140-Abbott 12/11/03 1:11 PM Page 239MEDICAL MALPRACTICE PREDICTORS AND RISK FACTORS FOROPHTHALMOLOGISTS PERFORMING LASIK AND PRK SURGERYBYRichard L. Abbott MDABSTRACTPurpose: To identify physician predictors in laser-assisted in-situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) surgery that correlate with a higher risk for malpractice liability claims and lawsuits.Methodology: A retrospective, longitudinal, cohort study comparing physician characteristics of 100 consecutiveOphthalmic Mutual Insurance Company (OMIC) LASIK and PRK claims and suits to demographic and practice patterndata for all active refractive surgeons insured by OMIC between 1996 and 2002. Background information and data wereobtained from OMIC underwriting applications, a physician practice pattern survey, and claims file records. Using anoutcome of whether or not a physician had a prior history of a claim or suit, logistic regression analyses were used separately for each predictor as well as controlling for refractive surgery volume.Results: Logistic regression analysis demonstrated that the most important predictor of filing a claim was surgicalvolume, with those performing more surgery having a greater risk of incurring a claim (odds ratio [OR], 31.4 for 1,000/year versus 0 to 20/year; 95% confidence interval [CI], 7.9 –125; P .0001). Having one or more prior claims wasthe only other predictor examined that remained statistically significant after controlling for patient volume (OR, 6.4;95% CI, 2.5 – 16.4; P .0001). Physician gender, advertising, preoperative time spent with patient, and comanagementappeared to be strong predictors in multivariate analyses when surgical volume was greater than 100 cases per year.Conclusion: The chances of incurring a malpractice claim or suit for PRK or LASIK correlates significantly with highersurgical volume and a history of a prior claim or suit. Additional risk factors that increase in importance with higher surgical volume include gender, advertising, preoperative time spent with patient, and comanagement with optometrists.These findings may be used in the future to help improve the quality of care for patients undergoing refractive surgeryand provide data for underwriting criteria and risk management protocols to proactively manage and reduce the risk ofclaims and lawsuits against refractive surgeons.Trans Am Ophthalmol Soc 2003;101:233-268INTRODUCTIONWe live in a culture in which displeased patients haveincreasingly turned to litigation as a means of obtainingredress from perceived deficiencies in the quality of carereceived from their physicians. Diminishing trust inphysicians, exaggerated claims of miracle cures, and widespread media publicity hinting at the wonders of newlydeveloped medical technology have resulted in unrealisticpatient expectations and have fueled the development ofour litigious society.The incidence and prevalence of medical errors,1combined with the upward spiraling of court monetaryawards, have created a system that is both enticing andfinancially rewarding for attorneys.2 Some lawyers haveFrom the University of California, San Francisco. Dr Abbott is a member ofthe Ophthalmic Mutual Insurance Company Board of Directors.Trans Am Ophthalmol Soc / Vol 101 / 2003rationalized medical malpractice litigation as a tool forerror reduction and as a means of spurring physicians toimprove the quality of medical care rendered to theirpatients.3 Those in the management field strongly disagreeand view medical malpractice litigation as a form of retrospective punishment for the individual physician thatcontributes little to system-wide quality improvement.3The incidence of malpractice claims is particularlyhigh for elective surgical procedures, especially those inwhich the cost of the procedure is borne by the patientrather than by third-party payers.4 The advent and growing popularity of refractive surgery is a case in point. Overthe past several years, consistent with its growing popularity, the incidence of malpractice cases related to laserassisted in-situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) has risen steeply. Data from theOphthalmic Mutual Insurance Company (OMIC) haveshown a threefold increase in LASIK claims and suits239

140-Abbott 12/11/03 1:11 PM Page 240Abbottbetween 1998 and 2001.5The present study has utilized data from OMIC filesand from responses of OMIC-insured refractive surgeonsto a detailed questionnaire in order to identify and analyzefactors that correlate with a higher risk of malpracticeliability claims and lawsuits. Additional analyses of procedure and patient data that might identify other risk factorsin these cases have also been performed. The findingsshould assist the development of guidelines for improvedquality of care for surgery patients. They may also provideuseful information for underwriting criteria and riskmanagement protocols to enable proactive reduction offuture claims and lawsuits against refractive surgeons.METHODSThe study was designed to identify physician predictorsand overall potential risk factors for incurring a claim orsuit for LASIK or PRK. A “predictor” is defined as a statistically significant (P .05) characteristic in a physician’sprofessional profile (ie, demographics or practicepatterns) that indicates the likelihood that an event (claimor suit) will occur. A “risk factor” is defined as an important, but not necessarily significant, characteristic in aphysician’s, patient’s, or case profile that indicates the likelihood that an event (claim or suit) will occur.An analysis of physician, patient, and case characteristics from 100 consecutive OMIC LASIK and PRKclaims and suits was undertaken and compared to demographic and practice pattern data for all active OMICinsured refractive surgeons between 1996 and 2002. Datawere derived from a detailed review of physician underwriting applications, a physician refractive surgery practice pattern survey, and both open and closed claim files.PHYSICIAN UNDERWRITING APPLICATIONSThe standard OMIC insurance application form includesdemographic and professional background information forthe physician (Appendix 1). The standard policy excludescoverage for refractive surgery. A physician applying formalpractice liability coverage for these operations mustcomplete both the standard underwriting application and asupplemental application for each refractive procedure.The supplemental application includes multiple questionsspecific to the refractive procedure (Appendix 2) and mustbe approved by the underwriting staff or physiciancommittee before coverage is granted.In addition, as a condition of coverage, insured physicians must agree to comply with OMIC’s standard refractive surgery guidelines and recommendations specific to aparticular procedure (Appendices 3 and 4). Theresponses to the questionnaire must fall within theseguidelines for coverage to be approved. Pertinent information from these applications and questionnaires was240entered into the physician database.PHYSICIAN REFRACTIVE SURGERY PRACTICE PATTERNSURVEYBetween January 2000 and December 2001, 750 refractive surgery surveys were sent out with renewal applications to all OMIC insured who had applied for LASIK orPRK coverage during this period. Seven hundred andeight completed surveys were returned, for a responserate of 94.4%. The surveys requested updated information on the insured physician’s practice patterns andspecifically requested the information listed in Table I.The data from these surveys were analyzed, andsurgeons with active refractive surgery practices, includingthose with and without claims or suits, were identified. Acomparison with statistical analysis was performed betweenthose physicians who were active refractive surgeons with aclaim or suit and the entire survey group. For the purposesof this study, a claim was defined as a written demand by thepatient (plaintiff) for compensation from a medical incident.A claim may be denied or settled and, if denied, the plaintiffmay file a suit. A suit was defined as a formal legal actioninitiated in the courts and requiring a formal response fromthe physician (defendant). There typically is a period ofdiscovery and then either a settlement or a jury trial.CLAIMS FILESThe first OMIC claim or lawsuit for PRK or LASIK wasfiled in August 1997 following PRK surgery performed inApril 1996. Beginning with this case, 99 additionalconsecutive claims or suits filed against individuals orentities between 1996 and 2002 were then reviewed, andpertinent information was entered into the database. Forthe purposes of this study, “individuals” were defined asspecific ophthalmologists, whereas “entities” were definedas a form of business organization, such as a partnership,professional association, or corporation that may need itsown separate liability coverage.DATA ENTRYAll data entries from the claim and suit files were dividedinto three categories: physician (defendant) data, casespecific information, and patient (plaintiff) background.The data collected included detailed information believedto be relevant as potential risk factors for medical malpractice litigation. There were a total of 47 separate dataentries for each claim or lawsuit (4,700 total entries) withonly 729 missing data entries (15.5%) for the entire study.Information within 43 of these categories (Table II) wasthen collated and compared to the data that were availablefor statistical analysis from the survey of the physiciangroup. Missing data were requested from the physician(defendant) or defense attorney by mail (Appendix 5).

140-Abbott 12/11/03 1:11 PM Page 241Medical Malpractice Predictors and Risk Factors for Ophthalmologists Performing Lasik and PRK SurgeryTABLE I: REFRACTIVE SURGEON PRACTICE PATTERN SURVEY1. and practice location?Approximately how many refractive surgery procedures do you perform annually?What percentage of your total practice does refractive surgery represent?Do you advertise specifically for refractive surgery?How much time, on average, do you (personally) spend with each patient prior to surgery (including time during preoperative visits, informed consentdiscussions, and other meetings leading up to the decision to have surgery)?6. Do you comanage your refractive patients?7. On what percentage of your patients do you perform bilateral simultaneous surgery?TABLE II: POTENTIAL RISK FACTORS FOR MALPRACTICE LITIGATIONDEFENDANT INFORMATIONAgeGroup vs solo practiceLocation statePrior suits and claimsUse of marketingFellowshipRefractive surgery experienceType of laserType of microkeratomeLocation of laserFee for surgeryComanagementWas consent form usedConsent processNote in chart by surgeonFrequency of visits presurgeryFrequency of visits postsurgeryConsultationPLAINTIFF INFORMATIONGenderAgeOccupationMarital statusHealthHabitsPrior disabilityLawsuits priorLocation stateSTATISTICAL ANALYSISUsing an outcome of whether or not a physician had aprior history of a claim or suit, logistic regression analyseswere used separately for each predictor while controllingfor refractive surgery volume. Controlling for volume wasdone in order to eliminate a possible confounding effectand more accurately determine if the risk of incurring aclaim or suit occurred more frequently in this group. Thepredictors analyzed were taken from the OMIC survey of708 refractive surgeons and were as follows: surgeongender, use of advertising, time (minutes) spent withpatient prior to surgery, region of the country (Eastern,Central, Mountain, or Pacific time zone), comanagementwith optometry, and prior OMIC claims. Volume wascategorized as 5 to 20 refractive surgeries per year, 21 to100 surgeries per year, 101 to 300 surgeries per year, 301to 1,000 surgeries per year, and greater than 1,000 surgeries per year. Odds ratios (ORs) with 95% confidenceintervals (CIs) and P values were determined for all relationships. All analyses were done using SAS, version 8.0.CASE INFORMATIONSuit versus claimTime: incident to open dateTime: open to close dateNegligent issueActual injuryPrior ocular surgeryPreop refractionDominant eyeOutcome refractionEnhancementsDisposition of caseExpense paidIndemnity paidIndemnity reserveExpense reserveBilateral versus unilateral surgeryRESULTSOVERALL DEMOGRAPHICSAs of October 31, 2002, there were a total of 2,933 OMICinsured: 2,500 (85.2%) were male and 433 (14.8%) werefemale; 2,274 (77.5%) were age 40 or older and 659(22.5%) were younger than age 40. The average age was48.9 years, and the median age was 48 years (Figure 1).Using the standard time zone boundaries, 1,186 (40.7%)practiced in the Eastern, 975 (33.5%) in the Central, 253(8.7%) in the Mountain, and 499 (17.1%) in the Pacifictime zone.Almost one third (971) of 2,933 insured on October31, 2002, indicated that they performed LASIK or PRKsurgery. Of the 971 refractive insured, 334 (34%) practiced in the Eastern, 290 (30%) in the Central, 99 (10%)in the Mountain, and 248 (26%) in the Pacific time zone(Figure 2). Eight hundred fifty-one had approved coverage for PRK and 850 for LASIK, with overlap betweenthe two groups.PRACTICE PATTERN SURVEY DEMOGRAPHICSOf the total 750 refractive surgeons who were insured by241

140-Abbott 12/11/03 1:11 PM Page 242AbbottFIGURE 1Age distribution of all OMIC-insured physicians (October 2002).FIGURE 2Distribution of OMIC insured physicians by region.OMIC between January 2000 and December 2001, allwere mailed surveys and 708 (94.4%) responded. Of theseresponses, 574 (81%) indicated that they were activelypracticing refractive surgery ( 5 cases per year). Fivehundred and four (87.8%) were male and 70 (12.2%) werefemale (Figure 3).One hundred eighty-five (32.2%) of the active refractive surgeons were located in the Eastern, 176 (30.5%) inthe Central, 78 (13.6%) in the Mountain, and 135 (23.5%)in the Pacific time zone (Figure 3).Within this survey group of active refractive surgeons,58 (10.1%) indicated that they had experienced a claim orsuit associated with PRK or LASIK surgery while insuredwith OMIC. These 58 physicians are included within thedatabase from the 100 consecutive claims or suits studied.This incidence (10.1%) is slightly lower than the overallratio for the entire OMIC cohort (124 claims or suits forPRK and LASIK among 971 refractive surgeons) (12.8%).(35.9%) of the LASIK cases and 4 of the PRK cases areclosed (Figure 6). The majority, 19 of 22 (86.4%), of theRK cases and ALK cases are now closed.OVERALL REFRACTIVE SURGERY CLAIMS AND SUITSIn January 1989, the first OMIC refractive surgery claimwas filed for a radial keratotomy performed in March1987. The first PRK claim was filed in August 1997 forsurgery performed in April 1996, and the first LASIKclaim was filed in April 1998 for surgery performed thatsame month. A total of 146 refractive surgery claims andsuits were filed between January 1989 and October 2002.Of this group, 116 (79.5%) have been for LASIK and 8(5.5%) have been for PRK, for a total of 124 cases. Theremaining 22 claims and suits (15.1%) were for radialkeratotomy (RK) and automated lamellar keratectomy(ALK) (Figure 4). As the popularity of LASIK hasincreased, so, too, have the claims and suits (Figure 5).Of the 146 total refractive surgery reported cases, 91were suits and 55 were claims. These may be divided asfollows: LASIK, 67 suits (57.3%) and 49 claims (42.2%);PRK, 6 suits and 2 claims; RK, 17 suits (81.8%) and 4claims; and ALK, 1 suit (Figure 6). Of these cases, only 42242IN-DEPTH ANALYSIS OF CASESAn analysis of the first 100 consecutive PRK and LASIKclaims and suits from the 124 (116 LASIK and 8 PRK)total OMIC cases was performed by examining data fromseveral sources. These data reflect information collectedfrom the physician underwriting applications, the refractive surgery practice survey, and open and closed claimand suit files. There were 58 physicians identified in thepractice pattern survey that overlapped with this group of100 cases. Follow-up letters were sent to physicians andattorneys requesting any missing information (Appendix5). There were a total of 47 separate data entries for eachclaim or suit examined, with only 15.5% missing dataentries for the entire study.Of the 100 cases studied, 77 represented “unique”defendants (74 individuals and 3 entities). Unique defendants are defined as physicians or entities that are enteredonly one time in the database and that may have one, two,or more claims or suits filed against them. Within thisgroup of 77, 62 had only one claim or suit, 9 had twoclaims or suits, and 6 had three or more claims or suits(Figure 7). An additional analysis of the group of physicians and entities with more than one claim or suit wasperformed (see discussion that follows).Of the 74 unique individual defendants, 51 (68.9%)were aged 40 and older and 23 (31.1%) were younger than40. The average and median age for the entire physiciangroup with a claim or suit was 46.0 years compared to 48.9(average) and 48.0 (median) years for all OMIC insured.Seventy-one (96%) of 74 unique physician defendantswere male, and 3 (4%) were female. Of 98 responses, forthe entire cohort, 50 (51%) of the refractive surgeonswere in a group practice, 45 (45.9%) were in solo practice,and 3 were employed full-time by a corporate entity. Of

140-Abbott 12/11/03 1:11 PM Page 243Medical Malpractice Predictors and Risk Factors for Ophthalmologists Performing Lasik and PRK SurgeryFIGURE 3Distribution of active (574) and inactive (134) approved refractivesurgeons.FIGURE 4Refractive claim/suit case distribution (January 1989 – October 2002, n 146).FIGURE 5Annual incidence of OMIC refractive claim and suits.Total OMIC refractive claims and suits.FIGURE6FIGURE 7Number of cases against individual unique refractive surgeons or entitiesin the case study (n 77).FIGURE 8Case study distribution by US region (n 100).93 responses, 64 (68.8%) of the physicians had no formalFellowship training in corneal or refractive surgery.The regional distribution of the 100 claims and suitswas as follows: 27 (27%) of the claims or suits occurred inthe Eastern, 21 (21%) in the Central, 15 (15%) in theMountain, and 37 (37%) in the Pacific time zone (Figure8). The Pacific region had the highest incidence of claimsor suits per refractive insured (27.4%) compared to theother regions (Figure 8).PHYSICIAN PREDICTORS FOR A CLAIM OR SUITThe predictors analyzed were taken from the OMICsurvey of 708 refractive surgeons (Table I). A comparisonwas made between those physicians (58) who were active243

140-Abbott 12/11/03 1:11 PM Page 244Abbottrefractive surgeons with a claim or suit and the totalsurvey group. Using logistic regression analysis, eachpredictor was examined and statistical significance determined (Table III). High surgical volume and a history ofa prior claim or suit were the most important predictors.Additional significant factors were also identifiedHigh VolumeThe most important predictor for a physician incurring aclaim or suit was patient volume, with greater probabilityof a claim among those treating more patients (OR, 31.4for 1,000 procedures/year versus 5 to 20procedures/year; 95% CI, 7.9-125; P .0001).Of the 574 active refractive surgeons from the OMICsurvey, 516 were without a claim or suit. Of these 516,373 (72.3%) performed 100 or fewer cases of PRK orLASIK per year, 61 surgeons (11.8%) performed over 300cases per year, and 13 (2.5%) performed over 1,000 casesper year. The average number of cases for this group peryear was 162.In examining the database of 100 OMIC cases with aclaim or suit, volume data were available for 85 cases.There appeared to be a substantial difference in increasedvolume for these cases compared to those without a claimor suit, with only 21 surgeons (24.7%) performing 100cases or less per year, 41 surgeons (48.2%) performingover 300 cases per year, and 23 surgeons (27.1%) performing over 1,000 cases per year. The number of cases forthis group averaged 491 per year, and this was significantlyhigher than the number of cases (162) in the group ofrefractive surgeons without a claim or suit (P .001)(Figure 9).Multiple Claims or SuitsPhysicians having one or more prior claims or suits wasthe only other predictor examined that remained statistically significant when controlled for patient volume (OR,6.4; 95% CI, 2.5-16.4; P .0001).Examination of the underwriting applications for the74 unique physician defendants revealed that only 18(24.3%) had no prior history of a claim or suit for theirentire practice. In contrast, 25 (33.8%) had one or twoprior claims or suits and 28 (37.8%) had three or moreclaims or suits. This differed significantly from the surveygroup of active refractive surgeons, in which only 58 of574 (10.1%) indicated a prior claim or suit within theirpractice (P .001).Additional Risk Factors for Incurring a Claim or SuitAdditional predictors that increased in importance andbecame statistically significant with multivariate analysisas surgical volume increased were gender, advertising,preoperative time spent with patient, and comanagement244with optometrists (Table IV). Bilateral same-day surgerywas not associated with increased risk.Gender. For those 93 physicians, including thosewith multiple cases, named in a LASIK or PRK claim orsuit, 87 (93.6%) were male and 6 (6.4%) were female. Forthe 58 physicians with a claim or suit identified from thesurvey, 56 (96.6%) were male and 2 were female. Usingunivariate analysis and without controlling for volume, theOR for a female physician incurring a claim or suitcompared to a male was 0.24 (95% CI, 0.06-0.99; P .048) (Table III). As the volume of surgery increased over100 cases per year, multivariate analysis revealed a significant increased risk for male surgeons (P .0001) (TableIV).Advertising. The incorporation of advertising into ahigher-volume refractive surgery practice showed a significant positive correlation with those who were involved ina claim or suit. Using univariate analysis, there was a 3.6OR (95% CI, 2.0-6.4; P .0001), indicating that advertising was a risk factor for incurring a claim or suit (TableIII). With multivariate analysis and adjusting for volume,a significant correlation was exhibited only with surgicalvolumes greater than 100 cases per year (P .0001) (TableIV).Sixty-one refractive surgeons within the study with aclaim or suit (93 of 100 responses) were using marketing,compared to 193 (37.4%) of 516 active refractive surgeonswithout claims or suits, according to data collected fromthe 2-year practice pattern survey (Figure 10).Time Spent With Patient. Physicians were asked onthe survey to estimate the average amount of time theypersonally spent with each patient prior to surgery(including examination and informed consent discussion).Of the 74 unique individuals having a claim or suit withinthe database, 58 (78.4%) completed this question on thepractice pattern survey. These physicians estimatedspending, on average, 55 minutes with each patientFIGURE 9Refractive volume comparison between case study refractive surgeonsand non–claim/suit refractive surgeons.

140-Abbott 12/11/03 1:11 PM Page 245Medical Malpractice Predictors and Risk Factors for Ophthalmologists Performing Lasik and PRK SurgeryTABLE III: PHYSICIAN PREDICTORS FOR INCURRING A CLAIM OR SUIT*CONTROLLED FOR PATIENTS/YRUNIVARIATE rgical volume/yr5-2021-100101-300301-1,000 1,0004/276 (1.4)8/243 (3.3)20/102 (19.6)20/68 (29.4)6/19 (31.6)Reference Category2.30.69 - 7.816.65.5 - 49.928.39.3 - 86.531.47.9 – 125.0.1750.0001.0001.0001Not ApplicableNot ApplicableNot ApplicableNot ApplicableGender of surgeon§MaleFemale56/621 (9.0)2/87 (14.3)Reference Category0.240.06 - 0.99.04850.390.09 - 1.7.2195AdvertisingNoYes19/416 (4.6)38/258 (14.7)Reference Category3.62.0 - 6.4.00011.100.56 - 2.2.7743Minutes spent with patient¶0-3031-6061-120121 19/126 (15.1)25/267 (9.4)11/211 (5.2)2/36 (5.6)Reference Category0.580.31 - 1.10.310.14 - 0.670.330.07 - 1.5.0963.0032.15080.680.450.570.3 - 1.370.2 - 1.050.1 - 2.82.2816.0655.4905Region of Country#EastCentralMountainPacific17/224 (7.6)12/237 (5.1)9/87 (10.3)20/159 (12.6)Reference Category0.650.30 - 1.391.400.60 - - 3.46.2673.4324.10670.871.091.500.4 - 1.960.44 - 2.70.7 - 3.14.7388.8548.2775Comanagement**NoYes26/470 (5.5)32/186 (17.2)Reference Category3.62.1 - 6.1Reference Category.00011.030.53 - 2.0.93Prior OMIC claims††None1 or more46/681 (6.8)12/27 (44.4)Reference Category11.04.9 - 25.0.00016.42.5 -16.4.0001*Data from 708 pysician practice pattern surveys.†Total number of 58 claims within the practice survey group.‡Total N represents 708 cases.§Number of males or females with a claim or suit compared to total number of males or females within the 708-physician survey cohort.¶Time spent by the physician with patients prior to surgery.#Location of physician practice.**Preoperative and postoperative comanagement with optometrists.††Prior claims or suits by physicians.compared to the group of physicians (516) without a claimor suit, who estimated spending 73 minutes, on average,with each patient (Figure 11).By dividing the time spent with patients into fourcategories of minutes (0 to 30, 31 to 60, 61 to 120, and121 ), an analysis was performed comparing each of thetime groups with those physicians who have incurred asuit or claim. The data showed that spending more timewith the patient lowered the risk of incurring a claim orsuit P .003) (Table III) and became increasingly significant with higher-volume surgeons (P .0001) (Table IV).Comanagement. Comanagement with an optometristboth preoperatively and postoperatively was documentedin 52 (55.3%) of the cases studied with a claim or suitfiled. There were no data on 6 of the 100 cases examined.In contrast, only 142 of 510 (27.8%) of refractive surgeonswithout a claim or suit responding to the practice patternsurvey stated that they comanaged (P .001) (Figure 12).In examining the results from the practice patternsurvey using multivariate analysis, surgeons performingover 100 cases per year and who comanaged demonstrated a significantly higher OR of incurring a claim orsuit (OR,13.90; 95%; CI, 4.48-43.10; P .0001) (TableIV).245

140-Abbott 12/11/03 1:11 PM Page 246AbbottTABLE IV: ADDITIONAL PREDICTORS OF INCURRING A CLAIM OR SUIT WITH INCREASING SURGICAL VOLUME*PREDICTORGender of surgeonVol cat 101-300 vs 520Vol cat 301-1000 vs 5-20Vol cat 1001 vs 5-20AdvertisingVol cat 101-300 vs 5-20Vol cat 301-1000 vs 5-20Vol cat 1001 vs 520Time spent with patient presurgeryVol cat 101-300 vs 5-20Vol cat 301-1000 vs 5-20Vol cat 1001 vs 5-20ComanagementVol cat 101-300 vs 5-20Vol cat 301-1000 vs 5-20Vol cat 1001 vs 5-20OR95% CIP hysicians with surgical volume greater than 100 cases/year were compared to those with a lower surgical volume, between 5 and 20 cases per year.Predictors of litigation that were highly significant (P .0001) and illustrated on this table included gender, advertising, time spent with patient, and comanagement.Bilateral Same-Day Surgery. This was performed by64 (67.4%) of 95 surgeons with a claim or suit and by 304(58.9%) of 516 surgeons without a claim or suit. Thus,there was no statistical significance between these twogroups.PHYSICIANS AND ENTITIES WITH MULTIPLE CLAIMS ORSUITSOf the 100 consecutive cases analyzed, there were a totalof 62 cases (61 physicians and 1 entity) with only oneclaim or suit filed against them and a total of 38 casesinvolving a physician or entity with multiple claims orsuits. Of the 38 cases, 32 (84.2%) were against 13 physicians and 6 (15.8%) were against 2 entities. Four (30.8%)of 13 physicians and both (2 of 2) entities had more thantwo claims or suits (Figure 7).Analysis of the physician and entity group with multiple claims and suits was performed to determine if therewere any specific factors that differentiated this groupfrom those with only one claim or suit against them.Of the 38 multiple claim or suit cases, the averagephysician age was 47.1. Twenty cases (52.6%) occurred inthe Pacific, 10 in the Eastern, and 8 in the Central timezone. No physicians or entities with multiple casesoccurred in the Mountain time zone (Figure 13). Thirtytwo of these multiple claim or suit cases were attributableto 13 individual physicians, 11 (84.6%) of which weremale and 2 (15.4%) female.In addition, by reviewing those cases with a history ofa prior claim or suit from the underwriting applications ofthis group, a similar pattern of regional distribution ofinsured physicians was evident. Of the 74 unique physi-246cian defendants, data were available for 71. Of 71, 53(74.7%) had a history of a prior claim or suit. Twenty ofthe 53 (37.7%) were located in the Pacific, 12 (22.6%) inthe Eastern, 13 (24.4%) in the Central, and 8 (15.1%) inthe Mountain region (Figure 13).Of the 74 unique physicians with a claim or suitwithin the database, 54 (73%) completed the practicepattern survey. Eleven of the 54 (20.4%) had multipleclaims and suits. Forty-three of 54 (79.6%) had a singleclaim or suit. Using the survey data for this group, as wellas information from the underwriting and case files, threespecific practice trends emerged as significant risks forincurring a claim or suit for physicians with multiple cases:Higher VolumeThe average annual case volume for physicians with multiple claims or suits was 751 versus 430 cases per year forthose with only a single claim or suit(P .0001).Use of MarketingTen (90.9%) of 11 physicians with multiple claims andsuits advertised their services as compared to 26 (60.9%)of 43 physicians with a single claim or suit (P .05).Comanagement With Optomet

useful information for underwriting criteria and risk management protocols to enable proactive reduction of future claims and lawsuits against refractive surgeons. METHODS The study was designed to identify physician predictors and overall potential risk factors for incurring a claim or suit for LASIK or PRK. A "predictor" is defined as a .