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Wen M, Li L, Zhang Y, Shao J, Chen Z, Wang J, Zhang L, Sun J. Advancements in defensive medicine research: Based on current literature. Health Policy 2024; 147:105125. [PMID: 39018785 DOI: 10.1016/j.healthpol.2024.105125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 07/05/2024] [Accepted: 07/10/2024] [Indexed: 07/19/2024]
Abstract
To investigate and comprehend the evolving research hotspots, cutting-edge trends, and frontiers associated with defensive medicine. The original data was collected from the Web of Science core collection and then subjected to a preliminary retrieval process. Following screening, a total of 654 relevant documents met the criteria and underwent subsequent statistical analysis. Software CiteSpace was employed for conducting a customized visual analysis on the number of articles, keywords, research institutions, and authors associated with defensive medicine. The defensive medicine research network was primarily established in Western countries, particularly the United States, and its findings and conceptual framework have significantly influenced defensive medicine research in other regions. Currently, quantitative methods dominated most studies while qualitative surveys remained limited. Defensive medicine research mainly focused on high-risk medical specialties such as surgery and obstetrics. Research on defensive medicine pertained to the core characteristics of its conceptual framework. An in-depth investigation into the factors that give rise to defensive medicine is required, along with the generation of more generalizable research findings to provide valuable insights for improving and intervening in defensive medicine.
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Affiliation(s)
- Minhui Wen
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Limin Li
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Yuqing Zhang
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Jiayi Shao
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Zhen Chen
- The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jinian Wang
- The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Liping Zhang
- School of Marxism, Anhui Medical University, Hefei, China
| | - Jiangjie Sun
- School of Health Care Management, Anhui Medical University, Hefei, China; School of Management, Hefei University of Technology, Hefei, Anhui, China.
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Zheng J, Lu Y, Li W, Zhu B, Yang F, Shen J. Prevalence and determinants of defensive medicine among physicians: a systematic review and meta-analysis. Int J Qual Health Care 2023; 35:mzad096. [PMID: 38060672 DOI: 10.1093/intqhc/mzad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/12/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
Defensive medicine, characterized by physicians' inclination toward excessive diagnostic tests and procedures, has emerged as a significant concern in modern healthcare due to its high prevalence and detrimental effects. Despite the growing concerns among healthcare providers, policymakers, and physicians, comprehensive synthesis of the literature on the prevalence and determinants of defensive medicine among physicians has yet been reported. A comprehensive literature search was conducted to identify eligible studies published between 1 January 2000 and 31 December 2022, utilizing six databases (i.e. Web of Science, PubMed, Embase, Scopus, PsycINFO, and Cochrane Library). A meta-analysis was conducted to determine the prevalence and determinants of defensive medicine. Of the 8892 identified articles, 64 eligible studies involving 35.9 thousand physicians across 23 countries were included. The overall pooled prevalence of defense medications was 75.8%. Physicians engaged in both assurance and avoidance behaviors, with the most prevalent subitems being increasing follow-up and avoidance of high-complication treatment protocols. The prevalence of defensive medicine was higher in the African region [88.1%; 95% confidence interval (CI): 80.4%-95.8%] and lower-middle-income countries (89.0%; 95% CI: 78.2%-99.8%). Among the medical specialties, anesthesiologists (92.2%; 95% CI: 89.2%-95.3%) exhibited the highest prevalence. Further, the pooled odds ratios (ORs) of the nine factors at the individual, relational, and organizational levels were calculated, and the influence of previous experience in medical-legal litigation (OR: 1.65; 95% CI: 1.13-2.18) should be considered. The results of this study indicate a high global prevalence of defensive medicine among physicians, underscoring the necessity of implementing targeted interventions to reduce its use, especially in certain regions and specialties. Policymakers should implement measures to improve physicians' medical skills, enhance physician-patient communication, address physicians' medical-legal litigation fears, and reform the medical liability system. Future research should focus on devising and assessing interventions to reduce the use of defensive medicine and to improve the quality of patient care.
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Affiliation(s)
- Junyao Zheng
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
- China Institute for Urban Governance, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai 200030, China
| | - Yongbo Lu
- School of Public Policy and Administration, Xi'an Jiaotong University, 28 West Xianning Road, Xi'an 710049, China
| | - Wenjie Li
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
| | - Bin Zhu
- School of Public Health and Emergency Management, Southern University of Science and Technology, 1008 Xueyuan Road, Shenzhen, Guangdong 518005, China
| | - Fan Yang
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
- China Institute for Urban Governance, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai 200030, China
| | - Jie Shen
- Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai 200030, China
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Khan A, Khunte M, Wu X, Bajaj S, Payabvash S, Wintermark M, Matouk C, Seidenwurm DJ, Gandhi D, Parizel P, Mezrich J, Malhotra A. Malpractice Litigation Related to Diagnosis and Treatment of Intracranial Aneurysms. AJNR Am J Neuroradiol 2023; 44:460-466. [PMID: 36997286 PMCID: PMC10084911 DOI: 10.3174/ajnr.a7828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/23/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND AND PURPOSE Approaches to management of intracranial aneurysms are inconsistent, in part due to apprehension relating to potential malpractice claims. The purpose of this article was to review the causes of action underlying medical malpractice lawsuits related to the diagnosis and management of intracranial aneurysms and to identify the factors associated and their outcomes. MATERIALS AND METHODS We consulted 2 large legal databases in the United States to search for cases in which there were jury awards and settlements related to the diagnosis and management of patients with intracranial aneurysms in the United States. Files were screened to include only those cases in which the cause of action involved negligence in the diagnosis and management of a patient with an intracranial aneurysm. RESULTS Between 2000 and 2020, two hundred eighty-seven published case summaries were identified, of which 133 were eligible for inclusion in the analysis. Radiologists constituted 16% of 159 physicians sued in these lawsuits. Failure to diagnose was the most common medical malpractice claim referenced (100/133 cases), with the most common subgroups being "failure to include cerebral aneurysm as a differential and thus perform adequate work-up" (30 cases), and "failure to correctly interpret aneurysm evidence on CT or MR imaging" (16 cases). Only 6 of these 16 cases were adjudicated at trial, with 2 decided in favor of the plaintiff (awarded $4,000,000 and $43,000,000, respectively). CONCLUSIONS Incorrect interpretation of imaging is relatively infrequent as a cause of malpractice litigation compared with failure to diagnose aneurysms in the clinical setting by neurosurgeons, emergency physicians, and primary care providers.
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Affiliation(s)
- A Khan
- From the Departments of Radiology and Biomedical Imaging (A.K., M.K., S.B., S.P., C.M., J.M., A.M.)
| | - M Khunte
- From the Departments of Radiology and Biomedical Imaging (A.K., M.K., S.B., S.P., C.M., J.M., A.M.)
| | - X Wu
- Department of Radiology (X.W.), University of California at San Francisco, San Francisco, California
| | - S Bajaj
- From the Departments of Radiology and Biomedical Imaging (A.K., M.K., S.B., S.P., C.M., J.M., A.M.)
| | - S Payabvash
- From the Departments of Radiology and Biomedical Imaging (A.K., M.K., S.B., S.P., C.M., J.M., A.M.)
| | - M Wintermark
- Department of Radiology (M.W.), MD Anderson Cancer Center, Houston, Texas
| | - C Matouk
- From the Departments of Radiology and Biomedical Imaging (A.K., M.K., S.B., S.P., C.M., J.M., A.M.)
- Neurosurgery (C.M.), Yale School of Medicine, New Haven, Connecticut
| | - D J Seidenwurm
- Department of Neuroradiology (D.J.S.), Sutter Health, Sacramento, California
| | - D Gandhi
- Departments of Interventional Neuroradiology, Radiology, and Nuclear Medicine (D.G.)
- Neurology (D.G.)
- Neurosurgery (D.G.), University of Maryland School of Medicine, Baltimore, Maryland
| | - P Parizel
- Department of Radiology (P.P.), University of Western Australia, Perth, Australia
| | - J Mezrich
- From the Departments of Radiology and Biomedical Imaging (A.K., M.K., S.B., S.P., C.M., J.M., A.M.)
| | - A Malhotra
- From the Departments of Radiology and Biomedical Imaging (A.K., M.K., S.B., S.P., C.M., J.M., A.M.)
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Ciarkowski C, Vaughn VM. Antibiotic documentation: death by a thousand clicks. BMJ Qual Saf 2022; 31:773-775. [PMID: 38467424 DOI: 10.1136/bmjqs-2022-015020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Claire Ciarkowski
- Internal Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Valerie M Vaughn
- Internal Medicine, University of Utah Health, Salt Lake City, Utah, USA
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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: 6.0] [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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Pappas MA, Sessler DI, Auerbach AD, Kattan MW, Milinovich A, Blackstone EH, Rothberg MB. Variation in preoperative stress testing by patient, physician and surgical type: a cohort study. BMJ Open 2021; 11:e048052. [PMID: 34580093 PMCID: PMC8477322 DOI: 10.1136/bmjopen-2020-048052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To describe variation in and drivers of contemporary preoperative cardiac stress testing. SETTING A dedicated preoperative risk assessment and optimisation clinic at a large integrated medical centre from 2008 through 2018. PARTICIPANTS A cohort of 118 552 adult patients seen by 104 physicians across 159 795 visits to a preoperative risk assessment and optimisation clinic. MAIN OUTCOME Referral for stress testing before major surgery, including nuclear, echocardiographic or electrocardiographic-only stress testing, within 30 days after a clinic visit. RESULTS A total of 8303 visits (5.2%) resulted in referral for preoperative stress testing. Key patient factors associated with preoperative stress testing included predicted surgical risk, patient functional status, a previous diagnosis of ischaemic heart disease, tobacco use and body mass index. Patients living in either the most-deprived or least-deprived census block groups were more likely to be tested. Patients were tested more frequently before aortic, peripheral vascular or urologic interventions than before other surgical subcategories. Even after fully adjusting for patient and surgical factors, provider effects remained important: marginal testing rates differed by a factor-of-three in relative terms and around 2.5% in absolute terms between the 5th and 95th percentile physicians. Stress testing frequency decreased over the time period; controlling for patient and physician predictors, a visit in 2008 would have resulted in stress testing approximately 3.5% of the time, while a visit in 2018 would have resulted in stress testing approximately 1.3% of the time. CONCLUSIONS In this large cohort of patients seen for preoperative risk assessment at a single health system, decisions to refer patients for preoperative stress testing are influenced by various factors other than estimated perioperative risk and functional status, the key considerations in current guidelines. The frequency of preoperative stress testing has decreased over time, but remains highly provider-dependent.
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Affiliation(s)
- Matthew A Pappas
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Value-based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
- Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, Ohio, USA
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andrew D Auerbach
- Department of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alex Milinovich
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eugene H Blackstone
- Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael B Rothberg
- Center for Value-based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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Bass GD, Zhao FS, Schweickert WD, Manaker S. A Retrospective Analysis of Malpractice-Related Procedure Rates for Internal Medicine Specialists at an Academic Medical Center. Jt Comm J Qual Patient Saf 2021; 47:704-710. [PMID: 34456152 DOI: 10.1016/j.jcjq.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although malpractice litigation is common in the United States, the risk of a malpractice claim for procedures performed by internal medical practitioners is unknown. This study determined the frequency of malpractice claims related to procedures in a large department of medicine at an academic medical center over a five-year period. METHODS Researchers retrospectively reviewed all malpractice claims and procedures performed by internal medicine practitioners of all specialties between July 1, 2014, and June 30, 2019, in a department of medicine at a large academic medical center. A list of all procedures and Current Procedural Terminology codes performed by internal medicine practitioners was compiled. Active procedure-related malpractice claims and the total number of procedures performed during the study period were counted. RESULTS During the study period, 353,661 procedures were performed by internal medicine practitioners. During the same period, 76 active malpractice claims were identified, of which only 13 (17.1%) were procedure-related. For 2 different malpractice claims, a single patient had 2 procedures; thus 13 total claims related to the performance of 15 procedures. The proportion of procedure-related claims per total number of procedures performed was 0.37 claims/10,000 cases. The frequency of procedure-related malpractice claims per number of procedures performed ranged from 1 in 38 for pulmonary artery thrombolytic therapy to 1 in 137,325 for colonoscopy. CONCLUSION Procedure-related malpractice claims against internal medicine practitioners at a large academic medical center over a five-year period were infrequent despite significant procedural volume. Contextualizing procedure-related malpractice claims in terms of procedure-specific volume reframes the reporting of malpractice risk.
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Schaffer AC, Yu-Moe CW, Babayan A, Wachter RM, Einbinder JS. Rates and Characteristics of Medical Malpractice Claims Against Hospitalists. J Hosp Med 2021; 16:390-396. [PMID: 34197302 DOI: 10.12788/jhm.3557] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/26/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hospitalists practice in high-stakes and litigious settings. However, little data exist about the malpractice claims risk faced by hospitalists. OBJECTIVE To characterize the rates and characteristics of malpractice claims against hospitalists. DESIGN, SETTING, AND PARTICIPANTS An analysis was performed of malpractice claims against hospitalists, as well as against select other specialties, using data from a malpractice claims database that includes approximately 31% of US malpractice claims. MAIN OUTCOMES AND MEASURES For malpractice claims against hospitalists (n = 1,216) and comparator specialties (n = 18,644): claims rates (using a data subset), percentage of claims paid, median indemnity payment amounts, allegation types, and injury severity. RESULTS Hospitalists had an annual malpractice claims rate of 1.95 claims per 100 physician-years, similar to that of nonhospitalist general internal medicine physicians (1.92 claims per 100 physician-years), and significantly greater than that of internal medicine subspecialists (1.30 claims per 100 physician-years) (P < .001). Claims rates for hospitalists nonsignificantly increased during the study period (2009-2018), whereas claims rates for four of the five other specialties examined significantly decreased over this period. The median indemnity payment for hospitalist claims was $231,454 (interquartile range, $100,000-$503,015), significantly higher than the amounts for all the other specialties except neurosurgery. The greatest predictor of a hospitalist case closing with payment (compared with no payment) was an error in clinical judgment as a contributing factor, with an adjusted odds ratio of 5.01 (95% CI, 3.37-7.45). CONCLUSION During the study period, hospitalist claims rates did not drop, whereas they fell for other specialties. Hospitalists' claims had relatively high injury severity and median indemnity payment amounts. The malpractice environment for hospitalists is becoming less favorable.
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Affiliation(s)
- Adam C Schaffer
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Chihwen Winnie Yu-Moe
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts
| | - Astrid Babayan
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts
| | - Robert M Wachter
- University of California, San Francisco, San Francisco, California
| | - Jonathan S Einbinder
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Williams PL, Williams JP, Williams BR. The fine line of defensive medicine. J Forensic Leg Med 2021; 80:102170. [PMID: 33878590 DOI: 10.1016/j.jflm.2021.102170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/27/2021] [Accepted: 04/07/2021] [Indexed: 11/25/2022]
Abstract
Defensive medicine is a practice that has been utilized by clinicians in efforts of preventing patient dissatisfaction and malpractice claims and may be done through either omission or commission. As much as 57% of physicians have disclosed that they practice defensive medicine. However, this practice does not necessarily prevent malpractice claims and more importantly, neither does it equate to good medical practice, with some leading to poor outcomes. Unfortunately, there is a high percentage of malpractice claims lodged against clinicians in both primary care and hospital settings. Specialists such as surgeons, obstetricians, and gynecologists face the highest claims. In particular, during the SARS CoV-2 pandemic, with new challenges and limited treatment algorithms, there is an even greater concern for possible bourgeoning claims. Counteracting defensive medicine can be accomplished through decriminalizing malpractice claims, leaving physician oversight up to state medical boards and hospital claims management committees. Additional tort reform measures must also be taken such as caps on noneconomic damages to ensure emphasis on beneficence and nonmaleficence. Once these are in place, it may well serve to increase clinician-patient trust and improve patient independence in the shared decision-making process of their treatment, allowing clinicians to practice their full scope of practice without feeling wary of potential malpractice claims.
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Affiliation(s)
- Preston L Williams
- University of Lynchburg, Doctor of Medical Science Program, 1501 Lakeside Drive, Lynchburg, VA, 24501, USA.
| | - Joanna P Williams
- Eisenhower Health, 39000 Bob Hope Drive, Rancho Mirage, CA, 92270, USA
| | - Bryce R Williams
- Palm Desert High School, 74910 Aztec Road, Palm Desert, CA, 92260, USA
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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: 18] [Impact Index Per Article: 6.0] [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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Niazi SK, Naessens JM, White L, Borah B, Vargas ER, Richards J, Cabral S, Clark MM, Rummans T. Impact of Psychiatric Comorbidities on Health Care Costs Among Patients With Cancer. PSYCHOSOMATICS 2019; 61:145-153. [PMID: 31864662 DOI: 10.1016/j.psym.2019.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/30/2019] [Accepted: 10/30/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Psychiatric disorders are common in cancer patients and impact outcomes. Impact on cancer care cost needs study to develop business case for psychosocial interventions. OBJECTIVE To evaluate the impact of preexisting psychiatric comorbidities on total cost of care during 6 months after cancer diagnosis. METHODS This retrospective cohort study examined patients diagnosed with cancer between January 1, 2009, and December 31, 2014, at one National Cancer Institute-designated cancer center. Patients who received all cancer treatment at the study site (6598 of 11,035 patients) were included. Patients were divided into 2 groups, with or without psychiatric comorbidity, based on International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes. Total costs of care during the first 6 months of treatment were based on standardized costs adjusted to 2014 dollars, determined by assigning Medicare reimbursement rates to professional billed services and applying appropriate cost-to-charge ratios. Quantile regression models with covariate adjustments were developed to assess the effect of psychiatric comorbidity across the distribution of costs. RESULTS Six hundred ninety-eight (10.6%) of 6598 eligible patients had at least one psychiatric comorbidity. These patients had more nonpsychiatric Elixhauser comorbidities (mean 4 vs. 3). Unadjusted total cancer care costs were higher for patients with psychiatric comorbidity (mean [standard deviation]: $51,798 [$74,549] vs. $32,186 [$45,240]; median [quartiles]: $23,871 [$10,705-$57,338] vs. $19,073 [$8120-$38,230]). Quantile regression models demonstrated that psychiatric comorbidity had significant incremental effects at higher levels of cost: 75th percentile $8629 (95% confidence interval: $3617-13,642) and 90th percentile $42,586 (95% confidence interval: $25,843-59,330). CONCLUSIONS Psychiatric comorbidities are associated with increased total cancer costs, especially in patients with very high cancer care costs, representing an opportunity to develop mitigation strategies.
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Affiliation(s)
- Shehzad K Niazi
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL; Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL.
| | - James M Naessens
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL; Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Launia White
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL
| | - Bijan Borah
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Emily R Vargas
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL
| | | | | | - Matthew M Clark
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | - Teresa Rummans
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL; Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
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