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Study Shows High Imaging Costs for Defensive Purposes in Healthcare Spending

By MedImaging International staff writers
Posted on 28 Feb 2011
Nearly 35% of all the imaging costs ordered for 2,068 orthopedic patient encounters in the US state of Pennsylvania were ordered for defensive reasons, according to a new study.

The study's findings were presented February at the 2011 annual meeting of the American Academy of Orthopedic Surgeons (AAOS), held in San Diego (CA, USA). For quite some time now, some physicians have ordered specific diagnostic procedures that are of little or no benefit to patients, mostly to protect themselves from a lawsuit. Until now, however, efforts to measure defensive medical practices have been limited primarily to surveys sent to physicians. Such surveys would simply ask whether that individual actually practiced defensive medicine. "This is the first study we know of that looked at the actual practice decisions of physicians regarding defensive imaging in real time--prospectively done," noted John Flynn, MD, associate chief of orthopedic surgery at Children's Hospital of Philadelphia (CHOP; USA), stated that many lawsuits hinge on the plaintiff's attorney's allegation that the physician should have ordered extra diagnostic testing. "And such a claim may be the driving force of so much of the defensive test ordering."

According to Dr. Flynn, 72 orthopedic surgeons, who are members of the Pennsylvania Orthopedic Society, voluntarily participated in this study, which included some 2,068 patient encounters throughout the state of Pennsylvania. Most patients in this study were adults. The study revealed that 19% of the imaging tests ordered were for defensive purposes. Defensive imaging was responsible for US$113,369 of $325,309 (34.8%) of total imaging charges for this patient cohort, based on US Medicare dollars. The overall cost of these tests was 35% of all imaging ordered because the most common test was a magnetic resonance imaging (MRI) scan, an imaging modality that costs more than a routine X-ray.

One part of this problem to consider, according to Dr. Flynn, is that the legal environment that drives physicians to order additional tests has an effect on patients too, in a way that involves more than costs. "Patients are sometimes put through tests that maybe otherwise would not be ordered."

The finding from this research that surprised Dr. Flynn the most was that surgeons were more likely to practice defensively if they had been in practice for more than 15 years. "This was counterintuitive," he stated. "I thought that young doctors would come out of medical school immediately after training, be less confident because they weren't experienced, and order more defensive tests. Then, as they become more comfortable and confident after 10 or 20 years in practice, they would order many fewer tests. In fact, the opposite was true. We found that--in Pennsylvania at least--a surgeon's defensive nature gets worse over time. In this legal environment, orthopedic surgeons order more imaging tests of a defensive nature, because over time they become more concerned that someone is going to second guess or sue them."

Dr. Flynn reported that medical liability awards typically are given in The United States because of the severity of a bad outcome, and not necessarily because of negligence. In fact, a May 2006 study published in the New England Journal of Medicine (NEJM) (authored by Studdert DM) showed that 37% of claims did not involve medical errors, and in 3% of claims, no injury occurred at all.

Dr. Flynn pointed to various studies that show that defensive medicine, in general, is quite prevalent. One such study in the June 2005 Journal of the American Medical Association (JAMA) (also authored by Studdert DM) reported that almost 93% of 824 physicians in Pennsylvania responding to a survey practiced defensive medicine. "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. Ultimately, if you had doctors from multiple specialties--from ob/gyn to neurosurgery to emergency medicine--do this type of practice audit, you could accurately quantify how much of [US] healthcare resources are wasted on defensive medicine," he concluded.

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88 (43.153762817383): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294733642 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1
89 (46.014785766602): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`
90 (90.122222900391): SELECT show_live FROM jos_com_show_setting LIMIT 1
91 (51.975250244141): SELECT show_live FROM jos_com_show_setting LIMIT 1
92 (55.074691772461): SELECT show_live FROM jos_com_show_setting LIMIT 1
93 (43.869018554688): SELECT show_live FROM jos_com_show_setting LIMIT 1
94 (51.975250244141): SELECT show_live FROM jos_com_show_setting LIMIT 1
95 (42.915344238281): SELECT show_live FROM jos_com_show_setting LIMIT 1
96 (99.897384643555): SELECT show_live FROM jos_com_show_setting LIMIT 1
97 (94.890594482422): SELECT show_live FROM jos_com_show_setting LIMIT 1
98 (59.843063354492): SELECT show_live FROM jos_com_show_setting LIMIT 1
99 (40.054321289062): SELECT show_live FROM jos_com_show_setting LIMIT 1
100 (41.961669921875): SELECT show_live FROM jos_com_show_setting LIMIT 1
101 (38.862228393555): SELECT show_live FROM jos_com_show_setting LIMIT 1
102 (45.061111450195): SELECT show_live FROM jos_com_show_setting LIMIT 1
103 (41.007995605469): SELECT show_live FROM jos_com_show_setting LIMIT 1
104 (114.91775512695): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
105 (66.995620727539): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
106 (86.069107055664): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294733642 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1
107 (77.962875366211): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294733642 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1
108 (139.95170593262): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
109 (89.883804321289): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
110 (92.983245849609): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294733642 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1
111 (835.18028259277): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294733642 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1
112 (843.04809570312): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1
113 (557.18421936035): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1
114 (173.09188842773): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
115 (88.930130004883): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
116 (101.08947753906): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
117 (66.995620727539): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
118 (128.03077697754): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
119 (60.081481933594): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
120 (104.90417480469): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
121 (62.227249145508): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
122 (400.06637573242): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`
123 (!!!!! 30222.89276123): SELECT * FROM jos_deeppockets WHERE jos_deeppockets.cat = 10 AND jos_deeppockets.type = 'deeppockets_item' AND jos_deeppockets.published = 1 AND jos_deeppockets.created + INTERVAL 14 DAY >= NOW() ORDER BY jos_deeppockets.hits DESC LIMIT 7
124 (788.92707824707): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294733642 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294733642 AND type='deeppockets_item' AND published='1' LIMIT 1
125 (!!!!! 10691.88117981): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3
126 (169.03877258301): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3
127 (82.969665527344): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1
128 (46.014785766602): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1
129 (82.969665527344): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1
130 (51.975250244141): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1
131 (442.0280456543): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1
132 (77.009201049805): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1
133 (56.028366088867): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1
134 (45.061111450195): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1
135 (612.97416687012): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1
136 (679.96978759766): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1
137 (393.15223693848): SELECT name FROM jos_deeppockets WHERE id=215
138 (61.988830566406): SELECT name FROM jos_deeppockets WHERE id=215
139 (991.8212890625): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))215((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3
140 (802.99377441406): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))215((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3
141 (113.96408081055): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
142 (84.161758422852): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
143 (!!!!! 11482.954025269): TRUNCATE TABLE jos_trademed_module
144 (149.96528625488): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294733642 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1
145 (91.075897216797): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294733642 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1
146 (657.08160400391): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1
147 (85.115432739258): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1
148 (112.05673217773): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
149 (77.962875366211): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
150 (!!!!! 1774.787902832): SELECT jos_item.* FROM jos_item INNER JOIN jos_number ON jos_item.numberID=jos_number.id WHERE 1=1 AND (jos_item.imgMini<>'') AND jos_item.type='L' AND jos_item.numberID= ( SELECT jos_number.id FROM jos_number WHERE jos_number.journalID IN (10) and jos_number.id in (select distinct jos_number.id from jos_number join jos_item on jos_item.numberid=jos_number.id where jos_item.type='P') ORDER BY (CONVERT(SUBSTRING(issue,1,2),SIGNED) + (CONVERT(SUBSTRING(issue,3,2),SIGNED)*100)) DESC LIMIT 0,1 ) ORDER BY RAND() DESC LIMIT 6
151 (121.11663818359): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
152 (72.956085205078): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
153 (72.956085205078): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294733642 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294733642 AND type='deeppockets_item' AND published='1' LIMIT 1
154 (648.97537231445): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=215 or channel_id is null)
155 (59.127807617188): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=215 or channel_id is null)
156 (63.180923461914): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1
157 (112.05673217773): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
158 (74.863433837891): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294733642 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294733642 AND published='1' LIMIT 1
159 (58.889389038086): select jos_twitters.link from jos_twitters where cat=10
160 (41.961669921875): select jos_facebook.link from jos_facebook where cat=10
161 (42.915344238281): select jos_google_plus.link from jos_google_plus where cat=10
162 (42.915344238281): select jos_linkedin.link from jos_linkedin where cat=10