Defensive Medicine Less Costly Than Suspected

Marcia Frellick

September 18, 2014

When physicians were asked to rate the "defensiveness" of their orders for tests or procedures, researchers found that "defensive medicine," or the overuse of tests and procedures from fear of malpractice litigation, is often clouded by other factors.

In results published online September 15 in JAMA Internal Medicine, researchers found that overuse attributed only to a physician's fear of litigation was a small part of the $46 billion a year problem. And because tort reform would target only that small segment of the problem, it may not be as powerful a tool in reducing costs to the healthcare system as it is promoted as being, they conclude.

Michael B. Rothberg, MD, MPH, from the Center for Value-Based Care Research, Medicine Institute at the Cleveland Clinic in Ohio, and colleagues estimated the costs of defensive medicine on hospital medicine services at 3 Massachusetts institutions: 1 tertiary care and 2 community hospitals. They asked physicians to assess the defensiveness of their orders from the previous day on a scale from 0 to 4, with 4 being completely defensive, and polled them on their attitudes about litigation.

The authors hypothesized that if physicians feared being sued, they would practice more defensively and have higher costs. However, the researchers found that 28% of orders and 13% of costs from the 39 participating hospitalists were rated at least partially defensive, but only 2.9% of costs were completely defensive. Most costs were a result of potentially unnecessary hospitalization, the authors note.

Physicians rated 4215 orders for 769 patients. The median number of orders was 3 per patient and 97 per physician. Four physicians said none of their orders was defensive; 21 physicians rated at least 1 as mostly defensive.

Physicians who reported 10% defensive orders or more placed a similar number of orders compared with those who reported fewer defensive orders (4.9 vs 5.4; P = .68), and costs were similar per patient ($1700 vs $1679).

The mean cost per patient was $1695 (95% CI, $1566 - $1824), $226 (13%) of which was defensive.

"[P]hysicians who wrote the most defensive orders spent less than those who wrote fewer such orders, highlighting the disconnect between physician beliefs about defensive medicine and their contribution to costs," the authors write.

Study limitations include its subjective nature, its small sample size, that it was not anonymous, and that it included services in only a single health system.

Howard Brody, MD, PhD, director of the Institute for the Medical Humanities at the University of Texas Medical Branch Galveston, said the study correctly points out that there may be other reasons physicians overprescribe, among them feeling 1 patient is slightly sicker than another, feeling time is short to evaluate alternatives, or even wanting to please patients by performing more tests as satisfaction surveys become more important under the Affordable Care Act.

However, he is skeptical that defensive medicine can be precisely quantified.

"I've frankly come to the conclusion that you can't measure defensive medicine," because you just cannot sort clearly the reasons you did something, he said.

"It's real typical for doctor to do something, and 1 reason would fall under defensive medicine and the other 2 or 3 reasons wouldn't, and whether you say that's defensive medicine or not depends more on your political agenda than on the pure description of the case," he said.

The authors and Dr. Brody have disclosed no relevant financial relationships.

JAMA Intern Med. Published online September 15, 2014. Extract

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