Greater than average spending was associated with reduced risk of incurring a malpractice claim across all physician specialties in a study of almost 25,000 doctors published Nov. 4 in the BMJ. The finding is consistent with widespread beliefs that higher resource use – sometimes defined as defensive medicine – limits the risk of litigation.
Dr. Anupam B. Jena of Harvard Medical School, Boston, and colleagues compared data from the Florida Agency for Health Care Administration on all acute care hospital discharges from 2000 to 2009 with data from the Florida Office of Insurance Regulation on all closed malpractice claims against Florida physicians during the same period. The data included 24,637 physicians (pediatricians, family physicians, general surgeons, obstetrician-gynecologists, and some subspecialists), more than 18 million hospital admissions, and 4,342 malpractice claims (BMJ 2015;351:h5516. doi: 10.1136/bmj.h5516). They looked at total hospital charges associated with patients treated by a given physician in a given year, averaged across all patients treated by that physician in that year, and adjusted for patient personal and clinical characteristics.
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Across all specialties, higher average spending per year was associated with a lower probability of an alleged malpractice incident in the subsequent year. For internists, mean risk-adjusted spending per physician ranged from $19,725 for each hospital admission in the bottom fifth of physician years to $39,379 in the top fifth. The probability for an alleged malpractice claim ranged from 1.5% in the bottom spending fifth to 0.3% in the top spending fifth. Similarly, for ob.gyns., the probability of experiencing an alleged malpractice incident ranged from 1.9% in the bottom fifth of spending to 0.4% in the top fifth. Ob.gyns. on the low end of resource utilization spent a risk-adjusted mean of $8,653, while ob.gyns. on the high end spent $18,162.
Dr. Jena and colleagues also studied more than 1.5 million deliveries performed by 1,625 obstetricians; 15% were cesarean deliveries. In total, 496 malpractice claims were filed against these obstetricians. Ob.gyns. with higher cesarean rates per year were less likely to face a malpractice claim. The probability of being sued ranged from 5.7% in the bottom fifth of cesarean delivery rates to 2.7% in the top fifth.
Authors note that if higher spending is motivated by concerns about malpractice, then the spending would be considered “defensively motivated. However, that spending may not be wasteful if it is associated with fewer errors and therefore lower malpractice claims. More study is needed to compare the costs of additional resource use and the value of reduced errors to learn whether such defensively motivated care is socially wasteful or reflects socially beneficial deterrence.”
The study was supported by the National Institutes of Health.
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