Thursday, April 28, 2011

Litigious nature of US medicare influences Canada

I was asked the question: how does the US data influence Canada?

Certainly, we know that the pharmaceutical industry influences research, access to particular drugs, and who the pharmaceuticals choose as their study populations. With many being situated in the US, much of the data is based on the US style of healthcare. The poor do not have access, as those with insurance, and skew potential survival rates. (Burstin HR, Lipsitz SR, Brennan TA. Socioeconomic status and risk for substandard medical care.JAMA1992;268:2383-7. [PubMed])

Ontario taxpayers have spent $1.1 billion in the past decade reimbursing doctors for most of the cost of their malpractice fees. Last year, it amounted to about $112 million.
The doctors themselves paid $24 million collectively. That means we -- the taxpayers, the patients -- covered about 83 per cent of the cost of malpractice insurance.

according to this study...
  • 51% physicians think that their ability to provide quality medical care to patients has gotten worse in the past five years. 
  • 76% of physicians feel that concern about malpractice litigation has hurt their ability to provide quality care in recent years. 
  • All respondent groups report increased levels of concern or awareness about the risks of malpractice liability over their career 
  • Nearly one-third (29%) of physicians state that they have been interested in a certain specialty but shied away from it due to fear of higher legal exposure. These findings seem to suggest that the broad impact of the fear of litigation is significant and growing.

Liability concerns on the provision of medical care
Broadly, nearly all physicians and hospital administrators feel that unnecessary or excessive care is very often or sometimes provided because of fear about litigation.

More specifically, physicians report that the fear of malpractice claims causes themselves and/or other physicians to do more than they would based only on their professional judgment of what is medically needed.

- Order more tests (91% have noticed other physicians, and 79% report they themselves do this due to concerns about malpractice liability)

- Refer patients to specialists more often (85% have noticed other physicians, and 74% report they themselves do this due to concerns about malpractice liability)

- Suggest invasive procedures such as biopsies to confirm diagnoses (73% have noticed other physicians, and 51% report they themselves do this due to concerns about malpractice liability)

- Prescribe more medications such as antibiotics (73% have noticed other physicians, and 41% report they themselves do this due to concerns about malpractice liability)

- Just under two-thirds (61%) of physicians have noticed physicians being reluctant to make what they believe to be humane choices because of concerns that a family member might bring suit.

- Half (50%) have noticed a physician resorting to aggressive treatments of terminally ill patients because of liability concerns.

- Just under half (42%) have noticed a physician or staff member going against a patient's expressed wishes concerning life-prolonging medical interventions because of concerns that a family member might bring suit.

Legal medicine 

Shafeek S. Sanbar, American College of Legal Medicine - 2004 - Law - 750 pages
The Canadian Medical Association has promulgated a new Code of Ethics ... which is part of medical training; the litigious nature of the medicolegal field.

In Table 1 of their recent article reporting results of the Canadian Adverse Events Study, Ross Baker and associates1 show that AE rates were lower in the United States and higher in Canada, Britain, Australia and New Zealand.

However, such differences between countries may be due more to differences in the medical systems rather than differences in the quality of patient care. The United States has a very different medical environment, partly because of the highly litigious nature of US culture.2 The fear of being sued may reduce the incidence of hindsight bias3 in US studies, since physicians may order more tests than are strictly necessary, which makes it more difficult for researchers such as Baker and associates to second-guess their decisions.

Such differences in medical cultures may not be well captured by these types of studies. Therefore, we should be cautious in comparing AE rates between the United States and Canada.
1. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ2004; 170 (11):1678-86. [PMC free article] [PubMed]
2. Abood S, Tehan T. Medical malpractice crisis. Am J Nurs2003;103(5):29. [PubMed]
3. H├ębert PC, Levin AV, Robertson G. Bioethics for clinicians: 23. Disclosure of medical error.CMAJ2001;164(4):509-13. [PMC free article] [PubMed]
4. Roos NP, Forget E, Walld R, MacWilliam L. Does universal comprehensive insurance encourage unnecessary use? Evidence from Manitoba says “no.” CMAJ2004;170(2):209-14. [PMC free article][PubMed]

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