Medicolegal Risks in Neurosurgery

NEUROSURGERY SOCIETY

05 August 2018

Mr. Volker von Widdern (CEO, Constantia)

Dr. Bettina Taylor (Clinical Risk Advisor)

Constantia, your Trusted Brand whose Responsive Teams

provide innovative Risk and Insurance Solutions in

Selected Markets.

Professional indemnity

EthiQal is a professional indemnity solution which was

launched in November 2016.

Constantia Insurance

Sources and Solutions for Risk

Sources of risk • Negligence • Data absence • Communication • Skills • Environment • Emergencies • “Hospital Passes” • Practice management • Clinical risk • Litigation

Impact / Cost of risk • Policy limit • Contingency Fees

Duration of risk • Litigation • Judiciary • Expert opinions

Solutions for risk • Basic training • Data strategy, infrastructure, analysis => SSSA database sponsorship • CPD • Consent => detailed interventions, eg: Neuro • Content => CP conference • Apology • Records => “single file” concept • Relationship => non adversarial policy defence stance • Peer review => sponsored by EthiQal • Judiciary education, assessors => SAMLA conference

Impact / Cost of risk • Mediation vs legal fees => Substantively implemented • Structured settlements => EthiQal tender model is ready

Duration of risk • Early intervention • Evidence based medical opinions => CP conference • Credentials for experts => Associations have commenced

Neurosurgery Premiums

0

100000

200000

300000

400000

500000

600000

700000

800000

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Data Analysis

All neurosurgeons who have

shared their claims history

with Constantia as part of

the policy application

process (n = 38)

Retrospective Analysis Age, claim type, claim

outcome, reason for

claim, anatomical

location, diagnosis,

procedure

Historic claims as forwarded

during policy application

process, plus claims

registered since policy

inception with Constantia

Real life data

Selection bias

Data Source Study Population Study Design Measurements Study Limitations

Neurosurgery claim distribution: International Experience

0

10

20

30

40

50

60

70

80

90

100

Spinal Cranial Other

NHS

US

SA

% c

ase

s se

ttle

d

1. Rovit R et al. 2007. J Neurosurg ; 106: 1108 – 1114 2. Mukherjee S et al. 2014. Ann R Coll Surg. Eng; 96: 266-70

Neurosurgery claims: SA experience

Neurosurgical claims settled/likely to be settled Some form of monetary settlement anticipated in ~ 1:3 cases

Cranial

Spinal

18%

82%

Reasons underpinning neurosurgery claims

Clinical decision-making & technical skills

Billing and behaviour

Informed Consent

No-no Events

80%

14%

3% 3%

Reasons underpinning cranial claims

2/3 cases settled relate to treatment of hydrocephalus in children

Post-operative complications

Inappropriate management

Injury to vessel

Failed procedure

Reasons underpinning spinal claims

Vast majority of cases appear to relate to

treatment of degenerative spinal disease.

Device-related complications highlighted in

1 out of 4 cases.

70% of cases appear to relate to ‘the failed

promise of back surgery’.

Failed procedure

Neurological injury

Post-operative complication

Inappropriate management

Injury other than neurological

42%

29%

13%

8%

8%

Neurosurgery claims: Number of claims/practitioner

0

10

20

30

40

50

60

70

80

0 1 2 3 4 5 6 7 8 9 10

Settled Claims

Medicolegal Cases% o

f su

rge

on

s

Number of cases per doctor

Neurosurgery claims: Number of claims/practitioner > 45 years

0

5

10

15

20

25

30

35

40

45

0 1 2 3 4 5 6 7 8 9 10

> 45 Years

All Ages

% o

f p

ract

itio

ne

rs

Number of medicolegal cases per practitioner

Outliers contribute significantly to

claim costs

Summary of neurosurgical claims risk

Spinal claims are driving

frequency of complaints and

settlements, in particular ‘the

failed promise of back surgery’

No/no cases are happening Whilst cases relating to

hydrocephalus are rare, their

financial impact is significant

Collaboration on the

Electronic Patient Record

Early identification of

high-risk surgeons and

the design of early

interventions programs

Appointment of expert

panels for balanced

adjudication of high-

quantum cases

Definition of clinical

guidelines and protocols in

relation to management of

high-risk diseases

Mentorship programmes

The way forward

Thank you Questions?