One-Fifth of Orthopedic Imaging is Defensive Medicine, says Study

Nineteen percent of imaging studies ordered by Pennsylvania orthopedic surgeons were done solely for defensive medicine, and they accounted for 35 percent of the imaging costs, according to a study presented this week at the 2011 annual meeting of the American Academy of Orthopaedic Surgeons (AAOS).

For the study, 72 surgeons prospectively tracked what imaging studies they ordered (and why) for 2,068 patient encounters.

They found that almost one-fifth of the studies ordered were for defensive purposes, to ward against possible malpractice lawsuits with evidence that all bases were covered.

Authors argue that these imaging procedures not only cost payers an extra $113,369, but put patients through unnecessary testing. The higher percentage for costs (35 percent) versus defensive studies ordered (19 percent) is because the most common test they ordered was an MRI, rather than a less expensive X-ray.

While practicing defensive medicine and is not a new concept, study author John Flynn, MD, associate chief of orthopedic surgery at Children's Hospital of Philadelphia says that past studies have been retrospective. "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," says Dr. Flynn.

Surprisingly, the study found that experienced physicians ordered more defensive studies than newer physicians, who might be expected to be less confident. “We found that, in Pennsylvania at least, a surgeon's defensive nature gets worse over time,” said Dr. Flynn. “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."

After reading the results of the study, Dr. David C. Levin, professor and emeritus chairman of radiology at Thomas Jefferson University in Philadelphia said that while he sees a certain amount of bias among the participating physicians, he believes that defensive medicine is a big problem.

“There’s going to be a certain amount of bias among the orthopedic surgeons who provide the answers. They want to see tort reform, so they’re more inclined to say the MRI was ordered purely for defensive purposes,” said Dr. Levin. “Notwithstanding that, I believe that a lot of MRIs and other imaging studies are ordered for defensive purposes and aren’t really necessary.”
While the study was done in Pennsylvania, Dr. Levin thought one could reasonably assume the results would be similar in other states. He anticipated, however, that states that have non-economic damage caps in place for malpractice awards, would have fewer defensive imaging orders.

And while Dr. Levin thought it was likely that other medical specialties also order unnecessary imaging procedures as a defensive medicine precaution, the biggest offenders are likely to be orthopedic surgeons, obstetricians and neurosurgeons, since they’re generally at highest risk of malpractice claims. Dr. Flynn acknowledged that a next step would be to do a national study in orthopedics, and similar audits of other specialties.

“If doctors didn’t have to worry about being sued, I think you’d see the cost of imaging drop like a stone,” Dr. Levin said.