Let the evidence show: Malpractice fears fuel aggressive testing

Physicians who say they are very concerned about malpractice risk may be more likely to recommend more aggressive tests for patients with specific complaints, based on an alternative analysis of nationwide data published in the August issue of Health Affairs.

The authors, led by Emily R. Carrier, MD, of the Center for Studying Health System Change in Washington, D.C., used a validated survey included in a national survey of physicians—the 2008 Center for Studying Health System Change Health Tracking Physician Survey—and linked responses about malpractice risk concern to Medicare claims for their patients treated from 2007 to 2009. Their sample included 1.9 million Medicare patients under the care of 2,469 physicians.

They focused on three measurements of “defensive medicine”—admission to the hospital, referral for specific imaging or other tests and referral to an emergency department (ED).

Previous research attempting to assess the link between concern over malpractice risk and defensive medicine utilized other risk measures, such as the costs of claims or tort reforms.

“In earlier work, we found state measures of malpractice risk and specific malpractice tort laws to be only weakly associated with physicians’ fears of malpractice suits, providing a possible explanation for the small estimates of the cost of defensive medicine in claims-based studies,” the authors explained.

Their analysis yielded a much stronger association that the state-level measures did not.

“This study found that physicians who reported concern about their malpractice risk and who evaluated patients visiting their offices with chest pain, headache, or lower back pain were significantly more likely to order certain diagnostic tests, a pattern consistent with the practice of defensive medicine,” they wrote.

Physicians based out of offices who indicated higher levels of concern were mote likely to order advanced imaging for patients with a headache and conventional imaging for patients with chest pain or low back pain. Higher levels of concern also led physicians to refer patients with chest pain to EDs more often than less-concerned physicians, who were more apt to order stress testing.

While it is still not clear which analytical approach paints a truer picture of the relationship between concern over malpractice and the use of more aggressive diagnostic tests, the authors argued their strategy is a better predictor of actual physician behavior.

It is also unclear how much the practice of defensive medicine contributes to rising healthcare costs, the authors explained, but in order to start addressing the issue of overuse, there should be strategies beyond malpractice reform.

“Reforms need to reassure physicians that medical injuries can be resolved expeditiously and fairly, in a less adversarial manner,” they wrote.

One approach is to enable communication between patients and physicians after an incident occurs. Physicians can explain the care they provided and offer compensation if standards of care are not met.

Another strategy involves the replacement of legal litigation in favor of a system similar to workers compensation that requires patients to prove only that their adverse outcome could have been prevented if certain standards were in place.

Lastly, the authors argued that physicians could also have a safety net if they can prove they followed an established, evidence-based practice guideline.

“Our study suggests that innovative reforms that address the underlying causes of defensive medicine have potential rewards far beyond their advantages for individual patients and clinicians rewards that make them worth pursuing,” they concluded.