Perioperative Support in the Rural Surgery World.

Perioperative support in a rural surgical environment encompasses unique challenges but ultimately should not substantially differ from those in resource-rich, urban hospitals. Perioperative support can be divided into 5 different phases of care, each with their own resource needs and challenges. These phases include (1) preoperative phase, (2) immediate preoperative phase, (3) intraoperative phase, (4) postoperative phase, and (5) postdischarge phase.

Perforated appendicitis among rural and urban patients: implications of access to care.

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.

The impact of laparoscopy on the volume of open cases in general surgery training.

OBJECTIVE: The purpose of this study was to evaluate the impact of laparoscopy on the volume of open cases in general surgery residency training over the past 10 years. DESIGN: The Accreditation Council for Graduate Medical Education (ACGME) database (1999-2008), which records all cases (by Current Procedural Terminology code) performed by graduating general surgery trainees, was retrospectively analyzed. SETTING: ACGME database (1999-2008). MAIN OUTCOME MEASURES: Trends were compared regarding the average number of the most common laparoscopic and open procedures (colectomy, hernia, and appendectomy) performed by graduating general surgery trainees during the reporting period. RESULTS: Across all procedures, an increase was noted in laparoscopic approaches with a reciprocal decrease in open cases. The number of open appendectomies decreased by 29% (30.7 to 21.7), whereas the number of laparoscopic appendectomies increased by 278% (8.5 to 32.1). Similarly, open inguinal hernia cases decreased by 12.5% (51.9 to 45.4) and open colectomy cases decreased by 10.4% (48 to 43). Conversely, laparoscopic hernia repair and laparoscopic colectomy increased by 87.5% (7.6 to 15.8) and 550% (2 to 13), respectively. CONCLUSIONS: In addition to the limitations placed on residency training by other factors (including work hour restrictions), changing practice patterns within the field of general surgery have a significant impact on the exposure of residents to open surgery cases. This trend might have far-reaching implications with regard to the overall competency of graduating residents and raises concerns for the future direction of surgical education.

Rural surgery: framing the issues.

Many rural residents have limited access to surgical care. Although this problem has been ongoing for the past few decades, several factors threaten to exacerbate the situation. The narrowing of general surgery practice, workforce shortages and inappropriate distribution of surgeons, changes in how surgeons are trained, and increasing health care costs contribute to the problem. Creative approaches to address these issues are needed to provide high-quality surgical services to the approximately 50 million Americans living in rural communities.

General surgery contributes to the financial health of rural hospitals and communities.

Rural hospitals and communities often profit from the ability to provide surgical services. There can also be substantial financial costs for individuals, hospitals, and communities associated with not having access to surgical care in rural areas. Despite these advantages, limitations that include a shortage of rural general surgeons and other surgical staff and financial constraints prevent some rural institutions from offering surgical services. Few concrete data are available on this subject, and more research is needed to confirm anecdotal reports regarding the positive economic impact derived from general surgical services. It is especially important to examine and quantify the direct and indirect financial contribution that a general surgeon makes to a rural hospital and community.

Are general surgery residency programs likely to prepare future rural surgeons?

BACKGROUND: Too few surgeons practice in small rural areas of the United States. Many newly graduating surgeons choose not to practice rurally because they feel unprepared for rural practice. Family medicine residencies have a track record of placing graduates in rural settings. Their experience shows that having a stated interest in training rural physicians, a rural-focused curriculum, and rural practice exposure opportunities are successful elements for graduating physicians who practice rurally. OBJECTIVE: To describe the extent to which general surgery residency training is likely to prepare future rural surgeons using criteria cited in reviews of rural family medicine residency programs. METHODS: Three criteria were used to assess whether general surgery residency programs are positioned to produce rural surgeons: rural location, rural-focused curriculum, and self-identified interest in rural training. Several search strategies were employed to identify residency programs that meet the criteria. Additionally, data extracted from the American Medical Association's Physician Masterfile was used to determine demographic characteristics of residency programs that have trained surgeons who currently practice rurally. RESULTS: Overall, 25 general surgery residency programs meet at least 1 of the 3 criteria. This finding represents approximately 10% of all residency programs in the United States. Residency programs located in the Midwest and the South have generally been more successful in graduating surgeons who are practicing rurally than those situated in the Northeast and West. CONCLUSIONS: Although a few general surgery residency programs have been successful in graduating surgeons who practice rurally, there has not been a coordinated effort among programs to accomplish this goal. Our findings suggest a need for organization and coordination among those programs committed to training surgeons for rural practice. The creation of a consortium of general surgical residency programs with an interest in training rural surgeons could be a useful first step in this process.

Operative choledochoscopic laser lithotripsy for impacted intrahepatic gallstones: a novel surgical approach.

INTRODUCTION: Occasionally patients present with hepatic duct stones or impacted common bile duct stones that either fail or are not amenable to endoscopic retrograde cholangiopancreatography (ERCP) extraction. More troublesome are patients with prior surgeries resulting in altered anatomy that makes traditional endoscopic extraction of ductal stones very difficult. We present a novel approach to these ductal stones using a combination of surgery, biliary endoscopy, and laser lithotripsy. METHODS: We report on five patients with ductal stones that either failed ERCP or were not candidates for ERCP extraction. Data was collected via chart review with Institutional Review Board approval. RESULTS: The average age of patients was 70.1 years. All patients presented with hepaticolithiasis and symptoms of cholangitis including elevated liver function tests and recurrent fever and chills. Patients had a mean of 2.8 failed ERCP or percutaneous attempts at stone clearance (range 2-4). A combination of surgery and intraoperative biliary endoscopy with laser lithotripsy (holmium laser) was used in all patients. In four patients the lithotripter was introduced via a choledochotomy or hepaticodochotomy. One patient had previously undergone a Roux-en-Y hepaticojejunostomy and was found to have a large hepatic duct stone sitting above a strictured anastomosis. Access was gained via an enterotomy in the Roux limb. Complete stone clearance was obtained in all patients. Average operative time was 349 min. All patients have normal liver function tests (27-36 month follow-up). CONCLUSION: Laser lithotripsy has been described as an adjunct to ERCP in the past for stones refractory to balloon or basket retrieval. The combination of a surgical enterotomy, biliary endoscopy, and laser lithotripsy provides a novel approach to treat patients with large intrahepatic stones who are not candidates for or have failed ERCP.

Use of locum tenens surgeons to provide surgical care in small rural hospitals.

BACKGROUND: Too few general surgeons practice in rural American communities, and many hospitals in the smallest rural areas do not have a surgeon. Therefore, it is likely that some small rural hospitals are using alternative arrangements to provide surgical care, including hiring locum tenens surgeons. We describe the degree to which small rural hospitals are using locum tenens surgeons to provide surgical services. METHODS: Administrators at 129 small rural hospitals were surveyed by telephone. The survey instrument was comprised of questions asking whether the hospital provides surgical services, if the hospital has recruited a surgeon, whether the hospital uses locum tenens surgeons and if so for what purposes. RESULTS: A total of 76% of surveyed rural hospitals have offered surgical services during the past 5 years. In all, 56% of hospitals providing surgical care have recruited a surgeon during the past 5 years. Of those who have been unsuccessful in their search, 30% have considered using a locum tenens surgeon, and 20% have done so. CONCLUSIONS: Given the difficulty of recruiting surgeons to practice in rural America, it is critical to develop strategies to address this problem. Although using locum tenens surgeons may allow rural hospitals to offer surgical services, the quality of surgical care could be compromised. Other means for delivering surgical services at rural hospitals that cannot recruit or retain a surgeon should be explored to ensure that rural residents have access to high quality surgical care.

How does degree of rurality impact the provision of surgical services at rural hospitals?

CONTEXT: Rural residents frequently have decreased access to surgical services. Consequences of this situation include increased travel time and financial costs for patients. There are also economic implications for hospitals as they may lose revenue when patients leave the area in order to obtain surgical services. Rural communities vary in size and distance from more populated centers. Since rural hospitals are located in varying types of rural communities, they likely differ with regard to the provision of surgical care. PURPOSE: To describe the differences between hospitals located in smaller versus larger rural areas regarding the provision of surgical care. METHODS: A 12-item survey instrument based on one previously used in a pilot study was mailed to a national random sample of rural hospital administrators (n = 233). Rural location was determined using rural-urban commuting area codes. FINDINGS: One hundred and eleven surveys were received, yielding a 48% response rate. Hospitals in larger rural areas had an average of 9 surgeons compared to 1 at hospitals in smaller rural areas. More administrators at hospitals located in larger rural areas viewed the ability to provide surgical care as very important to the financial viability of their hospital. CONCLUSIONS: Among rural hospitals located in communities of varying sizes there are significant differences in how surgical services are delivered and the financial importance of providing surgical care. Administrators at hospitals located in larger rural areas, more than in smaller ones, report financial reliance on their ability to offer surgical care and have significantly more resources available to do so.

General surgery at rural hospitals: a national survey of rural hospital administrators.

BACKGROUND: Many rural residents have limited access to surgical care. Rural hospitals frequently struggle to provide surgical services due to workforce shortages and financial constraints. The purpose of this study is to describe rural hospital administrators' perceptions regarding the state of their general surgery programs and the impact that providing surgical services has on their hospitals' financial viability. METHODS: A 12-item survey was mailed to a random sample of national rural hospital administrators (n=233). One hundred and eleven surveys were completed, yielding a response rate of 48%. In addition to overall descriptive analyses, comparisons were made between hospitals located in large versus small rural communities. RESULTS: Eighty-three percent of rural hospital administrators perceived their surgical program to be very important to the financial viability of their hospital and stated that they would reduce services if the hospital were to lose its surgery program. Thirty-four percent of hospitals have a surgeon leaving within the next 2 years and more than one-third of hospital administrators are currently searching for a surgeon. CONCLUSIONS: Surgical care is a vital component of the health care services delivered by rural hospitals. Surveyed administrators' view the ability to provide surgical services as crucial to the financial viability of their rural hospitals. A shortage of general surgeons is a potential major threat to these rural hospitals.

Trends in adoption of laparoscopic cholecystectomy in rural versus urban hospitals.

BACKGROUND: For many general surgeons, the professional isolation of rural practice serves as an obstacle to the adoption of new techniques. Whether this obstacle impeded the dissemination of laparoscopy in rural settings is not known. STUDY DESIGN: We performed a retrospective, descriptive comparison of the adoption rate of laparoscopic cholecystectomy in small rural versus urban hospitals in the US using the Nationwide Inpatient Sample from 1988 to 1997. Additionally, we examined differences in in-hospital mortality, length of hospital stay, and in-hospital reintervention rates. RESULTS: There were 4,985,465 cholecystectomies performed nationwide from 1988 to 1997. Over this time period, the proportion of procedures done laparoscopically increased from 2.5% to 76.6% for elective cholecystectomy and from 0.7% to 67.5% for urgent cholecystectomy. The proportion of elective procedures done laparoscopically increased sharply from 1989 to 1992, from 3.5% to 73.7%, and remained high in both rural and urban areas, with negligible difference in timing of adoption. Use of the laparoscopic approach for urgent cholecystectomy increased sharply from 1990 to 1992 (4.9% to 54.6%) and, since 1992, has increased similarly in both rural and urban areas. The adjusted in-hospital mortality rate for laparoscopic cholecystectomy did not differ significantly between rural and urban hospitals (0.47% and 0.57%, respectively, p=0.6). The in-hospital reintervention rate was 0.88% for both rural and urban hospitals (p=0.98). There were no significant differences in mortality or reintervention rates when cases were stratified by admission type (elective versus urgent). CONCLUSIONS: Most rural surgeons successfully overcame professional isolation in learning and adopting laparoscopic cholecystectomy.

Rural versus non-rural differences in surgeon performed endoscopy: results of a national survey.

The ongoing decline in the number of general surgeons practicing in rural areas of the United States is concerning. Existing data show that rural surgeons perform a broad spectrum of cases including procedures that are not considered to be in the repertoire of most general surgeons. In particular, rural surgeons seem to be performing a sizeable number of endoscopic procedures. A sixty-item survey was mailed to 1700 rural surgeons while a random sample of 154 urban surgeons were telephoned and administered the same questionnaire. The general surgeons were identified using a list obtained from the American Medical Association Masterfile. The response rate was 25 per cent and 74 per cent among rural and nonrural surgeons respectively. Seventy four per cent of rural surgeons performed more than 50 flexible endoscopies a year in contrast to 33 per cent of nonrural surgeons (P < 0.05). Approximately 42 per cent of rural surgeons reported doing more than 200 procedures annually, whereas only 12 per cent of the nonrural surgeons did so. Additionally, 63 per cent of rural surgeons wished they had further training in endoscopy before starting practice as compared with 46 per cent (P < 0.05) of nonrural surgeons. Rural surgeons perform flexible endoscopy at a much higher rate than their nonrural counterparts. The majority of rural surgeons feel they would have benefited from additional flexible endoscopy training before entering practice.

Starting a general surgery program at a small rural critical access hospital: a case study from southeastern Oregon.

CONTEXT: Surgical services are frequently unavailable in rural American communities. Therefore, rural residents often must travel long distances to receive surgical care. Rural hospitals commonly have difficulty providing surgical services despite potential economic benefits. PURPOSE: The purpose of this project was to identify the key challenges and describe the initial outcomes experienced by Harney District Hospital (HDH), a rural critical access facility in Oregon, as it develops a surgical program. Since few models exist, this information will be valuable for those considering offering surgical services in a rural setting. METHODS: This project employed a single case study design. Qualitative information was gathered from semi-structured interviews, a focus group, reviews of historical documents, and informal observations. Quantitative data sources included HDH financial and utilization records, US Census records, and economic and demographic statistics from the state of Oregon, Harney County, and the city of Burns. FINDINGS: HDH is learning that initiating a change such as expanding surgical services within an organization is a challenging process requiring collaboration among the administration, staff, and community. Preliminary findings indicate that the new surgical program has resulted in significant financial gains for the hospital. CONCLUSIONS: While starting a rural surgery program is a complex undertaking, there are benefits for the hospital. If a rural hospital is to be successful in this mission, collaboration and adaptability must be key components of the process.

A multicentre controlled study of the InLine radiofrequency ablation device for liver transection.

BACKGROUND: Surgical resection is the most effective therapy for liver cancer. Intraoperative blood loss during liver resection remains a major concern due to association with higher postoperative complications. The InLine radiofrequency ablation device (ILRFA) has achieved promising results in liver surgery with minimal blood loss and no increase of postoperative complications. In this multicentre controlled study, 108 patients undergoing liver resection were investigated. PATIENTS AND METHODS: A total of 108 patients underwent liver resections in 4 medical centres; the prospective sequential cohort study consisted of 54 ILRFA and 54 ultrasonic surgical aspirator transections as the control group. RESULTS: The type of liver resection performed was very similar in both groups. The median number of RFA deployments was 3 (range 1-12) with a median coagulation time of 9 (range 3-36) min. Median blood loss was 165+/-20 ml (range 5-675) in the ILRFA and 654+/-83 ml (range 80-3600) in the control group (p<0.001). The median transection time was 27 (2-219) min in the ILRFA group and 35 (5-62) min in controls. CONCLUSIONS: Our study indicates that ILRFA device for liver transection is effective in reducing blood loss and is safe. Precoagulation before parenchymal transection appears to be a valid concept in liver surgery. The avoidance of vascular inflow occlusion during parenchymal transection could also be of value.

Is a broadly based surgical residency program more likely to place graduates in rural practice?

BACKGROUND: There is a shortage of general surgeons practicing in rural America. Rural surgical practices differ from those in urban settings encompassing a broader case mix with a larger percentage of time spent performing abdominal, alimentary, gynecological, genitourinary, and orthopedic procedures. Present graduates of many general surgical residencies do not obtain the range of experience necessary to practice effectively in this environment. We hypothesize that general surgical residents undergoing broadly based training are more likely to practice in a rural location. METHODS AND MATERIALS: We conducted a survey of graduates from the Mary Imogene Bassett Hospital's (MIBH) broadly based surgical residency program in 2004. Additionally, the surgical resident logs from the Accreditation Council for Graduate Medical Education (ACGME) and the residency program were reviewed for years 2001-2004. RESULTS: Of the 56 surveys sent out, 42 (75%) were completed and used in the analysis. A majority of the general surgeons who were raised in a rural environment reported that they are residing and practicing in a rural setting. Graduates of the MIBH residency program, on average, performed more cases as residents in the following subspecialty areas: genitourinary, plastics/hand, gynecology, neurosurgery, and orthopedics than national residency graduates. CONCLUSIONS: Based on our findings, surgical residents graduating from a broadly based training program appear more likely to practice in a rural setting.

Rural versus urban inpatient case-mix differences in the US.

BACKGROUND: Preparation of surgeons for practice in rural settings is hindered by limited knowledge of case-mix differences between rural and nonrural surgical practices. Although surgical practice in isolated rural areas is believed to be very different from urban practice, little is known about actual inpatient case-mix differences. STUDY DESIGN: We performed a retrospective, descriptive comparison of inpatient general surgical procedures performed at rural versus urban hospitals in the US using the Nationwide Inpatient Sample database (2000 to 2001). Rural versus urban geographic designations were based on Rural-Urban Commuting Area codes developed by the Rural Health Research Institute. Inpatient surgical procedures were aggregated by the Clinical Classifications Software based on ICD-9-CM procedure codes. RESULTS: Operations on the bowel, appendix, and gallbladder constitute 61% of general surgical inpatient procedures in rural hospitals, compared with 46% in urban hospitals. Compared with urban general surgery practices, rural practices include substantially fewer operations on the stomach and esophagus (6% versus 11%), liver and pancreas (0% versus 1%), spleen and thyroid (3% versus 10%), and bowel (17% versus 19%). General surgical procedures constitute 42% of inpatient procedures in rural hospitals versus 25% in urban hospitals. A rural general surgeon more broadly trained in selected obstetric and gynecologic operations could potentially perform 66% of all inpatient procedures in rural hospitals. Addition of simple vascular cases (eg, arteriovenous fistula, vascular access), head and neck operations, amputations, and nephrectomies could increase this potential to 71% of all cases. CONCLUSIONS: Rural and urban general surgical inpatient case-mixes differ from each other substantially. Additional competence in a few surgical areas that are not currently emphasized in general surgical training could result in an increased role for general surgeons practicing in rural areas.

Small rural hospitals and high-risk operations: how would regionalization affect surgical volume and hospital revenue?

BACKGROUND: Because higher hospital procedure volume is associated with better outcomes for many high-risk procedures, regionalization to higher-volume hospitals has been proposed as a way to improve quality of surgical care. The potential impact of such policies on small rural hospital volume and revenue is unknown. STUDY DESIGN: We identified all hospitalizations in small rural hospitals (less than 50 beds) in New York State from 1998 to 2001 that included an ICD-9 procedure code for 1 of 9 procedures for which there is a documented volume-outcomes association: abdominal aortic aneurysm repair, aortic-valve replacement, carotid endarterectomy, colectomy, coronary artery bypass, cystectomy, esophagectomy, pancreatectomy, or pulmonary resection. Revenue from these procedures was estimated using gross charges and payor-specific reimbursement rates. We then compared these estimates with total hospital inpatient revenue for each rural hospital. RESULTS: We identified 14 small rural hospitals where at least one of the nine procedures was performed. All included hospitalizations for colectomy. Aortic aneurysm repairs, cystectomies, and pancreatectomies were performed in three hospitals; carotid endarterectomy in two; and esophagectomy in one. In no hospitals were cardiac procedures or pulmonary resections performed. Estimated average contribution to hospital net revenue for all 9 procedures was approximately 2%, nearly all attributable to colectomy. CONCLUSIONS: If all aortic aneurysm repairs, major cardiothoracic procedures, carotid endarterectomies, cystectomies, and pancreatectomies in New York State were regionalized to higher-volume hospitals, no small rural hospitals would experience substantial impact in terms of rural hospital procedure volume and revenue. Even regionalization of colectomy would have a small impact on inpatient volume and revenue.

General surgery programs in small rural New York State hospitals: a pilot survey of hospital administrators.

CONTEXT: Hospitals play a central role in small rural communities and are frequently one of the major contributors to the local economy. Surgical services often account for a substantial proportion of hospital revenues. The current shortage of general surgeons practicing in rural communities may further threaten the financial viability of rural hospitals and communities. PURPOSE: To describe hospital administrators' perceptions regarding the current state of general surgery programs at small rural hospitals in New York State, including the impact that surgical services have on hospital financial viability. METHODS: A list of hospitals belonging to the rural hospitals group of the Healthcare Association of New York State was obtained to determine prospective survey recipients. Sixty-eight administrators at each of the identified hospitals were subsequently surveyed and 38 respondents met all inclusion criteria. FINDINGS: Approximately 87% of hospital administrators perceive that the general surgery program is critical to the hospital's financial viability. Forty percent of respondents report that they would be forced to close the hospital if the surgical program was lost. Among the 42% of administrators trying to recruit a general surgeon, almost two thirds have been searching for more than 1 year. CONCLUSIONS: According to the perceptions of hospital administrators, the financial viability of rural hospitals in New York State depends in large part on their ability to provide surgical services. Additionally, general surgeons appear to be in high demand at a significant number of the surveyed institutions.