Maya A. Babu

Malpractice Liability and Defensive Medicine: A National Survey of Neurosurgeons

Background Concern over rising healthcare expenditures has led to increased scrutiny of medical practices. As medical liability and malpractice risk rise to crisis levels, the medical-legal environment has contributed to the practice of defensive medicine as practitioners attempt to mitigate liability risk. High-risk specialties, such as neurosurgery, are particularly affected and neurosurgeons have altered their practices to lessen medical-legal risk. We present the first national survey of American neurosurgeons’ perceptions of malpractice liability and defensive medicine practices. Methods A validated, 51-question online-survey was sent to 3344 practicing U.S. neurosurgeon members of the American Association of Neurological Surgeons, which represents 76% of neurosurgeons in academic and private practices. Results A total of 1028 surveys were completed (31% response rate) by neurosurgeons representing diverse sub-specialty practices. Respondents engaged in defensive medicine practices by ordering additional imaging studies (72%), laboratory tests (67%), referring patients to consultants (66%), or prescribing medications (40%). Malpractice premiums were considered a “major or extreme” burden by 64% of respondents which resulted in 45% of respondents eliminating high-risk procedures from their practice due to liability concerns. Conclusions Concerns and perceptions about medical liability lead practitioners to practice defensive medicine. As a result, diagnostic testing, consultations and imaging studies are ordered to satisfy a perceived legal risk, resulting in higher healthcare expenditures. To minimize malpractice risk, some neurosurgeons have eliminated high-risk procedures. Left unchecked, concerns over medical liability will further defensive medicine practices, limit patient access to care, and increase the cost of healthcare delivery in the United States.

Is Trauma Transfer Influenced by Factors Other Than Medical Need? An Examination of Insurance Status and Transfer in Patients With Mild Head Injury

BACKGROUND:The Emergency Medical Treatment and Active Labor Act was meant to provide access to emergency medical care irrespective of financial resources. Yet, many Level I trauma Centers have raised concerns about the financial drivers influencing transfer. OBJECTIVE:To study the relationship between insurance status and transfer, we focused on patients with mild head injury to tease apart the medical necessity for transfer from other potential drivers, such as financial factors. METHODS:Using the 2002 to 2006 American College of Surgeons National Trauma Databank and Massachusetts General Hospitals Trauma Databank from 1993 to 2009, we conducted a retrospective study and limited our population to patients with mild head injuries and mild to moderate systemic injuries as determined by the Glasgow Coma Scale, Abbreviated Injury Scale, or Injury Severity Score. Statistical analyses were conducted with STATA software. RESULTS:In a nationalized database, (1) uninsured patients with mild head injury are more likely to be transferred out of a Level II or III facility (adjusted odds ratio [OR]: 2.07; P = .000) compared with privately insured patients and (2) uninsured patients are less likely to be accepted by a Level II or III facility for transfer compared with privately insured patients (adjusted OR: = .143; P = .000l). For transfers received by 1 Level I trauma center (Massachusetts General Hospital), uninsured patients are more likely to be transferred to (1) Massachusetts General Hospital between midnight and 6 am (adjusted OR: 5.201; P = .000) compared with other time periods throughout the day and (2) Massachusetts General Hospital on Sunday (adjusted OR: 1.09; P = .000) compared with other days of the week. CONCLUSION:Insurance status appears to influence transfer patterns.

Investigating the Scope of Resident Patient Care Handoffs within Neurosurgery

Introduction Handoffs are defined as verbal and written communications during patient care transitions. With the passage of recent ACMGE work hour rules further limiting the hours interns can spend in the hospital, many fear that more handoffs will occur, putting patient safety at risk. The issue of handoffs has not been studied in the neurosurgical literature. Methods A validated, 20-question online-survey was sent to neurosurgical residents in all 98 accredited U.S. neurosurgery programs. Survey results were analyzed using tabulations. Results 449 surveys were completed yielding a 56% response rate. 63% of neurosurgical residents surveyed had not received formal instruction in what constitutes an effective handoff; 24% believe there is high to moderate variability among their co-residents in terms of the quality of the handoff provided; 55% experience three or more interruptions during handoffs on average. 90% of neurosurgical residents surveyed say that handoff most often occurs in a quiet, private area and 56% report a high level of comfort for knowing the potential acute, critical issues affecting a patient when receiving a handoff. Conclusions There needs to be more focused education devoted to learning effective patient-care handoffs in neurosurgical training programs. Increasingly, handing off a patient adequately and safely is becoming a required skill of residency.

Strategies to Decrease the Risk of Ventricular Catheter Infections: A Review of the Evidence

The use of antibiotic-coated external ventricular catheters has been controversial among practitioners; although several papers have documented decreased adherence of microbes to catheters treated with antibiotics, there is no universally accepted practice standard for the use of coated catheters for the prevention of clinical infection. In this paper, we review the in vivo and in vitro evidence for antibiotic-coated catheters.

A review of lumbar spinal instrumentation: evidence and controversy

Disability secondary to disorders of the spine is a significant problem worldwide. In the USA, there has been a recent surge in the costs associated with caring for spinal pathology; from 1997 to 2005, there was a growth of 65% in healthcare expenditures on spinal disease, totalling

The durability of carotid endarterectomy: long-term results for restenosis and stroke.

86 billion in 2005. Increasingly, there has been media and public scrutiny over the rapid rise in the volume of procedures with spinal instrumentation; some have suggested that this rise has been fuelled by non-medical drivers such as the financial incentives involved with the use of instrumentation; others suggest that innovation in spine technology and devices has led to improved options for the treatment of spine pathology.In this context, we conducted a review of the literature to assess the use of instrumentation in lumbar procedures and its relationship to successful fusion and patient outcome. Our review suggests that there is data supporting the thesis that lumbar instrumentation improves rates of fusion. However, there is no consistent correlation between increased rates of fusion and improved patient outcomes.

Recurrent prostatic adenocarcinoma with perineural spread to the lumbosacral plexus and sciatic nerve: comparing high resolution MRI with torso and endorectal coils and F-18 FDG and C-11 choline PET/CT

BACKGROUND Carotid endarterectomy is a low-risk treatment for carotid occlusive disease. Recent clinical trials have suggested that carotid angioplasty may be a viable alternative. One important issue that has not been evaluated is the long-term recurrent stenosis rate after either intervention. OBJECTIVE To examine the risk of recurrent stenosis after carotid endarterectomy and to provide long-term data on the durability of carotid endarterectomy. METHODS A total of 1335 sequential patients were followed up prospectively with annual carotid ultrasonography. All patients were maintained on antiplatelet therapy, and arteriotomies were closed with a patch graft. Operations were performed under general anesthesia with electroencephalographic monitoring and selective shunting. There were no changes in surgical technique during this study. RESULTS Two-thirds of the patients were men; the mean age was 70 years. Approximately 60% were symptomatic. The 90-day perioperative morbidity and mortality rate was 0.9% (0.4% stroke and 0.5% death). Five patients (0.4%) developed recurrent stenosis >70% over a mean follow-up of 15.8 years. Twelve patients (0.9%) had documentation of late stroke in the ipsilateral carotid distribution. The mean follow-up was 15.8 years. CONCLUSION Carotid endarterectomy is an extremely safe treatment for carotid stenosis with very low perioperative complications and low rates of recurrent stenosis or late stroke. When endarterectomy is compared with angioplasty, in addition to periprocedural complications, the durability of both interventions needs to be considered, given the risks and costs of repeat interventions.

Does the Open Payments Database Provide Sunshine on Neurosurgery

We present a patient with unexplained sciatica (radiating pain down the leg) found to have recurrent prostate adenocarcinoma within the sciatic nerve. High resolution MRI, especially use of an endorectal coil, improved visualization of the perineural spread of the disease. We believe that perineural spread resulting in sciatic symptoms in patients with known prostate adenocarcinoma may be an under-recognized phenomenon. The use of non-invasive modalities, high resolution endorectal coil MRI, and C-11 choline PET/CT can assist in the diagnosis of these patients.

Device innovation in neurosurgery: controversy, learning, and future directions.

BACKGROUND The Open Payments Database (OPD) was launched by the Centers for Medicare & Medicaid Services in 2014. Through this online searchable database, the public can explore physician-industry interactions. To date, there is no published literature on the accuracy of the database for neurosurgeons or any physician specialty. OBJECTIVE To study the accuracy of published records and scope of industry-neurosurgeon relationships between neurosurgeons and industry within the OPD. METHODS We searched 4.3 million records in 2013 and 11.41 million records in 2014 in the OPD for board-certified neurosurgeons verified by the American Board of Neurological Surgery. Delimit software was used to condense these data, Microsoft Access for database queries, and STATA to perform descriptive analyses. RESULTS Of the 3240 neurosurgeons in the OPD in 2013, 2020 were identified correctly as neurosurgeons within the database (62%). Of the 3593 neurosurgeons in the OPD in 2014, 2433 were identified correctly as neurosurgeons (68%). Within the OPD in 2013, there were 72 066 attributed records for neurosurgeons; within the 2014 OPD, there were 160  563 attributed records for neurosurgeons. Total payments to neurosurgeons in 2013 (for the 9 months published in OPD):

Physician-owned hospitals, neurosurgeons, and disclosure: lessons from law and the literature.

61  802  659.37; in 2014: