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Joshua M. Rosenow and Katie O. Orrico

Object

Medicare reimbursement for physician services has been declining even as the number of Medicare enrollees has been increasing. The number of Medicare participants will only continue to grow as the American population ages and the Patient Protection and Affordable Care Act goes into effect. Efforts to increase reimbursement for physician services through Medicare are often met with data showing that most neurosurgeons continue to participate in the program despite these cutbacks. To better understand this dichotomy, practicing neurosurgeons were surveyed to gauge their response to cutbacks in the Medicare program beyond just their participation status.

Methods

An Internet-based survey invitation was emailed to 3469 practicing neurosurgeons. Reminder emails were sent at intervals over several weeks to help increase the response rate.

Results

Among respondents, an overwhelming percentage (96.8%) participated in Medicare. The neurosurgeons indicated that about one-third of their patient population was covered by Medicare. They also reported limiting the number of Medicare patients they see through a variety of mechanisms: only seeing Medicare patients with a specific diagnosis or from certain referring physicians or limiting the number of appointment slots for Medicare patients. Many respondents stated that further declines in Medicare reimbursement would lead to a reduction in their participation.

Conclusions

While most responding neurosurgeons do participate in the Medicare program, a substantial proportion modulates their participation through a variety of mechanisms. These barriers to care access for Medicare patients are only expected to become greater if further declines in reimbursement are implemented through the program.

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Henry H. Woo, Adam S. Arthur, J Mocco, Katie O. Orrico, John A. Wilson, and Brian L. Hoh

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Deborah L. Benzil, Karin M. Muraszko, Pranay Soni, Ellen L. Air, Katie O. Orrico, and James T. Rutka

OBJECTIVE

The goal of this study was the creation and administration of a survey to assess the depth and breadth of sexual harassment across neurosurgery.

METHODS

A survey was created to 1) assess perceived attitudes toward systemic issues that might be permissive of sexual harassment; 2) measure the reported prevalence and severity of sexual harassment; and 3) determine the populations at highest risk and those most likely to perpetrate sexual harassment. Demographic information was also included to facilitate further analysis. The SurveyMonkey platform was used, and a request to complete the survey was sent to all Society of Neurological Surgeons and Congress of Neurological Surgeons (CNS) active and resident members as well as CNS transitional, emeritus, and inactive members. Data were analyzed using RStudio version 1.2.5019.

RESULTS

Nearly two-thirds of responders indicated having witnessed sexual harassment in some form (62%, n = 382). Males were overwhelmingly identified as the offenders in allegations of sexual harassment (72%), with individuals in a “superior position” identified as offenders in 86%. Less than one-third of responders addressed the incidents of sexual harassment when they happened (yes 31%, no 62%, unsure 7%). Of those who did report, most felt there was either no impact or a negative one (negative: 34%, no impact: 38%). Almost all (85%) cited barriers to taking action about sexual harassment, including retaliation/retribution (87%), impact on future career (85%), reputation concerns (72%), and associated stress (50%). Female neurosurgeons were statistically more likely than male neurosurgeons to report witnessing or experiencing sexual harassment, as well as assessing it as a problem.

CONCLUSIONS

This study demonstrates that neurosurgeons report significant sexual harassment across all ages and practice settings. Sexual harassment impacts both men and women, with more than half personally subjected to this behavior and two-thirds having witnessed it. Male dominance, a hierarchical environment, and a permissive environment remain prevalent within the neurosurgical community. This is not just a historical problem, but it continues today. A change of culture will be required for neurosurgery to shed this mantle, which must include zero tolerance of this behavior, new policies, awareness of unconscious bias, and commitment to best practices to enhance diversity. Above all, it will require that all neurosurgeons and neurosurgical leaders develop an awareness of sexual harassment in the workplace and establish consistent mechanisms to mitigate against its highly deleterious effects in the specialty.

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Brandon G. Rocque, Bradley E. Weprin, Jeffrey P. Blount, Betsy D. Hopson, James M. Drake, Mark G. Hamilton, Michael A. Williams, Patience H. White, Katie O. Orrico, and Jonathan E. Martin

OBJECTIVE

The number of children with complex medical conditions surviving to adulthood is increasing. A planned transition to adult care systems is essential to the health maintenance of these patients. Guidance has been established for the general health care transition (HCT) from adolescence to adulthood. No formal assessment of the performance of pediatric neurosurgeons in HCT has been previously performed. No “best practice” for this process in pediatric neurosurgery currently exists. The authors pursued two goals in this paper: 1) define the current state of HCT in pediatric neurosurgery through a survey of the membership of the American Society of Pediatric Neurosurgeons (ASPN) on current methods of HCT, and 2) develop leadership-endorsed best-practice guidelines for HCT from pediatric to adult neurosurgical health care.

METHODS

Completion of the Current Assessment of Health Care Transition Activities survey was requested of 178 North American pediatric neurosurgeons by using a web-based questionnaire to capture HCT practices of the ASPN membership. The authors concurrently conducted a PubMed/MEDLINE–based literature review of HCT for young adults with special health care needs, surgical conditions, and/or neurological conditions for the period from 1990 to 2018. Selected articles were assembled and reviewed by subject matter experts and members of the ASPN Quality, Safety, and Advocacy Committee. Best-practice recommendations were developed and subjected to peer review by external expert groups.

RESULTS

Seventy-six responses to the survey (43%) were received, and 62 respondents (82%) answered all 12 questions. Scores of 1 (lowest possible score) were recorded by nearly 60% of respondents on transition policy, by almost 70% on transition tracking, by 85% on transition readiness, by at least 40% on transition planning as well as transfer of care, and by 53% on transition completion. Average responses on all core elements were < 2 on the established 4-point scale. Seven best-practice recommendations were developed and endorsed by the ASPN leadership.

CONCLUSIONS

The majority of pediatric neurosurgeons have transition practices that are poor, do not meet the needs of patients and families, and should be improved. A structured approach to transition, local engagement with adult neurosurgical providers, and national partnerships between pediatric and adult neurosurgery organizations are suggested to address current gaps in HCT for patients served by pediatric neurosurgeons.

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Andrew K. Chan, Michele Santacatterina, Brenton Pennicooke, Shane Shahrestani, Alexander M. Ballatori, Katie O. Orrico, John F. Burke, Geoffrey T. Manley, Phiroz E. Tarapore, Michael C. Huang, Sanjay S. Dhall, Dean Chou, Praveen V. Mummaneni, and Anthony M. DiGiorgio

OBJECTIVE

Spine surgery is especially susceptible to malpractice claims. Critics of the US medical liability system argue that it drives up costs, whereas proponents argue it deters negligence. Here, the authors study the relationship between malpractice claim density and outcomes.

METHODS

The following methods were used: 1) the National Practitioner Data Bank was used to determine the number of malpractice claims per 100 physicians, by state, between 2005 and 2010; 2) the Nationwide Inpatient Sample was queried for spinal fusion patients; and 3) the Area Resource File was queried to determine the density of physicians, by state. States were categorized into 4 quartiles regarding the frequency of malpractice claims per 100 physicians. To evaluate the association between malpractice claims and death, discharge disposition, length of stay (LOS), and total costs, an inverse-probability-weighted regression-adjustment estimator was used. The authors controlled for patient and hospital characteristics. Covariates were used to train machine learning models to predict death, discharge disposition not to home, LOS, and total costs.

RESULTS

Overall, 549,775 discharges following spinal fusions were identified, with 495,640 yielding state-level information about medical malpractice claim frequency per 100 physicians. Of these, 124,425 (25.1%), 132,613 (26.8%), 130,929 (26.4%), and 107,673 (21.7%) were from the lowest, second-lowest, second-highest, and highest quartile states, respectively, for malpractice claims per 100 physicians. Compared to the states with the fewest claims (lowest quartile), surgeries in states with the most claims (highest quartile) showed a statistically significantly higher odds of a nonhome discharge (OR 1.169, 95% CI 1.139–1.200), longer LOS (mean difference 0.304, 95% CI 0.256–0.352), and higher total charges (mean difference [log scale] 0.288, 95% CI 0.281–0.295) with no significant associations for mortality. For the machine learning models—which included medical malpractice claim density as a covariate—the areas under the curve for death and discharge disposition were 0.94 and 0.87, and the R2 values for LOS and total charge were 0.55 and 0.60, respectively.

CONCLUSIONS

Spinal fusion procedures from states with a higher frequency of malpractice claims were associated with an increased odds of nonhome discharge, longer LOS, and higher total charges. This suggests that medicolegal climate may potentially alter practice patterns for a given spine surgeon and may have important implications for medical liability reform. Machine learning models that included medical malpractice claim density as a feature were satisfactory in prediction and may be helpful for patients, surgeons, hospitals, and payers.