There is little to no association between malpractice liability risk and healthcare quality in the United States, according to systematic review results published in JAMA. In states with more stringent tort laws, for example, no consistent relationship with patient outcomes was observed.

The tort liability system exists to compensate injured patients, rectify losses by punishing perpetrators, and deter further malpractice. Tort liability systems differ across states and healthcare systems. Investigators sought to examine the relationship between malpractice risk measures and care quality. A total of 5 databases were searched for studies regarding malpractice from 1990 through 2019. Exposure and outcome measures were systematically extracted from each publication. Due to variations in methodology across studies it was not possible to perform meta-analyses; instead, data were assessed qualitatively. Exposure measures included physicians’ malpractice insurance premiums, physicians’ claims history, total malpractice payments, the presence of malpractice immunity, jury awards, state tort laws and reforms, and the Medicare malpractice geographic practice cost index. Outcome measures included patient mortality, hospital readmissions, length of stay, adverse events, and other standardized measures of hospital care quality, including the Agency for Healthcare Research and Quality patient safety indicators. Risk for bias could not be computed quantitatively; reviewers instead summarized the strengths and limitations of each study.

A total of 37 studies were included in the qualitative synthesis, of which 28 assessed hospital care and 16 assessed obstetric care. Of the obstetric studies, 9 reported no association between liability risk and patient care outcomes, including Apgar score and rate of birth injuries. Of these studies, 7 found “limited evidence” of an association, most in the direction of malpractice risk acting as a deterrent. However, many of these studies failed to reach statistical significance, and the introduction of certain covariates typically attenuated associations.

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In 20 hospital care studies, 15 found no association between liability risk and health outcomes and 5 found limited evidence of an association. Of studies that examined the impact of malpractice risk on readmissions and avoidable initial hospitalizations (n=7), none found a liability deterrent effect. Of 12 studies of other patient care measures, including safety indicators and patient satisfaction, 7 found no association with liability risk. However, 5 studies identified correlations in some models. A 2018 study demonstrated a positive association between tort reforms and patient safety; results were consistent across states. The majority of studies, however, displayed no significant association between medical malpractice liability and patient outcomes. 

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Regarding the risk for bias analysis, most publications in the study demonstrated good quality assessment tools and robust analytic measures. However, the overall systematic review was limited to data from hospitals and obstetrics, excluding a number of other important disciplines. Between-study variability also precluded the use of pooled meta-analytics, which would have provided more precise estimates of the relationship between liability risk and patient care. Even so, “the available findings [suggest] that greater tort liability, at least in its current form, [is] not associated with improved quality of care,” the investigators wrote.


Mello MM, Frakes MD, Blumenkranz E, Studdert DM. Malpractice liability and health care quality: a review. JAMA. 2020;323(4):352-366.