APPENDIX: Figure A1. Three Common Symptoms Associated with High Diagnostic Uncertainty

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1 APPENDIX: Figure A1. Three Common Symptoms Associated with High Diagnostic Uncertainty Table A1. Survey questions used to construct the malpractice concern index Table A2. Adjusted Percentage Of Items In The Malpractice Concerns Scale With Which Physicians Agreed Or Strongly Agreed, By Specialty, Table A3. Adjusted Percentage Of Items In The Malpractice Concerns Scale With Which Physicians Agreed Or Strongly Agreed, By Physician And Practice Characteristics, Table A4. Inclusion and exclusion criteria (ICD-9 diagnostic codes) used to define chest pain, headache, and lower back pain initial visits and procedure codes used to define conventional imaging, advanced imaging, and supplemental testing Table A5. List of CPT imaging/testing codes for each condition Table A6. Unadjusted frequencies (proportions) for services within seven days of initial visit for one of three symptoms, by physician concern score and location of initial visit (emergency department or other ambulatory setting), stratified by physician malpractice concern index score. Table A7. Unadjusted frequencies (proportions) for services within seven days of initial visit for one of three symptoms, by physician concern score and location of initial visit (emergency department or other ambulatory setting), stratified by state malpractice risk score Tables A8-A14 1 Odds ratios from logistic regressions: Dependent variables are receipt of services within seven days of an initial visit for one of three symptoms. Separate tables for setting of initial visit (ED vs. non-ed) and for each of the three symptoms (chest pain, headache, and lower back pain.) These tables include malpractice terciles based on malpractice concern index scores. Tables A15-A19. Odds ratios from logistic regressions: Dependent variables are receipt of services within seven days of an initial visit for one of three symptoms. Separate tables for setting of initial visit (ED vs. non-ed) and for each of the three symptoms (chest pain, headache, and lower back pain.) These tables include malpractice terciles based on state malpractice risk score. Tables A20-A25. Odds ratios from logistic regressions: Dependent variables are receipt of services within seven days of an initial visit for one of three symptoms. Separate tables for setting of initial visit (ED vs. non-ed) and for each of the three symptoms (chest pain, headache, and lower back pain.) These tables include a variable indicating whether the state has a cap on malpractice damages. 1

2 Notes 1 Three Klabunde comorbidity variables are not reported in all logistic regression tables (A8-A25) because they occurred too infrequently in our samples to support inclusion in models: mild liver disease, moderate/severe liver disease, and AIDS. 2

3 Figure A1. Three Common Symptoms Associated with High Diagnostic Uncertainty Chest pain: This symptom is associated with many potentially worrisome diagnoses, including heart attack (myocardial infarction (MI)), pulmonary embolus (a blood clot in the lungs), and ruptured thoracic aortic aneurysm (the tearing of the wall of the large blood vessel leading from the heart). Some of these diagnoses can be ruled out with advanced imaging, while ruling out others (in particular myocardial infarction) generally requires hospital admission for observation and blood tests. A stress test can evaluate a patient s risk of myocardial infarction, but is generally ordered only when observation, initial test results and the patient s symptoms do not suggest an active heart attack to the treating physician. Conventional imaging (e.g. chest X-rays) is usually performed but is rarely sufficiently detailed to rule out severe problems. However, it can reveal another cause of the patient s symptoms (for example, pneumonia). Headache: Although usually not serious, headaches can signify worrisome diagnoses, including hemorrhagic stroke, meningitis, or cancer. Most of these can be ruled out through advanced imaging. Lumbar puncture, a procedure that retrieves spinal fluid for analysis, is necessary to diagnose some conditions (e.g., meningitis) and supplements advanced imaging for others. Hospital admission is infrequently necessary; however, physicians without rapid access to diagnostic imaging may refer patients to an ED for these studies. Conventional (X-ray) imaging is rarely useful. Low-back pain: Though typically not serious in origin and responsive to rest, low-back pain could indicate fracture, cancer in the spine, or infections affecting the spinal cord and surrounding tissues. X-rays are sometimes diagnostic, but advanced imaging may be required if soft tissues rather than bones are the focus of the study or if X-ray results are indeterminate. If those studies are negative, hospital admission is rarely useful for diagnosis but is sometimes necessary for pain management. As with headache, a physician concerned about a potentially time-sensitive diagnosis might refer a patient to the ED for rapid imaging. 3

4 Table A1. Survey Questions Used To Construct the Malpractice Concern Index Considering the full range of patients that you see, indicate your level of agreement with the following statements about medical malpractice. a 1. I am concerned that I will be involved in a malpractice case sometime in the next 10 years. 2. I feel pressured in my day-to-day practice by the threat of malpractice litigation. 3. I order some tests or consultations simply to avoid the appearance of malpractice. 4. Sometimes I ask for consultant opinions primarily to reduce my risk of being sued. 5. Relying on clinical judgment rather than on technology to make a diagnosis is becoming riskier because of the threat of malpractice suits. Source: 2008 Health System Change Health Tracking Physician Survey a Response categories are Strongly Disagree, Disagree, Not Sure, Agree, Strongly Agree. 4

5 Table A2. Adjusted Percentage Of Items in The Malpractice Concerns Scale With Which Physicians Agreed Or Strongly Agreed, By Specialty, Specialty % of physicians Composite score a Defensive medicine subscore b All physicians Malpractice concern subscore c Emergency physicians Obstetriciangynecologists Surgical specialists Adult primary care physicians (reference group) Pediatric specialists *** 77.3*** 83.3*** *** *** *** *** *** 62.5 Adult cognitive *** 55.8*** 61.7** specialists d Adult procedural *** 51.5*** 65.8 specialists d General pediatricians Psychiatrists (adult and pediatric) *** 56.3*** 56.3*** *** 43.8*** 54.2*** SOURCE Center for Studying Health System Change (HSC) Health Tracking Physician Survey, Adapted from Carrier ER, Reschovsky JD, Mello MM, Mayrell RC, Katz DA. Physicians fears of malpractice lawsuits are not assuaged by tort reforms. Health Aff (Millwood). 2010;29(9): NOTES: Adjusted for physician s sex, years in practice, and practice type; number of physicians in practice; percentage of revenue from Medicare and from Medicaid; percentage of patients with chronic illnesses; and percentage of patients who are members of a racial or ethnic minority group. Percentages may not add to 100 percent because of rounding. a Percentage of statements with which physicians agreed or strongly agreed. 5

6 b Percentage of statements related to defensive ordering of tests or consultations with which physicians agreed or strongly agreed. c Percentage of statements related to overall concern regarding malpractice with which physicians agreed or strongly agreed. d Cognitive specialists primary role involves providing diagnostic or therapeutic advice to reduce clinical uncertainty or recommend a course of treatment. Procedural specialists primary role involves performing a technical procedure to aid diagnosis, cure a condition, identify and prevent new conditions, or palliate symptoms. See Forrest C. A typology of specialists clinical roles. Arch Intern Med. 2009;169(11): **p 0.05 ***p

7 Table A3. Adjusted Percentage of Items in The Malpractice Concerns Scale With Which Physicians Agreed Or Strongly Agreed, By Physician and Practice Characteristics, 2008 Characteristic Percent of physicians Composite score a All physicians Years in practice Fewer than 5 (ref) More than ** Sex Male (ref) Female *** Percent of patients with a chronic illness <10% (ref) % 49% % *** Practice type/number of physicians 1 2 physicians (ref) physicians physicians ** 51 physicians Group/staff HMO Hospital, CHC, or other SOURCE Center for Studying Health System Change (HSC) Health Tracking Physician Survey, Adapted from Carrier ER, Reschovsky JD, Mello MM, Mayrell RC, Katz DA. Physicians fears of malpractice lawsuits are not assuaged by tort reforms. Health Aff (Millwood). 2010;29(9): NOTES: Excluding the characteristic of interest, reported malpractice concern scores are adjusted for physician specialty, sex, and years in practice; practice type and number of physicians; percentage of revenue from Medicare and from Medicaid; percentage of patients who suffer from chronic disease; and percentage of patients who are members of racial or ethnic minority groups. This exhibit omits characteristics for which no significant differences were found at the 0.05 level. The omitted characteristics are percentage minority patients, use of health information technology with clinical decision support, routine use of full electronic 7

8 medical record, and routine use of full electronic medical record with decision support. We also omitted urbanicity of practice location. We tested for differences between urban areas with a population of one million or more the reference group and urban areas with a population of less than one million and nonurban areas. The only difference we detected compared to the reference group was in nonurban areas (p < 0:05) on the malpractice concern score. Percentages may not add to 100 percent because of rounding. HMO is health maintenance organization. CHC is community health center. a Percentage of statements with which physicians agreed or strongly agreed. **p 0.05 ***p

9 Table A4. Inclusion and Exclusion Criteria (ICD-9 Diagnostic Codes) Used To Define Of Chest Pain, Headache and Lower Back Pain Initial Visits And Procedure Codes Used To Define Conventional, Advanced, and Supplemental Testing. Lower Back Pain Inclusion codes: Lumbosacral spondylosis without myelopathy Lumbar intervertebral disc without myelopathy Schmorl's nodes- Lumbar region Degeneration of thoracic or lumbar intervertebral disc- Lumbar or lumbosacral intervertebral disc Other and unspecified disc disorder - Lumbar region Spinal stenosis, other than cervical- Lumbar region Spinal stenosis, lumbar region, with neurogenic claudication Lumbago Sciatia Backache, unspecified Disorders of sacrum Disorders of coccyx Other acquired deformity of back or spine Nonallopathic lesions, not elsewhere classified- Lumbar Region Nonallopathic lesions, not elsewhere classified- Sacral Region Sprains and strains of sacroiliac region - Lumbosacral (joint) (ligament) Sprains and strains of other and unspecified parts of back- Lumbar Region Exclusion codes: Cancer Cancer V10 Personal history of malignant neoplasm Trauma Trauma Trauma Trauma Trauma Trauma 929 Trauma 952 Trauma Trauma IV drug abuse

10 304.4 IV drug abuse IV drug abuse Neurologic impairment Neurologic impairment Chest Pain Inclusion codes Intermediate coronary syndrome Other acute and subacute forms of ischemic heart disease- Other Angina decubitus Prinzmetal angina Other and unspecified angina pectoris Chest pain, unspecified Precordial pain Painful respiration Chest Pain- Other Exclusion codes: NONE Headache Inclusion codes: Tension headache Cluster headache syndrome, unspecified Episodic cluster headache Cluster chronic headache Episodic paroxysmal hemicrania Chronic paroxysmal hemicrania Short lasting unilateral neuralgiform headache with conjuctival injection and tearing Other trigeminal autonomic cephalgias Tension headache, unspecified Episodic tension headache Chronic tension headache 10

11 339.3 Drug induced headache New daily persistent headache Hypnic headache Headache associated with sexual activity Primary cough headache Primary exertional headache Primary stabbing headache Other headache syndromes Migraine Migraine, classical, not intractable Migraine with aura with intractable migraine, without mention of status migrainosus Migraine with aura, without mention of intractable migraine with status migrainosus Migraine with aura, with intractable migraine, so stated, with status migrainosus Common migraine Migraine without aura without mention of intractable migraine without mention of status migrainosus Migraine without aura with intractable migraine, without mention of status migrainosus Migraine without aura, without mention of intractable migraine with s status Migraine without aura, with intractable migraine, so stated, with status migrainosus Variants of migraine Variants of migraine, not elsewhere classified, without mention of intractable migraine without mention of status migrainosus Variants of migraine, not elsewhere classified, with intractable migraine, without mention of status migrainosus Variants of migraine, not elsewhere classified, without mention of intractable migraine, with status migrainosus Variants of migraine, not elsewhere classified, with intractable migraine, so stated, with status migrainosus Hemiplegic migraine, without mention of intractable migraine without mention of status migrainosus Hemiplegic migraine, with intractable migraine, so stated, without mention of status migrainosus Hemiplegic migraine, without mention of intractable migraine with status 11

12 migrainosus Hemiplegic migraine, with intractable migraine, so stated, with status migrainosus Menstrual migraine, without mention of intractable migraine without mention of status migrainosus Menstrual migraine, with intractable migraine, so stated, without mention of status migrainosus Menstrual migraine, without mention of intractable migraine with status migrainosus Menstrual migraine, with intractable migraine, so stated, with status migrainosus Persistent migraine aura without cerebral infarction without mention of intractable migraine without mention of status migrainosus Persistent migraine aura without cerebral infarction, with intractable migraine, so stated, without mention of status migrainosus Persistent migraine aura without cerebral infarction, without mention of intractable migraine with status migrainosus Persistent migraine aura without cerebral infarction, with intractable migraine, so stated, with status migrainosus Persistent migraine aura with cerebral infarction, without mention of intractable migraine without mention of status migrainosus Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, without mention of status migrainosus Persistent migraine aura with cerebral infarction, without mention of intractable migraine with status migrainosus Persistent migraine aura with cerebral infarction, with intractable migraine, so stated, with status migrainosus Chronic migraine without aura, without mention of intractable migraine without mention of status migrainosus Chronic migraine without aura, with intractable migraine, so stated, without mention of status migrainosus Chronic migraine without aura, without mention of intractable migraine with status migrainosus Chronic migraine without aura, with intractable migraine, so stated, with status migrainosus Other forms of migraine Other forms of migraine without mention of intractable migraine without mention of status migrainosus Other forms of migraine with intractable migraine, with status migrainosus Other forms of migraine, without mention of intractable migraine with status migrainosus Other forms of migraine, with intractable migraine, so stated, with status Migraine, unspecified 12

13 Migraine unspecified without mention of intractable migraine without mention of status migrainosus Migraine unspecified with intractable migraine, so stated, with status migrainosus Migraine unspecified without mention of intractable migraine with status migrainosus Migraine unspecified with intractable migraine, so stated, with status migrainosus Menopausal state, symptomatic Headache Exclusion codes: Dizziness and Giddiness Syncope and Collapse Reaction to spinal or lumbar puncture Abnormal involuntary movements Disturbances of sensation of smell and taste Abnormality of Gait Lack of Coordination 782 Skin Sensation Disturb 430 Subarachnoid Hemorrhage Hemicrania Continua Primary Thunderclap Headache Other complicated headache syndrome Neoplasms/Mass Swelling, Mass, Or Lump In Head And Neck Human Immunodeficiency Virus (HIV) Trauma Trauma Trauma Trauma Trauma Trauma 929 Trauma 952 Trauma 958 Trauma 959 Trauma Pregnancy 342 Hemiplesia and Hemiparesis 434 Occlusion of Cerebral Arteries 435 Transient Cerebral Ischemia 436 Acute, But Ill Defined, Cerebrovascular Disease 438 Late Effect of Cerebrovascular Disease 13

14 Table A5. List of CPT /Testing Codes for Each Condition CPT Code Description Convent -ional Advanced Supplemental Testing Lower Back Pain Radiologic examination, spine, entire, survey study, anteroposterior and lateral Radiologic examination, spine, single view, X specify level Radiologic examination, spine, lumbosacral; 2 or X 3 views minimum of 4 views X complete, including bending views, minimum of 6 X views bending views only, 2 or 3 views X Computed tomography, lumbar spine; without X contrast material with contrast material X without contrast material, followed by contrast X material(s) and further sections Magnetic resonance (eg, proton) imaging, spinal X canal and contents, lumbar; without contrast material Lumbar MRI X Radiologic examination, sacroiliac joints; less X than 3 views or more views X Radiologic examination, sacrum and coccyx, X minimum of 2 views Myelography, lumbosacral, radiological X supervision and interpretation Lumbar Puncture X Chest Pain Radiologic examination, chest; single view, X frontal stereo, frontal X Radiologic examination, chest, 2 views, frontal X and lateral; with apical lordotic procedure X with oblique projections X 14 X

15 71030 Radiologic examination, chest, complete, X minimum of 4 views; Computed tomography, thorax; without contrast X material with contrast material(s) X without contrast material, followed by contrast X material(s) and further sections Computed tomographic angiography, chest X (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing Magnetic resonance (eg, proton) imaging, chest X (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) with contrast material(s) X without contrast material(s), followed by contrast X material(s) and further sequences Magnetic resonance angiography, chest X (excluding myocardium), with or without contrast material(s) Exercise stress testing X X Myocardial perfusion imaging Headache Computed tomography, head or brain; without X contrast material with contrast material(s) X without contrast material, followed by contrast X material(s) and further sections Computed tomographic angiography, head, with X contrast material(s), including noncontrast images, if performed, and image postprocessing Magnetic resonance angiography, head; without X contrast material(s) with contrast material(s) X without contrast material(s), followed by contrast X material(s) and further sequences Magnetic resonance (eg, proton) imaging, brain X (including brain stem); without contrast material with contrast material(s) X without contrast material, followed by contrast X material(s) and further sequences 15

16 aggressive diagnostic testing in office-based practice. Health Aff (Millwood). 2013;32(8). Table A6. Unadjusted Percents Of Services Within Seven Days Of Initial Visit For One Of Three Symptoms, By Physician Concern Score And Location Of Initial Visit (Emergency Department Or Other Ambulatory Setting), Stratified By Physician Malpractice Concern Index Score. Initial visit symptom and location Site of initial visit Conventional Advanced Supplemental Testing (stress, LP) Physician malpractice concern Hospital Admission ED Visit Symptom Low Mediudiudiudiudium High Low Me- High Low Me- High Low Me- High Low Me- High Chest Non-ED Pain ED NA NA NA Headache Non-ED ED NA NA NA Lower Non-ED NA NA NA back pain ED NA NA NA NA NA NA Source: 2008 HSC Health Tracking Physician Survey linked with Medicare claims NA indicates the service is not applicable for clinical reasons, or because the ED visit measure is irreverent if the initial visit was to an ED. 16

17 aggressive diagnostic testing in office-based practice. Health Aff (Millwood). 2013;32(8). Table A7. Unadjusted Percents Of Services Within Seven Days Of Initial Visit For One Of Three Symptoms, By Physician Concern Score And Location Of Initial Visit (Emergency Department Or Other Ambulatory Setting), Stratified By State Malpractice Risk Score Initial visit symptom and location Site of initial visit Conventional Advanced Supplemental Testing (stress, LP) State Malpractice Risk Score Hospital Admission ED Visit Symptom Low Mediudiudiudiudium High Low Me- High Low Me- High Low Me- High Low Me- High Chest Non-ED Pain ED NA NA NA Headache Non-ED Lower back pain ED NA NA NA Non-ED NA NA NA ED NA NA NA NA NA NA Source: 2008 HSC Health Tracking Physician Survey linked with Medicare claims NA indicates the service is not applicable for clinical reasons, or because the ED visit measure is irrelevant if the initial visit was to an ED. 17

18 Table A8. Odds ratios from logistic regressions using physician perceived malpractice risk score terciles: Receipt of supplemental services within seven days of an initial non-emergency department visit for chest pain. ED Visit Hospital Admission Conventional Advanced Supplemental Testing Intercept 0.01 ** 0.01 ** 0.27 ** 0.01 ** 0.17 ** Physician malpractice risk index Low tercile Middle tercile 1.53 ** ** ** Upper tercile 1.40 * ** Physician specialty (initial visit) PCP Cardiologist 0.61 ** ** 0.52 ** 3.75 ** Other 2.45 ** 2.39 ** ** 0.52 ** Beneficiary age * ** 0.70 ** ** * 2.16 * ** Beneficiary is male ** Beneficiary race White Black Other ** 0.30 ** 0.76 Comorbidities Diabetes Chronic Pulmonary Disease ** 2.10 ** 0.89 Congestive Heart Failure * 1.25 Cerebrovascular Disease * Paralysis Peripheral Vascular Disease

19 Table A8. Odds ratios from logistic regressions using physician perceived malpractice risk score terciles: Receipt of supplemental services within seven days of an initial non-emergency department visit for chest pain. ED Visit Hospital Admission Conventional Advanced Supplemental Testing Acute Myocardial Infarction 3.48 ** ** 1.86 ** Old Myocardial Infarction 2.22 * Chronic Renal Failure Chronic Diabetes with Complications Peptic Ulcer Disease * Dementia 2.15 * Rheumatologic Disease Urbanicity Large metro (>1 million) Small metro (<1 million) 1.49 ** ** 1.39 * 0.96 Micropolitan * 2.01 ** 1.13 Noncore * 1.49 ** Beneficiary is a snowbird in Source: 2008 HSC Health Tracking Physician Survey linked with Medicare Claims *p 0.05; **p 0.01 Note: Supplemental testing refers to stress tests. 19

20 Table A9. Odds ratios from logistic regressions using physician perceived malpractice risk score terciles: Receipt of supplemental services within seven days of an initial emergency department visit for chest pain. Hospital Admission Conventional 20 Advanced Supplemental Testing Intercept 0.35 ** 6.35 ** 0.22 ** 0.35 ** Physician malpractice risk index Low tercile Middle tercile Upper tercile * Physician specialty (initial visit) 1.00 Emergency medicine ** PCP Other Beneficiary age ** ** 2.38 * * ** * Beneficiary is male 1.37 ** Beneficiary race White Black * 0.75 Other Comorbidities Diabetes Chronic Pulmonary Disease ** 1.49 ** 1.07 Congestive Heart Failure 1.47 ** Cerebrovascular Disease 1.37 * ** Paralysis Peripheral Vascular Disease Acute Myocardial Infarction 6.85 ** *

21 Table A9. Odds ratios from logistic regressions using physician perceived malpractice risk score terciles: Receipt of supplemental (Con t.) services within seven days of an initial emergency department visit for chest pain. Hospital Admission Conventional Advanced Supplemental Testing Old Myocardial 1.39 Infarction Chronic Renal Failure * 1.24 Chronic Diabetes with Complications Peptic Ulcer Disease Dementia ** Rheumatologic Disease Urbanicity Large metro (>1 million) Small metro (<1 million) 0.65 ** ** Micropolitan 0.61 ** Noncore 0.41 ** 0.36 * 0.26 ** 0.59 Beneficiary is a snowbird in Source: 2008 HSC Health Tracking Physician Survey linked with Medicare Claims *p 0.05; **p

22 Table A10. Odds ratios from logistic regressions using physician perceived malpractice risk score terciles: Receipt of supplemental services within seven days of an initial non-emergency department visit for headache. ED Visit Hospital Admission Advanced Intercept 0.01 ** 0.00 ** 0.03 ** Physician malpractice risk index Low tercile Middle tercile * Upper tercile ** Physician specialty (initial visit) PCP Neurologist ** Other * 0.43 ** Beneficiary age * ** ** ** 2.57 ** ** 5.67 * Beneficiary is male 2.03 ** 2.04 * 2.12 ** Beneficiary race White Black 2.55 ** Other Comorbidities Diabetes Chronic Pulmonary Disease Congestive Heart Failure Cerebrovascular Disease 2.13 ** 2.03 * 1.88 ** Paralysis ** 1.53 Peripheral Vascular Disease

23 Acute Myocardial Infarction Old Myocardial Infarction 3.08 * 2.62 * 0.82 Chronic Renal Failure Chronic Diabetes with Complications Peptic Ulcer Disease Dementia Rheumatologic Disease Urbanicity Large metro (>1 million) Small metro (<1 million) ** Micropolitan * Noncore Beneficiary is a snowbird in Source: 2008 HSC Health Tracking Physician Survey linked with Medicare Claims *p 0.05; **p 0.01; -- insufficient variation to generate odds ratio for subgroup Note: The model for conventional imaging is not reported because so few headache cases received this service. 23

24 Table A11. Odds ratios from logistic regressions using physician perceived malpractice risk score terciles: Receipt of supplemental services within seven days of an initial emergency department visit for headache. Hospital Admission Advanced Supplemental Testing Intercept 0.14 ** ** Physician malpractice risk index Low tercile Middle tercile Upper tercile Physician specialty (initial visit) Emergency medicine PCP Other Beneficiary age * ** ** * Beneficiary is male Beneficiary race White Black Other Comorbidities Diabetes * Chronic Pulmonary Disease Congestive Heart Failure Cerebrovascular Disease * 3.15 Paralysis ** 24

25 Table A11. Odds ratios from logistic regressions using physician perceived malpractice risk score terciles: Receipt of supplemental services within seven days of an initial emergency department visit for headache. Hospital Admission Advanced Supplemental Testing Peripheral Vascular Disease Acute Myocardial Infarction ** Old Myocardial Infarction Chronic Renal Failure Chronic Diabetes with Complications Peptic Ulcer Disease ** Dementia ** Rheumatologic Disease * 0.72 Urbanicity Large metro (>1 million) Small metro (<1 million) Micropolitan Noncore 2.96 * Beneficiary is a snowbird in ** Source: 2008 HSC Health Tracking Physician Survey linked with Medicare Claims *p 0.05; **p 0.01; -- insufficient variation to generate odds ratio for subgroup Note: The model for conventional imaging is not reported because so few headache cases received this service. Supplemental testing for headache refers to lumbar punctures. 25

26 Table A12. Odds ratios from logistic regressions using physician perceived malpractice risk score terciles: Receipt of supplemental services within seven days of an initial non-emergency department visit for low back pain. ED Visit Hospital Admission Conventional Advanced Intercept 0 ** 0 ** 0.15 ** 0.02 ** Physician malpractice risk index Low tercile Middle tercile 1.58 * ** 1.24 Upper tercile ** 1.55 ** Physician specialty (initial visit) PCP Orthopedist ** 6.09 ** Other ** 3.1 ** Beneficiary age ** ** * 8.62 ** 1.35 ** ** 7.36 ** 1.69 ** ** ** 2.05 ** * ** * Beneficiary is male Beneficiary race White Black Other Comorbidities Diabetes * 0.92 Chronic Pulmonary Disease 1.48 * Congestive Heart Failure * Cerebrovascular Disease Paralysis * Peripheral Vascular Disease ** 26

27 Table A12. Odds ratios from logistic regressions using physician perceived malpractice risk score terciles: Receipt of supplemental services within seven days of an initial non-emergency department visit for low back pain. ED Visit Hospital Admission Conventional Advanced Acute Myocardial Infarction 2.54 * Old Myocardial Infarction Chronic Renal Failure Chronic Diabetes with Complications Peptic Ulcer Disease Dementia Rheumatologic Disease Urbanicity Large metro (>1 million) Small metro (<1 million) * 1.19 Micropolitan ** Noncore ** Beneficiary is a snowbird in Source: 2008 HSC Health Tracking Physician Survey linked with Medicare Claims *p 0.05; **p

28 Table A13. Odds ratios from logistic regressions using physician perceived malpractice risk score terciles: Receipt of supplemental services within seven days of an initial emergency department visit for low back pain. Hospital Admission 28 Conventional Advanced Intercept 0.04 ** ** Physician malpractice risk index Low tercile Middle tercile Upper tercile * 1.56 Physician specialty (initial visit) Emergency medicine PCP 0.21 * Other Beneficiary age ** * ** 2.55 * 5.12 ** ** 3.86 ** 4.06 * ** Beneficiary is male Beneficiary race White Black Other 0.27 * Comorbidities Diabetes 1.83 * * Chronic Pulmonary Disease Congestive Heart Failure 2.33 ** Cerebrovascular Disease Paralysis ** Peripheral Vascular Disease

29 Table A13. Odds ratios from logistic regressions using physician perceived malpractice risk score terciles: Receipt of supplemental services within seven days of an initial emergency department visit for low back pain. Hospital Admission Conventional Advanced Acute Myocardial Infarction * 0.37 Old Myocardial Infarction Chronic Renal Failure Chronic Diabetes with Complications Peptic Ulcer Disease Dementia Rheumatologic Disease Urbanicity Large metro (>1 million) Small metro (<1 million) Micropolitan * Noncore Beneficiary is a snowbird in Source: 2008 HSC Health Tracking Physician Survey linked with Medicare Claims *p 0.05; **p

30 Table A14 Odds ratios from logistic regressions using state malpractice risk score terciles: Receipt of supplemental services within seven days of an initial non-emergency department visit for chest pain. ED Visit Hospital Admission 30 Conventional Advanced Supplemental Testing Intercept 0.02 ** 0.01 ** 0.34 ** 0.01 ** 0.11 ** State malpractice risk score Low tercile Middle tercile ** * Upper tercile ** ** Physician specialty (initial visit) PCP Cardiologist 0.59 ** ** 0.52 ** 3.80 ** Other 2.40 ** 2.37 ** ** 0.53 ** Beneficiary age * ** 0.70 ** ** * 2.16 * ** Beneficiary is male ** Beneficiary race White Black Other ** 0.31 ** 0.81 Comorbidities Diabetes * Chronic Pulmonary Disease ** 2.07 ** 0.87 Congestive Heart Failure * 1.26 Cerebrovascular Disease *

31 Table A14 Odds ratios from logistic regressions using state malpractice risk score terciles: Receipt of supplemental services within seven days of an initial non-emergency department visit for chest pain. ED Visit Hospital Admission Conventional Advanced Supplemental Testing Paralysis Peripheral Vascular Disease Acute Myocardial Infarction 3.34 ** ** 1.78 ** Old Myocardial Infarction 2.26 ** Chronic Renal Failure Chronic Diabetes with Complications Peptic Ulcer Disease ** Dementia 2.05 * Rheumatologic Disease Urbanicity Large metro (>1 million) Small metro (< 1 million) 1.55 ** ** Micropolitan ** 1.05 Noncore ** 1.42 * Beneficiary is a snowbird in Source: 2008 HSC Health Tracking Physician Survey linked with Medicare Claims *p 0.05; **p 0.01; -- insufficient variation to generate odds ratio for subgroup Note: Supplemental testing refers to stress tests. 31

32 Table A15. Odds ratios from logistic regressions using state malpractice risk score terciles: Receipt of supplemental services within seven days of an initial emergency department visit for chest pain. Hospital Admission Conventional Advanced Supplemental Testing Intercept 0.38 ** 8.77 ** 0.28 ** 0.39 ** State malpractice risk score Low tercile Middle tercile Upper tercile * 1.01 Physician specialty (initial visit) Emergency medicine PCP ** Other Beneficiary age ** ** 2.54 ** * ** * Beneficiary is male 1.37 ** Beneficiary race White Black * 0.76 Other Comorbidities Diabetes Chronic Pulmonary Disease ** 1.51 ** 1.07 Congestive Heart Failure 1.45 ** Cerebrovascular Disease 1.37 * ** Paralysis Peripheral Vascular Disease

33 Table A15. Odds ratios from logistic regressions using state malpractice risk score terciles: Receipt of supplemental services within seven days of an initial emergency department visit for chest pain. Hospital Admission Conventional Advanced Supplemental Testing Acute Myocardial Infarction 6.83 ** * Old Myocardial Infarction Chronic Renal Failure * 1.22 Chronic Diabetes with Complications Peptic Ulcer Disease Dementia ** Rheumatologic Disease Urbanicity Large metro (>1 million) Small metro (<1 million) 0.67 ** ** Micropolitan 0.61 ** * Noncore 0.42 ** 0.36 * 0.27 ** 0.61 Beneficiary is a snowbird in Source: 2008 HSC Health Tracking Physician Survey linked with Medicare Claims *p 0.05; **p 0.01 a Coefficient could not be estimated due to lack of variation in explanatory variable. Note: Supplemental testing refers to stress tests. 33

34 Table A16. Odds ratios from logistic regressions using state malpractice risk score terciles: Receipt of supplemental services within seven days of an initial non-emergency department visit for headache. ED Visit Hospital Admission Advanced Intercept 0.01 ** 0.00 ** 0.04 ** State malpractice risk score Low tercile Middle tercile Upper tercile Physician specialty (initial visit) PCP Neurologist ** Other * 0.48 ** Beneficiary age ** ** ** ** 2.62 ** * 5.54 * Beneficiary is male 2.04 ** 2.11 * 2.12 ** Beneficiary race White Black 2.65 ** Other Comorbidities Diabetes Chronic Pulmonary Disease Congestive Heart Failure Cerebrovascular Disease 2.20 ** 2.15 * 1.95 ** Paralysis ** 1.45 Peripheral Vascular Disease

35 Table A16. Odds ratios from logistic regressions using state malpractice risk score terciles: Receipt of supplemental services within seven days of an initial non-emergency department visit for headache. ED Visit Hospital Admission Advanced Acute Myocardial Infarction Old Myocardial Infarction 2.98 * 2.58 * 0.82 Chronic Renal Failure * Chronic Diabetes with Complications Peptic Ulcer Disease Dementia Rheumatologic Disease Urbanicity Large metro (>1 million) Small metro (<1 million) ** Micropolitan * Noncore Beneficiary is a snowbird in Source: 2008 HSC Health Tracking Physician Survey linked with Medicare Claims *p 0.05; **p 0.01; -- insufficient variation to generate odds ratio for subgroup Note: The model for conventional imaging is not reported because so few headache cases received this service. 35

36 Table A17. Odds ratios from logistic regressions using state malpractice risk score terciles: Receipt of supplemental services within seven days of an initial emergency department visit for headache. Hospital Admission Advanced Supplemental Testing Intercept 0.12 ** ** State malpractice risk score Low tercile Middle tercile Upper tercile Physician specialty (initial visit) Emergency medicine PCP Other Beneficiary age * * * Beneficiary is male Beneficiary race White Black Other Comorbidities Diabetes Chronic Pulmonary Disease Congestive Heart Failure Cerebrovascular Disease * 3.48 Paralysis ** 36

37 Table A17. Odds ratios from logistic regressions using state malpractice risk score terciles: Receipt of supplemental services within seven days of an initial emergency department visit for headache. Hospital Admission Advanced Supplemental Testing Peripheral Vascular Disease Acute Myocardial Infarction ** Old Myocardial Infarction Chronic Renal Failure Chronic Diabetes with Complications Peptic Ulcer Disease ** Dementia ** Rheumatologic Disease * 0.65 Urbanicity Large metro (>1 million) Small metro (<1 million) Micropolitan Noncore Beneficiary is a snowbird in ** Source: 2008 HSC Health Tracking Physician Survey linked with Medicare Claims *p 0.05; **p 0.01; -- insufficient variation to generate odds ratio for subgroup Note: The model for conventional imaging is not reported because so few headache cases received this service. Note: Supplemental testing refers to lumbar puncture. 37

38 Table A18. Odds ratios from logistic regressions using state malpractice risk score terciles: Receipt of supplemental services within seven days of an initial non-emergency department visit for low back pain. ED Visit Hospital Admission Conventional Advanced Intercept 0.01 ** 0.00 ** 0.21 ** 0.03 ** State malpractice risk score Low tercile Middle tercile Upper tercile 0.67 * Physician specialty (initial visit) PCP Orthopedist ** 7.25 ** Other ** 3.4 ** Beneficiary age ** ** 1.25 * * 8.45 ** 1.37 ** ** 7.28 ** 1.68 ** ** ** 2.07 ** * ** * Beneficiary is male Beneficiary race White Black Other Comorbidities Diabetes Chronic Pulmonary Disease 1.50 * Congestive Heart Failure * Cerebrovascular Disease Paralysis * Peripheral Vascular Disease ** 38

39 Table A18. Odds ratios from logistic regressions using state malpractice risk score terciles: Receipt of supplemental services within seven days of an initial non-emergency department visit for low back pain. ED Visit Hospital Admission Conventional Advanced Acute Myocardial Infarction 2.55 * Old Myocardial Infarction Chronic Renal Failure Chronic Diabetes with Complications Peptic Ulcer Disease Dementia * Rheumatologic Disease * 0.77 Urbanicity Large metro (>1 million) Small metro (<1 million) * 1.15 Micropolitan ** Noncore ** Beneficiary is a snowbird in Source: 2008 HSC Health Tracking Physician Survey linked with Medicare Claims *p 0.05; **p

40 Table A19. Odds ratios from logistic regressions using state malpractice risk score terciles: Receipt of supplemental services within seven days of an initial emergency department visit for low back pain. Hospital Admission Conventional Advanced Intercept 0.05 ** ** State malpractice risk score Low tercile Middle tercile 0.37 * Upper tercile Physician specialty (initial visit) Emergency medicine PCP 0.21 * Other * 0.32 Beneficiary age ** * ** 2.57 * 5.10 ** ** 4.03 ** 4.36 * ** Beneficiary is male Beneficiary race White Black Other 0.26 * Comorbidities Diabetes Chronic Pulmonary Disease Congestive Heart Failure 2.31 ** Cerebrovascular Disease Paralysis ** Peripheral Vascular

41 Table A19. Odds ratios from logistic regressions using state malpractice risk score terciles: Receipt of supplemental services within seven days of an initial emergency department visit for low back pain. Hospital Admission Conventional Advanced Disease Acute Myocardial Infarction Old Myocardial Infarction Chronic Renal Failure Chronic Diabetes with Complications Peptic Ulcer Disease Dementia Rheumatologic Disease Urbanicity Large metro (>1 million) Small metro (<1 million) Micropolitan * Noncore Beneficiary is a snowbird in Source: 2008 HSC Health Tracking Physician Survey linked with Medicare Claims *p 0.05; **p

42 Table A20. Odds ratios from logistic regressions including state damage cap indicator: Receipt of supplemental services within seven days of an initial non-emergency department visit for chest pain. ED Visit Hospital Admission 42 Conventional Advanced Supplemental Testing Intercept 0.02 ** 0.01 ** 0.27 ** 0.01 ** 0.08 ** State has damage cap ** Physician specialty (initial visit) PCP Cardiologist 0.58 ** ** 0.51 ** 3.89 ** Other 2.40 ** 2.37 ** ** 0.53 ** Beneficiary age * ** 0.69 ** ** * 2.17 * ** Beneficiary is male ** Beneficiary race White Black Other ** 0.29 ** 0.74 Comorbidities Diabetes Chronic Pulmonary Disease ** 2.07 ** 0.87 Congestive Heart Failure Cerebrovascular Disease * Paralysis Peripheral Vascular Disease Acute Myocardial Infarction 3.32 ** ** 1.82 **