Malpractice as a Perceived Barrier to Specialist Referral for Physicians Practicing in Rural Emergency Departments

Background: Multiple barriers exist for referral of emergency department (ED) patients to specialists, particularly in rural communities; however, little is known about malpractice as a potential barrier. Study Objective: In this preliminary study, we sought to evaluate specialist malpractice concern as a perceived barrier to specialist referral for rural physicians practicing in EDs. Methods: The 2009 Colorado Rural Physician Workforce Survey was sent to all physicians practicing in rural Colorado. The primary survey question used for this analysis was whether malpractice was a barrier to specialist referral. Institutional Affiliations: 1. Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 2. Department of Emergency Medicine, Denver Health Medical Center, Denver. CO Malpractice as a Perceived Barrier to Specialist Referral for Physicians Practicing in Rural Emergency Departments Garrett Mitchel, MD1,2 and Adit A. Ginde, MD, MPH1 Approximately 20% of the U.S. population resides in rural communities, however only 9% of physicians practice in these settings.1 Rural populations have higher rates of poverty, a greater burden of chronic diseases, and are in poorer general health when compared to urban and suburban communities.2-4 Despite being considered a “priority population” by the Agency for Healthcare Research and Quality,4 access to care, particularly specialist care, remains limited in rural communities. While many patients can be safely discharged from the emergency department (ED), urgent follow up is often needed to guide further evaluation and treatment. However, many potential obstacles exist in securing a specialist visit for discharged ED patients. These include provider shortage, insurance coverage, financial barriers, geographic or transportation barriers, patient compliance, and medical malpractice. Rural ED patients have even more difficulty obtaining specialty follow-up, although many obstacles are difficult to address.5 Malpractice risk may be an obstacle that is amenable to intervention, through tort reform, to improve access to care for ED patients. This may be particularly important in rural communities where a higher rate of poverty and lower rate of insurance coverage means specialist physicians may assume greater risk for lower compensation. Prior studies suggest that malpractice risk may limit access and scope of practice of rural family physicians.6,7 However, to the best of our knowledge, whether malpractice limits specialist’s willingness to accept patients referred by rural providers has not been studied. Therefore, we sought to evaluate the specialist malpractice concern as a perceived barrier to specialist referral for rural physicians practicing in EDs. We hypothesized that perception of specialist malpractice risk would be more commonly cited as a barrier for physicians in the ED compared to other specialty physicians. Figure 1 – The EBM Triad Results: The survey had a response rate of 56% (711 of 1,272). We analyzed responses from all 525 actively licensed physicians. When compared to other physicians in other practice settings, physicians in the ED were more likely to select malpractice as a perceived barrier to specialist referral (29% vs 11% primary care and 15% other physicians). Physicians in isolated rural EDs (52% vs 31% in small rural and 22% in large rural areas) and those with fewer insured patients (73% with 0-20% privately insured vs 19% with>20% privately insured patients) were more likely to report malpractice as a barrier to specialist referral. Conclusion: In our preliminary study, rural physicians practicing in EDs were more likely to report specialist malpractice concern as a barrier to specialist referral than other physicians, particularly in isolated and less insured communities. Further study is required to understand the potential reasons and significance of these results and to evaluate the impact of actual malpractice risk on access to follow-up care for rural ED patients. INTRODUCTION ORIGINAL CONTRIBUTIONS Journal of Rural Emergency Medicine 13 Volume 1, NO. 1: June 2014 Of the 1,272 survey recipients, 711 (56%) were returned. We analyzed responses from the 525 actively practicing physicians who refer patients to specialists (52 emergency, 231 primary care, and 238 other specialty physicians). Overall, physicians practicing in the ED were more likely to report specialist malpractice concern as a perceived barrier to specialist referral (29%, compared to 11% for primary care and 15% for other specialty physicians). The association between specialty type, physician characteristics, and specialist malpractice concern as an obstacle to securing specialty follow-up are presented in the Table. For all specialties, younger and male physicians, those with fewer annual patient visits, and those with a lower percentage of privately insured patients were more likely to report specialist malpractice concern as an obstacle to specialist referral. Similar demographic associations were present for physicians in the ED compared to other specialty physicians. Among physicians in the ED, those with the lowest rate of privately insured patients were most likely to report specialist malpractice concern as a perceived obstacle to specialist referral (73% with 0-20% privately insured vs 19% with >20% privately insured patients). Additionally, physicians practicing in isolated rural EDs were more likely to report specialist malpractice concern as a perceived obstacle (52% vs 31% in small rural and 22% in large rural areas). Malpractice and Referral MATERIALS AND METHODS This was a secondary, cross-sectional analysis of the existing Colorado Rural Physician Workforce Survey, conducted by the Colorado Health Institute in 2009. This study was approved by our institutional review board as an exempt protocol. The Colorado Health Institute sent surveys to all licensed physicians practicing in rural Colorado. Rural communities were defined according to the Rural/Urban Commuting Area (RUCA) codes, a ZIP Code based classification system of rural and urban status based on population and work commuting.8 The Colorado Health Institute used these RUCA codes to categorize rural locations as isolated, small rural, and large rural areas. Surveys were mailed in four waves (an initial postcard notifying physicians of the survey, a second mailing with the survey, a subsequent postcard reminder, then finally a second survey) to 1,362 actively licensed physicians in rural Colorado. There were 711 (55.9%) respondents (1,272 of the initial 1,362 physicians were eligible to complete the survey). The survey included questions on physician demographic information, self-reported primary specialty, practice characteristics, reasons for practicing in rural medicine and issues facing rural physicians in regards to access to care for their patients. The primary question used for this analysis was “Do you face any of the following obstacles in securing specialist visits for your patients?” We focused on the “yes” or “no” response to malpractice for this analysis. We presume that this survey item indicates the referring providers’ perception of specialist malpractice concern, though there is some ambiguity to the question that could lead to alternate interpretations by the respondents. Physician demographic information (age, sex, race) and practice characteristics (specialty, years in practice, total annual number of patient visits in the practice location, payer mix, and rural community size) were used as co-variates to compare physicians who did and did not report specialist malpractice concern as an important perceived obstacle to specialist followup. Prior training and board certification type were not available in the survey data.