Fear of Lawsuits Affects Emergency Physicians' Heart Care Decisions
Emergency physicians who have the greatest fear of malpractice suits are more likely than their colleagues to admit and order tests for patients with chest pain or other heart symptoms, even if those patients are at low risk for actual problems, according to a study led by a University of Iowa researcher.
These findings were based on surveys of 33 emergency doctors who participated in a prospective study of 1,134 patients at two teaching hospitals. The results appear in the July 13 online issue of the Annals of Emergency Medicine.
Nearly seven million Americans seek emergency care for heart-related symptoms each year, and nearly half of these individuals are hospitalized or admitted for further evaluation. However, most of these patients are subsequently shown not to have acute coronary syndromes such as unstable angina or heart attack.
Given the vast number of patients involved, these findings have implications for understanding how the practice of "defensive medicine" may increase the cost of health care, said the study's lead investigator, David Katz, M.D., associate professor of internal medicine in the UI Roy J. and Lucille A. Carver College of Medicine.
"The fear of malpractice accounts for a significant portion of the variability in what doctors do in the emergency room," said Katz, who also is a staff physician and researcher with the Department of Veterans Affairs Iowa City Health Care System.
Katz said the UI-led study was unique in focusing on a single clinical scenario and in examining documented physicians' decisions, instead of just asking physicians to report how concern over lawsuits affects what they do.
Through a survey of the emergency physicians, the researchers used a "malpractice fear scale" to rank the doctors into high, medium and low-fear groups. Then, by analyzing patient records, the team determined that physicians with the greatest fear of malpractice were less likely to discharge low-risk patients compared with physicians with low malpractice fear. Instead, these high-fear doctors were more likely to admit low-risk patients and to order chest X-rays and troponin tests, which can measure heart damage.
"In isolation, plain chest X-rays at $150 and troponin at $44 are relatively inexpensive health care costs, but the volume of patients getting them really raises the overall price tag," Katz said. "However, the greatest cost is the cost of admission, which can be as high as $1,200 per patient for a brief hospitalization.
"Emergency physicians must see all patients, regardless of how risky a patient's case may be. One way physicians may respond to this is by seeking consultations and admitting patients they are uncertain about," Katz added.