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A. Russell Localio, JD, MPH, MS; Ann G. Lawthers, ScD; Joan M. Bengtson, MD; Liesi E. Hebert, ScD; Susan L. Weaver; Troyen A. Brennan, MD, JD; J. Richard Landis, PhD

JAMA. 1993;269(3):366-373.

Abstract
Objective.
—To investigate whether an association exists between the probability of a cesarean delivery and the level of malpractice claims risk faced by hospitals and physicians.

Design.
—Survey of computerized discharge data linked with physician and hospital malpractice claims records based on stratified, random sample of hospitals.

Setting.
—Acute care hospitals in New York State in 1984.

Population.
—All deliveries (60490) at 31 hospitals.

Results.
—After controlling for the clinical risk of a cesarean delivery, patient socioeconomic status, and physician and hospital characteristics, cesarean delivery was positively associated with physician malpractice premiums (odds ratio [OR], 3.00; 95% confidence interval [CI], 2.13 to 4.24 for the difference between upstate and New York City levels), with the number of physician claims opened per 100 physicians at the hospital level (OR, 1.15; 95% CI, 1.02 to 1.30 for a 1-SD change), and with the number of hospital claims opened per 1000 discharges (OR, 1.26; 95% Cl, 1.10 to 1.43 for a 1-SD change). Measures of physician-perceived risk of suit also showed a significant association with cesarean delivery (OR, 1.96; 95% CI, 1.53 to 2.52, upstate vs New York City). Within hospitals, there was no significant association (OR, 1.15; P=.126) between the odds of cesarean delivery and the claims history (none vs one or more) of an individual physician.

Conclusion.
—Results support previous speculations of a positive association between malpractice claims risk and the rate of cesarean delivery.

(JAMA. 1993;269:366-373)

Author Affiliations
From the Center for Biostatistics and Epidemiology, The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey (Drs Localio and Landis and Ms Weaver); Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (Dr Lawthers); Departments of Obstetrics and Gynecology (Dr Bengtson) and Medicine (Dr Brennan), Brigham and Women's Hospital, Boston, Mass; and Center for Research on Health and Aging, Rush-Presbyterian—St Luke's Medical Center, Chicago, Ill (Dr Hebert).

Footnotes
Reprint requests to Center for Biostatistics, Penn State University College of Medicine, PO Box 850, Hershey, PA 17033 (Dr Localio).

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