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Physician spending and subsequent risk of malpractice claims: observational study

BMJ 2015; 351 doi: (Published 04 November 2015) Cite this as: BMJ 2015;351:h5516
  1. Anupam B Jena, associate professor12,
  2. Lena Schoemaker, research assistant3,
  3. Jay Bhattacharya, professor23,
  4. Seth A Seabury, associate professor24
  1. 1Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA; and Massachusetts General Hospital, Boston, MA, USA
  2. 2National Bureau of Economic Research, Cambridge, MA, USA
  3. 3Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA, USA
  4. 4Department of Emergency Medicine and Leonard D Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
  1. Correspondence to: A B Jena jena{at}
  • Accepted 5 October 2015


Study question Is a higher use of resources by physicians associated with a reduced risk of malpractice claims?

Methods Using data on nearly all admissions to acute care hospitals in Florida during 2000-09 linked to malpractice history of the attending physician, this study investigated whether physicians in seven specialties with higher average hospital charges in a year were less likely to face an allegation of malpractice in the following year, adjusting for patient characteristics, comorbidities, and diagnosis. To provide clinical context, the study focused on obstetrics, where the choice of caesarean deliveries are suggested to be influenced by defensive medicine, and whether obstetricians with higher adjusted caesarean rates in a year had fewer alleged malpractice incidents the following year.

Study answer and limitations The data included 24 637 physicians, 154 725 physician years, and 18 352 391 hospital admissions; 4342 malpractice claims were made against physicians (2.8% per physician year). Across specialties, greater average spending by physicians was associated with reduced risk of incurring a malpractice claim. For example, among internists, the probability of experiencing an alleged malpractice incident in the following year ranged from 1.5% (95% confidence interval 1.2% to 1.7%) in the bottom spending fifth ($19 725 (£12 800; €17 400) per hospital admission) to 0.3% (0.2% to 0.5%) in the top fifth ($39 379 per hospital admission). In six of the specialties, a greater use of resources was associated with statistically significantly lower subsequent rates of alleged malpractice incidents. A principal limitation of this study is that information on illness severity was lacking. It is also uncertain whether higher spending is defensively motivated.

What this study adds Within specialty and after adjustment for patient characteristics, higher resource use by physicians is associated with fewer malpractice claims.

Funding, competing interests, data sharing This study was supported by the Office of the Director, National Institutes of Health (grant 1DP5OD017897-01 to ABJ) and National Institute of Aging (R37 AG036791 to JB). The authors have no competing interests or additional data to share.


  • Contributors: All authors contributed to the design and conduct of the study; data collection, management, analysis, and interpretation; and preparation, review, or approval of the manuscript. ABJ is the guarantor. The research conducted was independent of any involvement from the sponsors of the study. Study sponsors were not involved in study design, data interpretation, writing of the manuscript, or the decision to submit the article for publication.

  • Funding: This study was supported by the Office of the Director, National Institutes of Health (NIH early independence award, grant 1DP5OD017897-01 to ABJ) and National Institute of Aging (R37 AG036791 to JB).

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The study was exempt from human subjects ethics review at Harvard Medical School.

  • Data sharing: No additional data available.

  • Transparency: The lead author (ABJ) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies are disclosed.

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