Orthopedists Say Tab for Defensive Medicine Is 'Billions'

By John Gever, Senior Editor, MedPage Today

Published: February 09, 2012

9 comment(s)

SAN FRANCISCO -- U.S. orthopedic surgeons in a large survey said roughly 30% of tests and referrals they ordered were medically unnecessary, with an estimated annual cost exceeding $2 billion, a researcher reported here.

The survey, which had responses from 1,241 orthopedic surgeons from across the country, indicated that large numbers of procedures and consultations were mainly aimed at reducing physicians' exposure to liability suits, said A. Alex Jahangir, MD, of Vanderbilt University in Nashville.

Not only were 19% to more than 44% of imaging studies and lab tests largely defensive, but survey respondents indicated that liability concerns had driven 7% of their hospital admission, Jahangir told attendees at the American Academy of Orthopaedic Surgeons' annual meeting.

He and colleagues had sent the survey to 2,000 orthopedic surgeons in all 50 states. The response rate was 61%.

Jahangir told MedPage Today that the survey was one of the largest and most comprehensive conducted to date. It asked for the total number of procedures in various categories that they order in a typical month, and the number ordered "due to concerns about liability."

Results for the different types of procedures, expressed as the percentage of procedures ordered for defensive purposes, were as follows:

• Plain x-rays: 19%

• CT scans: 26%

• MRI scans: 31%

• Ultrasound studies: 44%

• Blood and other lab tests: 23%

• Biopsies and aspirations: 18%

• Subspecialty referrals and consultations: 35%

• Hospital admissions: 7%

In response to another question, 77% of respondents said they would order fewer tests and procedures "if there was significant medical liability reform."

Moreover, 70% indicated they had reduced the number of high-risk patients they had taken on in the past five years, and 84% reported reducing the number of high-risk services or procedures they performed.

Using Medicare reimbursements for the categories of services covered in the survey, Jahangir and colleagues calculated that 23.6% of the total cost of these tests and procedures could be attributed to liability concerns.

Per respondent, the annual cost worked out to about $102,000, Jahangir said. And, extrapolated to the 20,400 orthopedic surgeons in the U.S., the yearly price tag for defensive medicine in orthopedics is about $2.1 billion.

"Defensive medicine drives up the cost of patient care and limits patient access to specialty care, neither of which are in the interest of our patients who deserve the best and least costly care possible," said Douglas W. Lundy, MD, an AAOS spokesman on medical liability, in a statement.

"Unfortunately, the current legal climate forces good doctors to order these tests and practice defensive medicine," he said.

Asked about the disconnect between the judicial system's and physicians' interpretations of medical necessity, Jahangir told MedPage Today that evidence-based clinical practice guidelines would go a long way toward eliminating it.

Such guidelines, he said, would better define what constitutes necessary versus unnecessary procedures -- "what really needs to happen [to achieve] the patient's best outcome."

The survey had no commercial funding.

Jahangir said he had no relevant financial interests. Lundy reported relationships with Synthes and Livengood Engineering.

Primary source: American Academy of Orthopaedic Surgeons
Source reference:
Sethi M, et al "The prevalence and costs of defensive medicine among orthopaedic surgeons: a national survey study" AAOS 2012; Abstract 378.