title: Defensive medicine in neurosurgery: does state-level liability risk matter?
abstract: BACKGROUND
  Defensive medicine is prevalent among US neurosurgeons due to the high risk of malpractice claims. This study provides national estimates of US neurosurgeons' defensive behaviors and perceptions.
  
  
  OBJECTIVE
  To examine the relationship of defensive medicine-both "assurance" behaviors and "avoidance" behaviors-to the liability environment.
  
  
  METHODS
  A 51-question online survey was sent to 3344 US neurosurgeon members of the American Board of Neurological Surgeons (ABNS). The survey was anonymous and conducted over 6 weeks in the spring of 2011. The previously validated questionnaire contained questions on neurosurgeon, patient, and practice characteristics; perceptions of the liability environment; and defensive-medicine behaviors. Bivariate and multivariate analyses examined the state liability risk environment as a predictor of a neurosurgeon's likelihood of practicing defensive medicine.
  
  
  RESULTS
  A total of 1026 neurosurgeons completed the survey (31% response rate). Neurosurgeons' perceptions of their state's liability environment generally corresponded well to more objective measures of state-level liability risk because 83% of respondents correctly identified that they were practicing in a high-risk environment. When controlling for surgeon experience, income, high-risk patient load, liability history, and type of patient insurance, neurosurgeons were 50% more likely to practice defensive medicine in high-risk states compared with low-risk-risk states (odds ratio: 1.5, P<.05).
  
  
  CONCLUSIONS
  Both avoidance and assurance behaviors are prevalent among US neurosurgeons and are correlated with subjective and objective measures of state-level liability risk. Defensive medicine practices do not align with patient-centered care and may contribute to increased inefficiency in an already taxed health care system.
authors.affiliation: *Department of Neurological Surgery, Northwestern University, Chicago, Illinois; ‡Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts; §Department of Neurological Surgery, Mayo Medical School, Rochester, Minnesota; ¶Department of Neurological Surgery, UMDNJ-New Jersey Medical School, Newark, New Jersey.
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Smith
authors.forename: Ali
authors.initials: A
authors.lastname: Habib
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Rosenow
authors.forename: Brian V
authors.initials: BV
authors.lastname: Nahed
authors.forename: Maya A
authors.initials: MA
authors.lastname: Babu
authors.forename: George
authors.initials: G
authors.lastname: Cybulski
authors.forename: Richard
authors.initials: R
authors.lastname: Fessler
authors.forename: H Hunt
authors.initials: HH
authors.lastname: Batjer
authors.forename: Robert F
authors.initials: RF
authors.lastname: Heary
mesh_terms: D000328:Adult; D003675:Defensive Medicine / Q000706:statistics & numerical data*; D003695:Delivery of Health Care; D005260:Female; D006801:Humans; D008297:Male; D008318:Malpractice; D009493:Neurosurgery / Q000706:statistics & numerical data*; D018802:Patient-Centered Care; D012306:Risk; D011795:Surveys and Questionnaires