Elsevier

World Neurosurgery

Volume 89, May 2016, Pages 112-120
World Neurosurgery

Original Article
Neurosurgical Defensive Medicine in Texas and Illinois: A Tale of 2 States

https://doi.org/10.1016/j.wneu.2016.01.080Get rights and content

Objective

To compare the self-reported liability characteristics and defensive medicine practices of neurosurgeons in Texas with neurosurgeons in Illinois in an effort to describe the effect of medicolegal environment on defensive behavior.

Methods

An online survey was sent to 3344 members of the American Board of Neurological Surgery. Respondents were asked questions in 8 domains, and responses were compared between Illinois, the state with the highest reported average malpractice insurance premium, and Texas, a state with a relatively low average malpractice insurance premium.

Results

In Illinois, 85 of 146 (58.2%) neurosurgeons surveyed responded to the survey. In Texas, 65 of 265 (24.5%) neurosurgeons surveyed responded. In Illinois, neurosurgeons were more likely to rate the overall burden of liability insurance premiums to be an extreme/major burden (odds ratio [OR] = 7.398, P < 0.001) and to have >$2 million in total coverage (OR = 9.814, P < 0.001) than neurosurgeons from Texas. Annual malpractice insurance premiums in Illinois were more likely to be higher than $50,000 than in Texas (OR = 9.936, P < 0.001), and survey respondents from Illinois were more likely to believe that there is an ongoing medical liability crisis in the United States (OR = 9.505, P < 0.001). Neurosurgeons from Illinois were more likely to report that they very often/always order additional imaging (OR = 2.514, P = 0.011) or very often/always request additional consultations (OR = 2.385, P = 0.014) compared with neurosurgeons in Texas.

Conclusions

Neurosurgeons in Illinois are more likely to believe that there is an ongoing medical liability crisis and more likely to practice defensively than neurosurgeons in Texas.

Introduction

The threat of medical liability can promote the practice of defensive medicine.1 In the United States, defensive medicine has been shown to increase health care costs and to expose patients to unnecessary tests and associated morbidity. It has been estimated that the total cost of the medical liability environment in the United States was $55.6 billion in 2008, approximately 2.4% of national health care spending.2 The practice of defensive medicine, which has been proposed as a driver of these costs, is generally divided into 2 categories: positive behaviors and negative behaviors. Positive defensive medicine is the practice of providing care that is unnecessary or repetitive, whereas negative defensive medicine is refusing to provide a type of care for a patient because of either perceived or actual medicolegal risk.3

Physicians in high-risk specialties such as neurosurgery have been shown to engage in defensive medicine practices.1, 4, 5, 6 Previous surveys of physicians in specialties with a high risk of litigation (emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology) found that 93% of physicians reported practicing defensive medicine.4 When asked to report their most defensive act, 43% of physicians reported ordering imaging in situations where it was not clinically indicated.4 In addition, 42% of physicians reported taking active steps to restrict their practice to avoid procedures prone to complications and avoiding patients with complex medical problems.4 A study on the prevalence of defensive medicine in orthopedic trauma surgeons found that an average of 22% of all ordered tests were for defensive medicine purposes and estimated this cost to be approximately $256.3 million annually.7

These studies highlight the climate that is generated around the fear of medical litigation.8, 9, 10 In an environment with widespread positive defensive medicine practices, patients are exposed to unnecessary medical procedures as well as their associated morbidities and risks and increases in health care costs.11, 12, 13 Negative defensive medicine practices impede the ability of high-risk patients to receive appropriate care in poor medicolegal environments because of fear of litigation.14, 15 Much effort has been put into determining predictors and motivators of defensive medical practices, with the end goal of eliminating incentives for physicians to practice defensively to reduce wasteful spending and protect high-risk patients.16, 17 In this study, we compare the self-reported liability characteristics and defensive medicine behaviors among neurosurgeons in 2 states: Illinois, a state with a generally poor medicolegal environment and no active cap on malpractice damages, and Texas, a state with a favorable medicolegal environment and limitations on damages for pain and suffering in malpractice lawsuits.18, 19

Section snippets

Materials and Methods

A 51-question online survey was sent by e-mail to 3344 board-certified members of the American Board of Neurological Surgery, using e-mail addresses listed in public records. The survey was designed to measure the perception of liability risk and defensive medicine practices among neurosurgeons in the United States, was open to responders for 60 days, and was completely anonymous. The 51 questions were contained in 8 domains: surgeon demographics, patient population demographics, physician

Results

Of 146 neurosurgeons surveyed in Illinois, 86 (58.9%) responded to the survey. In Texas, 65 of 265 (24.5%) neurosurgeons surveyed responded. Respondents were not required to answer every question. Most survey respondents from both states were men (140; 93.3%). Surgeons in Texas had a higher annual case volume compared with surgeons in Illinois (277 cases per year vs. 225 cases per year by frequency-based average, P = 0.003) but were otherwise well matched across self-reported experience and

Discussion

Addressing the overall medicolegal environment could be key to reducing defensive practices. If physicians are less likely to experience litigation, they may be less inclined to order unnecessary imaging, blood work, or referrals, and they may be more willing to take on patients deemed to be high risk.1, 6, 20, 21 To explore the association between perception of medicolegal environment and defensive practice further, we compared the self-reported defensive practices of neurosurgeons in 2 states

Conclusions

Neurosurgeons in Illinois, a state with high annual malpractice premiums and no active cap on malpractice settlements, are more likely to believe that there is an ongoing medical liability crisis and more likely to practice positive defensive medicine than neurosurgeons in Texas, a state with lower annual malpractice premiums and restrictions on damages for pain and suffering.

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  • Cited by (15)

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      The next largest proportion of papers reported on defensive practice in surgery: 16 papers (20.3 %) reported exclusively on surgeons; a further 15 of the mixed sample studies included general or specialist surgeons. Neurosurgery was the most investigated surgical specialty field: nine papers investigated only neurosurgeons [11,43–49] and three of the mixed sample papers included neurosurgeons [25,27,50]. Eleven papers reported on general surgery or surgery without identifying a specialty area.

    • Defensive medicine: Everything and its opposite

      2020, European Journal of Internal Medicine
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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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