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Defensive Medicine in U.S. Spine Neurosurgery

Din, Ryan S., BS; Yan, Sandra C., BS; Cote, David J., BS; Acosta, Michael A., BS; Smith, Timothy R., MD, PhD, MPH

doi: 10.1097/BRS.0000000000001687

Study Design. Observational cross-sectional survey.

Objective. To compare defensive practices of U.S. spine and nonspine neurosurgeons in the context of state medical liability risk.

Summary of Background Data. Defensive medicine is a commonly reported and costly phenomenon in neurosurgery. Although state liability risk is thought to contribute greatly to defensive practice, variation within neurosurgical specialties has not been well explored.

Methods. A validated, online survey was sent via email to 3344 members of the American Board of Neurological Surgeons. The instrument contained eight question domains: surgeon characteristics, patient characteristics, practice type, insurance type, surgeon liability profile, basic surgeon reimbursement, surgeon perceptions of medical legal environment, and the practice of defensive medicine.

Results. The overall response rate was 30.6% (n = 1026), including 499 neurosurgeons performing mainly spine procedures (48.6%). Spine neurosurgeons had a similar average practice duration as nonspine neurosurgeons (16.6 vs 16.9 years, P = 0.64) and comparable lifetime case volume (4767 vs 4,703, P = 0.71). The average annual malpractice premium for spine neurosurgeons was similar to nonspine neurosurgeons ($104,480.52 vs $101,721.76, P = 0.60). On average, spine neurosurgeons had a significantly higher rate of ordering labs, medications, referrals, procedures, and imaging solely for liability concerns compared with nonspine neurosurgeons (89.2% vs 84.6%, P = 0.031). Multivariate analysis revealed that spine neurosurgeons were roughly 3 times more likely to practice defensively compared with nonspine neurosurgeons (odds ratio, OR = 2.9, P = 0.001) when controlling for high-risk procedures (OR = 7.8, P < 0.001), annual malpractice premium (OR = 3.3, P = 0.01), percentage of patients publicly insured (OR = 1.1, P = 0.80), malpractice claims in the last 3 years (OR = 1.13, P = 0.71), and state medical-legal environment (OR = 1.3, P = 0.37).

Conclusion. State-based medical legal environment is not a significant driver of increased defensive medicine associated with neurosurgical spine procedures.

Level of Evidence: 3

Department of Neurosurgery, Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Address correspondence and reprint requests to Ryan S. Din, BS, Department of Neurosurgery, Neurosurgery Outcomes Center, Brigham and Women's Hospital, 15 Francis Street–PBB3, Boston, MA 02115; E-mail:

Received 9 November, 2015

Revised 10 April, 2016

Accepted 23 April, 2016

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

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