29 Advanced Practice Nurses Claim Survey
TABLE OF CONTENTS Page Background 3 Objectives.. 3 Methodology. 4 Response Rate.... 5 Interpretation of Results... 6 Scope and Limitation. 8 Respondent Demographics... 9 Gender, Age, Highest Education, Location of Practice Survey Highlights Advanced Practice Education/Preparation. 12 Advanced Practice Specialty 13 Advanced Practice Primary State Licensed.. 15 APN Program Clinical Hours Required..... 17 RN Years Prior to APN Certification. 18 State Regulations Governing Practice. 19 APN Employment 2 Staffing or Placement Services. 21 Named in Lawsuit 22 Years Practicing as an APN.... 26 Mentors. 28 APN Practice Setting... 32 Practicing Without Certification.. 34 Years Working in this Particular Position... 36 Prescriptive Authority... 38 Personnel Assistance. 39 Daily Patient Workload. 41 Daily Patient Quotas. 43 Overtime.... 44 Inadequate Staffing Levels... 45 Appropriate Training... 46 Electronic Medical Records..... 47 Claim Incidence Risk Factors Model... 48 Severity Risk Factors Model 51 Conclusion and Implications.... 55 Appendix Logistic Regression.... 2 Linear Regression..... 4 Tables....... 6 Claim Verbatim Comments... 51 Non-Claim Verbatim Comments... 56 Claim Questionnaire.... 84 Non-claim Questionnaire........ 88 2
BACKGROUND In the past 3 years the role of the Advanced Practice Nurse (APN) has evolved more than any other healthcare professional. Today, in many states, APNs can practice independently as a primary healthcare provider. However, with this greater autonomy comes greater accountability. In 24, Nurses Service Organization (NSO), in collaboration with CNA, released the first ever report analyzing professional liability claims brought against Advanced Practice Nurses. This current study was conducted to update the information acquired in the 24 study and was expanded to provide greater insight and additional risk management recommendations to assist APNs identify and minimize risk exposures. KRC () was contracted to conduct this study on behalf of AON s Affinity Insurance Services division. OBJECTIVES 1. To identify the high risk areas and other APN practice conditions that may have contributed to an incident by comparing the data gathered from APNs who have not had a claim against APNs who have been identified by CNA and NSO as having a claim incident. 2. To learn what differences, if any, exist between the demographics of APNs with claims and those without claims, including but not limited to primary state and location of practice, gender, age, etc. 3. To investigate the specialty areas and practice settings of APNs with claims and those without claims and to understand the relationship, if any, between the APN s practice setting and likelihood of a claim. 4. To determine the APN s perception of the causes of a professional liability incident. 5. To better understand the educational and clinical preparation for advanced practice nursing and to ascertain if there are any educational differences that may have left APNs with claims unprepared for their clinical practice. 6. To explore the relationships between claim severity and the demographics, educational preparation, practice settings, experience and other data elements collected in the online survey of APNs seeking to identify the potential predictors of claim severity. 3
METHODOLOGY The primary focus of this study was to compare and contrast the demographics, educational preparation and practice conditions of APNs who have had a claim with those who have not had a claim. In order to facilitate comparison and contrast between the claim and non-claim APNs, the questionnaires were designed with parallel questions appropriately asked of each segment. All NSO actively insured Advanced Practice Nurses were eligible to participate in this study of professional liability claims against APNs. Of the nearly 24, APNs invited to participate in the study, 1,38 were identified as having a professional liability claim filed with NSO/CNA in the past five years. In addition to active insured APNs, the sample included APNs who dropped their NSO policies if they had an incident in the past five years. On June 23, 29, an internet survey was launched. APNs with an email address on file were sent an email invitation from NSO to participate in the survey. APNs without an email address on file as well all email bounce backs were sent postcard invitations from NSO on June 29, 29 or June 3, 29 directing them to the NSO website to participate in the survey. All respondents were given a reference ID that was used to track their response. A $1, drawing was promoted as a premium incentive to help lift the survey response rate. Two follow-up reminder emails were sent to non-claim APNs and three follow-up reminder emails were sent to APNs with a claim. The deadline for the survey and drawing for the non-claim group was July 13, 29. Because of the sensitive nature of the survey, an additional snail mail letter was sent to claim non-respondents on July 17, 29 to assure the APNs of confidentiality and encourage those who did not think they had an incident to participate. The deadline for the claim group was extended to July 27, 29 to allow for responses to the third reminder email and snail mail invitation. Survey responses were collected until July 28, 29. 4
RESPONSE RATE Completed questionnaires were checked and edited for response clarity. For non-claim respondents a qualified completed survey required input for all questions up to, but not including the demographic questions (age, gender, highest educational degree earned and location of practice). Our sample included fewer APNs with claims. Finding value in the open-ended responses given by APNs with claims, even when the survey was otherwise incomplete, we decided to preserve as many claim respondents as possible. The criteria for a claim complete was therefore loosened to include all except duplicate responses and totally incomplete surveys. A total of 3,354 responses were received. 317 returns were disqualified because of duplication or incompleteness. 3,37 respondent surveys - 2,75 non-claim and 287 claim surveys - were tabulated and used for the initial report which was based solely upon incidence of claims as originally defined by CNA. This updated report takes a deeper dive into the data, readdressing the definition of claims to include only those which currently had a significant reserve (more than just a few dollars) or that actually resulted in a payment (indemnity and/or expense). 135 claims closed with no payment and pending or open claims with no significant reserve were eliminated from the analysis. 152 claim surveys were used for this second phase of the analysis. Total Claims Total Non-Claims Total Emails sent 592 13,175 13,767 Email bounce backs 6 6 Postcards mailed 848 9,385 1,233 Undeliverable postcards 1 268 278 Adjusted # sent/mailed 1,37 22,292 23,662 Total response 31 3,53 3,354 Return Rate 22.% 13.7% 14.2% Disqualified incomplete response 14 33 317 Disqualified "claim" response 135 Usable response 152 2,75 2,92 Usable Response rate 11.1% 12.3% 12.3% 5
INTERPRETATION OF RESULTS Results of a survey based on a sample chosen from a population of interest do not yield exact information about the population. Instead, the results represent estimates of the actual situation. The difference between the estimate and the actual figure is the statistical error or uncertainty. For any given level of confidence, the statistical uncertainty associated with any particular survey result varies according to both the size of the sample (or subsample) upon which the statistic is based and the actual estimate itself. Many of the statistical comparisons were made using the Chi-Square statistic. This non-parametric procedure allows for the efficient analysis of frequency type data. By this method, actual (un-weighted) data collected ( observed ) are numerically compared to what would be likely or expected. In conducting the Chi-Square analysis for this report, data from several categories were often collapsed, resulting in a 2 x 2 data matrix. It was upon this matrix that the statistical test was performed. In this case, the typical analysis consisted of number of cases (the frequency ) reported in a given category. Again, the.5 level of significance was applied. For nominal data, the statistical comparisons were made using the mean. The mean is a particularly informative measure of the "central tendency" of the variable if it is reported along with its confidence intervals. We are interested in statistics (such as the mean) from our sample only to the extent to which they can infer information about the population. The confidence intervals for the mean give us a range of values around the mean where we expect the "true" (population) mean is located (with a given level of certainty). Note that the width of the confidence interval depends on the sample size and on the variation of data values. The larger the sample size, the more reliable is its mean. The larger the variation, the less reliable is the mean. In marketing, like other social sciences, the general guideline is to use a 95% (alpha=.5) confidence level as the basis for estimating statistical error and the significance of differences between two or more statistical results. This means that we would expect re-administration of the survey with equivalent samples to yield substantially different results (thus suggesting different conclusions) no more than five times in one hundred. If you set alpha to a smaller value, then the interval would become wider thereby increasing the "certainty" of the estimate. These considerations should be taken into account when interpreting the results of this or any other statistical study. Consequently, when discussing the results, the text of this report will refer to difference in means in a definitive manner only if the probability of finding inconsistent results when re-administering the survey is less than five percent (i.e., p<.5). 6
Regression analyses were conducted in an attempt to identify potential predictors of APN liability claims. Linear regression is used to model the value of a dependent scale variable based on its linear relationship to one or more predictors. A multiple linear regression analysis was used to attempt to model the relationship between the dependent variable, severity ($$ amount of paid or reserved claims) against multiple independent predictor variables in the data. The severity of claims is a continuous variable and a linear or straight line relationship is assumed to exist between the dependent and independent variables. Independent variables that were categorical variables were recoded to binary (dummy) variables prior to modeling. For each value of the independent variable, the distribution of the dependent variable must be normal. The variance of the distribution of the dependent variable is assumed to be constant for all values of the independent variable. The relationship between the dependent variable and each independent variable should be linear, and all observations are assumed to be independent. Scatterplots of each independent variable against the dependent variable were examined checking for linearity, heteroscedascity, outliers and strength of the relationship to determine appropriateness in the model. Binary logistic regression was used to attempt to identify potential predictors of the dependent variable, having a claim or not having a claim. While linear regression can be quite powerful and useful for continuous variables, it is not suitable for predicting the relationship when the dependent variable is a dichotomous categorical variable. Since the dependent variable, Claim, has only two values, i.e. not having a claim, No = and having a claim, Yes = 1, the probability of an event must lie between and 1. It is impractical to model probabilities with linear regression techniques, because the linear regression model allows the dependent variable to take values greater than 1 or less than. The logistic regression model is a type of generalized linear model that extends the linear regression model by linking the range of real numbers to the -1 range. The binary discrete output is converted into continuous output by calculating the probability for the occurrence of a specific event. The procedure for modeling a logistic model is determining the actual percentages for an event as a function of the independent predictor variables and finding the best constant and coefficients fitting the different percentages. For both linear regression and logistic regression models, a p-value is calculated for each coefficient. If the p-value is low then there is a significant relationship between the independent variable and the dependent variable. "Goodness-of-fit" tests are conducted to see whether the model adequately fits the actual situation. Low p-values indicate a significant difference of the model from the observed data. Hence, the p-values should be above.5 to show that there are no significant differences between the predicted probabilities (from the model) and the observed probabilities (from the raw data). 7
SCOPE & LIMITATION This report is an extension of the previous reporting of the 29 APN survey. While the previous analysis was limited to the questions asked of the APNs in the online survey, this analysis incorporates the actual claim data matched to survey respondents. The data were examined by segments, specifically comparing and contrasting claim respondents vs. non-claim respondents. This analysis is limited to claims with payment only. For the purposes of this report, we have dropped APNs with claims if the claim was closed with no payment or is pending or open with a reserve of $3 or less. The net effect is a dataset of 152 APNs who had a paid claim (indemnity and/or expense) or have a pending open claim with a significant reserve as provided by CNA data. These 152 APNs with claims were compared to the 2,75 APNs without claims in an attempt to identify potential predictors of APN liability claims. The previous analysis was based on 287 APNs. With the deletion of 135 APNs who had a claim closed with no payment, it is expected that the details, outcome and projections about the APN claim data would be different from the previous results and may even appear to be contradictory to those stated in the previous report. Where contradictory information is being reported, this current report is considered to be more reliable. The predictor variables in the regression models are all significantly related to the outcome variables of incidence or total paid claims/reserved. While this indicates that there is a relationship between the predictors and the outcome event, it cannot be assumed that the predictors cause the outcome event. It is also important to note that while each of the predictors are significant, there is generally an overlap and predictors are only added to the models if they can add a unique contribution. Two or more predictive variables may explain the same variation in the outcome of incidence or severity. Therefore if these same models were built with variables removed or added, the unique contribution of the current set of predictors would be expected to change. Because the data are limited to APNs insured by CNA professional liability through NSO, the reader is cautioned from projecting these results to the entire population of APNs which would include uninsured APNs and APNs insured in other nurse practitioner professional liability programs. 8
RESPONDENT DEMOGRAPHICS There are proportionately more APNs without claims than with claims who are under age 5, female, well educated (Master s degrees) and/or working in urban practice settings. NURSE TYPE Claims (%) (Base=152) Non-Claims (%) (Base=2,75) Total (%) (Base=2,92) Nurse Practitioner 92.8 95. 94.9 Clinical Nurse Specialist 5.9 4.9 5. Other 1.3*.1.1 Gender Claims (%) (Base=136) Non-Claims (%) (Base=2,742) Total (%) (Base=2,878) Male 16.2* 6.6 7. Female 83.8 93.4* 93. *Denotes significantly higher differences. For example, the above table indicates there are significantly more male APNs among claims respondents than among non-claims (16.2% v.6.6%). Conversely there are significantly fewer female APNs among these claim respondents. Age Claims (%) (Base=136) Non-Claims (%) (Base=2,742) Total (%) (Base=2,878) 18-29. 4.3* 4.1 3-49 35.2 43.4* 43. 5-64 61.* 49.3 49.8 65 or over 3.7 3.1 3.1 Highest Education Level Completed Claims (%) (Base=136) Non-Claims (%) (Base=2,742) Total (%) (Base=2,878) Associates Degree (AA/AS/ADN) 2.9 1.3 1.4 Bachelor s Degree (BA/BS/BSN) 4.4 2.7 2.8 Master s Degree (MA/MS/MSN) 83.8 9.4* 9.1 Doctorate Degree (PhD/EdD/DNS/DNP/JD) 8.8 5.5 5.7 Location Of Practice Claims (%) (Base=135) Non-Claims (%) (Base=2,728) Total (%) (Base=2,863) Rural 32.6* 21.6 22.1 Suburban 43.7 4.9 41.1 Urban 23.7 37.5* 36.8 9
Claim Severity by Demographic Segment Significant findings are mentioned. Where there are no significant findings, the charts are provided for informational purposes only. Claim losses are less severe for clinical nurse specialists and APNs who are under age 3. $9, $8, $7, $6, $5, $4, $3, $2, $1, $ $85,323 Nurse Practitioner (N=141) $4,3 Clinical Nurse Specialist (N=9) $9,849 Other (please specify) (N=2) $79,532 Total (N=152) Q1. Are you a Nurse Practitioner or a Clinical Nurse Specialist? Clinical Nurse Specialists have significantly lower claims paid or reserved. $12, $1, $9, $8, $7, $92,156 $64,181 $79,532 $1, $8, $71,791 $99,143 $79,532 $6, $5, $6, $48,62 $4, $4, $3, $2, $1, $ $1,692 Missing (N=16) Female (N-114) Male (N=22) Total (N=152) Q28. What is your gender?. $2, $ $1,692 Missing (N=16) 3-49 (N=48) 5-64 (N=83) 65 or over (N=5) Q29. What is your age? It is significant that there are no APNs with claims under age 3. Total (N=152) 1
$16, $14, $148,664 $136,363 $12, $1, $8, $82,385 $79,532 $6, $49,15 $4, $2, $1,692 $ Missing (N=16) Associate's Degree (AA/AS/ADN) (N=4) Bachelor's Degree (BA/BS/BSN) (N=6) Master's Degree Doctorate Degree (MA/MS/MSN) (N=114) (PhD/EdD/DNS/DNP/JD) (N=12) Total (N=152) Q3. What is your highest level of education completed? $12, $19,246 $1, $8, $71,572 $71,937 $79,532 $6, $4, $2, $11,39 $ Missing (N=17) Rural (N=44) Suburban (N=59) Urban (N=32) Total (N=152) Q31. Which of the following best describes the location of your practice? 11
Percent SURVEY HIGHLIGHTS Advanced Practice Education/Preparation Regardless of their claim status, APNs have predominately earned their APN designation through a university or college on-site program 1 9 Q2. How did you earn your APN designation? Claim (Base=152) Non-claim (Base=2,75) Total (Base=2,92) 88 89 88 8 7 6 5 4 3 2 1 1 1 1 1 1 1 Community college program Hospital-based program University/college on-site program 5 5 5 On-line program None Other (please specify) 5 5 5 Few APNs have earned their APN designation through sources other than a university or college on-site program. 88% of all APN respondents maintain that they used a university on-site program to achieve their APN designation. Only 5% of all APNs reached APN status using on-line programs alone. Very few used only hospital based or community college programs. Among the 5% who used other specified sources, most often it was a combination of on-site programs and on-line programs. The average claims by APN program are shown below for informational purposes only. $1, $9, $8, $7, $6, $5, $4, $3, $2, $1, $ $5,98 $13,532 $88,25 $2,297 $19,4 $79,532 Community college program (N=1) Hospital-based program (N=2) University/college on-site program (N=135) On-line program (N=7) Other (please specify) (N=7) Total (N=152) Q2. How did you earn your APN designation? 12
Advanced Practice Specialty APNs with claims are more likely to be certified in Family Practice than APNs who have no claims Q3. In what specialty area(s) are you certified or licensed as an APN? (Check all that apply) Total (Base=2,92) Non-claim (Base=2,75) Claim (Base=152) Behavioral health Pediatrics Occupational health Oncology Obstetrics/perinatal Neonatal Gerontology Family practice Adult care 4 1 1 2 4 1 1 1 9 7 6 7 24 24 22 5 49 63 1 2 3 Percent 4 5 6 7 About half of the advanced practice nurses are certified or licensed to work in Family Practice. About a quarter of the APNs are certified in adult care and the remaining one-quarter are certified in a variety of other specialties. For most specialties, the proportion of claim APNs v. non-claim APNs is relatively equal; however there are a significantly greater proportion of APNs with claims found to be certified or licensed to work in Family Practice (63% v. 49%). 13
APNs certified in OB/perinatal have average claim losses three and a half times greater than other specialties APNs certified in obstetrics/perinatal have the highest average paid/reserved claims, 3.49 times greater than the average of all other specialties combined ($252,546 vs. $72,422) Other (please specify) (N=11) $35,784 Women's health (no OB) (N=7) $6,462 Behavioral health (N=14) $12,978 Pediatrics (N=6) $72,797 Occupational health (N=) $ Oncology (N=) $ Obstetrics/perinatal (N=6) $252,546 Neonatal (N=) $ Gerontology (N=1) $67,142 Family practice (N=95) $79,456 Adult care (N=34) $97,946 $ $5, $1, $15, $2, $25, $3, Q3. In what specialty area(s) are you certified or licensed as an APN? (Check all that apply) 14
Advanced Practice Primary State Licensed Missouri has a greater proportion of APNs with claims. Maryland has a lower proportion of APNs with claims Although most states within the country were equally proportioned between APNs with claims and those without, Missouri had significantly more APNs with claims than without (4.7% v. 1.7%). Conversely, Maryland had a lower percentage of APNs with claims than without (% v.2.7%) 15
WA VA TX TN SC PA OR OK OH NY NV NM NJ NC MT MS MO MN MI ME MA LA KY KS IN IL HI GA FL CT CO CA AZ AR AL Missing $34,28 $67,627 $13,3 $47,293 $67,46 $41,623 $35,228 $995 $89,143 $5,2 $3,322 $2,67 $5 $29,827 $14,946 $52,287 $95,262 $4,424 $24,55 $3,525 $42,87 $1,971 $8,32 $3,211 $19,449 $43,848 $6,925 $45,535 $77,351 $185,767 $172,892 $166,395 $186,244 $194,84 $266,599 $26,764 APNs with primary states PA, AL and NY have the highest average losses. APNs who have designated practice in primary states of Pennsylvania, Alabama and New York have significantly higher average claims paid or reserved than the remaining states. $ $5, $1, $15, $2, $25, $3, 16
Percent APN Program Clinical Hours Required APNs were required to spend an average of 635 clinical hours in their APN program Q6. How many clinical hours were required in your APN program? 35 3 25 2 15 Claim (Base=13) Non-claim (Base=2,265) Total (Base=2,368) 3 3 26 26 26 19 2 16 16 19 13 13 1 5 5 3 3 Other specified 1 1 1 hours Less than 1 hrs 6 3 3 1 to 399 hrs 4 to 599 hrs 6 to 799 hrs 8 to 999 hrs 1 hrs or more Some APNs found it was hard to answer this question because they have been an APN for many years and they had difficulty remembering the number of hours required in their APN program. 32% of the claim respondents and 18% of non-claim respondents did not answer. Among APNs who did answer the question, more than half were required to spend between 4 and 8 clinical hours in their APN program. 2% of APNs recalled needing less than 4 clinical hours and 21% recalled needing 8 hours or more. On average APNs say they spent 635 clinical hours in their APN program. 3 8 8 Average clinical hours required in APN program Total (Base=2272) Non-claim (Base=2,175) Claim (Base=97) M e a n 635 631 736 1 2 3 4 5 6 7 8 hours $12, $1, $8, $97,24 $86,58 $86,391 $85,966 $96,591 $79,532 $6, $4, $2, $27,17 $14,17 $24,142 $39,622 $ Missing (N=49) Other specified (N=5) hours (N=1) Less than 1 hrs (N=6) 1 to 399 hrs (N=2) 4 to 599 hrs (N=21) 6 to 799 hrs (N=27) 8 to 999 hrs (N=3) 1 hrs or more (N=2) Total (N=152) Q6. How many clinical hours were required in your APN program? 17
RN Years Prior to APN Certification On average, the APNs spent 13 years practicing as a registered nurse before becoming certified to practice as an APN 45 4 35 Q7. How many years did you practice as a registered nurse before becoming certified to practice Claim (Base=148) Non-claim (Base=2,75) Total (Base=2,898) 39 35 36 p e r c e n t 3 25 2 15 15 19 19 18 24 24 24 16 16 1 5 5 5 5 Less than 2 years 2 to 5 yrs 6 to 1 yrs 11 to 15 yrs More than 15 Only 5 % of the APNs had been an RN for less than 2 years before becoming certified to practice as an APN. About one-quarter of the APNs had been an RN for less than 6 years before getting their APN certification. More than half of the APNs practiced for more than 1 years as a registered nurse before acquiring their APN designation. On average, the APNs spent 13 years practicing as a registered nurse before becoming certified to practice as an APN. Average years as RN before becoming APN Total (Base=2,898) Non-claim (Base=2,75) Claim (Base=148) M e a n 12.9 12.9 13.6. 1. 2. 3. 4. 5. 6. 7. 8. 9. 1. 11. 12. 13. 14. 15. years $12, $1, $8, $6, $4, $2, $ $19,449 $15,137 Missing (N=4) Less than 2 years (N=8) $19,813 $94,457 $68,124 2 to 5 yrs (N=22) 6 to 1 yrs (N=26) 11 to 15 yrs (N=35) Q7. How many years did you practice as a registered nurse before becoming certified to practice as an APN? $71,789 More than 15 (N=57) $79,532 Total (N=152) 18
Percent State Regulations Governing Practice The majority of APNs maintain that regulations in their state require APNs to practice under a collaborative practice agreement Q8. (At the time of the incident), state regulations governing my practice require(d): (Check one) 1 Claim (Base=142) Non-claim (Base=2,75) Total (Base=2,892) 9 8 8 79 79 7 6 5 4 3 2 1 11 15 15 6 4 4 4 3 3 No physician oversight Collaborative practice agreements Direct physician supervision Other (please specify) The APNs scope of practice requirements vary by state, with most states allowing APNs to function collaboratively with physicians and other healthcare providers rather than under the direct supervision of a physician. Some states require APNs to operate under a formal agreement with a supervising physician specifically addressing the level of physician oversight for areas such as prescriptive authority. $12, $1, $8, $6, $4, $95,99 $62, $39,589 $79,532 $2, $8,244 $6,45 $ Missing (N=1) No physician oversight (N=16) Collaborative practice agreements (N=113) Direct physician supervision (N=8) Other (please specify) (N=5) Total (N=152) Q8. (At the time of the incident), state regulations governing my practice require(d): (Check one) 19
Percent APN Employment The vast majority of APNs work for an employer. Among those who are self-employed, there are a greater proportion of APNs with claims Q9. (At the time of the incident), what is(was) your employment status? (Check one) 1 Claim (Base=142) Non-claim (Base=2,75) Total (Base=2,892) 9 8 7 68 69 69 6 5 4 3 2 1 15 1 1 Self-employed, full time 4 4 4 Self-employed, part time (less than 24 hours per week) Employed full time 13 12 12 Employed part time (less than 24 hours per week 1 1 1 Retired or permanently disabled Unemployed, seeking work Student 4 4 Other (please specify) The vast majority of APNs work for an employer. 69% of all APNs are employed full-time and another 12% are employed part-time. Self-employed APNs account for 14% of positions, 1% working full-time and another 4% working part-time. Working as a self-employed APN represents an identified area of potential risk. A significantly greater proportion of APNs who have had a claim are self-employed fulltime (15% v. 1%). $16, $14, $12, $1, $8, $6, $4, $2, $ $8,244 $51,274 $11,773 $85,776 $144,941 $13,716 $79,532 Missing (N=1) Self-employed, Self-employed, full time (N=21) part time (less than 24 hours per week) (N=5) Employed full time (N=96) Employed part time (less than 24 hours per week) (N=18) Other (please specify) (N=2) Total (N=152) Q9. (At the time of the incident), what is(was) your employment status? (Check one) 2
Percent Staffing or Placement Services Few APNs provide services for a staffing or placement service Q1. (At the time of the incident, were) are you providing services for a staffing or placement service? Claim (Base=142) Non-claim (Base=2,75) Total (Base=2,892) 1 9 8 7 6 5 4 3 2 1 1 3 Yes 3 99 97 No 97 Very few APNs provide services for a staffing or placement service and there are no significant findings with regards to claims among these APNs. $9, $8, $7, $6, $5, $4, $3, $2, $1, $ $7,661 $8,244 $84,751 $79,532 Missing (N=1) Yes (N=14) No (N=2) Total (N=152) Q1. (At the time of the incident, were) are you providing services for a staffing or placement service? 21
Named in Lawsuit Three-quarters of APNs with claims were named in the lawsuit along with their employer, facility and/or other healthcare professionals 9% of the APNs with claims admit that they were named alone in the lawsuit. 74% of APNs with claims were named along with their employer, facility and/or other healthcare support staff. Q11. Who was named in the lawsuit? (Check one) Claim (Base=142) Do not know, 17% Self and others, 74% Only self, 9% 1 9 8 7 6 5 4 3 2 1 Q12. What others were named in the suit? (Check all that apply) (Claim Base=156) 92 3 43 Physician Hospital Facility NP RN Other healthcare support staff 22 13 24 In 92% of cases where someone else was named, it was a physician. 22
Being named in a lawsuit with others increases APN claim severity by eleven times. When an APN is involved in a suit alone, the average claim dollars are much lower than when APNs are named with others. Knowing that three-quarters of the lawsuits involving APNs named others as well, it is concerning that the average claim losses are 11 times greater for APNs named along with others. $12, $111,498 $1, $8, $79,532 $6, $4, $2, $8,244 $1,62 $7,17 $ Missing (N=1) Only self (N=13) Self and others (N=15) Do not know (N=24) Total (N=152) Q11. Who was named in the lawsuit? (Check one) $14, $12, $1, $8, $6, $4, $2, $ $115,733 (for APNs who were named with others) $75,382 $79,122 $98,597 $43,126 Physician (N=97) Hospital (N=32) Facility (N=45) NP (N=23) RN (N=14) Other healthcare support staff (N=25) $115,46 $111,498 Total (N=15) Q12. What others were named in the lawsuit? (Check all that apply) Since a physician is named in 92% of the cases where an APN is not named alone, it is not surprising that the average claim severity for APNs named with others is only 4% lower than the $115,733 average claims paid/reserved when a physician is named. 23
Being named in a lawsuit with a physician results in claim losses 92% greater than when someone else is named along with the APN It is interesting that when physicians are not named along with the APN (that is when the APN is named with someone other than a physician) the average claim paid/reserved is $6,138, indicating a severity factor of 1.92 times or 92% higher claim losses associated with being named along with a physician compared to being named with others. (for APNs who were named with others) Total (N=15) Other healthcare support staff named (N=25) Other healthcare support staff NOT named (N=8) $111,498 $115,46 $11,259 RN named (N=14) $43,126 RN NOT named (N=91) $122,16 NP named (N=23) NP NOT named (N=82) CNS NOT named (N=15) $98,597 $115,116 $111,498 Facility named (N=45) $79,122 Facility NOT named (N=6) $135,779 Hospital named (N=32) $75,382 Hospital NOT named (N=73) Physician named (N=97) $115,733 $127,329 Physician NOT named (N=8) $6,138 $ $2, $4, $6, $8, $1, $12, $14, $16, Q12. What others were named in the lawsuit? (Check all that apply) 24
Being named in a lawsuit with a physician increases claim severity by 7.4 times that of all APNs, including those named alone When we look at all APNs not named with a physician (that is APNs who are named alone or named with someone other than a physician) the average claim paid or reserved drops to $15,687, which is 7.4 times lower than when named with a physician. Total (N=152) $79,532 Other healthcare support staff named (N=25) $115,46 Other healthcare support staff NOT named (N=127) $72,46 RN named (N=14) $43,126 RN NOT named (N=138) NP named (N=23) NP NOT named (N=129) CNS NOT named (N=152) Facility named (N=45) Facility NOT named (N=17) Hospital named (N=32) Hospital NOT named (N=12) $83,226 $98,597 $76,133 $79,532 $79,122 $79,75 $75,382 $8,639 Physician named (N=97) $115,733 Physician NOT named (N=55) $15,687 $ $2, $4, $6, $8, $1, $12, $14, Q12. What others were named in the lawsuit? (Check all that apply) 25
Percent Years Practicing as an APN Years of experience as an APN can minimize the risk of an incident 5 45 4 35 Q13. (At the time of the incident), how many years have(had) you been an APN? Claim (Base=141) Non-claim (Base=2,75) 41 Total (Base=2,891) 35 3 25 2 15 1 5 9 12 12 24 25 27 28 6 2 2 9 17 16 Less than 2 years 2 to 5 yrs 6 to 1 yrs 11 to 15 yrs More than 15 During their first two years of practice, many APNs are being mentored and taking on less responsibility in their new role. While no significant differences were found among APN with less than 2 years of experience, it is not surprising that beyond their first two years of practice, increasing years of experience as an APN appears to be a factor in avoiding an incident. APNs are at increased risk of claims until they are sufficiently experienced and have been practicing for approximately 1 years. 76% of APNs with claims were practicing for 2 to 1 years compared to 51% in the non-claim group. 26
On average, the APNs with claims had been an APN for 7.6 years at the time of the incident while the average APN without claims has been an APN for 9.7 years. Average years as APN Total (Base=2,891) Non-claim (Base=2,75) Claim (Base=141) M e a n 7.6 9.6 9.7. 1. 2. 3. 4. 5. 6. 7. 8. 9. 1. yearss $16, $14, $12, $1, $8, $6, $4, $2, $ $7,647 $56,838 $8,3 $95,865 $142,69 $39,853 $79,532 Missing (N=11) Less than 2 years (N=12) 2 to 5 yrs (N=5) 6 to 1 yrs (N=58) 11 to 15 yrs (N=9) More than 15 (N=12) Total (N=152) Q13. (At the time of the incident), how many years have(had) you been an APN? 27
Mentors Half of APNs with claims had a mentor during their first two years of practice compared to only 37% of APNs without claims; the mentor was most often a physician (M.D.) It is remarkable that APNs with claims were more likely than APNs without claims to have been mentored during their first two years of advanced practice (5% v. 37%). Q14. Did you have a mentor during your first two years of advanced practice? 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % Claim (Base=141) Non-claim (Base=2,75) Total (Base=2,891) 63% 62% 5% 5% 37% 38% Yes No For those who had a mentor, most often the mentor was a physician. APNs with claims were even more likely to have had an M.D. mentor (87% v. 77%). APNs with claims were less likely than those without claims to have had an NP for a mentor (36% v. 51%). 28
Being mentored during their first two years of practice increases APN claim severity by 64% Compared to APNs who were not mentored, APNs who had a mentor during their first 2 years of advanced practice had 64% higher average claims paid or reserved. $12, $1, $8, $6, $4, $64,59 $15,984 $79,532 $2, $ $7,647 Missing (N=11) No (N=71) Yes (N=7) Total (N=152) Q14. Did you have a mentor during your first two years of advanced practice? $18, $16, $14, $12, $1, $8, $6, $4, $2, $ $163,358 $117,161 $17, $11,427 MD Mentor (N=61) NP Mentor (N=25) CNS Mentor (N=2) Other Mentor (please Q15. Who was the mentor or collaborator? (Check all that apply) specify) (N=3) $15,984 Total (N=7) Having an MD mentor during the first two years of APN practice is associated with significantly higher claim payouts. 29
Being mentored by an M.D. during the first two years of APN practice results in claim losses nearly four times greater than when mentored by persons other than an M.D. (for APNs who had a mentor during 1st 2 years) Total (N=7) $15,984 Other Mentor (please specify) (N=3) $11,427 NO Other Mentor (please specify) (N=67) $11,218 CNS Mentor (N=2) $163,358 NO CNS Mentor (N=68) $14,296 NP Mentor (N=25) $17, NO NP Mentor (N=45) $15,419 MD Mentor (N=61) $117,161 NO MD Mentor (N=9) $3,23 $ $2, $4, $6, $8, $1, $12, $14, $16, $18, Q15. Who was the mentor or collaborator? (Check all that apply) When mentored APNs do not have an MD mentor (that is when the APN had mentors other than an MD) the average claim paid/reserved drops to $3,23, which is 3.88 times lower than when mentored by a physician. 3
Being mentored by an M.D. during the first two years of APN practice increases claim severity by more than twice that of all APNs, including those not mentored Total (N=152) $79,532 Other Mentor (please specify) (N=3) $11,427 NO Other Mentor (please specify) (N=149) $8,94 CNS Mentor (N=2) $163,358 NO CNS Mentor (N=15) $78,415 NP Mentor (N=25) $17, NO NP Mentor (N=127) $74,125 MD Mentor (N=61) $117,161 NO MD Mentor (N=91) $54,39 $ $2, $4, $6, $8, $1, $12, $14, $16, $18, Q15. Who was the mentor or collaborator? (Check all that apply) When we look at all APNs with no MD mentor (that is when the APN had no mentor or had mentors other than an MD), the average claim size was $54,39. APNs with MD mentors, by contrast, had claims averaging 2.16 times or 116% higher. 31
Advanced Practice Settings Physician s office/clinic, nursing home and prison settings have a higher risk of APN incidents, while convenient care clinics, school/college clinics and community clinics and health centers may offer less risk Other (please specify) Convenient care clinic My own premises Staffing aggency School/college clinics Hospice centers Home healthcare agency Nurse practitioner practice Physician office/clinic Community clinic & health center Ambulatory care facility Q16. Which of the following best describes your(the) practice setting (where the incident occurred)? (Check one) Industry Surgicenter Prison Patient's home Nursing home Hospital 2 1 1 1 1 1 3 4 4 6 6 6 5 6 7 13 13 12 12 11 12 13 15 15 Total (Base=2,889) Non-claim (Base=2,75) Claim (Base=139) 33 33 44 About one-third of all working APNs practice in physician s offices or clinics. Hospitals are the primary practice setting for 12% of APNs. Within many practice settings, the proportion of APNs with claims and APNs without claims is relatively equal. 5 1 15 2 25 3 35 4 45 5 Percent Practice settings that may have an increased risk for malpractice incidents are: Physician s office/clinic (44% of APNs with claims v. 33% of APNs without claims) Nursing Homes (13% of APNs with claims v. 6% of APNs without claims) Prisons (6% of APNs with claims v. less than 1% of APNs without claims) Practice settings that may have a decreased risk of malpractice incidents are: Schools/college clinics (no APN claims v. 4% of APNs without claims) Community clinic & health center (4% of claim APNs v. 12% of APNs without claims) 32
APNs in physician office/clinic have average claim losses two and a half times greater than APNs in other practice settings Total (N=152) $79,532 Other (please specify) (N=17) $12,591 Prison (N=8) $38,776 Nursing home (N=18) $67,963 Hospital (N=16) $68,575 Nurse practitioner practice (N=1) $47,875 Physician office/clinic (N=61) $13,228 Community clinic & health center (N=5) $24,613 Ambulatory care facility (N=4) $142,868 Missing (N=13) $9,764 $ $2, $4, $6, $8, $1, $12, $14, $16, Q16. Which of the following best describes your(the) practice setting (where the incident occurred)? (Check one) APNs working in Physician office/clinic practices have average claims paid/reserved of $13,228, which are 2.53 times or 153% higher than the average for the remaining practice areas combined ($45,55, N=91). 33
Percent Practicing without certification Practicing without certification was not found to be a significant factor in claim incidence or severity. The majority (84%) of APNs say they do not practice outside their area of certification. Q17. (At the time of the incident), are(were) you practicing in a specialty area in which you were not certified? Claim (Base=137) Non-claim (Base=2,75) Total (Base=2,887) 1 8 87 84 84 6 4 2 13 16 16 Yes No Other (please specify) Women's health (no OB) Behavioral health Pediatrics Oncology Obstetrics/perinatal Neonatal Gerontology Family practice Adult care Q18.(At the time of the incident), in what specialty area do(did) you practice? (Check one) (Base=APNs who practice in area of specialty not certified) 1 1 4 3 6 6 5 5 6 8 7 9 9 8 8 1 1 11 11 17 17 17 22 49 5 1 2 3 4 5 6 Percent Total (Base=448) Non-claim (Base=43) Claim (Base=18) 13% of APNs with claims (N=18) admitted to practicing outside their specialty and worked in a variety of specialty areas as seen in the chart. 34
Most APNs do not practice outside their area of certification and the severity of claims is not significantly different for APNs practicing outside their area of certification. $9, $8, $7, $6, $5, $4, $3, $2, $1, $ $84,537 $79,532 $66,228 $57,533 Missing (N=15) No (N=119) Yes (N=18) Total (N=152) Q17. (At the time of the incident), are(were) you practicing in a specialty area in which you were not certified? (for APNs practicing in area NOT certified) Total (N=18) $57,533 Other (please specify) (N=4) Behavioral health (N=3) $4,868 $37,686 Oncology (N=2) $166,886 Neonatal (N=1) $1,157 Gerontology (N=3) Family practice (N=3) $33,533 $39,742 Adult care (N=2) $12,157 $ $2, $4, $6, $8, $1, $12, $14, $16, $18, Q18.(At the time of the incident), in what specialty area do(did) you practice? (Check one) 35
Percent Years Working in This Particular Position At the time of the incident, more than half of APNs with claims had been working in the position less than 4 years; nearly three-quarters had been in the position less than 6 years. By contrast, APNs without claims worked on average about 8 more months longer in the position. Q19. (At the time of the incident), how many years have(had) you worked in this particular position? Claim (Base=137) Non-claim (Base=2,75) Total (Base=2,887) 5 45 4 35 3 25 2 15 1 5 3 3 28 24 24 24 21 21 2 21 13 13 7 7 4 Less than 2 years 2 to 3.9 yrs 4 to 5.9 yrs 6 to 1.9 yrs 11 to 14.9 yrs At the time of the incident, more than half (52%) of the APNs with claims had worked in the particular position for less than 4 years and nearly three-quarters (73%) had worked in the position for less than 6 years. 36
Even though it is not a large difference, it is significant that APNs with claims worked in the particular position where the incident occurred for an average of only 4.4 years while APNs without claims have worked at their current specialty area position for an average of 5.1 years without incidence. Average years working in this particular position Total (Base=2,887) Non-claim (Base=2,75) Claim (Base=137 M e a n 4.4 5.1 5.1. 1. 2. 3. 4. 5. 6. years $12, $1, $8, $6, $66,228 $53,625 $85,27 $99,336 $17,31 $79,532 $4, $2, $19,5 $ Missing (N=15) Less than 2 years (N=33) 2 to 5 yrs (N=68) 6 to 1 yrs (N=29) 11 to 15 yrs (N=6) More than 15 (N=1) Total (N=152) Q19. (At the time of the incident), how many years have(had) you worked in this particular position? 37
Prescriptive Authority APNs with claims have less prescriptive authority, particularly for Schedule II-V drugs, than those without claims Q2. (At the time of the incident), what level of prescriptive authority do(did) you have? (Check all that apply) None of the above 6 6 8 Total (Base=2,863) Non-claim (Base=2,726) Claim (Base=137) Schedule II-V 5 6 6 Schedule III-V 26 27 23 Schedule V 13 13 12 Non-scheduled prescription or legend drugs (e.g. prescription medications such as antibiotics) 36 36 38 1 2 3 4 5 6 7 Percent While only 9% (N=14) of the claims had an allegation class of Medication, 64% of the APNs with medication error claims had authority to prescribe Schedule II-V drugs. However, the APNs with claims were generally less likely than those without claims to say they had authority to prescribe Schedule II-V (5% v. 6%). $12, $1, $8, $13,632 $88,268 $74,331 $96,168 $79,532 $6, $4, $38,262 $2, $ Non-scheduled prescription or legend drugs (e.g. prescription medications such as antibiotics)(n=52) Schedule V (N=16) Schedule III-V (N=31) Schedule II-V (N=68) None of the above (N=11) Total (N=152) Q2. (At the time of the incident), what level of prescriptive authority do(did) you have? (Check all that apply) 38
Personnel Assistance APNs with claims report having less personnel assistance than other APNs specifically, fewer had clerical support and other NP assistance at their practice Q21. (At the time of the incident), what kind of personnel assistance is (was) provided to you at your practice? (Check all that apply) Other (please specify) CNS 4 2 2 23 23 Total (Base=2,887) Non-claim (Base=2,75) Claim (Base=137) NP 16 24 24 Physicians Clerical 52 52 53 58 59 59 Aides 45 45 45 LPN 3 3 34 RN 33 45 45 1 2 3 4 5 6 7 Percent More than half of all APNs report having a physician available as personnel assistance at their practice. The APNs with claims reported significantly less RN assistance (33% v. 45%) and significantly less NP assistance (16% v. 24%) at their practice at the time of the incident. For remaining personnel assistance staffing, the APNs with claims were not significantly different from the APNs without claims. 39
APNs with personnel assistance such as clerical, NP and/or other assistance have twice the average claim payouts Total (N=152) $79,532 Other assistance (please specify) (N=27) $135,15 NOT Other assistance (please specify) (N=125) $67,548 CNS assistance (N=3) $2,164 NOT CNS assistance (N=149) $81,9 NP assistance (N=22) $144,919 NOT NP assistance (N=13) $68,467 Physicians assistance (N=79) $98,58 NOT Physicians assistance (N=73) $58,997 Clerical assistance (N=72) $111,72 NOT Clerical assistance (N=8) $5,564 Aides assistance (N=62) $99,719 NOT Aides assistance (N=9) $65,626 LPN assistance (N=47) NOT LPN assistance (N=15) $74,771 $9,169 RN Assistance (N=45) $55,165 NOT RN Assistance (N=17) $89,78 $ $2, $4, $6, $8, $1, $12, $14, $16, Q21. (At the time of the incident), what kind of personnel assistance is (was) provided to you at your practice? (Check all that apply) Personnel assistance associated with significantly higher average paid/reserved claims are: Clerical assistance 2.21 times or 121% greater than no clerical assistance NP assistance - 2.12 times or 112% greater than no NP assistance Other assistance 2 times or 1% greater than no other assistance 4
Percent Daily Patient Workload APNs typically see an average of 16 patients per day, while APNs with claims report seeing more than 19 patients per day at the time of the incident 35 Q22.(At the time of the incident), what is (was) your average patient workload per day? 3 25 24 24 26 27 Claim (Base=138) Non-claim (Base=2,75) Total (Base=2,888) 2 19 19 19 2 2 19 19 15 1 5 2 2 2 9 11 7 8 1 6 6 6 2 2 (None) Less than 1 1 to 14 15 to 19 2 to 24 25 to 29 3 to 39 4 or more Patient workload may be a contributing factor to malpractice incident exposure. APNs with claims report greater daily patient workloads than those without claims. While 45% of APNs without claims saw less than 15 patients per day, only 3% of those with claims were tending to less than 15 patients daily at the time of the incident. 41
The APNs surveyed say they typically see an average of 16 patients per day, while APNs with claims reportedly saw an average of more than 19 patients daily at the time of the incident. Average daily patient workload Total (Base=2,888) Non-claim (Base=2,75) Claim (Base=138) M e a n 16.3 16.2 19.1. 5. 1. 15. 2. patients If we exclude APNs who do not see any patients at all, the APNs who had claims are seeing nearly 2 patients per day on average while the typical APN seeing patients would be responsible for less than 17 patients. Average daily patient workload (excluding APNs who do not see any patients) Total (Base=2,831) Non-claim (Base=2,696) Claim (Base=135) M e a n 16.6 16.5 19.5. 5. 1. 15. 2. patients $14, $12, $1, $8, $6, $4, $2, $ $11,192 Missing (N=14) $2,41 (None) (N=3) $41,887 Less than 1 (N=11) $132,483 $85,128 1 to 14 (N=24) $73,244 15 to 19 (N=33) 2 to 24 (N=34) $7,811 $71,566 25 to 29 (N=14) 3 to 39 (N=12) Q22.(At the time of the incident), what is(was) your average patient workload per day? $92,952 4 or more (N=7) $79,532 Total (N=152) 42
Percent Daily Patient Quotas Daily patient quotas are not associated with claim incidence. APNs with claims were being asked to increase or maintain the daily number of patients seen with less frequency than reported by APNs without claims 1 9 8 7 6 5 Q23. (At the time of the incident, were), are you specifically asked to: Claim (Base=137) Non-claim (Base=2,75) 74 Total (Base=2,888) 51 52 4 3 2 1 9 22 22 Increase number of patients seen per day Decrease number of patients seen per day 17 27 26 Maintain number of patients seen per day Do not know / not applicable 17% of APNs with claims were specifically asked to maintain daily patient quotas and another 9% were asked to increase their daily patient workload at the time of the incident. It is noteworthy that a greater proportion of APNs without claims were specifically asked to maintain (27% v. 17%) or to increase (22% v. 9%) the number of patients being seen per day at their practice, leading us to surmise that increases in patient quotas are not a contributing factor to the incidence of malpractice suits against APNs. Not surprisingly, none of the APNs with claims and less than 1% of the APNs without claims were asked to decrease their patient workload. Perhaps because APNs tend to practice in a more autonomous setting, three-quarters of the APNs with claims and half of the APNs without claims reported that a required increase, decrease or maintenance of patients seen per day was not applicable to them or they did not know if there were daily patient quotas at their practice. $14, $12, $1, $8, $6, $4, $2, $ $1,59 Missing (N=15) $54,753 Increase number of patients seen per day (N=12) $118,561 Maintain number of patients seen per day (N=23) 43 $83,797 $79,532 Do not know / not applicable (N=12) Q23. (At the time of the incident, were), are you specifically asked to: (Check one) Total (N=152)
Percent Overtime While 11% of APNs with claims were required by their facility to work overtime at the time of the incident, this does not appear to be a contributing factor to the incidence of malpractice suits against APNs 1 9 8 7 Q24.(At the time of the incident, did), does your facility require you to work overtime? 89 83 83 Claim (Base=137) Non-claim (Base=2,75) Total (Base=2,887) 6 5 4 3 2 1 11 17 17 No Yes Among both APNs with claims and those without, the vast majority say they are not required by their facility to work overtime. From verbatim comments provided, it is evident that APNs can work in a salaried postion that does not exactly require overtime, but may have them putting in 5 hours per week or more in order to do their job thoroughly and completely. At the time of the incident, 11% of the APNs with claims say they were required to work overtime. This is not significantly different from the 17% of APNs without claims who acknowledged having overtime requirements at their facilities. $14, $12, $1, $8, $6, $82,972 $12,58 $79,532 $4, $2, $ $1,59 Missing (N=15) No (N=122) Yes (N=15) Total (N=152) Q24.(At the time of the incident, did), does your facility require you to work overtime? 44
Inadequate Staffing 12% of APNs with claims believe that inadequate staffing levels at their facility may have contributed to the cause of the incident Q25. Do you perceive that inadequate staffing levels at the facility contributed to the cause of the incident? (Claim Base=137) No, 88% Yes, 12% While 12% of APNs with claims perceive that inadequate staffing at their facility at the time of the incident may have been a contributing factor, the majority (88%) of APNs with claims do not believe that inadequate staffing levels at their facility was in any way responsible for causing the incident. $1, $9, $8, $7, $6, $5, $4, $3, $2, $1, $ $88,67 $8,187 $79,532 $1,59 Missing (N=15) Yes (N=17) No (N=12) Total (N=152) Q25. Do you perceive that inadequate staffing levels at the facility contributed to the cause of the incident? 45
Percent Appropriate Training The majority of APNs consider themselves fully trained to provide the clinical services required for their position Q26. (At the time of the incident, were) are you providing services in an area where you believe you were fully trained providing clinical services? 1 9 8 7 Claim (Base=137) Non-claim (Base=2,75) Total (Base=2,887) 9 93 93 6 5 4 3 2 1 1 7 7 No Yes 7% of all APNs admit not feeling sufficiently trained to be providing clinical services in the specialty area they were working at the time of the incident, however the vast majority (93%) of APNs feel fully trained to provide clinical services in the area they are currently working. $14, $12, $1, $8, $6, $4, $2, $ $119,48 $83,452 $79,532 $1,59 Missing (N=15) No (N=14) Yes (N=123) Total (N=152) Q26. (At the time of the incident, were) are you providing services in an area where you believe you were fully trained providing clinical services? 46
Percent Electronic Medical Records In contrast to current APN practices, few APNs with claims reported using electronic medical records at their facility when the incident occurred. Nearly three-quarters of APNs with claims utilized only handwritten medical records at the time of the incident 1 Q27. (At the time of the incident, did), does your facility: (Check one) 9 8 7 6 74 Claim (Base=137) Non-claim (Base=2,75) Total (Base=2,887) 5 4 3 29 28 36 37 32 31 2 1 7 15 4 4 4 Utilize electronic medical records Utilize handwritten medical records Utilize a combination of electronic and handwritten medical records Other (please specify) The utilization of handwritten medical records alone is being phased out in many practices, and being replaced by electronic medical records. However the APNs who had claims were far less likely than APNs without claims to have utilized electronic medical records (7% v. 29%). The APNs with claims were half as likely to have used a combination of electronic and handwritten medical records (15% v. 32%) and twice as likely to have relied on handwritten medical records at the time of the incident than APNs without claims currently do (74% v. 36%). $12, $1, $8, $6, $4, $2, $ $1,59 Missing (N=15) $97,472 Utilize electronic medical records (N=9) $91,13 Utilize handwritten medical records (N=12) $63,418 Utilize a combination of electronic and handwritten medical records (N=2) Q27. (At the time of the incident, did), does your facility: (Check one) $81,741 $79,532 Other (please specify) (N=6) Total (N=152) 47
Claim Incidence Risk Factors Model In an effort to identify potential predictors of APN liability, 152 APN with claims were compared to the 2,75 APNs without claims who completed the internet survey. So that the importance of this latter segment would not be over-inflated in the comparison, the 2,75 APNs without claims were weighted to create a representative segment of 152 APNs without claims. Binary logistic regression analysis was conducted on the data, describing the effects of each independent predictor variable on the severity of claims variable, while controlling for the other covariates in the model. All possible ordering and groupings of independent variables were evaluated to determine which combinations produced the most effective models. The models were built by sequentially adding variables to the analysis, evaluating the sensitivity of the model and examining the model 2LogLikelihood scores and Chi-square p-values calculated for each independent variable. Independent variables that did not increase model effectiveness were discarded. The predictor variables determined to have a relationship with the outcome variable are certification area, practice area, being specifically asked to increase or maintain the number of patient seen per day and use of electronic medical records. APNS WITH CLAIMS APNS WITH NO CLAIMS Outcome Variable: Claim Paid/Reserved 1 = Yes =No Predictor variables: Q3.2 Family practice certified or licensed as an APN Family practice certified or licensed as an APN Q16.2.11 Q16.3.8.1 Community clinic & health center OR school/college clinic best describes the practice setting where the incident occurred Physician office/clinic OR nursing home OR prison best describes the practice setting where the incident occurred Community clinic & health center OR school/college clinic best describes the current practice setting Physician office/clinic OR nursing home OR prison best describes the current practice setting Q23.1.3 At the time of the incident, specifically asked to increase or maintain number of patients seen per day Specifically asked to increase or maintain number of patients seen per day Q27.1.3 At the time of the incident, facility utilized electronic medical records or a combination of electronic and handwritten medical records Current facility utilizes electronic medical records or a combination of electronic and handwritten medical records 48
All categorical variables were converted to dichotomous variables for this analysis and have been assigned a parameter code of or 1, indicating it is false or true respectively. Notice that some variables in the table below have been inverted in the parameter coding. For example, q27.13 is true for APNs who do NOT use electronic medical records or a combination of electronic/handwritten medical records. This inversion was done to make the model easier to interpret by keeping outcome relationships consistently in the positive direction. q3.2 Family practice certified q23.13 NOT Increase OR Maintain number of patients seen per day q16.3.8.1 Phys Office OR Nursing home OR Prison q16.2.11 NOT Community clinic OR school/college clinic q27.13 NOT Electronic OR combination of electronic and handwritten Categorical Variables Codings Parameter coding Frequency (1) 1456. 1 1431 1. 153 1. 1 1384. 1734. 1 1153 1. 2442 1. 1 445. 1186 1. 1 171. The results of the binary logistic regression model results yielded the equation: Predicted Claims Paid/Reserved = -3.62 +.583 (Q3.2) + 1.421 (Q16.2.11) +.62 (Q16.3.8.1) + 1.11 (Q23.1.3) + 1.693 (Q27.1.3) The fit of the model is very good, accurately predicting 73.1% of the combined observed responses and accurately predicting 79.6% of the claims correctly. Classification Table a Observed Step 1 Claim Paid/Reserved Overall Percentage a. The cut value is.5 Predicted Claim Paid/Reserved Percentage No Yes Correct No 91 46 66.6 Yes 28 19 79.6 73.1 Hosmer and Lemeshow Test Step Chi-square df Sig. 1 1.372 8.995 A well-fitting model is confirmed by the Hosmer and Lemeshow test statistic =.995, much greater than.5, indicating that the observed values are not significantly different from the model predicted values. The overall model was significant with a Chi-Square p-value of less than.1. All of the explanatory variables related to APN liability claims are statistically significant at the five percent level. 49
Variables in the Equation 95% C.I.for EXP(B) B S.E. Wald df Sig. Exp(B) Lower Upper Step 1 a q27.13(1) 1.693.293 33.37 1. 5.436 3.59 9.661 q23.13(1) 1.11.298 11.471 1.1 2.748 1.531 4.931 q16.3.8.1(1).62.3 4.255 1.39 1.859 1.31 3.349 q16.2.11(1) 1.421.587 5.86 1.15 4.142 1.311 13.9 q3.2(1).583.286 4.151 1.42 1.791 1.22 3.136 Constant -3.62.656 3.158 1..27 a. Variable(s) entered on step 1: q27.13, q23.13, q16.3.8.1, q16.2.11, q3.2. In the Variables in the Equation table, the Exp (B) column represents the odds ratio. The odds ratio for Q27.13 (Not utilizing EMR or combo) is Exp (1.693) = 5.436. This tells us that, holding all the other predictors fixed, the odds for a claim paid or reserved are 5.436 times greater when APN practices are NOT utilizing electronic medical records or combo than in APN practices using electronic medical records or a combination of EMR and handwritten records. In terms of percent change, the odds for APNs NOT utilizing EMR or combo are 444% higher than APNs utilizing EMR or combo. The lack of utilization of Electronic medical records or a combination of EMR and handwritten records is the most significant factor associated with the incidence of APN liability claims. APNs certified or licensed in family practice (Q3.2) are 1.791 times more likely to have a claim than APNs with other certifications. Practicing in a physician s office, nursing home or prison (Q3.8.1) increases the odds of having a claim by a factor of 4.142 while NOT practicing in a community clinic & health center or school/college clinic (16.2.11) increases the odds by a factor of 1.859 times more than APNs in the remaining practicing settings. Not totally surprising because it was also observed in the actual data, the final somewhat inapt predictor forecasts the odds of an APN claim being nearly 3 times greater when NOT asked to increase or maintain the number of patients seen daily (Q23.13). 5
Severity Risk Factors Model While the previous model identified potential predictors of APN claim incidence, we are also interested in identifying the predictors related to the increasing size of the claim payments and reserves. This second model attempts to predict the risk factors associated with likelihood to have an incident resulting in high expenses, indemnity or reserves. Using the data collected from 152 APN claim survey respondents, a linear regression analysis was conducted to identify the probable predictors of claim severity. Examining the total dollars of claims paid and reserved revealed that it was a skewed distribution, which violates the assumption of normality. A log transformation of the values was conducted to normalize the distribution. Explanatory variables were selected using several different methods, forward, stepwise and backward removal in order to determine combinations which produced the most effective models. Independent variables that did not increase model effectiveness were discarded. Each of the explanatory variables 51