Issues that Face Rural Surgery in the United States
Nakayama DK, Hughes TG. J Am Coll Surg. 2014 Oct;219(4):814-818. doi: 10.1016/j.jamcollsurg.2014.03.056. Epub 2014 May 22.
This article discusses social and economic issues that threaten quality surgical care in rural communities.
- Rural communities have higher poverty and higher unemployment. These rural populations also have higher incidences of chronic disease, including cancer and heart disease.
- There is a critical shortage of surgeons in rural areas. Of 3,436 federally designated hospital service areas, 18% have no surgeons of any specialty and 30% have fewer than three surgeons per 100,000 population—the level defined by Ricketts and colleagues at the American College of Surgeons Health Policy Research Institute as a critical shortage.
- The economic impact of a general surgeon: one general surgeon will generate $700,000 for the practice, $1.4 million for the hospital, $2.7 million for the community, and 25.9 jobs.
Implementation of a Hospital-Based Quality Assessment Program for Rectal Cancer
Hendren S, McKeown E, Morris AM, et al. J Oncol Pract. 2014 May;10(3):e120-9. doi: 10.1200/JOP.2014.001387.
This study describes a first step in developing a program to improve rectal cancer care statewide. Michigan and other state-based surgical quality collaboratives have utilized hospital data to identity quality shortcomings and implement quality improvement programs to decrease surgical complications. Linking tumor registry data and quality improvement data will address an additional dimension of improving surgical patient care.
- A multi-hospital rectal cancer quality assessment program is feasible.
- Authors propose specific items to be included in the surgical operative report.
- Variable definitions must be standardized and clear.
Evaluation of a blended learning surgical skills course for rural surgeons
Halverson AL, DaRosa DA, Borgstrom DC, et al. Am J Surg. 2014 Jul;208(1):136-42. doi: 10.1016/j.amjsurg.2013.12.039. Epub 2014 Apr 5.
This article described the development and implementation of a skills course for rural surgeons. A total of 50 surgeons participated in two offerings of the course. The curriculum covered a variety of topics including communication skills, advanced endoscopy techniques, facial plastic surgery, and management of urologic and gynecologic emergencies.
- All participants reported that they had implemented changes in their communication skills as a result of attending the course.
- The majority of participants reported changes in their technique for endoscopic polypectomy and central line insertion.
- Eighty-nine percent of those who completed a post coursed follow-up survey felt that the quality of their patient care improved as a result of attending the course.
Identification of process measures to reduce postoperative readmission
Halverson AL, Sellers MM, Bilimoria KY, et al. J Gastrointest Surg. 2014 Aug;18(8):1407-15. doi: 10.1007/s11605-013-2429-5. Epub 2014 Jun 10.
This article describes Delphi analysis of factors that may reduce hospital readmissions. Recommended process measures included:
- Providing the patients with detailed written instructions prior to surgery and at the time of discharge
- Communication with the patient’s referring or primary care doctor
- Implementing standardized perioperative care protocols
National trends in patient safety for four common conditions, 2005-2011
Wang Y, Eldridge N, Metersky ML, et al. N Engl J Med. 2014 Jan 23;370(4):341-51. doi: 10.1056/NEJMsa1300991.
- This study includes 16,481 patients who required surgery.
- The most frequent discharge diagnoses among the surgical patients were osteoarthritis (39 percent), fracture of the neck of the femur (10 percent), malignant neoplasm of the colon (5 percent), acute myocardial infarction (5 percent), and chronic ischemic heart disease (4 percent).
- Between 2005–2006 and 2010–2011 the adverse event rates decreased for postoperative thromboembolic events, cardiac events, and falls.
- Adverse event rates increased for pressure ulcers, contrast-induced nephropathy associated with catheter-based angiography, and events associated with hip and knee replacement. The occurrence of an adverse event following surgery was associated with an increased mortality, 8.3 percent vs. 1 percent (p < 0.001).
- It is notable that the several measures to reduce surgical site infection that are included in The Joint Commission Surgical Care Improvement Project and American College of Surgeons National Surgical Quality Improvement Program are not included in the Medicare Patient Safety Monitoring.