The practice of cranial neurosurgery and the malpractice liability environment in the United States

Abstract

Object: 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.

Fig 1. Cohort selection for the study.

Fig 2. Scatter plot demonstrating the correlation of average state-level mortality for cranial neurosurgical procedures and average size (ln-transformed) (A) and number (B) of paid claims per physician per state.

Fig 3. Scatter plot demonstrating the correlation of average state-level length of stay for cranial neurosurgical procedures and average size (ln-transformed) (A) and number (B) of paid claims per physician per state.

Fig 4. Scatter plot demonstrating the correlation of the rate of unfavorable discharge after cranial neurosurgical procedures and average size (ln-transformed) (A) and number (B) of paid claims per physician per state.

Fig 5. Scatter plot demonstrating the correlation of the ln-transformed average state-level hospitalization charges for cranial neurosurgical procedures and average size (ln-transformed) (A) and number (B) of paid claims per physician per state.