1
|
Saadé S, Delafontaine A, Cattan J, Celanie D, Saiydoun G. Attractiveness and gender dynamics in surgical specialties: a comparative analysis of French medical graduates (2017-2022). BMC MEDICAL EDUCATION 2024; 24:197. [PMID: 38413964 PMCID: PMC10900538 DOI: 10.1186/s12909-024-05174-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/13/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND French medical graduates undertake a national examination at the end of their studies with a subsequent national ranking. Specialty is then chosen by each candidate according to their ranking. This study aims to describe the attractiveness of surgical specialties and the evolution of the male-female distribution among French medical graduates (FMG) from 2017 to 2022. METHODS Our database included the candidates' ranking, sex and choice of specialty from 2017 to 2022. It included all French medical graduates from 2017 to 2022 and all French medical schools. A linear regression was performed to predict future trends. Dependent variables were mean rankings and the percentage of women. The independent variable was year of application. A Pearson correlation was performed to examine any relationship with mean workweek. RESULTS A total number of 5270 residents chose a surgical programme between 2017 and 2022. The number of residents who were assigned their desired surgical programme held stable at 878 surgical residents per year. Plastic and reconstructive surgery remained the most frequently chosen surgical programme. Thoracic and cardiovascular surgery was the least frequently chosen surgical programme between 2017 and 2022. The mean ranking for a candidate choosing a surgical programme rose significantly by 9% from 2017 to 2022 (p < 0.01). Neurosurgery exhibited the greatest fall as a surgical specialty as its rankings decreased by 163.6% (p < 0.01). Maxillo-facial surgery was the only specialty with a statistically significant increase in its rankings by 35.9% (p < 0.05). The overall proportion of women was 51.1%. Obstetrics-and-gynecology was the highest represented specialty among female candidates, with a mean of 83.9% of women. Orthopedic surgery was the lowest represented, being composed of a mean of 28.6% of women. The number of female surgical residents increased significantly over the six-year period, by 7.6% (p < 0.01). CONCLUSIONS More and more medical school graduates decide not to choose surgery for their residency programme. Some specialties continue to be attractive while many are losing their appeal. While there does appear to be progress towards gender equity, further investigation is necessary to assess its actual implementation.
Collapse
Affiliation(s)
- Saadé Saadé
- Department of Cardiac Surgery, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 67000, Strasbourg, France.
| | - Arnaud Delafontaine
- Université Libre de Bruxelles, Faculté de Médecine, Route de Lennik, Bruxelles, 1070, Belgium
| | - Johann Cattan
- Department of Cardiac Surgery, CHU de Bordeaux, Place Amélie Raba Léon, Bordeaux, 33000, France
| | - Doris Celanie
- Université des Antilles, 97100, Pointe-à-Pitre, Guadeloupe, France
| | - Gabriel Saiydoun
- Department of cardiac surgery, Pitié-Salpêtrière, Bld Vincent Auriol, 75013, Paris, France
| |
Collapse
|
2
|
Kalata S, Nathan H, Ibrahim AM. Understanding Community Health Access and Rural Transformation Reform-Implications for Rural Surgical Care. JAMA Surg 2023; 158:437-438. [PMID: 36811874 DOI: 10.1001/jamasurg.2022.6834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
The Viewpoint describes the Community Transformation Track of the Community Health Access and Rural Transformation Model for improving financial stability at rural hospitals and its implications for rural surgical care.
Collapse
Affiliation(s)
- Stanley Kalata
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Andrew M Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| |
Collapse
|
3
|
Sundaram N, Sampson L, Marica S, Ronsivalle J, Rizzo A, Cagir B. Starting a Vascular Surgery Fellowship at a Rural Healthcare Center. J Surg Res 2023; 283:611-618. [PMID: 36446248 DOI: 10.1016/j.jss.2022.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/03/2022] [Accepted: 11/08/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION In the United States, there is an anticipated critical shortage of vascular surgeons in the coming decades. The shortage is expected to be particularly pronounced in rural areas. Our institution serves a rural and underserved population in which the incidence and prevalence of cardiovascular disease continues to rise. Our institution maintains a general surgery residency and has all the required Accreditation Council for Graduate Medical Education (ACGME) rotations and educational infrastructure to support a vascular surgery fellowship. This study aims to analyze the vascular caseload at our institution to determine if we and other institutions with similar surgical volumes can support the creation of a 2-year vascular fellowship. METHODS A single-site retrospective review of the number and type of vascular cases conducted at our institution between July 2016 and June 2021 was performed. The procedures were grouped into the following ACGME-defined categories: abdominal, cerebrovascular, complex, endovascular aneurysm repair, endovascular diagnostic or therapeutic, and peripheral. The total number and annual average for each category was obtained. Using the annual average, a 2-year estimate was calculated and compared to the ACGME minimum for each category. Our 2-year estimate was then compared to the national average for graduating vascular surgery fellows in order to generate a z-score for each category. RESULTS In the specified period, 6100 total surgical procedures were performed by three vascular surgeons at our institution. Two thousand five hundred and seventy-eight of the 6100 procedures met at least one of the ACGME-defined category requirements. Our center greatly exceeded the requirements for each category except for abdominal. This is consistent with trends observed in most centers across the nation, which are seeing a decline in open repairs across all categories, especially in open abdominal repairs. Our center's vascular case volume shows no significant difference the national average in each ACGME category (P ≥ 0.05 for all). CONCLUSIONS Despite our center's large vascular caseload and need for more vascular providers, there were not enough open abdominal cases performed to support the training of a vascular fellow. Given the continued decline in open aortic volume across the country, we anticipate that rural centers similar to our own will have difficulty establishing programs to train and recruit vascular surgeons. Flexibility in the abdominal category requirement or creation of open aortic fellowships may be necessary for smaller rural centers to train vascular surgeons and meet the future needs of the specialty.
Collapse
Affiliation(s)
- Niteesh Sundaram
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Lawrence Sampson
- Department of Vascular Surgery, The Guthrie Clinic, Sayre, Pennsylvania
| | - Silviu Marica
- Department of Vascular Surgery, The Guthrie Clinic, Sayre, Pennsylvania
| | - Joseph Ronsivalle
- Department of Interventional Radiology, The Guthrie Clinic, Sayre, Pennsylvania
| | - Anne Rizzo
- Department of General Surgery, The Guthrie Clinic, Sayre, Pennsylvania
| | - Burt Cagir
- Department of General Surgery, The Guthrie Clinic, Sayre, Pennsylvania
| |
Collapse
|
4
|
Min HS, Sung HK, Choi G, Sung H, Lee M, Kim SJ, Ko E. Operation of national coordinating service for interhospital transfer from emergency departments: experience and implications from Korea. BMC Emerg Med 2023; 23:15. [PMID: 36765283 PMCID: PMC9913013 DOI: 10.1186/s12873-023-00782-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/30/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Since 2014, Korea has been operating the National Emergency Medical Situation Room (NEMSR) to provide regional emergency departments (EDs) with coordination services for the interhospital transfer of critically ill patients. The present study aimed to describe the NEMSR's experience and interhospital transfer pattern from EDs nationwide, and investigate the factors related to delayed transfers or transfers that could not be arranged by the NEMSR. METHODS This study was a retrospective cross-sectional analysis of the NEMSR's coordination registry from 2017 to 2019. The demographic and hospital characteristics related to emergency transfers were analyzed with hierarchical logistic models. RESULTS The NEMSR received a total of 14,003 requests for the arrangement of the interhospital transfers of critically ill patients from 2017 to 2019. Of 10,222 requests included in the analysis, 8297 (81.17%) successful transfers were coordinated by the NEMSR. Transfers were requested mainly due to a shortage of medical staff (59.79%) and ICU beds (30.80%). Delayed transfers were significantly associated with insufficient hospital resources. The larger the bed capacity of the sending hospital, the more difficult it was to coordinate the transfer (odds ratio [OR] for transfer not arranged = 2.04; 95% confidence interval [CI]: 1.48-2.82, ≥ 1000 beds vs. < 300 beds) and the longer the transfer was delayed (OR for delays of more than 44 minutes = 2.08; 95% CI: 1.57-2.76, ≥ 1000 beds vs. < 300 beds). CONCLUSIONS The operation of the NEMSR has clinical importance in that it could efficiently coordinate interhospital transfers through a protocolized process and resource information system. The coordination role is significant as information technology in emergency care develops while regional gaps in the distribution of medical resources widen.
Collapse
Affiliation(s)
- Hye Sook Min
- grid.415619.e0000 0004 1773 6903Public Health Research Institute, National Medical Center, Seoul, South Korea
| | - Ho Kyung Sung
- grid.415619.e0000 0004 1773 6903National Emergency Medical Center, National Medical Center, 245 Eulgi-ro, Jung-gu, Seoul, 04564 South Korea
| | - Goeun Choi
- grid.415619.e0000 0004 1773 6903National Emergency Medical Center, National Medical Center, 245 Eulgi-ro, Jung-gu, Seoul, 04564 South Korea
| | - Hyehyun Sung
- grid.415619.e0000 0004 1773 6903National Emergency Medical Center, National Medical Center, 245 Eulgi-ro, Jung-gu, Seoul, 04564 South Korea ,grid.31501.360000 0004 0470 5905Seoul National University College of Nursing, Seoul, South Korea
| | - Minhee Lee
- grid.415619.e0000 0004 1773 6903National Emergency Medical Center, National Medical Center, 245 Eulgi-ro, Jung-gu, Seoul, 04564 South Korea ,grid.254187.d0000 0000 9475 8840Department of Nursing, Graduate School, Chosun University, Gwangju, South Korea
| | - Seong Jung Kim
- grid.415619.e0000 0004 1773 6903National Emergency Medical Center, National Medical Center, 245 Eulgi-ro, Jung-gu, Seoul, 04564 South Korea ,grid.254187.d0000 0000 9475 8840Department of Emergency Medicine, College of Medicine, Chosun University, Gwangju, South Korea
| | - Eunsil Ko
- National Emergency Medical Center, National Medical Center, 245 Eulgi-ro, Jung-gu, Seoul, 04564, South Korea.
| |
Collapse
|
5
|
Meade ZS, Li HW, Allison H, Bhatia MB, Joplin TS, Simon C, Darkwa L, Keung C, McDow AD. Demographics and medical school exposures to rural health influence future practice. Surgery 2022; 172:1665-1672. [PMID: 36127171 DOI: 10.1016/j.surg.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/08/2022] [Accepted: 08/13/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND One-fifth of the US population lives in rural areas. A record number of rural hospitals have closed, creating increased burdens on regional centers and delays in care. This study aimed to assess medical student perceptions of rural surgery and health care, and to elucidate influential factors for future practice. METHODS We administered a survey to medical schools throughout Indiana, Illinois, and Michigan. The survey was designed and evaluated by a survey content expert and piloted among a group of students. Student and faculty liaisons disseminated the survey between February and May 2021. Descriptive analysis of data was completed using Stata v.16.1 (StataCorp, LLC, College Station, TX). RESULTS The respondents included 700 medical students; 59.5% were female, with an equal distribution across medical school classes. More than 98% of students believe we "lack" or "are in great need of" rural health care providers, as well as rural surgeons; however, more than half of the students did not agree that the rural workforce is declining. Only 15.7% of students reported an interest in "pursuing a future career in a rural setting." Students with exposure to rural health care, coming from a rural hometown, or having a dependent had a positive association with interest in pursuing rural practice. CONCLUSION Although students are aware of the lack of rural surgeons and health care providers, there remains an educational deficit. Expanding exposure to rural health care and surgery while in medical school may increase the number of students interested in pursuing a career in a rural setting, potentially shrinking the rural workforce gap.
Collapse
Affiliation(s)
- Zachary S Meade
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, IL; General Surgery Department, Navy Medicine Readiness and Training Command San Diego, San Diego, CA.
| | - Helen W Li
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Hannah Allison
- Department of Surgery, Indiana University, Indianapolis, IN
| | | | | | - Chad Simon
- College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Louis Darkwa
- College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Connie Keung
- Department of Surgery, Indiana University, Indianapolis, IN
| | | |
Collapse
|
6
|
Hughes D, Wood R, Woods R, Sarap M. Resident Perspectives on the Value of Rural General Surgery Rotations: It's Not Just About the Cases. Am Surg 2022:31348221114056. [PMID: 36184959 DOI: 10.1177/00031348221114056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Understand the scope of cases that residents participate in during rural general surgery rotations and the value residents and program directors find in such rotations. In turn, our goal is to add to the ongoing conversation the value exposure to rural surgery brings to surgery training. METHODS Qualitative study analyzed reviews of residents' self-reported case lists and field notes from exit interviews with the site director. RESULTS Trainees participated in an average of 105 cases during the rotation, including basic and advanced endoscopy along with exposure to a wide array of surgical cases. Residents had exposure to the rural facility and its staff and participated in a busy outpatient surgical clinic, the hospital, and community activities. We received overwhelmingly positive qualitative feedback from residents regarding how this rural rotation advanced their skills, helped prepare them for life after residency, and for some confirmed their plans to practice in a rural location. CONCLUSION With the decline in the number of rural general surgeons and projected continuance of this trend, it is important to understand how trainees view their residency experiences and how those experiences may be shaping their outlook on career choices. Our single-site, qualitative study showed that a rural general surgery rotation during residency has broad importance and value in general surgery resident training. Having a rural rotation also allowed residents to gain understanding of a rural lifestyle, workflow, and the social fabric including the rural surgeons' connections with their communities.
Collapse
Affiliation(s)
- Dorothy Hughes
- Department of Population Health, 12251University of Kansas School of Medicine - Salina Campus, Salina, KS, USA
| | - Rebekah Wood
- 43191Sanford University of South Dakota School of Medicine General Surgery Residency Program, Sioux Falls, SD, USA
| | - Randy Woods
- 2829Wright State University Boonshoft SOM, Fairborn, OH, USA
| | - Michael Sarap
- 21457Southeastern Ohio Regional Medical Center, Cambridge, OH, USA
| |
Collapse
|
7
|
Bhatia MB, Darkwa L, Simon C, Li HW, Allison H, Joplin TS, Meade ZS, Keung C, McDow AD. Uncovering the Overlap of Global and Domestic Rural Surgery for Medical Trainees. J Surg Res 2022; 279:442-452. [PMID: 35841813 PMCID: PMC9404475 DOI: 10.1016/j.jss.2022.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/01/2022] [Accepted: 06/14/2022] [Indexed: 11/25/2022]
Abstract
Introduction Medical trainees who participate in global rotations demonstrate improved cultural sensitivity, increased involvement in humanitarian efforts, and ability to adapt to limited resources. The global coronavirus pandemic halted global rotations for medical trainees. Domestic rural surgery (DRS) may offer a unique alternative. We aimed to understand medical students’ perceptions of the similarities and differences between global surgery and DRS and how students’ priorities impact career choices. Methods An electronic survey was administered at eleven medical training institutions in Indiana, Illinois, and Michigan in spring 2021. Mixed methods analysis was performed for students who reported an interest in global surgery. Quantitative analysis was completed using Stata 16.1. Results Of the 697 medical student respondents, 202 were interested in global surgery. Of those, only 18.3% were also interested in DRS. Students interested in DRS had more rural exposures. Rural exposures associated with DRS interest were pre-clinical courses (P = 0.002), clinical rotations (P = 0.045), and rural health interest groups (P < 0.001). Students interested in DRS and those unsure were less likely to prioritize careers involving teaching or research, program prestige, perceived career advancement, and well-equipped facilities. The students who were unsure were willing to utilize DRS exposures. Conclusions Students interested in global surgery express a desire to practice in low-resource settings. Increased DRS exposures may help students to understand the overlap between global surgery and DRS when it comes to working with limited resources, achieving work-life balance and practice location.
Collapse
Affiliation(s)
- Manisha B Bhatia
- Indiana University, Department of Surgery, Indianapolis, Indiana.
| | - Louis Darkwa
- University of Illinois Chicago, School of Medicine, Chicago, Illinois
| | - Chad Simon
- University of Illinois Chicago, School of Medicine, Chicago, Illinois
| | - Helen W Li
- Washington University School of Medicine in St. Louis, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Hannah Allison
- Indiana University, Department of Surgery, Indianapolis, Indiana
| | | | | | - Connie Keung
- Indiana University, Department of Surgery, Indianapolis, Indiana
| | | |
Collapse
|
8
|
Kraus AC, Gunnells DJ, Chu DI, Kennedy AE, Hughes TG, Chen H, Hollis RH, Porterfield JR, Stahl RD, Kennedy GD. The University of Alabama at Birmingham Surgery Community Network: Tackling the Challenges of Rural Surgery. Am Surg 2022:31348221109471. [PMID: 35726516 DOI: 10.1177/00031348221109471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Over the past 5 years, The University of Alabama at Birmingham (UAB) Department of Surgery has taken a keen interest in the practice of surgery in rural Alabama and has established the UAB surgery community network. Our goal is to improve the delivery of surgical care in rural areas through active recruitment of rural surgeons, the development of research around rural surgery practice, and the expansion of a surgery network throughout the state. Here, we will present the challenges faced by rural surgery, our early work to address these challenges, and offer a plan for moving forward.
Collapse
Affiliation(s)
- Abigayle C Kraus
- Department of Surgery, 155569University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Drew J Gunnells
- Department of Surgery, 155569University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Daniel I Chu
- Department of Surgery, 155569University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Alexis E Kennedy
- Department of Surgery, 155569University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Tyler G Hughes
- Department of Surgery, 12251University of Kansas School of Medicine, Kansas, KS, USA
| | - Herb Chen
- Department of Surgery, 155569University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Robert H Hollis
- Department of Surgery, 155569University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - John R Porterfield
- Department of Surgery, 155569University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Richard D Stahl
- Department of Surgery, 155569University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Gregory D Kennedy
- Department of Surgery, 155569University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| |
Collapse
|
9
|
Edwards GC, Wong SL, Russell MC, Winslow ER, Shaffer VO, Pawlik TM. Society for Surgery of the Alimentary Tract Health Care Quality and Outcomes Committee Webinar: Addressing Disparities. J Gastrointest Surg 2022; 26:997-1005. [PMID: 35318595 DOI: 10.1007/s11605-022-05300-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/09/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Gretchen C Edwards
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandra L Wong
- Department of Surgery, Dartmouth-Hitchcock and Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Maria C Russell
- Department of Surgery, Winship Cancer Institute at Emory University, Atlanta, GA, USA
| | - Emily R Winslow
- Department of Surgery, Medstar Georgetown Medical Center, Washington, DC, USA
| | - Virginia O Shaffer
- Department of Surgery, Winship Cancer Institute at Emory University, Atlanta, GA, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
| |
Collapse
|
10
|
Dissanaike S. What Operations Should a Modern Rural Surgeon Do? State-of-the-Art Lecture. Am Surg 2022; 88:2090-2093. [PMID: 35448931 DOI: 10.1177/00031348221086799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rural patients have fewer complications and deaths, shorter hospital stay, and less resource utilization than their urban counterparts. They also tend to have fewer chronic illnesses; this reflects a system working as intended, with high-risk patients transferred to better-resourced institutions, while others receive surgical care closer to home. Deciding which operations a modern rural surgeon should-and shouldn't-perform starts with the question "Who decides?" Government, insurers, hospitals, surgeons, and patients are all stakeholders, with a vested interest in the answer.Rural hospitals depend on surgeons for their financial existence, and rural surgeons need hospitals to function. The closure of rural hospitals throughout the country threatens the future of rural surgery. Without surgeons, rural patients will die unnecessarily. During the first COVID surge, patients died from such basic surgical emergencies as small bowel obstruction, when tertiary referral hospitals were full. Rural surgeons are essential in providing timely care of the injured patient; even today, patients die in isolated facilities from treatable injuries from lack of a surgeon who can do a splenectomy, or tube thoracostomy for traumatic pneumothorax, for example.Recruitment of rural surgeons requires identifying interested trainees, often from rural backgrounds, and a defined residency curriculum with emphasis on endoscopy and vascular surgery plus basic gynecology, obstetrics, urology, and orthopedics. Financial incentives & credentials support are also essential for the new rural surgeon. We need to develop many more focused rural surgery programs, and quickly, before the possibility of a broadly skilled rural surgeon in the USAevaporates.
Collapse
|
11
|
Hopper W, Zeller R, Burke R, Lindsey T. The association between operating margin and surgical diversity at Critical Access Hospitals. J Osteopath Med 2022; 122:339-345. [DOI: 10.1515/jom-2022-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/02/2022] [Indexed: 11/15/2022]
Abstract
Abstract
Context
Surgical volume is correlated with increased hospital profitability, yet many Critical Access Hospitals (CAHs) offer few or no inpatient surgical services.
Objectives
This study aims to investigate the impact of the presence of different inpatient surgical services on CAH profitability.
Methods
The study design was a cross-sectional analysis of financial data from the most recent fiscal year (FY) of 1299 CAHs. Multiple linear regression was utilized to assess how the operating margin was affected by the number of different inpatient surgical services offered per hospital. Covariates known to be associated with hospital profitability included occupancy rate, case mix index (CMI), system affiliation, ownership status (public, private, or nonprofit), and geographic region.
Results
The regression model for the CAH operating margin returned an R2 value of 0.18. Each additional inpatient surgical service corresponded to a 1.5% increase in operating margin (p=0.0413). Each 10% increase in occupancy rate and 0.1 increase in CMI corresponded to a 0.9% increase in operating margin (p=0.0032 and p=0.0176, respectively). The number of surgical services offered per CAH showed positive correlations with occupancy rate (r=0.23, p<0.0001) and CMI (r=0.59, p<0.0001).
Conclusions
A positive correlation exists between operating margin and the diversity of inpatient surgical specialties available at CAHs. Furthermore, providing surgery allows CAHs to accommodate higher occupancy rates and case mixes, both of which are significantly and positively correlated with CAH operating margin.
Collapse
Affiliation(s)
- Wade Hopper
- Department of Surgery , Edward Via College of Osteopathic Medicine , Spartanburg , SC , USA
| | - Robert Zeller
- Department of Surgery , Edward Via College of Osteopathic Medicine , Spartanburg , SC , USA
| | - Rachel Burke
- Department of Surgery , Edward Via College of Osteopathic Medicine , Spartanburg , SC , USA
| | - Tom Lindsey
- Department of Surgery , Edward Via College of Osteopathic Medicine , Spartanburg , SC , USA
| |
Collapse
|
12
|
Probst J, Eberth JM, Crouch E. Structural Urbanism Contributes To Poorer Health Outcomes For Rural America. Health Aff (Millwood) 2020; 38:1976-1984. [PMID: 31794301 DOI: 10.1377/hlthaff.2019.00914] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Rural populations disproportionately suffer from adverse health outcomes, including poorer health and higher age-adjusted mortality. We argue that these disparities are due in part to declining health care provider availability and accessibility in rural communities. Rural challenges are exacerbated by "structural urbanism"-elements of the current public health and health care systems that disadvantage rural communities. We suggest that biases in current models of health care funding, which treat health care as a service for an individual rather than as infrastructure for a population, are innately biased in favor of large populations. Until this bias is recognized, the development of viable models for care across the rural-urban continuum cannot move forward.
Collapse
Affiliation(s)
- Janice Probst
- Janice Probst ( jprobst@mailbox. sc. edu ) is a distinguished professor emerita in the Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, in Columbia
| | - Jan Marie Eberth
- Jan Marie Eberth is an associate professor of epidemiology and biostatistics at the University of South Carolina
| | - Elizabeth Crouch
- Elizabeth Crouch is an assistant professor in the Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina
| |
Collapse
|
13
|
Manning SW, Orr SL, Mastriani KS. General Surgery Residency and Emergency General Surgery Service Reduces Readmission Rates and Length of Stay in Nonoperative Small Bowel Obstruction. Am Surg 2020; 86:1178-1184. [PMID: 32935996 DOI: 10.1177/0003134820939900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nonoperative management of adhesive small bowel obstruction (ASBO) results in resolution for the majority of patients. Previous studies have demonstrated that outcomes for patients with ASBO are improved when patients are admitted to a surgical service, but the effect of general surgery resident coverage is unclear. This study measures quality outcomes for patients with ASBO after the establishment of a new general surgery residency program. METHODS An institutional review board-approved retrospective chart review of admissions for ASBO was conducted following the implementation of a protocol for ASBO nested within a newly developed resident-run emergency general surgery (EGS) service. Patients successfully treated without operative intervention were analyzed. RESULTS During the study period, 612 patients were admitted for ASBO. After initiation of the residency, 74% of ASBO were admitted to a surgical service compared with 35% prior to residency (P < .01). Length of stay was reduced by 0.77 days (P = .016), average direct total cost per patient was reduced by 24% (P = .002), and 30-day readmissions were reduced by 35.7% (P = .046). There was no significant difference in mortality (1.4% vs 1.0%). DISCUSSION Admission to a resident-run surgical service was associated with statistically significant improvement in outcomes for patients with ASBO. These data corroborate prior studies demonstrating the positive impact of residency programs on patient outcomes and provide additional evidence that general surgery residency programs improve outcomes for patients with surgical disease.
Collapse
Affiliation(s)
| | - Scotta L Orr
- Department of General Surgery, Mission Hospital, Asheville, NC, USA
| | - Katherine S Mastriani
- General Surgery Residency, Mountain Area Health Education Center, Asheville, NC, USA.,Department of Quality and Safety, Mission Hospital, Asheville, NC, USA
| |
Collapse
|
14
|
Ellison EC, Satiani B, Way DP, Oslock WM, Santry H, Williams TE. The continued urbanization of American surgery: A threat to rural hospitals. Surgery 2020; 169:543-549. [PMID: 32773279 DOI: 10.1016/j.surg.2020.06.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/22/2020] [Accepted: 06/09/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND In 2011, we predicted that surgeon shortages for rural hospitals would contribute to closures of rural hospitals. Here, we update population trends, the distribution of rural and urban hospitals, and surgeon supply to estimate surgeon demand for rural and urban hospital settings by 2040. METHODS Surgeon supply was based on new certifications for general surgery, orthopedic surgery, and obstetrics and gynecology adjusted for retirement. Surgeon demand from 2020 to 2040 was projected based on the US Census and published practice ratios: general surgery 10.7/100,000, orthopedic surgery 7.9/100,000, and obstetrics and gynecology 13.0/100,000. RESULTS The US population grew from 309 million in 2011 to 327 million in 2017 with rural populations unchanged at 56 million. By 2040, the US population will be 374 million (urban 85% and rural 15%) creating shortages of general surgery (-31.5%), orthopedic surgery (-34.3%), and obstetrics and gynecology (-25.3). Future hiring needs for urban hospitals will be 5 times greater than rural hospitals. Urban hospitals will likely recruit most newly certified surgeons. CONCLUSION Increases in surgery trainees will not meet the demand. The continued urbanization of American surgery may push rural hospitals into a vicious financial cycle leading to additional closures of rural hospitals and worsening issues of access. An alternative training paradigm for the rural surgeon is recommended to meet the unique demands of rural hospitals.
Collapse
Affiliation(s)
| | - Bhagwan Satiani
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - David P Way
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH
| | | | - Heena Santry
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Thomas E Williams
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| |
Collapse
|
15
|
Abstract
Rural hospitals are closing at an increasing rate. From 2010 to 2014, 47 rural hospitals closed, affecting 1.5 million people. The presence of surgeons is critical to keeping these hospitals open; to provide initial trauma care, cancer screening, and care to populations that cannot easily travel; and to provide solid general surgery procedures to almost 60 million Americans. Actions to provide surgeons trained for rural practice include exposure of surgery to students in high school (and earlier), recruitment of rural students into medical school, rural rotations in medical school, rural tracts within surgical residencies, and programs to support and retain rural surgeons.
Collapse
Affiliation(s)
- John Patrick Walker
- Department of Surgery, The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0527, USA.
| |
Collapse
|
16
|
Eberth JM, Crouch EL, Josey MJ, Zahnd WE, Adams SA, Stiles BM, Schootman M. Rural-Urban Differences in Access to Thoracic Surgery in the United States, 2010 to 2014. Ann Thorac Surg 2019; 108:1087-1093. [PMID: 31238030 DOI: 10.1016/j.athoracsur.2019.04.113] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 03/15/2019] [Accepted: 04/29/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Because of recent lung cancer screening recommendations and corresponding insurance coverage, it is expected that more early stage cases will be identified that require thoracic surgery. However, these services may not be equally available in all regions. Our objective is to describe the availability of thoracic surgeons by examining geographic variation, rural-urban differences, and temporal changes before and after screening recommendation and insurance coverage policy changes. METHODS We examined the U.S. thoracic surgery workforce using the 2010 and 2014 Area Health Resource Files. We calculated the density of thoracic surgeons per 100,000 persons for each year at the state and county level. We performed descriptive statistics and developed maps highlighting changes over time and geographic regions. RESULTS Despite an overall increase in thoracic surgeons from 2010 to 2014, we observed declining density nationwide (1.5% change) and in sparsely populated states. The difference in thoracic surgeon density widened slightly between 2010 from 0.80 per 100,000 compared with 0.84 per 100,000 in 2014 in all rural counties compared with urban counties (P < .001 for both years). The difference in thoracic surgeon density was most pronounced between small adjacent rural and urban counties (0.95 and 0.96 per 100,000 for 2010 and 2014, respectively; P < .001 for both years). The Northeast held a disproportionate share of the thoracic surgery workforce. CONCLUSIONS Limited access to thoracic surgeons in rural areas is a concern, given an older and retiring surgical workforce, the higher burden of lung cancer in rural areas, and recent policy changes for screening reimbursement.
Collapse
Affiliation(s)
- Jan M Eberth
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina; Rural & Minority Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina; Cancer Prevention and Control Program, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.
| | - Elizabeth L Crouch
- Rural & Minority Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina; Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Michele J Josey
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina; Rural & Minority Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina; Cancer Prevention and Control Program, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Whitney E Zahnd
- Rural & Minority Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Swann Arp Adams
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina; Cancer Prevention and Control Program, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina; College of Nursing, University of South Carolina, Columbia, South Carolina
| | - Brendon M Stiles
- Department of Cardiothoracic Surgery, Weill Cornell Medical Center, New York, New York
| | | |
Collapse
|
17
|
Stiles R, Reyes J, Helmer SD, Vincent KB. What Procedures are Rural General Surgeons Performing and are They Prepared to Perform Specialty Procedures in Practice? Am Surg 2019. [DOI: 10.1177/000313481908500621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rural surgeons are performing operations typically performed by “specialists.” This study describes specialty procedures performed by general surgeons operating in a rural state and how prepared the surgeons felt starting their rural practice after residency A survey was sent to all exclusively rural surgeons actively practicing in the state, inquiring about their perception of preparedness for rural practice and specialty procedures performed. The survey had a 65.2 per cent response rate. Responders felt well prepared for rural practice after residency (mean response 4.6 ± 0.8 on a Likert scale from 1 to 5; 5 = “well prepared”). Noteworthy, specialty procedures performed by rural surgeons included hysterectomies (51.2%), thyroidectomies (81.4%), para-thyroidectomies (60.5%), carotid endarterectomies (11.6%), video-assisted thoracoscopic surgery (37.2%), and lobectomies (23.3%). Prominent write-ins included nephrectomies (n = 1), ileal conduits (n = 1), open and endovascular abdominal aortic aneurysm repair (n = 1), Whipples (n = 3), and liver resections (n = 2). Rural general surgeons perform many major operations usually performed by specialists. These surgeons felt well prepared for these operations out of residency.
Collapse
Affiliation(s)
- Roxanne Stiles
- Department of Surgery, The University of Kansas School of Medicine–Wichita, Wichita, Kansas; and
| | - Jared Reyes
- Department of Surgery, The University of Kansas School of Medicine–Wichita, Wichita, Kansas; and
| | - Stephen D. Helmer
- Department of Surgery, The University of Kansas School of Medicine–Wichita, Wichita, Kansas; and
- Department of Medical Education, Ascension Via Christi Hospital Saint Francis, Wichita, Kansas
| | - Kyle B. Vincent
- Department of Surgery, The University of Kansas School of Medicine–Wichita, Wichita, Kansas; and
| |
Collapse
|
18
|
Hospitals’ Financial Health in Rural and Urban Areas in Poland: Does It Ensure Sustainability? SUSTAINABILITY 2019. [DOI: 10.3390/su11071932] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Literature review suggests that rural hospitals are in the worst financial conditions due to several factors: They are smaller, located in remote areas, and they provide less specialized services due to their problems with employing well-qualified staff. We decided to check whether it is true in the case of Polish hospitals. Based on the literature review, we have assumed that rural hospitals have less favorable financial conditions. In order to verify this assumption, we use seven indicators of financial health as well as a synthetic measure of financial condition. We have found that, in fact, there is no difference in financial condition between rural and urban hospitals, or even that the financial health of rural hospitals is better if we employ the synthetic measure. Additionally, we have found that the form of activity can be a crucial driver of better financial performance. The concept of rural sustainability is supported by good financial conditions of rural hospitals, which helps to provide better access to medical services for inhabitants of rural areas.
Collapse
|
19
|
Availability of Common Pediatric Radiology Studies: Are Rural Patients at a Disadvantage? J Surg Res 2018; 234:26-32. [PMID: 30527482 DOI: 10.1016/j.jss.2018.08.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 08/24/2018] [Accepted: 08/24/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Many families wish to have radiologic tests performed locally, especially when obtaining these tests in specialized pediatric centers would require long-distance travel with associated costs and inconveniences. The differential availability of specialized and common pediatric uroradiographic tests in rural and urban areas has not been described. We undertook this study to describe the availability of common radiographic tests ordered by pediatric urologists, and to identify disparities in the availability of radiographic tests between urban and rural locations. MATERIALS AND METHODS We surveyed all freestanding hospitals in Washington State on the availability of flat-plate abdominal radiograph (AXR), renal-bladder ultrasounds (RBUS), voiding cystourethrograms (VCUG), MAG-3 renal scans, and nuclear cystograms (NC) for children, as well as testing restrictions, availability of sedation for urology tests, and presence of onsite radiologists. Rural and urban hospitals were compared on these characteristics. RESULTS The survey was completed by 74 of 88 institutions (84.1%); 17 (23.0%) were rural (population <2500), 32 (43.2%) were in urban clusters (population 2500-50,000), and 25 (33.8%) were in urban areas (population >50,000). Seventy-three (98.6%) institutions offered AXR, 68 (91.9%) offered RBUS, 44 (59.5%) offered VCUG, 26 (35.1%) offered MAG-3, and 15 (20.3%) offered NC to children. All urban and most (16/17; 94.1%) rural institutions had shareable digital imaging capability. AXR (100% versus 96%, P = 0.88) and RBUS (70.6% versus 96%, P = 0.15) availability was similar in rural and urban settings, whereas VCUG (11.8% versus 72%, P = 0.001), MAG-3 (5.9% versus 60%, P = 0.006), and NC (0% versus 44%, P = 0.017) were more commonly available in urban settings. Fewer rural hospitals employed full-time, in-house radiologists (35.3% versus 96%, P < 0.0001) or offered sedation (6.3% versus 36%, P = 0.01) for testing, but an equal proportion had age restrictions on the tests offered (40% versus 17.6%, P = 0.50). Fellowship-trained pediatric radiologists (0% versus 16%, P = 0.39) and child life specialists (0% versus 20%, P = 0.28) worked exclusively in urban settings. Most hospitals offering specialized radiographic tests (VCUG: 90.9%; P < 0.0001 and MAG-3: 92.3%; P = 0.002) had onsite radiologists. CONCLUSIONS The geographically widespread availability of AXR and RBUS may represent an opportunity to offer families care closer to home, realizing cost and time savings. Anxious children and those requiring more specialized studies may benefit from referral to urban centers. The lack of rural radiologists may be an actionable barrier to availability of specialized radiology testing.
Collapse
|
20
|
MacQueen IT, Maggard-Gibbons M, Capra G, Raaen L, Ulloa JG, Shekelle PG, Miake-Lye I, Beroes JM, Hempel S. Recruiting Rural Healthcare Providers Today: a Systematic Review of Training Program Success and Determinants of Geographic Choices. J Gen Intern Med 2018; 33:191-199. [PMID: 29181791 PMCID: PMC5789104 DOI: 10.1007/s11606-017-4210-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/22/2017] [Accepted: 09/28/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Rural areas have historically struggled with shortages of healthcare providers; however, advanced communication technologies have transformed rural healthcare, and practice in underserved areas has been recognized as a policy priority. This systematic review aims to assess reasons for current providers' geographic choices and the success of training programs aimed at increasing rural provider recruitment. METHODS This systematic review (PROSPERO: CRD42015025403) searched seven databases for published and gray literature on the current cohort of US rural healthcare practitioners (2005 to March 2017). Two reviewers independently screened citations for inclusion; one reviewer extracted data and assessed risk of bias, with a senior systematic reviewer checking the data; quality of evidence was assessed using the GRADE approach. RESULTS Of 7276 screened citations, we identified 31 studies exploring reasons for geographic choices and 24 studies documenting the impact of training programs. Growing up in a rural community is a key determinant and is consistently associated with choosing rural practice. Most existing studies assess physicians, and only a few are based on multivariate analyses that take competing and potentially correlated predictors into account. The success rate of placing providers-in-training in rural practice after graduation, on average, is 44% (range 20-84%; N = 31 programs). We did not identify program characteristics that are consistently associated with program success. Data are primarily based on rural tracks for medical residents. DISCUSSION The review provides insight into the relative importance of demographic characteristics and motivational factors in determining which providers should be targeted to maximize return on recruitment efforts. Existing programs exposing students to rural practice during their training are promising but require further refining. Public policy must include a specific focus on the trajectory of the healthcare workforce and must consider alternative models of healthcare delivery that promote a more diverse, interdisciplinary combination of providers.
Collapse
Affiliation(s)
- Ian T MacQueen
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Melinda Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Veterans Affairs/Robert Wood Johnson Clinical Scholars Program, UCLA, Los Angeles, CA, USA
| | - Gina Capra
- National Association of Community Health Centers, Bethesda, MD, USA
| | - Laura Raaen
- Evidence-Based Practice Center, RAND Corporation, Santa Monica, CA, 90407, USA
| | - Jesus G Ulloa
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Veterans Affairs/Robert Wood Johnson Clinical Scholars Program, UCLA, Los Angeles, CA, USA
- Department of Surgery, UCSF Medical School, San Francisco, CA, USA
| | - Paul G Shekelle
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Evidence-Based Practice Center, RAND Corporation, Santa Monica, CA, 90407, USA
| | - Isomi Miake-Lye
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Jessica M Beroes
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Susanne Hempel
- Evidence-Based Practice Center, RAND Corporation, Santa Monica, CA, 90407, USA.
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
| |
Collapse
|
21
|
Leberer D, Elliott JO, Dominguez E. Patient characteristics, outcomes and costs following interhospital transfer to a tertiary facility for appendectomy versus patients who present directly. Am J Surg 2017; 214:825-830. [PMID: 28129917 DOI: 10.1016/j.amjsurg.2017.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/06/2017] [Accepted: 01/08/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recent healthcare policy changes have emphasized pay-for-performance. Previous studies have not examined outcome differences between primary presenting appendicitis patients and transferred patients. METHODS A retrospective cohort design examined appendicitis patients between March 2011 and 2013. Patients < age 18, were scheduled for an elective appendectomy, who were pregnant or had an interval appendectomy were excluded. RESULTS The transfer cohort (n = 59) had more comorbidities, more severe American Society of Anesthesiologists status, a higher rate of pre-operative abscess/rupture as well as higher rates of perforation, gangrene, intra-operative drain placement and open conversion versus primary presenting patients (n = 622). After statistical regression adjustment, a higher open conversion rate in the transfer cohort, OR = 3.48 (95%CI: 1.04-11.61) and higher total costs $672.47 (95%CI: $68.75-$1276.19) remained. CONCLUSIONS Adjustments in clinical outcome/reimbursement metrics may be needed to address the complexity of transfers and the subsequent higher in-hospital costs on tertiary facilities. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Daniel Leberer
- Department of Surgery, Colon and Rectal Surgery Fellowship, University at Buffalo State, Buffalo, NY, USA.
| | | | - Edward Dominguez
- Department of General Surgery, OhioHealth Riverside Methodist Hospital, Columbus, OH, USA; Department of Medical Education, OhioHealth Riverside Methodist Hospital, Columbus, OH, USA.
| |
Collapse
|
22
|
Mccarthy MC, Bowers HE, Campbell DM, Parikh PP, Woods RJ. Meeting Increasing Demands for Rural General Surgeons. Am Surg 2015. [DOI: 10.1177/000313481508101215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Dynamic assessment of the effective surgical workforce recommends 27,300 general surgeons in 2030; 2,525 more than are presently being trained. Rural shortages are already critical and there has been insufficient preparation for this need. A literature review of the factors influencing the choice of rural practice was performed. A systematic search was conducted of PubMed and the Web of Science to identify applicable studies in rural practice, surgical training, and rural general surgery. These articles were reviewed to identify the pertinent reports. The articles chosen for review are directed to four main objectives: 1) description of the challenges of rural practice, 2) factors associated with the choice of rural practice, 3) interventions to increase interest and preparation for rural practice, and 4) present successful rural surgical practice models. There is limited research on the factors influencing surgeons in the selection of rural surgery. The family practice literature suggests that physicians are primed for rural living through early experience, with reinforcement during medical school and residency, and retained through community involvement, and personal and professional satisfaction. However, more research into the factors drawing surgeons specifically to rural surgery, and keeping them in the community, is needed.
Collapse
Affiliation(s)
- Mary C. Mccarthy
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Howard E. Bowers
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Damon M. Campbell
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Priti P. Parikh
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Randy J. Woods
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| |
Collapse
|
23
|
Kolkman P, Soliman M, Kolkman M, Stack A, Rao TS, Mukta S, Schmid K, Thompson J, Are C. Comparison of resident operative case logs during a surgical oncology rotation in the United States and an international rotation in India. Indian J Surg Oncol 2015; 6:36-40. [PMID: 25937762 DOI: 10.1007/s13193-015-0389-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 02/24/2015] [Indexed: 11/26/2022] Open
Abstract
This study compared the operative case log experience between rotations during General Surgery residency in the United States and an international rotation in India. A resident from the General Surgery residency program at University of Nebraska Medical Center participated in an international rotation in Surgical Oncology at Mehdi Nawaz Jung Institute of Oncology in Hyderabad, India for 3 months in 2009. The operative case log of this resident (INT) was compared to those of another resident (US) on a rotation in surgical oncology at the parent institution during the same time period. Both institutions were tertiary care centers. We noted that the INT resident performed a greater number of cases (132) when compared to the US resident (61). The INT resident also performed cases in a wider variety of disease categories such as: head and neck (26 %), gynecology (19 %), breast (14 %) and urology (4 %). In contrast, abdominal cases accounted for 68 % of the cases performed by the US resident with fewer cases in the other categories. The INT resident performed 98 % of the cases by the open approach, whereas the US resident performed only 81 % of cases by the open approach, with the remaining 19 % of cases performed by the laparoscopic approach. The results demonstrate that the INT resident performed a greater number of operative cases when compared to a resident (US) at the parent institution, and performed cases in more diverse disease categories with an emphasis on the open operative approach.
Collapse
Affiliation(s)
- Paul Kolkman
- Division of General Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE USA
| | - Mohsin Soliman
- Division of General Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE USA
| | - Marcy Kolkman
- College of Nursing, University of Nebraska Medical Center, 985330 Nebraska Medical Center, Omaha, NE USA
| | - Apollo Stack
- College of Medicine, University of Nebraska Medical Center, 985520 Nebraska Medical Center, Omaha, NE USA
| | - T Subramanyeshwar Rao
- MNJ Institute of Oncology & Regional Cancer Center, Hyderabad, 500004 Andhra Pradesh India
| | - Srinivasulu Mukta
- MNJ Institute of Oncology & Regional Cancer Center, Hyderabad, 500004 Andhra Pradesh India
| | - Kendra Schmid
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, 984375 Nebraska Medical Center, Omaha, NE USA
| | - Jon Thompson
- Division of General Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE USA
| | - Chandrakanth Are
- Division of General Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE USA
| |
Collapse
|
24
|
Nakayama DK, Hughes TG. Issues That Face Rural Surgery in the United States. J Am Coll Surg 2014; 219:814-8. [DOI: 10.1016/j.jamcollsurg.2014.03.056] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 03/25/2014] [Indexed: 11/29/2022]
|
25
|
Reply to letter: "perforated appendicitis: does rural residency really explain the delay?". Ann Surg 2013; 259:e59. [PMID: 24368642 DOI: 10.1097/sla.0000000000000302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
26
|
Paquette IM, Finlayson SR. Rural surgical workforce and care of colorectal disease. SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2013.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
27
|
Gadzinski AJ, Dimick JB, Ye Z, Miller DC. Utilization and outcomes of inpatient surgical care at critical access hospitals in the United States. JAMA Surg 2013; 148:589-96. [PMID: 23636896 DOI: 10.1001/jamasurg.2013.1224] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE There is a growing interest in the quality and cost of care provided at Critical Access Hospitals (CAHs), a predominant source of care for many rural populations in the United States. OBJECTIVE To evaluate utilization, outcomes, and costs of inpatient surgery performed at CAHs. DESIGN, SETTING, AND PATIENTS A retrospective cohort study of patients undergoing inpatient surgery from 2005 through 2009 at CAHs or non-CAHs was performed using data from the Nationwide Inpatient Sample and American Hospital Association. EXPOSURE The CAH status of the admitting hospital. MAIN OUTCOMES AND MEASURES In-hospital mortality, prolonged length of stay, and total hospital costs. RESULTS Among the 1283 CAHs and 3612 non-CAHs reporting to the American Hospital Association, 34.8% and 36.4%, respectively, had at least 1 year of data in the Nationwide Inpatient Sample. General surgical, gynecologic, and orthopedic procedures composed 95.8% of inpatient cases at CAHs vs 77.3% at non-CAHs (P < .001). For 8 common procedures examined (appendectomy, cholecystectomy, colorectal cancer resection, cesarean delivery, hysterectomy, knee replacement, hip replacement, and hip fracture repair), mortality was equivalent between CAHs and non-CAHs (P > .05 for all), with the exception that Medicare beneficiaries undergoing hip fracture repair in CAHs had a higher risk of in-hospital death (adjusted odds ratio = 1.37; 95% CI, 1.01-1.87). However, despite shorter hospital stays (P ≤ .001 for 4 procedures), costs at CAHs were 9.9% to 30.1% higher (P < .001 for all 8 procedures). CONCLUSIONS AND RELEVANCE In-hospital mortality for common low-risk procedures is indistinguishable between CAHs and non-CAHs. Although our findings suggest the potential for cost savings, changes in payment policy for CAHs could diminish access to essential surgical care for rural populations.
Collapse
Affiliation(s)
- Adam J Gadzinski
- Department of Urology, University of Michigan Health System, Ann Arbor, MI 48109, USA
| | | | | | | |
Collapse
|
28
|
Implications of Medicare procedure volumes on resident education. Am J Surg 2013; 205:737-44. [DOI: 10.1016/j.amjsurg.2012.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 10/26/2012] [Accepted: 11/06/2012] [Indexed: 11/20/2022]
|
29
|
Affiliation(s)
- Thomas H Cogbill
- Gundersen Lutheran Medical Foundation, University of Wisconsin School of Medicine and Public Health, La Crosse, Wisconsin, USA
| | | | | |
Collapse
|
30
|
Mell MW, Bartels C, Kind A, Leverson G, Smith M. Superior outcomes for rural patients after abdominal aortic aneurysm repair supports a systematic regional approach to abdominal aortic aneurysm care. J Vasc Surg 2012; 56:608-13. [PMID: 22592042 DOI: 10.1016/j.jvs.2012.02.051] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Revised: 01/18/2012] [Accepted: 02/23/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The impact of geographic isolation on abdominal aortic aneurysm (AAA) care in the United States is unknown. It has been postulated but not proven that rural patients have less access to endovascular aneurysm repair (EVAR), vascular surgeons, and high-volume treatment centers than their urban counterparts, resulting in inferior AAA care. The purpose of this study was to compare the national experience for treatment of intact AAA for patients living in rural areas or towns with those living in urban areas. METHODS Patients who underwent intact AAA repair in 2005 to 2006 were identified from a standard 5% random sample of all Medicare beneficiaries. Data on patient demographics, comorbidities, type of repair, and specialty of operating surgeon were collected. Hospitals were stratified into quintiles by yearly AAA volume. Primary outcomes included 30-day mortality and rehospitalization. RESULTS A total of 2616 patients had repair for intact AAA (40% open, 60% EVAR). Patients from rural and urban areas were equally likely to receive EVAR (rural 60% vs urban 61%; P = .99) and be treated by a vascular surgeon (rural 48% vs urban 50%; P = .82). Most rural patients (86%) received care in urban centers. Primary outcomes occurred in 11.6% of rural patients (1.3% 30-day mortality; 10.3% rehospitalization) vs 16.0% of urban patients (3% 30-day mortality, 13% rehospitalization; P = .04). In multivariate analyses, rural residence was independently associated with treatment at high-volume centers (odds ratio, 1.64; 95% confidence interval, 1.34-2.01; P < .0001) and decreased death or rehospitalization (odds ratio, 0.69; 95% confidence interval, 0.49-0.97; P = .03). CONCLUSIONS Despite geographic isolation, patients in rural areas needing treatment for intact AAAs have equivalent access to EVAR and vascular surgeons, increased referral to high-volume hospitals, and improved outcomes after repair. This suggests that urban patients may be disadvantaged even with nearby access to high-quality centers. This study supports the need for criteria that define centers of excellence to extend the benefit of regionalization to all patients.
Collapse
Affiliation(s)
- Matthew W Mell
- Division of Vascular Surgery, Stanford University, Stanford, Calif, USA.
| | | | | | | | | |
Collapse
|
31
|
Williams TE, Satiani B, Ellison EC. A comparison of future recruitment needs in urban and rural hospitals: the rural imperative. Surgery 2011; 150:617-25. [PMID: 22000172 DOI: 10.1016/j.surg.2011.07.047] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 07/11/2011] [Indexed: 10/16/2022]
Abstract
BACKGROUND The potential impact of shortages of the surgical workforce on both urban and rural hospitals is undefined. There is a predicted shortage of 30,000 surgeons by 2030 and the need to train and hire more than 100,000 surgeons. The aim of this study is to estimate the average recruitment needs in our nation's hospitals for 7 surgical specialties to ensure adequate access to surgical care as the U.S. population grows to 364 million by 2030. METHODS We used the census figure of 309 million in 2010 for U.S. population. Currently there are estimated to be 3,012 urban hospitals and 1,998 rural hospitals in the U.S. (American Hospital Association's Trend Watch report, 2009). At 253 million people (82 % of the population of 309 million in 2010) receive healthcare in urban hospitals; 56 million people receive healthcare in rural hospitals (18%). We assumed a work force model based on our previous publications, equal population growth in all geographic areas, recruitment by rural hospitals limited to Ob-Gyn, General Surgery, and Orthopedics, and that the percentage of the population receiving care at urban and rural hospitals will stay constant. RESULTS Rural hospitals will have to recruit an average of 3.4 OBGYN's, and an average of 1.6 Orthos, and 2.0 GS for a total of 7 full-time equivalents in the period from 2011 to 2030. Urban hospitals which have to recruit surgical specialists will have to recruit ten Ob-Gyns, about 5 Orthos, 6 GS's, 5 ear, nose, and throat surgeons (ENT's), an average of 2.5 urologists, a neurosurgeon, and a thoracic surgeon to meet the recruiting goals for the surgical services for their hospitals. CONCLUSION Rural hospitals will be in competition with urban hospitals for hiring from a limited pool of surgeons. As urban hospitals have a socioeconomic advantage in hiring, surgical care in rural areas may be at risk. It is imperative that each rural hospital analyze local future healthcare needs and devise strategies that will enhance hiring and retention to optimize access to surgical care.
Collapse
Affiliation(s)
- Thomas E Williams
- Department of Surgery, Ohio State University Hospital, Columbus, OH 43210, USA.
| | | | | |
Collapse
|
32
|
Cofer JB, Petros TJ, Burkholder HC, Clarke PC. General Surgery at Rural Tennessee Hospitals: A Survey of Rural Tennessee Hospital Administrators. Am Surg 2011. [DOI: 10.1177/000313481107700713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Rural communities face an impending surgical workforce crisis. The purpose of this study is to describe perceptions of rural Tennessee hospital administrators regarding the importance of surgical services to their hospitals. In collaboration with the Tennessee Hospital Association, we developed and administered a 13-item survey based on a recently published national survey to 80 rural Tennessee hospitals in August 2008. A total of 29 responses were received for an overall 36.3 per cent response rate. Over 44 per cent of rural surgeons were older than 50 years of age, and 27.6 per cent of hospitals reported they would lose at least one surgeon in the next 2 years. The responding hospitals reported losing 10.4 per cent of their surgical workforce in the preceding 2 years. Over 53 per cent were actively recruiting a general surgeon with an average time to recruit a surgeon of 11.8 months. Ninety-seven per cent stated that having a surgical program was very important to their financial viability with the mean and median reported revenue generated by a single general surgeon being $1.8 million and $1.4 million, respectively. Almost 11 per cent of the hospitals stated they would have to close if they lost surgical services. Although rural Tennessee hospitals face similar difficulties to national rural hospitals with regard to retaining and hiring surgeons, slightly more Tennessee hospitals (54 vs 36%) were actively attempting to recruit a general surgeon. The shortage of general surgeons is a threat to the accessibility of comprehensive hospital-based care for rural Tennesseans.
Collapse
Affiliation(s)
- Joseph B. Cofer
- Department of Surgery, The University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Tommy J. Petros
- Department of Surgery, The University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Hans C. Burkholder
- Department of Surgery, The University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | | |
Collapse
|
33
|
Weichel D. Orthopedic Surgery in Rural American Hospitals: A Survey of Rural Hospital Administrators. J Rural Health 2011; 28:137-41. [DOI: 10.1111/j.1748-0361.2011.00379.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
34
|
Rossi A, Rossi D, Rossi M, Rossi P. Continuity of care in a rural critical access hospital: surgeons as primary care providers. Am J Surg 2011; 201:359-62; discussion 362. [PMID: 21367379 DOI: 10.1016/j.amjsurg.2010.08.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Revised: 08/28/2010] [Accepted: 08/28/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND The question of volume and outcomes has perfused the surgical literature. Hopedale Hospital is a critical access hospital located in central Illinois. The authors elected to review surgical outcomes to establish quality benchmarks for similar facilities. They also propose a practice model in which general surgeons provide primary care. METHODS The authors consecutively reviewed retrospectively 100 each of 5 commonly performed procedures. These included carotid endarterectomy, laparoscopic cholecystectomy, laparoscopic Nissen fundoplication, hysterectomy, and inguinal hernia repair. Demographic data, c-morbidities, and outcomes up to 30 days postoperatively were summarized. RESULTS The overall complication rate was 4%. This exceeded any benchmarks found in a surgical literature review through Medline. CONCLUSIONS Critical access hospitals are capable of producing excellent surgical outcomes. Having a surgeon totally involved in perioperative management may contribute to the improved outcomes. This practice model could be used to recruit medical students into surgical training, perhaps alleviating shortages of rural surgeons and primary care physicians simultaneously.
Collapse
|
35
|
Abstract
OBJECTIVE To determine whether rural patients are more likely to present with perforated appendicitis compared with urban patients. BACKGROUND Appendiceal perforation has been associated with increased morbidity, length of hospital stay, and overall health care costs. Recent arguments suggest that high rates of appendiceal rupture may be unrelated to the quality of hospital care, and rather associated with inadequate access to surgical care. METHODS We performed a retrospective cohort study of 122,990 patients with acute appendicitis from the Nationwide Inpatient Sample from 2003 to 2004. International Classification of Diseases diagnosis 9 (ICD-9) codes were used to determine appendiceal perforation. Urban influence codes from the US Department of Agriculture were used to determine rural versus urban status. Univariate and multivariate analyses were used to determine patient and hospital factors associated with perforation. RESULTS Overall, 32.07% of patients presented with perforation. Rural patients were more likely than urban patients to present with perforation (35.76% vs. 31.48%). Factors associated with perforation in multivariate analysis were age more than 40 years, male gender, transfer from another facility, black race, poorest 25th percentile, Charlson score of 3 or higher, and rural residence. Thirty percent of rural patients were treated in urban hospitals. Rural patients treated at urban hospitals were more likely to present with perforation compared with rural patients treated at rural hospitals (OR = 1.23). CONCLUSIONS Patients from rural areas have higher rates of perforation with acute appendicitis than urban patients. This difference persists when accounting for other factors associated with perforation. These differences in perforation rates suggest disparities in access to timely surgical care.
Collapse
|
36
|
A Critical Evaluation of the Impact of Leapfrog's Evidence-Based Hospital Referral. J Am Coll Surg 2011; 212:150-159.e1. [DOI: 10.1016/j.jamcollsurg.2010.09.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 09/14/2010] [Accepted: 09/29/2010] [Indexed: 12/17/2022]
|
37
|
International Medical Graduates in General Surgery: Increasing Needs, Decreasing Numbers. J Am Coll Surg 2010; 210:990-6. [DOI: 10.1016/j.jamcollsurg.2010.02.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Revised: 02/02/2010] [Accepted: 02/02/2010] [Indexed: 11/21/2022]
|
38
|
Finlayson SRG. Assessing and improving the quality of surgical care in rural America. Surg Clin North Am 2010; 89:1373-81, x. [PMID: 19944820 DOI: 10.1016/j.suc.2009.09.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The quality of surgical care in rural hospitals is important, as surgery remains a critical component of rural health care systems. Current models for surgical quality assessment and improvement largely reflect the characteristics of larger urban hospital settings, which include proximity to other providers for peer review, higher procedure volumes to accurately assess outcomes, and greater financial resources to acquire data collection systems and finance participation in regional or national quality improvement programs, such as the American College of Surgeons National Surgical Quality Improvement Program. Although rural surgeons and hospitals face numerous challenges in their efforts to demonstrate or improve the quality of their surgical practices, developments in surgical quality favor their increased participation in quality improvement initiatives.
Collapse
Affiliation(s)
- Samuel R G Finlayson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
| |
Collapse
|
39
|
Doty B, Heneghan SJ, Zuckerman R. General Surgery Contributes to the Financial Health of Rural Hospitals and Communities. Surg Clin North Am 2009; 89:1383-7, x-xi. [DOI: 10.1016/j.suc.2009.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
40
|
Pathman DE, Ricketts TC. Interdependence of General Surgeons and Primary Care Physicians in Rural Communities. Surg Clin North Am 2009; 89:1293-302, vii-viii. [DOI: 10.1016/j.suc.2009.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
41
|
|