From RAND Health (D.A.W., M.D.G., M.S.R.) and RAND Institute for Civil Justice (P.H.), Santa Monica, CA; the Department of Emergency Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (D.A.W.); and Uniformed Services University of the Health Sciences, Bethesda, MD (A.L.K.).
N Engl J Med. 2014 Oct 16;371(16):1518-25. doi: 10.1056/NEJMsa1313308.
Many believe that fear of malpractice lawsuits drives physicians to order otherwise unnecessary care and that legal reforms could reduce such wasteful spending. Emergency physicians practice in an information-poor, resource-rich environment that may lend itself to costly defensive practice. Three states, Texas (in 2003), Georgia (in 2005), and South Carolina (in 2005), enacted legislation that changed the malpractice standard for emergency care to gross negligence. We investigated whether these substantial reforms changed practice.
Using a 5% random sample of Medicare fee-for-service beneficiaries, we identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. Using a quasi-experimental design, we compared patient-level outcomes, before and after legislation, in reform states and control states. We controlled for characteristics of the patients, time-invariant hospital characteristics, and temporal trends. Outcomes were policy-attributable changes in the use of computed tomography (CT) or magnetic resonance imaging (MRI), per-visit emergency department charges, and the rate of hospital admissions.
For eight of the nine state-outcome combinations tested, no policy-attributable reduction in the intensity of care was detected. We found no reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no reduction in charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction (95% confidence interval, 0.9 to 6.2) in per-visit emergency department charges.
Legislation that substantially changed the malpractice standard for emergency physicians in three states had little effect on the intensity of practice, as measured by imaging rates, average charges, or hospital admission rates. (Funded by the Veterans Affairs Office of Academic Affiliations and others.).
许多人认为，对医疗事故诉讼的恐惧促使医生开出不必要的医疗服务，而法律改革可以减少这种浪费性支出。急诊医生在信息匮乏、资源丰富的环境中工作，这可能导致昂贵的防御性医疗实践。三个州，德克萨斯州（2003 年）、佐治亚州（2005 年）和南卡罗来纳州（2005 年），颁布了立法，将急诊医疗的医疗事故标准改为重大过失。我们调查了这些重大改革是否改变了实践。
我们使用医疗保险按服务收费计划的 5%随机样本，确定了 1997 年至 2011 年期间在三个改革州和邻近（对照）州的所有到医院就诊的急诊患者。使用准实验设计，我们比较了改革州和对照州在立法前后的患者水平结局。我们控制了患者特征、医院不变特征和时间趋势。结果是政策归因于 CT 或 MRI 使用、每次就诊急诊室费用和住院率的变化。
在所测试的九个州-结果组合中的八个中，没有发现护理强度的政策归因减少。我们在三个改革州中没有发现 CT 或 MRI 使用或住院率的降低，在德克萨斯州或南卡罗来纳州也没有发现费用的降低。在佐治亚州，改革与每次就诊急诊室费用降低 3.6%（95%置信区间，0.9 至 6.2）相关。
在三个州，立法大大改变了急诊医生的医疗事故标准，但对实践强度几乎没有影响，衡量标准是成像率、平均费用或住院率。（由退伍军人事务部学术附属机构和其他机构资助）。
