title: International Defensive Medicine in Neurosurgery: Comparison of Canada, South Africa, and the United States.
abstract: OBJECTIVE
  Perception of medicolegal risk has been shown to influence defensive medicine behaviors. Canada, South Africa, and the United States have 3 vastly different health care and medicolegal systems. There has been no previous study comparing defensive medicine practices internationally.
  
  
  METHODS
  An online survey was sent to 3672 neurosurgeons across Canada, South Africa, and the United States. The survey included questions on the following domains: surgeon demographics, patient characteristics, physician practice type, surgeon liability profile, defensive behavior-including questions on the frequency of ordering additional imaging, laboratory tests, and consults-and perception of the liability environment. Responses were analyzed, and multivariate logistic regression was used to examine the correlation of medicolegal risk environment and defensive behavior.
  
  
  RESULTS
  The response rate was 30.3% in the United States (n = 1014), 36.5% in Canada (n = 62), and 41.8% in South Africa (n = 66). Canadian neurosurgeons reported an average annual malpractice premium of $19,110 (standard deviation [SD] = $11,516), compared with $16,262 (SD = $7078) for South African respondents, $75,857 (SD = $50,775) for neurosurgeons from low-risk U.S. states, and $128,181 (SD = $79,355) for those from high-risk U.S. states. Neurosurgeons from South Africa were 2.8 times more likely to engage in defensive behaviors compared with Canadian neurosurgeons, while neurosurgeons from low-risk U.S. states were 2.6 times more likely. Neurosurgeons from high-risk U.S. states were 4.5 times more likely to practice defensively compared with Canadian neurosurgeons.
  
  
  CONCLUSIONS
  Neurosurgeons from the United States and South Africa are more likely to practice defensively than neurosurgeons from Canada. Perception of medicolegal risk is correlated with reported neurosurgical defensive medicine within these countries.
authors.affiliation: Department of Neurosurgery, Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Sandra C
authors.initials: SC
authors.lastname: Yan
authors.affiliation: Department of Neurosurgery, Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: M Maher
authors.initials: MM
authors.lastname: Hulou
authors.affiliation: Department of Neurosurgery, Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Cote
authors.affiliation: Division of Neurosurgery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
authors.forename: David
authors.initials: D
authors.lastname: Roytowski
authors.affiliation: Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada.
authors.forename: James T
authors.initials: JT
authors.lastname: Rutka
authors.affiliation: Department of Neurosurgery, Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: William B
authors.initials: WB
authors.lastname: Gormley
authors.affiliation: Department of Neurosurgery, Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. Electronic address: trsmith@partners.org.
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Smith
mesh_terms: D002170:Canada; D003675:Defensive Medicine / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007351:Insurance, Liability / Q000191:economics; D016365:Liability, Legal; D016015:Logistic Models; D008297:Male; D008318:Malpractice; D015999:Multivariate Analysis; D009493:Neurosurgery; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D013019:South Africa; D011795:Surveys and Questionnaires; D014481:United States
keywords: Canada; Medico-legal environment; Neurosurgery; South Africa