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

2. Overview 1.General Issues Related to Quality of Surgical Care in Rural Areas 2.Evidence for Quality of Rural Surgical Care – review of scant literature 3.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 of adverse outcomes are low, or few procedures are performed … … statistical power is often insufficient to show any difference between your own outcome rate and the “benchmark” rate.

7. The Problem of Power Survived Died The Nation (benchmark) You 48,500 464 15003% 8% difference in mortality is NOT statistically significant!

8. The Problem of Power Survived Died The Nation (benchmark) You 48,500 460 15003% 0% difference in mortality is NOT statistically significant!

9. The Problem of Power Survived Died The Nation (benchmark) You 48,500 1000 15003% 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 Survived Died Highest volume surgeon Rest of Iowa 1331 233 4 73% 0.3% HV surgeon’s mortality is higher (p<0.001)

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

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. 6.94 6.54 6.30 5.52 0 2 4 6 8 10 12 UrbanLarge RuralSmall RuralIsolated General Surgeons per 100,000 population

29. # of HSAsLow supply HSAs Urban1273 Large Rural 689 Small Rural 660 Isolated 445 Proportion of HSAs with Low Surgeon Supply (< ½ nat’l ave.)

30. # of HSAsLow supply HSAs Urban1273254 (20%) Large Rural 689 147 (21%) Small Rural 660 255 (39%) Isolated 445 295 (66%) 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 AA 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 BB 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 CC C C C C C C C C C C C C C C C C C C C C C CC C C C

37. C AB B B B B B B B B B B B B BB B B B B B B B B B B B B B B B C C CC C C C C C C C C C C C C C C C C C C CC C C CA A A A A A A A A A A A AA A A A A A A A A A A A A A B B B B B B B B C C C A A A A A A A A A A A B B B B B B A A A A A A A A A A A A A A A 6 A’s 8 B’s 2 C’s 8 A’s 6 B’s 0 C’s

38. C A B

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. C A B 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. Urban/SuburbanLarge TownSmall TownIsolated Rural Diagnosis of Perforation with Appendectomy *Adjusted for age, sex, race

45. Urban/SuburbanLarge TownSmall TownIsolated Rural Diagnosis of Abscess with Appendectomy *Adjusted for age, sex, race

46. Urban/SuburbanLarge TownSmall TownIsolated Rural Negative Appendectomy Rate

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 29 30 31 32 33 34 35 36 37 none<1/2 national average 1/2 to 2x national ave >2x national average overallurban/suburbansmall rural