Circulation: Malpractice fears compel cardiologists to order unnecessary tests
Concerns among cardiologists of malpractice suits and push from referring physicians to order tests can help influence the rates of unnecessary testing. The use of cardiac testing and procedures as well as their costs vary among geographic locations, which could be a result of the use of physicians' non-clinical decision factors, based on study results in the April 15 issue of Circulation: Cardiovascular Quality and Outcomes.

“In an era of escalating healthcare costs and focus on the delivery of high-quality care at the lowest possible cost, it is critical to understand why some regions experience so much higher rates of healthcare utilization than others,” the authors wrote.

Frances Lee Lucas, PhD, of the Maine Medical Center in Portland, Maine, and colleagues aimed to better understand geographical and spending variance across the U.S. by surveying cardiologists about clinical decisions by having them assess hypothetical patient vignettes.

The researchers focused on two main objectives: Assessing whether self-reporting trends to treat/test for coronary artery disease (CAD) were based on non-clinical decisions such as malpractice suits, and evaluating the self-reporting trends of cardiologists for treating/testing CAD and how these correlated to population-based measures of variation in utilization.

The researchers used the Masterfiles of the American Medical Association database to identify 994 qualified physicians--62 percent (or 614) of whom responded to the survey. They evaluated how cardiologists would recommend interventions in accordance with each hypothetical patient case and how likely they would be to recommend a cardiac cath other than reasons that were strictly clinical.

Of the cardiologists surveyed, 93 percent were male, 82 percent were white and their average age was 52. Additionally, the survey sample was a mix of general cardiologists, invasive cardiologists, interventional cardiologists and electrophysiologists -- 36, 21, 36 and 7 percent, respectively.

The study focused on three vignettes regarding how cardiologists would treat patients: Patient one with a heavy onset of angina and heavy exertion to the hospital with high frequency; patient two with severe end-stage congestive heart failure (CHF) and non-sustained ventricular tachycardia; and patient three with exacerbation of end stage CHF due to inoperable artherosclerotic heart disease.

In measuring responses, researchers had physicians self-report their practice style by intensity as either "high-tech," "aggressive," or "invasive" treatment options based on how they would treat each of the aforementioned patient specific cases.

The results showed that 7 percent of cardiologists said that they would admit patient one to the hospital for treatment and only 6 percent of the sample said that they would repeat angiography “always” or “most of the time” for patient two. The researchers reported that only 2 percent of cardiologists said that they would insert an pulmonary artery catheter in patient three and a significant number said that they would recommend an intervention for both patients one and two--30 and 65 percent, respectively.

Additionally, survey results showed that international medical school graduates exhibited higher cardiac intensity scores than U.S. medical school graduates, while physicians practicing in HMOs had lower scores than those in other settings.

While differences among geographic location were not significant, according to the authors, those in the New England and Pacific areas exuded lower scores than those in the Mid-Atlantic, South Atlantic and West South Central regions.

In regard to trends in non-clinical factors for ordering cardiac testing, most cardiologists denied ordering a cardiac cath of “questionable clinical necessity” for any of the following reasons: Patients expected the procedure; colleagues would do so in the same situation; wanted to satisfy the expectations of the referring physician; protect against a possible malpractice suit; and ordering would enhance the financial stability at the practice.

Lucas and colleagues found that 27 percent of cardiologists said that they ordered cardiac cath because of peer pressure they felt from colleagues. And while no cardiologists said that they would order a cath in accord with financial reasoning, for all of the aforementioned non-clinical factors the majority responded they would order tests “frequently” or “sometimes.”

For those in the lowest spending quintiles, 19.1 percent and 11.9 percent said that they more frequently ordered a cardiac cath when a referring physician expected the test or out of fear of a possible malpractice suit. These same rates for the highest spending quintiles were 35.5 and 35.1 percent, respectively.

“Using a cardiologist survey and previously developed measures of variation in healthcare utilization in the population, we have shown that cardiologists report a higher propensity to test and treat intensively in high-utilization regions than in lower utilization regions,” the authors wrote.

Limitations stem from measures of utilization being limited to the Medicare population and also using hypothetical patient cases, rather than real-life situations.

“Our results suggest that malpractice concerns may be a target for intervention to reduce variations,” the authors concluded.