A Study of Medical Board Peer Reviews in Nevada

Method

The medical reviewer, who is a physician employee for the NSBME, conducted the study with the approval of the Board. Each peer review performed on a physician was counted as a separate review for the ease of statistical reporting. In some instances, multiple peer reviews were required regarding a single complaint. All percentages were rounded off to the nearest whole percentage. The physician against whom the complaint was filed is referred to as the complaint physician in this study.

Peer reviews were generally obtained only regarding complaints containing allegations of negligence or incompetence. Nevada's statutory definition of malpractice and its use in this text is “the failure of a physician, in treating a patient, to use reasonable care, skill, or knowledge ordinarily used under similar circumstances.” The protocol for the processing of complaints is addressed in table 1. Complaints filed against a licensee are generally reviewed at the onset by the Board's medical reviewer. The medical reviewer, who reviews all complaints dealing with negligence and/or incompetence, determines which complaints should be sent out for a peer review. Once the peer review is returned, the medical reviewer again reviews the matter. All peer reviews requested by the medical reviewer during the two-year period of this study were included in the data collected. Peer reviews were also occasionally requested by the Investigative Committees of the Board based on their initial review of the complaint. These committees are composed of two physician Board members and one layperson Board member. They are responsible for determining whether formal disciplinary action will be initiated against a licensee. The peer reviews requested by the Investigative Committee were also included in this study.

The study was divided into two time periods. The first was from Dec. 1, 2007 to Nov. 30, 2008. The second period was from Dec. 1, 2008 to Nov. 30, 2009. Totals were then compiled not only for each time period but also for the total two-year period. It should be noted that the total number of peer reviews from Dec. 1, 2007 to Nov. 30, 2008 most accurately reflects the actual number of peer reviews for that time period. For the later time period, there was an internal change in the manner in which peer reviews were processed through the system. This did not bias the results but did account for a decrease in the number of peer reviews entered into the study.

The actual number of peer reviews performed was roughly the same as the prior year.

Most of Nevada's physicians are concentrated in two counties, Washoe and Clark. These counties account for 92% of the total physicians practicing in the state. Washoe County is in the northwestern part of the state and includes the city of Reno. Clark County is in the southern part of the state and includes the cities of Las Vegas and Henderson. According to statistics kept by the licensing division of the NSBME, in 2008 a total of 4,481 physicians were actively practicing in the state of Nevada. Of these, 1,056 physicians, or 24% of the total, resided in Washoe County and 3,060, or 68% of the total, resided in Clark County.

The distance between the physician communities (approximately 500 miles) helped determine the selection of the peer reviewer. When a complaint involved a physician from one community, a peer reviewer from another community was generally chosen. This minimized any conflicts of interest. Whenever possible, physicians were used from within the state, which helped control costs if their testimony was needed in a hearing. Based on the prior stated distribution of physicians in the state, it is therefore not surprising that our data indicated 80% of the complaint physicians were located in Clark County and that only 12% were located in Washoe County (see table 2), and that 61% of the peer reviewers were located in Washoe County and 24% in the Clark County (see table 3).

The origins of the complaints initiating the peer reviews are addressed in table 4. The NSBME is statutorily required to investigate all civil malpractice cases filed in court. Sixty-nine percent of the total were from civil malpractice cases filed in court, 15% from patient complaints, 5% from coroner-prompted investigations, 3% from family member complaints, and 9% involved other origins of complaints—such as from government agencies or other physicians.

The number of years the complaint physicians had practiced in the state inclusive to the time the complaint was made is reflected in table 5. Physicians in practice for five years or less accounted for 12% of the total, 40% had practiced for 6 to 10 years, 20% for 11 to 15 years, 16% for 16 to 20 years, and 13% for more than 21 years. This five-year increment division was arbitrarily selected. Also recorded was the total number of complaints filed for each complaint physician, including the present complaint (see table 6). Forty-seven percent of the physicians had 1 to 3 complaints filed, 10% had 4 to 6 complaints, 17% had 7 to 10 complaints, and 26% had 11 or more complaints. These increments were also arbitrarily chosen.

The overall quality of the peer reviews was evaluated by the medical reviewer based on the overall content of the peer review, including the detail of the review and whether the peer reviewer's conclusion was justified by the supporting content of the review. Supporting content included specific references to the medical record supporting conclusions, along with pertinent reference materials included in the review. Fifty-nine percent were deemed to be excellent, 37% good, 1% adequate, and 3% sub-adequate (see table 7).

Forty-two percent of the peer reviews ordered by the medical reviewer had a finding of malpractice as defined legally by statute. Fifteen percent of the peer reviews ordered by the Investigative Committees had a finding of malpractice. Overall, 38% of the peer reviews requested had a finding of malpractice (see tables 8, 9, and 10).

We recorded not only the number and percentage of the complaint physicians by specialty but also the number and percent of findings of malpractice found in each specialty for each year of the study and during the total two years of the study (see tables 11, 12, and 13). Costs were recorded for each peer review with further sorting by the specialty of the peer reviewer. Average costs and highest cost were recorded by specialty of the peer reviewer (see table 14). These costs were further sorted by the year that the peer review was entered into the study and for the total two years of the study. The average cost of a peer review over the two-year study was $791. Costs were determined based on the hours spent performing the review as relayed by the peer reviewer. The hourly rate was $150. Many peer reviewers did not charge the Board for their time. Generalities concerning the data above are only suggestive at best due to the limited numbers in the study.

The time from when the peer review was requested until materials were sent from the Board to the peer reviewer was included in the data collection (see table 15). Forty-seven percent of the time materials were sent from the Board to the peer reviewer in 60 days or less, 21% were sent between 61 and 120 days, and 33% percent were sent more than 120 days from the request. Also included in this study was the time for the peer review to be performed by the peer reviewer, defined by when the materials for review were sent from the Board to the peer reviewer and the date the completed peer review was received by the Board (see table 16). Forty-eight percent were received back in 60 days or less, 24% were received back between 61 and 120 days, and 27% took 121 days or more to return.

Analyzing such data can be an effective tool in streamlining state medical board practices. Addressing outliers indentified by ongoing dynamic review can enhance state medical board performances. Regarding the time it took to send the materials from the Board to the peer reviewer, one could initially define outliers as having taken more than 120 days for the materials to be sent. By this initial definition of outliers, it would not be unreasonable to project that times for material distribution could be improved to an ultimate goal of 30 days. The same goal could be set for improving times for peer reviews to be returned within 30 days. Introducing a call-back system when target times are exceeded could achieve this goal. For example, if the time for return of the peer review exceeded the allotted target time of 30 days, a reminder call would be made at day 31 and every two weeks thereafter.

Peer reviewers, as defined and utilized by our Board, deliver “expert opinions” rendered on the Board's behalf. Therefore, it is not unreasonable to establish qualifications for those rendering such opinions (see table 17), including having an active license and actively practicing in the state whenever possible. It may be necessary to utilize out-of-state physicians due to a shortage of a particular specialty in the state. Controlling costs for transportation, time, and lodging are additional important considerations for utilizing in-state physicians whenever possible—especially should testimony in a hearing be required. Board certification is preferable, along with the physician practicing for three or more years in his or her particular specialty following the completion of specialty training. It is also important that the peer reviewer have current experience in the procedure at issue. It is essential that the peer reviewer have a low complaint history with the Board and be of high moral and ethical character. Knowledge of the peer reviewer's communication skills, in case testimony is needed in a hearing, can also be helpful.

Ideally, the peer reviewer should have guidelines stated in an agreement developed by the Board outlining what is expected of them. An example of such an agreement is delineated in table 18. This agreement should be discussed at the onset of the peer reviewer selection process so all parties know what is expected of each other in order to avoid problems down the road, such as instances in which consultation and preparation with Board attorneys is needed for hearing testimony. This agreement may be flexible, but it should include an established hourly reimbursement for time spent performing the peer review. Our reimbursement rate is $150 per hour. A standard format should also be established, which can be flexible, provided by the Board to the peer reviewer to guide the manner the peer review is to be written.

Spelled out in the agreement should be the peer reviewer's acceptance to participate in any consultation needed by the Board's attorney for preparation of the complaint for a hearing, and the peer reviewer agreeing to testify at a hearing if one should take place. There should be a brief discussion establishing that the peer reviewer has no conflicts of interest. The following question should be asked once a potential peer reviewer has been selected: If you find malpractice, would you have difficulty stating this? Once it is determined that the peer reviewer does not have difficulty in stating malpractice, an understanding should be sought as to the precise terminology the Board wishes the peer reviewer to use if malpractice is found to ensure it is correctly stated. There should also be a discussion regarding the timeframe for the peer review to be performed. Lastly, the Board should provide a statement in writing to the peer reviewer that he or she is immunized from any potential damages and liability in rendering his or her own forthright, honest opinion.

By ongoing review of peer reviewers, a medical board may develop a number of physicians in each specialty who can be utilized to perform peer reviews. A commitment is then made by each party. Of course, this is an ideal situation if a high number of physicians are willing to perform peer reviewers. Utilizing reviewers that the Board is comfortable with by past experience helps ensure these physicians gain more experience in performing reviews and in testifying during hearings. These peer reviewers then become themselves more comfortable with a process that can sometimes be daunting.