Context How often physicians alter their clinical behavior because of the threat of malpractice liability, termed defensive medicine, and the consequences of those changes, are central questions in the ongoing medical malpractice reform debate. Objective To study the prevalence and characteristics of defensive medicine among physicians practicing in high-liability specialties during a period of substantial instability in the malpractice environment. Design, Setting, and Participants Mail survey of physicians in 6 specialties at high risk of litigation (emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology) in Pennsylvania in May 2003. Main Outcome Measures Number of physicians in each specialty reporting defensive medicine or changes in scope of practice and characteristics of defensive medicine (assurance and avoidance behavior). Results A total of 824 physicians (65%) completed the survey. Nearly all (93%) reported practicing defensive medicine. "Assurance behavior" such as ordering tests, performing diagnostic procedures, and referring patients for consultation, was very common (92%). Among practitioners of defensive medicine who detailed their most recent defensive act, 43% reported using imaging technology in clinically unnecessary circumstances. Avoidance of procedures and patients that were perceived to elevate the probability of litigation was also widespread. Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous 3 years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious. Defensive practice correlated strongly with respondents' lack of confidence in their liability insurance and perceived burden of insurance premiums. Conclusion Defensive medicine is highly prevalent among physicians in Pennsylvania who pay the most for liability insurance, with potentially serious implications for cost, access, and both technical and interpersonal quality of care.
This 2008 survey of chronically ill adults in Australia,
This 2009 survey of primary care doctors in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States finds wide differences in practice systems, incentives, perceptions of access to care, use of health information technology (IT), and programs to improve quality. Response rates exceeded 40 percent except in four countries: Canada, France, the United Kingdom, and the United States. U.S. and Canadian physicians lag in the adoption of IT. U.S. doctors were the most likely to report that there are insurance restrictions on obtaining medication and treatment for their patients and that their patients often have difficulty with costs. We believe that opportunities exist for cross-national learning in disease management, use of teams, and performance feedback to improve primary care globally. Health Aff (Millwood). 2009;28(6):w1171-83 (published online 5 November 2009 10.1377/hlthaff .28.6.w1171)] P r i m a ry c a r e c l i n i c i an s i n m o s t c o u n t r i e s provide the foundation for health care systems and serve as the linchpin that improves access, connects care, and provides continuity for patients and families. Research shows that strong primary care is associated with good outcomes and lower costs.1-3 Aging populations, prevalence of chronic disease, and increasing ability to deliver complex care outside the hospital have prompted international efforts to redesign primary care to improve outcomes and efficiency. Consequently, primary care practices often face new requirements for accountability as well as incentives to improve. C a r e & C o s t s H E A LT H A F F A I R S~We b E x c l u s i v eTo varying degrees, health systems are investing in information technology (IT), round-the-clock access, providers working in teams, integration, and quality improvement. Reforms in delivery systems and payment policies seek to spur innovations for managing chronic conditions and supporting frail elderly or disabled people living in the community.Primary care physicians' experiences and perspectives in a period of rapid change offer a unique view from the front lines. To track developments in countries with diverse health systems, this 2009 study surveyed primary care physicians in eleven countries: Australia, Canada, France, Germany, Italy, New Zealand, the Netherlands, Norway, Sweden, the United Kingdom, and the United States. This survey, the twelfth in a series that informs a symposium of health ministers and policy experts, focused on access, chronic care management, health IT, and financial and information incentives-key areas that have been targets of reforms. Eleven-Country ContextThe countries studied represent a mix of primary care and insurance systems (Exhibit 1). The United States is distinct in its reliance on internal medicine and pediatrics for primary care and its highly decentralized referral systems. The other countries rely extensively on general or family practice (GP/FP) physicians, often augmented by use of pr...
This paper reports on a 2005 survey of sicker adults in Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States. Sizable shares of patients in all six countries report safety risks, poor care coordination, and deficiencies in care for chronic conditions. Majorities in all countries report that mistakes occurred outside the hospital. The United States often stands out for inefficient care and errors and is an outlier on access/cost barriers. Yet no country consistently leads or lags across survey domains. Deficiencies in transition care during hospital discharge and coordination failures among patients seeing multiple physicians underscore shared challenges of improving performance across sites of care.
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