Overutilization and Defensive Medicine in U.S. Hospitals: A Randomized National Survey of Hospitalists

1Brigham &
Women's Hospital, Boston, MA
2University of Michigan, Ann Arbor, MI
3University of Michigan, Ann Arbor, MI
4Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI
5University of Michigan, Ann Arbor, MI
6University of Michigan, Ann Arbor, MI
7University of Michigan, Ann Arbor, MI

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 516

Background:

Defensive medicine is an unwanted side effect of the medical liability system that happens when physicians order clinically unnecessary treatment or diagnostic procedures to reduce medical liability risk. As a result, defensive medicine not only causes overutilization but also undermines patient safety. However, relatively little is known about defensive practices in the inpatient setting. We sought to assess the extent of, and factors associated with, defensive practices in U.S. hospitals.

Methods:

We conducted a randomized national survey of physicians practicing adult hospital medicine (hospitalists). Respondents received a questionnaire that asked about practice patterns for 2 commonly encountered clinical scenarios: preoperative evaluation and syncope. Respondents received 1 of 4 versions of each scenario. Each version of a scenario contained the same clinical details but varied on factors commonly perceived to change legal risk (e.g., family member requesting further testing). We evaluated responses for the presence of overutilization (treatment in excess of national clinical guideline recommendations) caused by defensive medicine.

Results:

A total of 69% of hospitalists (1020 of 1483) responded; respondents had been practicing for an average of 11 years, and 7% spent the majority of their clinical time at a Veterans Affairs (VA) hospital. Two‐thirds were employed by a hospital, 26% had been previously sued for medical malpractice, and 64% had a friend or a close colleague who had been sued. Respondents reported overutilization in 52%–65% of the preoperative evaluations and 83%–85% of the syncope scenarios. Overutilization more frequently occurred because of defensive reasons rather than a belief that it was clinically indicated (preoperative evaluation, 64% vs. 36%; syncope, 69% vs. 31%; P < 0.001 for both). Overall, defensive medicine was reported in 37% of the preoperative evaluations and 58% of the syncope scenarios. Tables 1 and 2 display multivariable odds ratios for defensive medicine in both scenarios. Physicians practicing in VA hospitals reported less defensive practices in both the preoperative (OR, 0.32; P < 0.001) and syncope (OR, 0.43; P = 0.002) scenarios.

Conclusions:

Our results suggest that overutilization caused by defensive medicine is highly prevalent in the hospital setting. Legal fears appear to be causing practice to deviate from strong scientific evidence, even in common clinical situations. Health care reform efforts that address legal fears may help to improve quality and reduce cost in U.S. hospitals.

Table 1.Mutivariable Logistic Regression Odds Ratios for Defensive Medicine* Preoperative Evaluation Scenario (N=963)

Table 2.Mutivariable Logistic Regression Odds Ratios for Defensive Medicine* Syncope Scenario (N=970)

To cite this abstract:

Kachalia A, Berg A, Fagerlin A, Fowler K, Hofer T, Flanders S, Saint S. Overutilization and Defensive Medicine in U.S. Hospitals: A Randomized National Survey of Hospitalists. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 516. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/overutilization-and-defensive-medicine-in-u-s-hospitals-a-randomized-national-survey-of-hospitalists/. Accessed November 11, 2019.

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