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Defensive healthcare practice: Systematic review of qualitative studies and systems-based logic model

What do we want to know?

There is a concern that healthcare professionals may practice differently because they are afraid of litigation or patient complaints. For example, they might prescribe treatments or diagnostic tests which are not medically necessary, or avoid treatments which are beneficial but could be risky. If so, this could lead to lower-quality care and unnecessary costs. We aimed to find out how clinicians understand these issues, and how so-called ‘defensive practice’ might impact on healthcare delivery.

This work contained two parts: a synthesis of evidence from qualitative research of clinicians’ views; and a systems-based logic model drawing on theoretical literature to provide a conceptual model of defensive practice. 

Who wants to know?

This independent research report was commissioned by the National Institute for Health Research Policy Research Programme for the Department of Health and Social Care. The findings may be of interest to national and local policymakers, clinicians, patients, healthcare managers and professional or regulatory bodies.

What did we find?

The qualitative evidence synthesis included 15 studies, with a range of clinicians represented; the most common specialism was obstetrics and midwifery. Clinicians describe a range of practices which may be motivated by the risk of litigation, including Caesarean delivery, induction of labour, foetal monitoring, diagnostic testing, and referrals. Some report avoiding certain types of patients or settings which are seen as carrying higher risk of litigation.

However, not all participants who recognised the importance of defensive practice could cite specific examples. Many also described other dimensions of practice such as over-documentation. The threat of litigation is widely felt, but defensive practice is also motivated by other concerns, such as wanting to avoid adverse events, or feeling under pressure from patients or families. These themes suggest that the perception of defensive practice may be related to broader issues around clinicians’ roles and their relationships with patients.

The analysis for the systems-based logic model identifies that whilst defensive practice may have been initially driven by a rational fear of litigation, it appears that over time the fear of litigation has transcended the objective risk of litigation. The logic model also suggests that the widespread fear of litigation and common awareness of the phenomenon means that defensive practice has developed into a cultural norm. This normalisation has evolved to such an extent that key institutional practices and policies reflect, and thereby further entrench, defensive practice as a cultural norm.

What are the conclusions?

The findings highlight widespread concerns about defensive practice, but suggest that they may often not be linked to specific clinical decisions. This casts doubt on a linear model of causation, and on policy solutions narrowly focused on litigation risk. The idea of defensive practice includes a range of concerns, including perceptions that clinical roles are being deskilled and that practice more generally is becoming bureaucratised and depersonalised. 

There is wide variation in how clinicians understand the concept, and high self-reported rates of defensive practice do not conclusively prove that the objective risk of litigation is actually contributing to sub-optimal care. Our findings show that defensive motivations are bound up with other reasons for inappropriate treatment, and should be seen in the context of research on, for example, overtreatment and overdiagnosis in specific populations. This broader context should also include patient perspectives, which were absent from this review.

The finding that clinicians may avoid potentially risky or ‘difficult’ patients or areas of practice for defensive reasons is potentially worrying, as this could contribute to inequalities in access to care. Further research would be valuable to determine how far this is a factor in the UK context.

How did we get these results?

For the qualitative evidence synthesis, we searched ten database sources for qualitative studies relating to clinicians’ views about litigation risk and practice. Studies were critically appraised for rigour in sampling, data collection and other methodological domains. 

For the systems-based logic model, we drew on papers in the qualitative evidence synthesis and targeted searches using Microsoft Academic Graph. We drew on theoretical and empirical literature focusing on defensive practice. We drew on Bronfenbrenner’s Social Ecological Framework to categorise drivers of practice and synthesise them within an overall logic model.

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