Turkiye Klinikleri Journal of Health Sciences

.: ORIGINAL RESEARCH
Defansif Tıp Uygulamalarına İlişkin Maliyetin Belirlenmesi: Retrospektif Araştırma
Determining the Cost of Defensive Medicine Applications: Retrospective Study
Kubilay ÖZERa, Şebnem ASLANb
aKaramanoğlu Mehmetbey Üniversitesi Sağlık Bilimleri Fakültesi, Sağlık Yönetimi Bölümü, Karaman, TÜRKİYE
bSelçuk Üniversitesi Sağlık Bilimleri Fakültesi, Sağlık Yönetimi Bölümü, Konya, TÜRKİYE
Turkiye Klinikleri J Health Sci. 2022;7(1):194-202
doi: 10.5336/healthsci.2021-81016
Article Language: TR
Full Text
ÖZET
 Amaç: Hekimler, tıbbi uygulamalarında gelecekte yasaların karşısına çıkma riskini azaltmak ya da önlemek için rutin tıbbi işlemlerden saparak savunmaya dayalı tıp uygulamalarına yönelmektedir. Uygulamalar literatürde defansif tıp olarak adlandırılmaktadır. Çalışmada bu kapsamdaki uygulamaların ekonomik boyutu ele alınmıştır. Defansif tıp uygulamalarından kaynaklanan maliyetin belirlenmesi amaçlanmıştır. Gereç ve Yöntemler: Retrospektif, kesitsel ve keşfedici tasarımla gerçekleştirilen çalışmada nitel yöntemlerden derinlemesine görüşme ve doküman incelemesi yöntemleri kullanılmıştır. Veriler Aralık 2018-Ocak 2019 tarihleri arasında üniversite hastanesi polikliniklerinde toplanmıştır. Acil servis ve konsültasyon poliklinikleri kapsam dışında bırakılmıştır. Başlangıçta malpraktis davaları, meslektaşların defansif tıp uygulamaları yönündeki görüşler, defansif tıp nedeniyle oluşan maliyet, maliyetin belirlenmesi yönünde görüşmeler yapılarak doküman incelemesi aşamasına ortam hazırlanmaya çalışılmıştır. İkinci aşamada hekimlerin hasta bazında bir önceki gün laboratuvar ve görüntüleme istemlerindeki defansif tıp eylemlerini '1-Tamamen (%100), 2-Çoğunlukla (%75), 3-Biraz (%50), 4-Hafifçe (%25), 5-Hiç (%0)' olarak doküman incelemesi kapsamında değerlendirmeleri istenmiştir. Ocak ayının sonunda görüşmelerde kavramlar ve süreçler tekrar edilmeye başlamıştır. Cerrahi ve dahili branşlardan toplam 30 hekime ulaşılarak toplam 596 hasta dosyası incelenmiştir. Verilerin değerlendirilmesinde sayı, yüzde ve aritmetik ortalama kullanılmıştır. Bulgular: Defansif tıp uygulamalarının, hekim-hastanın içinde bulunduğu tüm değişkenlerden etkilenebileceği ve hekimlerin maliyet konusunda farkındalık düzeylerinin düşük olduğu sıklıkla ifade edilmiştir. Defansif tıp uygulamaları vaka bazında %12,58 tespit edilmiştir. Polikliniklerde defansif nedenlerle laboratuvar ve görüntüleme istemlerinin direkt maliyete etkisi en az %1,63 olarak hesaplanmıştır. Sonuç: Bulgular, gözlemlenemeyen ve kapsam dışı tutulan diğer finansal enstrümanlar ile sosyal maliyetlerin hekim görüşleriyle birlikte değerlendirildiğinde defansif tıp uygulamalarının sağlık hizmetlerinin maliyetlerinde küçük ama ihmal edilmeyecek düzeyde artışa neden olduğu anlaşılmaktadır.

Anahtar Kelimeler: Üniversite hastanesi; defansif tıp; maliyet
ABSTRACT
 Objective: Physicians are turning to defensive medical practices by deviating from routine medical procedures in order to reduce or prevent the risk of future law enforcement in their daily medical practice. Applications are called defensive medicine in the literature. In this study, the economic dimensions of the applications are discussed. It was aimed to determine the cost arising from the defensive medicine applications. Material and Methods: In the study, which was carried out with a retrospective, cross-sectional and exploratory design, in-depth interview and document review methods from qualitative methods were used. The data were collected in the university hospital in polyclinics between December 2018-January 2019 at which time where Emergency service and consultation polyclinics were excluded. Initially, discussions were held to determine the Malpractice cases, the opinions of colleagues about defensive medicine practices, the cost caused by defensive medicine, and the cost of the document review phase was tried to be prepared. In the second stage, the defensive medical actions of the physicians in the laboratory and imaging requests on the basis of the patient the previous day '1-Totally (100%), 2- Mostly (75%), 3-Some (50%), 4-Slightly (25%), 5-None (0%)' they were asked to choose as part of the document review. At the end of January, concepts and processes began to be repeated in the negotiations. A total of 596 patient files were examined by reaching 30 physicians from surgical and internal medicine of branches. Number, percentage and arithmetic mean were used in the evaluation of the data. Results: It has often been stated that defensive medicine practices can be affected by all variables in which the physician-patient is present, and physicians have low levels of awareness about cost. Defensive medicine practices were identified by 12.58% on a case-by-case basis. In polyclinics, the effect of laboratory and imaging requests on direct cost for defensive reasons was calculated as at least 1.63%. Conclusion: The findings, when other financial instruments that cannot be observed and excluded, and social costs are evaluated together with physician opinions, it is understood that defensive medicine practices cause a small but not negligible increase in the costs of health services.

Keywords: University hospital; defensive medicine; cost
REFERENCES:
  1. Vento S, Cainelli F, Vallone A. Defensive medicine: It is time to finally slow down an epidemic. World J Clin Cases. 2018;6(11):406-9. [Crossref]  [PubMed]  [PMC] 
  2. Summerton N. Positive and negative factors in defensive medicine: a questionnaire study of general practitioners. BMJ. 1995;310(6971):27-9. [Crossref]  [PubMed]  [PMC] 
  3. Rothberg MB, Class J, Bishop TF, Friderici J, Kleppel R, Lindenauer PK. The cost of defensive medicine on 3 hospital medicine services. JAMA Intern Med. 2014;174(11):1867-8. [Crossref]  [PubMed]  [PMC] 
  4. Tancredi LR, Barondess JA. The problem of defensive medicine. Science. 1978;200(4344):879-82. [Crossref]  [PubMed] 
  5. Hermer LD, Brody H. Defensive medicine, cost containment, and reform. J Gen Intern Med. 2010;25(5):470-3. [Crossref]  [PubMed]  [PMC] 
  6. Mello MM, Chandra A, Gawande AA, Studdert DM. National costs of the medical liability system. Health Aff (Millwood). 2010;29(9):1569-77. [Crossref]  [PubMed]  [PMC] 
  7. Catino M. Why do doctors practice defensive medicine? The side-effects of medical litigation. Safety Science Monitor. 2011;15(1):1-12. [Link] 
  8. He AJ. The doctor-patient relationship, defensive medicine and overprescription in Chinese public hospitals: evidence from a cross-sectional survey in Shenzhen city. Soc Sci Med. 2014;123:64-71. [Crossref]  [PubMed] 
  9. Chang TTY. An economic assessment of de­fensive medicine. university Of ABD: Hawaii; 1991. Erişim linki: [Link] 
  10. Massachusetts Medical Society [İnternet]. [Erişim tarihi: 17.05.2019]. Investigation of De­fensive Medicine in Massachusetts. 2008. Erişim linki: [Link] 
  11. Huesch M, Richman B. (2012). [Erişim tarihi: 29.01.2018]. Hidden costs? Malpractice alle­gationsand defensive medicine among cardiac surgeons. [Crossref] 
  12. Miller RA, Sampson NR, Flynn JM. The prevalence of defensive orthopaedic imaging: a prospective practice audit in Pennsylvania. J Bone Joint Surg Am. 2012;94(3):e18. [Crossref]  [PubMed] 
  13. Sathiyakumar V, Jahangir AA, Mir HR, Obremskey WT, Lee YM, Apfeld JC, et al. The prevalence and costs of defensive medicine among orthopaedic trauma surgeons: a national survey study. J Orthop Trauma. 2013;27(10):592-7. [Crossref]  [PubMed] 
  14. Panella M, Rinaldi C, Leigheb F, Knesse S, Donnarumma C, Kul S, et al. Prevalence and costs of defensive medicine: a national survey of Italian physicians. J Health Serv Res Policy. 2017;22(4):211-7. [Crossref]  [PubMed] 
  15. Saint S, Vaughn VM, Chopra V, Fowler KE, Kachalia A. Perception of Resources Spent on Defensive Medicine and History of Being Sued Among Hospitalists: Results from a National Survey. J Hosp Med. 2018;13(1):26-9. [Crossref]  [PubMed] 
  16. Yıldırım A, Şimşek H. Sosyal Bilimlerde Nitel Araştırma Yöntemleri, Nitel Araştırma Süreci. 8. Baskı. Ankara: Seçkin Yayıncılık; 2011. p.120-88.
  17. Goetz JP, LeCompte MD. Ethnograph and Qualitative Desing in Educational Research. 1st ed. Orlando, FL: Academic Press; 1984. p.217.
  18. Sümbüloğlu V, Sümbüloğku K. Sağlık Bilimlerinde Araştırma Yöntemleri. Örnekleme. 4. Baskı. Ankara: Hatipoğlu Basım ve Yayıncılık 2002. p. 64-5.
  19. Tutar F, Kılınç N. Türkiye'nin sağlık sektöründeki ekonomik gelişmişlik potansiyeli ve farklı ülke örnekleriyle mukayesesi [Economic development potential and comparative examples with different countries in Turkey's health sector]. Afyon Kocatepe Üniversitesi İktisadi ve İdari Bilimler Fakültesi Dergisi. 2007;9(1):31-54. [Link] 
  20. Şahin D. Doğumda yaşam beklentisinin belirleyicilerinin analizi: Apec ülkeleri örneği [Analysis of the determinants of life expectancy at birth: the case of Apec countries.] Ömer Halisdemir Üniversitesi İktisadi ve İdari Bilimler Fakültesi Dergisi. 2018;11(1):1-7. [Crossref] 
  21. Ağır H, Traş HH. Türkiye'de sağlık harcama türlerinin değerlendirilmesi [Evaluation of health spending species in Turkey]. Kahramanmaraş Sütçü İmam Üniversitesi Sosyal Bilimler Dergisi. 2018;15(2):643-70. [Link] 
  22. Gandhi R, Stiell I, Forster A, Worthington J, Ziss M, Kitts JB, et al. Evaluating physician awareness of common health care costs in the emergency department. CJEM. 2018;20(4): 539-49. [Crossref]  [PubMed] 
  23. Allan GM, Lexchin J, Wiebe N. Physician awareness of drug cost: a systematic review. PLoS Med. 2007;4(9):e283. [Crossref]  [PubMed]  [PMC] 
  24. Rubin RJ, Mendelson DN. How much does defensive medicine cost? J Am Health Policy. 1994;4(4):7-15. [PubMed] 

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