Low-Value Clinical Practices: Knowledge and Beliefs of Spanish Surgeons and Anesthetists

Defensive medicine through the lens of the managerial perspective: a literature review

PURPOSE

Several studies have been carried out on defensive medicine, but research from the managerial viewpoint is still scarce. Therefore, the aim of the present study is to conduct a literature review to better understand defensive medicine from a managerial perspective.

DESIGN/METHODOLOGY/APPROACH

A literature review was conducted of studies focusing on the organisational (meso) level of healthcare providers and managerial practices. A final sample of 28 studies was processed.

FINDINGS

Defensive medicine has mainly been studied in the USA, and scholars have principally used quantitative surveys. High-risk specialities have been a critical field of investigation, and a large portion of the papers are published in journals that cover medicine, health policy, education and law fields. The analysis showed that operations and the organisation of staffing were the most discussed managerial practices. No study considered planning and budgeting aspects.

ORIGINALITY/VALUE

The review confirmed that the managerial aspect of defensive medicine has not been fully addressed. Stimulated by this gap, this study analyses the managerial background of the defensive medicine phenomenon and shows which managerial practices have been most analysed. This paper also contributes to developing the literature on defensive medicine from the managerial side. Areas for future research include qualitative studies to investigate the behaviour of managers of healthcare companies to give a different perspective on defensive medicine and organisations' decision-making.

RESEARCH LIMITATIONS/IMPLICATIONS

Some important publications might have been missed in this work because of the choice of only two databases. A further limit could be imposed by the use of the English language as an inclusion criterion.

Description, Organization, and Individual Postgraduate Perspectives of One Italian School of Anesthesia and Intensive Care

INTRODUCTION

The study aims to describe the organization of one accredited school of Anesthesia and Intensive Care of University of Modena and Reggio Emilia, Italy. The analysis of the post-graduation period aims to measure the time-to-first job, the perceived challenges, what postgraduate residents choose as first employ, and the overall satisfaction rating of a cohort of residents completing their training until 2017 with the usual and standard training program.

METHODS

We collected organization and administrative records of the five-year program of the A-IC School of 4 cohorts of residents who joined from 2009 to 2012 and we performed a survey. We also analyzed the differences among school cohorts during the medical training. In the end, it was investigated as a reason to choose hub hospitals or not.

RESULTS

The focus of the training activities revolved around the operating room with a mean of 30.41 ± 6.6 (sd), months followed by Intensive care with 17.29 ± 4.49 (sd) months. Although 7.5% of the respondents were not fully satisfied of the school's program, 89.7% of residents rated their training as adequate. In fact, 97.2% respondents reported they could overcome the professional challenges they faced after graduation. The multiple variables logistic regression showed a correlation among working in hub hospitals and training performed in university hospitals with a p value of 0.015.

CONCLUSION

This paper describes the postgraduation period. This point should be examined as an integral part of the accreditation procedure. Knowing the satisfaction rate, perception autonomy, and which type of hospitals are preferred can measure the education training capacity of a postgraduation school.

Exploring emergency physicians’ knowledge, attitudes, and behaviour towards Choosing Wisely in Taiwan

Background

In 2012, the American Board of Internal Medicine Foundation launched the Choosing Wisely campaign to reduce unnecessary care. However, it is unclear how much emergency physicians in Taiwan understand about Choosing Wisely. The purpose of this study was to explore the knowledge, attitude, and behaviour of emergency physicians in Taiwan regarding Choosing Wisely and its related factors; the intention was to identify the baseline knowledge on the basis of which to promote Choosing Wisely in Taiwan.

Methods

This was a cross-sectional study including emergency physicians in Taiwan as research subjects who answered online questionnaires. A 42-item questionnaire was designed according to the Knowledge, Attitude, and Behaviour model (KAB). The questionnaire linkages were delivered to emergency physicians through social media (eg., Line, Facebook) and received assistance from different hospital directors. A total of 162 valid questionnaires were collected. Data analyses include t-test, analysis of variance, chi-square test, Pearson’s correlation, and multivariate linear regression model.

Results

The study determined that although only 38.9% of emergency physicians had heard of Choosing Wisely, the mean correct rate of knowledge score among emergency physicians was 70.1%. Attitude and the behaviour related to Choosing Wisely were positively associated, which means that the more positive the attitude towards Choosing Wisely is, the more positive the behaviour towards Choosing Wisely is. In multiple linear regression analyses, having served as a supervisor, belonging to divisions of health insurance service, and having heard of Choosing Wisely (P < 0.05) positively affect the knowledge of Choosing Wisely, but age presented a negative association.

Conclusion

This study found that physicians’ knowledge does not influence their attitudes and behaviours, which may be related to barriers of practicing Choosing Wisely activities. To effectively promote Choosing Wisely campaign, it is recommended to focus on the significant factors associated with emergency physicians’ perceptions regarding knowledge, attitude, and behavior of Choosing Wisely. Based on these factors, appropriate practice guidelines for Choosing Wisely can be formulated and promoted.

Surgical Error Compensation Claims as a Patient Safety Indicator: Causes and Economic Consequences in the Murcia Health System, 2002 to 2018

OBJECTIVES

Compensation claims are a useful source of information on patient safety research. The purpose of this study was to determine the main causes of surgical compensation claims and their financial impact on the health system.

METHODS

A descriptive observational study with analytical components was carried out on compensation claims brought against the surgical area of the Murcia Health System between 2002 and 2018. We analyzed the frequency, causes, consequences, locations and surgical settings of these claims, the time of judicial procedure, and compensation adjusted to the Consumer Price Index.

RESULTS

There were 1172 compensation claims. "orthopedic surgery and traumatology" (27.4%), "gynecology and obstetrics" (25.7%), and "general surgery" (17.2%) were the main surgical settings involved. The most frequent causes were surgical error (42.4%) and treatment error (30.9%). The main sequelae were musculoskeletal (20.0%), neurological (17.7%), and obstetric (17.7%). The average time from incident to resolution of claims was 6.3 years. A total of 20.1% of these claims were successful, particularly those involving retained surgical foreign bodies (71.4% successful claims; P < 0.001). The total compensation paid was €56,338,247 (an average of €17,207 per claim). Compensation was higher in cases with respiratory sequelae (median, 131,600; P = 0.033), death (75,916; P < 0.001), and neurological (60,000; P = 0.024).

CONCLUSIONS

Compensation claims associated with surgical procedures are made on a variety of grounds. They are drawn-out proceedings, and patients are only successful in 20% of cases.

Surgery Is in Itself a Risk Factor for the Patient

(1) Background: Adverse events (AE) affect about 1 in 10 hospitalised patients, and almost half are related to surgical care. The aim of this study is to determine the prevalence of AE in operated and non-operated patients in surgical departments in order to determine whether surgical treatment is a risk factor for AE. (2) Methods: A cross-sectional design that included 3123 patients of 34 public hospitals in the Community of Madrid determining the prevalence of AEs in operated and non-operated patients in surgical departments. (3) Results: The prevalence of AE in non-operated patients was 8.7% and in those operated was 15.8%. The frequency of AE was higher in emergency surgery (20.6% vs. 12.4%). The 48.3% of AEs led to an increase in hospital stay, and surgery was involved in 92.4% of cases. The most frequent AEs were related to hospital-acquired infection (42.63%), followed by those related to a procedure (37.72%). In the multivariate analysis, being operated on represented 2.3 times the risk of developing an AE. (4) Conclusions: Surgical sites are particularly vulnerable to AE. Surgical intervention alone is a risk factor for AE, and we must continue to work to improve the safety of both patient care and the working environment of surgical professionals.

How defensive medicine is defined in European medical literature: a systematic review

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.

Estimation of the Overuse of Preoperative Chest X-rays According to "Choosing Wisely", "No Hacer", and "Essencial" Initiatives: Are They Equally Applicable and Comparable?

BACKGROUND

Overuse reduces the efficiency of healthcare systems and compromises patient safety. Different institutions have issued recommendations on the indication of preoperative chest X-rays, but the degree of compliance with these recommendations is unknown. This study investigates the frequency and characteristics of the inappropriateness of this practice.

METHODS

This is a descriptive observational study with analytical components, performed in a tertiary hospital in the Community of Madrid (Spain) between July 2018 and June 2019. The inappropriateness of preoperative chest X-ray tests was analyzed according to "Choosing Wisely", "No Hacer" and "Essencial" initiatives and the cost associated with this practice was estimated in Relative Value and Monetary Units.

RESULTS

A total of 3449 preoperative chest X-ray tests were performed during the period of study. In total, 5.4% of them were unjustified according to the "No Hacer" recommendation and 73.3% according to "Choosing Wisely" and "Essencial" criteria, which would be equivalent to 5.6% and 11.8% of the interventions in which this test was unnecessary, respectively. One or more preoperative chest X-ray(s) were indicated in more than 20% of the interventions in which another chest X-ray had already been performed in the previous 3 months. A higher inappropriateness score was also recorded for interventions with an American Society of Anesthesiologists (ASA) grade ≥ III (16.5%). The Anesthesiology service obtained a lower inappropriateness score than other Petitioning Surgical Services (57.5% according to "Choosing Wisely" and "Essencial"; 4.1% according to "No Hacer"). Inappropriate indication of chest X-rays represents an annual cost of EUR 52,122.69 (170.1 Relative Value Units) according to "No Hacer" and EUR 3895.29 (2276.1 Relative Value Units) according to "Choosing Wisely" or "Essencial" criteria.

CONCLUSIONS

There was wide variability between the recommendations that directly affected the degree of inappropriateness found, with the main reasons for inappropriateness being duplication of preoperative chest X-rays and the lack of consideration of the particularities of thoracic interventions. This inappropriateness implies a significant expense according to the applicable recommendations and therefore a high opportunity cost.