title: Quantifying the defensive medicine contribution to primary care costs.
abstract: BACKGROUND
  Defensive medicine represents one cause of economic losses in healthcare. Studies that measured its cost have produced conflicting results.
  
  
  OBJECTIVE
  To directly measure the proportion of primary care costs attributable to defensive medicine.
  
  
  METHODS
  Six-week prospective study of primary care physicians from four outpatient practices. On 3 distinct days, participants were asked to rate each order placed the day before on the extent to which it represented defensive medicine, using a 5-point scale from 0 (not at all defensive) to 4 (entirely defensive).
  
  
  METHODS
  This study calculated the order defensiveness score for each order (the defensiveness/4) and the physician defensive score (the mean of all orders defensiveness scores). Each order was assigned a weighted cost by multiplying the total cost of that order (based on Medicare reimbursement rates) by the order defensiveness score. The proportion of total cost attributable to defensive medicine was calculated by dividing the weighted cost of defensive orders by the total cost of all orders.
  
  
  RESULTS
  Of 50 eligible physicians, 23 agreed to participate; 21 returned the surveys and rated 1234 individual orders on 347 patients. Physicians wrote an average of 3.6 ± 1.0 orders/visit with an associated total cost of $72.60 ± 18.5 per order. Across physicians, the median physician defensive score was 0.018 (IQR = [0.008, 0.049]) and the proportion of costs attributable to defensive medicine was 3.1% (IQR = [0.5%, 7.2%]). Physicians with defensive scores above vs below the median had a similar number of orders and total costs per visit. Physicians were more likely to place defensive orders if trained in community hospitals vs academic centers (OR = 4.29; 95% CI = 1.55-11.86; p = 0.01).
  
  
  CONCLUSIONS
  This study describes a new method to directly quantify the cost of defensive medicine. Defensive medicine appears to have minimal impact on primary care costs.
authors.affiliation: Medicine Institute Center for Value Based Care Research, Cleveland Clinic , Cleveland, OH , USA.
authors.forename: Andrei
authors.initials: A
authors.lastname: Brateanu
authors.forename: Sarah
authors.initials: S
authors.lastname: Schramm
authors.forename: Bo
authors.initials: B
authors.lastname: Hu
authors.forename: Kristen
authors.initials: K
authors.lastname: Boyer
authors.forename: Kelly
authors.initials: K
authors.lastname: Nottingham
authors.forename: Glen B
authors.initials: GB
authors.lastname: Taksler
authors.forename: Stacey
authors.initials: S
authors.lastname: Jolly
authors.forename: Kenneth
authors.initials: K
authors.lastname: Goodman
authors.forename: Anita
authors.initials: A
authors.lastname: Misra-Hebert
authors.forename: Nirav
authors.initials: N
authors.lastname: Vakharia
authors.forename: Aaron C
authors.initials: AC
authors.lastname: Hamilton
authors.forename: Robert
authors.initials: R
authors.lastname: Bales
authors.forename: Mahesh
authors.initials: M
authors.lastname: Manne
authors.forename: Amanda
authors.initials: A
authors.lastname: Lathia
authors.forename: Abhishek
authors.initials: A
authors.lastname: Deshpande
authors.forename: Michael B
authors.initials: MB
authors.lastname: Rothberg
mesh_terms: D003675:Defensive Medicine / Q000191:economics*; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data; D008297:Male; D011320:Primary Health Care / Q000191:economics* / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012737:Sex Factors; D014481:United States
keywords: Cost; Defensive medicine; Healthcare; Primary care