Evidence for Quality of Surgical Care in Rural America

1. Evidence for Quality of Surgical Care in Rural America Samuel R. G. Finlayson, MD, MPH

2. Overview • General Issues Related to Quality of Surgical Care in Rural Areas • Evidence for Quality of Rural Surgical Care • review of scant literature • Preview of new data from Mithoefer/Dartmouth collaboration

3. Quality in Rural Surgical Practice • Providing high quality surgical care may not be enough to satisfy all stakeholders • Payers want evidence of high quality • Patients do, too • Challenge is in providing evidence of high quality surgical care

4. Quality in Rural Surgical Practice: Challenges • Can I just keep track of my outcomes? • Problem of Small Numbers • Practical Realities • payer interests • Potential Solutions • Participation in quality initiatives • NSQIP, Michigan BC/BS, SCOAP • Aggregate measure

5. Quality in Rural Surgical Practice: Challenges • Can I just keep track of my outcomes? • Problem of Small Numbers • Practical Realities • payer interests • Potential Solutions • Participation in quality initiatives • NSQIP, Michigan BC/BS, SCOAP • Aggregate measure

6. Low-Volume Providers are Stuck Nearly Impossible to Demonstrate High Quality Results When rates ofadverse outcomes are low,orfew proceduresare performed … … statistical power is often insufficientto show any difference between your own outcome rate and the “benchmark” rate.

7. The Problem of Power Died Survived 48,500 1500 3% The Nation (benchmark) You 46 4 8% difference in mortality is NOT statistically significant!

8. The Problem of Power Died Survived 48,500 1500 3% The Nation (benchmark) You 46 0 0% difference in mortality is NOT statistically significant!

9. The Problem of Power Died Survived 48,500 1500 3% The Nation (benchmark) You 100 0 0% difference in mortality is NOT statistically significant!

10. Quality in Rural Surgical Practice: Challenges • Can I just keep track of my outcomes? • Problem of Small Numbers • Practical Realities • payer interests • Potential Solutions • Participation in quality initiatives • NSQIP, Michigan BC/BS, SCOAP • Aggregate measure

11. Practical Realities • Payers may not care about individual results • Bariatric Surgery in Durant, OK. • Proxies for quality are easier for insurers, align with their interests (easy approximations) • Procedure volume • Crude mortality rates • Special certifications

12. Quality in Rural Surgical Practice: Challenges • Can I just keep track of my outcomes? • Problem of Small Numbers • Practical Realities • payer interests • Potential Solutions • Participation in quality initiatives • NSQIP, Michigan BC/BS, SCOAP • Documents attention to quality • Aggregate outcome measures

13. Aggregation to Achieve Sample Size • Individual case volumes may be too small to demonstrate one’s results are in line with quality benchmarks • Evaluation of surgical results in the aggregate may help • Irate letter from Iowa

14. Aggregating Data Tells a Story Died Survived 233 Highest volume surgeon 7 3% Rest of Iowa 1331 4 0.3% HV surgeon’s mortality is higher (p<0.001)

15. Evidence for Quality in Rural Surgical Practice “Are you just pissing and moaning, or can you verify what you’re saying with data?”

26. (adj. OR 1.1)

27. Mithoefer/Dartmouth • Recall prior study of surgeon workforce based on Hospital Service Area (showed results at last symposium) • HSAs categorized along the urban-rural spectrum using RUCA designations • Calculated surgeons per capita (age/sex-adjusted) in each HSA • Compared surgeon workforce levels • across specialties • across the urban-rural spectrum

28. 12 General Surgeons per 100,000 population 10 8 6.94 6.54 6.30 5.52 6 4 2 0 Urban Large Rural Small Rural Isolated

29. Proportion of HSAs with Low Surgeon Supply (< ½ nat’l ave.)

30. Proportion of HSAs with Low Surgeon Supply (< ½ nat’l ave.)

31. Brief Review of Methods • Rural definitions • Hospital Service Areas

32. Defining Rural • Rural-Urban Commuting Areas (RUCA) • Developed by US Dept of Agriculture, the Health Resources and Service Administration (HRSA), and the Univ. of Washington • Classify U.S. census tracts using measures of • population density and urbanization • size and direction of daily commuting flow • UW developed ZIP code approximation of the RUCA codes based on an overlay of ZIP code areas on census tracts http://www.ers.usda.gov/briefing/Rurality/RuralUrbanCommutingAreas

33. Hospital Service Areas (HSA) • Developed using national Medicare inpatient claims • Defined as geographic area that includes one or more hospitals to which local residents generally have the plurality of their inpatient admissions • Based on zip code tabulation areas (ZCTA) • ZCTA is an approximate area representation of the US Postal Service's ZIP code service areas created by the US Census Bureau

34. A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A

35. B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B

36. C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C

37. B A A B A B B A A A B B A A A A B B B A B B B B A A A B C A A B C C 8 A’s 6 B’s 0 C’s A A A A B A C A B B B B B C B A B B C A B A A A A B B A A A B B A C A B C B B A B A A C A A A A A B B A B A C C A 6 A’s 8 B’s 2 C’s A A A C C C B B A C A C B C C C A B A B A C C C C C A B C A C B B C C C C C

38. A B C

39. Hospital Service Areas (HSA) • US parsed into 3067 HSAs • Reflect “health care markets” • Where people actually go for care (not necessarily closest hospital)

40. Defining Rural vs. Urban HSAs • Categorized hospital service areas into one of 4 RUCA categories • Urban • Large rural • Small rural • Isolated rural • RUCA categorization of a given HSA determined by the plurality of that HSA’s population

41. A B C Small Rural Small Rural Large Rural Large Rural Large Rural Large Rural Large Rural

42. Preview of New Data from Mithoefer/Dartmouth • Effort to study outcomes • By rurality of the HSA (patient origin) • By level of surgeon supply (surg-per-capita) • Appendectomy • A good model for studying access to surgical care • timeline, clinical decision making • proposed as potential quality indicator • rural patients have slightly higher rates of perforated appendectomy (adj. OR 1.11, 95%CI 1.02-1.22)* *NIS study, to be presented at ACS Surgical Forum 2009

43. Mithoefer/Dartmouth • Appendicitis Outcomes Study • National 100% sample of Medicare discharges (age over 65, 3 years of data, >92,000 cases) • Stratified outcomes by urban-rural designation • Specific Outcomes Studied • perforation rates • abdominal abscess rates • negative appendectomy rates

44. Diagnosis of Perforation with Appendectomy Urban/Suburban Large Town Small Town Isolated Rural *Adjusted for age, sex, race

45. Diagnosis of Abscess with Appendectomy Urban/Suburban Large Town Small Town Isolated Rural *Adjusted for age, sex, race

46. Negative Appendectomy Rate Urban/Suburban Large Town Small Town Isolated Rural

47. Surgeon Supply and Appendicitis Outcomes • From prior work, we know surgeons per capita for each HSA (population age sex adjusted) • Outcomes stratified by RUCA and surgeon supply • No surgeons • ½ the national average surg-to-pop ratio • ½ to 2x national average surg-to-pop ratio • >2x national average surg-to-pop ratio

48. Perforation Rates and Surgeon Supply 37 36 35 34 33 32 31 30 29 none <1/2 national 1/2 to 2x >2x national average national ave average overall urban/suburban small rural