Influence of malpractice history on the practice of screening and surveillance for Barrett's esophagus

BACKGROUND: Gastroenterologists' approach to surveillance for Barrett's esophagus is variable. We hypothesized that financial incentives and concerns over malpractice litigation influence gastroenterologists' usual practices regarding screening and surveillance. METHODS: We surveyed gastroenterologists (N = 224) regarding their usual practice of screening or surveillance for Barrett's esophagus, belief in the efficacy of screening, knowledge of published guidelines, demographic factors, compensation structure, volume of endoscopies, and malpractice history. Practices were characterized as aggressive or conservative in the utilization of services compared with a published guideline. RESULTS: Twenty-one percent of attending gastroenterologists reported being identified as a defendant in at least one malpractice suit. Prior malpractice defendants had practiced gastroenterology longer and performed a higher volume of endoscopies, but had similar knowledge regarding published screening guidelines to those who had not been defendants. They were more likely to be aggressive rather than conservative in screening and surveillance for Barrett's esophagus (odds ratio [OR] 3.6, 95% confidence interval [CI] 1.1-12), and remained so after controlling for other factors. In particular, they were more likely to recommend screening for populations with a lower risk of development of cancer, and to perform more frequent surveillance for low-grade dysplasia. Other factors were not associated with aggressive practice, including compensation structure. CONCLUSIONS: History of at least one prior malpractice suit appears to be associated with the more aggressive use of endoscopic screening and surveillance for Barrett's esophagus, irrespective of physician belief regarding the efficacy of that strategy in reducing mortality. Hypervigilance and fear of future malpractice suits may drive this increased use.