Trends in Rural Outreach by Orthopedic Surgeons.

BACKGROUND: Sixty million rural residents have limited access to orthopedic care due to a small rural orthopedic surgery workforce. Increases in specialized training add to the challenge of attracting orthopedic surgeons to rural communities. Answering the call for research on models to meet the needs of rural orthopedic patients, we examine long-term trends in visiting consultant clinics (VCCs) in Iowa, a state with a large rural population. METHODS: The Office of Statewide Clinical Education Programs (Carver College of Medicine) compiles an annual report of outreach clinic locations, frequencies and participating physicians. Trends in the total number of VCCs, days and locations (1989-2018) were analysed using joinpoint analysis. RESULTS: Total clinic days grew rapidly from 1992-1997 (Average Percent Change: 19.7%) before a decline ending in 2009 (APC: -4.1%). A new growth period (2009-2013, APC: 7.5%) preceded another decline (APC: -3.6%) ending in 2018. The number of cities hosting a VCC grew from 56 (1989) to a peak of 90 (1999) and fell an average of 0.9% a year thereafter. More than 80% of all VCCs in the last ten years were offered 2 or more times per month. The average participation rate for Iowa-based orthopedic surgeons was 44%. The mean number of VCCs staffed by a single physician was 1.32 (std. dev. = 0.53) with a median of 1. The average number of VCC days per month for a participating physician was 3.22 (std. dev. = 2.41) with a median of 2.66. CONCLUSION: The VCC model of rural outreach is sustainable (30+ year history) and self-funded. Most clinics occur with sufficient frequency to allow timely follow-up care. This model of rural outreach is supported by the participation of a large segment (44%) of Iowa's orthopedic surgeons. Visiting orthopedic surgeons provide access to care in 65 of the 76 Critical Access Hospitals in Iowa offering orthopedic services compared to 8 staffed by a local orthopedic surgeon.Level of Evidence: V.

Impact of nonphysician providers on spatial accessibility to primary care in Iowa.

OBJECTIVE: To assess the impact of nonphysician providers on measures of spatial access to primary care in Iowa, a state where physician assistants and advanced practice registered nurses are considered primary care providers. DATA SOURCES: 2017 Iowa Health Professions Inventory (Carver College of Medicine), and minor civil division (MCD) level population data for Iowa from the American Community Survey. STUDY DESIGN: We used a constrained optimization model to probabilistically allocate patient populations to nearby (within a 30-minute drive) primary care providers. We compared the results (across 10 000 scenarios) using only primary care physicians with those including nonphysician providers (NPPs). We analyze results by rurality and compare findings with current health professional shortage areas. DATA COLLECTION/EXTRACTION METHODS: Physicians and NPPs practicing in primary care in 2017 were extracted from the Iowa Health Professions Inventory. PRINCIPAL FINDINGS: Considering only primary care physicians, the average unallocated population for primary care was 222 109 (7 percent of Iowa's population). Most of the unallocated population (86 percent) was in rural areas with low population density (< 50/square mile). The addition of NPPs to the primary care workforce reduced unallocated population by 65 percent to 78 252 (2.5 percent of Iowa's population). Despite the majority of NPPs being located in urban areas, most of the improvement in spatial accessibility (78 percent) is associated with sparsely populated rural areas. CONCLUSIONS: The inclusion of nonphysician providers greatly reduces but does not eliminate all areas of inadequate spatial access to primary care.

Providing Cardiology Care in Rural Areas Through Visiting Consultant Clinics.

BACKGROUND: Workforce experts predict a future shortage of cardiologists that is expected to impact rural areas more severely than urban areas. However, there is little research on how rural patients are currently served through clinical outreach. This study examines the impact of cardiology outreach in Iowa, a state with a large rural population, on participating cardiologists and on patient access. METHODS AND RESULTS: Outreach clinics are tracked annually in the Office of Statewide Clinical Education Programs Visiting Medical Consultant Database (University of Iowa Carver College of Medicine). Data from 2014 were analyzed. In 2014, an estimated 5460 visiting consultant clinic days were provided in 96 predominantly rural cities by 167 cardiologists from Iowa and adjoining states. Forty-five percent of Iowa cardiologists participated in rural outreach. Visiting cardiologists from Iowa and adjoining states drive an estimated 45 000 miles per month. Because of monthly outreach clinics, the average driving time to the nearest cardiologist falls from 42.2±20.0 to 14.7±11.0 minutes for rural Iowans. Cardiology outreach improves geographic access to office-based cardiology care for more than 1 million Iowans out of a total population of 3 million. Direct travel costs and opportunity costs associated with physician travel are estimated to be more than $2.1 million per year. CONCLUSIONS: Cardiologists in Iowa and adjoining states have expanded access to office-based cardiology care from 18 to 89 of the 99 counties in Iowa. In these 71 counties without a full-time cardiologist, visiting consultant clinics can accommodate more than 50% of office visits in the patients' home county.

Improving Rural Access to Orthopaedic Care Through Visiting Consultant Clinics.

BACKGROUND: Patients from rural areas tend to be older and less physically active and are more likely to be obese, increasing their need for orthopaedic services. However, few orthopaedic surgeons practice in rural areas. One approach to meeting the needs of rural patients is visiting consultant clinics (VCCs). In this study, we examined orthopaedic surgery outreach in Iowa, a state with a large rural population. We assessed the involvement of the 2014 Iowa orthopaedic surgery workforce in outreach activities for the geographically disadvantaged rural population and its effect on patient travel distances. METHODS: The University of Iowa Carver College of Medicine annually tracks VCC locations and frequencies. Data from 2014 were used to estimate average trip length for participating orthopaedic surgeons and patients in all Iowa census tracts. Primary practice locations, visiting consultant clinic locations, and census tracts were classified according to the 2010 Rural-Urban Commuting Areas (RUCA) classifications. RESULTS: In 2014, 4,596 VCC days were provided in 80 predominantly rural sites. Overall, as a result of VCCs staffed by orthopaedic surgeons in Iowa and adjoining states, the number of Iowan counties with an orthopaedic surgeon increased from 35 (at his/her primary practice location) to 88 (at a VCC or primary practice location) of 99. Forty-five percent of all Iowa-based orthopaedic surgeons participated in a VCC. Visiting orthopaedic surgeons drove a total of 32,496 mi (52,297 km) per month to conduct these clinics. The average driving distance to the nearest orthopaedic surgeon was reduced from 19.2 mi (30.9 km) to 8.4 mi (13.5 km) for rural Iowans as a result of monthly VCCs. Monthly VCCs improved access to orthopaedic surgeons for between 450,000 and 670,000 Iowans from a total population of approximately 3 million. CONCLUSIONS: VCCs staffed by orthopaedic surgeons from Iowa and surrounding states improve access to orthopaedic care by reducing driving distances for rural patients.