Greater resource use among physicians is associated with fewer malpractice claims

Physicians with higher average hospital charges and greater resource use had a reduced risk of incurring a malpractice claim, according to an analysis of admissions to acute care hospitals in Florida between 2000 and 2009.

The researchers linked the admissions data to the malpractice history of the attending physicians to determine if physicians providing more costly care are less likely to face malpractice claims.

Across seven specialties, physicians whose adjusted hospital spending was among the highest 20 percent had a lower malpractice claim rate compared with those who were in the lowest 20 percent of spending. In six specialties, greater resource use was associated with statistically significant lower rates of alleged malpractice incidents.

Lead researcher Anupam B. Jena, MD, PhD, of the department of healthcare policy at Harvard Medical School in Boston, and colleagues published their results online in The BMJ on Nov. 5.

“The implications of our findings for understanding the relation between resource use and subsequent malpractice liability depend on the mechanism through which higher resource use is associated with fewer claims,” they wrote. “If higher spending is motivated by concerns about malpractice but is associated with fewer errors and therefore lower malpractice claims, then this spending would be considered defensively motivated but may not be wasteful because errors are lower…If, in contrast, greater resource use is not associated with fewer errors and adds no other clinical benefit, then this additional spending could be considered wasteful, whether defensively motivated or not.”

The researchers noted that critics of the malpractice system in the U.S. mention it leads to defensive medicine, which they defined as “medical care provided to patients solely to reduce the threat of malpractice liability rather than to further diagnosis or treatment.”

They also cited a few studies regarding defensive medicine, including one that found more than 80 percent of physicians in Massachusetts practiced defensive medicine and another national survey that found more than 60 percent of physicians ordered diagnostic tests or consultations to reduce the threat of liability.

In this study, the researchers examined data on 24,637 physicians and 4,342 malpractice claims. They obtained data from all non-state, non-federal Florida acute care hospitals from 2000 to 2009 and had the license number for the attending physicians for the hospital admissions. They also had information on closed malpractice claims against Florida physicians with active medical licenses.

The number of malpractice claims per 100 physician years was 1.6 in the pediatrics group, 1.9 in the family medicine group, 2.7 in the internal medicine group, 2.8 in the internal medicine subspecialty group, 3.2 in the surgical subspecialty group, 4.0 in the obstetrics and gynecology group and 4.1 in the general surgery group.

For the internal medicine group, physicians who were in the top 20 percent of adjusted hospital spending had a malpractice claim rate of 0.3 percent compared with 1.5 percent for physicians in the lowest 20 percent of spending. The corresponding malpractice claim rates were 0.2 percent and 1.7 percent for the internal medicine subspecialty group; 0.2 percent and 0.5 percent for the family medicine group; 0.1 percent and 0.7 percent for the pediatrics group; 0.4 percent and 2.3 percent for the general surgery group; 0.1 percent and 1.7 percent for the surgical subspecialty group; and 0.4 percent and 1.9 percent for the obstetrics and gynecology group.

The researchers cited a few limitations, including that they did not measure the illness severity of patients and thus physicians with higher adjusted hospital charges may treat sicker patients who are at a higher risk of adverse outcomes. They also relied on hospital data instead of outpatient data when classifying the intensity of care that physicians provided.

“Without evidence on rates of errors associated with greater resource use, we cannot definitively conclude that defensive medicine—as it is traditionally defined—reduces the number of malpractice claims,” the researchers wrote. “However, our findings still suggest that greater resource use is associated with fewer claims, which is consistent with physician beliefs that higher resource use, more generally, is associated with reduced liability of malpractice.”