Division of Orthopaedics, The Children's Hospital of Philadelphia, 2nd Floor Wood Building, 34th & Civic Center Boulevard, Philadelphia, PA 19104, USA.
J Bone Joint Surg Am. 2012 Feb 1;94(3):e18. doi: 10.2106/JBJS.K.00646.
Defensive medicine has been identified as an area of wasteful health-care spending. Estimates of its prevalence and its contribution to the cost of defensive practices have varied widely. To date, there has been no prospective evaluation of the use of defensive medicine for musculoskeletal conditions.
Members of the Pennsylvania Orthopaedic Society were queried by means of an anonymous, prospective audit of consecutive imaging decisions in their clinical practice. For each image order, respondents recorded the modality, the body region imaged, and whether the imaging was "required for clinical care" or "ordered for defensive reasons." We evaluated the proportion of images that were ordered defensively, identified demographic differences with use of the chi-square test of independence, and calculated the contribution of defensive imaging to the total cost with use of 2009 Medicare reimbursement rates.
Seventy-two orthopaedists recorded 2068 imaging decisions made during the day that their practice was audited. Defensive imaging represented 19.1% (396) of the orders and 34.7% ($113,675) of the total cost ($327,414). Magnetic resonance imaging (MRI) represented 48.7% of the defensive orders, and 38.5% (193) of the 501 MRIs were ordered for defensive reasons. The proportion of defensive imaging ordered by orthopaedists who had been sued for medical malpractice within the previous five years was significantly greater than the proportion ordered by those who had not been sued during the same time frame (24.6% compared with 15.1%, p < 0.001). The proportion of defensive imaging ordered by orthopaedists who had been in practice for more than fifteen years was significantly greater than the proportion ordered by those who had less experience (20.8% compared with 17.1%, p = 0.03).
In a prospective practice audit of orthopaedists, defensive imaging was found to be both common and costly. Recent litigation experiences and longer duration of orthopaedic practice were independent predictors of an increased use of defensive practices in ordering imaging studies. This real-time audit showed that a large proportion of MRI studies were ordered for primarily defensive medicine reasons.
防御性医疗已被确定为医疗保健浪费的一个领域。对其普遍性及其对防御性实践成本的贡献的估计差异很大。迄今为止，还没有对肌肉骨骼疾病的防御性医疗使用进行前瞻性评估。
宾夕法尼亚骨科协会的成员通过对其临床实践中连续影像学决策的匿名前瞻性审核进行了调查。对于每个图像订单，受访者记录了模式、成像的身体区域以及成像是否“临床护理所需”或“出于防御目的而订购”。我们评估了出于防御目的而订购的图像比例，使用独立性卡方检验识别使用中的人口统计学差异，并使用 2009 年医疗保险报销率计算防御性成像对总费用的贡献。
72 名骨科医生记录了他们的实践被审核的那一天进行的 2068 次影像学决策。防御性影像学占订单的 19.1%（396），占总成本的 34.7%（113675 美元）（327414 美元）。磁共振成像（MRI）占防御性订单的 48.7%，在 501 次 MRI 中，有 38.5%（193 次）是出于防御目的而订购的。在过去五年中因医疗事故而被起诉的骨科医生所开的防御性影像学订单比例明显高于同期未被起诉的医生（24.6%比 15.1%，p < 0.001）。从业超过 15 年的骨科医生所开的防御性影像学订单比例明显高于经验较少的医生（20.8%比 17.1%，p = 0.03）。
在对骨科医生的前瞻性实践审核中，发现防御性影像学既常见又昂贵。最近的诉讼经历和较长的骨科从业时间是影像学研究订购中防御性实践增加的独立预测因素。这种实时审核表明，很大一部分 MRI 研究主要是出于防御性医学的原因而订购的。
