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.

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.

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.

A rural, community-based program can train surgical residents in advanced laparoscopy.

BACKGROUND: Advanced laparoscopy requires mastery of complex surgical skills. A steep learning curve, lack of an adequate number of cases, and a shortage of experienced staff are reasons cited as barriers to the acquisition of these skills by surgical residents. We hypothesize that advanced laparoscopy can be taught during residency without additional fellowship training. STUDY DESIGN: ast surgical residents who completed training at our rural, community-based, 140-bed hospital from 1992 to 2000 were contacted by mailed surveys and a followup telephone interview. Advanced laparoscopy was defined as cases other than cholecystectomy, appendectomy, and diagnostic laparoscopy. Five attending surgeons routinely perform advanced laparoscopy. RESULTS: The response rate to the survey was 93.3% with 15 of 18 graduates currently practicing general surgery and 100% of the surgeons performing advanced laparoscopy. Laparoscopic herniorrhaphy, splenectomy, colectomy, Nissen fundoplication, and adrenalectomy were performed by 12 (85.7%), 10 (71.4%), 11 (78.6%), 13 (92.9%), and 9 (64.3%) surgeons, respectively. Eight (57.1%) surgeons reported confidence to perform advanced laparoscopy immediately after residency. All graduating chief residents from the last 3 years expressed this confidence. On average each of two chief residents from the past 3 academic years graduated with 99 basic and 50 advanced laparoscopic cases. CONCLUSIONS: A rural, community-based program can train residents to perform advanced laparoscopy. Increasing the volume of advanced cases handled by resident correlates with increasing confidence in graduates.