From the Journals

Malpractice reforms reduce invasive cardiac testing


Key clinical point: Physicians in states with medical malpractice damages caps perform fewer angiographies.

Major finding: In the damages-cap states, doctors ordered 24% fewer angiographies as a first diagnostic test compared with no-cap physicians.

Study details: A study of 36,647 doctors in nine states that have noneconomic damages caps and 39,154 doctors in 20 no-cap states.

Disclosures: No disclosures were reported.

Source: Farmer et al. JAMA Cardiol. 2018 June 6 doi: 10.1001/jamacardio.2018.1360.



Cardiologists in states with payment limits for medical malpractice claims practice less defensive medicine, a study suggests.

Steven A. Farmer, MD, PhD, of George Washington University, Washington, and his colleagues studied the coronary artery disease (CAD) testing practices of 36,647 doctors in nine states that have noneconomic damages caps for medical liability payouts and compared them with the testing practices of 39,154 doctors in 20 no-cap states. (The investigators studied only states that enacted damage limits between 2002 and 2005.) They studied physicians who ordered or performed two or more angiographies on a 5% random sample of Medicare fee-for-service beneficiaries between 1999 and 2013 who were 65 years or older.

Findings showed that in the cap states, doctors ordered 24% fewer angiographies as a first diagnostic test, compared with control physicians (relative change, −24%; 95% confidence interval, −40% to −7%; P = .005), but cap-state doctors also ordered 8% more noninvasive stress tests (7.8%; 95% CI, −3.6% to 19. P = .17), the authors reported in JAMA Cardiology.

Physicians in damages cap states referred 21% fewer patients for angiography following stress testing (−21%; 95% CI, −40% to −2%; P = .03) and fewer of their patients progressed from evaluation to revascularization. Changes in overall ischemic evaluation rates were similar for new-cap and no-cap physicians, the study found.

The authors noted that the decreased tendency for patients of cap-state physicians to progress from ischemic evaluation to revascularization had three possible channels: fewer initial angiographies, less progression from stress testing to angiography, and less progression from angiography to revascularization. The first two channels are statistically significant, while the third is directionally consistent, according to the study.

The overall results show a direct link between damage caps and cardiac care decisions, Dr. Framer wrote, adding that physicians are willing to tolerate greater clinical uncertainty in CAD testing if they face lower malpractice risk. The authors said the analysis builds on previous research showing that 12% of percutaneous coronary interventions for nonacute indications are inappropriate, and that CAD testing and treatments may be overused in the Medicare fee-for-service setting.

“Curtailing marginal or unnecessary angiography and revascularization spares patients invasive procedures and associated risk and saves resources,” Dr. Farmer wrote. “In addition, both the Department of Health and Human Services and commercial payers are moving rapidly toward alternate payment models. A core issue for these models is provider resistance to changing established practice patterns. Our study suggests that physicians who face lower malpractice risk may be less concerned with that risk, and thus more receptive to new care delivery strategies associated with alternate payment models.”

The study is believed to be the first to demonstrate changes in clinical behavior in the CAD testing and treatment setting after damages cap adoption.

SOURCE: Farmer et al. JAMA Cardiol. 2018 Jun 6 doi: 10.1001/jamacardio.2018.1360.

Next Article: