Fear of lawsuits affects emergency physicians' heart care decisions
Emergency physicians who have the greatest fear of malpractice suits are more likely than their colleagues to admit and order tests for patients with chest pain or other heart symptoms, even if those patients are at low risk for actual problems, according to a study led by a University of Iowa researcher.
These findings were based on surveys of 33 emergency doctors who participated in a prospective study of 1,134 patients at two teaching hospitals. The results appear in the July 13 online issue of the Annals of Emergency Medicine.
Nearly seven million Americans seek emergency care for heart-related symptoms each year, and nearly half of these individuals are hospitalized or admitted for further evaluation. However, most of these patients are subsequently shown not to have acute coronary syndromes such as unstable angina or heart attack.
Given the vast number of patients involved, these findings have implications for understanding how the practice of "defensive medicine" may increase the cost of health care, said the study's lead investigator, David Katz, M.D., associate professor of internal medicine in the UI Roy J. and Lucille A. Carver College of Medicine.
"The fear of malpractice accounts for a significant portion of the variability in what doctors do in the emergency room," said Katz, who also is a staff physician and researcher with the Department of Veterans Affairs Iowa City Health Care System.
Katz said the UI-led study was unique in focusing on a single clinical scenario and in examining documented physicians' decisions, instead of just asking physicians to report how concern over lawsuits affects what they do.
Through a survey of the emergency physicians, the researchers used a "malpractice fear scale" to rank the doctors into high-, medium- and low-fear groups. Then, by analyzing patient records, the team determined that physicians with the greatest fear of malpractice were less likely to discharge low-risk patients compared with physicians with low malpractice fear. Instead, these high-fear doctors were more likely to admit low-risk patients and to order chest X-rays and troponin tests, which can measure heart damage.
"In isolation, plain chest X-rays at $150 and troponin at $44 are relatively inexpensive health care costs, but the volume of patients getting them really raises the overall price tag," Katz said. "However, the greatest cost is the cost of admission, which can be as high as $1,200 per patient for a brief hospitalization.
"Emergency physicians must see all patients, regardless of how risky a patient's case may be. One way physicians may respond to this is by seeking consultations and admitting patients they are uncertain about," Katz added.
Katz said the UI findings are consistent with a recent investigation on defensive medicine by David Studdert, Sc.D., professor of law and health policy and management at the Harvard School of Public Health, that appeared in the June 1, 2005, issue of the Journal of the American Medical Association.
"Studdert showed that a high proportion of physicians, particularly in states characterized by high malpractice premiums, practice 'assurance behavior.' This is consistent with what we saw in our study, where a high proportion of emergency physicians in this specific clinical scenario ordered diagnostic tests and admitted patients for reasons of assurance."
Katz noted that a limitation of the UI study is that the physicians did not represent a national sample. He also said the study was not designed to examine whether there is an "upside" -- in terms of patient outcome -- to the behavior of physicians with malpractice concerns.
"The so-called high-fear physicians were more likely to order tests and admit patients who would normally not be recommended for admission. However, these same physicians also were more likely to admit patients who turned out to be intermediate to high risk," Katz said. "So in some ways, the question becomes: how can we encourage these positive aspects of care without promoting overutilization?"
Katz said there also are ways to reduce fears of malpractice in emergency departments, including developing systems to improve patient safety and to reduce risk of medical errors.
"As an example, a chest pain observation unit, such as the type we have at UI Hospitals and Clinics, can provide more extended observation and testing for selected patients in the emergency department and identify those high-risk patients who require hospitalization," Katz said.
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