitalists usually only care for their patients during the few days of the hospital admission, hospitalists are on site all day and thus are able to frequently communicate with patients and families face to face. This level of interaction may allow for a sufficiently healthy, even if time‐limited, physician‐patient relationship that meets patients' expectations.

For the claims that occur, deficiencies in communication and transitions of care, both of which have been cited as a special concern for hospitalists, were in fact present in 37.9% of the hospitalist cases we evaluated.[7] This proportion appears to be higher than previous work in the ambulatory setting that showed communication generally to be a factor in 30% of cases, and problems related to handoffs specifically to be a factor in 20% of cases.[20] These findings highlight the risks associated with the discontinuities inherent in the hospitalist model, which can occur on admission, during the hospitalization (where a number of hospitalists may care for one patient), and on discharge. These findings also point to the need for ongoing efforts to address these concerns.

More than half of the claims against hospitalists (50.4%; 95% CI: 44.3%‐56.5%) involved the death of the patient. However, this high rate of claims involving the death of the patient did not appear to be specific to hospitalists. Rather, this appeared to be true for inpatient internal medicine cases generally, because the rate of claims in which the severity of injury was death was significantly higher among nonhospitalist inpatient internal medicine cases (57.6%; 95% CI: 54.6%‐60.5%).

Our study has several limitations. Though the database that we used includes hospitals and physician groups from 20 different liability carriers covering multiple regions across the country, it nonetheless may not be entirely representative, especially given the variation in the hospitalist models used at different institutions (for example, coverage of intensive care unit patients) and because of geographic variability. However, the sample did contain a large proportion (approximately 30%) of closed claims nationally. Claims rates are based on data from a single insurance carrier, albeit one with 23,847 PCYs among internal medicine physicians during the study period. Second, we defined hospitalist cases as those cases in which the hospitalist was the attending of record at the time of the clinical event that gave rise to the malpractice claim. It is possible that this definition captured claims in which the hospitalist, although the attending of record, may not have been directly involved in the care leading to the claim (for example, a problem with a surgery gave rise to the claim). Third, we assessed liability risk by years covered, which does not account for risk that may vary based on clinical volume.

Overall, our results suggest that liability fears should not impede the adoption of the hospitalist model in internal medicine. Not only do hospitalists have a lower rate of claims, but there is also no difference in the rate at which claims are paid or mean indemnity amounts for the claims that are paid for hospitalists. Previous analyses of the costs associated with care by hospitalists, compared to care by other types of physicians, have not taken into account the decreased liability costs that are likely associated with care provided by hospitalists.[25, 26]

In conclusion, contrary to concerns that have been raised, we found that hospitalists face a lower rate of malpractice claims when compared to other internal medicine physicians and specialties. However, we did find that care discontinuities may be resulting in liability risk due to communication and handoff‐related errors. Improvements in the hospitalist model of care targeted at improving communication and clinical judgment may not only further reduce claims against hospitalists, but also improve the safety of care associated with this model.

The hospitalist model of care is becoming an increasingly prominent part of the inpatient clinical landscape. The percentage of hospitals in which hospitalists provide care has risen every year since 2003, and this trend is anticipated to continue.[1] In 2010, 59.8% of hospitals reported utilizing hospitalists to provide care, with a prevalence as high as 84.9% in New England.[1] Though the model started within internal medicine,[2] hospitalists can now be found in multiple medical disciplines including pediatrics, neurology, obstetrics‐gynecology, and orthopedics.[3] This model has many strengths, which include an improved provider presence in the hospital for acute issues, as well as a better understanding of hospital operations and knowledge of inpatient care. However, concerns have been raised that the hospitalist model, which does not usually involve longitudinal relationships with patients and introduces discontinuities in care, could carry a higher risk of malpractice claims.[4, 5, 6]

However, little is known about whether the hospitalist model actually leads to greater liability. Theoretical analyses suggest that failure to provide adequate follow up care, especially with regard to tests pending at discharge, may be a source of greater medical liability risk for hospitalists.[7] Coordination of care with consulting specialists and supervision of trainees may also be areas of increased liability risk.[7, 8] Prior research evaluating the difference in malpractice payments between the inpatient and outpatient settings found that the mean payment amounts were significantly higher in the inpatient setting.[9] Another study examined the rates of malpractice claims against physicians and determined that internal medicine physicians were at average risk of claims compared to other specialties.[10] However, none of the available data have provided direct information on liability risks specific to the hospitalist model.

METHODS

RESULTS

We identified 272 medical malpractice claims against hospitalists. The mean age of the claimants was 56 years (standard deviation, 22 years). Claimants were 51.8% female and 44.5% male (gender not available for 3.7%).

The rate of claims against hospitalists (0.52 claims per 100 PCYs; 95% CI: 0.30‐0.85) was significantly lower than the rate of claims against nonhospitalist internal medicine physicians (1.91 claims per 100 PCYs; 95% CI: 1.73‐2.11), as well as the other physician types studied (P<0.001 for all claims rate comparisons) (Table 1). The rate of claims against nonhospitalist internal medicine physicians and emergency medicine physicians were approximately 3.5 times and 7 times, respectively, the rate of claims against hospitalists.

The most common types of allegations against hospitalists were for issues related to medical treatment (41.5%; 95% CI: 35.6%‐47.6%) and diagnosis‐related claims (36.0%; 95% CI: 30.3%‐42.0) (Table 2). The most common steps in the diagnostic process implicated in the diagnosis‐related allegations were errors in the ordering of diagnostic or lab tests (16.2%; 95% CI: 12.0%‐21.1%) and the performance of the history and physical (12.1%; 95% CI: 8.5%‐16.6%).

The most common categories of contributing factors were errors in clinical judgment (54.4%; 95% CI: 48.3%‐60.4%) and lapses in communication (encompassing communication among clinicians and between the clinician and patient) (36.4%; 95% CI: 30.7%‐42.4%) (Table 3). Issues involving transitions of care were a factor in 37.9% of cases (95% CI: 32.1%‐43.9%). Supervision of housestaff was a factor in 1.5% of cases (95% CI: 0.4%‐3.7%).

The percentage of claims involving a patient death was significantly higher among hospitalist cases (50.4%; 95% CI: 44.3%‐56.5%) compared to all other inpatient cases (29.1%; 95% CI: 28.4%‐29.8%) or outpatient cases (18.2%; 95% CI: 17.6%‐18.9%) (P<0.001 for both comparisons), but lower than nonhospitalist inpatient internal medicine cases (57.6%; 95% CI: 54.6%‐60.5%) (P=0.035) (Table 4).

There were no significant differences in the percentage of hospitalist cases in which payment was made (32.0%; 95% CI: 26.5%‐37.9%) compared to any of the other 3 groups studied (Table 5). The median payment in hospitalist cases, $240,000 (interquartile range [IQR]: $100,000$524,245), was significantly higher than that in all other inpatient cases ($156,714; IQR: $39,188$488,996) (P=0.040) and in outpatient cases ($92,671; IQR: $20,895$325,461) (P<0.001), though not significantly different than the median payment in all other inpatient internal medicine cases ($206,314; IQR: $57,382$488,996).

DISCUSSION

In our analysis of closed medical malpractice claims, we found that hospitalists have a significantly lower rate of claims compared to the other types of physicians studied, including other internal medicine physicians and emergency medicine physicians. Although hospitalists had a relatively low rate of claims, the severity of injury involved in those claims was high.

Prior research has found that the proportion of internal medicine physicians who face a malpractice claim each year is between 7% and 8%.[10] The rate of claims against internal medicine physicians in this prior study was similar to that of emergency medicine physicians, who, like hospitalists, are defined by their site of practice. In addition, both frequently work with acutely ill patients with whom they do not have a longitudinal relationship. However, this prior analysis did not assess for any difference in malpractice risk based on whether internal medicine physicians were practicing primarily as outpatient physicians or as hospitalists, and so the liability risk of hospitalists (as opposed to internal medicine physicians generally) remains undefined. Our analysis sought to determine whether there is a difference in claims rates when adopting a hospitalist model.

Notably, two factors have been raised as potentially increasing the risk that hospitalists will be subject to malpractice claims. The first is that hospitalists have only a brief relationship with their patients, thus limiting their ability to form the strong physician‐patient relationships that decrease the likelihood of a malpractice claim.[14, 15, 16, 17] Second, hospitalists face the challenge of transitions of care as patients move from the outpatient to the inpatient setting, and vice versa.[4, 7, 18, 19] Despite these theoretical concerns, we found that hospitalists face a relatively low rate of claims compared to other physicians. The reasons for this low liability risk remain uncertain.

One possible explanation for this relatively low rate of claims against hospitalists is that hospitalists are actually at lower risk of missing a diagnosis, the most common reason for a malpractice claim in the ambulatory setting.[20, 21, 22] In contrast to how patients may present in the clinic or the emergency department, when patients are admitted to the hospital, it is likely that they present to the hospitalist with a known problem, rather than a clinical symptom without an etiology. For example, when a patient is admitted to the hospital for chest pain, other physicians may have already been concerned enough to raise clinical suspicion of a myocardial infarction and order basic testing, making the diagnosis less likely to be missed when the hospitalist assumes care of that patient. Indeed, we found that, among the claims made against hospitalists, the leading type of allegation was an error in treatment rather than an error in diagnosis.

It is also possible that the lower rate of claims against hospitalists reflects the high quality of care provided by hospitalists, resulting from their clinical expertise and knowledge of hospital systems. High clinical volume is associated with better outcomes for multiple surgical procedures,[23] and, to a lesser degree, for certain medical conditions.[24] Because hospitalists are likely to see a high volume of those medical conditions that regularly require admission to an inpatient medical service, this high volume could translate into higher quality of care, both because of medical expertise in managing these conditions and because of proficiency in dealing with hospital systems. However, this theory must be tempered by the conclusion from earlier work that did not show a large difference in outcomes among patients cared for by hospitalists.[25]

Another reason for the lower claims rate could be a direct result of how hospitalist jobs are structured. In prior research, an inadequate physician‐patient relationship has been found to be a factor in patients deciding to file a malpractice claim.[14, 15, 16, 17] Although hospitalists usually only care for their patients during the few days of the hospital admission, hospitalists are on site all day and thus are able to frequently communicate with patients and families face to face. This level of interaction may allow for a sufficiently healthy, even if time‐limited, physician‐patient relationship that meets patients' expectations.

For the claims that occur, deficiencies in communication and transitions of care, both of which have been cited as a special concern for hospitalists, were in fact present in 37.9% of the hospitalist cases we evaluated.[7] This proportion appears to be higher than previous work in the ambulatory setting that showed communication generally to be a factor in 30% of cases, and problems related to handoffs specifically to be a factor in 20% of cases.[20] These findings highlight the risks associated with the discontinuities inherent in the hospitalist model, which can occur on admission, during the hospitalization (where a number of hospitalists may care for one patient), and on discharge. These findings also point to the need for ongoing efforts to address these concerns.

More than half of the claims against hospitalists (50.4%; 95% CI: 44.3%‐56.5%) involved the death of the patient. However, this high rate of claims involving the death of the patient did not appear to be specific to hospitalists. Rather, this appeared to be true for inpatient internal medicine cases generally, because the rate of claims in which the severity of injury was death was significantly higher among nonhospitalist inpatient internal medicine cases (57.6%; 95% CI: 54.6%‐60.5%).

Our study has several limitations. Though the database that we used includes hospitals and physician groups from 20 different liability carriers covering multiple regions across the country, it nonetheless may not be entirely representative, especially given the variation in the hospitalist models used at different institutions (for example, coverage of intensive care unit patients) and because of geographic variability. However, the sample did contain a large proportion (approximately 30%) of closed claims nationally. Claims rates are based on data from a single insurance carrier, albeit one with 23,847 PCYs among internal medicine physicians during the study period. Second, we defined hospitalist cases as those cases in which the hospitalist was the attending of record at the time of the clinical event that gave rise to the malpractice claim. It is possible that this definition captured claims in which the hospitalist, although the attending of record, may not have been directly involved in the care leading to the claim (for example, a problem with a surgery gave rise to the claim). Third, we assessed liability risk by years covered, which does not account for risk that may vary based on clinical volume.

Overall, our results suggest that liability fears should not impede the adoption of the hospitalist model in internal medicine. Not only do hospitalists have a lower rate of claims, but there is also no difference in the rate at which claims are paid or mean indemnity amounts for the claims that are paid for hospitalists. Previous analyses of the costs associated with care by hospitalists, compared to care by other types of physicians, have not taken into account the decreased liability costs that are likely associated with care provided by hospitalists.[25, 26]

In conclusion, contrary to concerns that have been raised, we found that hospitalists face a lower rate of malpractice claims when compared to other internal medicine physicians and specialties. However, we did find that care discontinuities may be resulting in liability risk due to communication and handoff‐related errors. Improvements in the hospitalist model of care targeted at improving communication and clinical judgment may not only further reduce claims against hospitalists, but also improve the safety of care associated with this model.

The hospitalist model of care is becoming an increasingly prominent part of the inpatient clinical landscape. The percentage of hospitals in which hospitalists provide care has risen every year since 2003, and this trend is anticipated to continue.[1] In 2010, 59.8% of hospitals reported utilizing hospitalists to provide care, with a prevalence as high as 84.9% in New England.[1] Though the model started within internal medicine,[2] hospitalists can now be found in multiple medical disciplines including pediatrics, neurology, obstetrics‐gynecology, and orthopedics.[3] This model has many strengths, which include an improved provider presence in the hospital for acute issues, as well as a better understanding of hospital operations and knowledge of inpatient care. However, concerns have been raised that the hospitalist model, which does not usually involve longitudinal relationships with patients and introduces discontinuities in care, could carry a higher risk of malpractice claims.[4, 5, 6]

However, little is known about whether the hospitalist model actually leads to greater liability. Theoretical analyses suggest that failure to provide adequate follow up care, especially with regard to tests pending at discharge, may be a source of greater medical liability risk for hospitalists.[7] Coordination of care with consulting specialists and supervision of trainees may also be areas of increased liability risk.[7, 8] Prior research evaluating the difference in malpractice payments between the inpatient and outpatient settings found that the mean payment amounts were significantly higher in the inpatient setting.[9] Another study examined the rates of malpractice claims against physicians and determined that internal medicine physicians were at average risk of claims compared to other specialties.[10] However, none of the available data have provided direct information on liability risks specific to the hospitalist model.

METHODS

RESULTS

We identified 272 medical malpractice claims against hospitalists. The mean age of the claimants was 56 years (standard deviation, 22 years). Claimants were 51.8% female and 44.5% male (gender not available for 3.7%).

The rate of claims against hospitalists (0.52 claims per 100 PCYs; 95% CI: 0.30‐0.85) was significantly lower than the rate of claims against nonhospitalist internal medicine physicians (1.91 claims per 100 PCYs; 95% CI: 1.73‐2.11), as well as the other physician types studied (P<0.001 for all claims rate comparisons) (Table 1). The rate of claims against nonhospitalist internal medicine physicians and emergency medicine physicians were approximately 3.5 times and 7 times, respectively, the rate of claims against hospitalists.

The most common types of allegations against hospitalists were for issues related to medical treatment (41.5%; 95% CI: 35.6%‐47.6%) and diagnosis‐related claims (36.0%; 95% CI: 30.3%‐42.0) (Table 2). The most common steps in the diagnostic process implicated in the diagnosis‐related allegations were errors in the ordering of diagnostic or lab tests (16.2%; 95% CI: 12.0%‐21.1%) and the performance of the history and physical (12.1%; 95% CI: 8.5%‐16.6%).

The most common categories of contributing factors were errors in clinical judgment (54.4%; 95% CI: 48.3%‐60.4%) and lapses in communication (encompassing communication among clinicians and between the clinician and patient) (36.4%; 95% CI: 30.7%‐42.4%) (Table 3). Issues involving transitions of care were a factor in 37.9% of cases (95% CI: 32.1%‐43.9%). Supervision of housestaff was a factor in 1.5% of cases (95% CI: 0.4%‐3.7%).

The percentage of claims involving a patient death was significantly higher among hospitalist cases (50.4%; 95% CI: 44.3%‐56.5%) compared to all other inpatient cases (29.1%; 95% CI: 28.4%‐29.8%) or outpatient cases (18.2%; 95% CI: 17.6%‐18.9%) (P<0.001 for both comparisons), but lower than nonhospitalist inpatient internal medicine cases (57.6%; 95% CI: 54.6%‐60.5%) (P=0.035) (Table 4).

There were no significant differences in the percentage of hospitalist cases in which payment was made (32.0%; 95% CI: 26.5%‐37.9%) compared to any of the other 3 groups studied (Table 5). The median payment in hospitalist cases, $240,000 (interquartile range [IQR]: $100,000$524,245), was significantly higher than that in all other inpatient cases ($156,714; IQR: $39,188$488,996) (P=0.040) and in outpatient cases ($92,671; IQR: $20,895$325,461) (P<0.001), though not significantly different than the median payment in all other inpatient internal medicine cases ($206,314; IQR: $57,382$488,996).

DISCUSSION

In our analysis of closed medical malpractice claims, we found that hospitalists have a significantly lower rate of claims compared to the other types of physicians studied, including other internal medicine physicians and emergency medicine physicians. Although hospitalists had a relatively low rate of claims, the severity of injury involved in those claims was high.

Prior research has found that the proportion of internal medicine physicians who face a malpractice claim each year is between 7% and 8%.[10] The rate of claims against internal medicine physicians in this prior study was similar to that of emergency medicine physicians, who, like hospitalists, are defined by their site of practice. In addition, both frequently work with acutely ill patients with whom they do not have a longitudinal relationship. However, this prior analysis did not assess for any difference in malpractice risk based on whether internal medicine physicians were practicing primarily as outpatient physicians or as hospitalists, and so the liability risk of hospitalists (as opposed to internal medicine physicians generally) remains undefined. Our analysis sought to determine whether there is a difference in claims rates when adopting a hospitalist model.

Notably, two factors have been raised as potentially increasing the risk that hospitalists will be subject to malpractice claims. The first is that hospitalists have only a brief relationship with their patients, thus limiting their ability to form the strong physician‐patient relationships that decrease the likelihood of a malpractice claim.[14, 15, 16, 17] Second, hospitalists face the challenge of transitions of care as patients move from the outpatient to the inpatient setting, and vice versa.[4, 7, 18, 19] Despite these theoretical concerns, we found that hospitalists face a relatively low rate of claims compared to other physicians. The reasons for this low liability risk remain uncertain.

One possible explanation for this relatively low rate of claims against hospitalists is that hospitalists are actually at lower risk of missing a diagnosis, the most common reason for a malpractice claim in the ambulatory setting.[20, 21, 22] In contrast to how patients may present in the clinic or the emergency department, when patients are admitted to the hospital, it is likely that they present to the hospitalist with a known problem, rather than a clinical symptom without an etiology. For example, when a patient is admitted to the hospital for chest pain, other physicians may have already been concerned enough to raise clinical suspicion of a myocardial infarction and order basic testing, making the diagnosis less likely to be missed when the hospitalist assumes care of that patient. Indeed, we found that, among the claims made against hospitalists, the leading type of allegation was an error in treatment rather than an error in diagnosis.

It is also possible that the lower rate of claims against hospitalists reflects the high quality of care provided by hospitalists, resulting from their clinical expertise and knowledge of hospital systems. High clinical volume is associated with better outcomes for multiple surgical procedures,[23] and, to a lesser degree, for certain medical conditions.[24] Because hospitalists are likely to see a high volume of those medical conditions that regularly require admission to an inpatient medical service, this high volume could translate into higher quality of care, both because of medical expertise in managing these conditions and because of proficiency in dealing with hospital systems. However, this theory must be tempered by the conclusion from earlier work that did not show a large difference in outcomes among patients cared for by hospitalists.[25]

Another reason for the lower claims rate could be a direct result of how hospitalist jobs are structured. In prior research, an inadequate physician‐patient relationship has been found to be a factor in patients deciding to file a malpractice claim.[14, 15, 16, 17] Although hospitalists usually only care for their patients during the few days of the hospital admission, hospitalists are on site all day and thus are able to frequently communicate with patients and families face to face. This level of interaction may allow for a sufficiently healthy, even if time‐limited, physician‐patient relationship that meets patients' expectations.

For the claims that occur, deficiencies in communication and transitions of care, both of which have been cited as a special concern for hospitalists, were in fact present in 37.9% of the hospitalist cases we evaluated.[7] This proportion appears to be higher than previous work in the ambulatory setting that showed communication generally to be a factor in 30% of cases, and problems related to handoffs specifically to be a factor in 20% of cases.[20] These findings highlight the risks associated with the discontinuities inherent in the hospitalist model, which can occur on admission, during the hospitalization (where a number of hospitalists may care for one patient), and on discharge. These findings also point to the need for ongoing efforts to address these concerns.

More than half of the claims against hospitalists (50.4%; 95% CI: 44.3%‐56.5%) involved the death of the patient. However, this high rate of claims involving the death of the patient did not appear to be specific to hospitalists. Rather, this appeared to be true for inpatient internal medicine cases generally, because the rate of claims in which the severity of injury was death was significantly higher among nonhospitalist inpatient internal medicine cases (57.6%; 95% CI: 54.6%‐60.5%).

Our study has several limitations. Though the database that we used includes hospitals and physician groups from 20 different liability carriers covering multiple regions across the country, it nonetheless may not be entirely representative, especially given the variation in the hospitalist models used at different institutions (for example, coverage of intensive care unit patients) and because of geographic variability. However, the sample did contain a large proportion (approximately 30%) of closed claims nationally. Claims rates are based on data from a single insurance carrier, albeit one with 23,847 PCYs among internal medicine physicians during the study period. Second, we defined hospitalist cases as those cases in which the hospitalist was the attending of record at the time of the clinical event that gave rise to the malpractice claim. It is possible that this definition captured claims in which the hospitalist, although the attending of record, may not have been directly involved in the care leading to the claim (for example, a problem with a surgery gave rise to the claim). Third, we assessed liability risk by years covered, which does not account for risk that may vary based on clinical volume.

Overall, our results suggest that liability fears should not impede the adoption of the hospitalist model in internal medicine. Not only do hospitalists have a lower rate of claims, but there is also no difference in the rate at which claims are paid or mean indemnity amounts for the claims that are paid for hospitalists. Previous analyses of the costs associated with care by hospitalists, compared to care by other types of physicians, have not taken into account the decreased liability costs that are likely associated with care provided by hospitalists.[25, 26]

In conclusion, contrary to concerns that have been raised, we found that hospitalists face a lower rate of malpractice claims when compared to other internal medicine physicians and specialties. However, we did find that care discontinuities may be resulting in liability risk due to communication and handoff‐related errors. Improvements in the hospitalist model of care targeted at improving communication and clinical judgment may not only further reduce claims against hospitalists, but also improve the safety of care associated with this model.