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Baungaard N, Skovvang PL, Assing Hvidt E, Gerbild H, Kirstine Andersen M, Lykkegaard J. How defensive medicine is defined in European medical literature: a systematic review. BMJ Open 2022; 12:e057169. [PMID: 35058268 PMCID: PMC8783809 DOI: 10.1136/bmjopen-2021-057169] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/13/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Defensive medicine has originally been defined as motivated by fear of malpractice litigation. However, the term is frequently used in Europe where most countries have a no-fault malpractice system. The objectives of this systematic review were to explore the definition of the term 'defensive medicine' in European original medical literature and to identify the motives stated therein. DESIGN Systematic review. DATA SOURCES PubMed, Embase and Cochrane, 3 February 2020, with an updated search on 6 March 2021. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we reviewed all European original peer-reviewed studies fully or partially investigating 'defensive medicine'. RESULTS We identified a total of 50 studies. First, we divided these into two categories: the first category consisting of studies defining defensive medicine by using a narrow definition and the second category comprising studies in which defensive medicine was defined using a broad definition. In 23 of the studies(46%), defensive medicine was defined narrowly as: health professionals' deviation from sound medical practice motivated by a wish to reduce exposure to malpractice litigation. In 27 studies (54%), a broad definition was applied adding … or other self-protective motives. These self-protective motives, different from fear of malpractice litigation, were grouped into four categories: fear of patient dissatisfaction, fear of overlooking a severe diagnosis, fear of negative publicity and unconscious defensive medicine. Studies applying the narrow and broad definitions of defensive medicine did not differ regarding publication year, country, medical specialty, research quality or number of citations. CONCLUSIONS In European research, the narrow definition of defensive medicine as exclusively motivated by fear of litigation is often broadened to include other self-protective motives. In order to compare results pertaining to defensive medicine across countries, future studies are recommended to specify whether they are using the narrow or broad definition of defensive medicine. PROSPERO REGISTRATION NUMBER CRD42020167215.
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Affiliation(s)
- Nathalie Baungaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Pia Ladeby Skovvang
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Elisabeth Assing Hvidt
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| | - Helle Gerbild
- Health Sciences Research Centre, UCL University College, Odense, Denmark
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Merethe Kirstine Andersen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Lykkegaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Physicians' views and experiences of defensive medicine: An international review of empirical research. Health Policy 2021; 125:634-642. [PMID: 33676778 DOI: 10.1016/j.healthpol.2021.02.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 02/03/2021] [Accepted: 02/23/2021] [Indexed: 12/22/2022]
Abstract
This study systematically maps empirical research on physicians' views and experiences of hedging-type defensive medicine, which involves providing services (eg, tests, referrals) to reduce perceived legal risks. Such practices drive over-treatment and low value healthcare. Data sources were empirical, English-language publications in health, legal and multi-disciplinary databases. The extraction framework covered: where and when the research was conducted; what methods of data collection were used; who the study participants were; and what were the study aims, main findings in relation to hedging-type defensive practices, and proposed solutions. 79 papers met inclusion criteria. Defensive medicine has mainly been studied in the United States and European countries using quantitative surveys. Surgery and obstetrics have been key fields of investigation. Hedging-type practices were commonly reported, including: ordering unnecessary tests, treatments and referrals; suggesting invasive procedures against professional judgment; ordering hospitalisation or delaying discharge; and excessive documentation in medical records. Defensive practice was often framed around the threat of negligence lawsuits, but studies recognised other legal risks, including patient complaints and regulatory investigations. Potential solutions to defensive medicine were identified at macro (law, policy), meso (organisation, profession) and micro (physician) levels. Areas for future research include qualitative studies to investigate the behavioural drivers of defensive medicine and intervention research to determine policies and practices that work to support clinicians in de-implementing defensive, low-value care.
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Reschovsky JD, Saiontz‐Martinez CB. Malpractice Claim Fears and the Costs of Treating Medicare Patients: A New Approach to Estimating the Costs of Defensive Medicine. Health Serv Res 2018; 53:1498-1516. [PMID: 28127752 PMCID: PMC5980310 DOI: 10.1111/1475-6773.12660] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To estimate the cost of defensive medicine among elderly Medicare patients. DATA SOURCES We use a 2008 national physician survey linked to respondents' elderly Medicare patients' claims data. STUDY DESIGN Using a sample of survey respondent/beneficiary dyads stratified by physician specialty, we estimated cross-sectional regressions of annual costs on patient covariates and a medical malpractice fear index formed from five validated physician survey questions. Defensive medicine costs were calculated as the difference between observed patient costs and those under hypothetical alternative levels of malpractice concern, and then aggregated to estimate average defensive medicine costs per beneficiary. DATA COLLECTION METHODS The physician survey was conducted by mail. Patient claims were linked to survey respondents and reweighted to approximate the elderly Medicare beneficiary population. PRINCIPAL FINDINGS Higher levels of the malpractice fear index were associated with higher patient spending. Based on the measured associations, we estimated that defensive medicine accounted for 8 to 20 percent of total costs under alternative scenarios. The highest estimate is associated with a counterfactual of no malpractice concerns, which is unlikely to be socially optimal as some extrinsic incentives to avoid medical errors are desirable. Among specialty groups, primary care physicians contributed the most to defensive medicine spending. Higher costs resulted mostly from more hospital admissions and greater postacute care. CONCLUSIONS Although results are based on measured associations between malpractice fears and spending, and may not reflect the true causal effects, they suggest defensive medicine likely contributes substantial additional costs to Medicare.
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Saint S, Vaughn VM, Chopra V, Fowler KE, Kachalia A. Perception of Resources Spent on Defensive Medicine and History of Being Sued Among Hospitalists: Results from a National Survey. J Hosp Med 2018; 13:26-29. [PMID: 29068439 DOI: 10.12788/jhm.2800] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The United States spends substantially more per capita for healthcare than any other nation. Defensive medicine is 1 source of such spending, but its extent is unclear. Using a national survey of approximately 1500 US hospitalists, we report the estimates the US hospitalists provided of the percent of resources spent on defensive medicine and correlates of their estimates. We also ascertained how many reported being sued. Sixty-eight percent of eligible recipients responded. Overall, respondents estimated that 37.5% of healthcare costs are due to defensive medicine. Just over 25% of our respondents, including 55% of those in practice for 20 years or more, reported being sued for medical malpractice. Veterans Affairs (VA) hospital affiliation, more years practicing as a physician, being male, and being a non-Hispanic white individual were all independently associated with decreased estimates of resources spent for defensive medicine.
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Affiliation(s)
- Sanjay Saint
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Institute for Health Policy and Innovation & Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
- The Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Valerie M Vaughn
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Institute for Health Policy and Innovation & Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- The Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Vineet Chopra
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Institute for Health Policy and Innovation & Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- The Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Karen E Fowler
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- The Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Allen Kachalia
- Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
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The determinants of defensive medicine practices in Belgium. HEALTH ECONOMICS POLICY AND LAW 2016; 12:363-386. [PMID: 27873571 DOI: 10.1017/s174413311600030x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In 2010 the Belgian government introduced a low cost administrative procedure for compensating medical injuries to overcome the major shortcomings of the existing tort system. This paper examines, for the first time, to what extent this reform had an impact on physician specialists' defensive practices and what are the relevant determinants affecting physicians' clinical decision making. Based on a survey of 508 physicians, we find evidence of a relatively modest increase in defensive practices among physicians in various specialties. In general, 14% of the respondents, who were aware of the reform, reported to have increased their overall defensive behaviour, while respectively 18 and 13% altered their assurance and avoidance behaviour. Commonly used physician characteristics, such as claims experience and gender, have a similar impact on defensive medicine as documented in existing literature. Furthermore, the determinant physician's access to an incident reporting system is found to have a significant impact on most of the defensive medicine measures. Health care institutions may therefore play an important role in controlling and reducing physicians' defensive practices.
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Baicker K, Wright BJ, Olson NA. Reevaluating Reports of Defensive Medicine. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2015; 40:1157-1177. [PMID: 26447025 DOI: 10.1215/03616878-3424462] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
There is ongoing policy debate about the potential for malpractice liability reform to reduce the use of defensive medicine and slow the growth of health care spending. The effectiveness of such policy levers hinges on the degree to which physicians respond to liability pressures by prescribing medically unnecessary care. Many estimates of this relationship are based on physician reports. We present new survey evidence on physician assessment of their own use of medically unnecessary care in response to medical liability and other pressures, including a randomized evaluation of the sensitivity of those responses to survey framing. We find that while use of such care is potentially quite prevalent, responses vary substantially based on survey framing, with the way the question is phrased driving differences in responses that are often as great as those driven by physician specialty or whether the physician has personally been named in a lawsuit. These results suggest that self-reported use of medically unnecessary care ought to be used with caution in the formulation of malpractice liability system reform.
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Stacey D, Brière N, Robitaille H, Fraser K, Desroches S, Légaré F. A systematic process for creating and appraising clinical vignettes to illustrate interprofessional shared decision making. J Interprof Care 2014; 28:453-9. [PMID: 24766619 DOI: 10.3109/13561820.2014.911157] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Vignettes and written case simulations have been widely used by educators and health services researchers to illustrate plausible situations and measure processes in a wide range of practice settings. We devised a systematic process to create and appraise theory-based vignettes for illustrating an interprofessional approach to shared decision making (IP-SDM) for health professionals. A vignette was developed in six stages: (1) determine IP-SDM content elements; (2) choose true-to-life clinical scenario; (3) draft script; (4) appraise IP-SDM concepts illustrated using two evaluation instruments and an interprofessional concept grid; (5) peer review script for content validity; and (6) retrospective pre-/post-test evaluation of video vignette by health professionals. The vignette contained six scenes demonstrating the asynchronous involvement of five health professionals with an elderly woman and her daughter facing a decision about location of care. The script scored highly on both evaluation scales. Twenty-nine health professionals working in home care watched the vignette during IP-SDM workshops in English or French and rated it as excellent (n = 6), good (n = 20), fair (n = 0) or weak (n = 3). Participants reported higher knowledge of IP-SDM after the workshops compared to before (p < 0.0001). Our video vignette development process resulted in a product that was true-to-life and as part of a multifaceted workshop it appears to improve knowledge among health professionals. This could be used to create and appraise vignettes targeting IP-SDM in other contexts.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, Ottawa Hospital Research Institute, University of Ottawa , Ontario , Canada
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Minami CA, Chung JW, Holl JL, Bilimoria KY. Impact of Medical Malpractice Environment on Surgical Quality and Outcomes. J Am Coll Surg 2014; 218:271-8.e1-9. [DOI: 10.1016/j.jamcollsurg.2013.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 08/30/2013] [Accepted: 09/16/2013] [Indexed: 11/25/2022]
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Wise but Difficult Choices. South Med J 2012; 105:491-2. [DOI: 10.1097/smj.0b013e31826418a5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Asher E, Greenberg-Dotan S, Halevy J, Glick S, Reuveni H. Defensive medicine in Israel - a nationwide survey. PLoS One 2012; 7:e42613. [PMID: 22916140 PMCID: PMC3420907 DOI: 10.1371/journal.pone.0042613] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2011] [Accepted: 07/10/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Defensive medicine is the practice of diagnostic or therapeutic measures conducted primarily as a safeguard against possible malpractice liability. We studied the extent, reasons, and characteristics of defensive medicine in the Israeli health care system. METHODS AND FINDINGS Cross-sectional study performed in the Israeli health care system between April and July 2008 in a sample (7%) of board certified physicians from eight medical disciplines (internal medicine, pediatrics, general surgery, family medicine, obstetrics and gynecology, orthopedic surgery, cardiology, and neurosurgery). A total of 889 physicians (7% of all Israeli board certified specialists) completed the survey. The majority [60%, (95%CI 0.57-0.63)] reported practicing defensive medicine; 40% (95%CI 0.37-0.43) consider every patient as a potential threat for a medical lawsuit; 25% (95%CI 0.22-0.28) have previously been sued at least once during their career. Independent predictors for practicing defensive medicine were surgical specialty [OR=1.6 (95%CI 1.2-2.2), p=0.0004], not performing a fellowship abroad [OR=1.5 (95%CI 1.1-2), p=0.027], and previous exposure to lawsuits [OR=2.4 (95%CI 1.7-3.4), p<0.0001]. Independent predictors for the risk of being sued during a physician's career were male gender [OR=1.6 (95%CI 1.1-2.2), p=0.012] and surgery specialty [OR=3.2 (95%CI 2.4-4.3), p<0.0001] (general surgery, obstetrics and gynecology, orthopedic surgery, and neurosurgery). CONCLUSIONS Defensive medicine is very prevalent in daily physician practice in all medical disciplines. It exposes patients to complications due to unnecessary tests and procedures, affects quality of care and costs, and undermines doctor-patient relationships. Further studies are needed to understand how to minimize defensive medicine resulting from an increased malpractice liability market.
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Affiliation(s)
- Elad Asher
- Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel.
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11
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Analysis of 7-year physician-reported adverse events in esophagogastroduodenoscopy. J Patient Saf 2012; 8:65-8. [PMID: 22561847 DOI: 10.1097/pts.0b013e31824ab99a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The number of negligence claims against physicians and health institutes is increasing and has become a serious financial problem. Reporting adverse events became a mandatory behavior for quality assurance purposes and for preparing potential claims. AIM To evaluate endoscopists' reports on adverse events in esophagogastroduodenoscopy (EGD). METHODS We analyzed all the reports of gastroenterologists on EGD adverse events to the risk management authority, between January 1, 2000, and December 31, 2006. Clinical and epidemiological details about the patients, procedures, and adverse events were computed, discussed, and evaluated. RESULTS Thirty-nine cases of EGD adverse events were reported. There were 15 cases (38.5%) of men, and the average age was 58.1±21.6 years. In this period, 314,803 EGDs were performed by the institutes concerned, and the number of adverse events was 0.5 to 2.3 for 10,000 EGDs per year. Perforation occurred in 1 of 31,480 procedures, bleeding in 1 of 39,350 procedures, and respiratory complications in 1 of 157,401 procedures. Trauma to teeth happened in 1:31,480 procedures. CONCLUSIONS This is the first study in Israel about physicians' reports of EGD adverse events. Reporting adverse events in EGD should be encouraged for improving patients' safety.
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Niv Y, Gershtansky Y, Kenett RS, Tal Y, Birkenfeld S. Complications in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS): analysis of 7-year physician-reported adverse events. DRUG HEALTHCARE AND PATIENT SAFETY 2011; 3:21-5. [PMID: 21753900 PMCID: PMC3132860 DOI: 10.2147/dhps.s21369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Indexed: 11/23/2022]
Abstract
Introduction: The number of malpractice claims against physicians and health institutes is increasing continuously in Israel as in the rest of the Western world, and has become a serious financial burden. Aim: In this study we analyzed the reports of gastroenterologists on endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) adverse events to the risk management authority between January 1, 2000 and December 31, 2006. Methods: All the reported adverse events associated with ERCP and EUS of health institutes and covered by Madanes Insurance Agency were summarized and analyzed. Clinical and epidemiological details about the patients, procedures, and adverse events were coded into an Excel worksheet, discussed, and evaluated. Results: Forty-two cases of ERCP and EUS adverse events were reported. There were nine cases of men (21.4%) and the average age was 69.3 ± 14.3 years. During this period, 10,647 procedures were performed by the institutes concerned and the number of adverse events was 20.2 to 67.8 per year for 10,000 procedures. Perforation occurred in one out of 367 procedures, bleeding in one out of 5323 procedures, teeth trauma in one out of 5323 procedures, and respiratory complications in one out of 10,647 procedures. Conclusion: This is the first study in Israel about physicians’ reports of ERCP and EUS adverse events. Physicians reported only about severe adverse events with high rate of mortality and morbidity.
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Affiliation(s)
- Yaron Niv
- Department of Gastroenterology, Rabin Medical Center, Petach Tikva, Israel
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Stimson CJ, Dmochowski R, Penson DF. Health care reform 2010: a fresh view on tort reform. J Urol 2010; 184:1840-6. [PMID: 20846694 DOI: 10.1016/j.juro.2010.06.143] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Indexed: 11/16/2022]
Abstract
PURPOSE We reviewed the state of medical malpractice tort reform in the context of a new political climate and the current debate over comprehensive health care reform. Specifically we asked whether medical malpractice tort reform is necessary, and evaluated the strengths and weaknesses of contemporary reform proposals. MATERIALS AND METHODS The medical, legal and public policy literature related to medical malpractice tort reform was reviewed and synthesized. We include a primer for understanding the current structure of medical malpractice law, identify the goals of the current system and analyze whether these goals are presently being met. Finally, we describe and evaluate the strengths and weaknesses of the current reform proposals including caps on damages, safe harbors and health care courts. RESULTS Medical malpractice tort law is designed to improve health care quality and appropriately compensate patients for medical malpractice injuries, but is failing on both fronts. Of the 3 proposed remedies, caps on damages do little to advance the quality and compensatory goals, while safe harbors and health care courts represent important advancements in tort reform. CONCLUSIONS Tort reform should be included in the current health policy debate because the current medical malpractice system is not adequately achieving the basic goals of tort law. While safe harbors and health care courts both represent reasonable remedies, health care courts may be preferred because they do not rely on jury determination in the absence of strong medical evidence.
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Affiliation(s)
- C J Stimson
- Department of Urologic Surgery, Vanderbilt University, Nashville, Tennessee 37203-1738, USA
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Pines JM, Hollander JE, Isserman JA, Chen EH, Dean AJ, Shofer FS, Mills AM. The association between physician risk tolerance and imaging use in abdominal pain. Am J Emerg Med 2009; 27:552-7. [PMID: 19497460 DOI: 10.1016/j.ajem.2008.04.031] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Accepted: 04/28/2008] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE We sought to determine the impact of 3 validated scales of physician risk behavior on imaging use in emergency department (ED) patients with abdominal pain. METHODS We performed a prospective cohort study of nonpregnant ED patients with acute, nontraumatic abdominal pain and then administered 3 instruments (a risk-taking subscale of the Jackson Personality Index, the stress from uncertainty scale, and a malpractice fear scale) to attending physicians who had evaluated these patients and made decisions regarding abdominal imaging. Outcomes were the use of abdominal pelvic computed tomography (CT) and any imaging use (CT, ultrasound, or abdominal plain film). Hierarchical logistic regression was used to determine the effect of risk scales on abdominal imaging use. RESULTS Of 838 patients with acute abdominal pain, 487 (58%) received imaging studies; 395 (47%) received an CT, 111 (13%) ultrasound, and 122 (15%) an abdominal plain film. Both CT and any imaging use were lower among the physicians who were least risk-averse as measured by the risk-taking subscale (highest quartiles vs 3 lower quartiles). In adjusted analysis, probability of CT in the least risk-averse group was 35% (95% confidence interval [CI], 28%-44%) compared to 50% (95% CI, 45%-54%) among more risk-averse physicians, and the probability of any imaging was 53% (95% CI, 44%-61%) compared to 64% (95% CI, 61%-68%). Malpractice fear and stress due to uncertainty were not predictive of imaging use. CONCLUSION Self-reported physician risk-taking behavior predicts the use of imaging in ED patients with abdominal pain, whereas malpractice fear and stress due to uncertainty do not.
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Affiliation(s)
- Jesse M Pines
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Camps SM, Chevret S, Lévy V. How to use clinical vignettes in hematology--a pilot survey in the context of chronic lymphocytic leukemia. Leuk Res 2008; 33:1328-34. [PMID: 19095303 DOI: 10.1016/j.leukres.2008.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2008] [Revised: 10/19/2008] [Accepted: 11/10/2008] [Indexed: 11/25/2022]
Abstract
RATIONALE Case vignettes have been validated as an efficient tool for assessing the quality of clinical practices, and have been used in a variety of medical settings. However, their use in the field of hematology has not been tested. OBJECTIVES We undertook a study to pre-test seven case vignettes, and thereby to assess practice patterns and, when possible, guideline adherence in the treatment of chronic lymphocytic leukemia (CLL) by French hematologists. FINDINGS Of the 64 hematologists who agreed to participate, 26 (41%) completed the vignettes. We found significant differences in the physicians' patterns of ordering further investigations among young and old patients in the same clinical context. This is not consistent with published guidelines. Moreover, the most striking differences concerned the physicians' interpretations of prognostic factors and the use of radiological testing before treatment. Modalities of treatment were variable across clinical situations, especially with regard to second-line treatments. Clinicians understood the vignettes well, except for those that dealt with stem cell transplantation. CONCLUSIONS This pilot study showed the feasibility of the use of case vignettes to assess the quality of clinical practice in CLL. The initial results identified deviations from the published guidelines. A large-scale European survey will commence in a few months.
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Affiliation(s)
- Sandra M Camps
- INSERM 9504, Centre d'Investigations Cliniques, Hôpital Saint Louis, AP-HP, Université Paris 7, Paris, France
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Rubenstein JH, Saini SD, Kuhn L, McMahon L, Sharma P, Pardi DS, Schoenfeld P. Influence of malpractice history on the practice of screening and surveillance for Barrett's esophagus. Am J Gastroenterol 2008; 103:842-9. [PMID: 18076733 DOI: 10.1111/j.1572-0241.2007.01689.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastroenterologists' approach to surveillance for Barrett's esophagus is variable. We hypothesized that financial incentives and concerns over malpractice litigation influence gastroenterologists' usual practices regarding screening and surveillance. METHODS We surveyed gastroenterologists (N = 224) regarding their usual practice of screening or surveillance for Barrett's esophagus, belief in the efficacy of screening, knowledge of published guidelines, demographic factors, compensation structure, volume of endoscopies, and malpractice history. Practices were characterized as aggressive or conservative in the utilization of services compared with a published guideline. RESULTS Twenty-one percent of attending gastroenterologists reported being identified as a defendant in at least one malpractice suit. Prior malpractice defendants had practiced gastroenterology longer and performed a higher volume of endoscopies, but had similar knowledge regarding published screening guidelines to those who had not been defendants. They were more likely to be aggressive rather than conservative in screening and surveillance for Barrett's esophagus (odds ratio [OR] 3.6, 95% confidence interval [CI] 1.1-12), and remained so after controlling for other factors. In particular, they were more likely to recommend screening for populations with a lower risk of development of cancer, and to perform more frequent surveillance for low-grade dysplasia. Other factors were not associated with aggressive practice, including compensation structure. CONCLUSIONS History of at least one prior malpractice suit appears to be associated with the more aggressive use of endoscopic screening and surveillance for Barrett's esophagus, irrespective of physician belief regarding the efficacy of that strategy in reducing mortality. Hypervigilance and fear of future malpractice suits may drive this increased use.
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Affiliation(s)
- Joel H Rubenstein
- Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan 48105, USA
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Rodriguez RM, Anglin D, Hankin A, Hayden SR, Phelps M, McCollough L, Hendey GW. A longitudinal study of emergency medicine residents' malpractice fear and defensive medicine. Acad Emerg Med 2007; 14:569-73. [PMID: 17446194 DOI: 10.1197/j.aem.2007.01.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To determine the baseline level and evolution of defensive medicine and malpractice concern (MC) of emergency medicine (EM) residents. METHODS Using a validated instrument consisting of case scenarios and Likert-type scale questions, the authors performed a prospective, longitudinal (June 2001 to June 2005) study of EM residents at five 4-year California residency programs. RESULTS All 51 EM interns of these residencies were evaluated; four residents left their programs and one took medical leave, resulting in 46 graduating residents evaluated. MC did not affect the residency choice of interns. Although perceived likelihood of serious disease increased in case scenarios over time, defensive medicine decreased in 27% of cases and increased in 20%. On a scale with 1 representing extremely influential and 5 representing not at all influential, the mean (+/-SD) influence of MC on interns' and graduates' case evaluation and management was 2.5 (+/-1.1) and 2.7 (+/-1.0), respectively. Comparing interns and graduates, there was no significant difference in the percentages of respondents who declared MC (mean difference in proportions, 3.3%; 95% CI = -8.4% to 15%) or refused procedures because of MC (11.5%; 95% CI = -1.3% to 24.3%). More interns, however, declared substantial loss of enjoyment of medicine than graduates (48%; 95% CI = 30.3% to 65.5%). CONCLUSIONS Physicians enter four-year EM residencies in California with moderate MC and defensive medicine, which do not change significantly over time and do not markedly impact their decisions to perform emergency department procedures. Malpractice fear markedly decreases interns' enjoyment of medicine, but this effect decreases by residency completion.
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Affiliation(s)
- Robert M Rodriguez
- Department of Emergency Services, San Francisco General Hospital, University of California San Francisco School of Medicine, San Francisco, CA, USA.
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Hiyama T, Yoshihara M, Tanaka S, Urabe Y, Ikegami Y, Fukuhara T, Chayama K. Defensive medicine practices among gastroenterologists in Japan. World J Gastroenterol 2006; 12:7671-5. [PMID: 17171798 PMCID: PMC4088051 DOI: 10.3748/wjg.v12.i47.7671] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To clarify the prevalence of defensive medicine and the specific defensive medicine practices among gastroenterologists in Japan.
METHODS: A survey of gastroenterologists in Hiroshima, Japan, was conducted by mail in March 2006. The number of gastroenterologists reporting defensive medicine behaviors or changes in their scope of practice and the reported defensive medicine practices, i.e., assurance and avoidance behaviors, were examined.
RESULTS: A total of 131 (77%) out of 171 gastroenterologists completed the survey. Three (2%) respondents were sued, and most respondents (96%) had liability insurance. Nearly all respondents (98%) reported practicing defensive medicine. Avoidance behaviors, such as avoiding certain procedures or interventions and avoiding caring for high-risk patients, were very common (96%). Seventy-five percent of respondents reported often avoiding certain procedures or interventions. However, seasoned gastroenterologists (those in practice for more than 20 years) adopted avoidance behaviors significantly less often than those in practice for less than 10 years. Assurance behaviors, i.e., supplying additional services of marginal or no medical value, were also widespread (91%). Sixty-eight percent of respondents reported that they sometimes or often referred patients to other specialists unnecessarily.
CONCLUSION: Defensive medicine may be highly prevalent among gastroenterologists throughout Japan, with potentially serious implications regarding costs, access, and both technical and interpersonal quality of care.
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Affiliation(s)
- Toru Hiyama
- Health Service Center, Hiroshima University, 1-7-1 Kagamiyama, Higashihiroshima 739-8521, Japan.
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Madsen KA, Bennett JE, Downs SM. The role of parental preferences in the management of fever without source among 3- to 36-month-old children: a decision analysis. Pediatrics 2006; 117:1067-76. [PMID: 16585300 DOI: 10.1542/peds.2005-1865] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Recent analyses assessing the impact of the conjugate pneumococcal vaccine on the care of febrile children do not reflect the role parental preferences play in physicians' decisions. The objective of this study was to identify the management strategy that would best suit parents, on the basis of their values for possible outcomes of fever of > or =39 degrees C without source among well-appearing, 3- to 36-month-old children. METHODS A decision analysis was performed to compare the benefits and outcomes of 3 management options (treat: blood culture and antibiotics for all children; test: blood culture and complete blood count for all children, with antibiotics for selected children; observe: no immediate intervention). A hypothetical cohort of 100,000 children with fever of > or =39 degrees C with no obvious source of infection was modeled for each strategy. Using this model, we identified the treatment option that would best suit each parent's preferences, on the basis of parental utilities (from a prior study) for various interventions and outcomes at vaccine efficacies of 0% (ie, no vaccine) and 95%. In addition, we performed survival analyses to assess the morbidity and mortality rates associated with each treatment strategy at various vaccine efficacies. RESULTS At a vaccine efficacy of 0%, the majority of parents' preferences suggested the treat option, the strategy with the lowest mortality rate. At a vaccine efficacy of 95%, mortality rates were similar for all 3 management options (approximately 1 in 100,000), but parental preferences were still aligned with different options; 50% suggested observe, 42% suggested test, and 8% suggested treat. CONCLUSIONS Like physicians, parents have different approaches to risk. With the conjugate pneumococcal vaccine, risks of complications from fever without source are low regardless of treatment strategy. Rather than having a "one size fits all" approach, it is reasonable to incorporate parental preferences into the treatment decision.
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Affiliation(s)
- Kristine A Madsen
- Department of Pediatrics, University of California, San Francisco, CA 94118, USA.
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Brilla R, Evers S, Deutschländer A, Wartenberg KE. Are neurology residents in the United States being taught defensive medicine? Clin Neurol Neurosurg 2005; 108:374-7. [PMID: 16040189 DOI: 10.1016/j.clineuro.2005.05.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2005] [Accepted: 05/31/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To study whether and how fear of litigation and defensive medicine are communicated during residency training and to assess whether this affects residents' attitudes. METHODS Neurology residents in the US (n=25) and, as a control group, Neurology residents training in Germany (n=42) were asked to rate multiple items regarding litigation, defensive strategies and how often these issues are raised by teaching physicians. Statistic analysis was performed using nonparametric tests. RESULTS Residents in both countries indicated that litigation is an "important problem", although US residents stated this significantly more often (p<0.001). Initiation of tests motivated mainly by fear of litigation (p=0.004) and explicit teaching of defensive strategies by teaching physicians (p<0.02) were reported more often by US residents. CONCLUSION Neurology residents in both the US and Germany perceive a litigational threat, but significantly less so in Germany. This difference may result at least in part from teaching of defensive strategies reported more often in US programs.
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Affiliation(s)
- Roland Brilla
- School of Public Health at the University of Illinois at Chicago and Department of Neurology, Aurora Sheboygan Clinic, 2414 Kohler Memorial Drive, Sheboygan, WI 53081, USA.
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Elmore JG, Taplin SH, Barlow WE, Cutter GR, D'Orsi CJ, Hendrick RE, Abraham LA, Fosse JS, Carney PA. Does litigation influence medical practice? The influence of community radiologists' medical malpractice perceptions and experience on screening mammography. Radiology 2005; 236:37-46. [PMID: 15987961 PMCID: PMC3143020 DOI: 10.1148/radiol.2361040512] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess the relationship between radiologists' perception of and experience with medical malpractice and their patient-recall rates in actual community-based clinical settings. MATERIALS AND METHODS All study activities were approved by the institutional review boards of the involved institutions, and patient and radiologist informed consent was obtained where necessary. This study was performed in three regions of the United States (Washington, Colorado, and New Hampshire). Radiologists who routinely interpret mammograms completed a mailed survey that included questions on demographic data, practice environment, and medical malpractice. Survey responses were linked to interpretive performance for all screening mammography examinations performed between January 1, 1996, and December 31, 2001. The odds of recall were modeled by using logistic regression analysis based on generalized estimating equations that adjust for study region. RESULTS Of 181 eligible radiologists, 139 (76.8%) returned the survey with full consent. The analysis included 124 radiologists who had interpreted a total of 557 143 screening mammograms. Approximately half (64 of 122 [52.4%]) of the radiologists reported a prior malpractice claim, with 18 (14.8%) reporting mammography-related claims. The majority (n = 51 [81.0%]) of the 63 radiologists who responded to a question regarding the degree of stress caused by a medical malpractice claim described the experience as very or extremely stressful. More than three of every four radiologists (ie, 94 [76.4%] of 123) expressed concern about the impact medical malpractice has on mammography practice, with over half (72 [58.5%] of 123) indicating that their concern moderately to greatly increased the number of their recommendations for breast biopsies. Radiologists' estimates of their future malpractice risk were substantially higher than the actual historical risk. Almost one of every three radiologists (43 of 122 [35.3%]) had considered withdrawing from mammogram interpretation because of malpractice concerns. No significant association was found between recall rates and radiologists' experiences or perceptions of medical malpractice. CONCLUSION U.S. radiologists are extremely concerned about medical malpractice and report that this concern affects their recall rates and biopsy recommendations. However, medical malpractice experience and concerns were not associated with recall or false-positive rates. Heightened concern of almost all radiologists may be a key reason that recall rates are higher in the United States than in other countries, but this hypothesis requires further study.
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Affiliation(s)
- Joann G Elmore
- Dept of Internal Medicine, Univ of Washington School of Medicine, Harborview Medical Ctr, 325 Ninth Ave, Box 359780, Seattle, WA 98104-2499, USA.
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Abstract
Resident and subspecialty fellow trainees in the intensive care unit (ICU) present risks for patient safety because of their inexperience yet offer opportunities to promote safe patient care because of their around-the-clock presence and their involvement in frontline processes of care. Most trainees approach their ICU experiences without previous education in performance improvement or patient safety. This article reviews the barriers that are faced by residents in providing safe patient care and outlines the nature of a patient safety curriculum that could tap the opportunities that are presented by trainees to promote safer patient care.
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Affiliation(s)
- John E Heffner
- Department of Medicine, Medical University of South Carolina, 169 Ashley Avenue, P.O. Box 250332, Charleston, SC 29425, USA.
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Affiliation(s)
- Dean J Kereiakes
- The Lindner Center for Research and Education/Ohio Heart Health Center, 2123 Auburn Ave, Suite 424, Cincinnati, Ohio 45219, USA.
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Liang BA. Error in medicine: legal impediments to U.S. reform. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 1999; 24:27-58. [PMID: 10342254 DOI: 10.1215/03616878-24-1-27] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Error in medicine is common and can lead to significant patient injury. Although successful systematic efforts to reduce human error have been applied in other complex systems, the field of medicine has just begun to make a broad-based effort in this regard. However, both research in and implementation of patient safety measures may not occur without considering important legal issues that may impede these health policy efforts. Tort and contract law may interact with the vagaries of managed care to limit participation in these error reduction efforts by health care providers as well as by managed care organizations. Thus, for patient safety research to be successful, all members of the health care enterprise must participate in a coordinated effort to identify and establish effective practices that may reduce human error in medicine. But beyond this understanding, it is imperative that legal impediments be recognized and addressed before the goal of a continuously improving, increasingly safe health care system can become a reality.
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Kravitz RL, Rolph JE, Petersen L. Omission-related malpractice claims and the limits of defensive medicine. Med Care Res Rev 1997; 54:456-71. [PMID: 9437176 DOI: 10.1177/107755879705400404] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
To describe the malpractice environment as it relates to defensive medicine, the authors studied omission-related claims from a large physician-owned malpractice insurer covering 70 percent of physicians in a northeastern state. During a 12-year period (1977-1989), claims resulting from alleged diagnostic omissions were considered important in less than 9 percent of claims and of central importance in 4 percent. Compared with other claim types, omission-related claims were more likely to be paid, had a higher median payment, and were more often associated with significant patient injury or death; the association with more frequent payments remained after controlling for physician specialty, geographic region, and degree of patient injury. Malpractice claims alleging diagnostic and monitoring omissions are relatively uncommon but appear difficult to defend relative to other claim types. Taken in light of the changing health care environment, these results highlight the limits of defensive medicine and support an expanded focus for medical liability reform.
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Bovbjerg RR, Dubay LC, Kenney GM, Norton SA. Defensive medicine and tort reform: new evidence in an old bottle. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 1996; 21:267-288. [PMID: 8723178 DOI: 10.1215/03616878-21-2-267] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Quantitative analysis of medical liability's influence on medical practice is a small but growing field. The three foregoing articles illustrate three of the possible analytic approaches: case study of technological diffusion, survey of physician responses to detailed clinical scenarios, and multivariate analysis of the relation of physicians' scenario responses to objective liability experience. The articles also offer a good picture of the state of the art: Many difficulties hamper research in this area, and these articles, like others, offer considerable illumination but leave much uncovered. Defensive medicine surely exists, but its effects on health care spending and access are unclear. The most important lessons for public policy are that tort reform may be necessary but not sufficient to reduce the problems associated with defensive medicine, and that the major malpractice problem continues to be malpractice.
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