Rural surgery and the volume dilemma

Another 3:00 am phone call left me struggling toward wakefulness. This time it was the obstetrician. He went on too long, explaining how he had produced a large laceration in a patient’s bladder in the course of performing a cesarean delivery. Finally awake enough to interrupt, I said, “Whatever it is, I’ll take care of it.” For general surgeons in small rural hospitals, this is what we do— we take care of it, whatever it is.

Growing demand for rural surgeons

In the approximately two-thirds of the 1,300 critical access hospitals (CAH) located across the U.S. where general surgeons still operate, we engage in a scope of practice that has largely disappeared in metropolitan areas. As one contributor to the American College of Surgeons rural listserv wrote, “You know you are a rural surgeon when your OR [operating room] list for the day would require five subspecialists in a larger hospital.”

In light of the decline in general surgeons practicing in rural areas (an estimated 8.1 per 100,000 population in 1981, declining to 5 per 100,000 in 2005, and likely even fewer today), there is no shortage of patients in need of surgical services.¹ In comparison with their urban counterparts, of whom there are approximately 7.7 per 100,000 patients, rural surgeons take responsibility for 50 percent more lives.¹ Case loads are higher for surgeons practicing in both small and large rural hospitals by a similar proportion, as documented by analysis of the American Board of Surgery (ABS) recertification case logs.² Analysis of the Dakota Database for Rural Surgery yielded an average of 1,071 surgical procedures annually among the 43 rural surgeons participating. Case distribution included 48 percent of cases considered general surgery, 40 percent endoscopy, and 12 percent subspecialty.³ When it comes to the volume part of the volume/outcome equation, overall number of cases is rarely an issue for rural surgeons.

Unfortunately, outcomes research evaluating a variety of medical diagnoses has shown poorer results in CAHs than in larger hospitals. Surgical services suffer from guilt by association. Several recent publications have confirmed that as rural surgeons, we do well those procedures we do regularly. Gadzinski and colleagues, in a 2013 publication from the University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, compared results using administrative data sets from 1,283 CAHs and 3,612 non-CAHs for eight common procedures in general surgery, obstetrics and gynecology, and orthopaedics, including the following: appendectomy, cholecystectomy, colorectal cancer resection, cesarean delivery, hysterectomy, knee replacement, hip replacement, and hip fracture repair.⁴ Length of stay was statistically significantly shorter at CAHs for four procedures and risk-adjusted mortality rates were equivalent, with the exception of hip fracture in Medicare beneficiaries. The 2015 report of the Rural Health Research Center at the University of Washington, Seattle, showed that for a variety of common general surgery, obstetrics and gynecology, and orthopaedic procedures, patients treated in rural hospitals had fewer serious complications than their urban counterparts, although the rural hospital cohort appeared to have a lower risk profile.⁵

Most recently, Ibrahim and colleagues published an analysis of surgical outcomes and expenditures among Medicare beneficiaries treated in 828 CAHs and 3,676 non-CAHs in a retrospective review of 1,631,904 admissions. Four common general surgery procedures were included: appendectomy, cholecystectomy, colectomy, and hernia repair. The investigators concluded, “Among Medicare beneficiaries undergoing common surgical procedures, patients admitted to critical access hospitals compared with noncritical access hospitals had no significant difference in 30-day mortality rates, decreased risk-adjusted serious complication rates, and lower adjusted Medicare expenditures, but were less medically complex.”⁶

Higher risk, more diverse cases

The debate over the relationship between volume and outcomes is certainly much older than the modern era of research, which dates to the seminal article of health care economist Harold Luft, published in the New England Journal of Medicine in 1979.⁷ The list of procedures across multiple surgical specialties where a relationship between volume and outcomes has been documented in the surgical literature is much larger than the eight complex procedures listed in the “Volume Pledge.”⁸ Few common procedures have escaped such analysis; from inguinal herniorraphy to open heart surgery, the nearly universal result has been the documentation of a correlation.

Luft recognized that “practice makes perfect” was only one possible explanation.⁹ Another would be “selective referral”; that is, patients are more likely to be referred to surgeons and facilities with a good reputation for a particular procedure and that low-volume providers are low volume because they produce inferior results. The factors leading to better outcomes are more nuanced than surgeon and institutional volumes and include training, specialization, cumulative experience, and technical surgical skill.^10,11

In another study, a 2.5-fold difference in risk-adjusted mortality rates between institutions for six high-risk procedures was explained on the basis of failure to rescue; that is, lack of recognition or optimal management of surgical complications.¹² When I relocated to a CAH 17 years ago, I decided the days of performing high-complexity oncology procedures were over for me. This realization was not because I had developed selective amnesia after crossing the Hudson River, but because a 25-bed hospital with no full-time medical or surgical subspecialists cannot provide the level of support necessary to provide the postoperative care that patients need when undergoing high-morbidity procedures. The trip to a staffed surgical intensive care unit with a full complement of subspecialty consultants is not an elevator ride for CAH patients, but often a helicopter ride.

Rural surgical practices tend to generate diverse case loads, unlike the niche practices common in major metropolitan areas. Looking over the case log I submitted last year for ABS recertification, few of the procedures listed would pass muster individually by volume metrics. As individuals, it is rarely possible to accumulate sufficient data to prove that we are producing excellent results.

In an analysis of 5,033 colectomies performed over three years by 345 surgeons in the Michigan Surgical Quality Collaborative (MSQC) Colectomy Quality Improvement Intervention Project, a valid risk-adjusted surgeon-specific complication rate could be calculated for only one surgeon.¹³ A caseload of 168 colectomies over three years was required to calculate a reliable result. The average number of cases per surgeon annually calculates to 4.86. In the Ibrahim study cited earlier, average annual Medicare colectomies per CAH were 2.46.⁶ If one assumes an equal number of colectomies in non-Medicare beneficiaries (extrapolating from the MSQC data), the same number results. A single mortality after a colectomy by the average surgeon in a CAH would require six years of cumulative data without a mortality to come down to the 3.3 percent reported in Ibrahim’s study. We will not be much helped by individual scorecards.

Some health care policymakers would have rural surgeons give up doing all but the most basic of surgical procedures in favor of regionalization. However, this situation would present a number of problems for patients, hospitals, and surgeons. Rural patients on average are older, poorer, and less mobile than patients in larger metropolitan areas. Lack of mobility, whether as a result of economic, psychological, or physical limitations, represents a real barrier for poor and elderly patients. Some patients have such a strong preference for local care that they will opt for a local provider even in the face of greatly increased risk of mortality.¹⁴

At the hospital level, CAHs are dependent on the revenue generated by surgical services to sustain their financial viability. Recruitment and retention of general surgeons in rural areas is difficult already. Were the scope of practice of rural surgeons to be constrained by widespread restriction of surgical privileges on the basis of numerical quotas or mandated regionalization, fewer general surgeons would find rural practice attractive, further limiting access to emergency and elective surgical care.

Suggestions for rural surgeons

What, then, ought we do as rural surgeons to overcome these challenges? Here’s what I do. First, I try to “color inside the lines.” That is, I try to manage my patients according to accepted guidelines and the current literature. Clinical practice guidelines are available online from a variety of sources, including the American College of Surgeons, National Comprehensive Cancer Network, American Society of Breast Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, American Society of Colon and Rectal Surgeons, American College of Obstetrics and Gynecology, and others. These professional guidelines serve as “guardrails” to keep me on track.

Second, I try to maintain currency of knowledge and technical skills appropriate to my scope of practice. When your OR schedule on any given day might include a total thyroidectomy, an ultrasound-guided partial mastectomy with sentinel node biopsy, a laparoscopic cholecystectomy with common bile duct exploration, a components separation incisional hernia repair, or a laparoscopic hysterectomy, staying current can be daunting. Without the Internet, I could never manage. I limit the patients I treat and the procedures I perform to those I believe are within my areas of competence and the capabilities of my facility. When complications occur, I try to recognize and admit them and arrange for transfer to an appropriate level of care, whether across the hall to our intensive care unit or across the state to a tertiary care facility.

Finally, we have begun to expand the measurement of outcomes and to participate in collaborative quality improvement projects through the Illinois Surgical Quality Improvement Collaborative, a major new initiative for my facility.

To paraphrase Vince Lombardi, perhaps perfect practices will make perfect.

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References

1. Cogbill TH, Cofer JB, Jarman BT. Contemporary issues in rural surgery. Curr Probl Surg. 2012;49(5):263-318.
2. Valentine RJ, Jones A, Biester TW, Cogbill TH, Borman KR, Rhodes RS. General surgery workloads and practice patterns in the United States, 2007 to 2009: A 10-year update from the American Board of Surgery. Ann Surg. 2011;254(3):520-526.
3. Sticca RP, Mullin BC, Harris JD, Hosford CC. Surgical specialty procedures in rural surgery practices: Implications for rural surgery training. Am J Surg. 2012;204(6):1007-1013.
4. 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(7):589-596.
5. Doescher MP, Jackson JE, Fordyce MA, Lynge DC. Variability in general surgical procedures in rural and urban U.S. hospital inpatient settings. Final Report #142. WWAMI Rural Health Research Center, University of Washington, 2015.
6. Ibrahim AM, Hughes TG, Thumma JR, Dimick JB. Association of hospital critical access status with surgical outcomes and expenditures among Medicare beneficiaries. JAMA. 2016;315(19):2095-2103.
7. Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between surgical volume and mortality. New Eng J Med. 1979;301(25):1364-1369.
8. Sternberg S. Hospitals move to limit low-volume surgeries. U.S. News & World Report. Available at: www.usnews.com/news/articles/2015/05/19/hospitals-move-to-limit-low-volume-surgeries. May 19, 2015. Accessed August 17, 2016.
9. Luft HS, Hunt SS, Maerki SC. The volume-outcome relationship: Practice-makes-perfect or selective-referral patterns? Health Serv Res. 1987;22(2):157-182.
10. Bilimoria KY, Phillips JD, Rock CE, Hayman A, Prystowsky JB, Bentrem DJ. Effect of surgeon training, specialization, and experience on outcomes for cancer surgery: A systematic review of the literature. Ann Surg Onc. 2009;16(7):1799-1808.
11. Birkmeyer JD, Finks FF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. New Eng J Med. 2013;369(15):1434-1442.
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13. Shih T, Cole A, Al-Attar PM, et al. Reliability of surgeon-specific reporting of complications after colectomy. Ann of Surg. 2015;261(5):920-925.
14. Finlayson SR, Birkmeyer JD, Tosteson AN, Nease RF Jr. Patient preferences for location of care: Implications for regionalization. Med Care. 1999;37(2):204-209.