Liability Reform Changes How Docs Manage Suspected Coronary Artery Disease

The introduction of damage caps to limit financial compensation for malpractice plaintiffs significantly alters how physicians test and manage patients with suspected coronary artery disease, a new study shows.

Physicians practicing in states that have adopted noneconomic damage caps—which put a limit on the amount of money than can be awarded for pain, suffering, and emotional distress—are less likely to send a patient with suspected CAD directly to angiography and more likely to order an initial stress test than physicians practicing in states without damage caps.

Moreover, physicians working in states with damage caps are less likely to order more downstream testing following the initial stress test. For example, patients treated in states with these liability limits are less likely to be sent to angiography following the initial stress test and also less likely to undergo coronary revascularization when sent to the catheterization lab.

Ali Moghtaderi, PhD, who led the study along with Steven Farmer, MD, PhD (both from George Washington University, DC), said the results suggest that “physicians are willing to tolerate more clinical ambiguity after the adoption of damage caps” and are less likely to practice “defensive medicine.”   

George Rodgers, MD (Seton Heart Institute, Austin, TX), who was not involved in the study but worked toward extensive liability reform in Texas, said defensive medicine remains a significant issue for physicians working in states without liability caps. “Defensive medicine is alive and well,” he told TCTMD.

“I advocate for tort reform on Capitol Hill all the time, and I often challenge the congressmen,” continued Rodgers. “Walk into an emergency room in your state and tell them you have a headache. Even tell them you think it might be because you stopped drinking coffee 2 days ago. I tell them I’ll donate $100 to their campaign if they walk out of the emergency room without getting a CT scan. I’ve never had to pay up.”

The results of the study were published June 6, 2018, in JAMA: Cardiology.  

Caps on Damages for ‘Pain and Suffering’

To examine the impact of malpractice risk on clinical decisions in the testing and treatment of CAD, the researchers focused on nine states that adopted noneconomic damage caps between 2002 and 2005. These caps limit the amount of subjective financial compensation for pain and suffering a plaintiff can be awarded in a malpractice lawsuit (noneconomic caps vary by state and limits range from as low as $250,000 to as high as $1,000,000). Testing and treatment decisions were compared with physicians practicing in 20 states without noneconomic damage caps.

In total, the researchers analyzed the treatment decisions of 75,801 physicians, of whom 36,647 practiced in states with damage caps. These states tended to have younger populations, more minorities, lower per-capita incomes, fewer physicians per capita, and less managed care.

For patients with suspected CAD, there was no difference in the overall baseline assessment of ischemia—either with stress testing (stress electrocardiogram, stress echocardiogram, or SPECT) or coronary angiography—between states with and without damage caps. However, in the 3 years following adoption of the caps, there was a 24% reduction in angiography as the initial ischemic evaluation and an 8% increase in stress testing in states with the limits.   

“It means there is a substitution from the more invasive test to less invasive testing,” said Moghtaderi.

The researchers also observed less progression to more invasive procedures among physicians practicing in states with liability reform. For example, compared with physicians in states with no damage caps, they sent fewer patients for angiography after stress testing. Also, fewer patients treated in states with damage caps progressed from any ischemic evaluation to coronary revascularization. The lower revascularization rate was driven by reductions in PCI.

To TCTMD, Moghtaderi pointed out CAD symptoms can be variable and nonspecific, and that clinical guidelines on how and when to test grant a fair amount of leeway for practicing physicians. Additionally, many tests can return ambiguous results. As such, the diagnosis and treatment of suspected CAD makes it “sensitive to changes in the risk environment,” he explained.

“Missing a heart attack is one of the main reasons for malpractice lawsuits,” he said. “When patients visit physicians in different settings, including the emergency department, with serious symptoms that might indicate some coronary artery disease, physicians are rightfully concerned.”

Rodgers agreed. “It’s in your head that: ‘I might be missing something, so I’m going to go to extremes to show that this patient doesn’t have coronary artery disease. I’m going to cath them.’ The stakes are high. It’s everybody’s greatest fear the patient is going to leave your care and walk out and have a heart attack.”

In the emergency department, where there is no continuity of care, the introduction of high-sensitivity assays to detect small changes in cardiac troponin levels, have also led to a “better-be-sure” approach to patient care, said Rodgers.

An Exodus of Lawyers

The next step in the project for Moghtaderi and colleagues is to assess whether noneconomic liability caps affect patient outcomes. “Do patients suffer because of the change in behavior? It’s a very relevant question and we’re working on it,” he said. Moghtaderi noted that in another paper, which is currently under review, they did not observe any effect on mortality, but said they plan to flesh out the effect on other clinical outcomes.

For the researchers, an assessment of physician behavior is a more precise way to assess the effects of damage caps on the healthcare system, particularly since noneconomic caps haven’t yet been shown to reduce healthcare expenditures or attract physicians to a state. “Neither of those two assumptions are supported by the data,” said Moghtaderi. Some papers have suggested that damage caps might increase spending elsewhere in the healthcare system, such as in Medicare Part B spending.

In Texas, where he practices, Rodgers said the state legislature passed comprehensive liability reform bills that capped noneconomic damages for subjective, nonmonetary losses such as pain, suffering, inconvenience, emotional distress, and loss of companionship, among other reasons, 15 years ago. At the time, he said, there was a significant crisis, with liability insurers either leaving Texas, going bankrupt, or withdrawing from the market. Some areas had trouble retaining doctors, while the doctors that stayed had their own problems.  

“I am an invasive cardiologist, I’d never been sued, but my premiums were $60,000 per year,” said Rodgers. After the introduction of noneconomic damage caps, he said his insurance premiums declined to $6,000 per year and there was an exodus of personal injury lawyers from the state of Texas.