Good Medicine

Annually, it is estimated that 7% of all physicians in the United States will be sued for malpractice. It is further suggested that, by the time they turn 65-years-old, 75% of physicians in low-risk fields and 99% of physicians in high-risk fields will have been sued at least once. With a mean payment of $275,000, malpractice is a concern for all physicians. The question becomes whether the pervasiveness of malpractice in the U.S. health care system causes physicians to practice a more “defensive” form of medicine, in which physicians tend to “over-care” for a patient in order to reduce malpractice risks. This can lead to unnecessary costs (estimated at $55 billion) and treatments.

A recent JAMA study attempted to answer this question by examining whether emergency department physicians in states with higher malpractice claims were more likely to unnecessarily hospitalize “low-risk” patients who presented with syncope (also known as fainting, a condition that often requires no need for hospitalization). Using regression models and nationwide databases, the authors found that for every 1-in-100,000 person increase in the physician malpractice claims rate, there was a 35.6% relative increase in the unnecessary hospitalization rate of “low-risk” patients. This corresponded to a cost of $102 million in hospital costs for unnecessary syncope admissions. This is despite the fact that previous research showed physicians seem to exhibit good judgement in determining which syncope patients were likely to develop serious conditions and required hospitalization. Regardless of their judgement and syncope guidelines, physicians still admitted 28% of patients deemed “low-risk.” The authors conclude that defensive medicine is a learned behavior; in areas with higher malpractice claim rates, physicians are also more likely to unnecessarily prescribe care, which subjects patients to needless treatment and higher costs. 

This finding points to physician concerns about malpractice detrimentally affecting patient care. Policy-makers should consider tort reform by modifying the current legal environment so physicians can practice “good medicine” without being excessively worried by malpractice. One solution may be capping malpractice payments. A more clinically-oriented approach may be developing and strengthening standardized medical guidelines for ambiguous conditions, such as syncope, to reduce rates of unnecessary care.

This Health Policy Journal Club review is written by Anshul Bhatnagar as part of our collaboration with the Health Policy Journal Club at Baylor College of Medicine where he is a medical student.

Abstract

Importance: The US Government Accountability Office has changed its estimate of the annual costs of defensive medicine, largely because it has been difficult to objectively measure its impact. Evaluating the association of malpractice claims rates with hospital admission rates and the costs of admitting patients with low-risk conditions would help to document the impact of defensive medicine. Although syncope is a concerning symptom, most patients with syncope have a low risk of adverse outcomes. However, many low-risk patients are still admitted to the hospital, with associated costs of more than $2.5 billion per year in the US.

Objective: To assess whether hospital admission rates after emergency department visits among patients with lower-risk syncope are associated with state-level variations in malpractice claims rates.

Design, setting, and participants: This cross-sectional study of emergency department visits among patients with lower-risk syncope used deidentified data from the Clinformatics Data Mart database (Optum). Lower-risk syncope visits were defined as those with a primary diagnosis of syncope and collapse based on International Classification of Diseases, Ninth Revision, Clinical Modification code 780.2 or International Classification of Diseases, Tenth Revision, Clinical Modification code R55 that did not include another major diagnostic code for a condition requiring hospital admission (such as heart disease, cancer, or medical shock) or an inpatient hospital stay of more than 3 days. These data were linked to publicly available data from the National Practitioner Data Bank pertaining to physician malpractice claims between January 1, 2008, and December 31, 2017. The 2 data sets were linked at the state-year level. Data were analyzed from October 2, 2019, to September 12, 2020.

Main outcomes and measures: The association between the rate of hospital admission after emergency department visits among patients with lower-risk syncope and the rate of physician malpractice claims was assessed at the state-year level using a state-level fixed-effects model. Standardized costs obtained from the Clinformatics Data Mart database were adjusted for inflation and expressed in 2017 US dollars using the Consumer Price Index.

Results: Among 40 482 813 emergency department visits between 2008 and 2017, 519 724 visits (1.3%) were associated with syncope. Of those, 234 750 visits (45.2%) met the criteria for lower-risk syncope. The mean (SD) age of patients in the lower-risk cohort was 71.8 (13.5) years; 141 050 patients (60.1%) were female, and 44 115 patients (18.8%) were admitted to the hospital, representing an extra cost of $6542 per admission. The mean rate of physician malpractice claims varied from 0.27 claims per 100 000 people to 8.63 claims per 100 000 people across states and across years within states. A state-level fixed-effects regression model indicated that, for every 1 in 100 000-person increase in the physician malpractice claims rate, there was an absolute increase of 6.70% (95% CI, 4.65%-8.75%) or a relative increase of 35.6% in the hospital admission rate, which represented an additional $102 million in costs associated with this lower-risk cohort.

Conclusions and relevance: In this study, increases in physician malpractice claims rates were associated with increases in hospital admission rates and substantial health care costs for patients with lower-risk syncope, and these increases are likely associated with the practice of defensive medicine.

PMID: 33320263

Quinn, J. et al. JAMA Netw Open. 2020 Dec 1; 3 (12): e2025860.