Study: Defensive imaging common & costly among orthos
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Defensive medicine is associated with high costs and may account for 5 to 9 percent of healthcare expenditures. Diagnostic imaging is a primary culprit with overuse of imaging pegged as the most common type of defensive practice. However, previous studies calculating defensive medicine costs have relied on estimates.
Researchers designed a prospective study to evaluate the prevalence and costs of defensive medicine among orthopedic surgeons in Pennsylvania. They created an anonymous spreadsheet survey and mailed it to the 640 members of the Pennsylvania Orthopaedic Society, querying respondents about practice demographics and asking them to record imaging orders and indicate whether the image “was required for clinical care” or “ordered for defensive reasons.”
Among the 72 orthopedists who returned the survey, defensive imaging comprised 19 percent of the orders, reported John Flynn, MD, associate chief of orthopedic surgery at Children’s Hospital of Philadelphia. Defensive imaging was responsible for $113,369 of $325,309 of total imaging charges among the patient cohort, based on Medicare dollars.
MRI figured prominently in defensive orders and accounted for nearly half of defensive orders, nearly 85 percent of defensive costs and 29.5 percent of total costs. Knee, lumbar spine and shoulder MRI ranked as the most common defensive orders.
Flynn cited protocols for a torn meniscus as an example of unnecessary imaging. “A surgeon can safely rely on clinical diagnosis alone because it has been shown to be more accurate than an MRI in diagnosing meniscal surgical pathology,” he wrote. In practice, however, most patients proceed to surgical repair after an MRI.
The researchers noted that defensive ordering was more common among certain subsets of physicians. “A lawsuit within the last five years, experience over 15 years, private practice and specializing within orthopedics (i.e. hand, sports, spine, etc.) predicted an increased incidence of defensive orders,” according to Flynn and colleagues.
The authors emphasized the major strength of the study—its attempt to capture the empirical prevalence and subsequent cost of defensive medicine, while acknowledging that the definition of defensive is subjective.
“Ideally, as a next step, we would hope to try to get a broader national picture using this prospective practice audit methodology, so we could get a better sense of the true costs of defensive imaging in orthopedics,” said Flynn.