title: The practice of cranial neurosurgery and the malpractice liability environment in the United States.
abstract: OBJECTIVE
  The potential imbalance between malpractice liability cost and quality of care has been an issue of debate. We investigated the association of malpractice liability with unfavorable outcomes and increased hospitalization charges in cranial neurosurgery.
  
  
  METHODS
  We performed a retrospective cohort study involving patients who underwent cranial neurosurgical procedures from 2005-2010, and were registered in the National Inpatient Sample (NIS) database. We used data from the National Practitioner Data Bank (NPDB) from 2005 to 2010 to create measures of volume and size of malpractice claim payments. The association of the latter with the state-level mortality, length of stay (LOS), unfavorable discharge, and hospitalization charges for cranial neurosurgery was investigated.
  
  
  RESULTS
  During the study period, there were 189,103 patients (mean age 46.4 years, with 48.3% females) who underwent cranial neurosurgical procedures, and were registered in NIS. In a multivariable regression, higher number of claims per physician in a state was associated with increased ln-transformed hospitalization charges (beta 0.18; 95% CI, 0.17 to 0.19). On the contrary, there was no association with mortality (OR 1.00; 95% CI, 0.94 to 1.06). We observed a small association with unfavorable discharge (OR 1.09; 95% CI, 1.06 to 1.13), and LOS (beta 0.01; 95% CI, 0.002 to 0.03). The size of the awarded claims demonstrated similar relationships. The average claims payment size (ln-transformed) (Pearson's rho=0.435, P=0.01) demonstrated a positive correlation with the risk-adjusted hospitalization charges but did not demonstrate a correlation with mortality, unfavorable discharge, or LOS.
  
  
  CONCLUSIONS
  In the present national study, aggressive malpractice environment was not correlated with mortality but was associated with higher hospitalization charges after cranial neurosurgery. In view of the association of malpractice with the economics of healthcare, further research on its impact is necessary.
authors: Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States of America.
authors: Kimon
authors: K
authors: Bekelis
authors: Department of Neurosurgery, Cleveland Clinic Foundations, Cleveland, Ohio, United States of America.
authors: Symeon
authors: S
authors: Missios
authors: The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, United States of America.
authors: Kendrew
authors: K
authors: Wong
authors: The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, United States of America; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States of America.
authors: Todd A
authors: TA
authors: MacKenzie
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000601:surgery*; D005260:Female; D006760:Hospitalization / Q000191:economics; D006801:Humans; D016365:Liability, Legal; D008297:Male; D008318:Malpractice / Q000191:economics / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data; D008875:Middle Aged; D009493:Neurosurgery / Q000191:economics / Q000331:legislation & jurisprudence* / Q000592:standards / Q000706:statistics & numerical data; D014481:United States