Damage caps and defensive medicine,revisited

Does tort reform reduce defensive medicine and thus healthcare spending? Several (though not all) prior studies, using a difference-in-differences (DiD) approach, find lower Medicare spending for hospital care after states adopt caps on non-economic or total damages (“damage caps”), during the “second” reform wave of the mid-1980s. We re-examine this issue in several ways. We study the nine states that adopted caps during the “third reform wave,” from 2002 to 2005. We find that damage caps have no significant impact on Medicare Part A spending, but predict roughly 4% higher Medicare Part B spending. We then revisit the 1980s caps, and find no evidence of a post-adoption drop (or rise) in spending for these caps.     

Malpractice liability, technology choice and negative defensive medicine

We extend the theoretical literature on the impact of malpractice liability by allowing for two treatment technologies, a safe and a risky one. The safe technology bears no failure risk, but leads to patient-specific disutility since it cannot completely solve the health problems. By contrast, the risky technology (for instance a surgery) may entirely cure patients, but fail with some probability depending on the hospital’s care level. Tight malpractice liability increases care levels if the risky technology is chosen at all, but also leads to excessively high incentives for avoiding the liability exposure by adopting the safe technology. We refer to this distortion toward the safe technology as negative defensive medicine. Taking the problem of negative defensive medicine seriously, the second best optimal liability needs to balance between the over-incentive for the safe technology in case of tough liability and the incentive to adopt little care for the risky technology in case of weak liability. In a model with errors in court, we find that gross negligence where hospitals are held liable only for very low care levels outperforms standard negligence, even though standard negligence would implement the first best efficient care level.     

防御性医疗行为及其干预策略

文章简要概括了防御性医疗行为的主要表现，并对防御性医疗行为的成因进行了初步分析。在此基础上，重点探讨了防御性医疗行为的干预策略，认为积极构建法制环境下的现代医学模式，加强医务人员职业道德教育，建立与群众有效沟通的渠道，培育卫生行业“以人为本”的管理理念，是消除医务人员防御性医疗心理的有效措施。     

Thoughts on "defensive" medicine

"Defensive" medicine is called medical behaviour characterized by deformation of diagnostic and therapeutic activities due to fears endangering existence and work, thus some interventions are omitted or, on the contrary, superfluous examinations are proposed on account of internal uncertainty, the patient's distrust or hostile social environment. Trust relation between patient and physician is the most gravely damaged because of aggravation and distortion of some conscienceless physicians' abuses by the media; patient-physician relations may not be degraded to contractual legal relations. Young physicians must get acquainted with the joy of success in diagnostics that enriches the personality. They shall have healthy self-esteem and be ready to take diagnostic and therapeutic challenges on themselves. All of us have to fight against social atmosphere hostile to physicians, against causes inducing and augmenting practice of defensive medicine.     

防御性医疗与医疗免责

分析了防御性医疗行为产生的原因和特点,结合医疗免责的原则与标准,探讨建立医疗免责与减少防御性医疗行为的重要意义。     

防御性医疗的法律规制探讨

医疗行为的结果存在许多不确定性,随着患者维权意识的增强以及日益紧张的医患关系,医师在临床决策中不得不采取更多的防御性医疗行为。防御性医疗行为的危害主要包括患者医疗成本增加、医疗资源浪费、妨碍医学科技发展、医患互信进一步降低等。目前我国尚无立法明确对其进行规制。本文从现行医疗法律制度与防御性医疗行为的关系、医疗行为的“可容性危险”原则适用等角度出发,重点分析了防御性医疗行为的法律属性及构成,分析比较了防御性医疗和过度性医疗、保护性医疗的异同;为防御性医疗的法律判定与认定、侵权责任的法律构成与归责原则提供建议,同时为法律制度层面规制防御性医疗提供思路。     

防御性医疗行为现状及测量方法综述

在我国医患关系较为紧张的宏观环境下,防御性医疗成为医疗费用上涨的重要原因.本研究综述了防御性医疗行为的国内外现状及测量方法,为我国防御性医疗行为研究的开展提供借鉴.研究指出,目前我国医生中存在防御性医疗行为的比例较高,且国内相关实证研究较为缺乏,研究范围较小,测量指标不够全面.防御性医疗行为的测量方法主要包括医生自评、...     

区分撤诉投诉与不撤诉投诉的实践及意义

医疗投诉区分撤诉投诉与不撤诉投诉对于处理涉及医学人文服务不满意的投诉具有实用价值,它最大的特点是让被投诉者有机会处理医疗投诉,还主动权于被投诉者,从而让被投诉者学会处理医疗投诉,并在实践中主动地改进工作中存在的不足,提高医学人文服务水平,提高医学沟通能力,提高患者的综合满意度。     

从我国转型期医患关系特征谈对防御性医疗的思考

随着我国市场经济快速发展，传统的医患关系发生改变，取而代之是医患关系复杂化、多元化，尤其是医患关系不协调性矛盾客观存在，使得防御性医疗行为在医疗活动过程中普遍存在。文章对防御性医疗的产生背景、国内外现状、产生的负面效应及对策进行了初步探讨。     

Study on defensive medicine practices among obstetricians and gynecologists who provide breast care

The purpose of this study was to assess malpractice concerns, career satisfaction, defensive medicine, experience with liability lawsuits, and changes in breast care practices among obstetricians and gynecologists (ob-gyns) who provide breast care. Four hundred ACOG Fellows were randomly selected and invited to participate, 247 (62%) responded. A majority of responders had increased the number of referrals for the diagnosis of breast abnormalities (58.9%) and treatment of breast disease (53.6%) due to fears and concerns regarding malpractice. On average, there was a high level of career satisfaction (M=8.5 [SD=2.5] on a scale from 0 to 10); however, those who had been sued were significantly less satisfied than those who had not. Physicians who had decreased breast surgical procedures and increased referrals for diagnosis and treatment of breast disease reported practicing defensive medicine more frequently. In a regression analysis, having been sued was a significant predictor of practicing defensive medicine more often. Physicians from states with malpractice crisis reported practicing defensive medicine more frequently and more lawsuits than physicians from stable states. Malpractice fears and defensive medicine continue to affect the practices of ob-gyns, most specifically, as this study shows, ob-gyns who provide breast care.     

Media-portrayed idealized images, body shame, and appearance anxiety

OBJECTIVE: This study was designed to determine the effects of media-portrayed idealized images on young women's body shame and appearance anxiety, and to establish whether the effects depend on advertisement type and on participant self-objectification. METHOD: Participants were 39 female university students. Twenty-four magazine advertisements comprised 12 body-related and 12 non-body-related products, one half of each with, and the other one half without, idealized images. Preexposure and post exposure body shame and appearance anxiety measures were recorded. RESULTS: Appearance anxiety increased after viewing advertisements featuring idealized images. There was also a significant interaction between self-objectification level and idealized body (presence vs. absence). No differences emerged for body-related compared with non-body-related product advertisements. The only result for body shame was a main effect for time. Participants' body shame increased after exposure to idealized images, irrespective of advertisement type. DISCUSSION: Although our findings reveal that media-portrayed idealized images detrimentally affect the body image of young women, they highlight the individual differences in vulnerability and the different effects for different components of body image. These results are discussed in terms of their implications for the prevention and early intervention of body image and dieting-related disorders. (     

The importance of negative defensive medicine in the effects of malpractice reform

This article presents a model of physician and insurer behavior in which the practice of defensive medicine, both positive and negative, can arise. Accounting for negative defensive medicine, and insurers’ reaction to it, leads to different predictions of the effects of changing malpractice pressure compared to past models. Rising malpractice pressure causes both health care spending and quality to increase up to a threshold, and decrease thereafter. This non-monotonicity implies that malpractice reform is not a “silver bullet” capable of achieving both cost reductions and quality improvements for all consumers. The results can further explain inconsistent findings in the empirical literature and suggest alternative specifications for estimating the effects of malpractice reform.     

Discontinuation of Antihypertensive Medication,Cognitive Complaints,and Incident Dementia

ObjectivesTo evaluate whether discontinuation of antihypertensive medication in community-dwelling older people is associated with a reduction in memory complaints and/or incident dementia.DesignProspective observational cohort study within the Prevention of Dementia by Intensive Vascular Care (preDIVA) trial.Setting and ParticipantsCommunity-dwelling participants (aged 70-78 years at baseline) who underwent 2-yearly assessments during 6-8 years of follow-up.MeasuresCox regression analyses of the relation between discontinuation of antihypertensive medication during the study and change in subjective memory complaints, incident dementia, and mortality.ResultsDementia occurred more often in participants discontinuing antihypertensive treatment (13.4% vs 6.2%, P = .02); mortality was similar (16.5% vs 13.9%, P = .52). Discontinuation of antihypertensive medication was associated with a double dementia hazard [hazard ratio (HR) (95% confidence interval) = 2.15 (1.15-4.03)], which somewhat attenuated after adjustment for sex, blood pressure, number of antihypertensives and other medications [HR = 1.92 (1.01-3.65)], and additionally for stroke, cardiovascular disease, diabetes, smoking, memory complaints, and MMSE score [HR = 1.79 (0.93-3.44)]. Antihypertensive discontinuation was associated with an approximately 50% higher hazard of dementia and/or mortality combined [HR = 1.58 (1.04-2.40); model 2: HR = 1.64 (1.07-2.51); model 3: HR = 1.49 (0.96-2.30)]. Antihypertensive discontinuation was not associated with change in memory complaints [odds ratio (95% confidence interval) = 0.96 (0.55-1.67)]. Subgroup and sensitivity analyses addressing possible sources of bias and confounding gave similar results.Conclusions/ImplicationsOur results suggest that antihypertensive withdrawal in community-dwelling older people does not preserve cognition and may in fact increase dementia risk. This is not due to reduced mortality as competing risk. Additional analyses suggest results are unlikely to be explainable by confounding, reverse causality, or observational biases. Studies with person-specific reasons for antihypertensive discontinuation may be able to exclude reverse causality completely. Given the beneficial effects of antihypertensive medication on cardiovascular risk, observational data may be the best currently obtainable on the pressing issue of when withdrawal of antihypertensives in older people is acceptable and what consequences need to be weighed.