Survey shows that vast majority of US neurosurgeons participate in defensive medicine

More than three-fourths US neurosurgeons practice some form of defensive medicine--performing additional tests and procedures out of fear of malpractice lawsuits, reports a special article in the February issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The rates and costs of defensive medicine by neurosurgeons are especially high in states with high-risk liability environments. "Although ordering extra laboratory tests, imaging studies, etc. was prevalent everywhere, it was even more so in high-risk states," according to the survey study by Dr. Timothy R. Smith of Northwestern University, Chicago, and colleagues.

Most Neurosurgeons Report Defensive Medicine...

Dr. Smith and colleagues sent a questionnaire regarding defensive medicine to 3,344 Board-certified neurosurgeons. Defensive medicine refers to making medical decisions based on concerns over possible malpractice lawsuits, rather than any expected benefit to the patient. The study assessed the relationship between defensive medicine practice and an objective measure of the "liability risk environment" of the neurosurgeon's state.

The survey response rate was 31 percent, with 1,026 neurosurgeons responding. Those practicing in states with high-risk liability environments were more likely to respond. Most neurosurgeons correctly perceived their state's level of liability risk.

Based on the survey responses, "The vast majority of US neurosurgeons participate in some form of defensive medicine," Dr. Smith and colleagues write. More than 80 percent of surgeons said they had ordered imaging tests solely for defensive reasons, while more than three-fourths reported ordering laboratory tests and making extra referrals for defensive purposes. Up to half said they ordered more medications and procedures out of fear of being sued.

Rates of all of these defensive behaviors were higher for neurosurgeons in high-risk states. This included a 30 percent increase in the likelihood of ordering additional imaging studies for defensive purposes, 40 percent for additional laboratory tests.

...Even More So in States with High Risk of Liability

Nearly half of neurosurgeons in high-risk states said they had stopped performing high-risk procedures because of liability concerns. Nearly one-fourth had stopped performing brain surgery for fear of being sued, while close to 40 percent were considering retirement because of the local liability environment.

Overall, the rate of defensive medicine behaviors increased by 50 percent at each grade of the five-point risk scale. Thus, a neurosurgeon practicing in a state at highest risk of liability would be six times more likely to practice defensive medicine than one in a state at lowest risk.

Neurosurgeons in high-risk states paid almost twice as much in malpractice insurance premiums as those in low-risk states. Across states, most neurosurgeons believed their malpractice coverage was inadequate. Malpractice premiums cost 15 to 20 percent of the neurosurgeons' annual income.

Neurosurgery--like obstetrics/gynecology and orthopedic surgery--is a specialty with a high risk of costly malpractice claims. Amid ongoing debate over defensive medicine, few studies have focused on the extent of defensive medicine practice among neurosurgeons.

The new survey suggests high rates of defensive medicine practice among neurosurgeons, and finds that these behaviors are related to perceived and actual liability risk by state. "Defensive medicine practices do not align with patient-centered care, and may contribute to increased inefficiency in an already taxed health care system," Dr. Smith and coauthors conclude.