title: Association of Liability Concerns with Decisions to Order Echocardiography and Cardiac Stress Tests with Imaging.
abstract: Professional societies have made efforts to curb overuse of cardiac imaging and decrease practice variation by publishing appropriate use criteria. However, little is known about the impact of physician-level determinants such as liability concerns and risk aversion on decisions to order testing.
  
  
  
  A web-based survey was administered to cardiologists and general practice physicians affiliated with two academic institutions. The survey consisted of four clinical scenarios in which appropriate use criteria rated echocardiography or stress testing as "may be appropriate." Respondents' degree of liability concerns and risk aversion were measured using validated tools. The primary outcome variable was tendency to order imaging, calculated as the average likelihood to order an imaging test across the clinical scenarios (1 = very unlikely, 6 = very likely). Linear regression models were used to evaluate the association between tendency to order imaging and physician characteristics.
  
  
  
  From 420 physicians invited to participate, 108 complete responses were obtained (26% response rate, 54% cardiologists). There was no difference in tendency to order imaging between cardiologists and general practice physicians (3.46 [95% CI, 3.12-3.81] vs 3.15 [95% CI, 2.79-3.51], P = .22). On multivariate analysis, a higher degree of liability concerns was the only significant predictor of decisions to order imaging (mean difference in tendency to order imaging, 0.36; 95% CI, 0.09-0.62; P = .01).
  
  
  
  In clinical situations in which performance of cardiac imaging is rated as "may be appropriate" by appropriate use criteria, physicians with higher liability concerns ordered significantly more testing than physicians with lower concerns.
authors.affiliation: Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: vinay.kini@uphs.upenn.edu.
authors.forename: Vinay
authors.initials: V
authors.lastname: Kini
authors.affiliation: Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Rory B
authors.initials: RB
authors.lastname: Weiner
authors.affiliation: Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Fenton H
authors.initials: FH
authors.lastname: McCarthy
authors.affiliation: Division of Cardiovascular Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania.
authors.forename: Susan E
authors.initials: SE
authors.lastname: Wiegers
authors.affiliation: Division of Cardiovascular Medicine, University of Washington School of Medicine, Seattle, Washington.
authors.forename: James N
authors.initials: JN
authors.lastname: Kirkpatrick
mesh_terms: D001291:Attitude of Health Personnel; D000072096:Cardiologists / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D000066491:Clinical Decision-Making; D025401:Echocardiography, Stress / Q000706:statistics & numerical data*; D058005:General Practitioners / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D019538:Health Care Surveys; D016365:Liability, Legal; D008404:Massachusetts; D000069342:Medical Overuse / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data*; D010414:Pennsylvania; D012017:Referral and Consultation / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D014481:United States
keywords: Cardiac stress tests; Echocardiography; Liability; Malpractice