ORIGINAL ARTICLE

Orthopedic Surgery in Rural American Hospitals: A Surveyof Rural Hospital AdministratorsDerek Weichel, MD1

1 Department of Orthopaedic Surgery, University of South Florida, Tampa, Florida

For further information contact: Derek Weichel,

MD, University of South Florida Department of

Orthopaedic Surgery, 13220 USF Laurel Dr.,

MDF 5th Flr., Mail Code MDC 106, Tampa, FL

33613; e-mail dwweichel@gmail.com.

doi: 10.1111/j.1748-0361.2011.00379.x

Abstract

Rural American residents prefer to receive their medical care locally. Lack ofspecific medical services in the local community necessitates travel to a largercenter which is less favorable. This study was done to identify how rural hos-pitals choose to provide orthopedic surgical services to their communities.Methods: All hospitals in 5 states located in communities that met the criteriafor a rural town according to the Rural Urban Commuting Area codes were in-cluded. A survey with topics including community and hospital demographics,orthopedic surgical workforce and demand, surgical services, and the perceivedbenefit of orthopedic services was sent to the hospital administrators.Results: Of the 223 rural hospitals surveyed, 145 completed the survey. Ofthose completing the survey, 30% had at least one full-time orthopedic sur-geon, 25% did not provide any orthopedic surgical services, 65% never hadan orthopedic surgeon on ER call, 33% were recruiting an orthopedic sur-geon, 52% stated that it is more difficult to recruit an orthopedic surgeon vsa general surgeon, and 71% of the administrators acknowledged a need foradditional orthopedic surgical services in their community. For those hospitalsthat did not have a full-time orthopedic surgeon, members of those commu-nities traveled a mean distance of 55 miles for emergency orthopedic surgicalcare as reported by the hospital administrators.Conclusions: There are many rural communities that have limited access toorthopedic surgical services. While many of the rural hospital administratorsfeel that there is a need for additional orthopedic surgical services in theircommunities, it is difficult to recruit orthopedic surgeons to these areas.

Key words access to care, orthopedic surgery, physician supply, ruralhospitals.

Approximately one-fourth of the population in theUnited States lives in rural communities. When comparedto those who live in nonrural areas, many rural residentshave a more difficult time accessing health care. Severalstudies have shown that rural residents prefer to receivemedical services locally rather than having to travel to areferral center for both their general health care and or-thopedic needs.1-3 If they do not have access to an ortho-pedic surgeon in their local community, these residentsand their families must spend more time and money trav-eling to a larger referral center. This is also less favorablefor the local rural hospitals as they lose revenue when

their local patients travel to other areas to obtain theirorthopedic care.4

Quality of care should be a consideration when dis-cussing rural hospitals. It has been shown that patientswith open high-energy lower extremity trauma have alower risk of infection when transferred directly to atrauma center rather than being transferred from an out-side institution.5 However, when looking at the rate ofrevisions after total hip arthroplasty, there does not ap-pear to be any association between the rate of revisionand hospital volume.6 Similarly, Forte et al found thatthere is no benefit to transferring patients with routine

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Orthopedic Surgery in Rural American Hospitals Weichel

hip fractures to high-volume centers.7 It should be notedthat there is a wide range of both outpatient and inpa-tient procedures done by orthopedic surgeons; the num-ber and type of procedures routinely done by a particularorthopedic surgeon will likely have as great an impact onoverall outcome as the hospital volume.

Studies have looked at the delivery of general surgeryservices in rural areas. Doty et al have shown that manyrural hospitals face a shortage of general surgeons andthat few young surgeons are choosing a rural prac-tice.4,8 It has also been shown that there are significantdifferences in how surgical services are delivered in ru-ral hospitals.4 In addition, the financial importance ofdelivering these surgical services differs between ruralhospitals.4 Similarly, Thompson et al found that ruralgeneral surgeons are more likely to be older or interna-tional medical graduates when compared to urban gen-eral surgeons. He also found a smaller number of generalsurgeons per 100,000 people in small/isolated rural ar-eas, indicating limited access to surgical services in theseareas.9

There is little information on the delivery of orthope-dic surgical services in rural hospitals in the United States.Those studies that have been done on the delivery of or-thopedic services in rural America have largely focusedon the use of telemedicine.10-12 There have been no stud-ies specifically looking at how rural American hospitalschoose to provide orthopedic surgical services or lookingat the need for orthopedic surgeons in rural America. Theprimary objective of this study was to identify how ruralhospitals choose to provide orthopedic surgical services totheir communities.

Materials and Methods

After obtaining Institutional Review Board approval, alist of administrators at all the rural hospitals in Florida,Nebraska, West Virginia, Arizona, and Montana was ob-tained. All of the hospitals selected were located in ZIPcodes that met the criteria for large rural town, small ru-ral town, or isolated rural town according to the rural ur-ban commuting area (RUCA) codes. Therefore, they wereall located in ZIP codes that were associated with a RUCAcode of 4.0 or higher (excluding 4.1, 5.1, 7.1, 8.1, and10.1 as these are considered urban-focused for researchpurposes).13

These 5 states were selected because they are geo-graphically located in different regions of the UnitedStates. The total number of rural hospitals in these5 states (223) was similar to the number of rural hospitalssurveyed in a recently published study looking at generalsurgery in rural hospitals.8

Between November 2009 and March 2010, a29-question survey was mailed to the administrators. Thissurvey was a modification of a survey that was previouslyused for a study looking at the delivery of general surgeryat rural hospitals.8 This survey included questions thataddressed community and hospital demographics, ortho-pedic surgical workforce, orthopedic surgeon demand,surgical services in general, and the perceived hospitaland community benefit of orthopedic services. For thoseinitially not responding, a second survey was mailed. Ifthe administrators did not respond after receiving the sec-ond survey, they were called to see if they would be will-ing to complete the survey over the phone.

Results

Hospital and Community Demographics

A total of 223 hospitals in the 5 states met the inclusioncriteria and their administrators were contacted. A total of145 administrators completed the survey for a responserate of 65%. The response rate from each state wasArizona: 59% (17/29), Florida: 61% (19/31), Mon-tana: 60% (33/55), Nebraska: 77% (57/74), and WestVirginia: 56% (19/34). Of those hospitals responding,68% (98/145) were critical access hospitals. The mediannumber of beds per hospital was 25. The median popula-tion of the towns these hospitals were in was 5,000 andthe median service area population was 15,000.

Orthopedic Staffing

Twenty-five percent of the hospitals provided no or-thopedic care to their communities, while 35% of thehospitals had at least 1 full-time or part-time orthope-dic surgeon. However, only 17% of the hospitals actuallyemployed at least 1 of the full-time orthopedic surgeonswho worked at their hospital. There was at least 1 itiner-ant orthopedic surgeon but no full- or part-time orthope-dic surgeon at 40% of the hospitals. When a hospital didnot have a full-time orthopedic surgeon but provided or-thopedic care only through an itinerant surgeon, the av-erage number of days per month an itinerant was at thehospital was 4. The median distance traveled one way bythose itinerant surgeons was 60 miles as reported by thehospital administrators.

Emergency Orthopedic Coverage

Of those hospitals responding to the survey, 65% had noorthopedic ER coverage. Sixteen percent had an orthope-dic surgeon on call for the ER some but not all nights ofthe month, while 18% had an orthopedic surgeon on call

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Weichel Orthopedic Surgery in Rural American Hospitals

for the ER every night. Of those hospitals that do haveat least some orthopedic ER coverage, 22% stated thatthey provide the surgeons with additional compensationfor taking ER call and the median amount paid was $675(range $250-$1,000) per night.

Rural Orthopedic Surgeon Demand

Of the hospitals with an orthopedic surgeon, 48% had atleast one who was over the age of 50. Twenty-five per-cent have had an orthopedic surgeon leave or retire inthe last 2 years and 8% know that they will have at leastone orthopedic surgeon leave or retire in the next 2 years.Of those responding, 33% stated that they are currentlyrecruiting an orthopedic surgeon, and the median timerecruiting was 12 months. When asked about their com-munity’s needs, 71% of hospital administrators noted aneed for additional orthopedic surgical services. Whenasked about recruiting surgeons, 52% of administratorsstated that it is more difficult to recruit an orthopedic sur-geon when compared to a general surgeon, 44% statedthat it is the same, and 4% stated that it is easier to re-cruit an orthopedic surgeon. Compared to recruiting pri-mary care physicians, 78% of administrators stated thatit is more difficult to recruit an orthopedic surgeon, 15%stated that it is the same, and 7% stated that it is easierto recruit an orthopedic surgeon. Ten percent stated thatphysicians other than orthopedic surgeons perform or-thopedic procedures in the OR under general anesthesia.This included 6 hospitals with podiatrists, 5 hospitals withgeneral surgeons who did carpal tunnel releases and/orother hand surgery, 1 hospital where a general surgeondid hip fracture pinning, and 1 hospital where a familypractice physician did carpal tunnel releases.

Surgical Services

Of the administrators who responded to the survey, 77%indicated that their hospitals did both inpatient and out-patient surgical procedures, 10% reported that their hos-pital did outpatient surgery only, and the remaining 13%said their hospital provided no surgical services. Seventy-five percent of those hospitals that did provide surgi-cal services also provided full-time anesthesia coverage.Anesthesia services are provided only by an anesthesiol-ogist in 7% of the hospitals, a CRNA alone in 67% of thehospitals, and both a CRNA and anesthesiologist in 26%of the hospitals.

Perceived Hospital and Community Impact

The hospital administrators were asked to rank sev-eral statements on a scale from 1 to 5 with 1 be-

ing “strongly disagree” and 5 being “strongly agree.”The mean response to the statement that a full-timeorthopedic surgeon significantly improves the hospi-tal’s bottom line was 4.7. The mean response tothe statement that having a full-time orthopedic surgeonis viewed positively by the community citizens was 4.9.The mean response to the statement that having an or-thopedic surgeon affects the quality of care provided inthe community was 4.8. According to the hospital admin-istrators, for those hospitals that do not have a full-timeorthopedic surgeon, the median distance traveled oneway by their community citizens for emergency orthope-dic care is 50 miles (range 20-250 miles) and for electiveorthopedic care it is 45 miles (range 20-135 miles).

Discussion

The results of this study demonstrate that many ruralhospital administrators in these 5 states feel that thereis a need for additional orthopedic surgical services intheir communities. There are many rural communitiesthat have no orthopedic surgeon or that are only servedby an itinerant orthopedic surgeon. Likewise, orthopedicER coverage is quite poor in many of these rural commu-nities. In some situations the citizens of these rural com-munities must travel long distances for both elective andemergent orthopedic care. It is challenging to recruit or-thopedic surgeons to these rural communities. However,for those communities that do have an orthopedic sur-geon, it affects the quality of care provided in those com-munities and helps the local hospital financially.

There is no good data on the percentage of non-ruralhospitals who are currently recruiting orthopedic sur-geons and no surveys were sent to non-rural hospitalsas part of this study. It is possible that there is a signifi-cant need for orthopedic surgeons in both urban and ru-ral communities throughout the country.

The response rate of 65% is similar to others whohave reported response rates anywhere from 48% to79% when mailing surveys to rural hospital administra-tors.8,14,15 In this study, the rural hospital administratorsfrom West Virginia had the lowest response rate at 56%(19/34), while those from Nebraska had the highest re-sponse rate at 77% (57/74). Considering that we con-tacted all rural hospitals in these states rather than a selectgroup, these responses are a representative sample fromthese states.

While there appears to be a need for additional or-thopedic surgical services in these communities, it alsoappears as though it is difficult for these hospitals torecruit orthopedic surgeons. There are no good studiesspecifically looking at the recruitment or retention of

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Orthopedic Surgery in Rural American Hospitals Weichel

orthopedic surgeons in rural communities. The resultsof this study show that 33% of the rural hospitals arecurrently recruiting orthopedic surgeons. This number issimilar to the figure of 36% of hospitals currently re-cruiting general surgeons in a study done by Doty et al.8

MacDowell found that it was easier to recruit to ruralcommunities if the community is supportive of the fam-ily, the community cooperates and perceives a good fu-ture, and the community has attractiveness.14 For gen-eral surgery, it has been shown that those residents whochoose a rural practice are more likely to have a ruralbackground.16 However, Kassebaum found that a medicalschool’s output of rural physicians is also dependent onnurturing the interest in rural practice among nonruralstudents.17 Further research could be done to determineexactly what attracts orthopedic surgeons to rural areasand what could be done to help retain them once they arethere.

Many of these rural hospitals appear to use itinerantorthopedic surgeons to provide orthopedic surgical ser-vices to their communities. This study did not look intohow many of these surgeons actually did surgery in theserural hospitals. For many critical access hospitals, theitinerant orthopedic surgeon may be the sole orthopedicprovider in that community. This is consistent with thefindings of Kellerman who found that 68% of the ruralKansas hospitals had an itinerant orthopedic surgeon.18

In some of these communities, orthopedic services arealso provided by general surgeons or other specialists. Inthis study 10% of the administrators reported that some-one other than an orthopedic surgeon does orthopedicsurgical procedures in the OR. These procedures weredone by podiatrists in 6 hospitals, general surgeons in 6hospitals, and a family practice physician in 1 hospital.Some of the procedures performed by general surgeonsincluded carpal tunnel releases and pinning of hips. Somerural communities may not be able to support a full-timeorthopedic surgeon, necessitating an itinerant orthopedicsurgeon. According to the American Academy of Ortho-pedic Surgeons, there was approximately 1 orthopedicsurgeon for every 14,000 people in the United States in2008.19

It is likely that the anesthesia services provided in ruralhospitals are not as broad as those offered in urban hos-pitals. Of the rural hospitals completing our survey andwhich offered surgical services, 67% stated that anesthe-sia services were provided only by a CRNA. This is con-sistent with the findings of Doty et al who found that aCRNA is the only anesthesia service provider in 59% ofall hospitals in rural areas and 78% of hospitals in smallrural areas.8 In this study, 22% of hospitals that reportedthat anesthesia services were provided only by a CRNA

had at least 1 full-time orthopedic surgeon. The limitedanesthesia services may have an influence on the surgi-cal cases these orthopedic surgeons choose to do and thetypes of patients these surgeons choose to operate on atthese rural hospitals.

There are several areas in which this study could havebeen improved. A weakness of this study is the factthat there is no comparison group. Urban hospitals couldhave been surveyed as a comparison for some of the re-sults obtained through this survey. The results obtainedfrom large rural and small rural hospitals could also becompared. The characteristics of the hospitals which re-sponded were not compared to the characteristics of hos-pitals which did not respond to determine if there wasany bias. The administrators knew that an orthopedic sur-geon was conducting this survey and this may have influ-enced their responses. One significant limitation is the in-clusion of rural hospitals in only 5 states. This study couldhave been improved by sampling rural hospitals in moreor even all states rather than just these 5. In addition, thehousehold income in each of these states was not con-sidered to evaluate their similarity or difference in thoseregards. Finally, there were no questions asking specifi-cally what percentage of the surgical volume came frominpatient vs outpatient surgery or emergency vs electivesurgery. The addition of these questions could have alsostrengthened this study.

Conclusions

In summary, this study shows that there is a perceivedneed for additional orthopedic surgical services in manyrural communities in the United States. In many ruralcommunities, orthopedic services are provided by an itin-erant orthopedic surgeon. While there is a need, it is verydifficult for these rural hospital administrators to recruitan orthopedic surgeon. Anesthesia services are often pro-vided by only a CRNA at these rural hospitals. Basedon the opinion of the hospital administrators, having afull-time orthopedic surgeon appears to improve a hos-pital’s bottom line and is also viewed positively by thecitizens of the community. Additional research could bedone to determine the practice characteristics of a ru-ral orthopedic surgeon and to determine how to betterrecruit orthopedic surgeons to rural communities in theUnited States.

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