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Characteristics of PracticeCharacteristics of PracticeRural and Urban General SurgeonsRural and Urban General Surgeons
in North Carolinain North Carolina
Characteristics of PracticeCharacteristics of PracticeRural and Urban General SurgeonsRural and Urban General Surgeons
in North Carolinain North Carolina
Jennifer KingErin Fraher, MPP, Thomas C. Ricketts, PhD,
Anthony Charles, MD, George F. Sheldon, MD, Anthony Meyer, MD PhD
Funding provided by American College of Surgeons Health Policy Institute
and NC AHEC
BackgroundBackground
Integrating practice patterns inworkforce analyses
• Medical practice varies between individual physicians– Volume– Content– Breadth
• Still, many supply assessments rely on head counts– Sometimes adjusted for hours in clinical care
General Surgery
• Indications of increasing specialization– Over 70% of general surgeons pursue fellowship
training– ABS now offers primary certification in vascular
surgery– “Natural” narrowing of practice over career?
• Rural practice may be broader• Debate over “right” breadth of training for
general surgeons
Research Questions
What is the:– Content of general surgery practices?– Volume of procedures performed?– Breadth of procedures performed?
How much do these characteristics vary from surgeon to surgeon?
How do these practice characteristics vary by rural and urban location?
Data & MethodsData & Methods
Data
• NC Health Professions Data System, 2004– Data on all licensed physicians– Specialty, practice location, demographics
• NC Inpatient Discharge Database & Ambulatory Surgery Database, 2004– ICD-9 procedure codes for all discharges and
ambulatory surgery encounters– Attending physician UPIN
Analysis File
Active non-federal general surgeons
648
UPIN601
No UPIN47
Any procedures544
No procedures57
Methods: Collapse ICD-9 Codes
• Clinical Classification Software (CCS) - AHRQ – 231 Procedure Categories, such as:
• Cholecystectomy and common duct exploration (CCS 84)• Inguinal and femoral hernia repair (CCS 85)
– 4 Procedure Types• Major Therapeutic: Cholecystectomy (ICD-9 5122)• Minor Therapeutic: Skin incision & foreign body removal
(ICD-9 8605)• Major Diagnostic: Intraoperative cholangiogram (ICD-9 8753)• Minor Diagnostic: Colonoscopy (ICD-9 4523)
• Group CCS Procedure Categories into American Board of Surgery content areas
Methods: Analysis
• Descriptive statistics by county type– Core Based Statistical Area designations
• Metropolitan: county with an urbanized area with 50,000 or more population
• Micropolitan: county with urban cluster of 10,000 to < 50,000 population
• Rural
• OLS regression to examine rural-urban differences in breadth of practice controlling for individual characteristics
ResultsResults
51% 54%46%
35%
24%23%
25%
28%
6% 6%6%
3%
19% 17%23%
34%
Total Metro Micro Rural
Sh
are
of
All
Pro
ced
ure
s
Minor Diagst
Major Diagst
Minor Therptc
Major Therptc
Procedures Performed by CCS Type
N=301,294 N=213,176 N=64,263 N=23,855
Source: North Carolina Health Professions Data System and NC Hospital Inpatient and Ambulatory Surgery Discharge Data, 2004. Data include active, in-state, non-federal physicians who report a primary specialty of general surgery and had at least one procedure in 2004.
Procedures Performed by Content Area
43% 38%52%
62%
20%21%
17%
16%13%14%
12%
10%11% 13%8%
4%13% 14% 11% 9%
Total Metro Micro Rural
Sha
re o
f A
ll P
roce
dure
s
Other
Vascular
Abdomen
Breast/Skin
Alimentary
N=301,294 N=213,176 N=64,263 N=23,855
Source: North Carolina Health Professions Data System and NC Hospital Inpatient and Ambulatory Surgery Discharge Data, 2004. Data include active, in-state, non-federal physicians who report a primary specialty of general surgery and had at least one procedure in 2004.
Total Procedures = 511
Dr. JonesFictional Surgeon
CCS Procedure Category
Number Performed in
2004
Cholecystectomy and common duct exploration 107
Intraoperative cholangiogram 82
Inguinal and femoral hernia repair 42
Appendectomy 31
Other hernia repair 29
Hemorrhoid procedures 25
Other OR lower GI therapeutic procedures 25
Colonoscopy and biopsy 22
Colorectal resection 22
Upper gastrointestinal endoscopy; biopsy 21
Other non-OR therapeutic procedures on skin and breast 17
Other non-OR lower GI therapeutic procedures 16
Lumpectomy; quadrantectomy of breast 16
Other non-OR therapeutic procedures on skin and breast 16
Excision of skin lesion 7
Excision; lysis peritoneal adhesions 5
Breast biopsy and other diagnostic procedures on breast 4
Other vascular catheterization; not heart 3
Incision and drainage; skin and subcutaneous tissue 3
Other therapeutic procedures 3
Colostomy; temporary and permanent 2
Gastrectomy; partial and total 2
Biopsy of liver 2
Amputation of lower extremity 2
Mastectomy 2
Aortic resection; replacement or anastomosis 1
Other OR procedures on vessels other than head and neck 1
Small bowel resection 1
Endoscopic retrograde cannulation of pancreas (ERCP) 1
Laparoscopy (GI only) 1
Total 511
Variation in Procedure Volume
02
04
06
08
01
00N
umb
er o
f Gen
era
l Sur
geo
ns
0 500 1000 1500 2000Number of Procedures Performed
Number of Procedures Performed, 2004
25% performed >70025%
performed < 356
Average = 554Source: North Carolina Health Professions Data System and NC Hospital Inpatient and Ambulatory Surgery Discharge Data, 2004. Data include active, in-state, non-federal physicians who report a primary specialty of general surgery and had at least one procedure in 2004.
Metro: 24%
Micro: 27%
Rural: 31%
Metro: 25%
Micro: 23%
Rural: 31%
Total Procedures = 511
Dr. JonesFictional Surgeon
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Types of Procedures = 30
CCS Procedure Category
Number Performed in
2004
Cholecystectomy and common duct exploration 107
Intraoperative cholangiogram 82
Inguinal and femoral hernia repair 42
Appendectomy 31
Other hernia repair 29
Hemorrhoid procedures 25
Other OR lower GI therapeutic procedures 25
Colonoscopy and biopsy 22
Colorectal resection 22
Upper gastrointestinal endoscopy; biopsy 21
Other non-OR therapeutic procedures on skin and breast 17
Other non-OR lower GI therapeutic procedures 16
Lumpectomy; quadrantectomy of breast 16
Other non-OR therapeutic procedures on skin and breast 16
Excision of skin lesion 7
Excision; lysis peritoneal adhesions 5
Breast biopsy and other diagnostic procedures on breast 4
Other vascular catheterization; not heart 3
Incision and drainage; skin and subcutaneous tissue 3
Other therapeutic procedures 3
Colostomy; temporary and permanent 2
Gastrectomy; partial and total 2
Biopsy of liver 2
Amputation of lower extremity 2
Mastectomy 2
Aortic resection; replacement or anastomosis 1
Other OR procedures on vessels other than head and neck 1
Small bowel resection 1
Endoscopic retrograde cannulation of pancreas (ERCP) 1
Laparoscopy (GI only) 1
Total 511
Variation in Types of Procedures Performed
Average = 61Source: North Carolina Health Professions Data System and NC Hospital Inpatient and Ambulatory Surgery Discharge Data, 2004. Data include active, in-state, non-federal physicians who report a primary specialty of general surgery and had at least 50 procedures in 2004.
02
04
06
08
0N
umb
er o
f Gen
era
l Sur
geo
ns
0 50 100Types of Procedures Performed At Least Once
15% performed < 44
15% performed > 79
Metro: 14%
Micro: 8%
Rural: 7%
Metro: 13%
Micro: 13%
Rural: 31%
CCS Procedure Category
Number Performed in
2004
Cholecystectomy and common duct exploration 107
Intraoperative cholangiogram 82
Inguinal and femoral hernia repair 42
Appendectomy 31
Other hernia repair 29
Hemorrhoid procedures 25
Other OR lower GI therapeutic procedures 25
Colonoscopy and biopsy 22
Colorectal resection 22
Upper gastrointestinal endoscopy; biopsy 21
Other non-OR therapeutic procedures on skin and breast 17
Other non-OR lower GI therapeutic procedures 16
Lumpectomy; quadrantectomy of breast 16
Other non-OR therapeutic procedures on skin and breast 16
Excision of skin lesion 7
Excision; lysis peritoneal adhesions 5
Breast biopsy and other diagnostic procedures on breast 4
Other vascular catheterization; not heart 3
Incision and drainage; skin and subcutaneous tissue 3
Other therapeutic procedures 3
Colostomy; temporary and permanent 2
Gastrectomy; partial and total 2
Biopsy of liver 2
Amputation of lower extremity 2
Mastectomy 2
Aortic resection; replacement or anastomosis 1
Other OR procedures on vessels other than head and neck 1
Small bowel resection 1
Endoscopic retrograde cannulation of pancreas (ERCP) 1
Laparoscopy (GI only) 1
Total 511
Total Procedures = 511
Dr. JonesFictional Surgeon
Types of Procedures = 30
Share in Top 10 = 406 / 511 = 79%
1
2
3
4
5
6
7
8
9
10
Variation in Share of All Procedures Accounted for by Top 10 Procedure Types
02
04
06
08
0N
umb
er o
f Gen
era
l Sur
geo
ns
.4 .6 .8 1Share of All Procedures Accounted For By Top 10 Unique Procedures
Average = .67
13% of surgeons were > 80%
focused on 10 procedures
Source: North Carolina Health Professions Data System and NC Hospital Inpatient and Ambulatory Surgery Discharge Data, 2004. Data include active, in-state, non-federal physicians who report a primary specialty of general surgery and had at least 50 procedures in 2004.
Metro: 13%
Micro: 10%
Rural: 14%
15% of surgeons were < 55%
focused on 10 procedures
Metro: 17%
Micro: 13%
Rural: 0%
Some rural-urban differences smaller after controlling for individual characteristics
Percent of Total Procedures Performed Accounted For by Top 10 Procedures
Metropolitan Micropolitan Rural
Average 61.9 59.3 53.7
Simple Difference -2.6 -8.2**
OLS Coefficient -1.2(-4.5, 2.2)
-3.6(-9.4, 2.1)
Number of Different Types of Procedures Performed
Metropolitan Micropolitan Rural
Average 66.3% 67.2% 72.2%
Simple Difference 0.9 5.9**
OLS Coefficient -0.5(-2.9, 1.9)
3.9*(0.9, 6.9)
Source: North Carolina Health Professions Data System and NC Hospital Inpatient and Ambulatory Surgery Discharge Data, 2004. Data include active, in-state, non-federal physicians who report a primary specialty of general surgery and had at least 50 procedures in 2004 (N=517). OLS results control for years since medical school graduation, hours per week in clinical care, gender, and second specialty.
ConclusionsConclusions
Key Findings
• Rural-urban differences in content
• Wide variation in volume and breadth between individual surgeons
• No large rural-urban differences in breadth– Many urban surgeons have practices as
broad or broader than rural counterparts
Limitations
• Missing UPIN for some surgeons
• Self-reported specialty– No information on board certification
• Possible measurement error– If attending surgeon is not performing surgeon– If incorrect ICD-9 codes
• Limited information on hospital characteristics
Extensions of Analysis Strategy:Future Work
• More detail on differences between rural and urban practice
• Effect of formal sub-specialization on scope of practice
• Changes in scope of practice over career trajectory