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[현재위치]: 홈> 방어진료

방어진료 Defensive Medicine

[ 항생제 처방 ] [ 긍정요소 ] [ 부정요소 ] [ GAO Study ] [ 펜실베이니아 ]

  • 정의

    • 의료소송 등의 책임과 관련되어 그 책임을 벗어나고자  통상의 진료에 비하여 비필수적인 검사나 진료행위를 하여 의료비용을 증가시키는 것이나, 위험성이 높은 의료행위를 회피하는 것을 의미한다.

      • Defensive medicine occurs when doctors order tests, procedures, or visits, or avoid certain high-risk patients or procedures, primarily (but not necessarily solely) because of concern about malpractice liability

    • 주관적 기준

      • 의사 스스로가 느껴서 판단하는 방어진료

    • 객관적 기준

      • 다른 의사들도 똑같은 상황에서 해당 검사나 진료행위를 할 것인가

      • 검토

        • 검사전 확률에 대한 충분한 검토가 이루어졌는가

　

  • 개요

    • Most defensive medicine is not of zero benefit. Instead, fear of liability pushes physicians’ tolerance for medical uncertainty to low levels, where the expected benefits are very small and the costs are high.

    • Many physicians say they would order aggressive diagnostic procedures in cases where conservative management is considered medically acceptable by professional expert panels. Most physicians who practice in this manner would do so primarily because they believe such procedures are medically indicated, not primarily because of concerns about liability.

    • It is impossible to accurately measure the overall level and national cost of defensive medicine. The best that can be done is to develop a rough estimate of the upper limits of the extent of certain components of defensive medicine.

    • Overall, a small percentage of diagnostic procedures--certainly less than 8 percent—is likely to be caused primarily by conscious concern about malpractice liability. This estimate is based on physicians’ responses to hypothetical clinical scenarios that were designed to be malpractice-sensitive; hence, it overestimates the rate at which defensive medicine is consciously practiced in diagnostic situations.

    • 분만(제왕절개)과 두부외상에 대한 처치가 방어진료의 경향이 매우 강한 진료영역이다.

      • Defensive medicine has a substantial influence on physicians' behavior in certain isolated clinical situations; for example, Caesarean deliveries in childbirth and the management of head injuries in emergency rooms.

    • Physicians are very conscious of the risk of being sued and tend to overestimate that risk. A large number of physicians believe that being sued will adversely affect their professional, financial. and emotional status.

    • The role of the malpractice system as a deterrent against too little or poor-quality care--one of its intended purposes—has not been carefully studied.

    • Traditional tort reforms -- particularly caps on damages and amendments to "collateral source" rule-- reduce malpractice insurance premiums, but their effects on defensive medicine are largely unknown and are likely to be small. To the extent that these reforms do reduce defensive medicine, they do so without differentiating between defensive practices that are medically appropriate and those that are wasteful or very costly in relation to their benefits.

    • One malpractice reform that directly targets wasteful and low-benefit defensive medicine is to enhance the evidentiary status in malpractice court cases of selected clinical practice guidelines that address situations in which defensive medicine is a major problem. The overall effects of this reform on health care costs would probably be small,
      however, because only a few clinical situations represent clear cases of wasteful or low benefit defensive medicine.

    • The fee-for-service system both empowers and encourages physicians to practice very low risk medicine. Health care reform may change financial incentives toward doing fewer rather than more tests and procedures. If that happens, concerns about malpractice liability may act to check potential tendencies to provide too few services.

  • 프로토콜

    • A protocol for selecting patients with injured extremities who need x-rays

      • To help curb excessive radiography, we developed a protocol for selecting patients with injured extremities who need x-ray examination, and we tested the protocol prospectively in 848 patients to determine its safety and effectiveness. Strict adherence to the protocol would have reduced x-ray usage by 12 per cent for upper extremities and 19 per cent for lower extremities. The actual reductions were 5 per cent and 16 per cent, respectively, since further reductions were limited by patient's demands for x-ray examinations. One fracture in 287 were missed, but the treatment was appropriate and the outcome satisfactory. By eliminating superfluous x-ray procedures, the protocol could reduce charges by $79 million to $139 million nationwide, without compromising quality of care or increasing malpractice liability. Nevertheless, even the best protocol cannot eliminate all negative x-ray studies. These results should serve as a stimulus for judicious use of radiography, but also as a warning to avoid overzealous cost-containment strategies that would reduce x-ray usage to below a safe threshold.

      • http://www.ncbi.nlm.nih.gov/entrez
    • Webster, A P, Goodacre, S, Walker, D, Burke, D (2006). How do clinical features help identify paediatric patients with fractures following blunt wrist trauma?. Emerg Med J 23: 354-357 [Abstract] [Full Text]  
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    • Reilly, B. M., Evans, A. T. (2006). Translating Clinical Research into Clinical Practice: Impact of Using Prediction Rules To Make Decisions. Ann Intern Med 144: 201-209 [Abstract] [Full Text]  
    • Brehaut, J. C., Stiell, I. G., Visentin, L., Graham, I. D. (2005). Clinical Decision Rules "in the Real World": How a Widely Disseminated Rule Is Used in Everyday Practice. Acad Emerg Med 12: 948-956 [Abstract] [Full Text]  
    • Bachmann, L. M, Kolb, E., Koller, M. T, Steurer, J., ter Riet, G. (2003). Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ 326: 417-417 [Abstract] [Full Text]  
    • Papacostas, E, Malliaropoulos, N, Papadopoulos, A, Liouliakis, C (2001). Validation of Ottawa ankle rules protocol in Greek athletes: study in the emergency departments of a district general hospital and a sports injuries clinic. Br J Sports Med 35: 445-447 [Abstract] [Full Text]  
    • Pershad, J., Monroe, K., King, W., Bartle, S., Hardin, E., Zinkan, L. (2000). Can Clinical Parameters Predict Fractures in Acute Pediatric Wrist Injuries?. Acad Emerg Med 7: 1152-1155 [Abstract] [Full Text]  
    • Plint, A. C., Bulloch, B., Osmond, M. H., Stiell, I., Dunlap, H., Reed, M., Tenenbein, M., Klassen, T. P. (1999). Validation of the Ottawa Ankle Rules in Children with Ankle Injuries. Acad Emerg Med 6: 1005-1009 [Abstract] [Full Text]  
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    • Stiell, I., Wells, G., Laupacis, A., Brison, R., Verbeek, R., Vandemheen, K., Naylor, C D. (1995). Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. BMJ 311: 594-597 [Abstract] [Full Text]  
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