The composition of rural hospital medical staffs: the influence of hospital neighbors

The aging general surgeon of rural America

PURPOSE

Nonmetropolitan communities are faced with health care professional shortages and prior reports suggest that general surgeons are no exception. The purpose of this brief is to evaluate the age difference and distribution of rural versus urban general surgeons to highlight the growing need to recruit medical students and residents for rural practice.

METHODS

A secondary data analysis of residency graduated general surgeon demographics at the county level was performed using data from the Area Health Resource File. General surgeon demographic data were compared between nonmetropolitan and metropolitan areas.

FINDINGS

The number of general surgeons practicing in rural communities is decreasing by a rate of approximately 0.5%-1.0% annually. Moreover, the entry of younger (<35 years of age) general surgeons into rural counties (8.7%) was less than urban regions (12.1%). Rural general surgeons tended to be older than their urban peers, and on average, rural general surgeon age exhibits a negative skewed, platykurtic distribution.

CONCLUSIONS

Immediate action must be taken to generate more surgeons for rural practice. A failure to increase recruitment and retention of rural surgeons may have severe consequences on the health status of rural communities.

United States rural hospital quality in the Hospital Compare database-accounting for hospital characteristics

BACKGROUND

Rural hospitals in the United States have demonstrated lower adherence to evidence based guidelines than their urban counterparts in national public reporting initiatives. We compared the quality of rural hospitals participating in a public reporting initiative to that of their urban counterparts using Hospital Compare, a new national database containing process measures.

METHODS

Cross-sectional analyses of hospitals participating in Hospital Compare in 2005, evaluating percent adherence to guidelines for 10 processes of care for acute myocardial infarction (AMI), heart failure (HF), and community-acquired pneumonia (CAP) using multivariable linear regression analyses.

RESULTS

Participating rural hospitals demonstrated lower adherence to evidence based guidelines in MI and HF quality measures (p<0.05) and higher adherence to prescribing antibiotics in a timely manner in CAP (p<0.05). Differences increased with bed size (F test for linear trend, p<0.05). After adjustment, the trends demonstrating lower adherence persisted in 6 AMI and HF measures and higher adherence in 1 CAP measure in spite of a disproportionate number of drop-outs among lower performing urban hospitals.

CONCLUSIONS

Participating rural hospitals had lower performance than their urban counterparts. As the rural/urban quality gap varies by condition, bed size, and participation, we recommend comparing performance across a wide variety of condition-specific measures to enable targeted quality improvement.

Threats to rural surgery

BACKGROUND

Rural surgery is a subject that often is discussed but little has been done to address the problems of rural surgery. With a decreased interest in broad-based general surgery, an aging population (especially in rural America), an aging population of general surgeons who are retiring early, surgical care in rural North America is approaching a crisis.

METHODS

An internet search was performed to analyze the problems in rural surgery. Also, the experience of a 90-bed rural hospital in south central Kentucky was analyzed.

RESULTS

Approximately 17% to 25% of the population in America (55 million) live in a rural environment, depending on the way rural is defined. Rural general surgeons may become an endangered species because of multiple factors, including: lack of broad-based training, increased specialization, lifestyle issues, decreased interest in surgery, increased technology, aging rural surgeons, increased workload for the general surgeon, decreased reimbursement, increased expenses, increased expectations of the general public, and increased malpractice costs. Solutions include programs dedicated to training rural surgeons, networking with university tertiary care hospitals, equal pay for work performed regardless of the location, regionalization of rural surgery centers with multiple surgeons so the lifestyle issues can be addressed.

CONCLUSIONS

There is an increasing need for broad-based general surgeons in rural America. Training programs need to address the problem by offering dedicated training programs that should include primary training in general surgery and fellowships for special needs. A new specialty in rural general surgery needs to be created.

Itinerant surgical and medical specialist care in Kansas: report of a survey of rural hospital administrators

In most rural areas, specialist nonprimary care, when available, is provided by "itinerant" physicians and surgeons who periodically visit from a distant home base. Little is known about current usage and acceptability of itinerant specialists in rural communities. Administrators of hospitals in rural and frontier Kansas counties were asked to report the frequency of itinerant care in their facilities, the home base of each specialist and a listing of procedures performed during specialist visits. Administrators were also asked to respond on a Likert scale to six questions inviting their assessment of itinerant care. Responses were received from 53 of 56 hospitals. All offered at least one monthly session of itinerant medical or surgical care. The most common specialties represented were cardiology (in 87 percent of hospitals), urology (68 percent), orthopedics (68 percent) and radiology (60 percent). General surgeons consulted in over 80 percent of responding hospitals. Psychiatrists, dermatologists and neurologists were rarely available in the hospitals surveyed. Administrators generally rated itinerant care highly, though some expressed concern about revenue lost when specialists performed procedures in their home-base office or hospital. No associations were found between amount of care offered and potential explanatory variables such as hospital size, distance from subregional centers, or percentage of patients hospitalized locally. Further study is needed to better understand differences in itinerant specialist utilization and acceptance among rural Kansas hospitals. Because Kansas demographics are similar to those of many other American rural areas, such study may offer insights applicable to other regions.