Study Shows High Imaging Costs for Defensive Purposes in Healthcare Spending

Nearly 35% of all the imaging costs ordered for 2,068 orthopedic patient encounters in the US state of Pennsylvania were ordered for defensive reasons, according to a new study.

The study's findings were presented February at the 2011 annual meeting of the American Academy of Orthopedic Surgeons (AAOS), held in San Diego (CA, USA). For quite some time now, some physicians have ordered specific diagnostic procedures that are of little or no benefit to patients, mostly to protect themselves from a lawsuit. Until now, however, efforts to measure defensive medical practices have been limited primarily to surveys sent to physicians. Such surveys would simply ask whether that individual actually practiced defensive medicine. "This is the first study we know of that looked at the actual practice decisions of physicians regarding defensive imaging in real time--prospectively done," noted John Flynn, MD, associate chief of orthopedic surgery at Children's Hospital of Philadelphia (CHOP; USA), stated that many lawsuits hinge on the plaintiff's attorney's allegation that the physician should have ordered extra diagnostic testing. "And such a claim may be the driving force of so much of the defensive test ordering."

According to Dr. Flynn, 72 orthopedic surgeons, who are members of the Pennsylvania Orthopedic Society, voluntarily participated in this study, which included some 2,068 patient encounters throughout the state of Pennsylvania. Most patients in this study were adults. The study revealed that 19% of the imaging tests ordered were for defensive purposes. Defensive imaging was responsible for US$113,369 of $325,309 (34.8%) of total imaging charges for this patient cohort, based on US Medicare dollars. The overall cost of these tests was 35% of all imaging ordered because the most common test was a magnetic resonance imaging (MRI) scan, an imaging modality that costs more than a routine X-ray.

One part of this problem to consider, according to Dr. Flynn, is that the legal environment that drives physicians to order additional tests has an effect on patients too, in a way that involves more than costs. "Patients are sometimes put through tests that maybe otherwise would not be ordered."

The finding from this research that surprised Dr. Flynn the most was that surgeons were more likely to practice defensively if they had been in practice for more than 15 years. "This was counterintuitive," he stated. "I thought that young doctors would come out of medical school immediately after training, be less confident because they weren't experienced, and order more defensive tests. Then, as they become more comfortable and confident after 10 or 20 years in practice, they would order many fewer tests. In fact, the opposite was true. We found that--in Pennsylvania at least--a surgeon's defensive nature gets worse over time. In this legal environment, orthopedic surgeons order more imaging tests of a defensive nature, because over time they become more concerned that someone is going to second guess or sue them."

Dr. Flynn reported that medical liability awards typically are given in The United States because of the severity of a bad outcome, and not necessarily because of negligence. In fact, a May 2006 study published in the New England Journal of Medicine (NEJM) (authored by Studdert DM) showed that 37% of claims did not involve medical errors, and in 3% of claims, no injury occurred at all.

Dr. Flynn pointed to various studies that show that defensive medicine, in general, is quite prevalent. One such study in the June 2005 Journal of the American Medical Association (JAMA) (also authored by Studdert DM) reported that almost 93% of 824 physicians in Pennsylvania responding to a survey practiced defensive medicine. "Ideally, as a next step, we would hope to try to get a broader national picture using this prospective practice audit methodology, so we could get a better sense of the true costs of defensive imaging in orthopedics. Ultimately, if you had doctors from multiple specialties--from ob/gyn to neurosurgery to emergency medicine--do this type of practice audit, you could accurately quantify how much of [US] healthcare resources are wasted on defensive medicine," he concluded.

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