Tussing A D, Wojtowycz M A
Department of Economics, Maxwell Graduate School of Citizenship and Public Affairs, Syracuse University, NY 13244, USA.
Med Care. 1997 Feb;35(2):172-91. doi: 10.1097/00005650-199702000-00007.
The authors examine 58,441 obstetric deliveries in New York State outside New York City to test for the existence of defensive medicine in obstetrics.
The data consist of merged vital statistics and hospital discharge records from the New York State Department of Health, together with other merged variables. Physician fear of malpractice is proxied by cumulative obstetric malpractice suits by county for 1975 through 1986. A generalized probit analysis is used.
Malpractice exposure is shown to influence slightly the use of the electronic fetal monitor (EFM), a major diagnostic tool. Use of the EFM is shown to influence the diagnosis of fetal distress; fear of malpractice influences this diagnosis both directly and through the EFM. The diagnosis of fetal distress significantly affects the choice of cesarean section (c-section) as a method of delivery; hence, fear of malpractice influences the choice of a c-section both directly and through the diagnosis of fetal distress. Failure to include indirect effects via diagnostic procedures and diagnosis would result in an underestimate of the effect of fear of malpractice. Of an overall c-section rate of 27.6% in the data set, fear of malpractice accounts for an estimated 6.6 percentage points, of which 4.4 percentage points reflect a direct effect, and the remaining 2.2 percentage points reflect the effect of malpractice exposure on the use of the EFM and, directly and indirectly, the diagnosis of fetal distress.
The results appear to confirm the existence of defensive medicine in obstetrics. Whether this is a desirable or undesirable effect remains ambiguous, but it is costly.
作者对纽约市以外纽约州的58441例产科分娩进行研究，以检验产科防御性医疗行为的存在情况。
数据包括纽约州卫生部合并的生命统计数据和医院出院记录，以及其他合并变量。1975年至1986年各县产科医疗事故累计诉讼可作为医生对医疗事故恐惧程度的代理变量。采用广义概率单位分析。
医疗事故风险被证明对主要诊断工具电子胎儿监护仪（EFM）的使用有轻微影响。EFM的使用被证明会影响胎儿窘迫的诊断；对医疗事故的恐惧直接和通过EFM影响这一诊断。胎儿窘迫的诊断显著影响剖宫产（c-section）作为分娩方式的选择；因此，对医疗事故的恐惧直接和通过胎儿窘迫的诊断影响剖宫产的选择。若不考虑经由诊断程序和诊断产生的间接影响，会导致对医疗事故恐惧影响的低估。在数据集中总体剖宫产率为27.6%，对医疗事故的恐惧估计占6.6个百分点，其中4.4个百分点反映直接影响，其余2.2个百分点反映医疗事故风险对EFM使用的影响，以及对胎儿窘迫诊断的直接和间接影响。
结果似乎证实了产科防御性医疗行为的存在。这是一种可取还是不可取的影响仍不明确，但成本高昂。
