Quinn James, Chung Sukyung, Kim David
Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, CA, United States.
Quantitative Science Unit, Stanford University, Palo Alto, CA, United States.
Am J Med Open. 2023 Mar 26;9:100041. doi: 10.1016/j.ajmo.2023.100041. eCollection 2023 Jun.
Chest pain accounts for 5% of all emergency department visits and accounts for the highest malpractice payout against emergency physicians. To clarify the impact of defensive medicine, we assessed whether admission rates of low-risk chest pain patients are associated with malpractice claims rates.
A cross-sectional time-series analysis of state-year level malpractice claims rates, admission rates for low-risk chest pain (LRCP; requiring ED physician discretion), and admission rates for acute myocardial infarction (AMI; requiring minimal physician judgment for admission, used as a control) from 2008 to 2017 was performed. Admission rates were derived from Optum's deidentified Clinformatics Data Mart Database. LRCP visits were defined by primary ICD-9 or ICD-10 codes of 786.5, R07.9, or R07.89; length of stay of 2 or fewer days; and no previous major cardiac diagnosis and AMI visits with ICD-9 or ICD-10 codes 410, I21.3, or I121.9. Malpractice claims rates (MPCRs) were derived from the National Practitioner Database (NPD). The association between state-year level MPCR and admission rates for LRCP and AMI was estimated using state fixed-effects models. Standardized costs were inflation adjusted and are expressed in US dollar rate as of 2019.
There were 40,482,813 ED visits during the 10-year study period, of which 2,275,757 (5.6%) were for chest pain, and 1,163,881 met LRCP criteria. Mean age of LRCP patients was 67.8 years, 60.9% were female, and 16.6% were hospitalized, at a mean cost of $17,120. During the same period, 75,266 (0.2%) visits were for AMI, with 87% admitted. The MPCR by state-year varied widely, from 2.6 to 8.6 claims per 100,000 population. A state fixed-effects model showed that an additional physician malpractice claim per 100,000 population was associated with a 3.66% (95% CI 2.02%-5.30%) increase in the admission rate of LRCP. An analogous model showed no association between MPCR and admission rates for AMI (-1.52%, 95% CI -4.06% to 1.02%).
Higher MPCRs are associated with increased admission rates for LRCP, at substantial cost, which may be attributable to defensive medicine in the ED.
胸痛占急诊就诊人数的5%，也是针对急诊医生的医疗事故赔偿中最高的一项。为了阐明防御性医疗的影响，我们评估了低风险胸痛患者的住院率与医疗事故索赔率之间是否存在关联。
对2008年至2017年州年度水平的医疗事故索赔率、低风险胸痛（LRCP；需要急诊医生进行判断）的住院率以及急性心肌梗死（AMI；住院只需医生进行最少判断，用作对照）的住院率进行了横断面时间序列分析。住院率数据来自Optum的去识别化临床信息数据集市数据库。LRCP就诊由国际疾病分类第九版（ICD - 9）或第十版（ICD - 10）的主要编码786.5、R07.9或R07.89定义；住院时间为2天或更短；且既往无重大心脏诊断，AMI就诊则依据ICD - 9或ICD - 10编码410、I21.3或I121.9。医疗事故索赔率（MPCRs）来自国家从业者数据库（NPD）。使用州固定效应模型估计州年度水平的MPCR与LRCP和AMI住院率之间的关联。标准化成本经过通货膨胀调整，并以2019年的美元汇率表示。
在为期10年的研究期间，共有40482813次急诊就诊，其中2275757次（5.6%）是因胸痛就诊，1163881次符合LRCP标准。LRCP患者的平均年龄为67.8岁，60.9%为女性，16.6%住院治疗，平均费用为17120美元。同期，75266次（0.2%）就诊是因AMI，其中87%住院。各州年度的MPCR差异很大，每10万人中有2.6至8.6起索赔。州固定效应模型显示，每10万人中额外增加一起医生医疗事故索赔与LRCP住院率增加3.66%（95%可信区间2.02% - 5.30%）相关。类似模型显示MPCR与AMI住院率之间无关联（-1.52%，95%可信区间 - 4.06%至1.02%）。
较高的MPCR与LRCP住院率增加相关，成本高昂，这可能归因于急诊中的防御性医疗。
