characteristics of practice rural and urban general surgeons in north carolina jennifer king erin...

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


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%



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


Number Performed in

2004




Appendectomy 31



















Biopsy of liver 2


Mastectomy 2






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%


Number Performed in

2004




Appendectomy 31



















Biopsy of liver 2


Mastectomy 2






Total 511



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

characteristics of practice rural and urban general surgeons in north carolina jennifer king erin...

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