Defensive Medicine in U.S. Spine Neurosurgery

Din, Ryan S.; Yan, Sandra C.; Coté, David J.; Acosta, Michael; Smith, Timothy R.

doi:10.1097/brs.0000000000001687

Cited by 27 publications

(30 citation statements)

References 19 publications

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“…While we have attempted to isolate the effect of non-economic damages in our methods, the contributors to defensive practice are complex and interwoven. The clinical decision making of these specialized practitioners may be influenced by perception that they are targets for lawsuits [27], bias from the referral nature of their practices, specialty-based differences in treatment of LBP, and behaviors instilled from training or practice [10]. Our sensitivity analysis (with MRI and CT scans isolated) demonstrates that both the timing and type of test ordered are preference-sensitive, further showing the influence of individual practice.…”

Section: Discussionmentioning

confidence: 86%

Removal of Non-economic Damage Caps Is Not Associated with Reductions in Early Imaging for Low Back Pain

Keller

Sepper

et al. 2019

HSS Jrnl

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Background Supporters of medical liability reform contend that caps on non-economic damages will decrease defensive medicine. Questions/Purposes We examined whether removal of caps on non-economic damages affect one type of defensive medical practice, early imaging for new-onset low back pain. Patients and Methods Using administrative claims data, we retrospectively studied adult patients evaluated for new-onset low back pain from 2007 to 2012. We included patients from two states that had caps on non-economic damages struck down in 2010 (n = 462, 604) and patients from adjacent states (n = 781, 963). Using a difference-in-differences approach, we evaluated the impact of non-economic damage caps on early imaging while adjusting for physician specialty, patient characteristics, and year- and state-level fixed effects. Results There was no association between non-economic damage caps and early imaging for low back pain among all providers. Removal of a non-economic damage cap was also not associated with a significant change in early imaging within the two cap-removal states. Subgroup analysis by physician specialty demonstrated significantly increased use of early imaging for low back pain by orthopedic or neurological surgeons in the first 12 months following cap removal in one state (but this difference did not persist beyond 12 months). In the other cap-removal state, early imaging increased among orthopedic and neurological surgeons more than 12 months after cap removal. Conclusion We found no association between caps on non-economic damages and early imaging for low back pain among all physicians. However, our subgroup analysis suggests that physician specialties may respond to non-economic damage cap policies differently.

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Section: Discussionmentioning

confidence: 86%

Removal of Non-economic Damage Caps Is Not Associated with Reductions in Early Imaging for Low Back Pain

Keller

Sepper

et al. 2019

HSS Jrnl

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“…Similar results were also seen in more recent surveys focused on practicing defensive medicine in the neurosurgical field. 8,11,12 In the study by Smith et al, neurosurgeons in the US were 50% more likely to practice defensive medicine in states categorized as high-risk liability environments than in states categorized as low-risk liability environments. 12 Another survey among US neurosurgeons showed that neurosurgeons who mainly practice spine surgery were up to three times more likely to practice defensive medicine than other neurosurgeons.…”

Section: Comparison With Other Studiesmentioning

confidence: 99%

“…12 Another survey among US neurosurgeons showed that neurosurgeons who mainly practice spine surgery were up to three times more likely to practice defensive medicine than other neurosurgeons. 11 In contrast to earlier studies in which neurosurgeons employed in the US had been surveyed, Yan et al explored defensive medicine behaviors among Dutch neurosurgeons. 8 Their study showed that Dutch neurosurgeons viewed their practices to be less at risk in general compared to their American colleagues.…”

Section: Comparison With Other Studiesmentioning

confidence: 99%

“…Because of this, the practice of defensive medicine is quite common. 8,10,11 Previous research among neurosurgeons in Europe and the US showed that neurosurgeons may practice defensive medicine more frequently when the risk of medical malpractice lawsuits is greater. 8,12 It is, however, unclear to what extent this is correlated with having faced malpractice suits and to what extent this has influenced their practice of medicine.…”

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confidence: 99%

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Experiences of neurological surgeons with malpractice lawsuits

Gadjradj

Ghobrial

Harhangi

2020

Neurosurgical Focus

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OBJECTIVEAs a specialty that treats acute pathology and refractory pain, neurosurgery is at risk for high liability, making the practice of defensive medicine quite common. The extent to which the practice of defensive medicine is linked to experience with malpractice lawsuits remains unclear. The aims of this study were to clarify this by surveying neurosurgeons about the frequency of experiencing medical lawsuits and to show how neurosurgeons reflect on facing such lawsuits.METHODSA survey consisting of 24 questions was distributed among members of the Congress of Neurological Surgeons. The survey consisted of four parts: 1) demographics of participants; 2) the way malpractice lawsuits affect the way respondents practice medicine; 3) experiences with medical malpractice lawsuits; and 4) the effect of the medical malpractice environment on one’s own practice of medicine.RESULTSThere were a total of 490 survey respondents, 83.5% of whom were employed in the US. Of the respondents, 39.5% stated they were frequently or always concerned about being sued, and 77.4% stated their fear had led to a change in how they practice medicine. For 58.4%, this change led to the practice of defensive medicine, while for others it led to more extensive documentation (14.3%) and/or to referring or dropping complex cases (12.4%).Among the respondents, 80.9% at some time were named in a medical malpractice lawsuit and 12.3% more than 10 times. The main concerns expressed about being sued included losing confidence and practicing defensive medicine (17.8%), personal assets being at risk (16.9%), and being named in the National Practitioner Data Bank (15.6%). Given the medical malpractice environment, 58.7% of respondents considered referring complex patient cases, whereas 36.5% considered leaving the practice of medicine. The fear of being sued (OR 4.06, 95% CI 2.53–6.51) and the consideration of limiting the scope of practice (OR 3.08, 1.80–5.20) were both independently associated with higher odds of considering leaving the practice of medicine.CONCLUSIONSThe current medicolegal landscape has a profound impact on neurosurgical practice. The fear of being sued, the financial aspects of practicing defensive medicine, and the proportion of neurosurgeons who are considering leaving the practice of medicine emphasize the need for a shift in the medicolegal landscape to a system in which fear of being sued does not play a dominant role and the interests of patients are protected.

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“…The other interests of this alternative route are to counteract defensive practices by trying to reduce and control insurance and legal costs for the parties (in fact, lawyers are not necessarily involved in CCI procedures). 3,23,24 In addition, no-fault schemes make it easier to communicate and think about the identification and prevention of adverse events. 25,26…”

Section: National Solidarity and The Welfare Statementioning

confidence: 99%

Litigations following spinal neurosurgery in France: “out-of-court system,” therapeutic hazard, and welfare state

Debono

Gerson²,

Houselstein³

et al. 2020

Neurosurgical Focus

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OBJECTIVESpinal surgeries carry risks of malpractice litigation due to the random nature of their functional results, which may not meet patient expectations, and the hazards associated with these complex procedures. Claims are frequent and costly. In France, since 2002, a new law, the Patients’ Rights Law of March 4, 2002, has created an alternative, out-of-court scheme, which established a simplified, rapid, free-of-charge procedure (Commission for Conciliation and Compensation [CCI]). Moreover, this law has optimized the compensation provided to patients for therapeutic hazards by use of a national solidarity fund. The authors analyzed the consequences of this alternative route in the case of claims against private neurosurgeons in France.METHODSFrom the data bank of the insurer Mutuelle d’Assurances du Corps de Santé Français (MACSF), the main insurance company for private neurosurgeons in France, the authors retrospectively analyzed 193 files covering the period 2015–2019. These computerized files comprised the anonymized medical records of the patients, the reports of the independent experts, and the final judgments of the CCI and the entities supporting the compensation, if any.RESULTSDuring the 5-year study period (2015–2019), the insurance company recorded 494 complaints involving private neurosurgeons for spinal surgery procedures, of which 126 (25.5%) were in civil court, 123 (24.9%) were under amicable procedure, and 245 (49.6%) were in the out-of-court scheme administered by the CCI. Out of these 245 cases, only 193 were closed due to delays. The conclusions of the commission were rejection/incompetence decisions in 47.2% of the cases, therapeutic hazards in 21.2%, nosocomial infections in 17.6%, and practitioner fault in 13.5%. National solidarity compensated for 48 complaints (24.8%). The final decision of the CCI is not always consistent with the conclusions of the experts mandated by it, illustrating the difficulty in defining the concept of hazards. The authors found that the therapeutic hazards retained and compensated by the national solidarity included decompensated spondylotic myelopathies (15% of the 40 cases) and cauda equina syndromes (30%). As allowed by law, 11.5% of the patients who were not satisfied triggered a classical procedure in a court.CONCLUSIONSIn the French out-of-court system, trial decisions resulting in rulings of proven medical malpractice are rare, but patients can start a new procedure in the classical courts. The therapeutic hazard remains a subtle definition, which may be problematic and require further discussion between experts and magistrates. In spite of the imperfections, this out-of-court system proposes a major evolution to move patients and medical providers from legal battles to reconciliations.

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Defensive Medicine in U.S. Spine Neurosurgery

Abstract: 3.

Cited by 27 publications

References 19 publications

Removal of Non-economic Damage Caps Is Not Associated with Reductions in Early Imaging for Low Back Pain

Removal of Non-economic Damage Caps Is Not Associated with Reductions in Early Imaging for Low Back Pain

Experiences of neurological surgeons with malpractice lawsuits

Litigations following spinal neurosurgery in France: “out-of-court system,” therapeutic hazard, and welfare state

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