A research team from George Washington University showed that in nine states with new malpractice damage caps, physicians ordered 24 percent fewer angiographies as a first test than physicians in 20 states without caps. Angiographies reveal blocked coronary arteries on X-ray after a patient with heart attack concerns has been injected with dye. In those states, doctors also ordered 21 percent fewer coronary angiographies as a follow-up protocol and 23 percent fewer coronary procedures such as stenting in these patients. The George Washington researchers say their study is among the first to see if malpractice laws have made a difference in the willingness to risk misdiagnosis in “defensive medicine.”
“These findings suggest that physicians are willing to tolerate greater clinical uncertainty in CAD testing and treatment if they face lower malpractice risk,” wrote Steven A. Farmer, MD, PhD, FACC, FASE, associate professor of medicine and public health at George Washington University and associate director of the GW Center for Healthcare Innovation and Policy Research in Washington, D.C., along with his colleagues.
Ali Moghtaderi, an assistant research professor at the university added, “The physicians were more willing to tolerate more clinical ambiguity after the caps were adopted.”
“Cardiac care is always an area where the stakes are high if you make a mistake, and we know that misdiagnosis of a cardiac condition is a very common source of malpractice claims,” said Dr. Anupam Jena, an economist at Harvard Medical School. “Looking at whether physicians behave differently with respect to a workup of chest pain and seeing how that workup differs if they are less likely to be sued or face lower damages if they are sued — that question is really interesting.”
The researchers looked at more than 36,000 doctors who evaluated patients with chest pain in nine states with new laws capping malpractice damages. They compared those practicing under the new laws with more than 39,000 doctors in 20 states without malpractice caps. Overall testing rates didn’t change, but the kind of test doctors ordered did change in those states with newly instituted caps.
“I think it’s plausible the reduction in some of the more intensive procedures might be beneficial,” said Michelle Mello, a professor of health research and policy at Stanford. “It’s also possible they might have missed some things that were not caught.”
Also noted in the study, cardiologists across the nation are beginning to move away from more intensive procedures after a large study concluded that cardiac revascularization should not be done for people whose chronic chest pain is stable. This conclusion could have influenced the choices of the physicians studied in new-cap states toward the end of the study period in 2013.
“The findings are encouraging in the sense that the cardiologists seem to be practicing in ways that better comport with contemporary clinical practice guidelines,” said Mello. “The law change seems to be encouraging better practice.”
Follow-up studies might focus on whether a patient is best or worse off given these changes, and if the new laws put patients at a higher risk of not receiving timely treatment.
Mello explained, “This is a very relevant and important question. If physicians change their behavior, are there any consequences for the patient?”