Abstract
Background
Supporters of medical liability reform contend that caps on non-economic damages will decrease defensive medicine.
Questions/Purposes
We examined whether removal of caps on non-economic damages affect one type of defensive medical practice, early imaging for new-onset low back pain.
Patients and Methods
Using administrative claims data, we retrospectively studied adult patients evaluated for new-onset low back pain from 2007 to 2012. We included patients from two states that had caps on non-economic damages struck down in 2010 (n = 462,604) and patients from adjacent states (n = 781,963). Using a difference-in-differences approach, we evaluated the impact of non-economic damage caps on early imaging while adjusting for physician specialty, patient characteristics, and year- and state-level fixed effects.
Results
There was no association between non-economic damage caps and early imaging for low back pain among all providers. Removal of a non-economic damage cap was also not associated with a significant change in early imaging within the two cap-removal states. Subgroup analysis by physician specialty demonstrated significantly increased use of early imaging for low back pain by orthopedic or neurological surgeons in the first 12 months following cap removal in one state (but this difference did not persist beyond 12 months). In the other cap-removal state, early imaging increased among orthopedic and neurological surgeons more than 12 months after cap removal.
Conclusion
We found no association between caps on non-economic damages and early imaging for low back pain among all physicians. However, our subgroup analysis suggests that physician specialties may respond to non-economic damage cap policies differently.
Electronic supplementary material
The online version of this article (10.1007/s11420-018-9650-4) contains supplementary material, which is available to authorized users.
Keywords: defensive medicine, tort reform, malpractice, low back pain, early imaging
Introduction
Medical liability reform is a key point of policies proposed as alternatives [26, 31, 32] to the Affordable Care Act (ACA), including the Protecting Access to Care Act of 2017 (HR 1215) that passed in the House of Representatives [32]. Supporters of medical liability reform contend that tort reform will decrease cost and improve both access and quality of health care [21]. However, empirical analyses have questioned the magnitude of potential savings [22, 30]. Supporters emphasize that tort reform will ease physicians’ liability concerns and minimize the practice of defensive medicine, in which tests and procedures are ordered primarily to minimize the risk of a lawsuit [28]. While survey studies indicate that defensive medicine is commonplace [20, 28], both the frequency and impact of defensive medicine are difficult to assess. Carrier et al. demonstrated that physicians are uniformly concerned with liability, regardless of the liability environment of the state in which they are practicing [4]. It remains unclear whether tort reform affects the way physicians practice.
In the current study, we sought to examine whether medical liability reforms (in the form of removing caps on non-economic damages) affected the frequency of one type of defensive practice, early imaging for acute low back pain. Low back pain (LBP) is a common complaint among patients of physicians in all specialties but often improves within 4 to 6 weeks without intervention. To minimize unnecessary testing, clinical practice guidelines (CPG) recommend that imaging is not necessary for nonspecific LBP, specifically in the absence of neurologic deficits or concern for more serious underlying conditions [3, 8]. Therefore, avoidance of imaging within 28 days of a primary diagnosis of nonspecific LBP is an accepted measure of delivering high quality care [1]. For this study, we designated imaging within 28 days of nonspecific LBP as defensive practice because it is a deviation from accepted CPG. We hypothesized that removal of non-economic damage caps would result in increased use of early imaging for nonspecific LBP.
Patients and Methods
Following exemption from further review from our institutional review board, we used claims data from the Truven Health MarketScan® Commercial Claims and Encounters Database, which consists of private insurance claims for non-elderly individuals and their dependents who are employed, retired early, or on Consolidated Omnibus Budget Reconciliation Act (COBRA) plans. We used outpatient- and hospital-based practice claims for adults ages 18 to 63 years residing in one of 48 states (two states were excluded because they passed new caps on non-economic damages during the study period) or the District of Columbia and carried a diagnosis code for LBP on at least one service date between December 1, 2007, and December 31, 2012. All patients in this study had at least 12 months of continuous health insurance enrollment without (1) any previous coding for LBP or similar conditions, (2) any coding for a clinically concerning (“red flag”) condition associated with LBP [29], or (3) any trauma or intervention (surgery or injection) in the 28 days following the LBP diagnosis (see Online Resource 1 for additional cohort details).
Non-economic damages include compensation for pain, suffering, distress, and other emotional elements of injury, which are exclusive of objectively verifiable economic damages suffered. Two states had existing non-economic damage caps struck down by courts at different times in 2010, creating the opportunity to conduct a difference-in-differences analysis. We included only patients from these two states (referred to as “cap-removal states”) and their immediate geographically bordering states (referred to as “neighboring states”) in the first analyses. We created two groups (cap-removal state 1 and neighbors; cap-removal state 2 and neighbors) to account for differences in both financial limits and historical context between the two caps. Data use agreements with Truven Health prevent us from revealing identities of individual states.
To adjust for time-invariant differences among states and time-variant differences in practice, we constructed a patient-level hierarchical model with the outcome of imaging within 28 days as the dependent variable and fixed effects for year and state. The fixed effects model was used to control for factors unique to a particular state, or unique to a particular year, that may be confounders. The independent variables included cap status of the state for each year, provider specialty (details below), and patient characteristics (age, sex, comorbidities). The state-specific, time-varying damage cap status dummy variable is our main coefficient of interest in our difference-in-difference models. Potential interactions among independent variables were assessed. All data management was conducted using SAS Enterprise Guide 7.1 (Cary, NC, USA), and statistical tests were performed using STATA v.14 (College Station, TX, USA). Standard errors were clustered at the state level.
State malpractice policies, patient characteristics, and provider characteristics were studied as independent variables. Based on the patient’s state of residence and date of index diagnosis, we included an indicator variable for a cap on non-economic damages in medical liability lawsuits based on the Database of State Tort Law Reform, version 5 (DSTLR-5) [2]. We excluded two states bordering cap-removal state 2 that passed non-economic damage caps during the last year of our study period (leaving inadequate post-adoption time for analysis). Patients were assigned to a cap status based on individual date of index diagnosis for LBP: no cap for at least 12 months (cap = 0); less than 12 months prior to cap removal (cap = 1; to evaluate trends immediately preceding the policy change); less than 12 months following cap removal (cap = 2; to account for possible slow adoption into practice); and cap in place for more than 12 months (cap = 3), with cap = 3 used as the reference group. Of the states surrounding cap-removal state 1, none had caps on non-economic damages. Of the states surrounding cap-removal state 2, two had caps on non-economic damages and one did not have caps on non-economic damages. Although we chose to focus our analysis on caps on non-economic damages, we performed (but ultimately excluded) a sensitivity analysis that included other medical malpractice policy variables from DSTLR-5 (Online Resource 1).
Patient age was included as a categorical variable, with 18 years as the reference (Online Resource 2). The primary outcome was imaging—plain radiographs, computed tomography (CT), or magnetic resonance imaging (MRI)—identified by Current Procedural Terminology, 4th Edition (CPT-4), codes (Online Resource 3) within 28 days of the first LBP diagnosis. Patient sex, comorbidities, smoking-related diseases, and tobacco use disorder were also included in the models (Online Resource 4).
We categorized providers by specialty: emergency medicine, hospital-based physicians, orthopedic and neurological surgeons, other surgeons, obstetrician/gynecologists, anesthesiology/pain management, medical specialists, primary care (family or internal medicine), and non-physicians (including chiropractors). Subgroup analyses were conducted for each specialty type to examine for associations between cap status and early imaging.
To determine whether the outcome would be influenced by the type of imaging ordered, we performed a sensitivity analysis in which separate models were constructed for plain radiographs and for advanced imaging (MRI and CT scan).
Results
The two cap-removal states included 462,604 patients (270,730 in state one and 191,874 patients in state two) and their neighboring states contributed 781,963 patients (403,194 in neighbors of state one and 378,769 in neighbors of state two) (Fig. 1). Over the entire study period (2007 through 2012), the frequency of the primary outcome, early imaging for LBP, was 29.6% in cap-removal state 1; 28.7% in neighbors of cap-removal state 1; 33.3% in cap-removal state 2; and 35.1% in neighbors of cap-removal state 2.
Fig. 1.
Cohort selection flow chart
Within the models for both cap-removal state 1 and its neighbors and cap-removal state 2 and its neighbors, there was no significant association between removal of non-economic damage caps and early imaging (more than 12 months after cap removal compared to time period with cap in place—cap-removal state 1, OR 1.02 [0.94, 1.11]; cap-removal state 2, OR 1.04 [0.98, 1.10]) (Table 1) There was no association between cap status and early imaging in the periods immediately before or after cap removal for either state (Table 1).
Table 1.
Odds ratios for early imaging for low back pain, controlling for state-level and year-level fixed effects, non-economic damage cap status, patient age, gender, underlying comorbidities, and physician specialty category
| Model | Coefficient (reference group) | Odds ratio | Confidence interval |
|---|---|---|---|
| Cap removal state 1 and neighboring states | |||
| < 12 months prior to cap removal (cap in place) | 1.03 | 0.98–1.10 | |
| < 12 months after cap removal (cap in place) | 1.04 | 0.95–1.14 | |
| > 12 months after cap removal (cap in place) | 1.02 | 0.94–1.11 | |
| Female (male) | 0.86 | 0.85–0.87 | |
| Specialty category (primary care–32%) | REF | ||
| Orthopedic or neurological surgeons (2%) | 5.72 | 4.79–6.83 | |
| Medical specialists (3%) | 1.57 | 1.47–1.68 | |
| Hospital based (10%) | 2.67 | 2.38–2.99 | |
| Emergency department (8%) | 1.18 | 1.02–1.36 | |
| Other surgeons (1%) | 0.84 | 0.77–0.92 | |
| Obstetricians and gynecologists (2%) | 0.58 | 0.54–0.64 | |
| Anesthesiology and pain management (0.3%) | 0.93 | 0.77–1.13 | |
| Non-physicians, including chiropractors (42%) | 1.16 | 0.98–1.37 | |
| Cap removal state 2 and neighboring states | |||
| < 12 months prior to cap removal (cap in place) | 1.06 | 0.98–1.10 | |
| < 12 months after cap removal (cap in place) | 1.03 | 0.96–1.11 | |
| > 12 months after cap removal (cap in place) | 1.04 | 0.98–1.10 | |
| Female (male) | 0.87 | 0.86–0.88 | |
| Specialty category (primary care–42%) | REF | ||
| Orthopedic or neurological surgeons (5%) | 7.42 | 6.54–8.42 | |
| Medical specialists (4%) | 1.84 | 1.44–2.35 | |
| Hospital based (9%) | 2.77 | 2.23–3.44 | |
| Emergency department (10%) | 1.02 | 0.91–1.34 | |
| Other surgeons (2%) | 0.73 | 0.62–0.86 | |
| Obstetricians and gynecologists (2%) | 0.56 | 0.48–0.64 | |
| Anesthesiology and pain management (0.4%) | 0.88 | 0.60–1.29 | |
| Non-physicians, including chiropractors (25%) | 1.58 | 1.40–1.78 |
Figures 2 and 3 show that trends between cap-removal states and their neighbors were largely parallel before cap removal, except for one neighbor of state 1. The trends in cap-removal states were similar in the post-removal period, suggesting null effects of removing non-economic damage caps. While there were baseline differences in utilization of early imaging across states, the difference-in-difference model addresses this by deriving estimates that compare baseline differences across the periods before and after cap removal.
Fig. 2.
Frequency of early imaging for low back pain by age in cap-removal state 1 and its neighbor states. Presence or absence of non-economic damage caps in each state indicated (unless indicated, cap status remained the same during entire study period). Cap removal date shown with vertical line.
Fig. 3.
Frequency of early imaging for low back pain by age in cap-removal state 2 and its neighbor states. Presence or absence of non-economic damage caps in each state indicated (unless indicated, cap status remained the same during entire study period). Cap removal date shown with vertical line.
Female patients were significantly less likely to undergo early imaging (OR 0.86 [0.85, 0.87]) for cap-removal state 1 and its neighbors (OR 0.87 [0.86, 0.88]) and for cap-removal state 2 and its neighbors. Additionally, there was a significant increase in likelihood of early imaging with increasing patient age (with an almost linear dose-response): age over 45 years for cap-removal state 1 and neighbors and over 47 years for cap-removal state 2 and its neighbors (Online Resource 4). The following comorbidities were associated with significant differences in early imaging: anemia, arthritis, chronic lung disease, depression, diabetes, drug abuse, hypertension, electrolyte disorder, peripheral vascular disease, psychiatric diseases, pulmonary or circulatory disorders, renal failure, smoking, obesity, and tobacco usage (see Online Resource 4).
In the model with cap-removal state 1 and its neighbors, compared to the reference year (2007), the likelihood of early imaging was significantly lower in years 2009 (OR 0.86 [0.82, 0.91]), 2010 (OR 0.84 [0.77, 0.91]), 2011 (OR 0.81 [0.76,m0.88]), and 2012 (OR 0.78 [0.71, 0.85]). A significant time-related decrease in early imaging was present only in years 2009 and 2012 for cap-removal state 2 and its neighbors (2009, OR 0.94 [0.91, 0.99]; 2012, OR 0.90 [0.85, 0.95]).
In both models, individuals treated by orthopedic or neurological surgeons, hospital-based physicians, medical specialists, non-physician providers, and other physicians were significantly more likely than those treated by primary care physicians to undergo early imaging (Table 1). Those treated by other (non-orthopedic/neurological) surgeons and by obstetrician/gynecologists were significantly less likely than those treated by primary care physicians to undergo early imaging (Table 1). In cap-removal state 1 and its neighbors, of patients seen by orthopedic or neurological surgeons, 65.1% had early imaging; 46.1% of patients seen by hospital-based physicians had early imaging; and 33.5% of patients seen by medical specialists had early imaging. These percentages were 74.2%, 51.1%, and 41.2%, respectively, in cap-removal state 2 and its neighbors.
Subgroup analysis of patients treated by orthopedic or neurological surgeons in cap-removal state 1 demonstrated a significantly higher likelihood of ordering early imaging 0 to 12 months following cap removal (OR 1.18 [1.01, 1.39]) compared to when there was a non-economic damage cap in place, but this difference was not significant more than 12 months after cap removal (OR 1.11 [0.97, 1.26]). These findings are contrary to those found when looking at all providers contemporaneously: there was significantly decreased likelihood of ordering early imaging in all time periods (Table 2).
Table 2.
Odds ratios for early imaging for LBP, subgroup analysis based on physician specialty type. Adjusted for state-level and year-level fixed effects, patient sex, patient age, and Elixhauser comorbidities
| Physician specialty | Cap status (reference: cap) | OR (95% CI) |
|---|---|---|
| Cap-removal state 1 | ||
| Orthopedic or neurological surgeons | < 12 months prior to cap removal | 1.12 (0.97, 1.30) |
| < 12 months after cap removal | 1.18 (1.01, 1.39) | |
| > 12 months after cap removal | 1.11 (0.97, 1.26) | |
| Medical subspecialists | < 12 months prior to cap removal | 0.86 (0.74, 1.00) |
| < 12 months after cap removal | 0.84 (0.72, 1.00) | |
| > 12 months after cap removal | 0.86 (0.75, 0.98) | |
| Hospital-based physicians | < 12 months prior to cap removal | 0.85 (0.79, 0.91) |
| < 12 months after cap removal | 0.82 (0.76, 0.88) | |
| > 12 months after cap removal | 0.80 (0.76, 0.86) | |
| All providers | < 12 months prior to cap removal | 0.90 (0.88, 0.92) |
| < 12 months after cap removal | 0.88 (0.86, 0.90) | |
| > 12 months after cap removal | 0.82 (0.80, 0.83) | |
| Cap-removal state 2 | ||
| Orthopedic or neurological surgeons | < 12 months prior to cap removal | 1.08 (0.94, 1.25) |
| < 12 months after cap removal | 1.14 (1.00, 1.32) | |
| > 12 months after cap removal | 1.13 (1.01, 1.26) | |
| Medical subspecialists | < 12 months prior to cap removal | 1.03 (0.91, 1.16) |
| < 12 months after cap removal | 0.97 (0.86, 1.10) | |
| > 12 months after cap removal | 0.94 (0.86, 1.04) | |
| Hospital-based physicians | < 12 months prior to cap removal | 0.93 (0.84, 1.01) |
| < 12 months after cap removal | 0.93 (0.84, 1.02) | |
| > 12 months after cap removal | 0.93 (0.87, 1.01) | |
| All providers | < 12 months prior to cap removal | 0.99 (0.96, 1.02) |
| < 12 months after cap removal | 0.98 (0.95, 1.01) | |
| > 12 months after cap removal | 0.95 (0.92, 0.97) | |
Subgroup analysis of patients treated by orthopedic or neurological surgeons in cap-removal state 2 demonstrated a significantly higher likelihood of ordering early imaging more than 12 months after cap removal (OR 1.13 [1.01, 1.26]) compared to when there was a non-economic damage cap in place for 12 months or more. These findings are contrary to those found when looking at all providers contemporaneously (Table 2).
We performed a sensitivity analysis in which separate models were constructed for plain radiographs and for advanced imaging (MRI and CT scan) (Online Resources 5 and 6). When examining ordering of plain radiographs alone, there were no differences based on cap status in cap-removal state 1 and its neighbors and in cap-removal state 2 and its neighbors. When examining ordering of advanced imaging, there was no difference based on cap status in cap-removal state 1 and its neighbors. However, in cap-removal state 2 and its neighbors, there was a significant association between cap status and ordering of advanced imaging (more than 12 months after cap removal compared to time period with cap in place—cap-removal state 1, OR 1.21 [1.04, 1.42]). In this scenario, the impact of provider specialty was increasingly apparent, as the odds ratio associated with orthopedic or neurological surgeons was 10.0 [9.36, 10.69] (Online Resource 6).
Discussion
Physicians and physician advocacy groups have identified tort reform (specifically, caps on non-economic damages) as a principle strategy to establish environments in which physicians can care for patients without excessive fear of litigation. Physicians indicate that they overuse imaging due to fear of litigation and that tort reform may change these practices [23], but there is concern that these fears may be too deeply engrained for tort reform to change behavior [4]. We chose to study LBP because it is a common condition with established CPG for imaging that are not always followed [11, 18].
Our study has limitations inherent to administrative data and health policy research. We relied on accurate claims data but did not have access to clinical data that may justify ordering of imaging. We designed our study’s inclusion criteria to address the potential concern that imaging may need to be done on clinical grounds, such as “red-flag” type symptoms—we excluded patients who had neurologic impairment, cancer, trauma, spinal cord injury, or an intervention (surgery or spinal injection) within 28 days of the first imaging. The nature of administrative data research also limited our ability to understand regional practice patterns, which may vary widely. Our study design included neighboring states in an attempt to capture regional practice patterns, but they may vary widely even within smaller regions. Lastly, we are unable to determine the extent of physicians’ awareness about changes in health practice (namely caps on non-economic damages) during the years examined and the impact of that awareness on practice patterns. We tried to mitigate this effect by including different cap statuses to account for potential changes in the 12 months leading up to and the 12 months following cap removal.
Given physicians’ fear of litigation and its presumed effect on clinical decision making, we expected to find increased use of early imaging for LBP following the removal of non-economic damage caps. While we did not find an association between the removal of caps and early imaging among all physicians, specialty type had the largest association with early imaging. Unlike other providers, orthopedic and neurological surgeons in states where caps were removed demonstrated a relationship between early imaging and cap status. Consistent with a prior study [14], our data suggest that these surgeons contribute disproportionately to early imaging, but also indicate that they may respond differently than other physicians to policy changes such as caps on non-economic damages. While we have attempted to isolate the effect of non-economic damages in our methods, the contributors to defensive practice are complex and interwoven. The clinical decision making of these specialized practitioners may be influenced by perception that they are targets for lawsuits [27], bias from the referral nature of their practices, specialty-based differences in treatment of LBP, and behaviors instilled from training or practice [10]. Our sensitivity analysis (with MRI and CT scans isolated) demonstrates that both the timing and type of test ordered are preference-sensitive, further showing the influence of individual practice. These specialty-specific provider preferences may be as impactful, if not more so, than that associated with defensive practice. The importance of practitioner characteristics was demonstrated in Carrier’s study that linked survey and administrative claims data [5], showing that interventions targeted to affect practitioners’ perceptions of liability risk are most likely to decrease defensive practices. Also, our findings that patient age and sex are associated with early imaging indicate that variables inherent to clinical practice (such as physician biases and variability in decision making) further contribute to physicians’ behavior and practice [14, 17].
We did not find an overall association between non-economic damage caps and early imaging, which is consistent with prior findings of the unclear empirical effects of damage caps [24]. We focused on the effect of removing caps. It is possible that passage of caps may have a different effect than removal of caps, as physicians and their advocates may be more aware of the former after prolonged advocacy efforts, leading to a greater potential influence on practice. Furthermore, prolonged legal battles (such as caps being instated and then struck down, sometimes repeatedly) may blunt the effect of cap changes on physicians’ behavior [19]. Additionally, the effects of medical malpractice liability reform may extend beyond what can be quantified in empirical studies [13]. As described by Hermer and Brody [13], liability reform may provide the intangible support required to engage physicians in larger health care reforms.
The characteristics of each state’s cap (specifically, amount of liability protected) may introduce heterogeneity into the cap’s influence. To partially account for this, we present individual analyses of each cap-removal state and its neighbors. We cannot examine the direct relationship between malpractice-related policies and the frequency of malpractice-related litigation with current data sources and are limited to using early imaging as a surrogate of defensive medicine. Furthermore, changes in non-economic damage caps may differentially influence treatment of other conditions: while imaging for LBP may not be affected, treatment of other conditions such as coronary disease [2, 16] or high-risk pregnancies [9] may be affected. Also, our findings may not be generalizable beyond individuals ages 18 to 63 years with private health insurance.
We found that early imaging for LBP decreased over time, suggesting that secular trends (such as increasing adherence to CPG) may influence early imaging more than the policy variable that we studied. CPG advising against routine early imaging have been in development since the mid-1990s [3]. In 2007, the American College of Physicians and American Pain Society jointly issued a CPG [8] that was directly endorsed or reflected in similar recommendations from other specialty organizations [6, 7, 12]. Our finding of decreased early imaging over time may reflect the ACA’s emphasis on evidence-based, high-value care (including the introduction of quality reporting initiatives for outpatient care). Indeed, adherence to CPGs will remain important [25], and there have been advocates for legal safe harbor for physicians who adhere to the practices outlined in the guidelines [30]. Although simulated application of “safe harbor” legislation showed minimal impact on medical liability outcomes [15], the resultant increase in adherence to evidence-based guidelines may have a broad impact on patient safety and medical expenditure.
Our difference-in-differences analysis did not demonstrate a meaningful impact of non-economic damage cap removal on one measure of defensive medicine (early imaging for LBP), supporting the uncertainty as to whether tort reform policies influence physicians’ practice. We noted a trend over time toward a decrease in early imaging for LBP, regardless of malpractice policy. A continued focus on strategies to minimize high-volume, low-value services is needed to reduce excessive health care spending.
Electronic Supplementary Materials
(PDF 81 kb)
(PDF 87 kb)
(PDF 158 kb)
(PDF 117 kb)
(PDF 87 kb)
(PDF 163 kb)
(PDF 1225 kb)
Disclaimer
This article is the authors’ responsibility and does not necessarily represent the official views of the NCATS, the AHRQ, the NCI, or the NIH.
Compliance with Ethical Standards
Conflict of Interest
Michael F. Pesko, PhD, and Elizabeth Sepper, JD, declare that they have no conflicts of interest. Christopher J. Dy, MD, MPH, reports support from grant number UL1 TR000448, Sub award KL2 TR000450, from the National Institutes of Health (NIH) National Center for Advancing Translational Sciences (NCATS), and from the NIH Roadmap for Medical Research, during the conduct of the study. Margaret A. Olsen, PhD, MPH, reports grants and personal fees from Pfizer and grants from Sanofi Pasteur, outside the submitted work. Matthew Keller, MS, and Margaret A. Olsen, PhD, MPH, report partial support from the Center for Administrative Data Research at the Washington University Institute of Clinical and Translational Sciences, grant number UL1 TR000448 from NCATS, grant number R24 HS19455 from the Agency for Healthcare Research and Quality (AHRQ), and grant number KM1CA156708 from the National Cancer Institute (NCI) at the NIH.
Human/Animal Rights
N/A
Informed Consent
N/A
Required Author Forms
Disclosure forms provided by the authors are available with the online version of this article.
Footnotes
Level of Evidence: Level III: retrospective, prognostic study
References
- 1.Agency for Healthcare Quality and Research. National Quality Measures Clearinghouse. 2016. Available at https://www.qualitymeasures.ahrq.gov/.
- 2.Avraham R, Schanzenbach M. The impact of tort reform on intensity of treatment: evidence from heart patients. J Health Econ. 2015;39:273–288. doi: 10.1016/j.jhealeco.2014.08.002. [DOI] [PubMed] [Google Scholar]
- 3.Bigos S, Bowyer OR, Braen G, et al. Acute low back problems in adults. P. H. S. Agency for Health Care Policy and Research, U.S. Department of Health and Human Services. Rockville, MD. 1994. AHCPR Publication No. 95–0642.
- 4.Carrier ER, Reschovsky JD, Mello MM, Mayrell RC, Katz D. Physicians’ fears of malpractice lawsuits are not assuaged by tort reforms. Health Aff (Millwood). 2010;29(9):1585–1592. doi: 10.1377/hlthaff.2010.0135. [DOI] [PubMed] [Google Scholar]
- 5.Carrier ER, Reschovsky JD, Katz DA, Mello MM. High physician concern about malpractice risk predicts more aggressive diagnostic testing in office-based practice. Health Aff (Millwood). 2013;32(8):1383–1391. doi: 10.1377/hlthaff.2013.0233. [DOI] [PubMed] [Google Scholar]
- 6.Choosing Wisely. Imaging for low back pain. 2012. Available at: http://www.choosingwisely.org/clinician-lists/american-academy-family-physicians-imaging-low-back-pain/.
- 7.Choosing Wisely. Lumbar spine imaging in the ED. 2014. Available at: http://www.choosingwisely.org/clinician-lists/acep-lumbar-spine-imaging-in-the-ed/.
- 8.Chou R, Qaseem A, Snow V, Casey D, Cross JT, Jr, Shekelle P, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478–491. doi: 10.7326/0003-4819-147-7-200710020-00006. [DOI] [PubMed] [Google Scholar]
- 9.Currie J, MacLeod WB. First do no harm? Tort reform and birth outcomes. Q J Econ. 2008;123(2):795–830. [Google Scholar]
- 10.Din RS, Yan SC, Cote DJ, Acosta MA, Smith TR. Defensive medicine in US spine neurosurgery. Spine (Phila Pa 1976). 2017;42(3):177–185. doi: 10.1097/BRS.0000000000001687. [DOI] [PubMed] [Google Scholar]
- 11.Gidwani R, Sinnott P, Avoundjian T, Lo J, Asch SM, Barnett PG. Inappropriate ordering of lumbar spine magnetic resonance imaging: are providers Choosing Wisely? Am J Manag Care. 2016;22(2):e68–76. [PubMed] [Google Scholar]
- 12.Heggeness MH. AAOS endorses back pain guidelines. AAOS Now. Sept 2010. Available at: https://www.aaos.org/AAOSNow/2010/Sep/cover/cover1/?ssopc=1. Accessed 27 July 2017.
- 13.Hermer LD, Brody H. Defensive medicine, cost containment, and reform. J Gen Intern Med. 2010;25(5):470–473. doi: 10.1007/s11606-010-1259-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Hong AS, Ross-Degnan D, Zhang F, Wharam JF. Clinician-level predictors for ordering low-value imaging. JAMA Intern Med. 2017;177(11):1577–1585. doi: 10.1001/jamainternmed.2017.4888. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Kachalia A, Little A, Isavoran M, Crider LM, Smith J. Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by physicians. Health Aff (Millwood). 2014;33(1):59–66. doi: 10.1377/hlthaff.2013.0834. [DOI] [PubMed] [Google Scholar]
- 16.Kessler DP, McClellan M. Do doctors practice defensive medicine? Q J Econ. 1996;111(2):353–390. [Google Scholar]
- 17.Klingman D, Localio AR, Sugarman J, Wagner JL, Polishuk PT, Wolfe L, et al. Measuring defensive medicine using clinical scenario surveys. J Health Polit Policy Law. 1996;21(2):185–217. doi: 10.1215/03616878-21-2-185. [DOI] [PubMed] [Google Scholar]
- 18.Mafi JN, Russell K, Bortz BA, Dachary M, Hazel WA, Jr, Fendrick AM. Low-cost, high-volume health services contribute the most to unnecessary health spending. Health Aff (Millwood). 2017;36(10):1701–1704. doi: 10.1377/hlthaff.2017.0385. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Malani A, Reif J. Accounting of anticipation effects: an application to medical malpractice tort reform. John M. Olin Program in Law and Economics Working Paper no. 578, 2011. University of Chicago Law School. Chicago Unbound. Available at http://chicagounbound.uchicago.edu/law_and_economics/28/. Accessed 27 July 2017.
- 20.Massachusetts Medical Society. Investigation of defensive medicine in Massachusetts. 2008: 1–19. Available at http://www.massmed.org/defensivemedicine/. Accessed 27 July 2017.
- 21.Matsa DA. Does malpractice liability keep the doctor away? Evidence from tort reform damage caps. J Leg Stud. 2007;36(S2):S143–S182. [Google Scholar]
- 22.Mello MM, Chandra A, Gawande AA, Studdert DM. National costs of the medical liability system. Health Aff (Millwood). 2010;29(9):1569–1577. doi: 10.1377/hlthaff.2009.0807. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Nahed BV, Babu MA, Smith TR, Heary RF. Malpractice liability and defensive medicine: a national survey of neurosurgeons. PLoS One. 2012;7(6):e39237. doi: 10.1371/journal.pone.0039237. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Nelson LJ, 3rd, Morrisey MA, Kilgore ML. Damages caps in medical malpractice cases. Milbank Q. 2007;85(2):259–286. doi: 10.1111/j.1468-0009.2007.00486.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725–2732. doi: 10.1056/NEJMoa061115. [DOI] [PubMed] [Google Scholar]
- 26.Ryan, P. A better way: our vision for a confident America. 2017. Available at http://abetterway.speaker.gov/. Accessed 27 July 2017.
- 27.Smith TR, Habib A, Rosenow JM, Nahed BV, Babu MA, Cybulski G, et al. Defensive medicine in neurosurgery: does state-level liability risk matter? Neurosurgery. 2015;76(2):105–113. doi: 10.1227/NEU.0000000000000576. [DOI] [PubMed] [Google Scholar]
- 28.Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005;293(21):2609–2617. doi: 10.1001/jama.293.21.2609. [DOI] [PubMed] [Google Scholar]
- 29.Tan A, Zhou J, Kuo YF, Goodwin JS. Variation among primary care physicians in the use of imaging for older patients with acute low back pain. J Gen Intern Med. 2016;31(2):156–163. doi: 10.1007/s11606-015-3475-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Thomas JW, Ziller EC, Thayer DA. Low costs of defensive medicine, small savings from tort reform. Health Aff (Millwood) 2010;29(9):1578–1584. doi: 10.1377/hlthaff.2010.0146. [DOI] [PubMed] [Google Scholar]
- 31.US Congress. Empowering Patients First Act: HR 3400, 111th US Congress; HR 3000, 112th Congress; HR 2300, 113th Congress. 2017. Available at: https://www.congress.gov/bill/114th-congress/house-bill/2300. Accessed 27 July 2017.
- 32.US Congress. Protecting Access to Care Act of 2017. 2017. Available at https://www.congress.gov/bill/115th-congress/house-bill/1215. Accessed 27 July 2017.
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
(PDF 81 kb)
(PDF 87 kb)
(PDF 158 kb)
(PDF 117 kb)
(PDF 87 kb)
(PDF 163 kb)
(PDF 1225 kb)