Practice Patterns of Rural Surgeons in the Upper Midwest

1
Practice Patterns of Rural Surgeons in the Upper
Midwest

• Joel D Harris, MD, MPH
• Robert P Sticca, MD, FACS

University of North Dakota School of Medicine
and Health Sciences
2
Background

• 55 million rural Americans
• approximately 20 of population depending on
  definition
• 17,243 general surgeons in US 2005
• approximately 10-20 of general surgeons practice
  in rural areas
• Urban 6.53/100,000 population
• Large Rural 7.71/100,000 population
• Small or Isolated Rural Areas 4.67/100,000
  population

Shively EH. Am J Surgery Aug 2005 Thompson MJ.
Arch Surg Jan 2005 Heneghan SJ. J Am Coll Surg
Nov 2005
3
Previous Study Methods

• Caseload study data sources
• Medicare data
• American Board of Surgery recertification
  surgical operative log
• American Medical Association Masterfile
• Single surgeon databases
• Nationwide Inpatient Sample database

4
Rural vs. Urban Case-Mix

• Rural versus Urban Inpatient Case-Mix
  Differences in the US VanBibbler et al.
• Rural Urban Commuting Area (RUCA) codes
• Urban 50,000 population
• Rural lt49,999 population
• Nationwide Inpatient Sample Database
• Procedures performed 2000 to 2001
• International Classification of Diseases (ICD-9)
  codes
• Clinical Classification Software (CCS)

VanBibber, M. J Am Coll Surg, 2006
5
Proportion of Operating Room Procedures in Rural
Versus Urban Hospitals by Specialty
VanBibber, M. J Am Coll Surg, 2006
6
Rural Versus Urban Inpatient Case-Mix Across
Inpatient Procedures that Are Typically a Focus
of General Surgery Training
VanBibber, M. J Am Coll Surg, 2006
7
Rural vs. Urban Case-Mix

• Conclusions
• Rural and urban general surgical case-mixes
  differ from each other substantially
• Additional competence in a few surgical specialty
  areas could increase the role for general
  surgeons practicing in rural areas

VanBibber, M. J Am Coll Surg, 2006
8
Methods

• North and South Dakota medical boards
• Licensed general surgeons 2006
• Rural Surgeon Survey
• Procedure codes and volumes
• January 1, 2006 December 31,2006
• Current Procedural Terminology (CPT) codes
• Office procedures
• Outpatient OR
• Inpatient OR
• Outreach procedures

9
Rural Urban Commuting Area (RUCA) Codes
http//www.ers.usda.gov/Data/RuralUrbanCommutingAr
eaCodes
10
Response Flow Chart
n50 Active Rural North and South Dakota General
Surgeons
n2 Refused Participation
n7 Pending Responses
n2 No access to data
n39 (78) Obtained Data
n31 (79) Large Rural Surgeons
n8 (21) Small Rural Surgeons
11
Response Flow Chart

• Database
• Surgeon code
• RUCA code
• CPT code
• CPT volume

n50 Active Rural North and South Dakota General
Surgeons
n2 Refused Participation
n7 Pending Responses
n2 No access to data
n39 (78) Obtained Data
n31 (79) Large Rural Surgeons
n8 (21) Small Rural Surgeons
12
Statistical Analysis

• Clinical Classification Software (CCS)
• Developed by Healthcare Cost and Utilization
  Project (HCUP)
• Federal-State-Industry partnership sponsored by
  Agency for Healthcare Research and Policy
• 244 mutually exclusive categories
• Current Procedural Terminology (CPT) codes
• 49505 repair of initial inguinal hernia, age gt
  5y/o
• International Classification of Diseases, 9th
  Revision (ICD-9) codes
• 550 Inguinal hernia
• All analysis was performed using SPSS
• Chi square tests

www.hcup-us.ahrq.gov/tools_software.jsp
13
CCS code assignment for general surgical
procedures
CCS codes do not identify liver and pancreas by
individual codes. They were reclassified as
Liver CCS
245 CPT 47000-47130 47300-47399 Pancreas CCS
246 CPT 48000-48548 48999
14
CCS Code Assignment for Surgical Specialty
Procedures
15
Small and large rural general surgical procedure
volume during 2006
16
Based on two sided chi-square plt0.001

17
Percentage of surgical specialty procedures
performed by rural general surgeons
Based on two sided chi-square
18
General surgery caseload differences between
large and small rural general surgeons
Based on two sided chi-square
19
Surgical subspecialty caseload differences
between large and small rural surgeons
Based on two sided chi-square
20
Statistically significant differences between
large rural and small rural practices

• Large Rural
• Vascular
• Cardiothoracic
• Esophagus/Stomach
• Small/Large Bowel
• Appendectomy
• Spleen/Lymph
• Chole/CBD
• Hernia
• Breast
• Endocrine

• Small Rural
• Orthopedics
• OB/GYN
• Endoscopy
• Otolaryngology
• Anal/Rectal
• Skin/Soft Tissue

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Conclusions

• Significant differences exist between small and
  large rural general surgical practices
• Small rural surgeons average 33 more procedures
  per year than large rural surgeons
• Endoscopy comprises approximately 40 of rural
  surgeon procedures
• Endoscopy, OB/GYN, orthopedics, urology and
  otolaryngology, procedures make up approximately
  50 of rural general surgery practice
• Therefore, rural surgeons should have a different
  training curriculum

22
Future Research

• Comprehensive database
• Answer specific research questions by CCS
  category or CPT code
• i.e. percentage SLNBx vs ALND
• Compare to graduating general surgery resident
  case logs
• Generate resident curriculum
• Compare to urban practice

23
Acknowledgements

• Rural Surgeons of North and South Dakota
• Clint Hosford, PhD
• Dani Stramer
• Paula Rowland
• Barry Pederson
• Stephanie Borchardt, PhD, MPH