One of the arguments often raised in support of imposing restrictive tort reforms on medical malpractice victims is that doctors are forced to practice “defensive medicine” otherwise (that is, doctors order medical tests that are not medically necessary in order to avoid medical malpractice claims against them, which raises the costs of health care).
The defensive medicine argument suffered a serious blow in a study published in JAMA Oncology last month: the researchers found that cancer patients demands occur in 8.7% of patient-clinician encounters, that clinicians deem most demands or requests as clinically appropriate, that clinically inappropriate demands occur in only 1% of encounters, and that clinicians comply with very few clinically inappropriate demands (0.14% of all encounters).
The researchers concluded that “[a]t least in oncology, “demanding patients” seem infrequent and may not account for a significant proportion of [health care] costs … given the rarity of clinically inappropriate demands or requests, that few were high cost, and that few were complied with, they are unlikely to add significantly to health care costs.” The study’s authors also referenced the Congressional Budget Office’s assessment that medical malpractice reforms would produce only a 0.5% (one-half of one percent) reduction in health care costs, of which 0.3% would result from “slightly less utilization of health care services.”
The study’s findings were summarized as follows:
– Patients requested a test or treatment in 9% of all encounters with clinicians; clinicians deemed these requests as clinically appropriate over 70% of the time;
– Imaging studies constituted almost 50% of patient demands or requests and palliative measures comprised over 15%;
– In only 1% of encounters did a patient request a clinically inappropriate test or treatment;
– Clinicians ordered a clinically inappropriate test or treatment prompted by a patient demand or request in 0.14% of encounters.
The Study’s Methods
The study focused on the oncology practices of three Philadelphia-area hospitals. The researchers interviewed 60 clinicians (34 oncologists, 11 oncology fellows, and 15 nurse practitioner and physician assistants). There were 3,624 unique patients involving 5,050 patient-clinician encounters (96.5% of the patients had 3 or fewer encounters: 2,756 patients had 1 encounter, 535 patients had 2 encounters, 205 patients had 3 encounters, and 73 patients had 4 encounters).
The clinicians were interviewed immediately after they left examination rooms or after a half-day of clinic sessions, between October 2013 and June 2014, and were asked: “During today’s visit, did the patient request or demand a specific test or treatment?” A “no” response terminated the survey but a “yes” resulted in follow-up questions such as “On a scale from 1 to 10, how would you rate the level of appropriateness for the test or treatment?” A response of 10 was “extremely appropriate” and a response of “1” was “not appropriate at all.” The clinicians were also asked, “Did you ultimately order the test or treatment?” and to characterize the reason(s) why.
Clinically appropriate requests were classified as those ranked 8 to 10; inappropriate requests were ranked as 1 to 3; and, equivocal as 4 to 7.
The Study’s Findings
Of the 5,050 patient-clinician encounters, 440 (8.7%) of the patient-clinician encounters included a patient demand or request for a test, treatment, or other kind of medical intervention such as a consultation: the clinicians rated 316 (71.8%) of these demands or requests as clinically appropriate, 50 (11.4%) were rated clinically inappropriate, and 74 (16.8%) were equivocal.
Of the 440 patient demands or requests, clinicians complied with 365 (83.0%). Of the 316 clinically appropriate demands or requests, clinicians complied with 310 (98.1%). Of the equivocal ones, clinicians complied with 48 (64.9%).
Of the 50 clinically inappropriate demands or requests, clinicians complied with 7 (0.14%): 2 blood tests, 2 imaging studies, 2 chemosensitivity analyses, and 1 request for hemodialysis. Clinicians did not comply with inappropriate requests for proton beam therapy, chemotherapy agents, or surgical procedures. Of the 7 clinically inappropriate demands that clinicians complied with, clinicians said that not complying with 6 of the demands would hurt their relationship with the patient, and all thought the patient would have sought out the test or treatment from another clinician.
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