Fig. 49.1
Location of Critical Access Hospitals. Permission to reprint confirmed from location of critical access hospitals. Flex Monitoring Team. http://www.flexmonitoring.org/wp-content/uploads/2013/06/CAH_031816.pdf. Updated 2016. Accessed 03/24, 2016 [9]
The Rural Surgeon: Challenges and Solutions to Practicing in a Rural Setting
Rural surgeons often serve several clinical and administrative roles within the hospital. Their responsibilities may include medical director of the operating room, managing trauma systems and overseeing critical care. In the majority of rural hospitals , anesthesia is provided by nurse anesthetists and the surgeon is the supervising physician depending on individual state laws. Several studies have suggested this greatly increased the overall risk of anesthesia care. Silber et al., found 2.5 excess deaths within 30 days of admission and 6.9 excess failures-to-rescue (deaths) per thousand cases when an anesthesiologist was not involved [11]. Clinically rural surgeons have a broader scope of practice than their urban counterparts. In addition to cases commonly under the domain of general surgery, such as cholecystectomy , appendectomy , colectomy and hernia repair, rural surgeons may perform other oncologic, otolaryngology, vascular, urologic and orthopedic procedures. In some communities rural surgeons also perform gynecologic procedures and cesarean sections. A significant portion of the rural surgeon’s practice consists of upper and lower endoscopy , including both diagnostic and therapeutic procedures [12–15].
Many rural surgeons are in solo practice. Without partners, rural surgeons have frequent, if not continuous, call responsibilities, lack of highly skilled assistance for difficult cases, and lack of coverage for time away. Professional isolation has been singled out as the most important challenge faced by surgeons in rural practice [16]. Often rural surgeons are in solo practice and therefore have limited opportunities to discuss surgical problems with colleagues. Another commonly cited challenge is a relative lack of access to continuing medical education that matches the scope of practice of the rural surgeon and specifically addresses problems in the context of a rural practice [17]. These barriers exacerbate the ability of rural hospitals to attract and retain surgeons.
Various solutions to address the problem of work burden and professional isolation have been described in recent literature, including forming group practices of two to three surgeons to provide dependable coverage [16]. The Gunderson Lutheran system in LaCrosse, Wisconsin has created a model consisting of 25 regional sites that are supported by an academic, full-service tertiary care center. All regional sites in the system share a single integrated electronic medical record . All surgeons in the system are members of a single Department of Surgery within the Gunderson Health System and the surgeons at regional centers participate in patient-focused conferences and educational courses. The regional surgeons have developed a coverage system based on geographical locations of the regional practices .
Another unique approach is the University of North Dakota’s rural surgery support program. A full-time faculty member of the medical school’s Department of Surgery provides coverage to regional hospitals in 2-week increments. The billing for all services provided by the covering surgeons is the responsibility of the regional health care facility . In addition to coverage, the University offers continuing education and consultation services.
Recently the problem of professional isolation has been addressed through creating an electronic listserv, developed by Dr. Tyler Hughes, for rural surgeons to communicate about various topics related to rural life and surgical practice. Rural surgeons have an opportunity to present clinical scenarios in order to obtain the advice, and sometimes just empathy, of their surgeon colleagues. The overwhelming success of the listserv prompted the American College of Surgeons to establish “Communities” for various interest groups among its members [18].
To address the rural surgeons’ lack of access to continuing medical education that matches their learning needs, the American College of Surgeons established the course, “Advanced Skills Training for Rural Surgeons.” A team consisting of rural surgeons, academic surgeons, and individuals with expertise in adult education developed the course to be offered as part of the Nora Institute for Surgical Patient Safety. The initial planning for the course involved numerous discussions with rural surgeons, both one-on-one and in groups, to brainstorm potential topics for course content. The initial discussions were followed by conducting a needs assessment of rural surgeons as well as a literature review and review of rural surgeons’ case logs [19]. In a flipped classroom approach , course faculty provide participants with Web-based learning materials to review prior to attending the in-person session to maximize the time spent in hands-on, mentored skills practice . Each course module is developed with and taught by content experts. The course is held annually. The curriculum consists of 12 modules that rotate year-to-year [20] (Table 49.1).
Table 49.1
Rural surgery learning modules
Leadership and communication |
|---|
Advanced endoscopy |
Emergency gynecology |
Emergency urology |
Facial plastic surgery—lesion excision |
Facial plastic surgery—laceration repair |
Breast ultrasound |
Ultrasound for central line insertion |
Management of fingertip amputation |
Laparoscopic common bile duct exploration |
Anesthesia skills Vascular surgery skills |
The Rural Hospital in the Context of a Care System
A successful rural health care network relies on rural hospitals to provide readily accessible, high-quality care. Additionally, there must be established, formal relationships between small rural hospitals and regional hospitals to facilitate the transfer of patients when they require a higher level of care [21]. Considering the effectiveness of a health network raises this issue of how to measure quality, safety, and value of surgical care provided at rural hospitals. A second consideration is determining which clinical conditions warrant transfer to a regional center based on the facilities and professional resources of the local hospital. A third, often neglected component to consider is the patient’s resources and preferences in obtaining care at a regional versus a local hospital.
Measuring Quality in Rural Hospitals
Casey and coauthors reported the efforts of an expert panel to identify quality measures relevant to critical access hospitals [22]. The panel evaluated CMS inpatient and outpatient quality reporting and electronic health record meaningful use measures as well as the Joint Commission and other National Quality Foundation endorsed measures. Surgical quality measures that were identified as potentially useful and cost effective included perioperative antibiotic prophylaxis, venous thromboembolism, measures to reduce UTI and perioperative temperature control. Additionally, the panel supported the reporting of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data. The expert opinion panel recommended that future surgical quality measure developments include a surgical checklist measure and additional measures focused on high-volume outpatient procedures such as gastrointestinal endoscopy [22].
Prior studies have shown disparities in the quality of medical care in rural vs. urban hospitals. Joynt and coauthors evaluated quality process measures for Medicare beneficiaries admitted between 2002 and 2010 with pneumonia, acute MI and congestive heart failure in 1268 CAHs [23]. In 2002 the mortality rates for these conditions at critical access hospitals were similar to noncritical access hospitals. However, over the study interval, the mortality rates increased in critical access hospitals resulting in a significant gap for all three conditions compared to noncritical access hospitals. Even when compared to other rural noncritical access hospitals of similar size, increased mortality rates were again observed at the critical access hospitals. The authors compared critical access hospitals that improved over the study interval (414/857 (48 %)) to critical access hospitals that did not improve. The only observed difference was a slightly higher median resident income in the critical access hospitals that had a decreased mortality rate. The authors proposed several possible explanations for why mortality rates worsened at the majority of critical access hospitals aside from smaller sample sizes making results difficult to interpret. The first is that CAHs were not required to report the same quality measures as other hospitals. Second, payment systems for CAH may take away a financial incentive to improve quality and efficiency. Third, CAH have not kept pace with improved technologies that improve patient outcome. Finally, patients at CAHs have higher comorbidities and a higher burden of social and financial problems .
In contrast to a gap in outcomes for medical admissions , subsequent studies have found no such difference in outcomes for surgical admissions in CAH and non-CAHs. Gadzinski and coauthors utilized data from the American Hospital Administration and the National Inpatient Sample (NIS) to compare CAH and non-CAHs in terms of surgical outcomes [24]. Although CAHs comprised 26.2 % of patients included in the study, only 1.3 % of the operations were performed at CAHs. Patients admitted for surgery at CAHs were generally younger and had fewer measured comorbidities compared to patients at non-CAH facilities. The authors found that operative caseload at CAHs consists of mostly general surgery, OB/GYN, and orthopedic procedures. These classes of procedures comprised nearly 96 % of procedures in CAHs, compared with 77 % of non CAHs. The most common procedures performed included appendectomy cholecystectomy, colectomy, cesarean section, hysterectomy, hip fracture repair, hip replacement and knee replacement. Mortality rates for these procedures were similar for CAHs and non-CAHs. The exception was hip fracture repair. The mortality risk for this procedure was higher compared with non CAHs in patients with Medicare as the primary payer (adjusted odds ratio [AOR] = 1.37; 95 % CI, 1.01–1.87) and for patients with elective admissions (AOR = 2.65; 95 % CI, 1.20–5.82). The authors opine that increased mortality for hip fracture repair may reflect the urgent treatment of older patients with more comorbidities. An additional finding was that despite shorter lengths of stay, (p < .001 for four procedures), costs at CAHs were 9.9–30.1 % higher (p < .001 for all eight procedures).
Natafgi and coauthors also found similar rates of complications in CAHs compared to other small (fewer than 50 beds) hospitals without critical access designation. The authors evaluated hospitals on six patient safety indicators: death, postoperative hemorrhage and hematoma, respiratory failure, deep venous thrombosis or pulmonary embolism, sepsis and postoperative wound dehiscence. After adjusting for patient and hospital characteristics, the authors found that critical access hospitals performed the same or better than the small community hospitals in all indicators [25].
A recent study by Ibrahim and coauthors add more evidence that critical access hospitals provide high quality and cost effective care. The authors conducted a retrospective review of more than one million Medicare beneficiary admissions for one of four common surgical procedures including appendectomy, cholecystectomy, colectomy and hernia repair. The authors found that critical access hospitals had mortality and morbidity rates that were comparable to noncritical access hospitals. Critical access hospitals had significantly lower rates of serious complications (6.4 % vs. 13.9 %; OR, 0.35; 95 % CI, 0.32–0.39; p < 0.001). Furthermore, Medicare expenditures adjusted for patient factors and procedure type were lower at critical access hospitals than noncritical access hospitals. ($14,450 vs. 15.845, p < 0.001).
In addition to outcome measures, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores provide another measure of quality of care. A 2011 report showed that 41 % of CAHs reported HCAHPS scores . These results from these hospitals demonstrated significantly higher HCAHPS scores compared to all other hospitals [8, 22].
The majority of studies of quality in rural hospitals are based on large administrative databases. There is a paucity of studies utilizing risk-adjusted, abstracted data such as that used in professional databases, e.g., the National Surgical Quality Improvement Program (NSQIP) . Many rural hospitals operate on a narrow financial margin and do not have the financial resources to cover the cost of participation in these programs. Additionally, hospitals may lack personnel to abstract data and to develop and implement quality improvement programs. Just as the rural surgeon play several roles in the hospital, a hospital quality leader may also have several other clinical and administrative responsibilities to compete for their time and attention. A third challenge is the low volume of surgical procedures performed at rural hospitals which makes it difficult for a single hospital to track meaningful outcome measures [26].
Regionalization of Care
A well-functioning rural health network depends upon a predictable and reliable interaction between rural hospitals and larger regional hospitals. The role of the rural hospital in a health network is to provide local care for basic procedures. Patients with conditions requiring more complex treatment will be transferred to regional centers. With this approach, it is important to determine what cases are appropriate for local care and which patients should be transferred. Hospitals may determine a priori that certain conditions necessitating complex surgery should be managed at a larger hospital with appropriate resources. Challenges to developing and maintaining the smooth functioning of such a system for surgical patients include managing patients with acute conditions that warrant emergent intervention and managing patients with routine surgical problems who have significant medical comorbidities. Rural residents have higher rates of diabetes, cardiac failure, mental health, tobacco use and obesity. Additionally, an increasing proportion of rural patients are elderly [27].
There is the argument that regionalization of care equals better care. However, regionalization may unduly restrict the surgeons providing care . This is a complex issue that must take into account many factors, including the complexity of a procedure, the surgeon’s annual volume and the surgeon’s cumulative experience. In a systematic review of the effect of volume and experience on outcome, Marruthappu and coauthors found that the relationship between volume and outcome is not consistent. Also, determining adequate volume to reach a level of mastery varies widely among surgeons and procedures studied. The authors found that experience as measured by years in practice and annual case volume correlate to health outcome and are not related to specific procedures [28].
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