Malpractice fears influence cardiology decisions

by Charles Bankhead

For nearly a quarter of cardiologist respondents, malpractice concerns influenced their decisions to order tests or treatment for hypothetical cases included in a national survey.

Almost 30% of cardiologists acknowledged ordering cardiac catheterization because colleagues did so in the same situation, according to an article published online in Circulation: Cardiovascular Quality Outcomes.

Concerns about malpractice had a significant association with regional use of tests and treatment, Frances Lee Lucas, PhD, of Maine Medical Center in Portland, and colleagues reported.

“The factor most closely associated with [such geographic variability] was fear of malpractice suits. This factor may be appropriate targets of intervention,” they concluded.

Regional variation in use of healthcare services and resources has been well documented in the medical literature. However, the factors that influence the variation remain unclear, particularly physician-specific factors, the authors wrote.

To improve understanding about these factors, Lucas and colleagues analyzed data from a national-sample survey of primary care physicians and cardiologists regarding intensity of practice style. They defined intensity as the tendency to treat aggressively, particularly the tendency to order technologically advanced tests and treatment.

The analysis included 598 cardiologists, whose mean age was 52. More than 90% were male, 82% were white, 95% were board certified, and 54% practiced in a specialty group.

The cardiology survey included three patient vignettes:

* An otherwise healthy 75-year-old man with new-onset exertion chest pain, who smokes, and who has a family history of coronary disease
* A 75-year-old man with class IV congestive heart failure (CHF) on maximal medical treatment, who did not improve after coronary stent deployment, and who is not a candidate for surgery
* And an 85-year-old man with class IV CHF on maximal medical therapy, who is not a revascularization candidate, and who has worsening shortness of breath

All the patients were described as having health insurance adequate to cover tests and medication.

Each vignette was associated with multiple clinical strategies of varying intensity (rated on a scale of 1 to 10), and survey respondents indicated how often they would choose each strategy.

In general, few cardiologists said they would “always/almost always” choose the strategy with the highest intensity.

Overall, resource utilization in hospital referral regions was significantly associated with intensity scores for cardiologists practicing in the regions (P=0.0002).

In an effort to identify nonclinical factors that might influence testing and treatment intensity, Lucas and colleagues asked survey respondents how often they would order cardiac catheterization of questionable clinical necessity under certain conditions.

The authors assessed whether cardiac intensity score differed according to whether a cardiologist acknowledged that clinicians’ decisions were influenced by nonclinical factors.

Respondents indicated they rarely ordered cardiac catheterization because of financial indications.

About 17% of respondents said patient expectations frequently or sometimes affected the decision to order a test, increasing to 29% for expectations of referring physicians. However, neither type of influence had a significant association with cardiac intensity score.

The only factors significantly associated with intensity score were the propensities of colleagues in similar situations and concerns about malpractice (P=0.02 for both).

About 27% of respondents said they would order a cardiac catheterization if they knew a colleague would order the test in the same situation, and almost 24% said they would order cardiac catheterization solely because of malpractice concerns.

The authors examined the influence of nonclinical factors on regional utilization. They found that only malpractice concerns had a significant association with regional utilization (P<0.0001).

Charles Bankhead is a MedPage Today staff writer.

Originally published in MedPage Today. Visit for more cardiology news.