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Journal of Evaluation in Clinical Practice ISSN 1365-2753
A national survey of defensive medicine among orthopaedic surgeons, trauma surgeons and radiologists in Austria: evaluation of prevalence and context Michael Osti MD1 and Johannes Steyrer PhD2 1
Consultant, Department for Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria Professor, Research Institute for Health Care Management and Health Care Economics, Vienna University of Economics and Business, Vienna, Austria
2
Keywords defensive medicine, orthopaedics, prevalence, radiology, trauma Correspondence Dr Michael Osti Department for Trauma Surgery and Sports Traumatology Academic Hospital Feldkirch Feldkirch 6800 Austria E-mail: [email protected] Accepted for publication: 17 November 2014 doi:10.1111/jep.12305
Abstract Rationale, aims and objectives Defensive medical practice represents an increasing concern in European countries and is reported to account for rising health care expenditures. Malpractice liability, current jurisdiction and the increasing claim for accountability appear to result in additional diagnostic requests with marginal clinical benefit. Investigations that evaluate the national Austrian prevalence and contextual principles and consequences of defensive medicine are lacking so far. Method Orthopaedic and trauma surgeons as well as radiologists from public hospitals in Austria were invited to complete a study questionnaire retrieving personal estimation of the quantity of patient contacts and defensive requests in a typical month, subjective judgement of medico-legal climate, evolving defensive trends, working time usage for defensive considerations and prior confrontations with malpractice liability claims. Results The prevalence of defensive medicine was found to be 97.7%. The average orthopaedic or trauma surgeon requests 19.6 investigations per month for defensive reasons, which represents 28% of all diagnostic examinations. High-quality imaging modalities and short-term admissions yield increasing defensive significance. Participants are confronted with 1.4 liability claims per month. During the treatment of high-risk patients, 81% of doctors request additional diagnostic procedures for defensive considerations. Expenditure of time for defensive practice amounts to 9.2 hours/month in radiology and to 17 and 18% of total working time, respectively, in orthopaedic and trauma surgery. Conclusion Defensive medical practice represents a serious and common challenge in Austria. Our results indicate the urgent necessity for confrontation with and solution for the increasing effort of self-protection within the health care system.
Introduction Defensive medicine has been a major concern in the U.S. health care system for decades [1–12]. It is defined as medical practices that may exonerate doctors from liability without significant benefit to patients [9,13]. Several reports focused on prevalence and costs of defensive practice and identified a major impact on quality and access to health care services [4,6,8–12]. Malpractice liability, current jurisdiction and the increasing claim for accountability are considered as substantial catalysts and may result in adverse effects on patient’s safety [14–16] and ethical conflicts [17] as well as deteriorate a confiding relationship between doctor and patient [3–5,17]. Defensive medicine compels the benchmark for accurate medical care to the level of 278
a theoretical and legal standard, which is linked to the subjective perception of liability risks without employing professional skills for medical assessment [2,9]. Recent literature demonstrates the interrelation between liability and defensive medicine. Because of impending malpractice litigation concerns, 90% of doctors spend more time on documentation, 86% provide more detailed information about treatment plans and 40% recommend more screening tests than actually needed [18]. Nahed et al. report an engagement in defensive medicine by additional imaging in 72%, by laboratory testing in 67%, by consultant referral in 66% and by prescription of medication in 40% among 1028 neurosurgeons in the United States, who considered malpractice premiums a major or extreme burden in 64% and eliminated highrisk patients from their practice due to liability concerns in 45%
Journal of Evaluation in Clinical Practice 21 (2015) 278–284 © 2014 John Wiley & Sons, Ltd.
M. Osti and J. Steyrer
[9]. Sethi et al. find a prevalence of 96% for defensive practice and 24% additional diagnostic tests related to liability concerns among 1214 orthopaedic surgeons [11]. Defensive medicine was identified as a prevalent response to the fear of malpractice litigation and to pre-existing confrontations with judicial institutions [8]. Although because of procedural outcome and alleged verifiability, orthopaedic surgery has been identified as one of the high-risk disciplines for liability claims and, consequentially, defensive practice [3,12,19], several other medical specialties (i.e. gynaecology and obstetrics, general surgery, emergency medicine, radiology) represent a gateway for increasing liability litigation and defensive medicine [3,5,7,12]. Exposure to radiation for dispensable imaging procedures is considered to represent a factual treatment error [20]. Normative regulation for the dynamic interactive relationship between doctor and patient is discussed controversially [21], as merely adherence to legal standards adequately affects individual behaviour [22]. Increased transparency in patient safety and optimized legal expertise and awareness among doctors would be a significant requirement for legal enactment and appeal between the conflicting models of economy and systems theory [21–24]. Even though European literature recognizes the incorporation of defensive practice in routine medical services [25], a gap of knowledge about the factual defensive dimensions is evident. The objective of the present investigation was therefore to assess prevalence and medico-legal context of defensive practice to establish a solid basis for appreciation and discussion of adverse effects of defensive medicine on mutual trust, self-conception and patient safety in the Austrian health care system.
Materials and methods Between January and May 2014, a total of 286 residents and consultants for orthopaedic surgery, 1100 residents and consultants for trauma surgery, and 398 residents and consultants for radiology were invited to complete a study questionnaire presented via a Web-based provider for online surveys and accessible via a hyperlink, which the participants received by email. The 12-item questionnaire for orthopaedic and trauma surgeons and the 10-item questionnaire for radiologists were arranged according to the principles recommended by Sathiyakumar et al. [10] for their national analysis of defensive practice among orthopaedic surgeons in the United States with a validated study design [12]. Demographic data consisted of age, gender, professional position within the department (resident, consultant or department head), place of work corresponding to the federal states of Austria and sub-specialization. Participants from orthopaedic and trauma surgery departments were asked to reply to queries estimating the amount of patient visits as primary outpatient contact, follow-up outpatient contact and inpatient contact as well as their absolute count of diagnostic requests and defensive requests in a typical month regarding radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, ultrasound examinations, specialist referrals, routine blood samples, admissions and short-term admissions for clinical observation for 2 days or less (admission
Journal of Evaluation in Clinical Practice ISSN 1365-2753
A national survey of defensive medicine among orthopaedic surgeons, trauma surgeons and radiologists in Austria: evaluation of prevalence and context Michael Osti MD1 and Johannes Steyrer PhD2 1
Consultant, Department for Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria Professor, Research Institute for Health Care Management and Health Care Economics, Vienna University of Economics and Business, Vienna, Austria
2
Keywords defensive medicine, orthopaedics, prevalence, radiology, trauma Correspondence Dr Michael Osti Department for Trauma Surgery and Sports Traumatology Academic Hospital Feldkirch Feldkirch 6800 Austria E-mail: [email protected] Accepted for publication: 17 November 2014 doi:10.1111/jep.12305
Abstract Rationale, aims and objectives Defensive medical practice represents an increasing concern in European countries and is reported to account for rising health care expenditures. Malpractice liability, current jurisdiction and the increasing claim for accountability appear to result in additional diagnostic requests with marginal clinical benefit. Investigations that evaluate the national Austrian prevalence and contextual principles and consequences of defensive medicine are lacking so far. Method Orthopaedic and trauma surgeons as well as radiologists from public hospitals in Austria were invited to complete a study questionnaire retrieving personal estimation of the quantity of patient contacts and defensive requests in a typical month, subjective judgement of medico-legal climate, evolving defensive trends, working time usage for defensive considerations and prior confrontations with malpractice liability claims. Results The prevalence of defensive medicine was found to be 97.7%. The average orthopaedic or trauma surgeon requests 19.6 investigations per month for defensive reasons, which represents 28% of all diagnostic examinations. High-quality imaging modalities and short-term admissions yield increasing defensive significance. Participants are confronted with 1.4 liability claims per month. During the treatment of high-risk patients, 81% of doctors request additional diagnostic procedures for defensive considerations. Expenditure of time for defensive practice amounts to 9.2 hours/month in radiology and to 17 and 18% of total working time, respectively, in orthopaedic and trauma surgery. Conclusion Defensive medical practice represents a serious and common challenge in Austria. Our results indicate the urgent necessity for confrontation with and solution for the increasing effort of self-protection within the health care system.
Introduction Defensive medicine has been a major concern in the U.S. health care system for decades [1–12]. It is defined as medical practices that may exonerate doctors from liability without significant benefit to patients [9,13]. Several reports focused on prevalence and costs of defensive practice and identified a major impact on quality and access to health care services [4,6,8–12]. Malpractice liability, current jurisdiction and the increasing claim for accountability are considered as substantial catalysts and may result in adverse effects on patient’s safety [14–16] and ethical conflicts [17] as well as deteriorate a confiding relationship between doctor and patient [3–5,17]. Defensive medicine compels the benchmark for accurate medical care to the level of 278
a theoretical and legal standard, which is linked to the subjective perception of liability risks without employing professional skills for medical assessment [2,9]. Recent literature demonstrates the interrelation between liability and defensive medicine. Because of impending malpractice litigation concerns, 90% of doctors spend more time on documentation, 86% provide more detailed information about treatment plans and 40% recommend more screening tests than actually needed [18]. Nahed et al. report an engagement in defensive medicine by additional imaging in 72%, by laboratory testing in 67%, by consultant referral in 66% and by prescription of medication in 40% among 1028 neurosurgeons in the United States, who considered malpractice premiums a major or extreme burden in 64% and eliminated highrisk patients from their practice due to liability concerns in 45%
Journal of Evaluation in Clinical Practice 21 (2015) 278–284 © 2014 John Wiley & Sons, Ltd.
M. Osti and J. Steyrer
[9]. Sethi et al. find a prevalence of 96% for defensive practice and 24% additional diagnostic tests related to liability concerns among 1214 orthopaedic surgeons [11]. Defensive medicine was identified as a prevalent response to the fear of malpractice litigation and to pre-existing confrontations with judicial institutions [8]. Although because of procedural outcome and alleged verifiability, orthopaedic surgery has been identified as one of the high-risk disciplines for liability claims and, consequentially, defensive practice [3,12,19], several other medical specialties (i.e. gynaecology and obstetrics, general surgery, emergency medicine, radiology) represent a gateway for increasing liability litigation and defensive medicine [3,5,7,12]. Exposure to radiation for dispensable imaging procedures is considered to represent a factual treatment error [20]. Normative regulation for the dynamic interactive relationship between doctor and patient is discussed controversially [21], as merely adherence to legal standards adequately affects individual behaviour [22]. Increased transparency in patient safety and optimized legal expertise and awareness among doctors would be a significant requirement for legal enactment and appeal between the conflicting models of economy and systems theory [21–24]. Even though European literature recognizes the incorporation of defensive practice in routine medical services [25], a gap of knowledge about the factual defensive dimensions is evident. The objective of the present investigation was therefore to assess prevalence and medico-legal context of defensive practice to establish a solid basis for appreciation and discussion of adverse effects of defensive medicine on mutual trust, self-conception and patient safety in the Austrian health care system.
Materials and methods Between January and May 2014, a total of 286 residents and consultants for orthopaedic surgery, 1100 residents and consultants for trauma surgery, and 398 residents and consultants for radiology were invited to complete a study questionnaire presented via a Web-based provider for online surveys and accessible via a hyperlink, which the participants received by email. The 12-item questionnaire for orthopaedic and trauma surgeons and the 10-item questionnaire for radiologists were arranged according to the principles recommended by Sathiyakumar et al. [10] for their national analysis of defensive practice among orthopaedic surgeons in the United States with a validated study design [12]. Demographic data consisted of age, gender, professional position within the department (resident, consultant or department head), place of work corresponding to the federal states of Austria and sub-specialization. Participants from orthopaedic and trauma surgery departments were asked to reply to queries estimating the amount of patient visits as primary outpatient contact, follow-up outpatient contact and inpatient contact as well as their absolute count of diagnostic requests and defensive requests in a typical month regarding radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, ultrasound examinations, specialist referrals, routine blood samples, admissions and short-term admissions for clinical observation for 2 days or less (admission
