Rubenstein Joel H, Saini Sameer D, Kuhn Latoya, McMahon Laurence, Sharma Pratima, Pardi Darrell S, Schoenfeld Philip
Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan 48105, USA.
Am J Gastroenterol. 2008 Apr;103(4):842-9. doi: 10.1111/j.1572-0241.2007.01689.x. Epub 2007 Dec 12.
Gastroenterologists' approach to surveillance for Barrett's esophagus is variable. We hypothesized that financial incentives and concerns over malpractice litigation influence gastroenterologists' usual practices regarding screening and surveillance.
We surveyed gastroenterologists (N = 224) regarding their usual practice of screening or surveillance for Barrett's esophagus, belief in the efficacy of screening, knowledge of published guidelines, demographic factors, compensation structure, volume of endoscopies, and malpractice history. Practices were characterized as aggressive or conservative in the utilization of services compared with a published guideline.
Twenty-one percent of attending gastroenterologists reported being identified as a defendant in at least one malpractice suit. Prior malpractice defendants had practiced gastroenterology longer and performed a higher volume of endoscopies, but had similar knowledge regarding published screening guidelines to those who had not been defendants. They were more likely to be aggressive rather than conservative in screening and surveillance for Barrett's esophagus (odds ratio [OR] 3.6, 95% confidence interval [CI] 1.1-12), and remained so after controlling for other factors. In particular, they were more likely to recommend screening for populations with a lower risk of development of cancer, and to perform more frequent surveillance for low-grade dysplasia. Other factors were not associated with aggressive practice, including compensation structure.
History of at least one prior malpractice suit appears to be associated with the more aggressive use of endoscopic screening and surveillance for Barrett's esophagus, irrespective of physician belief regarding the efficacy of that strategy in reducing mortality. Hypervigilance and fear of future malpractice suits may drive this increased use.
胃肠病学家对巴雷特食管的监测方法各不相同。我们推测经济激励措施和对医疗事故诉讼的担忧会影响胃肠病学家在筛查和监测方面的常规做法。
我们调查了224名胃肠病学家，了解他们对巴雷特食管进行筛查或监测的常规做法、对筛查效果的看法、对已发表指南的了解、人口统计学因素、薪酬结构、内镜检查量以及医疗事故历史。与已发表的指南相比，根据服务利用情况将这些做法分为积极或保守两类。
21%的在职胃肠病学家报告称至少在一场医疗事故诉讼中被认定为被告。之前有过医疗事故诉讼的被告从事胃肠病学工作的时间更长，进行的内镜检查量也更高，但他们对已发表的筛查指南的了解与未成为被告的人相似。他们在巴雷特食管的筛查和监测中更倾向于采取积极而非保守的做法（优势比[OR]为3.6，95%置信区间[CI]为1.1 - 12），在控制其他因素后依然如此。特别是，他们更有可能建议对癌症发生风险较低的人群进行筛查，并对低级别异型增生进行更频繁的监测。其他因素与积极的做法无关，包括薪酬结构。
至少有一次医疗事故诉讼的历史似乎与更积极地使用内镜筛查和监测巴雷特食管有关，无论医生对该策略在降低死亡率方面的效果有何看法。过度警惕和对未来医疗事故诉讼的恐惧可能导致这种使用的增加。
