The effect of malpractice reform on emergency department care

Neurosurgical Malpractice Litigation: A Systematic Review and Meta-Analysis

BACKGROUND

Neurosurgery has 1 of the highest risks for medical malpractice claims. We reviewed the factors associated with neurosurgical malpractice claims and litigation in the United States and reported the outcomes through a systematic review of the literature.

METHODS

We conducted a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines using the Medline, Embase, Cochrane, PubMed, and Google Scholar databases. We sought to identify pertinent studies containing information about medical malpractice claims and outcomes involving neurosurgeons in the United States.

RESULTS

We identified 15 retrospective studies spanning from 2002 to 2023 that reviewed over 7890 malpractice claims involving practicing neurosurgeons in the United States. Disparities were evident in neurosurgical litigation, with 474 cases linked to brain-related surgeries and a larger proportion, 1926 cases, tied to spine surgeries. The most commonly filed claims were intraprocedural errors (37.4%), delayed diagnoses (32.1%), and failure to treat (28.8%). Less frequently filed claims included misdiagnosis or choice of incorrect procedure (18.4%), occurrence of death (17.3%), test misinterpretation (14.4%), failure to appropriately refer patients for evaluation/treatment (14.3%), unnecessary surgical procedures (13.3%), and lack of informed consent (8.3%). The defendant was favored in 44.3% of claims, while in 31.3% of lawsuits were dropped, 17.7% of verdicts favored the plaintiff, and 16.6% reached an out of court settlement. Only 3.5% of lawsuits found both parties liable.

CONCLUSION

Neurosurgery is a high-risk specialty with 1 of the highest rates of malpractice claims. Spine claims had a significantly higher rate of filed malpractice claims, while cranial malpractice claims were associated with higher litigation compensation. Predictably, spinal cord injuries play a crucial role in predicting litigation. Importantly, nonsurgical treatments are also a common source of liability in neurosurgical practice.

Patient safety in emergency departments: a problem for health care systems? An international survey

BACKGROUND AND IMPORTANCE

Patient safety in healthcare is one of the cornerstones of quality of care. The emergency department (ED) is by its very nature a place where errors and safety issues are liable to occur.

OBJECTIVE

The aim of the study was to assess health professionals' perception of the level of safety in EDs and to identify in which work domains safety appears most at risk.

DESIGN AND PARTICIPANTS

Between 30 January and 27 February 2023, a survey addressing the main domains of safety was distributed to ED health care professionals through the European Society of Emergency Medicine contact network. It addressed five main domains: teamwork, safety leadership, physical environment and equipment, staff/external teams, and organisational factors and informatics, with a number of items for each domain. Further questions about infection control and team morale were added. The Cronbach's alpha measure was calculated to assure internal consistency.

MEASURES AND ANALYSIS

A score was developed for each domain by adding the question's value using the following ranking: never (1), rarely (2), sometimes (3), usually (4), and always (5) and was aggregated in three categories. The calculated sample size needed was 1000 respondents. The Wald method was used for analysis of the questions' consistency and X2 for the inferential analysis.

MAIN RESULTS

The survey included 1256 responses from 101 different countries; 70% of respondents were from Europe. The survey was completed by 1045 (84%) doctors and 199 (16%) nurses. It was noted that 568 professionals (45.2%) had less than 10 years' experience. Among respondents, 80.61% [95% confidence interval (CI) 78.42-82.8] reported that monitoring devices were available, and 74.7% (95% CI 72.28-77.11) reported that protocols for high-risk medication and for triage (66.19%) were available in their ED. The area of greatest concern was the disproportionate imbalance between needs and the availability of staff at times of greatest flow, considered sufficient by only 22.4% (95% CI 20.07-24.69) of doctors and 20.7% (95% CI 18.41-22.9) of nurses. Other critical issues were overcrowding due to boarding and a perceived lack of support from hospital management. Despite these difficult working conditions, 83% of the professionals said they were proud to work in the ED (95% CI 81.81-85.89).

CONCLUSION

This survey highlighted that most health professionals identify the ED as an environment with specific safety issues. The main factors appeared to be a shortage of personnel during busy periods, overcrowding due to boarding, and a perceived lack of support from hospital management.

Association of physician malpractice claims rates with admissions for low-risk chest pain

Background

Chest pain accounts for 5% of all emergency department visits and accounts for the highest malpractice payout against emergency physicians. To clarify the impact of defensive medicine, we assessed whether admission rates of low-risk chest pain patients are associated with malpractice claims rates.

Methods

A cross-sectional time-series analysis of state-year level malpractice claims rates, admission rates for low-risk chest pain (LRCP; requiring ED physician discretion), and admission rates for acute myocardial infarction (AMI; requiring minimal physician judgment for admission, used as a control) from 2008 to 2017 was performed. Admission rates were derived from Optum's deidentified Clinformatics Data Mart Database. LRCP visits were defined by primary ICD-9 or ICD-10 codes of 786.5, R07.9, or R07.89; length of stay of 2 or fewer days; and no previous major cardiac diagnosis and AMI visits with ICD-9 or ICD-10 codes 410, I21.3, or I121.9. Malpractice claims rates (MPCRs) were derived from the National Practitioner Database (NPD). The association between state-year level MPCR and admission rates for LRCP and AMI was estimated using state fixed-effects models. Standardized costs were inflation adjusted and are expressed in US dollar rate as of 2019.

Results

There were 40,482,813 ED visits during the 10-year study period, of which 2,275,757 (5.6%) were for chest pain, and 1,163,881 met LRCP criteria. Mean age of LRCP patients was 67.8 years, 60.9% were female, and 16.6% were hospitalized, at a mean cost of $17,120. During the same period, 75,266 (0.2%) visits were for AMI, with 87% admitted. The MPCR by state-year varied widely, from 2.6 to 8.6 claims per 100,000 population. A state fixed-effects model showed that an additional physician malpractice claim per 100,000 population was associated with a 3.66% (95% CI 2.02%-5.30%) increase in the admission rate of LRCP. An analogous model showed no association between MPCR and admission rates for AMI (-1.52%, 95% CI -4.06% to 1.02%).

Conclusion

Higher MPCRs are associated with increased admission rates for LRCP, at substantial cost, which may be attributable to defensive medicine in the ED.

How defensive medicine is defined in European medical literature: a systematic review

OBJECTIVES

Defensive medicine has originally been defined as motivated by fear of malpractice litigation. However, the term is frequently used in Europe where most countries have a no-fault malpractice system. The objectives of this systematic review were to explore the definition of the term 'defensive medicine' in European original medical literature and to identify the motives stated therein.

DESIGN

Systematic review.

DATA SOURCES

PubMed, Embase and Cochrane, 3 February 2020, with an updated search on 6 March 2021.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we reviewed all European original peer-reviewed studies fully or partially investigating 'defensive medicine'.

RESULTS

We identified a total of 50 studies. First, we divided these into two categories: the first category consisting of studies defining defensive medicine by using a narrow definition and the second category comprising studies in which defensive medicine was defined using a broad definition. In 23 of the studies(46%), defensive medicine was defined narrowly as: health professionals' deviation from sound medical practice motivated by a wish to reduce exposure to malpractice litigation. In 27 studies (54%), a broad definition was applied adding … or other self-protective motives. These self-protective motives, different from fear of malpractice litigation, were grouped into four categories: fear of patient dissatisfaction, fear of overlooking a severe diagnosis, fear of negative publicity and unconscious defensive medicine. Studies applying the narrow and broad definitions of defensive medicine did not differ regarding publication year, country, medical specialty, research quality or number of citations.

CONCLUSIONS

In European research, the narrow definition of defensive medicine as exclusively motivated by fear of litigation is often broadened to include other self-protective motives. In order to compare results pertaining to defensive medicine across countries, future studies are recommended to specify whether they are using the narrow or broad definition of defensive medicine.

PROSPERO REGISTRATION NUMBER

CRD42020167215.

The Practice of Obtaining a Chest Radiograph in Pediatric Patients Presenting With Their First Episode of Wheezing: A Survey of Resident Physicians

A chest radiograph (CXR) is not routinely indicated in children presenting with their first episode of wheezing; however, it continues to be overused. A survey was distributed electronically to determine what trainees are taught and their current practice of obtaining a CXR in children presenting with their first episode of wheezing and the factors that influence this practice. Of the 1513 trainees who completed surveys, 35.3% (535/1513) reported that they were taught that pediatric patients presenting with their first episode of wheezing should be evaluated with a CXR. In all, 22.01% (333/1513) indicated that they would always obtain a CXR in these patients, and 13.75% (208/1513) would always obtain a CXR under a certain age (4 weeks to 12 years, median of 2 years). Our study identifies a target audience that would benefit from education to decrease the overuse of CXRs in children.

Post-Medicare Access and CHIP Reauthorization Act of 2015 Trends in Lumbar Magnetic Resonance Imaging Use for Patients with Low Back Pain at 1373 Hospitals

BACKGROUND

Lumbar Spine MRI Use for Low Back Pain (OP-8) is calculated by dividing the number of patients who received lumbar magnetic resonance imaging (MRI-L) before receiving alternative treatments (e.g., physical therapy) by the total number of patients receiving MRI-L in the outpatient setting at a given institution. Since the passage of the Post-Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), OP-8 scores became tied to hospital finances. This study aims to determine how MACRA has impacted OP-8 scores since its implementation. We also aim to investigate how regional designation, profit status (for-profit, government, and nonprofit), and hospital setting (critical access, non-critical access) affect OP-8 scores.

METHODS

Data from the Centers for Medicare and Medicaid Services Hospital Compare database were used to extract information on the national trends in OP-8 scores from 2014 to 2020. A multivariable linear regression model was fit to isolate the impact of hospital characteristics on OP-8 scores.

RESULTS

After a decrease from 2015 to 2016, the mean national OP-8 score plateaued, staying around 40% from 2017 through 2020. A critical access setting increased OP-8 scores by 5.41 (95% confidence interval, 3.51-6.77; P ≤ 0.001), compared with a non-critical access setting. Governmental status increased scores by 1.27 (95% confidence interval, 0.28-2.27; P = 0.012), compared with a nonprofit status.

CONCLUSIONS

The implementation of MACRA seems to have been unsuccessful in altering practice patterns, given the minimal change in OP-8 scores over the last 4 years. Furthermore, institutional factors are clearly correlated with a lack of adherence to magnetic resonance imaging guidelines. Given these findings, there is a need to modify health policies.

The Medical Legal Environment in Neurosurgery: An Informative Overview of the Stages of Litigation and Distinct Challenges

Medical malpractice litigation is something that every neurosurgeon encounters in his or her career and causes significant strife to amateur physicians attempting to navigate the medicolegal process. Neurosurgery in particular is one of the highest risk specialties for litigation. This calls to order the importance of a clear understanding of the medicolegal proceedings that may follow after a complaint has been filed. This report describes the steps to be taken by the physician in the instance that litigation is expected or considered a possibility. We describe the elements that comprise a medical malpractice claim, details of the lawsuit process including hospital peer review and expert witness selection, and how to communicate appropriately with the patients and their families in an empathetic way. It is imperative to gain an appropriate understanding of the entirety of the malpractice claim process to ease the anxiety of litigation for the physician and decrease the amount of avoidable complications.

Emergency Department and Urgent Care Medical Malpractice Claims 2001-15

Introduction

This study reviews malpractice, also called medical professional liability (MPL), claims involving adult patients cared for in emergency departments (ED) and urgent care settings.

Methods

We conducted a retrospective review of closed MPL claims of adults over 18 years, from the Medical Professional Liability Association’s Data Sharing Project database from 2001–2015, identifying 6,779 closed claims. Data included the total amount, origin, top medical specialties named, chief medical factors, top medical conditions, severity of injury, resolution, average indemnity, and defense costs of closed claims.

Results

Of 6,779 closed claims, 65.9% were dropped, withdrawn, or dismissed. Another 22.8% of claims settled for an average indemnity of $297,709. Of the 515 (7.6%) cases that went to trial, juries returned verdicts for the defendant in 92.6% of cases (477/515). The remaining 7.4% of cases (38/515) were jury verdicts for the plaintiff, with an average indemnity of $816,909. The most common resulting medical condition cited in paid claims was cardiac or cardiorespiratory arrest (10.4%). Error in diagnosis was the most common chief medical error cited in closed claims. Death was the most common level of severity listed in closed (38.5%) and paid (42.8%) claims. Claims reporting major permanent injury had the highest paid-to-closed ratio, and those reporting grave injury had the highest average indemnity of $686,239.

Conclusion

This retrospective review updates the body of knowledge surrounding medical professional liability and represents the most recent analysis of claims in emergency medicine. As the majority of emergency providers will be named in a MPL claim during their career, it is essential to have a better understanding of the most common factors resulting in MPL claims.

Higher Emergency Physician Chest Pain Hospitalization Rates Do Not Lead to Improved Patient Outcomes

BACKGROUND

Wide variation exists for hospital admission rates for the evaluation of possible acute coronary syndrome, but there are limited data on physician-level variation. Our aim is to describe physicians' rates of admission for suspected acute coronary syndrome and associated 30-day major adverse events.

METHODS

We conducted a retrospective analysis of adult emergency department chest pain encounters from January 2016 to December 2017 across 15 community emergency departments within an integrated health system in Southern California. The unit of analysis was the Emergency physician. The primary outcome was the proportion of patients admitted/observed in the hospital. Secondary analysis described the 30-day incidence of death or acute myocardial infarction.

RESULTS

Thirty-eight thousand seven hundred seventy-eight patients encounters were included among 327 managing physicians. The median number of encounters per physician was 123 (interquartile range, 82-157) with an overall admission/observation rate of 14.0%. Wide variation in individual physician admission rates were observed (unadjusted, 1.5%-68.9%) and persisted after case-mix adjustments (adjusted, 5.5%-27.8%). More clinical experience was associated with a higher likelihood of hospital care. There was no difference in 30-day death or acute myocardial infarction between high- and low-admitting physician quartiles (unadjusted, 1.70% versus 0.82% and adjusted, 1.33% versus 1.29%).

CONCLUSIONS

Wide variation persists in physician-level admission rates for emergency department chest pain evaluation, even in a well-integrated health system. There was no associated benefit in 30-day death or acute myocardial infarction for patients evaluated by high-admitting physicians. This suggests an additional opportunity to investigate the safe reduction of physician-level variation in the use of hospital care.

Association Between US Physician Malpractice Claims Rates and Hospital Admission Rates Among Patients With Lower-Risk Syncope

IMPORTANCE

The US Government Accountability Office has changed its estimate of the annual costs of defensive medicine, largely because it has been difficult to objectively measure its impact. Evaluating the association of malpractice claims rates with hospital admission rates and the costs of admitting patients with low-risk conditions would help to document the impact of defensive medicine. Although syncope is a concerning symptom, most patients with syncope have a low risk of adverse outcomes. However, many low-risk patients are still admitted to the hospital, with associated costs of more than $2.5 billion per year in the US.

OBJECTIVE

To assess whether hospital admission rates after emergency department visits among patients with lower-risk syncope are associated with state-level variations in malpractice claims rates.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of emergency department visits among patients with lower-risk syncope used deidentified data from the Clinformatics Data Mart database (Optum). Lower-risk syncope visits were defined as those with a primary diagnosis of syncope and collapse based on International Classification of Diseases, Ninth Revision, Clinical Modification code 780.2 or International Classification of Diseases, Tenth Revision, Clinical Modification code R55 that did not include another major diagnostic code for a condition requiring hospital admission (such as heart disease, cancer, or medical shock) or an inpatient hospital stay of more than 3 days. These data were linked to publicly available data from the National Practitioner Data Bank pertaining to physician malpractice claims between January 1, 2008, and December 31, 2017. The 2 data sets were linked at the state-year level. Data were analyzed from October 2, 2019, to September 12, 2020.

MAIN OUTCOMES AND MEASURES

The association between the rate of hospital admission after emergency department visits among patients with lower-risk syncope and the rate of physician malpractice claims was assessed at the state-year level using a state-level fixed-effects model. Standardized costs obtained from the Clinformatics Data Mart database were adjusted for inflation and expressed in 2017 US dollars using the Consumer Price Index.

RESULTS

Among 40 482 813 emergency department visits between 2008 and 2017, 519 724 visits (1.3%) were associated with syncope. Of those, 234 750 visits (45.2%) met the criteria for lower-risk syncope. The mean (SD) age of patients in the lower-risk cohort was 71.8 (13.5) years; 141 050 patients (60.1%) were female, and 44 115 patients (18.8%) were admitted to the hospital, representing an extra cost of $6542 per admission. The mean rate of physician malpractice claims varied from 0.27 claims per 100 000 people to 8.63 claims per 100 000 people across states and across years within states. A state-level fixed-effects regression model indicated that, for every 1 in 100 000-person increase in the physician malpractice claims rate, there was an absolute increase of 6.70% (95% CI, 4.65%-8.75%) or a relative increase of 35.6% in the hospital admission rate, which represented an additional $102 million in costs associated with this lower-risk cohort.

CONCLUSIONS AND RELEVANCE

In this study, increases in physician malpractice claims rates were associated with increases in hospital admission rates and substantial health care costs for patients with lower-risk syncope, and these increases are likely associated with the practice of defensive medicine.

Status of current medicolegal reform in the United States: a neurosurgical perspective

OBJECTIVE

There are approximately 85,000 lawsuits filed against medical practitioners every year in the US. Among these lawsuits, neurosurgery has been identified as a "high-risk specialty" with exceptional chance of having medical malpractice suits filed. Major issues affecting the overall medicolegal environment include tort reform, the formation of medical review panels, the increasing practice of defensive medicine, and the rising costs of medical insurance. In this study, the authors provide a concise update of the current medicolegal environments of the 50 states and provide a general guide to favorable and unfavorable states in which to practice neurosurgery.

METHODS

Data were acquired related to state-by-state medical review panel status, noneconomic damage caps, economic damage caps, and civil suit filing fees. States were placed into 5 categories based on the status of their current medicolegal environment.

RESULTS

Of the 50 states in the US, 18 have established a medical review panel process. Fifteen states have a mandatory medical review process, whereas 3 states rely on a voluntary process. Thirty-five states have tort reform and have placed a cap on noneconomic damages. These caps range from $250,000 to $2,350,000, with the median cap of $465,900. Only 8 states have placed a cap on total economic damages. These caps range from $500,000 to $2,350,000, with the median cap of $1,050,000. All states have a filing fee for a medical malpractice lawsuit. These costs range from $37 to $884, with the median cost for filing of $335.

CONCLUSIONS

Medicolegal healthcare reform will continue to play a vital role in physicians' lives. It will dictate if physicians may practice proactively or be forced to act defensively. With medicolegal reform varying greatly among states, it will ultimately dictate if physicians move into or away from certain states and thus guide the availability of healthcare services. A desirable legal system for neurosurgeons, including caps on economic and noneconomic damages and availability of medical review panels, can lead to safer practice.

Outcomes in CME/CPD - Special Collection: How to make the "pyramid" a perpetuum mobile

Continuing medical education (CME) should not be an end in itself, but as expressed in Moore's pyramid, help to improve both individual patient and ultimately community, health. However, there are numerous barriers to translation of physician competence into improvements in community health. To enhance the effect CME may achieve in improving community health the authors suggest a kick-off/keep-on continuum of medical competence, and integration of aspects of public health at all levels from planning to delivery and outcomes measurement in CME.

Headache and Neuroimaging: Why We Continue to Do It

The appropriate imaging of patients with headache presents a number of important and vexing challenges for clinicians. Despite a number of guidelines and studies demonstrating a lack of cost-effectiveness, clinicians continue to image patients with chronic nonfocal headaches, and the trend toward imaging is increasing. The reasons are complex and include the fear of missing a clinically significant lesion and litigation, habitual and standard of care practices, lack of tort reform, regulatory penalties and potential impact on one's professional reputation, patient pressures, and financial motivation. Regulatory and legislative reforms are needed to encourage best practices without fear of professional sanctions when following the guidelines. The value of negative findings on imaging tests requires better understanding because they appear to provide some measure of societal value. Clinical decision support tools and machine intelligence may offer additional guidance and improve quality and cost-efficient management of this challenging patient population.

The Practice of Obtaining a Chest X-Ray in Pediatric Patients Presenting With Their First Episode of Wheezing in the Emergency Department: A Survey of Attending Physicians

BACKGROUND

Routine use of chest X-ray (CXR) in pediatric patients presenting with their first episode of wheezing was recommended by many authors. Although recent studies conclude that a CXR is not routinely indicated in these children, there continues to be reports of overuse.

OBJECTIVE

To examine the attitudes of practicing physicians in ordering CXRs in pediatric patients presenting with their first episode of wheezing to an emergency department (ED) and the factors that influence this practice by surveying ED physicians.

METHODS

A survey targeting pediatric emergency medicine (PEM) and general emergency medicine attending physicians was distributed electronically to the nearly 3000 members of the PEM Brown listserve and the Pediatric Section of American College of Emergency Physicians listserve. The 14-item survey included closed ended and free text questions to assess the respondent's demographic characteristics, their belief and current practice of obtaining a CXR in pediatric patients presenting with their first episode of wheezing. Data were analyzed using descriptive statistics and χ test.

RESULTS

Of the 537 attending physicians who participated, their primary residency training was: 42% pediatrics, 54% emergency medicine, and 4% other. Seventy-two percent of participating physicians supervise residents, 54% were board-eligible or -certified in PEM. Thirty percent (95% confidence interval [CI], 26-34) of participants indicated that they would always obtain a CXR in pediatric patients presenting with their first episode of wheezing. Eighty-one percent (95% CI, 75-87) of those who always obtain a CXR believe that it is the standard of care. Of the 376 physicians who do not always obtain a CXR, 18% (95% CI, 15-23) always obtain a CXR under certain age (2 weeks to 12 years, median of 1 year). Physicians who report a primary residency in pediatrics, who supervise residents, who were board-eligible or -certified in PEM, and who were practicing for greater than 5 years were less likely to obtain a CXR (P < 0.001, P < 0.001, P < 0.001, P = 0.001).

CONCLUSIONS

In our study, a significant number of practicing ED physicians routinely obtain a CXR in children with their first episode of wheezing presenting to the ED. The factors influencing this practice are primary residency training, fellowship training, resident supervision, and years of independent practice. This identifies a target audience that would benefit from education to decrease the overuse of CXRs in children with wheezing.

Emergency Physician Practice Changes After Being Named in a Malpractice Claim

STUDY OBJECTIVE

Malpractice fear is a commonly cited cause for defensive medicine, but it is unclear whether being named in a malpractice claim changes physician practice patterns. We study whether there are changes in commonly used measures of emergency physician practice after being named in a malpractice claim.

METHODS

We performed a retrospective difference-in-differences study comparing practice patterns of emergency physicians named in a malpractice claim and unnamed matched controls working contemporaneously in the same emergency departments (EDs), using data from a national emergency medicine management group (59 EDs in 11 US states from 2010 to 2015). We studied aggregate measures of care intensity (hospital admission rate and relative value units/visit), studied care speed (relative value units/hour and discharged patients' length of stay), and assessed patient experience (monthly physician Press Ganey percentile rank).

RESULTS

A total of 65 emergency physicians named in at least 1 malpractice claim and 140 matched controls met inclusion criteria. After the malpractice claim filing date, there were no significant changes in measures of care intensity or speed. However, named emergency physicians' patient experience scores improved immediately after the malpractice claim filing date and showed sustained improvements by 6.52 Press Ganey percentile ranks (95% confidence interval 0.67 to 12.38), with the increase most prominent among those involved in the 46 failure-to-diagnose claims (10.52; 95% confidence interval 3.72 to 17.32).

CONCLUSION

We observed a temporal improvement in patient satisfaction scores for emergency physicians in this sample after their being named in a malpractice claim relative to matched controls. Measures of care intensity and speed did not significantly change.

Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries

IMPORTANCE

Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care.

OBJECTIVE

To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between April 1, 2013, and September 30, 2015, and underwent cataract surgery between July 1, 2014 and June 30, 2015. Data were analyzed from March 12, 2018, to April 9, 2019.

EXPOSURES

Receipt of a preoperative EKG. The comparison group included patients who underwent cataract surgery but did not receive a preoperative EKG.

MAIN OUTCOMES AND MEASURES

Cascade event rates and associated spending in the 90 days after preoperative EKG, or in a matched timeframe for the comparison group. Secondary outcomes were patient, physician, and area-level characteristics associated with experiencing a potential cascade.

RESULTS

Among 110 183 cataract surgery recipients, 12 408 (11.3%) received a preoperative EKG (65.6% of them were female); of those, 1978 (15.9%) had at least 1 potential cascade event. The comparison group included 97 775 participants (63.1% female). Those who received a preoperative EKG experienced between 5.11 (95% CI, 3.96-6.25) and 10.92 (95% CI, 9.76-12.08) additional events per 100 beneficiaries relative to the comparison group. This included between 2.18 (95% CI, 1.34-3.02) and 7.98 (95% CI, 7.12-8.84) tests, 0.33 (95% CI, 0.19-0.46) treatments, 1.40 (95% CI, 1.18-1.62) new patient cardiology visits, and 1.21 (95% CI, 0.62-1.79) new cardiac diagnoses. Spending for the additional services was up to $565 per Medicare beneficiary (95% CI, $342-$775), or an estimated $35 025 923 annually across all Medicare beneficiaries in addition to the $3 275 712 paid for the preoperative EKGs. Among preoperative EKG recipients, those who were older (adjusted odds ratio [aOR] for patients aged 75 to 84 years vs 66 to 74 years old, 1.42; 95% CI, 1.28-1.57), had more chronic conditions (aOR for each additional Elixhauser condition, 1.18; 95% CI, 1.14-1.22), lived in more cardiologist-dense areas (aOR, 1.05; 95% CI, 1.02-1.09), or had their preoperative EKG performed by a cardiac specialist rather than a primary care physician (aOR, 1.26; 95% CI, 1.10-1.43) were more likely to experience a potential cascade.

CONCLUSIONS AND RELEVANCE

Care cascades after preoperative EKG for cataract surgery are infrequent but costly. Policy and practice interventions to reduce low-value services and the cascades that follow could yield substantial savings.

Defensive Medicine: Evidence from Military Immunity

We estimate the extent of defensive medicine by physicians, embracing the no-liability counterfactual made possible by the structure of liability rules in the Military Heath System. Active-duty patients seeking treatment from military facilities cannot sue for harms resulting from negligent care, while protections are provided to dependents treated at military facilities and to all patients-active-duty or not-that receive care from civilian facilities. Drawing on this variation and exploiting exogenous shocks to care location choices stemming from base-hospital closures, we find suggestive evidence that liability immunity reduces inpatient spending by 5% with no measurable negative effect on patient outcomes.

The impact of tort reform on defensive medicine, quality of care, and physician supply: A systematic review

OBJECTIVE

To evaluate the impact of tort reform on defensive medicine, quality of care, and physician supply.

DATA SOURCES

Empirical, peer-reviewed English-language studies in the MEDLINE and HeinOnline databases that evaluated the association between tort reform and our study outcomes.

STUDY DESIGN

We performed a systematic review in accordance with the PRISMA guidelines.

DATA COLLECTION/EXTRACTION METHODS

Title and abstract screening was followed by full-text screening of relevant citations. We created evidence tables, grouped studies by outcome, and qualitatively compared the findings of included studies. We assigned a higher rating to study designs that controlled for unobservable sources of confounding.

PRINCIPAL FINDINGS

Thirty-seven studies met screening criteria. Caps on damages, collateral-source rule reform, and joint-and-several liability reform were the most common types of tort reform evaluated in the included studies. We found that caps on noneconomic damages were associated with a decrease in defensive medicine, increase in physician supply, and decrease in health care spending, but had no effect on quality of care. Other reform approaches did not have a clear or consistent impact on study outcomes.

CONCLUSIONS

We conclude that traditional tort reform methods may not be sufficient for health reform and policy makers should evaluate and incorporate newer approaches.

Trends and Risk Factors in Orthopedic Lawsuits: Analysis of a National Legal Database

Orthopedic surgeons frequently encounter medical malpractice claims. The purpose of this study was to assess trends and risk factors in lawsuits brought against orthopedic surgeons using a national legal database. A legal research service was used to search publicly available settlement and verdict reports between 1988 and 2013 by terms "orthopaedic or orthopedic" and "malpractice." Temporal trends were evaluated, and logistic regression was used to identify independent risk factors for case outcomes. A total of 1562 publicly reported malpractice cases brought against orthopedic surgeons, proceeding to trial during a 26-year period, were analyzed. The plaintiffs won 462 (30%) cases, with a mean award of $1.4 million. The frequency of litigation and pay-outs for plaintiffs increased 215% and 280%, respectively, between the first and last 5-year periods. The mean payout for plaintiff-favorable verdicts was highest in pediatrics ($2.6 million), followed by spine ($1.7 million) and oncology ($1.6 million). Fracture fixation (363 cases), arthroplasty (290 cases), and spine (231 cases) were the most commonly litigated procedures, while plaintiffs were most successful for fasciotomy (48%), infection-treating procedures (43%), and carpal tunnel release (37%). When analyzing data by state and region, adjusted for population, northeastern states had a higher frequency of lawsuits. Malpractice liability has increased during the past 3 decades while orthopedic surgeons continue to win most of the cases making it to court. As patients search for medical care via publicly available information, it is important for orthopedic surgeons to understand what aspects of their own practice carry different risks of litigation. [Orthopedics. 2019; 42(2):e260-e267.].

Malpractice Litigation in Brain Tumor Surgery: A 31-Year Analysis of Causative Factors in the United States from the Westlaw Database

BACKGROUND

Medical malpractice litigation is an issue of major concern in neurosurgery, with 19.1% of neurosurgeons facing a claim annually. Neurosurgery possesses the greatest risk of malpractice of any specialty, likely owing to the complex clinical environment and disease severity. In the present study, we have characterized such litigation to determine the common factors that compel plaintiffs to file these claims.

METHODS

WestLawNext, a prominent legal database, was used to identify all cases from 1985 to 2016 related to brain tumors. A total of 225 cases were identified, and each was analyzed for the cause of litigation (multiple causes were permitted). Because many had >1 ground for litigation, the reported percentages were based on the total counts of litigation rather than the number of cases. Additional information was collected from each case, including location, tumor type, and physician specialty.

RESULTS

The cases were distributed across 36 states and U.S. territories: California (n = 42; 20%) and New York (n = 28; 13%) had the greatest number of cases. The top reasons for litigation were failure to diagnose (n = 109; 28%), failure to treat (n = 72; 18%), procedural error (n = 63; 16%), and failure to refer for diagnostic tests (n = 55; 14%). The most common diagnoses included pituitary adenoma (n = 26; 12%), acoustic neuroma (n = 27; 12%), and meningioma (n = 23; 10%).

CONCLUSIONS

Malpractice litigation contributes to high overhead and physician burnout and escalates the cost of patient care. We found that benign brain tumors were the most common in litigation and that surgical issues accounted for only a small percentage.

Understanding Waste in Health Care: Perceptions of Frontline Physicians Regarding Time Use and Appropriateness of Care They and Others Provide

BACKGROUND

Approximately 30% of total US health care spending is thought to be "wasted" on activities like unnecessary and inefficiently delivered services.

OBJECTIVES

To assess the perceptions of clinic-based physicians regarding their use of time and appropriateness of care provided.

DESIGN

Cross-sectional online survey of all Southern California Permanente Medical Group partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers.

MAIN OUTCOME MEASURES

The proportion of time spent on direct patient care tasks perceived to require the respondent's clinical/specialty training as a physician or another physician who has similar years of clinical training (vs physicians with fewer years of clinical training, nonphysicians, or automated or computerized systems), and the proportion of care provided by the respondent and by other physicians with whom they are familiar that is perceived to be appropriate (vs equivocal or inappropriate).

RESULTS

More than 61% of respondents indicated that 15% of their time spent on direct patient care could be shifted to nonphysicians, and between 10% and 16% of care provided was equivocal or inappropriate.

DISCUSSION

The low proportion of care perceived as equivocal or inappropriate indicates there is little room for reducing such care or that physicians have difficulty assessing care appropriateness. The latter suggests that attempts to reduce or to eliminate inappropriate care may be unsuccessful until physician beliefs, knowledge, or behaviors are better understood and addressed.

CONCLUSION

On the basis of these findings, it is apparent that within at least one health care system, the opportunity to increase value through task shifting and avoiding inappropriate care is more narrow than commonly perceived on a national level.

Emergency Physician Risk Estimates and Admission Decisions for Chest Pain: A Web-Based Scenario Study

STUDY OBJECTIVE

We conducted this study to better understand how emergency physicians estimate risk and make admission decisions for patients with low-risk chest pain.

METHODS

We created a Web-based survey consisting of 5 chest pain scenarios that included history, physical examination, ECG findings, and basic laboratory studies, including a negative initial troponin-level result. We administered the scenarios in random order to emergency medicine residents and faculty at 11 US emergency medicine residency programs. We randomized respondents to receive questions about 1 of 2 endpoints, acute coronary syndrome or serious complication (death, dysrhythmia, or congestive heart failure within 30 days). For each scenario, the respondent provided a quantitative estimate of the probability of the endpoint, a qualitative estimate of the risk of the endpoint (very low, low, moderate, high, or very high), and an admission decision. Respondents also provided demographic information and completed a 3-item Fear of Malpractice scale.

RESULTS

Two hundred eight (65%) of 320 eligible physicians completed the survey, 73% of whom were residents. Ninety-five percent of respondents were wholly consistent (no admitted patient was assigned a lower probability than a discharged patient). For individual scenarios, probability estimates covered at least 4 orders of magnitude; admission rates for scenarios varied from 16% to 99%. The majority of respondents (>72%) had admission thresholds at or below a 1% probability of acute coronary syndrome. Respondents did not fully differentiate the probability of acute coronary syndrome and serious outcome; for each scenario, estimates for the two were quite similar despite a serious outcome being far less likely. Raters used the terms "very low risk" and "low risk" only when their probability estimates were less than 1%.

CONCLUSION

The majority of respondents considered any probability greater than 1% for acute coronary syndrome or serious outcome to be at least moderate risk and warranting admission. Physicians used qualitative terms in ways fundamentally different from how they are used in ordinary conversation, which may lead to miscommunication during shared decisionmaking processes. These data suggest that probability or utility models are inadequate to describe physician decisionmaking for patients with chest pain.

A 12-year analysis of closed medical malpractice claims of the Taiwan civil court: A retrospective study

Malpractices lawsuits cause increased physician stress and decreased career satisfaction, which might result in defensive medicine for avoiding litigation. It is, consequently, important to learn experiences from previous malpractice claims. The aim of this study was to examine the epidemiologic factors related to medical malpractice claims, identify specialties at high risk of such claims, and determine clinical which errors tend to lead to medical malpractice lawsuits, by analyzing closed malpractice claims in the civil courts of Taiwan.The current analysis reviewed the verdicts of the Taiwan judicial system from a retrospective study using the population-based databank, focusing on 946 closed medical claims between 2002 and 2013.Among these medical malpractice claims, only 14.1% of the verdicts were against clinicians, with a mean indemnity payment of $83,350. The most common single specialty involved was obstetrics (10.7%), while the surgery group accounted for approximately 40% of the cases. In total, 46.3% of the patients named in the claims had either died or been gravely injured. Compared to the $75,632 indemnity for deceased patients, the mean indemnity payment for plaintiffs with grave outcomes was approximately 4.5 times higher. The diagnosis groups at high risk of malpractice litigation were infectious diseases (7.3%), malignancies (7.2%), and limb fractures (4.9%). A relatively low success rate was found in claims concerning undiagnosed congenital anomalies (4.5%) and infectious diseases (5.8%) group. A surgery dispute was the most frequent argument in civil malpractice claims (38.8%), followed by diagnosis error (19.3%).Clinicians represent 85.9% of the defendants who won their cases, but they spent an average of 4.7 years to reach final adjudication. Increased public education to prevent unrealistic expectations among patients is recommended to decrease frivolous lawsuits. Further investigation to improve the lengthy judicial process is also necessary to relieve the stress of medical malpractice claims on clinicians and practitioners, as well as on the judicial system and rightful claimants.

Forensic Radiology: An Update

Forensic radiology is a specialized area of medical imaging using radiological techniques to assist physicians and pathologists in matters related to the law. The forensic application of diagnostic medical radiology can be applied in many fields; the prime target of evaluation is the osseous skeleton, but soft tissues and abdominal and thoracic viscera may offer key findings. The technological progress in clinical radiology provides a lot of potential tools to forensic radiology, allowing wider fields of applications in this matter.

How Do We Balance the Long-Term Health of a Patient With the Short-Term Risk to the Physician?

BACKGROUND

There is a wide variation in practice patterns among emergency medicine physicians; many factors weigh into the medical decision-making process including the health of the patient as well as short-term risk to the physician.

OBJECTIVE

The objective of our discussion is to illustrate specific scenarios where medical decisions are focused on the physician's short-term risk, then to propose an approach to shifting the balance to the patient's long-term health.

METHODS

Using recent data on the evaluation, disposition, and outcomes of patients with low-risk chest pain in the emergency department, we calculate the risk of outpatient evaluation compared to the common practice of admission or observation.

RESULTS

Patients with low-risk chest pain and negative initial evaluation in the emergency department with 2 normal cardiac biomarkers, normal vital signs, and non-ischemic, interpretable ECGs, have an extremely low-risk of a short term clinically relevant adverse cardiac event. There is a suggestion of a higher patient risk from admission, prompting consideration that continued evaluation of the chest pain as an outpatient may be safer than admission or observation.

CONCLUSION

A test/intervention should be done if the risk of a missed diagnosis or adverse outcome is greater that the risk of the test/intervention. Involving the patient in the decision-making process may help to shift the management balance from the physician's short-term concern of their own risk, to the patient's long-term health.

Provider and Practice Factors Associated With Emergency Physicians' Being Named in a Malpractice Claim

STUDY OBJECTIVE

We examine the association between emergency physician characteristics and practice factors with the risk of being named in a malpractice claim.

METHODS

We used malpractice claims along with provider, operational, and jurisdictional data from a national emergency medicine group (87 emergency departments [EDs] in 15 states from January 1, 2010, to June 30, 2014) to assess the relationship between individual physician and practice variables and being named in a malpractice claim. Individual and practice factors included years in practice, emergency medicine board certification, visit admission rate, relative value units generated per hour, total patients treated as attending physician of record, working at multiple facilities, working primarily overnight shifts, patient experience data percentile, and state malpractice environment. We assessed the relationship between emergency physician and practice variables and malpractice claims, using logistic regression.

RESULTS

Of 9,477,150 ED visits involving 1,029 emergency physicians, there were 98 malpractice claims against 90 physicians (9%). Increasing total number of years in practice (adjusted odds ratio 1.04; 95% confidence interval 1.02 to 1.06) and higher visit volume (adjusted odds ratio 1.09 per 1,000 visits; 95% confidence interval 1.05 to 1.12) were associated with being named in a malpractice claim. No other factors were associated with malpractice claims.

CONCLUSION

In this sample of emergency physicians, 1 in 11 were named in a malpractice claim during 4.5 years. Total number of years in practice and visit volume were the only identified factors associated with being named, suggesting that exposure to higher patient volumes and longer practice experience are the primary contributors to malpractice risk.

Emergency Physician Knowledge, Attitudes, and Behavior Regarding ACEP's Choosing Wisely Recommendations: A Survey Study

OBJECTIVE

In 2013, the American College of Emergency Physicians joined the Choosing Wisely campaign; however, its impact on emergency physician behavior is unknown. We assessed knowledge, attitudes, and self-reported behaviors regarding the Choosing Wisely recommendations.

METHODS

We performed a cross-sectional survey of emergency physicians at a national meeting. We approached 819 physicians; 765 (93.4%) completed the survey.

RESULTS

As a result of the Choosing Wisely campaign, most respondents (64.5%) felt more comfortable discussing low-value services with patients, 54.5% reported reducing utilization, and 52.5% were aware of local efforts to promote the campaign. A majority (62.97%) of respondents were able to identify at least four of five recommendations. The most prevalent low-value practices were computed tomography (CT) brain for minor head injury (29.9%) and antibiotics for acute sinusitis (26.9%). Few respondents reported performing lumbar radiograph for nontraumatic low back pain (7.8%) and Foley catheter for patients who can void (5.6%). Respondents reported patient/family expectations as the most important reason for ordering antibiotics for sinusitis (68%) and imaging for low back pain (56.8%). However, concern for serious diagnosis was the most important reason for performing CT chest for patients with normal D-dimer (49.7%) and CT abdomen for recurrent uncomplicated renal colic (42.5%). A minority (3.8% to 26.7%) of respondents identified malpractice risk as the primary reason for performing low-value services.

CONCLUSIONS

Despite familiarity with Choosing Wisely, many emergency physicians report performing low-value services. Primary reasons for low-value services differ: antibiotic prescribing was driven by patient/family expectations, while concern for serious diagnosis influenced advanced diagnostic imaging. Greater efforts are needed to promote effective dissemination and implementation; such efforts may be targeted based on differing reasons for low-value services.

Defensive Medicine in U.S. Spine Neurosurgery

STUDY DESIGN

Observational cross-sectional survey.

OBJECTIVE

To compare defensive practices of U.S. spine and nonspine neurosurgeons in the context of state medical liability risk.

SUMMARY OF BACKGROUND DATA

Defensive medicine is a commonly reported and costly phenomenon in neurosurgery. Although state liability risk is thought to contribute greatly to defensive practice, variation within neurosurgical specialties has not been well explored.

METHODS

A validated, online survey was sent via email to 3344 members of the American Board of Neurological Surgeons. The instrument contained eight question domains: surgeon characteristics, patient characteristics, practice type, insurance type, surgeon liability profile, basic surgeon reimbursement, surgeon perceptions of medical legal environment, and the practice of defensive medicine.

RESULTS

The overall response rate was 30.6% (n = 1026), including 499 neurosurgeons performing mainly spine procedures (48.6%). Spine neurosurgeons had a similar average practice duration as nonspine neurosurgeons (16.6 vs 16.9 years, P = 0.64) and comparable lifetime case volume (4767 vs 4,703, P = 0.71). The average annual malpractice premium for spine neurosurgeons was similar to nonspine neurosurgeons ($104,480.52 vs $101,721.76, P = 0.60). On average, spine neurosurgeons had a significantly higher rate of ordering labs, medications, referrals, procedures, and imaging solely for liability concerns compared with nonspine neurosurgeons (89.2% vs 84.6%, P = 0.031). Multivariate analysis revealed that spine neurosurgeons were roughly 3 times more likely to practice defensively compared with nonspine neurosurgeons (odds ratio, OR = 2.9, P = 0.001) when controlling for high-risk procedures (OR = 7.8, P < 0.001), annual malpractice premium (OR = 3.3, P = 0.01), percentage of patients publicly insured (OR = 1.1, P = 0.80), malpractice claims in the last 3 years (OR = 1.13, P = 0.71), and state medical-legal environment (OR = 1.3, P = 0.37).

CONCLUSION

State-based medical legal environment is not a significant driver of increased defensive medicine associated with neurosurgical spine procedures.

LEVEL OF EVIDENCE

3.

Does Every Patient Require Imaging after Cervical Spine Trauma? A Knowledge Translation Project to Support Evidence-Informed Practice for Physiotherapists

Purpose: This article evaluates, describes, and addresses a gap in British Columbia physiotherapists' knowledge of the decision making required for the diagnostic imaging of patients after traumatic neck injury. Method: An online survey of orthopaedic physiotherapists in British Columbia was undertaken to explore their awareness of, knowledge of, and attitudes toward the Canadian Cervical Spine Rule (C-Spine Rule) and decision making regarding the need for diagnostic imaging in managing patients with traumatic neck injury. The survey included questions about managing clinical scenarios; respondents' awareness, knowledge, and use of a specific clinical decision rule-the C-Spine Rule-and any perceived barriers to using clinical practice guidelines in general and the C-Spine Rule in specific. The survey also included questions about the facilitators of and barriers to using the C-Spine Rule. These data were used to guide development of a tool kit to facilitate use of the rule. Results: Of 889 physiotherapists, 467 (52.5%) completed the survey. Given a scenario in which imaging was indicated according to the C-Spine Rule, 95.2% of the respondents correctly recommended imaging. However, in a scenario in which imaging was not indicated, 42.7% incorrectly recommended it. The barriers to using the guidelines included their perceived rigidity, role limitation, and reliance on clinical judgment. The results indicated a need for, and guided development of, resources to facilitate the use of the C-Spine Rule by British Columbia physiotherapists. Conclusions: We identified a gap in the knowledge of British Columbia physiotherapists in identifying which patients were most likely to require imaging after sustaining a traumatic neck injury. We developed a tool kit to address these barriers. British Columbia physiotherapists have accessed this resource extensively. Evaluating its impact on clinical practice, although desirable, was not feasible.

Racial Disparities in Poverty Account for Mortality Differences in US Medicare Beneficiaries

Higher mortality in Blacks than Whites has been consistently reported in the US, but previous investigations have not accounted for poverty at the individual level. The health of its population is an important part of the capital of a nation. We examined the association between individual level poverty and disability and racial mortality differences in a 5% Medicare beneficiary random sample from 2004 to 2010. Cox regression models examined associations of race with all-cause mortality, adjusted for demographics, comorbidities, disability, neighborhood income, and Medicare “Buy-in” status (a proxy for individual level poverty) in 1,190,510 Black and White beneficiaries between 65 and 99 years old as of January 1, 2014, who had full and primary Medicare Part A and B coverage in 2004, and lived in one of the 50 states or Washington, DC.

Overall, black beneficiaries had higher sex-and-age adjusted mortality than Whites (hazard ratio [HR] 1.18). Controlling for health-related measures and disability reduced the HR for Black beneficiaries to 1.03. Adding “Buy-in” as an individual level covariate lowered the HR for Black beneficiaries to 0.92. Neither of the residential measures added to the predictive model. We conclude that poorer health status, excess disability, and most importantly, greater poverty among Black beneficiaries accounts for racial mortality differences in the aged US Medicare population. Poverty fosters social and health inequalities, including mortality disparities, notwithstanding national health insurance for the US elderly. Controlling for individual level poverty, in contrast to the common use of area level poverty in previous analyses, accounts for the White survival advantage in Medicare beneficiaries, and should be a covariate in analyses of administrative databases.

•

Socioeconomic disparities have important consequences for patient outcomes.

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Including poverty in analyses mitigates racial mortality disparities in the elderly.

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Poverty is an essential factor associated with Medicare racial mortality disparities.

Changes in Physician Practice Patterns after Implementation of a Communication-and-Resolution Program

OBJECTIVE

To test if a 2006 communication-and-resolution program to address unexpected adverse outcomes was associated with changes in cost and use trajectories.

DATA SOURCE

Records of patients discharged with a principal diagnosis of chest pain from 44 nonfederal general hospitals in Cook County, Illinois, between January 2002 and December 2009.

STUDY DESIGN

Propensity-score matched discharges from the intervention and comparison hospitals before computing difference-in-differences estimates of quarterly growth rates.

DATA COLLECTION METHODS

We used discharge records submitted to a central statewide repository.

PRINCIPAL FINDINGS

Relative to the comparison hospitals and to pre-implementation trends, and consistent with reduced testing at presentation, the intervention hospital recorded an increase in the number of patients with a principal diagnosis of chest pain. Among admitted patients, quarterly growth rates of clinical laboratory and radiology charges at the intervention hospital declined by 3.8 and 6.9 percentage points.

CONCLUSIONS

Among patients with chest pain, the implementation of a comprehensive communication-and-resolution program was associated with substantially reduced growth rates in the use of diagnostic testing and imaging services. Further research is needed to establish to what extent these changes were attributable to the program and clinically appropriate.

Association of Liability Concerns with Decisions to Order Echocardiography and Cardiac Stress Tests with Imaging

BACKGROUND

Professional societies have made efforts to curb overuse of cardiac imaging and decrease practice variation by publishing appropriate use criteria. However, little is known about the impact of physician-level determinants such as liability concerns and risk aversion on decisions to order testing.

METHODS

A web-based survey was administered to cardiologists and general practice physicians affiliated with two academic institutions. The survey consisted of four clinical scenarios in which appropriate use criteria rated echocardiography or stress testing as "may be appropriate." Respondents' degree of liability concerns and risk aversion were measured using validated tools. The primary outcome variable was tendency to order imaging, calculated as the average likelihood to order an imaging test across the clinical scenarios (1 = very unlikely, 6 = very likely). Linear regression models were used to evaluate the association between tendency to order imaging and physician characteristics.

RESULTS

From 420 physicians invited to participate, 108 complete responses were obtained (26% response rate, 54% cardiologists). There was no difference in tendency to order imaging between cardiologists and general practice physicians (3.46 [95% CI, 3.12-3.81] vs 3.15 [95% CI, 2.79-3.51], P = .22). On multivariate analysis, a higher degree of liability concerns was the only significant predictor of decisions to order imaging (mean difference in tendency to order imaging, 0.36; 95% CI, 0.09-0.62; P = .01).

CONCLUSION

In clinical situations in which performance of cardiac imaging is rated as "may be appropriate" by appropriate use criteria, physicians with higher liability concerns ordered significantly more testing than physicians with lower concerns.

Reevaluating Reports of Defensive Medicine

There is ongoing policy debate about the potential for malpractice liability reform to reduce the use of defensive medicine and slow the growth of health care spending. The effectiveness of such policy levers hinges on the degree to which physicians respond to liability pressures by prescribing medically unnecessary care. Many estimates of this relationship are based on physician reports. We present new survey evidence on physician assessment of their own use of medically unnecessary care in response to medical liability and other pressures, including a randomized evaluation of the sensitivity of those responses to survey framing. We find that while use of such care is potentially quite prevalent, responses vary substantially based on survey framing, with the way the question is phrased driving differences in responses that are often as great as those driven by physician specialty or whether the physician has personally been named in a lawsuit. These results suggest that self-reported use of medically unnecessary care ought to be used with caution in the formulation of malpractice liability system reform.

Advancing the Use of Administrative Data for Emergency Department Diagnostic Imaging Research

Administrative data are critical to describing patterns of use, cost, and appropriateness of imaging in emergency care. These data encompass a range of source materials that have been collected primarily for a nonresearch use: documenting clinical care (e.g., medical records), administering care (e.g., picture archiving and communication systems), or financial transactions (e.g., insurance claims). These data have served as the foundation for large, descriptive studies that have documented the rise and expanded role of diagnostic imaging in the emergency department (ED). This article summarizes the discussions of the breakout session on the use of administrative data for emergency imaging research at the May 2015 Academic Emergency Medicine consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The authors describe the areas where administrative data have been applied to research evaluating the use of diagnostic imaging in the ED, the common sources for these data, and the strengths and limitations of administrative data. Next, the future role of administrative data is examined for answering key research questions in an evolving health system increasingly focused on measuring appropriateness, ensuring quality, and improving value for health spending. This article specifically focuses on four thematic areas: data quality, appropriateness and value, special populations, and policy interventions.

Knowledge Translation and Barriers to Imaging Optimization in the Emergency Department: A Research Agenda

Researchers have attempted to optimize imaging utilization by describing which clinical variables are more predictive of acute disease and, conversely, what combination of variables can obviate the need for imaging. These results are then used to develop evidence-based clinical pathways, clinical decision instruments, and clinical practice guidelines. Despite the validation of these results in subsequent studies, with some demonstrating improved outcomes, their actual use is often limited. This article outlines a research agenda to promote the dissemination and implementation (also known as knowledge translation) of evidence-based interventions for emergency department (ED) imaging, i.e., clinical pathways, clinical decision instruments, and clinical practice guidelines. We convened a multidisciplinary group of stakeholders and held online and telephone discussions over a 6-month period culminating in an in-person meeting at the 2015 Academic Emergency Medicine consensus conference. We identified the following four overarching research questions: 1) what determinants (barriers and facilitators) influence emergency physicians' use of evidence-based interventions when ordering imaging in the ED; 2) what implementation strategies at the institutional level can improve the use of evidence-based interventions for ED imaging; 3) what interventions at the health care policy level can facilitate the adoption of evidence-based interventions for ED imaging; and 4) how can health information technology, including electronic health records, clinical decision support, and health information exchanges, be used to increase awareness, use, and adherence to evidence-based interventions for ED imaging? Advancing research that addresses these questions will provide valuable information as to how we can use evidence-based interventions to optimize imaging utilization and ultimately improve patient care.

Overtesting and the Downstream Consequences of Overtreatment: Implications of "Preventing Overdiagnosis" for Emergency Medicine

Overtesting, the downstream consequences of overdiagnosis, and overtreatment of some patients are topics of growing debate within emergency medicine (EM). The "Preventing Overdiagnosis" conference, hosted by The Dartmouth Institute for Health Policy and Clinical Practice, with sponsorship from consumer organizations, medical journals, and academic institutions, is evidence of an expanding interest in this topic. However, EM represents a compellingly unique environment, with increased decision density tied to high stakes for patients and providers with missed or delayed diagnoses in a professional atmosphere that does not tolerate mistakes. This article reviews the relevance of this reductionist paradigm to EM, provides a first-hand synopsis of the first "Preventing Overdiagnosis" conference, and assesses barriers to moving the concept of less test ordering to reality.

The safety of emergency medicine

The patient safety movement has been active for over a decade, but the issue of patient safety in emergency care and the emergency department (ED) has only recently been brought into the forefront. The ED environment has traditionally been considered unsafe, but there is little data to support this assertion. This paper reviews the literature on patient safety and highlights the challenges associated with using the current evidence base to inform practice due to the variability in methods of measuring safety. Studies looking at safety in the ED report low rates for adverse events ranging from 3.6 to 32.6 events per 1000 attendances. The wide variation in reported rates on adverse events reflects the significant differences in methods of reporting and classifying safety incidents and harm between departments; standardisation in the ED context is urgently required to allow comparisons to be made between departments and to quantify the impact of specific interventions. We outline the key factors in emergency care which may hinder the provision of safer care and consider solutions which have evolved or been proposed to identify and mitigate against harm. Interventions such as team training, telephone follow-up, ED pharmacist interventions and rounding, all show some evidence of improving safety in the ED. We further highlight the need for a collaborative whole system approach as almost half of safety incidents in the ED are attributable to external factors, particularly those related to information flow, crowding, demand and boarding.

Emergency physician sex and emergency department resource use

OBJECTIVE

We investigated whether there are differences in emergency department (ED) patient management associated with emergency physician (EP) sex, specifically in terms of ordering investigations and hospital admissions.

METHODS

We included all EPs working as consultants for at least 24 consecutive months at a Spanish ED during an 8-year period. Every annual period was considered independently. The classificatory variable was EP sex. For every annual period we compiled age and years of experience of each EP, the number of patients who attended, and patient distribution in triage categories. To analyze ED resource use by each EP and period, we recorded percentages of blood tests, radiography, ultrasonography, computerized tomography (CT) scan, and hospital admission orders.

RESULTS

Fifty EPs (27 women and 23 men) were included, 291 annual periods were analyzed (132 for women and 159 for men) and 256 524 patient attendances were recorded (114 086 by women and 142 438 by men). Blood tests were ordered in 57.2% of cases, radiography in 58.0%, ultrasounds in 5.0%, CT scans in 7.0%, and hospitalizations in 28.4%. Compared with men, women ordered 6.8% (95% confidence interval 6.1-7.5%) more blood tests, 4.6% (4.3-5.3%) more radiographies, 15.2% (11.6-18.9%) more ultrasonographies, 11.1% (8.1-14.1%) more CT scans, and 12.1% (10.8-13.4%) more hospitalizations. These differences maintained statistical significance in the stratified analysis by EP experience, and were observed for most of the years analyzed.

CONCLUSION

Female EPs order more investigations and admit more patients, although from our results the reason for this is unclear, and the impact on healthcare effectiveness and patient outcome is unknown.