Removal of Non-economic Damage Caps Is Not Associated with Reductions in Early Imaging for Low Back Pain

  • Christopher J. Dy
  • Michael F. Pesko
  • Matthew Keller
  • Elizabeth Sepper
  • Margaret A. Olsen
Original Article



Supporters of medical liability reform contend that caps on non-economic damages will decrease defensive medicine.


We examined whether removal of caps on non-economic damages affect one type of defensive medical practice, early imaging for new-onset low back pain.

Patients and Methods

Using administrative claims data, we retrospectively studied adult patients evaluated for new-onset low back pain from 2007 to 2012. We included patients from two states that had caps on non-economic damages struck down in 2010 (n = 462,604) and patients from adjacent states (n = 781,963). Using a difference-in-differences approach, we evaluated the impact of non-economic damage caps on early imaging while adjusting for physician specialty, patient characteristics, and year- and state-level fixed effects.


There was no association between non-economic damage caps and early imaging for low back pain among all providers. Removal of a non-economic damage cap was also not associated with a significant change in early imaging within the two cap-removal states. Subgroup analysis by physician specialty demonstrated significantly increased use of early imaging for low back pain by orthopedic or neurological surgeons in the first 12 months following cap removal in one state (but this difference did not persist beyond 12 months). In the other cap-removal state, early imaging increased among orthopedic and neurological surgeons more than 12 months after cap removal.


We found no association between caps on non-economic damages and early imaging for low back pain among all physicians. However, our subgroup analysis suggests that physician specialties may respond to non-economic damage cap policies differently.


defensive medicine tort reform malpractice low back pain early imaging 



This article is the authors’ responsibility and does not necessarily represent the official views of the NCATS, the AHRQ, the NCI, or the NIH.

Compliance with Ethical Standards

Conflict of Interest

Michael F. Pesko, PhD, and Elizabeth Sepper, JD, declare that they have no conflicts of interest. Christopher J. Dy, MD, MPH, reports support from grant number UL1 TR000448, Sub award KL2 TR000450, from the National Institutes of Health (NIH) National Center for Advancing Translational Sciences (NCATS), and from the NIH Roadmap for Medical Research, during the conduct of the study. Margaret A. Olsen, PhD, MPH, reports grants and personal fees from Pfizer and grants from Sanofi Pasteur, outside the submitted work. Matthew Keller, MS, and Margaret A. Olsen, PhD, MPH, report partial support from the Center for Administrative Data Research at the Washington University Institute of Clinical and Translational Sciences, grant number UL1 TR000448 from NCATS, grant number R24 HS19455 from the Agency for Healthcare Research and Quality (AHRQ), and grant number KM1CA156708 from the National Cancer Institute (NCI) at the NIH.

Human/Animal Rights


Informed Consent


Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article.

Supplementary material

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Copyright information

© Hospital for Special Surgery 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryWashington University School of MedicineSt LouisUSA
  2. 2.Department of Surgery, Division of Public Health SciencesWashington University School of MedicineSt. LouisUSA
  3. 3.Andrew Young School of Policy StudiesGeorgia State UniversityAtlantaUSA
  4. 4.Center for Administrative Data ResearchWashington University School of MedicineSt. LouisUSA
  5. 5.Washington University School of LawSt. LouisUSA

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